Introduction. Approximately 2,000 Skeletal transcutaneous osseointegration (STOI) procedures have been performed worldwide as of 2020, more than half of which have been performed by the Osseointegration Group of Australia using a press-fit technique with either ILP or OPL implant designs. Despite the consistently demonstrated clinical benefits, concerns regarding potential complications following STOI have slowed its widespread adoption. As more patients are followed for a longer period of time, longitudinal studies have confirmed complication rates are very acceptable, similar to those of total ankle and total elbow replacements. One of the major risk category is implant removal. The primary goal of this study was to investigate the complications and technical issues associated with transtibial osseointegration implant removal due to any cause. The focus here will be on the press-fit ILP and OPL implants, including the indications for removal and patient outcomes following removal. Materials & Methods. A review of our osseointegration registry between November 2010 and March 2022 was performed. Inclusion criteria were patients who have undergone removal of a transtibial osseointegration implant due to any cause. Selected patients either had a follow-up of at least two years or had their index osseointegration surgery at least two years prior to when the study was performed. Patients who have had osseointegration at other anatomic levels, and patients who underwent simultaneous total knee replacement with transtibial osseointegration were excluded from the registry search. Results. There were a total of 148 transtibial osseointegration procedures performed during the study period, with 97 (65.5%) performed in males and 51 (34.5%) performed in females. The average age at first stage osseointegration procedure is 50.4 years (range 16.8–87.9, SD 14.1). In the study cohort of 22 cases requiring implant removals, 12 (54.5%) were male and 10 (45.5%) were female. The average age at first stage osseointegration procedure in this cohort is 51.3 (range 37.4–82.6, SD 10.7) and average BMI 30.3 (range 21.9–40.9, SD 5.8). Although men comprised the majority of removals, women had a greater relative risk (Fisher exact test p=0.032). The average duration from time of STOI to removal was 2.6 years (range 0.1–6.8, SD 1.9) within this 11.5 year follow-up period. The most frequent indication was infection (54.6%, n=12) followed equally by pain (13.6%, n=3), aseptic loosening (13.6%, n=3) and implant fracture (13.6%, n=3), and lastly failure to integrate (4.6%, n=1). Conclusions. Of the 22 removals, 12 were reimplanted at the same anatomical level (10 were reimplanted within 6 months, 1 within 12 months, and 1 within 24 months). 11 of these cases currently wear their prosthetic legs for more than 13 hours daily. 1 case was recently reimplanted and still completing their loading program. Of the patients who were not reimplanted at the same anatomical level, 1 required proximal amputation with transfemoral osseointegration. 3 patients converted to traditional socket prostheses (TSP) due to pain, and 1 underwent proximal amputation and converted to TSP due to infection. 3 cases are currently awaiting transtibial osseointegration reimplantation, and 1 patient was deceased. 1 patient was lost to follow-up

Aims. The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods. All patients included in the ‘ROutine vs on DEmand removal Of the syndesmotic screw’ (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results. The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion. This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation. Cite this article: Bone Jt Open 2023;4(12):957–963

Aims. The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. Methods. We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. Results. There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. Conclusion. Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359–366

The Latarjet procedure is a well described method to stabilize anterior shoulder instability. There are concerns of high complication rates, one of these being a painful shoulder without instability due to screw irritation. The arthroscopic changes in the shoulder at time of screw removal compared to those pre-Latarjet have not been described in the literature. We conducted a retrospective review of arthroscopic videos between 2015 and 2022 of 17 patients at the time of their Latarjet screw removal and where available (n=13) compared them to arthroscopic findings at time of index Latarjet. Instability was an exclusion criterion. X-rays prior to screw removal were assessed independently by two observers blinded to patient details for lysis of the graft. Arthroscopic assessment of the anatomy and pathological changes were made by two shoulder surgeons via mutual consensus. An intraclass correlation coefficient (ICC) was analyzed as a measure for the inter-observer reliability for the radiographs. Our cohort had an average age of 21.5±7.7 years and an average period of 16.2±13.1 months between pre- and post-arthroscopy. At screw removal all patients had an inflamed subscapularis muscle with 88% associated musculotendinous tears and 59% had a pathological posterior labrum. Worsening in the condition of subscapularis muscle (93%), humeral (31%) and glenoid (31%) cartilage was found when compared to pre-Latarjet arthroscopes. Three failures of capsular repair were seen, two of these when only one anchor was used. X-ray review demonstrated 79% of patients had graft lysis. Excellent inter-rater reliability was observed with an ICC value of 0.82. Our results show a high rate of pathological change in the subscapularis muscle, glenoid labrum and articular cartilage in the stable but painful Latarjet. 79% of patients had graft lysis with prominent screws on X-ray

Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical. We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022. We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement. One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5). In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy. With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation

Introduction. Traditionally, radiological union of fractures treated with an Ilizarov frame is confirmed by a period of dynamization - destabilisation of the frame for a period prior to removal. Reduced clinic availability during the COVID-19 pandemic caused a shift to selective dynamisation in our department, whereby lower risk patients had their frames removed on the same day as destabilisation. This study investigates the effects of this change in practice on outcomes and complication rates. Materials & Methods. Adult patients treated with circular frames between April 2020 and February 2022 were identified from our Ilizarov database. Patients were divided into 2 groups: - “dynamised” if their frame was destabilised for a period to confirm union prior to removal; or “not dynamised” if the decision was taken to remove the frame without a period of dynamisation, other than a short period in the clinic. A retrospective review of clinical notes was conducted to determine outcome. Results. 175 patients were included in the final analysis, 70 in the dynamised and 103 in the not dynamised groups, median follow-up was 33 months. 3 patients in the dynamised group failed dynamisation and had their period of fixation extended, subsequently having their frames removed without complication. Two patients suffered a refracture or non-union after frame removal in the dynamised group and none in the not dynamised group, this difference was not statistically significant. Conclusions. In our practice, selective frame removal without a period of dynamisation appears safe. This has the potential to shorten frame time and reduce the number of clinic appointments and radiographic investigations for these patients. Some patients find the period of dynamisation uncomfortable and associated with pin site infection, which can be avoided. We plan to continue this practice and collect further data to confirm these findings in a larger dataset

At-home softcast removal with no routine clinical follow-up has shown to be safe and effective following paediatric orthopaedic trauma. It minimises clinician contact time and reduces cost. However, there is limited data on the caregiver experience. Retrospective analysis of paediatric fractures requiring application of circumferential softcast that was later removed at home. Two time points were included: (1)July–September 2022, (2)February–April 2023. Demographics data included age, fracture classification, angulation, manipulation requirement, complications or unplanned re-attendance. Caregivers were given an information leaflet on cast removal. Caregivers completed a telephone Likert questionnaire reviewing time taken to remove cast, qualitative descriptors of cast removal and overall satisfaction. 77 families were contacted at mean 93 days post injury. Mean age was 7.5 years. 41(53%) were distal radius and 20(26%) both-bone forearm fractures. The remaining were hand, elbow or tibia injuries. 40(52%) injuries required manipulation under procedural sedation with mean sagittal angulation 24 degrees. 13(17%) patients re-attended with cast problems. Caregivers estimated a mean 13 minutes to remove cast. 83% found it ‘extremely’ or ‘somewhat’ easy. 75% were ‘extremely’ or ‘somewhat’ satisfied. 71% were ‘extremely’ or ‘somewhat’ likely to recommend at-home cast removal. Qualitative descriptors ranged from from ‘traumatising’ to ‘fun’ and ‘straightforward’. The experience at our tertiary centre confirms at-home softcast removal with no further orthopaedic follow-up is safe and feasible, even in those requiring manipulation under sedation. The majority of families reported a positive experience; this however is not universal. Adequate patient information resources are integral to a positive caregiver's experiences

