Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis for tumour between 1997 and 2007. The mean age was 46 years (7-87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3 % and the mean TESS was 77.2 %.

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7 % and a mean TESS of 80.0%.

Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.

Introduction

Metal Artefact Reduction Sequence (MARS) MRI is being increasingly used to detect soft tissue inflammatory reactions surrounding metal-on-metal hip replacements. The UK MHRA safety alert announced in April 2010 recommended cross-sectional imaging such as MRI for all patients with painful MOM hips. The terms used to describe the findings include bursae, cystic lesions and solid masses. A recently used term, pseudotumour, incorporates all of these lesions. We aimed to correlate the pattern of abnormalities on MRI with clinical symptoms.

Patients with osteochondrodysplasia frequently require Total Hip Arthroplasty at a younger age, as a result of early degenerative disease of the hip joint. The outcome of Modular Total Hip Arthroplasty in this group of patients has been reported previously. In this retrospective study we evaluated the outcome of custom made (CADCAM) Total Hip Arthroplasty in patients with osteochondrodysplasia.

Between 1974 and 2009, twenty one CADCAM Total Hip Arthroplasty procedures were performed in fourteen patients in our institution. There were eight female and six male patients, with the mean age at time of surgery of 40.95 years (20 to 78). The patients were followed up clinically and with the Harris hip score for a mean of 7.12 years (0.5 to 17 years).

Four of the twenty-one hips (23.8%) required revision surgery at a mean of 11.54 years (6.5 to 17 years); one required it for aseptic loosening of the femoral component; one required complete revision of the acetabular component; one required exchange of acetabular liner; and one was for symptomatic non-union of a lesser trochanter avulsion.

This study shows encouraging clinical outcomes of custom made (CADCAM) Total Hip Arthroplasty in patients with osteochondrodysplasia,

Introduction

Melorheostosis is a rare bone dysplasia characterized by its classic radiographic appearance resembling dripping candle wax. The condition was originally described by Leri and Joanny in 1922. Its etiology is not fully known and treatment in most instances has been symptomatic. There are nearly 350 reported cases on melorheostosis, joint replacement has been successfully attempted in the shoulder and knee joint. We describe a case of severe melorheostosis affecting the left hip causing secondary osteo-arthritis, which was treated with a total hip replacement (THR). To the best of our knowledge this is the first reported case of its kind in the World literature.

Total hip replacements have shown great benefits to patients through relief of pain and restoration of function. However, because of the extensive variation in the size and shape of the femoral canal, especially for the situation encountered in the revision hip arthroplasty, standard uncemented hip systems with a limited number of sizes are unable to provide an accurate fit in every case. This study showed clinical results of 112 primary total hip replacements and 158 revision total hip replacements, using custom made CAD-CAM (Computer Aided Design-Computer Aided Manufactured) hip prostheses inserted between 1992 and 1998.

For primary hip replacements, the implants were designed to produce proximal line-to-line fit with the femoral bone and to provide optimal biomechanical environment of the hip. The stem was HA coated, 53 males and 58 females were included. Mean age was 46.2 years (range 24.6yrs - 62.2 yrs). The average duration of the follow up was 24 years (10 – 17 years). The mean Harris Hip Score (HHS) was improved from 42.4 to 90.3, mean Oxford Hip Score (OHS) was improved from 43.1 to 18.2 and the mean WOMAC hip score was improved from 57.0 to 11.9. There was 1 revision due to failure of the acetabular components but there were no failures of the femoral components. In the whole follow-up period, the survival of the femoral stem alone was 100%.

For revision hip replacements, the implants were designed using our design strategies of graduate approach to different revision situation based on Paprosky's classification of femoral bone defect. The implants were HA coated; some of them had distal cutting flutes. A total of 158 patients (97 males and 61 females) who had operation between 1991 and 1998 were followed up, among them 138 cases were due to aseptic loosening, 6 cases were periprosthetic fractures and 14 cases were infection. The average age was 63.1 years (range 34.6 – 85.9 years). The minimum follow up was 10 years (range 10 – 12 years). The mean Harris Hip Score was improved from 44.2 to 89.3, mean Oxford Hip Score was improved from 41.1 to 18.2 and the mean WOMAC hip score was improved from 52.4 to 12.3 respectively. 6 cases required further revision surgery, among them 3 were due to aseptic implant loosening, the overall survivorship at ten years was 97%.

The CAD-CAM hip stems are able to provide optimal implant fixation and restore hip function for every patient regardless their original femoral shape, bone condition and biomechanics of the hip. The excellent medium to long term clinical results justifies the use of CAD-CAM custom hip stems.

Summary

We report the first use of synchrotron xray spectroscopy to characterize and compare the chemical form and distribution of metals found in tissues surrounding patients with metal-on-metal hip replacements that failed with (Ultima hips) or without (current generation, large diameter hips) corrosion.

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations.

A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham).

An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 87 patients were assessed, with an age range of 5 to 17 years and follow up range of up to 88 months.

Primary diagnosis was osteosarcoma, followed by Ewing's sarcoma. We implanted distal femoral, proximal femoral, total femoral and proximal tibial prostheses. All implants involving the knee joint used a rotating hinge knee. 6 implants reached maximum length and were revised. 8 implants had issues with lengthening but only 4 of these were identified as being due to failure of the lengthening mechanism and were revised successfully. Deep infection was limited to 5% of patients.

Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.

There is very limited literature available on the use of prosthetic replacement in the treatment of primary and secondary tumours of the radius. In the past these were treated with vascularised and non-vascularised autografts which had associated donor site morbidity, problems of non union, graft or junctional fractures and delayed return to function. Our study is a mid to long term follow-up of implant survivorship and the functional outcome of metal prosthetic replacement used for primary and metastatic lesions of radius. We had 15 patients (8 males:7 females) with a mean age of 53 years. 8 patients underwent proximal radial replacement, 2 with mid-shaft radial replacement and 6 patients had distal radial replacements with wrist arthrodesis. The indications for replacement included metastatic lesions from renal cell carcinoma, primary giant cell tumours, ewings' sarcoma, chondroblastoma, radio-ulnar synostosis and benign fibrous histiocytoma. The average follow up was 5 years and 6 months (range 3 months - 18 years). Four patients died as a result of dissemination of renal cell carcinoma and two patients were lost to follow-up. There were no complications with the prosthesis or infection. Clinically and radiographically there was no loosening demonstrated at 18 years with secure fixation of implants. Two patients developed interossoeus nerve palsies which partially recovered. Functional outcomes of the elbow were assessed using the Mayo performance score with patients achieving a mean score of 85 postoperatively (range 65-95). All but one patient had full range of motion of the elbow. The patient with radio-ulnar synostosis had a 25 degree fixed flexion pot-operatively. Although the distal radial replacements had decreased range of movements of the wrist due to arthrodesis, they had excellent functional outcomes. Only one patient required revision surgery due to post-traumatic loosening of the implant. Our results of the use of endoprosthetic replacement of radius in the treatment of tumours are encouraging with regards to survivorship of the implant and functional outcome. This type of treatment results in an early return to daily routine activties, good functional outcome and patient satisfaction.

Purpose

The rate of arthroplasty or osteotomy in patients who had undergone autologous chondrocyte implantation (ACI) for osteochondral defects in the knee was determined. Furthermore, we investigated whether any radiographic evidence of osteoarthritis (OA) prior to ACI was associated with poorer outcome following surgery.

Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion.

We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The “SMILES spacer” was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24–70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients.

In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation.

SUMMARY

We report a prospective study of clinical data collected pre, intra and post operation to remove both cup and head components of 118 failed, current generation metal on metal (MOM) hips. Whilst component position was important, the majority were unexplained failures and of these the majority (63%) had cup inclination angles of less than 55 degrees. Poor biocompatibility of the wear debris may explain many of the failures.

SUMMARY

The relationship between component position, wear rate and edge loading was investigated for 115 explanted current generation Metal-on-Metal (MoM) hips. Edge wear was detected in: 63% of all hips; and 48% of those with cups positioned within Lewinnek's box.

Metal-on-metal (MOM) hip resurfacings release chromium and cobalt wear debris into the surrounding joint. The hip tissue taken from failed MOM hips shows specific histological features including a subsurface band-like infiltrate of macrophages with particulate inclusions, perivascular lymphocytic infiltrate and fibrin exudation. This tissue response has been called Aseptic Lymphocytic Vasculitis Associated Lesion (ALVAL).

There is a recognised carcinogenic potential associated with hexavalent chromium and epidemiological data from first generation MOM arthroplasties may suggest an increased incidence of haematological malignancy. The ALVAL type reaction includes a marked proliferation of lymphocytes in the perivascular space and thorough investigation of this lymphocytic response is warranted.

This study aims to further characterise the lymphocytic infiltrate using immunohistochemistry and to test clonality using polymerase chain reaction (PCR).

Tissues from revised all cause failed MOM hip arthroplasties (n=77) were collected and analysed initially using routine H&E staining. Those that met the diagnostic criteria of ALVAL described above (n=34) were further stained with a panel of immunohistochemical markers (CD3, CD4, CD8 (T-cell markers) and CD20 (B-cell marker)). 10 representative ALVAL cases were selected and sent for gene rearrangement studies using PCR to determine whether the lymphocytes were polyclonal or monoclonal in nature.

The analysis of the lymphocytic aggregates in ALVAL, showed a mixed population of B and T cells. Within the aggregates, there was a predominance of B cells (CD20) over T cells (CD3). Of the 10 cases which were analysed by PCR, 7 were suitable for interpretation. None of these cases showed evidence of monoclonal lymphocyte proliferation.

