Aims

The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

Aims

The aim of this study was to assess the clinical and radiological results of patients who were revised using a custom-made triflange acetabular component (CTAC) for component loosening and pelvic discontinuity (PD) after previous total hip arthroplasty (THA).

Abstract. Background. Scaphoid non-union can result in pain, altered wrist kinematics leading to a Scaphoid Non-union Advance Collapse, ultimately to symptomatic radio-carpal arthritis. Open techniques have their limitations. We describe the rationale, surgical technique and outcomes of our series of arthroscopic bone-grafting (ABG) and fixation of scaphoid non-union. Methods. We performed a prospective single-surgeon series of 22 consecutive patients with clinico-radiologically established scaphoid non-union between March 2015 and April 2019. Data was collected from Electronic Patient Records, Patient Archived Computer system (PACS) and hand therapy assessments. We collected demographic data including age, hand-dominance, occupation and mechanism of injury. The Disabilities of the Arm, Shoulder and Hand Score (Quick DASH), Mayo wrist score, Patient Rated Wrist Evaluation (PRWE) and grip-strength measurements were collected preoperatively and at follow-up appointments. Results. There was an improvement in all outcome measures when comparing preoperative and postoperative results. The Quick DASH score improved by a mean of 24 points, Mayo wrist and PRWE scores improved by 15.1 and 29.7 points, respectively. Grip-strength analysis also improved by 6.1 kgf (Right) and 3.3kgf (Left). Follow-up computerised tomography scans revealed union in 18/22 patients with 2 patients lost to follow-up. One patient required revision ABG procedure to achieve union. Conclusion. Arthroscopic bone grafting and fixation of scaphoid non-union allows a minimally invasive method of managing these injuries. It has advantages of minimal morbidity and accurate articular reduction resulting in less postoperative stiffness and increased functional outcomes. It is an effective alternative to conventional open treatment of established scaphoid non-union

Aims

Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery.

Aims

Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Aim. Post traumatic distal tibia osteomyelitis (DTOM) with an upper ankle joint involvement is a serious complication after primary osteosynthesis and can be a nightmare for the patient and the surgeon as well. Our aim was to identify mayor complications during treatment and to find the way to prevent or treat them. Method. It is a retrospective analysis of eight patients with DTOM and an upper ankle joint involvement treated in our institution from 2012 to 2018. The average size of a bone defect after a debridement was 9 centimeters (4–15). Patients were treated in two stages. First stage was segmental bone resection, external fixation and soft tissue envelope reconstruction if necessary. At second stage a distraction frame was applied and proximal corticotomy performed. In all but one case a circular frame was used. Results. We have had one major intra-operative complication, an injury of arteria tibialis posterior during the corticotomy procedure. Except in one patient we did not observe major problems with pin-track infections. Despite bone-grafting in all patients, we observed three nonunions of docking site. We treated them by external fixator in two and retrograde intramedullar nail in one case. In two patient the distraction callus was weak. We had to bone graft and secure the callus with a plate in one and use a retrograde reamed intramedullar nail in second patient. We have observed two callus fracture after removal of the frame. A surgery was needed for both because of the deformation. The first patient was treated by new external frame, the second by retrograde reamed intramedullar nail. Conclusions. Callus distraction is a valuable option to treat a bone defect. The procedure has many possible problems and complications, especially during treatment of defects larger than six centimeters. It is very difficult for patients to tolerate a frame more than one year. We have found the use of an intramedullar tibial nail inserted in a retrograde way as a helpful option not just to shorten the time of external frame, but in combination with reaming also to accelerate the healing of the distraction callus and the upper ankle joint arthrodesis as well

