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The Bone & Joint Journal
Vol. 106-B, Issue 9 | Pages 1000 - 1007
1 Sep 2024
Gong T Lu M Sheng H Li Z Zhou Y Luo Y Min L Tu C

Aims

Endoprosthetic reconstruction following distal femur tumour resection has been widely advocated. In this paper, we present the design of an uncemented endoprosthesis system featuring a short, curved stem, with the goal of enhancing long-term survivorship and functional outcomes.

Methods

This study involved patients who underwent implantation of an uncemented distal femoral endoprosthesis with a short and curved stem between 2014 and 2019. Functional outcomes were assessed using the 1993 version of the Musculoskeletal Tumour Society (MSTS-93) score. Additionally, we quantified five types of complications and assessed osseointegration radiologically. The survivorship of the endoprosthesis was evaluated according to two endpoints. A total of 134 patients with a median age of 26 years (IQR 16 to 41) were included in our study. The median follow-up time was 61 months (IQR 56 to 76), and the median functional MSTS-93 was 83% (IQR 73 to 91) postoperatively.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_14 | Pages 5 - 5
23 Jul 2024
Mohammed F Jones S Mansoor Z Mehta S Rathore S Azam A
Full Access

Paget's disease of bone (PDB) is characterised by increased bone resorption and development of an erratic bone structure that is highly fragile and susceptible to fracture. In addition, altered joint biomechanics lead to arthritis, more often in the hip and pelvis, resulting in disability and a Total hip Arthroplasty (THA) may be required. THA in PDB is associated with more complications compared to normal population. There is no consensus on the type of arthroplasty that performs better in people with PDB. To our knowledge, there is no meta-analysis in literature on this rare problem.

We undertook a systematic review and meta-analysis to compare the effectiveness of cemented versus cementless THA in patients with PDB. PRISMA guidelines were followed. Search strings were generated based on Boolean operators for identification of the reference articles.

31 studies were included overall. Revision rate was lower in the cementless group compared to the cemented group (chi square=4.36, p=0.04), aseptic loosening was lesser in the cementless group compared to the cemented group (chi square=4.13, p=0.04). The type of the arthroplasty did not affect the infection rate (chi square=2.51, p=0.11), pre and post op Harris Hip Score showed statistically significant difference, but there was no difference between types of arthroplasty

We conclude that THA with uncemented components is better and provided lower revision and aseptic loosening when compared to cemented groups in patients with PDB.


Bone & Joint Research
Vol. 12, Issue 5 | Pages 331 - 338
16 May 2023
Szymski D Walter N Krull P Melsheimer O Grimberg A Alt V Steinbrueck A Rupp M

Aims

The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture.

Methods

Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching.


Bone & Joint Research
Vol. 11, Issue 2 | Pages 91 - 101
1 Feb 2022
Munford MJ Stoddart JC Liddle AD Cobb JP Jeffers JRT

Aims

Unicompartmental and total knee arthroplasty (UKA and TKA) are successful treatments for osteoarthritis, but the solid metal implants disrupt the natural distribution of stress and strain which can lead to bone loss over time. This generates problems if the implant needs to be revised. This study investigates whether titanium lattice UKA and TKA implants can maintain natural load transfer in the proximal tibia.

Methods

In a cadaveric model, UKA and TKA procedures were performed on eight fresh-frozen knee specimens, using conventional (solid) and titanium lattice tibial implants. Stress at the bone-implant interfaces were measured and compared to the native knee.


The Bone & Joint Journal
Vol. 103-B, Issue 7 | Pages 1174 - 1175
1 Jul 2021
Haddad FS


The Bone & Joint Journal
Vol. 103-B, Issue 7 Supple B | Pages 135 - 144
1 Jul 2021
Kuyl E Shu F Sosa BR Lopez JD Qin D Pannellini T Ivashkiv LB Greenblatt MB Bostrom MPG Yang X

