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REVISTA DE ORTOPEDIE ªI TRAUMATOLOGIE JOURNAL OF ORTHOPAEDIC TRAUMA

Al XIII-lea Congres Naþional SOROT XIIIth National Congress SOROT Rin Grand Hotel, 21–24 octombrie, Bucureºti

VOLUM DE REZUMATE BOOK OF ABSTRACTS

Cu ocazia Congresului Naþional SOROT conducerea societãþii a decis lansarea online a revistei de Ortopedie ºi Traumatologie a Societãþii Române de Ortopedie ºi Traumatologie. Aici veþi regãsi atât articolele propuse spre publicare cât ºi articolele publicate în revista tipãritã, precum ºi alte subiecte care nu ºi-au gãsit locul în numerele curente ale revistei. Veþi gãsi toate aceste informaþii ºi sperãm multe altele la adresa www.sorot.ro/Revista

2009 • VOLUMUL 19 NUMÃRUL 2

ISSN 1220 – 6466


Autorii îºi asumã în integralitate conþinutul ºtiinþific ºi redactarea lucrãrilor din revistã


Cuprins

ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ . . . . . . . . . . . . . . pag. 5

FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL . . . . .

pag. 27

ACTUALITÃÞI ÎN BIOMATERIALE . . . . . . . . . . . . . . . . . . . . pag. 69

Summary UPDATES IN SPINAL SURGERY . . . . . . . . . . . . . . . . . . . . . . .

pag. 5

BIMALEOLAR AND TIBIAL PILON FRACTURES . . . . . . .

pag. 27

UPDATES IN BIOMATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . pag. 69


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ

IMPACTUL MECANISMULUI TRAUMATIC ASUPRA INSTRUMENTAÞIEI SPINALE I. Branea, T. Pitzen, J. Drumm W. Gera

Cuvinte cheie: coloanã, instabilitate, biomecanicã, instrumentaþie Leziunile coloanei vertebrale pot genera instabilitate, afectarea structurilor neurale sau ambele. Din punct de vedere istoric, tratamentul cuprinde reducerea ºi alinierea elementelor osteoarticulare urmate de imobilizarea de lungã duratã. Îmbunãtãþirea tehnicilor chirurgicale ºi a implantelor spinale permite stabilizarea precoce ºi eficientã minimizând trauma chirurgicalã ºi facilitând recuperarea precoce. Patobiomecanica joacã un rol decisiv în selectarea cazurilor chirurgicale, a abordului chirurgical, a necesitãþii unei fuziuni precum ºi în alegerea tipului de implant. Abordurile combinate sunt frecvent necesare pentru obþinerea stabilitãþii ºi pentru corecþia unei diformitãþi. Totuºi, complicaþiile legate de chirurgia ºi stabilizarea coloanei rãmân importante. Cunoaºterea mecanismelor patologice ne ajutã la evitarea pierderii corecþiei ºi stabilitãþii ºi a unei noi injurii ale elementelor neurale. Chirurgul trebuie sã fie familiar cu diversele aborduri pentru fiecare segment al coloanei pentru a adresa optim diversitatea tipurilor lezionale. IMPACT OF TRAUMA MECHANICS ON SPINAL INSTRUMENTATION Injuries to the vertebral column may result in mechanical instability, neurological compromise, or both. Historically, management has involved manipulative realignment of the osseous elements followed by a long period of immobilization. Improvements in surgical techniques and spinal internal fixation systems have allowed for early and effective surgical stabilization of unstable injuries while minimizing the physiological insult and facilitating early rehabilitation. Pathomecanics have a decisive role in the selection of surgical treatment, the appropriate

surgical approach, the need for fusion and the implant choice. Combined approaches and instrumentation are often needed in order to obtain stability and optimal deformity correction. However, the complications related to spinal surgery and stabilization remains important. Knowledge of mechanics help us to prevent loss of correction and new injury to neural elements. The treating surgeon needs to be familiar with different approaches in each segment to optimally address the diversity of injury patterns. Bibliografie 1. Panjabi M., White A. Cervical spine mechanics as a function of transection of components. J Biomech 1975. 2. Pitzen T et al. Implant complications, fusion, loss of lordosis, and outcome after anterior cervical plating with dynamic or rigid plates: two-year results of a multi-centric, randomized, controlled study. Spine. 2009 Apr 1; 34 (7): 641-6.

 UN MODEL DE INSTRUMENTARE PENTRU SCOLIOZELE IDIOPATICE CU UNGHI COBB DE 50±5 GRADE Gh. Burnei, ªt. Gavriliu, C. Vlad, Ileana Georgescu, Daniela Dan Ortopedie Pediatricã, Spitalul M.S. Curie

Cuvinte cheie: scoliozã idioapaticã, model de instrumentare, corecþie totalã Scop: Tentaþia de a corecta total o scoliozã reprezintã o provocare pentru toþi chirurgii de coloanã. Orice scoliozã idiopaticã cu unghi Cobb de 50 +/- 5 grade prezintã 3 sectoare ale curburii scoliotice. Am practicat mai multe modele de instrumentare în cazuri de scoliozã idiopaticã parþial flexibilã care ar fi putut fi corectate total. Prezentam un model de instrumentare posterioarã a scoliozelor toracolombare parþial flexibile cu unghi Cobb de 50+/- 5 grade. Acest model permite corectarea în plan frontal ºi sagital folosind o manierã individualizatã de instrumentare structuratã pe 3 secþiuni. Material ºi metodã: Studiul de faþã include 29 de pacienþi (21 fete ºi 8 bãieþi) cu vârsta medie de 14,5 ani (intre 5 si 17 ani). Criteriile de includere au fost:

2009, Vol. 19, nr. 2 / 5


AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 curbura unicã toracalã sau toracolombarã, cu unghi Cobb de 50 +/- 5 grade. Zona rigidã a coloanei la þestul de înclinare lateralã mãsura 24-32 grade. În funcþie de amplitudinea rotaþiei vertebrale ºi modificãrilor secundare evolutive ale vertebrei apicale ºi ale celor douã vertebre învecinate, au fost individualizate trei cadre spaþiale: proximal, mijlociu ºi distal. Segmentele proximal ºi distal conþin un numãr variabil de vertebre, segmentul intermediar conþine în mod constant 3 vertebre. Din 29 de pacienþi 17 au fost operaþi dupã modelul analizat iar 12 dupã alte principii. A fost folosit acelaºi instrumentar ºi aceeaºi echipã pentru toþi pacienþii. Instrumentarea a fost efectuatã dupã cum urmeazã: în segmentul proximal, pe faþa concavã, croºetele se ataºeazã pe prima ºi pe ultima vertebrã. O pensa este fãcutã între prima vertebrã neechilibratã ºi penultima vertebrã pe faþa convexã a segmentului. Pe segmentul mijlociu, pe faþa convexã, un croºet pedicular este plasat pe vertebra corespunzãtoare apexului curburii ºi pe faþa concavã un croºet supralaminar este plasat pe urmãtoarea vertebrã inferioarã. În segmentul distal vertebra neechilibratã situatã cea mai inferior este fixatã bilateral. Rezultate: Modelul studiat a permis cea mai bunã corecþie. Cei 17 pacienþi operaþi folosind modelul studiat au prezentat un unghi mediu restant de 5 grade (între 2 ºi 10 grade. Ceilalþi 12 pacienþi au prezentat un unghi restant de 14 grade (între 5 ºi 22 grade). Un caz a prezentat pareza tranzitorie remisã dupã 16 zile. Concluzii: Modelul studiat este eficient în cazul scoliozelor parþial flexibile cu unghi Cobb de 50 +/- 5 grade. A MODEL OF SPINAL INSTRUMENTATION FOR PATIENTS WITH COBB ANGLE OF 50±5° Key words: idiopathic scoliosis, instrumentation model, total correction Purpose: The temptation to totally correct a scoliosis by a posterior instrumentation is a challenge for all spine surgeons. Every idiopathic scoliosis of 50±5° presents 3 frames of the scoliotic curve. We performed many instrumentation models in case of partially flexible idiopathic scoliosis that might have been almost totally corrected.

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We present a posterior instrumentation model to correct partially flexible thoracal or thoracolumbar scoliosis with a 50±5° Cobb angle. This model allows a frontal and sagital plane correction using an individualized spine instrumentation model that is grouped in 3 planes. Materials and Method: Our study includes 29 patients (21 girls and 8 boys) with an average age of 14,5 years (range of 5-17). The inclusion criteria was an unique thoracal or thoraco-lumbar curve with a value of 50±5° Cobb angle. The stiff area of the spine in lateral bending test measured 24-32°. Regarding the amplitude of vertebral rotation and secondary (evolutive) structural changes of the apical vertebra and the two neighbouring vertebrae, three spacial frames of the curve individualized: a proximal, a middle and a distal frame. The proximal and distal ones presented a variable number of vertebrae and the middle one was constantly appreciated to three vertebrae. Out of 29 patients, 17 were operated using the analized model by us and 12 patients were instrumented using other principles. As a rule the instrumentation and the operating team were the same. Instrumentation was performed as follows: • in the proximal frame on the concave side the clips include the first and the last vertebra. A „claw“ is made between the first unbalanced and the last but one vertebra on the convexe side of the frame; • in the middle frame,on the convexe side, a pedicular clip is placed on the vertebra coresponding to the apex of the curve and on the concave side a supralaminar clip is placed on the next lower vertebra; • in the distal frame the lowest unbalanced vertebra is fixed on both sides (left and right). Results: The model studied by us allowed the best correction. The 17 patients operated using the studied model presented an average postoperative angle of 5°(ranged 2-10°). The other group of 12 patients presented an average postoperative angle of 14° (ranged 5-22°). One case of transient paresis cured after 16 days. Conclusions: This model is efficient when applied to partially flexible scoliosis with a 50±5° Cobb angle.


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ Bibliografie 1. Cotrel Y, Dubousset J. A new technic for segmental spinal osteosynthesis using the posterior approach. Rev Chir Orthop Reparatrice Appar Mot. 1984;70:489–494. 2. Cotrel Y, Dubousset J, Guillaumat M. New universal instrumentation în spinal surgery. Clin Orthop Relat Res. 1988; 227: 10–23. 3. Webb JK, Burwell RG, Cole AA, et al. Posterior instrumentation in scoliosis. Eur Spine J. 1995;4:2–5. 4. Helenius I, Remes V, Yrjonen T, et al. Harrington and Cotrel - Dubousset instrumentation in adolescent idiopathic scoliosis. Long-term functional and radiographic outcomes. J Bone Joint Surg Am. 2003; 85-A: 2303–2309. 5. Lenke LG, Bridwell KH, Blanke K, et al. Radiographic results of arthrodesis with Cotrel-Dubousset instrumentation for the treatment of adolescent idiopathic scoliosis. A five to tenyear follow-up study. J Bone Joint Surg Am. 1998;80:807–814. 6. Humke T, Grob D, Scheier H, et al. Cotrel-Dubousset and Harrington Instrumentation in idiopathic scoliosis: a comparison of long-term results. Eur Spine J. 1995;4:280–283. 7. Barr SJ, Schuette AM, Emans JB. Lumbar pedicle screws versus hooks. Results in double major curves in adolescent idiopathic scoliosis. Spine. 1997;22:1369–1379. 8. Burton DC, Asher MA, Lai SM. The selection of fusion levels using torsional correction techniques in the surgical treatment of idiopathic scoliosis. Spine. 1999; 24: 1728–1739. 9. Delorme S, Labelle H, Aubin CE, et al. Intraoperative comparison of two instrumentation techniques for the correction of adolescent idiopathic scoliosis. Rod rotation and translation. Spine. 1999; 24: 2011–2017. 10. Gaines RW Jr. The use of pedicle-screw internal fixation for the operative treatment.

 SCOLIOZA CONGENITALÃ. REZULTATELE DUPÃ HEMIVERTEBRECTOMIE, DISCECTOMIE ªI INSTRUMENTARE SOMATICÃ Gh. Burnei, C. Vlad, ªt. Gavriliu, Ileana Georgescu, Daniela Dan Secþia Ortopedie Pediatricã, Spitalul de Copii M.S. Curie

Cuvinte cheie: scoliozã congenitalã, instrumentare somaticã, hemivertebrectomie, discectomie. Scop: Experienþa clinicii noastre a arãtat cã artrodeza în situ ºi instrumentarea posterioarã nu reprezintã o garanþie pentru un bun rezultat, opþiunile noastre curente sunt pentru metode mai radicale. Studiul analizeazã efectele instrumentãrii dupã a. rezecþia de hemivertebrã cu corectarea curburii, b. hemidiscectomie pentru vertebre trapezoidale ºi c. discetomie ºi secþionarea barei de fuziune în cazurile de defecte de segmentare. Material ºi metodã: Între 1998 ºi 2006 am efectuat 23 de intervenþii la 22 de pacienþi cu scoliozã congenitalã, având vârste între 3 ºi 16 ani, vârsta

medie fiind 10 ani. La toþi pacienþii s-a efectuat CT, CT-3D ºi IRM. Malformaþiile au fost toracolombare, 2 defecte de segmentare ºi 20 defecte de formare (18 cazuri cu hemivertebre ºi 2 cazuri cu vertebre trapezoidale). În cele 2 cazuri, defectele de segmentare erau localizate lateral ºi prezentau un potenþial progresiv important. La toþi pacienþii s-a practicat instrumentarea somaticã scolioza fiind corectatã în diverse grade.La pacienþii cu hemivertebrã (18) s-a practicat abord dublu simultan, anterior ºi posterior, rezecþia hemivertebrei ºi discectomie. Am efectuat discectomie parþialã pe partea convexã prin abordul anterior pentru vertebrele trapezoide. În cazurile defectelor de segmentare am efectuat discectomie ºi secþionarea barei de fuziune ºi, în funcþie de gradul diformitãþii discectomie adiacentã prin abord anterior. Rezultate: Unghiul mediu preoperator a fost de 41 grade. Unghiul mediu postoperator a fost 16 grade cu o corecþie de 64%. Urmãrirea postoperatorie a fost pânã la 7 ani (în medie 5,4 ani). La ºase luni dupã operaþie toþi pacienþii au fost examinaþi clinic ºi radiologic. La un an postoperator unghiul restant a rãmas neschimbat. Nouã pacienþi au fost urmãriþi mai mult de 5 ani. Cinci au prezentat o pierdere a corecþiei de 5-10%, în 2 cazuri corecþia s-a îmbunãtãþit iar în douã cazuri a rãmas neschimbatã. Am întâlnit complicaþii în 3 cazuri: o leziune de aortã, un caz de pneumotorax ºi o rupturã a unui ºurub fãrã deteriorarea rezultatului final. Concluzii: Rezecþia de hemivertebrã ºi instrumentarea somaticã a mai multor vertebre învecinate evitã evoluþia cãtre o diformitate mai pronunþatã. Discectomia parþialã pe partea convexã în vertebrele trapezoidale permite o îmbunãtãþire spontanã a corecþiei dupã operaþie. Unghiul postoperator în cazurile cu defect de segmentare cu bara lateralã s-a menþinut constant pe toatã perioada de urmãrire. CONGENITAL SCOLIOSIS. RESULTS AFTER HEMIVERTEBRECTOMY, DISKECTOMY AND SOMATIC INSTRUMENTATION Key words: congenital scoliosis, somatic instrumentation, hemivertebrectomy, diskectomy. Purpose: Our clinics experience proved that in situ arthrodesis and posterior instrumentation in congenital scoliosis are not a certainty of good results and consecutive our current options are more radical methods.

2009, Vol. 19, nr. 2 / 7


AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 The study analyses the effects of instrumentation after a. hemivertebra resection with curve correction b.hemidiscectomy for trapezoidal vertebrae and c.discectomy, bar sectioning in case of segmentation defects of the spine. Materials and Method: We performed 23 operations in 22 patients with congenital scoliosis between 1998-2006. The patients age ranged 3 to 16 years, the average being 10 years. CT, 3D-CT and MRI were performed in all patients. The deformities were thoraco-lumbar and represented 20 forming (18 cases with hemivertebra and 2 cases of trapezoid vertebrae) and 2 segmentation defects. The 2 segmentation defects were laterally localized and presented a severe progression potential. All patients were somatically instrumented and the scoliosis was corrected in a variable range. The patients with hemivertebra (18) underwent a simultaneous double approach, anterior and posterior, hemivertebra resection and discectomy. We performed partial discectomy on the convex side by an anterior approach for trapezoid vertebrae. In case of segmentation defects we performed discectomy in the interested site by bar sectioning and depending on the deformity degree, adjacent discectomy by an anterior approach. Results: The average preoperative angle was 41°.The average postoperative angle was 16° with a 64% correction. The postoperative follow-up period was up to 7 years (average of 5.4 years). Six month after surgery all patients performed clinical and radiological examinations. One year after surgery the postoperative angle was unchanged. Out of all patients 9 had a more than 5-years follow-up period. 5 presented a 5-10% correction loss, in 2 cases correction improved and in 2 cases it maintained unchanged. We noticed complications in 3 patients: an aortic lesion, one pneumothorax and a screw breakdown without altering the final result. Conclusions: Hemivertebra resection and somatic instrumentation of more adjacent vertebrae avoids the evolution to a pronounced deformity. The partial discectomy on the convex side in trapezoidal vertebrae allows a spontaneous correction improvement after surgery.

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The postoperative angle of segmentation defects with lateral bar maintained constant all over the follow-up period. Bibliografie 1. Shands AR Jr, Eisberg HB. The incidence of scoliosis in the state of Delaware; a study of 50 000 minifilms of the chest made during a survey for tuberculosis. J Bone Joint Surg Am. 1955; 37-A:1243–1249. 2. Hedequist D, Emans J. Congenital scoliosis: a review and update. J Pediatr Orthop. 2007; 27:106–116. 3. Giampietro PF, Blank RD, Raggio CL, et al. Congenital and idiopathic scoliosis: clinical and genetic aspects. Clin Med Res. 2003; 1:125–136. 4. Tassabehji M, Fang ZM, Hilton EN, et al. Mutations in GDF6 are associated with vertebral segmentation defects in Klippel-Feil syndrome. Hum Mutat 2008; 29:1017–1027. 5. Seki T, Shimokawa N, Iizuka H, et al. Abnormalities of vertebral formation and Hox expression in congenital kyphoscoliotic rats. Mol Cell Biochem. 2008; 312:193–199. 6. McMaster MJ, Singh H. Natural history of congenital kyphosis and kyphoscoliosis. A study of one hundred and twelve patients. J Bone Joint Surg Am. 1999; 81:1367–1383. 7. Nakajima A, Kawakami N, Imagama S, et al. Threedimensional analysis of formation failure in congenital scoliosis. Spine. 2007; 32:562–567. 8. Basu PS, Elsebaie H, Noordeen MH. Congenital spinal deformity: a comprehensive assessment at presentation. Spine. 2002; 27:2255–2259. 9. Belmont PJ Jr, Kuklo TR, Taylor KF, et al. Intraspinal anomalies associated with isolated congenital hemivertebra: the role of routine magnetic resonance imaging. J Bone Joint Surg. 2004; 86-A:1704–1710. 10. Smith JT, Gollogly S, Dunn HK. Simultaneous anteriorposterior approach through a costotransversectomy for the treatment of congenital kyphosis and acquired kyphoscoliotic deformities. J Bone Joint Surg Am. 2005; 87:2281–2289. 11. Newton PO, Hahn GW, Fricka KB, Wenger DR. Utility of threedimensional and multiplanar reformatted computed tomography for evaluation of pediatric congenital spine abnormalities. Spine. 2002; 27:844–850. 12. Guarino J, Tennyson S, McCain G, et al. Rapid prototyping technology for surgeries of the pediatric spine and pelvis: benefits analysis. J Pediatr Orthop. 2007; 27:955–960.

 REZULTATE PE TERMEN SCURT ÎN TRATAMENTUL CU DISCOGEL AL HERNIILOR DE DISC D.C. Grecu, D.N. Tarniþã, D.R. Diþã, C. Constantin, D. Hertzog Ortopedie-Traumatologie, S.C.J.U. Craiova

Cuvinte cheie: hernie de disc, spondilodiscartrozã, discogel, rezultate Material ºi metodã: Au fost trataþi un numãr de 14 bolnavi, 7 bãrbaþi ºi 7 femei, diagnosticaþi cu:


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ – HDC C5-6 ºi spondilozã cervicalã; – 1 caz - HDL L4-5; – 10 cazuri, din care una extraforaminalã, 4 însoþite de artrozã interapofizarã ºi una recidivatã. Din acestea, 3 cazuri au avut ºi HDL L3-4, iar 6 ºi spondilozã; – HDL L5-S1: 3 cazuri. În 12 cazuri s-a practicat nucleoplastie cu etanol-celulozã la 1 nivel iar în 2 cazuri la 2 nivele. În 9 cazuri s-a practicat infiltraþie în feþiºoarele articulare sau periarticular la nivelul cel mai afectat. Rezultate: - Ameliorarea netã a durerilor în 10 cazuri. – Ameliorarea durerilor în 3 cazuri, perceputã ºi descrisã ca o senzaþie de eliberare. – 1 caz fãrã nici o ameliorare, chiar cu o accentuare a durerilor pe nervul sciatic ºi hipotonia halucelui. Acest caz a ajuns la intervenþie chirurgicalã – 1 caz: nucleoplastie mecanicã asociatã cu nucleoplastie cu Discogel – imediat postoperator a prezentat accentuarea sindromului lombar în ortostatism, care s-a ameliorat în 2 sãptãmâni. Discuþii: Am obþinut rezultate bune în 71% cazuri, rezultate satisfãcãtoare în 22% cazuri ºi rezultate proaste în 7% cazuri. Bolnavii cei mai mulþumiþi au fost cei mai bine echilibraþi psihic, cu sindrom vertebral acut în momentul procedurii ºi cu sciaticã incompletã. La bolnavii care nu sunt în puseu acut rezultatul imediat este cel mult satisfãcãtor, probabil datoritã morbiditãþii date de procedura terapeuticã. Herniile mari ºi cu compresie radicularã certã în foramenul intervertebral probabil cã nu beneficiazã de nucleoplastie. Concluzii: – Discogelul are rezultate clinice. – Trebuie explicat bolnavului foarte bine rezultatele la care se poate aºtepta. – Rezultatele par a fi cele mai bune la bolnavii cu suferinþã micã sau medie, în plin puseu clinic – Costul substanþei este prohibitiv. – Este indicat în special în cazurile în care pacientul este activ ºi doreºte evitarea intervenþiei chirurgicale.

SHORT TERM RESULTS IN THE TREATMENT WITH DISCOGEL OF DISC HERNIATIONS Key words: disc herniation, spinal arthrosis, discogel, results. Material and method: 14 patients were treated, 7 men and 7 women, with the following diagnosis: – 1 patient with cervical herniated disc C5-C6 with spondylosis; – 10 patients with lumbar herniated disc L4L5, 1 extraforaminal, 4 with apophyseal arthrosis and 1 recurrent; – 3 patients with lumbar herniated disc L5-S1. In 12 cases Discogel was injected in a single disc, in 2 cases it was injected in 2 discs. In 9 cases it was also practiced infiltration in the articular processes joints or periarticular at the most affected site. Results: – Important decrease of pain in 10 cases. – Decrease of pain in 3 cases, described as a total relief of symptoms – 1 case without any improvement and even with an increase of sciatica and also with hallux hypotonia. In this case a surgical intervention was later needed – In 1 case, where percutaneous nucleoplasty was associated with injection of Discogel, the lumbar syndrome was at first increased in standing position, but with a gradual decrease of symptoms in 2 weeks. Discussions: We have obtained good results in 71%, satisfactory results in 22% and bad results in 7%. Most satisfied patients were balanced psychologically, with an acute spinal syndrome and with incomplete sciatica. If the spinal syndrome was chronic, the immediate result was at most satisfactory, probably due to the morbidity given by the therapeutic procedure. Big herniated discs with radicular compression probably do not benefit from injection with Discogel. Conclusions: – Discogel has good clinical results – It is very important to explain the patient the results that can be expected – The better results appear to be in patients with minor or medium, acute symptomatology – The price of the substance is prohibitive – It is especially indicated in active patients that desire to avoid a surgical procedure.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Bibliografie 1. Jacques Theron, MD, Leopoldo Guimaraens, MD, Alfredo Casasco, MD, Teresa Sola, MD, Hugo Cuellar, MD, Patrick Courtheoux, MD, 2008 – Percutaneous treatment of cervical and thoracic intervertebral hernias with radiopaque gelified ethanol Meeting of American Society of Spine Radiology 2. Theron J., Sola T., Guimaraens L., Casasco A., Courtheoux P. 2006 – Gelified Ethanol (Discogel) in the treatment of disk herniations. A pilot study Réunion annuelle de la Société Française de Neurochirurgie.

 LOWER CERVICAL DEGENERATIVE DIASEASE HISTORY AND SURGICAL TREATMENT P. Kehr* * Professeur Piere Kehr. Professeur Honoraire d’OrthopédieTraumatologie à la Faculté de Médecine de Strasbourg (France). Editor in chief of European Journal of Orthopaedic Surgery and Traumatology (Springer)

The history of disease and treatment is often boring and we may hurt those authors we forget. History is eminently subjective because were not professional in this matter. I will thus present my personal experience, after 40 years of cervical surgery and over 1000 patients operated; my route corresponds to the main historic evolutions of this surgery. Our major steps are following: – 1961: the vertebral artery freeing according to Jung – 1968: the intervertebral fusion according to Cloward – 1970: the intervertebral fusion according to Robinson – 1972 the transdiscal osteophytectomy according to Magerº – 1972: the big freeing (vertebral artery, nerve roots and spinal cord) according to Kehr – 1974: the use of osteosynthesis – 1976: the corpectomies – 1982: the use of cage-plate type I – 1990: the use of bone substitutes (coral and HAP) – 1992: the use cage-plate type II – 2000: the use of Bryan Total Disc Prosthesis.

Vertebral artery freeing was frequent between 1962 and 1980 and we performed 249 operations 10 / Revista de Ortopedie ºi Traumatologie

with 44 transverectomies; 117 uncusectomies; 39 uncoforaminectomies and 49 Kehr’s freeing. The frequency decreases after 1980 by beneficial effect of seat-belts and head-rests. We performed 11 fusions according to Cloward and 99 according to Robinson, with ose of iliac crest grafting and without osteosynthesis. Then, the contribution of osteosynthesis was essential, with strongly diminution of post-operative neck pains, with yet bettered by the blocking of the screws and the use of Titanium. Between 1972 and 2003, we performed 461 anterior cervical osteosyntheses all surgeries merged. Between 1976 and 2003, we performed 156 corpectomies with 50 iliac crest grafting; 73 coral monobloc grafting and 33 with fibular grafting. Our first cage-plate in 1982 was a stainless steel cage-plate with a perforated alumina inserted grafting. The bone substitute we used starting since 1990, was shaped coral grafting as well for intersomatic fusions after osteophytectomy (106 cases) as for corpectomies (73 cases). The second cage-plate, type II, created in 1992 consists in a Titanium bearing ring with an insertion of two concentric layers, an ionic peripheric cement and a central Eurocer (HAP). Between 1992 and 2003, we placed 63 cage-plates type II. Finally, we placed 55 Bryan Total Cervical Fisc Prostheses between 200 and 2003. Posterior approaches ware also used, essentially laminectomy with osteosynthesis according to Roy Camille, but ony in 66 cases. Complications are presented and discussed. In conclusions, huge progress of degenerative spine surgery for the last thirty years: • Presision of imaging allowing better selection of patients. • Excellency of osteosynthesis. • Simplification of operative follow-up. • Least invasivity thanks to disc prostheses and mini-invesive surgery. • But remember that cervical arthritis is often well tolerated. • Operate only if the conservative treatments failed. • Check the coherence between clinical sings and imaging. • Operate patients and not images!


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ

 REZULTATELE CORECÞIEI CHIRURGICALE A DEFORMÃRII SCOLIOTICE A COLOANEI VERTEBRALE CU AJUTORUL ENDOCORECTOARELOR CU FIXARE PE MAI MULTE NIVELE («Medilar», LSZ) A. Laka, M. Sampiev, I. Popa Clinica II Ortopedie-Traumatologie, Spitalul Clinic Judeþean de Urgenþã Timiºoara

Cuvinte cheie: scoliozã, corecþie, implanturi În acest articol sunt prezentate rezultatele tratamentului chirurgical cu folosirea endocorectoarelor cu plãci la bolnavii cu deformãri scoliotice de diferite grade de complexitate. În afara rezultatelor obþinute în timpul operaþiei ºi în perioada postoperatorie imediatã (de pânã la 10 zile), este prezentatã ºi analiza evoluþiei corecþiei pe o perioadã îndelungatã (mai mult de 5 ani). Metoda permite, folosind combinarea detaliilor specifice implantului ºi urmãrind cu stricteþe procedura chirurgicalã a implantarii lor, corecþia deformãrii scoliotice a coloanei vertebrale la bolnavii de diferite vârste (în cadrul studiului nostru cuprinse între 7 ºi 44 ani), cu rezultate excelente (de la 70 la 100% corecþie în funcþie de vârstã ºi de gradul deformãrii). Aceastã metodã nu necesitã internarea îndelungatã a pacientului, în perioada postoperatorie se recomandã mobilizarea imediatã ºi nu este necesarã folosirea ortezelor. Metoda nu exclude alte intervenþii pe coloana vertebralã sau cutia toracicã, ca spondilodeza anterioarã sau posterioarã prin diferite procedee, discectomii, osteotomii de corectare, toracoplastii ºi altele. Intervenþia presupune lezarea minimã a þesuturilor moi, implicit pierderea de sânge este minimã, are o duratã scurtã ºi permite efectuarea într-o singurã etapã. Bibliografie 1. Cotrel Y., Dubousset J. C-D instrumentation in spine surgery. Principles, technicals, mistakes and traps // Sauramps Medical, 11 boulevard Henry IV – 34000 Montpellier. – 1992. – 159 p. 2. Dove J. Internal fixation of the lumbar spine: the Hartshill restangle // Clin. Orthop. Rel. Res.– 1986.– V.203.– P.135-240. 3. Dove J. Case for urgent removal of spinal instrumentation: time to think again? // J. Bone Jt. Surg.– 1989.– V.71-B, ¹ 1.– P.153. 4. Drummond D. Harrington instrumentation with spinous process wiring for idiopathic scoliosis // Orthop. Clin. Of North America.– 1984.– V.19, ¹ 2.– P.281-289.

5. Drummond D., Keene J., Guadagni J. et al. Interspinous process spinal instrumentation // J. Pe-diatr. Orthop.– 1984.– ¹ 4.– P.397-404. 6. Drummond D., Keene J., Breed A. Segmental spinal instrumentation without sublaminar wires // Arch. Orthop. Traumat.– 1985.– ¹ 103.– P.378. 7. Luque E. The anatomic basis and development of segmental spinal instrumentation // Spine.– 1982.– V.7.– P.256289. 8. Luque E. Segmental spinal instrumentation for correction of scoliosis // Clin. Orthop. Rel. Res.– 1982.– V.163.– P.193-198. 9. Luque E. Segmental Spinal Instrumentation (SSI) bei Neuromuscularenskoliosen // Or-thopade.– 1989.– ¹ 18.– P.128133. 10. Luk K.D.K., Leong J.C., Reyes L. et al. The comparative results of treatment in idiopathic tho-racolumbar and lumbar scoliosis using the Harrington, Dwyer and Zielke instrumentation // Spine.– 1989.– V. 14, ¹ 3.– P. 275-280. 11. Mitulescu A. // ARGOS Spine News. – 2002, April. – P. 33-36. 12. Resina J., Ferreira-Alves A.F. A technique of correction and internal fixation for scoliosis // J. Bone Jt. Surg.– 1977.– V.59-B, ¹ 2.– P.159-165.

 MICROABORDUL INTERLAMELAR ÎN SINDROMUL COMPRESIV RADICULAR LOMBAR DE CAUZÃ DEGENERATIVÃ DISCOVERTEBRALÃ. POSIBILITÃÞI ªI LIMITE D. Niculescu, D. Grecu, D. Anuºca, C. Mercuþ, D. Tarniþã, S. Didu, D. Rusu, P.R. Melinte Ortopedie Traumatologie, Spitalul Clinic Universitar de Urgenþã Craiova

Cuvinte cheie: laminectomie, miniabord interlamelar, stenozã canal, hernie disc Introducere: Abordul chirurgical clasic al coloanei vertebrale lombare, în cazul patologiei degenerative compresive este laminectomia, atât de criticatã datoritã destabilizãrii secundare rahidiene pe care o induce. Aceastã lucrare ia în discuþie calea chirurgicalã „nedestabilizatoare” a rahisului lombar, care permite, simultan cu prezervarea stabilitãþii segmentare, o decomprimare uni sau pluriradicularã eficientã. Material ºi Metode: Lotul studiat a cuprins un numãr de 815 pacienþi care au suferit o astfel de intervenþie chirurgicalã în clinica noastrã, în perioada 1998-2008. Etiologia patologiei compresive radiculare a fost reprezentatã de: hernie discalã – 374 cazuri (45,9%); stenozã degenerativã rahidianã (350 cazuri - 42,9%) asociatã cu grade variabile de

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 afectare discalã de tip compresiv; stenozã degenerativã rahidianã fãrã afectare discalã de tip compresiv – 91 cazuri (11,2%). Examenul clinic a precizat nivelul neurologic implicat : o rãdãcinã spinalã-690 cazuri; douã rãdãcini la acelaºi nivel vertebral – 28 cazuri; douã rãdãcini – 59 cazuri; trei rãdãcini – 23 cazuri; sindrom de coadã de cal – 15 cazuri. Examinarea imagisticã efectuatã de rutinã a constat în radiografia simplã, mielografia lombarã ºi examenul RMN. Rezultate: Urmãrirea rezultatelor, am realizat-o prin prisma evoluþiei sindromului neurologic ºi a celui vertebral. Scala globalã de codificare a rezultatelor este cea a lui Spangfort. Rezultatele precoce au fost dominate de schimbarea spectacularã a durerii iradiate, dispãrutã imediat postoperator la 750 pacienþi (92%), diminuatã semnificativ la 57 dintre aceºtia (6,9%) ºi uºor amelioratã la doar 8 cazuri (1,1%). Sindromul vertebral a diminuat semnificativ la 535 pacienþi (65,6%), la restul de 280 cazuri (34,4%) ameliorarea acestuia nefiind una majorã. Am reuºit monitorizarea la 3 luni a unui numãr de 751 pacienþi (92,14%), iar la 6 luni a 699 cazuri (85,76%), apreciind evoluþia deficitului motor radicular dupã scala ASIA. Concluzii: Microabordul interlamelar lombar sa dovedit a fi o soluþie chirurgicalã extrem de avantajoasã pentru patologia degenerativã discovertebralã complicatã cu suferinþa compresivã unisau pluriradicularã, obþinând o bunã expunere atât a rãdãcinii spinale în porþiunea ei intracanelarã, cât ºi a discului intervertebral în zona lui posterolateralã, fãrã destabilizarea iatrogena a rahisului lombar, cu o spitalizare scurtã ºi recuperare postoperatorie rapidã. MINI INVASIVE INTER LAMELLA APPROACH FOR LUMBAR RADICULAR COMPRESSIVE SYNDROME CAUSED BY DEGENERATIVE DISC AND VERTEBRAL DISEASE. POSSIBILITIES AND LIMITS Key words: laminectomy, mini invasive inter lamella approach, canal stenosis, disc hernia Introduction. The classic approach to lumbar vertebral column for degenerative compressive disease is laminectomy, intensely criticized due to the secondary induced instability. Our paper takes into consideration the “stability keeping” approach that allows for simultaneous segmental stability

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preservation and single or multi effective radicular decompression. Material and methods: Our study group had 815 patients that had such a surgical intervention in our clinic, during 1998-2008. The etiology of the radicular compressive pathology was represented by: disc herniation – 374 cases (45,9%); degenerative canal stenosis (350 cases – 42,9%) associated to different degrees of compressive disc disease; degenerative canal stenosis without compressive disc disease – 91 cases (11,2%). The clinic examination stated the neurological level implicated: single spinal radix – 690 cases; two spinal radix – 59 cases; three spinal radix – 23 cases; horse tail syndrome – 15 cases. The para clinic investigation was routinely achieved by simple x-ray, lumbar mielography and MRI. Results: We evaluated the results taking into consideration the vertebral and neurological syndromes. The Spangfort global results codification scale had been used. The initial results were dominated by the spectacular change in irradiated pain that disappeared immediately after surgery in 750 patients (92%), significantly diminished in 57 (6,9%) and was easily ameliorated in just 8 cases (1,1%). The vertebral syndrome significantly diminished in 535 patients (65,6%), in the rest 280 cases (34,4%) the amelioration not being a major one. We succeeded into monitoring for 3 months 751 patients (92,14%) and for 6 months 699 cases (85,76%), evaluating the motor radicular deficit after ASIA scale. Conclusions: The mini invasive lumbar inter lamella approach proved to be a surgical solution extremely advantageous for the degenerative disc and vertebral pathology complicated with compressive radicular sufferance, offering a good exposure of the spinal root inside the canal and of the posterior and lateral inter vertebral disc, without generating secondary instability with a short hospital stay and rapid after surgery recovery. Bibliografie 1. North American Spine Society Task Force on Clinical Guidelines (2000). Herniated disc. North American Spine Society Phase III Clinical Guidelines for Multidisciplinary Spine Care Specialists. La Grange, IL: North American Spine Society. 2. Atlas SJ, et al. (2001). Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: Five-year outcomes from the Maine Lumbar Spine Study. Spine, 26(10): 1179–1187.


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ 3. Atlas SJ, et al. (2005). Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10-year results from the Maine Lumbar Spine Study. Spine, 30(8): 927–935. 4. Deyo RA, Weinstein JN (2001). Low back pain. New England Journal of Medicine, 344(5): 363–370. 5. Jordan J, et al. (2007). Herniated lumbar disc, search date November 2006. Online version of Clinical Evidence (8).

 UTILIZAREA INSTRUMENTAÞIEI SEGMENTARE TRANSPEDICULARE ÎN TRATAMENTUL FRACTURILOR COLOANEI TORACO-LOMBARE R. Opriº, B. Voicu, M. ªtefana, A. Gulian U.M.F. Târgu-Mureº, Clinica Ortopedie Traumatologie I

Cuvinte cheie: coloanã toraco-lombarã, ºuruburi transpediculare, indicele lui Beck Scop: De a demonstra eficienþa sistemelor transpediculare în tratamentul leziunilor instabile ale coloanei toraco-lombare. Material ºi metodã: Între ianuarie 2004 ºi iulie 2008, 33 de pacienþi au fost incluºi în acest studiu, cu o vârstã medie de 44 de ani(24-71). Repartizarea pe sexe a fost astfel: 23 bãrbaþi respectiv 10 femei. Toþi prezentau fracturi sau fracturi-luxaþii ale coloanei toraco-lombare, instabile,60% interesând vertebra L1 ºi vertebra T12 [1], [2]. Complicaþii neurologice preoperatorii prezentau 6 bolnavi:o paraplegie, trei parapareze ºi douã sindroame de coadã de cal[5]. Bilanþul preoperator a constat în radiografii standard, tomografie computerizatã ºi examinare IRM a cazurilor mielice. În aprecierea instabilitãþii leziunilor am folosit ºi semnele radiografice sugestive de instabilitate descrise de JEND ºi HELLER în 1999 Am practicat abord posterior în decubit ventral, sub anestezie generalã prin IOT, practicând distracþia ºi reducerea prin ºuruburi transpediculare, mono ºi poliaxiale, fixate pe bare, din titan. În cazurile cu afectare neurologicã ºi în 3 cazuri cu stenozã de canal peste 30% am practicat ºi laminectomia. În douã cazuri de luxaþie am folosit grefe cortico-spongioase din creasta iliacã posterioarã, introduse intertransvers. Durata medie operatorie a fost de 85 de minute (55-130 minute).

La 24 de ore postoperator s-a permis mobilizarea bolnavilor în decubit lateral altern, iar la 48-72 ore mobilizarea cu cadru a celor amielici. Rezultate ºi Concluzii: Urmãrirea bolnavilor s-a fãcut la 3 luni, 6 luni ºi 1 an postoperator. Toþi pacienþii cu deficit neurologic prezentau ameliorarea simptomatologiei, cu un grad ASIA [3], [4], [5]. Evaluarea radiograficã a urmãrit raportul între zidul anterior ºi posterior al aceleiaºi vertebre (indicele lui Beck). Dacã preoperator indicele lui Beck era de 55% (35-75%), postoperator a crescut la 80% (60-100%), adicã o creºtere de 25% [3]. Au apãrut complicaþii minore, doi bolnavi au prezentat serom al plãgii la 7 ºi 8 zile postoperator, unul rezolvat prin puncþie unicã celelalt necesitând reinstituirea unui drenaj aspirativ, cu evoluþie favorabilã. Durata medie de spitalizare a fost de 11 zile (6-24 de zile). Studiul de faþã nu îºi propune altceva decât sã confirme eficacitatea instumentaþiei segmentare transpediculare în tratamentul leziunilor instabile ale coloanei toraco-lombare aºa cum rezultã ºi din alte comunicãri din literatura de specialitate [3],[4]. TRANSPEDICULAR SCREW INSTRUMENTATION IN TORACO-LUMBAR FRACTURES TREATMENT Key Words: thoracolumbar spine, pedicle screws, Beck’s index Objective: The aim of study was to evaluate the outcome of dorsal stabilization with transpedicular screw instrumentation with regard to the success of correction and the functional results in fractures of the toraco-lumbar spine. Material and Methods: From january 2004 to july 2008, a total of 33 patients (10 women, 23 men) underwent transpedicular spinal instrumentation. The average age of the patients was 44 years (range, 24-71 years). Surgery was performed for toraco-lumbar vertebral column instability secondary to fractures, and fracture-dislocation; the most frequently fractured vertebrae (60% of cases) were T12 and L1.[1], [2]. Signs or symptoms of neural compression were noted in 6 patients: paraplaegia in one patient, paraparesis in 3 patients and cauda equina syndrome in 2 patients [5]. Radiological evaluation included plain radiograps, toraco-lumbar computed tomography (CT) and MRI studies în neurological impaired

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 patients. The assessment of toraco-lumbar spine stability, related to the Jend and Heller’s signs of instability described 1999. With a posterior approach, under general anesthesia, we performed distraction and reduction of fractures with mono and/or poliaxial transpedicular instrumentation. Decompressive lumbar laminectomy was performed in 3 cases with greater than 30% stenosis of the neural canal and in all neurological impared patients. Intertransvers fusion with iliac crest bone graft was used in 2 fracture-dislocation lesions. The mean time of the surgery was 85 minutes(range 55-130). Early bedside mobilization of neurological impairment free patients at 24 hours post-op was permited, as well as assisted walking in 2nd-3rd days after surgery. Results and Conclusions: Follow up clinically and radiologically at 3, 6 months and 1 year after surgery. The functional results of treatment were also recorded and compared to the radiologic data. The increase in the Beck index as a result of operative intervention was significant-more than 25% - from 55% (35-75%) to 80% (60-100%). All patients with neurologic impairment improved after surgery. Minor postoperative complications were recorded in two cases: sterile wound serohematomas required revision (single punction; aspirative drainage).After their evacuation, the further postoperative course was uneventful. The mean period of hospitalisation was 11 days (6-24). The present study showed the effectiveness of transpedicular screw instrumentation in instable toraco-lumbar fractures. Bibliografie 1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries.Spine 1983; 8: 817-31. 2. Marnay T., Lesions traumatiques du rachis.In:manuel d’ostheoynthese vertebrale.Sauramps Medical, Montpellier, 1991, 75-108. 3. Knop C., Fabian H.F., Bastian L, Blauth M. Late results of thoraco-lumbar fractures after posterior instrumentation and transpedicular bone grafting. Spine 2001; 26: 88-99. 4. Been H.D.,Bouma G.J. (1994). Comparison of two types of surgery for thoraco-lumbar burst fracture:combined anterior and posterior stabilisation vs.posterior instrumentation only. Acta Neurochir (Wien) 141: 349-57. 5. American spinal injury association imsopai.International standards for Neurological and Functional Classification of Spinal Cord Injury. Chicago: American Spinal Injury Association; 1992.

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 TRATAMENTUL TRAUMATISMELOR VERTEBRO-MEDULARE CERVICALE. REZULTATELE UNEI SERII DE 23 DE CAZURI R. Opriº, M. ªtefana, B. Voicu, A. Gulian, B. Bumbu U.M.F. Târgu-Mureº

Cuvinte cheie: coloanã cervicalã, abord anterior, corporectomie, cuºcã de titan tip mesh, placã ºi ºuruburi Scop: de a demonstra eficienþa decompresiei ºi stabilizãrii pe cale anterioarã în traumatismele vertebro-medulare cervicale. Material ºi metodã: Am inclus în acest studiu 23 de bolnavi (20 bãrbaþi, 3 femei),operaþi de autor în perioada octombrie 2004-octombrie 2008, cu vârsta medie de 48 de ani (17-70). Dintre aceºtia,13 cazuri (60%) prezentau leziuni la nivel C5 ºi C6: fracturi, luxaþii ºi hernii de disc posttraumatice.Evaluarea imagisticã a constat în radiografii clasice,computer tomografie precum ºi rezonanþã magneticã.Din punct de vedere neurologic, încadrarea bolnavilor în scorul ASIA este urmãtoarea: 14-E, 4-D, 3-C, 2-B. Din punct de vedere al tehnicii operatorii am practicat abord latero-cervical drept.La 7 cazuri cu luxaþii am început cu abord posterior, repunerea luxaþiei ºi filodeza posterioarã, în 3 cazuri practicând ºi laminectomia. Decompresia anterioarã am realizat-o prin corporectomii ºi/sau discectomii. Somatodeza s-a facut prin grefon iliac tricortical în 13 (57%) cazuri iar în 10 (43%) cazuri am utilizat cuºti cervicale din titan tip “mesh”,umplute cu grefele rezultate din corporectomie. La toate cazurile am practicat osteosinteza cu placuþe ºi ºuruburi cervicale, din titan. Durata medie a operaþiilor a fost de 95 minute (65-140), cu un câºtig de cca 15 minute la cazurile unde am folosit cuºti.Drenajul sistat la 24 de ore iar mobilizarea în orstostatism la 24-48 de ore a bolnavilor neurologic indemni. Rezultate ºi concluzii: Evaluarea bolnavilor am fãcut-o la 6 sãptãmâni ºi la 3-6-12 luni. Am exclus din acest studiu 3 bolnavi cu sindroame neurologice complete ASIA A, care au decedat postoperator în primele 7 zile. Evaluarea radiograficã a urmãrit integrarea grefelor osoase. Am practicat radiografii clasice ºi dinamice. Tomografia computerizatã am utilizat-o în cazurile cu cuºti cervicale.


ACTUALITÃÞI ÎN CHIRURGIA SPINALà Rezonanþa magneticã s-a folosit la cazurile cu sechele neurologice. Toþi bolnavii mielici au câºtigat un loc în scara ASIA. Toþi au purtat gulere cervicale între 6-12 sãptãmâni. Am avut o mobilizare a unei cuºti cervicale, precoce, caz în care am prelungit imobilizarea pânã la 4 luni, bolnavul fiind asimptomatic la controlul de 1 an ºi pânã în prezent. Rezultatele acestui studiu corespund cu cele ale altor autori. Ele demonstreazã eficienþa decompresiei medulare prin abord anterior ºi posibilitatea stabilitãþii precoce a coloanei. Ameliorarea neurologicã ºi reintegrarea socioprofesionalã rapidã vorbesc de la sine în favoarea acestor tehnici chirurgicale. TREATMENT OF CERVICAL SPINE INJURIES. RESULTS IN A 23 CASES SERIES Key words: cervical spine, anterior approach, corporectomy, titanium mesh cages, plates and screws, Objective: To evaluate the effectiveness of anterior cervical decompression and stabilization in cervical spine injuries. Material and methods: From october 2004 to october 2008, 23 patients (3 women, 20 men) underwent cervical spine reconstruction procedures. The average age of the patients at the time of surgery was 48 years (range, 17-70 years). The patients were classified according to the type and the level of injury. ASIA‘s functional classification was used (2-ASIA B, 3-ASIA C, 4ASIA D and 14-ASIA E). C5 and C6 level lesions including fractures, disslocations and traumatic disc herniations were present in 13 patients (60%). Radiological evaluation included plain radiograps, axial cervical computed tomography (CT) and MRI. In most patients the anterior cervical approach was performed. Seven fracturedislocations lesions also required posterior open reduction and fixation, laminectomy beeing mandatory in 3 cases. Anterior decompression was achived by means of anterior cervical corporectomy w/o discectomy. Fusion with iliac crest bone graft (ICBG) was performed in 13 patients (57%), while titanium mesh cages (TMCs) filled with autologous bone grafts taken from the corpectomy were used in 10 patients (43%). Titanium anterior cervical plates (ACPs) for interbody fusion after anterior cervical corpectomy

were used in all cases. The mean time of the surgery was 95 minutes(range 65-140). Postoperatory drainage was removed at 24 hours after surgery, and early mobilization of neurological impairment free patients (24-48 hours post-op). Results and Conclusions: Six weeks, 3-6-12 months follow up imaging studies including: plain and dinamic X-rays, CT scans when TMCs were used, and MRI studies in neurological impaired patients, reported excellent results (cervical fusion, good stability of the cervical spine); one early cage subsidence in witch case the cervical collar was maintained for 4 months without development of any neurological signs till present. Average cervical collar imobilization was between 6-12 weeks. All patients with incomplete neurologic impairment improved after surgery. Three subjects, with complete ASIA A injury, died during the first 7 days postop and were excluded from this study. The present study showed the effectiveness of anterior cervical approach in decompression and early stabilization in cervical spine injuries. Bibliografie 1. Arseni C., Panoza Gh. (1981) – Patologie vertebromedularã cervicalã. Bucureºti. Editura Didacticã ºi Pedagogicã. 7-29, 199-236 2. Panoza Gh. (1971) – Contribuþii la tratamentul leziunilor traumatice vertebro-medulare cervicale. Teza de doctorat. Bucureºti: 3-21, 29-57. 3. Krag M.H., Robertson P.A., Johnson C.C. et al (1997). – Anterior cervical fusion using a modified tricortical bone graft:a radiographic analysis of outcome. J Spinal Disord 10: 420-30. 4. Connolly P.J., Esses S.I., Kostuik J.O. (1996) – Anterior cervical fusion:outcome analysis of patients fused with and without anterior cervical plates. J Spinal Disord 9: 202-6. 5. Mulholland R.C. (2000) – Cages:outcome and complications Eur Spine J 9: 110-3.

 GREFELE ILIACE TRICORTICALE ªI CUªTILE INTERVERTEBRALE TIP PLASÃ ÎN CHIRURGIA RECONSTRUCTIVÃ A COLOANEI CERVICALE R. Opriº, B. Voicu, M. ªtefana, A. Gulian, B. Bumbu U.M.F. Târgu-Mureº, Clinica Ortopedie Traumatologie I

Cuvinte cheie: grefe iliace, cuºti cervicale tip plasã. Scop: de a compara utilizarea grefelor iliace ºi a cuºtilor tip plasã (mesh) post decompresia pe cale anterioarã la nivelul coloanei cervicale.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Material ºi Metodã: În intervalul iunie 2003octombrie 2008 am operat 30 bolnavi (25 bãrbaþi ºi 5 femei) cu traumatisme vertebro-medulare cervicale. Dintre aceºtia 19 erau neurologic indemniASIA E (17 bãrbaþi ºi 2 femei) cu vârsta medie 46 de ani (17-70), iar 58% interesând C6 ºi C5. În toate cazurile decompresia a fost pe cale anterioarã. În 9 cazuri am utilizat grefon iliac ”tricortical” - (lotul I) iar în 10 cuºti cervicale din titan tip plasã (mesh) umplute cu bucãþile de os rezultat din corporectomie (lotul II). Osteosinteza s-a realizat cu plãci ºi ºuruburi cervicale din titan. Durata medie a operaþiilor a fost de 100 minute (90-140) în lotul I respectiv 85 minute (75-120) în lotul II. Pierderea de sânge de 260 ml (180-400) în lotul I respectiv 150 ml (100-200) în lotul II. Nu am avut complicaþii anestezice sau chirurgicale. Rezultate ºi Concluzii: evaluarea bolnavilor timp de 12 luni (3-36). Toþi bolnavii au avut evoluþie favorabilã spre consolidare-integrare grefe. În lotul I 3 bolnavi acuzau dureri moderate la nivelul crestei iliace donoare. În lotul II am avut o mobilizare a unei cuºti ce a necesitat prelungirea imobilizãrii. Lotul I a necesitat radiografii clasice pentru a aprecia consolidarea. Lotul II necesitã în plus radiografii dinamice ºi examen CT cu reconstrucþie sagitalã. Dezavantajul major în lotul II este economic: costuri foarte mari determinate de preþul implantului ºi necesitatea investigaþiei CT. ILIAC GRAFT VERSUS TITANIUM CERVICAL MESH IN ANTERIOR CERVICAL RECONSTRUCTION SURGERY Key words: iliac graft, titanium mesh cages, anterior approach. Purpose: a comparison in using iliac graft and titanium mesh cages in anterior reconstruction cervical surgery Material and Methods: The author performed surgery on 30 pacients with cervical spine injury between june 2003-october 2008. We included in this study only 19 pacients (17 men and 2 women) neurologically asymptomatic - ASIA E. Average medium age 46 years (17-70), 58% interested C5 and C6. In all cases we used anterior approach and decompression. In 9 cases (lot I) fusion with iliac graft and in 10 cases (lot II) titanium mesh cages filled with local bone. Fixation was achieved with cervical plate and screws. Average surgery time

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100 minutes (90-140) in lot I versus 85 minutes (75120) in lot II. Average loss of blood 260 ml (100-400) in lot I versus 150 ml (100-200) in lot II. No major complications occurred during surgery. Results and Conclusions: all pacients with favorable outcome, fusion occurred in all cases. In lot I 3 patients complained of moderate pain at iliac donor site. In lot II we had one cage subsidence. Patients in lot I needed only plain X-ray while in lot II additional dynamic X-rays and computedtomography with saggital reconstruction. Finally the major disadvantage of using titanium mesh cages is cost related: very expensive implant and the need for CT. Bibliografie 1. Arseni C., Panoza Gh. (1981) – Patologie vertebromedulara cervicala. Bucuresti. Editura Didactica si Pedagogica. 7-29, 199-236. 2. Panoza Gh. (1971) – Contributii la tratamentul leziunilor traumatice vertebro-medulare cervicale. Teza de doctorat. Bucuresti: 3-21, 29-57. 3. Krag M.H., Robertson P.A., Johnson C.C. et al. (1997) – Anterior cervical fusion using a modified tricortical bone graft:a radiographic analysis of outcome. J Spinal Disord 10: 420-30. 4. Connolly P.J., Esses S.I., Kostuik J.O. (1996) – Anterior cervical fusion: outcome analysis of patients fused with and without anterior cervical plates. J Spinal Disord 9: 202-6. 5. Mulholland R.C. (2000). Cages: outcome and complications Eur Spine J 9: 110-3. 6. Akamaru T., Kawahara N., Tsuchiya H., et al. – Healing of autologous bone in a titanium mesh cage used in anterior column reconstruction after total spondylectomy. Spine 2002; 27: E329- 33. 7. Eck K.R., Bridwell K.H., Ungacta F.F., et al. – Analysis of titanium mesh cages in adults with minimum two-year followup. Spine 2000; 25: 2407- 15. 8. Riew K.D., Rhee J.M. – The use of titanium mesh cages in the cervical spine. Clin Orthop Relat Res 2002; 394: 47 - 54.

 INTERESUL ECHILIBRULUI SAGITAL PELVI RAHIDIAN ÎN TRATAMENTUL DIFORMITÃÞILOR COLOANEI VERTEBRALE I. Petcu Clinica de Ortopedie, Spitalul Clinic de Recuperare, Iaºi

INTEREST OF PELVI-SPINAL SAGITTAL BALANCE ÎN SPINE DEFORMITIES TREATMENT Bibliografie 1. Stagnara P. – Les deformations du rachis: scolioses, cyphoses, lordoses. Paris: Masson, 1985.


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ 2. Dimeglio A., Herisson C., Simon L. eds – Les cyphoses:de l’enfant a l’adulte. Paris: Masson, 1995. 3. Biot B., Roussouly P., Le Blay G., Bernard J.-C. eds – Douleurs mecaniques et troubles de la statique vertebrale. Sauramps Med., 2006. 4. Voutsinas S.A., MacEwen G.D. – Sagittal profiles of the spine. Clin Orthop, 1986, 210, 235-242. 5. Jackson R.P. et al. – Congruent spinopelvic alignament on standing lateral radiographs of adult volunteers. Spine, 2000, 25, 2808-2815. 6. Vaz G., Roussouly P., Berthonnaud E., Dimnet J. – Sagittal morphology and equilibrum of pelvis and spine, Eur Spine J, 2002, 11, 80-87. 7. Guigui P., et al. – Valeur physiologique des parametres pelviens et rachidiens de l’equilibre sagittal du rachis, Rev Chir Orthop, 2003, 89, 6, 496-506.

radiografici preoperator, postoperator, cât ºi la controale la 6-12-18-24 luni. Nu au fost complicaþii intra- sau postoperatorii la nici unul dintre loturi care sã necesite spitalizare prelungitã sau reintervenþie. Concluzii: Dupã un recul minim de 12 luni analiza celor 2 tehnici chirurgicale de tratament a SIA Lenke 5C evidenþiazã rezultate sensibil comparative privind corecþia curburii majore, pierderi de corecþie în timp, durata spitalizãrii, progresia etapelor de reeducare vertebralã postoperatorie, totuºi cu predominenþa abordului anterior cu AVA instrumentatã cu 2 tije.

ANTERIOR SPINE FUSION VERSUS POSTERIOR SPINE FUSION FOR LENKE 5C ADOLESCENT IDIOPATIC SCOLIOSIS

ABORDUL ANTERIOR VERSUS POSTERIOR ÎN TRATAMENTUL SCOLIOZEI IDIOPATICE A ADOLESCENTULUI LENKE 5C I. Petcu, A. Sava, V. Cojocari Clinica de Ortopedie, Spitalul Clinic de Recuperare, Iaºi

Cuvinte cheie: Lenke 5C, scoliozã idiopaticã a adolescentului, instrumentaþie spinalã anterioarã, instrumentaþie posterioarã pedicularã Scop: Analiza a 2 loturi omogene de pacienþi trataþi chirurgical pentru scoliozã idiopaticã a adolescentului (SIA) tip Lenke 5C cu un recul de minimum 12 luni. Scopul acestui studiu a fost de a compara douã metode de tratament chirurgical pentru tipul Lenke 5C de scoliozã lombarã sau toracolombarã: artrodezã vertebralã anterioarã (AVA) cu instrumentaþie segmentarã cu 2 tije ºi artrodezã vertebralã posterioarã (AVP) cu excizie de relaxare ºi instrumentaþie cu ºuruburi pediculare. Material ºi Metodã: 28 de pacienþi cu SIA Lenke 5C operaþi în perioada Ianuarie 2006 – Septembrie 2008 în Clinica de Ortopedie a Spitalului Clinic de Recuperare din Iaºi de acceaþi echipã operatorie au fost urmãriþi clinic ºi radiografic : 12 pacienþi trataþi prin abord anterior cu AVA instrumentatã (2 tije) ºi 16 pacienþi trataþi prin abord posterior cu AVP instrumentatã cu ºuruburi pediculare. Rezultate: Analiza comparativã a celor 2 loturi a urmãrit elemente precum vârsta, aspectul clinic, durata operaþiei, pierderile sanguine, parametri

Key words: Lenke 5C, AIS, anterior dual rod instrumentation, posterior pedicle screws Objective: Analysis of 2 homogenous groups of patients surgically treated for Lenke 5C adolescent idiopathic scoliosis (AIS). The purpose of this study was to compare 2 methods of treatment for Lenke 5C lumbar and thoracolumbar scoliosis: anterior spinal fusion with anterior column support and dual rod instrumentation and posterior release with pedicle screw instrumentation. Material and Methods: 28th patients with Lenke 5C AIS were operated for the time periods January 2006 to September 2008 in the Department of Orthopaedic Surgery of the Iassy Rehabilitation Hospital, by the same surgical team. We analyzed 28 patients with Lenke 5C based on clinical and radiographic data: 12 patients treated with anterior dual-rod instrumented fusion and 16 patients with posterior pedicle-screw instrumented fusion. Results: Clinical and radiographic parameters pre- and postoperative were evaluated and compared. There were no complications in either group wich extended hospital stay or required an unplanned second surgery. Conclusion: At a minimum of 1 year follow-up adolescents with Lenke 5C curves demonstrated statistically comparative results in both groups, with better parameters in case of the anterior instrumented spinal fusion.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Bibliografie

Bibliografie 1. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopatic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001; 83-A: 1169-81. 2. Shufflebarger HL, Geck MJ, Clark CE. The posterior approach for lumbar and thoracolumbar adolescent idiopatic scoliosis: posterior shortening and pedicle screws. Spine 2004; 29: 269-76. 3. Hurtford RK Jr, Lenke LG, Lee SS, et al. Prospective radiographic and clinical outcomes of dual-rod instrumented anterior spinal fusion in adolescent idiopatic scoliosis: comparison with single-rod constructs. Spine 2006; 31: 2322-8.