Severe glenoid bone loss in patients with osteoarthritis with intact rotator cuff is associated with posterior glenoid bone loss and posterior humeral subluxation. Management of severe glenoid bone loss during shoulder arthroplasty is controversial and technically challenging and options range from humeral hemiarthroplasty, anatomic shoulder replacement with glenoid bone grafting or augmented glenoid component implantation, to reverse replacement with reaming to correct version or structural bone grafting or metallic augmentation of the bone deficiency. Shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complications and revisions. Hemiarthroplasty has limited benefit for pain relief and function especially if eccentric glenoid wear exists. Bone loss with >15 degrees of retroversion likely requires version correction include bone-grafting, augmented glenoid components, or reverse total shoulder replacement. Asymmetric reaming may improve version but is limited to 15 degrees of version correction in order to preserve subchondral bone and glenoid bone vault depth. Bone-grafting of glenoid wear and defects has had mixed results with graft-related complications, periprosthetic radiolucent lines, and glenoid component failure of fixation. Implantation of an augmented wedge or step polyethylene glenoid component improves joint version while preserving subchondral bone, but is technically demanding and with minimal short term clinical follow-up. A Mayo study demonstrated roughly 50% of patients with posteriorly augmented polyethylene had radiolucent lines and 1/3 had posterior subluxation. Another wedge polyethylene design had 66% with bone ingrowth around polyethylene fins at 3 years. Long term outcomes are unknown for these new wedge augmented glenoid components. Reverse shoulder arthroplasty avoids many risks of anatomic replacement glenoid component fixation and stability but is associated with a high complication rate (15%) including neurologic and baseplate loosening and often requires structural bone grafting behind the baseplate with suboptimal outcomes or metallic augmented baseplates with limited evidence and short term outcomes. Reverse replacement with baseplate bone grafting or metal augmentation is technically challenging due to limited native glenoid bone stock available for baseplate component ingrowth and long term fixation. Failure to correct glenoid superior inclination and restore neutral version within 10 degrees increases the risks of reverse baseplate failure of fixation, pull out, and failure of reverse replacement. Reverse baseplate failure rates in patients with severe glenoid bone loss and concomitant glenoid bone grafting range from 5–11%. The minimum native glenoid bony contact with the baseplate is unknown but likely is approximately 1cm of native bone contacting a central ingrowth post and a minority (∼15–25%) of native glenoid contacting the backside of the baseplate. Failure to correct posterior bone loss can lead to retroversion of the baseplate, reduced external rotation, posterior scapular notching, and posteromedial polyethylene wear. In summary, shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complication and revision

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.

Osteonecrosis of the femoral head (ONFH) is a debilitating, painful, progressive, and refractory disease that has multiple etiologic risk factors. It is caused by bone cell death, which itself has various causes, leading to femoral head collapse and subsequent osteoarthritis. ONFH primarily influences patients aged from 20 to 50 years; in addition, bilateral hip joints are involved in 75% of patients. Causes include use of corticosteroids, alcohol abuse, previous trauma, hemoglobinopathy, Gaucher disease, coagulopathies, and other diseases. No pharmacologic treatment has been shown to be effective for early ONFH. Outcomes of total hip arthroplasty (THA) for these young and active patients have some drawbacks, primarily due to the young age of these patients, limited lifetime and durability of the implants and their fixation, and the skeletal manifestations of osteonecrosis. As a result of these concerns, there has been an increased focus on early interventions for ONFH aimed at preservation of the native articulation. Core decompression is currently the most widely accepted surgical treatment at the early stage of avascular osteonecrosis (AVN); however, due to limited efficacy, its use has been debated. There is currently no standardised protocol for evaluating and treating osteonecrosis of the femoral head in adults in the United States. Although total hip replacement is the most frequent intervention for treatment of post-collapse (Steinberg stage-IIIB, IVB, V, and VI) osteonecrosis; core decompression is the most commonly offered intervention for symptomatic, pre-collapse (Steinberg stage-IB and IIB) osteonecrosis. Less frequently offered treatments include non-operative, pharmacologic or modality management, osteotomy, vascularised and non-vascularised bone-grafting, hemiarthroplasty, resurfacing and arthrodesis. A promising, minimally invasive, core decompression procedure combined with a mesenchymal stem cell grafting technique which restores vascularity and heals osteonecrotic lesions has become popularised. This procedure is called a bone marrow aspirate concentrate (BMAC) procedure. During a BMAC, mesenchymal stem cells (in the form of concentrated iliac crest bone marrow) are injected through a core decompression tract into the area of necrosis in the femoral head. Most patients with early (pre-collapse) disease have excellent results at 2 to 5 years of clinical follow-up. Patients are weight bearing as tolerated on crutches after the procedure for 6 weeks, and are able to go home on the same day or next day after surgery with minimal pain. We can report on the early, promising results of 300 patients with ONFH treated with BMAC in the United States by two expert hip surgeons with at least 75%-80% survivorship. The care of adults with osteonecrosis of the femoral head is highly variable. This paper will discuss the various non-operative and operative treatment algorithms for ONFH available today. We will also report on a promising, new technique (BMAC), which improves the efficacy of traditional core decompression for early ONFH. The goal of treatment of early ONFH is to avoid THA in young, active patients and this talk will discuss those interventions and treatments which help accomplish that goal