Aims. Aseptic loosening is a leading cause of uncemented arthroplasty failure, often accompanied by fibrotic tissue at the bone-implant interface. A biological target, neutrophil extracellular traps (NETs), was investigated as a crucial connection between the innate immune system’s response to injury, fibrotic tissue development, and proper bone healing. Prevalence of NETs in peri-implant fibrotic tissue from aseptic loosening patients was assessed. A murine model of osseointegration failure was used to test the hypothesis that inhibition (through Pad4-/- mice that display defects in peptidyl arginine deiminase 4 (PAD4), an essential protein required for NETs) or resolution (via DNase 1 treatment, an enzyme that degrades the cytotoxic DNA matrix) of NETs can prevent osseointegration failure and formation of peri-implant fibrotic tissue. Methods. Patient peri-implant fibrotic tissue was analyzed for NETs biomarkers. To enhance osseointegration in loose implant conditions, an innate immune system pathway (NETs) was either inhibited (Pad4-/- mice) or resolved with a pharmacological agent (DNase 1) in a murine model of osseointegration failure. Results. NETs biomarkers were identified in peri-implant fibrotic tissue collected from aseptic loosening patients and at the bone-implant interface in a murine model of osseointegration failure. Inhibition (Pad4-/-) or resolution (DNase 1) of NETs improved osseointegration and reduced fibrotic tissue despite loose implant conditions in mice. Conclusion. This study identifies a biological target (NETs) for potential noninvasive treatments of aseptic loosening by discovering a novel connection between the innate immune system and post-injury bone remodelling caused by implant loosening. By inhibiting or resolving NETs in an osseointegration failure murine model, fibrotic tissue encapsulation around an implant is reduced and osseointegration is enhanced, despite loose implant conditions. Cite this article: Bone Joint J 2021;103-B(7 Supple B):135–144


Bone & Joint 360
Vol. 10, Issue 2 | Pages 57 - 59
1 Apr 2021
Evans JT Whitehouse MR Evans JP


The Bone & Joint Journal
Vol. 103-B, Issue 3 | Pages 522 - 529
1 Mar 2021
Nichol T Callaghan J Townsend R Stockley I Hatton PV Le Maitre C Smith TJ Akid R

Aims. The aim of this study was to develop a single-layer hybrid organic-inorganic sol-gel coating that is capable of a controlled antibiotic release for cementless hydroxyapatite (HA)-coated titanium orthopaedic prostheses. Methods. Coatings containing gentamicin at a concentration of 1.25% weight/volume (wt/vol), similar to that found in commercially available antibiotic-loaded bone cement, were prepared and tested in the laboratory for: kinetics of antibiotic release; activity against planktonic and biofilm bacterial cultures; biocompatibility with cultured mammalian cells; and physical bonding to the material (n = 3 in all tests). The sol-gel coatings and controls were then tested in vivo in a small animal healing model (four materials tested; n = 6 per material), and applied to the surface of commercially pure HA-coated titanium rods. Results. The coating released gentamicin at > 10 × minimum inhibitory concentration (MIC) for sensitive staphylococcal strains within one hour thereby potentially giving effective prophylaxis for arthroplasty surgery, and showed > 99% elution of the antibiotic within the coating after 48 hours. There was total eradication of both planktonic bacteria and established bacterial biofilms of a panel of clinically relevant staphylococci. Mesenchymal stem cells adhered to the coated surfaces and differentiated towards osteoblasts, depositing calcium and expressing the bone marker protein, osteopontin. In the in vivo small animal bone healing model, the antibiotic sol-gel coated titanium (Ti)/HA rod led to osseointegration equivalent to that of the conventional HA-coated surface. Conclusion. In this study we report a new sol-gel technology that can release gentamicin from a bioceramic-coated cementless arthroplasty material. In vitro, local gentamicin levels are in excess of what can be achieved by antibiotic-loaded bone cement. In vivo, bone healing in an animal model is not impaired. This, thus, represents a biomaterial modification that may have the potential to protect at-risk patients from implant-related deep infection. Cite this article: Bone Joint J 2021;103-B(3):522–529


Bone & Joint Open
Vol. 2, Issue 1 | Pages 48 - 57
19 Jan 2021
Asokan A Plastow R Kayani B Radhakrishnan GT Magan AA Haddad FS

Cementless knee arthroplasty has seen a recent resurgence in popularity due to conceptual advantages, including improved osseointegration providing biological fixation, increased surgical efficiency, and reduced systemic complications associated with cement impaction and wear from cement debris. Increasingly younger and higher demand patients are requiring knee arthroplasty, and as such, there is optimism cementless fixation may improve implant survivorship and functional outcomes.

