Introduction. Since the expanded war in Ukraine in 2022, explosives, mines, debris, blast waves, and other factors have predominantly caused injuries during artillery or rocket attacks. These injuries, such as those from shelling shrapnel, involve high-energy penetrating agents, resulting in extensive necrosis and notable characteristics like soft tissue defects and multiple fragmentary fractures with bone tissue defects and a high rate of infection complications caused by multi resistant gram-negative (MRGN) pathogens. Material and Methods. We conducted a prospective study at our center between March 2022 and December 2023. Out of the 56 patients from Ukraine, 21 met the inclusion criteria who had severe war injuries were included in the study. Each of these patients presented with multiple injuries to both bones and soft tissues, having initially undergone treatment in Ukraine involving multiple surgeries. The diagnosis of infection was established based on the EBJIS criteria. Prior to our treatment patients had undergone multiple revision surgeries, including debridement, biopsies, implant and fixator replacement. Additionally, soft tissue management required previously VAC therapy and flap reconstruction for successful treatment. Results. All 21 infections manifested as bone infections (11; 52%), followed by implant-associated infections (5; 24%), soft tissue infections (4; 19%), and septic arthritis (1; 5%). In all patients, the infection was polymicrobial, caused by 3- and 4-MRGN pathogens, as Klebsiella pneumonia 4MRGN, Proteus mirabilis 4MRGN, Enterobacter cloacae 4MRGN etc. Upon admission, all patients carried a diagnosis and exhibited signs indicative of chronic infection. 19 (90.5%) patients required complex antibiotic regimens combined with multiple wound revisions and debridements, changes of fixators and combination of systemic and local antibiotic therapy. In 6 patients (28%) high dosages of local antibiotics such as gentamycin, vancomycin and meropenem were incorporated into a carrier of bio-absorbable calcium sulfate, calcium sulfate/hydroxyapatite which were introduced into the hip joint, femoral canal or bone defect for dead space management during the surgery. When local antibiotics were administered at intervals, the microbiology results at implantation showed negative results. 2 (9%) patients had new infections (different site, different pathogens), 1 (4.8%) is still under the treatment. In 17 (81%) patients infection complications were treated successfully with no recurrence of infection. Conclusion. War injuries result in complex bone and soft-tissue infections caused by 3-, 4-MRGN pathogens. Addressing this challenge necessitates multidisciplinary approach with multiple, thorough surgical debridements, effective local, and systemic antimicrobial therapy. As for the outlook we can see potential in local antibiotic carriers

Aim. Aim of this study was to establish the first clinical results after implantation of ultrathin silver-polysiloxane-coated. 1. plates in the treatment of infected non-union of the femoral shaft. Method. As part of the REFECT study, a prospective, non-interventional analysis was conducted encompassing all patients who received internal stabilization with a silver-coated. 1. plate from 01/2023 to 09/2024 as part of the treatment for infected non-union of the femur. Standardized clinical follow-ups including PROMs (WOMAC-Index, LEF-S, EQ-5D, VAS) and X-rays were performed 3, 6, 12 (and 24) months postoperatively. For comparison, a retrospective analysis of 76 patients with infected femoral non-union, who had received a stabilization with an uncoated plate in the past 10 years, was performed. Results. The mean follow-up of the 8 included patients (mean bone defect: 3.6 cm) was 9 months (as of 04/24). Multiresistant bacteria were found in the intraoperative samples of 5 patients. The concentration of silver ions in blood serum reached a maximum of 0.014 mg/l in the laboratory controls. All patients showed a positive healing process with no sign of re-infection and no adverse procedure-associated events. Full weight bearing was achieved after an average of 4 months (n=6) with improved WOMAC-, LEF-S-, EQ-5D and VAS-score at 1-year FU. In the reference group (uncoated, mean FU: 3.5 years), there was a re-infection rate of 25 %, mostly in the first 2 years. Difficult-to-treat bacteria were detected in 22%, multiresistant Staph. epidermidis in 28% of cases. Conclusions. -. The silver-coated. 1. implants showed good biocompatibility with no evidence of procedure-associated complications. -. The use of silver-coated. 1. implants could reduce the risk of re-infection. -. Further clinical data with longer follow-up are needed to assess the long-term value of the procedure

Aims

The Bankart and Latarjet procedures are two of the most common surgical techniques to treat anterior shoulder instability with satisfactory clinical and functional outcomes. However, the outcomes in the adolescent population remain unclear, and there is no information regarding the arthroscopic Latarjet in this population. The purpose of this study was to evaluate the outcomes of the arthroscopic Bankart and arthroscopic Latarjet procedures in the management of anterior shoulder instability in adolescents.

Introduction. The surgical treatment of critical-sized bone defects with complex three-dimensional (3D) geometries is a challenge for the treating surgeon. Additive manufacturing such as 3D printing enables the production of highly individualized bone implants meeting the shape of the patient's bone defect and including a tunable internal structure. In this study, we showcase the design process for patient-specific implants with critical-sized tibia defects. Methods. Two clinical cases of patients with critical tibia defects (size 63×20×21 mm and 50×24×17 mm) were chosen. Brainlab software was used for segmentation of CT data generating 3D models of the defects. The implant construction involves multiple stages. Initially, the outer shell is precisely defined. Subsequently, the specified volume is populated with internal structures using Voronoi, Gyroid, and NaCl crystal structures. Variation in pore size (1.6 mm and 1.0 mm) was accomplished by adjusting scaffold size and material thickness. Results. An algorithmic design process in Rhino and Grasshopper was successfully applied to generate model implants for the tibia from Ct data. By integrating a precise mesh into an outer shell, a scaffold with controlled porosity was designed. In terms of the internal design, both Voronoi and Gyroid form macroscopically homogeneous properties, while NaCl, exhibits irregularities in density and consequently, in the strength of the structure. Data implied that Voronoi and Gyroid structures adapt more precisely to complex and irregular outer shapes of the implants. Conclusion. In proof-of-principle studies customized tibia implants were successfully generated and printed as model implants based on resin. Further studies will include more patient data sets to refine the workflows and digital tools for a broader spectrum of bone defects. The algorithm-based design might offer a tremendous potential in terms of an automated design process for 3D printed implants which is essential for clinical application

Introduction. The management of pathologic fractures (PF) following osteomyelitis (especially acute subtype) has not been widely investigated. This is challenging due to the infection-induced destructive process causing bone architecture defects. Therefore, this study aims to assess a stepwise treatment plan for the acute incidence of PF in long bone following pediatric acute Hematogenous osteomyelitis(AHO) (the most common mechanism in children). Method. This case series was conducted in a tertiary pediatric center. Patients with fracture incidence within the first 10 days after AHO diagnosis were included. Patients’ characteristics were retrospectively reviewed. Result. Nine patients (7 boys, involved bone: the femur(4), tibia(3), Radius(1), and Ulna(1)) were included, with a mean age of 52.56±66.18 months (7-216) and a follow-up time of 11.62±3.61 years (6.5-16 years). The etiology in all patients was hematological(Methicillin-resistant Staphylococcus aureus). Our stepwise treatment plan was as follows:. 1. Intravenous antibiotics until ESR<20, then oral to ESR<5. 2. Debridemnt surgery was performed if abscesses were detected. 3. Fracture type determined initial fixation: external fixation (4 patients, 2 unions) or casting (2 patients, both unions). 4. If the union was not obtained, internal fixation (with (2 patients) or without (2 patients) bone graft) was applied (all obtained union). 5. Circular external fixation was applied if the union was not obtained or leg length discrepancy occurred (1 case). A mean of 3.2 surgical procedures (1-6) was required to control the infection, and 1.4 surgical procedures (0-4) were required to obtain union. Except for one patient who died of septic shock, all other patients (88.8%) reached complete recovery (average length of hospital stay of 19.2 days (5-35).), and the union was obtained (the average union time of 17.25 months(4-36)) without long-term sequelae of osteomyelitis. Conclusion. The outcome of the stepwise plan in this study suggests that acute PF following AHO in pediatrics can be managed efficiently

Aims

A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

The October 2024 Shoulder & Elbow Roundup360 looks at: Proximal humeral fractures with vascular compromise; Outcomes and challenges of revision arthroscopic rotator cuff repair: a systematic review; Evaluating treatment effectiveness for lateral elbow tendinopathy: a systematic review and network meta-analysis; Tendon transfer techniques for irreparable subscapularis tears: a comparative review; Impact of subscapularis repair in reverse shoulder arthroplasty; Isolated subscapularis tears strongly linked to shoulder pseudoparesis; Nexel and Coonrad-Morrey total elbow arthroplasties show comparable revision rates in New Zealand study; 3D MRI matches 3D CT in assessing bone loss and shoulder morphology in dislocation cases.