The carcinogenic potential of wear debris from MOM hips, particularly affecting the haematopoietic system should be investigated. This study has shown a predominantly B-lymphocyte response in tissues surrounding MOM hips which is polyclonal. Although the numbers are small, the study suggests an immune mediated response in MOM hip tissue and excludes a neoplastic proliferation.

However, long term follow up of patients with MOM hips may be prudent.

Introduction

We report the initial 2 and 3 year follow-up results of this randomised controlled trial of autologous chondrocyte implantation (ACI) using porcine-derived collagen membrane as a cover (ACI-C) versus matrix-carried autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the knee.

Aims

To investigate (1) The relationship between macroscopic grading and durability of cartilage repair following collagen-covered autologous chondrocyte implantation (ACI-C) in the knee; (2) The influence of histology on durability of cartilage repair; (3) The relationship between macroscopic appearance and histology of repair tissue.

It is thought that metal ions from metal on metal bearing hip replacements cause DNA damage and immune dysfunction in the form of T cell mediated hypersensitivity. To explore the hypothesis that there is a relationship between metal ion levels and DNA damage and immune dysfunction in matched patient groups of hip resurfacings and standard hip replacements reflected in the levels of lymphocyte subtypes (CD3+ T cells, CD4+ T helper cells, CD8 +T cytotoxic/suppressor cells, CD16 +Natural Killer and CD19+ B cells) in peripheral blood samples, we analysed peripheral blood samples from 68 patients: 34 in the hip resurfacing group and 34 in the standard hip arthroplasty group. Samples were analysed for counts of each sub-group of lymphocyte and cytokine production. Whole blood cobalt and chromium ion levels were measured using inductively-coupled mass spectrometry. All hip components were well fixed.

Cobalt and chromium levels were significantly elevated in the resurfacing group compared to the hybrid group (p<0.001). There was a statistically significant decrease in the resurfacing group's level of CD8+ cells (T cytotoxic/suppressor) (p=0.010). No other subgroup of lymphocytes was significantly affected. Gamma interferon levels post antigen challenge were severely depressed in the hip resurfacing group.

A threshold level of blood cobalt and chromium ions for depression of CD8+ T cells was observed. Hip resurfacing patients have levels above this threshold whilst standard hip replacements fall below it. The patients all had normal levels of CD16 +Natural Killer and CD19+ B cells suggesting that this is not a bone marrow toxic effect. Cytokine analysis confirmed that some aspects of T cell function in hip resurfacing patients are severely depressed.

Purpose

We report on minimum 2 year follow-up results of 71 patients randomised to autologous chondrocyte implantation (ACI) using porcine-derived collagen membrane as a cover (ACI-C) and matrix-induced autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the knee.

Introduction

The treatment of distal femoral cartilage defects using autologous chondrocyte implantation (ACI) and matrix-guided autologous chondrocyte implantation (MACI) is become increasingly common. This prospective 7-year study reviews and compares the clinical outcome of ACI and MACI.

Background

Endoprosthetic reconstruction is an established method of treatment for primary bone tumours in children. Traditionally these were implanted with cemented intramedullary fixation. Hydroxyapatite collars at the shoulder of the implant are now standard on all extremity endoprostheses, but older cases were implanted without collars. Uncemented intramedullary fixation with hydroxyapatite collars has also been used in an attempt to reduce the incidence of problems such as aseptic loosening. Currently there are various indications that dictate which method is used.

Autologous chondrocyte implantation (ACII) has been shown to have favourable results in the treatment of symptomatic chondral and osteochondral lesions. However, there are few reports on the outcomes of this technique in adolescents.

The aim was to assess functional outcome and pain relief in adolescents undergoing autologous chondrocyte implantation (ACI).

Thirty-one adolescent patients undergoing ACI or Matrix-assisted chondrocyte implantation (MACI) were identified from a larger prospective study. Mean age was 16.3 years (range 14 – 18) with a mean follow-up of 66.3 months (12–126 months).

There were 22 males and nine females. All patients were symptomatic; 30 had isolated lesions and one had multiple lesions. Patients were assessed pre and postoperatively using the Visual Analogue Score (VAS), the Stanmore/Bentley Functional Rating Score and the Modified Cincinnati Rating System.

The mean VAS improved from 5.8 pre-operatively to 2 post-operatively. The Stanmore/Bentley Functional Rating Score improved from 2.9 to 0.9 whilst the Modified Cincinnati Rating System improved from 49.8 pre-operatively to 81.3 postoperatively with 87% of patients achieving excellent or good results. All postoperative scores exhibited statistically significant improvement from pre-operative scores.

The results show that, in this particular group of patients, this procedure produces reduction in pain and a statistically significant improvement in function postoperatively. We strongly recommend this procedure in the management of adolescents with symptomatic chondral defects.