X CONGRESSO NAZIONALE IORS 2008

Transcript

SIOT
Società Italiana di
Ortopedia e Traumatologia
IORS
ITALIAN ORTHOPAEDIC
RESEARCH SOCIETY
Università degli Studi di Messina
Scuola di Specializzazione in
Ortopedia e Traumatologia
X CONGRESSO NAZIONALE IORS 2008
SOCIETÀ ITALIANA DI RICERCHE IN ORTOPEDIA E TRAUMATOLOGIA
MESSINA CONSENSUS CONFERENCE
“LE SCIENZE DI BASE
IN ORTOPEDIA E TRAUMATOLOGIA”
Messina 12-13 Settembre 2008
Centro Congressi - Policlinico Universitario - Messina
PRESIDENTE ONORARIO
Prof. Gianfranco Fineschi
PRESIDENTE
Prof. Michele Attilio Rosa
ITALIAN ORTHOPAEDIC RESEARCH SOCIETY (I.O.R.S.)
I
II
I.O.R.S.
Italian Orthopaedic Research Society
CONSIGLIO DIRETTIVO
Prof. Elena Brach del Prever
Prof. Nicola Baldini
Dott. Antonio Gigante
Dott. Guido Zarattini
Presidente
Consigliere
Consigliere
Consigliere
Tesoriere
COMITATO SCIENTIFICO
DEL CONGRESSO
Prof. Nicola Baldini
Prof. Armando Giunti
Prof. Francesco Greco
Prof. Ugo Ernesto Pazzaglia
SEGRETERIA SCIENTIFICA
DEL CONGRESSO
Dott. Massimiliano Alesci
Dott. Danilo Lo Vano
http://ww2.unime.it/ortopedia
[email protected]
I
II
PROGRAMMA SCIENTIFICO
12 Settembre 2008
08:00
Registrazione dei partecipanti
Messina Consensus Conference
“Orthopaedic Basic Sciences and Traumatology”
Presidente: P. Cherubino
Moderatori: D. C. Salpietro – C. Della Rocca
08:30
Structure and ultrastructure of the bone tissue
G.P. Anastasi (Messina)
08:50
The intracortical vessels system of long bones
U.E. Pazzaglia (Brescia)
09:10
Bone physiology: a 2008 update
09:30
Nutrition, prevention and bone health
E.B. Adamo (Messina)
09:50
Materials’ biocompatibility: positive results and pitfalls
P. Cherubino (Varese)
R. Marini (Messina)
ORAL PRESENTATIONS
10:10
The sealed osteons of cortical diaphyseal bone
F. Ranchetti, T. Congiu, S. Colombo, D. Quacci, U. E. Pazzaglia (Brescia)
10:15
3D reconstruction of the intracortical canals system with micro-TC. Experimental study in the
rabbit femour
G. Zarattini, D. Giacomini, A.M. Menti, G.P. Feltrin, U.E. Pazzaglia (Brescia)
10:20
Differential expression of homebox-containing genes in human osteogenic cells
L. Spugnesi, J. Picchi, L. Trombi, G. Barbanti Brodano*, M.. Petrini, S. Boriani*, M.C. Magli
(Pisa, *Bologna)
10:25
Biomaterials forms influence “in vitro” adhesion and proliferation of human mesenchimal stem
cells
C. Di Bona, G. Barbanti Brodano*, M. Manfrini, E. Lucarelli*, D. Donati*, J. Picchi°, L. Spugnesi°,
T. Greggi*, P. Parisini*, S. Boriani*, M. Tognon (Ferrara, *Bologna, °Pisa)
10:30
In vitro effect of platelet gel on human bone marrow stromal cells and endothelial cells for bone
engineering
C. Fotia, F. Perut, E. Cenni, L. Savarino, D. Dallari, A. Cenacchi, P. M. Fornasari, A. Giunti, N. Baldini
(Bologna)
10:35
Identification of genus useful to monitor the differentiation of human bone marrow stromal cells
(hMSC) into osteoblasts
S. R. Baglio, E. Leonardi, V. Devescovi, N. Baldini, G. Ciapetti, G. Ochoa*, D. Granchi, A. Giunti
(Bologna, *Derio,Spagna)
10:40
The role of phytoestrogen genistein in postmenopausal bone health
H. Marini, E.B. Adamo, R. D’Anna (Messina)
10:45
Ex-vivo transduced autologous skin fibroblasts expressing human Lim Mineralization
Protein-3 efficiently form new bone in animal models
E. Pola, G. Logroscino, P. D. Robbins* (Roma, *Pittsburgh, USA)
10:50
Biomechanical evaluation of a new Collagen I bioscaffold for tendon surgery
A. Gigante, A. Busilacchi, E. Cesari, T. Villa*, F. Greco (Ancona, *Milano)
I
10:55
Metaphyseal chondrodysplasia Schmid type: a diagnosis delayed
S. Briuglia, M. C. Cutrupi, A. Calabrò, B. Piraino, R. Gallizzi, D.C. Salpietro (Messina)
11:00
Enhancing muscle regeneration in mdx mice: beneficial effects of genistein and flavocoxid
S. Messina, A. Bitto, A. Mazzeo, M. Aguennouz, A. Migliorato, M. G. De Pasquale, F. Squadrito,
G. Vita (Messina)
11:05
Effect of pulsed electromagnetic fields on human tenocyte cultures. An in vitro study of tendon
healing
V. Denaro, S. Barnaba, L. Ruzzini, S. Campi, A. Sgambato, A. Cittadini (Roma)
11:10
Intoxication by metal ions released by a THR with a high rate of wear
U.E. Pazzaglia, G. Zarattini, P. Apostoli, A. Padovani (Brescia)
11:15
Physical and biological aspects of the cellular reaction of foreign body particles in
implants
G. Bonaspetti, G. Zarattini, U.E. Pazzaglia (Brescia)
11:20
Kinetics of metals ions before and after removal the releasing THR
G. Zarattini, P. Apostoli, A. Padovani, U.E. Pazzaglia (Brescia)
11:25
Leri Weill syndrome: a case report
S. Briuglia, M. C. Cutrupi, R. Gallizzi,
(Messina)
C. Munafò,
C. Cuppari,
orthopaedic
M. R. Cutrì, D. C. Salpietro
11:30
New Updates on the Charcot Neuroarthropathy Patogenesis. Study of the genic polymorphism
of the osteoprotegerin
M. Galli, D. Pitocco, C. Chinni, L. Mancini, S. Caputo, G Ghirlanda (Roma)
11:35
Numerical and experimental analisys of the mechanical behaviour of an innovative plantar
V. Filardi, G. Gambera*, E. Guglielmino (Messina, *Catania)
11:40
Morphological study of the effects of chemical and physical treatment of the intervertebral disk.
Experimental study in the pig
G. Zarattini, L. Rodella, A. Vesnaver, U.E. Pazzaglia (Brescia)
11:45
Transglutaminases expression in mice tendons and humans supraspinatus tendon ruptures
F. Oliva, M. Celi, G. Taurisano, D. Villella, U. Tarantino (Roma)
11:50
A dermal substitute enveloped on an arteriovenous loop as a new chamber for tissue
engineering: a promising tool for neoangiogenesis, new tissue formation, glial ingrowth and
neurovascular cross talk
M.R. Colonna, G. Delia, G. Risitano, G. Amadeo, A. Strano, M. Giacca*, S. Geuna°, V. Cavallari,
F. Stagno D’Alcontres (Messina, *Trieste, °Torino)
11:55
Discussione
II
1a SESSIONE: LE INFEZIONI DELL’OSSO
Presidente: G. Sessa
Moderatori: G. De Giorgi - F. Fanfani
12:10
Lettura magistrale: Osteogenesi riparativa nelle fratture infette
F. Greco (Ancona)
TAVOLA ROTONDA
12:30
La terapia medica delle infezioni osteoarticolari nei pazienti ospedalizzati:
il ruolo dell’infettivologo
G. Sturniolo (Messina)
12:40
Le nuove frontiere della chirurgia nelle infezioni ossee del rachide
N. Specchia (Ancona)
12:50
Le infezioni secondarie a trapianti omoplastici in chirurgia oncologica
R. Capanna (Firenze)
13:00
Le infezioni secondarie a mega-protesi oncologiche della pelvi e degli arti
M. Mercuri (Bologna)
13:10
Le infezioni nella chirurgia protesica dell’anca
F. Randelli (Milano)
13:20
Spaziatori antibiotati standard e custom-made nelle revisioni protesiche
settiche di ginocchio
G. Gasparini (Roma)
13:30
Il trattamento chirurgico del piede diabetico infetto e le amputazioni
M. Galli (Roma)
13:40
Le infezioni nella chirurgia della mano
L. D’Andrea (Messina)
13:50
Discussione
14:00
CONSIGLIO DIRETTIVO I.O.R.S. - ASSEMBLEA GENERALE SOCI I.O.R.S.
III
COMUNICAZIONI SUL TEMA: LE INFEZIONI DELL’OSSO
Presidente: L. De Palma
Moderatori: A. Cascio – G. Sturniolo
15:00
Imaging up-to-date in osteoarticular infections
F. Fiumara (Messina)
15:05
Immuno-therapy in treatment of cronic osteomyelitis
G. Gualdrini, C. Falcone* (Bologna, *Messina)
15:10
Complications of Ilizarov treatment in tibial infected pseudoarthrosis: personal experience
C. Di Paola, M. Ciotti* , G. Santisi, R. Orani* (Messina, *Cortina)
15:15
Reconstruction vs amputation in osteomyelitis: which one to choose ?
P. Guastafierro, P. A. D’Amato, A. Gambardella, A. Scotto di Luzio (Pozzuoli)
15:20
High-dose, three-times weekly teicoplanin in the out-patient treatment of osteomyelitis.
C. Negri, F. Pea, P. Menosso, E. Zamparini, P. Di Benedetto, M. Furlanut,
A. Causero, P. Viale (Udine)
15:25
The use of antibiotic-impregnated cement in infected reconstructions after resection for bone
tumors
C. Errani, D. Donati, M. Mercuri (Bologna)
15:30
Bone and joint infection in childhood
R. M. Toniolo, V. Guzzanti (Roma)
15:35
Differential diagnosis of spontaneous spondylodiscitis. The infectivologist advice
A. Cascio, R. Gembillo, L. Pernice, C. Iaria (Messina)
15:40 On a case of atypical spondilytis
T. C. Russo, G. Giuca*, M. Quartarone (Modica, *Messina)
15:45
Inhibition zone evaluation for manually-mixed and commercially-available antibiotic loaded bone
cements
M. Miola, A. Bistolfi, S. Ferraris, E. Verné, M. Boffano, A. Massè, M. Crova (Torino)
15:50
Bone and joint infection in children
N. Catena, F. Sénès (Genova)
15:55
Post-operative continous washing in surgical infection treatment
M. Ostuni, A. Pasquino, A.Piazzolla, G. Ognissanti, G. De Giorgi (Bari)
16:00
Discussione
IV
2aSESSIONE: IL CONDROSARCOMA:
L’INQUADRAMENTO PROGNOSTICO
E L’EVOLUZIONE TERAPEUTICA
Presidente: A. Giunti
Moderatori: F. Greco - E. Ippolito
16:10
Lettura magistrale: L’immunoistochimica e la genetica in oncologia ossea
C. Della Rocca (Roma)
TAVOLA ROTONDA
16:30
Problematiche non risolte sulla ereditarietà della malattia delle esostosi multiple.
Dal gene alla funzione; diagnosi e patogenesi
V. M. Fazio (Roma)
16:40 Grado di malignità istologica in rapporto alla sede ed alla radicalità chirurgica
E. Ippolito (Roma)
16:50
I fattori angiogenetici nel condrosarcoma
G. Maccauro (Roma)
17:00
Le lesioni cartilaginee border-line della mano: strategia chirurgica e valutazione dei risultati nelle
recidive
F. Fanfani (Roma)
17:10
Lesioni cartilaginee border-line nelle ossa lunghe: effetto degli adiuvanti locali nel basso e medio
grado
G. Maccauro, A. Piccioli (Roma)
17:20
Strategia chirurgica, complicanze meccaniche e risultati a distanza nel condrosarcoma della pelvi
M. Mercuri (Bologna)
17:30
Ricostruzioni con innesti omoplastici intercalari nelle resezioni oncologiche delle ossa lunghe
S. Mapelli (Milano)
17:40
La durata degli innesti omoplastici e delle sostituzioni protesiche nelle resezioni da condrosarcoma
nell’arto inferiore
R. Biagini (Roma)
17:50
Innesti osteoarticolari e ricostruzioni protesiche nelle resezioni da condrosarcoma nell’arto
superiore
D. A. Campanacci (Firenze)
18:00
Discussione
V
COMUNICAZIONI SUL TEMA: IL CONDROSARCOMA
Presidente: M. Mercuri
Moderatori: N. Baldini – G. Maccauro
18:20
Doxorubicin-loaded osteotropic nanoparticles for the treatment of skeletal metastases
M. Salerno, C. Fotia, S. Avnet, E. Cenni, D. Granchi, F. Castelli*, D. Miceli*, R. Pignatello*, N. Rucci°,
A. Teti°, N. Baldini (Bologna, *Catania, ° L’Aquila)
18:25
Study of marrow stromal cells osteogenic potential for the treatment of congenital pseudarthrosis
of the tibia associated with type I neurofibromatosis
V. Devescovi, E. Leonardi, S. R. Baglio, O. Donzelli, M. Magnani, N. Baldini,
D. Granchi, A. Giunti (Bologna)
18:30
Conservative treatment of low grade central chondrosarcoma (LGCCS)
S. Mapelli, S. Bastoni, A. Parafioriti (Milano)
18:35
Angiogenesis in hand chondroma
M. L. Ricciardella, G. Fadda, G. Falcone, B. Rossi, G. Maccauro and M. A. Rosa* (Roma, *Messina)
18:40
Angiogenesis in osteosarcoma: immunohistochemical analysis
B. Rossi, G. Schinzari, M. Valente, G. Maccauro and M.A. Rosa* (Roma, *Messina)
18:45
Synovial chondrosarcoma of the hip joint. Report of two cases and literature review
D. Matera, D.A. Campanacci*, A. Franchi*, R. Capanna* (Catania, *Firenze)
18:50
Lactoferrin immunoexpression in cartilage-forming tumours
A. Ieni, V. Barresi, M. Grosso, G. Tuccari (Messina)
18:55
Surgical approach to central low-grade chondrosarcoma
D.A. Campanacci, G. Scoccianti, G. Beltrami, D. Matera, P. Cuomo, F. Frenos, R. Capanna (Firenze)
19:00
Chondrosarcoma: diagnosis and treatment
F. Nicolosi, W. Leonardi (Catania)
19:05 Discussione
19:30
CERIMONIA INAUGURALE
Benvenuto del Presidente e delle Autorità Accademiche.
20:10 Lettura magistrale: La responsabilità professionale: aspetti giuridici e medico-legali
C. Crinò (Messina)
20:30
VI
Cocktail di benvenuto
12 Settembre 2008
AULA SATELLITE
COMUNICAZIONI LIBERE
Presidente: M. Marcacci
Moderatori: V. Guzzanti – D. Rosa
12:00
Physiological modification of laxity and flexibility in different tanner stages
C. Chinni, F. Falciglia, M. Giordano, A. G. Aulisa, V. Guzzanti (Roma)
12:05
Sovracetabular brown tumor due to a single retrosternal parathyroid adenoma
F. Trimarchi, E. Calamoneri, R. M. Ruggeri and M. A. Rosa (Messina)
12:10
Circulating Substance P levels are associated to shoulder joint contracture after arthroscopic
repair of the rotator cuff.
F. Franceschi, U. G. Longo, L. Ruzzini, G. Dicuonzo, N. Maffulli, V. Denaro (Roma)
12:15
Use of platelet gel in arthroscopic treatment for rotator cuff lesion: preliminary report
E. Barbieri (Messina)
12:20
The effect on articular cartilage of anterior cruciate ligament injury in growing
goats
F. Falciglia, C. Chinni, G. Mastantuoni, M. Giordano, V. Guzzanti (Roma)
12:25
Slipped capital femoral epiphysis: ultrastructural study before and after
osteochondrosynthesis
F. Falciglia, C. Chinni, A. G. Aulisa, M. Giordano, V. Guzzanti (Roma)
12:30
Humeral resurfacing emiarthroplasty. Our two years experience (preliminary report)
A. Pisani, D. Lo Vano, G. Arrabito and M. A. Rosa (Messina)
12:35
Histopathological and pathogenetic consideration about Kienböck’s disease
G. E. Bellina, A. Tulli, A. Pagliei, S. Serpieri (Roma)
12:40
Evalutation of bone quality in patients with hip osteoarthritis
I. Cerocchi, L. Perticarini, D. Lecce, M. Feola, A. Padolino, A. Scialdoni, U. Tarantino (Roma)
12:45
Anatomical study on lateral meniscal graft
L. Panarella, U. Tarantino, G. Puddu, N. Belot*, P. Boisrenoult*, P. Beaufils*
(Roma, *Rennes, Francia )
12:50
Polyethylene terephthalate mesh for soft tissue reattachment to skeletal modular prosthesis after
wide bone resection due to bone tumors
M. Alesci, D. Lo Vano, G. Maccauro* and M.A. Rosa (Messina, *Roma)
12:55
Determination of a safe range of knee flexion angle for grafts fixation in double bundle ACL
reconstruction: a human cadaveric study
F. Vercillo, S. Noorani, O. Dede, G. Cerulli, S. L-Y. Woo*
(Perugia, *Pittsburgh, USA)
13:00
Utilization of only one hamstrings tendon for single bundle ACL reconstruction using an All-Inside
Technique: a human cadaveric study
G. Zamarra, M.B. Fisher*, G. Cerulli, S.L-Y. Woo* (Perugia, *Pittsburgh, USA)
13:05
Kinematic evaluation of knee laxities in anatomical double-bundle ACL reconstruction
S. Zaffagnini, N. Lopomo, S. Bignozzi, G. M. Marcheggiani Muccioli, D. Bruni, G. Giordano,
M. Marcacci (Bologna)
13:10
Anatomic ACL reconstruction: our experience
A. Bombara, G. Gitto, G. Giorgianni, A. Tripodo, S. Mauro (Messina)
13:15
Rotator cuff tears: open versus arthroscopic treatment. Follow-up at 15 years
A. Pisani, E. Barbieri (Messina)
VII
13:20
Histological study of ruptures of the long head of the biceps tendon
U. G. Longo, F. Franceschi, L. Ruzzini, N. Maffulli, V. Denaro (Roma)
13:25
Histopathological study of supraspinatus tendon ruptures
13:30
Degenerative changes in supraspinatus tendon ruptures. An histological study
13:35
Discussione
SIMPOSIO: L’OSTEOPOROSI
Moderatori: N. Frisina - V. Nicita Mauro
16:00
Osteoporosi e genetica
U. Corapi (Milazzo)
16:15
La fisiopatologia dell’osteoporosi
S. Gatto (Napoli)
16:30
La terapia dell’osteoporosi basata sull’evidenza
S. Bartolone (Messina)
16:45
Gli isoflavoni nella prevenzione dell’osteoporosi
H. Marini (Messina)
17:00
Discussione
SIMPOSIO: IL DOLORE
Moderatori: R. Marini – S. Mapelli
18:00
Il dolore neuropatico
P. Marchettini (Milano)
18:15
Il dolore nocicettivo
F. S. Venuti (Messina)
18:30
Il dolore osteoarticolare
G. F. Bagnato (Messina)
18:45
Farmaci antinfiammatori e terapia del dolore
F. Squadrito (Messina)
19:00
Discussione
VIII
13 Settembre 2008
3a SESSIONE : LE COMPLICANZE BIOLOGICHE E MECCANICHE
DEI MATERIALI
Presidente: C. Fabbriciani
Moderatori: M. D’Arienzo – U. Corapi
08:30
Lettura magistrale:
Le nanotecnologie nei materiali di interesse ortopedico
1a TAVOLA ROTONDA
Le nuove frontiere della chirurgia sostitutiva
nei diversi distretti anatomici
08:50
Il polso e la mano
M. D’Arienzo (Palermo)
09:00
L’anca
A. Toni (Bologna)
09:10
Navigazione e chirurgia computer-assistita: quale progresso in ortopedia ?
V. Mazzone (Ascoli Piceno)
09:20
L’artroplastica unicompartimentale di ginocchio: protesi di superficie innovativa
S. Zaffagnini (Bologna)
09:30
La tibio-tarsica
F. Vannini (Bologna)
09:40
Discussione
Presidente: U. E. Pazzaglia
Moderatori: E. Brach del Prever – A. Toni
09:50
Lettura magistrale: I materiali e l’ambiente biologico
P. Tranquilli Leali (Sassari)
2a TAVOLA ROTONDA
La bioingegneria e la clinica
10:10
L’insuccesso protesico: problematiche correlate ai materiali metallici, stato dell’arte e soluzioni
future.
R. Chiesa (Milano)
10:20
Reazioni allergiche e sopravvivenza delle artroprotesi di anca metallo-metallo in 100 casi
consecutivi . Studio clinico retrospettivo ad un follow-up di 13 anni
F. Randelli (Milano)
IX
10:30
L’evoluzione del polietilene attraverso gli insuccessi clinici
D. Masoni (Bologna)
10:40
La durata del polietilene
G. Sessa (Catania)
10:50
Il cemento
G. Maccauro (Roma)
11:00
I materiali ceramici
C. Piconi (Roma)
11:10
L’usura negli accoppiamenti ceramici
N. Baldini (Bologna)
11:20
Discussione
11:40
Lettura magistrale: Gli innesti omoplastici nelle ricostruzioni osteoarticolari
S. Giannini (Bologna)
SIMPOSIO: LA RIGENERAZIONE TISSUTALE
Moderatori: R. Capanna - V.M. Fazio
12:00 Lettura magistrale: Effetto dei campi elettromagnetici statici, generati da correnti di
corrosione, sulle colture di osteoblasti ed osteoclasti umani
V. Denaro (Roma)
12:20
Ingegneria tissutale: la cartilagine
D. Rosa (Napoli)
12:35
Ingegneria tissutale: l’osso
N. Specchia (Ancona)
12:50
L’osteogenesi nelle diverse tecniche di trasporto
R. Aldegheri, G. Taglialavoro (Padova)
13:05
La rigenerazione tissutale: Il disco intervertebrale
V. Denaro, G. Vadalà (Roma)
13:20
Discussione
13:30 Lettura magistrale:
Le nuove frontiere ed i limiti delle protesi modulari in chirurgia
oncologica
R. Capanna (Firenze)
13:50
Compilazione schede questionario ECM
14:00
Chiusura dei lavori
X
13 Settembre 2008
AULA SATELLITE
SIMPOSIO: LE TECNICHE MINI INVASIVE
Moderatori: A. Causero - C. Impallomeni
10:00
La MIPO nelle fratture sovracondiloidee di femore
C. Impallomeni (Messina)
10:15
Indicazioni e limiti dell’artrorisi interspinosa nel rachide lombare
M. Comisso, M. Balsano (Vicenza)
10:30
L’efficacia della cifoplastica nel trattamento delle lesioni vertebrali litiche
C. A. Logroscino, S. Astolfi (Roma)
10:45
La tecnica mini invasiva nelle lesioni osteolitiche sovracetabolari.
G. Maccauro (Roma)
11:00
Stabilizzazione peduncolare toraco-lombare minivasiva
C. A. Logroscino, L. Proietti (Roma)
11:15
Discussione
COMUNICAZIONI SUL TEMA:
LE COMPLICANZE BIOLOGICHE
E MECCANICHE DEI MATERIALI
Presidente: P. Tranquilli Leali
Moderatori: G. Gasparini – A. Gigante
11:30
Microstructural features in cemented femoral stem revision after failure
L. Rizzi, R. Maggi, C. Castelli (Bergamo)
11:35
A comparison on in vivo effects of different ceramic materials: an experimental study
G. Maccauro, C. Piconi, D. Marotta, F. Muratori, A. Sgambato, A. Cittadini (Roma)
11:40
Intramedullary nail: clinical study of failures
G.Taglialavoro (Padova)
11:45
The role of metal surface finishing procedure in polyethylene wear of knee prosthesis
A. Gigante, V. Cigna, T. Villa*, S. Manzotti, M. Mattioli Belmonte, F. Greco (Ancona, *Milano)
11:50
Early failure of a locked titanium humeral plate
G. Logroscino, M. Venosa, V. Ciriello, S. Spinelli, G. Maccauro, C. Piconi (Roma)
11:55
New perspectives in polymeric materials: preliminary considerations on the use of the
cross-linked X3 polyethylene
M. Ferlazzo, L. Ciriaco, D. Amato (Messina)
12:00
Biolox®delta: The high performance ceramic composite
F. Macchi (Roma)
12:05
Failures in the fixation of the lateral fractures of femur: our experience
T. C. Russo, G. Giuca*, A. Tumino° (Modica, *Messina, °Scicli)
12:10
Radiographic-evaluated head penetration for crosslinked vs conventional UHMWPE
A. Bistolfi, D. Testa, G. Massazza, M. Boffano, P. Pautass, C. Faletti, M. Crova (Torino)
XI
12:15
Effects of thermal and mechanical treatment on the crystallinity of crosslinked-UHMWPE
A._Bistolfi, M. Boffano, P. Bracco, M. Crova, L. Costa, A. Bellare*, E. Brach del Prever
(Torino, *Boston, USA)
12:20
Surface modifications of ceramic ball heads: an ultrastructural analysis
G. Maccauro, F. Muratori, D. Marotta, C. Piconi (Roma)
12:25
Evolution of osteosynthesis in traumatology
C. Impallomeni (Messina)
12:30
Zirconia heads in perspective: a survey of zirconia outcomes in total hip replacement
G. Maccauro, M. Angeloni., D. Marotta, G. Magliocchetti, C. Piconi (Roma)
12:35
Discussione
SEZIONE POSTERS :
Loosening and osteolysis with metal-on metal prostheses at mean twelve years follow-up
S. Scarponi, R. Scarponi (Milano)
Knee re-revision arthroplasties complicated by infection: is arthrodesis now-a-days an acceptable
treatment?
M. Alesci, D. Lo Vano and M.A. Rosa (Messina)
Mechanical and biological properties of antiblastic loaded bone cement
G.Maccauro*, A.Spadoni*, F.Muratori*, M.Casarci*, A.Sgambato*, C.Piconi*, M. Alesci, D. Lo Vano and
M.A. Rosa (Messina, *Roma)
Chronic osteomyelitis in diabetic foot: minor amputation and bone resection
M. Galli*, M. Alesci, D. Lo Vano and M.A. Rosa (*Roma, Messina)
XII
X CONGRESSO NAZIONALE IORS ~ MESSINA CONSENSUS CONFERENCE
STRUCTURE AND ULTRASTRUCTURE OF THE BONE TISSUE
G.P. Anastasi (Messina)
In this review we showed the bone tissue analyzing it by SEM and TEM. According to classical histology, bone
tissues may be classified in relation to either the spatial orientation of collagen fibers or the time of appearance
during ontogenesis. In the former classification, two distinct types of bone tissue have been recognized: wovenfibered (or fibrous) bone and parallel-fibered bone which includes non-lamellar and lamellar varieties. The latter
classification distinguished between primary bone and secondary bone; moreover, it has generally been asserted
that primary (or immature) bone is made up of woven-fibered bone and parallel-fibered bone, whereas secondary
(or mature) bone consists of lamellar bone only. Woven-fibered bone consists of irregularly-arranged coarse
bundles of collagen fibers; it contains a higher number of osteocytes, enclosed within larger lacunae of globous or
lentil shape, irregularly distributed in cluster. The parallel-fibered bone consists of bundles of individual collagen
fibers running parallel to each other, almost occurs in tendons. The lamellar bone constitutes most of the adult
skeleton; it forms mainly as a consequence of bone remodelling. The lamellar appearance of bone is still the
subject of much controversy, and various model have been proposed of the structure of bony lamellae. In this
study, considering the particular architecture of the bone tissue, we analyzed also the bone ultrastructure, by SEM
technique, during treatment with bisphosphonates which provokes osteonecrosis. They are a class of
pharmaceutical used in the treatment of numerous bone disorders, including osteoporosis, cancer metastases to
bone and multiple myeloma. The prevalence of osteonecrosis of the jaw is though to be as high as 10% in cancer
patients receiving intravenous bisphosphonates therapy and much less for patients taking oral bisphosphonates.
The most peculiar feature of osteonecrosis associated with bisphosphonates treatment is the exclusive localization
of lesions to the mandibular and maxillary bone; there are no reports of other skeletal sites being affected by this
form of osteonecrosis. On this basis, here, we analyzed also the gingival epithelium associated with mandibular
bone in order to analyzed the effects of these drugs also in mucosal sites, using immunohistochemical techniques.
1
THE INTRACORTICAL VESSELS SYSTEM OF LONG BONES
Ugo E. Pazzaglia (Brescia)
The compact bone of the long bones diaphysis is supplied by a vascular network of vessels, which run in a system
of canals. The structure of the bone is conditioned by the remodeling process which in turn depends from the
vascular supply. The morphological study of these systems presents remarkable difficulties because it is
incorporates inside the hard matrix of the bone, however varying the planes of the histological sections it has
been possible to give a representation of the 3-D organization of the system. In this study the architecture of the
system was investigated with SEM on paired fractured surfaces of the cortical bone. The advantage of the
method employed was a direct representation from the inside of the canals system and with a stereometric
approach it was possible to measure the circumference of canals at different levels. The study was completed with
injection of the vessels which allowed to slow the 3-D aspects of the vessels network, so far documented only by
2-D image of histology.
2
BONE PHYSIOLOGY: A 2008 UPDATE
Rolando Marini, Ph.D.
Department of Biochemical, Physiological and Nutritional Sciences, Section of Physiology and Human Nutrition,
Faculty of Medicine, University of Messina, Italy
Preface: About 3800 million of years ago on earth life appears. Through detailed archaeopalaentogical analysis
the scientists who attend to history of life have recovered a plentiful documentation explaining the significant
and the role on various prehistoric ages. These documents are fossils. On his book “Los aborigenes” Juan Luis
Arsuaga writes “… a fossil is everithing that keep of a nature lived in the past and the only prove of a biological
activity too. A dinosaurus’s bone is a fossil, as well as paw’s footprint mud ”. The bone belongs of heart’s
memory: as regards the human evolution mortal remains and bones of our ancestors are reached until us. The lyfe
style, the look and the behaviour, which were rebuild studying them allowed Charles Darwin to demonstrate
“natural selection”. In the common imaginary it could think that the bone tissue is static, not large subjected to
alterations after the organism’s growth. In reality, the skeletal system is dynamic and subject to continuous
remodelling led by hormonal stimula . This report very briefly review the functions of bone, bone growth and
development, the process of bone remodelling and the effects of hormones. Furthemore, it also summarizes the
observations by H.M. Frost, described extensively in the Utah Paradigm of Skeletal Physiolog,y in the 1960’s
assigns great influence of neuromuscular physiology and physical activities on skeletal architecture, strength and
mechanical competence called Mechanostatic Theory, a refinement of Wolff’s law in 1892’s.
Anatomical and functional observations: Bone must solve a series of structural imperatives to achieve
physiologic utility and to avoid pathologic consequences of the loss of support. It must be strong for weightbearing but not brittle.It must be lightweight but stiff enough to facilitate energetically efficient locomotion and to
provide a dynamic architecture that allows growth, remodelling, and repair.
Bone tissue is a variety of connective tissue characterized by mineralization of the extracellular matrix which
gives to tissue a remarkable resistance and hardness.. The skeletal system is composed of 206 bones (flat,tubular
and cuboid).Calcium hydroxyapatite Ca (PO4)6(OH)2 is the organic component of bone and gives bone its
hardness and strength. It also store 99% of the body calcium, 85% of its phosphorus, and 65% of the bodies
sodium and magnesium.
The formation of calcium hydroxyapatite crystals is termed mineralization. There is a 12-15 days lag between
formation of matrix and mineralization. Bone that is unmineralized is called osteoid. The 95% of these matrix is
composed by collagen fibers. The remaining 5% of organic substance of bone tissue is called “basic amorphous
substance” formed by a misture of proteoglycans, compounds of high molecular weight, mad up proteins and
carbohydrates.
The linkage between hydroxyapatite crystals and collagenous fibers is responsible for form’s carachteristies and
hardness’s bone. If it happens a demineralization, bone’s form is protected but it begins flexible like a tendon.
The important cells involves in the process of bone formation and reabsorption are: osteoblasts, osteocytes and
osteoclasts . The generation and stimulation of these cells is mediated by FGF, PDGF, TGF-b and insulin-like
growth factor. Pluripotent mesenchymal cell (osteoprogenitors cells) can form osteocytes when stimulated by
members of the TGF-b superfamily.
Osteoblasts are located on the surface of bone and syntesise, transport matrix protein: they initiate the process
mineralization and express cell surface receptors that bind to hormones, PTH, Vit D and oestrogen . They have a
life span of three months after which they can either die via apoptosis or form osteocytes. Are characterized by
cytoplasmatics branches, reticulus endoplasmic plentiful and numerous Golgi’s complex.
Osteocytes more numerous are than any other bone forming cell: They are encased in bone but can comminate
with each other through an intricate network or canalicula. This network is involved in controlling fluctuations in
calcium and phosphorus levels. Their exact role is still under investigation, but probably the osteocytes direct
bone remodelling to accommodate mechanical strain an repair fatigue damage.
Osteoclasts derive from the same progenitor as monocytes and macrophages. They are involved in bone
reabsorption: RANK-RANKL interactions is involved in osteoclastogenesis: When mature they are multinucleated and have a life span of 2 weeks.
The proteins of bone include Type I collagen, which makes up 90% of the weight, and noncollagenous proteis
produces by osteoblasts, In particular, the osteoblasts can deposit collagen.
In either a random weave known as woven bone or in a orderly layered manner known as lamellar bone. Woven
bone is found in the fetus, in growth plates and during pathology such as a fracture. It can be formed quickly and
resists force equally in all directions.
3
Lamellar bone is found in adults, is produced more slowly and is stronger. There are 4 types of lamellar bone:
circumferential, concentric, interstitial and trabecular lamellae.
Bone Growth and Development: Blueprint for skeletal formation is encoded by Homeobox genes, the expression
of which produces localised cellular condensation of primitive mesenchyme at the site of future bones.
The mesenchymal cells differentiate into chondrocytes and osteoblasts. Most bones are formed as a cartilage
model and around eight weeks gestation, endochondral ossification begins.
There are two types of bone : the membranous bone and endochondral bone. For flat membranous bone, bone
develops directly in connective tissue, formed by osteoblasts (bone-forming cells) that differentiate locally from
mesenchymal cells. The rest of the skeleton appears first as a cartilagenous anlage. Osteoprogenitor cells start
depositing bone on the calcified cartilage that is subsequently removed by osteoclast-like cells. Osteoblasts and
osteoclasts act in coordination to model bone and are referred to as the Basic Multicellular Unit (BMU).
The process of bone formation and reabsorption are tightly coupled. Once the skeleton reaches maturity, the
breakdown and renewal of bone is called remodelling and is mostly experienced in areas experiencing fatigue and
microdamage. In the adult around 1 million BMU are active at any one time turning over 10% of bone every
year.
It should be noted for experimental studies in rodents that the epiphyses enclose and there is continous
longitudinal growth. In rats, the growth rate is significantly attenuated about 12 to 14 months of age. In humans,
epiphyses close around the age of 18 and longitudinal growth ceases.
However, peak bone mass (the maximum amount of bone before age-related loss starts) is only reached toward
the middle of the third decade.
Bone functions: Bone has four major functions: a) mechanical, including support of soft tissues and locomotion;
b) storage of ions and ions homeostasis; c) housing of the bone marrow and support hemopoiesis; and d)
protection of the central nervous system. By fulfilling these functions, the mineralized skeleton played a central
role in the evolution of terrestrial vertebrates.
It is important to recognize that to fulfil most of its functions, bone has to be destroyed and eventually rebuilt: for
mechanical function, bone is continuosly rebuilding itself to optimize its structure and architecture. For calcium
mobilization, bone packets are destroyed, potentially to be rebuilt when calcium is again available. There are
fewer fluctuations in bone mass related to the other two functions, except during very active physiological or
pathological hemopoiesis, when the marrow cavity expands at the expense of bone.
Bone metabolism is thus subject to a large multiple humoral, systemic and local factors many of which are part
of other physiological processes could be affected by microgravity, stress, nutrition fluid, and electrolyte balance
The mature bone is always remodelling: the old bone is reabsorbed and replaced with new bone. A team of
osteoblasts and osteoclasts move along the bone, dissolving and rebuilding: The osteoclasts and most of the
osteoblasts undergo a process called apoptosis, or cell suicide: they are not killed. There is no lack of oxygen or
nutrients. There are no toxic materials.. Instead, there are genes in the cell which can be activated, causing the cell
to disintegrate.
These genes are carefully regulated within the cell: the factors the regulate apoptosis are currently under
investigation: Some are related to estrogens, or to interleukins: medication which could modify apoptosis have the
potential for treating or preventing osteoporosis.
Endocrine effects on Bone: All bone active hormones and other humoral agents would constitute extraosseous
nexuses in the complex web of things that collectively, comprise and explain bone physiology.
Recent views about some bone effects of more important hormones are here illustrated:
Growth hormone (GH) is a growth promoting hormone produced by the pituitary gland.
It is “anabolic”, vhich means it stimulates bone formation, GH also stimulates the production of insulin-like
growth 1 (IGF-1) by the skeleton. It is important in stimulating longitudinal growth and also can increase bone
mass when given to adults.
Parathyroid hormone (PTH) is a peptide hormone produced by the parathyroid glands. It binds to receptors in the
bone and kidney. A decrease in serum calcium concentration and an increase in serum phosphorus concentration
stimulate PTH secretion. PTH also: stimulates osteoclastic bone reabsorption indirectly to release calcium from
bone; stimulates bone formation that is coupled to bone reabsorption; increases renal tubular reabsorption of
calcium; stimulates the renal production of 1,25 dihydroxyvitamin D to increase calcium absorption from the
intestine; enhances renal phosphate and bicarbonate excretion.
Vitamin D (1,25 dihydroxyvitamin D) is an active hormone which is produced by the kidney, under the control of
PTH. From precursors of dietary vitamin D intake and UV skin-production of vitamin D. It is not really a vitamin,
but the name was given may years ago, before anybody knew the function of this molecule. Vitamin D receptors
are present in bone, kidney intestine , and other cells The chemical name is 1,25-dihydroxycholecalciferol, and it
4
promotes gastrointenstinal absorption of calcium and phosphorus, is necessary for bone mineralization and
stimulates bone reabsorption when given in high doses.
Calcitonin (CT) is a peptide hormone produced by cells within the thyroid gland. Calcitonin secretin is stimulated
by high blood calcium concentration, and it acts a physiologic antagonist to PTH.Osteoclasts have receptors for
calcitonin, but the effects are transient. calcitonin also inhibits osteoclast reabsorption, delays calcium absorption
from the intestine and increase calcium urinary excretion.
Gonadal steroids are produced by the ovaries and testes ad are very important in maintaining bone balance. They
are also important in normal growth and development of peak bone mass. The mechanism of action is unclear but
receptors for estrogen and androgen are found in bone.
The estrogens are the principal sex steroids in females and are necessary for bone strength in males.
The concentration of estrogen in the blood decrease after menopause, contributing to development of
osteoporosis.
The androgens, such as testosterone, are necessary for bone strength in male, they may decrease with aging, but
the role of testosterone treatment is unknown. The androgens are also known as anabolic steroids and are abused
by some athletes (doping) and may increase bone formation in females.
Thyroid hormone is produced by the thyroid gland. Bone cells have receptors for thyroid. This hormone also
necessary for growth and maturation of the skeleton and causes increased osteoclastic bone reabsorption and
osteoporosis when levels are too high.
Glucocorticoid (also called cortisolo) is produced by the adrenal gland. Bone cells have receptors for
glucocorticoid. This hormone is absolutely essential for life, but excesses level cause multiple deleterious effects
on the skeleton. In particular, these steroid hormone deceases calcium absorption from the intestine, inhibits bone
formation and increase bone reabsorption. Besides, increase renal calcium excretion and decreases sex steroids
production.
Mechanostat Theory: By 1892, J.Wolff et Al. realized that mechanical loads can affect bone architecture in
living beings, but the mechanism responsible for this effect were unknown and it had no known clinical
applications. Clinical observations and human experimentation show that human bone mass and structure are
ideally suited to sustain loads exerted upon them there is well documented bone loss after the removal of
mechanical loading and some what more limited documentation of increased bone mass in response to
mechanical stimulation. This information is highly relevant to gravitational effects on the skeleton. The ability of
bone to adapt the mechanical forces has been extensively use in orthopedics and orthodontics.
The mechanical hypothesis according by H.M. Frost analysis the bone growth and bone loss is stimulated by the
local mechanical elastically degeneration of bone. The reason of the electrical organisation of bone are the peek
caused by muscles. The combination of factors that makes healthy load bearing bone satisfy needs in all
amphibians, birds, mammals and reptiles of any size, age and sex was named mechanostat. It would combine the
modelling and remodelling mechanism, their thresholds, the marrow mediator mechanism, the signaling
mechanisms, that connect, them and perhaps other things. The resulting negative feedback system would
determine, for mechanical reasons, whether, when and where bones needed more strength, or when bone was not
needed. Various non–mechanical factors, including hormones and other humoral agents, might modulate the
mechanostat’s effects on bone strength.
E. Schoenau, in a recent paper shown a functional model of bone development based on the mechanostatic theory.
The central piece of bone regulation is the feedback loop between bone deformation (tissue strain) and bone
strength. During growth this homeostatic system is continually forced to adapt to external changes.
Conclusions: As mentioned above, multiple, humoral , local and systemic factors affect skeletal growth and
development and the remodelling in adult. The actions of hormones that affect the skeleton by playing a role in
calcium homeostasis or bone metabolism. Systemic hormonal changes that stimulate bone reabsorption include a
rise in PTH (from calcium deficiency) a rise in TH, or a decrease in sex steroids. Both sex steroids (estrogens in
woman and andogens in men) have profound effects on the skeleton in both genders.
Bone reabsorption as well as defective mineralization is also caused by deficiency of 1,25 (OH)2 vitamin D3.
Only hormone that inhibits bone reabsorption is calcitonin, a 32-amino-acid peptide produced by the thyroid clear
cells . Calcitonin is released in response to elevated calcium concentration.
Another systemic hormone needed for skeletal development is growth hormone (GH).
In adults, with a GH or IGF-1 stimulate both bone formation and bone resoprtion without increasing bone mass.
Thyroid hormone deficiency during development cause short stature and skeletal malformation. Thyroid hormone
excess usually caused by hormone replacement therapy.
5
increase bone turnover and cause bone loss. Prostaglandin E (PGE) like PTH, stimulates both reabsorption and
bone formation. Potent local stimulators of bone reabsorption include interleukin-1 (IL-1) and tumor necrosus
factor (TNF ) which are oroduced by macrophages.
Verhaegh J et Al. suggested a link between insulin, diabetes and bone metabolism, but this hypothesis is not
clearly established.
Bone cells have receptors for many other factors and hormones, such as endothelin, enkephalin, thrombin,
epidermal growth factor , epinephrine, and norepinephrine, but their role in bone metabolism is uncertain.
According with the Utah’s Paradigm the Mechanostat theory suggested this : bone loss caused by paralysis and
immobilization, is well documented and selectively affects the immobilized bone. The increase in bone mass in
response to mechanical stimulation is less well documented. It had been noted that the bone mass is much larger
in the dominant arm of professional tennis players. Mechanical stimulation seems to be more effective in
increasing bone mass before peak bone mass is reached at approximately age 25. At present bone mass analysis is
very useful for epidemiological studies on factors that may have an impact on bone development.
In the updated bone physiology whole –bone strength would be more important than the physical parameters than
contribute to it. If so, whole bone strength should become an important datum in future studies that concern
fractures, bone healing, the design and use of load-bearing, endoprostheses and osteoporosis.
References:
Frost HM. The Utah paradigm of skeletal physiology: An overwiev of its insights for bone, cartilage and
collagenous tissue organs. J.Bone Miner Res. 18:305-316.2000
Frost HM. From Wolff’s Law to the Utah paradigm: insights about bone physiology and its clinical applications.
Anat Rec. 262:398-419, 2001
Frost HM. Could some biochemical effects of growth hormone help to explain its effects on bone formation and
reabsorbtion?. Bone, 23:395-398, 1998
Frost HM, Schoenau E. Longitudinal bone growth, short stature, and related maters: insights about cartilage
physiology from Utah paradigm. J, Pediatr Endocrinol. Metab. 14; 481- 496, 2001.
Jee WSS. Integrated bone tissue physiology: anatomy and physiology. In: Cowin SC ed., Bone Mechanics
Handbook.2nd ed. Boca Raton, Fla; CRC Press; 1-68, 2001,
Schiessl H, Ferreti JL,Tysarczyk- Niemeyer G, Willnecker J, Wilhelm G. The role of mucles to the
mechanical adaptation of bone. In Lyritis, ed Advances in Osteporosis Vol.1. Athens Hylonome Editions ;53-62.
1998.
Wolff J. Das Gesetz der Transformation der Knochen. Berlin: A Hirschwald (Springer – Verlag published in
1986) 1892.
Frost HM. A 2003 Update of bone Physiology and Wolff’s law for clinicians. The Angle Orthodontist,:74,1, pp
3-15, 2003
Frost HM. Muscle strength, bone mass, and age-related bone loss. J Bone Miner Res. 12: 1547-1551,1997.
Frost HM. From Wolff’s Law to the Mechanostat: A new ”Face” of Physiology. J. Orthopaedic Science, 3:282286, 1998
Frost HM. Bone “mass” and the “mechanostat”. A proposal. Anat Rec 219: 1-9, 1987.
Schoenau E. From mechanostat theory to development of the “Functional Muscle- Bone Unit”. J
Musculoskeletal Neuronal Interact. 5(3): 232-238, 2005.
Boron and Boulpaep. Medical Physiology, 1st ed, Saunders pp 1086-1102, 2003
Rhoades R. Pflanzer R. Human Physiology, 4rt ed, Brooks/Cole by Thomson Learning , 2003
Frost HM. The Utah paradigm of Skeletal Physiology, vol 1 ISMNI, 1960
Frost HM. The Utah paradigm of Skeletal Physiology, vol 2 ISMNI, 1960
Raisz LG. Hormonal regulation of bone growth and remodelling. Ciba Found Symp. 136: 226-238, 1988
Verhaegh,J. and Buillon,R. Effects of diabetes and insulin on bone metabolism. Pp 729-738 in Principle f Bone
Biology (Bilezikian J.P., Raisz L.G., and Rodan G.A. eds.) Academic Press, 1996.
Skerry T. Neurotransmitters in bone. J. Musculoskeletal Neuronal Interact. 2: 401-403, 2002.
Ferretti P, Cointry G.R. Capozza RF. Noninvasive analysis of bone mass, structure and strength. In: Yuehue A
(ed) An Orthopaedic issues in osteoporosis. CRC Press,Boca Raton,FI;145-161,2002.
6
NUTRITION, PREVENTION AND BONE HEALTH
Elena Bianca Adamo, M.D.
Department of Biochemical, Physiological and Nutritional Sciences, Section of Physiology and Human Nutrition,
Faculty of Medicine, University of Messina, Italy
Bone is a specialised connective tissue from which substances are constantly being removed and replaced. The
bones in the human skeleton grow in length, width, and mass in parallel with overall body growth. In infants,
skeletal growth and bone acquisition is initially rapid and then slows somewhat during most of childhood until
puberty when it again becomes very rapid.
About 85 to 90% of final adult bone mass is acquired by age 18 in girls and around age 20 in boys.
After the age of 30–35 years, the time at which peak bone mass is achieved, bone mass starts to fall; minerals and
collagen matrix are removed from bone more rapidly than new bone tissue is added. Bone loss is particularly
notable in women at the menopause when oestrogen levels decline sharply; oestrogen conserves bone.
The amount and quality of the skeleton achieved by adulthood depends on a number of factors including genetic
predisposition, gender, body weight, hormones, nutrient intake, environmental factors and physical activity.
About 75% of the variance in peak bone mass is determined by genetic factors that likely involve candidate genes
related to growth hormone and insulin-like growth factor pathways, including their receptors and binding
proteins.
Bone tissue consists of crystals of hydroxyapatite and other ions embedded in fibrils of collagen and a ground
substance of glycoproteins and proteoglycans. Bone formation therefore requires adequate supplies of energy,
amino acids and the main bone-forming minerals (calcium, phosphorus, magnesium, zinc) and of other ions
(copper, manganese, carbonate, citrate) and vitamins (C, D, K) that are involved in crystal and collagen
formation, cartilage and bone metabolism and/or Ca and phosphate homeostasis.
Classical nutrient deficiencies are associated with stunting, rickets and other bone abnormalities. In recent years
there has been interest in the role nutrition may play in bone growth at intakes above those required to prevent
classical deficiencies, particularly in relation to optimising peak bone mass and minimising osteoporosis risk.
Observational studies and randomized clinical trials in children, adults, and older adults have demonstrated the
importance of peak bone mass development for reducing the risk of osteoporosis and bone fracture rates later in
life. There is evidence to suggest that peak bone mass and later fracture risk are influenced by the pattern of
growth in childhood and by nutritional exposures in utero, in infancy and during childhood and adolescence.
Of the individual nutrients, particular attention has been paid to Ca, vitamin D, protein and P. There has also been
interest in several food groups, particularly dairy products, fruit and vegetables and foods contributing to acid–
base balance.
Calcium is the most common mineral in the body and 99% is stored in the skeleton. The composition of bone,
largely responsible for the structural and mechanical properties, is mainly calcium, phosphorus, and protein
(about 50% protein and 50% calcium phosphate crystals). An adequate intake of calcium is important throughout
life.
The recommended intake of calcium vary for individuals (700mg/day – 1300 mg/day).
The body’s ability to control the amount of calcium absorbed from the gut relative to physiological need; the
efficiency of calcium absorption from the diet is greater when there is an increased physiological need (such as
during infancy, childhood, adolescence and pregnancy or for milk production during lactation) or when dietary
intake is low. However, the efficiency of absorption declines in older adults. At all stages of life, it is essential to
consume and absorb enough dietary calcium to meet the body’s needs; if calcium losses exceed absorption of
calcium from the gut, calcium is mobilised from formed bone so that blood calcium levels can be maintained
within narrow limits.
Calcium is present in a wide range of foods, but not all of these are good sources of calcium, as the calcium that
they contain may not be well absorbed in the gut. Dairy products, such as milk, yoghurt and cheese, are all
plentiful sources of well-absorbed calcium and, in Western countries, dairy products supply up to two-thirds of
total calcium intake.
Numerous studies have reported that the intake of milk and other dairy foods improve the overall nutrient density
and quality of the diet in women, older adults, children, and adolescents.
Fish which is consumed with the soft edible bones, such as whitebait, canned sardines or canned salmon, is also a
good source of calcium.
Pulses, wholegrains, nuts and seeds, dried fruit, tofu and green vegetables, such as spinach, broccoli and kale, also
contain calcium.
However, some of these foods also contain substances (phytates in wholegrains and pulses, and oxalate in spinach
and rhubarb) that bind to calcium and inhibit absorption.
7