Implant removal is necessary in up to 25% of patients with plate osteosynthesis after proximal humeral fracture. Our new technique of arthroscopic implant removal offers all advantages of minimal invasive surgery. Additionally treatment of concomitant intraarticular lesions is possible. This study outlines the first results after arthroscopic implant removal in comparison with those of open implant removal. A prospective series of 40 consecutive treated patients had implant removal and arthrolysis after plate osteosynthesis of proximal humeral fracture. Implant removal was carried out due to limitation in range of movement, secondary implant dislocation and implant impingement. 30 patients (median age 63 (30–82) years) had arthroscopic, ten patients (median age 53 (34–76) years) had open implant removal. Median 10 months after implant removal subjective patient satisfaction, Constant Murley Score (CMS) and Simple Shoulder Test were determined. Arthroscopic implant removal showed comparable first results as open implant removal. There was no significant difference between CMS of both groups. The active shoulder abduction, flexion and external rotation improved significantly after arthroscopic and open implant removal. The simple shoulder test outlined advantages for the arthroscopic technique. After arthroscopic implant removal patients showed higher subjective satisfaction as well as faster pain reduction and mobilization. Analysis of perioperative data showed less blood loss in the group with arthroscopic implant removal. In 85% of patients with arthroscopic implant removal concomitant intraarticular lesions were observed and treated. The arthroscopic implant removal after plate osteosynthesis of proximal humeral fractures offers all advantages of minimal invasive surgery and comparable first results as the open implant removal. The subjective and objective satisfaction of patients is high. The technique can be applied and established by all arthroscopic trained shoulder surgeons

Introduction. Retention and removal of children's orthopaedic metalwork is a contentious issue that has implications for current resource allocation, health economics, complication risks and can impact on future treatments. Understanding how to guide families make informed choices requires an overview of all the relevant evidence to date, and knowledge of where the evidence is lacking. Our aim was to systematically review the literature and provide a meta-analysis where possible, recommending either retention or removal. Materials and Methods. A search of the literature yielded 2420 articles, of which 22 papers were selected for the study analysis. Inclusion criteria: Any paper (evidence level I-IV) assessing the risks or benefits of retaining or removing orthopaedic metalwork in children. Exclusion criteria: Spinal implants; implant number < 40; < 75% recorded follow up; papers including implants in their analysis that always require removal; patients aged >18 years. Results. In total, 4988 patients (6412 implants) were included across all 22 studies. There was a significant amount of heterogenicity between studies. Overall the short term risks of metalwork retention and removal are low, with a few exceptions. In forearm plating re-fracture rates following removal were lower than those seen in studies looking at retained metalwork, provided removal occurred later than 12 months from the initial operation. Forearm re-fracture rates after removal of flexible nails significantly increased if removal was performed before 6 months. Major complications following routine metalwork removal from the proximal femur are relatively rare, with re-fracture rates of 1–5%. The majority of these re-fractures are seen in neuromuscular patients or in patients where removal occurs earlier than 6 months. Routine metalwork removal following SUFE had a complication rate of 30–60%. Conclusions. We found that there are certain subgroups of children that benefit from retention of metalwork and some that benefit from removal. There are several subgroups that we have identified which do not yet have sufficient long term evidence to make a balanced recommendation. We advise that families are made aware of what is known and what is unknown in order to allow for shared decision making

Introduction. Circular frames in the lower limbs have been removed by Specialist nurses in our clinics for the past 20 years using Entonox. This standard of care has helped reduce the burden of health care cost by avoiding removal of frames in theatres. We have recently started using Penthrox and present our encouraging initial data suggestive of superior efficacy when compared to Entonox. Materials and Methods. We included in this study the last ten patients on whom Entonox was used during frame removal and the first ten patients on whom Penthrox was used. Visual analogue pain scale was used to quantify pain at the beginning, middle and at the end of frame removal in both groups. The data was found to be normally distributed and Unpaired T test was used to analyse it. Confidence interval of 95% and p-value 0.05 deemed significant. Results. At the beginning of frame removal the Entonox group had a mean VAS score of 5.3 and Penthrox group had 3 (p-value 0.1194). During the middle of frame removal the Entonox group had a mean VAS score of 7.3 and Penthrox group had 4.5 (p-value 0.0379, statistically significant). At the end of frame removal the Entonox group had a mean VAS score of 4.2 and Penthrox group had 2.3 (p-value 0.1734). Penthrox group showed a statistically significant improvement in the mean VAS pain score when assessed in the middle of frame removal. The mean VAS score of both groups were not statistically significant at the beginning and end of frame removal. Conclusions. We found Penthrox to offer better pain relief when compared to Entonox during circular frame removal. This will encourage more patients to choose the option of frame removal in the clinic thereby reducing health care cost to the NHS. This pilot study will be followed by a multicentre comparative study where Entonox is in use in comparison to patients at Salford where the practice has shifted to Penthrox

Aims. The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. Methods. Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). Results. There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). Conclusion. ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709–1716

Introduction. External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting. Materials & Methods. This prospective case series evaluated the first 20 consecutive cases of EF removal in the outpatient clinic between 10/06/22 to 16/09/22. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirement, asked to evaluate their experience and perceived pain using the Visual Analogue Scale (VAS). Results. Twenty patients were included in the study. The mean age was 46.6 years (range 21–85 years). Two thirds were male patients (N=13). Post procedure all patients indicated positive satisfaction ratings, each participant responding as either ‘satisfied’ (N=4), ‘very satisfied’ (N=15) or ‘highly satisfied’ (N=1). In addition, 85% of participants reported they would opt for this method of EF removal in future should it be necessary. VAS for pain immediately following completion of the procedure was low, with an average score of 0.45 (range 0–4), where a score of 0= ‘No pain’, and 10 = ‘worst pain possible’. Conclusions. We present the first description of outpatient EF removal using sole regional anaesthesia, with a prospective case series of 20 EF removed in fully awake patients. This novel technique is cost-effective, reproducible, and safe. This not only reduces the burden of these surgical cases on an operating list but also improves patient experience when compared to other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this project demonstrates a method of improving environmental sustainability of surgery, anaesthesia and operating theatres

Olecranon Osteotomy is a common approach used in the management of intraarticular distal humerus fractures. Significant complication rates have been associated with this procedure, including non-union rates of 0–13% and implant removal rates between 12–86%. This study is a multicentre retrospective study involving the largest cohort of olecranon osteotomies in the literature, examining implant fixation types, removal rates and associated complications. Patients were identified between 2007 and 2017 (minimum one year follow-up) via Canadian Classification of Health Interventions (CCI) coding and ICD9/10 codes by our health region's data information service. CCI intervention codes were used to identify patients who underwent surgery for their fracture with an olecranon osteotomy. Reasons for implant removal were identified from a chart review. Our primary outcome was implant removal rates. Categorical data was assessed using Chi square test and Fischer's Exact test. Ninety-nine patients were identified to have undergone an olecranon osteotomy for treatment of a distal humerus fracture. Twenty patients had their osteotomy fixed with a plate and screws and 67 patients were fixed with a tension band wire. Eleven patients underwent “screw fixation”, consisting of a single screw with or without the addition of a wire. One patient had placement of a cable-pin system. Of patients who underwent olecranon osteotomy fixation, 34.3% required implant removal. Removal rates were: 28/67 for TBW (41.8%), 6/20 plates (30%), 0/1 cable-pin and 0/11 for osteotomies fixed with screw fixation. Screw fixation was removed less frequently than TBW p<.006. TBW were more commonly removed than all other fixation types p<.043. Screws were less commonly removed than all other fixation types p<.015. TBW were more likely to be removed for implant irritation than plates, p<.007, and all other implants p<.007. The average time to removal was 361 days (80–1503 days). A second surgeon was the surgeon responsible for the removal in 10/34 cases (29%). TBWs requiring removal were further off the olecranon tip than those not removed p=.006. TBWs were associated with an OR of 3.29 (CI 1.10–9.84) for implant removal if implanted further than 1mm off bone. Nonunion of the osteotomy occurred in three out of 99 patients (3%). K-wires through the anterior ulnar cortex did not result in decreased need for TBW removal. There was no relation between plate prominence and the need for implant removal. There was no association between age and implant removal. The implant removal rate was 34% overall. Single screw fixation was the best option for osteotomy fixation, as 0/11 required hardware removal, which was statistically less frequent than TBW at 28/67. Screw fixation was removed less frequently than TBW and screw fixation was less commonly removed than all other fixation types. Only 6/20 (30%) plates required removal, which is lower than previously published rates. Overall, TBW were more commonly removed than all other fixation types and this was also the case if hardware irritation was used as the indication for removal. Nonunion rates of olecranon osteotomy were 3%

Aim. To evaluate the efficiency of pulse lavage combined with electrical fields to remove biofilm from a metallic surface. Method. Using a 12-well culture plate designed for the application of electrical fields, strains of S. epidermidis were incubated at each well for 24 hours at 37ºC. After incubation, supernatant culture medium was removed, and each well was filled with 3ml of normal saline. Six different models were compared: a) control, b) low-pressure pulse lavage, c) high-pressure pulse lavage, d) pulsed electrical fields, e) low-pressure pulse lavage in combination with pulsed electrical fields, and f) high-pressure pulse lavage in combination with pulsed electrical fields. In all cases, exposure time was set to 25 seconds. In the electrical field models, 50 pulses were applied. After exposure, each bottom electrode was scraped carefully to release adhered bacteria. Subsequently, different dilutions of biofilm removed were spread onto Müller Hinton agar plates and incubated for 24h at 37 ºC, and colony-forming units (CFU) per milliliters were counted. Bacterial counts were then compared to the control model. Results. High-pressure pulse lavage combined with pulsed electrical fields showed the greatest biofilm removal with reductions of up to 11.9 logarithms when compared to the control group. The lowest reduction was achieved by low-pressure pulsed lavage (4.7 logs). All reductions showed statistically significant differences. Conclusion. The results of our comparative study between different models demonstrates high reduction rates for biofilm removal. Further in vivo studies are needed to evaluate the capacity of the combination of high-pressure pulse lavage with pulsed electrical fields in removing bacterial biofilm in real conditions

Objectives. Previous studies have evidenced cement-in-cement techniques as reliable in revision arthroplasty. Commonly, the original cement mantle is reshaped, aiding accurate placement of the new stem. Ultrasonic devices selectively remove cement, preserve host bone, and have lower cortical perforation rates than other techniques. As far as the authors are aware, the impact of ultrasonic devices on final cement-in-cement bonds has not been investigated. This study assessed the impact of cement removal using the Orthosonics System for Cemented Arthroplasty Revision (OSCAR; Orthosonics) on final cement-in-cement bonds. Methods. A total of 24 specimens were manufactured by pouring cement (Simplex P Bone Cement; Stryker) into stainless steel moulds, with a central rod polished to Stryker Exeter V40 specifications. After cement curing, the rods were removed and eight specimens were allocated to each of three internal surface preparation groups: 1) burr; 2) OSCAR; and 3) no treatment. Internal holes were recemented, and each specimen was cut into 5 mm discs. Shear testing of discs was completed by a technician blinded to the original grouping, recording ultimate shear strengths. Scanning electron microscopy (SEM) was completed, inspecting surfaces of shear-tested specimens. Results. The mean shear strength for OSCAR-prepared specimens (33.6 MPa) was significantly lower than for the control (46.3 MPa) and burr (45.8 MPa) groups (p < 0.001; one-way analysis of variance (ANOVA) with Tukey’s post hoc analysis). There was no significant difference in shear strengths between control and burr groups (p = 0.57). Scanning electron microscopy of OSCAR specimens revealed evidence of porosity undiscovered in previous studies. Conclusion. Results show that the cement removal technique impacts on final cement-in-cement bonds. This in vitro study demonstrates significantly weaker bonds when using OSCAR prior to recementation into an old cement mantle compared with cement prepared with a burr or no treatment. This infers that care must be taken in surgical decision-making regarding cement removal techniques used during cement-in-cement revision arthroplasty, suggesting that the risks and benefits of ultrasonic cement removal need consideration. Cite this article: A. Liddle, M. Webb, N. Clement, S. Green, J. Liddle, M. German, J. Holland. Ultrasonic cement removal in cement-in-cement revision total hip arthroplasty: What is the effect on the final cement-in-cement bond? Bone Joint Res 2019;8:246–252. DOI: 10.1302/2046-3758.86.BJR-2018-0313.R1

