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Background When surgical treatment of dysplastic hip osteoarthrosis is necessary, osteotomy is preferable to fusion or THR. We evaluated periacetabular osteotomy as a method of choice. Patients and methods We treated 36 symptomatic dysplastic hip joints (32 patients) with the Bernese periacetabular osteotomy (PAO) between 1994 and 2001. We used the ilio-inguinal (I-I) approach in 32 hips and a modified Smith-Petersen (S-P) approach in 4. The patients were followed for mean 4 (1.5-8) years. In 1 patient with coxa valga, a varus femoral osteotomy was performed 1 year after PAO. 2 hips, in which we used the modified S-P approach, necessitated a capsulotomy. Results The median Merle d'Aubigne score increased from 13 points preoperatively to 16 points postoperatively. This improvement in terms of pain, motion and ambulation was accompanied by spatial reorientation and correction. The lateral center edge angle of Wiberg (CE) improved from an average of 7 degrees to 28 degrees. The anterior center edge angle of Lequesne (FP) improved from an average of 18 degrees to 28 degrees. The acetabular index angle (AC) improved from an average of 22 degrees to 10 degrees. Major complications included 1 partial lesion of the sciatic nerve, 1 malunion and 1 combined nonunion of the pubic and ischiatic osteotomy. 2 patients underwent subsequent total hip replacement (THR) for progressive osteoarthrosis with pain. Interpretation We found good radiographic correction of deformities, improvement of hip function and pain relief with an acceptable complication rate. With appropriate patient selection, this procedure is the most physiological treatment of symptomatic hip dysplasia in young adults. In addition to relieving symptoms, it may prevent and postpone the development of secondary osteoarthrosis.

Operationsziel Dreidimensionale Osteotomie um das Azetabulum zur Wiederherstellung der Uberdachung des Femurkopfs zur Schmerzverminderung ohne Gefahrdung der Beckenstabilitat.

Between 1982 and 1985, 23 Kessel total shoulder arthroplasties were performed on 22 patients with rheumatoid arthritis. A clinical and radiographic review of the 5-year experience was evaluated in 1988 and published in 1992. Ten years later a followup study was done. Of the 22 patients, 11 have died and two were seriously ill and could not participate. Of the remaining nine patients, one had revision surgery after 2 years, leaving eight patients with a mean age of 61 years for this followup study. Shoulder function was evaluated subjectively using the Simple Shoulder Test, and pain was evaluated using a visual analog scale. New radiographs were taken. In general, the patients had a low functional level, but they were able to sleep on the surgically treated side and to manage daily hygiene. Five patients were pain free, and the worst recorded pain during the day was 35 mm on the visual analog scale. Two patients had their scapular component cemented at primary surgery. The radiographs showed no radiolucent zones around these components. The six other scapular components had radiolucent zones of 1 to 3 mm. No radiolucent zones were detected around the humeral components.

The concept of partial rupture of the anterior cruciate ligament (ACL) has been confirmed by arthroscopic examination and palpation. We present a prospective study of 43 patients who were diagnosed arthroscopically as suffering from a partial rupture of the ACL by the same surgeon. The patients followed a rehabilitation protocol and were examined by an independant observer after 5 years. Twenty-five patients had a stable knee, whereas 18 eventually suffered a complete ACL rupture. ACL partial rupture is easily recognizable with arthroscopy, but the quantity and state of the still intact fibres is difficult to assess.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Hip problems are frequent and can represent a therapeutic challenge for the orthopaedic surgeon. In the wide spectrum of hip pathologies, coxarthrosis still remains the most common cause of hip disability. The treatment of hip disorders in adult patients has rapidly evolved during the past decades because of the enhanced understanding of osteoarthritis (OA) aetiology combined with improved imaging, better patient selection and refinements in surgical procedures. Despite great strides that have been made in the field of total hip arthroplasty (THA), femoral and pelvic osteotomy still play a successful role in the prevention and treatment of OA. Primary OA is rare, or may not exist at all, and the majority of cases that are considered as primary are secondary to a pre-existing anatomical deformity. If an identifiable anatomic and biomechanical hip abnormality is diagnosed, its surgical correction may prevent or lessen OA and postpone THA for many years or even indefinitely in certain cases. The success of such surgery depends on the correct indication, time of surgery, completeness with which osteotomies normalize the environment of the hip, and the grade of OA present when procedure is performed.

SummaryThe administration of recombinant activated factor VII (rFVIIa) by continuous infusion has provided a safe and convenient alternative to bolus injections in haemophiliacs with inhibitors, but it has only been reported in a single case with congenital factorVII (FVII) deficiency. The results of 12 consecutive surgical procedures in 7 patients with congenital FVII deficiency are reported here. rFVIIa was always given in continuous infusion, aiming at plasma FVII activity of 0.5 IU/mL. Treatment was given for 2 to 7 days with a mean total dose of 7.8 mg rFVIIa. Blood loss was as expected from the different types of procedures and the only thromboembolic complication was a superficial thrombophlebitis at the infusion site. This mode of substitution was therefore safe, effective and well tolerated.