A number of studies have investigated the potential role of increased calcium intake, either by increasing
consumption of specific foods rich in calcium or using calcium supplements.
High calcium intake, especially from dairy foods, along with adequate vitamin D, has been demonstrated to
maximize the genetic potential for peak bone mass, maintain skeletal mass in adulthood, and slow age-related
bone loss and reduce the susceptibility to fracture later in life. Furthermore, studies have shown that adequate
calcium intake from milk and other calcium-rich dairy foods has a significant positive effect on bone mass
development. Many studies have shown a positive relationship between bone mineral density in adult women and
their milk consumption in childhood and adolescence.
Intervention studies showed better bone balance, greater bone gain during growth, reduced bone loss, or
decreased fracture risk at high calcium intakes; other intervention studies that used dairy foods showed a
beneficial effect on bone health. It is becoming increasingly evident that dietary patterns containing naturally
nutrient dense foods consisting of milk and other dairy foods positively affect bone health.
A low fat, calcium, and mineral-rich diet that is high in fruits, vegetables, and dairy products that included
approximately 3 servings per day of milk, yogurt, and cheese significantly reduced bone turnover in adults that if
sustained may further reduce the risk of osteoporosis.
The National Institute of Child Health and Development has pointed out that “low-fat milk or lowfat milk
products are the best sources of calcium because they contain large amounts of calcium along with additional
nutrients to help the body better absorb calcium. Along with calcium, milk provides other essential nutrients,
including vitamin D, potassium, and magnesium, all essential for optimal bone health and human development.”
The 2005 Dietary Guidelines for Americans also recommend 3 cups of milk or the equivalent of milk products
per day, preferably nonfat or low-fat products for all persons with energy requirements ≥1,600 calories/day.
Studies have also investigated the effects of extra calcium on bone health in peri- and post-menopausal women
and in elderly women, and different effects have been seen. There is now a consensus that supplementary calcium
is effective in reducing bone loss in women who are more than 5 years post-menopausal, especially among those
women whose habitual calcium intake was low (<400mg / day).
Vitamin D is important for bone health because it enables the body to absorb calcium from food, and
consequently plays an important role in calcium homeostasis and bone metabolism.
Adequate vitamin D status during childhood and adolescence also helps in achieving peak bone mass.
Vitamin D is primarily made in the skin on exposure to sunlight; diet is a secondary source of vitamin D, as only
a few foods contain appreciable amounts. The richest dietary sources of vitamin D are: oily fish, such as herring,
mackerel and sardines; meat and meat products and offal; eggs, fortified margarines and spreads; fortified
breakfast cereals, fortified milk powder and evaporated milk.
In a study of elderly people from 11 European countries, ninety percent of the population were found to have
intakes below the recommended level and are reliant on sunlight exposure for sufficient vitamin D.
A deficiency of vitamin D over a period of time causes rickets in children whose bones are growing, and
osteomalacia in adults whose bone growth is completed. Vitamin D deficiency is also recognised to be an
important risk factor for osteoporosis. Studies in elderly people showed that vitamin D supplementation in
particular could reduce fracture risk. In the elderly, vitamin D seems to be at least as important as calcium in
maintaining bone health.
One way of improving vitamin D status is using dietary supplements of vitamin D. Vulnerable groups, such as
older adults who are housebound or rarely go out, those whose skin pigmentation reduces absorption of sunlight,
and those whose clothes fully cover their skin may benefit from taking a vitamin D supplement, particularly
during the winter months.
Encouraging children to be more physically active outside should ensure sufficient sunlight exposure and
achievement of optimal peak bone mass, but pre-school children (aged under 5 years) may need to take
supplementary vitamin D. Older people are also encouraged to expose some of their skin, face and arms, to some
sunlight.
Vitamin K acts as a co-enzyme in the formation of several proteins. It is involved in coagulation mechanisms and
is thought to be a regulator of bone mineralization, as vitamin K is required for the production of osteocalcin, one
of the main proteins involved in the formation of new bone.
Epidemiological studies provide evidence for an association between low vitamin K intake and increased
osteoporotic fracture; a randomized, double-blind, placebo-controlled intervention study showed that if
coadministered with minerals and vitamin D, vitamin K1 may substantially contribute towards reducing postmenopausal bone loss.
There are two forms of vitamin K found in the diet: phylloquinone (vitamin K1), which is synthesised in plants;
and menaquinones (vitamin K2), which are synthesised by intestinal bacteria. Most of the vitamin K in the diet is
in the plant form phylloquinone, and green, leafy vegetables are the richest sources of vitamin K. Other sources of
vitamin K include: fruits and vegetables, vegetable oils, dairy produce, and meat products.
8
Bone is made up of a number of other minerals in addition to calcium, including zinc, phosphorus and
magnesium, and so it is necessary to ensure adequate intakes of these, and also adequate protein, which is needed
for formation of the collagen matrix.
Zinc is needed for bone mineralization and osteoblast function. Plasma zinc concentrations have been reported to
be lower in elderly women with osteoporosis and research suggests that calcium supplements taken along with
trace mineral supplements, containing zinc and copper, may effectively reduce the rate of bone loss.
Phosphorus accounts for a significant proportion of bone mineral content, but it is unclear whether changing the
level of dietary phosphorus intake has any effect on bone health.
Magnesium intake is positively correlated with bone mass at serveral sites in the body and low serum magnesium
levels have been reported in women with osteoporosis.
In addition to specific nutrients, food groups have also been studied in an attempt to understand more fully the
role of diet on bone health.
Study showed that who habitually ate a diet based on fruit, vegetables, milk and cereals, had significantly higher
bone mass than those whose diet was characterised by high consumption of salty snacks, pizza and soda, or high
consumption of meat, bread and potatoes.
Fruit and vegetables may also have a positive effect on bone health.
Studies have demonstrated a correlation between bone health and nutrients found in fruits and vegetables, and
especially potassium.
Protein and sodium are dietary modulators of calcium homeostasis.
In the short term, high intakes of protein may increase the risk of bone loss through calcium excretion in the
urine. Conversely, an adequate supply of protein is essential for maintaining bone health and low protein diets
may also increase bone loss.
A high sodium intake has also been reported to increase urinary calcium loss, which may have adverse effects on
calcium metabolism and bone loss.
Natural phytoestrogens, found in foods such as soya, may also play a role in bone health.
Phytoestrogens are non-steroidal compounds naturally occurring in a wide range of foods of plant origin.
Epidemiological studies have suggested that there may be inverse associations between isoflavone consumption
(isoflavones are a subgroup of phytoestrogens mainly contained in soy and soy products) and hip fracture. Animal
studies have shown that, when provided at optimal doses, phytoestrogens have modest, positive effects on bone
tissue, maintaining bone mass.
Osteoporosis is a disease characterized as the progressive loss of bone mass and deterioration of bone tissue,
leading to skeletal weakness and an increased susceptibility to bone fractures. It affects millions of people in the
world; in Europe, one in three women and one in eight men aged over fifty will be affected by osteoporosis.
The incidence of vertebral and hip fractures increases with age, and osteoporotic fractures are a major cause of
morbidity and disability and premature death in older people.
Many factors are involved in the development of osteoporosis, including gender, age, body size, ethnicity, family
history, hormonal status, genetics, diet, lifestyle, cigarette smoking, alcohol consumption, anorexia nervosa,
immobility, medication use, intestinal malabsorption, chronic liver disease.
Diet is one of the key environmental factors that play a role in bone health.
Diet during childhood, adolescence and early adulthood is important for optimising bone mass.
Calcium and vitamin D have been the main nutrients of interest in terms of osteoporosis because they are of
central importance in optimising peak bone mass. There is some evidence to suggest that prolonged calcium
supplementation will provide a small benefit to post-menopausal women, but in older people, the evidence for
calcium and vitamin D supplementation is more convincing, showing a reduction in risk of fracture of the femur.
The WHO (2003) recommended that, although firm evidence is lacking, dietary and lifestyle recommendations,
which have been developed with prevention of other chronic diseases in mind, may be helpful in terms of
reducing fracture risk. Such recommendations include: increase physical
activity; reduce sodium intake; increase consumption of fruits and vegetables; maintain a healthy body weight;
avoid smoking; and limit alcohol intake.
References:
AA. VV., Bone Health and Osteoporosis, The 2004 Surgeon General’s Report, N.I.H. and Related Bone Disease,
National Resource Center, Washington D.C., 2004
Carpenter T.O., Barton C.N., Park Y.K., Usual dietary magnesium intake in NHANES III is associated with
femoral bone mass. J Bone Min Research 15: S292, 2000
Cashman K.D., Diet, Nutrition, and Bone Health, J. Nutr., 137(11 Suppl):2507S-2512S, 2007
National Osteoporosis Foundation Website, http://www.nof.org, 2005
9
Cooper C., Harvey N., Javaid K., Hanson M., Dennison E., Growth and bone development, Nestle Nutr
Workshop Ser Pediatr Program., 61:53-68, 2008
Coxam V., Prevention of osteopaenia by phyto-oestrogens: animal studies, Br J Nutr 89 (Suppl 1): S75-S85.,
2003
Early Prevention of Osteoporosis (http://orthoinfo.aaos.org/topic.cfm?topic=A00330), 2007
Goulding A., Major minerals: calcium and magnesium. In: Essentials of Human Nutrition. Eds: J Mann & AS
Truswell. pp. 129-143. Oxford University, Press: Oxford, 2002
Hannah E.T., Nutrition and Bone Health, British Nutrition Foundation, Holick M.F. and Hughes B.D. Eds.,
Humana Press Inc. Totowa, NJ, 2004
Huth P.J., Di Rienzo D.B., Miller G.D., Major Scientific Advances with Dairy Foods in Nutrition and Health,
Journal of Dairy Science, 2006
O’Shea B., Rosen C.J., Guyatt G. et al., A meta-analysis of Ca supplementation for the prevention of
postmenopausal osteoporosis. Osteoporosis International 11: S114, 2000
Phillips F., Diet and Bone Health, Health Professionals N° 5, British Nutrition Foundation, U.K., 2003
Prentice A. Bonjour J-P, Branca F. et al., Passclaim – bone health and osteoporosis, Eur J Clin Nutr 42 (Suppl 1):
1/28-1/49, 2003
Prentice A., Schoenmakers I., Laskey M.A., de Bono S., Ginty F., Goldberg G.R., Nutrition and health in children
and adolescents, Proc Nutr Soc., 65(4): 348–360, 2006
Valtuña S., Cashman K., Robins S.P. et al. Investigating the role of natural phytoestrogens on bone health in postmenopausal women. Br J Nutr 89 (Suppl 1): S87-S99, 2003
Van der Wielen R.P., Lowik M.R., van den Berg. H et al., Serum vitamin D conc 1995
Zittermann A. Effects of vitamin K on calcium and bone metabolism. Curr Opin Clin Nutr Metab Care. 4:483487, 2001
10
MATERIALS BIOCOMPATIBILITY: POSITIVE RESULTS AND PITFALLS
P. Cherubino
Dipartimento di scienze Ortopediche e Traumatologiche “M. Boni”
Università dell’Insubria, Varese
The term biocompatibility is related to behaviour of materials used for surgical devices. It reflects the evolution of
insights into how a materials interact with human body and how these interactions determine the clinical success
of the medical device.
The mechanical and chemical properties of metals, such as titanium, titanium-based alloys and cobalt-based
alloys, and ceramics, such as Bioglass and calcium phosphate, make them suitable for implant applications.
However, several factors affect the biologic response to these implanted materials. The predominant tissue found
at the implant interface is affected by implant initial stability and design, material biocompatibility. Improvements
in implant design and surface preparation may improve implant longevity and fixation for all implants materials.
In addition, the passive surface oxide layers have provided chemical inertness within biologic environments.
An example of the evolution of biomaterials is the introduction of the porous tantalum. This material is a carbon
scaffold covered by pure tantalum. The main features are: a high porosity up to 80%, a lower elastic modulus (3
GPa) and a high frictional stability against bone. Trabecular metal has an unusually large and interconnecting
porous surface which corresponds to between 75% and 80% of its total volume, and an overall geometry, shape
and size similar to those of cancellous bone. The high-volume porosity enables extensive tissue infiltration and
strong attachment. The metal elasticity of trabecular bone is 3 GPa, which is between those of cancellous (0.1
GPa), subchondral (2 GPa), and cortical bone (15 GPa). Titanium alloys (110 GPa) and cobalt-chromium alloys
(220 GPa) are much less elastic.
Despite all, an implant fails for many reasons:
- poor bone ingrowth
- wear debris in articulating surface
- interaction between bone and implant in terms of stress and strain
Thus, other aspect must be considered as the tribology of the materials but it is the evolution of the research in
terms of finding new ones as for example the new cross-linked polyethylene.
Finally, the new field of the research is the cellular processes that lead to efficient bone growth. This is the new
field of nanobiotechnology which is revolutionizing our knowledge in biological interaction. Nanomaterials (less
than 100nm) are believed to play a pivotal role in orthopaedic research as bone itself is an example of them.
Preliminary studies support their potentiality but significative advancements are necessary to achieve clinical use.
11
THE SEALED OSTEONS OF CORTICAL DIAPHYSEAL BONE
F. Ranchetti, T. Congiu, S. Colombo, D. Quacci, U.E. Pazzaglia (Brescia)
In previous studies of the cortical bone morphology sealed or blind osteons have been reported as an unusual and
peculiar finding. They present with the normal and concentrical lamellar pattern, but the central canal has no
vessel inside and is occluded by organic matrix not different from that of the bone lamellae. This study was
carried out in the diaphysis of the rabbit femur, decalcified and sectioned in transverse planes perpendicular to the
long axis of the bone. The frequence of sealed osteons resulted 17.44%. The central canal is filled by a
collagenous matrix, which appear as the product of osteoblasts. Occasionally these cells are included in the plane
of the histological section. The organic matrix observed with SEM and X-rays energy dispersive analysis
(EDAX) in undecalcified section showed the same inorganic spectrum of the surrounding lamellae. These aspects
can be explained by the adaptation of the vessels network to the dynamics of the intracortical blood flow; if a
branch of the network is shunted, osteoblasts living the canal wall can start again lamellar apposition as far as
they fill the central canal space.
12
3-D RECONSTRUCTION OF THE INTRACORTICAL CANALS SYSTEM WITH MICRO-TC.
EXPERIMENTAL STUDY IN THE RABBIT FEMOUR.
G. Zarattini, D.Giacomini, A.M. Menti, G.P. Feltrin, U.E. Pazzaglia (Brescia)
Segments of the cortical bone of the diaphysis of rabbit femur were prepared after digestion of the soft tissue with
oxygen peroxide and essication. The specimens with the shape of parallelepipedon, side 2x4x15 mm were studied
with micro-CT of resolution of 5 µ to evidentiate the 3-D architecture of the intracortical canal system. Size
variation of canal estended from 2.89 µ to 112.72 µ with a higher frequency in the size class 14.45-20.23 µ. Canal
volume/tissue volume, canal surface density, canal thickness and canal trabecular pattern factor were also
calculated in order to characterize the intracortical canal system. Area variation of canals in intranodal tract was
determined in consecutive serial sections whose reconstruction allowed classify the main shape patterns of
intracortical canals.
13
DIFFERENTIAL EXPRESSION OF HOMEOBOX-CONTAINING GENES IN HUMAN OSTEOGENIC
CELLS
1
L. Spugnesi, 1 J. Picchi, 2 L. Trombi, 3 G. Barbanti Brodano, 2 M. Petrini, 4 S. Boriani, 1 M. C. Magli
1
Institute of Biomedical Technologies- CNR, Pisa, Italy;
CUCCS, University of Pisa, Italy;
3
Spine Center – Istituti Ortopedici Rizzoli - Bologna, Italy;
4
Orthopedics and Traumatology – Spine Center - Ospedale Maggiore “C.A. Pizzardi”, AUSL Bologna, Italy
2
Aims: Mesenchymal Stem Cells (MSCs) have raised great interest as potential therapeutical tools for bone
regeneration. However, several aspects of their biology still need to be clarified, also in view of their optimal
therapeutical use. A growing body of evidence indicate that regulatory molecules orchestrating embryonic
development are also involved in the differentiation of adult tissues. Homeobox-containing genes encode
transcription factors that have a broad spectrum of functions in the development of multiple tissues, including
blood and bone. Here we investigated whether homeobox genes are active also during osteogenic differentiation
of primary human MSCs.
Methods: MSCs were grown in vitro from different samples of human bone marrow and maintained in expansion
conditions or induced to osteogenic differentiation following exposure to inducing agents. Cells at different stages
of differentiation were analyzed by quantitative Real Time PCR for the expression of homeobox genes known to
control embryonic skeletal and limb development.
Results: MSCs derived from several different donors exhibited similar homeobox gene expression profiles.
Members of various homeobox families, encoding HOX proteins and their co-factors, were differentially
expressed in undifferentiated MSCs. Moreover, the expression of these genes was differentially modulated during
osteogenic differentiation.
Conclusions: Regulatory genes governing embryonic bone development in the mouse, are active also in adult
human mesenchymal cells and involved in bone regeneration, as assayed in vitro. The identification of new
molecular cues regulating self-renewal and differentiation of osteogenic cells is critical to improve the
therapeutical use of adult stem cells and may allow the development of more efficient strategies for tissue
regeneration
Acknowledgements: This study was supported by Fondazione Cassa di Risparmio di Bologna.
14
BIOMATERIALS FORMS INFLUENCE “IN VITRO” ADHESION AND PROLIFERATION OF
HUMAN MESENCHYMAL STEM CELLS
Di Bona Cristina1, Barbanti Bròdano Giovanni2, Manfrini Marco1, Lucarelli Enrico3, Donati Davide3, Picchi
Jacopo4, Spugnesi Laura4, Greggi Tiziana2, Parisini Patrizio2, Boriani Stefano5, Tognon Mauro 1
1
Department of Morphology and Embryology, Section of Cell Biology and Molecular Genetics, and Centre of
Biotechnology, University of Ferrara, Ferrara, Italy
2
Spine Surgery, Istituti Ortopedici Rizzoli, Bologna, Italy
3
Laboratory of Bone Regeneration, Istituti Ortopedici Rizzoli, Bologna, Italy
4
Institute of Biomedical Technologies, National Research Council (CNR), Pisa, Italy
5
Orthopaedics and Traumatology, Ospedale Maggiore, AUSL Bologna, Italy
Aims:
In the orthopaedic perspective, tissue engineering is focused on the development of innovative materials, whose
action consists in recruiting bone progenitor cells and in stimulating their proliferation. In this study, we
investigated the effects of hydroxylapatite (HA) biomaterials on human mesenchymal stem cells (hMSCs).
Comparative analyses were carried out on two bioceramic materials, named SINTlife and ENGIpore (FinCeramica Faenza S.p.A., Faenza, Italy), to verify hMSCs adhesion, proliferation, and morphology.
Methods:
Culture of hMSCs: hMSCs were isolated from bone marrow samples of orthopaedic patients by density gradient.
Cell quantification: The AlamarBlue test has been used to analyze cell adhesion and proliferation on biomaterials
and the control.
Results:
hMSCs population obtained from bone marrow aspirates formed a confluent monolayer in approximately 3-4
weeks after the cell seeding and exhibited a fibroblast-like morphology. Comparative analyses of cell adhesion
and proliferation have been carried out on biomaterials and control. The best result has been observed for the
ENGIpore block with an adhesion percentage of 40%. The proliferation assay at 120h indicated that the number
of cells grown on biomaterials was higher than that of cells grown on control.
Conclusions:
The specific shape and the chemical composition of different biomaterials may influence the proliferation and the
pattern of distribution of several cellular types on their surface. Our data showed that hMSCs behave differently
on biomaterials with different composition in regard to the cellular adhesion and proliferation. Object of future
investigations could be the study of hMSCs differentiation on different biomaterials.
Acknowledgements: This study was supported by Fondazione Cassa di Risparmio di Bologna.
Key words: Spine surgery, biomaterials, stem cells.
15
IN VITRO EFFECT OF PLATELET GEL ON HUMAN BONE MARROW STROMAL CELLS AND
ENDOTHELIAL CELLS FOR BONE ENGINEERING
Fotia Caterina 1, Perut Francesca 1, Cenni Elisabetta 1, Savarino Lucia 1, Dallari Dante 2, Cenacchi Annarita 3,
Fornasari Pier Maria 3, Giunti Armando 1,2, Baldini Nicola 1,2
1
Laboratory for Pathophysiology of Orthopaedic Implants, Istituto Ortopedico Rizzoli, Bologna.
Department of Orthopaedic Surgery, Istituto Ortopedico Rizzoli, Bologna.
3
Transfusion Medicine and Immunohematology Unit, Istituto Ortopedico Rizzoli, Bologna
2
Aims: Platelet gel (PG) is used to accelerate bone repair through the growth factors released by platelets.
Angiogenesis plays an important role in bone healing. The purpose of this study was to evaluate the in vitro
effects of PG on human bone marrow stromal cells (BMSC) and human umbilical vein endothelial cells
(HUVEC).
Methods: PG was in vitro added to BMSC isolated from the iliac crest and the effects on differentiation genes
expression, cell-associated ALP, FGF-2 production and calcium deposition were evaluated at different end-points.
Moreover, the effect of PG was evaluated in vitro on HUVEC proliferation and expression of genes that have a
role in bone repair.
Results: Cell-associated ALP, osterix and FGF-2 were higher in BMSC incubated with PG. HUVEC proliferation
was significantly stimulated by PG, which induced also an increased expression of mRNAs for PDGF-B, ICAM1, and osteoprotegerin.
Conclusions: PG may contribute to bone healing through a favouring effect both on the differentiation of BMSC
towards osteoblasts and on angiogenesis. In particular, platelet gel not only stimulates the proliferation of
endothelial cells, but also induces the expression of genes for adhesion molecules for monocytes/macrophages and
for the recruitment of osteoblast precursors.
Key words: Platelet gel, BMSC, HUVEC
16
IDENTIFICATION OF GENES USEFUL TO MONITOR THE DIFFERENTIATION OF HUMAN
BONE MARROW STROMAL CELLS (hMSC) INTO OSTEOBLASTS
Baglìo Serena Rubina1, Leonardi Elisa1, Devescovi Valentina1, Baldini Nicola1, Ciapetti Gabriela1, Ochoa
Gorka2, Granchi Donatella1, Giunti Armando1
1
2
Laboratorio di Fisiopatologia degli Impianti Ortopedici, Istituto Ortopedico Rizzoli, Bologna, Italia;
Progenika Biopharma SA, Derio, Spain.
Aims: The main goal of this study was to obtain a list of genes which may be routinely used in vitro to monitor
the differentiation of human marrow stromal cells (hMSC) into bone-forming cells.
Methods: A microarray analysis of the whole human transcriptome was previously performed on hMSC obtained
from the femoral canal of patients undergoing hip replacement. We focused on genes which were significantly
up-regulated, belong to pathways and biological processes that play a key role in bone cell biology, and changed
considerably during differentiation and/or mineralization. The temporal changes of selected genes were validated
by real time PCR in 10 different primary cultures of hMSC. The RNA was extracted at time 0, representing the
basal gene expression of the adherent bone marrow mononuclear cells, at the first hMSC confluence, and 7 days
after the addition of mineralizing medium. Only cultures able to form mineral nodules, as revealed by Alizarin
Red staining, were considered for the gene expression analysis.
Results: Among the 233 genes identified by microarray analysis, we selected 13 molecular markers related to
specific steps of osteogenic differentiation. These included ALPL, POSTN, COMP, CLEC3B, COL12A1, IBSP,
TNFRSF11B, and SPARC (bone-related genes); COL1A1 (cell communication); Runx2, SMAD4, and THBS1
(TGF-beta signaling pathway); FZD8 (Wnt signaling pathway). Real time PCR analysis showed that transcript
levels of the above mentioned genes were modulated during different steps of hMSC culture. Moreover, the
selected genes showed reproducible results in spite of the inter-individual variability.
Conclusions: These results may be useful to monitor hMSC cultures, and to recognize in which step of
differentiation or mineralization they are. This opportunity may be widely exploitable, for instance when in vitro
experiments are performed to expand osteogenic precursors onto scaffolds for bone tissue engineering.
This work is part of the NANOBIOCOM project supported by the 6th Framework European R&D Program
(Project n° NMP3-CT-2005-516943).
Key words: human bone marrow stromal cells, bone regeneration, gene expression
17
THE ROLE OF PHYTOESTROGEN GENISTEIN IN POSTMENOPAUSAL BONE HEALTH
H. Marini, E.B. Adamo, R. D’Anna
Department of Biochemical, Physiological and Nutritional Sciences,
Section of Physiology and Human Nutrition, University of Messina, , Italy
Postmenopausal osteoporosis is a disease associated with a gradual thinning and weakening of the bones and is
caused primarily by the sharp decrease in estrogen levels that leads to the increased rate of bone remodelling.
Estrogen replacement therapy is an established treatment for the prevention of osteoporosis in postmenopausal
women, but it has been also associated with several adverse effects that reduce therapy compliance.
Epidemiological studies suggest that the lower incidence of osteoporosis and hip fractures in Asian women, might
be related to their high intake of phytoestrogen-rich soy food. Consequently, women seeking alternative
treatments to preserve bone often use phytoestrogens, but evidence of their effectiveness is lacking. Genistein is
an isoflavone found in low concentrations in soybeans and elevated amounts in certain soy derived food, whereas
genistin, the glucoside form of the aglycone genistein, is much more abundant in the unprocessed soybean. As a
natural selective estrogen receptor (ER) modulator, genistein can positively regulate bone cell metabolism
without the harmful estrogenic activity in the breast and uterus. This safe profile is likely a direct consequence of
a greater genistein affinity towards ERß which is abundant in bone during the mineralization phase, rather than
ERα, which is associated with the development of carcinogenesis in the reproductive tissues. On the basis of this
background our research group performed a randomized, placebo-controlled trial of the effects of pure genistein
on bone density and bone metabolism over 24 and 36 months in a larger cohort of osteopenic, postmenopausal
women. After a 4-week stabilization period during which participants received a low-soy, reduced-fat diet,
participants were randomly assigned to receive placebo or 54 mg of genistein, daily, for the period trial. Both the
genistein and placebo contained calcium and vitamin D3. The primary outcome was bone mineral density (BMD)
at the anteroposterior lumbar spine and femoral neck at 24 and 36 months. Secondary outcomes were serum
levels of bone-specific alkaline phosphatase (b-ALP) (bone formation marker), insulin-like growth factor I (IGFI) (bone growth marker) and urinary excretion of pyridinoline (PYR) and deoxypyridinoline (DPYR) (bone
resorption markers). We also evaluated the serum levels of osteoprotegerin (OPG) and soluble receptor activator
of NF-KB ligand (sRANKL) and their balance in osteopenic, postmenopausal women (after 24 months of
treatment) in order to better understand the effects of genistein on sRANKL/OPG balance. Finally, the continued
safety profile of genistein on breast and endometrium was assessed and data on adverse events were also
collected.
At 24 months, BMD had increased in genistein recipients and decreased in placebo recipients at the
anteroposterior lumbar spine and the femoral neck. Genistein significantly decreased urinary excretion of PYR
and DPYR, increased levels of b-ALP and IGF-I. Moreover, at the end of 24 months, genistein produced a
significant reduction of the sRANKL/OPG ratio compared with placebo. More genistein recipients than placebo
recipients experienced gastrointestinal side effects and discontinued the study. After 36 months the phytoestrogen
did not change mammographic breast density and endometrial thickness compared with placebo and continue to
show positive effects on bone. In conclusion, we found that genistein displays positive effects on bone health and
exhibits a promising safety profile in a cohort of osteopenic, postmenopausal women. On the basis of these data,
future studies in osteoporotic women are warranted to determine whether genistein also significantly decreases
fracture risk in this group. In addition, studies are needed to determine whether the genistein safety profile
demonstrated in our cohort of osteopenic, postmenopausal women extends to isoflavones as a class.
18
Ex-vivo transduced autologous skin fibroblasts expressing human Lim Mineralization
Protein-3 efficiently form new bone in animal models
Enrico Pola1, Giandomenico Logroscino1, Paul D. Robbins2
1
2
Department of Orthopaedics, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy;
Department of Molecular Genetics and Biochemistry, University of Pittsburgh, School of Medicine, Pittsburgh,
USA
Local gene transfer of the human LIM Mineralization Protein (LMP), a novel intracellular positive regulator of
the osteoblast differentiation program, can induce efficient bone formation in rodents. In order to develop a
clinically relevant gene therapy approach to facilitate bone healing, we have used primary dermal fibroblasts
transduced ex vivo with Ad.LMP3 and seeded on an hydroxyapatite/collagen matrix prior to autologous
implantation. Here we demonstrate that genetically modified autologous dermal fibroblasts expressing Ad.LMP-3
are able to induce ectopic bone formation following implantation of the matrix into the mouse triceps and
paravertebral muscles. Moreover, implantation of the Ad.LMP-3-modified dermal fibroblasts into a rat
mandibular bone critical size defect model results in efficient healing as determined by X-ray, histology and three
dimensional micro computed tomography (3DµCT). These results demonstrate the effectiveness of the nonsecreted intracellular osteogenic factor LMP-3, in inducing bone formation in vivo. Moreover, the utilization of
autologous dermal fibroblasts implanted on a biomaterial represents a promising approach for possible future
clinical applications aimed at inducing new bone formation.
19
BIOMECHANICAL EVALUATION OF A NEW COLLAGEN I BIOSCAFFOLD FOR TENDON
SURGERY
Gigante Antonio, Busilacchi Alberto, Cesari Eugenio, Villa Tommaso*, Greco Francesco
Department of Orthopaedics – Università Politecnica delle Marche - Ancona
*Department of Structural Engineering- Politecnico di Milano - Milano
The study evaluated the biomechanical properties of a new collagen type I membrane obtained from equine
tendon (Opocrin - Modena, Italy). The membrane is produced by treatment and purification of equine Achilles
tendon and, like normal, healthy tendon, its collagen fibres are oriented along the traction vector. Our previous in
vitro and in vivo experience has demonstrated its ability to faster tenocyte growth and reconstitution of tendon
tissue, as well as its absolute biocompatibility and safety. These properties make it suitable for use in orthopaedic
procedures, especially rotator cuff augmentation and Achilles tendon surgery.
In 10 adult male New Zealand White rabbits, a 3 x 0.5 cm defect was created in the middle third of the patellar
tendon that was then filled with the collagen type I membrane scaffold. As control, the unoperated, contralateral
patellar tendon was used.
After the procedure the animals were allowed to feed and move freely in their cages. They were then killed after 6
months to analyze the biomechanical features of the new tendon.
Tensile tests were conducted on the whole patellar tendon, removed with the patella proximally and the tibial
tuberosity distally, using an INSTRON machine. To avoid rupture or gliding in the machine, both ends of each
tendon were secured with methyl methacrylate. All tendons were then tested to rupture. The machine’s software
calculated the stress-strain curve and evaluated mechanical properties. Stumps were subjected to histological
study for fibril tear characteristics.
The stress-strain curve showed similar resistance and peak load of treated and unoperated tendons.
The type I collagen membrane tested thus proved to be a valuable and readily available scaffold for tendon
augmentation and substitution and to be endowed with optimal biomechanical properties.
Keywords: Collagen, Tendon healing, Tendon augmentation, Tendon scaffold, Tensile test, Biomechanics
collagen I
20
METAPHYSEAL CHONDRODYSPLASIA SCHMID TYPE: A DIAGNOSIS DELAYED
Briuglia S., Cutrupi M. C., Calabrò A., Piraino B., Gallizzi R., Salpietro D. C.
UOC Genetica ed Immunologia Pediatrica, Policlinico Messina
Aims: We described a 16 years old girl, the third daughter of health non consanguineous parents. She was born at
term by normal pregnancy. At 2 years old she showed bowing of legs. At 9 years old she was treated with GH
hormone for short stature, without improvement. X-ray of skeleton showed bilateral coxa vara, methaphyseal
abnormalities of femurs and tibias, normal bone age and spine. At 12 years old she underwent orthopedic
treatment, without a specific diagnosis of her disease.
Methods and Results: We examined the patient at the age of 16. She had short stature with short and bowing
legs. Face and hands were normal. Clinical and radiographic data were suggestive for the diagnosis of Schmid's
metaphyseal dysplasia.
Conclusions: Chondrodysplasia Schmid type is a rare disorder characterized by moderately small size usually
diagnosed during the 2nd or 3rd year of life. The abnormalities are short limbs, bow legs, coxa vara, normal hands
and metaphyseal lesions of limbs. Orthopedic correction is the only possible treatment for the moment.
Transmission is autosomal dominant. It is due to mutations in the gene coding for collagen X. We are waiting
for the result of the molecular analisys. We reported this case because of the diagnostic difficulty of
chondrodysplasias is the cause of the tardy diagnosis and long medical pilgrimage.
Key words: dysplasia Schmid type, Metaphyseal chondrodysplasia, rare diseases
21
ENHANCING MUSCLE REGENERATION IN MDX MICE: BENEFICIAL EFFECTS OF GENISTEIN
AND FLAVOCOXID.
Messina Soniaa, Bitto Alessandrab, Mazzeo Annaa, Aguennouz Mohammed a, Migliorato Alba a, De Pasquale
Maria Grazia a, Squadrito Francescob, Vita Giuseppe a
a
Department of Neuroscience, Psychiatry and Anaesthesiology and b Department of Clinical and Experimental
Medicine and Pharmacology, University of Messina, Italy
Aims: Soy isoflavones have been reported to have antioxidant bioactivities, scavenging free radicals and
increasing antioxidant protein expression, and also to inhibit the transcription factor NF-kB. We showed in
previous studies that the inhibition of the transcription factor NF-kB through drugs with also antioxidant
properties, have beneficial effects in the murine model of Duchenne muscular dystrophy (DMD), the mdx mice.
The drugs used are not available for clinical studies. We tested whether genistein and flavocoxid, supplements
with known antioxidant and antinflammatory properties readily available for clinical use, could have a beneficial
effect on muscle function, morphology and biochemical pattern in mdx mice.
Methods: Five-week old mdx mice received for five weeks genistein (2 mg/kg i.p. daily), flavocoxid (5 mg/kg i.p.
daily) or vehicle.
Results: Flavonoids treatment 1) increased forelimb strength ( p<0.05) and strength normalized to weight
(p<0.05) and decreased fatigue (p<0.05); 2) reduced serum creatine-kinase levels (p<0.01); 3) increased GPX
activity and reduced markers of oxidative stress (p<0.05); 4) blunted NF-κB DNA-binding activity (p<0.05); 5)
reduces muscle necrosis (p<0.01) and enhances regeneration (p<0.05) with an augmented number of myogeninpositive satellite cells and myonuclei, and of developmental myosin heavy chain-positive fibers.
Conclusions: Our results suggest that these flavonoids might have a beneficial effect on muscle function and
morphology in mdx mice. Further studies are needed to investigate the biochemical substrates of such
encouraging preliminary results taking into account that these supplements could be easily introduced in the daily
diet of patients with DMD.
Key words: Flavonoids, muscle regeneration, Duchenne muscular dystrophy
22
EFFECT OF PULSED ELECTROMAGNETIC FIELDS ON HUMAN TENOCYTE CULTURES.
AN IN VITRO STUDY OF TENDON HEALING.
Vincenzo Denaro, Simona Barnaba, Laura Ruzzini, Stefano Campi, Alessandro Sgambato, Achille Cittadini.
Department of Orthopaedic and Trauma Surgery, Università Campus Biomedico, Roma.
Aims: The aim of this study was to investigate the effects of pulsed electromagnetic fields on human tenocyte
cultures from different tendons.
Methods: Human primary tenocyte cultures of supraspinatus and quadriceps tendons were exposed to the
electromagnetic field stimulation for 72 hrs, 5 days and 10 days. Cell growth and cell cycle were evaluated. In
quiescent confluent tenocyte culture an in vitro wound was mechanically generated and the width of the cell free
zone was measured at 12, 24 and 36 hrs after the injury in the presence of PEMF stimulation.
Results: Tenocyte growth analysis and cell cycle analysis did not show statistically significant differences
between exposed and control groups. PEMF stimulation significantly accelerated wound closure by 12 and 24
hours after the injury.
Conclusions: Pulsed electromagnetic field comparable to the one that are usually used for the management of
acute fractures, delayed and nonunion and congenital pseudarthosis stimulate tendon healing in an in vitro model.
We can speculate that the enhancement of in vitro wound closure can be caused by chemotaxis process rather than
proliferation. We think that our results provide the in vitro work and the rational basis to support the study of the
effect of the PEMFs in vivo tendon ruptures or repair.
23
INTOXICATION BY METAL IONS RELEASED BY A THR WITH A HIGH RATE OF WEAR
U.E. Pazzaglia, G. Zarattini, P. Apostoli, A. Padovani (Brescia)
The author report the case of a 58 years old woman who underwent a first revision of total hip replacement
because the ceramic head broke. The ceramic component (head and liner) were removed and substituted with a
Co-Cr-Mo alloy head and a polyethylene liner. The titanium stem and cup, which were found to be stable were
not revised. 4 months later the patient started to complain reduction of sight and hearing which worses
progressively and after 1 year she was blind, deaf and with a sevear peripheral neuropathy which made
impossible to walk. Metal ions in serum resulted to be elevated (Co 90 µg/L, Cr 210 µg/L, Mo 2.4 µg/l) In a
second revision all tho components were removed. Massive wear of Co-Cr-Mo was found originating by thirdbody wear against ceramic particles set in the polyethylene liner. There was a reduction of the metal ions levels
following EDTA treatment and revision of the prosthesis. Improvement of the clinical conditions was observed,
with recovery of hearing and lower limb function. Optic nerves lesions showed the lowest improvement.
24
PHYSICAL AND BIOLOGICAL ASPECTS OF THE CELLULAR REACTION OF FOREIGN BODY
PARTICLES IN ORTHOPAEDIC IMPLANTS
G. Bonaspetti, G. Zarattini, U.E. Pazzaglia (Brescia)
Foreign body particles are produced in different mechanical conditions by joint prosthetic devices when there is
sliding or movement between components. A slow rate of wear is compatible with a good working of the
prosthesis for a remarkable number of years, while if rate of wear increases also the risk of loosening increases.
The physical properties of foreign body particles (material, size, shape) depend on the material and on the
mechanism of wear. Once they are released in the tissues, the cellular reaction and the damage on the bone
surrounding the prosthesis are determined by the primary physical properties of particles but also by other factors
like the rate of release, modality and rate of drainage from the site where they are produced. It is therefore
relevant the typization of foreign body particles in the periprosthetic tissues obtained by implant revisions. The
problem connected with typization of particles in the tissue and in organic fluids are presented.
25
KINETICS OF METALS IONS BEFORE AND AFTER REMOVAL THE RELEASING THR
G. Zarattini, P. Apostoli, A. Padovani, U.E. Pazzaglia (Brescia)
The serum, blood and urine levels of soluble metal ions released by the THR earlier reperted were determinated at
regular intervals of time for 70 days before removal of the prosthesis and 37 days after. Chelating agent treatment
(EDTA) produced an initial decrement after the two first administrations, but it increased again after about 3 days
even if at levels lower than before. Further decrements were smaller. Completed removal of the prosthesis
produced the most evident decrement of metal ions levels. EDTA treatment was maintained throughout the postoperative period. The efficacy of chelating agent treatment was more evident on the Co ions, while removal of the
source of wear particles produced a significant decrement of all the metal ions. Co levels in blood were about
twice higher than in serum and their profile was almost similar. Less evident resulted the effect on Cr and Mo
ions. Peaks of all metal ions were observed in urine after each EDTA administration: they were higher before
removal of the prosthesis than post-operatively.
26
LERI WEILL SYNDROME: A CASE REPORT
S. Briuglia, M. C. Cutrupi, R. Gallizzi, C. Munafò, C. Cuppari, M. R. Cutrì, D. C. Salpietro (Messina)
UOC Genetica ed Immunologia Pediatrica, Policlinico Messina
Aims: We described a 21 year-old girl, the only daughter of healthy non-consanguineous parents. Family history
was unremarkable. Pregnancy was normal. Delivery was preterm, with normal neonatal period. At 5 months hip
dysplasia was diagnosed. At 3 years-old she presented short stature (-3SD), bone age delay and partial GH deficit.
She was treated with GH for 2 years, without improvement. Skeletal X-ray showed meta-epiphyseal dysplasia,
with hypoplasia of femoral, ulnar, radial epiphyseal nucleous, short metacarpi and deformity of sternum. Spine
and cranium were normal. She underwent many orthopedic treatments to extend limbs, without the diagnosis of
her disease.
Methods and Results: We observed the patient when she was 21 years-old. Height was 140 cm with limbs
mesomelic shortening. A new radiological study described hip dislocation and Madelung deformity of the
forearm with bilateral wrist anomaly. We diagnosed Leri-Weill syndrome or Dyschondrosteosis, that is
characterized by bowed radius and ulna, along with small stature mainly from mesomelic origin.
Conclusions: Leri-Weill syndrome is a rare diseases and transmitted as an autosomal dominant trait. The
disorder may be detectable on radiographs. Intelligence is normal. The causative gene has been identified on the
common region to both the X and Y chromosomes, called SHOX gene. We are waiting for the result of the
molecular analisys. We reported this case because of the diagnostic difficulty of chondrodysplasias is the cause of
the tardy diagnosis and long medical pilgrimage.
Key words: Leri-Weill syndrome, Madelung deformity, rare diseases
27
NEW UPDATES ON THE CHARCOT NEUROARTHROPATHY PATOGENESIS. STUDY OF THE
GENIC POLYMORPHISM OF THE OSTEOPROTEGERIN
M. Galli, D. Pitocco, C. Chinni, L. Mancini, S. Caputo, G Ghirlanda (Roma)
Introduction and Aim of the study:
The pathogenesis of Charcot neuroarthropaty(CN) is still unknown. One feature of the CN is the bone
reabsorption. Osteoprotegerin (OPG) controls bone remodelling. OPG genic polimorphism has been associated
with osteoporosis. G1181C polymorphism is localized on the exon I and encodes for the signal peptide of the
OPG synthesis. T245G polymorphism instead encodes the promoter of the osteoprotegerin gene. The aim of this
study is to evaluate whether it exists a correlation between these two polymorphisms and the CN.
Materials and Methods:
41 affected by CN patients, 31 neuropathic diabetic without CN patients and 106 healthy people have been
enrolled in the study. The assessment of the genotype has been performed using PCR-RLFP.
Results:
We found a statistical significant correlation between the G allelle (OR 2,39;p<0,01) and the genotype G/G (OR
2,64;p<0,05), and a negative association between the C allele (OR 0,42; p<0,01) and the genotype C/C (OR 0,21;
p<0,01) when they have been compared to H. There was found no statistical difference between ND and H. The
allele G of the T245G polimorfism has been found positively associated with the CN (OR 2,65; p<0,05), whereas
the T allele has not been found associated with the CN (OR 0,27;p<0,05).
Conclusions:
This is the first study investigating the possible association between the CN and genotype affected by this
disease. Our data suggest a possible correlation between genetic polymorphism and the CN disease.
28
NUMERICAL AND EXPERIMENTAL ANALISYS OF THE MECHANICAL BEHAVIOUR OF AN
INNOVATIVE PLANTAR
V. Filardia, G. Gamberab, E. Guglielminoa
a) D.C.I.I.M.,Università degli Studi di Messina, Salita Sperone 31, 98166 - Messina.
b) D.I.I.M., Università degli Studi di Catania, V.le A. Doria 6, 95125 - Catania.
The present paper is focused on the study of an innovative plantar capable to redistributing the plantar pressures
dynamically, because of an increased supporting surface of the plantar zones, in all the several phases of the
step.The starting point is based on the “postural” equilibrium system of the human body taking into account the
"feedback" and the projections of the barycentre point on a plate. The proposed plantar, realized by two sheets of
PVC, presents four pressurised chambers, connected by means of the narrow sections, so that the fluid flow,
during the step, can follow the resultant force. The constant mass system is subjected to a relative inner pressure
of 0,3 bars, numerically determined, related with the volume variations and following the ideal gas equation of
state. It is possible to notice that by using a plantar with four communicating chambers the support surface is
increased therefore reduce the peaks of pressures in the foot. The approach followed to face the problem consists
of several numerical analyses, carried on a FE model of the plantar supported by experimental tests performed by
meaning of a digital differential manometer. These preliminary analyses have let to calculate a proper inner
pressure for the plantar and also to put on evidence same critical zones. The results, obtained confronting the
maximum pressures of the fluid, confirm a reduction of reduction of 9.6% for the heel, of 5.4% for the lateral arc,
of 13.8% for metatarsi and 2.7% for the fingers. In order to obtain a more complete information about the plantar
performances, in prospective of a more general application, different typologies of load corresponding to
different weights of the patient, have been further investigated. It is also possible to predict, by meaning of the
opportune numerical analyses, how the plantar behaves in presence of different pathologies which often can affect
the foot, such as: valgus big toe, hammer finger, etc. These pathologies basically arise when the big toe diverts
pitching toward the other fingers of the foot altering so the mechanics of the foot during the walk and the load,