Introduction. The optimal management of severe tibial and/or femoral bone loss in a revision total knee arthroplasty (TKA) has not been established. Reconstructive methods include structural or bulk allografts, impaction bone-grafting with or without mesh augmentation, custum prosthetic components, modular metal augmentations of prosthesis and tumor prosthesis. Recently metaphyseal fixation using porous tantalum cones (Zimmer, Warsaw, IN) has been proposed as alternative strategy for severe bone loss. Objectives. The purposes of this study were to determine the clinical and radiographic outcomes in patients who underwent revision knee arthroplasty with tantalum cones with a minimum of 5-year follow-up. Methods. From November 2005 to August 2008 a total of 26 porous tantalum metaphyseal cones were used to reconstruct severe tibial and/or femoral bone loss in 18 patients during revision TKA at a single institution. There were 12 females and 6 males with an average age of 73 years (range 55–84) at the time of revision. The mean clinical and radiographic follow-up was 6.3 years (range, 5–8). The reasons for revision were aseptic loosening (5 cases) and deep infection (13 cases). A Two stage procedure was used in all septic cases. According to the Anderson Orthopaedic Reseach Institute (AORI) bone defects classification all femoral and tibial defects were rated 2B and 3 (3 T2b, 9 T3, 3 F2b and 10 F3). A femoral cone was inserted in 6 patients, a tibial cone was inserted in 5, a double cone in 6 (femoral and tibial), and a triple cone in 1 (1 femoral and 2 tibial). A constrained condylar implant (LCCK, Zimmer, Warsaw) was inserted in 6 patients and a rotating hinge knee implants (RHK, Zimmer, Warsaw, IN) in 12 pateints. All patients were prospectively followed for clinical and radiographic evaluation preoperatively and postoperatively at 1, 3, 6 months, one year and yearly thereafter. Results. Knee Society knee scores improved from a mean of 31.3 points before surgery to 76.7 points at latest followup (p < 0.001). Knee Society function scores improved from a mean of 21.7 points before surgery to 65.4 points at latest followup (p < 0.001). The average flexion contracture was 6° and the average flection was 88°. At the time of the latest follow-up the average flexion contraction was 3° and the average flexion was 105°. No radiolucent lines were seen between the cones and the adjacent tibial and femoral bone at the latest follow-up. There was no evidence of loosening or migration of any implant at the time of the final follow-up. There have been two reoperations for recurrent infection (11%). Conclusions. Our experience demonstrates excellent clinical and radiographic mid-term outcomes and confirms that metaphyseal fixation with porous tantalum cones can be achieved. Long-term follow up and comparative studies are necessary

Massive bone loss on both the femur and tibia during revision total knee arthroplasty (TKA) remains a challenging problem. Multiple solutions have been proposed for small osseous defects, including morselised cancellous bone grafting, small-fragment structural allograft, thicker polyethylene inserts, and the use of modular augments attached to revision prosthetic designs. Large osseous defects can be treated with structural allografts, impaction bone-grafting with or without mesh augmentation, custom prosthetic components, and specialised hinged knee components. The metaphyseal area of the distal femur and proximal tibia is a particularly attractive option during revision TKA given that it is usually undamaged and well-vascularised. While multiple reconstructive options have been recommended, porous tantalum metaphyseal cones have the advantage of improved biologic fixation because of their high porosity (75–80%), interconnected pore space, and low modulus of elasticity (3 MPa) similar to that of cancellous bone. Such features allow tantalum cones to fill bone defects while tolerating physiological loads. Indications for porous tantalum metaphyseal cones include patients with Anderson Orthopaedic Research Institute Type 2B or greater defects. The surgical technique is simpler than structural allograft reconstructions with decreased preparation time, resulting in a possible decrease in infection rates. The modularity of porous tantalum metaphyseal cones also allows the surgeon to choose a size and position that best fits the individual defect encountered. Moreover, tantalum cones can be used with several revision systems. Short-term clinical follow up indicates that porous tantalum metaphyseal cones effectively provide structural support with the potential for long-term biologic fixation and durable reconstructions

The February 2014 Oncology Roundup³⁶⁰ looks at: suspicious lesions; limb salvage in pelvic sarcomas; does infection affect oncological survival?; cancer patient pathways; radiological arthritis with cement augmentation in GCT; and post-chemotherapy increase in tumour volume as a predictor of poor prognosis.

Despite the worldwide usage of the cemented Contemporary acetabular component (Stryker), no published data are available regarding its use in patients aged < 50 years. We undertook a mid- to long-term follow-up study, including all consecutive patients aged < 50 years who underwent a primary total hip replacement using the Contemporary acetabular component with the Exeter cemented stem between January 1999 and January 2006. There were 152 hips in 126 patients, 61 men and 65 women, mean age at surgery 37.6 years (16 to 49 yrs). One patient was lost to follow-up.

Mean clinical follow-up of all implants was 7.6 years (0.9 to 12.0). All clinical questionnaire scores, including Harris hip score, Oxford hip score and several visual analogue scales, were found to have improved. The eight year survivorship of all acetabular components for the endpoints revision for any reason or revision for aseptic loosening was 94.4% (95% confidence interval (CI) 89.2 to 97.2) and 96.4% (95% CI 91.6 to 98.5), respectively. Radiological follow-up was complete for 146 implants. The eight year survival for the endpoint radiological loosening was 93.1% (95% CI 86.2 to 96.6). Three surviving implants were considered radiologically loose but were asymptomatic. The presence of acetabular osteolysis (n = 17, 11.8%) and radiolucent lines (n = 20, 13.9%) in the 144 surviving cups indicates a need for continued observation in the second decade of follow-up in order to observe their influence on long-term survival.

The clinical and radiological data resulting in a ten-year survival rate > 90% in young patients support the use of the Contemporary acetabular component in this specific patient group.

Cite this article: Bone Joint J 2013;95-B:1617–25.

We analysed the outcome of patients with primary non-metastatic diaphyseal sarcomas who had en bloc resection with preservation of the adjoining joints and reconstruction with re-implantation of sterilised tumour bone after extracorporeal radiation (50 Gy). Between March 2005 and September 2009, 32 patients (16 Ewing’s sarcoma and 16 osteogenic sarcoma) with a mean age of 15 years (2 to 35) underwent this procedure. The femur was the most common site in 17 patients, followed by the tibia in 11, humerus in three and ulna in one. The mean resected length of bone was 19 cm (10 to 26). A total of 31 patients were available at a mean follow-up of 34 months (12 to 74). The mean time to union for all osteotomy sites was 7.3 months (3 to 28): metaphyseal osteotomy sites united quicker than diaphyseal osteotomy sites (5.8 months (3 to 10) versus 9.5 months (4 to 28)). There were three local recurrences, all in soft-tissue away from irradiated graft. At the time of final follow-up, 19 patients were free of disease, one was alive with disease and 11 had died of disease. The mean Musculoskeletal Tumor Society Score for 29 patients evaluated at the last follow-up was 26 (9 to 30).

Extracorporeal irradiation is an oncologically safe and inexpensive technique for limb salvage in diaphyseal sarcomas and has good functional results.

The purpose of this prospective study was to evaluate the long-term clinical and radiological outcomes of revision of the femoral component of a total hip replacement using impaction bone grafting. Femoral revision with an impacted allograft was performed on 29 patients (31 hips). In all, 21 hips (68%) had grade III or IV femoral defects according to the Endo-Klinik classification. A total of 11 patients (12 hips) died before the ten-year follow-up period. Of the remaining patients, 18 patients (19 hips) were followed for 10 to 15 years; three further patients died during this time. None of the 31 stems underwent further revision of their stem. However, four stems showed extensive subsidence (> 15 mm). One of these patients had a femoral fracture that required fixation. Three other patients had a femoral fracture, two of which required fixation and the other was treated conservatively. Patients with a femoral fracture and/or severe subsidence had significantly more grade IV defects (six of seven hips; p = 0.004). One patient needed a closed reduction for dislocation.

Impaction allografting in revision hip surgery gives good long-term results for femora with grades I, II and III Endo-Klinik-classified defects. Extensive subsidence and femoral fractures were seen mainly in patients with grade IV damaged femora.

Posterior lumbar interbody fusion (PLIF) is indicated for many patients with pain and/or instability of the lumbar spine. We performed 36 PLIF procedures using the patient’s lumbar spinous process and laminae, which were inserted as a bone graft between two vertebral bodies without using a cage. The mean lumbar lordosis and mean disc height to vertebral body ratio were restored and preserved after surgery. There were no serious complications.

These results suggest that this procedure is safe and effective.

In revision total hip arthroplasty (THA), it is essential to cope with the bone stock loss. The acetabular bone loss is reconstructed by bulk bone grafts, bone chips, bone cement or jumbo cup. The impaction bone-grafting (IBG) technique is a technique that can restore acetabular bone loss, while enough bone allografts are not easy to obtain and the quality is not always sufficient. Thus we mixed hydroxyapatite (HA) granules into bone chips to supplement the volume and the mechanical strength of allografts. To investigate the dynamic migration of cemented cup fixed with IBG, we made acetabular bone defect models and the migration of the cup was traced by a high-speed photography camera. Composite test blocks were used as synthetic acetabulum models. A hemisphere defect of 60mm in diameter was made. We tested 4 different bone/HA ratio; 100%/0%, 75%/25%, 50%/50% and 0%/100%. Each group consisted of 6 specimens. The grafted materials were impacted using impactors. Then, a 46 mm polyethylene cup was fixed with bone cement. The specimens were clamped to the MTS mechanical tester at an angle of 20 degrees. A dynamic load of 150 N to 1500 N with a frequency of 1 Hz was applied for 15 minutes, followed by a dynamic load of 300 N to 3000 N for the same time period. Then the load was released for 15 minutes. The cup migration was traced by the camera during loading and releasing. This camera captures 15 images per second thus it enables us to trace the migration of the cup during cyclic loading. The cup migration at the end of 3000N loading was measured. Elastic recoil was defined as the difference between the migration at the end of 3000N loading and that when the load reached to 0N. Visco-elastic recoil was defined as the difference between the migration at the release of loading and that after 15 minutes. Data were investigated by Pearson’s correlation coefficient test. A strong negative correlation (r = −0.71) was observed significantly between the amount of the migration and bone/HA ratio. In elastic recoil, statistically significant correlation was (r = −0.55) observed. In visco-elastic recoil, there is no correlation between the amounts of the visco-elastic recoil and bone/HA ratio. In the reconstruction of bone defects, initial stability of the cup is a first step to expect the long term survival. The initial stability depends on the mechanical properties of the grafted materials. To supplement the volume and mechanical strength of bone allografts, we added HA granules to the bone chips. In the current study, the cup migration was smaller by adding HA granules. Elastic recoil was affected, while visco-elastic recoil was not affected. These results indicated that the mixture of HA granules to bone chips stabilized the cup during loading period and load releasing period

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.

Introduction: Osteochondral lesions of the talus (OCL III–IV°) need both extensive debridement for revitalisation and osteochondral reconstruction of the joint surface. This can be achieved by autologous cancellous bone-grafting and combination with a cell-free bioresorbable collagen-I/III scaffold. Our first results with this technique are presented. Methods: 25 patients (13 female, 12 male, mean age 30.9 years) with 26 osteochondral lesions of the talus (OCL III–IV°, 15 right, 11 left, 24 medial, 2 lateral, 1 bilateral case) were treated by minimal-invasive debridement, autologous cancellous bone-grafting and application of a porcine collagen-I/III scaffold (ChondroGide. ®. ) and evaluated prospectively by clinical scoring and MRI. The average follow-up was 23.2 (6–36) months. The mean defect size was 2.0 cm. 2. , the mean depth 0.7 cm. 14 defects have had at least one (1–3) operation on the defect before. By the use of a distractor a malleolar osteotomy could be avoided in all cases. Results: The AOFAS-score increased from 67.4 ± 12.2 to 89.5 ± 7.4 points (p< 0.01, t-test). On a visual 10-point scale pain decreased significantly from 6.2 to 1.7 while subjective ankle function improved from a mean of 4.4 ± 1.9 to 7.2 ±1.5. The results were rated excellent in 10/26 cases (38.4%), good in 14/26 (53.8) and fair in 2/26 (7.8%) cases. MRI follow-ups showed a complete or nearly complete defect filling. In two ankles a second-look arthroscopy unveiled the defects filled completely by a regenerative tissue with a smooth surface and good bonding. Full-core biopsies showed a mixed, mostly fibrocartilagenous tissue. Conclusion: By combination of cancellous bone-grafting with a cell-free collagen-I/III scaffold typical osteochondral lesions of the talus can be adressed effectively in a minimal-invasive one-step procedure. By utilizing mesenchymal stem cells (MSC) for an autogenous reparation process the use of expensive cultured chondrocytes is not necessary. The results concerning clinical functional improvement, pain reduction and patients’ satisfaction as well as defect filling in MRI are promising