Aims. Osteoporosis can determine surgical strategy for total hip arthroplasty (THA), and perioperative fracture risk. The aims of this study were to use hip CT to measure femoral bone mineral density (BMD) using CT X-ray absorptiometry (CTXA), determine if systematic evaluation of preoperative femoral BMD with CTXA would improve identification of osteopenia and osteoporosis compared with available preoperative dual-energy X-ray absorptiometry (DXA) analysis, and determine if improved recognition of low BMD would affect the use of cemented stem fixation. Methods. Retrospective chart review of a single-surgeon database identified 78 patients with CTXA performed prior to robotic-assisted THA (raTHA) (Group 1). Group 1 was age- and sex-matched to 78 raTHAs that had a preoperative hip CT but did not have CTXA analysis (Group 2). Clinical demographics, femoral fixation method, CTXA, and DXA data were recorded. Demographic data were similar for both groups. Results. Preoperative femoral BMD was available for 100% of Group 1 patients (CTXA) and 43.6% of Group 2 patients (DXA). CTXA analysis for all Group 1 patients preoperatively identified 13 osteopenic and eight osteoporotic patients for whom there were no available preoperative DXA data. Cemented stem fixation was used with higher frequency in Group 1 versus Group 2 (28.2% vs 14.3%, respectively; p = 0.030), and in all cases where osteoporosis was diagnosed, irrespective of technique (DXA or CTXA). Conclusion. Preoperative hip CT scans which are routinely obtained prior to raTHA can determine bone health, and thus guide femoral fixation strategy. Systematic preoperative evaluation with CTXA resulted in increased recognition of osteopenia and osteoporosis, and contributed to increased use of cemented femoral fixation compared with routine clinical care; in this small study, however, it did not impact short-term periprosthetic fracture risk. Cite this article: Bone Joint J 2023;105-B(3):254–260

Aims. The aims of this study were to determine the success of a reconstruction algorithm used in major acetabular bone loss, and to further define the indications for custom-made implants in major acetabular bone loss. Methods. We reviewed a consecutive series of Paprosky type III acetabular defects treated according to a reconstruction algorithm. IIIA defects were planned to use a superior augment and hemispherical acetabular component. IIIB defects were planned to receive either a hemispherical acetabular component plus augments, a cup-cage reconstruction, or a custom-made implant. We used national digital health records and registry reports to identify any reoperation or re-revision procedure and Oxford Hip Score (OHS) for patient-reported outcomes. Implant survival was determined via Kaplan-Meier analysis. Results. A total of 105 procedures were carried out in 100 patients (five bilateral) with a mean age of 73 years (42 to 94). In the IIIA defects treated, 72.0% (36 of 50) required a porous metal augment; the remaining 14 patients were treated with a hemispherical acetabular component alone. In the IIIB defects, 63.6% (35 of 55) underwent reconstruction as planned with 20 patients who actually required a hemispherical acetabular component alone. At mean follow-up of 7.6 years, survival was 94.3% (95% confidence interval 97.4 to 88.1) for all-cause revision and the overall dislocation rate was 3.8% (4 of 105). There was no difference observed in survival between type IIIA and type IIIB defects and whether a hemispherical implant alone was used for the reconstruction or not. The mean gain in OHS was 16 points. Custom-made implants were only used in six cases, in patients with either a mega-defect in which the anteroposterior diameter > 80 mm, complex pelvic discontinuity, and massive bone loss in a small pelvis. Conclusion. Our findings suggest that a reconstruction algorithm can provide a successful approach to reconstruction in major acetabular bone loss. The use of custom implants has been defined in this series and accounts for < 5% of cases. Cite this article: Bone Joint J 2024;106-B(5 Supple B):47–53

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available. Cite this article: Bone Joint J 2024;106-B(10):1100–1110

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity. Cite this article: Bone Joint J 2024;106-B(4):312–318