thus a correct redistribution of the pressure acting on the foot could minimise this problems. In conclusion the
proposed solution undoubtedly can suggest a series of the advantages, particularly appreciable by those patients
which suffer some pathologies of the foot. Future improvements will be object of study with the aim to improve
the performance of plantar in terms of optimization of the amount and the speed of the fluid exchanged between
the chambers, and moreover to verify the reliability and the effects in the time of the innovative plantar.
keywords: baropodometry, FE modelling, plantar pressure, foot pathology.
29
MORPHOLOGICAL STUDY OF THE EFFECTS OF CHEMICAL AND PHYSICAL TREATMENT OF
THE INTERVERTEBRAL DISK. EXPERIMENTAL STUDY IN THE PIG
G. Zarattini, L. Rodella, A. Vesnaver, U.E. Pazzaglia (Brescia)
Nucleoplasty with coblation and molecular resonance are new procedures used for disc decompression in humans
with intervertebral disc protrusion. No data on local side effects are available. The aim of the study was to
evaluate the biological effect of coblation and molecular resonance on pigs intervertebral disc in order to
characterize the macroscopic and microscopic lesions after different application of power. 8 isolated lumbar
intervertebral discs of 2 pigs were treated with different increasing power from a minimum to a maximum
permitted from the system of coblation and molecular resonance. The temperatures during all the treatments were
measured to evaluate possible burn damage to nearby nervous tissue. Macroscopic and histological evaluations of
treated intervertebral discs and in control discs were performed. To allow histological evaluation all the discs
have been treated with decalcified to removed exceeding bone tissue. The temperature in both treatments did not
exceed 30°C peripherally to the discs. No macroscopic lesions have been identified in all the procedures except
for the one with maximum power in coblation. In this case the intervertebral disc showed a cylindrical burn where
the electrode was applied; also histological analysis showed the same lesion. Using molecular resonance no
macroscopic signs were present even with maximum power. Histological analysis of the other treated discs
revealed no significant lesions compared to controls discs. Our preliminary results showed that coblation and
molecular resonance at low or moderate power are not dangerous for intervertebral disc structure and nearby
tissue. Effects in intervertebral discs were obtained only with high power energy in coblation procedure. Further
in vivo studies are needed to confirm our results.
30
TRANSGLUTAMINASES EXPRESSION IN MICE TENDONS AND HUMANS SUPRASPINATUS
TENDON RUPTURES
Francesco Oliva, Monica Celi, Giovanni Taurisano, Villella Domenico, Umberto Tarantino
Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Viale Oxford 81, 00133,
Rome, Italy.
Aims: The diversity of tendon injuries spans from acute traumatic tendon rupture to chronic overuse injuries such
as tendinopathy and calcific tendinosis. Treatment mainly is based on triggering the natural healing process, but
the outcome of healing often is unsatisfactory. Transglutaminase (TGs) enzymes and proteins crosslinking have
for long time been implicated in the formation of hard tissue development, matrix maturation and mineralization.
Among the TGs family members, TG2 and factor XIII are the more studied in the contest of connective tissue
formation and stabilisation. We investigate the TGs expression pattern of Achilles tendons of TG2 knock-out and
wild type mice and both in normal and injured shoulder’s suprapinatus tendon biopsies.
Methods: Tendon samples were harvested from 5 individuals (2 men, 3 women; age, 60 +/- 1 year) who had
sustained a rotator cuff tear and underwent miniopen surgery repair of the lesion, and from 5 individuals who died
of cardiovascular events (mean age, 65 +/- 1 year). We analyze the consequences of TG2 deficiency, generated by
a gene-targeting approach, harvesting normal Achilles tendon of mice at 8 weeks of age TG2 knock-out and wild
type (five animals for each group).
Results: Histology revealed no gross anatomy differences between TG2 knock-out and wild type Achilles
tendons. RT-PCR experiments perform on wild type or TG2 knock-out mice reveal that TG1 and TG3 are
expressed, at transcriptional level, in WT and TG2 knock-out tendon biopsies. TG5 transcript is not detectedAfter
that the study has been performed also on human surgical specimens of torn supraspinatus tendon from patients
with rotator cuff tears. All five patients with a torn supraspinatus tendon showed a lost parallel arrangement of the
fibers, the nuclei became progressively rounded, an increased cellularity and vascular bundles were noted. The
collagen stainability was decreased. Control tendons show the typical normal histology with fibers arranged close
and parallel to each other with slight waviness, vascular bundles running parallel alongside of the collagen fibers,
tenocyte nuclei were flattened and spindle-shaped, sometimes arranged in rows. Factor XIII, TG1 and TG2,
unlike TG3 and TG5 are expressed in control group. Injured supraspinatus tendons shows a reduction of TG2
expression in all specimens analyzed.
Conclusions: The histologic appearance of supraspinatus injured tendons was of poor healing response with
absence of acute inflammation. The reduction of TG2 expression in all injured supraspinatus tendons suggest that
this ubiquitous transglutaminase could be important in maintaining tendon structural integrity thanks to its
mechanical or cross-linking function. We advocate more studies on this topic never before elucidated to add new
knowlegement on the obscure relationship between the ECM and healing tendons processes.
Key words: tendon rupture, transglutaminases, tendonitis
31
A DERMAL SUBSTITUTE ENVELOPED ON AN ARTERIOVENOUS LOOP AS A NEW CHAMBER
FOR TISSUE ENGINEERING: A PROMISING TOOL FOR NEOANGIOGENESIS, NEW TISSUE
FORMATION, GLIAL INGROWTH AND NEUROVASCULAR CROSS TALK
Colonna M.R.1, Delia G.1, Risitano G.1, Amadeo G.1, Strano A.1, Giacca M.2, Geuna S.3, Cavallari V.4, Stagno
d’Alcontres F.1
1 Cattedra di Chirurgia Plastica (Dir Prof F. Stagno d’Alcontres) Università degli studi di Messina
2 ICGEB (UN, Trieste)
3 Dip Scienze Cliniche e Morfologiche, Università degli studi di Torino
4 Dip Patologia Umana, Università degli studi di Messina
A commercially available dermal substitute consisting of bovine collagen and GAGs has been proven to be an
important tool for neoangiogenesis and new tissue ingrowth from an arteovenous loop in the rat groin. New
models for tissue engineering, using AV- VEGF 156 transfected muscle and femoral nerve distal stump, are
presented as promising techniques for achieving an increasing of neangiogenesis and glial ingrowth, both for
neurovascular cross-talk. A clinical confirmation of these data has been obtained in a case of lipomatous
macrodystrophy of the hand, where after removal of the neurofibroma the ulnar neurovascular pedicle was
covered by the same dermal susbstitute.
32
X CONGRESSO NAZIONALE IORS ~ 1a SESSIONE: LE INFEZIONI DELL’OSSO
REPARATIVE OSTEOGENESIS IN INFECTED FRACTURES
Francesco Greco
Department of Orthopaedics, Polytechnic University of Marche, Ancona - Italy
The aim of the present study was to analyze the bone healing process in the course of osteomyelitis, to point out
the differences from normal bone healing and to highlight the pathogenic mechanisms by which this process can
be altered.
An original and well characterized rat model of chronic staphylococcal osteomyelitis, developed by us, was used.
A tibial diaphyseal fracture was performed in 40 animals with chronic osteomyelitis (Group A), and in 20
unaffected animals, which were used as controls (Group B).
Each fracture was treated by intramedullary nailing, and the animals were housed for 3, 7, 14, 21, 30 and 60 days.
After sacrifice, each tibia underwent macroscopic, X-ray, histological, histomorphometrical and microbiological
analysis. As regards the bacterial count, each left tibia was crushed and powdered under sterile conditions, and the
number of bacterial colonies developed in Petri dishes was assessed.
In group B the pathological aspects of both chronic osteomyelitis and the inflammatory phase of bone callus
formation were observed during the early stage of fracture healing. Moreover, the organization of callus
haematoma was delayed and the cortical wall appeared osteoporotic.
Bone marrow was the site of extensive inflammation, the cortical wall was interrupted by numerous subperiosteal
and subendosteal abscesses and infected fragments of necrotic bone surrounded by fibrous tissue were observed.
The shell surrounding the sequestered bone was composed of an inner zone abounding in granulocytes and
macrophages, a middle zone with lympho-monocytes and an outer zone of reactive fibrous tissue. The fragments
of infected necrotic bone were of irregular shape, they were covered by purulent debris and actively resorbed
around the peripheral edges.
During the second and the third week, the callus haematoma was replaced by the fibrous and the fibrouscartilaginous callus. The healing process was slower and more disorderly as compared with the control group, and
both the periosteal and the endosteal reactions extensively involved a wider region, even far from the fracture site.
Actively proliferating osteoblasts covered the periosteal envelope, but the newly formed osteoid tissue was mixed
with abscesses, infected connective tissue and sequestra. The contemporary presence of histological aspects due to
both the healing process and the osteomyelitis were clearly shown. The fracture ends and the free bony fragments
were actively resorbed by numerous, multinucleated, giant cells. Osteoclasts surrounded not only the old, necrotic
and infected bone, but also around the not mineralized osteoid tissue. Osteoid trabeculae, which appeared to be
covered by the chronic inflammation tissue, characteristically showed the osteoblastic layer on one side and
numerous osteoclasts on the other.
After 1 month, newly formed bone and cartilage were observed within the fracture gap in the control group. It was
possible to identify the outer callus of periosteal origin, the inner callus of both endosteal and medullar origin, and
the middle callus of mixed origin. A marked delay of the healing process was seen in the group B specimens. The
amount of newly formed mature bone was poor, while woven bone, osteoid and fibrous tissue were widely
observed. Chronic inflammation, abscesses and sequestra inhibited reparative osteogenesis and it was difficult to
identify the inner, the outer and the middle callus. In particular, a remarkable osteoclastic activity was observed.
The osteoclasts resorbed the newly formed and even not mineralized trabeculae.
After 2 months, the healing process achieved union in all the control fractures, while 5 non-unions and 1 delayed
union were observed in group B. The fracture gap was filled by fibrous connective tissue in those zones which
were rich in vessels and cartilage in less vascularized zones. Osteoporosis of the cortical wall, isles of sclerotic
bone, abscesses and sequestrae were observed. The periosteal reaction was strong also far from the fracture site in
order to restore the mechanical strength of the diaphyseal structure.
Analysis of the results showed that osteomyelitis can inhibit fracture healing if an effective treatment is lacking. It
is known that reparative osteogenesis in infected bone depends on numerous biological and mechanical factors,
which are strongly related. As far as biological factors are concerned, our results clearly showed some changes in
the osteogenic process which can be schematically divided into 6 stages. Infection changes each one of these
stages. In particular, during the induction and the inflammation stages, cell types appeared to be much more
heterogeneous because of the recruitment and the activation of granulocytes, lympho-monocytes, macrophages
and giant cells. We can speculate that this cellular pleomorphism depends on the local presence of growth factors
and cytokines produced by the chronic inflammation.
The morpho-structural disorder, which hindered and slacked reparative osteogenesis, characterised both the
fibrous-cartilaginous and the bony callus stages. The most significant data which it is possible to highlight during
these stages is the high number of osteoclastic cells per unit surface and the increase in the resorption indexes,
above all towards the woven bone. Thus we think it is possible to highlight a close relationship between the
33
presence of chronic infection and the increase in osteoclastic activity as a pathogenic mechanism of delayed
fracture healing and non union. It is widely known that IL-1 and 6, which are cytokines of leukocyte origin, can
induce circulating monocytes to differentiate into osteoclasts, and can enhance their proliferation and activation.
The increase in the activity of IL-1 and 6 at the infected fracture site is able both to induce osteoclast recruitment
and to inhibit osteoblastic cells. The result is a vicious circle which negatively interferes with reparative
osteogenesis during both the recruitment and the osteoinduction phases. This, together with vascular injury and
the persistence of infection, could inhibit fracture union.
As regards mechanical factors, despite the stability of the synthesis, we think it is advisable to stress the fact that
the mechanical behaviour of the fracture is influenced by the presence of osteomyelitis, because the biological
changes weaken the mechanical properties of the material.
Nevertheless, the slow development of the osteomyelitic process allows bone to react. Mechanical adaptation is
achieved by the adjustment of the moment of inertia of the diaphyseal bone. This parameter is fitted by both
enlarging the total section area by periosteal apposition and widening the medullary section area by endosteal
resorption. These geometrical modifications can explain the different periosteal reaction which is stronger and
much more disorderly in the infected than in the control group.
In conclusion, our results clearly showed that infection can remarkably change fracture healing. Besides the type
of traumatic injury and the mechanical stability of the fracture, osteomyelitis may start the metabolic and
structural damage which interferes with the bone callus formation all along from the earliest stage.
34
THE MEDICAL THERAPY OF BONE AND JOINT INFECTIONS IN HOSPITALIZED PATIENTS:
THE ROLE OF INFECTIOUS DISEASE PHYSICIAN
Giuseppe Sturniolo (Messina)
With the exception of traumatic events, in all probability infections represent some of the most momentous
aspects in osteoarticular diseases. They may result from the extension of a previous or concomitant disease in
either contiguous or remote other districts, but frequently they are the consequence of deep wound or medical
practices.
Since cultures carried out on a wide range of specimen do not provide reliable results, unless they are performed
on bioptic samples, very frequently it is necessary to resort to empirical therapy, and therefore the choice of
antimicrobial agents often is especially difficult: a great deal of variable must be held in consideration, such as the
estimation of the possible aetiology by multiresistant microorganisms, the contemporary existence of other
prominent diseases (e.g. HIV, diabetes, immunosuppression, etc,) that require particular therapeutic strategies, the
ethical obligation of avoiding the selection of resistant strain, or the respect of pharmacoeconomic principles.
35
NEW FRONTIERS IN SPINE INFECTIONS
Nicola Specchia
Department of Orthopaedics, University of Ancona
Vertebral osteomyelitis and discitis account for about 2% to 4% of all bone infections. These bacterial infections
often jeopardize both the integrity of the spinal column and its neural contents. It is a consumptive process that
may be life threatening. In its early stages, vertebral osteomyelitis usually responds favorably to antibiotic
therapy. However, in cases of sepsis, delayed treatment, progression despite sufficient antibiotic therapy,
neurologic impairment, instability, significant deformity, or epidural abscess, surgical therapy has to be
considered.
Two general surgical principles in the treatment of osteomyelitis are: radical debridement of the infected area and
restoration of stability. In our opinion, these principles should be applied to spinal infections as well. Radical
debridement at the spine comprises resection of the entire infected or necrotic disc and bony tissue. Paravertebral
abscesses should be excised or drained. The spinal canal must be cleared of any pus and infectious debris.
The extent of debridement should not be limited by considerations concerning restabilization of the spinal
column. Regardless of the size of defect created by the debridement, a safe and reliable restoration of anterior
column stability is necessary.
Bridging of the surgical defect with autologous bone graft has its limitations in cases of extensive bone loss and
may be complicated by donor site morbidity. Titanium mesh cages have proven their effectiveness in the
reconstruction of spinal column stability in trauma and tumor surgery. However, there is significant controversy
regarding the use of metal implants in active infection.
The ideal implant to regain vertical resilience of the anterior column is the titanium mesh cage. This cage can be
adapted to every required size of defect. A titanium mesh cage in combination with rigid posterior
instrumentation is a biomechanically sound construct that meets the requirements of load sharing and tensionband principles.
36
INFECTION IN MASSIVE BONE ALLOGRAFT IN ORTHOPAEDIC ONCOLOGY
Capanna R, Campanacci DA, Beltrami G, Scoccianti G., Cuomo P.
Orthopaedic Oncology Department, Careggi Hospital, Florence
The principal use of frozen massive cadaveric allografts has been in the treatment of bone tumors. Allografts are
not without complications, and some investigators have indicated that success of the procedure is only 65-75% by
any standard system of analysis and that failures may be associated with local recurrence, joint incongruity,
allograft fracture, nonunions of the host-donor junction sites, and infection. Of the five problems cited, the most
injurious to patients are local recurrences, which in many cases may lead to amputation or death. Of the
remaining four problems, infection results in the worst outcome and often requires multiple procedures including
debridement, removal of the graft, insertion of a metallic device, or in some cases, amputation. Simultaneous with
the development of allograft technology, the rules regarding bone banking were established in numerous centers
and have become essential to allograft use. Donors are chosen in a similar manner as those who provide living
organs, and most of the time the bone resections occur after removal of the lungs, heart, kidneys, and liver for
transplant.
In the largest series on the literature from Harvard Medical Center (Mankin, Clin Orthop 2005) on 945 patients
who received allografts after resection of tumors and who were followed up for as many as 28 years primary
infections (not related to reoperations for nonunions or fractures of the graft) occurred in 75 patients (7.9%).
Other series from other centres (Capanna et al ISOLS 1991) reported a similar incidence (7%). The highest
frequency of infection occurred in patients with soft tissue tumors, radiated sites, blood transfusions, duration of
surgery, Musculoskeletal Tumor Society Stage IIB tumors, or surgeries consisting of an allograft arthrodesis.
Most of the infected grafts failed; however, none of the patients died. One patient had hepatitis C develop. A
comparison with other series of surgically treated patients, including those receiving metallic devices, suggests
that the infection rate may be related to the surgery or the graft’s immunologic resistance, rather than the graft.
The problem of infection is a major issue for tumor surgeons. With the advent of modern modular prostheses,
orthopaedic oncologists now are using fewer allografts.
37
INFECTION OF MEGAPROSTHETIC RECONSTRUCTIONS AFTER BONE TUMOR RESECTIONS
OF THE PELVIS AND THE EXTREMITIES
Mario Mercuri
V° Divisione, Istituto Ortopedico Rizzoli, Bologna
With the advent of effective adjuvant chemotherapy, superior imaging, improved surgical technique and advanced
biomaterials and mechanics, limb-salvage surgery has become the standard for local control of aggressive bone
and soft tissue tumors. Options for reconstruction after oncological resection of pelvic and extremity tumors
include biological (allograft) and megaprosthetic reconstruction. In the extremities, modular megaprosthetic
reconstructions have been regularly used after tumor resections since the early 1980s, and provide a consistently
predictable outcome compared with allograft reconstruction. They have the advantages of early mobilisation,
stability and weight-bearing. Despite the benefits of metallic megaprosthesis, there is a noteworthy risk of
morbidity arising from complications. Infection is an important complication that requires intensive management,
possibly involving multiple invasive procedures and long-term antibiotics, and has the potential to lead to
prosthetic failure and amputation.
The infection rate after limb-salvage reconstructions of the extremities has been reported between 8 and 15%,
with the highest infection rates in the distal segments (proximal tibia vs. distal femur vs. proximal femur). In the
pelvis the infection rate is significantly higher (25-60%) than in extremity reconstructions. Long-operative time,
poor soft tissue conditions and adjuvant chemo- and radiotherapy are important factors that increase the infection
risk.
For superficial wound infections, accurate wound care and surgical debridement and/or wound revision can be
sufficient. A deep infection requires an implant revision. If an infection occurs in the immediate postoperative
period, usually a one-stage revision is performed, which includes: extensive debridement, extensive pulse-lavage,
re-sterilization of the metal prosthetic body in the auto-clave, and substitution of the polyethylene components.
The surgical treatment is associated with long-term antibiotics. During surgical revision a broad spectrum i.v.
antibiotic treatment is started immediately after microbiological swaps and tissue samples are taken. The
antibiotic regimen is eventually adjusted if microbiology cultures are positive and antibiotic resistance has been
established. If infection persists after a one-stage revision or a late infection occurs, a two-stage revision is usually
required. This includes, besides debridement and extensive pulse-lavage, the removal of the prosthesis and
implantation of an antibiotic containing cement spacer, associated with a long-term antibiotic therapy. The
cement spacer is periodically substituted (every three months) until the clinical and laboratory parameters of
infection are normalized. At this stage a reimplantation is performed, which, if required, can be associated with a
muscle flap to improve the soft tissue coverage. In some cases, limb-salvage can be achieved performing an
arthrodesis, during which adequate soft tissue coverage is usually easier to achieve. The amputation rate due to
infection is reported between 19 and 46%.
The treatment of infection associated with tumor prostheses is often challenging and time-consuming, with a high
number of reoperations required. This long-standing treatment should be only performed if there is a good chance
for limb-salvage. Unfortunately, secondary amputation is still frequently required.
38
INFECTION AFTER TOTAL HIP ARTHROPLASTY
F. Randelli, P. Randelli, O. Visentin, L. Banci, M. Monteleone, G. Randelli
Centro di Chirurgia dell’Anca, Policlinico San Donato, San Donato Milanese (Milano)
Authors reviewed literature and state of the art about total hip replacement infection diagnosis and treatment.
Infection after total hip arthroplasty is an orthopedic surgeon major concern. Prevention is a key issue often
underestimated. Its incidence has not been reduced in last few decades. Diagnosis and treatment are often long
and difficult and final results unpredictable.
Laminar Airflow Systems popularized by Jhon Charnley and the new ultraviolet light in the operating theatre
seem to better reduced contamination even if not accepted by all.
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Methicillin-Resistant Staphylococcus Epidermidis
(MRSE) are growing everywhere, Vancomycin-Resistant Staphylococcus Aureus (VRSA) and VancomycinResistant Enterococci (VRE) have done their first appearance.
The Biofilm Theory described by Cristina and Costerton in 1985 discovered the pathogenetic basis of prosthetic
implant infection in human body. Different types of bacteria grow over implant surfaces in a shield matrix, the
biofilm, that protect them from immunological response and antibiotic effects. Only bacteria in the planktonic
phase (out of the biofilm shield) can be easily reached and killed. Furthermore biofilm bacteria are difficult to
grow in normal coltures.
Thus joint aspiration can be negative in biofilm joint infection. Because of this lack of sensitivity of
established microbiologic methods, molecular methods [eg, polymerase chain reaction (PCR) and fluorescence in
situ hybridization (FISH)] are more suitable for the detection of biofilm infections. The humoral and cellular
immune systems are also being used to detect the presence of developing biofilms in patients who have received
various kinds of prostheses.
Usually to isolate a bacteria in a implant surface biofilm at least a brief ultrasonication is needed.
Furthermore the evidence of biofilm infection let better understand the better clinical results of radical
debridement and the two stage procedure who has become the golden standard in periprosthetic infection
treatment. New vancomycin spacer out of the shelf or “homemade” have been used beside normal antibiotic
loaded cement available on the market.
Histological analysis for predicting the presence of microorganisms at the time of reimplantation after hip
resection arthroplasty for the treatment of infection has been described as usefulness. In fact the probability of
infection is high when at least five neutrophils per high-power field are found in the periprosthetic tissue, but it is
not possible to rule out infection when the number of neutrophils is less than five.
Interleukine-6 (IL-6) elevation seem to be strictly correlated with total hip infection. The combination of Creactive protein and interleukin-6 measurement provide excellent screening tests for infection of a deep implant.
Joint aspiration with prolonged time of colture is another method to detect slow and low grade infections.
Positron-Emission Tomography (PET) with 18F-fluorodeoxyglucose, and much less, Triple-Phase Bone Scanning
has been used positively in detecting even low grade infection.
39
STANDARD AND CUSTOM-AUGMENTED ANTIBIOTIC-LOADED SPACERS IN SEPTIC KNEE
ARTHROPLASTY REVISION
G. Gasparini, M. Giacobbe, C. Fabbriciani
Catholic University, Rome - Italy
Aims: Two-stage reimplantation is considered state-of-the-art in treatment of chronic knee arthroplasty infections
achieving the best results for eradication of infection (88-96%) and maintenance of function. Antibiotic-loaded
preformed cement spacers are widely used in this procedure. They preserve bone stock, keep collateral ligaments
from becoming contracted, avoid quadriceps fibrosis and reduce formation of scar tissue that obliterates the joint
space. These spacers allow both weight-bearing and motion during the period of antibiotic therapy (avoiding
stiffness and osteopenia and favouring exposure and soft tissue balance at reimplantation) and improve patient
satisfaction. Moreover, they deliver high-dose local antibiotics in concentrations greater than those achieved with
intravenous administration. Nevertheless, in some instances (i.e. infection following implantation of hinged or
augmented/stemmed prostheses) at time of first procedure bone loss, according AORI classification (Engh, 1997),
can be very wide as well as instability; moreover tibial and femoral canal are violated and infection spreads
deeply. In those cases preformed commercially available spacers are unable to fill the loss (T2 and F2 type), to
achieve enough stability (T3 and F3 type) and to deliver antibiotics deeply into the dyaphiseal canals.
Methods: We present a self-made antibiotic-impregnated cement modular stem, intended to be cemented both to
femoral and tibial preformed commercially available spacers. With this device we can intraoperatively obtain a
custom-augmented completely antibiotic-loaded articulating spacer that allows to manage wide bone loss (till to
T3 and F3 type) and to deliver antibiotic into the dyaphiseal canals as deep as needed. In the period 1996-2007 we
treated 39 knee arthroplasties infections using 11 fixed, 21 standard articulating and 9 augmented articulating
spacers. At reimplantation a CCK or a RHK modular prosthesis was used.
Results: A failure was observed in 9 patients (23%) at 1-11 years follow-up due to a late deep infection. Mean
HSS score improved from 31 preoperatively to 53 at time of second procedure (all patients) and to 81 at 1 year
follow-up (except of failed cases). Mean flexion improved from 60° to 77° at time of second procedure and to 98°
at 1 year follow-up, flexion contracture decreased from 8° to 1° at time of second procedure and to 2° at 1 year
follow-up, except for a patient that underwent extensor mechanism transplantation (active ROM: 60°-90° at 1
year follow-up).
Conclusions: The use of antibiotic-impregnated cement spacers and intravenous antibiotics with delayed
exchange arthroplasty demonstrates its reliability in treating infection and in recovering function. In the latter
field the custom-augmented spacer allows to satisfactory manage even cases that show the wider bone loss.
40
SURGICAL MANAGEMENT OF DIABETIC FOOT INFECTIONS AND AMPUTATIONS
Galli Marco (Roma)
The incidence of diabetes with severe foot infections (eg, necrotizing fasciitis, gas gangrene, ascending cellulitis,
infection with systemic toxicity or metabolic instability) has risen significantly during the past decade. Foot
infections are a major cause of hospitalization and subsequent lower extremity amputation among patients with
diabetes mellitus who have a history of a preexisting ulceration. Polymicrobial infection are frequently observed
in these patients. Pseudomonas aeruginosa among the gram-negative and Staphylococcus aureus among the grampositive are the predominantly isolated organisms, while Candida is the most frequently isolated fungus. Critical
limb ischemia, neuropathy, and an immunocompromised host, which often are associated with diabetic foot
infections, complicate treatment. Surgical management is often required. Surgical removal of all necrotic and
infected tissue and drainage of pus should be performed immediately without waiting for revascularization.
Adjunctive surgery will follow revascularization which is needed to save the limb. In the absence of significant
ischemia or after an effective revascularization, management of osteomyelitis traditionally involves surgical
removal of infected bone, combined with antibiotic therapy. Foot deformities resulting from surgery may cause
reulceration and a high morbidity that may eventually fail to save the leg. Thus, the aim of surgery should be to
control the infection, but also, to preserve a functional limb. Several demolitive interventions with limited loss of
bone segments of the forefoot or hindfoot have demonstrated to be well tolerated. 63 patients were operated on
and followed for at least one year after surgery. 33 single ray amputation, 21 metatarsal resections and 9 partial
calcanectomy gave an high rate of favourable results. Results are better if the patients are inserted in a postoperative protocol of surveillance with appropriate prescription of orthosis.
41
INFECTION IN HAND SURGERY
Letterio D’Andrea – Nunzio Catena *
Traumatology Unit -University of Messina
* Orthopaedic and Traumatology Unit, Scientific Institute “G. Gaslini”, Genoa - Italy
Aims: Infections of the hand are still a very common problems; until the advent of antibiotic therapy these often
resulted in severe disabilities as stiffness, contracture and amputation but also the improper treatment can results
in a disastrous outcome.
Methods: The authors consider the principal types of hand infections analyzing the characteristics of clinical
presentation, pathogens, diagnostic algorithm and treatment.
Results: The most common hand infections are paronychia, felon, web space abscess, palmar space infections
(midpalmar, thenar and hypothenar space) and infections secondary to humans or animal bites. Frequently the
flexor tendons are interesting by pyogenic tenosynovitis secondary to penetrating injury or after haematogenous
diffusion of pathogens. The most common infecting organism is Stafilococcus Aureus also if are possible
infections supported by Mycobacterium Tubercolosis or Atypical Mycobacteria or fungal infections.
Conclusions: A precocious diagnosis (within 24-48 hours of onset) is important because it permits to use high
doses of systemic antibiotic that can arrest the condition. After this time, the only antibiotics are not useful
because a thrombosis of local vessels and the peculiarity anatomy of the hand (many closed spaces and
compartments) permit early and rapid diffusion of infection and limit the circulation of antibiotics. Infections
begin as a cellulitis following by the formation of an abscess with possible extension to bone or joint. Surgical
drainage must be undertaken when the diagnosis is late or when the only antibiotics therapy does non produced
resolution; during surgical procedure is important the total excision of all necrotic tissue with particular attention
to avoid injury of vessels, nerves or tendons. Systemic antibiotics and splinting are integral parts of postoperative
regimen in all surgically treated infection.
Key words: infection, hand surgery
42
IMAGING UP-TO-DATE IN OSTEOARTICULAR INFECTIONS
F. Fiumara, B. Valenti
Centro di Diagnostica per Immagini, S. Teresa di Riva (ME) - Italy
Clinical signs and symptoms caused by osteoarticular infections often are subtle and insidious; therefore, clinical
suspicion in patients with non mechanical pain is important in making the correct diagnosis in the early stage of
disease. Serologic tests such as erythrocyte sedimentation rate and C-reactive protein are quite sensitive, but
specificity is relatively low. The main roads to infections imaging include plain radiographs, ultrasound
radionuclide studies, computed tomography scan, and magnetic resonance imaging. Changes on plain radiographs
appear at least 3 to 4 weeks after the onset of disease. Bone scan is a sensitive but not a specific test. Computed
tomography provides structural details in the bone but magnetic resonance imaging is a superior imaging test for
diagnosing infections earlier and more accurately. In many patients, percutaneous or open biopsy is required to
make the definitive diagnosis and the organism responsible for the infection.
We review the multi modality approach in primitive or secondary, post chirurgical, infection with emphasis on
strategies to load less invasive treatment for the patients.
43
ABOUT STAPHILOCCOCAL IMMUNOTHERAPY OF CHRONIC OSTEOMYELITIS
Giovanni Gualdrini*, Carmen Falcone°, Matteo Fosco*, Armando Giunti*
*VII Divisione di Ortopedia e Traumatologia, Direttore Prof. Armando Giunti, Istituto Rizzoli, Bologna.
°Clinica Ortopedica, Università degli Studi di Messina, Direttore Prof. Michele Attilio Rosa.
Treatment of chronic osteomyelitis (COM) in the last decades have been reached an important measures that is
changing its therapeutic protocol. Of course, the corner stone of its treatment is still the surgical part but good
preparation of the patient has purchase a role always more considerable. During the beginning of 60’s, it was
began to use the active immunotherapy with antigens of Staphylococcus for the treatment of the bony infections
resistant to antibiotics.
The immunotherapy stimulated by active bacterial vaccine (ITSB) is aqueous suspension of capsular factors of
Staphylococcus Aurous pools particularly of type V&VIII capsular fragments which acts by an active
immunization mechanism, the choice of the species V and VIII is due to the fact that during the infections from
Staphylococcus Aurous they are present in the 98% of the cases. The administration of this vaccine must follow a
specific schedule in order to avoid that too closer doses could exhaust the reactivity of the immunity system. The
administration is done with increasing doses through subcutaneous injection of this serous solution. The treatment
is performed without necessity of hospitalization during three months and a half.
In the VII division of the Orthopedic institute Rizzoli it has reached to a method of preparation of the patient with
COM to the surgical act that, from different years, we adopt to the VII Orthopedic Division of the Rizzoli
Institute. To the anamnesis they are identified situations that compromise the clinical status of the patient. The
smoking is always fought, clearly explaining what its effects are and how they happen. Concomitant pathologies
must be considered as complications. The patients that reach our observation have generally been performing
ABT for months without effect. It’s important to suspend the ABT and to verify if the COM has exhausted its
septic aggressive phase. The ITSB always starts before every surgical treatment, together with a cycle of OT,
generally during 4 weeks. At the end of the ITSB with OT, a control radiographs and computerized tomography
scan (CTS) should confirm or not the surgical indication.
In base to this therapeutic algorithm in the VII division of the Rizzoli Institutes of Bologna from 2000 to 2005, we
have been select randomly 128 patient from 245 patient admitted for COM. in those ITSB has been used, all the
patients have been examined before and after treatment with ITSB; the mean age of the patients was of 40,6 years
(range 16-80y); 40 patients were females, 88 males. Among these, 12 were boys in a preadolescent age (age <
15y). The cause of infection was in 54 by a fracture provoked by road accident (26 of which were open type); in
55 patients due to other causes (hematogenous infections, ulcers, accidental traumas, peri-prosthetic infections);
in 19 patients it has not been possible to know about the cause of the OM. All the patients had a situation of
COM, previously treated with antibiotic therapy. After therapy with ITSB, 43 patient have been surgical
intervention; they have surgically been treated the cases that still presented active clinical signs of infection, as
discharging fistula, important deep inflammation, or who had an radiological evidence of bony sequestrum or
well defined osteolytic areas. The mean Follow-Up time has been of 63.9 months (range 56-78 months). At the
end of the period of study, up to the 93% of the examined patients it has been possible to do a clinical and
radiological evaluation that has underlined the followings results: in 77 patients (64,7%) is got to a complete
recovery, in 23 pt (19,32%) is got to an improvement, in 1 pt (0,86%) a stabilization of the clinical situation. In 12
cases (10,08%) the clinical situation has been unchanged and in 6 (5,04%) it’s had to proceed to an amputation of
the infected limb.
The results appear very promising also for the high percentage of complete recovery without the necessity of
surgical treatment.
Key words: chronic osteomyelitis, medical therapy, immunotherapy
44
COMPLICATIONS OF ILIZAROV TREATMENT IN TIBIAL INFECTED PSEUDOARTHROSIS:
OUR PERSONAL EXPERIENCE
C. Di Paola*, M. Ciotti°, G. Santisi*, R. Orani°
*Policlinico Universitario “G. Martino”, Dipartimento Specialità Chirurgiche – Scuola di Specializzazione in
Ortopedia e Traumatologia, Università degli studi di Messina
° Istituto Codivilla- Putti, Cortina d’Ampezzo ( Bl)
Infected pseudoarthrosis is the result of worst complications in surgical treatment of fractures: non-union and
infection.
Ilizarov method is a selected treatment of tibial infected pseudoarthrosis, especially in the case of serious bone
defects.
It’s not a very invasive treatment and consent to solve infection and pseudoarthrosis at the same time; besides
patients can walk directly.
Ilizarov fixator however is encumbering, sometimes intolerable and requires attention and laborious management.
From 2000 to 2004 at the Institute “Codivilla- Putti” in Cortina d’Ampezzo we considered, retrospectively,
results of the treatment with Ilizarov fixator in tibial infected pseudoathrosis, to value its validity.
We considered 49 patients with age from 18 to 78; 43 males and 5 females.
Aetiology included fractures by incidents of the road (41), by occasional falls (3), by labour accidents (5).
We saw all patients with “fistulas”.
In 24 patients we had infection by Staphilococcus aureus, in 5 by Staphilococcus epidermidis, in 2 by
Pseudomonas, in 1 by Serratia marcescens and in 15 patients we had a polymicrobic infection.
Patients spent with Ilizarov fixator 10,3 months on the average ( from 6 to 19 months).
16 patients have been submitted to immunoterapia before the surgical intervention.
In all cases the scheme of treatment relied on assemblage of the apparatus after bone resection and successive
transport.
We’ve got a complete recovery in 37 on 48 of the treated cases.
In 11 patients the pseudoartrosis persisted. Consequently they had been submitted to further surgical intervention.
However the recovery has been obtained with limitations in 12 patients: 3 have introduced cutaneous
invagination, 3 defective bone lengthening ( in average of 4 cms), 3 axial deviation, 2 equinus foot and 1 sclerosis
of the dissected bone.
Our experience therefore proved good results. Ilizarov method however remain, in selected cases, the only way
out.
It is fundamental in the Ilizarov methodology a careful and periodic control of the clinical conditions and of the
results during the maintenance of the apparatus.
At any rate the patient is involved in final result with its active participation.
45
RECONSTRUCTION VS AMPUTATION IN OSTEOMYELITIS: WHICH ONE TO CHOOSE ?
Guastafierro Pasquale, D’Amato Pasquale Antonio, Gambardella Antonio, Scotto di Luzio Antonio
P.O. Santa Maria delle Grazie Pozzuoli (NA) reparto di Ortotraumatologia
Aims: to implement a reasoned choice to provide better indication between reconstruction and amputation.
Methods: we present five cases, four of which are polytrauma complicated by acute osteomyelitis and one
presenting chronic osteomyelitis. In all the patients we decided to rebuild the anatomical site, the patients
undergoing also multiple skin-grafts and/or corpse bone transplants with the help of a plastic surgeon.
Results: two cases healed, while in other two cases we got to amputation; in the first one it was necessary because
there was a massive necrosis of the grafted skin flap, in the second one because there was a severe vascular
complication. The last case is still under treatment.
Conclusions: considering our experience, we ask to look for and make new indications contemplating a variety
of cases, clarifying in which case amputation is to be considered as a resolving treatment of polytrauma patients
46
HIGH-DOSE, THREE-TIMES WEEKLY TEICOPLANIN IN THE OUT-PATIENT TREATMENT OF
OSTEOMYELITIS
C. Negri1, F. Pea3, P. Menosso2, E. Zamparini1, P. Di Benedetto2, M. Furlanut3, A. Causero2, P. Viale1
1
Clinica di Malattie Infettive Università degli Studi di Udine
Clinica Ortopedica e Traumatologica Università degli Studi di Udine
3
Istituto di Farmacologia Università degli Studi di Udine
2
Objective: To verify the possibility of managing, in settings other than hospital admission, patients with
osteomyelitis and undergoing parenteral antibiotic treatment of maximal activity, with teicoplanin tiw instead of
the standard schedule (i.e. qd).
Background: For osteomyelitis, a complex chronic condition requiring parenteral antibiotic treatment, it appears
increasingly important the availability of managing treatment strategies different from hospital admission, namely
on an out-patient basis. Teicoplanin, owing to its particular pharmacokinetics characteristics and good tolerability,
appears the ideal drug for out-patient antibiotic regimens extremely simplified.
Study design: Prospective study on patients with bone and joint infections (including osteomyelitis, prosthetic
joint infections, spondylodiscitis, septic arthritis) referred to the Clinic of Infectious Diseases of the Azienda
Ospedaliero-Universitaria of Udine in the period March 2004 - December 2007 undergoing treatment with threetimes weekly high-dose teicoplanin (± rifampin or other antibiotics according to microbiological isolate). Primary
end point: assessment of efficacy, tolerability, feasibility and patient compliance.
Methods: Data assessed were demographic, epidemiologic and clinical variables of 38 patients treated with threetimes weekly high-dose teicoplanin, at dosages optimized on the basis of plasma drug concentrations (Therapeutic
Drug Monitoring – TDM); assessments were performed weekly throughout treatment and monthly up to 6 months
after the end of treatment.
Results: Clinical response and cure rates were 79% and 91% respectively. Incidence of adverse effect (namely
infusion reactions and clinically relevant serum creatinine increase) were not relevant. Overall, 90% of patients
declared to be fully satisfied and did not report relevant practical issues.
Conclusions: The proposed regimen appears to be highly effective and feasible in the context of a highly
proficient clinical setting.
47
THE USE OF ANTIBIOTIC-IMPREGNATED CEMENT IN INFECTED RECONSTRUCTIONS AFTER
RESECTION FOR BONE TUMORS
Costantino Errani, Davide Donati, Mario Mercuri
Istituto Ortopedico Rizzoli, via pupilli n1, Bologna, Italy
Aims: significant advances in chemotherapy, radiography, and surgical techniques over the past two decades have
made limb salvage surgery procedure of choice for most malignant tumours of the extremities. However,
complications are frequent, resulting in reoperation and, at times, even amputation. Infection is the major cause of
early failure and the most challenging for both surgeon and patient. The antibiotic therapy alone is not enough,
while the association with debridement may be sufficient in early or superficial infection. Aggressive surgery
with debridement and resection of the implant is most common therapy. Reimplantation of the prosthesis is the
best choice with better functional result respect with other technique as arthrodesis.
Methods: 35 patients divided into two groups. We used gentamicin-PMMA beads in 25 patients ( first group) and
antibiotic-impregnated cement spacer in the second group (10 patients).
Results: antibiotic-impregnated cement spacer have been shown to be more effective in the rate and time of
healing, frequency of repeated surgery and functional results, as comparated with PMMA beads.
Conclusions: infection is a serious complication after segmental resection for bone tumours. The treatment of
deep infection after limb salvage surgery remains controversial. In early infection several methods can achieve
success in 50% to 70% of the cases, while for the remainder or in late infection, the removal of the implant and a
high local concentration of antibiotic are needed. Revision with antibiotic-impregnated cement is the only reliable
method for limb salvage following deep infection. Prevention is the key to reducing the incidence of this serious
complication.
Key words: bone tumors, infection, antibiotic-impregnated cement
48
BONE AND JOINT INFECTION IN CHILDHOOD
Toniolo Renato Maria, Guzzanti Vincenzo*
Ospedale Pediatrico Bambino Gesù, * Università di Cassino
Aims: Osteomyelitis and septic arthritis are frequent and serious cause of morbility in paediatric age. Antibiotics
and surgical therapy have considerably modified the prognosis, but not enough the incidence of these diseases.
A.A. have valued the cases of osteomyelitis treated in the last ten years at the U.O. of Orthopaedics and
Traumatology of the Paediatric Hospital Bambino Gesù (Rome –Italy) with the purpose to get epidemiological
and bacteriological data as well as therapeutic addresses.
Methods: Clinical papers have been revised (clinical features, laboratory and radiographic results, etc.). The data
of 152 selected patients have been picked dividing them by type (acute, chronic, specific, etc.) and way of
infection (acute haematogenous, post-traumatic, post-operative, etc.). The obtained data have been therefore
analyzed and reported.
Results: 125 acute osteomyelitis and 27 chronic osteomyelitis have been observed. Five cases were postoperative
osteomyelitis (operations involving metal implants). The males represent 56%. In the 71% of the cases the germ
has been isolated. S. Aureus mostly represents the isolated germ in all rang of ages. We describe some particular
cases (for site of infection and/or evolution, etc.)
Conclusions: Infection of bone in paediatric age remains a dangerous disease and cause of possible invalidating