 CRITERII DE ALEGERE A IMPLANTURILOR ÎN TRATAMENTUL CHIRURGICAL AL FRACTURILOR COLOANEI TORACOLOMBARE (implanturi bazate pe ºuruburi pediculare ºi tije vs. implanturi cu plãci fixate prin cârlige lamelare) I. Popa, Àl. Laka, M. Sampiev Clinica II Ortopedie-Traumatologie, Spitalul Clinic Judeþean de Urgenþã Timiºoara

Cuvinte cheie: fracturã vertebralã, implant, cârlige, ºuruburi În acest articol sunt prezentate rezultatele tratamentului chirurgical al fracturilor coloanei toracolombare cu folosirea implantelor cu plãci ºi cârlige la un numãr de 23 pacienti. În afara rezultatelor obþinute în timpul operaþiei ºi în perioada postoperatorie imediatã (de pânã la 10 zile), este prezentatã ºi evoluþia rezultatului pe o perioadã mai îndelungata (mai mult de 2 ani). Metoda permite, folosind combinarea detaliilor specifice implantului ºi urmârind cu stricteþe procedura chirurgicalã a implantãrii lor, reducerea fracturii, fixarea multisegmentarã stabilã, corecþia eficientã a deformãrii postfracturare în plan sagital, frontal ºi a rotaþiei coloanei vertebrale la bolnavii de diferite vârste ºi cu diverse traumatisme asociate. Metoda este facilã, cu o duratã între 1 ºi 2 ore, cu o traumatizare minimã a þesuturilor moi, însoþitã de o pierdere minimã de sânge (în medie 400 ml), nu necesitã internarea îndelungatã a pacientului (în medie 14 zile), iar în perioada postoperatorie se recomandã mobilizarea imediatã. Metoda nu necesitã folosirea ortezelor în perioada postoperatorie, fãcând-o extrem de utilã în cazul pacienþilor politraumatizaþi. Complicaþiile postoperatorii au fost serom într-un caz care s-a rezolvat spontan fãrã intervenþie terapeuticã ºi nevralgie intercostalã într-un caz. În nici un caz nu a apãrut deteriorarea implantului.

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1. Gaines R.W. Jr. (2000) – The use of pedicle screw internal fixation for the operative treatment of spinal disorders. J Bone Surg Am; (10): 1458-1476. Review. 2. Arand M., Wilke H.J., Schultheiss M. et al (2000) – Comparative stability of the „internal fixator” and the „universal spine system” and the effect of cross-linking transfixating systems. A biomechanical în vitro study. – Biomed Tech (Berl); 45 (11): 311-316. 3. Cripton P.A., Jain G.M.,Wittenberg R.H., et al. (2000) – Load sharing characterisitics of stabilized lumbar spine segments. – Spine; 25 (2): 170-179). 4. Panjabi M.M., Abumi K., Duranceau J. Et al (1988) – Biomechanical evaluation of spinal fixation devices: II. Stability provided by eight fixation devices. Spine; 13 (10): 1135-1140). 5. Halvorson T.L., Kelley L.A., Thomas K.A., et al. (1994) – Effects of bone mineral density on pedicle screw fixation. Spine; 19(21): 2415-2420. 6. Valdevit A., Kambic H.E.,Mc Lain R.F. (2005) – Torsional stability of cross-linkink configurations: a biomechanical analysis. Spine J.; 5 (4): 441-445. 7. Rohlmann A., Calisse J., Bergmann G. Et al (1999) – Internal spinal fixator stiffness has only a minor influnce on stresses in the adjacent discs. Spine; 24 (12): 1192-1195). 8. Rohlmann A., Calisse J., Ber5gmann G. Et al. (1999) – Internal spinal fixator stiffness has only a minor influnce on stresses in the adjacent discs. Spine;24 (12): 1192-1195) 9. (Arand M., Wilke H.J., Schultheiss M. et al (2000) – Comparative stability of the „internal fixator” and the „universal spine system” and the effect of cross-linking transfixating systems. A biomechanical in vitro study. – Biomed Tech (Berl); 45 (11): 311-316). 10. (Dvorak M., MacDonald S., Gurr K.R. et al (1993) – An anatomic, radiographic and biomechanical assessment of extrapedicular screw fixation in the thoracic spine. Spine; 18 (12): 1689-1694). 11. (Morgenstern W., Ferguson S.J., Berey S., et al. (2003) – Posterior thoracic extrapedicular fixation: a biomechanical study. Spine; 28 (16): 1829-1835 12. Cotrel Y., Dubousset J. C-D instrumentation in spine surgery. Principles, technicals, mistakes and traps // Sauramps Medical, 11 boulevard Henry IV – 34000 Montpellier. – 1992. – 159 p. 13. Guidera K.J., Hooten J., Wearherly W. Et al (1993) – Cotrel-Dubousset instrumentation. Results in 52 patients. Spine; 18 (4): 427-431); 14. Dove J. Case for urgent removal of spinal instrumentation: time to think again? // J. Bone Jt. Surg. – 1989.– V.71-B, ¹ 1.– P.153 15. Aebi M., Thalgott J.S., Webb J.K. (1998) – AO principles in Spine surgery. Berlin Heidelberg: Springer Verlag.) si (Laxer E. (1994) – A further development in spinal instrumentation. Technical comission for spinal surgery of the ASIF. Eur. Spine J.; 3 (6): 347-352 16. Berlemann U., Cripton P., Nolte L.P. et al. – (1995) – New means in spinal pedicle hook fixation. A biomechanical evaluation. Eur. Spine J.; 4 (2): 114-122


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ 17. Drummond D., Keene J., Breed A. Segmental spinal instrumentation without sublaminar wires // Arch. Orthop. Traumat.– 1985.– ¹ 103.– P.378 18. Luque E. The anatomic basis and development of segmental spinal instrumentation // Spine.– 1982.– V.7.– P.256-289.

 CRITERII IMAGISTICE DE EVALUARE ÎN ALEGEREA TIPULUI DE TRATAMENT AL FRACTURILOR VERTEBRALE TORACOLOMBARE I. Popa, D. Negoescu, D. Poenaru, F. Bãrsãºteanu Clinica II Ortopedie-Traumatologie, Spitalul Clinic Judeþean de Urgenþã Timiºoara

Cuvinte cheie: RMN, CT, radiografia simplã, fracturi. Introducere: Managementul fracturilor toracolombare reprezintã una din cele mai controversate zone în chirurgia spinalã modernã. În ciuda progreselor imagisticii, a înþelegerii evouate a stabilitãþii coloanei vertebrale ºi a sistemelor de clasificare, nu existã un consens privind tratamentul fracturilor toracolombare. Scopul acestei lucrãri este de a sublinia importanþa evaluãrii complete a pacientului în vederea alegerii metodei de tratament optime. Material ºi Metodã: Am studiat retrospectiv un grup de 92 pacienþi (23 femei, 69 bãrbaþi) cu o medie de vârstã de 41 ani care s-au prezentat la noi în clinicã în perioada ianuarie 2007- martie 2008. Am preferat tratamentul conservator pentru fracturile toracolombare fãrã deficit neurologic ºi stabile (n=18). În prezenþa deficitului neurologic ºi a instabilitãþii, care au fost cele mai frecvent întâlnite scenarii am preferat tratamentul chirurgical prin abord posterior cu scopul restaurãrii aliniamentului sagital ºi frontal ºi a stabilitãþii (n=74). Rezultate: Deteriorarea implantului nu a apãrut în niciun caz. Un singur caz a prezentat infecþie ºi a trebuit sã îndepãrtãm implantul. Media pierderii corecþiei în cazul stabilizãrii simple posterioare a fost de 4,4 grade. Concluzii: Evaluarea corectã a pacientului este fundamentalã în alegerea tratamentului leziunilor toracolombare. Vârsta pacientului, starea de sãnãtate, ocupaþia, stilul de viaþã, tipul constituþional corelate cu studiile imagistice ºi clasificarea corectã a tipului de fracturã sunt esenþiale în obþinerea unui rezultat satisfãcãtor în urma tratamentului.

Bibliografie 1. Kewalramani LS, Taylor RG. Multiple Non-Contiguous Injuries to the Spine. Acta Orthop Scand 1976; 47: 52–8. 2. Henderson RL, Reid DC, Saboe LA. Multiple Noncontiguous Spine Fractures. Spine 1991; 16: 128–31. 3. Vaccaro AR, Daugherty RJ, Sheehan TP, Dante SJ, Cotler JM, Balderston RA, Herbison GJ, Northrup BE – Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine.1997: 22 :2609-13 4. Holdsworth F. Fractures, Dislocations, and FractureDislocations of the Spine. J Bone Joint Surg Am 1970; 52: 1534–51. 5. Denis F. Spinal Instability As Defined by the ThreeColumn Spine Concept in Acute Spinal Trauma. Clin Orthop 1984; 189: 65–76. 6. Denis F. The Three Column Spine and Its Significance in the Classification of Acute Thoracolumbar Spinal Injuries. Spine 1983; 8: 817–31. 7. White AA 3rd, Panjabi MM – Clinical biomechanics of the spine. Philadelphia: Lipincott; 1990 8. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A Comprehensive Classification of Thoracic and Lumbar Injuries. Eur Spine J 1994; 3: 184–201. 9. Panjabi MM, Oxland TR, Kifune M, Arand M, Wen L, Chen A. Validity of the Three-Column Theory of Thoracolumbar Fractures. A Biomechanic Investigation. Spine 1995; 20: 1122–7. 10. James KS, Wenger KH, Schlegel JD, Dunn HK. Biomechanical Evaluation of the Stability of Thoracolumbar Burst Fractures. Spine 1994; 19: 1731–40. 11. Haher TR, Bergman M, O’Brien M, Felmly WT, Choueka J, Welin D, et al. The Effect of the Three Columns of the Spine on the Instantaneous Axis of Rotation in Flexion and Extension. Spine 1991; 16: S312–8. 12. McAfee PC, Yuan HA, Lasda NA. The Unstable Burst Fracture. Spine 1982; 7: 365– 73. 13. Ballock RT, Mackersie R, Abitbol JJ, Cervilla V, Resnick D, Garfin SR. Can Burst Fractures Be Predicted From Plain Radiographs? J Bone Joint Surg Br 1992; 74: 147–50. 14. McCormack T, Karaikovic E, Gaines RW. The Load Sharing Classification of Spine Fractures. Spine 1994; 19: 1741–4. 15. Parker JW, Lane JR, Karaikovic EE, Gaines RW. Successful Short-Segment Instrumentation and Fusion for Thoracolumbar Spine Fractures: a Consecutive 41/2-Year Series. Spine 2000; 25: 1157–70. 16. Shono Y, McAfee PC, Cunningham BW. Experimental Study of Thoracolumbar Burst Fractures. A Radiographic and Biomechanical Analysis of Anterior and Posterior Instrumentation Systems. Spine 1994; 19: 1711–22 17. Anderson PA, Rivara FP, Maier RV, Drake C. The Epidemiology of Seatbelt-Associated Injuries. J Trauma 1991; 31: 60–7. 18. Been HD, Bouma GJ. Comparison of Two Types of Surgery for Thoraco-Lumbar Burst Fractures: Combined Anterior and Posterior Stabilisation Vs. Posterior Instrumentation Only. Acta Neurochir Wien 1999; 141: 349–57. 19. Aligizakis A, Katonis P, Stergiopoulos K, Galanakis I, Karabekios S, Hadjipavlou A. Functional Outcome of Burst Fractures of the Thoracolumbar Spine Managed Non-

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Operatively, With Early Ambulation, Evaluated Using the Load Sharing Classification. Acta Orthop Belg 2002; 68: 279–87 20. Dai LY, Jin WJ. Interobserver and Intraobserver Reliability in the Load Sharing Classification of the Assessment of Thoracolumbar Burst Fractures. Spine 2005; 30: 354–8. 21. Gertzbein SD. Scoliosis Research Society. Multicenter Spine Fracture Study. Spine 1992; 17: 528–40 22. Dimar JR, Glassman SD, Raque GH, Zhang YP, Shields CB. The Influence of Spinal Canal Narrowing and Timing of Decompression on Neurologic Recovery After Spinal Cord Contusion in a Rat Model. Spine 1999; 24: 1623–33. 23. Hashimoto T, Kaneda K, Abumi K. Relationship Between Traumatic Spinal Canal Stenosis and Neurologic Deficits in Thoracolumbar Burst Fractures. Spine 1988; 13: 1268–72.

 NEURONAVIGAÞIA ÎN CHIRURGIA SPINALÃ E.C. Popescu, B.Costãchescu, Fl. Grãmadã

PEEK CAGES IN CERVICAL INTERVERTEBRAL ARTHRODESIS Key words: Cage, cervical arthrodesis This paper presents our experience in using PEEK cages in treating cervical disc herniation. Cho DI. Preliminary experience using a polyetheretherketone (PEEK) cage in the treatment of cervical disc disease. Neurosurgery 2002, 51, 1349.

 RELAÞIA ANATOMICÃ DINTRE PEDICULUL VERTEBRAL ªI RÃDÃCINILE NERVOASE LA NIVEL TORACAL M. Sopon, I. Baier, C. Matei, L. Tãnase, C. Mohor Clinica Ortopedie Traumatologie Sibiu

Spitalul Clinic „Prof. N. Oblu“, Clinica Neurochirurgie, Iaºi

Cuvinte cheie: neuronavigaþie, chirurgie spinalã. Autorii prezintã avantajele utilizãrii neuronavigaþiei în chirurgia spinalã ºi experienþa lor pe un lot de 30 pacienþi. NEURONAVIGATION IN SPINAL SURGERY Key words: neuronavigation, spinal surgery The authors present the advantages in using neuronavigation in spinal surgery and their experience in a 30 patients survey. Bibliografie 1. Menchetti P. Neuronavigation CT scan guided in minimal invasive spinal surgery. The Internet Journal of minimally invasive Spinal Technology. 2007, vol.1, nr.1 2. Clinical experience in neuronavigation. Stereotact Funct Neurosurg 2001, 76: 145-147.

 UTILIZAREA CAGE-URILOR DIN PEEK ÎN ARTRODEZA INTERVERTEBRALÃ CERVICALÃ E.C. Popescu, B. Costãchescu, I. Poeata, C. Tarasi Spitalul Clinic „Prof. N. Oblu“, Clinica Neurochirurgie, Iaºi

Cuvinte cheie: cage, artrodeza cervicalã. Lucrarea prezintã experienþa noastrã în utilizarea cage-urilor intervertebrale în tratamentul herniei de disc cervicale pe un lot de 40 pacienþi trataþi în clinica noastrã în perioada 2005-2007.

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Cuvinte cheie: pedicul toracic, nerv spinal, fixarea transpedicularã Lucrarea reprezintã un studiu anatomic care evalueazã relaþia dintre rãdãcinile nervilor spinali ºi pediculii vertebrali la nivel toracic, între nivelurile T4 ºi T12. Material si Metodã: studiul s-a efectuat pe patru cadavre adulte. Dupã ce s-a efectuat laminectomia, ºi s-a incizat duramater longitudinal, s-au identificat rãdãcinile nervoase intradural, ulterior acestea putând fi urmãrite cu mai multã uºurinþã pe traiectul lor. Am mãsurat apoi distanþele dintre marginea inferioarã a pediculului superior ºi rãdãcina nervosã ºi marginea superioarã a pediculului inferior ºi rãdãcina nervoasã. Aceste distanþe sunt deosebit de importante în abordul posterior al coloanei vertebrale toracale prin fixare cu ºuruburi transpediculare. Cunoaºterea acestor distanþe permiþând un abord sigur al pediculului cu reducerea riscului lezãrii radiculare, la introducerea ºurubului transpedicular. Concluzii: Distanþa dintre marginea inferioarã a pediculului superior ºi rãdãcina nervului spinal nu prezintã o evoluþie clarã crecãtoare sau descrecãtoare a valorilor în funcþie de nivelul vertebrei. Distanþa dintre marginea superioarã a pediculului subiacent ºi radãcina nervoasã prezintã o scãdere progresivã a acesteia în sens cranio-caudal. În ceea ce priveºte diametrele transvers ºi sagital al pediculilor se observã o creºtere progresivã în dimensiuni a pediculilor toracici de la nivelul lui T4 la T12.


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ ANATOMICAL RELATIONS BETWEEN THORACIC PEDICLE AND SPINAL ROOTS Key words: thoracic pedicle, spinal roots, transpedicular fixation The study represent an antomical study about the relation between spinal roots and thoracic pedicle at level T4 to T12. Study was made on four adult human cadavare spines. After specific cadaver preparation, with an electronic calipers we made anatomical measurements of sagittal and transverse diameters of vertebral pedicle and the distance between vertebral pedicles and spinal roots from T4 to T12. Conclusions: The distance between the lower part of the upper pedicle and the nerve root presents no clear evolution of the values in connection to the level of the vertebra, neither asccendent nor desccendent. The distance between the upper end of the sub- adjacent pedicle and nerve root presents a progressive reduction of value from the cranium to the caudal area. When reffering to the transverse and sagittal diameter of the pedicles we can observe a progressive growth in size of the thoracic pedilces from the level of T4 to T12. Bibliografie 1. Galibert P, Deramond H, Rosat P, Le Gars D (1987) Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie 33: 166–168. 2. Berry JL, Moran JM, Berg WS, Steffee AD (1987) A morphometric study of human lumbar and selected thoracic vertebrae. Spine 12: 362–367. 3. Ebraheim NA, Xu R, Ahmad M, Yeasting RA (1997) Projection of the thoracic pedicle and its morphometric analysis. Spine 22: 233–238. 4. Lutz Weise, Olaf Suess, Thomas Pich, Theodoros Kombos, Neurochirurgische Klinik, Charité – Universitätsmedizin, Berlin, Berlin, Germany, Transpedicular screw fixation in the thoracic, and lumbar spine with a novel cannulated polyaxial screw system, Medical Devices: Evidence and Research 2008: 1 33–39. 5. Yongjung J. Kim, Lawrence G. Lenke One Barnes-Jewish Hospital Plaza, 11300 West Pavilion, St. Louis, Missouri - 63110, USA - Thoracic pedicle screw placement: Free-hand technique Neurology India | December 2005 | Vol 53 | Issue 4 6. Sandeep P. Datir, MS, MRCS, and Sajal R. Mitra, MS Morphometric Study of the Thoracic Vertebral Pedicle in an Indian Population - SPINE Volume 29, Number 11, pp 1174–1181, ©2004, Lippincott Williams & Wilkins, Inc 7. Kai Ming Liau, MD, Mohd Imran Yusof, MMed(Ortho), Mohd Shafie Abdullah, MMed(Radiology), Sarimah Abdullah, MMed(Biostatistics) and Abdul Halim Yusof, MMed(Ortho) Computed Tomographic Morphometry of Thoracic Pedicles -

SPINE Volume 31, Number 16, pp E545–E550 ©2006, Lippincott Williams & Wilkins, Inc. 8. McCormack BM, Benzel EC, Adams MS, et al. Anatomy of the thoracic pedicle. Neurosurgery. 1995;37:303–308. 9. Martin Krbeck, University Hospital Brno – Injuries of the thoracic and lumbar spine – European Instructional Course Lecture, Volume 7, 2005, p 87-104 10. Aospine Manual, Principles and Techniques & Clinical Applications, Max Aebi, Vol. 1, Vol. 2 11. Hasan Çaglar Ugur, Ayhan Attar, Aysun Uz, Ibrahim Tekdemir, Nihat gemen, and Yasemin Genç, Thoracic Pedicle: Surgical Anatomic Evaluation and Relations, Journal of Spinal Disorders, Vol. 14, No. 1, pp. 39–45, © 2001

 SCOLIOZA IDIOPATICÃ A ADULTULUICONSIDERENTE PATOGENETICE ªI TERAPEUTICE T. Ursu, Georgiana Nedelea Secþia Ortopedie, Spitalul Clinic „Foiºor“ Bucureºti

Cuvinte cheie: scoliozã idiopaticã, adult, tratament chirurgical, criterii de evoluþie. Scolioza reprezintã o deformare lateralã a coloanei vertebrale însoþitã ºi de o componentã rotatorie. În funcþie de vârsta pacientului în momentul diagnosticului, existã mai multe tipuri de scoliozã idiopaticã: infantilã, juvenilã, a adolescentului ºi a adultului. Existã trei tipuri de pacienþi în cadrul scoliozei idiopatice a adultului: pacienþi tineri fãrã modificãri degenerative, adulþi cu modificãri degenerative extensive pe o diformitate preexistentã ºi adulþi fãrã diformitate pânã la 40 de ani care se prezintã cu scoliozã degenerativã de novo. Tratamentul acestei afecþiuni se va adresa atât diformitãþii propriu-zise cât ºi patologiei asociate: durere, stenozã de canal lombar, degenerescenþã discalã. Material ºi metodã: În studiu au fost incluºi 74 de pacienþi cu scoliozã idiopaticã a adultului operaþi în Spitalul Foiºor în perioada 2001-2008. În toate cazurile s-a practicat Artrodeza posterioarã cu instrumentaþie segmentarã. La 61 de pacienþi fuziunea s-a efectuat pânã la S1 iar la restul fuziunea s-a oprit la nivel lombar. Rezultate: Corecþia medie obþinutã a fost de 42%. Durata medie a intervenþiilor chirurgicale a fost de 3 ore ºi 20 minute. Durata medie de spitalizare a fost de 8 zile. Pacienþii au fost urmãriþi clinic ºi radiologic la 6 sãptãmâni, 3 luni, 6 luni, un an postoperator ºi apoi anual. La 2 pacienþi a fost necesarã reintervenþie pentru extinderea fuziunii.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Concluzii: Deºi intervenþiile chirurgicale prezintã o serie de riscuri intra ºi postoperatorii, stabilizarea chirurgicalã a coloanei vertebrale se impune mai ales pentru rezolvarea durerilor ºi a deficitelor neurologice ce însoþesc aceastã patologie. ADULT IDIOPATHIC SCOLIOSISPATHOGENETIC THERAPEUTICAL CONSIDERATIONS Key words: idiopathic scoliosis, adult, surgical treatment Scoliosis is a lateral curvature of the spine. Acording with the age of the patient when it is first diagnosed, idiopathic scoliosis is divided into infantile, juvenile, adolescent and adult. There are three different categories of patient: young patients with spinal deformity and without degenerative degeneration, adult patient with previous deformity and discal degeneration and patients with degenerative scoliosis de novo. Treatment of diformity will address specific symptoms ( quick progression of deformity, pain, spinal stenosis). Material and methods: The current study involves 74 patients diagnosed with adult idiopathic scoliosis and undergoing surgery in our clinic between 2001 and 2008. Surgery comprised in all cases in posterior spinal fusion and segmental instrumentation. In 61 patients fusion included S1, fusion in remaining patients included only lumbar level. Results: Average correction achieved was 42%. Average operating time was 3 hours and 20 minutes, blood loss averaged 850 ml. Hospital stay time was 8 days, patients were evaluated at 6 weeks, 3 and 6 months and 1 year post-surgery. Two patient required surgery for extending fusion level. Conclusions: In spite of the risks the surgery involves, spinal fusion is necessary in order to treat pain and neurologic desease produced by spinal deformity. Bibliografie 1. An HS, Vaccaro AR, Dolinskas CA, et al: Differentiation between spinal tumors and infections with magnetic resonance imaging. Spine 1991; 16 (suppl 8): S334—S338. 2. Azouz Em, Kozlowski K, Martin D, et al: Osteoid osteoma and osteoblastoma of the spine in children: Report of 22 cases with brief literature review. Pediatr Radiol 1986; 16: 25–31.

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3. Bouchard JA, Koka A, Bensusan JS, et al: Effects of irradiation on posterior spinal fusions: A rabbit model. Spine 1994; 19: 1836—1841. 4. Dahlin DC: Giant-cell tumor of vertebrae above the sacrum: A review of 31 cases. Cancer 1977;39:1350—1356. Delamarter RB, Sachs BL, Thompson GH, et al: Primary neoplasms of the thoracic and lumbar spine: An analysis of 29 consecutive cases. Clin Orthop 1990; 256: 87–100. 5. Emery SE, Brazinski MS, Koka A, et al: The biological and biomechanical effects of irradiation on anterior spinal bone grafts in a canine model. J Bone Joint Surg 1994; 76A: 540—548. Healy JH, Ghelman B: Osteoid osteoma and osteoblastoma: Current concepts and recent advances. Clin Orthop 1986; 204: 76–85. 6. Huvos AG, Woodward HQ, Cahan WG, et al: Postirradiation osteogenic sarcoma of bone and soft tissues: A clinicopathologic study of 66 patients. Cancer 1985; 55: 1244— 1255. 7. Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg 1992; 74A: 179—185. 8. Kostuik JP, Weinstein JN: Differential diagnosis and surgical treatment of metastatic spine tumors, in Frymoyer JW, Ducker TB, Hadler NM, et al (eds): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 1, pp 861–888. 9. Mankin HJ, Lange TA, Spanier SS: The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg 1982; 64A: 1121—1127. 10. McClain RF, Weinstein JN: Solitary plasmacytomas of the spine: A review of 84 cases. J Spinal Disord 1989;2:69—74. Rogalsky RJ, Black GB, Reed MH: Orthopaedic manifestations of leukemia in children. J Bone Joint Surg 1986;68A:494—501. Rougraff BT, Kneisl JS, Simon MA: Skeletal metastases of unknown origin: A prospective study of a diagnostic strategy. J Bone Joint Surg 1993; 75A: 1276—1281. 11. Shives TC, McLeod RA, Unni KK, et al: Chondrosarcoma of the spine. J Bone Joint Surg 1989; 71A: 1158—1165. 12. Shives TC, Dahlin DC, Sim FH, et al: Osteosarcoma of the spine. J Bone Joint Surg 1986; 68A: 660-668. 13. Siegal T, Siegal T: Current considerations in the management of neoplastic spinal cord compression. Spine 1989;14:223—228. 14. Sim FH, Dahlin DC, Stauffer RN, et al: Primary bone tumors simulating lumbar disc syndrome. Spine 1977; 2: 65—74. 15. Tomita K, Kawahara N, Baba H, et al: Total en bloc spondylectomy for solitary spinal metastases. Int Orthop 1994;18:291—298. 16. Vergel De Dios AM, Bond JR, Shives TC, et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992; 69: 2921—2931. 17. Weinstein JN: Spine neoplasms, in Weinstein SL (ed): The Pediatric Spine: Principles and Practice. New York, NY, Raven Press, 1994, vol 1, pp 887—916. 18. Weinstein JN, McLain RF: Primary tumors of the spine. Spine 1987; 12: 843—851. 19. Weinstein JN: Differential diagnosis and surgical treatment of primary benign and malignant neoplasms, in Frymoyer JW, Ducker B, Hadler NM, et al (eds): The Adult


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 1, pp 829—860. 20. Weinstein JN, Mclain RF: Tumors of the spine, in Rothman RH, Simeone FA (eds): The Spine, ed 3. Philadelphia, PA, WB Saunders, 1992, vol 2, pp 1279—1318.

 METASTAZELE COLOANEI VERTEBRALE T. Ursu, Georgiana Nedelea Secþia Ortopedie, Spitalul Clinic „Foiºor“ Bucureºti

Cuvinte cheie: metastaze, localizare secundarã, sistem osos, vertebrã, tratament, clasificare Coloana vertebralã este locul cel mai frecvent de metastazare scheletalã a neoplasmelor (50 – 75%) urmat de pelvis, femur ºi humerus proximal. Mai mult de 70% dintre pacienþii ce decedeazã de cancer prezintã evidenþã anatomo-patologicã de metastaze vertebrale. Cel mai frecvent tip de neoplazie metastatica întâlnitã în practica curentã este carcinomul 75%. Dintre acestea 84% sunt de sân ºi afecteazã de regulã coloana toracalã, 84% de prostatã dar care afecteazã de regulã coloana lombarã ºi zona sacro-pelvinã, 47% sunt date de neoplaziile renale, 44% de cele pulmonare ce afecteazã mai frecvent zona toracalã ºi apoi în procente mai mici neoplaziile tiroidiene, limfoamele ºi mieloamele. Diagnosticul va trebui sã încadreze pacientul în una din cele 5 categorii diagnostice dupã cum urmeazã: - tipul I – fara deficit neurologic sau distrucþie osoasã - tipul II – distrucþie osoasã fãrã colaps ºi discretã instabilitate - tipul III – deficit motor ºi sau senzitiv dar fãrã distrucþie osoasã importantã - tipul IV – colaps vertebral cu durere de cauzã mecanicã sau instabilitate dar fãrã deficit neurologic - tipul V – colaps vertebral ºi instabilitate cu deficit neurologic important. Ca ºi regulã de aur decompresia trebuie sã se adreseze sediului compresiei ºi nu indirect (laminectomie), rezecþia pe cât posibil în bloc ºi înlocuirea defectului cu instrumentaþie augmentatã cu grefã osoasã ºi stabilizare posterioarã este sufucientã atunci când se folosesc suruburi pediculare 3 nivele deasupra ºi 3 sub nivelul decompresiei. Intervenþiile chirurgicale sunt de regula complaxe de lungã duratã iar echipele trebuiesc bine antrenate în acest sens.

VERTEBRAL COLUMN METASTASES Key words: metastasis, secondary location, bone system, vertebra, treatment, classification Vertebral spine is the most frequent site for the skeletal metastases (50 – 75%) followed by pelvis, femur and proximal humerus. More than 70 % of the cancer deceased patients are presenting evidence of vertebral metastases. The most frequent type of neoplastic disease is carcinoma 75%. From this a percentage of 84% are breast metastases ad they affect regularly the thoracic spine, 84% prostatic cancer that is affecting regularly the lumbar and sacral spine and then less frequent thyroidal neoplastic disease, lymphomas and myelomas. The diagnose is described at each step and at the end it should include the patient in one of the following categories, that will indicate us also the election treatment method. - type I – without any neurological deficit and bone destruction - type II – discrete bone destruction with no collapse and slight local instability - type III – motor and sensorial deficit without severe bone destruction - type IV – vertebral collapse with mechanical pain or instability but without neurological deficit - type V – vertebral collapse and instability with important neurological deficit. As a gold rule the decompression in all this cases when needed should address the site of compression not indirectly (laminectomy), the resection as wide as possible en bloc and the replacement of the defect of choice with metal implant augmented with bone graft and then posterior segmental instrumentation. When pedicular screws are used three levels above and three below are mechanically sufficient. The surgery for spinal metastases is a demanding one and long so the surgical team must be trained into this direction. Bibliografie 1. Dahlin D.C.: Giant-cell tumor of vertebrae above the sacrum: A review of 31 cases. Cancer 1977; 39: 1350—1356. 2. Delamarter R.B., Sachs B.L., Thompson G.H., et al: Primary neoplasms of the thoracic and lumbar spine: An analysis of 29 consecutive cases. Clin Orthop 1990; 256: 87—100.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 3. Emery S.E., Brazinski M.S., Koka A., et al: The biological and biomechanical effects of irradiation on anterior spinal bone grafts in a canine model. J Bone Joint Surg 1994; 76A: 540—548. 4. Healy J.H., Ghelman B: Osteoid osteoma and osteoblastoma: Current concepts and recent advances. Clin Orthop 1986; 204: 76—85. 5. Huvos A.G., Woodward H.Q., Cahan W.G., et al: Postirradiation osteogenic sarcoma of bone and soft tissues: A clinicopathologic study of 66 patients. Cancer 1985; 55: 1244— 1255. 6. Kneisl J.S., Simon M.A.: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg 1992; 74A: 179—185. 7. Kostuik J.P., Weinstein J.N.: Differential diagnosis and surgical treatment of metastatic spine tumors, in Frymoyer JW, Ducker TB, Hadler NM, et al (eds): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 1, pp 861— 888. 8. Mankin H.J., Lange T.A., Spanier S.S.: The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg 1982; 64A: 1121—1127. 9. McClain R.F., Weinstein J.N.: Solitary plasmacytomas of the spine: A review of 84 cases. J Spinal Disord 1989; 2: 69—74. 10. Rogalsky R..J, Black G.B., Reed M.H.: Orthopaedic manifestations of leukemia in children. J Bone Joint Surg 1986; 68A: 494—501. 11. Rougraff B.T., Kneisl J.S., Simon M.A.: Skeletal metastases of unknown origin: A prospective study of a diagnostic strategy. J Bone Joint Surg 1993; 75A: 1276—1281. 12. Shives T.C., McLeod R.A., Unni K.K., et al: Chondrosarcoma of the spine. J Bone Joint Surg 1989; 71A: 1158—1165. 13. Shives T.C., Dahlin D.C., Sim F.H., et al: Osteosarcoma of the spine. J Bone Joint Surg 1986; 68A: 660-668. 14. Siegal T., Siegal T.: Current considerations in the management of neoplastic spinal cord compression. Spine 1989; 14: 223—228. 15. Sim F.H., Dahlin DC, Stauffer R.N., et al: Primary bone tumors simulating lumbar disc syndrome. Spine 1977;2:65—74. 16. Tomita K., Kawahara N., Baba H., et al: Total en bloc spondylectomy for solitary spinal metastases. Int Orthop 1994; 18: 291—298. 17. Vergel De Dios A.M., Bond J.R., Shives T.C., et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992; 69: 2921—2931. 18. Weinstein J.N.: Spine neoplasms, in Weinstein SL (ed): The Pediatric Spine: Principles and Practice. New York, NY, Raven Press, 1994, vol 1, pp 887—916. 19. Weinstein J.N., McLain R.F.: Primary tumors of the spine. Spine 1987; 12: 843—851. 20. Weinstein J.N.: Differential diagnosis and surgical treatment of primary benign and malignant neoplasms, in Frymoyer J.W., Ducker B., Hadler N.M., et al (eds): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 1, pp 829—860. 21. Weinstein J.N., Mclain R.F.: Tumors of the spine, in Rothman R.H., Simeone F.A. (eds): The Spine, ed 3. Philadelphia, P.A., W.B. Saunders, 1992, vol 2, pp 1279—1318.

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 PROTEZA DISCALÃ LOMBARÃ - FOLLOW-UP LA 5 ANI C. Vâjeu Clinique du Parc - Perigueux - France

Cuvinte cheie: disc lombar, protezã discalã, discopatia degenerativã. Înlocuirea discului degenerativ cu o protezã este posibilã de peste 10 ani. Tehnica chirurgicalã ºi urmãrirea a peste 140 de proteze lombare timp de 5 ani este subiectul acestei prezentãri. Bibliografie 1. Onimus M – Extraperitoneal approach to the lombar spine with video assistance-Spine 1996; 21: 2491-4. 2. Rahn – Adjacent-segment degeneration after lombar fusion with instrumentation-J Spinal Disord 1996; 9: 392-400. 3. Lemaire - Intervertebral disc prosthesis - Clin Orthop 1997; 337: 64-76. 4. Bertagnoli – Indications for full prosthetic disc arthroplasty - Euro spine J. 2002; 2: 131-136.

 STABILIZAREA DINAMICÃ POSTERIOARÃ PRIN IMPLANT INTER SPINOS-DIAM C. Vâjeu Clinique du Parc - Perigueux - France

Cuvinte cheie: fuziune, implant interspinos O alternativã la fuziune spinalã o constituie stabilizarea dinamicã prin implant interspinos. Acestã tehnicã aproape percutanatã poate prelungi viaþa discului degerativ pentru câþiva ani. Bibliografie 1. Taylor – A new posteriorshock absorber-Munich mai 2001. 2. Graf – Instabilité vértebrale, traitement à l’aide d’un systeme souple-Rachis; 4: 1233-137.

 INCIDENÞA INFECÞIILOR NOZOCOMIALE ÎN CHIRURGIA SPINALÃ - STUDIU RETROSPECTIV D. Vermeºan, R. Prejbeanu, V. Dumitraºcu, H. Petrescu, Simona Vermeºan Clinica I Ortopedie-Traumatologie S.C.J.U.T.

Cuvinte cheie: infecþii nozocomiale, chirurgie spinalã.


ACTUALITÃÞI ÎN CHIRURGIA SPINALÃ Chirurgia spinalã implicã proceduri solicitante ºi dificile ce duc la rate înalte de complicaþii. Recunoaºterea precoce a cazurilor cu risc înalt de complicaþii este foarte importantã pentru a putea reduce incidenþa prin mãsuri adiþionale particularizate cazurilor. Metodã: am efectuat un studiu retrospectiv pe 37 pacienþi internaþi ºi trataþi în departamentul nostru de chirurgie spinalã între ianuarie 2005 ºi septembrie 2009. S-au observat factorii predispozanþi ºi etiologia bacterianã a infecþiilor. Rezultate: majoritatea complicaþiilor ºi infecþiilor au apãrut la pacienþi vârstnici (peste 60 ani) cu comorbiditãþi. Numãrul infecþiilor a crescut semnificativ dupã operaþii lungi (peste 5 ore). Alþi factori de considerat sunt diabetul ºi obezitatea.În concluzie, rezultatele noastre concordã cu cele din literaturã ºi aratã cã chirurgia spinalã are cea mai ridicatã ratã de infecþi dintre specialitãþile ortopedice. Am constatat cã vârsta înaintatã a pacienþilor, durata crescutã a operaþiei ºi abordurile extinse sunt factorii de risc principali pentru infecþie. NOSOCOMIAL INFECTION INCIDENCE IN SPINAL SURGERY – RETROSPECTIVE STUDY Key words: nozocomial infections, spinal surgery. Spine surgeries are high demanding procedures that lead to high complication rates. The early recognition of high risk cases in paramount so we can apply an exact prevention protocol to improve outcome. Method: we performed a retrospective study on 37 patients admitted and

treated in our spinal surgery department between January 2005 and September 2009. Predisposing conditions and bacterial etiology of infections were observed. Results: most complications and infections were seen with elderly patients (over 60) with associated risk factors. The number of infections increased significantly after long operative duration (more than 5h). Other factors to be considered were diabetes and obesity. In conclusion, we found similar results with the literature, showing that spinal surgery has the highest infection rates among orthopedic surgeries. We found increased age, duration of surgery and extended approaches to be the main risk factors for infection. Bibliografie 1. Pull ter Gunne A.F., Cohen D.B. – Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine (Phila Pa 1976). 2009 Jun 1; 34 (13): 1422-8. 2. Rodríguez-Caravaca G., Santana-Ramírez S., Villar-DelCampo M.A., Martín-López R., Martínez-Martín J., Gil-deMiguel A. – Adequacy Assessment of Antibiotic prophylaxis in orthopedic and traumatologic surgery. Enferm Infecc Microbiol Clin. 2009 Apr 28. 3. Urrutia J., Bono C.M., Mery P., Rojas C., Gana N., Campos M. – Chronic liver failure and concomitant distant infections are associated with high rates of neurological involvement in pyogenic spinal infections. Spine (Phila Pa 1976). 2009 Apr 1; 34 (7): E240-4. 4. Nagashima H., Yamane K., Nishi T., Nanjo Y., Teshima R. –Recent trends in spinal infections: retrospective analysis of patients treated during the past 50 years. Int Orthop. 2009 Mar 11.

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FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL TRATAMENTUL CHIRURGICAL ÎN LEZIUNILE SINDESMOZEI TIBIO-PERONIERE O. Alexa, I. Popia, C. Trandabat Spitalul Clinic de Urgenþã Iaºi

Cuvinte cheie: sindesmoza tibio-peronierã, diastazis tibio-peronier . Leziunile sindesmozei tibio-peroniere dezorganizeazã pensa tibio-peronierã ºi conduc la incongruenþa cu suprafeþele articulare ale astragalului. Scopul lucrãrii este de a analiza rezultatele diferitelor moduri de fixare ale sindesmozei în cazul unui diastazis tibio-peronier. Material ºi metodã: Au fost analizate 102 de cazuri de diastazis tibio-peronier înregistrate în clinica autorului într-o perioada de 3 ani. Diagnosticul a fost stabilit pe baza radiografiei de gleznã efectuatã în poziþia de rotaþie internã 10-15°. Sindesmoza poate fi corect apreciatã numai pe aceasta incidenþã. Normal suprapunerea peroneului peste tibie este de 1 mm. Lipsa suprapunerii sau îndep��rtarea celor douã oase pe aceastã incidenþã a fost definitã ca diastazis tibio-peronier. Leziunile sindesmozei au fost apreciate în unele cazuri ºi intraoperator: dupã fixarea peroneului, cu un cârlig peroneul a fost tracþionat extern. Dacã acesta s-a îndepãrtat de tibie peste 3 mm, s-a impus fixarea sindesmozei. Fixarea s-a fãcut utilizând abordul pentru osteosinteza maleolei externe atunci când placa de fixare a peroneului era atât de joasã încât ºurubul de diastazis a putut fi trecut prin placã. În situaþiile în care fractura maleolei externe a fost înaltã, ºurubul pentru fixarea sindesmozei a fost plasat prin intermediul unei incizii separate de 1-2 cm. Au fost folosite mai multe tipuri de ºuruburi: ºuruburi corticale filetate pe toatã lungimea (metoda AO), ºuruburi maleolare filetate numai distal. ªurubul a fost plasat în ambele corticale ale tibiei în 62% din cazuri sau numai în corticala externã a tibiei în 38% din cazuri. La pacienþii obezi sau necooperanþi fixarea s-a fãcut cu douã ºuruburi. Au fost folosite atât ºuruburi de 3,5 cât ºi de 4,5 mm.

Rezultate: Rezultatele au fost apreciate clinic ºi radiologic pentru 76 de pacienþi la un an postoperator. S-a constatat ruperea ºurubului în 4 cazuri de fixare în ambele corticale tibiale ºi deraparea ºurubului în 3 cazuri de fixare unicorticalã. 74% dintre pacienþi prezentau o funcþie normalã a gleznei la un an postoperator. SURGICAL TREATMENT IN LESIONS OF THE TIBIO-FIBULAR SYNDESMOSIS Key words: tibio-fibular syndesmosis, tibiofibular diastasis The lesions of the tibio-fibular syndesmosis disorganize the tibio-fibular mortese and lead to incongruency with the corresponding talar articular surfaces. The purpose of this paperwork is to analyze the results of several types of internal fixation in diastatic lesions of the tibio-fibular syndesmosis. Material and method: 102 cases of diastatic lesions of the tibio-fibular syndesmosis, recorded over a 3-year period in the author’s clinic, were analyzed. The diagnosis was established based on the roentgenoghraphic examination of the ankle positioned in 10-15 degrees of internal rotation. The syndesmosis can only be correctly assessed in this incidence. Normally, there is a 1 mm overlapping of the fibula and tibia. Absence of this overlapping or the existence of a distance between the two bones on this incidence was defined as tibio-fibular diastasis. The syndesmotic lesions were also assessed intraoperatively: following the fibular internal fixation, the fixed fibula was tractioned laterally with a hook. If the fibula went away from the tibia more than 3 mm, the internal fixation of the syndesmosis was performed. The fixation of the syndesmosis was accomplished through the same approach used for the fixation of the fibula, when the fibular fracture site was distal enough to require passing the screw through a hole in the fibular plate. în cases of more proximal fibular fracture sites, a 1-2 cm separate incision was made in order to pass the screw.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Several types of screws were used: cortical (whole-length threaded) screws, malleolar screws (threaded only distally), both 3.5 and 4.5 mm in diameter. The screw was placed in both cortices of the tibia in 62% and only in the lateral cortex of the tibia in 38% of cases. în obese of non-compliant patients two screws were used. Results: The results were appreciated clinically and roentgenographically in 76 patients 1 year postoperatively. Breaking of the screw was noted in 4 cases in which the screw was placed in both tibial cortices and loosening of the screw was noted in 3 cases in which the screw was placed only in the lateral tibial cortex. 74 patients were having a normal function of the ankle at 1 year postoperatively. Bibliografie 1. Moore J.A. Jr, Shank J.R., Morgan S.J., Smith W.R. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int. 2006 Aug;27(8):567-72. 2. Bragonzoni L., Russo A., Girolami M., Albisinni U., Visani A., Mazzotti N., Marcacci M. The distal tibiofibular syndesmosis during passive foot flexion. RSA-based study on intact, ligament injured and screw fixed cadaver specimens. Arch Orthop Trauma Surg. 2006 Jul; 126 (5): 304-8. Epub 2006 Mar 28. 3. Hoiness P., Stromsoe K. Tricortical versus quadricortical syndesmosis fixation in ankle fractures: a prospective, randomized study comparing two methods of syndesmosis fixation. J Orthop Trauma. 2004 Jul; 18 (6): 331-7. 4. Hansen M., Le L., Wertheimer S., Meyer E., Haut R. Syndesmosis fixation: analysis of shear stress via axial load on 3.5 mm and 4.5 mm quadricortical syndesmotic screws. J Foot Ankle Surg. 2006 Mar-Apr; 45 (2): 65-9. 5. Thompson M.C., Gesink D.S. Biomechanical comparison of syndesmosis fixation with 3.5 and 4.5 millimeter stainless steel screws. Foot Ankle Int. 2000 Sep; 21 (9): 736-41. 6. Kukreti S., Faraj A., Miles J.N. Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury. 2005 Sep; 36 (9): 1121-4. 7. Kaukonen J.P., Lamberg T., Korkala O., Pajarinen J. Fixation of syndesmotic ruptures in 38 patients with a malleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw. J Orthop Trauma. 2005 Jul;19(6):392-5. 8. Cox S., Mukherjee D.P., Ogden A.L., Mayuex R.H., Sadasivan K.K., Albright J.A., Pietrzak W.S. Distal tibiofibular syndesmosis fixation: a cadaveric, simulated fracture stabilization study comparing bioabsorbable and metallic single screw fixation. J Foot Ankle Surg. 2005 Mar-Apr; 44 (2): 144-51.

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 PARTICULARITÃÞI ALE TRATAMENTULUI FRACTURILOR COMPLEXE ALE GLEZNEI B.C. Andor, J.M. Pãtraºcu, S. Florescu, H. Boss, B. Angliþoiu Clinica Ortopedie II, Timiºoara

Cuvinte cheie: traumatism, fracturã, gleznã, clasificare, LCP, articulaþie Introducere: Fracturile de gleznã sunt printre cele mai frecvente traumatisme osteoarticulare. Fracturile stabile (de exemplu, fracturile maleolei externe) în general, sunt tratate ortopedic; fracturile instabile (de exemplu, fracturile bimaleolare) sunt tratate de obicei prin reducerea deschisã ºi fixare internã . Obiectivele tratamentului acestor fracturi sunt: (1), restabilirea relaþiilor normale la nivelul mortezei tibio-peroniere,(2), restabilirea axelor biomecanice normale ºi (3)refacerea suprafeþei articulare. Material ºi metodã: Lotul studiat a constat din 193 de pacienþi cu diverse tipuri de fracturi de gleznã, între anii 2000 -2008. Rezultate: Cele mai bune rezultate se obþin prin refacere anatomicã; metodã folositã pentru a realiza acest lucru poate fi reducere deschisã sau închisã ºi fixare internã. Complicaþiile postoperatorii au constat în infecþie în 3 cazuri, dehiscenþa plãgii cu suturã per secundam 1 caz. Discuþii: Fracturile fãrã deplasare pot fi uneori tratate prin mijloace nechirurgicale, cu imobilizare gipsatã; cu toate acestea, mijloace de fixare internã pot fi necesare pentru a grãbi vindecarea ºi reabilitarea. Concluzii: Reducerea anatomicã a fracturilor gleznei este esenþialã pentru obþinerea unor rezultate funcþionale acceptabile. TREATMENT PARTICULARITIES IN COMPLEX FRACTURES OF THE ANKLE Key words: trauma, Ankle, fractures, classification, low compression plates, joint. Introduction: Ankle fractures are among the most frecvent ostheoarticular traumas. Stable fractures (eg. Fractures of the external malleolus), generally are treated orthopedic, Instable fractures (eg. bimalleolar fractures) are


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL usually treated by open reduction and internal fixation. The objectives in ankle fractures treatment are: (1) reestablish of the normal relations in mortise, (2) reestablish of the normal biomechanical axes , (3) restore normal articular surface. Material and method: Our study lot consisted of 193 patients with different types of ankle fractures, between 2000-2008. Results: The best results were obtained through anatomical reduction; the selected method can be through open or closed reduction and internal fixation. Postoperative complications were in infection 3 cases, nonunion of wound edges, treated by per secundam suture in 1 case. Discusions: Undisplaced fractures can be treated in some cases with cast imobilization, anyway internal fixation can be necessary for faster healing and rehabilitation. Conclusions: Anatomical reduction of the ankle fractures is essential for obtaining of acceptable functional results. Bibliografie 1. Barrett J.A., Baron J.A., Karagas M.R., Beach M.L.: Fracture risk in the U.S. Medicare population. J Clin Epidemiol 1999; 52: 243–249. [ISI] [Medline]. 2. Flynn J.M., Rodriguez-del Río F., Pizá P.A.: Closed ankle fractures in the diabetic patient. Foot Ankle Int 2000; 21: 311–319. [ISI] [Medline]. 3. Blotter R.H., Connolly E., Wasan A., Chapman M.W.: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999; 20: 687–694. [ISI] [Medline] 4. Campbell’s Operative Orthopedics, Eleventh edition pag 3094-95.

 PREZENTARE DE CAZ: FRACTURÃ TRIMALEOLARÃ (MALEOLÃ INTERNÃ, MARGINALÃ POSTERIOARÃ ªI DIAFIZÃ PERONEU) AO 44-C2 – ABORDUL MINIM INVAZIV ÎN CHIRURGIA GLEZNEI R.M. Badea, Jemna Constantin Spitalul Clinic de Urgenþã „Bagdasar-Arseni”, Bucureºti

Cuvinte cheie: fracturã trimaleolarã, gleznã, minim invaziv, diafizã peroneu

Pacientul în vârstã de 41 de ani, supraponderal, s-a prezentat pentru durere ºi impotenþã funcþionalã totalã gleznã dreaptã în urma unei sãrituri din barcã pe mal. În urma investigaþiilor efectuate, s-a stabilit diagnosticul de mai sus. S-a intervenit chirurgical la 24 h de la accident (pacientul fiind imobilizat gipsat temporar). Datoritã cominuþiei marcate ºi întinse de la nivelul peroneului, s-a optat pentru osteosinteza acestuia cu o placã în punte („bridging plate”) prin abord minim lateral al gambei; s-a fixat maleola tibialã cu un ºurub trecut percutanat; s-a optat pentru neintervenirea la nivelul fracturii marginale posterioare, datoritã dimensiunilor reduse ale fragmentului; s-a investigat intraoperator fluoroscopic prezenþa diastazisului tibio-peronier. Evoluþia postoperatorie a fost favorabilã. În concluzie, deºi mai dificilã ºi necesitând control fluoroscopic, tehnica minim invazivã se dovedeºte extrem de utilã, evitând, în cazuri selecþionate, traumatizarea suplimentarã a pãrþilor moi ºi favorizând vindecarea osoasã. CASE PRESENTATION: TRIMALLEOLAR FRACTURE (MEDIAL AND POSTERIOR MALLEOLI AND FIBULAR DIAPHYSIS) AO 44-C2 – MINIMAL INVASIVE APPROACH ÎN ANKLE SURGERY Key words: trimalleolar fracture, ankle, minimal invasive, fibular dyaphisis The patient, 41 years old overweight male, jumped off a boat. Pain, swelling and total functional impotence were the presentation symptoms. Following X-rays, the diagnostic above was established. The surgical procedure was performed in 24h from the accident. Due to extensive comminution in fibula, the choice was made for a minimal invasive approach and bridging-plate osteosynthesis for fibular diaphysis; for the tibial malleoli one percutaneous inserted lag-screw was used; the posterior malleoli was too small so it was not fixed; intraoperative we checked for tibio-fibular diastasis using the mobile X-ray device. The postoperative evolution was good. în conclusion, although more difficult and requiring fluoroscopic control, the minimal invasive approach is extremely useful, avoiding, în particular cases, the additional trauma to the soft tissues and stimulating the bone healing.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Bibliografie 1. Krenk D.E., Molinero K.G., Mascarenhas L., Muffly M.T., Altman G.T. – Results of Minimally Invasive Distal Fibular Plate Osteosynthesis – The Journal of TRAUMA, Injury, Infection, and Critical Care 2009 66: 570-575. 2. Donatto K.C. - ANKLE FRACTURES AND SYNDESMOSIS INJURIES - Orthopedic Clinics of North America Volume 32, Issue 1 (January 2001).

 OSTEOSINTEZA EXTERNÃ ÎN FRACTURILE ÎNCHISE ALE PILONULUI TIBIAL A. Bãdilã, R. Rãdulescu, O. Nuþiu, R. Manolescu, C. Niþã Spitalul Clinic Universitar de Urgenþã Bucureºti

Cuvinte cheie: fracturi, pilon tibial, fixator extern. Scop: Evaluarea rezultatelor pe termen mediu ale fracturilor închise de platou tibial tratate prin osteosinteza externã. Material ºi metodã: Indicaþiile osteosintezei externe în fracturile închise ale pilonului tibial includ leziunile extinse ale þesuturilor moi ºi cominuþia explozivã. 34 de pacienþi cu leziuni cutanate importante sau cominuþie extremã au fost incluºi în studiul nostru retrospectiv. Reducerea ortopedicã a fost urmatã de osteosinteza externã cu fixator tip AO. Vârsta medie a fost de 36 ani (extreme: 22 – 67 ani). Sex raþio a fost 22 bãrbaþi / 12 femei. Intervalul mediu între producerea fracturii ºi intervenþia chirurgicalã a fost 42 de ore, atunci când indicaþia a fost reprezentatã de cominuþia extremã ºi 122 de ore atunci când leziunile cutanate au fãcut necesarã aceastã abordare. Fixatorul extern a fost menþinut în medie pentru 82 de zile (extreme 44 – 105 zile). Perioada medie de urmãrire postoperatorie a fost de 3 ani ºi 4 luni. Rezultate: Reducerea suprafeþei articulare a fost îndeobºte bunã. În 4 cazuri realinierea fixatorului sub anestezie ºi control fluoroscopic a fost necesarã. Dezaxãri reziduale (valgus, varus, flexum sau recurvatum) au fost înregistrate în 3 cazuri. Infecþii patente la nivelul fiºelor au fost observate în 5 cazuri, necesitând repozitionarea fiºelor în 2. În 3 cazuri, leziuni precoce de artrozã au fost decelate radiologic. La un an postoperator, extensia medie a gleznei era de 12 grade, iar flexia plantarã de 37 de grade. Uºoarã schiopatare persistã în 3 cazuri. Concluzii: Osteosinteza externã reprezintã o soluþie rezonabilã atunci când leziunile extinse ale

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þesuturilor moi sau cominuþia extremã contraindicã reducerea deschisã ºi osteosinteza internã. Obþinerea consolidãrii fracturii reprezintã regulã. Mobilitatea gleznei este redusã, dar acceptabilã. Fracturile foarte cominutive tratate prin reducere ortopedicã ºi osteosintezã externã sunt asociate cu un risc crescut de apariþie precoce a unor leziuni degenerative. EXTERNAL FIXATION IN CLOSED TIBIAL PILON FRACTURES Key words: fractures, tibial pilon, external fixator. Aim: to evaluate the midterm clinical results of closed tibial pilon fractures treated by external fixation Material and methods: Indications of external fixation in tibial pilon closed fractures include extensive skin lesions and important comminution. 34 patients with either extensive skin lesions or important comminution were included in our retrospective study. Orthopedic reduction was followed by osteosynthesis with an AO external fixator. The mean age was 36 years (extremes: 22 – 67 years).The sex ratio was 22 men / 12 women. The average time interval between trauma and surgical treatment was 42 hours when the indication for external fixation was extreme comminution and 122 hours when skin lesions required external fixation. The external fixation was maintained for an average interval of 82 days (extremes: 44 – 105 days). The mean follow-up was 3 years and 4 months. Results: The reduction of the articular surface was usually good. în 4 cases a realignement of the fixator under anesthesia and fluoroscopic control was performed. Residual malalignement (valgus, varus, flexum or recurvatum) was recorded in 3 cases. Infection at pins level was observed in 5 cases, requiring repositioning of pins in 2. în 3 cases early osteoarthritis lesions were radiologically visible. At one year postsurgery, the mean dorsiflexion was 12 degrees, while the mean plantar flexion was 37 degrees. Gait was present in 3 cases. Conclusions: External fixation represents a reasonable solution when extensive skin lesions or extreme comminution make open reduction and internal fixation unsuitable. Union is achieved in all cases. The ankle mobility is reduced, but


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL acceptable. Very comminuted articular fractures treated by orthopedic reduction and external fixation are associated with an increased risk of early osteoarthritis. Bibliografie 1. Bartolozzi P., Lavini F. – Fractures of the tibial pilon. Springer Verlag Italia, Milano, 2004. 2. Papadokostakis G., Kontakis G., Giannoudis P., Hadjipavlou A. – External fixation devices in the treatment of fractures of the tibial plafond: a systematic review of the literature. J Bone Joint Surg Br. 2008 Jan; 90 (1): 1–6. 3. Ristiniemi J. – External fixation of tibial pilon fractures and fracture healing Acta Orthopaedica, Volume 78, Issue S326 May 2007 , pages 2–34. 4. Scott A.T, Owen J.R, Khiatani V, Adelaar R.S, Wayne Jennifer. – External fixation in the treatment of tibial pilon fractures : Comparison of two frames in torsion. Foot & Ankle International ISSN 1071-1007. 2007, vol. 28, no7, pp. 823-830.

În fracturile tip C3 doar 60% au avut rezultate bune þinând cont de reducerea anatomicã uneori imperfectã, fixarea dificilã, dezaxare, artrozã. Discuþii: În alegerea tipului de osteosintezã trebuie luate în consideraþie câteva elemente: de multe ori fractura se produce pe osteoporozã ceea ce creazã dificultãþi suplimentare în alegerea implantului adecvat, deperiostarea fragmentelor fracturate trebuie sa fie minimã, delabrarea minimã a þesuturilor moi, reconstituirea dacã e posibil a suprafeþelor articulare dupã principiul stabilitãþii absolute. Concluzii: Osteosinteza fracturilor de pilon tibial trebuie sã evite devitalizarea þesuturilor moi, sã asigure o fixare stabilã chiar în condiþiile osteoporozei cu un abord minim, realizând în final o reconstrucþie cât mai aproape de perfect a segmentului fracturat.

TRATAMENTUL CHIRURGICAL ÎN FRACTURILE DE PILON TIBIAL

OPERATIVE TREATMENT FOR TIBIAL PILON FRACTURES

D. Barbu, A. Ursache, H. Barbu, C. Toma, C. Burnei

Key words: tibial pilon, Fracture, ostheo-sintesis, surgical treatement Introduction: Tibial pilon fractures are most often complex, difficult lesions due to the particulaties of the fracture line, of ankle joint involvement, but also due to soft tissues asociated lesions (skin, tendons, nerves, blood vessels). The surgical treatment should anatomicaly reconstruct the joint line, acording to absolute stability principles with minimal soft tissue damage. Material and method: We analised the results obtained in the last two years of the surgical treatment of tibial pilon A, B, C fractures (AO classification) According to the severity of the lessions we realised firm osteosintesis respecting the AO principles, with joint line reconstruction as anatomicaly as possible or in highly comminuted fractures (C type) restored the axis of the distal fragment with peroneus osteosintesis and a minimal tibial pilon osteosintesis using minimal invasive approaches. Results: The A and B type fractures underwent open reduction and internal fixation with good results in 80 percent of thecases. în C3 type fractures we only had good results in 60 percent of the cases due to imperfent joint line reconstruction, difficult fixation, malaligment and artrosis.

