The management of severe acetabular bone defects poses a complex challenge in revision hip arthroplasty. Although biological fixation materials are currently dominant, cage has played an important role in complex acetabular revision in the past decades, especially when a biological prosthesis is not available. The purpose of this study is to report the long-term clinical and radiographic results of Paprosky type Ⅲ acetabular bone defects revised with cage and morselized allografts. We retrospectively analyzed 45 patients who underwent revision hip arthroplasty with cage and morselized allografts between January 2007 and January 2019. Forty-three patients were followed up. There were 19 Paprosky type IIIA bone defect patients and 24 Paprosky type IIIB bone defect patients and 7 patients of the 24 were also with pelvic discontinuity. Clinical assessment included Harris Hip Score (HHS) and Short Form-12 (SF-12). Radiographic assessment included cage stability, allografts incorporation, and center of rotation. All patients were followed up with a mean follow-up of 10.6 years, HHS and SF-12 improved significantly at last follow-up in comparison to the preoperative. There were 2 re-revisions, one at 5 years after surgery, another at 13.6 years after surgery. Two patients had nonprogressive radiolucency in zone III and the junction of zone II and zone III at the bone implant interface. Allografts of 40 (93%) cases incorporated fully. The combination of cage and morselized allograft is an alternative option for acetabular revision with Paprosky type III bone defects with satisfactory long-term follow-up results

Background. Total ankle replacements (TARs) are becoming increasingly more common in the treatment of end stage ankle arthritis. As a consequence, more patients are presenting with the complex situation of the failing TAR. The aim of this study was to present our case series of isolated ankle fusions post failed TAR using a spinal cage construct and anterior plating technique. Methods. A retrospective review of prospectively collected data was performed for 6 patients that had isolated ankle fusions performed for failed TAR. These were performed by a single surgeon (IW) between March 2012 and October 2014. The procedure was performed using a Spinal Cage construct and grafting in the joint defect and anterior plating. Our primary outcome measure was clinical and radiographic union at 1 year. Union was defined as clinical union and no evidence of radiographic hardware loosening or persistent joint lucent line at 1 year. Results. The mean follow-up was 37.3 months (SD 13.2). Union was achieved in 5 of the 6 patients (83%). One patient had a non-union that required revision fusion incorporating the talonavicular joint that successfully went on to unite across both joints. Another patient had radiographic features of non-union but was clinically united and asymptomatic and one required revision surgery for a bulky symptomatic lateral malleolus with fused ankle joint. Conclusion. The failing TAR presents a complex clinical situation. After removal of the implant there is often a large defect which if compressed leads to a leg length discrepancy and if filled with augment can increase the risk of non-union. Multiple methods have been described for revision, with many advocating fusion of both the ankle joint and subtalar joint. We present our case series using a spinal cage and anterior plating that allows preservation of the subtalar joint and a high rate of union

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique. At our center we use three types of cage constructs –. (A) Conventional cage ± structural or morselised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture. This reconstruction is used in young patients where restoration of bone stock is important. (B) Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage. (C) Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity. Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven cup-cage procedures with an average follow-up of 74 months (range, 24–135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Failure was defined as revision surgery for any cause, including infection. The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval, 83.1–97.4), and the 10-year survival rate was 85% (95% CI, 67.2–93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 pre-operatively to 13 post-operatively (p < 0.001). Four cup-cage constructs had non-progressive radiological migration of the ischial flange and they remain stable

Introduction. Acetabular revision surgery is challenging due to severe bone defects. Burch-Schneider anti-protrusion cages (BS cage: Zimmer-Biomet) is one of the options for acetabular revision, however higher dislocation rate was reported. A computed tomography (CT)-based navigation system indicates us the planned direction for implantation of a cemented acetabular cup during surgery. A large diameter femoral head is also expected to reduce the dislocation rate. The purpose of this study is to investigate short-term results of BS cage in acetabular revision surgery combined with the CT-based navigation system and the use of large diameter femoral head. Methods. Sixteen hips of fifteen patients who underwent revision THA using allografts and BS cage between September 2013 and December 2017 were included in this study with the follow-up of 2.7 (0.1–5.0) years. There were 12 women and three men with a mean age of 78.6 years (range, 59–61 years). The cause of acetabular revision was aseptic loosening in all hips. The failed acetabular cup was carefully removed, and acetabular bone defect was graded using the Paprosky classification. Structural allografts were morselized and packed for all medial or contained defects. In some cases, solid allograft was implanted for segmental defects. BS cage was molded to optimize stability and congruity to the acetabulum and fixed with 6.5 mm titanium screws to the iliac bone. The inferior flange was slotted into the ischium. The upside-down trial cup was attached to a straight handle cup positioner with instrumental tracker (Figure 1) and placed on the rim of the BS cage to confirm the direction of the target angle for cement cup implantation under the CT-based navigation system (Stryker). After removing the cement spacer around the X3 RimFit cup (Stryker) onto the BS cage for available maximum large femoral head, the cement cup was implanted with confirming the direction of targeting angle. Japanese Orthopedic Association score (JOA score) of the hip was used for clinical assessment. Implant position, loosening, and consolidation of allograft were assessed using anterior and lateral radiographies of the pelvis. Results. Fifteen hips had a Paprosky IIIB defect, and one hip had a pelvic discontinuity. JOA score significantly improved postoperatively. No radiolucent lines and no displacement of BS cage could be found in 9 of 15 hips. Consolidation of allografts above the protrusion cage was observed in these patients. Displacement of BS cage (>5mm) was observed in 6 hips and displacement was stopped with allograft consolidation in 5 of 6 hips. The other patient showed lateral displacement of BS cage and underwent revision surgery. Average cup inclination and anteversion angles were 37.7±5.0 degree and 24.6±7.2 degree, respectively. 12 of 16 patients were included in Lewinnek's safe zone. One patient with 32 mm diameter of the femoral head had dislocation at 17 days postoperatively. All patients who received ≥36mm diameter of femoral head showed no dislocation. Conclusions. CT-based navigation system and the use of large femoral head may influence the prevention of dislocation in the acetabular revision surgery with BS cage for severe acetabular bone defects

Background. The rate of subsidence for lumbar fusion surgery is variable from 7- 89%. Subsidance can affect the outcome of surgery by compramising alignment, foraminal height and stability. Modic changes have been shown to affect the stiffness and strength of the vertebral end plate and shown to affect both fusion rates and clinical outcome. Ongoing laboratory investigations into the material properties of the degenerate lumbar spine show modic changes affect the end plate and trabecular bone mechanics. This study aims to bridge this basic science research into clinical practice. Methods. A retrospective analysis of all patients in two tertiary spinal centres who have undergone lumbar interbody fusion with the implantation of a ‘cage’ over the past 6 years were analysed by two independent spinal surgeons. Pre-operative MRI findings were correlated with post-operative interbody cage subsidence after 1 year. Results. A total of 108 Interbody cages were included. Comparison of demographics did not reveal and significant between group variations. Comparison made between those displaying no modic changes and those displaying any of the three modic change types revealed a significantly higher subsidence rate in those displaying modic changes (p=0.003). Subgroup analysis showed that Type 2 modic changes (n=27) had a significantly higher subsidence rate (p=0.002). Those displaying type 3 modic changes (n=7) did not have any incidents of subsidence. Conclusions. Type 2 modic changes are associated with a higher rate of Lumbar interbody cage subsidence in this study. Those displaying type 3 changes seem to be protected from interbody cage subsidence. No Conflict of Interest. Funding: Produced as part of a research grant from the Gwen Fish Trust and Action Arthritis

In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity. Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultraporous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultraporous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven cup cage procedures with an average follow-up of 74 months (range, 24–135 months; SD, 34.3 months) were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Failure was defined as revision surgery for any cause, including infection. The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval, 83.1–97.4), and the 10-year survival rate was 85% (95% CI, 67.2–93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 pre-operatively to 13 post-operatively (p < 0.001). Four cup-cage constructs had non-progressive radiological migration of the ischial flange and they remain stable

Transforaminal lumbar interbody fusion (TLIF) using an implanted cage is the gold standard surgical treatment for disc diseases such as disc collapse and spinal cord compression, when more conservative medical therapy fails. Titanium (Ti) alloys are widely used implant materials due to their superior biocompatibility and corrosion resistance. A new Ti-6Al-4V TLIF cage concept featuring an I-beam cross-section was recently proposed, with the intent to allow bone graft to be introduced secondary to cage implantation. In designing this cage, we desire a clear pathway for bone graft to be injected into the implant, and perfused into the surrounding intervertebral space as much as possible. Therefore, we have employed shape optimization to maximize this pathway, subject to maintaining stresses below the thresholds for fatigue or yielding. The TLIF I-beam cage (Fig. 1(a)) with an irregular shape was parametrically designed considering a lumbar lordotic angle of 10°, and an insertion angle of 45° through the left or right Kambin's triangles with respect to the sagittal plane. The overall cage dimensions of 30 mm in length, 11 mm in width and 13 mm in height were chosen based on the dimensions of other commercially available cages. The lengths (la, lp) and widths (wa, wp) of the anterior and posterior beams determine the sizes of the cage's middle and posterior windows for bone graft injection and perfusion, so they were considered as the design variables for shape optimization. Five dynamic tests (extension/flexion bending, lateral bending, torsion, compression and shear compression, as shown in Fig. 2(b)) for assessing long term cage durability (10. 7. cycles), as described in ASTM F2077, were simulated in ANSYS 15.0. The multiaxial stress state in the cage was converted to an equivalent uniaxial stress state using the Manson-Mcknight approach, in order to test the cage based on uniaxial fatigue testing data of Ti-6Al-4V. A fatigue factor (K) and a critical stress (σcr) was introduced by slightly modifying Goodman's equation and von Mises yield criterion, such that a cage design within the safety design region on a Haigh diagram (Fig. 2) must satisfy K ≤ 1 and σcr ≤ SY = 875 MPa (Ti-6Al-4V yield strength) simultaneously. After shape optimization, a final design with la = 2.30 mm, lp = 4.33 mm, wa = 1.20 mm, wp = 2.50 mm, was converged upon, which maximized the sizes of the cage's windows, as well as satisfying the fatigue and yield strength requirements. In terms of the strength of the optimal cage design, the fatigue factor (K) under dynamic torsion approaches 1 and the critical stress (σcr) under dynamic lateral bending approaches the yield strength (SY = 875 MPa), indicating that these two loading scenarios are the most dangerous (Table 1). Future work should further validate whether or not the resulting cage design has reached the true global optimum in the feasible design space. Experimental validation of the candidate TLIF I-beam cage design will be a future focus. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aims: Both partial and total functional disorders of spine are one of the most disabling, common and costly problem of current surgery. The surgical treatment may involve the partial or total resection of the Intervertebral Disc (IVD). Thus, implants for vertebral fusion are often required in order to immobilize the diseased column. Cage implants are designed in order to separate contiguous vertebrae allowing an adequate stress transfer and favoring bone growth. In this paper the biomechanical and histological properties of novel composite cages and commercial titanium implants have been in vitro and in vivo investigated. Materials: Novel composite lumbar cages were designed by F.E.M., manufactured and implanted in porcine spine at the L4-L5 lumbar zone of five pigs (large white-duroc race of 50–55 Kg by weight and 1.9–2.1 months old). Each composite cage was prepared by filament winding technology by using PEI (PolyEtherImmide – GE Polymerland ULTEM 1000/1000) as matrix and Carbon fibre (Torayca T400-B 6000-50B) as reinforcement with a winding angle of 45A1 degree. Mechanical properties were investigated according to ASTM standard on composite material, novel composite cage, titanium cage and the natural disc. The device was coated with PEI – HA (hydroxyapatite) solution in order to improve the bone interaction. The behaviour of the composite cage was compared to titanium lumbar cages (SOFAMOR Danek) through biomechanical and histological tests. Results: Tensile test performed on composite material have showed a Young’s Modulus equal to 40,1 GPa, maximum tensile strength equal to 602 MPa. Compressive test on the composite cage showed an Elastic Modulus value of 22 GPa. The comparison among the three systems displayed comparable compliance for titanium (0,0014mm/mm) and composite cage (0,0031mm/mm) while an higher compliance in the case of natural disc (0,0521mm/mm). All pigs showed good health up to the sacrificing date. Particularly, histological tests after two months from the implantation already showed abundant the presence of new-formed tissue around the composite cage. Conclusions:. The results demonstrate that PEI reinforced with Carbon fibres composite cages coated with HA show excellent performance. Mechanical properties of the composite cages are closer to the properties of cortical bone than those of titanium cages, thus reducing the effect of stress concentration and stress shielding and as observed for stiff metal implants

Introduction. Degenerative, inflammatory, and posttraumatic arthritis of the ankle are the primary indications for total ankle arthroplasty. Ankle arthrodesis has long been the “gold standard” for the surgical treatment. Total Ankle Arthroplasty. implant survivorship has been reported to range from 70% to 98% at three to six years. The combination of younger age and hindfoot arthrodesis or osteoarthritis may lead to a relative increase in failure rates after TAA. Intraoperative complication include malaligment, fracture and tendon Postoperative complications include syndesmotic nonunion, wound problems, infections and component instability and lysis. After TAA few difficulties mainly due to poor Talar and Tibial bone stock. It is difficult to stabilize the fusion and usually there is shortening after removal of the implant. Also there is a need for massive bone graft-allograft or autograft. In cases when there is significant bone loss there is a need for stable reconstruction and stabilization of the hindfoot. Bone grafting with structural bone graft may collapse and it has to be stabilized with screws or nail. Methods. We developed technique which included distraction of the fusion area and inserting a Titanium cylindrical spinal cage filled with bone graft. Than guide wire was inserted in through the cage under fluoroscopy and a compression screw was introduced causing compression of the fusion area against the cage gaining stabilization of the fusion area. Results. By 6 months all the patients were fused and could walk full weight bearing with no pain. Discussion and Conclusions. Spinal cages are widely used in spine fusions in order to achieve stable spacer. Usually it has to be stabilized using posterior fusion stabilizing system. By performing distraction of the fusion area by spinal cage used as spacer and compression at the same time using compression screw we achieved primary good stability with minimal shortening

Introduction. Degeneration of the cervical spine can lead to neurological symptoms that require surgical intervention. Often, an anterior cervical discectomy (ACD) with fusion is performed with interposition of a cage. However, a cage substantially increases health care costs. The polymer polymethylmethacrylate (PMMA) is an alternative to cages, associated with lower costs. The reported high-occurrence of non-fusion with PMMA is often seen as a drawback, but evidence for a correlation between radiological fusion and clinical outcome is absent. To investigate if the lower rate of fusion with PMMA has negative effects on long-term clinical outcome, we assessed the clinical results of ACD with PMMA as a intervertebral spacer with a 5–10 year follow-up. Methods. A retrospective cohort study among all patients who underwent a mono-level ACD with PMMA for degenerative cervical disease, between 2007–2012, was performed. Patients filled out an online questionnaire, developed to assess clinical long-term outcome, complications and re-operation rates. The primary outcome measure was the Neck Disability Index (NDI), secondary outcome measures were re-operation and complication rates. Results. Of 196 eligible patients, 90 patients were assessed (response rate 53%). The average NDI score at follow-up (mean 7.5 years) was 19.0 points ± 18.0 points. Complications occurred in 10% and re-operation in 8.8%. Conclusion. This study provides evidence of good long-term clinical results of ACD with PMMA, as the results were similar with long-term outcomes of ACD with a cage as spacer. Therefore, the results of this study may suggest that the use of PMMA is an lower-cost alternative. No conflicts of interests. No funding obtained

Introduction. Support cages are often used for reconstruction of acetabular bone defects in revision total hip arthroplasty. A Burch-Schneider cage is one of the most reliable systems that has shown good clinical results. It has an ischial flange and an iliac plate for screw fixation to the ilium. It is sometimes necessary to bend the flange or the plate to fit the shape of the peri-acetabulum. However, the frequency, indications, and characteristics of bending the flange or plate have not been reported. To clarify them, a simulation study was conducted. Materials and methods. Twenty-five cases with acetabular bone defects of Paprosky type 2, 3, or 4 were the subjects of this study. A 3D template surgical simulation was conducted using 3D surface models of the Burch-Schneider cage and acetabulum. The size of the cage was determined by the size of the cavitary bone defect. Placement of the cage was performed in two ways. One was the iliac plate fitting method, in which fitting of the iliac plate to the ilium was performed first, followed by bending of the ischial flange to keep the flange in the center of the ischium. When bending of the flange was needed, it was bent at the base. The other method was the ischial flange fitting method, in which the ischial flange was inserted from the center of the ischium, followed by bending of the iliac flange to adapt to the ilium. When bending of the plate was needed, it was bent at the base. In both methods, the direction and angle of bending were measured. Results. In the iliac plate fitting method, the cage adapted the acetabulum without bending the ischial flange in 12 cases, and with lateral bending in 11 cases. The bending angle was less than 30° in 8 cases. Three cases required more than 30° of bending and there were also 2 cases which were impossible to fit the acetabulum even with bending the ischial flange. This was due to the large bone defect at the superolateral region of the acetabulum. In the ischial flange fitting method, the cage adapted the acetabulum without bending in 12 cases. The remaining 13 cases required less than 30° of iliac plate lateral bending. Discussion. The iliac plate fitting method is a clinically oriented method since the insertion position of the ischial flange is determined after fitting the provisional cage with an iliac plate. However, in cases with a large bone defect in the superolateral region of the acetabulum, some were impossible to fit. On the other hand, with the ischial flange fitting method, the cage could fit all types of acetabular defects. This suggests that, even in cases with a bone defect in the superolateral region of the acetabulum, the Burch-Schneider cage is a usable instrument. Conclusion. The half of the cases required lateral bending of the ischial flange or iliac plate. If there is a large bone defect at the superolateral region of the acetabulum, the iliac plate may need to be bent

Introduction. The management of periprosthetic pelvic bone loss is a challenging problem in hip revision surgery. This study evaluates the minimum 10-year clinical and radiographic outcome of major column structural allografts combined with the Burch-Schneider antiprotrusio cage for acetabular reconstruction. Methods. From January 1992 to August 2005, 106 hips with periprosthetic osteolysis underwent acetabular revision using massive allografts and the Burch-Schneider antiprotrusio cage. Forty-five patients (49 hips) died for unrelated causes without further surgery. Fifty-nine hips in 59 patients underwent clinical and radiographic evaluation at an average follow-up of 15.1 years. There were 17 male and 42 female patients, with age ranging from 29 to 83 years (mean 59). Results. Ten hips required rerevision because of infection (3), aseptic loosening (6), and flange breakage (1). Moreover, 4 cages showed x-ray signs of instability with severe bone resorption. The survivorship of the Burch-Schneider cage at 21.9 years with removal for any reason or radiographic migration and aseptic or radiographic failure as the end points were 76.3 and 81.4, respectively. The average Harris hip score improved from 33.2 points preoperatively to 75.7 points at the latest follow-up (p < 0.001). Discussion. In hip revision surgery, severe deficiency of pelvic bone stock is a critical concern because of the difficulty in providing a stable and durable fixation of the prosthesis. Although antiprotrusio cages have a limited role in acetabular revision, the use in association with massive allografts in extended bone loss demonstrated highly successful long-term results, enabling bone stock restoration and cup stability

Background. The improvement of the rib cage deformity (RCD) after surgery correction has not been correlated in detail with the correction of vertebral axial rotation (AR). The loss of at the rib cage after correction has been never monitored. The hypothesis of this work was that the aesthetic improvement of RCD in adolescent idiopathic scoliosis (AIS) does not follow completely the reduction of thoracic AR after correction surgery. Moreover, lesser correction of thorax deformity could be expected in mature patients with more rigid curves. Methods. Multicenter prospective study of the modifications of the rib cage deformity in 24 patients operated because of AIS Lenke type 1A. RDC was assessed in the preoperative MRI exams including the thoracic perimeter. Vertebral AR was quantified by the RaSac angle. Anterior and posterior rib hump, and the translation of the sternum were measured in mm according to standard protocols. All these parameters were assessed in the immediate post-op period and 2-years after surgery using CT-scan axial slides. In all cases, a vertebral derotation technique performed by asymmetric rod bending was used. Immature (Risser 0–2) and mature (Risser 3–4) patients were compared. Results. Mean age of patients was 14±2 years. The preoperative curve magnitude was 56.2±8.3 Cobb degrees. RaSac at the apex was 27.2±2.8 degrees. There were 10 immature and 14 mature patients. There were no differences between the two groups in all the radiological measurements of the curves. Immature patients showed lesser posterior rib hump as compared to mature cases (14.9±4.1 mm versus 38.1±22.9; p<0.001). Postoperative vertebral AR was lesser in immature patients (2.0±1.2 versus 7.9±2.4 degrees) and increased slightly at 2-year check-up. The posterior rib hump showed also a slightly increased 2 years after surgery. In 18 cases (75%), a contralateral anterior rib hump less than 3 mm emerged after surgery that diminished but not disappeared at 2-year check-up. Conclusions. The rib cage deformity showed a lesser correction than the vertebral axial rotation. Besides this finding, immature patients showed more rib cage plasticity showing both greater modifications after surgery, and higher loss of correction during follow-up. Level of evidence. Level IV

We developed a device for the treatment of Ficat and Arlet stage II and III osteonecrosis of the femoral head. This device, which we named the “super-elastic cage,” was designed to provide mechanical support for the necrotic weight-bearing area of the femoral head to prevent its collapse. The cage was used in combination with surgical removal of necrotic bone, insertion of vascularized pedical bone graft, or impacted autologous cancellous bone graft. A total of 93 hips in 62 patients at Ficat stage II to III were included in a 8-year study. Implantations were performed by 2 different approaches: Smith-Peterson approach and minimal invasive approach by the lateral side of great trochanter. The follow-up period was between 72 and 107 months. Of the femoral heads in this study, 82.7% survived. The superelastic cage implantation technique may offer an alternative treatment to the early and middle stages of osteonecrosis of the femoral head

The treatment of acetabular metastases with total hip arthroplasty is technically challenging often with significant loss of structural continuity in the medial wall and roof of the acetabulum, as described by Harrington in 1981 as class III defects. Traditionally the acetabular component is stabilised with Harrington rods but the risk of post-operative complications, especially bleeding is significant. We performed 10 consecutive total hip arthroplasties in patients with metastases involving the acetabulum with Harrington class III defects. The first three patients had acetabular reconstruction with a Kerboull cage, (Stryker Howmedica.) The cage was secured using a combination of screw fixation to the ileum and PMMA cement filling voids behind the cage. A polyethylene acetabular cup is then cemented into the cage. There was concern about the superior fixation using this implant and so the remaining 7 patients were treated using the Graft Augmentation Prosthesis (GAP II), (Stryker How-medica.) This is a titanium reconstruction cage with two superior flanges allowing extensive screw fixation onto the ileum. Two patients had very large defects where there was not sufficient support to use this cage alone, so the technique was augmented with Harrington rods. No implants have failed to date. One patient, an 83 year old female, died 23 days post-operatively after suffering a stroke. Two patients died of their disease 95 and 115 days after surgery. The remaining patients continue to have good pain and mobility following surgery as demonstrated by the Oxford hip score. We conclude that in suitable patients with extensive metastatic involvement of the acetabulum, a flanged acetabular reconstruction cage prosthesis is much improved way of providing support for a total hip replacement. This procedure can greatly improve quality of life, and to date we have had no mechanical failures of fixation using this technique

Instability and aseptic loosening are the two main complications after revision total hip arthroplasty (rTHA). Dual-mobility (DM) cups were shown to counteract implant instability during rTHA. To our knowledge, no study evaluated the 10-year outcomes of rTHA using DM cups, cemented into a metal reinforcement ring, in cases of severe acetabular bone loss. We hypothesized that using a DM cup cemented into a metal ring is a reliable technique for rTHA at 10 years, with few revisions for acetabular loosening and/or instability. This is a retrospective study of 77 rTHA cases with severe acetabular bone loss (Paprosky ≥ 2C) treated exclusively with a DM cup (NOVAE STICK; SERF, DÉCINES-CHARPIEU, FRANCE) cemented into a cage (Kerboull cross, Burch-Schneider, or ARM rings). Clinical scores and radiological assessments were performed preoperatively and at the last follow-up. The main endpoints were revision surgery for aseptic loosening or recurring dislocation. With a mean follow-up of 10.7 years [2.1-16.2], 3 patients were reoperated because of aseptic acetabular loosening (3.9%) at 9.6 years [7-12]. Seven patients (9.45%) dislocated their hip implant, only 1 suffered from chronic instability (1.3%). Cup survivorship was 96.1% at 10 years. No sign of progressive radiolucent lines were found and bone graft integration was satisfactory for 91% of the patients. The use of a DM cup cemented into a metal ring during rTHA with complex acetabular bone loss was associated with low revision rates for either acetabular loosening or chronic instability at 10 years. That's why we also recommend DM cup for all high risk of dislocation situations

Posterior lumbar interbody fusion (PLIF) enables us to perform posterior decompression and anterior reconstruction with single posterior midline approach. We designed trapezoid titanium mesh cage (TPM type N cage) to realign postoperative normal lordotic curve that prevents the progressive degeneration of the disc adjacent to the PLIF-D. Patients: We had 60 PLIFs by using TPM type N cage. There were 41 males and 19 females. The age was 52.6 year-old in average. The patients consisted of 19 degenerative spondylolisthesis, 12 multiply operated back syndromes (MOB), 16 intracanal ossifications, 5 spondylolytic spondylolisthesis, 7 unstable spines, 3 spinal canal stenosis. Operation methods: Intracanal or extracanal approach was used. The reduction was achieved by restoring the disc heights with rotating disc shaver. The posterior 2/3 endplate were preserved to prevent the cage from sinking into the vertebral body. TPM type N cage with 13mm anterior, 11mm posterior height was used. The trapezoid shape reestablished the lordotic curvature. Results: Mean follow-up period was 3.3 years (4.4–2.6 years). We evaluated the clinical results with Japanese Orthopedic Association score (JOA score). The preoperative 15.8 JOA score statistically improved to 25.0 in average. There was neither postoperative neurological deterioration nor contamination. Pre-operative 6.4 ± 3.2 mm disc height was statistically improved to 11.5 ± 1.8 mm. Pre-operative 6.4 ± 10.8° lumbar lordotic was statistically improved to 10.5 ± 3.9° The progressive degeneration of the disc adjacent to PLIF was identified in 7case (11%). They had no clinical symptoms. Conclusion: Trapezoid titanium mesh cage reestablishes lumbar lordotic curvature and prevents progressive degeneration of the disc adjacent to PLIF

Introduction:. Circumferential arthrodesis of the spine may be achieved by posterior-only or anterior and posterior surgery. Posterior-based interbody fusions have significant limitations including unreliable improvement of segmental lordosis and variable rates of post-operative radiculopathy. Combined anterior and posterior surgery introduces significant cost and peri-operative morbidity. The purpose of this paper is to report the radiographic and clinical outcomes of posterior-based circumferential arthrodesis using a novel expandable interbody cage. Methods:. A prospective pilot clinical trial with one year follow-up of the only expandable cage approved by the FDA for interbody application. Clinical outcomes measured include ODI and VAS for back and leg. Radiographic outcomes include arthrodesis rates based upon CT scan. Statistical significance for change in health status was calculated using Student's t-test. Results:. 10 consecutive patients (11 levels) with lumbar degenerative pathology underwent circumferential arthrodesis with a transforaminal interbody approach. 10 of 11 levels were fused based upon CT scan. ODI scores improved a median of 37 to 20 at 6 months and 17 at one year (p = 0.0003). The VAS for back and leg pain likewise from 6 to 2 at 12 months (p = −.003). No patient reported an increase in leg pain from pre-op to post-op. One patient with a 2-level fusion had a non-union at 1 level requiring revision surgery. Conclusion:. Circumferential arthrodesis with a TLIF approach is an important technique for the management of lumbar degenerative pathology. The experience with a novel expandable TLIF cage demonstrates excellent results based upon clinical outcome and fusion rates. The expandable interbody cage allows in-situ height increase which is useful for optimizing clinical and radiographic outcomes in TLIF surgery

Acetabular components of total hip joint replacement (THJR) in previously irradiated pelvis show high rates of failure. We present a literature review and a retrospective series evaluating the survival of acetabular cages in this difficult situation. Our hypothesis was that cage reinforcement of the acetabulum after previous pelvic irradiation would lead to early failure. A cohort of 11 patients (12 hips) was identified, who had undergone THJR utilising an acetabular cage, after previous pelvic irradiation for malignant tumours. All operations were performed by a single surgeon in Waikato over the period of 1997–2007. Six patients (six hips) died within one year of their operation, the further five patients (six hips) were analysed for survival and radiograpical loosening of the acetabular component. Complications attributed to previous irradiation are also reported. There is a paucity of literature of THJR survivorship after pelvic irradiation. The first series from the 1970’s showed 50% acetabular loosening at 5 years in cemented cups. Two conflicting series are published with 44% vs. 0% failure of uncemented cups. Only one previous series (22 hips) reports the use of acetabular reinforcement rings, and showed a 20% loosening and 10% deep infection rate at 4 years. In our cohort of 12 hips in 11 patients, only five patients survived greater than one year after joint replacement. The average follow up of the remaining six hips is five years (two to ten years). Two out of six of the acetabular cages have catastrophically failed. Of the remaining four cages, one is probably, and three are possibly radiologically loose. Two out of six have raised concerns in regards to deep infection that were not proven microbiologically. Overall of the patients who survived greater than one year after their THJR for pelvic irradiation, only four out of six of the acetabular cages remained insitu, and all had concerns raised in regards to radiographical loosening. We report a high rate of clinical and radiographic failure of cage reconstruction of the acetabulum after previous pelvic irradiation. A superior method of acetabular reconstruction in this difficult situation is yet to emerge. Alternative methods of reconstruction continue to develop, with trabecular metal options a possible consideration

The Synex cage is an expanding titanium implant designed for reconstruction of the anterior column in injury, post-traumatic kyphosis or tumour of the thoracolumbar spine. It is supplemented by a stabilizing implant. As it is expandable in situ it therefore can be inserted via a relatively small exposure. The design enables good purchase of the endplates and reduces the possibility of secondary displacement. Surgery for anterior reconstruction is usually performed via an anterior approach, however, there are incidences were a posterolateral approach is indicated. The Synex cage is useful in these circumstances, as being expandable, posterolateral insertion with preservation of the nerve roots is possible. The Synex cage is then supplemented with a posterior construct. The cage can be inserted via a left or right posterolateral approach. A specially designed angled screwdriver is now available to release the ratchet mechanism and if necessary collapse the cage. We present, what is, to the best of our knowledge and that of the manufacturer, the first two patients where a Synex cage has been inserted using the posterolateral approach. Conclusion: Synex cage has the advantage of being expandable and it is therefore possible to insert this via a potentially small exposure, between the nerve roots, using a posterolateral approach