sequelae. Diagnostic suspect and the correct iter to reach the definitive diagnosis are preliminary to the timely
formulation of a fit therapy that must not be limited only to administration of antibiotics. The type and the timing
of surgical procedures are often essential to modify the prognosis.
Key words: Osteomyelitis, Joint infection, Child
49
DIFFERENTIAL DIAGNOSIS OF SPONTANEOUS SPONDYLODISCITIS. THE INFECTIVOLOGIST
ADVICE
Antonio Cascio, Roberto Gembillo, Lucia Pernice and Chiara Iaria
UOS Parassitologia, Scuola di Specializzazione in Ortopedia e Traumatologia, AILMI (Associazione Italiana
Lotta contro le Malattie Infettive)- Universita` di Messina
Aims: Spondylodiscitis is a rare infectious disease. However, the incidence of the disease has increased in the last
10-15 years, which may be associated with higher incidence of bacteremia and sepsis attacks due to common use
of invasive diagnostic and treatment methods. This study aimed to compare clinical, laboratory, and radiological
features of spontaneous spondylodiscitis secondary to tuberculosis and brucellosis, both of which are endemic in
Italy, and spondylodiscitis due to other bacterial causes (pyogenic spondylodiscitis).
Methods: Data for this review were identified by searches of Medline and PubMed using a combination of search
terms including “Spondylodiscitis”, “spondylitis”, “Brucellosis”and , “Tuberculosis” .
Results: Magnetic resonance imaging is the investigation method of choice for the diagnosis of spondylodiscitis,
because it presents some advantages including high sensitivity in early stages, better definition of the
paravertebral and epidural extension, and the possibility of distinguishing tubercular infections from those of
other origin in the late stages. In pyogenic infections in the acute stage, MRI shows low-signal intensity in T1weighted images and hyperintensity on T2-weighted images of the intervertebral disc and the adjacent vertebral
bodies. In tubercular spondylitis in the acute stage, the MRI signal intensity is rather similar to that observed in
other spinal infections, although the intervertebral disc is scarcely involved. In spondylodiscitis in the chronic
stage, however, the changes of the signal intensity seem to be related to the etiology of the infectious process. In
fact, tubercular spondylitis shows a slightly hyperintense signal on T1-weighted images, which may be
considered rather specific of this etiology. Tuberculous spondylitis is characterized by some peculiar findings,
including a lack of abnormal signal of the intervertebral disc space, the presence of a gross paraspinal soft tissue
mass, the involvement of posterior vertebral bodies and arches, and the involvement of many vertebral bodies.
Usually, the size of the paraspinal mass is larger tuberculosis than in the brucellar infection.
Key words: Spondylodiscitis, Brucellosis, tuberculosis
50
ON A CASE OF ATYPICAL SPONDILYTIS
Tullio Claudio Russo *, Giuliano Giuca **, Massimo Quartarone ***
*Manager Unit of Orthopedics and Traumatology Major Hospital of Modica and Scicli
**Orthopedic clinic, University Polyclinic Messina
***Unit of Orthopedics and Traumatology Major Hospital of Modica
Aims: A 60 years-old patient affected from ingravescent back pain and hyperthermia. Submitted to repeated
refuges and made diagnosis of septicemia of S. Aueurs with suspicious spondilytis D8-D9 was practised
antibiotic therapy without resolution of the back pain and neither of the feverish episodes.
Methods: During the hospitalization near our U.O.C. an multidisciplinar approach has been chosen with
involvement of the infectious diseases specialist and the microbiologist and after having excluded a spondilytis of
tubercular nature or brucella, the patient has been treated through antibiotic therapy to ample ghost and surgery of
stabilization D7-D10 with intraoperative biopsy with negative result.
Results: In the post-operating we have assisted to a clean improvement of the back pain. The ipertermia hasn't
reappeared anymore and to the control after one month the patient had taken back the normal walking.
Conclusions: From this case it is deduced as often the multidisciplinar approach to the patient, represents the
"Gold standard" especially in the treatment of the bony pathologies of infectious nature more if atypical.
Key words: spondilytis, multidisciplinar approach, dorsal stabilization
51
INHIBITION ZONE EVALUATION FOR MANUALLY-MIXED
AVAILABLE ANTIBIOTIC LOADED BONE CEMENTS
AND
COMMERCIALLY-
Marta Miola2, Alessandro Bistolfi1, Sara Ferraris2, Enrica Verné2, Michele Boffano1, Alessandro Massè1,
Maurizio Crova1.
1
Department of Traumatology, Orthopedics and Occupational Medicine, University of Turin
Materials Science and Chemical Engineering Department. Politecnico di Torino, Italy
2
Introduction: Infection around orthopaedic prosthetic implants is a serious problem, which is usually favoured by
the formation of a biofilm onto the material surface and which can cause implant failure. For prevention,
particularly in revision surgery, it has been suggested to introduce antibiotics directly into the PMMA
(polymethylmethacrylate) based cements used to fix prostheses to bone. The technique to introduce antibiotics
into cement (manual or industrial mixture) and the choice of the antibiotic (vancomicine and gentamicine) are still
open problems. This study evaluates the differences of the preparation of the mixture, of the cement density and
the efficacy of different antibiotics.
Materials: A medical grade PMMA bone cement (Palacos R® and Palacos LV®), has been manually enriched
with gentamicine sulphate and then compared with the industrially antibiotic-loaded version (Palacos R+G®) by
means of in vitro antibacterial test (inhibition zone evaluation). Cylinders of 4mm height and 10mm diameter
have been prepared and tested with a standardized procedure (NCCLS M2-A9: Performance Standards for
Antimicrobial Disk Susceptibility Tests, Approved Standard); after spreading of a standard bacterial suspension
(Staphylococcus aureus) and incubation the inhibition zones around cement samples have been evaluated and the
results compared.
Results: All tested samples (except control ones) produced halos higher than 3mm demonstrating Staphylococcus
aureus susceptibility to both gentamicine and vancomicine. The industrial formulation produced a bit larger and
regular inhibition zone than the manual one. Vancomicine halo was smaller but clearer than gentamicine one. The
addition of vancomicine to gentamicine-containing bone cements did not significantly increase the halo
dimensions. Cement viscosity did not influence halo dimensions both for gentamicine and vancomicine.
Conclusions: One of the problems related to the evaluation of the inhibition zone as antibacterial test method is
the low correspondence between in vitro and in vivo behaviour. However, the inhibition zone dimension is
proportional to drug diffusion rate into cement matrix and to antibacterial efficacy of the antibiotic. According to
the results, commercial antibiotic loaded bone cements could be more effective in bacterial inhibition; besides,
they are easier to use. Gentamicine is the antibiotic of choice, while vancomicine could be interesting as second
addictive antibiotic.
Keywords: PMMA cement, antibiotic, prosthetic infection
52
BONE AND JOINT INFECTION IN CHILDREN
Nunzio Catena – Filippo M. Sénès
Orthopaedics and Traumatology Unit - Scientific Institute G. Gaslini Genoa (Italy)
Aims: Muscolo-skeletal infection is a common evenience in orthopaedics and traumatology practice, affecting all
musculo-skeletal segments; during developmental age a physeal injury following infection can determine a
growth arrest with limb shortening or skeletal deviation.
Methods: The authors considered 34 cases of bone infections in children treated from 1994 to 2006; 26 cases had
lower limb involvement while 8 had upper arm compromising. Therapeutic approach was antibiotic therapy alone
in 17 cases while surgical dedridement in association to antibiotic treatment was the chose solution for the
remnant 17 patients.
Results: The infection healed in all patients in a period between 6 to 10 weeks; the average follow up was 4,6
years. Growth plate arrest was observed in 3 cases of septic arthritis of scapular humeral joint; these 3 patients
had bone humeral lengthening with axial external fixator. A septic arthritis of the knee was followed by joint
stiffness.
Conclusions: Osteomyelitis and septic arthritis in children show different clinical aspects. The most of acute
haematogenous infections appear during first infancy while bone infections secondary to acute or chronic form
are typical of teenage. The great part of infections are bacterical; Stafilococcus Aureus, Streptococcus Agalactie
and Enterical Gram negative. Bacterial are common of perinatal and neonatal infection, while Stafilococcus
Aureus is the principle pathogen of the other age; nosocomial or post surgical infection are often caused by
Stafilococcus epidermidis. Serology is characterized by an elevation of CRP, ESR and white blood cell count. At
the onset X Ray do not show any bone changes and only after 2 or 3 week signs of infection appear. Magnetic
resonance or radionuclide imaging are useful to have in advance some information and distinguish bone infection
to bone or soft tissue tumor. The antibiotical therapy is the hinge of treatment but often surgical dedridement is
mandatory to obtain healing.
Key words: septic arthritis, osteomyelitis children, pediatric bone infection.
53
THE TREATMENT OF POST-OPERATIVE INFECTIONS BY CONTINUOUS IRRIGATIONSUCTION DRAINAGE
M. Ostuni, A. Pasquino, A.Piazzolla, G. Ognissanti, G. De Giorgi
The continuous irrigation-suction drainage represents one of the treatments more used in the post-operative
infections in Orthopaedics both for easily used for low aggressive. Since June 2003 to June 2008 in the I
Orthopaedic Clinic of the University in Bari have treated by continuous irrigation-suction drainage for postoperative infection 6 patients ( 1 Male and 5 Females, middle age 63 aa, least 25 maximum 77). The patients had
been treated by total knee arthroplasty (1), by total hip arthroplasty (2), by fusion and spinal instrumentation (Pott
and Neurological Scoliosis) and by external-fixation for open bifocal fracture of the femur (1).
The continuous irrigation-suction drainage has been executed using an antibiotic solution chosen on the basis
microbiological exam and of ABG executed on secretion of cutaneous fistula.
Authors take back the results obtained by the executed study with the evidence that the treatment effectiveness is
conditioned by the following factors: execution time (< 60 days from the infection), nonloose of prosthetic
components, no osteitis, susceptibility of the antibiotic treatment, absence of concomitant pathologies
(Immunodeficiencies, Rheumatoid Arthritis, etc.).
54
X CONGRESSO NAZIONALE IORS ~ 2a SESSIONE: IL CONDROSARCOMA
IMMUNOISTOCHEMISTRY AND GENETICS IN BONE ONCOLOGY
Carlo Della Rocca
Dipartimento di Medicina Sperimentale, “Sapienza” Università di Roma, Polo Pontino – Sede di Latina
Diagnosis of bone tumours is historically mainly based on a multidisciplinary approach. Histopathologic
interpretation has to be always red in the clinical and radiologic contest. In particular, with the enormous
improvement of the radiology techniques, the imaging of the lesion represent a real gross pathology picture to
which the biopsy interpretation has to be correlated.
Over the last twenty years immunohistochemistry has been developed as a very useful tool in tumour diagnosis;
several markers have been tested also in bone neoplasms and sometime considered specific of peculiar lesion.
Unfortunately, today we know that the specificity of immunohistochemical markers simply does not exist and
the rare exceptions to this rule will be probably denied in the near future. In particular in bone oncology
immunohistochemistry has to be considered as an ancillary techniques for diagnostic purposes and its results have
to be interpreted on the morphologic and clinical grounds. More value are gaining the immunohistochemical
markers as prognostic and target therapy indicators. A review of such problems will be proposed on the basis of
practical examples.
Genetic studies of bone tumours are very difficult because of the peculiarity of the calcified material, but in the
last years molecular biology techniques have been developed for bone investigation. Also in this case specific
genetic abnormalities have been described over the time and then they have been found to be not specific; the
diagnostic value of such findings is not completely established at the moment, but they seem to be very
important for the understanding of the pathogenesis of the neoplastic transformation, mainly in the chondroid
lesions. The more recent data will be discussed.
55
MULTIPLE UNRESOLVED QUESTIONS IN HEREDITARY MULTIPLE OSTECHODROMAS.
FROM GENE TO FUNCTION, DIAGNOSIS AND DISEASE MECHANISM.
Vito Michele Fazio, Emanuela Signori, Emanuela Massi, Monica Poscente, Gianluca Falcone and Michele Attilio
Rosa.
Background: Hereditary multiple osteochondromas (MO) is characterised by development of cartilage capped
bony outgrowths (osteochondromas) of the long bones. The prevalence is estimated at 1:50,000 in Caucasians.
Osteochondromas develop and increase in size in the first decade of life, ending to grow when the growth plates
close at puberty. The severity disease and the number of osteochondromas may differ significantly within and
between families. The most important complication is malignant transformation of osteochondroma towards
secondary peripheral chondrosarcoma (0.5–3%). MO is an autosomal dominant disorder and it is genetically
heterogeneous. Two genes have thus far been identified as causing the disease, namely EXT1 and EXT2. A third
genetic locus has been proposed (EXT3). It has long been thought that osteochondromas are the result of skeletal
dysplasia. It is now generally agreed that osteochondromas are neoplastic lesions, since EXT-genes behave as
tumour suppressor genes and loss of the remaining EXT wildtype allele has been found in the cartilage cap of
osteochondromas from MO patients. The gene products, exostosin-1 (EXT1) and exostosin-2 (EXT2), are
endoplasmic reticulum localized type II transmembrane glycoproteins which form a Golgi-localised heterooligomeric complex that catalyzes heparan sulphate (HS) polymerization (heparan sulphate proteoglycansHSPG). EXT and HSPGs are required for high-affinity binding of fibroblast growth factor to its receptor and for
the diffusion of the morphogens: Hedgehog, TGF together with BMP and Wnt. These three pathways are
critical during development and stem cell control, and are specifically active in the growth plate during
endochondral bone formation.
Methods: To improve the identification rate of pathogenetic mutations in EXT1 and EXT2 and to address the
effective prevalence of EXT1-2 mutations in affected populations, we developed a combined technical approach
to identify both point mutations and mid-size rearrangements in a wide cohort of Italian MO families (100 MO
patients), respectively by SSCP and high-throughput DHPLC analysis and by new two-color multiple ligationdependent probe amplification (MLPA) analysis. Genotype-phenotype analysis was attempted.
Results and Conclusions: The increased sensitivity of mutation detection and the use of new techniques
screening for larger deletions, such as MLPA, have dramatically decreased the proportion of MO patients without
an EXT1 or EXT2 mutation to <15%. These data question the existence of an EXT3-gene at 19p. As in other
reports, no clear-cut evidences supporting genotype-phenotype correlations have been identified, including intraand inter- familial differences in disease severity based on the same EXT mutation. We confirmed the relevance
of loss-of-function mutations. On the basis of these results and the updated data from the literature, some opened
questions will be discussed:
• What is the role of EXT in normal cartilage growth and differentiation and in osteochondroma formation? Can
we speculate a local targeted inhibition of disregulated hedgehog signalling?
• How can the enormous difference in disease severity within and between families be explained? Are there
involved other genetic, epigenetic or environmental factors?
• What drives malignant transformation of osteochondroma and can this be prevented?
Int. J. Cancer (Pred. Oncol.) 95: 378–383 (2001)
Genes, Chromosomes & Cancer 46:470–477 (2007).
56
PROGNOSIS OF CHONDROSARCOMA ACCORDING TO TUMOR LOCATION, SURGICAL
MARGINS AND HISTOPATHOLOGICAL GRADING
Ernesto Ippolito, Pasquale Farsetti, Fernando De Maio, Matteo Benedetti Valentini
Dept. of Orthopaedic Surgery - University of Rome “Tor Vergata”
Aims: To asses the most significant prognostic factors of chondrosarcoma. Previous studies have pointed out that
histopathological grading, location as well as surgical margins are the most significant prognostic factors.
Methods: We examined the clinical records, the histopathological reports, and the surgical records of 27 cases of
chondrosarcomas treated during the last ten years. Twenty-one cases were skeletal chondrosarcomas, whereas six
cases were extra skeletal chondrosarcomas.
Results: At follow-up 18 cases were still alive whereas nine cases had died. Of the nine died patients , four had
extra skeletal chondrosarcomas whereas five had either pelvic or scapular highly malignant chondrosarcomas
with uncertain surgical margins.
Conclusions: According to our results, the most significant prognostic factors of chondrosarcoma are: a) tumor
location; b) surgical margins; c) histopathological grading. Soft tissues chondrosarcomas had the worst prognosis
of the whole series.
Key words: chondrosarcoma, surgical margins, histopathological grading
57
VEGF EXPRESSION IN CARTILAGINEOUS TUMOURS
G. Maccauro (Roma)
Catholic University, Institute of Orthopaedics, Roma, Italy
Aim: Angiogenic factors, as Vascular Endothelial Growth Factor (VEGF), have a negative influence on prognosis
of carcinomas, because of their involvement in the progression of metastasis. Few data about the potential role of
angiogenesis in non-vascular neoplasm, as cartilaginous ones, are reported in literature. The aim of our study was
to investigate the clinical significance of VEGF expression in cartilaginous tumours and its potential association
with grading.
Materials and Methods: We retrospectively analysed 21 chondroid tumours. Eight of these were benign tumours
and thirteen were malignant. Among the malignant, five tumours were low grade chondrosarcomas, five were
high grade and three were dedifferentiated chondrosarcomas. Tissue blocks from the resected tumours were
stained using immunohistochemical methods for VEGF expression.
Results and Discussion : Benign tumours did not express angiogenic factors except one case of periosteal
chondroma. Low grade chondrosarcomas were not stained by antibody to VEGF , however high grade
chondrosarcomas were strongly positive for VEGF expression. We assessed a statistically significant correlation
between VEGF expression and grading ( p=0,001 ).
These results suggested that antiangiogenic therapy, by inhibition of the action of VEGF, should be considered as
a new strategy for treatment of dedifferentiated chondrosarcomas.
58
CHONDROMAS OF THE HAND
F. Fanfani
Divisione di Ortopedia e Chirurgia della Mano. Complesso Integrato Columbus. Policlinico A. Gemelli.
Università Cattolica del Sacro Cuore. Roma.
Via Moscati, 31 – 00168 Roma
Aims: The curettage is universally performed in surgical treatment of chondromas, but in literature, there is not
agree about the accessory surgical treatment, expecially about filling or not the pathological cavity and about the
material to use. This study demonstrates that a very accurate curettage, without any accessory surgical procedure,
in every case, carries to a complete healing of the lesion without any functional limitation.
Methods: Between 1975 and 2007 we performed simple and very accurate curettage in 176 chondromas of the
hand.
Results: In our experience, we obtained a complete healing of the lesion and a complete restoration of the bone’s
trophism performing a very accurate simple curettage in a short period of time (2-4 months), without post
surgical rigidity and spontaneous fractures. Possible but infrequent is a relapsing lesion (2%).
Conclusions: Although the literature insists about the need to fill the pathological cavity by a bone graft or a
osteogenic material after curettage of a chondroma, in our experience these accessory procedures have proved
unnecessary given the rapid and costant restoration of the bone’s trophism. This assertion has proved its worth in
chondromas that are large with severe swelling of cortical, severe thinning of residual bone and pathological
fracture. Just to have found healing in these extreme cases there has not convinced of the legitimacy of accessory
surgical procedures.
Key words: Chondroma, Curettage.
59
L’USO DEGLI ADIUVANTI LOCALI NELLA CHIRURGIA ONCOLOGICA DELL’APPARATO
MUSCOLOSCHELETRICO.
A. Piccioli, G. Maccauro (Roma)
Nel trattamento chirurgico delle lesioni metastatiche dello scheletro riveste una grande importanza l’uso degli
adiuvanti locali, la cui scelta è in genere determinata dalla esperienza personale del chirurgo. L’uso di queste
sostanze serve ad estendere ulteriormente il margine ottenuto chirurgicamente con il curettage, eliminando le
cellule neoplastiche residue. Il loro utilizzo ha permesso di diminuire in maniera significativa la percentuale di
recidive locali.
I primi adiuvanti locali usati nella chirurgia ortopedica oncologica sono stati, all’inizio degli anni Settanta, la
crioterapia con azoto liquido, sviluppata da Marcove al Memorial Sloan-Kettering di New York e la
cementazione con PMMA descritta per la prima volta da Persson e Wouters.
A queste esperienze si sono aggiunti con il tempo altri adiuvanti locali, chimici come il fenolo, l’etanolo e H2O2, e
fisici come la termocoagulazione con elettrobisturi, soprattutto ad Argon e la crioterapia con Cryoprobes.
È importante sottolineare che qualsiasi agente fisico o chimico usato come adiuvante non può correggere o
risolvere un curettage mal eseguito. Esso infatti deve essere aggressivo, utilizzando frese motorizzate ed
eliminando accuratamente i residui della fresatura. Tutto ciò è cruciale per il successo oncologico della procedura
chirurgica.
Nel presente studio, gli Autori analizzano le attuali possibilità terapeutiche degli adiuvanti locali, descrivendone il
meccanismo di azione, le indicazioni terapeutiche ed il razionale del loro impiego
60
SURGICAL MANAGEMENT, MECHANICAL COMPLICATIONS AND OUTCOME OF PELVIC
CHONDROSARCOMA.
Mario Mercuri
V° Divisione, Istituto Ortopedico Rizzoli, Bologna
Chondrosarcoma is the second most common primary malignant tumor of bone after osteosarcoma, and often
occurs in the pelvis. These tumors can arise de novo or in a previously existing benign cartilage tumor, such as
osteochondroma or enchondroma. When chondrosarcomas arise in an osteochondroma, it is called peripheral,
when it arises inside the bone, it is called central. Histologically, conventional chondrosarcoma can be classified
in three grades. The incidence of grade 1 is 61%, grade 2 36%, and grade 3 3%. Other histologic variants are
dedifferentiated chondrosarcoma, mesenchymal chondrosarcoma, clear cell chondrosarcoma and myxoid
chondrosarcoma. Patients with a high-grade tumor are at increased risk for metastasis and have decreased overall
survival.
Because chemotherapy and radiotherapy are not effective against conventional chondrosarcoma, surgery is the
mainstay of treatment. Several studies have demonstrated a correlation between the margin of resection and the
prevalence of local recurrence. Therefore, the goal of surgery is to resect the entire lesion with wide surgical
margins. In the pelvis, this can be obtained by either a hindquarter amputation or an internal hemipelvectomy.
The often large tumor size and the proximity of important structures, such as bladder, rectum, and neurovascular
bundles, make these resections challenging. Local recurrence rate in pelvic chondrosarcoma resections varies
between 19 and 40%. In case of a local recurrence occurs, the risk of a second recurrence increases to 71%. The
risk of distant metastasis is strongly correlated with tumor grade, and in large series of pelvic chondrosarcoma has
been reported between 17% and 36%. The 10-year overall survival varies from 54% to 66%.
In case of limb-sparing resection, the type of reconstruction depends on several factors: size and extension of the
tumor, the anatomical site of the tumor, patient related factors, such as age, comorbidity, and activity level. In
recent years, many reconstruction methods have been developed, for example: ileofemoral arthrodesis, saddle
prosthesis, hemipelvic custom made prosthesis, allograft prosthetic composite reconstructrions. Functional
outcome varies widely and complication rates are generally high (between 40% and 60%). The most frequent
major complications are infection, mechanical failure (dislocation, loosening, implant breakage/fracture) and local
recurrence.
Treatment of pelvic chondrosarcoma is very challenging. In the absence of effective adjuvant therapies, wide
surgical resection is essential in the treatment of this tumor. Improved imaging studies and surgical techniques
have increased the rate of limb-salvage procedures. However, this difficult surgery is associated with variable
functional results and high complication rates.
61
ALLOGRAFT INTERCALARY RECONSTRUCTION AFTER ONCOLOGICAL RESECTIONS
Mapelli Sergio, Zorzi Roberto, Daolio Primo, Perrucchini Giuseppe, Bastoni Stefano.
Orthopaedic Oncology Unit – Gaetano Pini Orthopaedic Institute – Milano – Italy
Aims: the evaluation of positive course, problems, complications and final orthopaedics and functional results
in the use of intercalary allografts after oncological resections with attention to the bone behavior more than to
the oncological evolution.
Methods: the complete and continuous series of intercalary allografts employed from 1986 to 2007 in the
Surgical Oncology Unit of the G.Pini Orthopaedic Institute for the reconstruction of segmental bone defects
after oncological resections vas revalueted. The Authors examined particularly the diagnosis, the anatomical
sites, the length of the reconstructions, the devices of the internal fixation, the main complications (fractures,
infections, non-unions), and the functional results.
Results: the series includes 51 intercalary reconstructions ( 10 other cases with association of V.F. are not
considered in this study). 5 case were excluded for a too short follow-up. The main diagnoses were:
Osteosarcoma 50%, Ewing Family Tumors 20%, Chondrosarcoma 7%, Adamantinoma 7%. The femur (31)
was the main site of the lesions followed by the tibia (12) and the humerus (3). The average resection length was
15,5 cm. Plates and screws were mainly used (40); only 6 nail were implanted. 21 patients had no
complications; 25 had one or more complications (4 infections, 14 fractures, 18 non-unions). The final functional
results, after the treatment of the complications, was good or excellent in the 87% of the cases.
Conclusions: the use of the intercalary allografts for reconstruction of oncological bone defects is a demanding
technique that require long time to cure but allows very satisfactory results. It is joined with more than 50% of
complications whose treatment requires one or sometimes more operations but the final result is good or
excellent also in the 76% of the complicated cases.
62
ALLOGRAFTS AND PROSTHESIS SURVIVAL AFTER RESECTION FOR CHONDROSARCOMA OF
THE LOWER LIMB
Biagini R., Erba F., Salducca N., Zoccali C.
Istituto Regina Elena, Roma, Italia.
Chondrosarcoma is a rare malignant tumor with cartilaginous differentiation. It has a little predilection for male
and arises in adult age from 40 to 70 years. Central chondrosarcoma is the more commune; it arises in the femur
and proximal tibia in the 40% of cases, especially in metaphysial area.
The treatment is exclusively surgical, based on resection with wide margins and reconstruction. Reconstruction is
usually performed by massive homograft in metaphysial region and with prosthesis for the lesions arising in
epyphysial area.
Global survival depends on wide surgical margins and histology grade of the tumor: in grade I chodrosarcoma it
is 90%, in grade II is the 70% and in grade III the 40-50%.
Because of patients with chondrosarcoma have a long-term prognosis with a global high percentage of survivals
they should be a good model to study prosthesis implants life. However chondrosarcoma is a rare disease and
specific series study are not present in literature.
Basing on data deducted by series comprising different sarcomas of inferior limbs it is possible to assume that
prosthesis survival varies from 68% to 83% after 5 years and decrease to 70% after 10 years and to 60% after 15
years.
Principals failure causes are aseptic loosening , infection and more rarely stem rupture.
Massive homograft have a total survival of 70% after 5 years. Principal causes of failure are: infection, fractures,
instability and non union. Massive homograft in patient undergone to chemotherapy.
63
OSTEOARTICULAR ALLOGRAFTS AND PROSTHETIC
CHONDROSARCOMA RESECTIONS IN UPPER LIMB
RECONSTRUCTIONS
AFTER
Campanacci Domenico Andrea
Orthopaedic Oncology, CTO, Azienda Ospedaliera Universitaria Careggi, Firenze
In upper limb, osteoarticular bone loss after tumoral resections may be reconstructed using modular prostheses,
osteoarticular allografts or allograft-prosthesis composites (association between a conventional prosthesis and an
allograft).
Shoulder: the most frequent site of occurrence of a primary chondrosarcoma in upper limb is proximal humerus
followed by the scapula. In case of total scapulectomy, with removal of periscapular muscles, active abduction
and elevation of the shoulder are completely lost. In selected cases, when no extraosseus tumoral extension is
evident, scapulectomy may be performed preserving the periscapular muscles and their innervation
(subscapularis, sovraspinatus, infraspinatus, teres minor and maior); in these cases, scapular replacement by
scapular allograft or custom made prosthesis is possible with satisfactory recovery of abductive function.
When tumoral extension into the articular space is present, an extra-articular resection is required (Tikoff-Linberg
procedure) with complete removal of scapula, periscapular muscles and proximal humerus. In this case, proximal
humerus may be replaced by a spacer anchored to residual clavicular stump to achieve stability, and no residual
function except external and internal rotation is expected.
In proximal humerus resections, when glenoid surface, deltoid muscle and axillary nerve are preserved, a
functional recovery of active abduction and elevation may be achieved. In this situation, expecially in young and
active patients, osteoarticular allografts have shown better functional results than modular prostheses due to more
adequate and durable tendon reattachment of rotator cuff and deltoid. On the contrary, modular prostheses are
preferred when resection of abductor apparatus is required, in older patients with lower functional requirements
and when adjuvant radiationtherapy is indicated. Both procedures may be used for reconstruction of total humerus
when required by tumoral extension. The most frequent complication of osteoarticular allografts are articular and
diaphyseal fractures, ranging from 25 to 50% of cases in literature reports. Intramedullary rehinforcement of the
allograft with acrylic cement consistently decreased fracture rate. In most recent series, proximal humerus
allograft 5 years survival was reported from 68% to 78%. Allograft-prosthesis composite associate the
advantages of prosthesis (early functional recovery; long term durability of articular surface) and allografts (bone
stock preservation; biologic tendineous rehinsertion). A conventional long stem shoulder prosthesis is cemented
into a proximal humerus allograft and the distal part of the stem is cemented into the humeral diaphysis. A
residual instability and proximal migration of the humeral head due to rotator cuff insufficiency lead to the
introduction of reverse prosthesis in allograft-prosthesis composites reconstruction of the proximal humerus.
Preliminary results of this technique are promising showing excellent function and stability of the shoulder.
Elbow: when distal humerus have to be replaced, modular prosthesis is considered the best reconstructive option.
In extra-articular resections, when distal humerus has to be removed together with proximal ulna and radius,
reconstruction my be achieved by total elbow massive allografts or by custom-made prostheses. Massive bone
allografts have been employed in elbow reconstructions of post-traumatic and oncologic bone loss and in
prosthetic revisions. After this procedure, complications such as non union, articular fractures and instability were
very frequent ranging from 69% to 100% in literature reports. Allograft-prosthesis composite of the elbow with
long cemented stems allows bone stock preservation and tendineous structures reattachment avoiding allograft
complication (non union, fractures and instability). This procedure may be employed as a primary reconstruction
procedure or as a salvage revision option in fractured total elbow allografts.
Wrist: distal ulna bone loss usually does not require any reconstruction, resulting in a stable and functional wrist.
Distal radius resections may be reconstructed by an osteoarticular allograft, by a proximal fibular autograft or by
wrist arthrodesis with either an allograft or an autograft. No reliable modular prostheses of the distal radius have
been purposed so far. Massive allograft replacement of the distal radius showed excellent functional results. The
most frequently reported complication was dorsal instability with subluxation of the transplanted radius, with no
residual functional impairment. Articular fractures were reported in 14-17% of cases and surgical revision with
allograft removal and wrist arthrodesis was required in 14-29% of cases in literature.
Conclusions: in proximal humerus reconstructions massive allografts provide excellent results when abductor
apparatus may be preserved. Allograft-prosthesis composites prevent complications and provide a functional
improvement by the use of reverse prostheses. At the elbow level, massive allografts showed a very high
complication rate and they are indicated just in selected cases as alternative to custom-made prostheses. Allograftprosthesis composites provide a better stability and long-term results allowing tendineous rehinsertions to the
graft. Distal radius massive allografts provide excellent long term functional results. Implant failure requiring
allograft removal and wrist arthrodesis was reported in one fourth of cases.
64
DOXORUBICIN-LOADED OSTEOTROPIC NANOPARTICLES FOR THE TREATMENT OF
SKELETAL METASTASES
Salerno Manuela1, Fotia Caterina1, Avnet Sofia1, Cenni Elisabetta1, Granchi Donatella1, Castelli Francesco2,
Miceli Dorotea 2, Pignatello Rosario3, Rucci Nadia4, Teti Anna4, Baldini Nicola1.
Laboratory for Pathophysiology, Istituto Ortopedico Rizzoli, Bologna; 2Dept. of Chemical Sciences and 3Dept. of
Pharmaceutical Sciences, University of Catania; 4Dept. of Experimental Medicine, University of L'Aquila
Aims: The controlled delivery of anticancer drugs through osteotropic nanoparticles (NP) is a novel approach for
the adjuvant therapy of osteolytic bone metastases. Doxorubicin (DXR) is widely used in chemotherapy but its
activity is restricted by the dose-dependent cardiotoxicity and marrow toxicity. However, its efficacy can be
improved when specific targeting at the tumor site is obtained.
Methods: Osteotropic biodegradable NP had been previously obtained by nanoprecipitation of a copolymer
between poly(D,L-lactide-co-glycolide) (PLGA) and sodium alendronate (ALE). NP were subsequently
characterised for their chemical-physical properties and biocompatibility, and then loaded to DXR.
The aim of this study was to analyse the effectiveness of NP-loaded DXR through in vitro and in vivo
experiments, in comparison to that of free DXR. For the in vitro analysis, six human cell lines were used as a
panel of bone tumors, including breast and renal adenocarcinoma, osteosarcoma and neuroblastoma. The in vitro
uptake was verified after exposure to NP-loaded DXR or free DXR for 30 minutes through direct observation by
confocal microscopy. To evaluate the effects on tumor cell proliferation, the percentage of growth inhibition was
determined after incubation with NP-loaded DXR or free DXR for 48-72 hours. To analyse the in vivo activity of
NP-loaded DXR, BALB/c-nu/nu mice were used for intratibial inoculation of a human breast cancer cell line. The
free or NP-loaded DXR was given by intraperitoneal administration for 4 weeks and the progression of the tumor
was monitored by X-rays. The radiographs were analyzed for lesion number and cumulative area of osteolytic
lesions.
Results: All of the cell lines were able to uptake both free and NP-loaded drug, and their proliferation was
inhibited up to 80% after incubation with free and NP-loaded DXR. NP-loaded DXR also reduced the in vivo
incidence of bone metastases, not only in comparison with untreated mice, but also with free DXR-treated mice.
Conclusions: Osteotropic PLGA-ALE NP are suitable to be loaded with DXR and offer as a valuable tool for a
tissue specific treatment of skeletal metastases.
Keywords: Nanoparticles, Metastases, Bone targeting
65
STUDY OF MARROW STROMAL CELLS OSTEOGENIC POTENTIAL FOR THE TREATMENT OF
CONGENITAL PSEUDARTHROSIS OF THE TIBIA ASSOCIATED WITH TYPE I
NEUROFIBROMATOSIS
Devescovi Valentina1, Leonardi Elisa1, Baglìo Serena R.1, Donzelli Onofrio2, Magnani Marina2, Baldini Nicola1,
Granchi Donatella1, Giunti Armando1
1
Laboratorio di Fisiopatologia degli Impianti Ortopedici, e
Traumatologica Pediatrica, Istituto Ortopedico Rizzoli, Bologna.
2
8^ Divisione di Chirurgia Ortopedica e
Aims: Type 1 neurofibromatosis (NF1), the most common single gene disorder found in humans, may be
associated with congenital pseudarthrosis of the tibia. New strategies based on the use of autologous marrow
stromal cells (MSC) have been recently suggested for this condition, since the MSC pool contains precursors of
osteogenic differentiation, that in turn may enhance bone repair and regeneration. In this study, we compared the
osteogenic potential of MSC derived from the tibia with those obtained from the iliac crest, to establish the
rationale for the use of the autologous MSC transplantation for the treatment of pseudarthrosis.
Methods: Bone marrow samples were collected from the iliac crest (IC) and from the pseudarthrosis site (P).
Both IC-MSC and P-MSC were cultured in differentiating medium containing a-MEM added with 10% fetal
bovine serum (FBS) or with 10% autologus serum (AUT). MSC osteogenic potential was evaluated through cells
metabolic activity, colony-forming-unit (CFU) capability and mineral deposition. The expression of osteoblast
related genes and the release of soluble factors involved in the regulation of osteogenesis, were also mesured at
different endpoints.
Results: The differentiation of MSC into osteoblasts varied among patients. IC-MSC cultures showed an
increased cell number and viability in comparison to P-MSC. Moreover, the number of alkaline phosphatase
(ALP)-positive colonies was higher in IC-MSC than in P-MSC. The amount of ALP transcripts reflected the ALP
activity viewed in CFU cultures. The addition of FBS or AUT in the culture medium did not change the
osteogenic potential of IC-MSC.
Conclusions: These results show that autologous MSC derived from the iliac crest are able to differentiate into
osteoblasts better than MSC derived from the site of pseudarthrosis, suggesting that autologous MSC
transplantation is a promising strategy for the therapy of congenital pseudarthrosis.
This study was supported by grants from the Istituto Superiore di Sanità (Programma Italia-USA ‘Malattie Rare’)
and the 'Io ci sono' Association.
Keywords: osteogenic potential, bone regeneration
66
CONSERVATIVE TREATMENT OF LOW GRADE CENTRAL CHONDROSARCOMA (LGCCS)
Mapelli Sergio, Bastoni Stefano, Parafioriti Antonina
Orthopaedic Oncology Unit – Gaetano Pini Orthopaedic Institute – Milano – Italy
Aims: the clinical features, the radiologic pattern and the pathological studies, together help to the diagnosis and
directly affects the surgical treatment of the low grade malignant central chondroid tumors. On the bases of that
consideration, the Authors checked all the 365 chondrosarcomas (CS) treated at their Institution from 1957 to
2007, evaluating the surgical techniques employed in the different periods and their results.
Methods: 277 cases considered from 1957 to 2004 have been studied in two different periods. The first group
includes 84 pts, treated between 1957 and 1987: 24 of them had LGCCS and all tumors were resected. The second
one includes 193 pts, treated from 1988 to 2004: 49 of them had LGCCS that was resected in 14 cases while the
others 35 lesions received an aggressive curettage plus adjuvants and cement or grafting.
Results: none of the patients died for the tumor nor underwent recurrence in the two groups; one surgical
complication occurred in the first group and two fractures in the second; in the resection group the functional
results were unsatisfactory in the 25% of the cases while the conservative treatment allowed 100% of good or
excellent functions.
Conclusions: in the past, resection and reconstruction were the usual treatment of the LGCCS; conservative
surgery, avoiding resection, is now used in most of the cases. When the clinical features and the radiologic
pattern are adequate and the pathological diagnosis is reliable, the conservative surgery proved to be effective and
achieve better functional results.
Keywords: low grade central chondrosarcoma, conservative treatment, bone tumors
67
ANGIOGENESIS IN HAND CHONDROMA
M. L. Ricciardella, G. Fadda, G. Falcone, B. Rossi, G. Maccauro and M. A. Rosa* (Roma, *Messina)
Aim: Angiogenic factors, as Vascular Endothelial Growth Factor (VEGF), have a negative influence on prognosis
of carcinomas, because of their involvement in the progression of metastasis. Few data about the potential role of
angiogenesis in non-vascular neoplasm are reported in literature. Recently we demonstrated the expression of
VEGF in cartilagineous neoplasm and in particular its correlation with malignancy. Hand chondroma is a
particular tumour because it is morphological malignant, but clinically is benign. The aim of our study was to
investigate the role and potential clinical significance of VEGF expression in hand chondroma.
Materials and Methods: We retrospectively analysed 8 cases of hand chondroma. Age, sex, tumour location,
symptoms declared by patient upon admission, treatment, treatment complications, local or distant relapses and
survival were all taken into consideration. The preoperative radiographs were accurately studied. Histological
sections were obtained by inclusion in paraffin from the archives of Department of Pathology. The glass-slides
were stained with Ematossilina-Eosina and observed by the anatomy pathologist. The diagnosis for each case was
carried out by integrating the clinical radiographical histological data. The growth factors and cellular
proliferation markers were analysed through immunohistochemistry. Tissue blocks from the resected tumours
were stained using immunohistochemical methods for VEGF, PDGF, FGF1, TGFβ2, TNFα2, Ki-67 and p53
expression.
Results and Discussion: VEGF was expressed in all the hand chondromas. Taking into account the history of this
tumour, Authors suggested that VEGF expression may be related more to morphological patterns than clinical
behaviour of cells.
68
ANGIOGENESIS IN OSTEOSARCOMA: IMMUNOHISTOCHEMICAL ANALYSIS
Rossi Barbara, Schinzari Giovanni*, Valente Monica*, Maccauro Giulio and Rosa Michele Attilio°
Department of Orthopaedics, Department of Medical Oncology UCSC Rome*, Department of Orthopaedics
Messina°
Angiogenesis is an early stage in the growth of carcinomas and mesenchimal tumors. The role of angiogenesis in
osteosarcoma is well known, and it is most commonly assessed by VEGF expression or intratumoral CD31
positive microvessel density (MVD). VEGF expression both before and after chemotherapy is predictive of poor
prognosis, revealing a potential role of chemotherapy in the selection of angiogenic pattern. The aim of this study
was to investigate the clinical and diagnostic significance of VEGF and CD31 in osteosarcoma, both at diagnosis
and after neoadjuvant chemotherapy, in order to identify a potential role of chemotherapy in angiogenic
phenotype. A retrospectively clinico-pathological analysis was performed on 16 patients with high grade
osteosarcoma. In all cases archival pre-treatment biopsy tissue and post- chemotherapy tumoral specimen were
immunohistochemically stained against CD31 and VEGF, as markers of angiogenic proliferation both in newly
diagnosed primary osteosarcoma and after chemotherapy and surgical resection.
Expression of VEGF was showed in 70% of cases at diagnosis: 50% of tumors were poorly VEGF-positive, while
VEGF expression was increased in only 20% of cases. Moreover, 50% of untreated osteosarcomas were CD31negative, but the remaining 50% showed an increased expression of CD31. Therefore, in primary lesions, VEGF
expression is more significant than CD31.
In all cases, an increased expression of VEGF and CD31 in the tumor cells surviving after neoadjuvant
chemotherapy was observed; some tumors VEGF or CD31-negative at biopsy showed a high level of expression
of angiogenic markers after chemotherapy.
Even if the study included few patients, these results confirm that the expression of VEGF and CD31 is increased
by chemotherapy, probably through hypoxia induced by chemotherapy itself. The expression of angiogenic
factors which facilitate an increased microvessel density can contribute to the penetration of chemotherapic drugs
in tumoral mass also in the adjuvant stage of treatment. So VEGF could have a paradoxical effect: it is associated
with a poor outcome but it could be even a potential target for antiangiogenic therapy .
69
SYNOVIAL CHONDROSARCOMA OF THE HIP JOINT. REPORT OF TWO CASES AND
LITERATURE REVIEW
D. Matera1 , D.A. Campanacci2, A. Franchi3, R. Capanna2
1: Clinica Ortopedica, Università degli Studi di Catania, c/o Azienda Ospedaliera “Vittorio Emanuele”, Via
Plebiscito, 628, 95124 - Catania
2: II Divisione di Ortopedia Oncologica e Ricostruttiva, Centro Traumatologico Ortopedico, A.O.U. Careggi,
Largo Palagi 1, 50139 - Firenze
3: Dipartimento di Anatomia Patologica, Università degli Studi di Firenze, c/o A.O.U. Careggi, Largo Palagi 1,
50139 Firenze
Synovial chondrosarcoma is a rare malignant tumor. The lesion may arise de novo in intra-articular space or,
more frequently, it may occur as a malignant degeneration of synovial chondromatosis. The authors report two
cases of synovial chondrosarcoma of the hip joint occurred on a synovial chondromatosis diagnosed 23 years
earlier in one case and 10 years earlier in one case. In both cases the synovial chondrosarcoma showed an
intermediate grade of malignancy at histology (grade 2). In the first case, the patient underwent an external
hemipelvectomy and he was disease free 10 years after the operation. In the second case, the patient refused the
purposed demolitive surgery and underwent palliative radiation therapy and she was alive with disease 5 years
after diagnosis. A review of the literature reports on synovial chondrosarcoma was carried out. The knee was the
most
affected joint, followed by the hip. A demolitive surgical procedure was performed in two third of cases.
Amputation was done as primary surgery in 20% of cases and for tumor recurrence after sinoviectomy in 80% of
the cases. Metastatic dissemination was seen in 29% of cases. An early detection of malignant transformation of
synovial chondromatosis might improve the rate of limb salvage surgery in these patients, although no reliable
clinical and radiographical elements have been identified so far.
The epidemiological infrequency with which this disease appears makes it a clinical entity difficult to detect; in
patients with synovial condromatosys should be considered the possibility of malignant transformation and
therefore, in subjects showing symptoms, should be recommended a careful screening, clinical and instrumental,
in order to make a diagnosis as early as possible. An early diagnosis of the transformation of synovial
condromatosys in synovial condrosarcoma may help to increase the percentage of limb salvage procedures.
However, up to now, reliable clinical criteria and X-rays signs to detect the degeneration of malignant synovial
condromatosys have not been identified.
70
LACTOFERRIN IMMUNOEXPRESSION IN CARTILAGE-FORMING TUMOURS
IENI Antonio, BARRESI Valeria, GROSSO Maddalena, TUCCARI Giovanni
Dept. Human Pathology, University of Messina - Italy
Aims: We have investigated lactoferrin (Lf) immunoexpression as well as its biological meaning in a series of