Spitalul Clinic de Urgenþã „Floreasca”, Bucureºti

Cuvinte cheie: pilon tibial, fracturã, osteosintezã, tratament chirurgical Introducere: Fracturile de pilon tibial sunt cel mai adesea fracturi complexe cu un înalt grad de dificultate datorat atât particularitãþilor traiectului de fracturã, interesãrii articulaþiei gleznei dar ºi leziunilor asociate ale pãrþilor moi (tegumente, tendoane, nervi, vase). Tratamentul trebuie sã realizeze reconstituirea anatomicã a articulaþiei pe principiile stabilitãþii absolute dar cu minimum de delabrãri ale þesuturilor moi. Material ºi metodã: Sunt analizate rezultatele obþinute în ultimii doi ani ale tratamentului a fracturilor de pilon tip A, B si C (clasificare AO). În funcþie de gravitatea leziunilor am realizat fie osteosintezã fermã dupã principiile A.O. cu refacerea cât mai aproape de anatomie a suprafeþelor articulare sau în fracturile cu înalt grad de cominuþie (C) am axat segmentul distal prin osteosinteza peroneului ºi osteosinteza minimã a pilonului tibial prin aborduri miniinvazive. Rezultate: Fracturile tip A ºi B (AO) au beneficiat de tratament chirurgical prin reducerea sângerândã ºi fixare internã cu 80% rezultate bune.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Discusions: When chosing the type of osteosintesis e few elements are to be considered: when we have an osteoporotic fracture, witch creates a more difficult implant choice selection, the periostal stripping should be minimal, the soft tissues debridement reduced as much as possible, and the joint line reconstruction, if possible, accordind to the absolute stability principle. Conclusion: Pilon fracture osteosintesis should avoid soft tissue debridement, to ensure a stable fixation even in osteoporotic bone trough a minimal invasive approach, realising in the end a perfect reconstruction of the fractured segment. Bibliografie 1. Tscherne H., Lobenhoffer P. (1993) – Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res; (292): 87–100. 2. Bennett W.F., Browner B. (1994) – Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma; 8 (3): 183–188. 3. Cole P.A., Zlowodzki M., Kregor P.J. (2003) – Compartment pressures after submuscular fixation of proximal tibia fractures. Injury; 34 (Suppl 1): 43–46. 4. Shepherd L., Abdollahi K., Lee J., et al (2002) – The prevalence of soft tissue injuries in nonoperative tibial plateau fractures as determined by magnetic resonance imaging. J Orthop Trauma; 16 (9): 628–631. 5. Chan P.S., Klimkiewicz J.J., Luchetti W.T., et al (1997) – Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma; 11 (7): 484–489. 6. Brophy D.P., O’Malley M., Lui D., et al (1996) – MR imaging of tibial plateau fractures. Clin Radiol; 51 (12): 873–878. 7. Yacoubian S.V., Nevins R.T., Sallis J.G., et al (2002) – Impact of MRI on treatment plan and fracture classifi cation of tibial plateau fractures. J Orthop Trauma; 16 (9): 632–637. 8. Weber W.N., Neumann C.H., Barakos J.A., et al (1991) – Lateral tibia rim (Segond) fractures: MR imaging characteristics. Radiology; 180 (3): 731–734. 9. Martinez A., Sarmento A., Latta L.L. (2003) – Closed fractures of the proximal tibia treated with a function brace. Clin Orthop Relat Res; (417):293–302. 10. Bai B., Kummer F.J., Sala D.A., et al (2001) – Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau. J Orthop Trauma; 15(2):101–106. 11. Georgiadis G.M. (1994) – Combined anterior and posterior approaches for complex tibial plateau fractures. J Bone Joint Surg Br; 76(2):285–289. 12. Duwelius P.J., Rangitsch M.R., Colville M.R., et al (1997) – Treatment of tibial fractures by limited internal fixation. Clin Orthop Relat Res; (339):47–57. 13. Court-Brown C.M., McBirnie J. (1995) – The epidemiology of tibial fractures. J Bone Joint Surg Br; 77 (3): 417–421. 14. Hansen M., Mehler D., Voltmer W., et al (2002) – [The extraarticular proximal tibial fractures.] Unfallchirurg; 105 (10): 858–872.

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15. Schutz M., Kaab M.J., Haas N. (2003) – Stabilization of proximal tibial fractures with the LIS-System: early clinical experience in Berlin. Injury; 34 (Suppl 1): 30–35. 16. Wagner M. (2003) – General principles for the clinical use of the LCP. Injury; 34 (Suppl 2): 31–42. 17. Gosling T., Schandelmaier P., Müller M., et al (2005) – Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin Orthop Relat Res; 439:207–214. 18. Bono C.M., Levine R.G., Rao J.P., et al (2001) – Nonarticular proximal tibia fractures: treatment options and decision making. J Am Acad Orthop Surg; 9 (3): 176–186. 19. Roberts C.S., Dodds J.C., Perry K., et al (2003) – Hybrid externalfixation of proximal tibia: strategies to improve frame stability. J Orthop Trauma; 17 (6): 415–420. 20. Cole J.D. (1998) – Intramedullary fixation of proximal tibia fractures. Techniques in Orthopaedics; 13:27–37. 21. Krettek C., Miclau T., Schandelmaier P., et al (1999) – The mechanical effect of blocking screws (“Poller screws“) în stabilizing tibia fractures with short proximal or distal fragments after insertion of small diameter intramedullary nails. J Orthop Trauma; 13 (8): 550–553. 22. Buchko G.M., Johnson D.H. (1996) – Arthroscopy assisted operative management of tibial plateau fractures. Clin Orthop Relat Res; (332): 29–36. 23. Biyani A., Reddy N.S., Chaudhury J., et al (1995) – The result of surgical management of displaced tibial plateau fractures in the elderly. Injury; 26 (5): 291–295. 24. Stevens D.G., Beharry R., McKee M.D., et al (2001) – The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma; 15 (5): 312–320. 25. Honkonen S (1995) – Degenerative arthritis after tibial plateau fractures. J Orthop Trauma; 9 (4): 273–277.

 OSTEOSINTEZA CU PLÃCI BIODEGRADABILE ÎN FRACTURILE EPIFIZEI DISTALE DE RADIUS D.Barbu, D. Putineanu, H. Barbu, C. Toma, I. Caracudovici Spitalul Clinic de Urgenþã „Floreasca”, Bucureºti

Cuvinte cheie: biodegradabil, placã, fracturã, osteosintezã Introducere: Fracturile articulare cominutive de EDR constituie ºi în prezent o problemã terapeuticã dificilã. Introducerea ºi dezvoltarea în ultimele douã decenii a tehnicilor de fixare externã, fixare internã cu plãci mulate ºi plãci bioresorbabile a fracturilor epifizei distale radiale, a permis o ameliorare considerabilã a rezultatelor operatorii. Clasificare: Autorii trec în revistã cele mai cunoscute clasificãri ºi subliniazã avantajele ºi


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL limitele acestora. Ele sunt utile pentru identificarea fracturilor instabile ºi a indicaþiei terapeutice optime. Indicaþiile sunt stabilite în funcþie de avantajele ºi limitele principalelor metode de tratament, clasificarea fracturii, vârsta ºi gradul osteoporozei. Se atrage atenþia asupra faptului cã aplicarea plãcilor biodegradabile are imensul avantaj de a scuti pacientul de o nouã operaþie. Complicaþii: Calusul vicios reprezintã complicaþia cea mai frecventã cu consecinþe importante atât funcþionale cât ºi estetice. Celelate complicaþii (sindromul de tunel carpian, algodistrofia, artroza etc.) apar în procent redus ºi pot altera la rândul lor funcþionalitatea pumnului. Concluzii: În fracturile cominutive, instabile, intervenþia chirurgicalã asigurã alinierea osoasã, menþinerea lungimii radiusului ºi creazã condiþiile anatomice ale unei recuperãri funcþionale integrale. Plãcile biodegradabile deºi scumpe, reprezintã o soluþie modernã ºi elegantã mai ales pentru femei BIODEGRADABLE PLATES OSTEOSINTESIS FOR DISTAL RADIUS FRACTURES Key words: biodegradable, plate, fracture, ostheosintesis Introduction: Comminuted articular distal radius fractures represent a difficult terpeutical problem. The introduction and development of new external and internal fixation tehniques with precontured and bioresorbable plates for distal radius lead to a considerable improuvement of the postoperative results. Clasification: The authors review the main classifications scores and underline their advantages and limits. The allow the identification of unstable fractures and their optimal terapeutical indication. The indication for treatment is according to the advantages and limits as the main treatment options, fracture classification, age and osteoporosis. We also outline that the use of biodegradable plates has the strang advantage of not putting th patient trough a second surgical intervention. Complications: The malalignment represents the most frequent complication with important functional and aestetic consequences. The other complications (carpal tunnel sindrom, algoneuro-

distrophy, artrosis) rarely appear but they can interfear with function of the wrist. Conclusions: In comminuted, unstable fractures the surgical treatment ensures bone alignment, radius lenght restoration and creates the anatomical conditions for a good functional wrist recovery. Biodegradable plates, although expensive, represent a modern suitable solution especialy for ladies. Bibliografie 1. Böstman O.M., Pihlajamäki H.K.: Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop 2000, 371: 216-227. 2. Cooney W.P. III, Dobybs J.H., Linscheid R.L. Complications of Colles fractures J. Bone Joint Surg. (Am) 1979; 61A: 840-845. 3. Cornell C.,: Fixation considerations in osteoporotic bone fractures. Curr. Opin. Orthop. 2005, 16, 376-381. 4. Hackl W., Fink C., Benedett K.P., et al: Transplant fixation by anterior cruciate ligament reconstruction. Metal vs. bioabsorbable polyglyconate interference screw. A prospective randomized study of 40 patients. Unfallchirurg 2000, 103: 468474. 5. Hoffmann R., Krettek C., Hetkemper A. et al: Osteosynthesis of distal radius fractures with biodegradable fracture rods. Results of two years follow-up. Unfallchirurg 1002, 95 (2): 99-105.

 STRATEGII TERAPEUTICE ÎN FRACTURILE SUBTROHANTERIENE D. Barbu, D. Putineanu, H. Barbu, C. Toma, C. Burnei Spitalul Clinic de Urgenþã „Floreasca” Bucureºti

Cuvinte cheie: subtrohanteriene, fracturi, opþiuni terapeutice. Introducere: Fracturile subtrochanteriene apar la douã grupe populaþionale distincte: tineri ca urmare a unor accidente prin înalta energie ºi vârstnici cu osteoporozã la care fracturile se produc dupã traumatisme minore. Indiferent de cauzã particularitãþile biomecanice ale acestor fracturi sunt aceleaºi. Înþelegerea ºi respectarea lor reprezintã condiþia esenþialã succesului tratamentului acestei fracturi. Tratamentul conservator (extensie, gips etc.) este de domeniul trecutului. Sigur chirurgical poate da rezultate în aceste fracturi cu un înalt grad de dificultate ºi cu un procent încãa crescut de

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 eºecuri (calus vicios, deteriorarea montajului, pseudartroza). Autorii iau în discuþie cele mai eficiente mijloace de tratament cu indicaþiile ºi limitele lor, cu micile secrete care asigurã osteosinteza eficientã. Discuþii: În regiunea subtrochanter se dezvoltã forþe importante de încovoiere datoritã soilicitãrii mecanice aplicate excentric pe capul femural. Mai mult, anumite particularitãþi biomecanice cum ar fi scurtimea segmentului proximal, braþul lung al segmentului distal ºi grupele musculare voluminoase care acþioneazã asupra acestor segmente explicã dificultatea de reducere dar mai ales de menþinere a fragmentelor. În concluzie, alegerea implantului depinde de particularitãþile traiectului de fracturã iar în fracturile multifragmentare nu trebuie urmãritã reducerea anatomicã a fragmentelor ei, mai curând refacerea lungimii, axului ºi a rotaþiei femurului. TERAPEUTICAL STRATEGIES IN SUBTROCHANTERIC FRACTURES Key words: subtrochanteric, fractures, terapeutical strategies Introduction: Subtrochanteric fractures apear in two distinct populational groups: în young people following high energy trauma and in old osteoporotic people resulting after low energy trauma. în both cases the biomechanical properieties of these fractures are the same. Understanding and respecting these properieties are the keys for succesfully treating these fractures. The conservative treatment ( skeletal traction, cast immobilisation) is outrated nowadays. Surely the operative treatment of these difficult cases is a better option but it can also lead to a high percent of complications ( malunion, secondary loss of reduction, pseudartrosis) The authors present the most effective methods of treating these fractures with their indications and their limits but also the small tips and tricks for an effecient osteosinthesis. Discutions: în the subtrochanteric region important bending forces are applied due to the mechanical load excentricaly applied on the femural head. Even more, some biomechanical properties such as the shortening of the proximal fragment, the long arm of the distal fragment and important powerful muscular groups acting at ths

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level explain the difficulty of fracture reduction and especially maintaining this reduction. In conclusion, the implant choice is dependent on the particularities of fracture patern and, în multifragmentary fractures, there is no need to achieve anatomical reduction but to restore the lenght, axis and rotation of the limb. Bibliografie 1. Herrera A., Domingo L.J., Calvo A., et al (2002) – A comparative study of trochanteric fractures treated with the Gamma nail or the proximal femoral nail. Int Orthop; 26 (6): 365–369. 2. Davis T.R., Sher J.L., Horsman A., et al (1990) – Intertrochanteric femoral fractures. Mechanical failure after internal fixation. J Bone Joint Surg Br; 72 (1): 26–31. 3. Larsson S., Friberg S., Hansson L.I. (1990) – Trochanteric fractures. Influence of reduction and implant position on impaction and complications. Clin Orthop Relat Res; (259): 130–139. 4. Schipper I.B., Steyerberg E.W., Castelein R.M., et al (2004) – Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br; 86 (1): 86-94. 5. O’Brien P.J., Meek R.N., Blachut P.A., et al (1995) – Fixation of intertrochanteric hip fractures: gamma nail versus dynamic hip screw. A randomized, prospective study. Can J Surg; 38 (6): 516–520. 6. Adams C.I., Robinson C.M., Court-Brown C.M., et al (2001) – Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma; 15 (6): 394–400. 7. Baumgaertner M.R., Curtin S.L., Lindskog D.M., et al (1995) – The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am; 77 (7): 1058–1064. 8. Babst R., Martinet O., Renner N., et al (1993) – [The DHS (dynamic hip screw) buttress plate in the management of unstable proximal femoral fractures.] Schweiz Med Wochenschr; 123 (13): 566–568. 9. David A., Hüfner T., Lewandrowski K.U., et al (1996) – [The dynamic hip screw with support plate – a reliable osteosynthesis for highly unstable “reverse” trochanteric fractures?] Chirurg; 67 (11): 1166–1173. 10. Janzing H.M., Houben B.J., Brandt S.E., et al (2002) – The Gotfried Percutaneous Compression Plate versus the Dynamic Hip Screw in the treatment of pertrochanteric hip fractures: minimal invasive treatment reduces operative time and postoperative pain. J Trauma; 52 (2): 293–298. 11. Pauwels F. (1935) – Der Schenkelhalsbruch, ein mechanisches Problem. Grundlagen des Heilungsvorganges, Prognose und kausale Therapie. Z Orthop Chir; 6 (Suppl 3). 12. Swiontkowski M.F. (1994) – Intracapsular fractures of the hip. J Bone Joint Surg Am; 76 (1): 129–138. 13. Manninger J., Kazar G., Fekete G., et al (1989) – Significance of urgent (within 6h) internal fixation in the


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL management of fractures of the neck of the femur. Injury; 20 (2): 101–105. 14. Davison J.N., Calder S.J., Anderson G.H., et al (2001) – Treatment for displaced intracapsular fractures of the proximal femur. A prospective, randomised trial in patients aged 65 to 79 years. J Bone Joint Surg Br; 83 (2): 206–212. 15. Parker M.J., Khan R.J., Crawford J., et al (2002) – Hemiarthroplasty versus internal fi xation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone Joint Surg Br; 84 (8): 1150–1155. 16. Tidermark J., Ponzer S., Svensson O., et al (2003) – Internal fi xation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br; 85 (3): 380-388. 17. Bonnaire F., Kuner E.H., Lorz W. (1995) – [Femoral neck fractures in adults: joint sparing operations. II. The significance of surgical timing and implant for development of aseptic femur head necrosis.] Unfallchirurg; 98 (5): 259–264. 18. Pipkin G. (1957) – Treatment of grade IV fracturedislocation of the hip. J Bone Joint Surg Am; 39 (5): 1027–1042. 19. Stockenhuber N., Schweighofer F., Seibert F.J. (1994) – [Diagnosis, therapy and prognosis of Pipkin fractures (femur head dislocation fractures).] Chirurg; 65 (11): 976–982. 20. Dreinhofer K.E., Schwarzkopf S.R., Haas N.P., et al (1996) – [Femur head dislocation fractures. Long-term outcome of conservative and surgical therapy.] Unfallchirurg; 99 (6): 400–409. 21. Asghar F.A., Karunakar M.A. (2004) – Femoral head fractures: diagnosis, management, and complications. Orthop Clin North Am; 35 (4): 463–472. 22. Siebenrock K.A., Gautier E., Woo A.K.H., et al (2002) – Surgical dislocation of the femoral head for joint debridement and accurate reduction of fractures of the acetabulum. J Orthop Trauma; 16 (8): 543–552.

 RISCUL ªI TRATAMENTUL FRACTURILOR DE FRAGILITATE LA NIVELUL ªOLDULUI C. Budicã, Gh. Panait, ªt. Cristea, C. Mihai Spitalul Clinic de Urgenþã „Sfântul Pantelimon” Bucureºti

Cuvinte cheie: fracturi de fragilitate, risc de fracturã, osteoporozã, fracturi de ºold, scor FRAX, FRISK. Scopul: dezvoltarea unui protocol de îmbunãtãþire a diagnosticãrii ºi tratamentului osteoporozei la pacienþii cu fracturi de fragilitate. Obiective: – Detectarea factorilor de risc în osteoporozã ºi a gradului cu care aceºtia participã la creºterea riscului de apariþie a fracturilor de fragilitate; – Identificarea unui algoritm de tratament complex (preventiv ºi curativ) al fracturilor de fragilitate.

Material ºi metodã: am realizat un studiu de tip retrospectiv, cu o componentã de urmãrire prospectivã. S-au analizat aspectele clinicoterapeutice ale cazurilor cu fracturi de fragilitate la nivelul ºoldului din clinica ortopedie a Spitalului Clinic de Urgenþã Sfântul Pantelimon Bucureºti în perioada 2002-2008. S-a completat un chestionar cu informaþii demografice ºi altele specifice osteoporozei, mãsurile de prevenire ºi de tratament ale acesteia. Din cei 1843 pacienþi au fost incluºi 400, peste 50 de ani, care nu luau tratament pentru osteoporozã. Rata de rãspuns a fost de 75%(300 pacienþi). S-a diagnosticat osteoporoza, (DEXA), urmãrindu-se evoluþia leziunii fracturare ºi a osteoporozei, eficienþa tratamentului complex preventiv, inclusiv medicamentos, kinetoterapeutic, al afecþiunilor asociate ºi de reducere a riscului de cãderi, reducerea factorilor de risc controlabili, iar în ceea ce priveºte tratamentul chirurgical, o parte din cazuri au beneficiat ºi de plombaj cu ciment acrilic în focarul de fracturã. Rezultate: În ceea ce priveºte consolidarea, recuperarea funcþionalã, reducerea complicaþiilor, prevenirea apariþiei unei noi fracturi, au fost cu atât mai bune cu cât: momentul operator ºi debutul kienetoterapiei au fost mai precoce, cu cât bolile de fond au fost þinute sub control, pacientul a fost mai cooperant, cu cât s-a reuºit eficient reducerea riscului de cãderi, cu cât alimentaþia a fost adecvatã ºi tratamentul antiosteoporotic a fost respectat. Procentul de apariþie a unei noi fracturi a fost de 6% (18 din 300), 11 pacienþi necesitând spitalizare ºi reintervenþii chirurgicale. Concluzii: Rezultatele postoperatorii au fost ameliorate prin respectarea protocolului de tratament curativ ºi profilactic, prin reducerea factorilor de risc de osteoporozã ºi de cãdere, scorurile FRAX ºi FRISK dovedindu-ºi eficienþa în predicþia apariþiei unei noi fracturi HIP FRAGILITY FRACTURES – FRACTURE RISK AND TREATMENT Key words: fragility fracture, fracture risk, osteoporosis, hip fractures, FRAX, FRISK score. Purpose: to develop a better protocol for the diagnostic and treatment of osteoporosis in patients with bone fragility fractures. Method: we made a clinical retrospective study, with a tracking prospective component. The retrospective component of the study analyzed the

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 clinical and therapeutic aspects of the hip fragility fractures cases interned and surgically treated in the Orthopaedics and Traumatology Department of Clinical Emergency Hospital Sfântul Pantelimon Bucharest between 2002-2008. A questionnaire was filled out, questionnaire with demographic and osteoporosis informations, prevention and treatment measures. 400 patients over 50 years with no previous treatment for osteoporosis were selected from 1843 patients. The response rate was 75% (300 patients). The osteoporosis was diagnosed postoperative (DEXA method). Subsequently the parameteers followed were: the fracture lesion and osteoporosis evolution and the efficiency of the complex preventive treatment including medical treatment with antiresorbtivedrugs, calcium and vitamin D, aggressive kinetotherapeutic treatment, efficient treatment of the associated diseases and application of measures to reduce the risk of falling, the reduction of the controllable risk factors (quit smoking and alcohol consumption, diets that decrease the bone metabolism) and, regarding the surgical treatment, în some cases acrylic cement was used in the fracture outbreak. We also followed: the appearance rate of a new fracture, establish the correlation between DMO and the appearance of a new fracture, evaluation of DMO specificity, FRISK and FRAX scores. Results: the results (the fracture consolidation, function recovery, fewer complications, prevention of a new fracture) were better as the operative moment was earlier, as associated diseases were treated, the start of kinotherapic treatment was sooner, patient cooperation, reducing the falling risk, compliance with osteoporosis treatment. The apparition rate of a new fracture was 6% (18 from 300), from which 11 patients required surgical treatment. Conclusions: postoperative results were ameliorated by complying with the treatment protocol, reducing osteoporosis risk factors and the risk of falling. FRISK and FRAX scores proved their worth for predicting a new fracture. Bibliografie 1. Henrz, M.J., Pasco, J.A., Sanders, K.M., Nicholson, G.C., Kotowicy, M.A. – Fracture Risk (FRISK) Score: Geelong Osteoporosis Study, Radiology-Volume 241, Number 1: 190-196, October 2006. 2. 1. WHO Scientific Group Technical Report Kanis J.A., on behalf of the World Health Organisation Scientific Group.

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Assessment of osteoporosis at the primary health care level. WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield 2008. Assessment of osteoporosis at the primary health care level (slide12) 3. World Health Organisation Scientific Group on the assessment of osteoporosis at the primary health care level. Summary Meeting Report. World Organisation 2007. May be downloaded from 4. Kanis J.A. – Diagnosis of osteoporosis and assessment of fracture risk. Lancet 2002: 359; 1929-1936. 5. Kanis J.A., Black D., Cooper C., Dargent P., DawsonHughes B., De Laet C., Delmas P., Eisman J., Johnell O., Jonsson B., Melton L.J., Oden A., Papapoulos S., Pols H., Rizzoli R., Silman A., Tenehouse A. – On behalf of the International Osteoporosis Foundation and the National Osteoporosis Foundation, USA. A new approach to the development of assessment guidelines for osteoporosis. Osteoporosis International 2002: 13; 527-536. 6. Kanis J.A., Borgstrom F., De Laet C., Johansson H., Johnell O., Jonsson B., Oden A., Zethraeus N., Pfleger B., Khaltaev N. – Assessment of fracture risk. Osteoporosis International 2005; 16: 581-589. (slide 6) 7. Guidelines incorporating FRAX®: Kanis J.A., Burlet N., Cooper C., Delmas P.D., Reginster, J.Y., Borgstrom F., Rizzoli R. – On behalf of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). European guidance for the diagnosis and management of osteoporosis in postmenopausal women (PDF, 531.6 KB). Osteoporos Int (2008) 19:399-428. 8. Geusens P. – Osteoporosis in Clinical Practice, Springer, 1998. 9. Terry Canale, S. – CAMPBELL’S OPERATIVE ORTHOPAEDICS 9th ed., Mosby-Year Book, Inc., 1998. 10. New, S.A. Nutrition, exercise and bone health. Proceedings of the Nutrition Society. 60:265-274, 2001. 11. Bruce Martin, R.; David, B. Burr; Neil, A. Sharkey – Skeletal Tissue Mechanics, Springer-Verlag, New York, Inc., 1998.

 MANAGEMENTUL CHIRURGICAL ÎN DOI TIMPI AL FRACTURILOR DESCHISE GUSTILO TIP IIIA ªi IIIB DE PILON TIBIAL I. Caracudovici, D.C. Putineanu, Simona Pãiuº, R. Caraman, D. Barbu Spitalul Clinic de Urgenþã „Floreasca“, Bucureºti

Cuvinte cheie: fracturã deschisã, pilon, Gustilo, tibie, articular Introducere: Fracurile deschise de pilon tibial sunt leziuni provocatoare de tratat datoritã implicãrii articulare care necesitã reducere anatomicã ºi fixare internã stabilã, datoritã leziunilor de parþi moi care interferã cu acoperirea fracturii ºi nu în ultimul rând datoritã vasularizaþiei precare a acestei regiuni.


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL Material ºi metodã: 18 fracturi deschise de pilon tibial Gustilo tip IIIA ºi IIIB au fost tratate în spitalul nostru în perioada 2005-2009 (6 tip IIIA ºi 8 tip IIIB). Toþi pacienþii prezentaþi în aceastã lucrare au urmat o strategie terapeuticã în doi timpi. În urgenþã s-a practicat lavaj abundent, excizia þesuturilor devitalizate ºi stabilizarea fracturilor cu fixator extern medial. Dupã o medie de 22 zile s-a practicat extragerea fixatorului extern ºi reducere sângerândã ºi fixare internã ale fracturilor de pilon tibial. Rezultate: În medie, perioada de urmãrire a pacienþilor a fost de 11 luni timp în care majoritatea pacienþilor au fost evaluaþi dupã criterii obiective, subiective ºi radiologice. Amplitudinea miºcãrilor ºi complicaþiile postoperatorii au fost urmãrite. Toate fracturile s-au consolidat într-o perioadã medie de 3,6 luni. Amplitudinea medie a miºcãrii a fost de 14 grade flexie dorsalã ºi 31 grade de flexie plan-tarã. Mãsurãtorile subiective ºi obiective au arãtat 77% rezultate bune, 14% rezultate acceptabile ºi 9% rezultate slabe. Evaluarea radiologicã a arãtat reducere anatomicã în 73 % din cazuri ºi 27?% reducere acceptabilã a liniei articulare. Complicaþii: Complicaþiile legate de plagã: necroze tegumentare sau incapacitatea de a închide plaga chirurgicalã a fost înregistratã în 6% ºi 22% în fracturile deschise tip IIIA respective IIIB. În 22 de cazuri s-au utilizat grefe de piele. În patru cazuri au fost detectate semne radiologice de artrozã, unul dintre aceºtia necesitând artrodezã de gleznã. Concluzii: O abordare în doi timpi oferã rezultate acceptabile pentru tratamentul fracturilor deschise de pilon tibial. Primul timp permite abordarea leziunilor de þesuturi moi, stabilizarea focarului de fracturã, în timp ce în a doua etapã principalul obiectiv este reducerea anatomicã a capetelor articulare. Aceste rezultate sunt favorabile faþã de reducere deschisã ºi osteosintezã per primam. Principalele avantaje sunt reprezentate de: diminuarea complicaþiilor legate de pãrþi moi ºi de o mai bunã reconstrucþie a suprafeþelor articulare. TWO STAGE SURGICAL MANAGEMENT IN GUSTILO TYPE-IIIA AND TYPE-IIIB OPEN TIBIAL PILON FRACTURES Key words: fracture, open, pilon, Gustilo, tibial, articular.

Introduction: Open tibial pilon fractures are challenging lesions to treat due to joint line involvement requiring anatomical reduction and stable internal fixation, due to soft tissues lesions often impending fracture covering and last but not least due to the poor vascularisation of this region. Material and metod: 18 Gustilo type-IIIA and typeIIIB open tibial PILON fractures were treated between 2005- 2009 in our hospital (6 Gustilo typeIIIA and 8 type-IIIB ). All patients presented in this paper underwent a two stage therapeutical strategy. Emergency wound irrigation and debridement and placement of a medial spanning external fixator was performend. After, on average, twenty-two days, patients underwent removal of the external fixator and open reduction and internal fixation of the pilon fractures. Results: At average follow-up of eleven months, most of the patients were evaluated by using subjective, objective, and radiographic measurements .Range of motion and postoperative complications were also recorded. All fractures healed within an average of 3.6 months. Average range of motion was 14 degrees of dorsiflexion, 31degrees of plantar flexion. Subjective and objective measurements showed 77 percent good results, 14 percent fair results, and 9 percent poor results. Radiographic reduction showed 73 percent anatomic and 27 percent fair fracture reduction. Complications: Wound complications consisting of wound slough or inability to close the surgical wound was encountered in 6 and 22 %of the Type A and B fractures. Twenty two percent of these patients required skin grafting. Four patients had some degree of osteoartritis on plain radiographs at the time of the latest follow-up one requiring ankle arthrodesis. Conclusions: A two-stage approach offers acceptable results for the treatment of open pilon fractures. The first stage allows soft tissue management and fracture stabilization while in the second stage anatomical reduction of the joint line is the main objective. These results compare favorably with those of primary open reduction and of internal fixation. The major advantages include limited soft tissue complications and improved articular reconstruction.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Bibliografie 1. Cole JD. Two—staged delayed open reduction and internal fixation of severe Pilon fractures-P MJ - J Orthop Trauma, 1999 2. Mary Beth Nierengarten, MA Host Orthopaedic Surgeon: Lawrence X. Webb, MD Chief Resident: John Birkedal, MD Open Tibial Pilon Fractures: Complications and Issues of Limb Salvage-Medical -Medscape Orthopaedics &Sports Medicine Published: 01/24/2002 3. David B. Thordarson, MD -Complications After Treatment of Tibial Pilon Fractures: Prevention and Management Strategies - J Am Acad Orthop Surg, Vol 8, No 4, July/August 2000, 253-265. 4. Andrew N. Pollak, Melissa L. McCarthy, R. Shay Bess, Julie Agel, and Marc F. Swiontkowski-Outcomes After Treatment of High-Energy Tibial Plafond FracturesJ. Bone Joint Surg. Am., Oct 2003; 85: 1893 - 1900. 5. Brad Wyrsch, Mark a. Mcferran, Mark Mcandrew, Thomas j. Limbird, Marion c. Harper, Kenneth d. Johnson, and Herbert s. Schwartz-Operative Treatment of Fractures of the Tibial Plafond. A Randomized, Prospective Study-J. Bone Joint Surg. Am., Nov 1996; 78: 1646 - 57.

 TIJA GAMMA VERSUS DHS ÎN TRATAMENTUL FRACTURILOR TROHANTERIENE R. Caranfil Spitalul Judeþean de Urgenþã Piatra-Neamþ

Cuvinte cheie: fracturã, ºold, Gamma/DHS. Studiul prospectiv ce comparã rezultatele între douã sisteme ºi concepte diferite de osteosintezã pentru rezolvarea fracturilor regiunii trohanterine. Seria analizatã se referã la 113 de pacienþi, 52 operaþi cu tija Gamma ºi 61 operaþi cu DHS. Analiza seriei a urmãrit clasificarea fracturii AO/OTA, sex, vârstã, boli asociate etc. S-au urmãrit de asemenea ºi alþi parametri: timp operator, dificultãþi chirurgicale, timp de expunere la radiaþii, pierderile de sânge intra ºi postoperator. Evoluþia consolidãrii s-a urmãrit prin examen clinic (durere, mobilitate) ºi radiografic. Reculul a fost între ºase luni ºi trei ani. S-a constatat cã fracturile simple ºi stabile sunt rezolvate mai bine cu DHS, iar cele instabile ºi cominutive sunt rezolvate mai bine cu tija Gamma. S-a constatat cã la nivelul complicaþiilor postoperatorii nu existã diferenþe semnificative statistic, dar în majoritatea cazurilor timpul operator pentru tija Gamma este semnificativ mai redus decât în cazul DHS. Nu am constatat fracturi femurale tardive la cazurile tratate cu tija Gamma, în schimb au fost douã

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rupturi ale implantului DHS în 2 cazuri. În opinia noastrã osteosinteza cu tija Gamma este prima opþiune în rezolvarea fracturilor complexe trohanteriene, cu o agresiune chirurgicalã ºi o dificultate tehnicã mult diminuate comparativ cu DHS. GAMMA NAIL VS DHS FOR THE SURGICAL MANAGEMENT OF TROCHANTERIC FRACTURES Key words: fracture, hip, Gamma nail/DHS. A prospectiv comparison of the results of two different concepts and sistems to address the fractures of the trochanteric region. Our series refears to 113 patients, 52 treated with Gamma nail and 61 treated with DHS. All patients was analised regarding facture classification AO/OTA, gender, age, associated pathology. Other data was investigated: operative time, blood loss, fluoroscopy time, surgical difficulty. The outcome of fractures was measured by clinical (pain, mobility) and radiologycal data. The follow-up was six month to three years. We found that simple-stable fractures was better addressed with DHS and the cominuted-instable fractures was better addressed with Gamma nail. There were no statistically significant differences of postoperative complications, but for the majority of cases the operative time was significantly lower for Gamma nail.We did not find late femoral fractures for pacients with Gamma nail, but two implants failure in pacients with DHS. We belive that Gamma nail is the first option to address the complex trochanteric fractures, with less surgical and technical dificulties. Bibliografie 1. Albareda J., Laderiga A., Palanca D., et al. – Complications and technical problems with gamma nail. Int Orthop. 1996; 20: 4750. 2. Baumgaertner M.R., Curtin S.L., Lindskg D.M., Keggi J.M. – The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995; 77: 1058-64. 3. Butt M.S, Krikler S.J., Nafie S., Ali M.S. – Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury. 1995; 26: 615-8. 4. Clawson D.K. – Trochanteric fractures treated by the sliding screw plate fixation method. J Trauma. 1964 Nov; 4: 737–752.


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL 5. Ecker M.L., Joyce J.J., 3rd, Kohl E.J. – The treatment of trochanteric hip fractures using a compression screw. J Bone Joint Surg Am. 1975 Jan; 57 (1): 23–27. 6. Egan M., Jaglal S., Byrne K., Wells J., Stolee P. – Factors associated with a second hip fracture: a systematic review. Clin Rehabil. Mar 2008; 22 (3): 272-82. 7. Russell T.A. – Fracture of the hip and pelvis. Campbell’s operative ortho paedics. Grenshaw AH. 8th Edition, St. Louis Missouri, USA: Mosby yearbook Inc. 1992; 2: 895-987. 8. Laros G.S.: – Intertrochanteric fractures. Surgery of the musculoskeletal system. Evarts CM. 1st Edition, New York: Churchill Livingstone. 1983; 2(5): 123-148. 9. Ganz R., Thomas R.J. & Hammerle C.P.: – Trochanteric fracture of the femur. Treatment and results. Clin Orthop. 1979; 138: 30-40. 10. Kyle R.F., Gustilo R.B., Premer R.F. – Analysis of six hundred and twentytwo intertrochanteric hip fractures. A retrospective and prospective study. J Bone Joint Surg (Am). 1979; 61: 216-21. 11. Haidukewych G.J., Israel T.A., Berry D.J. – Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg (Am). 2001; 83-A(5) : 643-50. 12. Kinast C., Bolhofner B.R., Mast J.W. & Ganz R. – Subtrochanteric fractures of the femur. Results of treatment with the 95 0 condylar bladeplate. Clin Orthop. 1989; 238: 122-130. 13 .Marshall L.M., Zmuda J.M., Chan B.K., Barrett-Connor E., Cauley J.A., Ensrud K.E., et al. – Race and ethnic variation in proximal femur structure and BMD among older men. J Bone Miner Res. Jan 2008; 23 (1): 121-30. 14. Nungu K.S., Olerud C., Rehnberg L. – Treatment of subtrochanteric fractures with the AO dynamic condylar screw. Injury. 1993; 24 (2): 90-92. 15. van de Kerkhove M.P., Antheunis P.S., Luitse J.S., Goslings J.C. – Hip fractures in nonagenarians: perioperative mortality and survival. Injury. Feb 2008; 39 (2): 244-8.

 REZULTATE TERAPEUTICE DUPà FRACTURI DE PILON TIBIAL – STUDIU RETROSPECTIV B. Deleanu, H. Vermeºan, R. Prejbeanu, Fl. Bãrsãºteanu Clinica I Ortopedie-Traumatologie, Spitalul Clinic Judeþean de Urgenþã Timiºoara

Cuvinte cheie: fracturi pilon, rezultate, scor funcþional Fracturile de pilon sunt dificil de tratat datoritã severitãþii. De cele mai multe ori sunt cominutive ºi implicarea articularã poate duce la incongruenþa ulterioarã reducerii ºi artrozã posttraumaticã. Aceste fracturi se asociazã frecvent cu leziuni tegumentare ºi de pãrþi moi care fac crucialã alegerea timpului operator optim. Scopul acestui

studiu este de a evalua rezultatele dupã fracturi de pilon tibial. Metodã: Am fãcut un studiu retrospectiv pe 38 de pacienþi trataþi în clinica noastrã în ultimii 3 ani. Fracturile au fost clasificate folosind sistemul AO ºi evaluate funcþional cu AOFAS Ankle Hindfoot Scale. Rezultate: Foarte bune în 48% din cazuri, bune în 42% ºi proaste în 10%. Scorul AOFAS Ankle Hindfoot mediu este 72. Concluzii: Tratamentul chirurgical este cel mai bun dar dificil tehnic. Ar trebui efectuat cât mai devreme posibil. Evaluarea CT preoperatorie este cea mai bunã pentru investigarea suprafeþei articulare. Fracturile de pilon ar trebui evluate fiecare în parte ºi nu privite prin prisma unui tratament standardizat. THERAPEUTIC RESULTS AFTER PILON FRACTURES – RETROSPECTIVE STUDY Key words: pilon fractures, outcome, AOFAS Ankle Hindfoot Scale. Pilon fractures are dificult to treat due to their severity. Most often they are comminuted and the articular involvement can lead to articular incongruence and posttraumatic arthrosis. These fractures are frequently associated with skin and soft tissue lesions that make selecting the optimal operative timing crucial. The purpose of this study is to evaluate the results after pilon fractures. Method: we performed a retrospective study on 38 patients treated in our clinic in the last 3 years. The fractures were classified using AO system and the function evaluated using AOFAS Ankle Hindfoot Scale. Results: very good outcome in 48% cases, good in 42% and poor in 10%. The mean AOFAS Ankle Hindfoot score was 72. Conclusions: operative treatment is best but difficult. The surgery should be performed as soon as possible. CT evaluation of the articular surface is ideal preoperative imaging. It is difficult to judge pilon fractures with standardised treatment in mind, better to approach each as individual cases. Bibliografie 1. Brown T.D., Johnston R.C., Saltzman C.L. – Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. 2006 NovDec; 20 (10): 739-44.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 2. Chen S.H., Wu P.H. – Long-term results of pilon fractures. Arch Orthop Trauma Surg. 2007 Jan; 127 (1): 55-60. 3. Ibrahim T., Beiri A., Azzabi M., Best A.J. – Reliability and validity of the subjective component of the american orthopaedic foot and ankle society clinical rating scales. J Foot Ankle Surg. 2007 Mar-Apr; 46 (2): 65-74. 4. Katz J.N., Gomoll A.H. – Advances in arthroscopic surgery: indications and outcomes. Curr Opin Rheumatol. 2007 Mar;19 (2): 106-10. 5. Kouluovaris P., Stafylas K., Mitsionis G. – Long-term results of various therapy concepts in severe pilon fractures. Arch Orthop Trauma Surg. 2007 Mar 13. 6. Niek van Dijk C. – Anterior and posterior ankle impingement. Foot Ankle Clin. 2006 Sep; 11 (3): 663-83. 7. SooHoo N.F., Vyas R. – Responsiveness of the foot function index, AOFAS clinical rating systems, and SF-36 after foot and ankle surgery. Foot Ankle Int. 2006 Nov; 27 (11): 930-4. 8. Tocci S.L., Madom I.A., Bradley M.P. – The diagnostic value of MRI in foot and ankle surgery. Foot Ankle Int. 2007 Feb; 28 (2): 166-8. 9. Unger F., Lajtai G., Ramadani F., Aitzetmuller G. – Arthroscopy of the upper ankle joint. A retrospective analysis of complications. Unfallchirurg. 2000 Oct; 103 (10): 858-63. 10. Utsugi K., Sakai H., Hiraoka H., Yashiki M. – Intraarticular fibrous tissue formation following ankle fracture: the significance of arthroscopic debridement of fibrous tissue. Arthroscopy. 2007 Jan; 23 (1): 89-93. 11. Zgonis T., Roukis T.S. – Alternatives to ankle implant arthroplasty for posttraumatic ankle arthrosis. Clin Podiatr Med Surg. 2006 Oct; 23 (4): 745-58.

fracturi izolate de peroneu tratate cu IP-XS-NAIL, iar în lotul martor 73 de fracturi tratate cu ajutorul unor plãci cu ºuruburi. Studiul s-a desfãºurat pe o perioadã de 5 ani între martie 2004 ºi septembrie 2009. Rezultate: În urma studiului efectuat am constatat o ratã crescutã de consolodare (99% pentru IP-XS-NAIL respectiv 97% pentru placã) în ambele loturi atât cel tratat cu IP-XS-NAIL cât ºi cel tratat cu ajutorul metodei standard de tratament, diferenþele semnificative fiind legate de timpul operator ºi rata complicaþiilor imediate care au crescut semnificativ timpul de spitalizare în lotul martor. Concluzii: Taratamentul cu IP-XS-NAIL este o alternativã la osteosinteza cu placã ºi ºuruburi. Datoritã poziþionãrii centromedulare a implantului ºi o bunã stabilitate datoritã sistemului de zãvorâre, acesta scade semnificativ rata de complicaþii infecþioase ºi a dehiscenþelor de plagã. Placa înºurubatã asigurã o bunã reducere ºi stabilizare a focarului de fracturã însã datoritã poziþiei acesteia pe os ºi a unui strat de pãrþi moi redus în regiunea distalã a peroneului, predispune la complicaþii, în special în cazul pacienþilor vârstnici cu tegumente friabile.

TREATMENT OF PERONEAL FRACTURES USING IP-XS-NAIL

TRATAMENTUL FRACTURILOR DE PERONEU CU AJUTORUL IP-XS-NAIL W. Friedl*, D. Vermeºan**, H. Haragus** * Klinikum Chirugie II Aschaffenburg Germany ** Victor Babeº University of Medicine and Pharmacy, Timiºoara

Cuvinte cheie: IP-XS-NAIL, fracturi maleolã peronierã. Introducere: Tratamentul fracturilor 1/3 distale a peroneului este o practicã curentã în ortopedie. Acestea pot apãrea fie ca entitate separatã, fie în cadrul fracturilor complexe bimaleolare sau trimaleolare. Datoritã frecvenþei cu care chirurgii ortopezi se confruntã cu ele, tratamentul acestora este bine cunoscut ºi standardizat; totuºi, practica curentã poate fi îmbunãtãþitã, motiv pentru care vom încerca sã vã prezentãm experinþa noastrã cu un nou implant. Material ºi metodã: Am efectuat un studiu retrospectiv cu IP-XS-NAIL, un implant centromedular utilizat în tratamentul fracturilor de peroneu. Am inclus în studiu un numãr de 57 de

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Key words: IP-XS-NAIL, peroneal maleollae fractures. Introduction: Fractures of the distal third of the peroneus are frequent findings in trauma centers. They can be isolated or associated to bi or trimaleollar fractures. Due to their high incidence the treatment is well standardized. Nevertheless, there is room for improvement and therefore we present our experience with a new implant. Material and Method: We conducted a retrospective study with IP-XS-NAIL, a centromedullary implant for peroneal fractures. We included 57 isolated peroneal fractures treated with IP-XS-NAIL and compared them to 73 isolated peroneal fractures treated with plate and screws, over 5 years, between March 2004 and September 2009. Results: The study showed a consolidation rate of 100% for IP-XS-NAIL as well as for plate and screws (97%). Significant differences were found with operative time and soft tissue injury which were higher for plate and screws.


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL Conclusions: In conclusion we consider IP-XSNAIL an alternative to standard plate and screw fixation, with better disturbance of the covering soft tissues and decreased wound healing complications, especially for elderly patients. Bibliografie 1. Blotter, R.H., Connolly, E., Wasan, A., Chapman, M.V.V. (1999): “Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus”. Foot Ankle Int. Nov 20(11): 687-694. 2. Cedell, C.A. (1967): “Supination-outward rotation injuries of the ankle”. Dissertation. Acta Orthop. Scand. (Suppl.) 110. 3. Destot, E. (1911): Traumatisme du pied et rayons X malleoles, astragale, calcaneum, avant-pied. Masson, Paris. 4. Friedl, W. (1998): “Zuggurtungsnagelsystem für axiale Kompressionsosteosynthese der Patella”, 62 Jahrestag der Deut. Ges. für Unfallchirurgie e.V.: 721. 5. Gehr, J., Friedl, W. (2001): “Probleme der Zuggurtungsosteosynthese von Patellafrakturen und deren Konsequenzen für weitere Implantatentwicklungen. Der XS-Nagel . Der Chirurg. 72:1309-1318. 6. Henke, G. (1964): Vergleichende Ergebnisse der konservativen und operativen Knochenbruchbehandlung unter Berücksichtigung der Einteilung nach Niels Lauge Hansen. Dissertation, Basel. 7..Hughes, J.L., Weber, H. (1979): “Evaluation of ankle fractures”. Clin. Orthop. 138: 111 8. Learch, W.J., Fordyce, M.J. (1994). “Audit of ankle fracture fixation in the elderly”. J R Coll Surg Edinburgh, Apr; 39(2):124-127 9 .Lindsjö, U. (1981): “Operative treatment of ankle fractures”. Acta Orthop Scand Suppl 52. 10 .Lindsjö, U. (1985): “Operative treatment of ankle fracture-dislocations”. Clin Orthop 199: 28-38. 11 .Low, C.K., Pang, H.Y., Wong, H.P., Low, Y.P. (1997): “A retrospective evaluation of operative treatment of ankle fractures”. Ann Acad Med Singapore. Mar 26(2):172-174. 12. Mc Cormack, R.G., Leith, J.M. (1998): “Ankle fractures in diabetics. Complications of surgical management”. J Bone Joint Surg Br. Jul 80(4) :689-692. 13. Nonnemann, H.C., Plötsch, J. (1993): “Verrenkungsbrüche des oberen Sprunggelenkes. Klassifizierung-Behandlung-Ergebnisse”. Aktuell Traumatol 23: 183. 14. Olerud, C., Molander, H. (1984): “A scale for symptom evaluation after ankle fractures”. Arch Orthop Trauma Surg 103: 190-194. 15. Ponzer, S., Nasell, H. (1999): “Functional Outcome and Quality of Life in Patients with Type B Ankle Fractures: A TwoYear Follow-Up Study”. J Orthop Trauma, Vol. 13, No. 5: 363-368 16. Ramsey, P.L., Hamilton, W. (1976): “Changes in tibiotalar area of contact caused by lateral talar shift”. J Bone Surg [Am] 58: 356-357. 17. Richter, J., Schulze, W., Muhr, G. (1999): “Stabile Knöchelbrüche. Indikation zur Operation oder konservativer Therapie?”, Orthopäde 28: 493-499. 18. Riede, U. N., Schenk, R., Willenegger, H. (1971): “Gelenkmechanische Untersuchungen zum Problem der

posttraumatischen Arthrosen im oberen Sprunggelenk”. Langenbecks Arch. Klein. Chir. 328: 258-271. 19. Schweiberer, L., Seiler, H. (1978). “Spätergebnisse bei operativ behandelten Malleolarfrakturen”. Unfallheilkunde 81: 195-202. 20. Sinisaari, I. et al. (1996): “Metallic or absorbable implants for ankle fractures: a comparative study of infections in 3111 cases”. Acta Orthop Scand Feb, 67 (1): 16-18. 21. Tassler, H. (1981): “Behandlungsprinzipien bei drittgradigen offenen Frakturen des distalen Unterschenkels”. Unfallheilkunde 84: 509. 22. Weber, B.G. (1966). Die Verletzungen des oberen Sprunggelenkes. Huber: Bern, Stuttgart.

 TRATAMENTUL PERCUTAN AL PSEUDARTROZELOR DE TREIME INFERIOARÃ DE TIBIE T. Golia, C.I. Stoica, N. Horhocea, Al. Drãghici, T. Sorin Spitalul Clinic Ortopedie Traumatologie ºi TBC Osteoarticular “Foiºor” - Bucureºti

Scop: Evaluarea procedeelor miniminvazive în tratamentul pseudartrozelor distale de tibie. Material ºi Metodã: 2 cazuri cu pseudartrozã de tibie, unul dintre ele cu multiple intervenþii chirurgicale, la care s-a decis tratamentul minim invaziv prin injectarea de substanþã osteoinductivã, fiind urmãriþi periodic pânã în prezent clinic ºi radiologic. Rezultat: Pe parcursul urmãririi, pe o perioadã de 18 luni de la injectare se constatã apariþia de calus osos la nivelul focarului de pseudartrozã ºi absenþa durerii, fãrã a mai necesita deschiderea focarului de pseudartrozã. Concluzii: În ciuda costului iniþial ridicat al acestui tip de tratament cu substanþe osteoinductive, considerãm cã aceastã alternativã ºi-a dovedit eficienþa, având în vedere rezultatul ºi tehnica minim invazivã folositã. PERCUTANEOUS NON-UNION TREATMENT OF TIBIAL DISTAL FRACTURE Purpose: Minimally invasive procedure evaluation in non-union distal tibial fracture treatment. Materials and Methods: 2 tibial non-union cases , in which one of them with multiple surgery, for whom we decide minimally invasive treatment with injectable osteoinductive substance, with clinically and radiologically periodical follow-up untill the present day.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Results: during the 18 months follow-up we observed the formation of the callus at the nonunion site and the absence of pain; no reintervention was necessary. Conclusions: despite the initial high cost of this kind of treatment with osteoinductive substance , we consider that this is an alternative of choice in the treatment of non-union based on the results and the minimally invasive techniques used.

 VALOAREA ARTRODEZEI TIBIOASTRAGALIENE ÎN ARTROZA POSTTRAUMATICÃ DE GLEZNÃ N. Gorun, R. Alexandrescu, ªt. Andrei, A.Topor Spitalul Clinic de Urgenþã „Sfântul Ioan”, Bucureºti

Cuvinte cheie: fracturi, maleolare, artrozã, artodezã, gleznã, durere. Lucrarea noastrã îºi propune sã arate valoarea artrodezei tibioastragaliene în artrozele post fracturi maleolare, adesea tratate incorect. La instalarea artrozei posttraumatice participã trei factori: mecanic, static ºi trofic. Aceºtia acþioneazã atât prin incongruenþa articularã ºi dezaxarea gleznei, rezultând o încãrcare neuniformã a suprafeþelor articulare, uzura condralã localizatã ºi scleroza subcondralã, cât ºi prin scleroza pãrþilor moi periarticulare ºi perturbarea circulaþiei locale. Aceste elemente definesc artroza tibioastragalianã, boalã care beneficiazã de artrodezã. Studiul nostru are la bazã analiza unei serii personale de 90 de cazuri la care am practicat artrodeza tibioastragalianã. În alegerea procedeului de artrodezã, am avut în vedere suferinþa subiectivã ºi aspectul clinicoradiologic al gleznei, care stã la baza clasificãrii acestor artroze în axate si dezaxate. În 38 de cazuri (42,2%), am practicat artrodeza pe cale externã, transperonierã, cu grefon peronier alunecat ºi fixat la tibie ºi astragal (dupã avivare), cu 3-4 ºuruburi (tehnica Adams-Crawford). În 42 de cazuri (46,4%), am recurs la artrodeza pe cale anterioarã cu grefon tibial alunecat ºi încastrat în astragal (tehnica Watson-Jones), fixat la tibie ºi astragal cu 3-4 ºuruburi. În 14 cazuri din acest lot, la osteosinteza cu ºuruburi, am asociat 2-3 broºe transplantare.

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La 10 pacienþi, am practicat artrodeza tibioastragalianã pe cale anterioarã, cu douã ºuruburi încruciºate, dupã tehnica Meary, în 8 cazuri ºi cu tijã K transplantarã, în 2 cazuri. Ca gesturi chirurgicale complementare am efectuat artrodeza subastragalianã în 2 cazuri, rezecþia uneia sau ambelor maleole ºi folosirea lor ca grefe în 27 cazuri, osteotomia maleolelor la bazã ºi aplicarea lor, dupã avivare, pe feþele laterale avivate ale astragalului, ca în procedeul Spitzy, în 11 cazuri. Am obþinut rezultate foarte bune în 188 cazuri (94,4%) ºi rezultate nesatisfãcãtoare în 12 cazuri (5,6%), impunând reluarea artrodezei în 7 cazuri ºi artrodeza subastragalianã de axare în 5 cazuri. În marea majoritate a cazurilor cu artrozã tibioastragalianã posttraumaticã dureroasã, rezultatele artrodezei sunt foarte bune ºi bune, motiv pentru care o recomandãm cu deplinã convingere. Artrodeza tibioastragalianã oferã confortul unei glezne stabile, nedureroase, cu preþul unui blocaj articular definitiv bine suportat pe plan funcþional. THE EFFECTIVENESS OF TIBIOTALAR ARTHRODESIS ON POSTTRAUMATIC ANKLE ARTHROSIS Key words: fractures, malleolar, arthrosis, arthodesis, ankle, pain Our study aims to demonstrate the need and value of tibiotalar arthrodesis as a treatment for arthrosis that has appeared after incorrectly treated malleolar fractures. There are three factors involved in posttraumatic ankle arthrosis: mechanical, static and trophic. They act firstly by joint incongruity and bad ankle alignment, which cause an uneven loading of articular surfaces, localized chondral wearing and subchondral sclerosis and secondly by periarticular sclerosis and disruption of local circulation. All these elements define tibiotalar arthrosis. The effects of this disease can be alleviated by tibiotalar arthrodesis. Our study is based on the analysis of 90 cases of posttraumatic arthrosis of the ankle that we treated by tibiotalar arthrodesis. In order to select the arthrodesis procedure, we considered subjective symptoms and clinical and radiologic aspects of the affected ankle. By


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL considering these, the ankle arthroses are classified as aligned or misaligned. We performed an external, transperoneal arthrodesis with a peroneal slide graft fixed to the tibia and astragalus with 3-4 screws (AdamsCrawford technique) in 38 cases (42.2%). We carried out an anterior arthrodesis with a tibial graft (Watson-Jones technique) fixed to the tibia and astragalus with 3-4 screws in 42 cases (46.4%). We added 2-3 wires through the sole of the foot to the screws in 14 cases. We performed an anterior tibiotalar arthrodesis with 2 crossed screws without a tibial graft (Méary technique) in 8 cases and a tibiotalar arthrodesis with 2 K wires through the sole of the foot in 2 cases. As additional surgical manoeuvres, we performed a subastragalar arthrodesis in 2 cases, we resected both malleoli and used them as grafts in 27 cases and we carried out a Spitzy procedure in 11 cases. We achieved very good results in 188 cases (94.4%) and unsatisfactory results in 12 cases (5.6%) of which 7 cases needed to be redone and a subastragalar arthrodesis was needed in the other 5 cases. The arthodesis’ results are very good or good in the majority of cases of painful posttraumatic tibiotalar arthrosis so we strongly recommend it. The tibiotalar arthrodesis provides a stable and painless ankle but for the price of an irreversible blocked joint. The surgeon and the patient accept this disadvantage due to the fact that the foot can provide a satisfactory compensation. Bibliografie 1. Méary R., Roger A., Tomeno B. – Arthodèse tibioastragaliènne, E.M.C. – Techniques, Paris, 1970, 44-502. 2. Shelton M.L., Anderson R.L. Jr. – Complications of fractures and dislocations of the ankle, p. 599–648 (in EPPS CH. H. Jr. and all – Complications in orthopaedic surgery, J.B. Lippincot Company, Philadelphia, 1986). 3. Baciu Cl. – Artrodeza rapida a gleznei prin verticalizarea spatiului articular, p. 337–343 (in Constantinescu C. si colab. – Actualitati in chirurgie, Ed Medicala, Bucuresti, 1989). 4. Kitaoka H.B., Anderson P.J.,Morrey B.F. – Revision of ankle arthrodesis with external fixation for non-union, J. Bone, Jt. Surg., 1992, vol. 74-A, no. 8, p. 1191 - 1200. 5. Bresler F., Molé D., Blum A., Rio B. – Arthrodèse tibioastragaliènne: retentissment de la position de fixation sur le pied, Rev. Chir. Orthop. (Paris), 1993, t. 79, no. 8, p. 643-650.

6. Stranks G. J., Cecil T., Jeffery I. T. A. – Anterior ankle arthrodesis with cross-screw fixation. A dowel graft method used in 20 cases, J. Bone Jt. Surg., 1994, vol 76-B, no. 6, p. 943-946. 7. Gorun N. – Fracturi maleolare, Ed Curtea Veche, Bucuresti, 2000, p. 171-193. 8. Smith R., Wood P. L. R. – Arthrodesis of the ankle in the presence of a large deformity in the coronal plane, J. Bone Jt. Surg. Br, 2007, vol. 89-B, no. 5, p. 615-619. 9. Niculescu D. L. – Fracturi ale extremitatilor inferioare ale oaselor gambei, p. 384-391 (in Antonescu D. – Patologia aparatului locomotor, vol. II, Ed Medicala, Bucuresti, 2008). 10. Hintermann B., Barg A., Knupp M., Valderrabano V. – Conversion of painful ankle arthrodesis to total ankle arthroplasty J. Bone Jt. Surg. Am., 2009, vol. 91 no. 8, p. 20442044.

 OSTEOTOMIA SCARF PENTRU TRATAMENTUL HALLUX VALGUS F. Groºeanu, A. Prundeanu, Gh. Panait, ªt. Cristea Clinica de Ortopedie-Traumatologie, Spitalul Clinic de Urgenþã „Sfântul Pantelimon“ Bucureºti

Cuvinte cheie: hallux valgus, scarf, osteotomie. În clinica noastrã au fost efectuate în perioada 2005-2009 40 de osteotomii Scarf pentru tratamentul hallux valgus asociate unei osteotomii de varizare sau scurtare a falangei proximale ºi o plastie de adductor. Material ºi metodã: 36 de femei ºi 4 bãrbaþi au fost operaþi cu o vârstã medie de 50 ani. Preoperator varusul primului metatarsian era de 15°. Unghiul M1M5 era de 31°. Unghiul metatars 1falanga proximalã era în medie 38°. Rezultate: Au fost apreciate folosind criteriile Groulier cu un follow-up de 1 an. Unghiul de metatarsus varus s-a îmbunãtãþit cu o medie de 10° ca ºi unghiul M1M5 (25°). Postoperator unghiul metatars 1-falanga proximalã a fost în medie 22°. Aceste rezultate sunt semnificative statistic. Rezultatele globale au fost excelente sau bune în 75%, satisfãcãtoare în 20% ºi proaste în 5% din cazuri. Discuþii: Osteotomia Scarf permite corecþia completã a metatarsus varus. Valoarea preoperatorie a DMAA este cel mai important factor în evaluarea hallux valgus. Procedura se poate aplica la orice vârstã. Trebuie completatã cu osteotomie falangianã de varizare sau scurtare ºi plastie de adductor.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 FIRST METATARSAL SCARF OSTEOTOMY IN HALLUX VALGUS Key words: hallux valgus, scarf, metatarsal osteotomy 40 hallux-valgus were treated with Scarf Osteotomy of the first metatarsal associated to a phalangeal varisation or shortening osteotomy and an adductor plasty. Material and methods: 36 females and 4 males were operated with an average age of fifty years. The pre operative metatarsus varus was of 15°. Mean alignment of metatarsal bar was 31°. The average metatarso-phalangeal great toe valgus was 38°. Results: They were appreciated with a minimal follow-up of one year according to the 3 Groulier’s criteria. The metatarsus varus improved with an average of 10° as well as the alignment of the metatarsal bar (25°). The post operative average phalangeal valgus was 22°. These results were statistically significant. Global result was excellent or good in 75% satisfactory in 20% and bad in 5% of cases. Discussion: Scarf Osteotomy of the first metatarsal allows complete correction of metatarsus varus. The preoperative DMAA value is the most important factor in the hallux valgus evaluation. The surgical approach can be proposed at every age. There are no vascular trouble or arthrosis worsening. It must be completed with a phalangeal varisation or shortening osteotomy and adductor plasty. Bibliografie 1. Balding M.G., Sorto L.A. Jr : Distal articular set angle, etiology and X-ray evaluation. J Am Podiatr Med Assoc, 1985, 75, 648-652. 2.Barouk L.S.: Ostéotomie Scarf du premier métatarsien. Med Chir Pied, 1994, 10, 111-120. 3. Barouk L.S.: Nouvelles ostéotomies de l’avant pied, Chirurgie de l’avant pied. Cahiers d’enseignements de la SOFCOT (54), Exp Sci Fr, Paris, 1996, 55-84. 4. Barouk L.S.: Forefoot reconstruction, Springer-Verlag – Paris-Berlin, 2003 5. Groulier P.: Du traitement chirurgical de l’hallux valgus et de ses complications, Chirurgie de l’avant pied. Cahiers d’enseignements de la SOFCOT (54), Exp Sci Fr, Paris, 1996, 3954. 6. Jarde O., Trinquier-Lautard J.L. , Gabrion A., Ruzic J.C. , Vives P., Hallux valgus traité par une ostéotomie de Scarf du premier métatarsien et de la première phalange associée à une

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plastie de l’adducteur A propos de 50 cas avec 2 ans de recul Revue de chirurgie orthopédique1999 ; 85 374-380. 7. Maestro M., Daoud A., Deschapms L., Fernane M.: L’axe du 2ème métatarsien dans le pied bot varus équin, corrélation anatomo-clinique et radiologique, intérêt pronostic. Med Chir Pied, 1992, 8, 89-94.

