We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator. In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide en bloc resection and tibiotalar arthrodesis was undertaken. The defect was reconstructed using non-vascularised free autogenous fibular strut graft in three patients and a vascularised pedicular fibular graft in three, all supplemented with iliac cancellous graft at the graft-host junction. An Ilizarov external fixator was used for stabilisation of the reconstruction. In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy. Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation

We compared the effects of continuous passive motion with those of intermittent active motion on the results of the resurfacing with autogenous periosteal grafts of full-thickness defects on the articular surface of rabbit patellae. Of 45 rabbits with defects, 30 received grafts. Fifteen of these had continuous passive motion for two weeks and intermittent active motion for four weeks; the other 15 had intermittent active motion for six weeks. In 15 the defects were not grafted (control group) and they had intermittent active motion for six weeks. Ten more rabbits had a sham operation. Six weeks after surgery, the results were assessed by the gross appearance, histology, histochemistry, immunohistochemistry and electron microscopy. By all assessments the quality of neochondrogenesis produced by periosteal grafts was superior to that in ungrafted defects (p less than 0.05) and the results in continuous passive motion treated animals were superior to those in intermittent active motion treated animals (p less than 0.05). The periosteal grafts produced hyaline cartilage containing type II collagen but the organisation of its fibres was irregular

The continual cycle of bone formation and resorption is carried out by osteoblasts, osteocytes, and osteoclasts under the direction of the bone-signaling pathway. In certain situations the host cycle of bone repair is insufficient and requires the assistance of bone grafts and their substitutes. The fundamental properties of a bone graft are osteoconduction, osteoinduction, osteogenesis, and structural support. Options for bone grafting include autogenous and allograft bone and the various isolated or combined substitutes of calcium sulphate, calcium phosphate, tricalcium phosphate, and coralline hydroxyapatite. Not all bone grafts will have the same properties. As a result, understanding the requirements of the clinical situation and specific properties of the various types of bone grafts is necessary to identify the ideal graft. We present a review of the bone repair process and properties of bone grafts and their substitutes to help guide the clinician in the decision making process.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):6–9.

We examined osteochondral autografts, obtained at a mean of 19.5 months (3 to 48) following extracorporeal irradiation and re-implantation to replace bone defects after removal of tumours. The specimens were obtained from six patients (mean age 13.3 years (10 to 18)) and consisted of articular cartilage (five), subchondral bone (five), external callus (one) and tendon (one). The tumour cells in the grafts were eradicated by a single radiation dose of 60 Gy. In three cartilage specimens, viable chondrocytes were detected. The survival of chondrocytes was confirmed with S-100 protein staining. Three specimens from the subchondral region and a tendon displayed features of regeneration. Callus was seen at the junction between host and irradiated bone.

We describe a new method of biological repair of osteochondral defects. In rabbit knees an osteochondral defect was reconstructed with a callo-osseous graft made of a superficial sheet of medullary fracture callus attached to a base of cancellous bone. This was taken from the iliac bone of the same animal which had been osteotomised ten days earlier. The reparative tissues were evaluated for 24 weeks by quantitative histology, biochemical analysis of the uronic acid content, and immunohistochemical staining of collagen constituents. The callo-osseous graft provided significantly faster and better repair of the articular surface than an untreated defect or a callo-osseous graft in which the cells had been devitalised by irradiation before transplantation. Our findings indicate that the callo-osseous graft contributes to the repair process by providing both favourable extracellular matrices and pluripotential mesenchymal cells. Our study tested the hypothesis that early medullary callus generates hyaline cartilage instead of bone after transfer to an articular surface.

1. Experimental evidence suggests that the autogenous graft exhibits some advantage over refrigerated homogenous grafts in that healing takes place more rapidly but that in the end the results are the same. 2. Histological study of fragments of healing grafts, both autogenous and refrigerated, that have been removed from human hosts shows no significant difference in the rate or method of repair. 3. Study of the clinical results of the use of homogenous transplants in 307 operations shows the bone to be well tolerated. The rate of infection in clean cases was 2·6 per cent; loss of bone occurred in only two cases. 4. Follow-up studies of 248 cases showed successful results obtained in 210, or 85 per cent. These are comparable with the results obtained with autogenous grafts. The healing of cancellous transplants takes place more rapidly than with cortical grafts. Transplants that have been preserved for more than one year do not heal as well as those that have been preserved for a shorter period and the failure rate is higher. 5. The operation of a bone bank is safe and practical. It offers great advantages to the patient and the surgeon from the standpoint of availability, abundance and the elimination of the necessity of secondary operations to obtain bone. When a bone bank is available the number of operations in which bone transplants are used will show a sharp increase

There are few reports of the treatment of lumbar tuberculous spondylitis using the posterior approach. Between January 1999 and February 2004, 16 patients underwent posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation. Their mean age at surgery was 51 years (28 to 66). The mean follow-up period was 33 months (24 to 48). The clinical outcome was assessed using the Frankel neurological classification and the Kirkaldy-Willis criteria. On the Frankel classification, one patient improved by two grades (C to E), seven by one grade, and eight showed no change. The Kirkaldy-Willis functional outcome was classified as excellent in eight patients, good in five, fair in two and poor in one. Bony union was achieved within one year in 15 patients. The mean pre-operative lordotic angle was 27.8° (9° to 45°) which improved by the final follow-up to 35.8° (28° to 48°). Post-operative complications occurred in four patients, transient root injury in two, a superficial wound infection in one and a deep wound infection in one, in whom the implant was removed. Our results show that a posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation for tuberculous spondylitis through the posterior approach can give satisfactory results

1. Three cases of infantile pseudarthrosis of the tibia treated successfully by delayed autogenous by-pass graft are reported. 2. The delayed autogenous graft is stouter, stronger and more easily handled and has enhanced osteogenic properties than a graft transferred immediately. 3. The by-pass graft commends itself, firstly, because it does not disturb the pseudarthrosis, which in consequence helps the immobilisation of the graft; secondly, because it is well embedded in healthy bone above and below, well away from the abnormal bone; thirdly, because it lies under compression and, ideally, is vertically disposed between the knee and the ankle; and fourthly, because there is no devitalising stripping of periosteum or introduction of foreign bodies. 4. Support to the grafted leg is needed for at least five years, but only by a polythene splint after four to six months. 5. With early grafting the deformity straightens out and shortening is overcome, as there is early return to normal use of the limb. 6. Prolonged follow-up is called for lest the basic lesion in the tibia should extend. 7. Fibrous dysplasia and similar fibrous lesions of bone account for many cases of infantile pseudarthrosis of the tibia. Many of these lesions are congenital and subsequently lead to fracture. 8. Postponement of surgery should not be countenanced

Comparison was made between the behaviour of fresh autogenous grafts of rabbit tendon and that of homogenous grafts inserted after the graft had been preserved for approximately one week, either in ethanol or merthiolate or by lyophilisation. Regardless of the method of transplantation or preservation, a viable tendon-like structure of compact connective tissue bundles longitudinally oriented was eventually present at the sites of the grafts, with ingrowth of fibroblasts and capillaries from host to graft. The period between transplantation and recognisable viability of the grafts varied from less than one week for the autogenous transplants, to from three to five weeks for the preserved grafts. Either autogenous or homogenous grafts will take in rabbits

Costoplasty can reduce the important cosmetic deformity of rib prominence in scoliosis but there are few objective reports of correction. We recorded the results of three objective methods of assessing back shape before and after short-segment costoplasty in 55 patients. We showed that significant improvement was maintained over a two-year follow-up period. Primary costoplasty at the time of scoliosis surgery (n = 35) achieved greater proportional correction than secondary costoplasty performed after fusion of the spine (n = 20). The rib segments removed at primary surgery provided enough bone for the autogenous graft; harvesting from the pelvis was unnecessary. We report a new classification of rib morphology which helps in planning the site and extent of costoplasty, and in predicting the possible correction

We have described a method of anatomical reconstruction of the lateral ligaments of the ankles with instability using allogeneic fascia lata dried with solvents and sterilised with gamma irradiation. Twenty ankles of 20 patients were assessed objectively and subjectively after a mean follow-up of 4.2 years (3.1 to 10). The result was excellent in 12 (60%), good in seven (35%) and fair in one (5%); none had a poor result. Stress radiography showed that the angle of talar tilt improved from 12.3 ± 4.2° (mean ±. sd. ) to 5.9 ± 3.0° and that the anterior drawer distance decreased from 9.2 ± 3.9 mm to 4.4 ± 2.5 mm. Neither infection nor limitation of movement occurred after operation. Fascia lata allografts provide a good alternative to autogenous grafts such as the peroneus brevis tendon

In nine patients of median age 34 years who had sustained an amputation of the thumb at a median 24 (5 to 131) months previously, we lengthened the first metacarpal by 30 (17 to 36) mm. Seven amputations had been through the proximal phalanx and two through the metacarpal. The first two patients had autogenous grafting at a second stage, but the other seven had callotasis alone. In these patients the external fixators were removed at a median 189 (115 to 271) days after osteotomy. In six cases the adductor pollicis tendon was transferred proximally and the first web deepened. There was late fracture or palmar flexion of the callus in five patients, but this required further surgery in only one. Treatment was complete at 326 (140 to 489) days after osteotomy. The extended thumb retained its sensitivity; both grasp and key-pinch strength were satisfactory and only one patient felt that the result did not warrant the long course of treatment. Metacarpal lengthening by this method is a prolonged procedure, but provides a valuable alternative to more complex reconstructions

A technique for stabilising the superior tibiofibular joint using an autogenous biceps graft passed through a tibial tunnel is described. The common peroneal nerve should be decompressed and the lateral inferior genicular artery protected. The technique proved to be safe and effective in two patients who were followed for at least two years

About 20% of patients with leprosy develop localised granulomatous lesions in peripheral nerves. We report experiments in guinea-pigs in which freeze-thawed autogenous muscle grafts were used for the treatment of such mycobacterial granulomas. Granulomas were induced in guinea-pig tibial nerves and the animals were left for 7 to 100 days in order to assess maximal damage. The local area of nerve damage was then excised and the gap filled with denatured muscle grafts. Clinical assessment after periods up to 150 days showed good sensory and motor recovery which correlated well with the histological findings. The muscle graft technique may be of value for the treatment of chronic nerve lesions in selected cases of leprosy

This review summarises the technique of impaction grafting with mesh augmentation for the treatment of uncontained acetabular defects in revision hip arthroplasty.

The ideal acetabular revision should restore bone stock, use a small socket in the near-anatomic position, and provide durable fixation. Impaction bone grafting, which has been in use for over 40 years, offers the ability to achieve these goals in uncontained defects. The precepts of modern, revision impaction grafting are that the segmental or cavitary defects must be supported with a mesh; the contained cavity is filled with vigorously impacted morselised fresh-frozen allograft; and finally, acrylic cement is used to stabilise the graft and provide rigid, long-lasting fixation of the revised acetabular component.

Favourable results have been published with this technique. While having its limitations, it is a viable option to address large acetabular defects in revision arthroplasty.

Cite this article: Bone Joint J 2017;99-B(1 Supple A):25–30.

Aims

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy.

Structural allografts may be used to manage uncontained bone defects in revision total knee replacement (TKR). However, the availability of cadaver grafts is limited in some areas of Asia. The aim of this study was to evaluate the mid-term outcome of the use of femoral head allografts for the reconstruction of uncontained defects in revision TKR, focusing on complications related to the graft.

We retrospectively reviewed 28 patients (30 TKRs) with Anderson Orthopaedic Research Institute (AORI) type 3 bone defects, who underwent revision using femoral head allografts and stemmed components. The mean number of femoral heads used was 1.7 (1 to 3). The allograft–host junctions were packed with cancellous autograft.

At a mean follow-up of 76 months (38 to 136) the mean American Knee Society knee score improved from 37.2 (17 to 60) pre-operatively to 90 (83 to 100) (p < 0.001). The mean function score improved from 26.5 (0 to 50) pre-operatively to 81 (60 to 100) (p < 0.001). All the grafts healed to the host bone. The mean time to healing of the graft was 6.6 months (4 to 16). There have been no complications of collapse of the graft, nonunion, infection or implant loosening. No revision surgery was required.

The use of femoral head allografts in conjunction with a stemmed component and autogenous bone graft in revision TKR in patients with uncontained bone defects resulted in a high rate of healing of the graft with minimal complications and a satisfactory outcome. Longer follow-up is needed to observe the evolution of the graft.

Cite this article: Bone Joint J 2013;95-B:643–8.

We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3).

Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results.

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients.

However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively.

The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head.

Cite this article: Bone Joint J 2017;99-B:1267–79.