Aims. This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices. Methods. Using a life-cycle assessment approach, we conducted a prospective study on ten cemented and ten hybrid THA cases, evaluating carbon emissions from anaesthetic room to recovery. Scope 1 and scope 2 emissions were considered, focusing on direct emissions and energy consumption. Data included detailed assessments of consumables, waste generation, and energy use during surgeries. Results. The carbon footprint of an uncemented THA was estimated at 100.02 kg CO2e, with a marginal increase to 104.89 kg CO2e for hybrid THA. Key contributors were consumables in the operating theatre (21%), waste generation (22%), and scope 2 emissions (38%). The study identified opportunities for reducing emissions, including instrument rationalization, transitioning to LED lighting, and improving waste-recycling practices. Conclusion. This study sheds light on the substantial carbon footprint associated with THA. Actionable strategies for reducing emissions were identified, emphasizing the need for sustainable practices in orthopaedic surgery. The findings prompt a critical discussion on the environmental impact of single-use versus reusable items in the operating theatre, challenging traditional norms to make more environmentally responsible choices. Cite this article: Bone Jt Open 2024;5(9):742–748

Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655

Background. Simply stated, carbon reinforced carbon (C/C) may be considered as fibre reinforced pyrocarbon. Pyrocarbon is used e.g. in finger joints and artificial heart valves. Aim of the present study was to evaluate if C/C could broaden the field of orthopaedic applications compared to pyrocarbon. Technically, C/C is used e.g. for brakes of F-1 race cars. Methods. The mechanical strength of the C/C material was characterised by a biaxial flexural bending test according ISO 6474-1. Three C/C shoulder heads articulating against vitamin E stabilised, highly cross-linked UHMWPE (E-XLPE) underwent a shoulder simulator study up to 106 cycles. The Coefficient of Friction (CoF) of C/C disks (Ra: 0.045 μm) against cartilage was analysed by a reciprocal cartilage wear tester. The test was conducted in cell culture medium for 4 h and 12 h using bovine cartilage. All test data is compared to the corresponding test results with Al2O3 ceramic. Conclusions. The strength of C/C is 30 % lower than that of Al2O3 ceramic. Its wear rate measured in the shoulder simulator against E-XLPE is in tendency higher than that of ceramic heads. The CoF against cartilage is double compared to the same test with Al2O3. - C/C seems to have limited a potential as material for orthopaedic application. However, more investigations and optimisation of the C/C type and quality are necessary. Level of evidence. Laboratory test on material samples. Study financed by Mathys Ltd Bettlach

Aims. In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. Methods. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”. Results. A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training. Conclusion. Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary. Cite this article: Bone Jt Open 2022;3(8):628–640

Total knee arthroplasty is one of the most common surgeries. About 92% of all implanted knee endorposthesis in 2020 were manufactured from uncoated CoCrMo articulating on ultra-high-molecular-weight polyethylene. All articluations generate wear particles and subsequent emission of metal ions due to the mechanical loading. These wear particles cause diverse negative reactions in the surrounding tissues and can lead to implant loosening. Coating technologies might offer the possibility to reduce this wear. Therefore, we investigated the applicability of tetrahedral amorphous carbon (ta-C) coating on CoCrMo alloy. Polished specimens made of CoCrMo wrought alloy according to ISO 5832-12 were coated with ta-C coatings with different layer structure using pulsed laser deposition (PLD). This process allows the deposition of ta-C coatings with low internal stress using an additional relaxation laser. Surface quality and mechanical properties of the coating were characterised using optical surface measurements (NanoFocus μsurf expert, NanoFocus AG) and a nanoindentation tester NHT. 3. (Anton Paar GmbH). Scratch tests were performed on Micro Scratch Tester MST. 3. (Anton Paar TriTec SA) to define the coating adhesion. Pin-on-plate tribological tests, with a polyethylene ball sliding on the ta-C-coated plate under a defined load according to ISO 14243-1 were performed using a linear tribometer (Anton Paar GmbH) to evaluate the tribological and wear properties. The ta-C coatings showed a mean roughness Ra of 5-20 nm and a hardness up to 60 GPa (n=3). The adhesion of the ta-C coatings (n=3) was comparable to the commercial coatings like TiN and TiNbN. The pin-on-plate tests showed an improvement of tribological properties in comparison with the polished uncoated CoCrMo specimens (n=3). The ta-C coatings applied by DLP technology show increased hardness compared to the base material and sufficient adhesion. Further research will be needed to investigate the optimal coating strategy for implant coating