 EXPERIENÞA NOASTRÃ ÎN TRATAMENTUL FRACTURILOR DE PILON TIBIAL UTILIZÂND FIXATORUL EXTERN F. Groºeanu, A. Prundeanu, C. Budicã, V. Predescu, V. Georgeanu, A. Atasiei, St. Cristea Clinica de Ortopedie-Traumatologie, Spitalul Clinic de Urgenþã „Sfântul Pantelimon”,, Bucureºti

Cuvinte rare: pilon, fixator, broºã. În perioada 2007–2009 au fost trataþi 42 pacienþi cu fracturi de pilon tibial. În 19 cazuri am utilizat fixatorul extern asociat osteosintezei peroneului cu 1 broºã Kirschner. Material ºi metodã: 14 bãrbaþi ºi 5 femei au fost operaþi cu o vârstã medie de 48 ani. Conform clasificãrii Mast ºi Spiegel am avut 2 fracturi tip A, 1 tip B ºi 16 tip C. În toate cazurile am utilizat ºi o broºã Kirschner pe peroneu. Am avut 13 fracturi deschise ºi 6 fracturi închise de pilon tibial. Intraoperator am utilizat instrumentaþia cu broºã Kirschner pentru refacerea suprafeþelor articulare. Rezultate: Au fost apreciate þinând cont de refacerea suprafeþelor articulare, refacerea lungimii peroneului ºi axarea fragmentelor proximal ºi distal pe radiografiile de faþã ºi profil. Am gãsit 70% rezultate bune, 10% rezultate satisfãcãtoare ºi 20% rezultate proaste. Concluzii: Osteosinteza cu fixator extern este o metodã reproductibilã, rapidã de rezolvare a fracturilor de pilon tibial. Este de mare ajutor mai ales în cazul fracturilor deschise ºi al politraumatismelor, fiind de preferat utilizarea ei în urgenþã. Poate fi folositã ºi ca metodã de temporizare, în locul tracþiunii transcalcaneene, pânã la reducerea deschisã ºi fixarea internã a fracturii de pilon tibial OUR EXPERIENCE IN TREATING PILON FRACTURE USING EXTERNAL FIXATION Key words: pilon, fixation, wire.


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL Between 2007-2009 we treated 42 patients with pilon fractures. In 19 cases we used external fixation associated to ostheosynthesis with Kirschner wire for fracture of the lateral malleolus. Matherial and method: 14 men and 5 women have been operated with an average age of 48 years. According to Maast and Spiegel classification we had 2 fractures type A, 1 fracture type B and 16 fractures type C.In every cases we used a Kirschner wire for lateral malleolus also. We had 13 open fractures and 6 closed fractures. Intraoperatively we used instrumentation with a wire for restoring the articular surfaces. Results: Were appreciated taking care of restoring the articular surfaces, restoring length of the peroneus and restoring the axes for the fractures fragments using X-ray in both axes. We find 70% good results, 10% sufficient and 20% poor results. Conclusions: Ostheosynthesis with external fixation is a reproductive, rapid method of resolving pilon fractures. It is useful especially for open fractures and politrauma, being preffered at emergency room. It can also be used temporary, instead of scheletal traction, until open reduction and internal fixation of the pilon fracture. Bibliografie 1. Rockwood and Green - Fractures in Adults, Fifth Edition. 2. Campbell Operative Orthopaedics - Ninth Edition.

 OSTEOTOMIA DE DESCHIDERE A BAZEI MT I COMBINATÃ CU OPERAÞIA KELLER – BRANDES MODIFICATÃ LA PACIENÞII CU HALLUX VALGUS ªI METATARSUS PRIMUS VARUS SEVER ªI ARTROZA METATARSO – FALANGIANÃ ASOCIATÃ C. Huszar, L. Ojoga, E. Vulpe, R. Dragomir, A. Dima Clinica Ortopedie, Spitalul de Urgenþã Universitar Bucureºti

Cuvinte cheie: hallux valgus, osteotomie proximalã metatarsian I. Introducere: La pacienþii cu Hallux Valgus sever asociat cu valori mari ale unghiului intermetatarsian I – II, posibilitãþile de corecþie ale osteotomiilor clasice, izolate, sunt limitate ºi procedurile devin tehnic dificile. Propunem o metodã simplã ºi cu mare putere de corecþie în tratamentul acestor cazuri.

Material ºi metodã: În perioada noiembrie 2007 iunie 2009, 15 pacienþi ( 17 picioare) – 14 femei ºi 1 bãrbat, au fost trataþi în Clinica noastrã pentru patologia mai sus menþionatã. Am asociat o osteotomie de deschidere proximalã a metatarsianului I, urmatã de fixarea cu miniplacã în “T” ºi ºuruburi, cu un timp distal constând în: excizia exostozei MT I + release capsular lateral + excizia unei porþiuni minime din baza falangei proximale + capsulorafia. Am utilizat aceastã tehnicã la pacienþi cu vârsta mai mare de 40 ani ºi cu activitate fizicã zilnicã moderatã. Rezultatele radiologice ºi clinice pe termen scurt au fost satisfãcãtoare în toate cazurile. Nu am avut complicaþii legate de metodã. Concluzii: În opinia noastrã, asocierea terapeuticã descrisã, este uºor de realizat, asigurã o bunã corecþie a diformitãþii, în cazul în care fixarea este robustã permite mobilizarea cu sprijin parþial ºi recuperarea precoce ºi conferã rezultate bune în cazurile selecþionate. PROXIMAL OPENING WEDGE OSTEOTOMY OF THE FIRST METATARSAL COMBINED WITH MODIFIED KELLER PROCEDURE ÎN PATIENTS WITH SEVERE HALLUX VALGUS AND METATARSUS PRIMUS VARUS ASSOCIATED WITH MTP ARTHRITIC LESIONS Key words: hallux valgus, proximal metatarsal osteotomy. Introduction: în patients with severe hallux valgus and metatarsus primus varus associated with degenerative changes of the first MTP joint, regular isolated osteotomies are technically difficult and provide insufficient results. în these case we are coming forward with a simple and efficient technique. Material si Methods: Between November 2007 and June 2009 a number of 15 patients (17 feet) – 14 females and 1 male, suffering from this pathology, were treated in our Department. We combined a proximal opening wedge osteotomy of the first metatarsal with a distal procedure consisting in excision of the bunion + lateral capsular release + excision of a small portion of the base of the proximal phalanx + capsuloraphy. We used this technique in patients older than 40 with moderate daily physical activity. Satisfactory short term clinical and radiological results were achieved in

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 all patients. We didn’t record any complication related to the method. Conclusions: în our opinion, the above mentioned method is easy to perform, allows us to achieve a good correction of the deformity, gives the patient the possibility of an early partial weight - bearing and yields good results in selected cases. Bibliografie 1. Correction of metatarsus primus varus with an opening wedge plate: a review of 18 procedures. Wukich D.K., Roussel A.J., Dial D.M.J Foot Ankle Surg. 2009 Jul-Aug; 48 (4): 420-6. Epub 2009 May 9. 2. Proximal opening-wedge osteotomy of the first metatarsal for correction of hallux valgus. Cooper M.T., Berlet G.C., Shurnas P.S., Lee T.H. Surg Technol Int. 2007; 16: 215-9. 3. Valgus-producing opening wedge proximal tibial osteotomy: what, when, and how. Parker RD. Orthopedics. 2005 Sep; 28 (9): 977-9.

 OPÞIUNI TERAPEUTICE ÎN LEZIUNILE NEGLIJATE ALE GLEZNEI O. Lupescu, M. Nagea, Gh.I. Popescu, Cristina Pãtru, ªt. A. Niculescu Clinica de Ortopedie ºi Traumatologie Spitalul Clinic Universitar de Urgenþã, Bucureºti

Cuvinte cheie: incongruenþã, instabilitate, repere radiologice, artrozã. Introducere: Diagnosticul ºi tratamentul precoce reprezintã dezideratul esenþial pentru restabilirea post-traumaticã a anatomiei ºi funcþionalitãþii articulaþiei gleznei. Existã situaþii în care diagnosticul leziunilor sau tratamentul acestora se instituie tardiv. În astfel de situaþii opþiunea terapeuticã depinde de factori locali ºi generali. Autorii analizeazã cazuri în care tratamentul a trebuit adaptat în aºa fel încât sã se realizeze o funcþionalitate cât mai apropiatã de cea normalã. Material ºi Metodã: Sunt analizate 25 cazuri care au fost tratate în intervalul 01.01.2004-01.08.2007 pentru leziuni traumatice ale gleznei cu indicaþie chirurgicalã la care tratamentul s-a efectuat, din diferite motive, la minimum 4 sãptãmâni de la traumatism (maximum 3 luni). Pacienþii au fost evaluaþi dupã urmãtoarele criterii: - vârsta ºi starea generalã a pacientului; - vechimea traumatismului; - structurile afectate de traumatism; - evaluarea imagisticã pre-operatorie;

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- leziunile post-traumatice decelate intraoperator. Rezultate: Reducerea chirurgicalã ºi osteosinteza s-a realizat în 20 din cele 25 cazuri (80%), iar în celelalte 5 cazuri a fost necesarã artrodeza gleznei (20 %). Tehnica stabilitã pre-operator a fost aplicatã în 22 cazuri, în 3 cazuri în care iniþial se pãrea cã se poate realiza reducerea a fost necesarã artrodeza. Esenþialã în stabilirea indicaþiei terapeutice a fost concordanþã între starea structurilor gleznei, în special a cartilajului, cu tipul de solicitare characteristic pacientului. Pacienþii au fost evaluaþi la 1, 2, 6 ºi 24 luni post-operator. În 2 din cele 20 cazuri s-a pus indicaþia secundarã de artrodezã de gleznã. Concluzii: În cazul leziunilor vechi ale gleznei, opþiunea terapeuticã este dificilã întrucât chirurgul trebuie sa adapteze starea structurilor afectate de un traumatism vechi la solicitãrile articulaþiei gleznei. Alegerea trebuie fãcutã între stabilizare ºi artrodezã funcþie de starea structurilor osoase ºi mai ales cartilaginoase, ce este complet evaluatã imagistic ºi intraoperator. THERAPEUTIC OPTIONS IN NEGLECTED ANKLE INJURIES Key words: incongruence, instability, radiological reference points, arthrosis Introduction: Early diagnosis and treatment are essential to post-traumatic reestablishment of the anatomy and function of the ankle joint. There are situations in which the injuries are diagnosed or treated too late. In these situations, the therapeutic option depends on local and general factors. The authors present cases in which the treatment had to be somehow adapted to achieve near-normal functionality. Materials and Method: The authors analyse 25 patients treated between 01.01.2004-01.08.2007 for ankle injuries with surgical indication. For various reasons, surgical treatment was applied after more than 4 weeks (3 months, at most) after the injury. The patients were evaluated according to the following criteria: age and general condition : time from the injury; structures affected by the injury; pre-surgery imagistical evaluation, posttraumatic injuries that were discovered during surgery Results: Surgical reduction and osteosynthesis were achieved in 20 out of 25 cases (80%), and in the remaining 5 cases ankle arthrodesis was necessary (20%). The technique established before


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL the surgery was applied in 22 cases. In 3 cases it was originally thought that reduction could be performed, but arthrodesis was necessary. The congruence between the state of the ankle structures, especially the cartilage, and the amount of wear on the ankle, specific to the patient, was essential in establishing the therapeutic indication. The patients were evaluated 1, 2, 6 and 24 months after the surgery. In 2 of the 20 cases, secondary ankle arthrodesis was indicated. Conclusions: In the case of old ankle injuries, the therapeutic option is difficult because the surgeon must adapt the state of the structures affected by the old injury to the wear on the ankle joint. The choice between stabilization and arthrodesis must be made according to the state of the bony and especially the cartilaginous structures, which is completely evaluated imagistically and during surgery.

 OSTEITA POST - FRACTURARE DE PILON TIBIAL - CAZ CLINIC O. Lupescu, M. Nagea, Gh.I. Popescu, Cristina Pãtru, Cornelia Letiþia Vasilache Clinica de Ortopedie ºi Traumatologie Spitalul Clinic de Urgenþã „Floreasca“, Bucureºti

Cuvinte cheie: osteitã, sechestrectomie, osteoplastie. Tratamentul osteitei post-fracturare presupune intervenþii chirurgicale seriate, un interval mare de timp pentru vindecare ºi multiple riscuri. Autorii prezintã un caz clinic – pacient de sex masculin, 32 ani, cu osteitã post-fracturare a pilonului tibial dupã fractura cominutivã de pilon tibial operatã cu placã ºi ºuruburi, prezentat la Spitalul Clinic de Urgenþã dupã scoaterea materialului de osteosintezã. S-a practicat evaluare RMN a extremitãþii distale a gambei ºi gleznei, pentru a se evidenþia zona afectatã septic; evaluarea RMN a arãtat afectarea unei arii mult mai întinsã decât cea aparentã pe radiografie. S-a practicat sechestrectomie pânã în þesut sãnãtos, conform „hârtii“ alcãtuite pe baza RMN. Ulterior, s-au practicat pansamente repetate pânã la granularea defectului osos ºi s-a repetat evaluarea RMN, pentru a aprecia statusul osos local, dupã care s-a acoperit defectul osos prin

osteoplastie, iar pe defectul cutanat s-a aplicat o peliculã de colagen. Evoluþia a fost favorabilã, dar cu respectarea individualitãþii fiecãrui timp al tratamentului ºi a intervalelor de timp necesare între operaþii. Concluzii: Tratamentul osteitei post-fracturare pune probleme datoritã riscului de recidivã ºi necesitãþii asanãrii certe a focarului osteitic. Fiind respectaþi timpii operatori ºi intervalele dintre aceºtia, evoluþia pacientului a fost favorabilã, dar este necesarã urmãrirea la distanþã pentru a fi siguri de dispariþia procesului septic. POST-TRAUMATIC OSTEITIS OF DISTAL TIBIA - CLINICAL CASE Key words : osteitis, sequstrectomy, osteoplasty Treatment of post-fracture osteitis requires serial surgical procedures, considerable time for healing and meay risks. The authors present a clinical case – male, 32 yrs, with post-fracture osteitis of distal tibia, examined in our hospital after implant removal (plate and scrwes). MRI (ankle and distal tibia) evaluation was performed in order to visualize precisely the affected area; the MRI showed that considerable amount of tibial bone was affected compared to the area indicated by the digital Xray. So, based on MRI, a “map of the injury” was drawn and sequestrectomy was performed, affecting all the injured area, until healthy bone. After this, the bone deffect was taken care of until i twas covered with granulation tissue and MRI was again used to check the local status. Since no sequestrum was to be found, the bone defect was filled with cancelous bone, which was covered with a collagen bandage. The outcome was very good, but the condition was to respect the surgical “steps” and the time between them. Conclusions: A lot of problems can be identified when treating post-fracture osteitis, due to the risk of relapse and of the obvious need to fulfill complete clearing of the osteitic zone. Once the surgicakl procedures and the time between them respect the local characteruistics and the therapeutic protocols, the outcome is usually favourable, but long term follow-up is required in order to be sure that the infection has disappeared.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009

 PROBLEME PRIVIND DIAGNOSTICUL LEZIUNILOR CAPSULO-LIGAMENTARE ALE GLEZNEI O. Lupescu, M. Nagea, Gh.I. Popescu, Cristina Pãtru, Cornelia Letiþia Vasilache Clinica de Ortopedie ºi Traumatologie Spitalul Clinic de Urgenþã „Floreasca“, Bucureºti

Cuvinte cheie: instabilitate, incongruenþã, complex capsulo-ligamentar, sindesmozã. Introducere: Termenul “articulaþia gleznei” se referã la un complex de structuri osoase ºi capsuleligamentare ce pot fi afectate în diferite grade de traumatisme. Datoritã evidenþierii radiologice facile, problemele de diagnostic apar rareori în ceea ce priveºte patologia osoasã; în schimb, leziunile capsulo-ligamentare pot pune probleme de evaluare. Autorii se referã, în aceastã lucrare, la cazuri ce au ridicat probleme din punct de vedere al diagnosticului leziunilor capsulo-ligamentare. Material ºi Metodã: Au fost incluºi în analiza 150 pacienþi cu vârste medii între 18-61 ani, examinaþi între 01.01.2005-01.01.2009 consecutiv unor traumatisme ale gleznei de vechime între 1 orã ºi 6 sãptãmâni. Criteriile de analizã s-au referit la modalitãþile în care s-a pus diagnosticul leziunilor capsulo-ligamentare prin: - examen clinic; - examen radiologic standard; - alte evãluari imagistice. Rezultatele au fost evaluate diferenþiat funcþie de vechimea leziunii: în 75% din cazuri, diagnosticul de certitudine s-a pus la prima evaluare radiologicã. În 25% din cazuri, însã, leziunea capsulo-ligamentarã a fost evidenþiatã fie prin repetarea examenului radiologic (15%) fie prin evaluare RMN. În 18% din cazuri diagnosticul leziunii capsulo-ligamentare a fost pus la peste 1 sãptãmâni de la traumatism, iar in 6% din cazuri, la pest 4 sãptãmâni. Concluzii: Diagnosticul corect al traumatismelor gleznei este unul complet ºi precoce, care trebuie sã reflecte nu numai leziunile osoase, dar ºi pe cele capsulo-ligamentare, data fiind importantã acestora în funcþionarea gleznei. Autorii propun un algoritm de diagnostic , cu valoare practicã, al cãrui scop este optimizarea diagnosticului pentru instituirea precoce a unui tratament corect.

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PROBLEMS CONCERNING THE DIAGNOSIS OF CAPSULO-LIGAMENTOUS INJURIES OF THE ANKLE Key words: instability, incongruence, capsuloligamentous complex, syndesmosis Introduction: The term “ankle joint” refers to a complex of bony and capsulo-ligamentous structures which can be affected by trauma to various degrees. Due to the easy radiological recognition, bony pathology rarely presents diagnostic problems. In contrast, capsulo-ligamentous injuries may pose a problem in the evaluation. In this article, the authors refer to cases that had problems concerning the diagnosis of capsulo-ligamentous injuries. Materials and Methods: 150 patients were included in the analysis. They were 18-61 years old and were all examined between 01.01.2005– 01.01.2009 following ankle trauma that had happened between 1 hour and 6 weeks before. The analysis criteria refferedto the method of diagnosis of the capsulo-ligamentous injuries was made, by: - clinical examination - standard radiological examination - other imagistic evaluations The Results were assessed differently according to the age of the lesion. In 75% of cases, the definitive diagnosis was made at the first radiological evaluation. In 25% of cases, however, the capsulo-ligamentous injuries were recognized either after repeating the radiological examination (15%) or after MRI. In 18% of cases, the diagnosis of the capsulo-ligamentous injury was made more than 1 week following the trauma, and in 6% of cases, more than 4 weeks. Conclusions: The correct diagnosis of ankle trauma is a complete and early one, reflecting not only bone injuries, but also capsulo-ligamentous ones, due to their importance in ankle function. The authors suggest a practical diagnostic algorithm in order to performan optimal diagnosis and correct early treatment. Bibliografie 1. Ferran N.A., Maffulli N. – Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin 2006; 11:659-662 2. Frost S.C., Amendola A. – Is stress radiography necessary in the diagnosis of acute or chronic ankle instability? Clin J Sport Med 1999 3. Griffith J.F., Brockwell J. – Diagnosis and imaging of ankle instability. Foot Ankle Clin 2006


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL 4. Harper M.C., Keller T.S. – A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle 1989 5. Ebraheim N.A., Lu J., Yang H., Mekhail A.O., Yeasting R.A. – Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: A cadaver study. Foot Ankle Int 1997 6. Oae K., Takao M., Naito K., et al – Injury of the tibiofibular syndesmosis: Value of MR imaging for diagnosis. Radiology 2003 7. Jenkinson R.J., Sanders D.W., Macleod M.D., Domonkos A., Lydestadt J. – Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma 2005. 8. Marsh J.L., Saltzman C.L. – Ankle fractures, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA: Lippincott Williams and Wilkins, 2001, vol 2, pp 2001-2090. 9. Michael P. Recht, Brian G. Donley – Magnetic Resonance Imaging of the Foot and Ankle J Am Acad Orthop Surg; Vol 9; 187-199.

 OPÞIUNI TERAPEUTICE ÎN TRAUMATISMELE DESCHISE ALE GLEZNEI M. Nagea, O. Lupescu, Gh. I. Popescu, Cristina Pãtru, ªt.A. Niculescu Clinica de Ortopedie ºi Traumatologie Spitalul Clinic de Urgenþã „Floreasca“, Bucureºti

Cuvinte cheie: incongruenþã, instabilitate, leziune cutanatã, sepsis, artrozã. Introducere: Dacã în traumatismele închise ale gleznei atitudinea terapeuticã este relativ standardizatã, în cele deschise alegerea tratamentului este îngreunatã de existenþa leziunii cutanate care, funcþie de vechimea traumatismului ºi de tipul deschiderii, poate influenþa într-un mod hotãrâtor atât calea de abord cât ºi tipul de stabilizare osoasa. Mai mult decât atât, necesitatea efectuãrii intervenþiei în urgenþã nu lasã de obicei timp pentru evaluãri imagistice suplimentare în afarã de cea radiologicã standard. Material ºi Metodã: Autorii analizeazã 16 pacienþi cu traumatisme deschise ale gleznei soldate cu instabilitate ºi incongruenþã articularã, trataþi între 01.01.2005-01.01.2007, cu vârste între 24-52 ani. Dintre aceºtia, 13 aveau leziuni mixte osoase ºi capsulo-ligamentare, iar 3 pacienþi luxaþii deschise fãrã fracturi, intervenþia chirurgicalã efectuându-se în urgenþã, la 3-36 ore de la traumatism. Din punct de vedere al deschiderii fracturii, aceasta a fost: tip I (Gustillo-Andersen) în

2 cazuri (12.5%), tip II în 6 cazuri ( 37,5%) ºi tip III în 8 cazuri ( 50%), dintre care III A în 2 cazuri, III B în 3 cazuri ºi III C în 3 cazuri. Sunt prezentate problemele de tratament pentru fiecare dintre tipurile de deschidere ºi tipurile de intervenþii chirurgicale practicate. Perioada de follow-up a fost de 24 luni (la 1,2,6,12 ºi 24 luni post-traumatic). Rezultate: Evoluþia post-operatorie a fost evaluatã din punct de vedere al restabilirii funcþionalitãþii gleznei, al reintegrãrii socio-profesionale, cât ºi din punct de vedere al complicaþiilor. Factorii care au influenþat evoluþia post-traumaticã au fost: precocitatea tratamentului, tipul deschiderii, ºi amploarea leziunilor de pãrþi moi. Incidenþa complicaþiilor septice a fost de 12.5% (2 pacienþi) cu Staphylococcus aureus, fãrã a fi necesarã extragerea materialului de sintezã. Deoarece într-unul dintre cele 3 cazuri de fracturã deschisã tip III C traumatismul se petrecuse cu 36 ore anterior intervenþiei ºi ischemia era ireversibilã, a fost necesara amputaþia de gambã. Concluzii: Tratamentul traumatismelor deschise este dificil deoarece deschiderea cutanatã îngusteazã posibilitãþile terapeutice ºi complicaþiile post-operatorii sunt mai frecvente. Adaptarea tratamentului la leziunile de pãrþi moi ºi precocitatea intervenþiei chirurgicale reprezintã cheia succesului în astfel de cazuri. TREATMENT OPTIONS IN OPEN TRAUMA OF THE ANKLE JOINT Key words: incongruence, instability, skin injury, sepsis, osteoarthritis Introducere: Therapeutic rules are relatively clear in closed trauma of the ankle, while skin injury which characterizes the open trauma makes sometimes quite difficult the choice between different techniques, especially concerning the incision and the type of bone stabilization, which are definitely influenced be the time from trauma and mainly by the injury of the skin Material and Method: The authors analyze 16 patients with open trauma producing instability and incongruence of the ankle, operated between 01.01.2005-01.01.2007, age 24-52 yrs. The injuries were both bony and capsule-ligamentous in 13 cases, while 3 patients had open dislocations without fractures; surgery was performed immediately after arriving in our hospital, 3-36 hrs after trauma. Following Gustillo-Andersen classi-

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 fication, the injuries were type I -2 cases (12.5%), type II-6 cases (37.5%), type III-8 cases (50%), from which- type IIIA-2 cases, III B- 3 cases and III C-3 cases. Different therapeutical problems were raised for each type of open injury requiring different surgical techniques. Follow-up was performed until 24 months (1, 2, 6, 12 and 24 months). RESULTS Post-operative outcome was evaluated from the point of view of: functional recovery, social and professional re-integration, and the incidence of the complications. The circumstances influencing post-operative outcome were: the time between trauma and surgery, the type of the skin and soft tissue injuries. Septic complications appeared in 12.5% cases (2 patients) with Staphylococcus aureus, without the need of implant removal. Because one of the 3 cases with type III C injury arrived at our hospital 36 hrs after trauma with irreversible ischemia, amputation was indicated. Conclusions: The treatment of open trauma of the ankle is difficult since the cutaneous injury narrows the therapeutical options and postoperative complications are more frequent. The key of success in these cases is represented by early surgery adapted to the soft tissue injury.

 EXPERIENÞA PRIVIND VASCOSUPLEAÞIA ÎN ARTICULAÞIA GLEZNEI : 2007-2009 V. Orbeanu, B. Obadã, S. Ureche, M. Mataranga, V. Lupescu Ortopedie-Traumatologie Spitalul Clinic Judeþean de Urgenþã Constanþa

Cuvinte cheie: gleznã, artrozã, vascosupleaþie, hialuronat Procesul degenerativ artrozic, primar sau secundar afecteazã cca 12 -15 % din populaþia globului, dar este prezent radiologic la cca 80% din populaþia trecutã de 55 ani. Tratamentului clasic i s-a adãugat în ultimii ani vascosupleaþia; hyaluronatul, compus chimic natural, care se gãseºte în mod normal în corpul uman în particular la nivelul þesuturilor articulaþiilor ºi în fluidul intraarticular, scade în cantitate ºi calitate în artroze; administrat în injecþii intraarticulare în tratament standard de 5 injecþii administrate la un interval de o

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sãptãmânã, are ca efect îmbunãtãþirea mobilitãþii, fiind un lubrifiant ºi un absorbant al ºocurilor, un important „pain killer”. Este prezentatã comparativ, experienþa noastrã privind administrarea hialuronatului în articulaþia gleznei, în perioada 2007–2009. OUR EXPERIENCE ABOUT VISCOSUPPLEMENTATION IN ANKLE POSTTRAUMATIC ARTHRITIS: 2007–2009 Key words: ankle, arthrosis, viscosupplementation, hyaluronic acid Arthrosis process affect 12-15% of population, but xray manifestations are pressent at 80% of over 55 years people. Viscosupplementation is a type of therapy in which the hyaluronic acid can be augmented through a series of 5 injections, in a joint. The mode of action is not fully understood but mechanisms include physical effects (viscosity, lubrication and elasticity), pain receptors and pain mediators blocking („pain killer”). We present our experience between 2007-2009 regarding hyaluronic acid administration in ankle joint. Bibliografie 1. Abramson S., Attur M., Dave M., Leung M., Patel J., Gomez P.; Amin A. – Paracrine pathways of cartilage destruction in osteoarthritis Arthritis Res Ther 2003, 5 (Suppl 3): 2. 2. Bellamy N., Campbell J., Robinson V., Gee T., Bourne R., Wells G.: – Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006, (2): CD 005321. 3. Fam H., Bryant J.T., Kontopoulou M.: Rheological properties of synovial fluids. Biorheology 2007, 44 (2): 59-74. 4. Jiang D., Liang J., Noble P.W.: Hyaluronan in Tissue Injury and Repair. Annu Rev Cell Dev Biol 2007, 23: 435-61. 5. Kotz R.; Kolarz G. – “Intra-articular hyaluronic acid: duration of effect and results of repeated treatment cycles.” Am J Orthop. 1999; 28 (suppl 11S): 5-7. 6. Scalli J.J. – „Intra-articular hyaluronic acid in the treatment of osteoarthritis of the knee: a long term study. Eur J Rheumatol Inflamm. 1995; 15: 57-62. 7. Toole, B.P., – „Hyaluronan in morphogenesis” . Seminars in Cell & Developmental Biology .Vol. 12, 2, April 2001, pag. 79-87 8. Zhang, W., Watson, C.E., Liu, C., etc.- „Glucocorticoids induce a near-total suppression of hyaluronan synthase mRNA in dermal fibroblasts and in osteoblasts: a molecular mechanism contributing to organ atrophy”. Biochem J. 2000 July 1; 349 (Pt 1): 91–97. 9. xxx – „Manual tehnicã infiltraþii” – CSC Pharmaceuticals


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL

 OXIGENOTERAPIA HIPERBARÃ – TRATAMENT ASOCIAT TRAUMATISMELOR GLEZNEI V. Orbeanu, M. Enescu, I. Bãdãrãu, A. Ivaºcu, B.C. Ion Secþia Ortopedie-Traumatologie, Spitalul Clinic Judeþean de Urgenþã Constanþa

Cuvinte cheie: oxigen hiperbar, traumatism, gleznã, vindecare tisularã Aerul pe care-l respirãm conþine teoretic 21% O² (în aglomerãrile urbane scade la 15%) ºi 78% N²; în terapia hiperbaricã procentul de O² inhalat de pacient se apropie de 100% ceea ce genereazã conform legii gazelor a lui Henry creºterea de la 3ml la 60 ml oxigen dizolvat plasmatic ºi livrat celulelor îmbunãtãþind astfel procesul vindecãrii tisulare. Prezentãm câteva cazuri clinice tratate în Eurohiperbar- primul centru de medicinã hiperbarã din România ºi clinica ortopedie S.C.J.U. Constanþa - centru pilot în tratamentul afecþiunilor ortopedice ºi traumatologice, O-HBO. HYPERBARIC OXYGEN THERAPY IN ANKLE TRAUMA Key words: Oxygen hyperbaric, ankle trauma, tissue healing Air contains nearly 21% oxygen, and more than 78% nitrogen; in hyperbaric oxygen therapy (HBO), the oxygen percentage breathed by the patient is nearly 100%. Based on Henry’s gas law, oxygen increased tissue tensions maximize tissue oxygenation which improves tissue healing. Orthopedic clinic, Constanta Clinic Emergency County Hospital, became pilot center for trauma and orthopedic diseases: O-HBO with Eurohiperbar. We present some of results. Bibliografie 1. Bouachour G., Cronier P., Gouello J.P., Toulemonde J.L., Talha A., Alquier P. – Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial. J Trauma 1996; 41 (2): 333-9. 2. Coles, C., Williams, M., Burnet, N., Trytko, B. E, Bennett, M., Leach, R., Wilmshurst, P. – Hyperbaric oxygen therapy. BMJ 318 (1999): 1076c-1076 3. Cosgrove, H., Bryson, P. – Hyperbaric medicine in soft tissue trauma. Trauma 3: (2001): 133-141 4. Greif R., Akca O., Horn E.P., Kurz A., Sessler D.I. – Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med 2000; 342 (3): 161-7.

5. Hunt T.K. – Oxygen and wound healing. In: Hyperbaric Medicine 2000, 8th Annual Advanced Symposium. Columbia: S.C. Palmetto Richland Memorial Hospital and the University of South Carolina School of Medicine, 2000. 6. Ishii Y., Myanaga Y., Shimojo H., Ushida T., Tateishi T. – Effects of hyperbaric oxygen on procollagen messenger RNA levels and collagen synthesis in the healing of rat tendon laceration. Tissue Eng 1999; 5: 279-86. 7. James P.B. – Hyperbaric oxygen treatment for crush injury BMJ Dec 1994; 309: 1513 8. Kawashima M., Tamura H., Nagayoshi I., Takao K., Yoshida K, Yamaguchi T – „Hyperbaric oxygen therapy in orthopedic conditions“. Undersea Hyperb Med 31 (1), (2004): 155–62. 9. Kindwall E. – Contraindications and side effects to hyperbaric oxygen treatment. In: Kindwall EP, Whelan HT, eds. Hyperbaric Medicine Practice. 2nd ed. Best Publishing Co; 1999: 83-97. 10. Leach R.M., Rees, P.J.; P. Wilmshurst – ABC of oxygen: Hyperbaric oxygen therapy BMJ Oct 1998; 317: 1140 - 1143 11. Shirley, P. J. – Fluids as oxygen carriers and the potential role in trauma resuscitation. Trauma 10 (2008).: 139-147 12. Zamboni W.A., Roth A.C., Russell R.C., et al. – Morphologic analysis of the microcirculation during reperfusion of ischemic skeletal muscle and the effect of hyperbaric oxygen. Plast Reconstr Surg. May 1993; 91 (6): 1110-23. 13. Yang, G.P. Longaker M.T. – Hyperbaric Oxygen for Treating Wounds – Invited Critique Arch Surg. 2003; 138 (3): 280.

 MINERALIZAREA ªI DINAMICA OSTEONICÃ ÎN PATOGENEZA FRAGILITÃÞII OSOASE DIN OSTEOPOROZÃ Gh. Panait, C. Budicã, C. Mihai Spitalul Clinic de Urgenþã „Sfântul Pantelimon” Bucureºti

Cuvinte cheie: mineralizarea osteonicã, fragilitate osoasã, osteoporozã. Duritatea ºi plasticitatea þesutului osos sunt ca particularitãþi biomecanice ºi biologice (turnover) legate de funcþia pe care o are de îndeplinit în organism, sunt strîns legate de natura cristalinã a principalilor sãi componenþi extracelulari (colagenul ºi mineralul sãu osos) ºi de dinamica osteonicã, unitatea microfuncþionalã ºi microstructuralã a osului. Înþelegerea fenomenelor patologice de la acest nivel reprezintã cheia patogeniei scãderii rezistenþei osoase în osteoporoza ºi apariþia fracturilor de fragilitate osoasã la persoanele în vârstã. Lucrarea are la bazã cercetãrile efectuate în Clinica de Ortopedie ºi Traumatologie a Spitalului Clinic de Urgenþã Sf Pantelimon în ultimii 15 ani.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 BONE MINERALIZATION AND DYNAMICS IN THE PATHOGENESIS OF BONE FRAGILITY IN OSTEOPOROSIS Key words: osteon mineralization, bone fragility, osteoporosis The hardness and plasticity of bone tissue are, as biomechanical and biological particularities, in relationship with their function in organism, deeply connected with the crystalline nature of its principal extracellular components (collagen and minerals) and osteon dynamics, bone microfunctional and micro-structural unit. Knowing the pathology at this level represent the first step in understanding the reduction of bone resistance in osteoporosis and the appearance of bone fragility fractures in elderly. This study is based on the last 15 years research in Orthopaedic Clinic in St. Pantelimon Emergency Hospital Bibliografie 1. Mineralizarea biologicã ºi adaptativã biomecanicã a oaselor. Osteoporoza Autor: Prof. Dr. Gheorghe Panait, U.M.F Carol Davila Bucureºti, colaboratori Cristian Budicã, Aurelian Panait, Radu Necula Editura Publistar, Bucureºti, 2009.

 ARTRODEZA ÎN TRATAMENTUL ARTROZELOR DE GLEZNÃ T.S. Pop, O. Nagy, I. Gergely, O. Russu Clinica de Ortopedie ºi Traumatologie II, Târgu-Mureº

Cuvinte cheie: artrodezã, artrozã gleznã. Introducere: Artrodeza de gleznã este consideratã de mulþi autori ca fiind metoda chirurgicalã de elecþie în tratamentul artrozei de gleznã. Scopul acestui studiu retrospectiv este de a evalua rata de consolidare, evoluþia clinicã ºi frecvenþa complicaþiilor dupã artrodeza de gleznã efectuatã prin metoda Watson-Jones modificatã. Material ºi metodã: La 42 pacienþi (31 bãrbaþi, 11 femei) cu vârsta medie de 48 de ani (27-69) s-au efectuat 42 artrodeze de gleznã, fiind urmãriþi în medie 6,3 ani (5-12 ani). Modificarea tehnicii originale constã în conservarea marginii anterioare a pilonului tibial ºi alunecarea oblicã (anteroposterioarã) a grefonului. Evaluarea clinicã a fost efectuatã pe baza scorului AOFAS.

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Rezultate: Durerea a dispãrut sau diminuat în toate cazurile, iar consolidarea a apãrut la 39 de cazuri (93%), în medie dupã 14,5 sãptãmâni (13-18). Ca ºi complicaþii am înregistrat doar o infecþie superficialã (2%). Concluzii: Tehnica folositã este simplã, uºor de reprodus, oferã rezultate clinice excelente ºi o ratã înaltã de consolidare. Pãstrarea intactã a marginii anterioare a pilonului tibial ºi plasarea oblicã a grefonului posterior de aceasta asigurã o stabilitate suficientã, astfel încât materialul de osteosintezã nu mai este necesar. Pe termen lung, efectul artrodezei asupra celorlalte articulaþii ale membrului inferior rãmâne încã de clarificat. ARTHRODESIS AS A TREATMENT IN ANKLE ARTHROSES Key Words: arthrodesis, ankle arthrosis Introduction: Ankle arthrodesis is considered by many authors as being the method of choice in ankle arthrosis treatment. The purpose of this retrospective study is evaluation of bone fusion rate, clinical evolution and complications rate frequency after an modified Watson-Jones ankle arthrodesis. Material and method: in 42 patients (31 men, 11 women) with an average age of 48 years (27-69) were performed 42 ankle arthrodesis, with an average follow-up of 6.3 years (5-12 years). Modification of Watson-Jones technique consists in preserving of the anterior margin of tibial lower extremity and oblique sliding (antero-posterior) of the bone graft. Clinical evaluation was made according to AOFAS score. Results: Pain diminished or dissapeared in all cases and bone fusion appeared in 39 cases (93%), after an average of 14.5 weeks (13-18). As complications we noted only a superficial infection (2%). Conclusions: This technique is simple, easy reproductible, it offers excellent clinical results and a high bone fusion rate. Preserving of anterior margin of tibial lower extremity and oblique sliding of the bone graft posterior to this assures a good stability, so that is no need of further osteosynthesis material. In long term, the ankle arthrodesis effect on other articulations of the lower limb remains to be clarified.


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL

VALOAREA EVALUÃRII PRIN TOMOGRAFIE COMPUTERIZATÃ A FRACTURILOR DE PILON TIBIAL Gh.I. Popescu, O. Lupescu, Cristina Pãtru, M. Nagea, B. Duicã

ARTRODEZA GLEZNEI – REZULTATE PE TERMEN LUNG

Clinica de Ortopedie ºi Traumatologie Spitalul Clinic de Urgenþã „Floreasca“, Bucureºti

Cuvinte cheie: fractura articularã, evaluare tridimensionalã, planning pre-operator. Introducere: Fracturile de pilon tibial se caracterizeazã printr-o mare varietate lezionalã, dar mai ales prin impactul lor asupra funcþionalitãþii locale datoritã caracterului lor de fracturi articulare. Stabilirea unui tratament corect necesitã, mai ales în cazul fracturilor cominutive, evaluarea corectã a traiectelor de fracturã, pentru alegerea adecvatã a modalitãþii de stabilizare osoasã. Întrucât imaginea radiologicã oferã informaþii limitate, tomografia computerizatã cu reconstrucþie tridimensionalã este absolut necesarã pentru diagnosticul complet. Material ºi Metodã: Au fost analizaþi 25 pacienþi cu vârste între 19-60 ani trataþi între 01.01.200501.01.2009 pentru fracturi de pilon tibial. În cazul acestor pacienþi s-a realizat un planning iniþial pe baza radiografiei, dupã care s-a efectuat un al doilea planning dupã evaluarea CT, ºi cele douã planning-uri au fost comparate. Rezultate: Fracturile au fost clasificate dupã AO. Concordanþa dintre cele douã planning-uri a fost totalã la pacienþii cu fracturi tip 43A (4 pacienþi), neconcordante existând (cu frecvenþã crescânda) la tipurile 43B3, C1, C2 si C3. Datoritã acestor diferenþe, în 6 cazuri a fost schimbatã indicaþia terapeuticã (tipul de osteosintezã) iar în 16 cazuri la planning-ul iniþial au fost fãcute modificãri privind lungimea plãcii, numãrul, tipul ºi direcþia ºuruburilor. Concluzii: Diagnosticul corect al fracturilor de pilon tibial impune evaluarea tridimensionalã, informaþiile oferite de radiografie fiind incomplete. Stabilirea tehnicii operatorii corecte necesitã, de aceea, evaluarea completã prin tomografie computerizatã.

Al. Pop, D. Fruja Clinica de Ortopedie, Arad

Cuvinte cheie: artrodezã, disfuncþie picior Scop: Evaluarea rezultatelor pe termen lung dupã artrodeza de gleznã ºi efectul artrodezei asupra celorlalte articulaþii ale membrului inferior. Material ºi metodã: Au fost analizate rezultatele pe termen lung (în medie 9 ani, cu extreme între 7 ºi 12 ani) la un lot de 14 pacienþi cu artrodezã de gleznã, operaþi în serviciul nostru, în perioada 1993-2002. Toate intervenþiile au fost efectuate pentru artoze severe post-traumatice, survenite în urma unor fracturi bimaleolare, trimaleolare sau de pilon tibial. Controlul a inclus atât examinarea clinico-radilogicã a gleznelor artrodezate (cu aprecierea funcþiei gleznei dupã indexul WOMAC), cât ºi evaluarea clinico-radiologicã a genunchiului, gleznei ºi piciorului bilateral (cu evidenþierea semnelor de artrozã). Rezultate: Deºi artrodezele gleznei dau rezultate funcþionale satisfãcãtoare, sun însoþite în timp de repercusiuni la distanþã asupra celorlalte articulaþii ale membrului inferior; astfel, artrozele la nivelul articulaþiilor piciorului (astragalocalcaneene, mediotarsiene, tarso-metatarsiene, metatarso-falangiene), sunt mult mai frecvente la membrul artrodezat (32%), faþã de membrul pelvin contralateral (2%); nu s-au evidenþiat diferenþe în acest sens la nivelul genunchilor. De asemenea, pacienþii cu artrodezã a gleznei acuzã un discomfort de diferite grade, cu limitarea activitãþilor cotidiene, la nivelul piciorului ipsilateral (comparativ cu piciorul contralateral neoperat). Concluzii: – artrodeza gleznei (efectuatã pentru artroze post-traumatice severe), dã rezultate satisfãcãtoare pe termen lung (9 ani), dar cu repercusiuni la distanþã asupra articulaþiilor piciorului ipsilateral (artroze tarsiene de diferite grade, în cca. 32% din cazuri, cu discomfort funcþional de diferite grade la nivelul piciorului ipsilateral, comparativ cu piciorul neoperat);

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 – genunchiul ipsilateral nu pare sã fie afectat de artrodeza gleznei subiacente; – trebuie evaluate rezultatele pe termen lung ale artroplastiilor de gleznã, pentru a fi comparate cu cele ale artrodezelor. LONG-TERM RESULTS FOLLOWING ANKLE ARTHRODESIS Key words: ankle arthrodesis, foot disfunction The aim of this study was to perform an evaluation of of the long term results (9 years) of ankle arthrodesis and his effect on the development of osteoarthritis in the ipsilateral lower-extremity joints. Material and methods: We had evaluated 14 patients who had had an isolated ankle arthrodesis for the treatment of severe painful post-traumatic arthritis following bimaleolar, trimaleolar or tibial plafond fractures. These arthrodesis were performed in our department between 1993-2002, and patients were followed for a mean 9 years (range 7 to 12 years). The follow-up evaluation was included a clinical and radiographic examinations of the ankle, foot and knee bilaterally (with evaluation of the ankle function by WOMAC index). Results: Osteoarthritis of the ipsilateral foot (talo-calcanean, talo-navicular, midtarsal, tarsometatarsal and first metatarsofalangean joints) was consistently more frequent than the contralateral lower-extremity joints (32%, in comparison to 2%). Osteoarthritis did not develop more frequently in the ipsilateral knee, in comparison to contralateral knee. Significant differences between the two sides were found with regard pain and disability, which were more consistently to lower-limb with previous ankle arthrodesis. Conclusions: – ankle arthrodesis (performed for severe posttraumatic arthritis) may provide good long-terms results (9 years), but it is associated with premature deterioration of other joints of the foot (in 32% of cases), pain and disfunction (in comparison to contralateral foot joints) – ipsilateral knee did not be affected by ankle arthrodesis – ankle arthroplasty may be a better solution than the ankle arthrodeses, but the long-term results of this procedure is still unclear

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Bibliografie 1. Coester L.M., Saltzman C.L., Leupold J., Pontarelli W. – Long term results following ankle arthrodesis for posttraumati arhritis, JBJS (Am), Feb. 1, 2001, 83 (2): 219-22. 2. Hintermann B., Barg A., Knupp M., Valderabano V. – Conversion of painful ankle arthrodesis to total ankle arthroplasty, JBJS (Am), August 1, 2009; 91 (8): 2044-2044. 3. Morgan C.D., Henke J.A., Bailey R.W., Kaufer H.J. – Long term results of tibiotalar arthrodesis, JBJS (Am), 1985, Apr, 67 (4): 546-50.

 STABILITATEA RELATIVÃ: TEHNICI INTRAMEDULARE DE OSTEOSINTEZÃ M.R. Popescu, D.V. Poenaru., S. Drãguºanu Politrauma Casa Austria Timiºoara

Cuvinte cheie: stabilitate relativã, fracturi diafizare ºi metafizare, osteosintezã centromedularã Osteosinteza ce asigurã o stabilitate relativã a focarului de fracturã determinã vindecarea osoasã indirectã prin formare de calus. Scopul lucrãrii: Trecerea în revistã a tehnicilor centromedulare de osteosintezã. Tipurile de tije folosite pot fi: elastice, clasice nezãvorâte (Kuntscher), tije zãvorâte cu sau fãrã alezare. Alezarea constituie un subiect controversat în continuare cu indicaþie fermã în monotraumatisme ºi de evitat la politraumatizaþi. Principalele avantaje sunt reprezentate de stabilitatea crescutã a montajului ºi de aport de autogrefã osoasã. Pasajul trombilor în circulaþia pulmonarã ºi lezarea circulaþiei endostale constituie dezavantajele majore. Tehnicile generale se grupeazã în: preoperatorii, de reducere a fracturii, de inserþie a tijei, de control al reducerii ºi de zãvorâre. Indicaþiile de elecþie sunt fracturile din 1/3 medie a oaselor diafizare lungi. Noile generaþii de tije determinã extinderea indicaþiilor în zonele metafizare proximalã ºi distalã. Prezentarea se bazeazã ºi pe o cazuisticã de peste 200 de tije centromedulare anterograde pentru fracturi de tibie ºi femur cu ilustrarea indicaþiilor, a tehnicilor operatorii ºi a posibilelor complicaþii. Concluzii: osteosinteza cu tije centromedulare permite tratamentul fracturilor diafizare ºi metafizare ale oaselor lungi. Prezervarea inte-


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL gritãþii þesuturilor moi înconjurãtoare ºi a circulaþiei periostale, realizarea consolidãrii indirecte precum ºi preluarea parþialã de cãtre os a forþelor contribuie la vindecarea fracturii. Este o metodã minim invazivã ce poate fi aplicatã cu rezultate foarte bune ºi riscuri reduse la pacienþii politraumatizaþi. RELATIVE STABILITY: INTRAMEDULLARY TECHNIQUES Key words: relative stability, diaphyseal and metaphyseal fractures, intramedullary osteosynthesis. The bone fixation that assures a relative stability of the fracture site determines indirect bone healing by callus formation. The aim of this paper is to present the intramedullary techniques for the bone fixation. The types of nails used are the following: elastic, classical unlocked (Kuntscher) nails, locked nails with or without reaming. The reaming is still a controversial subject and it is strongly recomended in monotrauma, while in politrauma it is better to be avoided. The main advantages are the increased stability of the fixation and the contribution to the bone autograft. The main disadvantages are the passage of thrombi into the pulmonary circulation and the damage of internal cortical blood supply. The general techniques can be summarized in: preoperative, reduction of the fracture, insertion of the nail, control of the alignment and interlocking. The main indications for intramedullary techniques for bone fixation are the medium 1/3 of the long diaphyseal bones. The new generations of nails can also be used for the metaphyseal proximal and distal fractures. The presentation is also based on more than 200 cases with tibial and femural fractures treated by antegrade nails, with the illustration of the indications, of the surgical techniques and possible complications. Conclusions: the intramedullary nail fixation is indicated for the treatment of long bones diaphyseal and metaphyseal fractures. The decreased damage to surrounding soft tissues and periosteal circulation, the indirect consolidation and the partial assumption of the forces by the bone contribute to the bone healing. It is a minimum invasive method which can be applied with good results and minor risks in politrauma patients.

Bibliografie 1. Babikian M.G., White R.R., Tibia: shaft, in Ruedi T.P., Murphy W.M. – AO principles of fracture management, Thieme, Stuttgart – New York, 2000, 519 – 537. 2. Hontzsch D. – Femur: shaft (incl. Subtrohanteric), in Ruedi T.P., Murphy W.M., AO principles of fracture management, Thieme, Stuttgart – New York, 2000, 457 – 467. 3. Keel M., Labler L., Trentz O. – Damege control in severely injured patients, European Journal of Trauma, 2005, 31: 212 – 221. 4. Krettek C. – Intramedullary nailing, in Ruedi T.P., Murphy W.M., AO principles of fracture management, Thieme, Stuttgart – New York, 2000, 195 – 219. 5. Nowotarsky P.J., Norris B.L. – Femoral shaft fractures in Stannard P.J., Schmidt A.H., Kregor P.J., Surgical treatment of orthopaedic trauma, Thieme, Stuttgart – New York, 2007, 611 – 632. 6. Obremskey W.T., Shuler F.D. – Tibial shaft fractures in Stannard P.J., Schmidt A.H., Kregor P.J., Surgical treatment of orthopaedic trauma, Thieme, Stuttgart – New York, 2007, 742 – 765. 7. Whittle Paige A. – Fractures of lower extremity, in Campbell’s operative orthopaedics, ninth edition, Mosby, 1998, 2067 – 2094, 2119 – 2179.

 ROLUL ARTROSCOPIEI ÎN TRATAMENTUL ARTROZEI SECUNDARE FRACTURILOR DE GLEZNÃ – CAZURI R. Prejbeanu, H. Haragus, Simona Vermeºan, O. Ghiba, Iulia Avram Clinica I Ortopedie-Traumatologie, Spitalul Clinic Judeþean de Urgenþã Timiºoara

Cuvinte cheie: artrozã posttraumaticã, fracturi gleznã, tratament artroscopic. Fracturile maleolare sunt o patologie frecventã a centrelor de traumã. Ne-am propus o prezentare a câtorva cazuri reprezentative pentru exemplificarea rolului important al artroscopiei în managementul artrozei secundare posttraumatice dupã fracturile gleznei. Cazurile au fost selecþionate în colaborare cu Klinikum WelsGrieskirchen din pacienþii trataþi între iulie 2008 ºi iulie 2009. Deºi nu sunt frecvente, artrozele de gleznã dupã fracturi în aceastã regiune apar independent de vârstã la 1-10 ani dupã traumatismul iniþial. Tratamentul artroscopic este o metodã excelentã de explorare, debridare, sinovectomie ºi exostozectomie, cu îmbunãtãþirea funcþiei, cuparea durerii ºi stress operator mic local ºi pentru pacient.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 ROLE OF ARTHROSCOPY IN TREATING POSTTRAUMATIC ANKLE OSTEOARTHRITIS FOLLOWING ANKLE FRACTURES – CASE SERIES Key words: posttraumatic osteoarthritis, ankle fractures, arthroscopic treatment Ankle fractures and malleolar fractures in particular are a frecvent reason for presentation in trauma centers. We present a total of seven of what we consider to be representative cases with the purpose of emphasising the importance of arthroscopy in the management of posttraumatic ankle osteoarthritis after malleolar and pilon ankle fractures. The cases were selected following our collaboration with Klinikum Wels-Grieskirchen from patients operated between July 2008 and July 2009. The conclusion is that even though they are not frequent after correct treatment, ankle osteoarthritis develops independently of age at 110 years after the initial trauma. Arthroscopy of the talo-crural space is an excellent method for exploration, debridement, sinovectomy and exostosis resection with conseqvent improvement of function, decrease of pain and reduced perioperative stress both locally and for the patient in general. Bibliografie 1. Brown T.D., Johnston R.C., Saltzman C.L. – Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. 2006 NovDec; 20 (10): 739-44. 2. Chen SH, Wu P.H. – Long-term results of pilon fractures. Arch Orthop Trauma Surg. 2007 Jan; 127 (1): 55-60. 3. Ibrahim T., Beiri A., Azzabi M., Best A.J. – Reliability and validity of the subjective component of the american orthopaedic foot and ankle society clinical rating scales. J Foot Ankle Surg. 2007 Mar-Apr; 46 (2): 65-74. 4. Katz J.N., Gomoll A.H. – Advances in arthroscopic surgery: indications and outcomes. Curr Opin Rheumatol. 2007 Mar; 19 (2): 106-10. 5. Kouluovaris P., Stafylas K., Mitsionis G. – Long-term results of various therapy concepts in severe pilon fractures. Arch Orthop Trauma Surg. 2007 Mar 13. 6. Niek van Dijk C. – Anterior and posterior ankle impingement. Foot Ankle Clin. 2006 Sep;11 (3): 663-83. 7. SooHoo N.F., Vyas R. – Responsiveness of the foot function index, AOFAS clinical rating systems, and SF-36 after foot and ankle surgery. Foot Ankle Int. 2006 Nov; 27 (11): 930-4. 8. Tocci S.L., Madom I.A., Bradley M.P. – The diagnostic value of MRI in foot and ankle surgery. Foot Ankle Int. 2007 Feb; 28 (2): 166-8. 9. Unger F., Lajtai G., Ramadani F., Aitzetmuller G. – Arthroscopy of the upper ankle joint. A retrospective analysis of complications. Unfallchirurg. 2000 Oct; 103 (10): 858-63.

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10. Utsugi K., Sakai H., Hiraoka H., Yashiki M. – Intraarticular fibrous tissue formation following ankle fracture: the significance of arthroscopic debridement of fibrous tissue. Arthroscopy. 2007 Jan; 23 (1): 89-93 11. Zgonis T., Roukis T.S. – Alternatives to ankle implant arthroplasty for posttraumatic ankle arthrosis. Clin Podiatr Med Surg. 2006 Oct; 23 (4): 745-58.

 TRATAMENTUL FRACTURILOR PILONULUI TIBIAL – ABORDAREA TERAPEUTICÃ MODERNÃ – EXPERIENÞA CLINICII Fl. Purghel, A. Anastasiu, R. Ciuvicã, Jemna Constantin Spitalul Clinic de Urgenþã „Bagdasar-Arseni“, Bucureºti

Cuvinte cheie: fracturã, pilon tibial, fixator extern, fracturi articulare Patologia traumaticã a pilonului tibial (excluzând fracturile marginale posterioare ale tibiei distale, întâlnite în traumatologia specificã gleznei) este rarã, dar sechelele ºi dificultãþile tratamentului pun probleme deosebite. În Clinica Noastrã, în ultimul an (iulie 2008 – iulie 2009) am întâlnit 32 de fracturi de pilon tibial (31 pacienþi din 1777 de prezentãri în aceeaºi perioadã), din care 10 deschise, majoritatea prezentând cominuþii. Dupã clasificarea AO, încadrarea s-a fãcut în felul urmãtor: 16 fracturi 43-A, din care 9 au fost 43-A3 (cominutive), 9 fracturi 43-B (B1 ºi B2) ºi 7 fracturi 43-C (C1 ºi C2); 4 fracturi au avut ºi interesare diafizarã. Vârsta pacienþilor a fost între 15 ºi 81 ani, cu o medie de 42,4 ºi o medianã de 37,5 ani. S-a intervenit chirurgical în urgenþã, în cazul fracturilor deschise practicându-se debridare, toaletã chirurgicalã ºi aplicare de fixator extern, apoi în cazul tuturor fracturilor de pilon s-a realizat osteosinteza definitivã. S-au folosit în acest scop majoritatea tehnicilor chirurgicale descrise (de la osteosintezã mixtã - percutanatã cu broºe ºi ºuruburi ºi aplicare fixator extern ºi osteosintezã cu plãci mulate ºi ºuruburi pânã la plãci cu ºuruburi blocate introduse prin abord minim invaziv). Alegerea tehnicii de osteosintezã a fost influenþatã primar de starea pãrþilor moi ºi complexitatea fracturii, preferându-se adesea în fracturile deschise sau în cele cu suferinþe vasculare marcate sã se realizeze temporar o osteosintezã internã minimã, urmatã de aplicarea unui fixator extern. Evoluþia imediatã a fost favorabilã. În 10 din aceste cazuri, bazându-ne pe literatura de specialitate ºi de experienþa cazurilor anterioare, anticipãm evoluþii la distanþã mai dificile (pacienþi cu nivel scãzut de educaþie, alcoolici etc).


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL TIBIAL PILON FRACTURES TREATMENT – THE MODERN APPROACH – OUR EXPERIENCE Key words: tibial pilon, fracture, external fixator, articular fracture Tibial plafond traumatic pathology (excluding from our presentation the distal tibial posterior marginal fractures, related more to the ankle traumatic specific pathology) is rare, but the long term complications and treatment difficulties are serious challenges. in Our Clinic, the last year (July 2008 - July 2009) we recorded 32 tibial plafond fractures (31 patients from 1777 admissions in the same period), 10 of them were open fractures, often comminuted. According to AO classification, we had 16 43-A fractures, 9 of them comminutive (43A3), 9 43-B fractures (B1 and 2) and 7 43-C fractures (C1 and 2); 4 of these fractures had diaphyseal involvement. The patient age was between 15 and 81 years, with an average of 42.4 and a median of 37.5 years. Emergency surgery was performed; for the open fractures surgical debridement and external fixation was performed; definitive surgical fixation was later performed for all the fractures. An extensive array of surgical techniques was employed (from mixed osteosynthesis – percutaneous K-wires and screws and external fixator, classic plates and minimal invasive locked screw plates). The technique choice was influenced mainly by the soft tissue status and the fracture complexity; often in open fractures or with circulatory impairment a minimal temporary internal fixation, followed by external fixation was preferred. The immediate evolution was good. in 10 of these cases, based on literature and our past experience, we expect difficult evolutions (patients with lower education levels, alcoholics). Bibliografie 1. Lawrence Masrh J., Weigel D.P., Dirschl, D.R. – Tibial Plafond Fractures – How Do These Ankles Function Over Time? – JBJS 2003 85A-2:287-295 2. Williams T.M., Nepola J.V., DeCoster T.A., Hurwitz S.R., Dirschl D.R., Lawrence Marsh J. – Factors affecting Outcome in Tibial Plafond Fractures – Clinical Orthopaedics and Related Research 2004 423:93-98 3. Manca M., Marchetti S., Restuccia G., Faldini A., Faldini C., Giannini S. – Combined Percutaneous Internal and External Fixation of Type-C Tibial Plafond Fractures – A Review of Twenty-Two Cases – JBJS 2002 84A-S2:109-115 4. Pollak A.N., McCathy M.L., Bess R.S., Agel J, Swiontkowski M.F. – Outcomes After Treatment of High-Energy Tibial Plafond Fractures – JBJS 2003 85A-10:1893-1900

5. Wade A.M., Crist B.D., Khazzam M., Della Rocca G.J., Calhoun J.H. – Pilon fractures – Current Orthopedic Practice – 2008 19-3:242:248 6. Dunbar R.P., Barei D.P., Kubiak E.N., Nork S.E., Bradford Henley M. – Early Limited Internal Fixation of Diaphyseal Extensions in Select Pilon Fractures: Upgrading AO/OTA Type C Fractures to AO/OTA Type B - J Orthop Trauma 2008 226:426-429.

 SIMPOZIONUL AO PRINCIPII DE TRATAMENT ÎN FRACTURILE ARTICULARE D. Putineanu, D. Barbu Spitalul Clinic de Urgenþã „Floreasca”, Bucureºti

Cuvinte cheie: fracturã, articularã, cartilaj Prezentarea îºi propune sã treacã în revistã urmãtoarele aspecte: 1. mecanismul de vindecare al cartilajului articular ºi importanþa acestuia în decizia de tratament 2. principiile de tratament ale suprafeþei articulare: reducerea anatomicã, fixarea stabilã ºi reluarea rapidã a funcþiei membrului operat 3. importanþa refacerii corecte a axului mecanic 4. trecerea în revistã a principalelor tehnici ºi implante utilizate în tratamentul chirurgical al fracturilor intraarticulare Managementul fracturilor intraarticulare se referã la urmãtoarele aspecte: 1. componenþa intraarticularã 2. componenþa metafizarã 3. pãrþile moi 4. leziunile asociate 5. eventualele luxaþii asociate Factorii de decizie în tratamentul chirurgical sunt urmãtorii: a. tipul traumatismului b. mãrimea incongruenþei articulare c. vârsta d. profesia ºi activitãþile extraprofesionale e. articulaþia afectatã f. obiectivele de tratament g. expectaþiile pacientului Principiile de tratament pentru fracturile intraarticulare sunt: 1. înþelegerea leziunii – evaluarea pãrþilor moi, Rx, CT, RMN 2. planningul preoperator 3. timingul 4. abordul chirurgical

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 5. reducerea componentei articulare 6. stabilizarea metafizei 7. îngrijirea postoperatorie În concluzie, înþelegerea anatomiei cartilajului articular, a mecanismelor sale de vindecare, a fiziopatologiei sunt esenþiale pentru stabilirea corectã a obiectivelor ºi metodelor de tratament. Cunoaºterea amãnunþitã a tehnicilor operatorii ºi metodelor moderne de osteosinteza simplificã intervenþia operatorie ºi asigurã o ratã mai mare a consolidãrii osoase, o incidenþã mai micã a complicaþiilor ºi o recuperare mai rapidã a pacientului. AO SYMPOSIUM PRINCIPLES IN ARTICULAR FRACTURE CARE Key words: fracture, articular, cartilage The learning objectives of this presentation are the following: 1. To overview the healing mechanisms of articular cartilage and how they can be affected by treatment. 2. To stress the importance of anatomical reduction, rigid fixation and early active movement for treatment of the articular surface 3. To stress the importance of restoring the correct mechanical axis. 4. To overview the techniques and implants used for the treatment of intraarticular fractures The management of articular fractures must deal with the followings: 1. articular injury 2. metaphyseal injury 3. soft tissues 4. Dislocations 5. Articular structures The decision factors in operative management of intraarticular fractures are: a. Type of trauma b. Magnitude of incongruency c. Age d. Profession / leisure activities e. Affected joint f. Treatment goals g. Patient’s expectations The treatment principles for articular fractures to be discussed are: 1. Understand the injury – with soft tissue evaluation X-rays, MRI and CT examination 2. Preoperative planning

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3. Timing 4. Surgical approach 5. Articular reduction 6. Buttress of the metaphysis 7. Postoperative care In conclusion, the understanding of tha anatomy of articular cartilage, of its healing mechanisms and pathophysiology are essential for appropriate decision making concerning treatment objectives and methods. The perfect knowledge of surgical techniques and modern methods of osteosynthesis are making easier the surgical procedure. In the same time, we will have a higher rate of bone union, a lower rate of complications and a shorter time of recovery for the patient. Bibliografie 1. Joseph Schatzker, Marvin Tile – The rationel of operative fracture care, 2005, 413: 415. 2. John A. Elston, Walter W. Virkus, Arsen Pankovich – Handbook of fractures, 2006, 235: 242.. 3. Roberth Rutha Simon, Steven J. Koenigsknecht – Emergency Ortopedics, 2001, 294: 297 4. Rockwood and Green. Fractures in the Adults, 6th Edition 2006, 55: 2294: 2298. 5. Ruedi T. P., Murphy W. M. – AO principles of Fracture Management. 2000, 110: 115.

 IMPORTANÞA EXAMENULUI CT ÎN EVALUAREA PREOPERATORIE A FRACTURILOR EXTREMITÃÞII DISTALE A TIBIEI D.C. Putineanu, Simona Pãiuº, I. Caracudovici, R. Caraman, S. Stanciu Spitalul Clinic de Urgenþã „Floreasca”, Bucureºti

Cuvinte cheie: CT, pilon, fracturã, planing. Introducere: Fracturile metafizei distale a tibiei cu extindere în suprafaþa articularã, sau fracturile de pilon, se datoreazã de obicei traumatismelor de compresie verticalã, sau în cazuri mai rare, forþelor de torsiune ce duc la o fracturã spiroidã a tibiei distale cu extindere înspre suprafaþa articularã. Este important sã evaluãm atât severitatea afectãrii articulare cât ºi gradul de cominuþie metafizarã în vederea stabilirii strategiei terapeutice de urmat. Material ºi metodã: Am utilizat examenul computer tomograf atât în diagnosticul corect ºi complet al fracturilor articulare cât ºi în pregãtirea judicioasã preoperatorie a tratamentului chirur-


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL gical. Este util în special în fracturile cu traiecte complicate, în localizarea traiectelor de fracturã: anterior, posterior, medial, anteromedial, anterolateral ºi în special în identificarea fracturilor – tasare. Problema principalã în cazul acestor fracturi este dificultatea de a realiza o reducere anatomicã. Poziþia medialã sau lateralã a cominuþiei va determina abordul chirurgical. Rezultate: Au fost studiate un numãr de 9 cazuri de fracturi de pilon tibial operate în ultimele 24 de luni în Secþia Ortopedie 2 a Spitalului Clinic de Urgenþã Floreasca. S-a efectuat un planning preoperator pe baza radiografiilor standard, apoi acelaºi chirurg a repetat planningul preoperator dupã efectuarea examenului computertomograf cu reconstrucþie tridimensionalã. În 33% din cazuri au existat traiecte de fracturã ce nu au fost observate pe radiografiile standard ºi care au fost bine identificate pe examenul CT, iar 4 din 9 cazuri au prezentat fracturi tasare de plafon tibial identificate doar pe examenul CT ºi neidentificate pe radiografiile standard, care au necesitat reducere directã ºi grefã osoasã. Concluzii: Examenul computer tomograf este obligatoriu în toate fracturile extremitãþii distale tibiale care au ºi o componentã intraarticularã, pentru un inventar complet ºi corect al leziunilor osoase ºi efectuarea planingului preoperator. THE IMPORTANCE OF THE CT EXAM ÎN PREOPERATIVE EVALUATION OF FRACTURES OF THE DISTAL METAPHYSIS OF THE TIBIA Key words: CT, pilon, fracture, planning Introduction: Fractures of the distal tibial metaphysis with extension into the articular region or, pilon fractures, are commonly due to vertical compression trauma, or more rarely, to torsional forces which result in a spiral fracture of the distal tibia with ankle joint extension. It is important to evaluate both the severity of joint involvement and the degree of metaphyseal cominution in order to determine the appropriate strategy to be followed. Material and method: We used the computer tomography (CT) in the complete and corect diagnostic and in the preoperative meticulous planning of articular fractures. It is particularly helpful in anatomic regions with complex anatomy

and in fractures with complicated patterns, in the localization of fracture lines: anterior, posterior, medial, anterolateral, posterolateral and especially in compression fractures. The main problem of this type of fractures is the difficulty to achive an anatomical reduction. The medial or lateral position of the cominution is determining the surgical abord. Results: We studied 9 tibial pilon fractures operated in the last 24 months in the Second Department of “Floreasca” Emergency Hospital. A preoperative planning was made using plane Xrays and then the same surgeon repeted the planning using a computer tomography (CT) with 3-D reconstruction. In 33% of there were fracture lines not noticed on the regular X-rays witch were identified using the CT exam, while 4 out of 9 cases has compression fractures of the tibial plafond identified just on the CT scan and requiring bone graft. Conclusions: Computer tomography (CT) is obligatory in all the fractures of the distal extremity of the tibia that have an intra-articular pattern and for a complete and exact evaluation of all bone lesions and preoperative planning. Bibliografie 1. Arthur Mark Davis, Richard W. Whitehouse, Jeremy P. R. Jenkins, Thomas Berg: Imaging of foot and ankle:techniques and applications. 2003; 232-25 2. Chapman Mihael W: Chapman’s Orthopedic Surgery. 2002; 2954-2987 3. Rockwood and Green: Fractures in adults 6th ed. 2006; 2148-2168 4. Stephan J. McPhee, Lawreance M.Tiemey, Maxime A. Papadakis; Curent medical diagnosis and tratament.2007; 845 5. Verne Thompson: The joint of the ankle. 1996; 121-123

 ASPECTE TERAPEUTICE ALE FRACTURILOR DESCHISE DE GLEZNÃ, PREZENTARE DE CAZ D. Putineanu, Simona Pãiuº, I. Caracudovici, S. Stanciu, D. Barbu Sectia Ortopedie, Spitalul Clinic de Urgenþã „Floreasca”, Bucureºti

Cuvinte cheie: pilon, deschis, placã, leziune, diastazis, vascularã

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Introducere: Fracturile deschise de gleznã ºi fracturile luxaþie au o incidenþã scãzutã comparativ cu fracturile închise de la nivelul gleznei fiind rezultatul unor traumatisme de înaltã intensitate în special accidente rutiere ºi cãderi de la înãlþime. Metodã: Pacient în vârstã de 41 de ani victima unui accident rutier este diagnosticat cu fracturã bimaleolarã stângã deschisã tip IIIC cu luxaþia externã a talusului. S-a intervenit de urgenþã constatându-se: leziune arterã tibialã posterioarã, sindrom de compartiment, fracturã tasare pilon tibial. Irigarea abundentã ºi debridarea þesuturilor necrotice este o mãsurã extrem de importantã având în vedere riscul crescut ºi prognosticul slab al infecþiilor asociate cu fractura deschisã. S-a redus luxaþia, s-a efectuat fasciotomia medialã de decompresiune ºi stabilizarea fracturii cu fixator extern ºi broºe Kirschner. La remiterea edemului ºi inflamaþiei locale s-a acoperit tranºa de fasciotomie cu plastie de piele liberã despicatã urmatã de osteosinteza maleolei peroniere cu plãcuþã semitubularã ºi ºurub de diastazis, osteosinteza maleolei tibiale cu 2 ºuruburi 6.5 mm, dezimpactarea fragmentului de la nivelul pilonului tibial ºi plombaj cu autogrefã recoltatã din platoul tibial lãsându-se pe loc fixatorul extern.La 6 sãptãmâni se extrage ºurubul de diastazis ºi fixatorul extern ºi imobilizare în ortezã de gleznã fãrã sprijin pe picior pânã la 3 luni. Rezultate: Evoluþia lent favorabilã, pacientul a început recuperarea la 6 sãptãmâni de la data operaþiei cu o limitare algicã a miºcãrii de flexie plantarã ºi dorsalã a piciorului dar care evolueazã favorabil. Sprijinul progresiv este început la 3 luni de la data operaþiei. Concluzii: Fracturile asociate cu leziuni de pãrþi moi trebuie considerate urgente medico chirurgicale necesitând un protocol elaborat, cunoaºterea riscurilor ºi beneficiilor diferitelor metode de tratament. Riscul crescut de infecþie al unei fracturi deschise asociatã cu leziune vascularã ºi poluare intensã impune temporizarea osteosintezei definitive ºi un management corespunzãtor.

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THERAPEUTICAL MANAGEMENT OF OPEN ANKLE FRACTURES, CASE PRESENTATION Key words: plafond, open, plate, injury, screw, vascular. Introduction: Open ankle fractures result more often from higher energy trauma than closed fractures and motor vehicle accidents and falls from a hight are the most frequent situationes . Nervous and vascular minutious exploration is required because of the frequent association with open fractures. Method: 41 years old male patient with open IIIC bimaleolar fracture and external dislocation of the talus is the victim of motor vehicle accident. Emergent surgery set out: posterior tibial artery lession, compartment syndrome, open medial luxation of the distal tibia. Irigation and debridement of necrotic tissues is an important step because of a high risk and poor prognosis of open fractures associated with infection.The tibio talar dislocation was reduced ,fasciotomy on the medial side of the calf and fractures stabilization with external fixator and Kirschner wires were perfomed. When the swelling and inflamation of the sorounding tissues subsided the surgery was performed:the fasciotomy was covered with free flaps, osteosinthesys of the lateral maleolus with semitubular 3.5 mm plate, diastazis screw, dezimpaction of tibial plafond fragment and filling the void with autograft from the proximal tibia, osteosinthesys of the medial maleolus with 2 partial threaded 6.5 mm screws. 6 weks after the ostheosinthesys the diastazis screw and external fixator were removed and imobilization of the ankle in orthosis without weight bearing until 3 months. Results: The evolution of the patient was increasingly favorable, at 6 weeks was started phisiotheraphy with an algic limitation of dorsiflexion and plantar flexion. Partial weight bearing was started at 3 moths. Conclusions: Fracture associated with soft tissues injury must be considered emergency and requires a special protocol ,appropiate knowledge of risks an benefits of different type of treatement. The association of open fractures and vascular injury with a high risk of infection requires the


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL timing of the final ostheosinthesys and an apropiate management of soft tissue injuries in addition with a coresponding antibiotheraphy. Bibliografie

 OSTEOSINTEZA MINIM INVAZIVÃ CU PLÃCI (MIPO) ÎN FRACTURILE OASELOR LUNGI P.D. Sîrbu, R. Asaftei, T. Petreuº, G. Berea, P. Botez

1. The effect of the syndesmotic screw on the extension capacity of the ankle joint. Arch Orthop Trauma Surg 19. 2. Xenos J.S., Hopkinson W.J., Mulligan M.E., et al. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am 1995; 77. 3. Reckling F.W., McNamara G.R., DeSmet A.A. Problems in the diagnosis and treatment of ankle injuries. J Trauma 1981; 21 (11): 943. 4. Egol K.A., Dolan R., Koval K.J. Functional outcome of surgery for fractures of the ankle. A prospective, randomised comparison of management in a cast or a functional brace. J Bone Joint Surg Br 2000; 82 (2). 5. Shaffer M.A., Okereke E., Esterhai J.L. Jr, et al. Effects of immobilization on plantar-flexion torque, fatigue resistance, and functional ability following an ankle fracture. Phys Ther 2000; 80 (8).

 POSIBILITÃÞI DE OSTEOSINTEZÃ ÎN FRACTURILE BIMALEOLARE ªi DE PILON TIBIAL COMINUTIVE CU TULBURÃRI CIRCULATORII E.S. Salca, Adina Pojar, O. Gabor, V. Cotuþi Clinica de Ortopedie ºi Traumatologie Cluj-Napoca

Cuvinte cheie: fracturi cominutive, osteosintezã Frecvenþa crescutã a fracturilor bimaleolare ºi de pilon tibial cu complicaþii tegumentare ne-a obligat la o serie de artificii non ortodoxe de tratament OSTEOSYNTHESIS OPTIONS IN THE TREATEMENT OF COMMINUTIVE ANKLE FRACTURES WITH CIRCULATORY TROUBLES Key words: comminutive ankle fractures, circulatory troubles. The high rate of comminutive ankle fractures with circulatory troubles determined us to use „non orthodox“ solutions of treatement Bibliografie 1. Dan Lucaciu – Curs de Traumatologie, Litografia U.M.F. Cluj-Napoca, 2004. 2. Gheorghe Tomoaia – Curs de Traumatologie, Litografia U.M.F. Cluj-Napoca, 2006.

Ortopedie Traumatologie/U.M.F. „Gr. T. Popa”, Iaºi

Cuvinte cheie: MIPO, TARPO, plãci cu stabilitate angularã, periarticular fractures. Introducere: Ideea osteosintezei centromedulare blocate ºi rãspunsul biologic prompt a determinat utilizarea plãcilor într-o manierã similarã ºi introducerea conceptului de osteosinteza minim invazivã cu plãci. MIPO include 4 etape sau tehnici: A. MIPO cu incizii proximale ºi distale; B. Osteosinteza minim invazivã percutanatã cu plãci (MIPPO); C. Abordul transarticular ºi osteosinteza retrogradã cu plãci (TARPO), pentru fracturile intraarticulare ale femurului distal; D. Tehnici cu implante specifice pentru MIPO (plãcile blocate). Material ºi metodã: Prezentãm lot substanþial de pacienþi operaþi prin tehnica MIPO cu plãci clasice: 38 fracturi subtrohanteriene (MIPO), 52 de fracturi femur distal (25 cu MIPO, 27 cu TARPO), 12 fracturi complexe ale tibiei proximale (MIPO prin abord medial), 9 fracturi ale tibiei distale (MIPO prin abord medial) ºi 22 fracturi complexe ale humerusului (MIPO prin abord anterior). Plãcile cu stabilitate angularã au fost utilizate în 16 cazuri cu fracturi ale femurului distal (LISS-DF – 10 cazuri, LCP-DF – 5 cazuri, placã cu stabilitate angularã poliaxialã – 1 caz), 8 fracturi ale tibiei proximale (LISS-PLT sau LCP-PLT), 1 fracturã a humerusului proximal (placã tip Phylos). Rezultate: Majoritatea fracturilor s-au consolidat fãrã necesitatea grefãrii (excepþie – o pseudartrozã strânsã a tibiei proximale dupã MIPO cu placã clasicã ºi o fracturã a femurului distal, deschisã tip IIIA cu defect de substanþã osoasã. Nu s-au înregistrat infecþii sau deteriorãri semnificative ale montajelor. Deficitele de ax sau diferenþele de lungime au fost acceptabile. Discuþii: Rezultatele bune obþinute sunt materializate prin consolidãri rapide ºi o rezistenþã mecanicã crescutã a plãcii; fixarea cu plãci lungi distal ºi proximal faþã de focar asigurã obþinerea unei stabilitãþi relative. Dezavantajele utilizãrii plãcilor clasice au determinat introducerea plãcilor cu stabilitate angularã, datoritã atât avantajelor

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 biologice cât ºi avantajelor biomecanice ale fixatoarelor interne. Concluzii: Tehnicile MIPO au avantajele unei consolidãri mai rapide, fãrã necesitatea grefãrii osoase ºi cu o incidenþã scãzutã a complicaþiilor. Tehnicile sunt însã pretenþioase, o atenþie deosebitã trebuie acordatã restabilirii axului, rotaþiei ºi lungimii. Plãcile cu stabilitate angularã reprezintã în acest moment implantele ideale în fracturile complexe periarticulare. MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS (MIPO) ÎN LONG BONE FRACTURES Key Words: MIPO, TARPO, plates with angular stability, periarticular fractures Introduction: The idea of the locked centromedullary osteosynthesis and the fast biological response determined the plates usage in a similar manner and the issuing of the minimally invasive plate osteosynthesis. MIPO includes 4 steps or techniques: A. MIPO with proximal and distal incisions; B. Minimally Invasive Percutaneous Plate Osteosynthesis; C. Transarticular Approach and Retrograde Plate Osteosynthesis, for the intraarticular femoral fractures of the distal femur; D. Techniques with specific implants for MIPO (locked plates). Material and methods: We show a large study group represented by patients operated by MIPO with classic plates: 38 subtrochanteric fractures, 52 distal femoral fractures, 12 complex proximal tibial fractures (MIPO by medial approach), 9 distal tibial fractures (MIPO by medial approach) and 22 complex humeral fractures (MIPO by anterior approach). Plates with angular stability were used in 16 cases with distal femoral fractures (LISS-DF – 10 cases, LCP-DF – 5 cases, plate with polyaxial angular stability – 1 caz), 8 proximal tibial fractures (LISS-PLT or LCP-PLT), 1 proximal humeral fracture (Phylos type plate). Results: Most of the fractures consolidated without the need for primary or secondary grafting (exception – one tight pseudarthrosis of the proximal tibia following MIPO with classical plate and a distal femoral fracture, opened type IIIA with bone defect. There were no infections or significant construct loosening. Axis deficit or length differences were acceptable.

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Discussions: Good results obtained by MIPO are due to a fast union by vascularization preservation and also to an increased mechanical plate resistance; fixation by long plates only distally and proximally from the fracture insures an elastic construct and maintains the required instability degree for a good consolidation (relative stability). The disadvantages of the classical plates determined the usage of the angular stability plates, due to the biological advantages and the biomechanical advantages of the internal fixators. Conclusions: MIPO techniques have the advantage of a faster union without bone graft requirements and a reduced complications incidence. Techniques are demanding with a special attention that should be addressed to axis, rotation and length reestablishment. Plates with angular stability represent at this time the ideal implants in complex periarticular fractures, especially in osteoporosis. Bibliografie 1. P.D. Sirbu, N. Schwarz, W.D. Belangero, B. Livani, Margrit List, P. Botez, R. Mihaila (2008) – Minimally invasive plate osteosynthesis in long bone fractures, Casa de Editura „VENUS” Iasi, Romania. 2. P.D. Sirbu, W. Friedl, P. Botez, L. Stratan, S. Hopulele, R. Asaftei, (2008) – Osteosinteza minim invaziva cu placi fixatoare interne, Casa de Editura „VENUS” Iasi, Romania 3. Krettek C., Miclau T., Stephan C., Tscherne H. (1999) – Transarticular approach and retrograde plate osteosynthesis (TARPO) for complex distal intraarticular femur fractures, Techniques Orthopaed, 14, 219-229. 4. Krettek C., Schandelmaier P., Miclau T., Tscherne H. (1997) – Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures, Injury, 28, Suppl. 1, 20-30. 5. Kregor P.J, Stannard J.A, Zlowodzki M., et al (2004) – Treatment of distal femur fractures usind the less invasive stabilization system: surgical experience and early clinical results in 103 fractures; J. Orhop. Trauma, 18 (8): 5 09-520.

 FIXAREA EXTERNÃ ÎN FRACTURILE DESCHISE ALE TIBIEI DISTALE P.D. Sîrbu, R. Bruja, Georgiana Eftimie, B. Bãrbieru, G. Berea Ortopedie-Traumatologie, Spitalul Clinic de Urgenþe Iaºi, U.M.F. „Grigore T. Popa“ Iaºi

Cuvinte cheie: fixare externã, fracturã deschisã, tibie distalã


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL Introducere: Tratamentul fracturilor deschise ale tibiei distale reprezintã o provocare pentru chirurgul ortoped. Numeroase complicaþii întunecã prognosticul acestor leziuni: infecþii, pseudartroze, artroze, redori ale gleznei. Material ºi metodã: Studiul include 17 fracturi ale tibiei distale. Conform clasificãrii AO au fost incluse 6 fracturi tip A ºi 11 fracturi tip C. Conform clasificãrii Gustilo, au fost 4 fracturi deschise tip I, 5 tip II, 5 tip III A ºi 3 tip III B. Toate fracturile au fost tratate cu fixare externã dupã toaletare chirurgicalã. Fracturile tip III B au necesitat proceduri de chirurgie plasticã. Rezultate: Toate fracturile au consolidat într-un interval mediu de timp de 12 sãptãmâni. S-au înregistrat urmãtoarele complicaþii: întârzieri în consolidare (3 cazuri), calusuri vicioase metafizodiafizare (3 cazuri), calusuri vicioase articulare ( 3 cazuri), redori accentuate de gleznã (2 cazuri), infecþii superficiale ( 2 cazuri). Concluzii: Autorii susþin cã rezultatele bune în aceste fracturi dificile depind de argumente cruciale: intervenþie chirurgicalã în urgenþã, tratament intensiv cu antibiotice, în funcþie de tipul fracturii ºi de contaminare, condiþii tehnice ºi cooperare eficientã între echipele chirurgicale.

Conclusions: The authors concluded that good results depend on some essential arguments: proper surgical timing, intensive treatment with antibiotics, according to the type of fractures and contamination, technical conditions with accurate surgical team cooperation.

EXTERNAL FIXATION IN OPEN FRACTURES OF THE DISTAL TIBIA

Cuvinte cheie: fracturi, pilon tibial, instabilitate, cominuþie, reconstrucþie, mobilizare. Scop: Fracturile pilonului tibial sunt leziuni grave ce afecteazã articulaþia tibio-tarsianã ºi care sunt dificil de tratat oricare ar fi metoda aleasã. Aceste fracturi se produc pe un os cu vascularizaþie precarã ºi au consecinþe funcþionale grave asupra articulaþiei gleznei. Dacã fractura este cu deplasare, reducerea anatomicã ºi fixarea internã stabilã urmatã de mobilizare precoce se impun ca principiu de bazã. Majoritatea problemelor care se ridicã în rezolvarea acestor fracturi pot fi schematizate astfel: 1. Natura traumatismului cauzator 2. Tipul de fracturã 3. Starea þesuturilor moi de acoperire 4. Dificultatea tehnicilor de fixare. Material ºi metodã: Fracturile tibiei distale se produc adesea la persoane în vârstã cu osteoporozã, ceea ce face ca fixarea internã stabilã sã se obþinã cu dificultate. În stabilirea diagnosticului pe lângã un examen radiografic avem nevoie ºi de un examen TC sau

Key words: External fixation, open fracture, distal tibia, wound debridment, delayed healing Introduction: Treatment for the open fractures of the distal tibia represents a challange for the orthopaedic surgeons. Complications range from osteomyelitis, non-unions, arthrosis, and lost of ankle motion. Material and methods: The present study includes 17 fractures of the distal tibia; according to AO classification, there were 6 fractures type A and 11 type C. The degree of open fractures was classified according to Gustilo: 4 fractures type I, 5 type II, 5 type III A, 3 type III B. All fractures were treated by external fixation after surgical wound debridment. Three fractures type III B were treated by plastic surgery with local flaps. Results: All fractures healed within a mean time of 12 weeks; the complications consisted in delayed healing (3 cases), axial malunion (3 cases), articular malunion (3 cases), loss of ankle motion (2 cases) and superficial infection (2 cases).

Bibliografie 1. Borelli J, Catalano L. Open reduction and internal fixation of pilon fractures, Journal of Orthopaedic trauma, 1999, 13 (8): 573–582. 2. Bonar SK, Marsh JL. Unilateral external fixation for severe pilon fractures. Foot Ankle, 1993, Feb; 14 (2): 57–64. 3. Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical optioins for the treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma. 2001 Mar-Apr., 15 (3): 153–60. 4. Bahari S, Lenehan B, Khan H, McElwain JP. Minimally invasive percutaneous plate fixation of distal tibia fractures, Acta orthop Belg. 2007 Oct; 73 (5): 635–40.

 CRITERII DE DIAGNOSTIC ªI TRATAMENT ÎN FRACTURILE PILONULUI TIBIAL Gh. Tomoaia, H. Benea, M. Macovei, R. Bora, C. Bardaº Clinica de Ortopedie Traumatologie, Cluj-Napoca

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 un TC cu 3D mai ales pentru stabilirea gradului cominuþiei suprafeþei articulare. Imobilizarea gipsatã se practicã în fracturile cu minimã deplasare, iar în cele cu deplasare semnificativã se practicã reducerea deschisã ºi fixare internã. În fracturile cu tegumente de calitate îndoielnicã se practicã la început tracþiune continuã sau imobilizare cu fixator extern pânã la vindecarea þesuturilor moi, dupã care fixare internã a tibiei ºi fibulei. Rezultate: Tratamentul chirurgical are ca obiective restabilirea suprafeþei articulare tibiale ºi aliniamentului maleolei fibulare. Tratamentul chirurgical constã în: 1. Restaurarea lungimii normale a fibulei 2. Reconstrucþia suprafeþei articulare a tibiei 3. Stabilizarea medialã sau lateralã a tibiei cu placã de susþinere ºi ºuruburi. 4. Grefarea golurilor metafizare tibiale cu autogrefe spongioase. Este importantã efectuarea osteosintezei ferme care permite mobilizarea activã a gleznei fãrã încãrcare pentru a preveni redorile articulare ºi osteoporoza algicã. Concluzii: Fixarea internã rigidã ºi adãugarea grefelor spongioase eliminã necesitatea imobilizãrii gipsate ºi permite o miºcare activã precoce. Sprijinul complet pe picior dupã fixarea internã este permis numai dupã consolidarea clinicã ºi radiologicã a fracturilor, la un interval de 8-10 sãptãmâni de la operaþie. În caz de consolidãri vicioase cu artrozã marcatã se impune artroplastia sau artrodeza gleznei. DIAGNOSIS AND TREATMENT CRITERIA FOR TIBIAL PILON FRACTURES Key words: fractures, tibial pilon, instability, comminution, reconstruction, mobilization Objective: Tibial pilon fractures are serious injuries of the ankle joint that are difficult to treat by any method. These fractures occur on a bone with poor irrigation and have severe consequences on joint function. If the fracture is displaced, as a basic principle anatomical reduction and stabile internal fixation are required.

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Most of the problems that arise during the treatment of these fractures are: 1. Nature of the trauma 2. Fracture type 3. Condition of the soft tissues 4. Difficulty of fixation techniques Material and methods: Distal tibia fractures often occur in older persons with osteoporosis that makes difficult to obtain a stable internal fixation. In order to asses the diagnosis we need a simple CT scan or with 3D reconstruction, especially to evaluate the articular surface comminution. Plaster casting is performed only for minimally displaced fractures, open reduction and internal fixation for fractures with significant displacement. In case of poor tegument condition continuous traction or external fixation is applied first until good soft tissue healing, followed by internal fixation of tibia and fibula. Results: The objectives of surgical treatment are to reestablish the tibial articular surface and the alignment of fibular malleolus. Surgical treatment consists of: 1. Restoration of normal fibular length with fixation of the malleolus 2. Reconstruction of tibial articular surface 3. Medial or lateral stabilization of the tibia with buttress plates and screws 4. Grafting of tibial metaphyseal bone deffects with autologus iliac cancellous grafts. It is important to perform a stable osteosynthesis that allows rapid active mobilization without loading of the ankle in order to avoid joint stiffness and algic osteoporosis. Filling of tibial bone empty spaces is done with iliac grafts. Conclusions: Rigid internal fixation and the addition of cancellous grafts eliminate the necessity of plaster immobilization and allow early active movement. After internal fixation, complete weight bearing on the affected leg is allowed only after clinical and radiological fracture consolidation, after 8 to 10 weeks from the intervention. Bibliografie 1. Alexa O. – Tehnici chirurgicale uzuale în traumatismele osteo-articulare, Ed. „Gr. T. Popa“, UMF Iaºi, 2007. 2. Baier I.– Diagnosticul ultrasonografic în patologia aparatului locomotor, Editura Universitãþii „Lucian Blaga”, Sibiu, 1997.


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL 3. Barbu D., Lupescu O., Oprescu S., Nagea M., Popina S.T., Niculescu D. – Tratamentul în urgenþã al fracturilor diafizare de gambã la politraumatizaþi, Rev. de Ortopedie ºi Traumatologie (Bucureºti), 2001, vol. 11, nr. 1-2, p. 91-96. 4. Canale S.T., sub red. – Campbell’s Operative Orthopaedics, tenth edition, vol. 3, Ed. Mosby, Philadelphia, 2003. 5. Filipescu N. – Dispozitivul de fixare externã minim invazivã. Un nou concept în fixarea, axarea ºi stabilizarea fracturilor deschise ale oaselor gambei, Ed. “Gr. T. Popa”, UMF Iaºi, 2008. 6. Gorun N. – Aspecte etiopatogenice ºi terapeutice în artroza post-traumaticã tibioastragalianã, Rev. de Ortopedie ºi Traumatologie (Bucureºti), 1992, vol. 2, nr. 1, p. 55-71. 7. Gorun N. – Fracturi maleolare, Ed. Curtea Veche, Bucureºti, 2000. 8. Gorun N. – Valoarea artrodezei tibioastragaliene în artroza post-traumaticã de gleznã, Al IV-lea Congres Naþional de Ortopedie ºi Traumatologie, Bucureºti, 9-11 octombrie 1986, p. 172-173 9. Lau T.W., Leung F., Chan C.F., Chow S.P. – Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures, Intern. Orthop, 2008, vol. 32, nr. 5, p. 697-703. 10. Megas P., Zouboulis P., Papadopoulos A.X., Karageorgos A., Lambiris E. – Distal tibial fractures and nonunions treated with shortened intramedullary nail, Intern. Orthop., 2003, vol. 27, nr. 6, p. 348-351 11. Müller M.E., Allgöver M., Schneider R., Willenegger H. – Manual of internal fixation. Tehniques recommended by the AO-GROUP, second edition, Ed. Springler-Verlag, Berlin, Heidelberg, New York, 1979 12. Obadã B. – Etapele terapeutice în fracturile deschise de gambã (referat general din cadrul tezei de doctorat), Rev. de Ortopedie ºi Traumatologie (Bucureºti), 2007, vol. 17, nr. 1, p. 3-11. 13. Poenaru V.D. – Curs de traumatologie, Ed. Orizonturi Universitare, Timisoara, 1999. 14. Popescu M. – Stabilizarea focarului in fractura deschisa de tibie, Ed. Sofitech, Bucuresti, 1997. 15. Rockwood C.H. A., Green P. D. – Fractures in Adults, sixth edition, vol.II, Ed. Lippincott, Williams&Wilkins, Philadelphia, 2006. 16. Schatzker J., Tile M. sub red. – The rationale of operative fracture care, second edition, Ed. Springer, Berlin, Heidelberg, New York, Barcelona, London, Paris, 1996. 17. Sîrbu D.P. – Osteosinteza minim invazivã cu plãci în fracturile femurului distal, Ed. Venus, Iaºi, 2007. 18. Tomoaia Gh. – Clasificarea comprehensiva a fracturilor oaselor lungi, Ed. Risoprint, Cluj-Napoca, 2006. 19. Tomoaia Gh. – Tratamentul fracturilor instabile ale gleznei prin fixare internã rigidã, urmatã de mobilizare articularã precoce, Rev. de Ortopedie si Traumatologie (Bucuresti), 1995, vol. 5, nr. 3, p. 125-131. 20. Voinea A., Gorun N. – Practica osteosintezei metalice; Ed. Didacticã ºi Pedagogicã, Bucureºti, 1976.

 RECUPERAREA FUNCÞIONALÃ ÎN FRACTURILE BIMALEOLARE OPERATE Alina Daniela Totorean, D.V. Poenaru, Roxana Onofrei Clinica II Ortopedie Timiºoara – Compartimente Recuperare Posttraumaticã

Cuvinte cheie: fracturi bimaleolare, recuperare funcþionalã, scorul Olerud-Molander. Scopul lucrãrii: Importanþa tratamentului de recuperare funcþionalã a gleznei la pacienþii cu fracturi bimaleolare operate. Fracturile maleolare sunt relativ frecvente în traumatologie, putând compromite atât indoloritatea, mobilitatea cât ºi stabilitatea gleznei, având potenþial artrogenic pe termen lung atât la nivel local, precum ºi la nivelul articulaþiilor învecinate. Material ºi metode: Lotul luat în studiu a fost compus din 64 de pacienþi cu fracturi bimaleolare operate, cãruia i s-a aplicat un protocolul de recuperare standardizat, dar adaptat fiecãrui caz, pe o perioadã de 24 de sãptãmâni. Evaluarea a fost fãcutã cu scorul Olerud-Molander pentru gleznã (valoare maximã 100, scor excelent = 91-100, bun = 61-90 mediu = 31-60, slab < 30) la 6 sãptãmâni postoperator, respectiv 12 ºi 24 de sãptãmâni. Rezultate: Conform evaluãrii cu scorul OlerudMolander, am obþinut rezultate bune ºi excelente în 78% din cazuri, în 18% din cazuri un scor mediu, iar rezultate slabe la 4% din pacienþi..Am observat cã evoluþia scorurilor funcþionale a fost infuenþatã de calitatea osului, vârsta pacientului, comorbiditãþi asociate ºi stabilitatea montajului. Concluzii: Tratamentul de recuperare vine sã completeze tratamentul chirurgical în fracturile bimaleolare ºi se constituie ca o necesitate în obþinerea unei glezne indolore, cu o mobilitate ºi o stabilitate cât mai bunã. FUNCTIONAL REHABILITATION OF SURGICALLY TREATED BIMALLEOLAR ANKLE FRACTURES Key words: Bimalleolar Fractures, Functional Rehabilitation, Olerud-Molander ankle score. Aims: To evaluate the functional rehabilitation protocol in patients with surgically treated bimalleolar ankle fractures. The incidence of

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 bimalleolar ankle fractures is relatively high, affecting the ankle’s mobility and stability. Posttraumatic arthritis is a common complication of these fractures, not only in ankle, but also in other joints. Methods: 64 patients with bimalleolar ankle fractures had undergone an individualized rehabilitation protocol for 24 weeks. The OlerudMolander ankle score was used for the evaluation of these patients at 6, 12 and 24 weeks post surgery (maxim = 100, very good = 91-100, good = 61-90, medium = 31-60, poor < 30). Results: Good and very good results in OlerudMolander scores were obtained in 78% patients. 18% had medium results and 4% poor results. A relation between the rehabilitation outcomes and the bone’s quality, patients’ age, associated diseases and the stability of fixation material was seen. Conclusion: The rehabilitation treatment is needed after the surgery in bimalleolar ankle fracture in order to achieve a in dolor ankle with a good mobility and stability. Bibliografie 1. Nilsson Gertrude, Nyberg Perr, Ekdahl Charlotte, Eneroth M: performance after surgical treatment of patients with ankle fractures-14-month follow-up. Physiotherapy Research International, 2006; 8 (2): 69-82. 2. Olerud C., Molander H. – A scoring scale for symptom evaluation after ankle fracture. Archives of Orthopaedic and Trauma surgery, 1984; 103 (3). 3. Chanusot J.C. Danowski R.G. – Rééducation en traumatologie du sport-tome 2: membre inferieur et rachis. 4e édition Masson, Paris, 2005.

 ROLUL ARTROSCOPIEI ÎN EVALUAREA ªI TRATAMENTUL LEZIUNILOR ACUTE ªI CRONICE ALE GLEZNEI B. Voicu, R. Opriº, R. Melinte, T. Bataga Clinica de Ortopedie Traumatologie I, Târgu-Mureº

Cuvinte cheie: artroscopie, gleznã, entorsã, instabilitate. Lucrarea de faþã vrea sã demonstreze valoarea artroscopiei în diagnosticul ºi tratamentul entorselor de gleznã ºi a instabilitãþilor cronice restante. Au fost incluºi în studiu 25 de pacienþi la

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care s-a practicat artroscopia gleznei în scop diagnostic ºi/sau terapeutic. Rezultatele obþinute duc la concluzia cã artroscopia gleznei rãmâne o metodã sigurã, miniinvazivã de diagnostic ºi tratament al leziunilor gleznei. Bibliografie 1. Bataga, T.; Nagy, O ºi alþii – Sindromul de impingement al gleznei la sportivi - evaluarea rezultatelor clinice dupã tratamentul artroscopic. Revista de Ortopedie ºi Traumatologie (Bucureºti), 2005, vol. 15, nr. 3-4, 23-25. 2. Buchhron, T.; Ziai, P. Ventrales Impingementsyndrom am oberen Sprunggelenk. Arthroskopie. 2009, 22: 109-115. 3. Chauveaux D. – L`arthroscopie de cheville:imperatifs techniques et apports diagnostiques. Med. Chir. Pied., 1993, 9, 63-70. 4. Feiwell L.A., Frey C. – Anatomic study of arthroscopic debridement of the ankle. Foot and Ankle int, 1994, 15, 11: 614621. 5. Ferkel R.D. – Historical developments in Arthroscopic Surgery: The Foot and Ankle, Ferkel RD Ed, Lippincott-Raven, Philadelphie, 1996. 7-11. 6. Ferkel R.D. – Arthroscopic surgery: The foot and ankle Lippincott-Raven. Philadelphia 1996. 7. Galla, M.; Lobenhoffer, P. – Modifizierte Technik der Tibiaosteotomie bei OATS-Plastik am zentralen Talus. Arthroskopie. 2009, 22: 149-152. 8. Guhl J. F. – Ankle arthroscopy: pathology and surgical techniques. Thorofare, N.J., 1988. 9. Hangody L., Kish G., Zarpati Z., Szerb I., Eberhardt R. – Treatement of osteochondritis dissecans of the talus: use of the mosaicoplasty technique: a preliminary report. Foot and Ankle int., 1997, 18, 623-624. 10. Hangody, L. et all. – Autologous osteochondral mosaicplasty. Surgical technique. 2004, J. Bone Joint Surg(Am) 86-A (Suppl1): 65-7. 11. Hauwkins R.B. – Arthroscopic stapling repair for chronic lateral instability. Clin. Podiatr. Med. Surg., 1987, 4,: 875-883. 12. Herman S., Christel P., Witovet J. – Chirurgie arthroscopique de la cheville sous distraction articulaire. Apropos de 29 cas. J. Med. Lyon, 1990, 161-169. 13. Jerosch J., Steinbeck J., Schroder H. – Arthroscopic treatment of anterior synovitis of the ankle in athletes. Knee Surg. Sports Traumatol. Arthroscopy 1994, 2: 176-181. 14. Kashuk K.B., Carbonell J.A., Blum J.K. – Arthroscopic stabilization of the ankle. Clin.Podiatr. Med. Surg., 1997, 14, 3: 459-478. 15. Kouvalchouck J.F., Watin-Augouard L. Lesions osteochondrales du dome astragalien par curetage-comblement. J. Traumatol. Sport., 1993, 10, 212-216. 16. Ogilvie-Harris D.J., Gilbart M.K., Chorney K. – Chronic pain following ankle strains in athletes: The role of arthroscopic surgery. Arthroscopy, 1997, 13,5:564-574.


FRACTURILE BIMALEOLARE ªI DE PILON TIBIAL 17. Paul, J.; Kirckhhoff, C.; Hinterwi Mmer, S.; Iimhoff, A. B. Behandlung osteochondraler Läsionen am Sprunggelenk. Arthroskopie. 2009, 22: 102-108 18. Schafer D., Hinterman B. – Arthroscopic assessment of the chronic unstable joint. Knee Surg. Sports Traumatol. Arthroscopy, 1996, 4: 48-52. 19. Taga I., Shino K., Inove M., Nakata K., Maeda A. – Articular cartilage lesions in ankles with lateral ligament injury. Am. J. Sports Med., 1993, 21, 1: 120-127. 20. Van Dijke C.N., Scholte D. – Arthroscopy of the ankle joint. Arthroscopy 1997, 13, 1: 90-96.

 VALOAREA ECOGRAFIEI ÎN DIAGNOSTICUL ENTORSEI DE GLEZNA B. Voicu, R. Opriº, Liliana Nemeº Clinica Ortopedie Traumatologie I, Târgu-Mureº

Cuvinte rare: ecografie, entorsã de gleznã, hemo-hidartozã. Lucrarea de faþã vrea sã demonstreze utilitatea folosirii examenului ecografic în explorarea entorsei acute de gleznã. Au fost incluºi în studiu 53 de pacienþi cu entorsã lateralã recentã a gleznei. Atunci când ecografia a diagnosticat prezenþa unei fluidartroze (hemo-hidartrozã) s-a efectuat ºi un examen IRM. Rezultatele ne determinã sã credem cã ecografia este o metodã sigurã, non-invazivã, care, cu costuri scãzute, poate aprecia gravitatea unei entorse de gleznã. Bibliografie 1. Frey C., Bell J., Teresi L., Kerr R.: – A comparation of MRI and clinical examination of acute lateral ankle sprains. Foot Ankle Int., 1996, 17, 533-537. 2. Cohen M., Piclet-Legre B., Duby J., et al. – Apport de l’echographie dans les entorses recentes de la cheville. J. Traumatol. Sport, 1999, 16, 101-109. 3. Dubrana F. et al. – Instabilite chronique autour de la cheville. Rev. Chir. Orthop., 2006, 92, 11-40. 4. Jacobson JA., Andersen R., Jaovisidha S. et al. – Detection of ankle effusions: comparation study in cadavers using radiography, sonography and MR imaging. AJR Am. J. Roentgenol, 1998, 170, 1231-1238. 5. Chandnani V.P., Harper MT., Ficke JR. et al.: Chronic ankle instability: evaluation with MR arthrography, MR imaging and stress radiography. Radiology, 1994, 192, 189-194. 6. Nyska M., Mann G., The unstable ankle, 2002, Human Kinetics, Champaign, IL.

 IMPLICAREA LIGAMENTULUI TALOFIBULAR ANTERIOR ÎN INSTABILITÃÞILE CRONICE ALE GLEZNEI. STUDIU PE CADAVRE B. Voicu, R. Opriº, A. Ivãnescu Clinica de Ortopedie Traumatologie I, Târgu-Mureº

Cuvinte cheie: ligament talofibular anterior, instabilitate cronicã de gleznã Lucrarea de faþã îºi propune sã studieze la 18 specimene de gleznã implicarea ligamentului talofibular anterior în instabilitãþile de gleznã. Pentru aceasta a fost creat un sistem original, bipolar, de fixare a gleznei într-un aparat motorizat de testare Imada, prevãzut cu un dispozitiv digital de mãsurare a forþei. Gleznele au fost supuse unor forþe în trei poziþii, neutrã, flexie planatarã ºi dorsoflexie, înainte ºi dupã secþionarea ligamentului talofibular anterior iar valorile obþinute au relevat laxitãþi maxime în poziþia de flexie plantarã, pentru miºcãri de inversiune ºi rotaþie internã, mecanism care corespunde celui din entorsele curente. Bibliografie 1. Asla, R.J; Kozanek, M; Wan, L.U; Rubash, H.E. and L.I., G.: Function of anterior talofibular and calcaneofibular ligaments during in-vivo motion of the ankle loint complex. J.of orthopedic surgery and research. 2009. 2. Chrisman, O.D., and Snook, G.A.: Reconstrucion of Lateral Ligament Tears of the Ankle. An Experimental Study and Clinical Evaluation of Seven Patients Treated by A New Modification of the Elmsie Procedure. J. . Bone and Joint Surg. 51-A: 904-912, July 1969. 3. Glasgow, Malcolm; Jackson, Andrew; and Jamieson, A. M.: Instability of Ankle after Injury to the Lateral Ligament. J. Bone and Joint Surg. 62-B(2): 196-200, 1980. 4. Hamilton, W.G. Point de vue sur le traitement de l’instabilite aigue et chronique de la cheville. Pathologie osteoarticulaire du pied et de la cheville. Bouysset M., Springer, 2004 5. Johnson E.E., and Makolf K.L.; The Contribution of the Anterior Talofibular Ligament to Ankle Laxity. J. Bone and Joint Surg., 65-A: 81-88, January 1983. 6. Louwerens, J.W.K. Ankle and Subtalar InstabilityEvaluation. 7th EFAS Instructional Course. Copenhagen, Denmark, May 2005. 7. McCullough, C.J., and Burge, P.D.: Rotary Stabilty of the Load-Bearing Ankle. An Experimental Study. J. Bone and Joint Surg., 62-B (4): 460-464, 1980.

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ACTUALITÃÞI ÎN BIOMATERIALE

UTILIZAREA UNUI CARRIER IMPREGNAT CU ANTIBIOTIC, BIOABSORBABIL (HIDROXIAPATITA NANOCRISTALINà ªI SULFAT DE CALCIU – PELETE) ÎN OSTEOMIELITA CRONICÃ. REZULTATE PE TERMEN SCURT B. Andor*, I. Popa*, S. Florescu*, B. Angliþoiu* Secþia Ortopedie-Traumatologie, U.M.F. „Victor Babeº“ Timiºoara

Rezumat: Acest sudiu încearcã sã evalueze eficienþa utilizãrii unui carrier impregnat cu antibiotic, bioabsorbabil (hidroxiapatita nanocristalinã ºi sulfat de calciu – pelete de Perossal) în tratamentul osteomielitei cronice. Material ºi metodã: 21 pacienþi ce necesitã debridare chirurgicalã pentru infecþie osoasã doveditã prin culturi pozitive (la 9 dintre aceºtia se asociazã pseudartrozã) au fost incluºi în acest studiu prospectiv. Oasele implicate au fost tibie (11 cazuri), femur (7 cazuri), humerus (2 cazuri) ºi ulna (1 caz). Toate defectele au fost de origine posttraumaticã ºi fiecare pacient a suferit în antecedente intervenþii chirurgicale la acel nivel (între 1 ºi 8 intervenþii). Durata infecþiei a fost între 4 luni ºi 26 de ani. Conform clasificãrii lui CiernyMader, trei cazuri au fost stadiul I (osteomielitã medularã), 4 au fost stadiul II ( osteomielitã superficialã), 6 cazuri stadiul III (osteomielitã localizatã) ºi 8 cazuri stadiul IV (osteomielitã difuzã). Defectul osos a avut în medie 24,6 cc. Toþi pacienþii cu osteomielitã doveditã au fost operaþi; tehnica chirurgicalã a constat în tratament clasic (debridare, foraj, lavaj) ºi umplerea defectului rezultat cu un carrier impregnat cu antibiotic conform antibiogramei. Rezultate: Perioada de urmãrire a fost în medie 12 luni (de la 6 la 18 luni). Radiologic, peletele s-au resorbit în medie la 2,6 luni postoperator. Infecþia sa eradicat la 20 de pacienþi (95,23 %). Consolidarea s-a obþinut la 8 din cei 9 pacienþi. Complicaþiile au fost persistenþa infecþiei (1 caz), refracturã (1 caz), persistenþa pseudartrozei (1 caz). 8 pacienþi au prezentat scurgeri de lichid seros steril din plagã.

Concluzii: La pacienþii cu osteomielitã cronicã, carrierul impregnat cu antibiotic a umplut spaþiul creat prin debridare ºi a fost eficient în eradicarea infecþiei. Datoritã biodegradabilitãþii sale a fost evitatã intervenþia chirurgicalã secundarã. Consolidarea osoasã a fost rapidã ºi de bunã calitate. Acest protocol operator cu implantarea de hidroxiapatitã nanocristalinã ºi sulfat de calciu – pelete Perossal s-a dovedit o excelentã metodã de tratament definitiv al osteomielitei cronice. SHORT-TERM RESULTS OF USING A BIOABSORBABLE, ANTIBIOTICIMPREGNATED CARRIER (NANOCRYSTALLINE HYDROXYAPATITE AND CALCIUM SULPHATE - PELLETS) IN CHRONIC OSTEOMYELITIS Aims: The present study is designed to evaluate the use of a bioabsorbable, antibiotic-impregnated carrier (nanocrystalline hydroxyapatite and calcium sulphate: PEROSSAL pellets) in the treatment of patients with chronic osteomyelitis. Material and Methods: Twenty-one patients, requiring surgical debridement of culture-positive bone infection (9 with associated non-union) were entered into an ongoing consecutive, prospective clinical trial. Involved bones included the tibia (11), femur (7), humerus (2) and ulna (1). All defects were posttraumatic in origin, and each patient has had previous surgery at the involved site (range 18 surgeries). The duration of infection ranged from 4 months to 26 years. According to the CiernyMader classification system, there was 3 stage I (medullary osteomyelitis), 4 stage II (superficial osteomyelitis) 6 stage III (localized osteomyelitis), and 8 stage IV (diffuse osteomyelitis) lesions. There were 9 normal (A) hosts and 12 locally and/or systemically compromised (B) hosts. Mean bone defect/void was 24,6 cm3. All patients with verified osteomyelitis and soft tissue defect were operated; surgical technique consisted of classical treatment (debridement and forage, lavage ) with antibiotic-impregnated carrier loaded according to antibiogram.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Results: Mean follow-up was 12 months (range 6-18 months). Radiographically, pellets were resorbed at a mean of 2.6 months postoperatively. Infection was eradicated in 20 patients (95,23%). Union was achieved in 8 of 9 nonunion patients. Complications included persistent infection (one), refracture (one), persistent nonunion (one). Eight patients developed sterile wound leakage. Conclusions: In patients with chronic osteomyelitis, the antibiotic-impregnated carrier managed the dead space created by debridement surgery and was effective in eradicating bone infection. Because of it’s biodegrability we avoided a secondary surgical procedure. Bone consolidation was fast and of good quality. Suggested operative protocol with implantation of --- pellets is an excelent methode in definitive treatment of chronic osteomyelitis. Bibliografie 1. Klemm K.W. – Treatment of infected pseudoarthrosis of the femur and tibia with interlocking nail. Clin Orthop 212: 174184, 1986. 2. Rauschmann M.A., Wichelhaus T..A, Stirnal V., Dingeldein E., Zichner L., Schnettller R., Alt V. – Nanocrystalline hydroxy-apatite and calcium sulphate as biodegradable composite carrier material for local delivery of antibiotics in bone infections. Biomaterials. 2005 May; 26 (15): 2677-84. 3. Huber F.X., MacArthur N., Hillmeier J., Kock H.J., Baier M., Diwo M., Berger I., Meeder P.J. – Void filling of tibia compression fracture zones using a novel resorbable nanocrystalline hydroxyapatite paste in combination with a hydroxyapatite ceramic core: first clinical results. Arch Orthop Trauma Surg. 2006 Oct;126 (8): 533-40. 4. Huber F.X., Hillmeier J., Herzog L., McArthur N., Kock H.J., Meeder P.J. – Open reduction and palmar plateosteosynthesis in combination with a nanocrystalline hydroxyapatite spacer in the treatment of comminuted fractures of the distal radius. J Hand Surg (br). 2006 Jun; 31 (3): 298-303. 5. Laschke M.W., Witt K., Pohlemann T., Menger M.D. – Injectable nanocrystalline hydroxyapatite paste for bone substitution: In vivo analysis of biocompatibility and vascularization. J Biomed Mater Res B appl Biomater. 2007 Feb 05. 6. Huber F.X., Belyaev O., Hillmeier J., Kock H.J., Huber C., Meeder P.J., Berger I. – First histological observations on the Incorporation of a novel nanocrystalline hydroxyapatite paste OSTIM in human cancellous bone. BMC Musculoskelet Disord 206 Jun 8; 7:50 7. Englert C., Angele P., Fierlbeck J., Dendorfer S., Schubert T., Muller R., Lienhard S., Zellener J., Nerlich M, Neumann C. – Conductive bone substitute material with variable antibiotic delivery. Unfallchirurg. 2007 Feb 21.

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 SISTEME DE CEDARE A MEDICAMENTELOR PE BAZÃ DE COLAGEN ªI DOXICICLINÃ PENTRU PROFILAXIA INFECÞIILOR ÎN OASE M.G. Albu*, L. Popa**, M.V. Ghica**, M. Leca***, E. Cremenescu****, C. Borlescu****, V. Trandafir* * Departament Colagen, Institutul de Cercetare Pielãrie Încãlþãminte, Bucureºti, ** Faculatea de Farmacie, Universitatea de Medicinã ºi Farmacie “Carol Davila”, Bucureºti, ***. Facultatea de Chimie, Universitatea din Bucureºti, **** S.C. ELMI PRODFARM S.R.L., Bucureºti

Cuvinte cheie: matrici colagenice, eliberare medicament, infectii. Introducere: Rãnile infectate ºi alte tipuri de infecþii dobândite în spital cauzeazã morbiditatea semnificativã dupã refacerea internã a fracturilor (osteosintezã). Administrarea agenþilor antimicrobieni (antibiotice) poate reduce frecvenþa infecþiilor. Tratamentul infecþiilor, rãnilor prin administrare sistemicã a medicamentelor poate conduce la o dozã insuficientã sau o supradozã a concentraþiei de medicament la locul infectat. Aceastã problemã poate fi rezolvatã prin eliberarea localã a antibioticelor. Scopul: Dezvoltarea de sisteme de cedare a medicamentelor pe bazã de colagen ca suport de cedare ºi doxiciclinã ca antibiotic cu spectru larg de activitate contra bacteriilor gram-pozitive ºi gramnegative. Materiale ºi metode: Gelul de colagen fibrilar tip I extras din piele de viþel, hiclatul de doxiciclinã, hidroxidul de sodium ºi soluþia tampon fosfat, PBS, (pH = 7,4) au fost utilizate pentru prepararea de sisteme de cedare a medicamentelor sub formã de geluri. Pentru a obþine forme spongioase gelurile au fost liofilizate cu liofilizatorul Delta 2-24 LSC Christ. Cedarea in vitro a hiclatului de doxiciclinã a fost determinatã la 37±0,50C utilizând un dispozitiv USP adaptat. Determinarea contaminãrii microbiene a fost analizatã pe Staphylococcus aureus. Rezultate: Gelurile de colagen cu pH 3,8 ºi 7,4 cu sau fãrã doxiciclinã au fost liofilizate pentru obþinerea matricilor. Cedarea medicamentului a fost efectuatã pentru geluri ºi matrici cu doxiciclinã pentru a evalua mecanismul de cedare al antibioticului la þesutul infectat. Atât gelurile cât ºi matricile urmeazã acelaºi mecanism de cedare,


ACTUALITÃÞI ÎN BIOMATERIALE “power law”, cu constante cinetice ºi exponenþi de cedare diferiþi. Pentru matricile studiate a fost determinatã activitatea antibacterianã faþã de Staphylococcus aureus. Concluzii: atât gelurile cât ºi matricile cedeazã peste 80% din doxiciclinã în timp de douã ore fiind sisteme de cedare a medicamentului corespunzãtoare pentru infecþiile osoase. Mai mult, datoritã conþinutului de doxiciclinã acestea nu permit dezvoltarea Staphylococcus aureus. Sistemele de cedare a medicamentelor studiate, datoritã proprietãþilor lor oferã o soluþie pentru profilaxia infecþiilor în os. Mulþumiri: Aceastã lucrare a fost susþinutã financiar de CNMP în cadrul proiectului PN II 72-198/2008. FAILURE SYSTEMS OF DRUGS BASED ON COLLAGEN AND DOXYCYLINE FOR PROPHYLAXIS IN BONES INFECTIONS Key words: collagen matrices, drugs release, infections Introduction: Wound infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures (osteosynthesis). The administration of antimicrobial agents (antibiotics) may reduce the frequency of infections. The wound infection treatment by systemic administration of drugs may lead to insufficient or overdose drug concentration on the site of infection. This problem can be solved by local delivery of antibiotics. Scope: Development of drug delivery systems based on collagen as support for delivery and doxycycline as antibiotic with broad spectrum of activity against gram-positive and gram-negative bacteria. Materials and methods: Type I fibrillar collagen gel extracted from calf hide, doxycycline hyclate, sodium hydroxide and phosphate buffer solution, PBS, (pH = 7.4) were used for preparation of drug delivery systems as gels form. In order to obtain spongious form the gels were freeze-drying using Delta 2-24 LSC Christ lyophilizer. In vitro release of doxycycline hyclate was determined in triplicate at 37±50C using a modified USP paddle method (“sandwich” device). Determination of microbial contamination was assessed on Staphylococcus aureus. Results: Collagen gels at pH 3.8 and 7.4 with or without doxycicline were freeze drying in order to

obtain matrices. The drug release was performed for collagen gels and matrices with doxycycline in order to evaluate the release mechanism of antibiotic to the infected tissue. Both gels and matrices follow the same mechanism of release, power law, with different kinetic constants and release exponents. The antibacterial activity against Staphylococcus aureus was determined for the studied matrices. Conclusions: Both gels and matrices release over 80% of doxycycline during two hours being proper drug delivery systems for bone infections. Furthermore, because the doxycycline content they don’t allow development of Staphylococcus aureus. Due to their properties the studied drug delivery systems offer a solution for infection prophylaxy in bone. Acknowledgement: This work was financial supported by CNMP within the PN II 72-198/2008 project. Bibliografie 1. T.G. Donley (2002) PPAD 4(2):165-38. 2. V. Trandafir, G. Popescu, M.G. Albu et al (2007), Bioproduse pe baza de collagen, Ed.Ars Docendi, pp 99-103.

 BIOFUNCÞIONALIZAREA BIOMATERIALELOR METALICE I. Antoniac*, C. Cotruþ*, D. Lãptoiu**, M. Istodorescu*** * Universitatea Politehnica din Bucureºti, ** Spitalul Clinic Colentina, Bucureºti, *** Medical Ortovit, Bucureºti“

Modificarea suprafeþelor este o tehnicã importantã pentru a îmbunãtãþi biofuncþionalizarea ºi biocompatibilitatea materialelor metalice utilizate frecvent în aplicaþiile biomedicale. Modificarea suprafeþelor este un proces cu ajutorul cãruia se pot schimba structura, compoziþia ºi morfologia suprafeþelor materialelor metalice fãrã a influenþa caracteristicile mecanice ale materialului de bazã. În prezent o mare varietate de metode de modificare a suprafeþelor constau în utilizarea unui bombardament ionic în medii lichide sau uscate în scopul de a îmbunãtãþi compatibilitatea þesutului osos cu biomaterialele metalice cum ar fi titanul, oþelul inoxidabil ºi aliajele de CoCr. Dintre proprietãþile cele mai importante care pot fi îmbunãþite prin procese de modificare a suprafeþei fac parte rezistenþa la coroziune ºi uzura, proprietãþile antibacteriene ºi

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 compatibilitatea cu þesutul osos. Rigozitatea suprafeþei este un parametru important al rãspunsului tisular osos la implanturile metalice. Mai mult, macro-design-ul implanturilor poate oferi diferenþe specifice zonelor de contact os implant. Prin osteointegrare directã, topografia suprafeþelor biofuncþionalizate ale implanturilor ortopedice poate intensifica integrarea ºi, pe termen lung, stabilitatea. În acest sens, proiectarea controlatã a topografiei suprafeþei a fost demonstratã ca un modulator major al funcþia celulelor osteogenice, oferind potenþial un mediu favorabil în jurul implantului pentru depunere ºi întreþinere a aderenþei osului. O altã soluþie tehnicã pentru osteointegrare utilizeazã bio - molecule funcþionale (PEG) fixate pe suprafete metalice, care inhibã adsorbþia proteinelor ºi celulelor, precum ºi aderenþa bacterianã. În plus, biomolecule cum ar fi colagenul poate fi cu uºurinþã electrodepuse pe suprafeþe metalice, deoarece conþin molecule cu sarcini electrice. Scopul final al schimbãrii suprafaþei unei biomaterial este de a crea o suprafaþã care este optimã pentru aplicaþia destinatã. O serie de aplicaþii practice vor fi prezentate. Cuvinte cheie: „biomateriale metalice, implanturi osteosintezã, depuneri, osteointegrare BIOFUNCTIONALIZATION OF METALLIC BIOMATERIALS Surface modification is an important technique for obtaining both function and biocompatibility in metals intended for biomedical use. The surface modification is a process that changes the surface structure, composition and morphology of a metallic material leaving the deep mechanical properties intact. A large number of surface modification techniques, using wet processes performed in aqueous solutions and dry processes using ion beams, improve the hard tissue compatibility of metallic biomaterials like titanium, stainless steel and cobalt-chromium alloy. The chief purpose of surface modification is to improve the corrosion resistance, wear resistance, antibacterial property and tissue biocompatibility. Surface roughness is an important parameter for the bone response to implants. Further, the macro-design of implants provides site-specific differences in bone-to-implant contact. Through direct osteointegration, topographical surface biofunctio-

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nalization of orthopedic implants may enhance their integration and long term stability. In this respect, the controlled design of surface topography has been shown as a major modulator of osteogenic cell function thus, potentially, providing favorable environment around the implant for bone deposition and maintenance. Another technical solution is the immobilization of biofunctional molecules (PEG) to metal surfaces. The PEG-immobilized surface inhibited the adsorption of proteins and cells, as well as the adhesion of bacteria, indicating that this electro -deposition technique is useful for the bio-functionalization of metal surfaces. In addition, biomolecules such as collagen can be easily electrodeposited onto metal surfaces because molecules contain many electrical charges. The ultimate aim of changing the surface of a biomaterial is to create a surface which is optimal for the intended application. Bibliografie 1. Hamilton DW, Brunette DM. Biomaterials. 2007 Apr ; 28 (10): 1806-1819. 2. C. Larsson, P. Thomsen, J. Lausmaa, M. Rodahl, B. Kasemo, L.E. Ericson, Biomaterials 15 (1994) 1062. 3. Morra et al. Surface engineering of titanium by collagen immobilization. Surface characterization and in vitro and in vivo studies Biomaterials 24 (25): 4639-54.

 BIOMATERIALE UTILIZABILE ÎN REGENERAREA ªI REPARAREA DISCURILOR INTERVERTEBRALE I. Antoniac*, C. Cotruþ*, M. Mãgureanu**, D. Lãptoiu**, I. Stancu*, F. Miculescu* * Universitatea Politehnica din Bucuresti, ** Spitalul Clinic Colentina, Bucuresti“

Cuvinte cheie: disc intervertebral, regenerare, biomateriale Discul intervertebral (IVD) este componenta fibrocartilaginoasã din complexul “tri-articular“ care reglementeazã miºcarea, flexibilitatea ºi sprijinul la nivelul coloanei vertebrale. Ca parte a acestui complex, discul trece printr-o evoluþie de tip “uzurã ºi rupere“, care contribuie la apariþia a numeroase patologii ºi la consecinþe de tip invaliditate pentru pacient. Numeroase proceduri chirurgicale au fost dezvoltate pentru a trata afecþiunile discale, în mare parte concentrate


ACTUALITÃÞI ÎN BIOMATERIALE asupra fuziunii osoase pentru a restaura stabilitatea ºi eliminarea simptomelor. Majoritatea acestor proceduri s-au bazat pe dispozitive de fixare pentru a inhiba miºcarea în timpul procesului de fuziune osoasã. Principala strategie de regenerare IVD a fost includerea de celule întrun suport de tip reþea din biomateriale pentru a permite producþia ºi întreþinerea pe termen lung a þesutului nou generat. Au fost investigate diverse biomateriale care sã permitã fenotiparea celularã adecvatã ºi biosinteza matricii, sau degradarea polimericã ºi resorbþia. Studiile efectuate pe complexe celule-biomateriale cultivate in vitro au demonstrat potenþialul unor materiale, inclusiv geluri termosensibile precum chitosanul, polipeptidele, geluri auto-asociate compuse din agarozã, colagen ºi fibrinã sau forme modificate ale acestor acelaºi materiale, alginaþi reticulaþi, polietilenglicoli, poliacizi glicolici, ºi altele. În aceastã lucrare, va fi prezentatã o sintezã a cercetãrilor în domeniul biomaterialelor utilizabile pentru regenerarea IVD, cu accent pe unele biomateriale compozite polimerice, cu structura poroasã ºi proprietãþi biomecanice optime, capabile sã controleze ºi fenomenul de angiogenezã, la diferite niveluri necesare în diferite regiuni ale structurii discului. BIOMATERIALS USED IN REGENERATION AND REPAIR THE INTERVERTEBRAL DISKS The intervertebral disc (IVD) is the fibrocartilaginous part of a “three-joint complex” that governs motion, flexibility and weight-bearing in the spine. As part of this complex, the disc undergoes a lifetime of “wear and tear” that contributes to multiple IVD disorders of enormous consequence for human disability and suffering. Numerous surgical procedures have been developed to treat IVD disorders, largely focused on bony fusion across the disc space to restore stability and eliminate symptomatic motions and weightbearing. The majority of these procedures have relied on fixation of devices to inhibit motion during the bony fusion process. The main strategy for IVD regeneration has been the inclusion of cells with biomaterials to enable production and long term maintenance of newly generated tissue. Biomaterials that enable appropriate cellular phenotypes and matrix biosynthesis, and that

sometimes enable polymeric degradation or resorption, have been proposed as alternative implantable biomaterials and have been studied largely in vitro. Studies of cell-biomaterial constructs cultured in vitro have demonstrated potential for many materials, including thermosensitive gels such as chitosan, modified chitosans and elastin-like polypeptides, self-associating gels composed of agarose, collagen and fibrin or modified forms of these same materials, crosslinkable alginates, polyethylene glycol, poly (glycolic acids) and more. In this paper, a review of the biomaterials-based tissue engineering solutions will be provided along with evaluations of their adaptation and implementation for treatment of IVD disorders, especially about the highly porous biomaterials with optimal biomechanical properties and capable of controlling angiogenesis at the different extents required in the different regions of the disc structure. Bibiliografie 1. Carl, A., E. Ledet, et al. (2004). “New developments in nucleus pulposus replacement technology.” Spine J 4 (6 Suppl): 325S-329S. 2. Wilke, H. J., F. Heuer, et al. (2006). “Is a collagen scaffold for a tissue engineered nucleus replacement capable of restoring disc height and stability in an animal model?” Eur Spine J 15 Suppl 3: S433-8. 3. Hutmacher DW. Scaffold design and fabrication technologies for engineering tissues-state of the art and future perspectives. J Biomater Sci Polym Ed 2001; 12: 107–24. 4. Yoon ST, Patel NM: Molecular therapy of the intervertebral disc. Eur Spine J 15 [Suppl 3]: 379 –388, 2006.

 NANOCOMPOZITE CHITOSAN-MAGNETITA CU POTENÞIALE APLICAÞII ÎN DETOXIFIEREA SÂNGELUI V. Bãlan*, Liliana Verestiuc**, M.I. Popa* * Universitatea Tehnicã “Gh. Asachi”, Facultatea de Inginerie Chimicã ºi Protecþia Mediului, Iaºi ** Universitatea de Medicinã ºi Farmacie “Gr. T. Popa”, Facultatea de Bioinginerie Medicalã, Iaºi

Cuvinte cheie: nanoparticule, oxid de fier, chitosan, surfactant, TPP. În domeniul biomedical, nanoparticulele magnetice ºi-au gãsit aplicabilitate ca agenþi de contrast în IRM, ca “purtãtori” în eliberarea þintitã de medicamente, hipertermia cu fluide magnetice, ºi tehnici de detoxificare sangvinã. Materialul cel

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 mai des folosit în aplicaþiile biomedicale datoritã biocompatibilitãþii sale demonstrate precum ºi a proprietãtilor magnetice excelente este oxidul de fier (magnetita, Fe3O4) sau varianta sa oxidatã, aFe2O3 (maghemita) [1]. Datoritã interacþiunilor hidrofobe puternice, aceste particule au tendinþa de a agrega, motiv pentru care se recomandã acoperirea suprafeþei lor cu surfactanþi sau compuºi polimerici cu scopul de a le mãri stabilitatea coloidalã [2]. Chitosanul este un material adecvat pentru acoperirea oxidului de fier atât datoritã proprietãþilor sale biologice (biodegradabilitate, biocompatibilitate, bioactivitate) cât ºi chimice (polication, prezenþa grupãrilor reactive hidroxil ºi aminice). Studiul de faþã prezintã sinteza ºi caracterizarea unor nanoparticule compozite chitosan-magnetita cu scopul de a obþine purtãtori funcþionalizaþi biocompatibili. Particulele magnetice au fost obþinute prin metoda co-precipitãrii în mediu bazic a soluþiilor apoase de clorurã feroasã ºi fericã, stabilizate în suspensie prin adãugarea de surfactanþi (Pluronic F127, Tween 20, Tween 80 ºi CTAB). Particulele sintetizate au fost apoi acoperite cu chitosan prin procedeul de gelifiere ionicã cu tripolifosfat de sodiu. Particulele magnetice obþinute au fost caracterizate prin spectroscopie FT-IR ºi microscopie electronicã de baleiaj. S-a studiat influenþa naturii ºi concentraþiei surfactantului asupra caracteristicilor particulelor (dimensiune, indice de polidispersitate, potenþial zeta). Dimensiunile particulelor stabilizate cu CTAB precum ºi potenþialul zeta al acestora recomandã folosirea acestui surfactant pentru obþinerea de suspensii coloidale stabile cu potenþiale aplicaþii în detoxifierea sângelui.

such as surfactants or polymeric compounds have been used to modify magnetic particle surface in order to increase their colloidal stability [2]. Due to its significant biological (biodegradable, biocompatible and bioactive) and chemical properties (polycation, reactive groups such as OH and NH2) chitosan is a biopolymer with promising coating properties for magnetic particles. This paper presents synthesis and characterization of composites nanoparticles based on chitosan and magnetite in the order to obtain biocompatible and functionalized carriers. The Fe3O4 nanoparticles were prepared by co-precipitation method of ferric and ferrous chloride, in the presence of a base, as precipitating agent, and stabilized by addition of surfactants (Pluronic F127, Tween 20, Tween 80 and CTAB). Iron oxide particles were subsequently coated with chitosan and cross linked with sodium tripolyphosphate (STPP) by ionic gelation. The magnetic composites were characterized by FT-IR spectroscopy and scanning electronic microscopy (SEM). The influence of surfactant nature and concentration on particles characteristics (particles size, polydispersity and zeta potential) has been evaluated. The particles size and their zeta potential recommend the use of CTAB in order to obtain steady colloidal suspensions with potential applications in blood detoxification.

CHITOSAN-MAGNETITE NANOCOMPOSITES WITH POTENTIAL APLICATIONS IN THE DETOXIFIATION OF BLOOD

Iron oxide nanoparticles have many applications in biomedical field as contrast enhancement materials in tissue magnetic resonance imaging, carriers for targeted drug delivery, hyperthermia cancer treatment and in blood detoxification techniques. Due to its biocompatibility already proven, iron oxide (magnetite/ maghemite) is the most used magnetic sensitive material in the medical fields [1]. Magnetite particles are hydrophobic and tend to aggregate in large clusters. Therefore, stabilizers

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Bibliografie [1] A.K. Gupta, M. Gupta, “Synthesis and surface engineering of iron oxide nanoparticles for biomedical applications”, Biomaterials, vol. 26, pp. 3995-4021, 2005. [2] Z. Ma, H. Liu, “Synthesis and surface modification of magnetic particles for application in biotechnology and biomedicine”, China Particuology ,vol.5, pp.1-10, 2007.

STUDII DE HEMOCOMPATIBILITATE A UNOR MEMBRANE PE BAZÃ DE POLIURETANI ªI DERIVAÞI CELULOZICI Maria Butnaru*, Doina Macocinschi**, Daniela Filip**, Cristina-Daniela Dimitriu* * Universitatea de Medicinã ºi Farmacie „Gr. T. Popa” Iasi, ** Institutul de Chimie Molecularã „P. Poni” Iaºi

Cuvinte cheie: hemocompatibilitate, membrane, poliuretani. Poliuretanii (PU) sunt o clasã importantã de biomateriale biocompatibile, cu numeroase aplicaþii biomedicale. Poliuretanii segmentaþi sunt


ACTUALITÃÞI ÎN BIOMATERIALE candidaþii promiþãtori pentru obþinerea protezelor cardiovasculare sau a sistemelor perfuzabile care intrã în contact cu sângele. Studiul în cauzã a urmãrit îmbunãtãþirea proprietãþilor de hemocompatibilitate a unor materiale poliuretanice, prin introducerea în compoziþia lor a hidroxipropilcelulosei (HPC). Materialele poliuretanice studiate au fost obþinute prin reacþia de poliadiþie a unui diizocianat aromatic (metilen difenilen diizocianat-MDI) cu poli (etilen glicol )adipat (PEGA), polipropilenglicol (PPG) sau politetrahidrofuran (PTHF) ºi etilen glicol (EG), în dimetil formamidã (DMF), realizarea de amestecuri cu HPC ºi formarea de membrane. Au fost studiate proprietãþile hidrofil-hidrofobe, adsorbþia proteinelor plasmatice, timpul de protrombinã, adeziunea trombocitelor pe suprafaþa ºi formarea cheagului pentru poliuretanii celulozici PUPPGHPC, PUPEGA-HPC, PUPTHF-HPC ºi poliuretanul de referinþã – PUPEGA. Rezultatele studiului au arãtat cã introducerea HPC în membranele poliuretanice a diminuat semnificativ proprietãþile trombogene ale suprafeþelor acestora, a scãzut senificativ adeziunea fibrinogenului din soluþiile fiziologice, fluidele fiziologice simulate ºi plasma sanguinã, a redus numãrul de trombocite aderate ºi mãrimea chegului format la interfaþa biopolimer-sânge. Cele mai evidente semne de hemocompatibilizare au fost înregistrate în cazul amestecului PUPTHF-HPC, ceea ce a corelat cu o porozitate mai accentuatã ºi o capacitate de hidratare mai mare (170% din greutatea uscatã). În acelaºi timp s-a observat, cã sistemul PUPPG-HPC s-a manifestat diferit în comparaþie cu celelalte materiale. Astfel, fibrinogenul adsorbit de PUPPGHPC din plasma sanguinã s-a dovedit a fi mai crescut comparativ cu cel înregistrat în soluþia amestec alcãtuitã din albumin ºi fibrinogen. Fenomenul ar putea fi explicat prin afinitatea materialului pentru proteine plasmatice, care intermediazã adsorbþia fibrinogenului ºi în absenþa cãrora aceasta este mai redusã. În concluzie, studiul a demonstrat cã prin combinarea poliuretanilor cu derivatul celulozic, de tipul HPC, se pot îmbunãtãþi performanþele biologice ale acestora, în sensul hemocompatibilizãrii interfeþelor material-sânge.

HAEMOCOMPATIBILITY STUDIES OF MEMBRANES BASED ON POLYURETHANE AND CELLULOSE DERIVATES Polyurethanes have gained considerable position as biocompatible biomaterials for many of biomedical devices. Segmented polyurethanes are the promising candidates for the cardiovascular prosthesis and other medical devices that interfere with blood. The main goal of this study is to analyze the haemocompatibility of the some polyurethanes materials by combining them with cellulose derivative as hydroxipropylcellulose (HPC). The samples were prepared by polyaddition reaction of aromatic diisocyanates such as methylene diisocyanate (MDI) with poly (ethylene glycol adipate) (PEGA), polypropylenglycol (PPG) or polytetrahydrofuran (PTHF) and diethylene glycol (DEG) as chain extender, in N,N-dimethylformamide (DMF). We were studied the hydrophilic – hydrophobic properties, plasma protein adsorption, prothrombin time reaction, platelet adhesion to the surface and amount of the clot formation for the cellulose derivative polyurethanes PUPPG-HPC, PUPEGA-HPC, PUPTHFHPC and for their referece sample – PUPEGA. The obtained data have shown that HPC in the polyurethane structure has significantly decreased the thrombogenic properties of the surface and has significantly diminished the fibrinogen adsorption from the fibrinogen physiological solution, simulated physiological fluids or blood plasma; the platelet adhesion and amount of clot formation at the interface biomaterial-blood were also decreased. The best results on haemocompatibility were obtained for cellulose polyurethane PUPTHFHPC, which are correlated with the greatest hydration capacity (170% from the dry mass). At the same time it was observed that PUPPG-HPC membranes had different characteristics by comparison with other materials. So, the adsorbed fibrinogen from the blood plasma proved to be higher compared with that adsorbed from fibrinogen-albumin solution. This phenomenon may be explained by material affinity for plasma proteins which are interacting with fibrinogen adsorption. In conclusion, the study demonstrated that by combining polyurethanes with cellulose derivatives as HPC, it can improve their biological performance, especially their haemocompatibility.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Bibliografie 1. M. Vallet-Regí, J.M. González-Calbet, Progress in solid state Chemistry, 32, 2004, 1-31.

 ARTRODEZA DE GENUNCHI FOLOSIND O SINGURÃ PLACÃ TORSIONATÃ STUDIU BIOMECANIC M. Calciu, N. Mihailide, Lauria Tiberiu, ªt. Mogoº, V. Sufletu Spitalul Clinic de Ortopedie ºi T.B.C. Articular „Foiºor”

Cuvinte cheie: artrodezã, genunchi, placã torsionatã, studiu biomecanic Artrodeza de genunchi este un procedeu cu aplicaþii limitate dar eficient în obþinerea unui genunchi stabil ºi nedureros în cazul eºecului artoplastiei de genunchi datorat infecþiilor, pierderilor masive de os sau þesut moale ºi leziunilor ireversibile ale aparatului extensor. Utilizarea unei singure plãci de compactare anterioare torsionate aplicate ca o hobanã oferã mai multe avantaje comparativ cu tehnicile folosite în mod curent. Studiul prezent a fost conceput sã dovedeascã avantajele biologice ºi biomecanice ale acestei tehnici: abord anterior, disecþie limitatã, puþine implanturi metalice, lipsa necesitãþii grefei osoase. În plus, studiul biomecanic a dovedit compactarea optimã a fragmentelor de os, stabilitatea fixãrii ºi un risc redus de apariþie a „stress risers” ºi a fracturilor la capetele plãcii. De asemenea, placa torsionatã asigurã o compresie staticã ºi dinamicã ºi permite mobilizarea rapidã fãrã necesitatea unui suport extern postoperator. Utilizare plãcii torsionate reprezintã una dintre cele mai eficiente metode de artrodezã a genunchiului accesibilã în prezent. KNEE ARTHRODESIS USING A SINGLE TORSION PLATE. A BIOMECHANICS STUDY Key words: arthrodesis, Knee, torsion plate, biomechanics study. Arthrodesis of the knee is a procedure with limited applications but efficient to obtain a stable and painless knee for failed total knee arthroplasty secondary to persistent infection, massive bone or soft tissue loss, or irreparable damage to the extensor mechanism. Using a single anterior torsion dynamic-compression plate applied as a tension band has some advantages in comparison

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with the other techniques frequently used. The present study was designed to provide the biological and biomechanical advantages of this technique: anterior approach, limited dissection, using less metallic materials, no need for bone grafts. in addition, the biomechanics study proves a proper compression of bone fragments, the stability of fixation and a low risk of stress risers and fracture at the end of plate. The torsion of the plate gives a static and dynamic compression as well, and allows a rapid mobilization without the need for external support postoperatively. Using a single torsion plate represents one of the most efficient methods of knee arthrodesis that is currently available. Bibliografie 1. Charnley, John, and Baker, S. L. : Compression Arthrodesis of the Knee. A Clinical and Histological Study. J. Bone and Joint Surg. , 34-B (2): 187-199, 1952. 2. Griend, R. V.: Arthrodeses of the Knee with Intramedullary Fixation. Clin. Orthop., 181: 146-150, 1983. 3. Insall, J. N., and Sculco, T. P.: Section 37, Knee and Leg Reconstruction. in Orthopedic Knowledge Update I: Home Study Syllabus, p. 341. Chicago, American Academy of Orthopaedic Surgeons, 1984. 4. Lucas, D. B. , and Murray, W. R. : Arthrodesis of the Knee by Double-Plating. J. Bone and Joint Surg. , 43-A: 795-808, Sept. 1961. 5. Müller, M. E.; Allgower, M. ; Schneider, R.: and Willenegger, H.: Manual of Internal Fixation. Techniques Recommended by the AO Group.Ed. 2, New York, Springer, 1979.

 PERFORMANÞELE BIOLOGICE ALE ACOPERIRILOR DURE PE BAZÃ DE ZR UTILIZATE PENTRU CREªTEREA OSTEOINTEGRÃRII IMPLANTURILOR ORTOPEDICE C.M. Cotruþ*, L. Braic**, T. Petreuº***, A. Kiss**, C.E. Cotrutz***, I. Antoniac*, A.Vlãdescu**, C.N. Zoiþa**, M. Braic** * Universitatea Politehnicã din Bucureºti, ** Institutul Naþional pentru Optoelectronicã, Mãgurele, *** Universitatea de Medicinã ºi Farmacie “Gr. T. Popa” Iaºi

Cuvinte cheie: Implanturi metalice, depuneri, straturi subþiri, biocompatibilitate. În aceastã lucrare sunt prezentate performantele biologice ale unor acoperiri dure pe bazã de Zr, în structuri mono ºi multistrat, cu scopul de a fi utilizate în aplicaþii biomedicale. Depunerile au


ACTUALITÃÞI ÎN BIOMATERIALE fost realizate în instalaþia de depunere prin pulverizare magnetron într-o atmosferã reactivã de N2 + CH4, utilizând o þintã din Zr (puritate 99,9%). Pentru multistraturile de tip Zr/ZrCN, cu un conþinut de carbon ridicat sau scãzut, gazul reactiv a fost introdus/evacuat periodic în/din incinta de depunere în anumite perioade de timp. Performanþele biologice au fost investigate cu ajutorul testelor “in vivo” efectuate pe ºobolani Wistar adulþi. Implanturile au fost sterilizate în plasma ºi apoi implantate periosos, la nivelul femurului. Acoperirile au mai fost analizate ºi din punct de vedere al compoziþiei elementale ºi fazice, texturii, rigurozitãþii, duritãþii ºi aderenþei prin utilizarea tehnicilor GDOS ºi XRD, profilometrie de suprafaþã, mãsurãtori ale microduritãþi Vickers ºi teste de aderenþã. Pentru evidenþierea situsurilor antigenice s-a utilizat o tehnicã de imunohistochimie cu scopul de a detecta anticorpi de tip anti-MMP8 marcaþi cu peroxidazã. Detectarea anticorpilor anti-MMP-8 se face prin realizarea unui cuplu peroxidazã-antiperozidazã care se coloreazã brun cu ajutorul diaminobenzidinei (DAB). Astfel, MMP8 a fost identificatã în celulele din þesuturile periimplantare, extrase dupã sacrificarea ºobolanilor la 8 sãptãmâni de la implantare. A fost fãcutã biopsie pe þesuturile periimplantare, acestea fiind prelucrate prin fixare în formol neutru ºi includere în parafinã. S-au efectuat secþiuni de 5 μm grosime ºi s-a efectuat colorarea secþiunilor seriate prin metoda uzualã cu hematoxilinã eozinã ºi prin metoda imunohistochimicã. Prezenþa unei capsule fibroase periimplantare sau a proceselor inflamatorii asociate au fost puse în evidenþã prin coloraþie uzualã. O reacþie imunosupresoare superioarã, generatã de un rãspuns fagocitar redus, a fost observatã pentru implanturile acoperite cu multistraturi. Rezultatele experimentale au arãtat cã implanturile acoperite cu multistraturi de Zr/ZrCN sunt cele mai biocompatibile, nefiind detectatã prezenþa unui infiltrat celular inflamator. Un numãr redus de celule pozitive pentru MMP-8 a fost prezent, ceea ce indicã o bunã biocompatibilitate ºi iniþierea unui proces de remodelare. Deoarece multistraturile Zr/ZrCN cu un conþinut scãzut de carbon au prezentat cele mai mari valori ale microduritãþi, precum ºi proprietãþi biologice bune, acest tip de multistrat reprezintã o soluþie adecvatã pentru creºterea performanþelor biologice ale implaturilor din oþel inoxidabil 316L.

BIOLOGICAL PERFORMANCES OF HARD COATINGS BASED ON ZR USED FOR INCREASING THE OSTEOINTEGRATION ORTHOPHAEDIC IMPLANTS The goal of the work was to determine biological performance of Zr based hard coatings, as mono and multilayer, intended to be used in biomedical applications. The coatings were prepared by the reactive magnetron sputtering method, in a N2 + CH4 gas mixture using a metallic Zr cathode (purity 99.9%). For the Zr/ZrCN structure, with low and high carbon contents, the reactive gas being periodically introduced/evacuated in/from the deposition chamber for predetermined durations. For “in vivo” experiments there were used rats, the plasma sterilized implants being implanted in close contact with the femur bone. Additional information such as elemental and phase composition, texture, surface roughness, hardness, adhesion were investigated as a function of gas composition and total gas flow rate, using GDOES and XRD techniques, surface profilometry, microhardness and scratch adhesion measurements. An indirect immunohistochemical technique consisting of hematoxilin/eosin (HE) staining by peroxidase induced conversion of DAB (3,3-diaminobenzidine), an enzyme conjugate, was used to reveal the localisation of antibody-bound antigenic sites by means of a coloured reaction. DAB, a chromogenic substrate for peroxidase, stains the antigen-antibody sites in brown, indicating the presence of the metalloproteinases-8 (MMP-8) in the cells surrounding the implant. The rats were sacrificed after a period of 8 weeks and biopsies were carried out in order to investigate the periimplant tissues and the implants themselves. After being embedded in paraffin, peri-implant tissues were cut in 5 ìm thick sections placed on slides and stained with regular HE in order to evaluate the peri-implant tissues and the presence of eventual fibrous capsule or inflammatory process associated. The superior immunosuppressive reactions, generated by a decreased phagocytic response were found only for the multilayer coated implants. The Zr/ZrCN coated specimens with low carbon content exhibited the best biocompatibility, without any inflammatory cells infiltration. Only few cells were positively stained

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 for MMP-8, their lesser number indicating a better biocompatibility, a more important remodeling process and only a negligible inflammatory response. Due to their good mechanical and biological properties, the Zr/ZrCN multilayer coatings with low carbon content proved themselves to be promising candidates for biocompatible coatings for biomedical applications, substantially improving the biocompatibility of 316L implants. Bibliografie C. Larsson, P. Thomsen, J. Lausmaa, M. Rodahl, B. Kasemo, L.E. Ericson, Biomaterials 15 (1994) 1062.

 COROZIUNEA ªI RATA DE ELIBERARE A IONILOR DIN SUBSTRATURILE DE NI ACOPERITE CU STRATURI BIOCOMPATIBILE DE OXINITRURI C.M. Cotruþ*, A. Vlãdescu**, M. Bãlãceanu**, L. Braic**, C.N. Zoiþa**, M. Braic**, A. Kiss**, V. Braic** * Universitatea Politehnicã din Bucureºti, ** Institutul Naþional pentru Optoelectronicã, Mãgurele, Bucureºti

Cuvinte cheie: acoperiri biocompatibile, coroziune, ioni de nichel. Acoperierea cu straturi subþiri este o metodã eficientã de a îmbunãtãþi durabilitatea implanturilor într-un mediu agresiv. Timpul de viaþã al implanturilor poate fi îmbunãtãþit printr-o alegere corectã a tipului de metodã de depunere ºi a materialului. Acoperirile cu oxinitruri ale metalelor de tranziþie s-au dovedit a avea proprietãþi remarcabile, cum ar fi microduritãþi mari, stabilitate chimicã, rezistenþã la uzura ºi coroziune ridicate, fiind astãzi investigate pe scarã largã. Din marea varietate de oxinitruri cunoscute, oxinitrura de titan (TiNxOy) este foarte adesea utilizatã deoarece aceasta prezintã proprietãþi mecanice superioare ºi rezistenþã la coroziune bunã. În aceastã lucrare sunt prezentate rezultatele cercetãrilor privind depunerea de straturi subþiri de TiOxNy, ZrOxNy ºi TiOxNy/ZrOxNy pe substraturi de Ni, obþinute prin metoda pulverizãrii magnetron pulsat, cu o cantitate mai mare sau mai micã de oxigen în compoziþie. Analiza depunerilor s-a fãcut din punctul de vedere al structurii, compoziþiei elementale ºi morfologiei prin utilizarea tehnicilor

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AES ºi XRD. Comportarea la coroziune a fost investigatã cu ajutorul testelor electrochimice. De asemenea, au fost determinate ºi caracteristicile mecanice, ºi anume: microduritatea Vickers ºi aderenþa. Aºa cum era de aºteptat, proprietãþile depunerilor depind de raportul debitelor masice de gaze reactive. Pentru toate tipurile de depuneri, creºterea conþinutului de oxigen a determinat o scãdere a microduritãþii ºi aderenþei straturilor. Comportarea la coroziune a nichelului a fost semnificativ îmbunãtãþitã prin depunerea cu straturi subþiri de TiOxNy, ZrOxNy ºi TiOxNy/ ZrOxNy. Acoperirile au determinat o scãdere a cantitãþii de ioni eliberate din substrat, comparativ cu cea a unui substrat neacoperit. Structurile multistrat s-au dovedit a fi o barierã de difuzie pentru ioni de Ni eliberaþi din substrat, comparativ cu cele monostrat. Cele mai mari valori ale microduritãþii ºi aderenþei au fost mãsurate pentru depunerile multistrat cu un conþinut scãzut de oxigen. CORROSION AND IONS RELEASE RATE OF NICKEL SUBSTRATES COATED WITH LAYERS OF BIOCOMPATIBLE OXYNITRIDE Coatings deposition is an effective method to improve the durability of the implants used in an aggressive environment. By properly selecting the coating method and materials, the life of the implants can be prolonged. Due to the excellent properties of the transition metal oxynitride coatings, such as high hardness, good wear resistance, chemical stability, corrosion resistance and biocompatibility, they have been extensively investigated in current decade. More recently, titanium oxynitride (TiNxOy) has been attracting attention for its superior mechanical properties and corrosion resistance. In this work, we carried out the deposition of TiOxNy, ZrOxNy and TiOxNy/ ZrOxNy thin films, on Ni substrates, using reactive pulsed magnetron sputtering deposition techniques, at low and high oxygen content in the deposition atmosphere. The films structure, composition and morphology were studied by using AES and XRD techniques. To investigate the corrosion behavior of the coatings, electrochemical measurements were carried out. Mechanical characteristics as Vickers microhardness and adhesion (scratch tests) were also determined. As


ACTUALITÃÞI ÎN BIOMATERIALE expected, the coatings properties depended on ratios of the mass flow rates of the reactive gases. For all coatings, microhardness and adhesion became worse with the increase of the oxygen flow rate. The Ni corrosion behavior was improved by deposition of TiOxNy, ZrOxNy and TiOxNy/ ZrOxNy thin films. Also, as compared with the uncoated samples, a lower ion release from the Ni substrates was found for all coated specimens. As compared with the monolayers, the multilayered structures exhibited a better behaviour as barriers to ion diffusion. The highest microhardness and the best adhesion were measured for the multilayered coatings with low oxygen content. Bibliografie 1. J.N. Ding, Y.G. Meng, S.Z. Wen (2000) – Thin Solid Films 371: 178-82. 2. J. Musil (2000) – Surf. Coat. Technol. 125: 322-30. 3. A. Vlãdescu, A. Kiss, A. Popescu et al. (2008) – J. Nanosci. Nanotechno. 8: 717.

 EVALUAREA COMPARATIVÃ IN VIVO A BIOCOMPATIBILITÃÞII PENTRU DOUÃ IMPLANTURI DE TITAN Carmen E. Cotrutz, Monica Neamþu, Ana Maria Filioreanu, L. Bãdescu , T. Petreuº Universitatea de Medicinã ºi Farmacie “Gr. T. Popa” Iaºi

Cuvinte cheie: biocompatibilitate, þesut periimplantar, imunohistochimie, microscopie electronicã de transmisie. Testarea in vivo este importantã pentru testarea biomaterialelor ca supliment la testarea in vitro. Material ºi metode: Studiul nostru a inclus testarea biocompatibilitãþii unor materiale metalice din titan pe 6 grupe de 10 ºobolani Wistar. Implanturile metalice acoperite ºi neacoperite au fost sterilizate ºi implantate subcutanat. ªobolanii au fost sacrificaþi la 4 sãptãmâni respectiv la 8 sãptãmâni, alãturi de membrii martor. S-au efectuat teste biochimice sangvine ºi teste histologice de evidenþiere a inflamaþiei. Rezultate: S-a remarcat o biocompatibilitate redusã la 4 ºi 8 sãptãmâni respectiv pentru unul dintre implanturile neacoperite, cu alterarea rãspunsului general imun, cu o creºtere moderatã a numãrului de leucocite. Cel mai bun rãspuns imun umoral s-a obþinut pentru implanturile acoperite, toþi parametrii indicând absenþa creºterii numã-

rului de celule inflamatorii (4,78x103 leucocite la 4 sãptãmâni ºi 4,68x103 leucocite la 8 sãptãmâni, comparativ cu 5,66x103 leucocite la 4 sãptãmâni ºi 5,44 x103 leucocite la 8 sãptãmâni la lotul martor) ºi inducþia rãspunsului imunosupresor exprimat printr-o activitate redusã a complementului seric (UHC50 de 52,60 comparativ cu media normalã de 54,05); a fost considerat cel mai biocompatibil. Þesuturile periimplantare pentru implanturile neacoperite prezintã prezenþa moderatã de MMP8 în timp ce pentru implanturile acoperite, þesuturile periimplantare prezintã o marcare redusã pentru MMP8 ºi la 4 ºi la 8 sãptãmâni. Concluzii: Implanturile de titan acoperite prezintã o biocompatibilitate mai bunã in vivo faþã de implanturile neacoperite, ceea ce include un uºor rãspuns imunosupresor, ceea ce poate reprezenta un beneficiu pentru aplicaþii ulterioare in implantarea intraosoasã. COMPARATIVE TESTING IN VIVO OF BIOCOMPATIBILITY FOR TWO TITANIUM IMPLANTS In vivo testing is important for biomaterials testing while in vitro tests cannot replace them, but only can be complementary. Material and methods: In our study, the implant compatibility testing procedure was performed on 6 groups or 10 white Wistar rats each. The metallic coated and uncoated titanium implants were sterilized and implanted subcutaneously. We have performed rat sacrifice at 4 weeks for rats in one group and at 8 weeks for the other 10 rats in the investigated groups, together with witness. We have performed blood tests and histology tests for inflammation signs. Results: We have observed a slightly reduced biocompatibility at 4 and 8 weeks respectively for one uncoated implant, with alteration of the general immune response, with a moderate increased number of WBC (lymphocytes, neutrophils and monocytes). The best humoral immune response was obtained for coated implant, all parameters indicating no increase of inflammatory cells (4,78x103 WBC at 4 weeks and 4,68x103 WBC at 8 weeks respectively, compared to a 5,66x103 WBC at 4 weeks and 5,44 x103 WBC at 8 weeks in witness groups) and induction of immune suppressive effects expressed by a reduced seric complement activity (UCH50 of 52,60 compared to mean normal

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 of 54,05); thus this was considered the most biocompatible implant from all investigated. Periimplant tissues for uncoated implants showed moderate presence of MMP8, while for coated implant we have observed reduced presence of MMP8 either at 4 weeks or at 8 weeks, only perivascular. Thus, the results showed the absence of periimplant tissue inflam-matory reaction for uncoated implants and the best biocompatibility for all coated implants. Conclusions: Zr/ZrCN coated titanium implants shows a better in vivo biocompatibility by subcutaneous application by comparison with un-coated implants, including a slight immuno-suppressive effect, which may be a benefit regarding applications in further bone implantation. Bibliografie James M. Anderson, J. Langone, Issues and perspectives on the biocompatibility and immunotoxicity evaluation of implanted controlled release systems, Journal of Controlled Release, Volume 57, Issue 2, 1 February 1999.

 APRECIEREA ACÞIUNII COLORANTE A UNOR BÃUTURI NEALCOOLICE ASUPRA RêINILOR COMPOZITE DE RESTAURARE DIRECTà PRIN METODE DE ANALIZà COMPUTERIZATà A IMAGINII B. Culic*, Diana Dudea*, V. Prejmerean**, Marioara Moldovan**, Laura Silaghi Dumitrescu**, Anca Mesaros*, Alina Tofan* * U.M.F. Iuliu Haþieganu Cluj-Napoca, ** I.C.C.R.R. Raluca Ripan, U.B.B. Cluj-Napoca“

Cuvinte cheie: rãºini compozite, imagistica medicalã, estetica dentarã. Obiectivul lucrãrii a fost evaluarea modificãrilor de culoare a unor materiale compozite experimentale si comerciale de restaurare directã, supuse unor teste accelerate de colorare prin metode de analiza computerizata a imaginii. S-au realizat 48 de eºantioane din 4 tipuri de rãºini compozite (n= 12), din urmãtoarele materiale: Premise (KerrHawe), Gradia (GC), Napoglass ºi respectiv Radopacril (produse de ICCRR Cluj-Napoca). Probele au fost prelucrate, astfel încât o parte a epruvetei sã prezinte o suprafaþã mai rugoasã, iar cealaltã o suprafaþã lucioasã ºi netedã. Ulterior, fiecare grup s-a împãrþit în 4 subgrupe de câte 3 eºantioane, care au fost imersate dupã un protocol

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standardizat în: 1.saliva artificiala, 2. cafea, 3. bãutura racoritoare carbogazoasa A, cu continut în azorubinã (E 122), Tartrazinã (E 102) ºi Verde Brilliant (E 142) ºi 4. bãutura rãcoritoare necarbogazoasã B cu conþinut în colorant Sunset Yellow (E 110) ºi Tartrazina ( E102) (B). Înainte ºi dupã colorarea acceleratã, eºantioanele au fost fotografiate ºi analizate din punct de vedere al parametrilor de culoare L*, a* , b*, utilizând software-ul DetColorDent (realizat în cadrul UBB Cluj-Napoca), soft care a permis ºi calculul DEab, pentru arii definite la nivelul fiecarui eºantion. Ulterior, s-a calculat DEab mediu pentru fiecare grup analizat. Limitele de variaþie ale modificãrilor de culoare ΔEab au fost cuprinse între urmãtoarele valori: cafea ΔEab =3.55 -11.05, bãutura racoritoare A ΔEab =2.64 -10.99, bãutura racoritoare B=ΔEab 2.34 – 8.42, saliva artificiala ΔEab =1.35 - 3.05. Se constatã cã pentru cele mai multe grupe de eºantioane, efectul colorant cel mai mare îl are cafeaua: excepþie a fãcut compozitul Gradia, în cazul cãruia efectul de colorare maximã s-a obþinut pentru bãutura rãcoritoare B. În toate cazurile, expunerea în saliva artificialã a generat modificãrile de culoare cele mai puþin importante. Cu o singurã excepþie (compozitul Gradia imersat în bãutura rãcoritoare A), în toate cazurile colorarea a fost mai intensã pe suprafeþele lustruite comparativ cu suptafeþele rugoase, indiferent de soluþia de imersare. In concluzie: soluþiile de imersare utilizate au determinat în majoritatea cazurilor, prin protocolul de colorare acceleratã utilizat, o variaþie a culorii ΔEab mai mare decât limita clinic acceptabilã ΔEab 2.7.; metodele de prelucrare a suprafeþei prin lustruire au redus considerabil efectul de colorare; pentru cele mai multe grupe de eºantioane, efectul colorant cel mai mare il are cafeaua.“ ASSESSMENT OF SOFT DRINKS COLORING ACTION ON RESINS DIRECT COMPOSITE RESTAURATION BY MEANS OF COMPUTERIZED IMAGE ANALYSIS Objectives: to assess changes in color of experimental and commercial composite resins due to immersion in soft coloured drinks, using a computerized image analysis method. Material and methods: 48 samples of 4 types of resin composites (n = 12) have been produced,


ACTUALITÃÞI ÎN BIOMATERIALE using: Premise (KerrHawe), Gradia (GC), Napoglass and Radopacril respectively (ICCRR products Cluj-Napoca). Samples were processed in order to obtain one rough and one glossy and smooth surface for each. Subsequently, the main groups were divided into 4 subgroups each with 3 samples, which were submerged after a standardized protocol: 1. saliva artificial 2. Coffee, 3. A carbonated soft drinks, containing the carmoisine (E 122), Tartrazine (E 102) and Brilliant Green (E 142) and 4. B carbonated soft drinks containing the dye Sunset Yellow (E110) and Tartrazine (E102) (B) Before and after accelerated dying process, the samples were photographed and analyzed in terms of color parameters L *, a *, b *, using the software DetColorDent (developed in UBB Cluj-Napoca), software that allowed the calculation of the colour difference DEab, for defined areas within each sample. Subsequently, average DEab was calculated for each group analyzed. Results: The limits of variation of discoloration ranged as follows: ΔEab = 3.55 -11.05 for Coffee, ΔEab = 2.64 -10.99 for refreshments A, ΔEab= 2.34 8.42 for refreshments B, ΔEab = 1.35 - 3.05 for artificial saliva.It is noted that for most groups of samples, the major colouring effect was generated by the coffee; exception was represented by composite Gradia, where the maximum color effect was obtained for refreshments B. In all cases, exposure to artificial saliva caused the color changes less important. With one exception (Gradia composite immersed in a soft drink), in all cases staining was more intense when compared the rough surface with the polished one, regardless of the immersion solution. Conclusion:s 1. During the accelerated staining protocol used, a variation of color ΔEab, higher than the clinically acceptable limits ΔEab 2.7 were determined in most cases. 2. Polishing methods considerably reduced the coloring effect. 3. For most groups of samples, the most important coloring effect was generated by the coffee. Bibliografie C. Kolbeck, M. Rosentritt, R. Lang, G. Handel – Discoloration of facing and restorative composites by UVirradiation and staining food, Dental Materials, Volume 22, Issue 1, Pages 63-68, 2006.

 SUPORTURI POLIMERICE PENTRU RECONSTRUCÞIE OSOASÃ Diana Drãguºin*, Alexandra Mocanu*, Edina Rusen*, D.S. Vasilescu*, I.C. Stancu* * Universitatea Politehnica din Bucureºti

Cuvinte cheie: polimeri, reconstrucþie osoasã, substituenþi osoºi. O serie de structuri polimerice a fost creatã pentru reconstrucþie osoasã sub diverse forme: matrici microporoase cu porozitate interconectatã, acoperiri nanostructurate ºi nanoparticule purtãtoare de peptide de aderenþã celularã ºi factori de creºtere. S-au folosit diverse suporturi polimerice, de la macromolecule biodegradabile precum gelatina ºi alginat la poli(met)acrilaþi nebiodegradabili. Pentru a conferi proprietãþi specifice, s-a apelat atât la copolimerizãri cât ºi la reticulãri. Abordãrile chimice/arhitecturale au fost adaptate pentru a crea substituenþi osoºi. Matricile obþinute au fost caracterizate din punct de vedere al unor parametri specifici; printre cei mai importanþi, porozitatea, proprietãþile biomecanice ºi nanorugozitatea au fost evaluate prin tehnici moderne precum microscopia electronicã de baleiaj, microscopia de forþã atomicã, μ-tomografia, difuzia luminii. Substituenþii osoºi necesitã proprietãþi mecanice apropiate de cele ale osului, pentru a putea rãspunde forþelor la care este supus scheletul. Polimetacrilaþii liniari hidrataþi nu sunt adecvaþi implantãrii în os, însã cei reticulaþi corespund acestei aplicaþii. Structurile poroase sintetizate combinã biocompatibilitate ºi proprietãþi biomecanice cu o microarhitecturã care permite osteoconducþie prin colonizarea implantului cu celule osoase ºi vascularizare. Porozitatea în intervalul 58-66% este apropiatã de cea a osului trabecular. Comportamentul biomecanic este similar cu al xenogrefelor bovine. Celulele osoase sunt obiºnuite cu un mediu înconjurator de dimensiune nanometricã (hidroxiapatita, fibrile de colagen în acest interval dimensional), acesta fiind motivul unui comportament celular superior pe nanomateriale. Suprafeþele nanostructurate ºi nanoparticulele corespund acestor dimensiuni ºi vor fi biofuncþionalizate specific pentru substituþie osoasã. În concluzie, biomaterialele polimerice sintetizate prezintã real potenþial ca substituenþi osoºi.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 POLYMERIC SUPPORTS FOR BONE REPAIR Polymer constructs for bone repair were developed as microporous scaffolds with controlled interconnected porosity, as nanostructured coatings and as nano-beads to be loaded with adhesion peptides and growth factors. Different polymer supports ranging from biodegradable macromolecules such as gelatin and alginate to nonbiodegradable poly(meth)acrylates were used. To confer particular properties, copolymerization or/and cross-linking was used. Various chemical/ architectural approaches were applied in order to best suit the bone replacement requirements. The resulted scaffolds were characterized with respect to specific parameters; among the most important: the porosity, the biomechanical performances and the nano-roughness have been assessed through modern investigation techniques such as Scanning Electron Microscopy, Atomic Force Microscopy, μComputed Tomography and Dynamic Light Scattering. Bone substitutes require mechanical properties close to bone to support strengths exerted on the skeleton. Biomechanical behavior of hydrated linear methacrylates appeared not sufficient for bone implantation and the use of a cross-linker seemed suitable to enhance mechanical properties. The developed porous constructs combine biocompatibility and biomechanical performances with a microarchitecture allowing for osteoconduction through bone cells colonization and vascularization of the implant. Porosity was in the range of 58-66%, close to that of trabecular bone. The biomechanical behavior was similar to that of bovine xenografts. Bone cells are naturally accustomed to nanoscale environment (hydroxyapatite, fibrilar collagen within nano-range) and this is the main reason for enhanced cellular performance on nanomaterials. The nanostructured surfaces and the nano-beads subscribe this dimensional range and are going to be specifically biofunctionalized to best match bone repair application. In conclusion the developed polymer scaffolds present real potential for bone repair. Bibliografie Laurencin, C. T., Ko, F. K., Attawia, M. A., and Borden, M. D. – Studies on the development of a tissue engineered matrix for bone regeneration. Cells and Materials, 1998;8:175-181.

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 AUTOGREFA VERSUS SILICAT CALCIU FOSFAT CA SUBSTITUENT OSOS ÎN PSEUDARTROZE M. Drignei, A. Barbilian Spitalul Clinic de Urgenþã Militar Central „Carol Davila”

Cuvinte cheie: silicat, calciu fosfat, autogrefã, pseudartrozã. Introducere: Autogrefa spongioasã este consideratã standardul de aur în fuziunea osoasã cu rezultate confirmate de mai bine de 50 de ani. Eficacitatea autogrefei osoase este atribuitã proprietãþilor de: osteoconducþie, osteoinducþie ºi osteogenezã. Siliciul a fost identificat în osul imatur ºi a sugerat faptul cã joacã un rol în formarea noului os. În aceastã formã solubilã, siliciul are rol de regulator al sintezei de colagen ºi de stimulator osteoblastic in vitro. Material ºi metodã: Au fost urmãriþi clinic ºi radiologic 11 pacienþi, cu vârste cuprinse între 30 ºi 58 de ani, pe o perioada medie de 2 ani. Pacienþii au fost trataþi dupã acordul scris ºi bine informat al fiecãruia, cu autogrefa din creasta iliacã sau cu silicat, substitut calciu fosfat (Si-CaP) – Actifuse. Dintre cei 2 pacienþi cu pseudartrozã de humerus, unul a fost tratat cu autogrefã ºi cel de-al doilea cu Actifuse. Dintre cei 9 pacienþi cu pseudartrozã de radius sau ulnã au beneficiat de autogrefã 4 ºi 5 de tratament cu Actifuse. Defectul mediu a fost de 1,5 cm iar cantitatea maximã de substituient a fost de 5 ml. Rezultate: Urmãrirea clinicã ºi radiologicã s-a fãcut la intervale stabilite de 1,5 luni, 3, 6, 9 ºi 12 luni. Toþi pacienþii au prezentat consolidare osoasã indiferent de metoda de substituþie osoasã, autogrefã sau Actifuse, dupã o perioadã medie de 1,5 ani, perioada medie de ablaþie a materialului de osteosintezã, placã ºi ºuruburi. În cazul unei pseudartroze de ulnã tratatã cu autogrefã ºi a uneia de radius, tratatã cu SI- CaP a existat o întârziere de consolidare, având drept cauzã o stabilitate insuficientã a montajului, care a fost reluatã. Concluzie: Testele biomecanice, radiologice (computer-tomograf) ºi analiza histologicã, fãcute cu ocazia mãsurãtorii rezultatelor, au aratãt cã SiCaP este echivalent cu autogrefã. În plus, rezultate favorabile au fost obþinute cu Si-CaP prin creºterea volumului de fuzionare într-un timp mai scurt.


ACTUALITÃÞI ÎN BIOMATERIALE AUTOGRAFT VS SILICATE-SUBSTITUTED CALCIUM PHOSPHATE AS A BONE VOID FILLER AFTER PSEUDARTHROSIS Key words: silicate calcium phosphate, autograft, pseudarthrosis. Bibliografie 1. Clinical and radiographic evaluation of silicatesubstituted calcium phosphate ceramic in posterolateral lumbar spinal fusion, Louis G. Genis, Robert Banco, Boston Spine Group, Newton, MA, US. 2. Comparative performance of three ceramic bone graft substitute - Karin Hing, Lester Wilson, Thomas Buchland, The spine journal, vol. 7, Nr. 4, iuly 2007.

 STUDIU CLINIC ªI MORFOLOGIC ASUPRA LEZIUNILOR TUMORALE BENIGNE DE TIP EPULIS Ana Maria Filioreanu, Eugenia Popescu, Carmen E. Cotrutz, Monica Neamþu

of tumoral lesions of epulis. As a general rule, all three pathological types are characterised by a reactive conjunctive stroma which respect the interested teritory (superficial chorion or profound) and in the same time the epithelial modification have a strict reactional character. Particular aspects was observed in each of three types of epulis and concerns the inflamatory infiltration, bone tissue or the disposition of fibrous zones. Bibliografie Sebastian Kühl, R. Schulze, A.Kreft, B.d’Hoedt, Epulis granulomatosa as an oral manifestation of Klippel-Trénaunay syndrome, Journal of Oral Pathology & Medicine, Volume 35 Issue 9, Pages 576 – 578.

 EXPERIENÞA NOASTRÃ ÎN TRATAMENTUL FRACTURILOR CU DEFECTE OSOASE ªI A PSEUDOARTROZELOR S. Florescu, B. Angliþoiu, J.M. Pãtraºcu, I. Popa

Universitatea de Medicinã ºi Farmacie “Gr. T. Popa” Iaºi

Clinica II Ortopedie Traumatologie Timisoara

Cuvinte cheie: epulis, granuloma periferic cu celule gigante, stromã conjunctivã de reacþie. Studiul de faþã a fost realizat pe þesuturi tumorale obþinute prin biopsie excizionalã. Fragmentele, provenind de la subiecþi de diferite vârste, au fost recoltate de la nivelul fibromucoasei gingivale vestibulare fixe. A fost urmãritã evidenþierea particularitãþilor clinico-morfologice a trei tipuri de leziuni tumorale de tip epulis. Ca o regulã generalã, toate cele trei tipuri patologice sunt caracterizate de o stromã conjunctivã de reacþie la nivelul zonei de interes (corionul superficial sau profund) iar în acelaºi timp modificãrile epiteliale au character strict reacþional. Au fost observate câteva aspecte particulare în fiecare dintre cele trei tipuri de epulis care se manifestã printr-un infiltrat inflamator, þesut osos sau depunere de zone fibroase.

Tratamentul fracturilor complicate cu pierderea capitalului osos ºi a pseudartrozelor reprezintã o temã complexã datoritã alegerii tipului de sintezã specific cât ºi problema umplerii defectului osos per primam - în cazul fracturilor complexe sau a lipsei de substanþã rezultatã în urma curei focarului de pseudartrozã. Material ºi metoda: în perioada mai 2007- martie 2008 am tratat în clinica noastrã 8 pacienþi cu defecte osoase postraumatice folosind substituenþi osoºi de tipul hidroxiapatitei monocristaline fãrã autogrefã osoasã, pacienþi ce au fost urmãriþi în medie 18 luni: - 2 fracturi olecran - OSM cu LC Polecranon - 2 fracturi pilon tibial - LCP distal tibiae - 2 pseudartroze diafizã femur - LCP-DCP femur - 1 pseudartrozã diafizã femur-tija zãvorâtã de femur - 1 fracturã periproteticã supracondilianã femur pe fond de pseudoartrozã - LCP distal femural În 4 cazuri s-a optat pentru un abord minim invaziv, celelalte necesitând un abord clasic. Toate cazurile operate au beneficiat de umplerea defectelor osoase cu substituent osos de tipul hidroxiapatitei monocristaline.

CLINICAL AND MORPHOLOGICAL STUDIES ON THE TYPE OF BENIGN TUMOR LESIONS EPULIS The present study was realised on tumoral tissue sections obtained by excisional biopsy. The fragments, from subjects with different ages, was taken from gingival fibromucosa vestibular fixe or oral.The research followed the evidentiation of clinical-morphological particularities of three types

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Rezultatele clinico-radiologice imediate ºi pe termen mediu au fost bune ºi foarte bune. Concluzii: - substituenþii osoºi de tipul hidroxi-apatitei monocristaline se impun ca alternativã fiabilã la autogrefa osoasã rezultatele fiind similar sau chiar superioare acestora mai ales în cazul pacienþilor care refuzã o altã intervenþie de recoltare; - rezultatele postoperatorii depind de abord, de calitatea osteosintezei ºi de umplerea defectului osos cu material suficient de substituþie. Bibliografie 1. Inorganic bone substitutes – Schnettler R, Dingeldein Elvira. 2. Tissue engineering and biodegradable equivalents – scientific and clinical applications – Lewandrowski K-U, Debra J. Trantolo, Yaszemski M. 3. The use of a nanoparticles hydroxylapatite gel as a bone substitute – Schwartz C., Dingeldein Elvira.

 REMODELAREA OSOASÃ PERIPROTETICÃ ÎN ARTROPLASTIA NECIMENTATÃ A ªOLDULUI. EVALUAREA CANTITATIVÃ PE TERMEN SCURT I. Gergely, T.S. Pop, O. Russu, Zuh Sándor, O. Nagy Clinica Ortopedie Traumatologie nr. II, Târgu-Mureº

Cuvinte cheie: remodelarea osoasã, artroplastia necimentatã a ºoldului Introducere: Creºterea osoasã pe suprafaþa poroasã a componentei endoprotetice din canalul femural este consideratã esenþialã în artroplastia necimentatã a ºoldului. În urma implantãrii endoprotezelor necimentate se schimbã nivelul ºi magnitudinea forþelor care acþionezã la interfaþa os-implant. Tipul endoprotezei folosite, respectiv densitatea osoasã preoperatorie ar putea influenþa procesul de remodelare. Scop: Autorii îºi propun cuantificarea procesului de remodelare în jurul componentei femurale necimentate cu ajutorul osteodensitometriei de tip DEXA. Material ºi metodã: Din cazuistica clinicii de Ortopedie ºi Traumatologie nr. II din Târgu-Mureº a fost selectatã o serie consecutivã de 32 de bolnavi cu coxartrozã primarã, la care s-a practicat artroplastia necimentatã. În afara evaluãrii clinice

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ºi radiologice postoperatorii, au fost evaluate ºi modificãrile cantitative din jurul componentelor femurale conform zonelor Gruen cu ajutorul osteodensitometriei de tip DEXA (Lunar), atât precât ºi postoperator la 3, 6 12 ºi 24 luni. Rezultate: La nivelul pãrþii proximale a femurului corespunzãtor zonelor Gruen (1-7) rezultatele la ultima examinare au fost dupã cum urmeazã: în zonele 2-6 densitatea osoasã a crescut în medie cu 13%, în zona 7 a scãzut în medie cu 29%, iar în zona 1 a scãzut în medie cu 6% faþã de densitatea preoperatorie. În mod evident, scãderile evidenþiate nu reprezintã un pericol de stabilitate (pe termen scurt) a tijelor necimentate, dar la o eventualã revizie ar trebui sã se þinã cont de aceastã pierdere de masã osoasã. Concluzii: În evaluarea artroplastiilor necimentate osteodensitometria DEXA este una dintre metodele cele mai precise care ne permite cuantificarea modificãrii masei osoase din jurul componentelor protetice. A QUANTIFYING STUDY OF BONE CHANGES OF THE PROXIMAL FEMUR AFTER TOTAL HIP ARTHROPLASTY. A SHORT TERM STUDY Key words: Bone changes of th eproximal femur, total hip arthroplasty Introduction: Bone ingrowth on a porous coating endoprosthesis is essential for the success of uncemented total hip arthroplasty. The implanted endoprosthesis changes the levels of stress within the proximal part of the femur, causing remodeling in the areas adjacent to the prosthesis. Stem size as well as the initial bonemineral density around the distal portion of the stem may affect postoperative bone remodeling. Aim of study: The purpose of this study was to quantify the rate of bone remodeling around an uncemented femoral component with the use of dual-energy x-ray absorptiometry, at specific intervals after the operation. Material and method: From the patients treated in the Clinic of Orthopedics and Traumatology II Târgu-Mureº, we selected a number of 32 cases of primary arthrosis of the hip that were managed with uncemented total hip arthroplasty. Besides postoperative clinical and radiological assessment, we also evaluated the quantitative changes around the femoral component according to the Gruen


ACTUALITÃÞI ÎN BIOMATERIALE zones, using DEXA-osteodensitometry, both preoperatively and postoperatively (at 3, 6, 12 and 24 months respectively). Results: At the latest follow-up, the results for the Gruen zones 1-7 at the proximal part of the femur were the as follows: in zones 2-6 osseous density was increased by a mean of 13%, in zone 7 it decreased by a mean of 29%, while in zone 1 a mean decrease of 6% was observed. Obviously these decreases in osseous density do not represent a risk for the stability of the uncemented femoral stems (in the short term), but in case of a future revision arthroplasty, these changes should be taken into account. Conclusions: For the assessment of uncemented total hip arthroplasty, DEXA-osteodensitometry is one of the most precise methods that allow the quantification of changes in bone mass that occur around the implanted components. Bibliografie 1. Brodner W., Bizan P., Lomoschitz F., et al. – Changes in bone mineral density in the proximalfemur after cementless total hip arthroplasty: a five-year longitudinal study. J Bone Joint Surg [Br] 2004; 86-B: 20-6. 2. Engh, C.A.; Bobyn, J.D.; and Glassman, A.H. – Porouscoated hip replacement. The factors governing bone ingrowth. stress shielding,and clinical results.J. Bone andJoint Surg., 69-B (1): 45-55, 1987. 3. Martini F., Lebherz C., Mayer F., et al. – Precision of the measurement of periprosthetic bone mineral density in hips with a custom-made femoral stem. J Bone Joint Surg [Br] 2000; 82-B: 1065-71. 4. Rosenthall L., Bobyn J.D., Brooks C.E. – Temporal changes of periprosthetic bone density in patients with a modular noncemented femoral prosthesis. J Arthroplasty 1999; 14:71-6. 5. Wixson R.L, Stulberg S.D., Van Flandern G.J., Puri L. – Maintenance of proximal bone mass with an uncemented femoral stem: analysis with dual-energy x-ray absorptiometry. J Arthroplasty 1997; 12: 365-7.

 STUDII ASUPRA ÎMBUNÃTÃÞIRII FIXÃRII IMPLANTELOR DE ªOLD O. Ghiba, R. Prejbeanu, L. Rusu, D. Vermeºan Departamentul de Mecatronicã, U.P.T.

Cuvinte cheie: proteza ºold, prototipare rapidã, distribuþia tensiunilor. Introducere. Datoritã apariþiei tehnologiei de Prototipare Rapidã (PR) precum Topirea cu Fascicul de Electroni (EBM) implantele ortopedice pot avea o formã mai complexã. Scopul studiului

nostru a fost realizarea unui model teoretic de implant de ºold, cu structuri de tip scaffold pe suprafaþã, care sã permitã îmbunãtãþirea fixãrii acestuia în þesutul osos. Material ºi metodã: Implantul a fost proiectat într-un program CAD ºi simulat în vederea evaluãrii distribuþiei tensiunilor echivalente ºi deformaþiilor totale. Rezultate. S-a observat cã valorile distribuþiei tensiunilor echivalente ºi a deformaþiilor totale la nivelul suprafeþei structurii sunt mai scãzute în cazul structurii cu densitate crescutã aliniatã orizontal. Concluzii: Simulãrile realizate în acest fel ne permit o bunã evaluare a diferitelor tipuri de implante, rezultatele fiind predictibile. Acest tip de abordare a problemelor poate fi utilizat ºi pentru alte tipuri de implanturi. STUDY ON IMPROVING THE HIP IMPLANT FIXATION Key words: hip implants, rapid prototyping. Since the development of rapid prototyping technology like Electron Fascicle Melting, orthopedic implants can have a more complex shape. The purpose of the study was to realize a theoretical hip implant model, with scaffold surface type structures that will allow for improvement of the implant fixation into bone. Method: the implant was made using CAD software and simulated to determine the equivalent tension distribution and total deformation. Results: we observed that the values of equivalent tension distribution and those of total deformation at the surface of the structure are lower for horizontal alignment high density structures. Conclusions: The simulations presented above allow us to better evaluate the diffrent implant types with predictable results. This type of approach can also be used for other types of implants. Bibliografie 1. H. Kusakabe, T. Sakamaki, K. Nihei, et al. – “Osseointegration of a hydroxyapatite-coated multilayered mesh stem”, Disponibil online din 21 Noiembrie 2003: http://www.sciencedirect.com. 2. M. O. Ghiba, L. Rusu, R. Prejbeanu, D. Vermeºan – ”Design process of custom-made femoral stem prosthesis”,

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Annals of the Oradea University, I.M.T. Oradea 2009, în curs de publicare. 3. A. Christensen, A.L. Lippincott, and R. Kircher, “Qualification of Electron Beam Melted (EBM) Ti6Al4V-ELI for Orthopaedic Implant Applications”, Medical Modeling LLC, 2007, www.medicalmodeling.com, U.S.A. 4. P. Cremascoli, U. Lindhe, and P. Ohldin, “New orthopaedic implants produced with Rapid Manufacturing improve people’s quality of life”, Disponibil online: www.arcam.com. 5. M. Taylor, B., and M. Wroblewski, “Effect of Hip Stem Taper on Cement Stresses”, Disponibil online: www.orthosupersite.com.

 ANALIZA DEGRADÃRII ªURUBULUI DE INTERFERENÞà ÎN RECONSTRUCÞIA LIA – STUDIU PROSPECTIV H.G. Haragus, R. Prejbeanu, Fl. Bãrsãºteanu, D. Vermeºan, O. Ghiba Clinica I Ortopedie-Traumatologie S.C.J.U.T.

Cuvinte cheie: orthomed bioabsorbabil, reconstructie LIA, ºurub de interferenþã. Fixarea autogrefonului din semitendinos ºi gracilis cu ºuruburi de interferenþã bioabsorbabile este o procedurã standard în clinica noastrã. Scopul studiului a fost examinarea in vivo a degradãrii ºi biocompatibilitãþii ºurubului de interferenþã bioresorbabil Orthomed pe care îl folosim în principal în ultimii ani. Metoda: studiu prospectiv pe pacienþi selectionaþi randomizat dintre cei operaþi în clinica noastrã pentru reconstrucþie LIA artroscopicã între iulie 2007 ºi iulie 2008 cu fixare femuralã ºi tibiala cu ºurub de interferenþã resorbabil. Din 92 de pacienþi am selecþionat 6 la care am efectuat RMN pre ºi postoperator ºi la 3, 6 si 12 luni, alãturi de mãsurãtoare KT-1000 ºi formular de calitatea vieþii SF-36. Rezultate: la 6, 6 ºi 12 luni ºuruburile au prezentat o scãdere medie de volum de 4.4%, 56.1% ºi 70.9% respectiv. Creºtere osoasã s-a observat la toþi pacienþii. În concluzie, pattern-ul de reabsorbþie al ºurubului Orthomed e paralel cu integrarea autogrefonului. Lotul mic de pacienþi poate genera rezultate nesemnificative statistic.

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ANALISYS OF INTERFERENCE SCREW DEGRADATION IN ACL RECONSTRUCTION – PROSPECTIVE STUDY Key words: orthomed bioabsorbable, ACL reconstruction, interference screws ACL graft fixation with bioabsorbable interference screws is a standard procedure in ligament replacement in our clinic. The aim of this study was to examine the in vivo degradation and biocompatibility of the Orthomed bioabsorbable interference screw that we mainly use for the last several years. Method: we conducted a prospective study on randomly selected patients that were operated in our clinic between July 2007 and July 2008. Arthroscopic single bundle ACL reconstruction was performed using hamstring tendon grafts in all the patients, with the same bioabsorbable interference screw being used for both femoral and tibial fixation. From the total of 92 patients we selected 6 using GraphPad Random Selector. MRI, KT-1000 and SF-36 were performed on all patients preoperatively, postoperatively, at 3, 6 and 12 months after surgery. During the examinations, the volume loss of the screw, tunnel enlargement, presence of osteolysis, fluid lines, edema and postoperative screw replacement by bone tissue were evaluated, as well as ACL stability and patient quality of life. Results: at 3, 6 and 12 months, the screws showed an average volume loss of. Bone ingrowth was observed in all the patients. In conclusion, the resorption behaviour of the Orthomed screw is closely linked to the graft healing process. The screws were resorbed after 6 months and at 12 months. The screws are biocompatible and allow bone ingrowth during resorption. Tunnel enlargement is reduced by bone ingrowth after 12 months. Bibliografie 1. Poly-L-lactic acid - hydroxyapatite (PLLA-HA) bioabsorbable interference screws for tibial graft fixation in anterior cruciate ligament (ACL) reconstruction surgery: MR evaluation of osteointegration and degradation features. Macarini L, Milillo P., Mocci A., Vinci R., Ettorre G.C. Radiol Med. 2008 Dec; 113 (8): 1185-97. Epub 2008 Oct 25. 2. MRI evaluation of the tibial tunnel/screw/tendon interface after ACL reconstruction using a bioabsorbable interference screw. Singhal M.C., Holzhauer M., Powell D., Johnson D.L.Orthopedics. 2008 Jun; 31 (6): 575-9.


ACTUALITÃÞI ÎN BIOMATERIALE 3. Magnetic resonance imaging analysis of the bioabsorbable Milagro interference screw for graft fixation in anterior cruciate ligament reconstruction. Frosch K.H., Sawallich T., Schütze G., Losch A., Walde T., Balcarek P., Konietschke F., Stürmer K.M. 4. Strategies Trauma Limb Reconstr. 2009 Aug 21.

 ACOPERIREA ªI FUNCÞIONALIZAREA NANOPARTICULELOR MAGNETICE UTILIZATE PENTRU APLICAÞII BIOMEDICALE D. Lãptoiu*, R. Marinescu*, I. Antoniac**, C. Cotruþ**, C. Petcu***, C. Corobea*** * Spitalul Clinic Colentina Bucureºti, ** Universitatea Politehnicã din Bucureºti, *** ICECHIM Bucureºti“

Cuvinte cheie: nanoparticule magnetice, vascosuplimentare, imagisticã medicalã, dispozitive medicale. În afarã de dimensiunile lor reduse ºi toxicitatea redusã pentru om, nanoparticulele magnetice (NPM-urile) pot fi transportate printr-un câmp magnetic externe pentru a fi orientate la nivelul þesuturilor umane. În acest fel, este realizabil transportul controlat al substanþelor active cãtre site-urile þintã. Utilizarea finalã este realizatã fie prin ataºarea unui medicament la un carrier biocompatibil NPM, prin injectarea de Ferrofluid în sânge, articulaþii, organe þintã, urmatã de aplicarea unui câmp magnetic extern a se concentra substanþele active / complexele de transport la locul de þintã. Ca exemplu, acest principiu este folosit cu medicamente citotoxice, în tratamente pentru cancer. Vascosuplimentarea controlatã magnetic este un concept nou de tratament bioactiv, care combinã avantajele incontestabile ale terapiei intraarticulare asistatã de un sistem adjuvant de fixare ºi suplimentare a mobilitãþii articulare. S-au sintetizat nanoparticule de tip magnetitã prin procedeul co-precipitãrii în cataliza bazicã prin adaptarea procedeului Massart. Particulele au fost analizate în sistem dispers coloidal prin DLS ºi Potential Zeta arãtând alternanþa sensului câmpului nanoparticulelor ºi dimensiunile acestora. Particulele obþinute prezintã puternice fenomene de autoagregare coloidalã atât în mediul de dipsersie (apa) cât ºi în stare solidã. Ulterior, particule magnetice sintetizate au fost acoperite prin metoda ”layer by layer” cu chitosan ºi acid hialuronic. Analizele DLS

ºi Potential Zeta au confirmat în mod direct depunerea straturilor de chitosan ºi acid hialuronic. Confirmarea indirectã a depunerilor a fost realizatã ºi prin analize DLS, FTIR, SEM ºi EDAX. Prezenþa chitosanului permite modificarea încãrcãrii electrice pe suprafaþa particulelor (de la sarcini negative la sarcini pozitive). Utilizând acest principiu se pot dezvolta ulterioare aplicaþii pe baza selectivitãþii de sarcinã. Stratul de acoperire pe bazã de chitosan permite o stabilizare mai avansatã a particulelor în mediul de dispersie, dar ºi eliminarea fenomenelor puternice de agregare în faza solidã. Acidul hialuronic poate avea un rol complementar pozitiv pentru stabilizarea particulelor acoperite cu primul strat (chitosan). Excesul de acid hialuronic însã poate provoca fenemenele de agregare coloidalã. Particulele cu douã straturi de acoperire (tip magnetitã - chitosan - acid hialuronic), prezintã cea mai bunã stabilitate, distribuþia cea mai îngustã, potenþialul de sarcinã cel mai pozitiv ºi cu cea mai scãzutã tendinþã de agregare coloidalã. Studii ulterioare pot exploata posibilitãþile de optimizare a sintezei în vederea proiectãrii unor anumite dimensiuni sau a proprietãþilor de suprafaþã pe baza modelãrii matematice, dar ºi utilizarea directã a particulelor sub formã de vectori medicamentoºi, particule pentru imagistica medicalã, acoperiri în câmp magnetic, sistem de tip senzor/marker biologic. COVER AND FUNCTIONALISATION OF MAGNETIC NANOPARTICLES USED FOR BIOMEDICAL APPLICATIONS Aside from their small size and low toxicity to humans, MNPs can be transported through an external magnetic field gradient, penetrating deep into the human tissue. In this way, controlled transport of drugs to target sites can be achieved. The latter usage is realized by attaching a drug to a biocompatible MNP carrier, injecting the ferrofluid into the bloodstream, articulation, body organ and applying an external magnetic field to concentrate the drug/carrier complexes at the target site. As one example, this principle is used with cytotoxic drugs in cancer treatments. Magnetically controlled viscosupplimentation is a new bioactive treatment concept, combining the demonstrated effects of intraarticular therapy with a new articular support system. S-type magnetite nanoparticles were synthesized by co-precipitation

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 process in alkaline catalysis by Massart adaptation process. The particles were analyzed in colloidal dispersion system by DLS and Zeta Potential showing alternation of magnetic field noparticles and their size. The obtained particles show powerful auto-aggregation colloidal phenomena both in dipsersion environment (water) and solid. Subsequently, magnetic particles were synthesized covered by the „“layer by layer“„ with chitosan and hyaluronic acid. DLS and Zeta Potential Analysis confirmed the deposit layers of chitosan and hyaluronic acid. Indirect confirmation of the deposit properties was made by DLS analysis, FTIR, SEM and EDAX. The presence of chitosan allows the load change electric particle surface (the tasks negative to positive charges). Using this principle further selectivity based applications can be developed. Chitosan coating based allows an advanced stabilization of particulate in dispersion medium, but also eliminate the phenomena of strong aggregation in the solid phase. Hyaluronic acid may play a complementary role positive to stabilize the particles coated with first layer (chitosan). Excess hyaluronic acid but may cause colloidal aggregation phenomena. Particles with two coatings (type magnetite -chitosan-hyaluronic acid), have the best stability, the narrowest distribution, most positive charge potential and the lowest tendency colloidal aggregation. Further study may exploit opportunities of optimization of synthesis for the design of certain size or surface properties on mathematical modeling, and direct use of particles as drug carriers, particles for medical imaging, coatings field for magnetic sensor system type / biological markers. Bibliografie 1. Frey NA, Peng S, Cheng K, Sun S. Magnetic nanoparticles: synthesis, functionalization, and applications in bioimaging and magnetic energy storage. Chem Soc Rev. 2009 Sep; 38 (9): 2532-4. 2. Epub 2009 Jun 23.; 2: Xie J, Huang J, Li X, Sun S, Chen X. Iron oxide nanoparticle platform for biomedical applications. Curr Med Chem. 2009; 16 (10): 1278-94. 3. De la Fuente JM, Alcántara D, Penadés S. Cell response to magnetic glyconanoparticles: does the carbohydrate matter? IEEE Trans Nanobioscience. 2007 Dec; 6 (4): 275-81. 4. Du L, Chen J, Qi Y, Li D, Yuan C, Lin MC, Yew DT, Kung HF, Yu JC, Lai L. Preparation and biomedical application of a non-polymer coated superparamagnetic nanoparticle. Int J Nanomedicine. 2007; 2 (4): 805-12.

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 UTILIZAREA IMAGISTICII MEDICALE ÎN PROIECTAREA IMPLANTURILOR RESORBABILE D. Lãptoiu*, R. Marinescu*, I. Antoniac**, M. Târcolea**, D. Vlãsceanu**, R. Istrate*** * Spitalul Clinic Colentina Bucureºti, ** Universitatea Politehnicã din Bucureºti, *** MED4MED Bucureºti“

Cuvinte cheie: proiectare computerizatã, imagisticã medicalã, implante resorbabile. Modelarea virtualã este mai mult ºi mai mult folositã ca instrument de evaluare pre-clinicã ºi testare în domeniul biomedical. Metoda este noninvazivã, validat pentru a anticipa comportamentul biomecanic al diverselor aplicaþii ºi poate fi efectuate pentru a obþine informaþii înainte de aplicaþii clinice, sporind astfel eficienþa procesului de proiectare. Imagistica RMN ºi CT pot furniza date cu privire la forma ºi densitatea unui þesut necesare pentru un model virtual de reconstrucþie a ligament încruciºat anterior, cu o grefã os -tendonos patelar. MIMICS10 (Materialize, Belgia) a fost utilizatã pentru a obþine modelul în 3D. Utilizarea procedurii ”thresholding - nivele”, au fost create „“mãºti“„, care au constat dintr-un grup de pixeli în intervalul relevant ale HU’s (valori gri: Hounsfield Units, HU). Odatã ce valorile thresholding sunt alese, programul grupeazã pixeli cu densitãþi în intervalul ales (cum ar fi densitãþi osoase). Modele 3D de suprafaþã au fost realizate reticular, cu triunghiuri folosind Mimcs, apoi o reþea de volum a fost creatã cu elemente de formã tetrahedral, ºi densitatea a fost repartizatã la fiecare element, pe baza HU-lui. Test FEA s-au efectuat cu ANSYS V11 software. Tensiunea iniþialã în tendonul grefã a fost stabilit, respectiv, la corespunzãtoare 0, 20, 40 ºi 60 de N. Aceste tensiuni iniþiale au fost incluse în model în conformitate cu metodologia descrisã de Gardiner ºi Weiss (2003). Diferite modele de implante: ºuruburi (interferenþa cu modele diferite, concepute în CATIA V5 R ºi exportate ca fiºiere *. igs) au fost încãrcate cu o forþã de 200 N regizat de-a lungul axei tunel, o aproximare a tensiunii din grefã la extinderea genunchiului în timpul mersului (Harrington, 1976 citat de precedenþii). Efectele simulãrii implantului - componenta grefã pe peretele tunelului, a izolat


ACTUALITÃÞI ÎN BIOMATERIALE regiuni protejate de stress din tunelele create chirurgical ºi a subliniat zonele care sunt supuse la risc pentru resorbþia osoasã care pot duce la lãrgirea tunelului ºi eºecul implant. Stress-ul maxim a apãrut în regiunea posterioarã de inserare a grefei femurale de la 30 de grade de flexiune, cu valori medii de 12 MPa. Cu toate cã a fost asumat faptul cã o tensiune de 200 N are loc în grefã la extensie completã, aceastã forþã ar putea varia în timpul mersului ºi afecteazã rezultatele testului. USES OF MEDICAL IMAGING IN RESORPTIONS IMPLANT DESIGN Virtual modeling is more and more used as a pre-clinical evaluation and testing tool in the biomedical field. It is a non-invasive method that was validated to predict biomechanical behavior; it can be performed to gain insights before clinical applications, thus increasing the efficiency of the design process. MRI and CT scans can provide data on the shape and density distribution of a tissue required for a virtual model of anterior cruciate ligament replacement with a bone patellar tendonbone graft. MIMICS 10 (Materialise, Belgium) was used to obtain our 3-D model. Using the thresholding procedure, “masks” were created which consisted of a group of pixels within the relevant range of HU’s (gray values: Hounsfield Units, HU). Once appropriate thresholding values are chosen, the program groups pixels with densities within the thresholding range (such as bone densities). The 3D models were surfacemeshed with triangles using Mimics a volume mesh was created with tetrahedral shaped elements, and density was assigned to each element, based on the HU’s. FEA test were conducted with ANSYS v11 software. The initial strain in the tendon graft was set respectively to the corresponding 0, 20, 40 and 60 N of pretension. These initial strains were included in the model following the methodology described in Gardiner and Weiss (2003). Different implant models (interference screws with different designs, designed in Catia V5 R and exported as *.igs files) were loaded with a force of 200 N directed along the tunnel axis, an approximation of the graft tension at full extension of the knee during gait (Harrington, 1976 cited by previous). The simulated effects of the implant - graft component

on the tunnel wall, isolated stress shielded regions from surgically created tunnels and highlighted areas that are at risk for bone resorption that can lead to tunnel widening and implant failure. Maximum principal stress appeared in the posterior region of the femoral insertion of the graft, at 30 degrees of flexion, with average values of 12MPa. Although it was assumed that a 200 N graft force occurs at full extension, this force could vary during gait and affect the stress results. Bibliografie 1. Blankevoort, L., Huiskes, R., 1991 – Ligament-bone interaction in a three-dimensional model of the knee. J. Biomech. Eng. 113, 263–269. 2. Gardiner, J., Weiss, J., 2003 – Subject-specific finite element analysis of the human medial collateral ligament during valgus knee loading. J Orthopeadic Res. 21, 1098–1106. 3. Jacobs, C.R., 1994 – Numerical simulation of bone adaption to mechanical loading. Ph.D. thesis, Stanford University, Stanford,California. 4. Kampen, A.V., Wymenga, A.B., vad der Heide, H.J.L., Bakens, H.J.A.M., 1998. – The effect of different graft tensioning in anterior cruciate ligament reconstruction: a prospective randomized study.J. Arthroscopy 14, 845–850. 5. Lewis, J.L., Lew, W.D., Hill, J.A., Hanley, P., Ohland, K., Kirstukas,S., Hunter, R.E., 1989 – Knee joint motion and ligament forces before and after ACL reconstruction. J. Biomech. Eng. 111, 97–106. 6. Li, G., Gil, J., Kanamori, A., Woo, S.L., 1999 – A validated 3D computational model of a human joint. J. Biomech. Eng. 121, 657–662. 7. Song, Y., Debski, R., Musahl, V., Thomas, M., Woo, S.L.Y., 2004 – A three-dimensional finite element model of the human anterior cruciate ligament: a computational analysis with experimental validation. J. Biomech. 37, 383–390.

 OSTEOTOMIA ONE - STAGE ÎN TRATAMENTUL DISPLAZIEI ªI LUXAÞIEI CONGENITALE DE ªOLD Ilona Laszlo, Zsuzsanna Incze-Bartha, Incze-Bartha Sandor Clinica Ortopedie Traumatologie II

Cuvinte cheie: osteotomie one-stage, displazie, one-stage, ºold, luxatie. Introducere: În DDH târziu diagnostizate atunci, când concomitent cu reducerea chirurgicalã rezolvãm ºi componenta osoasã prin osteotmie de bazin ºi de femur varizare-derotare intertrohanterianã, vorbim despre osteotomia onestage. În studiul nostru prezentãm rezultatele

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 obþinute ºi analizãm dezvoltarea arhitecturalã postoperatorie pe termen mediu. Material ºi metode: În perioada 1995-2008 am efectuat 79 osteotomii one-stage la 68 copii între vârsta de 2,5- 14 ani / vârsta medie de 7,8 ani/, cu o perioada de urmãrire de 1-15 ani / în medie de 8,9 ani/. Gravitatea luxaþiei preoperator am stabilit dupã clasificarea lui Tonnis. Prealabil la 23 de copii a fost efectuatã reducerea sângerândã. Radiologic am urmãrit pre- ºi postoperator modificarea indexului acetabular al lui Hilgenreiner, unghiului Wiberg ºi cel colo-diafizar. Pe termen lung analiza parametrelor radiologice am efectuat dupã criteriile date de Severin, clinic mobilitatea ºoldului operat am apreciat dupã schema lui Fergusson ºi Howorth. Cazurile complicate cu AVN au fost analizate dupã metoda Kruczynski. Rezultate: Postoperator valoarea medie al indexului acetabular ºi al unghiului Wiberg a crescut cu 25° respectiv 23°, iar cel colo-diafizar cu 30°. La sfârºitul perioadei de urmãrire radiologic în 72,2% am obþinut dupã Severin rezultate bune / gr. I. ºi II./. Rezultatele radiologice postoperatorii de gradul de Severin III ºi IV, am obþinut în 47%, dintre care 89% preoperator erau de luxaþie Tonnis III, IV. Clinic am observat o mobilitate acceptabilã ºi bunã al ºoldului în 75%. În 5,8% am notat apariþia AVN- ului, de gr. II./III. în 68% în luxaþiile înalte. Concluzii: Rezultatele radiologice obþinute depind de gradul severitãþii DDH- ului ºi de felul tratamentului aplicat prealabil. Funcþional mobilitatea ºoldului la copii este independentã de rezultatul radiologic. Descoperirea DDH-ului în primele trei luni are o importanþã majorã, în acest scop programul screening prin examinare clinicã ºi ultrasonograficã este necesarã. FOLLOW-UP STUDY AFTER ONE-STAGE OSTEOTOMY IN DDH Key words: one-stage osteotomy, hip, displasyia, DDH The aim of this retrospective study is the presentation of our results and analysis of the postoperative development of the hip after one/stage osteotomy in late detected DDH.

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Material and methods: Between 1995- 2008 we had performed 79 one - stage osteotomies for DDH in 68 children. The patients age at the time of operation was between 2.5-14 years, with the average of 7.8 year, and the medium length followup was 8.7 years (between 1-15 years), 23 patients had previous hip operation. For measuring the severity of the dyspasia we used the Tonnis classification. We evaluated pre- and postoperative the centre-edge angle, of the acetabular index and the CD angle. The radiographic follow-up evaluation was made after Severin`s classification and the hip mobility was evaluated after Fergusson and Howorth. We used the Kruczysnski classification in the case of postoperative avascular necrosis/AVN/. Results: Radiographic assessment showed postoperative improvement of the average centreedge angle by 25°, the acetabular index by 23° and the CD angle by 30°. Radiologically 72.2% of the cases met Severin`s classification grade I-II. In the case of Tonnis III and IV DDH, the post-operative results after Severin`s classification were not so good as in Tonnis I, II, respectively 47% of the cases postoperative were Severin`s III and IV. Clinically 73.4% were classified as excellent and good. The postoperative necrosis rate was 5.8 %. Conclusions: The radiographic results show the relation between preoperative severity and preoperative treatment. Functional results do not correspond in childhood with the radiology. It is important, that if we live in the region with high percentage of late detected DDH the general clinical and ultrasonographic screening program should be used. Bibliografie 1. Tonnis D. - Congenital dislocation of the hip - Avascular necrosis, Thieme – Stratton, 1982. 2. Ozonoff M.B. - Pediatric Orthopedic Radiology, W.B. Saunders Company: Philadelphia, 1992: 181. 3. Banskota A.K., Paudel B., Pradhan I., Bijukachhe B., Vaidya R., Rajbhandary T. - Results of simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip, Kathmandu University Medical Journal, (2005); 1: 6-10. 4. Ahmad A., Richard A., Gengi F., Smith D., Benson M. Reliability of the Severin Classification in the Assessment of Developmental Dysplasia of the Hip, Journal of Pediatric Orthopaedics, (2001); 10 (4): 293-297.


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 STUDII TRIBOLOGICE PENTRU CÂTEVA CUPLE DE MATERIALE UTILIZATE LA PROTEZELE TOTALE DE ªOLD L. Tiberiu*, G. Chiºiu* * Universitatea Politehnicã din Bucureºti

Cuvinte cheie: proteze de ºold, uzurã, UHMWPE. Proteza totalã de ºold introdusã în anii 60’ de Charnley reprezintã cel mai important progres al chirurgiei ortopedice din secolul 20. Cupla de frecare metal-polietilenã a reprezentat un succes clinic dar a fost însoþitã ºi de câteva probleme. Din nefericire, prin uzarea componentei acetabulare din polietilenã UHMWPE (Ultra High Molecular Weight Polyethylene) se genereazã particule microscopice, particule ce pot determina reacþii biologice însoþite de osteolizã. Numeroase studii de laborator au arãtat legãtura dintre rata de uzare a polietilenei ºi starea suprafeþei capului femural protetic. În plus, studiile pe proteze explantate demonstreazã corelarea dintre numãrul de macrofage ºi volumul particulelor de uzurã de polietilenã din þesuturile adiacente. Cu ajutorul unui stand tribologic cu configuraþie ºtift-pe-plan cu miºcare rectlinie oscilantã s-au testat trei perechi de materiale utilizate în mod curent la fabricarea protezelor de ºold: aliaj CoCrMo-UHMWPE, aliaj Ti6Al4V-UHMWPE ºi oþel inoxidabil de tip 316LUHMWPE. S-a utilizat un stand tribologic CETRUMT echipat cu modulul de miºcare rectilinie oscilantã. Pentru fiecare cuplã de materiale s-au derulat teste sub patru sarcini diferite, obþinânduse valori ale presiunii medii de contact de 1, 2, 4 ºi 6 MPa. Fiecare test s-a derulat pe o perioadã de 30 minute cu o frecvenþã a miºcãrii de 1.024 Hz ºi o cursã de 10 mm. Toate problele au fost testate imersate în soluþie Ringer la temperatura de 37°C. În cazul fiecãrei perechi de materiale s-au observat foarte clar douã zone distincte: una care a fost în contact cu frecare cu ºtiftul din UHMWPE ºi cealaltã neatinsã. S-au înregistrat valorile coeficientului de frecare versus timp pentru fiecare caz studiat. Deasemenea, s-a înregistrat ºi evoluþia în timp a uzurii ºtifturilor de UHMWPE, monitorizând apropierea relativã a ºtifturilor de suprafeþele metalice. În toate cazurile studiate s-a observat fenomenul de transfer de material de pe ºtifturile de polietilenã pe suprafeþele metalice.

Coeficienþii de frecare ºi uzura prezintã valori distincte ce diferenþiazã clar din punct de vedere al proprietãþilor tribologice perechile de materiale studiate. Sunt evidenþiate proprietãþile superioare ale cuplei aliaj CoCrMo-UHMWPE în comparaþie cu celelalte douã studiate. TRIBIOLOGICAL STUDIES FOR SEVERAL MATERIALS COUPLINGS FOR TOTAL HIP PROSTHESES The total hip replacement operation introduced by Charnley in the 1960s is the major achievement of orthopedic surgery in the 20th century. The friction couple metal-on-polyethylene was featured successfully clinical, but it had a few problems. Unfortunately, wear of the polyethylene acetabular component articulating against hard metallic or ceramic femoral heads leads to the generation of UHMWPE particles that can trigger a biological reaction followed by osteolysis. Laboratory studies have shown that there is a clear dependency between polyethylene wear rate and femoral head damage and roughness. Retrieval studies have clearly demonstrated a correlation between the number of macrophages and the volume of UHMWPE debris in the tissues adjacent to areas of aggressive osteolysis. The aim of this study is to determine the tribological behavior of metallic materials like CoCrMo, titanium alloy and stainless steel against UHMWPE. A pin-on-flat configuration with reciprocating motion was used to test three commonly used friction couples: CoCrMo-UHMWPE, Ti6Al4V-UHMWPE and 316L stainless steel -UHMWPE. The test machine was a CETR-UMT equipped with the reciprocation module. For each friction couple four different loads were applied in order to obtain mean contact pressures of 1, 2, 4 and 6 MPa respectively. Each test was run for 30 min with a motion frequency of 1.024 Hz and a stroke of 10 mm. The samples were immersed in Ringer solution maintained at 37°C. For each material it was observed two distinct areas: one that was in contact with the UHMWPE pin and the other that was not in contact and shows the initial state of the surface. Values for the friction coefficient versus time for each friction pair were recorded. Wear of each UHMWPE pin was monitored by recording its vertical position relative to the flat metallic surface. In all cases a material transfer phenomenon from the plastic pin

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 to the metallic surfaces was observed. Distinct values for friction coefficient and wear were observed among the three material couples. They clearly point out the superior tribological behavior of CoCrMo-UHMWPE by comparison with the other two pairs. Bibliografie 1. Elfick, A. P. D. and Green, S. M. and Krikler, S. and Unsworth, A. (2003) – The nature and dissemination of UHMWPE wear debris retrieved from periprosthetic tissue of THR.’, Journal of biomedical materials research part A., 65A (1). pp. 95-108.

 SINTEZA DE MATERIALE DENTARE PE BAZÃ DE MONOMERI METACRILICI MEDIATÃ DE ORGANOGELIFIANÞI A. Lungu*, N. M. ªulcã*, R. L. Stan*, H. Iovu* * Facultatea de Chimie Aplicatã ºi ªtiinþa Materialelor, Universitatea Politehnicã Bucureºti

Cuvinte cheie: biomateriale dentare; monomeri metacrilici. Organogelifianþii sunt compuºi cu masa molecularã micã care se pot organiza într-o reþea 3D nanofibrilarã. Dibenziliden sorbitolul (DBS) este un cunoscut agent de gelifiere care poate induce gelifierea fizicã pentru o gamã foarte variatã de solvenþi organici ºi monomeri (mono- ºi difuncþionali). 1. S-a sintetizat un compus funcþionalizat pornindu-se de la D-sorbitol (IEM-DBS) prin modificarea DBS cu izocianatoetilmetacrilat (IEM). 2. Scopul acestui studiu constã în utilizarea acestor compuºi ca aditivi în procesul de fotopolimerizare a unor monomeri dimetacrilaþi – Bisfenol A Glicidil metacrilat (Bis-GMA), Uretan dimetacrilat (UDMA) pentru a îmbunãtãþi unele proprietãþi ale materialelor precum conversia dublelor legãturi din grupãrile metacrilice ºi/sau proprietãþile termo-mecanice. Influenþa DBS/ IEMDBS asupra gradului de conversie a grupãrilor metacrilice din matricea polimericã s-a monitorizat prin spectroscopie FT-IR. S-a realizat ºi o caracterizare termicã prin DMA si TGA. În continuare s-a efectuat ºi o analiza morfologicã a sistemelor prin SEM ºi MO. Rezultatele obþinute în urma studiului cinetic prin FT-IR confirmã ipotezã cã adãugarea unei anumite cantitãþi de organogelifiant poate determina creºterea conversiei grupãrilor meta-crilice. Capacitatea de gelifiere a

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organo-gelifiantului conduce la o creºtere a conversiei dublelor legãturi în timpul procesului de fotopolimerizare a monomerilor dimetacrilaþi folosiþi pentru obþinerea materialelor dentare, datoritã efectului “TROMMSDORFF”. Imaginile SEM aratã cã prezenþa organogelifiantului transformã structura relativ omogenã a matricei polimerice într-o structurã mai puþin compactã. SYNTHESIS OF DENTAL MATERIALS BASED ON METHACRYLIC MANOMERS MEDIATED BY ORGANOGELATORS An organogelator is a low molecular compound, which is capable to self-assemble into a 3D nanofibrillar network. Dibenzylidene sorbitol (DBS) is known as a versatile gelling agent which promotes physical gelation in a variety of organic solvents and monomers (mono- and difunctional) 1. A functionalized D-sorbitol based organogelator (IEM-DBS) was synthesized from DBS and isocyanatoethylmethacrylate (IEM) 2. The aim of this study was to use these compounds as additives in the photopolymerization of several dimethacrylate monomers - Bisphenol A Glycidyl methacrylate (Bis-GMA), Urethane dimethacrylate (UDMA) in order to improve some of the material’s properties like vinyl conversion of the metacrylates groups and/or thermo- mechanical properties. The influence of DBS/ IEM-DBS on the degree of conversion of methacrylic groups from the polymeric matrix was monitored by FT-IR spectroscopy. A thermal characterization was made by DMA and TGA. The systems were morphologically characterized by SEM and OM. The obtained results after the FTIR kinetic, confirm the hypothesis that the addition of a certain amount of organogelator, leads to a higher conversion of metacrylic groups. The gelation ability of the organogelator increases vinyl conversion for photopolymerization of dimethacrylate monomers used for dental materials, due to the “TROMMSDORFF” effect. The SEM images show that the presences of the organogelator convert the relatively homogeneous structure of the polymeric matrix into a less compact structure. Bibliografie 1. E. A. Wilder, K. S. Wilson, J. B. Quinn, D. Skrtic, J. M. Antonucci, Chem.Mater., 2005, 17, 2946-2952.; 2. R. Stan, C. Ott, N. ªulcã, A. Lungu, H. Iovu, Mat. Plast., acceptat 2009.


ACTUALITÃÞI ÎN BIOMATERIALE

 EFECTUL OSTEOTOMIE DE DESCHIDERE TIBIALE (FOLOSIND SPACER DE CIMENT) ASUPRA PANTEI PLATOULUI TIBIAL ªI PRESIUNE DE CONTACT LA NIVELUL PLATOULUI TIBIAL N. Mihailide, L. Tiberiu, M. Calciu, ªt. Mogoº, V. Sufletu Spitalul Clinic de Ortopedie ºi T.B.C. articular „Foiºor”

Cuvinte cheie: osteotomie de deschidere, pantei platoului tibial, spacer de ciment Între anii 1996-2009 autorii au efectuat mai mult de 300 de osteotomii de deschidere tibiale superioare conform tehnicii originale GoutallierHernigou care foloseºte un “ic” de ciment pentru a obþine corecþia în plan frontal a deformãrii în genum varum (din 1998 cea mai mare parte a osteotomiilor au fost precedate de o evaluare artroscopicã a genunchiului implicat). Studii recent publicate au sugerat cã ODT poate creºte în mod semnificativ înclinarea platoului tibial în ciuda corecþiei în plan frontal, observaþii care nu sunt congruente cu experienþa noastrã clinicã. Autorii au efectuat un studiu comparativ pe 100 de cazuri de ODT atent selectate pentru a observa dacã existã modificãri ale înclinaþiei platoului tibial postoperator, înainte de îndepãrtarea plãcilor ºi ºuruburilor ºi la 5 ani dupã intervenþie. De asemenea, a fost studiat modul în care poziþia “ic-ului”de ciment (situat anterior sau posterior), înãlþimea ic-ului de ciment ºi mãrimea metafizei tibiale pot influenþa înclinaþia platoului tibial. Rezultatele au fost comparate cu un model teoretic computerizat care a permis determinarea celei mai adecvate poziþii pentru ic-ul de ciment în fiecare caz, ceea ce a dus la obþinerea unei înclinaþii optime a platoului tibial. Concluzii: unul dintre avantajele tehnicii ODT folosind ic de ciment (aºa cum au descris-o Goutallier ºi Hernigou), dincolo de simplitate ºi acurateþe, este ca poziþionarea diferitã a ic-ului de ciment poate influenþa rezultatele pe termen lung ale procedurii chirurgicale prin realizarea unor condiþii geometrice adaptate paternului regional.

THE EFFECT OF OPEN-WEDGE HIGH TIBIAL OSTEOTOMY (USING A CEMENT SPACER) ON THE TIBIAL SLOPE AND TIBIAL PLATEAU CONTACT PRESSURE Key words: open-wedge high tibial osteotomy, cement spacer, tibial slope The authors have performed since 1996 up to 2009 more than 300 high tibial osteotomies (HTO) following the original Goutallier-Hernigou technique which uses a cement block wedge in order to achieve the desired frontal plane correction of genu varum deformities (since 1998 almost all osteotomies were preceded by an arthroscopic evaluation of the involved knee). Recently published studies suggested that open wedge osteotomies could significantly increase the posterior tibial slope, regardless of the degree of correction in the frontal plane and metaphiseal size, observations that did not match our experience. The authors have studied comparatively 100 adequately selected cases of HTO in order to establish if there was any change of the tibial slope postoperatively, before plate and screws removal and at five years after the intervention. We have also studied the influence of the cement wedge positioning (more anteriorly or posteriorly) of the height of the cement block (needed in order to achieve a proper correction) and of the tibial metaphisis size at the site of the osteotomy on the tibial slope. The results were then compared to a theoretical computer-based model that allowed us to determine the most adequate position of the cement wedge for each case that would lead to a more appropriate tibial plateau loading after HTO that would best fit our arthroscopic preoperative findings. Conclusion: one of the advantages of the HTO using a cement block (as described by Goutallier and Hernigou), apart its simplicity and accuracy, is that a different positioning of the cement wedge can influence the long-term outcome of the surgical procedure by achieving different geometrical conditions that lead to more adequate tibial plateau regional loading patterns. Bibliografie 1. Bauer G.C., Insall J., Koshino T. – Tibial osteotomy in gonarthrosis (osteo-arthritis of the knee). J Bone Joint Surg Am. 1969; 51: 1545-63.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 2. Coventry M.B., Ilstrup D.M., Wallrichs S.L. – Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am. 1993; 75: 196-201. 3. Hernigou .P, Medevielle D., Debeyre J., Goutallier D. – Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am. 1987; 69: 332-54. 4. Koshino T., Murase T., Saito T. – Medial opening-wedge high tibial osteotomy with use of porous hydroxyapatite to treat medial compartment osteoarthritis of the knee. J Bone Joint Surg Am. 2003; 85-A: 78-85. 5. Marti C.B., Gautier E., Wachtl S.W., Jakob R.P. – Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy. 2004; 20: 366-72. 6. Hernigou P., Ma W. – Open wedge tibial osteotomy with acrylic bone cement as bone substitute. Knee. 2001; 8: 103-10.

 CERCETÃRI PRIVIND COMPATIBILITATEA TERMICÃ ÎN CUPLURILE METAL-CERAMICÃ PENTRU IMPLANTURI DENTARE M. Miculescu*, D. Bojin*, I. Antoniac*, F. Miculescu*, M. Târcolea* * Universitatea Politehnicã din Bucureºti“

Cuvinte cheie: compatibilitate termicã, metaloceramicã. Implanturile dentare pot prezenta diverse morfologii dar cea mai des studiatã este aceea a unui ºurub din titan pur sau aliaj de titan trecând prin placa corticalã externã a mandibulei sau maxilarului în osul trabecular intern. Implanturile au în general diametrul de 3,3-6 mm ºi lungimea de 7-20 mm. Pânã în prezent au fost realizate studii privind transferul termic al cãldurii prin implanturile dentare, dar þinându-se cont doar de partea metalicã a acestora. Temperatura hranei care intrã în contact cu implantul poate varia de la cea a unei bãuturi cu gheaþã pânã la cea a supei fierbinþi, adicã temperaturi ale structurilor intra-orale cuprinse între 0 ºi 70°C. Cantitatea de cãldurã transferata de la hrana la mucoasã, limba ºi partea expusã a dinþilor sau protezelor depinde însã de tipul ºi temperatura materiei precum ºi de durata contactului. Odatã cu creºterea temperaturii la interfaþa metal ceramicã vor apãrea tensiuni, care în funcþie de duratã ºi intensitatea lor pot duce la crãparea pãrþii ceramice ºi deci distrugerea protezei. Coeficientul de dilatare termica liniarã/ volumicã este unul dintre cei mai importanþi parametrii necesari în stabilirea cuplurilor metaloceramice optime. Metoda de determinare a

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acestora presupune utilizarea unui dilatometru vertical în mod de lucru diferenþial utilizând un etalon de monocristal de safir, regimul de încãlzirerãcire programat variind între de 5 ºi 50°C/min. Pornind de la aceste premise am conceput un program de determinare a coeficienþilor de dilatare pentru un set de 4 tipuri de ceramice utilizate în mod curent în implantologia oralã în combinaþie cu Ti pur ºi un aliaj TiAlV, coroborat cu determinãri ale difuzivitãþii termice ale aceloraºi materiale, proprietate ce furnizeazã date foarte utile în studiul potenþialului unui material de a transfera cãldura. În prezenta lucrare se studiazã compatibilitatea metalo-ceramicã din punct de vedere termic, în sensul stabilirii unui cuplu metal-ceramicã cu coeficienþi de dilatare apropiaþi dintre materialele frecvent utilizate in implantologia oralã. RESEARCHES ON THERMAL COMPATIBILITY IN METALL-CERAMIC COUPLES FOR DENTAL IMPLANT Dental implants can present different morphologies but most often studied is that of a pure titanium screw and titanium alloy passing through the external cortical plate of the mandible or jaw internal cancellous bone. Implants generally have a diameter of 3,3-6 mm and 7-20 mm long. To this date studies have been conducted regarding the termal transfer of the heat through dental implants, but taking into account only the metal part of the implant. Temperature of food in contact with the implant may vary from that of a ice beverage to that of hot soup meaning structure of intra-oral temperature between 0 and 70°C. The amount of heat transferred from food to the mucosa, tongue and the teeth or prothesis exposed to, depends on the type and material temperature and duration of contact. With temperature increasing on the metal ceramic interface, strains will appear and depending on their duration and intensity, can lead to cracking of the ceramic and thus destroy of the prosthesis. The linear thermal expansion/volume coefficient of is one of the most important parameters necessary to establish optimal metalceramic couples. Determining method assume the use of a drop in work differential dilatometer using a standard monocrystal of sapphire, heatingcooling system programmed range between 5 and 50°C/min. Based on these premises we designed a program for determining the expansion coefficients


ACTUALITÃÞI ÎN BIOMATERIALE for a set of 4 types of ceramics commonly used in oral implantology in combination with pure Ti and an TiAlV alloy, toghether with determinations of heat diffusivity of the same materials, property which provides very useful data in the study a material potential to transfer heat. In this paper it is studied the compatibility of metal-ceramic in terms of heat, in the purpose of establishing a metalceramic couple with expansion coefficients close among the materials commonly used in oral implantology. Bibliografie 1. Fan, P.L. (1991) – Porcelain repair materials. Council on dental materials, instrument and equipment prepared at the request of the council. Journal of American Dental Association, 122, 124. 2. Farah, J.W. & CRAIG, R.G. (1975) – Distribution of stresses in porcelain fused to metal and porcelain jacket crowns. Journal of Dental Research, 54, 255.

 COMPATIBILITATEA TERMICÃ ÎNTRE ALIAJELOR NI-CR ªI CERAMICA DENTARÃ M. Miculescu*, D. Bojin*, I. Antoniac*, F. Miculescu*, M. Brânzei* Universitatea Politehnicã din Bucureºti

Cuvinte cheie: aplicaþii stomatologice, metaloceramicã. Restaurãrile metalo-ceramice sunt studiate intens în literaturã, existând câteva teorii clare privind interacþiunea dintre acestea. THERMAL COMPATIBILITY BETWEEN NI-CR ALLOYS AND DENTAL CERAMICS Metal-ceramic restorations are commonly received, and several theories concerning the interfacial adherence of the metal-ceramic system have been introduced. However, there are also disadvantages such as occasional failures of the veneer. Moreover, the metallic coping can be distorted after the porcelain application. Usually, to evaluate the thermal compatibility of the metalceramic system, the discrepancy of the thermal expansion coefficients is first considered. However, some dental alloys with the same thermal expansion coefficients showed different residual stresses in metal-ceramic interface after firing, which might be caused by the large difference in elastic modulus. Although the metal-ceramic

interface is difficult to understand, metal-ceramic restorations must be exactly designed, and wellmatched materials should be correctly handled. NiCr is well known as a useful biomaterial, having strong reactivity to non-metallic elements, such as oxygen, hydrogen, and nitrogen, at high temperatures. The high melting temperature and chemical reactivity at high temperature of NiCr cause problems, when dental ceramics are fused to NiCr. Thus, although commercial NiCr ceramic systems are available today, they still have unsolved problems related to the fusing of dental ceramics to them. The aim of this study is to evaluate the thermal compatibility in ceramic NPNiCr systems, (ceramic fused to commercially NiCr alloy) and to determine the effective thermal contraction difference. Bibliografie Bergman B., Marklund S., Nilson H., Hedlund S.O., (1999), An intraindividual clinical comparison of 2 metal-ceramic systems, Int J Prosthodont 12, 444 -447.

 COMPOZITE METACRILICE – STRUCTURÃ ªI PROPRIETÃÞI MECANICE M. Moldovan*, M. Trif*, V. Popescu**, C. Sarosi*, G. Popescu**, I. Cojocaru***, S. Boboia* * Universitatea Babeº Bolyai – Institutul de Cercetãri în Chimie “Raluca Ripan”, Cluj-Napoca, ** Universitatea Tehnicã din ClujNapoca, *** Universitatea din Craiova

Cuvinte cheie: compozite dentare, micro-structura, proprietãþi mecanice. Polimerii cu proprietãþi speciale reprezintã punctul de plecare pentru obþinerea unei game largi de noi materiale cu utilizãri în domenii variate. Scopul actualului studiu este de a urmãrii efectul unor nanoumpluturi asupra proprietãþilor mecanice prin determinarea, rezistenþei la compresie (RS), tractiune (RT), incovoiere (RI) ºi studiul structurii prin microscopie electrinicã (SEM) pentru 6 materiale compozite experimentale. Componenta lichidã a compozitului metacrilic este formatã din metacrilat de metil comercial (Merck), monomer de reticulare BisGMA - C29 H36 O28 - 2,2-bis (4-(2-hidroxi-3metacriloxi-propoxi)-fenil)-propanol (sintetizat la UBB-ICCRR - Cluj-Napoca)) ºi activatorul de polimerizare (N,N-dimetil-p-toluidinã (Merck)). Componenþã solidã sub formã de pulbere a fost

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 obþinutã prin amestecarea pulberilor de polimetcrilat de metil cu pulberile de TiO2 ºi hidroxilapatitã (HAp) si un activator de initiere peroxidic.Dupã preparare pastele compozite autopolimerizabile au fost întãrite sub forma unor epruvete standard, realizate în matriþe de teflon de construcþie specialã pentru detrminarea proprietãþilor mecanice (RS, RT, RI). Determinãrile au fost executate pe un aparat universal de încercãri mecanice LLOYD LR5K Plus si microscopul electronic scanning QUANTA 133 a companiei FEI. Adãugarea pulberilor TiO2 ºi hidroxilapatitã a condus la modificarea microstructurii PMMA-ului (care este un material poros) ºi acest lucru este esenþial pentru a obþine o performanþã a proprietãþilor mecanice. Proprietãþile mecanice cresc cu creºterea în gradului de umplere ºi diferã funcþie de compoziþia umpluturii. În toate cazurile, încorporarea particulelor de dioxid de titan ºi hidroxilapatitã, îmbunãtãþeºte modul de stocare a compozitelor cu PMMA ºi îmbunãtãþeºte proprietãþile mecanice. Aceste performanþe sporite sunt realizate de cãtre o dispersie bunã a particulelor anorganice selectate în matrice de polimeri. Utilizarea particulelor mai mici, creeazã posibilitatea minimizãrii spaþiului dintre particule ºi o aranjare a particulelor mai uniformã. Imaginile SEM pentru compozitele cu PMMA-TiO2 ºi PMMA-HAp aratã structuri compacte, particulele de umpluturã sunt bine încorporate în matricea organicã ºi asigurã compozitelor duritate. Aceste perfomanþe la care se adaugã o polizabilitate bunã sunt atribuite atât naturii sferice a unor particule de PMMA, cât ºi a distribuþiei granulometrice largi, fapt ce permite în procesul de realizare a materialului compozit o bunã aranjare a particulelor în amestecul de monomeri ºi un grad de ºarjare mare. Cele mai bune rezultate s-au obþinut în acest studiu cu 33% HAp - 30% PMMA combinaþie care comparatã cu compozitul cu PMMA 60% creºte ºi este comparabilã cu valorile obþinute cu alte sisteme similare, într-o concentraþie aproximativã. METHACRYLIC COMPOSITES – STRUCTURES AND MECHANICAL PROPERTIES The polymers with special properties represent the starting point in order to obtain a wide range of new materials used in various fields of activity. The purpose of the present study is to observe the effect of some nanofillings on the mechanical properties

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by determining the compression strength (CS), diametral tensile strength (DTS), flexural strength (FS) and by establishing the structure of six experimental composite materials. The liquid component of the methacrylic composite is made of commercial methyl methacrylate (Merck), reticulation monomer Bis-GMA - C29H36O28 - 2,2bis (2-hydroxy-3-methacryloxy-propoxy) phenyl)propanol (synthesized at UBB-ICCRR - ClujNapoca), and the polymerization activator (N,Ndimethyl-p-toluide (Merck)). The solid component in the form of powder was obtained by mixing the methyl methacrylate powders with TiO2 ºi hydroxyapatite (HAp) powders and a peroxide initiation activator. After preparation, the selfcured composite pastes were hardened in the shape of some standard test pieces, made in speciallyconstructed Teflon matrices in order to measure the mechanical properties (CS, DTS, FS). The determinations were carried out with the help of a universal device for mechanical trials LLOYD LR5K Plus, and the electronic microscope scanning QUANTA 133 from FEI Company. The addition of TiO2 ºi hydroxyapatite powders has led to a change in the PMMA structure (which is a porous material) and this is essential in order to obtain a performance of the mechanical properties. The mechanical properties rise with the increase in the degree of filling and differ according to the composition of the filling. In all cases, the incorporation of the titanium dioxide and hydroxyapatite improves the storage mode of the composites with PMMA and improves the mechanical properties. These increased performances are achieved by a good dispersion of the inorganic particles selected in a polymer matrix. The use of smaller particles creates the possibility to minimize the space between the particles and to have a more even arrangement of the particles. The SEM images for the composites with PMMA-TiO2 and PMMA-HAp show compact structures, the filling particles are well incorporated in the organic matrix and give hardness to the composites. These performances, besides good polizability, are due both to the spherical nature of some PMMA particles and to the large granulometric distribution, which allows for a good arrangement of the particles in the monomer structure and a high charging degree in the process of making the composite material. The best results have been


ACTUALITÃÞI ÎN BIOMATERIALE obtained with 33% HAp – 30% PMMA, combination which, compared to the composite with PMMA 60%, increases and is comparable to the values obtained in other similar systems, in an approximate concentration. Bibliografie Ottenbrite, R. M. (ed) – Frontiers in Biomedical Polymer Applications, vol. 1, Technomic Publishing Company, Inc., Lancaster (1998).

 TRATAMENTUL OSTEOLIZEI PERIPROTETICE PRIN ADMINISTRAREA LOCALÃ A BISFOSFONAÞILOR J. Neamþu, F. Sima, C. Ristoscu, C. N. Mihãilescu, I.N. Mihãilescu Universitatea de Medicinã ºi Farmacie, Craiova

Cuvinte cheie: protezã, osteolizã, bisfosfonaþi, MAPLE. Prevenirea osteolizei periprotetice a determinat iniþierea unor ample programe de cercetare care sã aibã ca rezultat final grãbirea osteointegrãrii, ducând astfel la o mai bunã fixare a protezei ºi implicit la creºterea duratei de viaþã a acesteia. Evitarea pierderii osoase periprotetice a pus, însã, accentul ºi pe scheme terapeutice ce utilizeazã medicamente cu acþiune antiresorbtivã. O clasã de medicamente cu acþiune antiresorbtivã, cunoscutã ca inhibitoare a activitãþii osteoclastice este cea a bisfosfonaþilor (BP). Medicamentele din aceastã clasã sunt cunoscute ca inhibitoare ale activitãþii osteoclastice fiind des utilizate într-o serie de boli osoase (boala Paget, osteoporozã, hipercalcemie). Studiile preclinice aratã o creºtere substanþialã a densitãþii osoase minerale din zona periproteticã doar în cazul unei doze mari, comparabile cu cele administrate pacienþilor cu afecþiuni tumorale. Pe de altã parte efectul tratamentului este pus în evidenþã abia la 3 luni de la administrare, timp în care studiile clinice aratã o reducere a volumului osos din zona periproteticã cu pânã la 15%. Pentru a evita aceastã pierdere osoasã ºi unele efecte secundare raportate la tratamentul pe termen lung (osteonecroza gingiilor), o soluþie studiatã frecvent în ultimii ani este cedarea locala a BP. Dintre soluþiile de includere a BP pe suprafaþa protezei am optat în aceastã lucare pentru folosirea unei tehnici de depunere MAPLE, care permit transferul cu

succes al unui compozit HA-alendronat, pe suprafaþa unor substraturi din titan. Analizele XRD ºi cele de microscopie SEM ºi AFM aratã cã filmele astfel obþinute sunt cristaline ºi au o structura poroasã. În acelaºi timp testele biochimice efectuate pe culturi de osteoblaste ºi osteoclaste umane aratã o inhibare a activitãþii osteoclastice însoþitã ºi de o proliferare osteoblasticã. LOCAL ADMINISTRATION OF BIPHOSPHONATES FOR THE TREATMENT OF PERIPROSTHETIC OSTEOLYSIS Cuvinte cheie: prosthesis, osteolysis, biphosphonates, MAPLE The prevention of periprosthetic osteolysis has provoked the launch of systematic research programs aiming for the fast osteointegration which could better fix and prolong the lifetime of the implanted prosthesis. In order to avoid the bone periprosthetic loss, there is a grown interest in the use of drugs with antiresorbable action. Biphosphonates (BPs) stand for a class of drugs which inhibit the osteoclasts activity. They are therefore currently used in some bone diseases cure as Paget bone disease, osteoporosis, or hypercalcemia. However, the preclinical studies evidenced an important increase of mineral bone density in the periprosthetic region but only in cases of high concentrated doses, similar with those administrated to patients with tumoral affections. On the other hand, the effect of treatment becomes obvious 3 months after administration when the clinical studies reveal a reduction of the bone volume with up to 15% in respect with the periprosthetic region. To overlap the bone loss and secondary effects caused by long term treatment (as e.g. gingival osteonecrosis) one challenging approach is the local administration of BPs. We used, to our acknowledge for the first time, the matrix assisted pulsed laser evaporation (MAPLE) to coat Ti based implants with thin film nanostructures of hydroxyapatite-alendronate composites for the local administration of BP. XRD investigations along with SEM and AFM studies demonstrated that the synthesized films were crystalline and have a porous structure. Also, the in vitro studies proved the expected inhibition of osteoclasts activity along with the proliferation of osteoblasts.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Bibliografie 1. Boanini E., Torricelli P., Gazzano M., Giardino R., Bigi A. – Alendronate hydroxyapatite nanocomposites and their interaction with osteoclasts and osteoblast like cells. Biomaterials 2008; 29: 790-796. 2. Peter B., Pioletti D.P., Laib S., Bujoli B., Pilet P., Janvier P., et al. – Calcium phosphate drug delivery system: influence of local zoledronate release on bone implant osteointegration. Bone 2005; 36: 52-60.

 IMPLICAREA MMP8 ÎN RÃSPUNSUL TISULAR Monica Neamþu, Carmen E. Cotrutz, T. Petreuº, A. Neamþu, Ana Maria Filioreanu Universitatea de Medicina ºi Farmacie “Gr. T. Popa” Iaºi

Cuvinte cheie: MMP-8, plase colagenate, biocompatibilitate, regenerare. Matricea extracelularã reprezintã un sistem suport pentru celule ºi de asemenea un rezervor de citokine ºi factori de creºtere. Metaloproteinazele matriciale (MMP-urile) sunt implicate în remodelarea þesutului conjunctiv în timpul vindecãrii leziunilor precum ºi pe parcursul dezvoltãrii embrionare, angiogenezei sau creºterii osoase. În timpul proceselor de regenerare, fibroblastele ºi macrofagele reprezintã o sursã importantã de sintezã a MMP. MMP-8 denumitã ºi colagenaza 2 este o colagenazã de tip I, implicatã în procesul de regenerare lezionalã. Acest tip de colagenazã este produs în special de cãtre neutrofile la nivelul granulelor secretoare. Expresia sa devine evidentã doar în stãrile inflamatorii. Colagenazele prezintã abilitatea unicã de a cliva helixul fibrilar de colagen într-un singur lanþ peptidic. Studiul de faþã evidenþiazã implicarea markerilor inflamatori de tipul MMP-8 în regenerarea tisularã dupã implantarea subcutanatã a plaselor colagenate la ºobolani. Þesuturile periimplantare prezintã un proces inflamator moderat, fapt ce a fost observat ºi macroscopic. Reacþia obþinutã a indicat cã plasele colagenate prezintã o bunã biocompatibilitate cu þesuturile înconjurãtoare. MMP8 IN TISSUE RESPONSE INVOLVEMENT The ECM (extracellular matrix) not only provides a solid state support for cells, it also acts a reservoir for embedded cytokines and growth factors and harbours cryptic information within molecules that make up the ECM network. Matrix

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metalloproteinases (MMPs) are involved in connective tissue remodelling during lesions healing but also during embryo development, angiogenesis or bone growth. During regeneration process, fibroblasts and macrophages represent an important source of MMP synthesis. MMP-8, also named colagenase-2, is a type I collagenase involved in lesion healing process. This type is produced especially by neutrophils where is concentrated in the secretory granules. It’s expression became evident only in inflammatory states. Collagenases presents the same unique ability to cleave the fibrillar collagen helix into a only one peptidic chain. The present study, evidentiate the involvement of the inflammatory markers, as MMP-8, in tissues regeneration, after subcutaneous implantation of collagenated nets implants in rats. The periimplantation tissues present an moderate inflammatory process in the periimplantary region, which was observed also macroscopically. The reaction obtained, indicate that the collagenated nets have a good biocompatibility with the surrounding tissues. Bibliografie 1. Karim Bordjih, J. Jouzeau, D. Mainard, et al. – Evaluation of the effect of three surface treatments on the biocompatibility of 316L stainless steel using human differentiated cells, Biomaterials, Volume 17, Issue 5, 1996.

 PARTICULARITÃÞI DE ATITUDINE ÎN TRATAMENTUL CHIRURGICAL AL OSTEOMIELITEI CRONICE D. Noveanu, Al. Poll, N. Telja Spitalul Clinic „Foiºor“ Bucureºti

Cuvinte cheie: osteomielita cronicã, transportor, asanare, lavaj-drenaj, timp de spitalizare, cost. Scopul lucrãrii: Evaluarea tratamentului chirurgical al osteomielitei cronice inclusiv prin utilizarea transportorilor de antibiotic. Material ºi metodã: În studiu am utilizat clasificarea Cierny-Mader pentru încadrarea clinicã a cazurilor de osteomielitã cronicã din cazuistica Spitalului Clinic de Ortopedie Foiºor. Criteriile de evaluare sunt: tehnica chirugicalã utilizatã, tipul de transportor utilizat, controlul drenajului cantitativ ºi calitativ atunci cand a fost utilizat ºi sistemul de instilaþie-aspiraþie, aspectul local al plãgii post-


ACTUALITÃÞI ÎN BIOMATERIALE operatorii, starea generalã a pacientului ºi durata spitalizãrii. Rezultate ºi concluzii: Osteomielita cronicã reprezintã o provocare pentru chirurgul ortoped. Astãzi nu mai este de conceput tratamentul osteomielitei cronice fãrã a avea în recuzitã cel puþin un transportor de antibiotic la care sã se adauge antibioterapia sistemicã. Folosirea unui sistem de instilaþie-aspiraþie pare astãzi în curs de pãrãsire dar în opinia noastrã el este de mare valoare ca primã armã de atac a zonei septice. Un lavaj de cca. 3-7 zile are drept urmare atenuarea masivã a virulenþei de ansamblu a focarului septic, acordând ºanse maxime transportorului de antibiotic pe care îl vom instala în cursul altei intervenþii. Am preferat utilizarea transportorului de antibiotic de tip hidroxiapatita nanocristalinã pentru rolul sau eliberator de antibiotic ºi osteoconductiv. Nu spunem nimic nou dar ne facem datoria sã reamintim termenii decisivi ai terapeuticii în discuþie: – asanarea mecanicã ºi chimicã a pãrþilor moi ºi osoase; – fixare fermã; – antibioterapie mixtã, localã ºi generalã, lambouri de acoperire, sau – piele liberã despicatã. ATITUDE PARTICULARITY IN SURGICAL TREATMENT OF CHRONIC OSTEOMYELITIS Key words: chronic osteomyelitis, transportor, surgical sanitation, lavage, time of spitalisation, price-cost. Document’s aims is to asses the surgical treatment of chronic osteomyelitis.The study included the application of antibiotic transporters. Material and method: In the study we used the Cierney-Mader classification for clinicaly puttingin of casuistry of Foisor Orthopedics Hospital from Bucharest, between 2004-2008. The clinical evaluation criteria are: Surgical technique used, type of transporters, control drainage quantity and quality when used and instillation-suction system, the local aspect of postoperative wound, the patient’s general condition, and hospitalization time. Results and conclusions: Chronic osteomyelitis is a challenge for orthopedic surgery, especially since the equipment for this fight is extremely poor, let

alone be a national program similar to the prosthesis. Today is not conceivable without the treatment of chronic osteomyelitis in props at least one carrier of antibiotics to be added to systemic antibiotherapy, not insignificant price, but priceless for ultimate success. Use of instillation-suction system appears today in the process of leaving. In our opinion, however, is of great value as a first weapon of attack septic area. A lavage of about 3-7 days is therefore alleviate massive overall virulence of the outbreak septic, giving the wearer maximum chance of antibiotic that you install in another intervention, an occasion to resume and debridement. Debridement repeated success is key battle started. The value of this maneuver depends solely excizionale surgeon experience and less of his conscientiousness. „Failure“ of a non-viable tissue may induce failure of all attempts. I preferred using the antibiotic carrier containing nanocrystalline hydroxyapatite for its liberating role of antibiotic and at osteoconductiv. Do not say anything new, but do our duty to remind you terapeuticii decisive terms in question: – Sanitation judicious, mechanical and chemical parts soft and bone; – Fixing farm; – Antibiotics mixed local and general; – Free skin flap coverage or split.