Developmental hip dysplasia (DDH) is characterized by an anomalous growth of the hipjoint. Without adequate treatment, the natural history of DDH is development of secondary osteoarthritis in adulthood. The correction of the deformities modifies the biomechanics of the hip, which is important in order to slow down the progression of osteoarthritis and maybe to prevent and postpone this development. The Bernese periacetabular osteotomy is a procedure which reorientates the acetabular articular surface. Several surgical approaches have been used to achieve the same effective osteotomy. No surgical approach represents "the optimum", with selection of appropriate exposure representing a balance of advantages and disadvantages. We used the ilioinguinal approach in 32 periacetabular osteotomies for acetabular dysplasia performed between 1996 and 2002. The operation was successful in 30 patients with acceptable operation time and blood loss and few complications. The advantages and disadvantages with the ilioinguinal approach as compared to other possibile incisions are discussed.

Abstract 3053 Poster Board II-1029 In patients with hemophilia, repeated joint bleedings leads to synovitis and bleeding arthropathy is the major cause of morbidity in these patients. The synovitis is characterized by a highly vascular synovial membrane with prominent proliferation of synovial fibroblasts and infiltration by inflammatory cells. This chronic inflammation, as well as a direct toxic effect of blood on chondrocytes ultimately leads to cartilage and bone destruction and a crippling arthropathy. It has recently been shown that. Inflammatory cells isolated from hemophilic joints synthesize pro angiogenic factors (matrix metalloproteas-9, basic fibroblast growth factor and cyclooxygenas-2). Angiogensis in the adult is a complex process involving breakdown of connective tissue, proliferation and migration of endothelial cells but also recruitment of supporting cells, pericytes, important for vessel maturity. The aim of this study was to determine whether repeated joint bleedings in hemophilia patients induce a pro angiogenic reaction [increased micro vascular density (MVD) and expression of vascular endothelial growth factor (VEGF)] in the hemophilic joint and to study if also pericytes are involved in the process. After informed consent, synovial biopsies were collected from patients with severe hemophilia (n=5) when undergoing knee surgery on clinical grounds. As control, synovial biopsies from one patient undergoing diagnostic arthroscopy were used. Biopsies were snap frozen in liquid nitrogen and sectioned by cryotome. After fixation, sections were double stained for CD34 (for detection of endothelial cells) and SMA-a (for detection of pericytes) by immuno fluorescence. Sections were also stained for VEGF by immuno histochemistry. As shown in Table 1 patients with hemophilia had a very high MVD and pericyte coverage as compared to control samples. We also measured levels of VEGF by ELISA in plasma from 23 patients and 4 controls, but in all samples the concentration was below detection level. However, in synovial biopsies from patients with hemophilia, VEGF was clearly expressed by the endothelial cells as well as mononuclear cells present in the section. Table 1 Angiogenesis parameters in patients with hemophilia Synovial biopsies plasma MVD (vessels/HPF) Pericyte coverage (%) VEGF+ (cells/HPF) VEGF (pg/mL Hemophilia patients 17±8 91±0.1 22±19 Based on these preliminary data we suggest that hemophilic arthropaty is characterized by increased angiogenesis and mobilization of pericytes. Although no increase of VEGF was detected systemically it was shown to be expressed locally, within the inflamed joint. Anti-angiogenic drugs are currently successfully used in different types of cancers and a specificVEGF inhibitor for topical administration has successfully been developed for proliferative diabetic retinopathy. The results presented in this study could be part of a rationale to design studies using these drugs also in hemophilic arthropaty, a condition currently lacking specific treatment. Disclosures No relevant conflicts of interest to declare.

In a consecutive series of primary total hip replacements (THR) 54 patients were operated upon with and 78 patients without trochanteric osteotomy. Follow-up at least 2.5 years postoperatively failed to disclose any differences between the two groups in bleeding during operation, the incidence of early complications or the infection rate. A longer operation time was noted for the osteotomized group. Mechanical failure was more frequent in the non-osteotomized group. The clinical end result was similar in both groups. In complicated cases or when accessibility to the operation site is poor a trochanteric osteotomy is recommended.

Forty patients were reviewed 24 to 52 months after their second, third and fourth arthroplasty of the same hip. The protocol assessed pain, range of motion, leg shortening, gait performance, radiological appearance of the endoprosthesis and included the patient's own evaluation. Results of re arthroplasty were inferior to those of the primary procedure, but still good enough, both in the surgeon's and the patient's opinion, to be the method of choice for revision of a failed total hip replacement.