27 formalin-fixed, paraffin-embedded surgical samples cartilage-forming tumours (15 enchondromas, 6
osteochondromas, 3 chondroblastomas, 3 chondrosarcomas; age range: 15-75 yrs). Samples of unaffected human
cartilage tissue, taken at autopsy (3 foetuses, 14-16 weeks of gestation and 5 adults, 50-75 yrs), were utilized as
normal tissue controls. Relationships of Lf immunoreactivity with proliferation index (Ki-67) as well as sex
steroid receptors (ER and PgR) were also analyzed.
Methods: Antigen retrieval (0,01 M citrate buffer, pH 6.0 in a microwave oven for 3 cycles x 5 min) was
performed before adding primary antibodies. The immunoreactions were performed utilizing primary monoclonal
antibodies against Lf (clone 1A1; Biodesign International, USA; w.d. 1:75; 60 min at room temperature), ER
(clone ID5, DBA, Italy; 1:10), PgR (PgR-ICA, Abbott, USA; 1:10) and Ki-67 (MIB1, DakoCytomation; 1:200).
Quantification of Lf immunoreactivity was performed using the intensity-distribution ID score, elsewhere
reported (Giuffrè et al., 2007). ER, PgR and MIB1 staining scores were evaluated by counting the percentage of
positive nuclei x 1000 malignant cells. The possible correlations between Lf immunoexpression and clinicopathological parameters as well as ER, PgR and MIB1 of cartilage-forming tumours were investigated using nonparametric methods (Mann-Whitney U test, Kruskal-Wallis H test).
Results: Lf immunostaining was mainly localized in the cytoplasm and occasionally in the nucleus of the
chondroblast-like cells within the chondroblastomas, while chondrosarcomatous elements neither
osteochondromas or enchondromas exhibited any staining. Lf immunolabelling was found in all foetuses, mainly
localized in the nucleus of chondrocytes encountered in the cartilage matrix adjacent to the calcified area; no Lf
expression was noted in adult samples. No relationships between Lf immunoreaction and ER, PgR or MIB1 were
found, with the exception of a slight immunoreactivity encountered for ER and PgR in chondroblastomas.
Conclusions: Lf appears to inhibit cell proliferation and suppresses tumour growth in vivo, although its presence
may be related to cell phenotype. Lf immunostaining in fetal cartilage as well as in chondroblastomas may
suggest an oncofetal role, but the molecular mechanisms remain unknown.
Key words: lactoferrin, cartilage-forming tumours, immunohistochemistry
71
SURGICAL APPROACH TO CENTRAL LOW-GRADE CHONDROSARCOMA
D.A. Campanacci, Scoccianti G., Beltrami G., Matera D., Cuomo P., Frenos F., Capanna R.
Department of Orthopaedic Oncology, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
Central low grade chondrosarcoma (CHS) has a scarce tendency to local recurrence and metastatic dissemination.
In literature, the cure rate of these lesions ranges from 80% to 95% at ten years. The appropriate surgical
treatment of grade 1 CHS is still controversial and although most of the authors recommend to achieve wide
surgical margins, intralesional curettage has been reported as an appropriate treatment. Some cartilagineous
lesions present clinical, radiographical and histological features which are defined border-line between a benign
chondroma and a malignant CHS. The appropriate approach towards these lesions has not been clearly defined
yet and surgeons are debated between clinical observation of the patient and surgical treatment. The authors
analyze their experience on central low grade CHS with the aim to define surgical guidelines on the basis of
clinical, radiographical and histological considerations.
A series of 74 grade 1 central CHS was reviewed occurring in 73 patients (one patient had two localization). The
surgical treatment was a resection in 36 cases and an intralesional curettage in 38 cases. At an average follow-up
of 53 months, 2 local recurrences were observed and both the patients underwent surgical resection. Metastatic
dissemination was never observed.
From the analysis of the presented series of patients it appears that a lesion, showing the radiographical features
of a cartilagineous tumor, when it is painless, with no endosteal cortical scalloping and extending for less than
5cm in the medullary canal, it should be followed in time with clinical and radiographical observation. In case of
painful lesion, with endosteal scallopping and /or an intramedullary extension of more than 5cm, a biopsy should
be performed of a specimen including the cortex and the transition area between the cortex and the tumor. When
the histological diagnosis indicates a border-line lesion or a grade 1 CHS an accurate curettage with the use of
local adjuvants may be the appropriate treatment. In case of grade 1 CHS with cortical thickening or expansion or
periosteal reaction and in case of pelvic or scapular lesions a resection with wide margins should be performed.
72
CHONDROSARCOMA: DIAGNOSIS AND TREATMENT
Nicolosi Francesco, Leonardi Walter
Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione
Garibaldi,S.Luigi-S.Curro,Ascoli Tomaselli
Presidio Ospedaliero Garibaldi Nesima
U.O. Ortopedia e Traumatologia via Palermo 632 Catania
Direttore Walter Leonardi.
Chondrosarcomas represented 9.2% of the malignant tumors in patients at our institution and approximately 86%
of these were primary chondrosarcoma. The age distribution of patients with chondrosarcoma shows a gradual
age-related increase, with the peak incidence occurring during the sixth and seventh decades of life. The majority
of patients are older than 50 years. Chondrosarcoma has a predilection for the trunk bones and the upper end of
long bones, particularly the humerus and femur.
It’s are a group of tumors with highly diverse features and behaviour patterns,ranging from slow-growing nonmetastasizing lesions to highly aggressive metastasizing sarcomas.Are classified as central or peripheral,lesion
and primary when they arise de novo or a secondary when they occur within a pre-existing lesion as an
enchondroma or osteochondroma.Tumors are further categorized in three grade,the first represents the least
aggressive and grade 3 the most aggressive.Another chondrosarcoma is the dedifferentiated is a well-recognized
neoplasm composed of high-grade sarcoma that is directly associated with a low-grade chondrosarcoma.
The adequacy of treatment (defined as the complete removal of the neoplasm and biopsy site without entering the
tumor) is one of the most important factors in determining the incidence of recurrence and survival. Surgery is the
main treatment option for this disease because chondrosarcoma typically does not respond to radiation and
chemotherapy.
The standard of surgical treatment is wide resection, but depending on the location, this may cause increased
morbidity or require complex reconstruction.
We have treated some patients with chondrosarcoma,because chemotherapy and radiotherapy do not influence the
prognosis,the goal of surgery, is to resect the entire lesion with wide margins.We show the protocol for the
diagnosis and the treatment of some chondrosarcoma.
73
PROFESSIONAL LIABILITY: MEDICO-LEGAL AND JURIDICAL ASPECTS
Claudio Crinò
University of Messina - Italy
Malpractice phenomenon is nowadays widely expressed in Italy; statistics show that
denunciation number exceed 10000 cases each year. Physician’s blame has been proved in a
number of cases which is still unknown.
Changed relation between medicine and society, or between doctor and patient, the demand of
a perfect health and recovery from diseases and compensation profit seem to be the most
important factors to keep this phenomenon so prominent.
As regards judicial field, several judges, even from Supreme Court, share a marked severity,
above all in civil proceedings.
74
X CONGRESSO NAZIONALE IORS ~ COMUNICAZIONI LIBERE
PHYSIOLOGICAL MODIFICATION OF LAXITY AND FLEXIBILITY IN DIFFERENT TANNER
STAGES
Chinni Carmela, Falciglia Francesco , Giordano Marco , Aulisa Angelo Gabriele , Guzzanti Vincenzo *
Children’s Hospital Bambino Gesù – Institute of Scientific Research Orthopaedic Department – Rome – Italy
* Orthopaedic Department of the University of study of Cassino
Aims: The relationship of physiologic laxity and age has been reported in only cross sectional studies but the
authors suggested further investigations to include Tanner staging to understand how much increases in maturity
influence alterations in laxity.
Methods: With cross-sectional and longitudinal study assessed knee joint laxity and flexibility in 172 normal
adolescents using a KT 2000 arthrometer, anthropometric measurements and Carter and Wilkinson tests.
Correlation of these evaluations was done with gender and Tanner stage. Data from clinical and KT 2000
measurements at the initial evaluation were analyzed as the cross-sectional, single assessment phase of the study.
The longitudinal phase of the study reviewed modulation of laxity and flexibility with growth by repeated
examination of the above tests in individual subjects during their adolescent growth phase.
Results: Increased flexibility was seen significantly more frequently in females than males in both study phases.
Age, Tanner stage and anthropometric values were not significantly associated with laxity in the cross-sectional
study. In the longitudinal study, an inverse relationship was demonstrated between Tanner stage and KT 2000
laxity measures after adjusting for other variables. Sequential evaluation showed a progressive decrease of sagittal
laxity at the onset of Tanner stage 2. Laxity was significantly greater in adolescents with signs of joint
physiologic hyperflexibility.
Conclusions: Evaluation of laxity and flexibility during the adolescent growth phase (considering the Tanner
stage) is important for better definition of muscle strengthening or flexibility programs to avoid functional
overloads and injury. Moreover literature reports describe association of anterior knee pain, patellar instability,
gleno-humeral instability, and ankle sprains association with patients with joint hyperflexibility or hypermobility.
75
SOVRACETABULAR BROWN TUMOUR DUE TO ISOLATED PARATHYROID ADENOMA: CASE
REPORT
F. Trimarchi, E. Calamoneri, R. M. Ruggeri and M. A. Rosa (Messina)
Context: Primary hyperparathyroidism due to parathyroid adenoma is relatively frequent but mostly
asymptomatic. We report the case of a 63-years old woman who presented to our Unit with worsening limp of
right hip by three months, deep pain related to the iliac region and severe functional restriction of right hip’s
articularity in the maximum degrees of ROM. The woman was also affected by cronic renal failure (low-moderate
stage).
Biochemical and instrumental evidences: Imaging detected “an osteolytic and expansive lesion of the right
sovracetabular region” (X-Rays) with “structural reabsorption of the right iliac wing” (TC). Histological
examination revealed multinucleated giant cells suggesting a brown tumour.
Chemical blood analysis revealed elevations in parathyroid hormone’s concentration (PTH=1020 pg/ml). The
serum calcium levels, instead, resulted normal, in several blood test (max. val. 9.4 mg/dl), especially considering
renal disease. Whole body bone SCAN (Tc99-mibi) showed high retrosternal uptake that turned out to be a
voluminous parathyroid adenoma associate with multinodular goitre.
Management and Conclusions: The patient suffered a primary hyperparathyroidism that was the main stimulus
for the brown tumour made by multinuclear giant cells. She underwent surgery including parathyroidectomy and
thyroidectomy. Since three months from the surgery the imaging showed a substantial regression of the osteolytic
lesion and a resolution of the clinical features avoiding any orthopaedic surgery.
76
CIRCULATING SUBSTANCE P LEVELS ARE ASSOCIATED TO SHOULDER
CONTRACTURE AFTER ARTHROSCOPIC REPAIR OF THE ROTATOR CUFF.
JOINT
Francesco Franceschi , Umile Giuseppe Longo, Laura Ruzzini, Giordano Dicuonzo, Nicola Maffulli , Vincenzo
Denaro.
Aims: We determined the plasma levels of SP in patients with postoperative stiffness after arthroscopic repair of a
rotator cuff tear, and compared them with those in patients with a good outcome after arthroscopic rotator cuff
repair.
Methods: Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent
arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years,
range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2,
30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after
successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits
to detect the plasma levels of SP. Statistical analysis were performed with Wilcoxon Sign Rank test. Significance
was set at P< 0.05
Results: Patients with postoperative stiffness had statistically significant greater plasma levels of SP than patients
in whom arthroscopic repair of rotator cuff tears had resulted in a good outcome (P < 0.05)
Conclusions: Our results show that the plasma concentrations of substance P in patients with shoulder stiffness
after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good
postoperative outcome. We cannot determine the cause of POS in our patients, but the findings of this study
suggest a possible neuronal role in the pathophysiology of POS after arthroscopic repair of rotator cuff tears. The
knowledge of the pathophysiological role of sensory nerve peptides in tissue repair in these patients could open
new therapeutic options to manage conditions of the musculo-skeletal system with impaired tissue-nervous
system interaction.
77
USE OF PLATELET GEL IN ARTHROSCOPIC TREATMENT FOR ROTATOR CUFF LESION:
PRELIMINARY REPORT
E . BARBIERI
Istituto Ortopedico del Mezzogiorno d’Italia “F. Scalabrino”, MESSINA
Rationale: The PRP system is a platelet’s extract from a venous blood 9 cc amount enhanced by calcium chloride
or gluconate and autologous thrombine melange purposed to obtain a PRP. The platelet’s alpha grains have an
high growth factors ( PDGF; EGF; IGF;TGF beta; VEGF) contained, whose application speeds the tissue healing
and regeneration.
The present paper intends compare the results of rotator cuff lesions treated in arthroscopic surgery with local use
of platelet gel with those of similar lesions treated only by surgical procedure.
Methods: Between January 2006 and April 2007 have been examined 150 patients treated in arthroscopic surgery
for rotator cuff lesion with local use of platelet gel and 100 treated with the simple surgical procedure:
All the patients were submitted to: careful anamnesis; complete clinical examination; X Ray in AP and LL
projections. Each clinical suspicion was confirmed by RMN investigation. The rotator cuff lesions repair was
performed in both patient’s groups with reasorbable anchors and twisted reasorbable sutures. The rehabilitation
program was the same for both group patients.
Results: The Follow–up was performed between 4 and 18 months. The results evaluation was performed
following the Constant schedule and a VAS staircase in immediately post- surgery.
The group with platelet gel use showed improvement of the Constant schedule and of VAS and furthermore ROM
rescue related to control group. A shoulder’s RMN was performed at 1, 3, 6 and 12 months post-op in both
groups.
Conclusions: The results of the present research confirm that the use of platelet gel in arthroscopic treatment of
rotator cuff lesions abbreviates significately the post-op pain, reduces the rescue times and allows an
improvement of all the Constant staircase’s parameters compared with those of the group without local PRP use.
Even if preliminary, these results confirm the choice of systematic utilization of local PRP in the rotator cuff
arthroscopic treatment.
78
THE EFFECT ON ARTICULAR CARTILAGE OF ANTERIOR CRUCIATE LIGAMENT INJURY IN
GROWING GOATS
Falciglia Francesco, Chinni Carmela, Mastantuoni Giuseppe , Giordano Marco, Guzzanti Vincenzo*
Aims: Development and function of articular cartilage (AC) depends on the tissue ability to answer to mechanical
stress and hormonal variation. When mechanical stress overcome the physiological limits lesions which may lead
to arthritis appear. Anterior cruciate ligament (ACL) lesion is responsible in adults of knee instability that
determines degenerative alterations of the AC. ACL injry in teen-agers, contrarily to what until now thought, is
today so frequent to arise always great attention. The therapeutic solution is controversial. The fear to damage the
growth plate with the reconstruction techniques used in the adult for the instability recovery exists. Many
authors for this reason postpone the surgical treatment to the end of growth. How long is the time that we may
wait for operation without causing irreversible damage to the AC ? Up to now, there are no studies that describe
the pathological findings and the evolution of the lesions of the AC during the growing period.
Methods: An experimental study on 16 goats of 6 months of life was performed. These animals were separated
into two groups: A and B. In the group A (8 animals) a partial ACL lesion was performed while in the group B
(8 animals) the lesion performed was complete. The animals were sacrificed two for group at intervals of 1, 3, 6,
9 months from the operation. The knees specimen were submitted to a radiographic examination, macroscopic
evaluation, fixed in 10% collided formalin, decalcified in 4 N formic acid and included in paraffin.
The 5 microns thickness hystological sections, colored with hematoxylin-eosin, Alcian-P.A.S. and Sufranina O,
were studied at the light microscope.
Results: In the group A the cartilage did not show any type of lesion. In the group B the presence of articular
cartilage lesions with progressive aspect were hystologically underlined.
Conclusions: The hystological observations show that the complete ACL lesion is cause of articular cartilage
alterations which lead to arthritis in growing goats after 3 months from injury. These experimental data suggest
that it should be better not to wait the end of growth to indicate the ACL reconstruction in growing patients.
79
SLIPPED CAPITAL FEMORAL EPIPHYSIS: ULTRASTRUCTURAL STUDY BEFORE AND AFTER
OSTEO-CHONDRO-SYNTHESIS
Falciglia Francesco, Chinni Carmela,. Aulisa Angelo Gabriele, Giordano Marco, Guzzanti Vincenzo*
Aims: Etiology and pathogenesis of slipped capital femoral epiphysis are yet not well known. We are aware of
only three previous electron microscopic studies during the various stage of the disease. The aim of the study is to
evaluate if the growth plate can improve the pathologic alterations after osteo-chondro-synthesis (reducing the
mechanical factors).
Methods: An ultrastructural study under a transmission electron microscope of core biopsies specimens of the
growth plate from 6 patients with slipped capital femoral epiphysis (2 pre-slipping, 2 acute, 2 chronic), obtained
during the first operation and, in 3 of these cases (2 chronic – 1 acute) when removing the screw before the
epiphyseodesis, was performed.
Results: In all specimens obtained before operating on it was possible to observe a marked distorsion of the
architecture of the plate, disorganization and disarray of chondrocyte columns and replacement of the columns by
enlarged, irregular lobules of cells. The amount of collagen in the extracellular matrix was decreased and
consisted of haphazardly oriented nonbanded fibrils.
In two of the three specimens obtained removing the osteosynthesis before the epiphysiodesis the growth plate
showed a better organization. In the extracellular matrix and in longitudinal septa the collagen consists of better
oriented banded fibrils with a normal thickness enmeshed in a network of branching proteoglycans. In one case it
was not observed any improvement.
Conclusions: The aetiology of SCFE is anyway not clear. Up to now endocrine, mechanical, biochemical,
inflammatory and other factors have been observed in literature. The improvement of the pathologic alterations
observed in two cases after stabilizing the plate, leads us to consider possible, when the mechanical factors are
reduced, the recovering of the morpho-functional characteristics of the growth plate and then its growth process.
The observation of the architectural modification of the growth plate and the change of the cellular chondrocytes
cycle even in the pre-slipping forms underlines the importance also of an endocrine factor. The biological factors
are probably transitory and the stabilization (reduction of mechanical factors)of the growth plate without
compression may help the recovery process.
80
HUMERAL RESURFACING EMIARTHROPLASTY.
OUR TWO YEARS EXPERIENCE (PRELIMINARY REPORT)
A. Pisani, *D. Lo Vano, *G. Arrabito and *M. A. Rosa
Istituto Ortopedico del Mezzogiorno d’Italia “F. Scalabrino” Messina
* Dipartimento Specialità Chirurgiche. Sezione di Ortopedia – Università di Messina,
Scuola di Specializzazione in Ortopedia e Traumatologia
Aims: The innovative surgical procedure of humeral resurfacing emiarthroplasty is currently used for the
treatment of younger patients, in need of a bone-preserving implant, affected by primary glenohumeral
osteoarthritis and rheumatoid arthritis, secondary degenerative joint disease, post-traumatic arthritis or malunions
of the humeral head, loss of articular cartilage, joint incongruity and stiffness, avascular osteonecrosis of the
humeral head, combined loss of the gleno-humeral joint surface and rotator cuff loss of function and pain
unresponsive to nonoperative measures. Specific humeral resurfacing implants, properly designed, can also
articulate with a glenoid component, in the required cases of severe degeneration and destruction of glenoid
cartilage (total arthroplasty). The presence of an active infection, local or systemic, or an inadequate bone stock in
the proximal humerus represent the main contraindications for the humeral resurfacing hemiarthroplasty.
Published reports have indicated a large variation in the benefits of this procedure. The aim of this study is to
analyse the clinical results obtained by the authors in a preliminary report of a two-years experience in the
surgical actuating of this procedure, that represents one of the more innovative options in the field of the shoulder
arthroplasty.
Materials and Methods: The authors report the outcomes of their experience in humeral head surface
replacement emiarthroplasty. In the last two years 25 selected patients have been treated according to the surgical
implantation of the “bone sparing” Global Cap conservative anatomic prothesis (DePuy). The mean age of the
patients was 52 years (range, 34 to 76 years). They have been followed for a mean of 8 months, (range, 4 to 16
months). Preoperative diagnoses were: osteoarthritis, rheumatoid arthritis, psoriasic arthritis, osteonecrosis and
post traumatic arthrosis. 8 patients underwent contextual cuff tear repair.
Results: Constant scores for the whole group improved from a mean preoperative score of 22 to 60 at the last
follow-up. Periprosthetic osteolisys was seen in 3 cases. One case of stiffness required narcosis mobilization at
5th months from surgery. Our results are comparable those obtained with others modern R. R. H. and are similar
to Copeland’s own series.
Conclusions: The preliminary results of our study show how some pre-operative factors appear to influence the
functional improvement and the personal satisfaction rate of the patients after humeral resurfacing
emiarthroplasty. The most important are represented by: the presence of erosions in the glenoid cartilage, possible
previous shoulder surgery and associated cuff tears. The gender of the patients doesn’t appear a discriminating
factor. The age appears to influence only boundedly the clinical post-operative outcomes.
In our opinion, the initial diagnoses is determinant: patients affected by systemic pathology, like rheumatoid
arthritis, by cuff tear or capsulorrhaphy arthropathy obtain the least functional improvement and satisfaction; on
the contrary, patients affected by primary and secondary degenerative joint diseases, post-traumatic cartilage
lesions and avascular osteonecrosis of the humeral head obtain better results.
Keywords: Humeral Resurfacing Emiarthroplasty, Gleno-humeral Joint Diseases, Humeral Head Avascular
Osteonecrosis, Treatment.
81
HISTOPATHOLOGICAL
DISEASE
AND
PATHOGENETIC
CONSIDERATION
ABOUT
KIENBöCK’S
Bellina Giorgio Emanuele*, Tulli Antonio, Pagliei Antonio, Serpieri Saverio
* U.O.C. Ortopedia e Traumatologia, Ospedale Cristo Re, Roma.
Divisone di Chirurgia della Mano, Dipartimento di Scienze Ortopediche, Università Cattolica del Sacro Cuore,
Roma.
Aims: the purpose of our experimental study has been that to formulate a new pathogenetic hypothesis on
Kienbock Disease (KD), analysing the histopathological data in our possession.
Methods: We conducted an histological study on three human os semilunaris removed from three patients in
different evolutionary stages of the disease (two in II stage and one in IV stage, according to Lichtmann’s
classification), using different coloration techniques of the slices and the polarized light (PL).
Results: The histological study of the II stage cases documents that great part of the bone is in a good vital status,
but with expansion of the venous vessels and enlargement of the arterial walls, as from chronic venous stasis.
Numerous microscopic lines of fracture separate the most recent osteonic formation from the surrounding tissue,
that preserve residual of pre-existing osteonic structures, never reabsorbed. This finding deposes for a tissue with
a metabolism globally slackened, with poor mechanical quality for the presence of never renewed bone tissue. In
the most central portion of the bone affected, numerous fractures that separates the trabecular bone are evident.
The study with the PL clearly shows the mosaic-like aspect of the bone tissue, consequence of a reduced
metabolic activity. The new-formed bone tissue is not able to expand itself in the context of an old bone tissue.
The histological study of the IV stage case documents that the aspect of the tissue is of the Primitive Type, with
vital osteocites. In these slices we did not find mature bone. These data are confirmed with the PL study, which
shows an anarchic architectural structure of the bone.
Conclusions: We believe that KD is the result of a relative vascular insufficiency of the os semilunaris, with the
loss of the equilibrium between the metabolic demands of the bone and the availability of nutrient substances.
The disease doesn't have the characteristics of an acute ischemia, but manifests chronic progression, with the
possibility to restore the equilibrium among requests and supplies during the disease evolution.
We sustain that the pathogenesis of KD is not is imputable only to a single cause, but at least to two causes, that
are both necessary, but no one alone is enough to induce the disease. These causes are the functional local
overload and the circulatory insufficiency of bone. KD does not threaten the bone tissue survival, but its
mechanical efficiency, hindering the collagen fibres and the osteonic structure turn over, that are essential for the
maintenance of the physiological elastic proprieties of the bone, favouring therefore the creation of innumerable
micro-fractures in its context.
The loss of form of the bone that happens during the evolution of KD is destined then to negatively influence the
mechanics of the whole complex of the carpal bones.
Key words: Kienböck Disease, Pathogenesis, Histopathology
82
EVALUTATION OF BONE QUALITY IN PATIENTS WITH HIP OSTEOARTHRITIS
Cerocchi Irene, Perticarini Loris, Lecce Domenico, Feola Maurizio, Padolino Antonello, Scialdoni Alessandro
and Tarantino Umberto
Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Viale Oxford 81, 00133,
Rome, Italy
Aims: Osteoarthritis (OA) and osteoporosis (OP) are two common disorders affecting the quality of life in the
elderly. The association between OA and OP has always been debated. The purpose of our study is that to analyze
from an anatomo-pathological point of view bone quality in samples of heads and neck femur withdrawn in
patient affected by hip osteoarthritis submit to hip arthroplasty.
Methods: These samples have been submitted to a microscopic evaluation grade of arthritis with classification
introduced by OARSI (osteoarthritis research society International, 2000) and an histomorphometric evaluation,
with the purpose to identify quantity and quality of trabecular bone. The patients selected for the study have been
stratified for age and risk factors, including in a first evaluation patient not smokers, without apparent
cardiovascular illness, not diabetic and that didn't make use of analgesic, non steroidal anti-inflammatory and
steroidal drugs. As positive controls we have used samples of patients submitted to hip endoprosthesis or total hip
arthroplasty following osteoporotic femur neck fractures, with hip or spine Bone Mineral Density measured using
DXA and results more than 2,5 standard deviations below the young normal mean (T<-2,5). The investigation
has been conducted in blind.
Results: There was no significant difference among proximal femur bone between patient affected with hip
osteoarthritis and controls (osteoporotic fracture).
Conclusions: In conclusion, osteoarthritis and osteoporosis are illnesses that can coexist, unlike some literary
works that consider these illnesses inversely correlated.
Key words: Histomorphometric, Osteoarthritis, Osteoporosis
83
ANATOMICAL STUDY ON LATERAL MENISCAL GRAFT
L. Panarella, U. Tarantino, G. Puddu, N. Belot*, P. Boisrenoult*, P. Beaufils*
University of Rome Tor Vergata, Rome - Italy
Valle Giulia Private Hospital, Rome - Italy
*University of Rennes, Rennes, France, Hospital Center of Versailles, Le Chesnay - France.
Aims: The objective of this anatomical study was to verify the feasibility of an all-arthroscopic lateralmeniscal
transplantation.
Methods:
An original arthroscopic technique was developed on 12 cadaver specimens and was
performedthrough the two standard antero-medial and antero-lateral approaches. The fixation was securedtwo
bone plugs into two orthogonal tunnels.
Results: Progressing with the technique, meniscal positioning was found to be more and more adequate.
Conclusions: Bone plugs quality, correct meniscal sizing and careful dissection of the menisco-synovial
junctionare mandatory to ensure a good preparation of the meniscal transplant.
Key words: meniscus, graft, anatomy
84
POLYETHYLENE TEREPHTHALATE MESH FOR SOFT TISSUE REATTACHMENT TO
SKELETAL MODULAR PROSTHESES AFTER WIDE BONE RESECTION DUE TO BONE TUMORS
M. Alesci, D. Lo Vano, G. Maccauro* and M.A. Rosa
Surgical Specialties Department - Orthopaedic Section - University of Messina, Italy
* Department of Orthopaedic Sciences - Catholic University - Rome, Italy
Introduction: One of the main problems in reconstructive surgery after wide resection for malignant bone
tumours is still the soft tissue reconstruction and in particular their anchoring to modular or custom made
megaprostheses. This surgical aspect is particularly important if composite prostheses are not utilized. It is well
known that the entity of soft tissue sacrifice induces a functional deficit of the operated limb. “Trevira” tube is
currently used in reconstruction after resection for improving soft tissue anchoring to megaprostheses, but few
papers are still published concerning the biological mechanisms of this adhesion. The aim of this study was to
analyse soft tissue adhesion to “Trevira” tube using in vitro and in vivo studies.
Methods: In vitro studies were performed analysing with scanning electron microscopy the adhesion and
spreading of fibroblasts onto “Trevira” tube and measuring with MTT test cell viability and proliferation on this
material in comparison to Ti-alloy used as a control. We also observed, using SEM, tissue anchoring on
prostheses retrieved at the time of revision surgery for aseptic loosening.
Results and Conclusions: Our studies showed the good adhesion and spreading of cells onto “Trevira” tube,
demonstrating the good metabolic status of cells. MTT showed that fibroblasts can attach and proliferate on this
material. The adhesion was stronger (p <0.05) than the one on Ti-alloy, demonstrating that “Trevira” Tube
constitutes an improvement of anchoring soft tissues in comparison to Ti alone. SEM of specimens retrieved at
the time of revision surgery for aseptic loosening showed soft tissue on “Trevira” tube. Through the emission of
lamellipodia and filipodia, cells adhered on substrate. This is the basis of cytoskeleton modifications before cell
proliferation confirming the good metabolic status of cells. Our study confirmed that “Trevira” may be considered
a useful system for soft tissue anchoring on megaprostheses, because it allows a good adhesion of fibroblasts on
the tube.
Key words: Trevira tube, malignant bone tumours, modular or custom made megaprostheses
85
DETERMINATION OF A SAFE RANGE OF KNEE FLEXION ANGLE FOR GRAFTS FIXATION IN
DOUBLE BUNDLE ACL RECONSTRUCTION: A HUMAN CADAVERIC STUDY
F. Vercillo M.D., S. Noorani B.S., O. Dede M.D., G. Cerulli M.D. and Savio L-Y. Woo Ph.D., D.Sc.
Musculoskeletal Research Center, Department of Bioengineering, University of Pittsburgh – Pittsburgh, PA
Background: For anterior cruciate ligament reconstruction with a double-bundle procedure, one of the major
concerns is to not predispose either one of the grafts to risk of failure by overloading.
Hypothesis: Knee flexion angles between 15 degrees and 45 degrees for anteromedial graft fixation and 15
degrees for posterolateral graft fixation are safe for both grafts in double-bundle anterior cruciate ligament
reconstruction.
Study Design: Controlled laboratory study.
Methods: Nine human cadaveric knees were tested. The double-bundle anterior cruciate ligament reconstruction
was conducted with both grafts fixed at 15 degrees of knee flexion (fixation protocol 15/15) and again with the
anteromedial and posterolateral grafts fixed at 45 degrees and 15 degrees of knee flexion (fixation protocol
45/15). For both fixation protocols, the knee kinematics and the in situ forces of the reconstructed anterior
cruciate ligament and its individual grafts were measured and collected under an anterior tibial load of 134 N and
combined rotatory loads of 10 N.m of valgus and 5 N.m of internal tibial torque. The data from both fixation
protocols were compared with those of an intact knee.
Results: In response to the 2 external loading conditions, both fixation protocols (15/15 and 45/15) could restore
the knee kinematics to within 2 mm of the intact knee (although statistically significant differences were found
between fixation protocol 15/15 and the intact knee) and the overall in situ forces in the grafts similar to the intact
anterior cruciate ligament. In response to the 134-N anterior tibial load, the in situ forces in the anteromedial graft
for both fixation protocols did not exceed those of the intact anteromedial bundle. But at 30 degrees and 45
degrees of knee flexion, the in situ forces for fixation protocol 15/15 were 20.7% and 22.1% lower, respectively,
when compared with the intact anteromedial bundle. Under combined rotatory loads, the anteromedial graft for
fixation protocol 15/15 had in situ forces that were 45% lower than the intact anteromedial bundle at 30 degrees
of knee flexion. The in situ force in the posterolateral graft for both fixation protocols did not exceed those of the
intact posterolateral bundle, nor were they significantly different from the intact posterolateral bundle at any of
the flexion angles tested.
Conclusion: Both fixation protocols restored knee kinematics without predisposing either graft to failure.
Therefore, knee flexion angles between 15 degrees and 45 degrees for graft fixation were found to be safe for the
anteromedial graft, while 15 degrees of knee flexion was safe for the posterolateral graft.
Clinical Relevance: A range of knee flexion angles that is safe for the fixation of both grafts in double-bundle
anterior cruciate ligament reconstruction was determined.
86
UTILIZATION OF ONLY ONE HAMSTRINGS TENDON FOR ACL RECONSTRUCTION: AN “ALLINSIDE” TECHNIQUE
G. Zamarra+, M.B. Fisher**, G. Cerulli+,** and S. L-Y. Woo**
** Musculoskeletal Research Center/Department of Bioengineering, University of Pittsburgh
Pittsburgh, PA, USA
+
Department of Orthopadics and Traumatology, University of Perugia
Perugia, Italy
Introduction: In recent years, surgeons have favored the hamstrings tendon autograft for anterior cruciate
ligament (ACL) reconstruction over use of the bone-patellar tendon-bone autograft to avoid the associated
complications that could ultimately lead to osteoarthritis 1. However, use of the hamstrings graft also presents
other problems including the loss of active knee flexion at deeper flexion angles as well as muscular weakness,
which could negatively impact knee function and stability 2. Therefore, it has become desirable to preserve as
much of the hamstrings tendon autograft as possible for ACL reconstruction, particularly for young and active
patients.
Recently, a new “All-inside” technique has been developed by one of the authors (CG) in which the femoral and
tibial tunnels are only drilled manually halfway through the bone. As a result, only one hamstrings tendon
(semitendinosus or gracilis) folded in triple or quadruple strands would be needed for ACL reconstruction. In a
clinical follow-up study using this technique, the overall patient satisfaction was good with a rapid return to
previous activity, and muscle function and knee stability were preserved 3.
In order to support these clinical findings, the objective of this laboratory study was to determine if the use of one
hamstring tendon (semitendinosus or gracilis) autograft could restore normal knee kinematics and in-situ force of
the graft to the level of an intact ACL. Since a single hamstring tendon graft can be used in multiple strands in the
“All-inside” technique, we hypothesized that ACL reconstruction using either the semitendinosus or gracilis
tendon grafts could restore the knee kinematics and the in-situ forces in the ACL (similar to previous findings
using a quadrupled semitendinosus and gracilis tendon autograft. Further, since the semitendinosus and gracilis
autografts have similar size and biomechanical properties 4, we again hypothesized that there would be no
significant differences in knee kinematics and the in-situ forces in the grafts between the reconstructions using the
semitendinosus or gracilis tendons alone. To do this, we applied anterior tibial and combined rotatory loads using
a robotic/UFS testing system, and measured and compared the resulting knee kinematics as well as in-situ forces
of the ACL, as well as those the reconstruction grafts.
Experimentation: Ten fresh-frozen human cadaveric knees (54±8.7 years of age; range, 42-64 years) were used
in this study. Each specimen was mounted in a robotic/universal force moment sensor (UFS) testing system 5, 6.
The femoral side was rigidly mounted to the base of the robotic manipulator (KUKA Model KR 210), while the
tibial side was attached to the end-effector of the robotic manipulator via a load cell. Two external loading
conditions were applied to the knee: 1) a 134-N anterior tibial load with the knee at full extension, 15°, 30°, 60°,
90°, and 120° of flexion; and
2) a combined 10 N·m of valgus torque and 5 N·m of internal-external tibial torque at 15° and 30° of knee
flexion. The knee kinematics were compared for the following knee states: 1) intact, 2) ACL-deficient, and
3) ACL reconstruction with the “All-inside” technique using the a) gracilis tendon, or b) semitendinosus tendon
alone. The forces in the ACL and replacement grafts were obtained by cutting the ACL or releasing the grafts and
replaying the knee kinematics to measure the changes in forces.
In the “All-inside” technique for ACL reconstruction, the drilling of the bone tunnels is made with a special
manual drill from the inside of the joint. The graft was first fixed on the femoral side, pulled through the tibial
tunnel, preconditioned through 5 cycles of the full range of knee flexion under a 22-N pretension, and fixed on the
tibial side. The grafts were fixed at 30° of knee flexion, under 22-N of initial graft tension. Statistical analysis was
performed using a repeated measures analysis of variance and a Bonferroni post-hoc test. Statistical significance
was set at p<0.05.
Results: In response to a 134-N anterior tibial load, the anterior tibial translation (ATT) for the intact knee ranged
from 3.4 ± 0.8 mm at full extension to 7.0 ± 2.6 mm at 60° of flexion (Figure 1). After ACL transection, these
values significantly increased by 2- to 3-fold (p <.05). After ACL reconstruction, the ATT was restored to within
1.3 mm of the intact knee using either graft (p>0.05). For example, the ATT at 30° of knee flexion was 7.7 ± 1.5
mm for the semitendinosus graft and 7.3 ± 1.5 mm for the gracilis graft protocols. When comparing the ATT
between the two reconstructions, the maximum difference was only 0.8 mm (p >0.05).
In response to the 134-N anterior tibial load, the in-situ force in the intact ACL ranged from 76 ± 21 N at 120° of
knee flexion to 137 ± 10 N at 30° of knee flexion. For the semitendinosus and gracilis grafts, the corresponding
87
values were 54 ± 22 N to 121 ± 30 N and 66 ± 19 N to 125 ± 96 N, respectively, and were not statistically
different compared with the intact knee (p>0.05). Further, no statistical differences in in-situ force were detected
between the semitendinosus and gracilis grafts (p>0.05), except at 120° of knee flexion where the in-situ force of
the semitendinosus graft was significantly lower than that of the the gracilis graft (p<0.05). However, the absolute
difference was only 12 N, which is within the repeatability of our testing system and is considered clinically
insignificant.
In response to the combined rotatory loads, the coupled ATT of the intact knee was 0.5 ± 1.7 mm at 15° and 2.1 ±
2.5 mm at 30° of knee flexion (Figure 2). After transection of the ACL, the ATT values increased significantly
(p<0.05). With reconstruction, the coupled ATT was restored to those for the intact knee (p>0.05). In the case of
ACL reconstruction with the semitendinosus graft, the ATT was 0.8 ± 2.0 mm at 15° and 2.5 ± 2.4 mm at 30°.
After ACL reconstruction with the gracilis graft the ATT was 0.5 ± 2.0 mm at 15° and 2.3 ± 2.3 mm at 30°. No
significant differences were detected when comparing the two reconstruction procedures to each other (p>0.05).
Under the combined rotatory loads, the in-situ force of the intact ACL was 83 ± 34 N at 15° and 73 ± 36 N at 30°
of knee flexion. The corresponding values for the semitendinosus graft were 74 ± 30 N and 67 ± 35 N, while the
values for the gracilis graft were 85 ± 28 N and 75 ± 30 N, respectively. No statistically significant differences
could be found between the in-situ force of the grafts and the intact ACL (p>0.05).
Discussion: In this study, quantitative data on knee kinematics as well the in-situ force of the reconstruction
grafts suggest that the “All-Inside” technique, with the use of the semitendinosus or gracilis tendon can indeed
restore knee stability and function under both anterior tibial and rotatory loads, confirming our first hypothesis.
Further, both the kinematics of the reconstructed knee and in-situ forces of the semitendinosus and gracilis grafts
were not different from each other, supporting our second hypothesis. As we have previously shown using our
robotic system that a quadrupled semitendinosus and gracilis tendon graft for ACL reconstruction could similarly
restore knee stability and function 7, 8, the current findings support the use of a single hamstrings tendon in the
“All-Inside” technique.
A limitation of this study is that the relatively simple external loading conditions used in this study could only
simulate those used in clinical examinations. As such, the level of loading used in this study may be substantially
lower than that experienced while performing activities of daily living. In addition, this study considered graft
loads much less than the failure load of the graft, which will need to be examined in future experiments.
Nevertheless, this time-zero study was able to support clinical findings of the “All-inside” technique for single
bundle ACL reconstruction, which could potentially allow for preservation of hamstrings tendon and muscle
function important for young and athletic patients.
Acknowledgements: Financial support of National Institutes of Healing (AR41820), Let People Move, LARS and
Innovazione Medica (instrumentation and development of technique)
88
KINEMATIC EVALUATION OF KNEE LAXITIES IN ANATOMICAL DOUBLE-BUNDLE ACL
RECONSTRUCTION
S. Zaffagnini, N. Lopomo, S. Bignozzi, G.M. Marcheggiani Muccioli, D. Bruni, G. Giordano, M. Marcacci
Laboratorio di Biomeccanica, Istituti Ortopedici Rizzoli, Bologna, Italy
Aims: The pivot-shift clinical test is commonly used for the qualitative dynamic evaluation of knee instability and
can be a useful indicator in the prediction of later osteoarthritis; on the other hand anatomical double-bundle (DB)
ACL reconstruction controls anterior-posterior knee instability as also tibial subluxation (highlighted with pivotshift test). The objective of this study was thus to quantify intra-operatively the improvements in knee stability
due to an anatomical DB reconstruction.
Methods: 15 patients (32.8±7.6 y) with isolated ACL injury were included in this study. To evaluate joint
kinematics we used a commercial kinematic navigation system (Klee, Orthokey). The operating surgeon
performed manually clinical tests at maximum force: valgus/varus (VV) at 0° and 30° of flexion, internal/external
(IE) rotation at 30° and 90°, antero/posterior (AP) displacement at 30° and 90° and pivot-shift test. Anatomical
double-bundle ACL reconstruction was, then, performed and the same kinematic tests were re-acquired. For what
concerns pivot-shift test we analysed the decomposition of AP translation and IE rotation with respect to
flexion/extension angle; for each decomposition we evaluated the areas included by the curves and the difference
in the peaks before and after the surgery at a specific flexion angle.
Results: The mean manual maximum AP tibial displacement was 11.9 ± 3.5 mm at 30º of knee flexion and at 9.1
± 3.3 mm 90º mm before ACL reconstruction, 5.3 ± 1.6 mm at 30º and 4.2 ± 1.3 mm at 90º after reconstruction (p
< 0.05); the mean manual maximum IE of the tibia was 27.6 ± 4.8º at 30º and 28.3 ± 3.9º at 90º before
reconstruction, 21.5 ± 5.8º at 30º and 24.0 ± 4.4º at 90º after reconstruction p < 0.05); the mean manual maximum
VV of the tibia was 5.4 ± 1.3º at 0º and 4.4 ± 1.9º at 30º before reconstruction, 3.0 ± 1.1º at 0º and 3.3± 1.1º at 30º
after reconstruction (p < 0.05). Interesting results have been obtained with the analysis of pivot-shift test: coupled
peaks in AP translation, at 25.0±1.8º of flexion, are reduced from 11.3±4.7mm to 3.1±3.1mm (p<0.01) after
reconstruction as also in IE rotation are reduced from 10.8±4.7º to 2.6±4.9º (p<0.01) after surgery. The analysis of
the area highlighted a huge recovery of the dynamic stability of the joint, from 211.5mm*deg to 57.3mm*deg
(p<0.01).
Conclusions: The navigation protocol, applied to anatomical DB ACL reconstruction, allowed a quantitative
evaluation of knee global kinematics before and after surgery; anatomical DB seems to eliminate both static
anterior/posterior instability (Lachman test) and to control pivot-shift (subluxation of the lateral femoral condyle)
reducing tibial translation and controlling tibial rotation.
Key words: Knee Kinematics, ACL DB Reconstruction, Pivot-shift
89
ANATOMIC ACL RECONSTRUCTION: OUR EXPERIENCE
A. Bombara, G. Gitto, *G. Giorgianni, A. Tripodo, *S. Mauro
Istituto Ortopedico del Mezzogiorno d’Italia “F. Scalabrino” Messina
* Dipartimento Specialità Chirurgiche. Sezione di Ortopedia – Università di Messina
Scuola di Specializzazione in Ortopedia e Traumatologia
Anatomical and biomechanical studies have shown that the ACL consists of two distinct bundles, the
anteromedial (AM) and the posteromedial (PL) bundle. Convention ACL reconstruction have focused on the
restoration of the AM bundle. The purpose of the study is to evaluate the outcome of 12 cases of reconstruction of
the ACL with double bundles technique.
The authors have used the Cristel guide. For the reconstruction of the AM bundle the authors have used the ST
tendon and the GR tendon for the reconstruction of the PM bundle.
The fixation method utilized has been the endobutton proximally and the interference screw distally.
The outcome were analysed with the IKDC score radiographic evaluation and KT1000 evaluation.
At the follow up the rotational stably has been evaluated with the pivot shift test.
90
ROTATOR CUFF TEARS: OPEN VERSUS ARTHROSCOPIC TREATMENT.
FOLLOW-UP AT 15 YEARS
A. Pisani, E. Barbieri
Istituto Ortopedico del Mezzogiorno d’Italia “F. Scalabrino”, MESSINA
Materials and Methods: One thousand patients with rotator cuff tears of various degree, treated in last 15 years
with open (650) and arthroscopic surgery (350) were examined with a middle range of 54 months follow-up.
The score of both groups in global revision give evidence of enough good results referred pain lowering, motility
and functional restore.
Results: Our results confirm that there are not significant differences for the same pathology, between open and