Compared to cemented implants, the National Joint Registry (NJR) currently reports higher revision rates in cementless total knee arthroplasty (TKA), but lower in unicompartmental knee arthroplasty (UKA). However, recent studies are beginning to show excellent outcomes with cementless implants, particularly with UKA which has shown superior performance to cemented varieties. Cementless TKA has yet to show long-term benefit, and currently performs equivalently to cemented in short- to medium-term cohort studies. However, with novel concepts including 3D-printed coatings, robotic-assisted surgery, radiostereometric analysis, and kinematic or functional knee alignment principles, it is hoped they may help improve the outcomes of cementless TKA in the long-term. In addition, though cementless implant costs remain higher due to novel implant coatings, it is speculated cost-effectiveness can be achieved through greater surgical efficiency and potential reduction in revision costs. There is paucity of level one data on long-term outcomes between fixation methods and the cost-effectiveness of modern cementless knee arthroplasty.

This review explores recent literature on cementless knee arthroplasty, with regards to clinical outcomes, implant survivorship, complications, and cost-effectiveness; providing a concise update to assist clinicians on implant choice.

Cite this article: Bone Jt Open 2021;2(1):48–57.


The Bone & Joint Journal
Vol. 102-B, Issue 8 | Pages 965 - 966
1 Aug 2020
Haddad FS Plastow R


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1292 - 1299
1 Oct 2019
Masters J Metcalfe D Parsons NR Achten J Griffin XL Costa ML

Aims

This study explores data quality in operation type and fracture classification recorded as part of a large research study and a national audit with an independent review.

Patients and Methods

At 17 centres, an expert surgeon reviewed a randomly selected subset of cases from their centre with regard to fracture classification using the AO system and type of operation performed. Agreement for these variables was then compared with the data collected during conduct of the World Hip Trauma Evaluation (WHiTE) cohort study. Both types of surgery and fracture classification were collapsed to identify the level of detail of reporting that achieved meaningful agreement. In the National Hip Fracture Database (NHFD), the types of operation and fracture classification were explored to identify the proportion of “highly improbable” combinations.


The Bone & Joint Journal
Vol. 101-B, Issue 7_Supple_C | Pages 108 - 114
1 Jul 2019
Ji G Xu R Niu Y Li N Ivashkiv L Bostrom MPG Greenblatt MB Yang X

Aims

It is increasingly appreciated that coordinated regulation of angiogenesis and osteogenesis is needed for bone formation. How this regulation is achieved during peri-implant bone healing, such as osseointegration, is largely unclear. This study examined the relationship between angiogenesis and osteogenesis in a unique model of osseointegration of a mouse tibial implant by pharmacologically blocking the vascular endothelial growth factor (VEGF) pathway.

Materials and Methods

An implant was inserted into the right tibia of 16-week-old female C57BL/6 mice (n = 38). Mice received anti-VEGF receptor-1 (VEGFR-1) antibody (25 mg/kg) and VEGF receptor-2 (VEGFR-2) antibody (25 mg/kg; n = 19) or an isotype control antibody (n = 19). Flow cytometric (n = 4/group) and immunofluorescent (n = 3/group) analyses were performed at two weeks post-implantation to detect the distribution and density of CD31hiEMCNhi endothelium. RNA sequencing analysis was performed using sorted CD31hiEMCNhi endothelial cells (n = 2/group). Osteoblast lineage cells expressing osterix (OSX) and osteopontin (OPN) were also detected with immunofluorescence. Mechanical pull-out testing (n = 12/group) was used at four weeks post-implantation to determine the strength of the bone-implant interface. After pull-out testing, the tissue attached to the implant surface was harvested. Whole mount immunofluorescent staining of OSX and OPN was performed to determine the amount of osteoblast lineage cells.


The Bone & Joint Journal
Vol. 101-B, Issue 6_Supple_B | Pages 62 - 67
1 Jun 2019
Tanzer M Chuang PJ Ngo CG Song L TenHuisen KS

Aims

The purpose of this study was to evaluate the biological fixation of a 3D printed porous implant, with and without different hydroxyapatite (HA) coatings, in a canine model.

Materials and Methods

A canine transcortical model was used to evaluate the characteristics of bone ingrowth of Ti6Al4V cylindrical implants fabricated using laser rapid manufacturing (LRM). At four and 12 weeks post-implantation, we performed histological analysis and mechanical push-out testing on three groups of implants: a HA-free control (LRM), LRM with precipitated HA (LRM-PA), and LRM with plasma-sprayed HA (LRM-PSHA).


The Bone & Joint Journal
Vol. 100-B, Issue 8 | Pages 1087 - 1093
1 Aug 2018
Barenius B Inngul C Alagic Z Enocson A

Aims

The aim of this study was to compare the functional and radiological outcomes in patients with a displaced fracture of the hip who were treated with a cemented or a cementless femoral stem.

Patients and Methods

A four-year follow-up of a randomized controlled study included 141 patients who underwent surgery for a displaced femoral neck fracture. Patients were randomized to receive either a cemented (n = 67) or a cementless (n = 74) stem at hemiarthroplasty (HA; n = 83) or total hip arthroplasty (THA; n = 58).


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_10 | Pages 33 - 33
1 Jun 2018
Callaghan J
Full Access

Successful nonarthroplasty solutions for the treatment of osteonecrosis of the femoral head continued to be sought. However, no definitive nonarthroplasty solutions have to date been found. Hence, even in the best of hands a large number of patients with osteonecrosis end up with debilitating end-stage osteoarthritis. In the inception of total hip arthroplasty (THA), the results of treatment of femoral head osteonecrosis by THA were inferior to total hip replacement performed for osteoarthritis. Reasons for this included the young age of many osteonecrosis patients, the high numbers of comorbidities in this population (SLE, sickle cell anemia, alcoholism), and the poor bone quality at the time of surgery. Arthroplasty considerations included bipolar replacement, hemiresurfacing, resurfacing (non metal-on-metal and later metal-on-metal), cemented total hip arthroplasty and cementless total hip arthroplasty. Previous to the use of cementless arthroplasty, all of these procedures had a relatively high 5 to 10 year failure rate of 10–50%. Even our own 10-year results using contemporary cementing techniques demonstrated 10% failure compared to 1–2% failure in our nonosteonecrosis patients. For this reason, it made sense to continue exploring nonarthroplasty solutions for osteonecrosis of the hip. The introduction of cementless fixation for total hip arthroplasty changed the entire thinking about hip osteonecrosis treatment for many of us. Although initially we were concerned about whether bone would grow into the prosthesis in the environment of relatively poor bone, the early results demonstrated that it can and does. Most recently, with the use of crosslinked polyethylene, the cementless construct gives many of us hope that with cementless fixation, the treatment of many patients including the young (especially if followed closely to exchange bearing surfaces if necessary) will last a lifetime with THA being the only and definitive procedure. Our most recent 10-year results demonstrated a femoral stem revision rate of 1.5% will all other stems (other than the stem revised) bone ingrown. Acetabular fixation was also 100% and although 6% required liner exchange, our own and others' results with crosslinked polyethylene would suggest that this problem should be markedly reduced


Bone & Joint Research
Vol. 7, Issue 5 | Pages 357 - 361
1 May 2018
Shin T Lim D Kim YS Kim SC Jo WL Lim YW

Objectives

Laser-engineered net shaping (LENS) of coated surfaces can overcome the limitations of conventional coating technologies. We compared the in vitro biological response with a titanium plasma spray (TPS)-coated titanium alloy (Ti6Al4V) surface with that of a Ti6Al4V surface coated with titanium using direct metal fabrication (DMF) with 3D printing technologies.

Methods

The in vitro ability of human osteoblasts to adhere to TPS-coated Ti6Al4V was compared with DMF-coating. Scanning electron microscopy (SEM) was used to assess the structure and morphology of the surfaces. Biological and morphological responses to human osteoblast cell lines were then examined by measuring cell proliferation, alkaline phosphatase activity, actin filaments, and RUNX2 gene expression.


The Bone & Joint Journal
Vol. 99-B, Issue 5 | Pages 666 - 673
1 May 2017
Werthel J Lonjon G Jo S Cofield R Sperling JW Elhassan BT

Aims

In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder.

Patients and Methods

All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_3 | Pages 69 - 69
1 Feb 2017
Kim J Cho H
Full Access

Purpose. We evaluated the clinical and radiographic outcomes of cementless bipolar hemiarthroplasty using rectangular cross-section stem for femoral neck fracture in elderly patients more than 80 years of age with osteoporosis. Material and Methods. 76(cemented 46, cementless 30) bipolar hemiarthroplasties for femur neck fracture were performed in elderly patients more than 80 years old. The mean follow-up period was 4.3 years (2 to 7 years). The Harris hip score at last follow-up and pre-postoperative daily living activity scale according to Kitamura methods were analyzed clinically. The radiological results were assessed using stability of femoral stem and other complications were evaluated. Results: At last follow-up, there were no significant differences of Harris hip score and daily living activity between two groups. Stem loosening and instability were not observed in cementless arthroplasty. There were 18 cases of osseous fixation in radiologic study. There were 1 case of dislocation and 1 case of superficial infection in cemented arthroplasty and 1 case of deep infection in cementless arthroplasty. Conclusion. Cementless bipolar hemiarthroplasty using rectangular cross-section stem for elderly patients with a femoral neck fracture showed satisfactory short-term clinical and radiological results compared to using cement stem


The Bone & Joint Journal
Vol. 98-B, Issue 7 | Pages 865 - 866
1 Jul 2016
Haddad FS


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_10 | Pages 35 - 35
1 May 2016
Shin T Kang K Park S Kwon S Lim Y Lim D
Full Access

Introduction. Cementless arthroplasty has been widely used for younger patients with osteoarthritis and other joint pathology. Cementless arthroplasty will be required to porous surface which is to similar to the trabecular bone for bone ingrowth. Titanium Plasma Spray (TPS) has been worldwide used for the porous coating method on arthroplasty. However, TPS coating is limited that would not to establish optimal porosity for bone ingrowth due to arbitary position of melted powder by plasma gas on substrate. Therefore, it is reported coating detached from its substrate (i.e. arthroplasty) is induced implant loosening. Thus, a novel Laser-aided Direct Metal Tooling (DMT) based on Additive Manufacturing (AM) was developed to overcome these limitations. In this study, we were done to assess stereological analysis, static tensile, shear, abrasion test, and physical analysis for evaluation of the efficacy of DMT which was newly-developed coating technology. Then, mechanical characteristics of DMT coating were compared to commercial TPS coating's. Materials and Methods. First, porosity of the DMT coating was evaluated using Microphotography and Scanning Electron Microscopy (SEM), as described in Figure 1. Static tensile and shear test for assessment of mechanical characteristic in relation to the DMT and TPS coating specimens were conducted on the basis of ASTM F1147 and F1044 using universal testing machine (Endolab®, Servohydraulic Test Frame, DE). Maximum tensile strength and maximum shear strength were evaluated for each specimen (n=5). Abrasion test was performed based on ASTM F1978 using Taber® Rotary Platform Abraser Model 5135 (TABER®Industries, USA). Abrasion losses for each specimen (n=6) were measured at 2, 5, 10, and 100 cycles, respectively. Results. Porosity of the DMT coating was found to be 64 ± 11%. Maximum tensile strength (mean ± SD) of the DMT coating (48.6 ± 4.3 MPa) was lower than TPS's (51.5 ± 11.6 MPa) about 5.6%, but detached position of one of the TPS specimens was observed at coating layer not in adhesive layer. Maximum shear strength of the DMT coating (46.3 ± 1.9 MPa) was 10.2% higher, compared to TPS's (42.0 ± 0.6 MPa). Abrasion losses of the DMT (2 cycles, 1.0 ± 0.5 mg; 5 cycles, 2.5 ± 0.9 mg; 10 cycles, 4.2 ± 0.7 mg; 100 cycles, 20 ± 1.4 mg) were significantly higher (71.9% – 77.8% higher) than that of TPS's (2 cycles, 4.5 ± 1.4 mg; 5 cycles, 9.8 ± 2.8 mg; 10 cycles, 17.0 ± 3.4 mg; 100 cycles, 71.1 ± 4.2 mg), as shown in Figure 2. Roughness of the DMT coating was Ra 62.5 ± 2 μm, Rz 316.1 ± 8.1 μm which were 33.5%, 40.6% (Ra, Rz sequence) higher than that of TPS coating (Ra 46.8 ± 8.9 μm, Rz 224.9 ± 28.8 μm), as shown in Figure 3. Conclusions. Our results suggested that a novel DMT coating technology was feasible to apply coating method on the surface of the arthroplasty in terms of outstanding mechanical characteristics which were compared to commercial TPS coating