The regenerative potential of bone is enormous, and it is possible to lengthen limbs by bone distraction. However, there remains a major risk of fracture after lengthening the bone. Previous studies have described how the pixel value ratio may be used for determining the time for frame removal. The aim of this study was to investigate the intrarater and the interrater reliability of pixel value scores from radiographs in tibial lengthening prior to frame removal. Moreover, the study aimed to determine the overall number of X- rays obtained during circular frame treatment. Retrospective study. Patients treated with tibial lengthening by a circular frame at Aalborg University Hospital from January 1st 2000 to December 31st 2017 and a minimum of 12 months after frame removal were included. The bone was divided in proximal-, regenerate- and distal bone zone. These 3 zones were in AP x-ray divided in an anterior and posterior zone and in sagittal X-ray medial and lateral zone producing 6 zones in which the pixel value was measured. Pixel value ratio was calculated as: (Proximal pixel value+Distal pixel value)/2/Regenerate pixel value. Interrater correlations were calculated from measurements obtained by an orthopaedic registrar and an orthopaedic specialist. Intrarater correlation was calculated from repeated measurements obtained by an orthopaedic specialist. Mean duration of circular frame treatment was: 6 (+-3) months. Median number of x-ray controls during frame treatment were: 9 (+-4). Out of 90 tibial lengthening it was only possible to measure pixel value in all six areas of interest on 20 lengthening prior to frame removal. Major reasons for inability to obtain measurements were metal hardware crossing the areas of bone interest on x-rays. The mean (95 % confidence intervals) pixel ratios values were: 1) lateral: 0.96 (0.93–1.00); 2) medial: 0.95 (0.92–0.99); 3) anterior: 0.94 (0.90–0.97); 4) posterior: 0.96 (0.93–0.99). The mean (95 % confidence intervals) inter ratter ICC estimates were: 1) lateral: 0.8 (0.5–0.9); 2) medial: 0.8 (0.4–0.9); 3) anterior: 0.4 (−0.5–0.8); 4) posterior: 0.6 (0.1–0.9). The mean (95 % confidence intervals) intra ratter ICC estimates were: 1) lateral: 1.0 (0.9–1.0); 2) medial: 1.0 (1.0–1.0); 3) anterior: 0.9 (0.9–1.0); 4) posterior: 1.0 (1.0–1.0). Out of the 20 lengthening examined one fracture occurred in the bone regenerate after frame removal. Prospective studies are warranted to determine whether the pixel value ratio can be used as an indicator for frame removal

The technique for removal of bone ingrown extensively coated devices involves cutting the stem below the metaphyseal portion of the stem, followed by removal of the proximal stem and trephine removal of the cylindrical distal portion of the stem. This can be done with or without an extended trochanteric osteotomy (ETO). When the proximal portion of the stem is not bone ingrown (extensive proximal osteolysis, or the stem is broken) or the metaphyseal bone is easily accessed (there is no collar) the stem can be cut through a bone window. In all other cases an ETO at the level where the stem becomes a cylinder is required to disrupt the metaphyseal bone prosthesis interface, cut the stem and extract the proximal portion of the stem. Glassman described the techniques for removal of cementless stems in 1992. Forty-two loose stems were easily removed, 11 fibrous stable implants were removed with thin osteotomes, and 11 bone ingrown, canal filling, extensively coated stems were removed with trephines. In no cases was reconstruction precluded by stem removal. The critical tools required included manufacturer specific removal tools, high speed burs, thin osteotomes, universal extraction device for connection to the neck, and multiple trephines. More recently, Kancherla reported the use of trephines to remove 36 porous coated stems. Eighty-six percent of cases were bone ingrown after removal, however complications included an extruded trephine causing a femoral fracture and two periprosthetic fractures thought to be secondary to trephine induced osteonecrosis. The authors recommend bypassing the most distally trephined bone by a minimum of 4cm. Trephines are very helpful for removing distally fixed stems. Multiple trephines need to be irrigated and changed frequently to avoid dull cutting teeth which can lead to bone necrosis

Aim. There is a lack of data supporting the use of doxycycline as a single agent after removing infected orthopaedic metalwork. We evaluated the efficacy and safety of doxycycline compared with other single antibiotic regimens used at our specialist orthopaedic hospital. Methods. A retrospective observational study including all adult patients diagnosed with an orthopaedic metalwork infection due to staphylococci. All patients were managed with the removal of metalwork, and multiple intraoperative samples were sent for culture, followed by the administration of at least four weeks of oral antibiotics. Antibiotic selection was on the recommendation of an infection consultant. Infection outcome was assessed as the proportion of patients meeting the OVIVA Trial definition of definite failure at follow-up. The probability of definite failure for doxycycline and the alternatives group was estimated using the Kaplan-Meier survival method. All adverse drug reactions (ADR) during treatment were analysed. Results. Seventy-nine orthopaedic metalwork infections were identified between July 2017 and July 2021. Forty-four were prosthetic joints, and 35 were fracture-related metalwork. In 54 cases, the infecting organism was Staphylococcus aureus, and 25 were due to coagulase-negative staphylococci. Forty-four were treated with doxycycline 100mg 12 hourly, and 35 were treated with alternatives (flucloxacillin 1g 6-hourly n=21 and clindamycin 450mg 6-hourly n=14). Overall, 70 patients (88.6%) were infection-free after a median follow-up of 23 months (IQR, 19 – 44). 38 (82.3%) were infection-free in the doxycycline group compared with 32 (91.4%) patients treated with alternatives. Of the failures in the alternatives group, all 3 received flucloxacillin. Survival analysis showed no significant difference in time to treatment failure between doxycycline and alternative antibiotics. Eighteen patients experienced an ADR: 2 nausea, one rash and one vaginal candidiasis due to doxycycline. Four diarrhoea, one reflux, two rashes and one headache due to clindamycin; 1 nausea and five diarrhoea due to flucloxacillin. Four patients required discontinuation therapy, two due to clindamycin and two due to flucloxacillin. Conclusions. In our cohort of patients, doxycycline monotherapy was an effective and well-tolerated oral option for treating staphylococcal infection following debridement and removal of orthopaedic metalwork

The aim of this study was to report the restauration of the normal vertebral morphology and the absence of curve progression after removal the instrumentation in AIS patients that underwent posterior correction of the deformity by common all screws construct whitout fusion. A series of 36 AIS immature patients (Risser 3 or less) were include in the study. Instrumentation was removed once the maturity stage was complete (Risser 5). Curve correction was assessed at pre and postoperative, before instrumentation removal, just post removal, and more than two years after instrumentation removal. Epiphyseal vertebral growth modulation was assessed by a coronal wedging ratio (WR) at the apical level of the main curve (MC). The mean preoperative coronal Cobb was corrected from 53.7°±7.5 to 5.5º±7.5º (89.7%) at the immediate postop. After implants removal (31.0±5.8 months) the MC was 13.1º. T5–T12 kyphosis showed a significant improvement from 19.0º before curve correction to 27.1º after implants removal (p<0.05). Before surgery, WR was 0.71±0.06, and after removal WR was 0.98±0.08 (p<0.001). At the end of follow-up, the mean sagittal range of motion (ROM) of the T12-S1 segment was 51.2±21.0º. SRS-22 scores improved from 3.31±0.25 preoperatively to 3.68±0.25 at final assessment (p<0.001). In conclusion, fusionless posterior approach using a common all pedicle screws construct correct satisfactory scoliotic main curves and permits removal of the instrumentation once the bone maturity is reached. The final correction was highly satisfactory and an acceptable ROM of the previously lower instrumented segments was observed

Background. Medial open wedge high tibial osteotomy (MOWHTO) has been accepted as a highly effective option for the treatment of medial unicompartmental osteoarthritis of the knee. Although pain in the medial joint line is significantly relieved after MOWHTO, some patients complain of pain over pes anserinus after the osteotomy, necessitating implant removal for pain relief. Purpose. The purpose of this study is to define the implant removal rate after MOWHTO due to patient complaints. Methods. 103 knees of 72 patients who underwent MOWHTO for medial unicompartmental osteoarthritis between 2010 and 2018 with a follow-up of at least 24 months were enrolled in the study. Patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS) and Visual Analogue Score (VAS) for pain in the medial knee joint (VAS-MJ). All tests were performed before the surgery, at 12 months after surgery. VAS value for pain over pes anserinus (VAS-PA) was recorded at 12 months after MOWHTO and at 3 months after implant removal. Results. Mean follow-up was 31±5.4 months. TomoFix® medial high tibia plate (DePuy Synthes, Raynham, MA, USA) was used for the fixation of osteotomy in all cases. Significant improvement in KOOS, OKS and VAS-MJ were observed 12 months after MOWHTO. Average values of VAS-MJ and VAS-PA were 21.7±7.1 and 34±8.4, respectively. Implant removal was needed for 65 (63.1%) knees. There were no significant differences in regard of postoperative KOOS (p=0.134), OKS (p=0.287) and VAS-MJ (p=0.416) scores between patients for which implant removal was needed or not. VAS-PA value decreased significantly at 3 months after implant removal (p<0.001). Conclusion. A large portion of patients needed implant removal after MOWHTO to relieve pain over pes anserinus even if knee function was significantly improved. Lower profile plates may be preferred to avoid secondary implant removal surgery after MOWHTO