arthroscopic procedures. After our prolonged experience, currently we prefer (obviously in the cases of the same
pathology) the arthroscopic technique, for more speed functional restore and lower post-op pain, evidently for the
reduced soft tissues damage. Although the open technique, in our opinion, remains always the best for some
particular indications.
Conclusions: The advantages of the arthroscopic procedures are: best patient’s compliance, for cosmetic matters
(three incisions of less than 1 centimetre each one), complete ROM rescue, possible exploration of the whole
articular district and consequently treatment of eventual intrarticular associated lesions.
Comparing open and closed procedures, for similar pathology, we could observe percent ROM reduction, lesser
of about 5°, with the open surgery treatment.
Keywords: rotator cuff tears, open surgery, arthroscopic surgery
91
HISTOLOGICAL STUDY OF RUPTURES OF THE LONG HEAD OF THE BICEPS TENDON
Umile Giuseppe Longo, Francesco Franceschi, Laura Ruzzini, Nicola Maffulli*, Vincenzo Denaro.
* Department of Trauma and Orthopaedic Surgery, University Hospital of North Staffordshire, Keele University
School of Medicine, Stoke on Trent, ST4 7LN United Kingdom.
Aims: We aimed to examine the relative prevalence of histological changes which have been associated with the
process of tendinopathy in lesions of the tendon of the long head of the biceps brachii and to evaluate the
reliability of histopathologic evaluation of tendon tissue in lesions of the tendon of the long head of the biceps.
Methods: Samples of ruptured tendons were obtained from 51 patients (31 men, 20 women; mean age, 63.2
years) who underwent arthroscopic release of the LHBT because of refractory biceps tendinopathy.
Two LHB tendons were obtained from each of 5 male patients who had died of cardiovascular events (mean age
69.6 years). The tendon was harvested in the postmortem room under sterile conditions.
The slides were interpreted using the modified semi-quantitative grading scale which assesses various aspects of
the tissue.
Results: The mean pathologic sum-score of ruptured tendons was greater than the mean pathologic score of
control tendons (15.76 + 3.11 versus 3.4 + 1.9, P 0.001).
Conclusions: The LHB tendons of patients undergoing arthroscopic
tendinopathy show marked histopathologic changes. On the other hand, the
with no known tendon abnormalities have, as a group, little histologic
Moreover, tendon changes are not only localized at the site of macroscopic
intact tendon portion.
tenotomy for a refractory biceps
same tendons from aged individuals
evidence of degenerative changes.
rupture, but also in the macroscopic
Key words: arthroscopy, shoulder, biceps
92
HISTOPATHOLOGICAL STUDY OF SUPRASPINATUS TENDON RUPTURES
* Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Stoke on Trent, United
Kingdom.
Aims: In the present study, we analyze the histopathological features of surgical specimens of supraspinatus
tendon from patients with rotator cuff tears. We hypothesised that the macroscopically intact supraspinatus tendon
shows changes that may be shown by microscopic examination, and can represent the pathogenic precursor to a
subsequent rotator cuff tear.
Methods: Tendon samples were harvested from 88 individuals who had sustained a rotator cuff tear and
underwent arthroscopic repair of the lesion, and from 5 male patients who died of cardiovascular events. Using
Haematoxylin and Eosin staining, slides were interpreted using a semiquantitative grading scale assessing fiber
structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity,
decreased collagen stainability and hyalinization.
Results: The mean pathologic sum-score of ruptured tendons was significantly greater than the mean pathologic
score of control tendons (15.66 ± 1.82 versus 3.7 ± 2.31, P 0.001).
Conclusions: Tendon changes were not only localized at the site of rupture, but occur also in the middle portion
of the macroscopic intact supraspinatus tendon. We can speculate that it is not necessary during arthroscopic cuff
repair to excessively freshen the torn tendon to bleeding tissue, because, in the presence of a rotator cuff tear, the
macroscopically intact supraspinatus tendon is degenerated as well, and the failed healing response is not limited
to the ends of the torn tendon. Therefore, the tissue at the distal end of the tendon may be left intact at the time of
repair.
Key words: arthroscopy, shoulder, supraspinatus
93
DEGENERATIVE CHANGES IN SUPRASPINATUS TENDON RUPTURES. AN HISTHOLOGICAL
STUDY.
* Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Stoke on Trent, United
Kingdom.
Aims: we aimed to analyze supraspinatus tendon samples obtained from patients undergoing arthroscopic repair
of a rotator cuff tear to examine the distribution of tendinopathic changes associated with this condition.
Methods: Tendon samples were harvested from 31 subjects who underwent arthroscopic repair of a rotator cuff
tear, and from 5 male patients who died of cardiovascular events. Histologic examination was performed using
Haematoxylin and Eosin, Masson´s Trichrome, and Van Gieson’s connective tissue stain. The specimens were
examined under white light and polarized light microscopy. Particular effort was made to asses any evidence of
the changes associated with tendinopathy. This included evidence of thinning and disorientation of collagen
fibers, chondroid metaplasia, lipoid degeneration, and mucoid degeneration.
Results: Within each specific category of tendon abnormalities, the chi square test showed significant differences
between the control and ruptured tendons (P < 0.05). Using the kappa statistics, the agreement between the two
readings ranged from 0.57 to 0.84.
Conclusions: Our study shows that supraspinatus tendon changes in patients affected by rotator cuff tears occur
more often on the articular side of the rotator cuff. The present study provides a detailed structural
characterization of human surgical specimens of supraspinatus tendon from patients with rotator cuff tears, and
may be useful for further investigations on the pathogenesis of rotator cuff tears.
Key words: arthroscopy, shoulder, supraspinatus
94
X CONGRESSO NAZIONALE IORS ~ 3a SESSIONE: COMPLICANZE DEI MATERIALI
GENETICS AND OSTEOPOROSIS
U. Corapi, M. Alesci (Milazzo)
Osteoporosis is characterized by a decrease in bone mass as well as a deterioration of the bone architecture
resulting in an increased risk of fracture. Although the disease is multifactorial, twin studies have shown that
genetic factors account for up to 80% of the variance in bone mineral density, the best known predictor of the risk
of osteoporosis.
The etiology of osteoporosis is clearly multifactorial in nature. While many of the non-genetic factors
contributing to the risk for the disorder have been widely investigated in recent decades, the search for genetic
determinants is relatively new, albeit very intense.
From family histories, twin studies, and molecular genetics, it is quite evident now that some of the predisposition
for osteoporosis can be inherited. Genetic control of osteoporosis is polygenic; the specific genes involved are
beginning to be enumerated.
Both structural and regulatory genes have been implicated in the propensity toward osteoporosis. Variance or
mutation in genes that control bone mass (and its mineral content) and/or bone turnover are obvious candidate
genes. Estimation of the genetic component to the variance found in bone mineral density (BMD), for example,
ranges from 60% to 90%.
The feasibility of detecting associations between fractures and candidate genes is unlikely. Bone mineral density
(BMD) is a predictor of fracture, but association studies with candidate genes -- such as vitamin D receptor
(VDR), estrogen receptor, androgen receptor, and collagen type 1 alpha 1 (COL1A-1) -- have produced
inconsistent and contradictory observations.
Several studies confirmed that bone mass is heritable. The heritability of a trait is not an unmodifiable constant. If
a trait has a high "heritability", this does not mean that little can be done to influence it. About 80% of the ageadjusted variance in BMD is "heritable" or "genetically determined." The view is often expressed that there is,
therefore, 20% of variation left to modify. The implication is that environmental factors account for little
variation between individuals, thus it is difficult to alter BMD in an individual. Look at the increases in total
height during the last 50 years, a highly heritable trait. Heritability is the proportion of total variance attributable
to genetic factors, it is not the proportion of an individual's BMD attributable to genetic factors.
The hunt for the gene for osteoporosis can go on, but it will be fruitless because there is no such thing. There is no
single gene or single environmental factor responsible for osteoporosis. This disease is bone fragility, and it will
have as many causes as there are mechanisms and structural characteristics that influence bone strength.
95
PHYSIOPATHOLOGY OF OSTEOPOROSIS
Salvatore Gatto (Napoli)
Osteoporosis is a syndrome characterized by bone fragility and predisposition to fractures that happen for smalls
traumas too . Whereas some years ago it was thought that it was caused by the gradual decrease of skeletal bone
density during the aging both for men that for women , and quickly after menopause in 20% of women, today it is
known that it is present in bone with low decrease of density too and for that defined osteopenic bone.
The bone fragility can involve all the skeleton but over all same districts , for that reason it seems mainly depend
on alteration of organic and mineral components of bone trabecola. In fact alteration of collagen fibres
production, quality and quantity of proteins that compose the extracellular context too , can modify the hastiness
of mineral salts forming a bone with different mechanicals properties.
So the skeletal composition depends on functioning of others human body organs and more others factors as
drugs , food ,diseases ext. As bone forming happens slowly in the years, it is clear that this factors can explicate
theirs action since tender age.
96
EVIDENCE BASED OSTEOPOROSIS TREATMENT
Sebastiano Bartolone
UO di Reumatologia AOU G. Martino Messina.
The most devastating consequence of osteoporosis is bone fracture, particularly at the vertebral or femoral level.
As defined by WHO, patient with osteoporosis who have had one or more fragility fractures have severe
osteoporosis. Those who sustain a vertebral fracture represent a particularly vulnerable group whose risk of
another vertebral fracture within the following year is increased by a factor of 3-5. In addition, the presence of a
vertebral fracture is associated with an increased risk of hip fracture. In light of these data, treatment of
osteoporosis is extremely important to prevent the fragility fractures. The drugs approved by the US FDA for the
treatment of osteoporosis that have been shown to reduce the incidence of new fractures are: Alendronic acid
(alendronate), risedronic acid (risedronate), calcitonin, raloxifene, strontium ranelate and teriparatide. All these
drugs are able to prevent vertebral fractures in patients with osteoporosis. Only alendronate and risedronate have
been specifically schown to reduce the risk of fracture at the femoral level, but they are controindicated in patients
with upper gastrointestinal diseases. Calcitonin is a good option in subjects with back pain because of its
analgesic effect. Raloxifene is useful when patients have high plasma lipid levels or a family history of breast
cancer. Strontium ranelate is useful in patients who suffer with gastro intestinal disease. Teriparatide is indicate in
subjects with very low BMD and multiple vertebral fractures. Patients characteristics should determine selection
of therapy but the decision is always difficult and fraught with uncertainty.
97
SOY ISOFLAVONES AND PREVENTION OF OSTEOPOROSIS
Herbert Marini
Department of Biochemical, Physiological and Nutritional Sciences,
Section of Physiology and Human Nutrition, University of Messina, , Italy
Osteoporosis is a systemic disease, characterized by reduced bone mass and structural deterioration of bone
tissue. Often presenting as a silent disease, it generally occurs asymptomatically and, consequently, the afflicted
individuals will only be diagnosed after the occurrence of fractures. Menopause is characterized by the loss of
estrogen production by the ovaries. This loss of estrogens accelerates bone loss for a period ranging from 5 to 8
years. Currently available treatments for postmenopausal osteoporosis include hormone replacement therapy
(HRT), bisphosphonates, calcitonin, strontium ranelate, teriparatid and selective estrogen receptor modulators
(SERMs), such as raloxifene. HRT is commonly used to treat postmenopausal bone loss. Without estrogen
therapy, about a third of Central European women become osteoporotic within 15 years after the onset of
menopause. However, even if HRT is effective in reducing menopausal symptoms, it is associated with a higher
risk for breast, endometrial and ovarian cancer as well as cardiovascular disease manifested as venous
thromboembolism and stroke. The increased risks of taking HRT have stimulated the research of therapeutic
alternatives. Isoflavones, a subgroup of phytoestrogens are mainly contained in soy and soy products. The
chemical structure of isoflavones is very similar to that of our own estrogen and depending on the type of
estrogen receptor (ER) on the target cells, isoflavones may reduce or increase the activity of estrogens.
Epidemiological data support a positive relationship between isoflavone intake, fracture incidence, and bone
mineral density (BMD). These data may account, at least in part, for lower fracture rate among Asian women
compared to Western women. Importantly, the relationship between isoflavone intake and bone loss is more
robust in postmenopausal women, suggesting that isoflavone intake restores the metabolic balance of bone
formation and resorption disrupted by menopausal ovarian hormone loss. Although it is difficult to identify the
specific isoflavone(s) most responsible for preventing or restoring bone loss, current evidence suggests that
aglycone genistein may be the most active isoflavone on bone. Although its mechanism of action on bone is not
yet fully understood, it is likely that the positive effects of aglycone genistein are a direct consequence of a
greater binding affinity for the ER- , compared with that for ER- , causing positive effects on trabecular bone
during the mineralization phase without the harmful estrogenic activity on reproductive tissues. Recently, it has
been shown that treatment with pure genistein aglycone increased BMD at the lumbar spine and femoral neck in a
cohort of osteopenic, postmenopausal women with no clinically significant adverse effects on the uterus. More
specifically, genistein aglycone decreased levels of bone resorption markers and increased levels of markers of
new bone formation, producing a net gain in bone mass after 2 years of therapy. This effect was time-dependent,
suggesting that long-term intake of genistein produces ongoing effects on bone metabolism. These clinical data
indicate genistein aglycone as a possible safe therapeutic alternative for the prevention of postmenopausal
osteoporosis. To date, the relationship between isoflavone intake and bone is complex since in a number of
controlled clinical studies contradictory results have been obtained with respect to effects of isoflavones on BMD
or bone markers. These discrepancies could be related to differences in study design, estrogen milieu, metabolism
of isoflavones among individuals and other dietary factors. Collectively, current literature on soy phytoestrogens
based on dietary intervention, epidemiological, as well as other preclinical and clinical data indicates that
aglycone genistein is the most effective isoflavone for managing postmenopausal bone loss.
98
NEUROPATHIC PAIN: THE PATIENT PERSPECTIVE
Paolo Marchettini (Milano)
The current definition of neuropathic pain according to the International association for the study of pain is “pain
initiated or caused by primary lesion or dysfunction of the nervous system. It has been proposed that the
definition should amended withdrawing the term dysfunction that opens the gate for including as neuropathic pain
condition any painful disorder produced by the brain, including psychosomatic somatoform disorders.
Neurological integralists have recently proposed to confine the definition of neuropathic pain to conditions with
“objective evidence of injury of the somatosensory system”. From a pathophysiological perspective defining a
landmark (i.e. the evidence of a neurological injury) guarantees clinicians a working instrument to classify
patients with precision and fruitfully contribute to pain research. Consequently this allows sound epidemiological
quantification of neuropathic pain entities and provides working data to the health payers who decide
reimbursement policies. However, debating about the definition is not merely intellectual onanism. Confining the
focus on the “objective evidence “of nervous system injury excludes from the diagnosis painful conditions
originating from the nervous system in which pain is exclusively a positive neurological phenomenon, not
associated with negative findings (weakness or sensory loss). Such is the case of some trigeminal neuralgias, or
other dynamic sensory disorders where there is transient nerve hypoxia or entrapment. To exemplify with a few
such cases: cauda equina syndrome due to narrow spinal canal or carpal tunnel in the early stages where
conduction slowing might not yet be evident. Additionally, confining the anatomical boundary to the ascending
somatosensory system eliminates awareness and clinical care for diseases affecting the descending inhibitory
system, a research proven existing entity. From the patient perspective a too rigorous definition implies
deprivation of a medical diagnosis of neuropathic pain that could be based on symptoms recognition instead. That
means for the patient remaining excluded from a very much deserved treatment and also be denied access to
reimbursement. Patient and clinical science needs not always and not necessarily match, when in conflict between
these needs the pendulum should preferably swing towards the patient’s side. When in doubt, adherence of the
reported symptom complex to one of the neuropathic pain scales or inventories should be an acceptable
diagnostic criterion in the clinic.
99
MANAGEMENT OF NEUROPATHIC AND NOCICEPTIVE PAIN
Francesco Saverio Venuti
University of Messina, Italy
Pain may be the most common reason patients seek treatment from physicians. When persistent and unrelieved,
pain can frustrate both the person suffering with this condition and the physician trying to alleviate it. Relief from
chronic pain may be particularly difficult to achieve and fraught with misconceptions. Treatment usually requires
trials of physical, pharmacologic, and surgical interventions to achieve resolution. In cases that remain insoluble,
patients must accept partial relief and seek adaptive strategies. The source of persistent pain may be nociceptive
or neuropathic. Both utilize the same nervous system pathways for transmission, but significant physiologic
differences exist in the mechanism through which the body processes and resolves these painful stimuli.
Nociceptive pain that results from a known or obvious source (eg, trauma, cancer metastasis, ischemia, arthritis)
is often easy to identify. Neuropathic pain, however, may occur in the absence of an identifiable precipitating
cause. Neuropathic pain is a chronic pain condition arising from injury or disease of the peripheral or central
nervous system with a substantial impact on quality of life. Neuropathic pain syndromes are characterized by
intense and long lasting pain that is resistant to usual analgesics. Randomized controlled trials have consistently
shown efficacy of tricyclic antidepressants, gabapentin/pregabalin, opioids, tramadol, and serotonin and
noradrenaline-reuptake inhibitors for the treatment of various neuropathic pain conditions, lidocaine patches for
postherpetic neuralgia and cannabinoids for pain in multiple sclerosis. Carbamazepine or oxcarbazepine is the
treatment of choice for trigeminal neuralgia. The efficacy of these drugs in other neuropathic pain conditions as
well as the efficacy of lamotrigine and topical capsaicin is questionable, but they may be useful in a subgroup of
patients. Considerations on the underlying pain mechanisms, immediate and potential long-term side effects, and
price as well as comorbidities and concurrent medications will decide which drug should be the first choice, but
until further progress is made towards a mechanism-based classification, treatment is likely to be a trial-and-error
process where drug combinations may also be considered.
100
OSTEOARTICULAR PAIN
Gianfilippo Bagnato, Gianluca Bagnato, Annalisa Caliri
U.O. Reumatologia, Policlinico Universitario “G. Martino” - Messina
Patients with rheumatic disease experience pain that is most prevalent and disabling symptom and so important
that aspects of the pain experience (eg, severity) are key considerations in clinical decision-making and in the
outcome of trials and interventions. This pain is frequently multifactorial in origin and has both central and
peripheral components; it can be described as a multidimensional experience with many contributing and
interacting biological and pathobiological mechanism: nociceptive, peripheral neurogenic, central affective,
cognitive or relate to the poor concordance between the motor and autonomic neuvous system. Major progress
has recently been made in the elucidation of rheumatic pain processing and, based on this information, it can be
distinct in nociceptive and non-nociceptive. In the former, pain perception is proportional to inflammation or
damage, usually in joint structures (eg, rheumatoid arthritis): pain genesis entails both peripheral and central
sensitization, and also neurogenic inflammation. In this case antinociceptive mechanisms are activated. In the
latter, peripheral noxious stimulation is minimal or unidentifiable, at least at presentation (eg. fybromialgia):
despite the absence of obvious peripheral nociceptive stimulation, features in keeping with central sensitization
have similarly been documented of late, while antinociceptive mechanisms seem defective. However it is
possible that both components (nociceptive and non-nociceptive rheumatic pain) are present in the same patient.
There is compelling evidence that neuroendocrine axes disturbances, particularly hypothalamic–pituitary–adrenal
axis hypofunction, may mediate the onset and persistence of both kind of rheumatic pain, underlining that the
process is affected by the interaction of cognitive, sociocultural and environmental factors of the individual,
which affect the perception and interpretation of pain. Because of the array of conditions that can cause
musculoskeletal pain, patient management must begin with a complete clinical assessment that identifies possible
etiologies and evaluates objective findings against subjective complaints. Besides, patient’s experience of pain
may be similar in different diseases involving bones, joints, tendons, muscles or peripheral nervous system. The
analysis of some characteristics of pain may be helpful in the diagnostic approach. In this perspective pain must
be analyzed according to the type, localization, occurrence, elicitation and concomitant clinical signs. In the
majority of cases this analysis allows a preliminary differential diagnosis which is essential to drive further
assessments.
Since there is an interaction of the somatic components (nociception and its central transmission) with the
cognitive components (belief, mood and behavior), by applying a comprehensive therapy plan of drugs, physical
therapy, and patient education, significant benefits can often be achieved.
101
NSAIDS FOR THE PHARMACOLOGICAL TREATMENT OF PAIN
Francesco Squadrito
Department of Clinical and Experimental Medicine and Pharmacology, University of Messina - Italy.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to treat pain in several muscular and skeletal
disorders and clinicians have relied heavily on their use, as numerous studies have proven these drugs to be
effective. However success of the therapy is frequently limited by injury to the gastrointestinal tract and
complications such as bleeding, ulceration and perforation.
The cyclooxygenase (COX)-2 selective inhibitors celecoxib and rofecoxib have been found to be more effective
than placebo and comparably effective to nonselective NSAIDs in the treatment of pain. However controversy
has been arisen regarding their use as first-line therapy, due to increasing awareness of their cardiovascular risks.
Phase II, phase III and epidemiological studies have pointed out that the efficacy of COX-2 selective inhibitors is
comparable to that of conventional NSAIDs but with lower gastrointestinal toxicity, although the efficacy may
not be demonstrated in every patient. Clinical studies have also shown that renal effects of COX-2 selective
inhibitors are similar to those of conventional NSAIDs. Since adverse effects increase with the degree of renal
impairment, monitoring of renal function should be carried out in patients at risk. Further studies are needed to
determine whether COX-2 selective inhibitors are safer and more effective than non-selective NSAID.
Clinicians need to weigh up the benefits and risks of NSAIDs on a case-by-case basis.
102
NANOMATERIALS IN ORTHOPAEDICS
Nanotechnologies is gaining great interest in many areas of manufacture from electronics, mechanics to energetic.
The importance of modification and characterization of the material nanostructure is related to the fact that the
characteristics are different from those of bulk materials of the same composition, which is mainly because of size
effects, the magnetic and electronic properties, and the role played by surface phenomena as the size is reduced.
The advent of Nanotechnology in Medicine enables a new approach to pathologies from diagnosis to treatment
and follow-up paving the way to Nano-medicine.
Nowadays the most suitable applications of nanomedicine are (i) Magnetic contrast agents in magnetic resonance
imaging (MRI); (ii) Hyperthermia agents, where the magnetic nanoparticles (NPs) are heated selectively by
application of an high frequency magnetic field. (e.g. in thermal ablation/hyperthermia of tumors); and (iii)
Magnetic vectors that can be directed by means of a magnetic field gradient towards a certain location, such as in
the case of the targeted drug delivery. The scientific community is seeking to exploit the intrinsic properties of
magnetic NPs to obtain medical breakthroughs in diagnosis, and drug delivery.
Our approaches in the direction of novel nanomaterials for orthopedics : (i) nanostructured scaffold based on
magnetic properties (in which a controlled supply of selected growth factors to the scaffolds is obtained by
biofunctionalized magnetic nanoparticles (MNP) that can transport the bio-agents (BA) towards the static scaffold
guided by an external magnetic field) and (ii) nanostructured interfaces for joint replacement.
103
THE NEW FRONTIERS IN THE SUBSTITUTIVE SURGERY IN THE WRIST AND IN THE HAND
M. D’Arienzo, N. Galvano, M. Ferruzza, A. Parlato.
Clinica Ortopedica e Traumatologica dell’Università di Palermo
Direttore: Prof. M.D’Arienzo
Via del vespro 129, Palermo 90127.
In the last years there have been made notable progress in wrist and hand prosthesis with the introduction of new
materials. Among these the carbon pirolitico, broadly used already in the prostheses of the cardiac valves, it
belongs to the ceramic biomaterials; it’s highly resistant to the traction and the compression and it has low usury
and mechanical characteristics like a cortical bone. In our study the prostheses realized with this biomaterial, it
has been employed in the articulation of the hand, to the purpose to give back to the patient a good articular
functionality and to reduce the invalidating pain. The results of our study show that the prostheses from us
installed in pirolitic carbon are suitable and they return a good articular functionality and they resolve the pain. It
is important to act before that is established serious osteoarthritis and deformities like the ulnar deviation of the
fingers because it can bring more easily to failures. The disadvantages of the viscoelasticis prostheses model
Swanson in Silastic are absent, what fracture of the plant, progressive contracture of the articular capsule and the
siliconitis.
In the wrist where indications to the substitution protesicas are limited, also because there is an elevated incidence
of complications, numerous types of prosthesis have been employed. They are currently in study prosthesis in
ceramics whose employment can resolve a lot of problem of the other types of prosthesis. To the actual state they
are necessary further clinical studies to verify better the validity of this type of plant but the biocompatibility, the
high resistance to the load and the good clinical results encourage the further use of it in the pathology of the wrist
and the hand.
104
NEW FRONTIERS IN HIP REPLACEMENT SURGERY
A. Toni
Istituto Ortopedico Rizzoli, Bologna
Hip replacement surgery is relatively fast, reproducible, and reliable. Many developments in surgical technique
and implant technology have dramatically improved the durability and longevity of the prosthetic joint system.
New frontiers upon hip prosthesis may be found at different levels: biomaterials, prosthesis design, surgical
approach, patient activity and patient age, both versus younger and ultra older ones.
Nowadays, hip prostheses are much more resistant versus wear then once upon a time: ceramic and metal surfaces
are there to show undetached improvements for debris generation and the disappearance of the terrible osteolysis
that caused so many failure from the past to the present times. Nevertheless, both these new materials still have
minor problems like ions release and LYDIA immunologic reaction (for metals) and liner chipping or squeaking
(for ceramics) that challenge their use in surgery! A new frontier is the combined used of ceramic (head) and
metal (liners) to achieve the same low wear rate, lowering the ions release and the liners chipping and squeaking.
For the historical alternative for hip prosthetic bearing, polyethylene has been improved with the molded and
highly crossed linked polyethylene that shows the most promise, but still its efficacy has to be proven by longer
clinical experience. A totally new product is the low wear polycarbonate polyurethane acetabular cup liner, which
is presently under initial clinical application.
For the prosthesis design, shortest stem as possible and resurfacing are the most updated novelties: the former still
waiting for clinical results, the latter jeopardized by the mid-term results from different hip registers stating some
2-3% higher revision rate versus standard prosthesis.
Mini-invasive surgery had been the most criticized topic of the new century: the use of the most innovative 2incisions surgery (with constant use of x-ray control) has been significantly reduced; still the concept of a tissue
sparing surgery has now been widely accepted, followed by better cosmesis. Even though its primary goal is to
minimize morbidity. This type of surgery is in need of more investigation and instrument modification.
The age of the patients will be the next challenge for orthopedic surgeons: younger and more active patients ask
for the prosthesis to recover their quality of life (sports included) and our prosthesis, even as improved as they are
today, may be not suitable for long lasting service at these very high levels of activity! Either we obtain even
better prosthesis or we may have to set limits for our patients after surgery.
At Mayo Clinic, Pagnano reports remarkably favorable outcome data for patients 90 years of age and older who
had primary or revision total hip arthroplasty (THA). Surgery was performed to treat either advanced,
symptomatic arthritis of the hip or symptomatic failure of a prior total hip replacement. Perhaps this study
provides a glimpse into the future and highlights the challenge that physicians, orthopedists in particular, are
likely to confront. The most rapidly growing segment of the population is the group 85 years of age and older, but
perhaps even more dramatic is the increase in centenarians with a predicted doubling each decade in the future.
105
NAVIGATION AND COMPUTER-ASSISTED SURGERY: WHAT SORT OF PROGRESS FOR
ORTHOPAEDIC SURGERY?
Vincent Mazzone
U.O. Ortopedia – Ospedale Mazzoni
ASUR Marche ZT13
Ascoli Piceno
The Author, on the basis of his own personal experience presents a review of the most recent literature on
computer-assisted orthopaedic surgery. The discussion is mainly focused on those problems and questions which
are arising now as navigation is starting to be more popular.
There is a general agreement that navigation is able to reduce significantly the amount of outliners of experienced
surgeons and beginners as far as alignment is concerned. Papers tend now to study parameters usually less evident
but which appear to have a significant role on the implant survival and on patient satisfaction. Are discussed
papers that emphasize the capability of navigation to assess a correct rotation of both the femoral and the tibial
components, to assess the quality of the data related to the cutted surfaces and to show in quite an unexpected way
advantages of fixed tibial components compared to the mobile ones. The Authors discuss also cases (TKA after
malunion of femoral shaft and TKA after lateral closed wedge HTO) in which a knee arthroplasty is easier and
more accurate with navigation compared to conventional TKA.
Papers about navigation in UKA, HTO and ACL reconstruction are also discussed
There is already a good level of evidence that acetabular cups can be inserted with better accurancy as far as
inclination and antiversion while using navigation. New studies point out that the best unexpected advantage of
navigating an acetabular cup is not achieving a perfect orientation but sparing the bone stock by minimizing the
reaming of the acetabulum. Several reported experiences show that the learning curve of resurfacing of the hip
can be safier and mechanical results of the implant can be far better by computer-assisted surgery.
In the last part of the presentation papers on complications, cost- effect and problems related to the learning curve
of the staff are discussed.
106
UNICOMPARTMENTAL KNEE ARTHROPLASTY: INNOVATIVE RESURFACING PROSTHESIS
S. Zaffagnini, F. Iacono, M. Lo Presti, A. Di Martino, G. Giordano, A. Bondi, M. Marcacci
IX Division
Rizzoli Orthopaedics Institute
Bologna - Italy
From more than 1 year in IX Division of Rizzoli Orthopaedics Institute we use, in selected cases with only one
articular compartment damaged, an innovative resurfacing prosthesis.
We mad a new design of focal resurfacing (MAIOR) that is possible to implant with arthroscopic technique and
that realize both mini-invasive and mini-traumatic surgery.
It is a focal resurfacing device of degenerated areas of the knee joint. It has a biological fixation system with the
aim of stimulating repair of the subchondral bone and better integration and fixation of the prosthesis.
Resurfacing the degenerated area, restoring the shape of the condyle and the direction of the tibial plateau,
restoring the height of the cartilaginous lesion are the basic points of the rationale of this new prosthesis. The
fixation system involves an immediate mechanical press-fit, which is achieved by a self-locking stem system and
a secondary fixation system by bone regrowth obtain by an osteoconductive material inside the stem. The fixation
method of the MAIOR allows higher osteointegration by biomaterials and hydrossiapatite of new generation that
permit a press-fit fixation of the implant.
The new philosophy of this implant consist of early focal treatment with low compromise of bone. Many
surgeons, in case of focal articular damage, prefer to attend to made an unique definitive surgical operation when
the degenerative changes are more severe.
This new implant permit to substitute, also in arthroscopic technique, only the articular damage and to avoid to
attend a more important and diffuse articular damage.
We evaluated clinical and radiographic outcomes of 70 “maior” with mean f.u. 12 months(min 6 – max 18).The
Radiographic study showed no differences between
pre and post-operative measurement. Insall Modificated score system and Visual analogic Scale were used for
related results pre and post operative treatment: Final HSS and VAS score were significantly higher than their
respective preoperative values. No complications( mobilization, infection,..) was evaluated at follow up
The preliminary results are interesting and encouraging with subjective evaluation equal to 85% of normal knee.
107
LE NUOVE FRONTIERE DELLA CHIRURGIA SOSTITUTIVA: LA TIBIO TARSICA
S Giannini, R. Buda, F. Vannini, R. Bevoni, M. Romagnoli, R. Ghermandi (Bologna)
L’artrosi della caviglia di grado severo rappresenta un problema terapeutico complesso per il chirurgo ortopedico.
L’insorgenza di artrosi a livello di quest’articolazione, infatti è prevalentemente secondaria a traumi o fratture ed
è un’evenienza frequente che interessa un’ampia percentuale di pazienti giovani ed attivi. Le opzioni chirurgiche,
in alternativa all’artrodesi, che sacrifica il movimento articolare, sono interventi di sostituzione articolare
mediante protesi o trapianto bipolare osteocondrale totale.
La sostituzione protesica a livello della caviglia, sebbene abbia subito negli ultimi anni diversi perfezionamenti
che hanno portato alla disponibilità di disegni protesici validi e più affidabili, ha indicazioni specifiche e limitate,
e fallimenti dell’impianto sono riportati a medio-lungo termine in particolare modo nel paziente giovane ed attivo.
Il recente uso degli allografts come alternativa ricostruttiva nella cavglia artrosica del paziente giovane e attivo ha
dato risultati incoraggianti ed aperto un nuovo campo applicativo e di ricerca dalle straordinarie potenzialità.
Gli aspetti tecnici e biomeccanici sono punti fondamentali nella riuscita di un trapianto osteoarticolare che
presenta tuttavia una tecnica chirurgica complessa ed un’alta incidenza di complicanze oltre a lunghi tempi di
recupero nel post-operatorio. La preservazione della vitalità dei condrociti e l’immunogenicità del tessuto
condrale rappresentano temi ancora aperti di indagine. La difficoltà e l’impredicibilità del reperimento degli
allografts stessi infine, rappresentano uno svantaggio della metodica che difficilmente potrà venire superato.
Nuovi studi vedono nell’uso delle cellule mesenchimali coltivate su scaffolds strutturali biomimetici
opportunamente sagomabili il futuro della chirurgia sostitutiva articolare, in grado di ovviare agli svantaggi degli
interventi attualmente in uso, mediante la creazione di bioprotesi.
Scopo di questo lavoro è di descrivere lo stato dell’arte della chirurgia sostitutiva nella caviglia artrosica.
108
BIOMATERIALS: ACTIVITY – REACTIVITY
Paolo Tranquilli Leali
Clinica Ortopedica Università degli Studi di Sassari
In the last decades, research on biomaterials, is becoming one of the most exciting areas of clinical applied
research.
Early activities in this field dealt with the selection and characterization of well-established materials already used
for industrial or military applications. These materials (metal alloys, methacrylate, ultrahigh-density polyethylene,
ceramics, etc.) are not originally developed as biomaterials to be used for human repair.
Therefore the research was mostly devoted to the biocompatibility testing in simulated environments (animal
experiments, cell coltures, lubricating fluids, etc.). The main goal was the research of “inertness” of a material,
consequentely intended to be lifelong a permanent implant able to substituted a structure and/or a function
without eliciting any adverse reaction.
In fact an “inactive” material don’t exists and the host , with different degrees of activity, always “reacts” to the
implant.
These aspects can be observed with all the currently used implant materials but in the last decade another concept
was introduced “the function related biocompatibility”: in fact polyethylene is almost the same, but the reactions
in hip and knee arthroplasty are quite different.
The extension of this concept of functionally modulated reactivity carried to the design of materials that can
interact specifically with the biological environment for a given purpose. The materials became scaffolds for
stimulating, conducting, inducing tissue responses and also for delivering drugs, molecules, factors, genes and
everything considered favourable for the healing processes.
During the years the materials at the beginning bioinerts, became biodegradables, later bioactives and nowadays
biomimetics: very smart micro- and nano-biomaterials.
All these efforts are defining an exciting new field of biomaterials science and engineering that targets living
tissues science and technology innovation.
109
PROSTHESIS FAILURE: MATERIALS DUE DRAWBACKS, STATE OF THE ART AND FUTURE
SOLUTIONS
Roberto Chiesa – Politecnico di Milano
Dipartimento di Chimica Materiali e Ingegneria Chimica “G. Natta”
The unique structural, mechanical, and chemical properties of various metals make them well suited for
manufacturing a wide variety of implantable biomedical devices. In particular, their high strength and stiffness are
critical factors where metals are used in load-bearing medical applications, such as where the structural function
of the musculoskeletal system must be restored. As a consequence, orthopedic and dental applications that require
the use of metals commonly opt to use titanium and titanium alloys, cobalt chromium alloys, and stainless steels.
In general, where devices are required to bear high levels of stress with a controlled low strain, the mandatory
dimensional and geometrical requirements dictate that metal-based products offer the only possible solution. In
addition, metals provide numerous other biomedical functions [Leppaniemi, 2000].
The application of metals in biomedical fields is well established, with a number of well-known metal-based
materials used routinely in different situations. Biomedical research involving metals continues to be a very active
area, with much current research devoted to modifying and improving metal surfaces to inhibit or promote
specific tissue reactions. It is likely that a new generation of biomedical devices will result from the current
advances in understanding the complex phenomena that occur at the interface between the metal biomaterial
surface and biological tissues. The ultimate goal is to improve the functional capability of implanted devices over
their lifetime [Pilliar, 1998; Dearnaley, 1993].
A wide variety of surface treatments have been applied to metal components to improve specific properties. In
general, every metal device is subject to an appropriate surface finishing process at the end of its manufacture.
Many traditional industrial finishes, including sandblasting, pickling, etching, degreasing, and polishing, have
been commonly applied to metallic implants. Other surface treatments that are specific to the biomedical field
include the deposition of metals, ceramics, and polymers employing a variety of coating procedures. Primarily,
surface treatments are applied to improve the mechanical performance or biological compatibility, or to trigger
specific biological responses. For example, the surface roughness of non-cemented hip prosthetic stems is
commonly increased by a mechanical or physical finishing process, such as grit blasting, deposition of a porous
metal film, or coating with metal microfilaments or micro-beads. The increase in roughness ensures better load
transfer. It provides a wider contact area and ensures stronger mechanical interconnection with bone tissue that
grows on the metal interface [Hanawa, 1999; Browne, 1994]. Elsewhere, the wear resistance of a hip or knee
metal joint can be improved by polishing and hardening the metal surface. Hard ceramic coatings can help to
reduce metal ion release and improve wear performance of sliding bearing surfaces [Jones, 2001]. Metal
osteosynthesis devices are usually finished by mechanical or electrochemical polishing to increase their fatigue
resistance and to reduce localized corrosion potential.
Although most finishing techniques applied to metallic biomedical devices were not developed specifically with
biomedical applications in mind, a considerable proportion of current biomaterials research is focused on
developing specific new treatments capable of modifying surface properties to address precise biological needs.
Titanium and its alloys are of particular interest due to their superior mechanical properties, optimal
biocompatibility, and especially to the intriguing if somewhat peculiar properties of their surface oxide layers.
These surface layers can be used to modify the interface properties of implants [Southerland, 1993; Ong, 1995].
They are composed mainly of TiO2 and grow spontaneously on titanium in the presence of oxygen to a thickness
of approximately 5 nm. Thermodynamically, they are very stable. Despite their presence, however, some
reactions still occur with surrounding tissue and body fluids [Albreksson, 1983; Nanci, 1999] but an increase in
the thickness of this layer may help reduce dissolution of the titanium and titanium alloy elements in body fluids.
Over the last several decades, there have been a number of attempts to improve the osseointegration of titanium.
These have included treatments developed to modify the surface morphology and topography of metal implants as
well as their chemical composition at the interface. A significant proportion of the non-cemented hip prostheses
currently on the market in Europe have hydroxyapatite (HA) coatings, usually applied by plasma spray
technology [Duheyne, 1988]. Thick HA ceramic coatings, commonly ranging from 40 to 150 µm, improve
implant-to-bone bonding and hence reduce the formation of fibrous tissue at the interface [Chae, 1992].
Nevertheless, some issues remain concerning possible long term failures related to adhesion and cohesion of
plasma sprayed HA coatings and their dissolution rates, which are dependent largely on the crystallinity of the
HA [Bauer, 1991]. These questions have led researchers to look for alternative surface modification methods,
such as electrodeposition, magnetron sputtering, and ion beam sputtering.
Electrochemical coating techniques are proving of particular interest given their versatility. They allow for
cathodic deposition of different calcium phosphate phases and were investigated extensively by many groups in
the 1990s [Shirkhanzadeh, 1995; Redepenning, 1996]. Deposition using cathodic polarization and subsequent
110
thermal treatments allow titanium and other metals to be coated effectively with calcium phosphate. However,
such methods allow only suboptimal mechanical adhesion of the film to the substrate in comparison with plasma
spray coating technologies. Nonetheless, there has been renewed interest in cathodic polarization due to its ability
to coat porous structures and to allow doping of the coating with drugs, other macromolecules, and thermally
degradable materials.
Anodic oxidation is also suitable for modifying titanium surfaces. This technique makes it possible to
predetermine the surface oxide layer thickness, its chemical composition, and its morphology. Anodic spark
deposition or anodic spark discharge (ASD) is a high-voltage anodic oxidation technique that allows a thin,
porous surface layer to be applied to titanium. By combining ASD with other chemical or physical processes, it is
possible to design surfaces of specific chemical compositions and morphologies [Sandrini, 2005; Chiesa, 2007].
The mechanical stability of the anodized layer is very high and chemical species other than calcium and
phosphate can be inserted into the layer, for the triggering of specific biological answers.
References
Albreksson T, Hansson H-A, Kasemo B, Larson K, Lundstrom I. The interface zone of inorganic implants in
vivo: titanium implants in bone. Annals of Biomedical Engeneering 11 (1983) 1-27.
Bauer TW, Geesink RC, Zimmermann R, MaMahon JT. Hydroxyapatite-coated femoral stems: Histological
analysis of components retrieved at autopsy. Journal of Bone Joint Surgery, 1991;73:1439-1452.
Browne M, Gregson P.J. Surface modification o titanium alloy implants. Biomaterials 15 (1994) 894-898.
Chae JC, Collier JP, Mayer MB, Surprenant VA, Dauphinais LA. Enhanced ingrowth of porous-coated CoCr
implants plasmaspray with tricalcium phospate. Journal of Biomedical Materials Research 56 (1992) 93-102.
Chiesa R, Giavaresi G, Fini M, Sandrini E, Giordano C, Bianchi A, Giardino R., In vitro and in vivo performance
of a novel surface treatment to enhance osseointegration of endosseous implants. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2007 Jun;103(6):745-56