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Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

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

Bone regeneration and repair are crucial to ambulation and quality of life. Factors such as poor general health, serious medical comorbidities, chronic inflammation, and ageing can lead to delayed healing and nonunion of fractures, and persistent bone defects. Bioengineering strategies to heal bone often involve grafting of autologous bone marrow aspirate concentrate (BMAC) or mesenchymal stem cells (MSCs) with biocompatible scaffolds. While BMAC shows promise, variability in its efficacy exists due to discrepancies in MSC concentration and robustness, and immune cell composition. Understanding the mechanisms by which macrophages and lymphocytes – the main cellular components in BMAC – interact with MSCs could suggest novel strategies to enhance bone healing. Macrophages are polarized into pro-inflammatory (M1) or anti-inflammatory (M2) phenotypes, and influence cell metabolism and tissue regeneration via the secretion of cytokines and other factors. T cells, especially helper T1 (Th1) and Th17, promote inflammation and osteoclastogenesis, whereas Th2 and regulatory T (Treg) cells have anti-inflammatory pro-reconstructive effects, thereby supporting osteogenesis. Crosstalk among macrophages, T cells, and MSCs affects the bone microenvironment and regulates the local immune response. Manipulating the proportion and interactions of these cells presents an opportunity to alter the local regenerative capacity of bone, which potentially could enhance clinical outcomes. Cite this article: Bone Joint Res 2024;13(9):462–473

The management of severe acetabular bone defects poses a complex challenge in revision hip arthroplasty. Although biological fixation materials are currently dominant, cage has played an important role in complex acetabular revision in the past decades, especially when a biological prosthesis is not available. The purpose of this study is to report the long-term clinical and radiographic results of Paprosky type Ⅲ acetabular bone defects revised with cage and morselized allografts. We retrospectively analyzed 45 patients who underwent revision hip arthroplasty with cage and morselized allografts between January 2007 and January 2019. Forty-three patients were followed up. There were 19 Paprosky type IIIA bone defect patients and 24 Paprosky type IIIB bone defect patients and 7 patients of the 24 were also with pelvic discontinuity. Clinical assessment included Harris Hip Score (HHS) and Short Form-12 (SF-12). Radiographic assessment included cage stability, allografts incorporation, and center of rotation. All patients were followed up with a mean follow-up of 10.6 years, HHS and SF-12 improved significantly at last follow-up in comparison to the preoperative. There were 2 re-revisions, one at 5 years after surgery, another at 13.6 years after surgery. Two patients had nonprogressive radiolucency in zone III and the junction of zone II and zone III at the bone implant interface. Allografts of 40 (93%) cases incorporated fully. The combination of cage and morselized allograft is an alternative option for acetabular revision with Paprosky type III bone defects with satisfactory long-term follow-up results

Extensive and severe bone loss of the femur may be a result of a failed total hip arthroplasty (THA) or total knee arthroplasty (TKA) with multiple revision surgeries which may be caused by factors such as infection, periprosthetic fracture or osteolysis. The aim of this study was to assess outcomes of using the “Push-Through Total Femoral Prosthesis” (PTTF) for revision of a total hip replacement with extreme bone loss. Fourteen patients who had extensive bone defects of the femur due to failed THR's and were treated with PTTF between 2012 and 2020 were included in this study. Primary functional outcomes were assessed using Harris Hip Score (HHS), Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) scores. Range of motion, complications, and ambulatory status were also recorded to assess secondary outcomes. Two of 14 patients underwent surgery with PTTF for both knee and hip arthroplasty revision. The mean time between index surgery and PTTF was 15 years (3 to 32 yrs.). Acetabular components were revised in six of 14 patients. After a mean follow-up of 5.9 years, hip dislocations occurred in 3 patients. All dislocated hips were in patients with retained non-constrained acetabular bearings. Patient satisfaction was high (MSTS: 67%, HHS: 61.2%, TESS 64.6%) despite a high re-operation rate and minor postoperative problems. PTTF is a unique alternative that may be considered for a failed THA revision procedure in patients with an extreme femoral bone defect. Patients are able to ambulate pain free relatively well. Routine usage of constrained liners should be considered to avoid hip dislocation which was our main problem following the procedure