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required

Aims. Severe acetabular bone loss and pelvic discontinuity (PD) present particular challenges in revision total hip arthroplasty. To deal with such complex situations, cup-cage reconstruction has emerged as an option for treating this situation. We aimed to examine our success in using this technique for these anatomical problems. Patients and Methods. We undertook a retrospective, single-centre series of 35 hips in 34 patients (seven male, 27 female) treated with a cup-cage construct using a trabecular metal shell in conjunction with a titanium cage, for severe acetabular bone loss between 2011 and 2015. The mean age at the time of surgery was 70 years (42 to 85) and all patients had an acetabular defect graded as Paprosky Type 2C through to 3B, with 24 hips (69%) having PD. The mean follow-up was 47 months (25 to 84). Results. The cumulative five-year survivorship of the implant with revision for any cause was 89% (95% confidence interval (CI) 72 to 96) with eight hips at risk. No revision was required for aseptic loosening; however, one patient with one hip (3%) required removal of the ischial flange of the cage due to sciatic nerve irritation. Two patients (6%; two hips) suffered from hip dislocation, whereas one patient (one hip) required revision surgery with cement fixation of a dual-mobility acetababular component into a well-fixed cup-cage construct. Two patients (6%; two hips) developed periprosthetic infection. One patient was successfully controlled with a two-stage revision surgery, while the other patient underwent excision arthroplasty due to severe medical comorbidities. For the whole series, the Harris Hip Score significantly improved from a mean of 30 (15 to 51) preoperatively to 71 (40 to 89) at the latest follow-up (p < 0.001). Conclusion. Our findings suggest that cup-cage reconstruction is a viable option for major segmental bone defects involving the posterior column and PD. It allows adequate restoration of the acetabulum centre with generally good stability and satisfactory postoperative function. Instability and infection remain drawbacks in these challenging revision cases. Cite this article: Bone Joint J 2018;100-B:1442–48

The treatment of bone loss in revision total knee arthroplasty has evolved over the past decade. While the management of small to moderate sized defects has demonstrated good results with a variety of traditional techniques (cement and screws, small metal augments, impaction bone grafting or modular stems), the treatment of severe defects continues to be problematic. The use of a structural allograft has declined in recent years due to an increased failure rate with long-term follow-up and with the introduction of highly porous metal augments that emphasise biological metaphyseal fixation. Recently published mid-term results on the use of tantalum cones in patients with severe bone loss has reaffirmed the success of this treatment strategy. . Cite this article: Bone Joint J 2016;98-B(1 Suppl A):120–4

Aims. Loss or absence of proximal femoral bone in revision total hip arthroplasty (THA) remains a significant challenge. While the main indication for the use of proximal femoral replacements (PFRs) is in the treatment of malignant disease, they have a valuable role in revision THA for loosening, fracture and infection in patients with bone loss. Our aim was to determine the clinical outcomes, implant survivorship, and complications of PFRs used in revision THA for indications other than malignancy. Patients and Methods. A retrospective review of 44 patients who underwent revision THA using a PFR between 2000 and 2013 was undertaken. Their mean age was 79 years (53 to 97); 31 (70%) were women. The bone loss was classified as Paprosky IIIB or IV in all patients. The mean follow-up was six years (2 to 12), at which time 22 patients had died and five were lost to follow-up. Results. The mean Harris Hip Score improved from 42.8 (25.9 to 82.9) pre-operatively to 68.5 (21.0 to 87.7) post-operatively (p = 0.0009). A total of two PFRs had been revised, one for periprosthetic infection eight years post-operatively and one for aseptic loosening six years post-operatively. The Kaplan-Meier survivorship free of any revision or removal of an implant was 86% at five years and 66% years at ten years. A total of 12 patients (27%) had a complication including six with a dislocation. Conclusion. PFRs provide a useful salvage option for patients, particularly the elderly with massive proximal femoral bone loss who require revision THA, with significant clinical improvement. While the survivorship of the implant is good at five years, dislocation continues to be the most common complication. The judicious use of larger femoral heads, dual-mobility constructs, or constrained liners may help to minimise the risk of dislocation. Cite this article: Bone Joint J 2017;99-B:325–9

The management of bone loss in revision replacement of the knee remains a challenge despite an array of options available to the surgeon. Bone loss may occur as a result of the original disease, the design of the prosthesis, the mechanism of failure or technical error at initial surgery. The aim of revision surgery is to relieve pain and improve function while addressing the mechanism of failure in order to reconstruct a stable platform with transfer of load to the host bone. Methods of reconstruction include the use of cement, modular metal augmentation of prostheses, custom-made, tumour-type or hinged implants and bone grafting. The published results of the surgical techniques are summarised and a guide for the management of bone defects in revision surgery of the knee is presented