A radiological and histological analysis of five knee joints after a minimum of 15 years following the implanting of carbon fibre which had been used as a treatment for knee instability was undertaken. All patients underwent Total Knee replacement for secondary osteoarthritis. Histological analysis demonstrated a variable amount of macroscopically visible carbon particles in the synovium, hyaline cartilage and menisci showed . At microscopy these particles were found enveloped by giant cells and lying quiescent with no active inflammatory changes. No intact carbon fibre ligament was noted within the joint, small portion of the old ligament were covered with a thin fibrous layer but there was no evidence of any structure resembling neo-ligament. Extra articularly the carbon fibre was covered with a thick fibrous sheath with no active inflammatory changes inflammation. In the bone tunnels the carbon fibre- bone interface showed an apposition of the bone to the carbon fibre without any interposing fibrous sheath. The histology suggests that carbon fibre bonds directly with the bone without fibrous interposition and that there is no evidence of synovitis changes related to the carbon fibre material. The study suggest that although carbon fibre failed structurally as a ligament replacement it did not cause any significant long term inflammatory pathology

Background. Carbon fibre (CF) instrumentation is known to be radiolucent and has a tensile strength similar to metal. A specific use could be primary or oligometastatic cancer where regular surveillance imaging and Stereotactic Radiotherapy are required. CT images are inherently more prone to artefacts which affect Hounsfield unit (HU) measurements. Titanium (Ti) screws scatter more artefacts. Until now it has been difficult to quantify how advantageous the radiolucency of carbon fibre pedicle screws compared to titanium or metallic screws actually is. Methodology. In this retrospective study, conducted on patients from 2018 to 2020 in SGH, we measured the HU to compare the artifact produced by CF versus Ti pedicle screws and rods implanted in age and sex matched group of patients with oligometastatic spinal disease. Results. Eleven patients were included in each group. We compared the change of HU between preoperative and postoperative cases of both CF & Ti screws, which clearly shows Ti screws scatter lot more artefacts than CF screws. We are proposing a CT artefact grading system from grade 0 to grade 4 based on the percentage change of HU for unequivocal understanding of the CT artefacts. Conclusion. This study clearly shows the artefacts produced by the metallic implants are significantly higher than the carbon fibre implants. Considering the efficacy of the RT and the increased life expectancy as a consequence, carbon instrumentation MAY BE superior to titanium or metallic instrumentation. The artefact grading system will help the clinicians in describing and planning where the artefacts need to be factorized

Orthopaedic surgical hoods rely on an intrinsic fan to force clean external air over the wearer and allow potentially contaminated and expired air to flow down and away from the surgical field. Carbon dioxide (CO. 2. ) is produced through aerobic metabolism and can potentially accumulate inside the hood. Levels above 2500ppm have been shown to affect cognitive and practical function in flight simulator studies. Maximum Health and Safety Executive (HSE) 8-hour exposure limit is 5000ppm There is a paucity of data on real-world CO. 2. levels experienced during arthroplasty surgery whilst wearing a hood. CO. 2. levels were continuously recorded during 31 elective arthroplasties, both primary and revision. Data was collected for surgeon and assistant. Data was recorded at 0.5Hz throughout the procedure utilising a Bluetooth CO. 2. detector, worn inside a Stryker Flyte. ™. surgical helmet worn with a toga gown. Four surgeons contributed real time data to the study. This data was augmented with experimental data, investigating varying fan speeds and activity levels. Median operative duration was 82 minutes (range 36–207). The average CO. 2. level across all procedures was 2952ppm, with 22 of the cases having a mean above 2500ppm, but none having a mean above 5000ppm. For each procedure, the time spent above 2500 and 5000 ppm was calculated, with the average being 68.4 % and 5.6% respectively. The experimental data demonstrated higher CO. 2. levels with lower fan speed, and at higher activity levels, and levels exceeding 15000 ppm during gentle exercise. During operative cases, low fan speed cases did have a marginally higher mean CO. 2. value than high fan speed (3033.02 and 2903.56 respectively) but the small numbers of cases (n=10) where this data was captured limit the relevance of this difference. The use of surgical helmets for elective orthopaedic surgery, can results in CO. 2. levels regularly rising to a point which may affect cognitive function. This study recommends the use of a higher fan speed where possible to minimise the risk of such CO. 2. levels, and recommends further research in this area

Osteoarthritis (OA) is a degenerative joint disease affecting millions worldwide. Early detection of OA and monitoring its progression is essential for effective treatment and for preventing irreversible damage. Although sensors have emerged as a promising tool for monitoring analytes in patients, their application for monitoring the state of pathology is currently restricted to specific fields (such as diabetes). In this study, we present the development of an optical sensor system for real-time monitoring of inflammation based on the measurement of nitric oxide (NO), a molecule highly produced in tissues during inflammation. Single-walled carbon nanotubes (SWCNT) were functionalized with a single-stranded DNA (ssDNA) wrapping designed using an artificial intelligence approach and tested using S-nitroso-N-acetyl penicillamine (SNAP) as a standard released-NO marker. An optical SWIR reader with LED excitation at 650 nm, 730 nm and detecting emission above 1000 nm was developed to read the fluorescence signal from the SWCNTs. Finally, the SWCNT was embedded in GelMa to prove the feasibility of monitoring the release of NO in bovine chondrocyte and osteochondral inflamed cultures (1–10 ng/ml IL1β) monitored over 48 hours. The stability of the inflammation model and NO release was indirectly validated using the Griess and DAF-FM methods. A microfabricated sensor tag was developed to explore the possibility of using ssDNA-SWCNT in an ex vivo anatomic set-up for surgical feasibility, the limit of detection, and the stability under dynamic flexion. The SWCNT sensor was sensitive to NO in both in silico and in vitro conditions during the inflammatory response from chondrocyte and osteochondral plug cultures. The fluorescence signal decreased in the inflamed group compared to control, indicating increased NO concentration. The micro-tag was suitable and stable in joints showing a readable signal at a depth of up to 6 mm under the skin. The ssDNA-SWCNT technology showed the possibility of monitoring inflammation continuously in an in vitro set-up and good stability inside the joint. However, further studies in vivo are needed to prove the possibility of monitoring disease progression and treatment efficacy in vivo. Acknowledgments: The project was co-financed by Innosuisse (grant nr. 56034.1 IP-LS)

Carbon fibre reinforced polyetheretherketone (CFR-PEEK) has been introduced recently as an alternative material to be used in joint prostheses. During injection moulding of the CFR-PEEK the carbon fibres tend to become orientated in the direction of the plastic flow. The direction of these fibres may affect the wear produced by these materials. Reciprocation only and reciprocation plus rotation (multi-directional) pin-on-plate wear tests were performed on PAN-based CFR-PEEK against itself. The plates were manufactured with the carbon fibres mainly orientated either longitudinally (in the direction of reciprocation motion) or mainly transversally (perpendicular to the direction of motion) to determine the effect of carbon fibre orientation on the wear of these materials. For each test, four pin and plate samples were tested (two reciprocation only and two reciprocation plus rotation) for three and a half million cycles at a cycle frequency of 1 Hz under a 40 N load (which resulted in a contact stress of about 2 MPa). The lubricant used was bovine serum diluted with de-ionised water to a protein content of 17 gl-1. This was maintained at 37 °C. The wear was determined gravimetrically. Soak control specimens were used to account for any weight changes due to lubricant absorption. The average steady-state wear for the CFR-PEEK samples that underwent reciprocation motion only was found to be 5.41 and 18.7 × 10-8 mm3N-1m-1 for the longitudinal carbon fibres and the transverse fibres respectively. For the multi-directional tests, the average steady-state wear was 5.88 and 19.9 × 10-7 mm3N-1m-1 for the longitudinal and transverse fibres respectively. It is clear from these results that for both reciprocation motion only and reciprocation plus rotation the wear was considerably lower with the fibres orientated in the longitudinal direction than the transverse direction. Also, these tests show that reciprocation only gives approximately an order of magnitude lower wear than multi-directional motion. It can be concluded that the wear rate of CFR-PEEK is lower when the sliding motion occurs in the same direction as the carbon fibre orientation. Also, in these pin-on-plate tests, the wear produced using reciprocation motion only was an order of magnitude lower than that for the tests using multi-directional motion. The authors wish to thank INVIBIO Ltd for funding this research

Carbon nanotubes are an exciting new type of material and have extraordinary properties (. 1. ). A special category of carbon nanotubes (multiwalled or MWNT) is flexible yet have tensile strengths 200 times stronger than traditional carbon fibers (. 2. ). Because of their extremely large surface area-to-volume ratio, theory suggests that MWNTs can bond more strongly to polymethylmethacrylate (PMMA) than any other material tested (. 2. ). The combination of large tensile strength and strong interfacial (PMMA matrix) bonding suggests that when added to bone cement, MWNTs could bridge and arrest fatigue or impact cracks and thereby favorably improve the clinical performance of bone cement. The objective of this study was to determine the validity of this hypothesis and whether MWNTs can significantly improve the tensile properties of PMMA. Methods MWNTs (20–30 nanometers in diameter, 20–100 microns long) were grown on a fused quartz substrate by the thermal decomposition of xylene in the presence of a metal catalyst. They are formed in well-aligned mats and grow perpendicular to the walls of a tubular reactor. As a first approach MWNTs were separated and dispersed through the liquid monomer component of PMMA by using an ultrasonic probe. The remaining polymer component was then mixed with this dispersion and the product was used to prepare specimens by casting in molds. Since prior work in other polymer systems (. 3. ) indicated that small concentrations of MWNTs could significantly affect a polymer’s physical properties, only fractions (1/16, ¼ and ½) of 1% of MWNTs (by weight) were used to prepare tensile test specimens. Control (0% MWNTs) and experimental (MWNT containing) groups of PMMA specimens were cured in air at room temperature for 7 days and then pulled to failure at 6 mm/min in a protocol conforming to ASTM D638. Maximum load, strength, results a total of 41 specimens have been prepared and tested: 13 controls, 9 with 0.063%, 10 with 0.25%, and 9 with 0.5% (by weight) of MWNTs. Carbon nanotubes improved the tensile load bearing properties of all experimental groups from 17% to 24%, and these values were significant (p=0.01 and p=0.02) for the 0.25% and 0.5% concentrations. The lowest concentration of MWNTs made the smallest improvement (17%) and this was not significant (p=0.07). Scanning electron microscopic examination of the fractured surface revealed nanotubes that were well distributed throughout the matrix. Discussion: These preliminary results clearly demonstrate that carbon nanotubes can significantly improve the mechanical performance of bone cement. This result is especially encouraging because the MWNTs were added only to the monomer component. Additional performance enhancement may be expected from ongoing work using higher concentrations of MWNTs and their dispersion into the polymer component of bone cement in addition to the monomer component. Since MWNTs are also electrically conducting and have magnetic properties, MWNTs may also help dissipate the heat generated by polymerization or permit bone cement with an “engineered” mechanical anisotropy. Although static tensile tests are an incomplete measure of bone cement, these preliminary results are very encouraging and motivate continuing study of the more clinically relevant (impact resistance, fatigue properties, etc.) measures of the mechanical performance of MWNT augmented bone cement

Background. Due to their tailored porous texture, breathability and flexibility, carbon cloths (CCs) are good scaffolds for biomedical application. However, biocompatibility of CCs depends on their physic-chemical properties. Calcium phosphate ceramics (CaP) are well known for their use in orthopaedic field. So, carbon cloth-reinforced CaP composites are promising bioceramic materials for bone regeneration. Methods. CaP coating are performed using sono-electrochemical deposition method. The electrolyte consisted in an aqueous solution of calcium and phosphates precursors. CC was used as work electrode in three-electrode system. SEM, TEM, XRD, 1H and 31P MAS NMR and FTIR spectroscopies were performed to characterise the deposits. In vitro biocompatibility of CCs with and without coatings is tested with human osteoblasts. Results. The current density influences the morphology and the chemical composition of deposit: it consists mainly in carbonated hydroxyapatite with plate-like shape for lower current densities and needle-like shape for the highest. A hydrophobic surface of CC with due to small amount of oxygenated functions leads to a poor biocompatibility. Conclusion. The wettability of CCs is an important parameter of biocompatibility. Biomimetic CaP deposits obtained by sono-electrodeposition present a microstructure and a chemical composition close to the mineral phase of natural bone. This work was supported by Region Centre project: bioactive hybrid materials for bone reconstruction. 2014–2016

Introduction. Recently ventral plating implants made of carbon/PEEK composite material have been developed with apparently superior material properties in terms of implant fatigue and imaging suitability. In this study we assessed the outcome of the first clinical application of this new implant. Methods. Retrospective, single-center case series of 16 consecutive patients between 2011 and 2013 undergoing ventral stabilization surgery with a new carbon plating system (see figure 1). We collected data in terms of safety of the procedure (screw positioning, blood loss, operation time), quality and reliability of the implant (revisions, dislocations, screw loosening, fusion, adjacent segment degeneration), clinical outcome and biological tolerance (cervical pain / discomfort, dysphagia). Results. All patients were available for clinical and radiological follow up. Mean surgery time was 128 minutes, in 11 cases one in 5 cases 2 segments were treated. The clinical findings and patient's satisfaction were good in 14 and fair in two cases. All patients who completed the 6 months control had a radiographically confirmed interbody fusion; no implant loosening or failure and no infections were observed. (see figure 2). There was one implant related complication (dysphagia due to malpositioning of the plate which was removed 4 days after implant insertion) and one complication related to the approach (Horner's syndrome). Conclusion. In this retrospective study of 16 patients we found that the use of a carbon-composite plating system lead to results comparable to the “gold standard” metal plates in terms of safety / clinical outcome and reliability of the implant. There was one revision due to dysphagia. The MR imaging of the patients who have been operated with the carbon/PEEK system showed superior quality with reduced artifacts and improved diagnostical properties, especially when evaluating the neurogical structures. (see figure 3). The overall clinical outcome and patient acceptance of the implant was good. The radiologic findings on follow up of 2, 6 and 12 months have shown a high fatigue strength with no signs of implant failure in terms of dislocation, loosening or breakage. Therefore we conclude that the use of the carbon/PEEK plating system is suitable for ventral stabilization in trauma and degenerative disease

Objectives. The purpose of this study was to evaluate in vivo biocompatibility of novel single-walled carbon nanotubes (SWCNT)/poly(lactic-co-glycolic acid) (PLAGA) composites for applications in bone and tissue regeneration. Methods. A total of 60 Sprague-Dawley rats (125 g to 149 g) were implanted subcutaneously with SWCNT/PLAGA composites (10 mg SWCNT and 1gm PLAGA 12 mm diameter two-dimensional disks), and at two, four, eight and 12 weeks post-implantation were compared with control (Sham) and PLAGA (five rats per group/point in time). Rats were observed for signs of morbidity, overt toxicity, weight gain and food consumption, while haematology, urinalysis and histopathology were completed when the animals were killed. Results. No mortality and clinical signs were observed. All groups showed consistent weight gain, and the rate of gain for each group was similar. All groups exhibited a similar pattern for food consumption. No difference in urinalysis, haematology, and absolute and relative organ weight was observed. A mild to moderate increase in the summary toxicity (sumtox) score was observed for PLAGA and SWCNT/PLAGA implanted animals, whereas the control animals did not show any response. Both PLAGA and SWCNT/PLAGA showed a significantly higher sumtox score compared with the control group at all time intervals. However, there was no significant difference between PLAGA and SWCNT/PLAGA groups. Conclusions. Our results demonstrate that SWCNT/PLAGA composites exhibited in vivo biocompatibility similar to the Food and Drug Administration approved biocompatible polymer, PLAGA, over a period of 12 weeks. These results showed potential of SWCNT/PLAGA composites for bone regeneration as the low percentage of SWCNT did not elicit a localised or general overt toxicity. Following the 12-week exposure, the material was considered to have an acceptable biocompatibility to warrant further long-term and more invasive in vivo studies. Cite this article: Bone Joint Res 2015;4:70–7

The purpose of this study: is to test the hypothesis that there is little or no stress shielding afforded by a carbon composite femoral hip prosthesis when implanted in the human subject, and to investigate the possibility that a hydroxyapatite coating would prevent loosening. The need for this development: is that loosening remains a problem for young patients who need a long term, reliable fixation of hip replacements, and it appears that if a solution exists to this problem then it probably lies away from the traditional cemented metal varieties. One of the causes of loosening is stress shielding caused by rigid metal implants and a carbon composite femoral stem has been developed to overcome this. Paradoxically, flexible stems result in increased micro-motion at the prosthetic-bone interface and as a result they tend to loosen more frequently than metal ones. To overcome this, the carbon stem has been coated on its proximal third with hydroxyapatite, in order to get a secure fixation to the upper femur, but left bare distally to minimise weight transfer within the lower shaft. The Study: 50 patients have entered the trial to date, and the detailed results of the first 35, which have been followed up for an average of 4 years will be presented. Stress shielding by the prosthesis was assessed, clinically, radiologically, and by dexa-scanning (usinga Hologic scanner with metal exclusion software). Two dexa-scan studies were carried out on each patient, at 1 and 2 years post operatively, and the bone mineral density of the implanted bone was compared with that of the normal contralateral side, using the Gruen zones as the basis of comparison. These results were compared with published figures for metal stems, and also with a small series of our own metal stems. Results: 13 males and 22 females entered the trial, with an average age of 61. Bone density around the carbon composite hip was found to increase by an average of 2% between the measurements carried out at 1 and 2 years post-op. In the contralateral hip, bone density remained unchanged over the period. Bone density around comparable metal stems reduced by an average of 3% in our cases, but losses over 20% are quoted by others especially for zones 1& 7. Follow up is very short for responsible prognosis to be offered regarding loosening, but to date the function of the hips remains good. Conclusion: it appears that this prosthesis is fulfilling the predictions made for it, and although there is a spread of responses to it, the average patient is showing a steady increase in periprosthetic bone mineral density and is. Clinically asymptomatic. Progress to a wider trial can now be recommended

Method: One hundred and twenty-eight knees treated by carbon fibre resurfacing pads and rods for grades III and IV articular cartilage lesions were assessed arthroscopically, with an average follow-up of 22.6 months. The mean age was 37.4 years. Results were scored by an independent observer, using the ICRS scale (1–12) as grade I, normal; grade II, nearly normal; grade III, abnormal; grade IV, severely abnormal. Results: The mean scores were: medial femoral condyle, 10.5; lateral femoral condyle, 9.76; trochlea, 9.9; patella 9.4. Grades I & II scores for rods were: medial femoral condyle, 95.1%; lateral femoral condyle, 76.0%; trochlea, 86.1%; patella, 89.7%. The pads were used in significant numbers only on the patella. Of the total, 76.7% of the repairs were for grades I and II changes. Patellar resurfacing was combined with realignment and an ‘anteriorisation’ procedure in 77 knees. We found that 96.7 % of repairs for grades I & II disease were seen with rods on the patella, when combined with a mechanical correction, compared with 66.0%, when used on the patella without a realignment procedure. However, when the use of pads was combined with mechanical corrections the score was 76% and a lower proportion were grade I repairs (13%) than with rods (30.0%). The mean Waddell Score (0–4) was 2.9. From the survey 81.8% regarded the procedure as worthwhile and 9.1% were doubtful. Conclusions: We concluded that carbon fibre resurfacing was an effective method of treating articular cartilage defects. Rods were more effective than pads and are recommended as the universal method. The results were improved by the correction of abnormal biomechanical alignment. Stabilisation of the cartilage defects resolved synovitis

Background context. Fusion is a fundamental procedure in spine surgery. Although autogenous grafts have ideal bone graft characteristics, their use may remain limited due to various morbidities. Even though ceramic based synthetic bone grafts are used commonly at present, in order to enhance their efficacy, their combined use with other materials has been investigated. The use of carbon nanotubes (CNTs) together with synthetic bone grafts such as hydroxyapatite (HA) has contributed to positive developments in bone tissue engineering. Purpose. The aim of the present study was to investigate the effect of CNTs/ HA- tricalcium phosphate (TCP) composite prepared in posterolateral spinal fusion model. Study Design/Setting. Experimental animal study. Methods. At first, CNTs and CNTs/HA-TCP composites were prepared. Twenty adult male Spraque Dawley rats were randomized into four groups with five rats in each group. Decortication was carried out in standard manner in all animals. Group 1 (only decortication), group 2 (CNTs), group 3 (HA-TCP) and group 4 (CNTs/HA-TCP) were formed. Eight weeks later all animals were sacrificed and obtained fusion segments were evaluated by manual palpation, histomorphometry and micro computed tomography (mCT). Results. In all evaluations, highest fusion values were obtained in Group 4. In mCT investigations, bone volume/ tissue volume (BV/TV) ratio was found to be significantly higher in composite group (group 4) only compared to ceramic group (group 3). Although in Group 2, in which only CNTs were used, the ratio was found to be significantly higher than group 1, the difference was not considered significant in terms of fusion and in addition in group 2, CNTs were completely surrounded by fibrous tissue, i.e. no bone formation was observed. Conclusions. The combined use of carbon nanotubes with ceramic based bone grafts enhances spinal fusion markedly. Although CNTs are inadequate in producing spinal fusion when they are used by themselves, due to especially their high biocompatibillity and unique bicomechanic characteristics compatible with bone tissue, they increase fusion rates significantly, particularly together with ceramic based synthetic grafts. Keywords. Spinal fusion; Rat; Carbon nanotube(s); Ceramic(s); Bone graft subsitutes; Hydroxyapatite

Introduction. Ten explanted pyrolytic carbon components of a number of finger prostheses were obtained at revision surgery for wear analysis. Implants were removed for either dislocation or failure of fixation. Hypothesis Failure of the components was due to wear from the articulating surfaces, as occurs in many hip and knee prostheses. Methods. The articulating surfaces were examined using a ZYGO NewView 5000 non-contact profilometer with a resolution of 1nm, to determine the roughness average (RA) of the surface. A total of 86 RA measurements were taken. Detailed images of the surface displayed as a 3D map of were acquired. The RA values for each component were averaged and compared against the British standard for orthopaedic implants, which states that the articulating surfaces of devices made of metal or ceramic should have RA values lower than 0.050 µm. Results. The low surface roughness demonstrated that the vast majority of the articulating surfaces of the components were relatively unworn with RA values lower than British standard, even following use in vivo. ZYGO images showed light unidirectional scratching on four of the explanted components, but despite the scratching, the RA values of these components were still low (<0.050 µm) showing that this was superficial damage. No other significant damage was observed. Discussion. Due to the lack of damage on the articulating surfaces and the low RA values recorded the failure of these prostheses is not considered to be wear related. Significance This is the first report of ex vivo analysis of pyrolytic carbon finger prostheses

INTRODUCTION: Improved factors influencing component wear with regards to bearing surfaces, metallurgy, tribology, and manufacturing technology allowed reintroduction of metal-on-metal (MOM) articulation in total hip arthroplasty (THA) and surface replacement arthroplasty (SRA). MATERIALS AND METHODS: Sixty three patients were implanted with a forged, high carbon content, chrome-cobalt, MOM SRA component (Durom, Zimmer, USA). Samples of whole blood and serum were collected pre-operatively and, post-operatively at three months, six months one year and two years. Chromium and cobalt concentrations were measured using a a high-resolution, sector-field, inductively-coupled plasma mass spectrophotometer (HR-SF-ICP-MS). RESULTS: At two years, whole blood levels were Cr 1.25 umol/L (SD 0.55), Co 0.62 umol/L (SD 0.26). In comparison to the pre-operative levels, the levels increased significantly for both elements Cr 1.3X, Co 5.0 X. Component size was inversely proportional to the chromium and cobalt ion levels at one year post operatively (ANOVA regression analysis, p = 0.0404, for Co and p = 0.0156 for Cr). Other factors such as age and activity level did not correlate with the metal ions levels. DISCUSSION AND CONCLUSION: Chromium and cobalt metal ions measured in patients following implantation of the high carbon content, forged, metal on metal SRA implants used in this study are very low in comparison to other published results with different SRA implants. We believe that these encouraging results found with the SRA components used are resultant of favourable manufacturing and tribologic factors such as low surface roughness, high carbon content, forged chromium and cobalt material, component clearance, and optimum component sphericity. The results of this study are also in accordance with the concepts of reduced wear with larger diameter MOM articulations

Aims: Presentation of modified anterior cervical discectomy by Smith- Robinson method with stabilisation by Cornerstone Carbon Cage (CCS). Methods: Since November 2001, we have been performing unique anterior intervertebral stabilisation procedures with use of carbon implants. Cornerstone Carbon Cage is an artificial intervertebral graft with empty space inside to be filled by bone chips. Cages are from 5 to 7millimetres high, with a higher anterior edge for restoration of physiological lordosis. During the operation we use typical right-side approach to vertebral column. Using intervertebral retractor we perform very wide discectomy until obtaining complete decompression of lateral recesses with exposition of joints of Luschka, which are anatomical lateral limits of the disc space. Afterwards, the wedge-shaped resection of posterior edges of the upper and lower vertebral body which are formed by osteophytes, is performed. Then, we fill the cage by bone chips and osteophytes, and using intervertebral retractor we wedge it into intervertebral space. Results: The procedure allows us to obtain the restoration of lordosis, good stabilisation of vertebral column, and additionally, through a minor distraction, procures decompression of spinal roots in intervertebral foramina. Conclusions: Through a wide intra-operational view, after discectomy and wedge-shaped resection of the vertebral body, it is possible to entirely decompress spine and nerve roots. The above modification of Smith-Robinson method creates ideal conditions for use of CCS