 UTILIZAREA DE CHONDROTISSUE ÎN REPARAREA LEZIUNILOR CARTILAGINOASE ALE GENUNCHIULUI J. M. Pãtraºcu, S. Florescu, B. C. Andor, H. Boss Clinica II Ortopedie Timiºoara

Cuvinte cheie: cartilaj, refacere, artrozã, biomateriale, transplant de celule Leziunile cartilaginoase ale genunchiului sunt frecvent întâlnite. Incidenþa totalã a leziunilor traumatice osteocondrale nu este cunoscutã exact. Manifestãrile clinice în cadrul unei leziuni izolate apar tardiv, uneori sunt gãsite întâmplator dupã o intervenþie chirurgicalã. De asemenea, ele nu sunt întotdeauna observate pe Rx sau RMN.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 Capacitatea de reparare a cartilajului este limitatã, de aceea leziunile netratate duc la degenerescenþa cartilajului. Studiile preclinice aratã cã chondrotissue stimuleazã repararea tisularã a cartilajului dupã microfracturi. Matricea e alcãtuitã dintr-un polimer resorbabil ºi hialuronat. Material ºi metodã: În Clinica Ortopedie II Timiºoara s-a utilizat chondrotissue pe o perioadã de 4 ani, pe un lot de 5 pacienþi. La toþi pacienþii s-a efectuat examen clinic ºi RMN preoperator. Artroscopic s-a efectuat o inspecþie atentã a articulaþiei genunchiului, prin care s-a evidenþiat leziunea cartilaginoasã. Recuperarea a început a 2-a zi postoperator, însã mersul cu încãrcare totalã a fost permis doar dupã 9-12 sãptãmâni. Discuþii: RMN-ul de control postoperator a demonstrat umplerea completã a defectului. Existã date care aratã cã implantarea artroscopicã de chondrotissue dupã microfracturi îmbunãtãþesc refacerea cartilajului. Noi considerãm cã aceastã metodã este extrem de promiþãtoare, dupã cum aratã rezultatele pacienþilor din lotul studiat. UTILISATION OF CHONDROTISSUE IN REPAIRING OF CARTILAGE LESIONS OF THE KNEE Key words: cartilage, repair, arthritis, biomaterials, cells transplant The articular cartilage lesions in the knee are common. The total incidence of traumatic lesions of the cartilage and the osteochondral is not known. Clinically, it takes time to an isolate lesion to manifest. The lesions may be incidentally discovered after a knee intervention. They are not always visible on standard X-ray or on MRI. The cartilage has limited self repairing capacity; therefore untreated lesions will lead to cartilage degeneration and eventually to progressive loss of function in the joint. Preclinical studies suggest that chondrotissue promotes the growth of cartilaginous repair tissue after microfracturing. The matrix consists of a resorbable polymer felt and hyaluronat. Material and method: We used chondrotissue for a period of 4 years, on 5 patients. Clinical

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examination and MRI were performed preoperatively to all the patients. A complete inspection of the knee joint was performed through arthroscopy, revealing the chondral lesion. Rehabilitation was started from the day 2 postoperatory, but full weight bearing was permited only after 9 to 12 weeks. Discutions: MRI follow up showed a complete filling of the defect. There are some evidences that sugests that arthroscopic implantation of chondrotissue after microfractures will improve the healing of the cartilage. We think that this method may be very promising, as the results from our study have shown. Bibliografie 1. Marcacci M., Zaffagnini S., Kon E.: Poster presentation: Outcomes and results of 2nd generation autologous chondrocyte implantation. Presented at the Annual Meeting of the American Orthopaedic Society for Sports Medicine, Keystone, Colorado, July 2005. 2. Odenbring S., Egund N., Lindstrand A., Lohmander L.S., Willén H: Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis: An arthroscopic, roentgenographic, and histologic study. Clin Orthop 1992; 277: 210–216. 3. Dr. Med. Thore Zantop, Dr. med. Wolf Petersen : Case report: Arthroscopic implantation of chondrotissue in microfracture- one year clinical follow-up.

 SINTEZA ªI CARACTERIZAREA UNOR NOI COPOLIMERI FLUORURAÞI CU APLICABILITATE ÎN STOMATOLOGIE C. Petrea*, A. Trifan*, H. Iovu*, C. Prejmerean**, D. Prodan**, L. Silaghi-Dumitrescu**, G. Furtos**, M. Filip**, V. Pãscãlãu** * Universitatea Politehnicã din Bucureºti, Facultatea de Chimie Aplicatã ºi ªtiinþa Materialelor, Departamentul de ªtiinþã ºi Ingineria Polimerilor, ** Universitatea Babeº Bolyai, Institutul de Cercetare în Chimie „Raluca Ripan” Cluj-Napoca

Cuvinte cheie: copolimeri fluoruraþi, compozite dentare. Proprietãþile ºi de aici performanþele materialelor dentare sunt dependente de natura ºi caracteristicile componentelor materialului. Co-


ACTUALITÃÞI ÎN BIOMATERIALE polimerii cu conþinut de fluor în moleculã sunt hidrofobi ºi prezintã o rezistenþã crescutã la înmuiere într-o gama mare de substanþe chimice. Mai mult decât atât, sunt rezistenþi la colorare ºi la atacul microorganismelor, au în general o bunã biocompatibilitate, caracteristici care îi fac interesanþi pentru domeniul stomatologiei. Obiectivul prezentului studiu a fost sinteza unor noi copolimeri fluoruraþi cu aplicabilitate în stomatologie ºi de a investiga influenþa compoziþiei rãºinii asupra gradului de conversie, a absorbþiei de apã ºi respectiv asupra proprietãþilor mecanice ale copolimerilor obþinuþi prin fotopolimerizare. În acest studiu s-a realizat sinteza ºi caracterizarea avansatã a noilor monomeri fluoruraþi: sinteza a fost efectuatã cu ajutorul unei rãºini epoxi rezultatã din reacþia dintre epiclorhidrinã, bisfenol A ºi bisfenol F. Produºii de reacþie au fost caracterizaþi din punct de vedere chimic prin HPLC ºi FT-IR. De asemenea s-a realizat ºi o caracterizare termicã prin DSC ºi TGA. Ulterior s-au obþinut copolimerii dentari experimentali. Biomaterialele dentare au fost evaluate din punct de vedere al conversiei de reticulare ºi respectiv determinarea gravimetricã a absorbþiei de apã în saliva artificialã la 37°C. În continuare s-au determinat ºi proprietãþile mecanice prin studierea rezistenþei la compresie (CS) ºi a rezistenþei la încovoiere (FS). Analiza DSC a relevat faptul cã temperatura de topire pentru monomerii noi sintetizaþi are valori negative (în intervalul -17 ÷ -2°C). Dublele legãturi reziduale (RDB) implicã atât monomerul nereacþionat (rezidual), cât ºi dublele legãturi pendante ataºate de reþeaua copolimerului. Analogul fluorurat al Bis-GMA conduce la obþinerea unor copolimeri cu un grad de conversie mai ridicat decât monomerul Bis-GMA0 ºi oligomerii superiori Bis-GMA0-2. RDB scad cu 10% în cazul în care a fost utilizat analogul fluorurat Bis-GMA în locul monomerului comercial Bis-GMA0 (referinta). Valorile absorbþiei de apã pentru copolimerii fluoruraþi s-au plasat în acelaºi domeniu cu valorile obþinute pentru copolimerii pe baza de Bis-GMA0. Proprietãþile mecanice au fost superioare în cazul copolimerilor fluoruraþi.

SYNTHESIS AND CHARACTERIZATION OF NEW FLUORINATED COPOLYMERS APPLICATION IN DENTISTRY The properties, and hence the performance of the dental materials are dependent upon the nature and features of the components of the material. Fluorocarbon – containing copolymers are highly hydrophobic and display excellent resistance to softening to a wide range of chemicals. Furthermore, the potential resistance to staining and microbial attachment, as well as the generally good biocompatibility make fluorinated polymers very attractive for dental applications. The objective of the present study is to synthesize novel dental fluorinated copolymers and to investigate the influence of the resin composition upon the degree of conversion, water sorption and respectively on the mechanical properties of the light-cured materials. In this work synthesis and characterization of new fluorinated Bis-GMA analogue was performed: the synthesis was done using an epoxy resin resulted from the reaction of epichlorohydrin with bisphenol A and bisphenol F. The products were chemically characterized by HPLC and FTIR methods. Also a thermal characterization by DSC and TGA was performed. The second step was the obtaining of the experimental dental copolymers. Dental biomaterials were evaluated firstly by degree of conversion and determination of water sorption in artificial saliva at 370C gravimetrically. Secondly determination of strength properties was made through compression strength (CS) and the flexural strenght (FS). DSC studies revealed that the melting temperature for the synthesized monomers has negative values (in the range -17 ÷ -2°C). The initial residual double bonds (RDB) involve both the unreacted monomers and the pendant double bonds attach to the copolymer network. The fluorinated Bis-GMA analogue leads to the obtaining of copolymers with higher degree of conversion relative to Bis-GMA0 monomer and Bis-GMA0-2 superior oligomers. The RDB decreased with 10% when fluorinated Bis-GMA analogues were used instead of Bis-GMA0 commercial monomer (control). The water sorption

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 values of the fluorinated copolymers are in the same range with the values presented by the BisGMA0 based copolymers. The mechanical properties were superior in the case of fluorinated copolymers. Bibliografie Norbert Moszner, Ulrich Salz, „New developments of polymeric dental composites”, Prog. Polym. Sci. 26 (2001) 535-576.

 EVALUAREA ACTIVITÃÞII BIOLOGICE A ACIDULUI DIHOXAMIC CA INHIBITOR AL METALOPROTEINAZELOR ªI A IMPACTULUI ASUPRA EVALUÃRII BIOCOMPATIBILITÃÞII T. Petreuº, A. Neamþu, Monica Neamþu, Ana Maria Filioreanu, Carmen E. Cotrutz Universitatea de Medicina ºi Farmacie “Gr. T. Popa” Iaºi

Cuvinte cheie: studiu in silico, modelare molecularã, metaloproteinaze. Metaloproteinazele matriceale (MMP) reprezintã o clasã de enzime înrudite structural ºi implicate în evaluarea biocompatibilitãþii unor materiale destinate implantãrii. MMP reprezintã enzime dependente de Zn ºi Ca care pot fi inhibate de o serie de inhibitori naturali tisulari (TIMP). Material ºi metode: Structurile inhibitorilor propuºi pentru studiu au fost recompuse în Hyperchem iar structurile moleculare au fost preluate din PDB (protein databank) (coduri PDB 1QIB ºi 1CK7 pentru MMP2, 1L6J ºi 1GKC pentru MMP9). S-au folosi proceduri de andocare ºi calculare a energiei minime de cuplare cu programul Autodock 4 iar reprezentãrile grafice cu PyMol v.0.98. Rezultate: Am obþinut valori similare pentru structurile cuplu cunoscute enzima inhibitor ca ºi pentru inhibitorii sintetici noi propuºi pentru testare. Concluzii: Testarea in silico prin andocare molecularã permite evaluarea unor inhibitori ai MMP cu implicaþii în procesul de evaluare a biocompatibilitãþii.

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EVALUATION OF BIOLOGICAL ACTIVITY OF DIHOXAMIC ACID AS METALLOPROTEINASES INHIBITOR AND OF THE IMPACT ON BIOCOMPATIBILITY EVALUATION Matrix metalloproteinases (MMP) represent a class of structural and functional kindred enzymes that are involved in altering the natural compounds of the extracellular matrix. MMP are Zn and Ca dependent enzymes that are intracellular synthesized as zymogens that can be inhibited by 4 classes of natural inhibitors called TIMPs (tissue inhibitor for matrix metalloproteinases). Material and methods: The structures of the proposed inhibitors were recomposed in Hyperchem and the MMP molecular structures were taken from ProteinDataBank (PDB codes 1QIB and 1CK7 for MMP2, 1L6J and 1GKC for MMP9 respectively). Specific Molecular Docking software (Autodock 4.0) was user for docking procedures and energy binding calculations, while and graphic representations were performed by PyMol v.0.98. Results: Following docking procedures and energy binding calculations, performed on enzymes with included/excluded Zn ion from the catalytic site, we have obtained values similar to the known and clinically tested synthetic inhibitors, as batimastat. Molecular docking was performed in 8 cases, by coupling two dihydroxamic compounds ADH and ATDH consecutively on MMP2 and MMP9. Each of the two enzymatic structures was considered with/ without the Zn ion in order to investigate the importance of this ion for the activation/ inactivation procedure. Conclusions: Molecular docking allows our products evaluation as potential inhibitors for the matrix metalloproteinases with specific catalytic Zn ions., Regarding the inhibition constants experimentally (in silico) determined, they may play an important role in locking the substrate access to the catalytic site of the enzyme, impeding its overreaction during pathological processes. Bibliografie 1. James M. Anderson, J. Langone, Issues and perspectives on the biocompatibility and immunotoxicity evaluation of implanted controlled release systems, Journal of Controlled Release, Volume 57, Issue 2, 1 February 1999.


ACTUALITÃÞI ÎN BIOMATERIALE

 HIDROGELURI PE BAZÃ DE COLAGEN FUNCÞIONALIZAT CU ACID ACRILIC ªI POLI(HEMA) CU APLICAÞII BIOMEDICALE Simona Potorac*, M. Popa*, Liliana Verestiuc** * Universitatea Tehnicã ”Gh. Asachi”, Facultatea de Inginerie Chimicã ºi Protecþia Mediului, Iaºi ** Universitatea de Medicinã ºi Farmacie ”Gr. T. Popa”, Facultatea de Bioinginerie Medicalã, Iaºi

Cuvinte cheie: colagen, hidrogel, funcþionalizare, inginerie tisularã. Hidrogelurile pe bazã de polimeri naturali prezintã un interes major atât pentru domeniul medical cât ºi pentru cel farmaceutic, datoritã proprietãþilor fizico-chimice pe care le posedã [1,2]. Materialele colagenice au fost intens utilizate pentru obþinerea de hidrogeluri cu aplicaþii în ingineria tisularã, atât datoritã biocompatibilitãþii lor, cât ºi datoritã posibilitãþilor de obþinere din þesuturi animale [3]. Obiectivul acestui studiu este sinteza unor hidrogeluri natural-sintetice cu structurã hibridã pe bazã de colagen ºi poli (2hidroxietil metacrilat) ºi evaluarea proprietãtilor materialelor sintetizate. În scopul functionalizãrii colagenului cu grupãri chimice cu legãturi duble s-a realizat imobilizarea acidului acrilic pe catenele macromoleculare proteice, printr-un procedeu mediat de carbodiimide solubile în apã. Funcþia chimicã cu legãturi duble a acidului acrilic permite colagenului sã participe ulterior la reacþii de copolimerizare radicalicã cu HEMA ºi sã formeze reþele tridimensionale, fãrã implicarea unor agenþi de reticulare specifici, cu potenþial de inducere a unor efecte toxice. Hidrogelurile obþinute au fost caracterizate din punct de vedere fizico-chimic (spectroscopie FT-IR, analizã termogravimetricã), iar compoziþia a fost determinatã prin analizã elementalã. De asemenea, a fost stabilitã morfologia prin microscopie electronicã de baleiaj (SEM), precum ºi caracteristicile de interacþiune cu soluþii tampon ºi s-a analizat degradarea enzimaticã in vitro a hidrogelurilor. Rezultatele de analizã elementalã ºi datele FT-IR confirmã imobilizarea acidului acrilic pe materialul colagenic ºi formarea de reþele tridimensionale cu HEMA. Proprietãþile de interacþiune cu soluþii tampon ºi caracteristicile de degradabilitate aratã cã hidrogelurile sintetizate sunt materiale promiþãtoare pentru utilizarea ca sisteme de eliberare controlatã a medicamentelor.

HYDROGELS BASED ON FUNCTIONALIZED COLLAGEN WITH ACRYLIC ACID AND POLY(HEMA) WITH BIOMEDICAL APPLICATIONS Natural polymer-based hydrogels have attracted medical and pharmaceutical interests due to their physico-chemical properties [1,2]. Collagenic materials have been extensively studied in order to obtain hydrogels with aplications in tissue engineering, due to their biocompatibility and availability in the animal life [3]. The aim of the present study is to obtain natural-sythetic hydrogels with hybrid structure, based on collagen and poly(2-hydroxyethyl methacrylate) (pHEMA) and the evaluation of the synthetized materials properties. In order to obtain the functionalization of collagen with double chain functional groups, acrylic acid moieties were immobilized on the macromolecular collagen chain, through a process mediated by water-soluble carbodiimides. The double chain chemical function of the acrylic acid allows collagen to participate in radicalic copolymerisation reactions with HEMA and to form three-dimensional networks, without the involvement of typical, potentially more toxic, crosslinkers. The obtained hydrogels were physicochemically characterized (FT-IR spectroscopy, thermogravimetric analysis) and the composition was determined by elemental analysis. The morphology of the samples was examined by Scanning Electron Microscopy (SEM). The buffer solution interaction caracteristics and in vitro enzymatic degradation rate of the sythetized hydrogels were also determined. The elemental analysis rezults and FT-IR data confirmed the succes of acrylic acid immobilization onto collagenic material and the formation of threedimensional networks in the presence of HEMA. The properties of buffer solution interaction and the degradability caracteristics reveal that the synthesized hydrogels are promising materials as drug delivery systems. Bibliografie 1. A. Pourjavadi, M. Kurdtabar, G. R. Mahdavinia, H. Hosseinzadeh – Synthesis and super-swelling behavior of a navel protein-based superabsorbent hydrogel., Polym Bull 2006; 57: 813. 2. Fleischmayer R., Bjorn O., Kuhn K. – Structure, Molecular Biology and Pathology of Collagen, vol.580, New York Academy of Sciences, 1990. 3. H. Yan, A. Saiani, J. E. Gough, A. F. Miller, Thermoreversible protein hydrogel as cell scaffold. Biomacromol 2006; 7: 2776.

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 UTILIZAREA STUDIULUI DISTRIBUÞIEI TENSIUNILOR LA NIVELUL ARTICULAÞIEI COXO-FEMURALE ÎN VEDEREA PROTEZELOR PERSONALIZATE R. Prejbeanu, O. Ghiba, D. Vermeºan, S. Rãducan Clinica I Ortopedie-Traumatologie S.C.J.U.T.

Cuvinte cheie: proteze personalizate, distribuþia tensiunilor . Introducere. Protezele personalizate pot aduce îmbunãtãþiri semnificative în prelungirea duratei de viaþã a implantului ºi a rezultatelor funcþionale. Scopul studiului nostru a fost acela de a evalua distribuþia tensiunilor echivalente la nivelul articulaþiei coxo-femurale. Material ºi metodã: Am efectuat o reconstrucþie tridimensionalã a articulaþiei coxo-femurale pe baza imaginilor CT, în vederea realizãrii unui model teoretic pentru studiul distribuþiei tensiunilor echivalente. Rezultate. Din analiza datelor s-a observat o distribuþie nonuniformã a tensiunilor echivalente la nivelul articulaþiei coxofemurale. Concluzii. Modelul teoretic propus poate fi folosit cu succes în determinarea distribuþiei fortelor ºi aprecierea biointegrãrii endoprotezelor personalizate. THE USE OF TENSION DISTRIBUTION AT THE COXO-FEMORAL JOINT FOR THE USE OF PERSONALIZED PROSTHESIS Key words: personalized prosthesis, tension distribution. Personalized prosthesis can significantly improve the lifespan of the implant and improve the functional outcome. The purpose of the study was to evaluate the equivalent tension distribution at the level of the hip joint. Method: we made a 3D reconstruction of the hip joint based on the CT scans with the purpose of making a theoretical model for the study of equivalent tension distribution. Results: from the data analyzed we found a nonuniform distribution of equivalent tension at the hip joint. Conclusions: the presented theoretical model can be used with success in determining force distribution and the appreciation of the biointegration of the personalized prosthetic implants.

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Bibliografie 1. Mavcic, B., Pompe, B., Antolic, V., Daniel, M., Iglic, A., and Kralj-Iglic, V., 2002, „Mathematical Estimation of Stress Distribution in Normal and Dysplastic Hips,“ Journal of Orthopaedic Research, 20, pp. 1025-1030. 2. Goel, V. K., Valliappan, S., and Svensson, N. L., 1978, „Stresses in the Normal Pelvis,“ Comput Biol Med, 8, pp. 91-104. 3. Rapperport, D. J., Carter, D. R., and Schurman, D. J., 1985, „Contact Finite Element Stress Analysis of the Hip Joint,“ J Orthop Res, 3, pp. 435-46.[168] Russell, M. E., Shivanna, K. H., Grosland, N. M., and Pedersen, D. R., 2006, „Cartilage Contact Pressure Elevations in Dysplastic Hips: A Chronic Overload Model,“ Journal of Orthopaedic Surgery and Research, 1.

 VARIAÞII ANATOMICE ÎN STRUCTURILE POSTERIOARE DE ÎNTÃRIRE ALE ARTICULAÞIEI GENUNCHIULUI S. Rãducan, R. Prejbeanu, D. Vermeºan, R. Caggiano, D. Nemeº Clinica I Ortopedie Traumatologie S.C.J.U.T.

Cuvinte cheie: artroscopia genunchiului, capsulã posterioarã, anatomia genunchiului. Anatomia regiunii posterioare a articulaþiei genunchiului a fost puþin studiatã din punct de vedere a structurilor de întãrire capsulare situate la acest nivel. Scopul studiului nostru a fost acela de a identifica structurile situate la acest nivel. Am efectuat un studiu anatomic pe specimene de cadavru în colaborare cu Disciplina de Anatomie din cadrul U.M.F. Timiºoara, coroborat cu o analizã a imaginilor intraoperatorii de care dispunem. Analiza datelor s-a efectuat punându-se accentul pe identificarea ºi mãsurarea structurilor capsulare posterioare de la nivelul articulaþiei genunchiului. Am identificat ºi mãsurat ataºamentele distale ale tendonului semimembranos, expansiunea tibialã a acestuia, ligamentul oblic popliteal, expansiunea capsularã poplitealã. Muºchiul plantar, ligamentul popliteofibular ºi bursa semimembranosului au fost structuri constant prezente. Anatomia regiunii posterioare a articulaþiei genunchiului este complexa ºi identificarea ºi mãsurarea structurilor de la acest nivel poate conduce la o mai bunã înþelegere a biomecanicii articulare ºi la efectuarea unor studii imagistice ulterioare.


ACTUALITÃÞI ÎN BIOMATERIALE ANATOMICAL VARIATIONS IN THE POSTERIOR STABILIZING STRUCTURES OF THE KNEE CAPSULE Key words: arthroscopy, knee anatomy, posterior capsular structures Posterior knee anatomy was less studied concerning the capsular stabilizing structures. The purpose of our study was to identify and analyze their importance.Method: we conducted a study on cadaver specimens in collaboration with the Department of Anatomy within the University of Medicine and Pharmacy ‘Victor Babes’ Timisoara, corroborated with intraoperative findings. We identified and measured the distal attachments of the semimembranous tendon, its tibial expansion, the oblique popliteal tendon and capsular popliteal expansion. The plantar muscle, popliteofibular ligament and semimembranous bursa were constant findings. In conclusion, the anatomy of the posterior region of the knee is complex and a better understanding and knowledge of the structures at this level will lead to better understanding of the biomechanics of the knee and further imaging studies. Bibliografie 1. Árpád Illyés, Zoltán Bejek, István Szlávik, Róbert Paróczai, Rita M. Kiss. Three-dimensional gait analysis after unilateral cemented total hip arthroplasty facta universitatis. Series: Physical Education and Sport Vol. 4, No 1, 2006, pp. 27 – 34. 2. Jurak, M., & Kocsis, L., (2002). New package for calculation of gait parameters. Proceedings of Third Conference on Mechanical Engineering (pp. 500-504). Budapest , Hungary. 3. Kaufman K.R., Hughes C., Morrey B.F., Morrey B., An K.N. (2001) Gait characteristics of patients with knee osteoarthritis. J Biomech 34: 907–915 4. Borjesson M., Weidenhielm L., Atsson E., Olsson E. (2005) Gait and clinical measurements in patients with knee osteoarthritis after surgery: prospective 5-year follow-up study. Knee 12: 121–127.

 ANALIZA DINAMICÃ A UNUI MODEL SIMPLIFICAT DE PROTEZÃ A MEMBRULUI INFERIOR L. Rusu, Mirela Toth Taºcãu, Cosmina Vigaru Universitatea Politehnicã din Timiºoara

Scop: Obiectivele acestei lucrãri sunt: modelarea unui model simplificat de protezã pentru membrul inferior amputat deasupra genunchiului, respectiv realizarea analizei dinamice a modelului conceput.

Metoda: Modelul simplificat al protezei de membru inferior este format din trei componente majore (partea femuralã, partea tibialã ºi talpa) care simuleazã pãrþile anatomice (gambã, coapsã, talpã) precum ºi trei componente care asigurã mobilitatea articulaþiilor (1, 2, 3). Analiza dinamicã ºi simulãrile ciclului de mers al membrului protezat au fost realizate cu ajutorul mediului Solid Edge 19 (4), folosind modulul Dynamic Designer-Motion Professional. Pentru modelele proiectate se considerã durata medie a unui pas ca fiind 2 secunde. Pentru analiza dinamicã a protezei modelate se considerã pasul format din douã secvenþe ºi anume extensia membrului inferior din poziþia A (hiperflexie) pânã în poziþia B (sprijin), respectiv flexia membrului inferior reprezentând revenirea din poziþia B în poziþia A. Poziþia A corespunde unei hiperflexii a membrului inferior, iar poziþia B corespunde finalului fazei de sprijin. Greutatea protezei trebuie sã fie comparativã cu cea a membrului inferior amputat. Astfel pentru modelul realizat au fost alese urmãtoarele materiale: polietilenã pentru cupa femuralã, oþel inoxidabil pentru partea tibialã ºi pentru sistemul piuliþã – bucºã – ºurub strângere, respectiv aliaj de aluminiu pentru talpã. In aceste condiþii masa protezei este 4,365 Kg. Rezultate ºi concluzii: În cazul extensiei se observã o reacþiune mai mare în articulaþia gleznei decât în cea a genunchiului acest lucru fiind datorat faptului cã glezna este mai aproape de suprafaþa de contact decât genunchiul. Pentru momentul rezultant situaþia este exact invers ºi anume momentul rezultant din articulaþia genunchiului are o valoare mai ridicatã decât cel din articulaþia gleznei deoarece braþul este mai mare în cazul genunchiului decât în cel al gleznei. În cazul flexiei se observã cã atât reacþiunea cât ºi momentul rezultant sunt mai mari în articulaþia genunchiului decât în cea a gleznei. Acest lucru se datoreazã lipsei reacþiunii normale la nivelul solului. Þinând cont de proprietãþile materialelor folosite ºi de forþele ºi momentele care apar în proteza proiectatã putem spune cã acestea nu depãºesc proprietãþile de material ºi astfel modelul proiectat poate sta la baza realizãrii unei soluþii constructive.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 THE DYNAMIC ANALYSIS OF A SIMPLIFIED PROSTHESIS OF THE LOWER LIMB Objective: The aim of this paper is to obtain a simplified prosthesis model of the above knee amputated lower limb and to analyzed it from the dynamic point of view. Method: The simplified model of the lower limb prosthesis has three major components (femur part, tibial part and foot part) which simulated the anatomical parts (thigh, shank, foot) and also three components which assured the joint mobility (1, 2, 3). The dynamic analysis and the simulation of the walking cycle of the prosthetic limb were realized using Solid Edge 19 software (4) and the Dynamic Designer - Motion Professional module. The average time step for the obtained model was considerate as 2 second. For the dynamical analysis of the prosthesis, the walking step was divided in two steps. The first step is the extension of the lower limb from the A position (hyperflexion) to the B position (stance) respectively the second step is flexion representing the reverse motion from B to A position. The A position correspond to the hyperflexion of the lower limb and the B position represent the end of the stance step. The weight of the lower limb prosthesis has to be comparative with the weight of the amputated limb. For the obtained model were choose the follows materials: polyethylene for the femur part, stainless steel for the tibial part and for the joints systems, respectively aluminum alloy for foot part. In this conditions the prosthesis weight reach 4.365 Kg. Results and conclusions: In the case of the extension step the reaction in the ankle joint is higher that the one in the knee joint. This difference appears because the ankle is closer to the contact surface than the knee. For the torque, the situation is exactly oppose, The torque in the knee joint been higher than the torque in the ankle joint because the arm is longer for the knee than for the ankle. In the case of flexion, it observe that both reaction and torque are higher in the knee joint that in the ankle joint . This difference appears because in the flexion case there are no reactions from the contact surface. Taking in account the materials properties, the forces and torques that appears in the prosthesis

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model, it can been said that they do not exceed the materials properties and the model can be used as a stating point for a constructive solution of the prosthesis Bibliografie 1. Baciu C. – Anatomia funcþionalã ºi biomecanica aparatului locomotor, Editura Medicalã, Bucureºti, 1983. 2. Clement C. B., Dobre I., Ciobãnel P., Aldea A. – Chirurgia ºi protezarea aparatului locomotor Vol.1, 2, Editura Medicalã, Bucureºti, 1986. 3. Panjabi M., WHITE A. – Biomechanics in the muskuloskeletal system, Churchill Livingstone, New York, 2001. 4. Lower Limb – www.ottobockus.com.

 EVALUAREA UZURII A TREI MATERIALE COMPOZITE UTILIZATE ÎN STOMATOLOGIE C. Saroºi*, M. Moldovan*, O. Fodor**, M. Rusu***, M.Trif*, O. Muºat****, B. Stanca*, G. Popescu***** * Universitatea “Babeº Bolyai” - Institutul de Cercetãri în Chimie “Raluca Ripan” Cluj-Napoca, ** Universitatea Oradea, Facultatea de Medicinã ºi Farmacie Oradea, *** Universitatea “Babeº Bolyai”-Facultatea de Chimie ºi Inginerie Chimicã ClujNapoca, **** S.C.Remed Prodimpex S.R.L. Bucureºti, ***** Universitatea Tehnicã din Cluj-Napoca, ROMÂNIA“

Cuvinte cheie: compozite dentare, uzurã, microscopie electronic. Estetica compozitelor dentare este puternic influenþatã de suprafaþa lustruitã iniþial. O suprafaþã netedã este idealã pentru a preveni cariile secundare ºi petele care rezultã din placa de retenþie. Scop: Obiectivele acestui studiu constau în evaluarea efectului procedeelor de finisare ºi lustruire a unor suprafeþe rugoase cu trei materiale diferite de compozite dentare (Herculite XRV Ultra, Radopacril, Nanouretandent), în comparaþie cu banda Mylar-cu format de suprafaþã. Materiale ºi Metode: Probele au mãsurat 6 mm în diametru x 3 mm grosime, au fost fabricate în forme de teflon bine acoperit cu o bandã Mylar, folosind trei materiale compozite. Un grup de control de cinci exemplare din fiecare material nu a primit nici o lustruire dupã ce a fost uscat cu banda Mylar. Zece probe din fiecare material compozit utilizat au fost aleator împãrþite în douã grupuri pentru finisare ºi lustruire. Fiecare grup a fost ºlefuit folosind un sistem de discuri de finisare diferite: Optidisc (KerrHawe) ºi Kerr. Rugozitatea


ACTUALITÃÞI ÎN BIOMATERIALE medie a suprafeþei a fost mãsuratã cu un profilometru. Dupã aceea, suprafeþele au fost studiate cu un microscop electronic. Rezultate ºi Discuþii: Diferenþe semnificative s-au gãsit în funcþie de rugozitatea suprafeþei (p <0,05), cu interacþiunea dintre rãºini compozite precum ºi a sistemelor de finisare utilizate (p <0,05). Grupul care a folosit banda Mylar nu a fost în mod semnificativ diferit de Optidisc dar în mod semnificativ a fost diferit de Kerr de finisare. Suprafeþele compozitelor cu nanoumpoluturã Herculite XRV Ultra ºi Nanouretandent au fost semnificativ mai uºoare decât cele ale compozitei cu umpluturã microhibridã Radopacril. Aceastã diferenþã a venit, probabil, ca urmare a diferenþelor dintre dimensiunile particulelor materialelor compozite utilizate. Particulele de umplere individuale au fost strãmutate lãsând goluri pe suprafaþã. Particulele de umplere au fost mai mici în nanocompozite lãsând astfel goluri mai mici ºi rezultând deci o suprafaþã în mod semnificativ mai uºoarã. Optidisc a dus la formarea unei suprafeþe în mod semnificativ mai finã în comparaþie cu celelalte sisteme de finisare. Concluzii: Suprafeþele mai uºoare au fost înregistrate de Optidisc ºi de folosirea benzi Mylar. Drintre toate compozite, suprafeþele cele mai fine au fost obþinute pentru Herculite XRV Ultra, Nanouretandent ºi Radopacril. WEAR EVALUATION OF THREE COMPOSITES MATERIALS USED IN DENTISTRY The esthetics of dental composites is strongly influenced by the final surface polish at initial placement. A smooth surface restoration is ideal to prevent secondary caries and stains resulting from plaque retention. Purpose: The aims of this study were to evaluate the effect of two finishing and polishing procedures on the surface roughness of three different composite resin materials (Herculite XRV Ultra, Radopacril, Nanouretandent), compared with Mylar strip-formed surface. Materials & Methods: Specimens measuring 6 mm in diameter x 3 mm in thickness were fabricated in Teflon moulds well covered with a Mylar strip using three dental composite. A control group of five specimens of each material received no polishing after being cured under the Mylar strip. Ten specimens for each composite were

randomly divided among two finishing and polishing groups. Each group was polished using a different system: Optidisc (KerrHawe) finishing discs and Kerr fine finishing burs. The average surface roughness was measured with a surface profilometer. After that, the specimen surfaces were studied with a scanning electron microscope. Results & Discussions: Significant differences were found for the surface roughness (p<0.05) with interaction among composite resins and the finishing systems used (p<0.05). The Mylar strip group was not significantly different from the Optidisc but significantly different from Kerr finishing burs groups. The surfaces of the composite with nanofiller Herculite XRV Ultra and Nanouretandent were significantly smoother than those of the composite with microhybrid filler, Radopacril. This difference was probably due to the composites having different particle sizes. Individual filler particles were displaced, leaving voids on the surface. The filler particles were smaller in nanocomposites, thus, leaving smaller voids and resulting in a significantly smoother surface. Optidisc resulted in significantly smoother surfaces when compared to the other finishing systems for all specimens. Conclusions: Smoother surfaces were recorded for the Optidisc and the Mylar strip-formed surface control group. Among de composites, the smoother surfaces were obtained for Herculite XRV Ultra, Nanouretandent and Radopacril. Bibliografie Ottenbrite, R. M. (ed), Frontiers in Biomedical Polymer Applications, vol. 1, Technomic Publishing Company, Inc., Lancaster (1998).

 EXPLORAREA BIOINTERFEÞEI DINTRE MATERIALE SINTETICE ªI SISTEME BIOLOGICE Viorica Simon

Cuvinte cheie: biomateriale, biointerfete, DRX, microscopie, XPS, FTIR Interfeþele formate între materiale sintetice ºi sisteme biologice – biointerfetele – reprezinta unul din cele mai dinamice domenii ale ºtiinþei biomaterialelor. Principalele studii efectuate asupra interfeþelor vizeazã sinteza biomaterialelor ºi

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 caracterizarea suprafeþei lor în urma interacþiunilor specifice cu mediile biologice, fie ele in vivo sau în vitro, urmãrind procesele cinetice ºi moleculare ce apar la biointerfaþa. Lucrarea abordeazþ cu precãdere autoasamblarea biomimeticã pe suprafaþa biomaterialelor a unor nanostructuri evidenþiate prin analize microscopice, difracþie de raze X, spectroscopie în infraroºu ºi spectroscopie fotoelectrronicã cu radiaþie X. INVESTIGATION OF INTERFACES BETWEEN SYNTHETIC MATERIALS AND BIOLOGICAL SYSTEMS – BIOINTERFACES Key words: biomaterials, biointerfaces, XRD, microscopy, FTIR, XPS Interfaces between synthetic materials and biological systems – biointerfaces – constitute one of the most dynamic and expanding fields in biomaterials science. The main approach in biointerfacial studies involves preparation and characterization of functional surfaces for specific interactions with bio-systems, in vivo and in vitro, and studies of the molecular and kinetic processes occurring at such interfaces. This communication is focussed on biomaterials and biointerfaces, with respect to biomimetic selfassembly on biomaterials surface of nanostructures, evidenced by microscopic analysis, X-ray diffractions, infrared and Xray photoelectron spectroscopy. Bibliografie 1. M. Stevens, J.H. George, Science 310 (2005) 1135-1138.

 ANALIZA BIOMECANICÃ A ANSAMBLULUI MEMBRU SUPERIOR – EXOSCHELET AMPLIFICATOR DE FORÞÃ D.I. Stoia, Mirela Toth-Taºcãu, Cosmina Vigaru, Karoly Menyhardt Universitatea Politehnica din Timiºoara

Scopul lucrãrii: Lucrarea îºi propune determinarea parametrilor biomecanici ai unui exoschelet realizabil cu buget redus, destinat multiplicãrii forþei de ridicare prin ataºare la membrul uman superior, în scopul multiplicãrii forþei de ridicare. Parametrii biomecanici se referã la: parametrii cinematici ai braþului mecanic (amplitudini ºi viteze unghiulare) ºi forþa care

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poate fi dezvoltatã de cãtre sistem. În vederea efectuãrii acestor determinãri s-a realizat modelul CAD 3D, s-au efectuat calculele de rezistenþã, alegându-se în prealabil materialele utilizate în construcþie. Material ºi metodã: În construcþia exoscheletului, alegerea materialelor s-a efectuat în concordanþã cu ideea realizãrii unei construcþii cu un buget redus ºi a posibilitãþilor tehnologice de realizare. Toate componentele 3D ale structurii exoschelet, au fost verificate în mediul de analizã cu element finit Cosmos. Ansamblul este constituit din urmãtoarele elemente: cadrul trapezoidal, braþele articulate, douã actuatoare electrice (motor + reductor), articulaþia mecanicã a umãrului, ºuruburi ºi piuliþe standardizate, elemente de agãþare. Pentru a determina pe cale experimentalã parametrii biomecanici s-au utilizat douã tipuri de echipamente: celula de analizã cinematicã Zebris ºi standul motorizat de încercãri mecanice Multitest 5i. S-au utilizat douã metode experimentale, fiecare fiind specificã echipamentului utilizat. Astfel, pentru a putea utiliza echipamentul cu ultrasunete Zebris, markerii acestuia s-au atasat pe efectorul final al exoscheletului, respectiv pe partea superioarã a braþului. Ansamblul exoschletul s-a plasat în faþa difuzorului de ultrasunete. Pentru determinarea forþei capabile a exoscheletului acesta a fost introdus între cei doi montanþi (celula de forþã ºi masa fixã) ai maºinii de încercat. Pentru diferite tensiuni aplicate motoreductoarelor s-au determinat forþele statice pe care le poate dezvolta braþul mecanic, fãrã ajutorul unui operator. Rezultate ºi concluzii: Analiza cinematicã a exoschletului a pus în evidenþã amplitudinile unghiulare în flexia ºi extensia braþului, precum ºi vitezele unghiulare cu care s-au realizat miºcãrile. S-au înregistrat astfel amplitudini unghiulare maxime de 55 grade atât în flexie cât ºi în extensie, faþã de o poziþie intermediarã a braþului uman (90 de grade flexie). Viteza unghiularã medie înregistratã a fost de 3.74 grade/secundã. Forþa staticã maximã înregistratã de cãtre celula echipamentului multitest a fost de 470 N. Aceasta a putut fi atinsã ºi menþinutã constantã la


ACTUALITÃÞI ÎN BIOMATERIALE o tensiune de 20 V aplicatã actuatorului. Curentul absorbit în acest caz a fost de 1 amper. Se poate spune deci cã, exoscheletul aduce un plus considerabil de forþã braþului uman, în condiþiile unei viteze medii de aproximativ 3.7 grade/sec. Dezavantajul construcþiei îl reprezintã intervalul unghiular restrictiv în comparaþie cu braþul uman. BIOMECHANICAL ANALYSIS OF THE ASSEMBLY UPPER LIMB – FORCE AMPLIFIER EXOSKELETON Purpose of the paper: The paper proposes a biomechanical study on an exoskeleton designed and constructed to amplify the human upper limb force. One of the exoskeleton construction concepts was to join the mechanical system in a low budget project. The biomechanical parameters refer to: kinematical parameters of the mechanical arm (angular amplitudes and velocities); the force that can be provide by the mechanical system, in addition to the human arm force. In order to determine the biomechanical parameters, the following steps were achieving: 3D modelling of the components and the assembly; mechanical strength calculations, choosing the right materials; exoskeleton building. Material and Method: All the 3D components of the exoskeleton structure were analyzed using Finite Element Method (FEM) in CosmosWorks environment. In analyze, real material parameters and geometries of the build components were taken into account. The components of the assembly are: one trapezoidal frame, articulated robotic arms, two electromechanical actuators, shoulder’s mechanical articulation, standard screws and nuts and hanging elements. In order to experimentally determine the biomechanical parameters, two equipments were used: Zebris Cell for kinematical analyzes and the Mechanical testing stand, Multitest 5i. Two experimental methods were used, each one being specific to a equipment. In this way, in order to use the ultrasounds based Zebris equipment, two sets of markers were attached on the exoskeleton. One set was placed on the final effector, while the other one was placed on the upper extremity of the arm. The exoskeleton

assembly was placed on front of the ultrasound emitter. In order to determine the carrying capacity of the arm, the skeleton was placed between the two top (force cell and fixed table) of the testing machine. For discreet electrical current applied on the actuator, static forces provided by the arm were determined. Results and Conclusions: The kinematical analysis of the exoskeleton behavior was put in evidence the angular amplitudes in flexion and extension of the arm, together with the angular velocities of the movement. Those, angular amplitudes of 55 deg in both flexion and extension were recorded. These ranges have as reference the human arm intermediary position: 90 deg of flexion. The mean angular velocity was computed from the instantaneous values as a value of 3.74 deg/sec. On the other hand, the maximum static force recorded by the Multitest 5i equipment was 470 N. This value was achieved and constantly maintained at a voltage of 20, applied to the actuator. The electrical current in this case was 1 A. We can affirm that, the exoskeleton add considerably force to the users arm, at a mean angular velocity of 3.7 deg/sec. The disadvantage of the construction is represented by the reduced angular range of movement, comparing with the human arm. Bibliografie 1. Aaron M. Dollar, A. – Comparison of the Force Dynamics of the Precision Grip of Humans and Robots, Harvard BioRobotics Laboratory Technical Report Harvard University January 17, 2001. 2. Benhabib, B. (2003) – Manufacturing-design, production, automation and integration Marcel Dekker, inc. pp. 112-122. 3. Bralla, J.G.(1999), Design for ManufacturabilityHandbook, McGraw-Hill, second edition, pp.4.83-4.103. 4. Dreucean, M., Stoia, D.I. – Fabrication of Medical Devices using Rapid Prototyping (RP) Technologies Based on Metal Powder, 33rd Jupiter Conference, 2007. 5. Ern, A., Guermond, J.L.(2004) – Theory and practice of finite elements, published Springer. 6. LaCourse, D.E. (2007) – “Handbook of solid modeling”, University of Michigan, digitized nov 28, 2007. 7. N. Strimpakos, V. Sakellari, G. Gioftsos et al. – Cervical spine ROM measurements: optimizing the testing protocol by using a 3D ultrasound-based motion analysis system. Cephalalgia 25 (12): 1133-45, 2005.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009

 STUDIUL INFLUENÞEI ACIDULUI HIALURONIC/CHONDROITIN SULFATULUI ASUPRA PROPRIETÃÞILOR COMPOZITELOR CHITOSAN-HIDROXIAPATITÃ C.E. Tãnase*, Liliana Verestiuc**, Adriana Lungu***, M.I. Popa* * Universitatea Tehnicã “Gh. Asachi”, Facultatea de Inginerie Chimicã ºi Protecþia Mediului - Iaºi, ** Universitatea de Medicinã ºi Farmacie “Gr. T. Popa”, Facultatea de Bioinginerie Medicalã - Iaºi, *** Universitatea Politehnicã Bucureºti, Facultatea de Chimie Aplicatã ºi ªtiinþa Materialelor“

Cuvinte cheie: biomateriale compozite, biomimetic, chitosan, hidroxiapatita, glicozaminoglicani. În prezent existã o mare cerere de materiale sintetice pentru substituþie osoasã, datoritã inconvenientelor atribuite grefelor osoase. Alogrefele ºi autogrefele sunt deseori asociate cu infecþii ºi risc ridicat de transmitere a bolilor. Compozitele sintetice sau natural-sintetice pe bazã de hidroxiapatita ºi polimeri (chitosan, colagen, poli(acid lactic), poli(acid glicolic)) prezintã proprietãþi adecvate ca materiale pentru substituþia þesutului osos [1]. Hidroxiapatita (Hap) s-a dovedit ca fiind un excelent material pentru reconstrucþia þesutului osos datoritã proprietãþilor de osteoconductivitate, biocompatibilitate ºi a structurii chimice asemãnãtoare cu faza mineralã din þesutul osos [2]. Chitosanul (Cs) a fost intens studiat pentru diferite aplicaþii precum tratamentul arsurilor, substituienþi osoºi, inginerie tisularã datoritã proprietãþilor de biodegradabilitate, biocompatibilitate, bioresorbabilitate, nontoxicitãþii, antibacterine ºi hemostatice; acesta poate fi degradat de cãtre enzime în organism iar produºii rezultaþi sunt nontoxici [3]. Glicozaminoglicanii sunt cunoscuþi ca fiind un factor de stimulare pentru creºterea osteoblastelor (acidul hialuronic Hya) [4] cât ºi ca medicamente cu eficaciate evidentiaþã în osteoartrita (chondroitin sulfat A ChS-A) [5], iar prezenþa acestora îmbunãtãþesc proprietãþile compozitului final. Acestã lucrare prezinta sinteza prin metode biomimetice de compozite pe baza de fosfaþi de calciu, Cs ºi alþi biopolimeri (Hya ºi ChS-A) ºi evaluarea proprietãþilor acestora. Compoziþia ºi structura materialelor a fost analizatã prin spectroscopie FTIR, microscopie electronica de baleaj-

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SEM. S-a studiat degradarea enzimaticã in vitro, comportamentul compozitelor în soluþii de interes biologic ºi s-au efectuat teste mecanice. Microstructura, proprietãþile de absorbþie, rãspunsul în urma degradãrii ºi studiile mecanice indicã aceste compozite ca având potenþial de utilizare în ingineria þesutului osos. STUDY ABOUT INFLUENCE OF HYALURONIC ACID/CHONDROITIN SULPHATE ON CHITOSAN-HYDROXIAPATITE COMPOSITE PROPERTIES Nowadays, there is a high clinical requirement for synthetic bone substitutes materials, due to the drawbacks associated with biological bone grafts. Autografts and allografts are generally associated with potential infection and high risk of disease transmission. More recently synthetic or naturalsynthetic composites, such as hydroxyapatite (Hap) mixed with polymers - chitosan, collagen, poly (lactic acid) and poly (glycolic acid) are considered as material for bone substituted [1]. Hydroxyapatite, a ceramic material, was proved as an excellent material for bone tissue repair due to its osteoconductive, biocompatible properties and chemical structure similar to bone mineral [3]. Chitosan (Cs) is one of the most widely used natural polymers in tissue engineering field and can be molded in various forms. It is biocompatible and can be degraded by enzymes in human body and the degradation products are non-toxic [2]. Glycosaminoglycans are well-known as a stimulation of osteoblasts cell (hyaluronic acid) [4] and as a drug with very high efficacy in osteoarthritis (chondroitin sulfate A) [5] and their presence enhances the properties of the final composites. The paper present the synthesis by biomimetic method of new composite based on calcium phosphate, Cs and another biopolymers (Hya and ChS-A). The obtained composites were characterized by Fourier Transform Infrared Spectroscopy (FTIR), Scanning Electronic Microscopy (SEM). Mechanical properties, absorption in physiological solutions were evaluated and in vitro enzymatic degradation was also studied. The microstructures, physicochemical and biological response of these composites indicate them as scaffolds with applications in bone tissue engineering.


ACTUALITÃÞI ÎN BIOMATERIALE Bibliografie 1. R. Langer and J.P.Vacanti, Science 260 (1993), 920-926. 2. M. Vallet-Regí, J.M. González-Calbet, Progress in solid state Chemistry, 32, 2004, 1-31. 3. R. A.A. Muzzarelli, Carbohydrate Polymers, 76, 2009, 167-182. 4. Huang L, Cheng YY, Koo PL, Lee KM, Qin L, Cheng JCY, Kumta SM, J Biomed Mater Res 2003; 66 A: 880–884. 5. Leeb BF, Schweitzer H, Montag K, Smolen JS., J Rheumatol, 2000 , 27: 205-211.

 COLONIZAREA CU CELULE ENDOTELIALE UMANE ªI CELULE OSTEOPROGENITOARE UMANE A DIFERITELOR MATRICI COLAGENICE CU APLICABILITATE ÎN INGINERIA TISULARÃ OSOASÃ I. Titorencu*, M. Albu**, V. Jinga*, V.Trandafir**, C. Zaharia***, M. Simionescu* * Culturi Celulare, Institutul de Biologie ºi Patologie Celularã “Nicolae Simionescu”, Bucureºti, ** Departamentul Colagen, Institutul de Cercetare Pielãrie - Încãlþãminte, Bucureºti, *** Departamentul de Ortopedie ºi Traumatologie II, Institutul Clinic Colentina, Bucureºti“

Cuvinte cheie: matrici colagenice, angiogenezã, ingineria þesuturilor. Introducere: Adeziunea celulelor la matricea extracelularã este esenþialã în dezvoltarea, creºterea ºi remodelarea þesutului osos. Matricile tridimensionale compuse din colagen funcþioneazã ca suporturi pentru creºterea celularã, faciliteazã interacþia cu multiple tipuri celulare promovând expansiunea acestora. Strategiile recente de inginerie tisularã vizeazã utilizarea structurilor tridimensionale alcãtuite din polipeptide (colagen) ºi polizaharide (glicozaminoglicani) ca un model alternativ al grefãrii autogene. ay Scop: Testarea comparativã a colonizãrii in vitro a diferitelor matrici colagenice cu celule endoteliale umane ºi celule osteoprogenitoare umane în vederea determinãrii biocompatibilitãþii ºi a potenþialului angiogenic al celulelor pe aceste suporturi. Materiale ºi Metodã: Matricile colagenice au fost obþinute din colagen fibrilar tip I extras prin tratamente chimice (alcaline si acide) din derm bovin. Au fost utilizate urmãtoarele suporturi:

matrice de colagen cu acid hialuronic; matrice de colagen cu condroitin sulfat ºi matrice colagenicã simpla (control). Celulele endoteliale (linia EA hy 926) ºi celulele osteoprogenitoare umane (OPC) au fost cultivate în DMEM cu 4,5‰ glucoza suplimentat cu 10% ser fetal bovin au fost însãmânþate pe biomateriale cu o densitate de 50.000 celule/ml (EA hy 926) si 75.000 celule/ml (OPC). Colonizarea biomaterialelor a fost urmãritã prin tehnici de microscopie de fluorescenþã ºi microscopie electronicã de transmisie, viabilitatea celulelor prin tehnica MTT ºi capacitatea lor de angiogeneza prin cultivarea pe Matrigel. Rezultate: Microscopia de fluorescenþã ºi testul MTT au evidenºiat rate diferite de colonizare ºi viabiliate a celulelor cultivate pe suporturile colagenice testate. Celulele endoteliale expuse matricilor de colagen cu acid hialuronic ºi matricilor de colagen cu condroitin sulfat au prezentat nivele de colonizare mai ridicate comparativ cu matricea control. În cazul OPC viabilitatea cea mai ridicatã s-a înregistrat în cazul matricilor de colagen cu condroitin sulfat. Toate materialele au permis pãtrunderea celulelor endoteliale în interiorul lor datoritî macroporilor din structurã. Examinarea ultrastructuralã a celulelor integrate în matricile colagenice a evidenþiat prezenþa unui reticul endoplasmatic rugos, a numeroºi ribosomi liberi ºi lisosomi secundari. Testul de angiogeneza in vitro (cultivarea celulelor însãmânþate pe suporturile colagenice pe Matrigel) a evidenþiat faptul cã doar matricea colagenicã cu acid hialuronic ºi matricea control au susþinut dezvoltarea structurilor de tip capilar. Concluzii: Încorporarea de molecule caracteristice matricei extracelulare în suporturile colagenice testate favorizeazã adeziunea celulelor endoteliale. Matricile colagenice cu acid hialuronic ºi cu condroitin sulfat au prezentat nivele crescute de colonizare cu celulele endoteliale ºi OPC comparativ cu matricea martor; matricea de colagen cu acid hialuronic promoveazã angiogenezã in vitro sugerând cã ele sunt avantajoase în tratamentul defectelor de osificare datoritã promovãrii vascularizãrii ºi prevenirii necrozelor care pot surveni la nivelul implantului.

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AL XIII-LEA CONGRES NAÞIONAL SOROT, Bucureºti, 21–24 octombrie 2009 COLONIZATION WITH HUMAN ENDOTHELIAL CELLS AND HUMAN OSTEOPROGENITAR CELLS TO VARIOUS COLLAGEN MATRIX WITH APPLICABILITY IN BONE TISSUE ENGINEERING Introduction: Cell adhesion to extracellular matrices is essential for the development, maintenance, and remodeling of osseous tissues. Three-dimensional matrices based on collagen function as scaffolds for cellular growth, facilitate the interaction with various cell types and promote their expansion. Recent tissue engineering strategies involve the use of three-dimensional structures made of polypeptides (collagen) and polysaccharide (glycosaminoglycans) as an alternative model of bone grafts. Objective: Comparative testing of in vitro colonization of various compositions of collagen scaffolds with human aortic endothelial cells to determine their biocompatibility in terms of proliferation and angiogenic potential. Materials and Methods: Type I fibrillar collagen gels were obtained from calf hide by acid and alkaline treatments. The EA hy 926 endothelial cell line, human osteoprogenitor cells (OPC) and different biocompatible collagen supports were used: collagen matrices with hyaluronic acid, collagen matrices with chondroitin sulphate, collagen matrices (control). The cells were grown in DMEM 4,5‰ glucose medium supplemented with 10% fetal bovine serum, seeded on biomaterials at a density of 50.000 cells/ml (EA hy 926) and 75.000 cells/ml (OPC). Biomaterials colonization was monitored by fluorescence microscopy, transmission electron microscopy, viability by MTT assay and angiogenesis by Matrigel assay. Results: Fluorescence microscopy and MTT tests showed different colonization and viability rates on collagen biocompatible supports. The highest viability of OPC was obtained on collagen matrices with chondroitin sulphate. Collagen matrices with hyaluronic acid and chondroitin suphate revealed higher level of colonization than control matrices. All collagen matrices allowed penetration of cells due to their macropores. Ultrastructural examination of the cells integrated in the biocompatible collagen supports displayed the presence of a well developed rough endoplasmatic reticulum, numerous free ribosomes and large number of secundary

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lysosoms. In vitro angiogenesis assay showed that only control collagen and collagen with hyaluronic acid matrices sustained capillary-like structures formation. Conclusions: The collagen matrices that mimic the extracellular matrix (morphostructural and chemical) not only increased the adhesion surface area but also provided structural and organizational stability for endothelial cells. These scaffolds achieve a high level of colonization with endothelial cells that effectively promotes osteogenesis, prevents ischemic necrosis, and improves the mechanical properties of the engineered bone tissue. Bibliografie 1. Keresztes, Z. (2006) – Supramolecular assemblies of adsorbed collagen affect the adhesion of endothelial cells. Journal of Biomedical Materials Research Part A 76a (2).

 ARTROPLASTIA NECIMENTATÃ ÎN TRATAMENTUL COXARTROZEI SECUNDARE DISPLAZIEI CONGENITALE DE ªOLD S. Zuh, T.S. Pop, I. Gergely, O. M. Russu, Ö. Nagy Clinica de Ortopedie-Traumatologie II, Târgu-Mureº

Scopul autorilor a fost evaluarea rezultatelor pe termen mediu cu privire la plasarea ºi stabilitatea componentei acetabulare necimentate în artroplastia ºoldului displazic. Între 2000-2003 în Clinica de OrtopedieTraumatologie II Târgu-Mureº la 46 pacienþi cu displazie congenitalã de ºold s-au efectuat 54 artroplastii totale cu endoproteze necimentate, folosind tehnica protruziei mediale. Conform clasificãrii lui Crowe severitatea displaziei a fost: 14 ºolduri tipul I, 20 tipul II, 18 tipul III ºi 2 tipul 4. Vârsta medie a fost de 39 ani (28-56 ani), iar perioada medie de urmãrire 6,4 ani (5-9 ani). Componentele acetabulare au fost plasate medial de linia Köhler cu 1-6 mm (în medie 4,8 mm), iar procentul din suprafaþã a fost între 16-41% (în medie 24%). La 3 ºolduri am utilizat grefe osoase din capul femural. Centrul capului protetic a fost medializat cu 7-19 mm (în medie 13 mm). Nici una dintre cele 54 componente acetabulare nu a fost revizuitã, iar la 48 s-a constatat o fixare


ACTUALITÃÞI ÎN BIOMATERIALE excelentã, fãrã apariþia liniilor radiotransparente. Preoperator, valoarea medie a scorului Harris a fost de 42 puncte, postoperator la 3-6 luni de 87 puncte, iar la ultima evaluare de 92 puncte. Ca ºi concluzie putem afirma cã tehnica protruziei mediale este o metodã simplã care reduce durata intervenþiei, faciliteazã reabilitarea printr-o încãrcare precoce a ºoldului ºi permite o fixare stabilã a componentelor acetabulare. UNCEMENTED ACETABULAR COMPONENT IN DISPLAZIC HIP ARTHROPLASTY The aim of this study is to evaluate mid-term results regarding placement and stability of the uncemented acetabular components. Between 2000-2003 in 46 patients with acetabular dysplasia we performed 54 total hip arthroplasties without cement, using the medial protrusio technique. According to the criteria of Crowe, 14 hips were type I of dysplasia, 20 were

type II, 18 were type III and 2 were type IV. The average age was 39 years (28-56 years) and the mean follow-up period was 6,4 years (5-9 years). The acetabular components were placed with 1-6 mm (mean 4,8 mm) medial to the Köhler line, and the percent of the surface was between 16-41% (mean 24%). In 3 cases we use bone grafts. The center of the metalic femoral head was medialized with 7-19 mm (mean 13 mm). None of these 54 aceatbular components was revised and in 48 we noticed an excellent fixation, without adiacent transparent lines. Preoperatively, the mean Harris Hip Score was 42 points, postoperatively at 3-6 months it was 87 points and at the last evaluation 92 points. The medial protrusio technique is a simple method, it reduces the duration of intervention, facilitates the reabilitation by an early loading and offers a stabile fixation of the acetabular components.

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Numarul 2 - 2009