If a surgeon is faced with altered lesser trochanter anatomy when revising the femoral component in revision total hip replacement, a peri-prosthetic fracture, or Paprosky type IIIb or type IV femoral bone loss, a modular tapered stem offers the advantages of accurately controlling femoral version and length. The splines of the taper allow rotational control, and improve the fit in femoral canals with diaphyseal bone loss. In general, two centimetres of diaphyseal contact is all that is needed to gain stability with modular tapered stems. By allowing the proximal body trial to rotate on a well-fixed distal segment during trial reduction, appropriate anteversion can be obtained in order to improve intra-operative stability, and decrease the dislocation risk. However, modular stems should not be used for all femoral revisions, as implant fracture and corrosion at modular junctions can still occur. Cite this article: Bone Joint J 2013;95-B, Supple A:95–7

In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient. We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication

Aims. Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone. Methods. A metaphyseal cone was combined with diaphyseal impaction grafting and cemented stems for 35 revision TKAs. There were two patients with follow-up of less than two years who were excluded, leaving 33 procedures in 32 patients in the study. The mean age of the patients at the time of revision TKA was 67 years (32 to 87); 20 (60%) were male. Patients had undergone a mean of four (1 to 13) previous knee arthroplasty procedures. The indications for revision were aseptic loosening (80%) and two-stage reimplantation for prosthetic joint infection (PJI; 20%). The mean follow-up was four years (2 to 11). Results. Survival free from revision of the cone/impaction grafting construct due to aseptic loosening was 100% at five years. Survival free from any revision of the construct and free from any reoperation were 92% and 73% at five years, respectively. A total of six patients (six TKAs, 17%) required a further revision, four for infection or wound issues, and two for periprosthetic fracture. Radiologically, one unrevised TKA had evidence of loosening which was asymptomatic. In all unrevised TKAs the impacted diaphyseal bone graft appeared to be incorporated radiologically. Conclusion. When presented with a sclerotic diaphysis and substantial metaphyseal bone loss, this technique combining diaphyseal impaction grafting with a metaphyseal cone provided near universal success in relation to implant fixation. Moreover, radiographs revealed incorporation of the bone graft and biological fixation of the cone. While long-term follow-up will be important, this technique provides an excellent option for the management of complex revision TKAs. Cite this article: Bone Joint J 2020;102-B(6 Supple A):116–122

Revision total hip arthroplasty (THA) is projected to increase by 137% from the years 2005 to 2030. Reconstruction of the femur with massive bone loss can be a formidable undertaking. The goals of revision surgery are to create a stable construct, preserve bone and soft tissues, augment deficient host bone, improve function, provide a foundation for future surgery, and create a biomechanically restored hip. Options for treatment of the compromised femur include: resection arthroplasty, allograft prosthetic composite (APC), proximal femoral replacement, cementless fixation with a modular tapered fluted stem, and impaction grafting. The purpose of this article is to review the treatment options along with their associated outcomes in the more severe femoral defects (Paprosky types IIIb and IV) in revision THA.

Aims. There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA. Methods. We retrospectively reviewed 88 cases which met the Musculoskeletal Infection Society (MSIS) criteria for PJI. Mean follow-up was seven years (1 to 14). Septic failure was diagnosed with a Delphi-based consensus definition. Any reoperation for mechanical causes in the absence of evidence of infection was considered as non-septic failure. A competing risk regression model was used to evaluate factors associated with septic and non-septic failures. A Kaplan-Meier estimate was used to analyze mortality. Results. The cumulative incidence of septic failure was 8% (95% confidence interval (CI) 3.5 to 15) at one year, 13.8% (95% CI 7.6 to 22) at two years, and 19.7% (95% CI 12 to 28.6) at five and ten years of follow-up. A femoral bone defect worse than Paprosky IIIA (hazard ratio (HR) 13.58 (95% CI 4.86 to 37.93); p < 0.001) and obesity (BMI ≥ 30 kg/m. 2. ; HR 3.88 (95% CI 1.49 to 10.09); p = 0.005) were significantly associated with septic failure. Instability and periprosthetic fracture were the most common reasons for mechanical failure (5.7% and 4.5%, respectively). The cumulative incidence of aseptic failure was 2% (95% CI 0.4 to 7) at two years, 9% (95% CI 4 to 17) at five years, and 12% (95% CI 5 to 22) at ten years. A previous revision to treat PJI was significantly associated with non-septic failure (HR 9.93 (95% CI 1.77 to 55.46); p = 0.009). At the five-year timepoint, 93% of the patients were alive (95% CI 84% to 96%), which fell to 86% (95% CI 75% to 92%) at ten-year follow-up. Conclusion. Massive femoral bone loss was associated with greater chances of developing a further septic failure. All septic failures occurred within the first five years following the one-stage exchange. Surgeons should be aware of instability and periprosthetic fracture being potential causes of further aseptic revision surgery. Cite this article: Bone Joint J 2021;103-B(7):1247–1253

Nonunion of the humerus with bone loss and shortening due to osteomyelitis is rare but difficult to treat. We describe our experience with a callus distraction technique using a monolateral external fixator for the treatment of this condition. Between October 1994 and January 2004, 11 patients were treated. There were seven males and four females, with a mean age of 14 years (10 to 17). The mean bone loss was 1.9 cm (1 to 2.7) and the mean length discrepancy in the upper limb was 5.6 cm (3.5 to 8.0). The mean follow-up was for 106 months (54 to 166). The mean external fixation index was 34.8 days/cm (29.8 to 40.5). The mean lengthening was 9.5 cm (5.5 to 13.4). There were seven excellent results, three good and one poor. There were nine excellent functional results and two good. The treatment of humeral nonunion with bone loss and shortening due to osteomyelitis by callus distraction is a safe and effective means of improving function and cosmesis

The histodynamic response to long-term "non-traumatic" immobilisation was studied in young adult Beagle dogs by means of radiomorphometry and histomorphometry, the right forelimb being encased in plaster and the left forelimb serving as a control. The dogs were killed at two, four, six, eight, twelve, sixteen, twenty, twenty-four, thirty-two and forty weeks and the third metacarpal, radius, ulna and humerus removed for analysis of the contributions of the periosteal, haversian and endosteal envelopes to the bone loss at the mid-diaphysis. The bone mass responded to long-term immobilisation in three stages. First there was a rapid initial loss of bone, reaching its maximum (some 16 per cent of original mass) at six weeks, to which all three bone envelopes, to some extent, contributed. A rapid reversal followed, the bone mass approaching the control values between eight and twelve weeks after immobilisation. A second stage of slower but longer lasting bone loss ended twenty-four to thirty-two weeks after immobilisation; the periosteal envelope was the main contributor (80 to 90 per cent of the total loss). The third stage was characterised by maintenance of the bone mass which had been reduced by some 30 to 50 per cent of original values. This pattern was qualitatively similar in all four bones but the distal bones lost more bone than the proximal bones. The extent of resorption surface and the total histologically "active" periosteal envelope increased parallel to the phases of bone loss. The linear mineralisation rate did not differ significantly between the experimental and control sides

Aims. A failed total ankle arthroplasty (TAA) is often associated with much bone loss. As an alternative to arthrodesis, the surgeon may consider a custom-made talar component to compensate for the bone loss. Our aim in this study was to assess the functional and radiological outcome after the use of such a component at mid- to long-term follow-up. Patients and Methods. A total of 12 patients (five women and seven men, mean age 53 years; 36 to77) with a failed TAA and a large talar defect underwent a revision procedure using a custom-made talar component. The design of the custom-made components was based on CT scans and standard radiographs, when compared with the contralateral ankle. After the anterior talocalcaneal joint was fused, the talar component was introduced and fixed to the body of the calcaneum. Results. At a mean follow-up of 6.9 years (1 to 13), 11 ankles were stable with no radiological evidence of loosening. Only one was lost to follow-up. The mean arc of movement was 21. °. (10. °. to 35. °. ). A total of nine patients (75%) were satisfied or very satisfied with the outcome, two (17%) were satisfied but with reservations and one (8%) was not satisfied. All but one patient had an improvement in the American Orthopaedic Foot and Ankle Society hindfoot score (p = 0.01). Just one patient developed deep infection, leading to arthrodesis. Conclusion. A custom-made talar component yielded satisfactory results with regard to function, stability and satisfaction. This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA. Cite this article: Bone Joint J 2017;99-B:231–6

We have carried out in 24 patients, a two-stage revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect. There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D’Aubigné and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis. The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in revision surgery after septic conditions restores bone stock without the risk of recurrent infection

We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site. Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients