Numerous techniques of arthrodesis of the ankle have been described in the literature with variable results. Although arthrodesis achieves satisfying results in most cases, high complication rates have been reported. We utilized a medial compression T plate to achieve fusion and the aim of this study is to present the early to mid term results of this procedure at our institution. 20 patients (23 ankles) underwent ankle arthrodesis by a single surgeon using the same surgical technique. Under tourniquet control, a medial longitudinal incision centering on the medial malleolus was used. After osteotomising the medial malleolus to expose the ankle joint, chevron cuts were made in the tibia and the talus removing only enough bone. The cut surfaces are apposed and then compressed together by using a medial compression T plate. The excised medial malleolus was used as bone graft. The fixation was protected in a plaster cast and allowed only partial weight bearing for up to 10 weeks. The ankles were clinically assessed by Mazur ankle scoring system and radiologically assessed until fusion was solid. The mean age at operation was 56 years (range 20–76) and the sex distribution was equal. Indication for surgery included either posttraumatic or rheumatoid arthritis. At a mean follow-up of 73 months (range 6–112), all the patients had complete pain relief. Complications included deep infection in two ankles (Rheumatoid patient, needed implant removal), subtalar pain in four and nonunion in one ankle. There was late loss of position in 2 ankles (same patient), who was later diagnosed with charcot’s joints. All the fusions occurred within 16 weeks. The fusion rate with this technique was 96% with the medial T plate providing a stable internal fixation. Our experience suggests that medial compression arthrodesis of the ankle is a reliable and an easily reproducible technique with a very low incidence of complications.
The main object of acetabular revisions is to restore bone stock and provide adequate support for the cup. Allograft bone has been used to reconstruct the acetabulum with variable results. This study is a prospective assessment of the performance of the uncemented cups with morsellized allograft bone in revision acetabular reconstruction. A single surgeon using a direct lateral approach performed 98 acetabular revisions. An uncemented hemispherical cup with multiple screw holes and morsellized allograft bones was used in all the reconstructions. Patients were clinically assessed by Harris Hip score. Acetabular defects were classified by AAOS Classification system using standard AP pelvis x-rays. Massin’s criteria was used for assessing cup migration; evidence of screw breakage and acetabular bone incorporation were also looked for. 5 patients died before the 3-year follow-up, leaving 93 hips for final analysis. Mean age at surgery was 66 years (range 24–87). Majority of the acetabular defects belonged to AAOS type III. The mean follow-up was 76. 13 hips have undergone repeat revisions, five of which for aseptic loosening of the cup. Meantime to revision was 42 months. Reconstruction of the bone-deficient acetabulum in revision arthroplasty of the hip is a difficult problem and no single procedure is universally good. However, the use of allograft bone provides a biological solution by restoring the bone stock. The use of uncemented cups with screws provides the primary stability that is supplemented later by the incorporated allograft bone. The rate of revisions for aseptic loosening of the cup in our series is low at 6% after a mean of 6 years. Even in these cases the repeat revisions were significantly easier due to restored bone stock.
This is a retrospective assessment of the performance of a consecutive series of the titanium uncemented Gemini femoral component. The Gemini uncemented stem (De Puy) is a modular titanium femoral stem with a cobalt chrome head. It has proximal porous coating allowing stable fixation by bony in-growth and a smooth distal stem allowing mechanical fixation. Using a direct lateral approach, 152 consecutive patients underwent a total hip replacement using the Gemini uncemented femoral component and an unce-mented cup. Patients were regularly assessed clinically (Harris hip score) and radiologically (Engh’s criteria for fixation of the prosthesis). Kaplan Meier survivorship analysis was used to assess survival. 16 patients were lost to follow-up and 30 were dead with the THR in situ, leaving 106 hips for final analysis, at a mean follow-up of 106 months. The mean age of the group was 60 years (range 25–83) and OA was the commonest diagnosis. The mean Harris hip score improved from 34 to 92(range 83–100). 7 stems have been revised, four of which for aseptic loosening and a further two are radiologically loose. Mean time to revision was 41 months (range 14–76). By Engh’s criteria, 90% of the hips had stable bony fixation; only 4% of the patients complained of thigh pain at final follow-up. Kaplan Meier survivorship analysis with aseptic loosening as endpoint indicated a survival of 93% at 8 years. A mid-term result with the Gemini uncemented stems at a mean follow-up of approximately 9 years was excellent. This is in sharp contrast to the cemented stem of similar design, even though the uncemented version was used in younger and more active group of patients. Titanium alloy is biocompatible allowing for excellent bony in growth, making it an ideal alloy in the manufacture of uncemented stems. Having a modulus of elasticity close to that of bone explains the low incidence of thigh pain.
This is a prospective study assessing the results of patients receiving large fragment allograft and a vascularised fibular graft following primary malignant tumour resections around the hip and the knee. 18 patients underwent tumor resection followed by reconstruction with large fragment allograft and vascularised fibular graft. Eight patients underwent resection arthrodesis of the hip, four underwent resection arthrodesis of the knee and six underwent intercalary resections. Following tumour resection with adequate margins, an appropriate sized allograft fragment was internally fixed with either a plate or an intramedullary nail. A vascularised fibular graft was used to span the gap between the remaining host bones. Osteosarcoma was the commonest diagnosis. The patients were clinically assessed by MSTS functional scoring system and radiologically assessed at regular intervals. The mean age was 26 years (range12–70) and majority of the patients was men. 11 patients received preoperative chemotherapy. Mean follow-up was 85 months (range 8–153). Six patients have died of metastatic disease at a mean of 33 months. Complications included local recurrence in two, deep infection in one and stress fracture of the fibula in two cases. One patient with local recurrence and the other with deep infection underwent an amputation. Majority of the patients had good or excellent MSTS scores at final follow-up and 75% of the patients are engaged in physically active occupations. Graft hypertrophy was evident in majority of the patients. Our experience clearly indicates that reconstruction with large fragment allograft and vascularised fibular graft is a useful limb salvage procedure with the fibula hypertrophying slowly with time. The eventual fracture of the allograft or failure of the allograft-plate composite is to be expected but is not deleterious due to the physiological response of the vascularised fibula to the weight bearing stresses over time. We feel that this biological solution is likely to demonstrate superior long-term results compared to a prosthetic reconstruction.
This is a retrospective assessment of the performance of the titanium cemented Gemini femoral component. The Gemini stem (DePuy) is a modular titanium femoral stem with a cobalt chrome femoral head. It has a roughened proximal surface finish to enhance cement bonding and a fixed distal centraliser. 205 total hip replacements were performed using a titanium cemented Gemini stem and an uncemented cup. All the operations were performed by a lateral approach using modern cementing technique. Patients were assessed clinically (Harris hip score) and radiologically. Kaplan Meier Survivorship analysis was used to assess survival. 8 patients were lost and 36 patients died with their total hip prosthesis in situ. The average follow-up in the remaining 161 hips was 70 months (range 37–124 months). The average age was 70 years (range 35–91). Osteoarthritis was the commonest diagnosis and majority of the patients was female. Using the Barrack’s criteria for cementing quality, more than 85% of the hips belonged either to grade A or B with an adequate proximal cement mantle. 28 hips have been revised (26 of which for aseptic loosening) and a further ten have been recognized as radiological failures. A small sized stem was used in over 85% of the failures. Mean time to revision was 3.1 years. Survival according to Kaplan-Meier Survivor curves at 6 years was 72%. There is a high incidence of early failure associated with these cemented titanium stems (28%). The possible mechanism of failure is as follows. The rough surface finish and the flexible titanium alloy are likely to produce large amounts of wear debris and the centraliser which is fixed to the stem probably acts as an area of stress concentration causing accelerated destruction of the distal cement mantle. Based on our experience, the continued use of this cemented stem is no longer justified.