The Paprosky acetabular bone defect classification system and related algorithms for acetabular reconstruction cannot properly guide cementless acetabular reconstruction in the presence of porous metal augments. We aimed to introduce a rim, points, and column (RPC)-oriented cementless acetabular reconstruction algorithm and its clinical and radiographic outcomes. A total of 123 patients (128 hips) were enrolled. A minimum 5-year radiographic follow-up was available for 96 (75.8%) hips. The mean clinical and radiographic follow-up durations were 6.8±0.9 (range: 5.2–9.2) and 6.3±1.9 (range: 5.0–9.2) years, respectively. Harris hip score (HHS) improved significantly from 35.39±9.91 preoperatively to 85.98±12.81 postoperatively (P<0.001). Among the fixation modes, 42 (32.8%) hips were reconstructed with rim fixation, 42 (32.8%) with three-point fixation without point reconstruction, 40 (31.3%) with three-point fixation combined with point reconstruction, and 4 (3.1%) with three-point fixation combined with pelvic distraction. Complementary medial wall reconstruction was performed in 20 (15.6%) patients. All acetabular components were radiographically stable. Nine-year cumulative Kaplan–Meier survival rates for 123 patients with the endpoint defined as periprosthetic joint infection, any reoperation, and dissatisfaction were 96.91% (confidence interval [CI]: 86.26%, 99.34%), 97.66% (CI: 92.91%, 99.24%), and 96.06% (CI: 86.4%, 98.89%), respectively. Cup stability in cementless acetabular reconstruction depends on rim or three-point fixation. The continuity of the anterior and posterior columns determines whether the points provide adequate stability to the cup. Medial wall reconstruction is an important complementary fixation method for rim or three-point fixation. The patients who underwent cementless acetabular reconstruction guided by the RPC decision-making algorithm demonstrated satisfactory mid-term clinical function, satisfaction levels, radiographic results, and complication rates

In primary total hip arthroplasty (THA) for patients with Crowe II or higher classes developmental dysplasia of the hip (DDH) or rapidly destructive coxopathy (RDC), the placement of the cup can be challenging due to superior and lateral acetabular bone defects. Traditionally, bone grafts from resected femoral heads were used to fill these defects, but bulk graft poses a risk of collapse, especially in DDH with hypoplastic femoral heads or in RDC where good quality bone is scarce. Recently, porous metal augments have shown promising outcomes in revision surgeries, yet reports on their efficacy in primary THA are limited. This study retrospectively evaluated 27 patients (30 hips) who underwent primary THA using cementless cups and porous titanium acetabular augments for DDH or RDC, with follow-up periods ranging from 2 to 10 years (average 4.1 years). The cohort included 22 females (24 hips) and 5 males (6 hips), with an average age of 67 years at the time of surgery. The findings at the final follow-up showed no radiographic evidence of loosening or radiolucency around the cups and augments, indicating successful biological fixation in all cases. Clinically, there was a significant improvement in the WOMAC score from an average of 39.1±14.7 preoperatively to 5.1±6.4 postoperatively. These results suggest that the use of cementless cups and porous titanium acetabular augments in primary THA for DDH and RDC can lead to high levels of clinical improvement and reliable biological fixation, indicating their potential as a viable solution for managing challenging acetabular defects in these conditions

The August 2024 Oncology Roundup. 360. looks at: What factors are associated with osteoarthritis after cementation for benign aggressive bone tumour of the knee joint: a systematic review and meta-analysis; Recycled bone grafts treated with extracorporeal irradiation or liquid nitrogen freezing after malignant tumour resection; Intercalary resection of the tibia for primary bone tumours: are vascularized fibula autografts with or without allografts a durable reconstruction?; 3D-printed modular prostheses for the reconstruction of intercalary bone defects after joint-sparing limb salvage surgery for femoral diaphyseal tumours; Factors influencing the outcome of patients with primary Ewing’s sarcoma of the sacrum; The significance of surveillance imaging in children with Ewing’s sarcoma and osteosarcoma; Resection margin and soft-tissue sarcomas of the extremities treated with limb-sparing surgery and postoperative radiotherapy

Aims

To systematically review the predominant complication rates and changes to patient-reported outcome measures (PROMs) following osteochondral allograft (OCA) transplantation for shoulder instability.

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In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility.

Aims

Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up.

Aims

To explore the clinical efficacy of using two different types of articulating spacers in two-stage revision for chronic knee periprosthetic joint infection (kPJI).

Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results. All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion. Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities