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A series of 136 tibial fractures treated with locked Grosse-Kempf nailing is reviewed, evaluating the results according to rapidity of healing, functional recovery, and complications. Locked nailing proved so reliable that immediate mobilization was possible. There was only a 6% incidence of delayed union, including infections (3 cases, 2%) and nail breakage (2 cases, 1.5%). Several details of the operative technique that were decisive in the final result are discussed.

Two cases of solitary cartilaginous bone tumours are presented. They were slow growing and the radiographs never showed any certain evidence of malignancy. The writers emphasize the difficulties in planning treatment, in view of the tendency towards malignancy shown by these tumours.

The authors discuss their findings resulting from an analysis of a large series (195 cases) of Ewing's sarcoma. In particular they compare the clinical and radiographic pictures and prognosis prior to and after the introduction of adjuvant chemotherapy. This reveals such marked differences in the past and present features of this neoplasm that some of our previous criteria and attitudes to diagnosis and treatment have undergone radical reappraisal.

Resection of the distal end of the radius is indicated in the treatment of locally aggressive primary bone tumours, such as giant cell tumour. This requires reconstruction of the resected segment. Various techniques are examined and the one using an autoplastic fibular graft is described in detail. This method preserves good function of the wrist joint.

The modern treatment of fractures of the proximal femur in the adult usually involves surgery. Open plating has proved to be reliable, but often involves a high percentage of complications: axial deformity, delayed union, breakage of the plate and/or screws (the risk of which increases in relation to the degree of comminution). At this site, in fact, the plate is submitted to strong flexion stress. It therefore becomes essential to associate cancellous grafts (as proposed by the AO School) (Muller et al., 1981) or a homoplastic cortical craft (as in our experience) (Zinghi and Masetti, 1982). Furthermore, open osteosynthesis is time consuming and this means considerable blood loss and a risk of infection. There are thus many reasons for preferring closed surgery, but effective stabilisation can only be obtained with blocked nailing; in fact, only metadiaphyseal screwing is capable of neutralising the rotation or axial stresses which cause deviation, instability or telescoping of the fracture (Kempf et al., 1978; Tigani et al., 1986; Zinghi et al., 1984). Osteosynthesis with Grosse-Kempf nailing is thus an effective alternative to open nailing, particularly in those fractures which would require additional bone grafting with this method. The purpose of our study was to verify the effectiveness of intramedullary osteosynthesis with Grosse-Kempf blocked nailing, in particular analysing the problems encountered in the use of this method.

An exceptional case is presented in which osteoblastoma was associated with osteomalacia. The clinical and pathogenetic aspects are discussed in the light of a review of the literature.

Sarcomatous degeneration in giant cell tumours (G.C.T.) usually only occurs in patients of late adult age. Unlike other Centres, we have not up to now observed primary malignant G.C.T. In 327 cases registered at the Tumour Centre of the Rizzoli Institute, there were 10 cases of sarcomatous degeneration. In 8 of these, radiotherapy had been used as the initial treatment of the tumour. The incidence of sarcomatous degeneration when the radiation dose exceeded 4000r was 29%. The prognosis in such cases is very serious, the only feasible treatment being amputation. The possibility of sarcomatous degeneration must be considered before deciding to adopt radiotherapy as the method of primary treatment in giant cell tumours.

Septic complications occurring in 482 resections for bone tumours performed from 1976 to 1984 at the Rizzoli Orthopaedic Institute Tumour Centre are reviewed. There were 56 cases of infection (11.6%), the incidence of which was related to the type of resection surgery, type of reconstruction, and such risk factors as radiotherapy, the use of acrylic cement, and immunodepression due to antiblastics. With the proper treatment of such septic complications, however, good functional results may be maintained and amputation avoided.

Some aspects of the pathogenesis of acute spinal epidural haematoma are still obscure. However, if the possibility of an iatrogenic lesion is excluded, it must be assumed that there is a congenital or acquired vascular lesion, or else a haemorrhagic diathesis, with minimal trauma or repeated effort acting as a trigger factor. In the vast majority of cases, the syndrome of medullary of cauda equina compression by an acute epidural haematoma has a sudden onset in apparently healthy individuals after a normal amount of effort. In such circumstances the search for predisposing causes can only be speculative. In the present case, there were severe arthrosic changes, whose effect on the dural sac was demonstrable myelographically, but which was previously asymptomatic. Treatment is exclusively surgical. It is effective the earlier it is undertaken. The need for emergency surgery is clearly demonstrated by its inefficacy if delayed for twenty-four hours after the onset of the symptoms.

The authors studied a group of 215 comminuted or open (Grade 1) fractures of the tibial diaphysis in order to compare two methods successively adopted at the 1st Clinic and 3rd Division of the Rizzoli Orthopaedic Institute. We at first chose to delay nailing in these two types of fracture for 4 weeks (131 cases) and obtained good results in terms of consolidation, but only fair results in terms of functional recovery of ankle and subtalar movement and axial alignment of the tibia. Successively, we used immediate osteosynthesis with a screwed nail (84 cases), the results of which were better for all the parameters considered. The criteria for delaying intramedullary osteosynthesis in grade 1 open fractures are still valid, particularly when there are problems which necessarily delay operative treatment within 8 hours of injury. However, immediate treatment is essential in these fractures when they are associated with vascular lesions or in patients with multiple injuries. Finally, the authors express their preference for intramedullary nailing as compared with external fixation for the treatment of these open fractures with limited exposure.

The authors report 38 cases of bone metastases of neuroblastoma. They discuss the problems of diagnosis and treatment from the point of view of the orthopaedic surgeon, who is frequently confronted with a patient with localised bone symptoms in whom the primary neuroblastoma has not previously been diagnosed. The authors propose a diagnostic protocol and discuss the situations in which operative intervention by the orthopaedic surgeon may be indicated.

A standardized preoperative diagnostic approach in correct stages is essential in the prognostic evaluation and therefore in the subsequent treatment of bone tumours. A protocol is proposed, based on an initial (primary) series of investigations followed by a more sophisticated (secondary) series of examination based on the suspected diagnosis so obtained. The usefulness and indications for the different instrumental tests available today are evaluated (bone scintigraphy, CT scan, arteriography) both in benign and malignant bone tumours. Various biopsy techniques are discussed and illustrated.

A study of 181 cases of Brodie's abscess, in which the diagnosis was histologically confirmed, was made in order to demonstrate radiographic factors common to other conditions, and therefore likely to pose questions of differential diagnosis. Some of the pathological characteristics of Brodie's abscess are described and correlated with the differing radiographic appearances of this inflammatory bone lesion.

The authors report a study of 408 cases of exostosis (318 single and 90 multiple) from the records of the Tumour Centre of the Rizzoli Institute. Special attention was paid to the relationship with peripheral chondrosarcoma, 73 cases of which are also in the records of the Institute, and were separately studied. The authors conclude that it is impossible to determine the incidence of malignant transformation of solitary exostosis. The incidence of malignant transformation of multiple exostoses in the present case material was 13 per cent, but the true incidence would undoubtedly be higher if all patients were followed up for life.

The results of 131 cases of classic non-metastatic osteosarcoma of the extremities treated with preoperative chemotherapy, surgery and postoperative chemotherapy are reported. Preoperatively, the patients were given Methotrexate (MTX) intravenously (high and average doses) and Cisplatinum (CDP) intraarterially. For postoperative chemotherapy, the drugs and treatment protocols were based on the degree of necrosis observed (good, fair, poor). Conservative surgery was performed in 73% of the cases and amputation in 27%. At an average 30 month follow-up (9-48 months) 59.5% of the patients had remained disease-free, 37.5% had developed metastases, and 3% had developed local recurrence. The percentage of disease-free patients was higher for those treated with high doses of MTX (68% vs. 51%) and for those in whom preoperative chemotherapy had induced good necrosis (75% vs. 44%). Neither the age or sex of the patients, nor the site of the tumor or type of surgery performed influenced prognosis.

Eleven cases of breakage of the Grosse-Kempf nail were observed in a series of 297 operations performed at the Rizzoli Orthopaedic Institute in Bologna. Seven of the 9 femoral nails were not the latest available model, which is capable of supporting more stress because areas of less resistance have been eliminated. However, breakage is still a possibility as a result of errors of technique and incorrect planning of weightbearing.

Twelve patients who had undergone osteosynthesis with a metal plate combined with a frozen homoplastic bone graft for the treatment of fractures or pseudarthrosis were subjected to bone scintigraphy with 99 Tc MDP. This investigation showed the graft to be a site of early and specific accumulation of the tracer. This finding supports early colonization of the graft by vascular structures and osteoblastic cells. In view of the small number of cases studied and our incomplete knowledge of the metabolic processes involved these considerations must remain hypotheses but given the excellent clinical results obtained, the relationships between homoplastic bone and host bone merit further investigation.

Arachnoid cyst is a rare cause of cord compression; less than a hundred cases have been found in a critical review of the literature. A case observed personally is reported to illustrate and discuss some special aspects of this syndrome. Some of the characteristics that differentiate it from other cystic formations of the meningeal sheaths are emphasized.

The authors report the method used and the results obtained in 42 vertebral needle biopsies with CT scan monitoring. Material sufficient for a positive histological diagnosis was obtained in 67% of the cases. Indications for the use of this method are conditioned by a suitable clinical and instrumental evaluation, and limited to cases where a histological monomorphous lesion or when en bloc resection are predicted. The need to follow precise rules in terms of technique and manual skill is emphasized.

The authors report a case of Mazabraud's syndrome in a patient aged 57 years with a history of fibrous dysplasia of the skeletal system which had commenced at the age of 10. This became associated with myxomas of the soft tissues at the age of 42. This rare association was described by Mazabraud in 1957. A review of the literature up to 1985 shows that 16 cases have been reported. These are reviewed.

The authors review the literature and discuss the biomechanical aspects of extension fractures of the spine in ankylosing spondylitis and report 3 cases. They conclude that, although such lesions are rare, patients with ankylosing spondylitis who sustain such trauma must be subjected to thorough radiological examination. The milder lesions have a favourable prognosis, but those involving dislocation are extremely dangerous, both because of the frequent appearance of immediate or delayed medullary complications and because of the high incidence of pseudarthrosis.

265 cases of solitary chondroma, multiple chondromas and chondromatosis were analysed. Two hundred cases had a long term follow up of 1-50 years (average ten years). Recurrence after surgical removal is rare. It is exceptional for malignancy to develop in chondromas of the hand. Malignant degeneration (chondrosarcoma, fibrosarcoma, etc.) was found in 12 per cent of the solitary chondromas and in 32 per cent of the multiple chondromas and chondromatosis involving the bones elsewhere than in the hand. The first of these figures is probably excessive, since many of the solitary chondromas elsewhere than in the hand remain asymptomatic and unrecognised; but the second figure is probably too low, since the risk of sarcomatous degeneration remains present throughout the patient's life.

Based on a study of 749 consecutive cases submitted to open biopsy over a 12 year period, the authors discuss the possible grave consequences that can arise out of wrong attitudes or faulty technique. The statistical analysis, together with illustrative cases, demonstrates the difficulties, mistakes and biological damage that can result. Biopsy should always be associated with other methods of investigation, such as C.A.T. scanning, scintigraphy and angiography. It is a delicate and sometimes difficult procedure which requires close collaboration with the radiologist and pathologist. At the present time, our tendency is towards biopsy at the time of operation (with frozen sections) or to needle biopsy.

A case of leontiasis ossea, observed over a period of fifty years, is described with particular reference to certain similarities and differences as compared with Paget's disease of bone (osteitis deformans) and fibrous dysplasia. The differential diagnosis is discussed and it is concluded that leontiasis ossea is an entity in its own right.

The authors report 16 cases of infected lesions of the humerus with delayed consolidation or pseudarthrosis. The treatment consisted of radical surgical debridement, freshening of the bone fragments with removal of all necrotic tissue, and stabilisation with a Hoffmann-Vidal external fixation device. Healing occurred between 3 and 6 months after operation. The one case of failure was attributable to inappropriate technique (inadequate resection of the ends of the fragments).