Dearnaley G. Diamond-like carbon: a potential means of reducing wear in total joint replacements. Clin Mater.
1993;12(4):237-44.
Duheyne P, Healy KE. The effect of plasma-sprayed calcium phosphate ceramic coatings on the metal ion release
from porous titanium and cobalt-chromium alloys. Journal of Biomedical Materials Research 22 (1988) 11371163.
Jones VC, Barton DC, Auger DD, Hardaker C, Stone MH, Fisher J. Simulation of tibial counterface wear in
mobile bearing knees with uncoated and ADLC coated surfaces. Biomed Mater Eng. 2001;11(2):105-15.
Hanawa T. In vivo metallic biomaterials and surface modification. Materials Science and
Engeneering A267 (1999) 260-266.
Leppaniemi A, Rich N, Pikoulis E, Rhee P, Burris D, Wherry D. Sutureless vascular reconstruction with titanium
clips. Int Angiol. 2000 Mar;19(1):69-74.
Nanci A, Poleo DA. Understanding and controlling the bone -implant interface. Biomaterials 20 (1999) 23112321
Ong JL, Lucas LC, Raikar GN, Connatser R, Gregory JC. Spectrospopic characterization of passivated titanium
in a physiologic solution. J Mater Sci Mater Med 6 (1995) 113-119
Pilliar RM. Overview of surface variability of metallic endosseous dental implants: textured and porous surfacestructured designs. Implant Dent. 1998;7(4):305-14.
Redepenning J, Schlessinger T, Burnham S, Lippiello L, Miyano J. Characterisation of electrochemically
prepared brushite and hydroxyapatite coatings on orthopaedic alloys. Journal of Biomedical Materials Research,
1996;30:287-294.
Sandrini E, C. Morris, R. Chiesa, A. Cigada, M. Santin. In Vitro assessment of the osteointegrative potential of a
novel multiphase Anodic Spark Deposition coating for orthopaedic and dental implants. Journal of Biomedical
Materials Research, 73B, 2, 392-399 (2005)
Shirkhanzadeh M. Calcium phosphate coatings prepared by electrocrystallization from aqueous electrolytes.
Journal of Material Science Letters, 1995;6:90-93
Southerland D.S., Foreshow P.D., Allen G.C., Brown I.T., Willims K.R. Surface analysis of titanium implants.
Biomaterials 12 (1993) 893
111
ALLERGIC REACTIONS AND SURVIVALSHIP IN METAL METAL HIP ARTICULATION IN 100
CONSECUTIVE CASES. A RETROSPECTIVE CLINICAL STUDY AT 13 YEARS FOLLOW UP
F. Randelli, P. Randelli, O. Visentin, L. Banci, M. Monteleone, G. Randelli
Centro di Chirurgia dell’Anca, Policlinico San Donato, San Donato Milanese (Milano)
Aims: Allergic reaction to Metal particles in Metal on Metal coupling has been demostrated in the past years
leading to implant failures. Aims of the present study was to evaluate the rate of allergic reactions and
survivorship of the Metasul Metal-on-Metal total hip replacement after a mean duration of follow up of 13 years
(11-14).
Methods: We retrospectively analyzed 111 patients (149 hips) who had undergone cementless total hip
replacement with Metasul bearings between 1993 and 1996. All the procedures were consecutive and performed
by a single surgeon. The mean patient age at the time of the THR was 50 years (19-74). The study group included
82 women and 29 men. Of the 111 patients, 11 died for reasons unrelated to the hip surgery-prosthesis who was
referred as well functioning, leaving 100 patients (138 hips) available for analysis. Medical history for allergic
reaction, pain, range of motion, and function were recorded and a Harris Hip Score was deduced. Standard
anteroposterior and lateral radiographs were made, analysed and compared with the immediate postoperative
anteroposterior pelvic radiograph and the most current anteroposterior radiograph. Femoral diaphysis bone
ingrowth was evaluated and the stability of femoral component fixation was assessed with a study of the presence
of radiolucent lines;
Results: Of the 149 THRs, 7 hips (7 patients) were revised (4.6%): aseptic loosening of custom made femoral
stem ( 1 hip), aseptic loosening of Zweymüller femoral component (1 hip), traumatic loosening of acetabular
componet (1 hip), mechanical failure of acetabular component (1 hip), septic loosening (1 hip), recurrent
dislocation (2 hips). The whole survival rate of the prosthesis at 5 years, with revision for any reason as the end
point, was 98.7%, at 10 years was 96% and at 13 years was 95.4%. Of the 7 revisions only one seems to be
caused by a hypersensitivity-like reaction to metal-on-metal. Two patients developed skin reactions to metal
without any clinical involvement about the replaced hip. The tribologic survivorship rate of Metasul metal-onmetal bearings at 13 years was 99.3%. At an average of 12.6 years after the operation the average total Harris hip
score for the patients evaluated who did not have a revision was 91.38 (31-100). The majority of the patients
returned to high level of range of motion, flexion > 90 degrees was observed in 91% .
Conclusions: After a mean duration of follow-up of 13 years, aseptic loosening was not the major reason for
failure of Metasul metal-on-metal prosthesis. Of the total 7 failures of the metal-on-metal implants, 6 were not
related to the Metasul alloy articulation. Reducing the bearings wear and the occurrence of aseptic loosening
because of debris, Metasul articulation appears to be particularly indicated for young and more active patients
with a long life expectation. Allergic reaction in Metal on Metal bearing was not a major problem in this
specimen.
112
THE EVOLUTION OF POLYETHYLENE: LESSONS LEARNT
Davide Masoni
Stryker Italia srl
Aims: Despite the success of ultra-high molecular weight polyethylene (UHMWPe) as a bearing material in
implant applications, wear damage has been one of the major factors limiting the service life of UHMWPE
components (i.e. sub-surface cracks and delamination f.i.) that can eventually lead to revision surgery.
Historically osteolysis, caused by UHMWPe wear debris, has been demonstrated to play a major role in implants
failure. Cross-linking UHMWPe has been introduced in the attempt to reduce wear.
Crosslinking improves UHMWPE wear resistance and has seen widespread industry introduction since its first
introduction as a process for hip with limited application to the knee up to present.
Traditional cross-linking is a two step process:
- Radiation or chemical treatment
- Subsequent Heat treatment step
Contemporary highly crosslinked polyethylenes fall into two classes (annealed or remelted).
Annealed PEs still contain free radicals but maintain mechanical strength.
Remelted PEs have virtually no free radicals but reduction in mechanical properties .
Our goal was to develop a highly crosslinked UHMWPE (X3) that maintains strength, reduces wear and has
minimal free radicals.
Methods: The thermal stabilization process used in producing highly crosslinked UHMWPE materials dictates
their physical/mechanical properties. Stryker developed of a new technology (X3) through a sequentially
irradiated material followed by a thermal (annealing) treatment, so that greater cross-linking is achieved with
gradual lower doses of radiation
Results: Based on functional wear and structural integrity performance, we have demonstrated that sequentially
irradiated and annealed ultra-high molecular weight polyethylene maintains structural fatigue strength of
conventional polyethylene, internal in-vitro Lab tests showed a decrease in wear for hip bearing components by
up to 97% and up to 79% for knee bearing components, and resists delamination.
Conclusions:Sequential irradiation and annealing allows for more efficient crosslinking and a lower level of free
radicals in UHMWPE. Annealing rather than remelting maintains the microstructure and hence the
physical/mechanical properties. The sequential irradiation annealing process provides the basis for the next
generation of highly crosslinked UHMWPE materials that combines high oxidation resistance and desirable
physical/mechanical properties.
The X3 sequential crosslink and anneal process for treating polyethylene improves wear performance over both
standard polyethylene, as well as a control highly crosslinked polyethylene.
This is expected to yield a benefit to patients when applied clinically
Key words: UHMWPe, sequential cross-linking, annealing
113
THE CROSS LINKED POLYETHYLENE DURATION IN TOTAL HIP REPLACEMENT
G. Sessa, L. Costarella, RF. Evola, V. Pavone
Department of Medical – Surgery Speciality, Orthopaedic and Traumatologic Section, University of Catania, Italy
Polyethylene (PE) has undergone many changes over the past several years, including modifications in
consolidation process, resin types, sterilization methods, packaging and the quantity of cross linking. Highly
crosslinked ultra high molecular weight polyethylene (UHMWPE) has become the bearing material of choice
for total hip replacement (THR) over the past decade. It showed significant reduction in wear of acetabular liners
in comparison with conventional types, improving strength and fatigue resistance. Its property is related to
components storage and radiation exposure in an oxygen free environment together with post processing to
stabilize free radicals.
Aim of the present study is to evaluate the mid term results of the “DURASUL”, UHMWPE liner, utilized at the
Orthopaedic Clinic, University of Catania since March 1999.
At the Orthopaedic and Traumatologic Clinic, University of Catania, between March 1999 and December 2007,
305 total hip arthroplasty were performed in 275 patients with a mean age of 69 years (range 41- 81 years). The
group of study comprised 134 male and 171 female, operated for degenerative disease in 210 cases and for
traumas in 95 cases, the left limb was involved in 115 cases, the right in 160 while 30 cases were bilateral. All
subjects were operated with a cementless prosthesis for both acetabular and femoral components using always the
Durasul (Zimmer, Usa) liner characterised by: e-beam irradiation type, EtO sterilization method, irradiation
temperature 125° C, total radiation dose level of 95 KGy.
A 28 mm femoral head was utilized in all patients but 44 subjects in which a 36 mm femoral head was implanted
in order to improve the stability and range of motion of the prosthesis.
The implants were followed both clinically, using the Merlè- D’Aubigne - Postel scale (0-18 points), and through
the conventional radiology with serial control at 3, 6 and12 months and every year.
The average follow up was 5 years (range 1- 8 years). Clinical results were good with a mean score that increases
from 6 to 15 points. Radiographically there were no major sign of liner wear or. fracture or periprosthetic
osteolysis. Only 3 implants needed revision due to septic loosening in 1 case and aseptic failure in 2 subjects with
a rupture of a portion of the acetabular component. Moreover radiographic evaluation showed 3 cases of femoral
subsidence, 25 cases of radioluceny lines, 11 cases of heterotopic ossifications, 1 periprosthetic fracture, 12 cases
of cortical hypertrophy around zone 2 and 5 of Gruen.
The UHMWPE has become the bearing material of choice for THR over the past decade and its use in total knee
arthroplasty is increasing. Our series showed good results at mid term follow up, with a significant reduction in
wear. However clinical research must be directed to documenting the long term outcome of the use of various
form of PE in joint arthroplasty.
114
THE BONE CEMENT
G. Maccauro (Roma)
Background: Deposits of metylmethacrylate are always found in the tissue adjacent to the implant when the
components of artificial joint were anchored with bone cement.
In the joint capsule metylmethacrylate fragments are to be found, expecially when the cement bed is disorganised
and destroyed e.g. in loosening or fracture of the implant.
Methods: Periprosthetic tissue membrane were retrieved at the time of revision surgery for aseptic loosening. Six
cemented total hip replacements were revised for aseptic loosening. Stem were made of titanium alloy, ballhead
was made with cobal crhome coupled with cemented polyethylene socket. Tissues were immediately fixed in
formalin. Specimens were then decalcified in EDTA. For histological examination serial sections were made of
material embedded in paraffin and evaluated by light and polarized microscopy.
Results: The larger metylmethacrylate particles are polycyclically shaped and surounded by foreign body giant
cells. The smaller particles are completely incorporated in te palsma of multinucleated foreignbody giant cells.
Infiltration with lymphocyte and plasmacells may occur even without a bacterial infection.
Discussion: Our cases demonstrated that also in case of metylmethacrylate particles an equilibrium between
material wear and tisue reaction is present: low entity of wear material is currently eliminated, if higher entity
arise, the capability of eliminated it will no longer be sufficient and particles accumulated, leading to boneimplant loosening
115
CERAMIC MATERIALS
Corrado PICONI
Università Cattolica del S. Cuore, Facoltà di Medicina e Chirurgia - Università di Tor Vergata, Dipartimento di
Scienze Odontostomatologiche
A number of ceramic materials is used today as osteoconductive or wear-resistant coatings, either in bearings of
orthopedic prostheses. In this last role the most popular material is Alumina (Aluminum oxide, Al2O3) which in
orthopedics is simply “the ceramic ”.
The hardness and stiffness of bearing components is relevant to the wear of the system. Many technical solutions
have been developed to enhance such behavior in bearing materials, but the tribological behavior of Alumina
bearings are still unsurpassed in terms both of wear volume, both of biocompatibility of wear debris, and are the
reference for the development of new bearing thus far.
Today THR are frequently implanted in patients young and active patients, with a long expectation of life. This
makes the selection of the bearing couple more demanding taking into account the role of wear debris in the
cascade of events leading to the implant aseptic loosening, that still remains the main cause of implant revision.
Moreover, it is noted that a number of implants may be operating in off-normal conditions, and that complications
specific to the different bearing type can arise from this situation.
The fracture of alumina THR heads is perceived as an high risk event, but clinical evidences are showing that it is
much less frequent than THR stem or neck fracture, either than the collapse of the UHMWPE inlay in metal
backed sockets. Alumina for clinical implants has been greatly improved in 38 year of clinical use, but it is noted
that no material has unlimited performances especially in the more challenging design. Today head fractures are
usually associate to high-energy shocks, as e.g. in road accidents, or to technical errors, e.g. random head-taper
matching in modular implants. Other fractures that could be ascribed to this class are the chipping of the inlay
rim, taking place intraoperatively or in case of impingement with the implant neck, while the cases of squeaking
recently reported as well as the inlay fractures in sandwich cups looks more related to some implant design than
to the characteristics of ceramic components.
Key words: Hip Implants, Alumina, Ceramic bearings
116
CERAMIC COUPLING WEAR
Nicola Baldini
7^ Divisione di Chirurgia Ortopedica Generale-Traumatologica e Laboratorio di Fisiopatologia degli Impianti
Ortopedici, Istituto Ortopedico Rizzoli, Bologna
Ceramic-on-ceramic is an attractive alternative to conventional metal-on-polyethylene bearing for , but little is
known about the in vivo effects induced by the alumina wear-debris dissemination in the periprosthetic tissues.
Clinical, radiographic, laboratory and microbiological data of 30 consecutive patients with failed alumina-onalumina arthroplasties, 19 with screwed socket, and 11 with press-fit socket, were collected and evaluated.
Retrieved peri-implant tissues and prosthesis wear were analyzed. In all cases, loosening was due to
malpositioning, trauma, primary mechanical instability, or infection. Bone stock was generally preserved, even if
screwed implants showed higher osteolysis levels and mechanical instability, perhaps due to vascular damage and
necrosis. Variable implant wear and tissue macrophage reaction were present but giant cell/osteoclast activation
was never induced. These findings indicate that wear debris and minor periprosthetic osteolysis are the effect
rather than the cause of failure, differently from metal-on-polyethylene bearings, and confirm that press-fit socket
fixation is the preferable socket fixation design.
117
GLI INNESTI OMOPLASTICI NELLE RICOSTRUZIONI OSTEOARTICOLARI
S. Giannini, R. Buda, F. Vannini, R. Bevoni, F. Di Caprio, R. Ghermandi
Introduzione: L’artrosi nel paziente giovane ed attivo rappresenta un problema terapeutico importante per il
chirurgo ortopedico e un campo di ricerca in espansione. L’artrodesi infatti, invalidante a livello del ginocchio e
della spalla, consente di ottenere dei risultati soddisfacenti in termini di risoluzione del dolore, applicata alla tibio
tarsica o alla I metatarsofalangea, a scapito tuttavia di una limitazione funzionale e di una difficile accettazione di
questo tipo di intervento da parte del paziente. Al contrario, la chirurgia protesica è inevitabilmente destinata a
necessità di revisione nel paziente giovane ed attivo. Pertanto, le nuove tendenze terapeutiche si sono indirizzate
alla ricerca di un metodo biologico di sostituzione articolare.
Il trapianto osteocondrale fresco ha dimostrato di essere in grado di offrire cartilagine che sopravvive al trapianto
ed una struttura ossea di supporto in grado di essere riabitata da osso autologo e sta godendo di crescente
popolarità nel trattamento di una specifica popolazione di pazienti, anche se necessita di ulteriori
approfondimenti.
Metodi: 60 pazienti, (età media 38±12 anni) affetti da rispettivamente da artrosi del ginocchio, della spalla, della
caviglia e della I metatrsofalangea, sono stati sottoposti a trapianto osteocondrale bipolare fresco (allograft) delle
articolazioni affette in toto. L’ideale accoppiamento tra allograft e paziente è stato ottenuto tramite TAC e Rx. La
valutazione clinica è stata condotta pre-operatoriamente e ad intervalli regolari mediante scheda AOFAS, in
associazione a valutazioni radiografiche e strumentali mediante RMN e TAC.
Risultati: Il follow up medio è di 30 mesi (range 55-5). Tutti i pazienti hanno dimostrato una buona
consolidazione radiografica ad un tempo medio di 5 mesi. Risultati buoni e ottimi sono stati ottenuti in 38 dei
pazienti a fine trattamento. Dei nove risultati insoddisfacenti, tre sono stati sottoposti a protesi di ginocchio, 4
sono stati sottoposti ad artrodesi di caviglia e 2 sono stati sottoposti a revisione dell’allograft di caviglia. I
rimanenti pazienti sono ancora in corso di trattamento. Un prelievo della cartilagine trapiantata eseguito in tutti i
pazienti ad un anno dal trapianto ha dimostrato una vitalità della cartilagine > 90%.
Discussione: Il razionale dell’allograft è l’evidenza clinica e sperimentale della possibilità di mantenere la vitalità
dei condrociti dopo il trapianto, e la capacità dell’osso autologo di riabitare e sostituire la componente
subcondrale trapiantata. Tuttavia nonostante i buoni risultati di questo trattamento relativamente recente, bisogna
considerare che la tecnica chirurgica è complessa e che l’evoluzione del trapianto può essere influenzata dal micro
ambiente artrosico e da una possibile reazione immunitaria, anche se non eclatante, che possono favorire una
ricomparsa di segni artrosici. Considerevole attenzione deve essere prestata alla selezione del paziente e alla
correzione degli eventuali malallineamenti. Importante è mantenere lo spessore dell’allograft intorno ad 1 cm per
avere una completa rivascolarizzazione del trapianto.
Sono in corso ulteriori studi biologici per valutare l’influenza del micro ambiente e di possibili reazioni
immunitarie allo scopo di migliorare la qualità dei risultati a distanza.
118
X CONGRESSO NAZIONALE IORS ~ SIMPOSIO: LA RIGENERAZIONE TISSUTALE
EFFECT OF STATIC ELECTROMAGNETIC FIELDS GENERATED BY CORROSION CURRENTS
ON HUMAN OSTEOBLAST AND OSTEOCLAST CULTURES
V. Denaro, S. Barnaba, L. Ruzzini, N. Papapietro, A. Sgambato, A. Cittadini
Spinal fusion is performed for a variety of disorders including trauma, degenerative diseases, deformity,
infections and tumors .
There are many reports describing complications following spinal fusion: intraoperative complications such as
dural tears, neurologic injury, epidural bleeding and vascular injury; early postoperative complications (up to 1
month postoperatively) like infections, deep vein thrombosis, kidney failure and other associated medical
conditions and late postoperative complications that often pose challenging clinical situations to the spine
surgeon.
Complications occurring in the late postoperative period are pseudoarthrosis, prosthesis loosening and failure due
to mechanical or infective factors.
Many authors focalized their attention on the pathogenesis of implants loosening and periprosthetic bone loss
concluding that corrosion and wear of metal implants can release metal ions leading to an adverse cellular
response to these degradation products.
Recent studies have pointed out that mechanically assisted crevice corrosion represents the initial failure of
spinal implants, resulting in the local decrease of pH which leads to osteolysis.
Corrosion of orthopaedic implants is a process that occurs when materials of different elettrochemical potential
are placed in close proximity in an electrolytic environment, in this way two metals can form a galvanic cell and
generate electric currents.
We hypothesized that the loss of electrons due to periprosthetic corrosion process could generate electric and
electromagnetic phenomena causing osteolysis.
The aim of this study was to investigate the electrochemical behaviour of spinal implants removed from patients
affected by periprosthetic osteolysis and to investigate the electromagnetic fields generated by corrosion currents
and their effect on human osteoblast and osteoclast cultures.
An electrochemical analysis was performed to characterize the corrosion currents and the electromagnetic field
(SMF) generated around the implants retrieved.
In order to evaluate the potential biological effects of the SMF generated by spinal implants, in vitro cultures of
human osteoblasts and osteoclasts were exposed to a SMF of the same intensity that the one occurring in vivo
around metal devices. Osteoblasts were evaluated for alkaline phosphatase (ALP) activity and mRNA expression
levels of osteocalcin, Runx2 and Collagen I genes. Osteoclasts were evaluated for tartrate-resistant acid
phosphatase (TRAP) activity.
During the electrochemical corrosion tests both the screws and the bar showed a passivation current of 0,312
µA/cm2 and 0.05 µA/cm2 respectively. Through Biot-Savart law we calculated the value of static electromagnetic
field generated around spinal devices.
Osteoblasts exposed to the electromagnetic field displayed a decreased proliferation rate of 10,5% after 48h,
13,5% after 72h, 18,5% after 7 days and 23% after 14 days of exposure.
Quantification of ALP activity of exposed osteoblasts cultures showed a lower activity compared with the
untreated control group at each observation time. RT-PCR demonstrated that Runx2 and Collagen I mRNA were
downregulated following SMF stimulation, while no change in osteocalcin mRNA was observed.
Quantification of TRAP-specific activity of SMF- exposed osteoclast cultures revealed an higher activity
compared with the untreated control group after 7 and 10 days of exposure.
Our findings suggest that continuous low intensity electromagnetic field comparable to the one that generates
around metal devices because of the generation of corrosion currents inhibits osteoblasts differentiation pattern
and increases osteoclasts differentiation rate.
Based on these findings we can hypothesize that aseptic periprosthetic bone loss can be due, at least in part, to the
generation of electric and electromagnetic phenomena around metal devices which lead to a decreased osteoblasts
activity and to an increased osteoclasts activity.
This might contribute at least in part to the reduced periprosthetic bone formation occurring in vivo. We believe
that our experimental findings are of interest with respect to titanium devices failure characterized by
periprosthetic aseptic osteolysis and warrant further studies to better analyze the effects of static electromagnetic
fields generated by corrosion currents on the clinical performance of titanium spine implants.
119
TISSUE REGENERATION: THE CARTILAGE
D. Rosa, G. Di Napoli, V. Bellotti, C. D’Esposito
Università degli Studi di Napoli “Federico II” – Dipartimento di Chirurgia, Ortopedia, Traumatologia,
Microchirurgia e Riabilitazione (D.A.E.R.)
Aims: The treatment of the cartilaginous pathology represents one of the most actual and discussed arguments in
orthopedic surgery. With autologous chondrocyte implantation (ACI) the tissue obtained has biomechanical and
histologic characteristics as similar as possible to those of the healthy cartilage (that is quite difficult to achieve!).
Methods: Since 1997 to 2008, 35 selected patients underwent autologous chondrocyte implantation for the
treatment of large full thickness (1.5-9cm²) of the knee and ankle. 22 patients were affected by OCD and 13
patients were treated for post-traumatic lesions.
Results: Using IKDC score for the pain, we have seen that 84% of patients have evaluated the knee “normal”; at
the clinical evaluation in 92% of cases we observed that the pain was absent or minimal during the examination
of medial condyle. Using Tegner score we observed in 40% of patients a better level of activity.
Conclusions: The articular cartilage and its response to injury remain a very exciting area of orthopaedic
research. Understanding the basic science of repair is the first step in altering the course of damage and hopefully
preventing osteoarthritis. Several surgical techniques have been shown to improve function and athletic activity
after articular cartilage repair. The rate of improvement and ability to return to athletic activity is dependent on
age, length of the preoperative intervals, lesion size, and activity level. Articular cartilage regeneration is an
exciting technique that was recently described and is quickly evolving. Early clinical results for articular cartilage
regeneration techniques are encouraging. Long-term studies in this population will determine the efficacy of
articular cartilage repair to reverse chondropenia and to prevent development of secondary arthritic degeneration.
Key words: Cartilage, Chondrocyte transplantation, A.C.I.
120
TISSUE ENGINEERING: THE BONE
Nicola Specchia
Department of Orthopaedics, University of Ancona
The repair of large bone defects remains a major clinical orthopaedic challenge. Bone is a highly vascularised
tissue reliant on the close spatial and temporal connection between blood vessels and bone cells to maintain
skeletal integrity. Angiogenesis thus plays a pivotal role in skeletal development and bone fracture repair. Current
procedures to repair bone defects and to provide structural and mechanical support include the use of grafts
(autologous, allogeneic) or implants (polymeric or metallic). These approaches face significant limitations due to
insufficient supply, potential disease transmission, rejection, cost and the inability to integrate with the
surrounding host tissue. The engineering of bone tissue offers new therapeutic strategies to aid musculoskeletal
healing. Various scaffold constructs have been employed in the development of tissue-engineered bone; however,
an active blood vessel network is an essential pre-requisite for these to survive and integrate with existing host
tissue. Combination therapies of stem cells and polymeric growth factor release scaffolds tailored to promote
angiogenesis and osteogenesis are under evaluation and development actively to stimulate bone regeneration. An
understanding of the cellular and molecular interactions of blood vessels and bone cells will enhance and aid the
successful development of future vascularised bone scaffold constructs, enabling survival and integration of
bioengineered bone with the host tissue. The role of angiogenic and osteogenic factors in the adaptive response
and interaction of osteoblasts and endothelial cells during the multi step process of bone development and repair
will be highlighted in this review, with consideration of how some of these key mechanisms can be combined
with new developments in tissue engineering to enable repair and growth of skeletal fractures. Elucidation of the
processes of angiogenesis, osteogenesis and tissue engineering strategies offer exciting future therapeutic
opportunities for skeletal repair and regeneration in orthopaedics.
121
OSTEOGENESIS IN BONE TRANSPORT
R. Aldegheri and G. Taglialavoro
Orthopaedic Clinic - University of Padova, Italy
“Bone transport” (BT) is that operating technique proposed in the international literature by G.A. Ilizarov in 1992,
to treat extensive loss of diaphyseal bone, mainly tibial. The technique has met with great success in very many
countries, particularly on the part of surgeons expert in external fixation of circular type.
We too, at the Orthopaedic Clinic of Padova, have applied bone transport in the cases recommended by Ilizarov,
extending it to the femur, experimenting with many variations on the original method, and using both Ilizarov's
external circular fixator and the “unilateral rail” of the External Axial Fixator. The considerable experience thus
acquired allows us to make significant assessments of many factors leading to good-quality results in bone
transport in cases of loss of both tibial and femoral bone. Among these, we analyse the problem of osteogenesis
with changes in the bony segment, presence or absence of infection, and type of fixator used. On the basis of
these observations, we have prepared a protocol and guide-lines when we choose bone transport for
reconstruction of loss of femoral or tibial bone.
We code the variations according to site and extent of bone loss as follows:
- Upward or downward monofocal BT, with unilateral or circular EF;
- Bifocal BT with unilateral EF;
- Twin BT with circular EF.
When we associate extemporary shortening, we ensure that it does not exceed 15% in the femur and 10% in the
tibia. We prefer routine use of the AEF rail model for the femur. Our clinico-radio-ecographic studies have shown
that the process of ossification is characteristic of distractional osteogenesis: the capacity for ossification is
independent of the site of osteotomy or transport variation. Consolidation time, as assessed by the Healing Index,
is similar to that typical of femoral and tibial callotasis. Treatment times become very long as a consequence of
marked extent of lengthening. To reduce them, the authors propose both biological and mechanical operations.
122
TISSUE REGENERATION: THE INTERVERTEBRAL DISC
Vincenzo Denaro, Gianluca Vadalà, Alberto Di Martino, Rocco Papalia, James D. Kang*
Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
*Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Low back pain is one of the major health problems in the Western society as leading source of disability in people
under 45 years of age, and intervertebral disc degeneration (IDD) has been identified as a main cause. IDD is a
relentlessly progressive phenomenon and treatments currently available are focused on treating the symptoms of
IDD rather than the underlying cause. Recent advances in the understanding of the biology of the intervertebral
disc (IVD), have led to increased interest in the development of novel treatments. Stem cell therapy might support
IVD regeneration by overcoming the limitation of self-regeneration, which is considered the main cause of
degeneration mediated functional loss of the IVD. The potential use of different adult stem cell types, such as
undifferentiated and predifferentiated bone marrow-derived mesenchymal stem cells (MSCs), adipose tissuederived stem cells, muscle-derived stem cells has been described with promising prospects. In vivo experiments
on animal model of IDD have shown that MSCs are a feasible and possibly effective approach for the prevention
and treatment of IDD. In vitro studies suggested the regenerative potential of MSCs results from the interactions
with disc cells that up-regulate extracellular matrix synthesis, witch is the results of MSCs differentiation toward
disc cells and their trophic effect upon the IVD. Future work is needed to evaluate the value of different carriers,
stem cell preconditioning, and effectiveness in larger animal models or primates. This paper will show the
contribution of our research group in the field and will review the current existing literature on the status of stemcell based therapy for IDD and the critical issues that still remain before clinical application can be realized.
123
PROSTHETIC RECONSTRUCTION IN LIMB SALVAGE SURGERY OF THE LOWER LIMB:
RESULTS OF A NEW MODULAR SYSTEM WITH POSSIBILITY OF CONVENTIONAL AND
COMPOSITE PROSTHESES
Capanna R, Campanacci DA, Beltrami G, Scoccianti G., Cuomo P.
Department of Orthopaedic Oncology, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
Goals: Prosthetic replacement of articular bone loss is considered a reliable reconstructive technique in limb
salvage surgery. In 2001, a new modular prosthetic system was introduced for reconstruction of the lower limb by
Waldemar Link. The system was designed to replace the proximal femur, the distal femur, the total femur and the
proximal tibia and for intercalary reconstructions of the femur and arthrodesis of the knee. The same modular
system allowed the assembling of an allograft as allograft-prosthesis composite in proximal femur and proximal
tibia replacements. The authors present a review of 190 consecutive cases of prosthetic reconstruction performed
during the last five years with the new modular system.
Methods: Between june 2001 and february 2007, 190 patients underwent prosthetic reconstruction of the lower
limb with the new modular system. There were 98 males and 92 females with an average age of 48 years (11-90).
The diagnosis was a primary malignant bone tumor in 78 cases, a bone metastasis in 70 cases, an aggressive
benign bone tumor in 13 cases, plasmocitoma in 2 cases and linfoma in 1 case. In 26 cases the prosthesis was
implanted as revision of a failed periarticular osteosynthesis (15 cases) or of a failed prosthesis (11 cases). A
proximal femur replacement was done in 100 cases, a distal femur in 63, a total femur in 12 and a proximal tibia
in 6 cases. In 6 cases an extra-articular resection of the knee was performed and both the distal femur and the
proximal tibia were replaced using an allograft-prosthesis composite with the extensor mechanism of the
allograft. In 3 cases the prosthesis was employed to achieve a knee arthrodesis.
Results: Twentyfive major complications were observed in 21 patients. The most frequent complication was
infection of the implant which occurred in 14 cases (7.3%). The mechanical failure of the morse taper of the
prosthetic body occurred in 6 cases (3.1%) requiring surgical revision and component replacement preserving the
stem in place. Aseptic loosening was seen in 2 cases (1%) and prosthetic dislocation in 3 cases (1.5%). At final
follow up, 75% of the evaluable patients presented a satisfactory functional result (excellent or good following
MSTS-ISOLS classification).
Conclusions: In conclusion, the new modular prosthetic system for the lower limb may be successfully
employed for prosthetic reconstruction or for allograft-prosthesis composite assembling. The preliminary data of
the presented series of patients showed satisfactory functional results which need to be confirmed by a long term
follow up.
124
X CONGRESSO NAZIONALE IORS ~ SIMPOSIO: LE TECNICHE MINI INVASIVE
TREATMENT FOR SUPRACONDYLAR FRACTURES OF THE FEMUR: MINIMALLY INVASIVE
PLATE OSTEOSYNTHESIS (MIPO) TECHNIQUE
C.Impallomeni, F.Furci, D. Pontoriero, T.Tavernini
U.O.C. di Ortopedia e Traumatologia, Policlinico Universitario “G.Martino” - Messina
Supracondylar fractures of femur have always been difficult to treat even for the most skilled surgeons.
Treatments depend on the fracture site and characteristics as well as on biomechanical aspects of the fixation such
as bone quality, especially in the elderly.
In recent years, the ongoing improvement in osteosynthesis techniques has produced more reliable and versatile
devices to treat fractures and as a consequence, despite their success, previous methods were abandoned.
Bloodless treatments (included functional treatments) have been supplanted by other methods (Intramedullary
Nailing and External Fixation) that assure better results and reduced recovery time. Similarly, Open Reduction
Internal Fixation (ORIF) has been progressively replaced by less invasive techniques. In fact, latest closed
osteosynthesis systems with angular stability have shown high reliability.
Less Invasive Stabilization System (LISS) has been used for several years in treating distal fractures of femur and
it gives good results in reducing particular fracture patterns such as periprosthetic fractures, which otherwise
should be treated with more invasive techniques.
Between February 2004 and July 2008, 36 supracondylar fractures of distal femur were treated with MIPO and
evaluated according to A.O. classification. Follow up continued until complete recovery (on average, 4-month
follow up). Clinical criteria and radiographic images (Range of Motion R.O.M., fracture alignment, X-ray with
consolidations) were considered in order to evaluate the cases. The results in eleven fractures were classified as
excellent; in sixteen, as good; in eight, as fair; only one elderly woman had a nonunion.
The results of this study cannot be considered as relevant because of the reduced number of cases taken into
consideration. Nonetheless, they support what is described from many Authors previously.
According to our experience, thanks to its characteristics, LISS is a good alternative to both traditional internal
fixation (Intramedullary Nailing and plating) and external fixation, especially in case of complex fractures.
125
LUMBAR INTERSPINOUS DEVICES: INDICATIONS AND LIMITS
M. Comisso, M. Balsano
U.O ORTOPEDIA E TRAUMATOLOGIA
REGIONAL SPINE DEPARTMENT
ULSS 4 ‘ALTO VICENTINO’ SCHIO-THIENE, VICENZA, ITALY
Direttore: Dott.M.Balsano
Introduction: Lumbar interspinous devices are implants which are introduced between the spinous process to
achieve a segmental stabilization , and a widening of the foraminal and spinal canal.
In 1988 Senegas has began to develop the concept of the interspinous devices in the treatment of spinal
instability.
The principles were: reduction of ROM, fixation of instantaneous axis of rotation (IAR) and indirect
decompression of neurological structures.
Nowadays, after 20 years from the first studies, many interspinous devices are available on the market, and offer
many different solutions to the surgeons for recover lumbar pathologies.
The principle indications are:
Microinstability of lumbar spine,
Mild disc lumbar degeneration,
Disc herniations in previous low back pain,
Recurrent disc herniations,
Lumbar spinal stenosis (central and lateral).
Methods: From 2004 to 2007 in our department we have treated 95 patients, (47 Lumbar stenosis, 26 Disc
herniations, 7 Recurrent Disc Herniations, 8 Disc Degeneration, 7 Microinstability). In 85 cases one level has
been instrumented , in 10 cases 2 levels.
The average age of the patients is 40.2 yrs. (range 19-85), 55 females, 40 males.
The patients have been controlled with clinical examination, X-ray, RM at last check and with OSWESTRY and
VAS scale.
Results: We reported short operative times, discharge from hospital very quickly, no significant complications
and marked improvement in ODI and VAS scores that were sustained at least 1 year of follow-up.
Conclusions: Interspinous lumbar devices are nowadays a very useful and safe instruments for recover many
spinal pathologies.
The simple surgical technique and the low complications’ rate justify the increase of their utilization.
In order to achieve the best results, the clinical indications and the selection of the patients must be done with
scientific criterions, otherwise the use of this device can bring to unsuccessful treatments.
126
THE EFFICACY OF KYPHOPLASTY IN THE TREATMENT OF MULTIPLE VERTEBRAL LYTIC
LESIONS
Carlo Ambrogio Logroscino, Stefano Astolfi
Departement of Orthopedic Science and Traumatology Spine Surgery Division Catholic University Rome
Aims: Pain is the main symptom of vertebral osteolysis due to metastatic localitations and multiple myeloma and
is frequently associated to pathologic fractures. Radiotherapy alone usually is not effective for obtaining pain
control and allowing weight bearing. Surgical procedures requiring an aggressive approach and as a consequence
high morbidity are rarely indicated in multiple metastatic patients. PMMA has been widely used in neoplastic and
spinal surgery as a bone filler, for his mechanical and biologic behaviours. The aim of the study was to evaluate
the functional results of percutaneous injection of PMMA for the treatment of multiple vertebral osteolysis of
different aetiology .
Methods: From 2002 to 2008 by Spine Surgery Division of Departement of Orthopaedic Science and
Traumatology of Catholic University 80 kyphoplasty were performed in 35 patients with multiple myeloma or
lytic metastatic lesions, 19 male and 16 female, with a mean age of 63 years ( range 54-76 years). From two to
five vertebral collapse in a single patient were treated. In all procedures was used PMMA as filler and a bioptic
exam of the affected vertebrae was effected. All patients were evaluated post-operative with an anteroposterior
and lateral X-ray at 1 m, 3m, 6 m, 12 m and then every year. The percentage height restored and Cobb angle for
segmental kyphosis were calculated. Clinical outcome was evaluated by SF-36 questionnaire, Oswestry Disabilty
Index, VAS
Results: All the patients demonstrated a significant improvement, in the first six months, in term of pain and
independence in daily life. A slower improvement was evident in the next six months till to constant values at
annual medical controls. Results’ improvement was strictly related to the compliance and response to adjuvant
pharmacological therapy. Clinical improvement was manteined at follow-up. Restoration of vertebral body mean
height showed a mean decrease of 1 mm (range 0-2,7 mm) at latest follow-up radiographic control although
higher than pre-operative. Segmental kyphosis angle correction showed a mean decrease of 2° ( range 0°-2,5°) at
radiographic control at follow-up, respect to the immediate post-operative X-ray, although lower than preoperative.
Conclusions: Kyphoplasty is effective in the treatment of multiple vertebral collapse in multiple myeloma and
lytic lesions. Results achieved with this minimally invasive technique were clinically and biomechanically
satisfactory. Although if unquestioned is its action on pain reduction and quality of life’s improvement, also in
multiple vertebral collapses, other studies have to be conducted to evaluate its action on morpho-structural
restoration of the interested vertebras.
Key words: kyphoplasty, lytic lesions, kyphosis
127
MINI-INVASIVE TECHNIQUE IN SUPRA-ACETABULAR OSTEOLITIC LESIONS
G. Maccauro (Roma)
Background: Osteolytic metastases around the acetabulum are frequent in tumour patients, and may cause intense
and drug-resistant pain of the hip. These lesions also cause structural weakening of the pelvis, limping, and poor
quality of life. Percutaneous acetabuloplasty is a mini-invasive procedure for the management of metastatic
lesions due to carcinoma of the acetabulum performed in patients who cannot tolerate major surgery, or in
patients towards whom radiotherapy had already proved ineffective.
Methods: We report a retrospective study in 25 such patients (30 acetabuli) who were evaluated before and after
percutaneous acetabuloplasty, with regard to pain, mobility of the hip joint, use of analgesics, by means of
evaluation forms: Visual Analog Scale, Harris Hip Score, Western Ontario and McMaster Universities Index of
Osteoarthritis (WOMAC), Eastern Cooperative Oncology Group (ECOG). The results obtained were analysed
using the χ2 Test and Fisher's exact test. Significance was sent at P < 0.05.
Results: Marked clinical improvement was observed in all patients during the first six post-operative months,
with gradual a worsening thereafter from deterioration of their general condition.
Complete pain relief was achieved in 15 of our 25 (59%) of patients, and pain reduction was achieved in the
remaining 10 (41%) patients. The mean duration of pain relief was 7.3 months. Pain recurred in three patients
(12%) between 2 weeks to 3 months. No major complications occurred. There was transient local pain in most
cases, and 2 cases of venous injection of cement without clinical consequences.
Conclusion: Percutaneous acetabuloplasty is effective in improving the quality of life of patients with osteolytic
bone tumours, even though the improvement is observed during the first 6 months only. It can be an effective aid
to chemo- and radiotherapy in the management of acetabular metastases.
128
MINI-INVASIVE THORACO-LUMBAR PEDICLE SCREWS FIXATION
C.A. Logroscino, L. Proietti
Departement of Orthopedic Science and Traumatology Spine Surgery Division Catholic University Rome
Aims: Minimally invasive spine surgery (MIS) has gained popularity in recent years. To date there are several
MIS systems with the capability to perform pedicle screw and rod fixation. Only few of these, nevertheless, are
able to perform multi-segmental pedicle screw and rod fixation . This study examines the advantages, the
accuracy of screws’ positioning and limits of one (Pathfinder) of these systems for the treatment of dorsolumbar spine disorders.
Methods: From 2005 to 2008 by Spine Surgery Division of Departement of Orthopaedic Science and
Traumatology of Catholic University 40 patients 25 male and 15 female, with a mean age of 46 years ( range 2070 years) underwent the index procedure to treat traumatic pathologies of the spine. A maximum of 4 level were
fused with a single instrumentation in a single surgical procedure. All patients were evaluated post-operative with
an anteroposterior and lateral X-ray at 1 m, 3m, 6 m, 12 m and then every year, and with a CT of the treated
levels to evaluate the screws’ positioning. Clinical outcome was evaluated by SF-36 questionnaire and Oswestry
Disabilty Index.
Results: Mean surgical time was 142 min (80-180 min), mean time of percutaneous screws’ positioning was
92min (60-150 min) with a mean blood loss of 120cc. Patients were discharged 6,6 days after procedure (range
3-15 days). There were no intra-operative or post-operative complications. Clinical outcome was very good in 30
patients , good in 9 and satisfactory in 1 patients. Screws’ positioning was very good in 90% of cases, good in 10
% cases.
Conclusions: The advantages of Minimally invasive spine surgery are short surgical time, low blood loss, and
minimal surgical complications with an equal accuracy in screws’ positioning. The new wave of minimally
invasive posterior spinal procedures is not a revolution but is, instead, an evolution of familiar, time-proven
operative techniques. The traditional procedures often involve extensive muscular and bony dissection that can be
associated with significant morbidity and prolonged recovery time. MIS techniques, instead, have been
successfully used for different surgical approaches, such as diskectomy, foraminotomy, fusion, and
instrumentation for the treatment of a wide variety of pathological features, preserving the musculoligamentous
complex and giving, so, to patients a faster complete independence in daily life activities. Our opinion is that the
classical goals of open spinal surgery can now be allowed through much smaller corridors and with far less
iatrogenic damage to the vital dorsal musculoligamentous complex.
Key words: Thoraco-lumbar, Mininvasive, Fixation
129
Comunicazioni sul tema
MICROSTRUCTURAL FEATURES IN CEMENTED FEMORAL STEM REVISION AFTER FAILURE
Rizzi Luigi, Maggi Roberto, Castelli Claudio
Orthopaedic and Trauma Department, Ospedali Riuniti, Bergamo, Italy
Aims: Fatigue fracture of the femoral component of total hip arthroplasty is a rare complication. The reported
incidence of stem fractures range from 0,23% to 11%. Microstructural analisys after removal of these implants are
reported in a few papers. This study aims to investigate metallurgical factors that lead to two different mechanical
failures of cemented revision femoral stem in hip arthroplasty.
Methods: Two cemented revision femoral stems after two different mechanical failure (fatigue fracture and
bending deformation) were referred to the department of Chemistry of the Politecnico of Milan for investigation.
Each component was examined macroscopically to assess for mechanical damage. Stereomicroscopy, SEM,
spectrometry and microhardness tests were performed.
Results: Large grain size and less microhardness tests were found in stem with the bendig deformation due to a
low rate of annealing of the steel. Uniform and fine grain size was found in the stem with the fatigue fracture, but
this stem had a small diameter that caused the rupture.
Conclusions: Several factors are involved in failure of the femoral stem in hip arthroplasty. Our results suggest
that the types of failure of the stem are related to the microstructural features of the steel besides the diameter of
the stem. In hip revision surgery, the femoral component of the prosthesys is always subjected to high stress of
load due to anatomical situation of the femur so therefore microstructural features of the implants should warrant
a greater safety margin and allow a longer survival.
Key Words: Hip arthroplasty, Femoral component, Failure analisys
130
A COMPARISON ON IN VIVO EFFECTS OF DIFFERENT CERAMIC MATERIALS: AN
EXPERIMENTAL STUDY
Giulio Maccauro, Corrado Piconi, Domenico Marotta, Francesco Muratori, Alessandro Sgambato°, Achille
Cittadini °
Catholic University, Institute of Orthopaedics, Roma - Italy
° Catholic University, Institute of Pathology, Roma - Italy
Aim: Ceramic-ceramic coupling is currently used in Orthopaedics in younger patients with longer life expectance,
for the high biocompatibility of these materials. More recently new ceramic materials have been developed with
better mechanical properties in comparison to Alumina, as the Alumina Matrix Composites by Transformation
Toughened and in situ Plateled Reinforcement (ZPTA). The aim of the study was to analyze the biological
properties of this material in comparison to Alumina and Zirconia.
Materials and methods: Cylinders of different ceramic materials were inserted into surgical created defect of
proximal metaepiphysis of New Zealand White adult rabbits to analyze the bone response to ceramics. Percentage
of bone ceramic contact was measured. Massive inflammatory response was analyzed by intraarticular injection
of powders of different materials; while chronic low grade response as the one observed in long term well
functioning implants was tested by implantation of low cohesive ceramic pellets under patellar tendons of rabbits:
thank to leg movements few particles were released in time. Systemic host response was tested analyzing
peripheral organs of animals.
Results: Connective tissue was present at bone ceramic interface whatever materials used: no statically
differences were observed in term of bone ceramic contact among Alumina, Zirconia and ZPTA. Inflammatory
response with new vessels was observed around powders, especially with small diameter; while low cohesive
pellets did not elicited inflammatory response neither systemic toxicity.
Discussion and conclusion: Our results confirm that Alumina Matrix Composites by Transformation Toughened
and in situ Plateled Reinforcement, as well as Alumina and Zirconia ceramics, induces a low inflammatory
reaction in periprosthetic tissues without any systemic toxicity, due to massive or chronic release. So thank to its
higher mechanical properties than Alumina and Zirconia, it should be indicated for ceramic to ceramic coupling
in Orthopaedic Surgery.
131
INTRAMEDULLARY NAILING: CLINICAL STUDY OF FAILURES
G. Taglialavoro
Orthopaedic Clinic – University of Padova, Italy
The intramedullary nail technique, as we know it today, is the fruit of the orthopaedic school of Strasbourg. It
finds application in both traumatology (treatment of fractured long bones) and in orthopaedics (osteotomy and
bone lengthening). Patients treated with this technique normally do not require plaster casts, can stand erect and
walk freely, and can achieve complete functional recovery very rapidly.
Although intramedullary nailing is an easily executed surgical technique and essential in modern orthopaedics, it
is not without its risks and complications. Among the most frequent are anterior pain of knee and shoulder (6771%). Among the most serious are delayed consolidation and pseudoarthrosis (8-16.7%), compartmental
syndrome (2.72%), acute infection (1-2%), osteomyelitis (0-1.5%), fatty embolia (very rare) and algodystrophy
(not encountered).
Adverse events do not necessarily irreversibly compromise results. True failure of the procedure occurs when
the implant has to be removed, and a new and different procedure has to be carried out.
Even when intramedullary nailing is indicated surgically, failure may occur for biological reasons (infection,
pseudoarthrosis, intolerance to synthetic implants) or mechanical ones (breakage of nails or locking screws).
Aim of study: The aim of our work was to verify, quantify and analyse failures after osteosynthesis operations in
the Orthopaedic Clinic, University of Padova, in the last three years (July 1 2005 to June 30 2008).
Materials and methods: All operations to remove implants and carry out new procedures were extrapolated from
the records of our operating theatre.
Results: In the study period, surgical operations for trauma totalled 4,928. Nailing was carried out in 710 cases
(14.41%), counting only operations on the femur (498 fractures; 70.14%), humerus (123; 17.32%) and tibia (74;
10.42%), for a total of 695.
There were 24 recorded failures (3.4%), of which 19 involved the femur (79.1%) and five the tibia (20.9%). No
failure in cases of humerus fractures was recorded.
Of the 24 cases, the most frequent causes of fracture were road accidents, followed by accidental falls and trauma
in the workplace.
In 12 cases, positioning the nail was the primary procedure. In the other 12, nailing was carried out after applying
an AEF (11 cases) and, in only one case, after applying a nail with metal wire encircling the fracture, in another
site.The most frequent post-operative complications were anaemia and hyperpyrexia.
Table 1
Cause of failure
Osteomyelitis
Delayed consolidation
Infection
Pseudoarthrosis
Infected pseudoarthrosis
Loss of reduction of fracture
Shortening
Nail breakage
Necrosis of head of femur
Of 695
2
8
2
5
1
1
2
2
1
%
0.29%
1.00%
0.29%
0.72%
0.14%
0.14%
0.29%
0.29%
0.14%
% of 24
8.33
33.33
8.33
20.83
4.17
4.17
8.33
8.33
4.17
Among the failures (Table 1), delayed consolidation was the most frequent complication, followed by
pseudoarthrosis, osteomyelitis, superficial infection, shortening of limb, nail breakage, necrosis of the head of the
femur, infected pseudoarthrosis, and loss of reduction.
The types of nail involved in failures were: Cannulated Femoral Nail, Cannulated Tibial Nail, Lateral Femoral
Nail, Proximal Femoral Nail A, Proximal Femoral Nail A Long, Unreamed Tibial Nail, Export Tibial Nail, and
Distal Femoral Nail.
132
Conclusions: Although our data are only partially comparable with others in the literature, a failure rate of 3.4%
(24 cases out of 695) shows that osteosynthesis with an intramedullary nail, although still improvable, must be
considered in view of its advantages, and is a technique which cannot be avoided in modern orthopaedic surgery.
Naturally, the general condition of the patient, type of fracture, and characteristics of the nail used must all be
taken into account.
References:
Keene GS, Robinson AHN, Bowcitch MG, Edwards DJ (1999), “Intramedullary nailing techniques”, Key
Topics in Orthopaedic Trauma Surgery, BIOS Scientific Publishers Ltd, Oxford, pp 128-129.
Mousa HA, Hamdan TA, Bakr SS. “Clinical and microbiological evaluation of osteomyelitis”. Bahrain Medical
Bulletin, 2001, 23: 61-65.
G W Wood II, “General principles of surgical treatment”. In: Canale ST. Campbell's Operative Orthopaedics.
10th ed., St. Louis, MI: Mosby; 2003. p. 2705-2711
Mullet H , Al-Abed K, Prasad CVR, O'Sullivan M, “Outcome of compartment syndrome following
intramedullary
nailing
of
tibial
diaphyseal
fractures”
Elsevier,
Oxford,
ROYAUMEUNI2001, vol. 32, no5, pp. 411-413 (9 ref.)
Aso M, Ramaswamy S, Zammit J & King R, “Intramedullary tibial nailing in distal third tibial fractures: distal
locking screws and fracture non-union”, International Orthopaedics (SICOT) (2008) 32: 547–549
Zottola V, Romanò F, Mazza E, “Reamed intramedullary nailing of femoral shaft fractures in adult patients with
multiple orthopaedic injuries”, G.I.O.T. 2004; 30: 144-150
Jarmo AK, Toivanen, Olli V, Pekka K, Yösti L, Seppo E and Markku J, “Anterior Knee Pain After
Intramedullary Nailing of Fractures of the Tibial Shaft”, The journal of bone and joint surgery, 2002
Andreas A, Norbert S, Martin B, Peter-Jürgen M, “Complications after Intramedullary Stabilization of
Proximal Femur Fractures: A Retrospective Analysis of 178 Patients”, European Journal of Trauma Emergency
Surgery 2007; 33: 262–7
133
THE ROLE OF METAL SURFACE FINISHING PROCEDURE IN POLYETHYLENE WEAR OF
KNEE PROSTHESIS
A.Gigante, V. Cigna, # T. Villa, S. Manzotti, * M. Mattioli Belmonte, F. Greco
Department of Othopaedics and *Histology – Polytechnic University of Marche – Ancona –
University of Milan - Italy
#
Polytechnic
Polyethylene wear is one of the main factor that affect the life span of knee prostheses. Three are the possible
kinds of wear: abrasive wear (smoothness of the harder surface, presence of debris), adhesive wear (attractive
molecular forces), fatigue wear (accumulation of minor cracks and subsequent fracture). Strategies to reduce the
polyethylene wear can be based on the evolution of the design and biomechanics of prosthesis (congruent
prosthesis) and/or of biomaterials surfaces (ceramic, high molecular weight polyethylene, finishing of the metal
component).
Prosthesis components (both metal and polyethylene ones) are produced using numerical controlled milling
machines. Using traditional procedures, metal component is polished as they came out from the mill. Microloy®
is a new processing method that, adding a numerical controlled grinding step, eliminate less material during the
polishing passage, thus making the metal component more congruent with the project design. This procedure
allows a reduction of the wear stress between the two (metal and polyethylene) components.
The aim of the present study was to determine if Microloy® procedure can actually reduce the loss of material
due to wear stress in a knee prosthesis.
Microloy® finishing procedure was compared with a traditional finishing method. Pin on disk wear and knee
simulator wear tests (LABS of Polytechnic University of Milan) were performed. Wear was assessed by
gravimetic method and Scanning Electron Microscopy (SEM) associated with morphometric analysis of both the
metal components and polyethylene wear debris (LABS of Department of Othopaedics and Histology –
Polytechnic University of Marche).
Pin on disk test (500,000 cycles) showed a reduction (8%) of material loss from polyethylene pins in Microloy®
procedure compared with the traditional finishing one.
Simulation test performed with 4 axis knee simulator mounting GKS Prime in 37°C bovine serum and 1Hz
simulating walk, (1500,000 cycles) showed a wear reduction (40%) of the polyethylene component in the
Microloy® procedure in comparison with traditional finishing one. A reduction of 2/3 of the wear rate
(Microloy® 0,47mg/10^6cycles vs traditional 1,32mg/10^6cycles) was observed
Metal surfaces SEM and morphometric analysis showed that, after 10^6cycles, Microloy® surfaces were
significantly smoother compared to the ones undergone traditional finishing procedure ones.
SEM and morphometric analysis of polyethylene wear debris isolated from bovine serum used inside the
simulator, digested with proteinase K and filtered through 10um, 1um e 0,4um polycarbonate filters
(polycarbonate cylopore membranes, Whatman International ltd), showed an important reduction of polyethylene
wear debris in the bovine serum from the Microloy® procedure compared to serum from the traditional finishing
ones.
For wear debris with dimension ranging from 0,4um up to 10um (detected in filter with 1um and 0,4um in
diameter) a reduction of the filter area took up by debris higher than 80% was observed in the Mycroloy®
procedure Debris between 1um and 0.4um (0.4um filters) generated by Mycroloy® procedure were also different
in shape.
In conclusion these results indicate that Microloy® procedure significantly reduce the prosthetic components
wear and the production of polyethylene debris in knee prosthesis.
134
EARLY FAILURE OF A LOCKED TITANIUM HUMERAL PLATE
G. Logroscino, M. Venosa, V. Ciriello, S. Spinelli, G. Maccauro, C. Piconi
Department of Orthopaedics, Catholic University, Rome - Italy
Introduction: fractures of proximal humerus are quite common, especially in elder patients with osteopenic bone,
or in young patients as a consequence of high-energy trauma, constituting about 5 % of all fractures.
Many different techniques have been described for the fixation of displaced proximal humerus fractures. Several
locking plates have been designed to improve fracture stability and healing: Recently low-profile locked titanium
plates are available for clinical use on the market. These plates are indicated for fractures and fracture
dislocations, osteotomies and nonunions of the proximal humerus, particularly for patients with osteopenic bone.
The screws in the humeral head are locked into the plate and cannot pull out, and this is a particular advantage in
osteoporotic bone. The screws alternatively diverge and converge, improving the retain in the humeral head. The
plate have a low profile which minimizes the risk of impingement syndrome.
Matherials and Methods: this report describes the mechanical failure of a titanium last generation locked
humeral plate (Philos- Synthes) occurred 3 months after surgery in a 72 year old female patient who had suffered
a two part proximal humerus fracture as a consequence of casual fall. The fracture was classified by the Neer and
AO classification, and the patient was periodically clinically and radiographycally evaluated (Constant score,
VAS, SF-12). The implant was removed and the two parts of the plate, that have been retrieved during the
revision surgery, have undergone optical and instrumental visual examinations (Wild stereomicroscope,
Heidelberg, Germany and by FEG-SEM, LEO 1530, Oberkochen, Germany, equipped with a backscatter
CENTAURUS detector).
Results: the fracture was treated acutely with open reduction-internal fixation plate (ORIF) and than immobilized
in a shoulder cast for 3 weeks. Two months after surgery the patient was very healthy, clinical results were
excellent, and the fracture was apparently radigraphically healed. At three months acute pain developed locally.
The x-ray showed a complete fracture of the plate near the surgical neck. The patient underwent revision surgery
with IM nail and healed 8 months later, with excellent clinical results. The retrieved implant showed that the
fracture took place in the plate section characterized by the presence of two threaded holed. The fracture surface
exhibits striation typical of fatigue rupture. It is noted the absence of metallurgical defects, e.g. tooling defects,
inclusions or porosities.
Discussion and Conclusion: locked titanium plates improved stability and healing of proximal humerus fractures
even in osteoporotic patients. Here it is demonstrated that in certain instances such some unstable oblique
fractures, plate failure can occur due to fatigue stresses. In this cases IM proximal nailing is a valid alternative. In
conclusion, the locked plate under investigation should be avoided in certain proximal humerus fractures.
Keywords: locked plates, proximal humerus fracture, plate failure
135
NEW PERSPECTIVES IN POLYMERIC MATERIALS: PRELIMINARY CONSIDERATIONS ON THE
USE OF THE CROSS-LINKED X3 POLYETHYLENE
M. Ferlazzo, L. Ciriaco, *D. Amato
Casa di Cura COT, Messina
* Dipartimento Specialità Chirurgiche, Sezione di Ortopedia – Università di Messina, Scuola di Specializzazione
in Ortopedia e Traumatologia
Most recent bearing technologies have focused on hip application. While these technologies have helped to
improve hip bearing, they have not been widely applied to knee bearings as wear patterns and modes vary
between hips and knees. Most commercial crosslinking process involve both irradiation and a subsequent
remelting step, which decreases the strength of the polyethylene. The annealing process provides wear reduction
without compromising structural strength. Wear performance technologies for knee applications cannot come at
the expensive of the structural strength of polyethylene. Has been developed, by a factory, a next generation
process with three sequential irradiation/annealing steps to create X3 polyethylene. The X3 polyethylene starting
material is hig quality compression molded GUR 1020 UHMWPE. Compression molded GUR 1020 UHMWPE
is irradiated to 3 MRads followed by an annealing heat treatment process. This step is repeated two more times
for a total of 9 MRads resulting in sequentially crosslinked polyethylene. X3 product components are machined
and packaged in gas permeable packing (gas plasma sterilization is used). X3 polyethylene was created to
improve contact fatigue strength and maintain structural fatigue strength and wear resistance. The resulting highly
crosslinked polyethylene has maintained mechanical strength, demonstrated contact fatigue strength, improve
structural fatigue strength, 70% wear reduction over Crossfire Polyethylene, oxidation resistance in oxygen bomb
accelerated age testing.
Keywords: crosslinked X3 polyethylene, UHMWPE, wear.
136
BIOLOX®DELTA: THE HIGH PERFORMANCE CERAMIC COMPOSITE
F. Macchi
Ceramtec AG Medical Product Division
The introduction of zirconia into an alumina matrix results in a class of ceramic materials with increased
toughness, known as Zirconia Toughened Alumina (ZTA). This first evolution of the ceramic composite achieved
toughness up to 12 MPam1/2 and bending strength up to 700MPa. The stabilising oxide and the constraint exerted
by the alumina matrix on the metastable tetragonal zirconia particle maintains them in the tetragonal state. The
toughening of the material is due to the tetragonal-to-monoclinic transformation of the zirconia particles. Due to
the difference in elastic modulus, between the alumina matrix and the zirconia particles, crack will tend to move
across the less stiff zirconia particles inducing a phase transformation and then dissipating the crack energy. ZTA
has the drawback of the decrease in hardness and it has been balanced with the introduction of small percentage
of chromium oxide (Cr2O3). To increase the toughness of this material have been used the results of the studies on
the toughening of the alumina by addition of whiskers that use the crack energy deflection concept. Elongated
grains (platelets) can be enucleated in-situ within the structure of an alumina matrix ceramic composite during the
sintering exploiting the solid-state diffusion phenomena that take place during high temperature processing. It
lead to a material known as ZPTA (Zirconia Platelet Toughness Alumina BIOLOX®delta). This composite
ceramic is nearly as hard (1975 HV) as alumina, has a bending strength of around 1150 MPa and a fracture
toughness of about 8,5 MPa m1/2. From the stability in wet environment point of view, BIOLOX®delta show a
significant increase in hydrothermal stability due to the Yttria coated powders and the diffusion of Al3+ ions at the
grain boundaries. BIOLOX®delta is opening new and interesting opportunities in the application of ceramics in
arthroplasty like extra long necks (XL), revision ball-heads, thin-walled Ø 36-40-44 mm ceramic inserts, ceramic
knee femoral component and other applications like ankle, shoulder and spine already under study.
137
FAILURES IN THE FIXATION OF THE LATERAL FRACTURES OF FEMUR: OUR EXPERIENCE
Tullio Claudio Russo *, Giuliano Giuca **, Andrea Tumino ***
*Manager Unit of Orthopedics and Traumatology Major Hospital of Modica and Scicli
** Orthopedic clinic, University Polyclinic Messina
***Unit of Orthopedics and Traumatology “ Busacca “ Hospital of Scicli
Aims: Our study has revised n.221 side fractures of femur, treated both with intramedullary and extramedullary
fixation , with the purpose to value its failures and to underline the possible complications owed to the fixation
materials used.
Methods: From April 2004 to June 2008 near the our Unit of Orthopedics and Traumatology, n. 221 side
fractures of femur have been surgically treated : of which 135 females and 86 males, with 83 year-old middle age
for the females and of 75 years for the males. For the treatment of such fractures in 172 cases has been used
through intramedullary fixation ( Endovis, Gamma nail, PFN, Veronail ) and in 49 cases a synthesis through plate
( DHS , PCCP ). The patients have subsequently been revalued after 6 months by the intervention considering
subjective and objective clinical parameters as the range of motion, the pain, the deformity and the limp but also
x-ray parameters through the acquisition of x-ray images in the standard projections. Besides, they have been
considered the cervico diaphysial angle , the position of the cephalic screw, the distale block, the concomitant
presence of coxarthrosis, the diastasis of the stumps of fracture as well as the point of entry of the nail.
Results: Our revision has only underlined 4 cases of mechanical complications of the fixation materials, of which
one due to bad position of the plate, one characterized by the consequent cephalic necrosis, one by the migration
of the cephalic screw hesitated in breakthrough of the acetabulum and finally one by the breakup of the same
implant.
Conclusions: From our study it is deduced as the complications of the actual fixation materials, as it regards the
side fractures of femur, primarily are not due to a scarce validity of the same but rather they depend on a correct
anatomical reduction, on an exact indication to the use of the same and at the end on the surgeon's good feeling
with the materials of fixation.
Key words: femur lateral fracture, intramedullary and extramedullary fixation, mechanical complications of the
fixation materials
138
RADIOGRAPHIC-EVALUATED HEAD PENETRATION FOR CROSSLINKED VS CONVENTIONAL
UHMWPE
Alessandro Bistolfi1-3, Diego Testa1, Giuseppe Massazza1-3, Michele Boffano1, Patrick Pautass2, Carlo Faletti2-3,
Maurizio Crova1
1
Department of Traumatology, Orthopedics and Occupational Medicine, University of Turin, Italy
Department of Diagnostics and Imaging
3
AO CTO/Maria Adelaide of Turin
2
Aims: Laboratory tests and simulators showed superior wear resistance for crosslinked compared to conventional
UHMWPE (Ultra High Molecular Weight Polyethylene); moreover, after over eight years of clinical use there are
no reports of large-scale failures for crosslinked liners due to wear, weakness and ruptures. Although
questionable, the roentgenographic measurement of the penetration of the head into the polyethylene cup
represents an indicator of the performance of the implant.
We compared the penetration on plain radiographs of two groups of respectively crosslinked and conventional
inserts at 5 years.
Methods: From 2000 to 2002 we implanted the TrilogyTM (Zimmer, USA) cup system with crosslinked (over 100
cases) and conventional (over 80 cases) acetabular liner inserted randomly. Radiographic assessment after
implantation have been performed at 3 and 6 months and then yearly, using a digitalized image system. A
dedicated protocol based on Auto-CAD has been used for bi-dimensional measurements by the same operator: the
borders of the cup and of the prosthetic head have been identified using a 3-point circle tool and then the
distances from the head to the metal-back and the head diameter have been measured; finally the numbers have
been converted to real measures with a proportion based on the known head diameter. The radiographs have been
evaluated for signs of mobilization, osteolysis and loosening of the implants too. Repeated measurements of the
prosthetic head have been taken to obtain the error of the protocol and statistical analysis have been performed.
Results: We randomly selected 20 implants with a conventional-UHMWPE insert and 20 with a crosslinkedUHMWPE insert, choosing among the active and healthy patients. No signs of loosening, mobilization or
osteolysis have been detected for all implants. A wear rate of 0.116mm/year for the conventional-UHMWPE and
of 0.067mm/year for the crosslinked-UHMWPE have been detected, respectively. No statistically significant
differences between the linear wear of crosslinked and conventional polyethylene were detected at five years
(p>0.05).
Conclusions: The limited follow up is not sufficient to demonstrate a statistically significant superiority for one
material compared to the other in terms of wear, duration and clinical use; nevertheless crosslinked-UHMWPE
showed a reduced head penetration, which could be explained as an indirect sign of better wear resistance and, in
addiction, some amount of such a penetration for crosslinked material has been correlated to a plastic deformation
and not to wear. Although this is only one of the many variables, roentgenographic measurements might be useful
for clinical practice and for periodical evaluation of the implants. The method does not take in consideration the
role of the different reactivity of the respective debris.
Poster.
Keywords: crosslinked, UHMWPE, wear.
139
EFFECTS OF THERMAL AND MECHANICAL TREATMENT ON THE CRYSTALLINITY OF
CROSSLINKED-UHMWPE
Alessandro Bistolfi1-3, Michele Boffano1-3, Pierangiola Bracco2, Maurizio Crova1, Luigi Costa2, Anuj Bellare3,
Elena Brach del Prever1
1
Department of Traumatology, Orthopedics and Occupational Medicine, University of Turin, Italy
2
Chemistry Department IFM, University of Turin, Italy
3
Department of Orthopedic Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
Aims: It is known that post-irradiation remelting decreases several mechanical properties of crosslinkedUHMWPE (Ultra High Molecular Weight Polyethylene) including fracture toughness and resistance to fatigue
crack propagation; lower crystallinity and ill-formed crystalline lamellae in such crosslinked UHMWPEs are
major factors associated with mechanical properties. It is therefore of great value to increase the crystallinity of
irradiated, remelted UHMWPE. We hypothesized that uniaxial compression and thermal treatments could
disentangle UHMWPE macromolecules and would assist in modifying the crystallinity since disentangled
polymer chains would be more readily incorporated into crystalline lamellae.
Methods: Extruded cylinders of GUR 1050 UHMWPE (Ticona, TX) were gamma-irradiated, remelted at 170°C
for 4 hours, cooled and sectioned in disks with initial height 26mm. The cylinders were placed in a Carver
hydraulic press, heated to 130°C (group-A and B) and to 150°C (group-C) and compressed to several progressive
compression ratios (CR=final height/initial height) and then water-cooled to room temperature. Some of the
samples were taken for analysis (group-A1, group-B1, group-C1) and the rest were thermally treated for 24h at
130°C (A2, C2) and 145°C (B2). A Perkin Elmer Pyris 6 differential scanning calorimeter was used to determine
the peak temperature and the degree of crystallinity for all samples (n=3, heat of fusion of 293 J/g).
Results: The crystallinity in all samples was within a range of 42%-48%. In most cases, there was no statistically
significant increase in crystallinity, at least not in the conditions of these experiments. In fact, the crystallinity
slightly decreased with increase in the compression ratio. The applied thermal treatment increased the crystallinity
for group-C2 and B2 and not for group-A2
Conclusion: Basically there was no difference in crystallinity regardless of compression ratio. Neither postdeformation heat treatment, whether melting or annealing, changed the crystallinity substantially. The conclusion
is that even though it is well known that uniaxial compression leads to disentanglement, and disentangled chains
can easily be incorporated into crystals, leading to increase in crystallinity, it was not effective in increasing
crystallinity in this case because the UHMWPE probably re-entangled during the cool-down in the compressed
state and/or during heat treatment.
Keywords: UHMWPE, crosslinked, crystallinity.
140
SURFACE MODIFICATIONS OF CERAMIC BALL HEADS: AN ULTRASTRUCTURAL ANALYSIS
Giulio Maccauro, Francesco Muratori, Domenico Marotta, and Corrado Piconi
Catholic University, Department of Orthopaedics, Rome - Italy
Introduction: In the early 70 Boutin introduced the use of ceramics in Orthopaedics, thanks to their excellent
biological and mechanical properties. It was remarked that the low friction of Alumina may not induce
polyethylene wear rate, revealing that ceramic ball head should not contribute to implant failure.
Nevertheless surface macroscopic and /or microscopic modifications of ceramic ball head structure may in vivo
abraded polyethylene inlay and contribute to the activation of the cascade processes leading to implant failure.
The aim of the study was to analyze macroscopic and ultrastructural surface modification of Alumina ball heads
to reveal if this ceramic material may have or not a role in PE damage.
Materials And Methods: This study consisted on the analysis of 6 cases of Alumina ball heads retrieved at time
of revision surgery. At time of surgical revision socket ceramic ball heads were retrieved and analyzed following
a specific protocol for prosthetic implants retrieval developed at Authors’ Department. Briefly, materials
underwent visual, stereomicroscopic and SEM or SEM-EDAX (energy dispersive x-ray analysis) coupled
analysis. Visual and stereomicroscopic analysis of ceramic fragments were used to detect the grossly structural
pattern and, in case of fracture, also the fracture pattern. Selected fragments were analysed by FEG-SEM (LEO
1520, Oberkochen, Germany) with backscattered CENTAURUS detector, after a specific procedure of cutting
in oil by a diamond saw to avoid Sub critical Crack Growth during preparation. The microstructure of the samples
was observed on polished, uncoated surfaces after thermal etching at 1500K/1h. Grain size was measured both by
SEM-coupled Image Analysis both according to EN 623-1.
Results: At Scanning Electron Microscopy balls which appeared not macroscopically abraded some holes
scattered on the surface were seen at low magnification. These holes were related to small defects and/or grain
removal due to wear. At higher magnification some grooves with different direction were observed. These
grooves seems to be related to the surface abrasion due to cutting edge of removed particles randomly running on
ceramic surface. On the surface of ceramic grossly abraded (Fig. 1) wide asperities were seen, consisting of
deposits of dark material, combined with grooves differently orientated and voids less than 2 microns in diameter
(Fig. 2). EDAX demonstrated that high entity of titanium particles are related to metal back failure and corrosion
of taper. Ceramic fracture showed in case of alumina typical grains orientation. The analysis of the mechanisms
of failure showed that wide abrasion was related to surgical mistakes (cup angle 60°), and fracture to a material
not manufactured to ISO 6474.
Conclusion: This study revealed that many retrieved ceramic balls appeared macroscopically not abraded, thanks
to high mechanical and biological properties, but also in absence of macroscopic signs of wear may induce PE
wear process. Grossly abrasion is not related to material but to surgical errors.
141
EVOLUTION OF OSTEOSYNTHESIS DEVICES IN TRAUMATOLOGY
C. Impallomeni, D. Pontoriero, F. Furci, L. Accetta
U.O.C. di Ortopedia e Traumatologia
POLICLINICO UNIVERSITARIO “G. Martino” - Messina
In the “modern age” the first techniques of operative fracture treatment were developed at the end of the
eighteenth and in the beginning of the nineteenth century. In all cases, “osteosynthesis” consisted of an open
reduction of the fracture followed by a very unstable fixation with cerclage wires, pins, etc . This method resulted
in the combination of the disadvantages of the conservative and the operative fracture treatment : the fracture had
to be opened with a real risk for (sometimes lethal) infections, the bone healing was disturbed, there was muscular
atrophy and joint stiffness. The successes were very rare and catastrophes were often seen. At the early stage of
plating, firstly invented and described from Lambotte (1907) and later developed from Danis (1949), and the A.O.
Group (1960), mechanical aspects were the focus, and the biology of the bone was sometimes neglected.
In the same years many surgeons started to use rods made in various materials, but Küntscher’s intramedullary
rod (1939) can be considered as the first useful implant in the treatment of diaphyseal fractures.
In the last decades there has been a gradual tendency towards treating diaphyseal and metaphyseal fractures as
biologically as possible. That has been brought home by a critical examination of the results of rigid fixation with
plates and the numerous studies which have demonstrated that the best bone callus is 'naturally' formed.
Among the pioneers of this tendency the work by A. Sarmiento (1970) should be remembered, who in addition
advocated the use of function as an essential moment of the treatment itself. In time Sarmiento's so-called
'functional method' has been slowly but greatly modified in its practical application.
Nevertheless, the principles that inspired it are still valid.
A practical result of this complex train of thought has been the progressive diffusion of nailing as the most
'biological' (or less non-biological) method of treatment .
In diaphyseal and metadiaphyseal fractures intramedullary nailing has become more and more established using
Küntscher nails (or similar) and later using interlocking nails, mainly because nailing does not involve opening
the fracture site and enables earlier function compared to plates.
During the 1980s the AO group started to work on new plate designs to minimize the disadvantages of plating
with respect to cortical perfusion. To overcome the negative effect of compression forces on the periosteum, a
new generation of plates, or internal fixators, were created. The key to these internal fixators is the locking
mechanism of the screw in the implant, which provides angular stability. This technical detail ensures that
compression forces on the bone surface are not necessary to gain stability of the bone-implant construct, which
improves fracture healing and provides an excellent holding force even in osteoporotic bone. The locking
mechanism also makes the technique of percutaneous plating easier because, in contrast to conventional plates,
the fragments are not pulled toward the implant by the locking screws. The LISS plate and the others more recent
devices using poliaxial stability, offer new approaches to trauma surgery especially for metaphyseal fractures of
humerus, femur and tibia.
142
ZIRCONIA HEADS IN PERSPECTIVE: A SURVEY OF ZIRCONIA OUTCOMES IN TOTAL HIP
REPLACEMENT
Maccauro Giulio., Angeloni Marina., Marotta Domenico, Magliocchetti Gianpiero, Piconi Corrado
Università Cattolica del Sacro Cuore, Dipartimento di Scienze Ortopediche e Traumatologia, Roma - Italia
Background: Up to the year 2000, approximately 900,000 zirconia heads has been implanted in THR, with
contradictory results. Some authors recommend to abandon the use of zirconia for the high penetration rate of
zirconia head when coupled with PE, others report very positive clinical results. However, few papers are
reporting clinical failures, leading to hypothesize that a large majority of zirconia-PE bearings are performing in
the intended way. Aim of the study was to measure head-cup penetration rate in an homogeneous series of hip
prostheses with zirconia-PE bearings, as index of increased risk of revision.
Patients: From Jan 2000 to Oct 2001, 26 Synergy THR (Smith&Nephew) with 28mm zirconia heads (Prozyr®)
coupled with metal backed UHMWPE inserts were implanted in 11 male and 15 female patients with average age
of 58 years (23 osteoarthritis, 1 osteonecrosis, 1 rheumatoid arthritis, 1 revision surgery). Patients were followed
radiographically at 1, 3, 6 months postop, then sixmonthly. Average follow-up was 5.8 years. SF-36 schedule was
administered to the patients.
Methods: Penetration of zirconia head in PE insert was measured on standard AP XRays using a specially
developed software based on Delphi (Borland Corp). The penetration was measured as displacement of head inlay rotation centres. Pixel-to-mm conversion is based on the knowledge of nominal head diameter.
Results: In our series we obtained good clinical outcomes (good range of motion and no functional activity
limitation) within the time limits of the follow-up. No head fracture, nor osteolysis had been observed thus far. As
only complication was reported a recurrent dislocation treated incruently. We observed a penetration rate of
zirconia ball heads (range: 100-170 µm/yr) lower than the critical limit for the expectation of implant failure.
The literature concerning clinical wear of zirconia-PE bearings reports contradictory results, likely due to the
dishomogeneity in the implants (different technology stage and manufacturing processes of zirconia heads,
different PE sterilisation routes) and in terms of patients (age, activity) implant design, implant fixation, surgical
technique. We remark the importance of considering homogeneous series of implants, made of high quality
materials.
On the basis of our results we confirm the opportunity to strictly follow patients with zirconia-PE bearings to
achieve long-term follow up data, and we remark that low clinical wear observed in our series challenges the
reports of surface degradation due to lack of stability of zirconia ceramics.
143
X CONGRESSO NAZIONALE IORS ~ SEZIONE POSTERS
LOOSENING AND OSTEOLYSIS WITH METAL-ON-METAL PROSTHESES AT MEAN TWELVE
YEARS FOLLOW-UP
Sara Scarponi, Renato Scarponi.
Ex Department Orthopaedic Passera, Niguarda Hospital, Milano.
Aims: Second-generation metal-on metal total Hip Replacement were introduced in the early 1990 ‘s , with the
aim to eliminating polyethylene wear. The goal of present study is to evaluate the durability of implants at
medium term in a series of patients managed with one of these implants.
Methods: Between 1993 and 1998, 46 total hip replacements in 42 patients were operated with use of cementless
METASUL. In 41 cups implanted with press-fit tecnique, the polyethylene liner included a metal inlay (metasul)
coupling with metal femoral head. Clinical and radiographic evaluation was performed at mean twelve years post
operatively. The head diameter was 28 mm for 40 cups and 38 mm for 6 cups, all cementless.
Results: None patient was revised for infection, aseptic loosening or other reasons. The survival rate of these
prostheses as whole of twelve years, without revisions, was 98%. The survival rate of the cup was 0.98 (100%
confidence interval, 0.90 to 100). Linear or expansile osteolysis, or both, was observed on the radiographic of five
these 46 Hips. One large defect was present in trochanteric area, the others osteolysis were type 3A or less, based
on the Paprosky system.
Conclusions: After a mean duration f.u. of twelve years, aseptic loosening was present, but no rapresenting
failure of implants. The large osteolysis was in trochanteric area, in supero-lateral of rim and in supero-medial of
rim, valutaded with Parosky systhem. Second generation metal-on metal bearing were introduced with great
optimism in the 1990’s as an improvement over other types of bearing. Our results to date for Metasul implants,
are better than those reported with metal-on polyethilene coupling, in similar period of f.u. The extremly low
weare rate is the probabylity of the long survival at the intermediate-term of f.u.
Key words: Metal-on Metal, Osteolysis, Weare rate
144
KNEE RE-REVISION ARTHROPLASTIES COMPLICATED BY INFECTION: IS ARTHRODESIS
NOW-A-DAYS AN ACCEPTABLE TREATMENT ?
M. Alesci, D. Lo Vano and M. A. Rosa
Surgical Specialties Department - Orthopaedic Section - University of Messina – Italy
Introduction and Methods: Authors have made a retrospective study of the last 7 years (from 2000 to 2007) on
20 patients, mean age 71, the gender was female in 12 and male in 8, in 14 cases the left knee and in 6 the right
one was involved. All patients underwent to total knee arthroplasties (TKA) and all of them were complicated by
a “late” infection. Re-revision with a “two step surgery” could not stop the infection and arthrodesis with different
techniques was finally performed. Follow-up ranged between 6 and 48 months and good results were obtained in
all cases. No particular complications were observed except in 1 case where dehiscence of the surgical wound
verified at the removal of stitches, healing resulted after few cycles of medications.
Arthrodesis was performed employing :
• An axial external fixation in 1 case,
• Axial external fixation associated with two crossed Steinmann nails in 4 cases,
• Femur-tibial long locked nail in 1 case,
• Ilizarov method external fixation in 2 cases,
• In the great majority of our series, 12 cases, arthrodesis was performed with a modular prosthesis and in 2 cases
of them the prosthesis was “silver” coated.
Antibiotic therapy has been administered for a longterm period, of at least three months, in association with
arthrodesis following to the individuation of responsible pathogen.
Results and Conclusions: In all cases arthrodesis resulted for all patient the end of suffering also if it meant the
loss of the articular function. This technique was chosen by the patient to avoid amputation. In Authors opinion
arthrodesis in infected re-revision arthroplasties must be considered as a long lasting surgery.
145
MECHANICAL AND BIOLOGICAL PROPERTIES OF ANTIBLASTIC LOADED BONE CEMENT
G.Maccauro 1, A. Spadoni 1, F.Muratori 1, M. Casarci 1, A. Sgambato 1, C. Piconi 1, M. Alesci 2, D. Lo Vano 2 and
M.A. Rosa 2
1
Section Orthopaedics - University of Messina – Surgical Specialties, Messina (Italy)
2
Institute Orthopaedics Catholic University Rome (Italy)
Introduction: PMMA is currently used as grouting agent of arthroprostheses and for filling of bone cavities after
bone curettage. It is moreover used as a carrier of antibiotics in the local treatment of bone infections and it has
been proposed as a carrier of antiblastic drugs in the local treatment of bone metastases.
Aim: The Authors demonstrated the suitability of adding different chemotherapeutic drugs to acrylic cement for
the treatment of bone metastases. The best results so far have been obtained with methotrexate (MTX ) for which
diffusion from the implanted cement has been demonstrated both in vitro and in vivo. In this study the suitability
of adding MTX Lo acrylic cement as local adjuvant chemotherapy was investigated.
Methods: Using an in vitro model of human breast cancer cells the Authors demonstrated that the drug is eluted
in an active form able to exert a cytotoxic effect over a long period of time. The use of different concentrations of
drug on the kinetic of elution and on the mechanical properties of cement was also evaluated.
Results: The results obtained suggest that the release of MTX is higher at the beginning and progressively
decreases over time being affected by the concentration of drug used. Our results also demonstrated that the
addition and the subsequent elution of MTX does not alter the compressive properties of the cement.
Conclusion: These findings confirm the suitability of MTX-supplemented cement and support its use as an
effective aid for the management of bone metastases requiring surgical curettage and acrylic cement implantation
for structural support.
Keywords: methotrexate (MTX ), acrylic cement, bone metastases
146
CHRONIC OSTEOMYELITIS IN DIABETIC FOOT: MINOR AMPUTATION AND BONE
RESECTION
M. Galli, M. Alesci*, D. Lo Vano* and M.A. Rosa*
Department of Orthopaedic Sciences -Catholic University , Rome - Italy
*Surgical Specialties Department-Orthopaedic Section, University of Messina - Italy
Introduction and Methods: Foot bones infection is common in the diabetic patient and represent a rapidly
evolving condition in the presence of ischemia. 63 patients were operated on and followed for at least one year
after surgery. 33 single ray amputation, 21 metatarsal resection and 9 partial calcanectomy gave an high rate of
favourable results. Early recognition and prompt treatment is mandatory in order to avoid the loss of the limb or
the patient itself.
Discussion and Conclusion: Surgical removal of all necrotic and infected tissue and drainage of pus should be
performed immediately without waiting for revascularization. Adjunctive surgery will follow revascularization
which is needed to save the limb. In the absence of significative ischemia or after an effective revascularization,
management of osteomyelitis traditionally involves surgical removal of infected bone, combined with antibiotic
therapy. Foot deformities resulting from surgery may cause reulceration and a high morbility that may eventually
fail to save the leg. Thus, the aim of surgery should be to control the infection, but also, to preserve a functional
limb. Various demolitive interventions with limited loss of bone segments of the forefoot or hind foot have
demonstrated to be well tolerated. Results are better if the patients is inserted in a post-operative protocol of
surveillance with appropriate prescription of orthosis. The best results are achieved within a multidisciplinary
setting.
147
X CONGRESSO NAZIONALE IORS ~ AUTHORS’ INDEX
(Messina)
(Messina)
(Messina)
(Padova)
(Messina)
(Messina)
(Bergamo)
(Catania)
(Genova)
(Udine)
(Messina)
(Roma)
(Bologna)
(Bologna)
(Roma)
(Perugia)
(Ancona)
(Varese)
(Milano)
(Roma)
(Bologna)
(Ancona)
(Cortina)
(Messina)
(Roma)
(Roma)
(Brescia)
(Messina)
(Vicenza)
(Brescia)
(Milazzo)
(Torino)
(Catania)
(Messina)
(Torino)
(Firenze)
(Messina)
(Messina)
(Messina)
(Pozzuoli)
(Messina)
(Messina)
(Palermo)
(Napoli)
(Bologna)
(Milano)
(Bari)
(Roma)
(Ancona)
(Messina)
(Perugia)
(Messina)
(Roma)
(Roma)
50
130
65
42,53
47
32
(Messina)
31
Amadeo G.
(Messina)
16
Amato D.
(Messina)
16,65
Anastasi G. P.
(Roma)
83
Angeloni M.
(Brescia)
86,87
Apostoli P.
(Messina)
20
Arrabito G.
(Roma)
11
Astolfi S.
(Roma)
110
Aulisa A. G.
(Bologna)
28,75,79,80
Avnet S.
(Bologna)
17
Baglio S. R.
(Messina)
134
Bagnato G.
(Messina)
45
Bagnato G. F.
(Bologna)
136
Baldini N.
(Vicenza)
135
Balsano M.
(Milano)
23,119,131
Banci L.
12
Barbanti Brodano G. (Bologna)
(Messina)
32
Barbieri E.
(Roma)
126
Barnaba S.
(Messina)
12
Barresi V.
(Messina)
95
Bartolone S.
(Milano)
140
Bastoni S.
(Rennes, Francia)
114
Beaufils P.
74
(Boston, USA)
Bellare A.
52,139,140
Bellina G. E.
(Roma)
37,72,124
Bellotti V.
(Napoli)
27
Belot N.
(Rennes, Francia)
27
Beltrami G.
(Firenze)
21,27
Benedetti
46
57
Valentini M.
(Roma)
42
108,118
Bevoni R.
(Bologna)
18
63
Biagini R.
(Roma)
104
89
Bignozzi S.
(Bologna)
120
52,139,140
Bistolfi A.
(Torino)
16
22
Bitto A.
(Messina)
62
52,139,140
Boffano M.
(Torino)
54
84
Boisrenoult P.
(Rennes, Francia)
57
90
Bombara A.
(Messina)
IV
25
Bonaspetti G.
(Brescia)
22
107
Bondi A.
(Bologna)
86
14,15
Boriani S.
(Bologna)
32
140
Bracco P.
(Torino)
55
140
Brach del Prever E.
(Torino)
23,77,92,93,
21,27
Briuglia S.
(Messina)
94,119,123
89
Bruni D.
(Bologna)
17,66
108,118
(Bologna)
Devescovi
V.
Buda R.
(Bologna)
47
20
(Udine)
Di
Benedetto
P.
Busilacchi A.
(Ancona)
15
21
(Ferrara)
Di Bona C.
Calabrò A.
(Messina)
118
76
(Bologna)
Di Caprio F.
Calamoneri E.
(Messina)
107
101
(Bologna)
Di Martino A.
Caliri A.
(Messina)
123
37,64,70,72,124 Di Martino A.
(Roma)
Campanacci D.A.
( Firenze)
120
23
(Napoli)
Di Napoli G.
Campi S.
(Roma)
45
37,70,72,124
(Messina)
Di
Paola
C.
Capanna R.
(Firenze)
77
28
(Roma)
Dicuonzo
G.
Caputo S.
(Roma)
15,48
146
(Bologna)
Donati
D.
Casarci M.
(Roma)
49,75,79,80
66
(Roma)
Guzzanti V.
Donzelli O.
(Bologna)
107
63
(Bologna)
Iacono F.
Erba F.
(Roma)
50
48
(Messina)
Iaria C.
Errani C.
(Bologna)
71 A
114
(Messina)
Ieni A.
Evola R.F.
(Catania)
125,142
40
(Messina)
RESEARCH
SOCIETY
(I.O.R.S.)
Impallomeni
C.
Fabbriciani C. ITALIAN
(Roma)ORTHOPAEDIC
57
68
(Roma)
Ippolito
E.
Fadda G.
(Roma)
123
75,79,80
(Pittsburgh,
USA)
Kang
J.
D.
Falciglia F.
(Roma)
Accetta L.
Adamo E. B.
Aguennouz M.
Aldegheri R.
Alesci M.
142
7,18
22
122
85, 95,
145,146,147
32
136
1
143
24,26
81
127
75,80
65
17,66
101
101
65,66,117
126
39,112
14,15
78,91
23,119
71
97
62,67
84
140
82
120
84
37,72,124
Cascio A.
Castelli C.
Castelli F.
Catena N.
Causero A.
Cavallari V.
Celi M.
Cenacchi A.
Cenni E.
Cerocchi I.
Cerulli G.
Cesari E.
Cherubino P.
Chiesa R.
Chinni C.
Ciapetti G.
Cigna V.
Ciotti M.
Ciriaco L.
Ciriello V.
Cittadini A.
Colombo S.
Colonna M.R.
Comisso M.
Congiu T.
Corapi U.
Costa L.
Costarella L.
Crinò C.
Crova M.
Cuomo P.
Cuppari C.
Cutrì M. R.
Cutrupi M. C.
D’Amato P. A.
D’Andrea L.
D’Anna R.
D’Arienzo M.
D’Esposito C.
Dallari D.
Daolio P.
De Giorgi G.
De Maio F.
De Palma L.
De Pasquale M. G.
Dede O.
Delia G.
Della Rocca C.
Denaro V.
IORS
ITALIAN ORTHOPAEDIC
RESEARCH SOCIETY
X
CONGRESSO
MESSINA
12 - 13 SETTEMBRE

X CONGRESSO NAZIONALE IORS 2008

Transcript

Documenti analoghi

FILMING IN ITALY Successful films in a successful incentive

NAZIONALE PILOTI vs TURKEY ALL STARS Wednesday 4th May

Diapositiva 1 - Rete Oncologica Piemonte

ITA 2030C - St. John`s University

italian food

SPAZIO RICERCA

maxillary sinus lift using concentrated growth factors

English - ProZ.com

La Notte invite FINAL2

The Italian Consiglio Nazionale delle Ricerche (CNR) has recently

Italian association of clinical endocrinologists (AME) position