Aims. The purpose of this systematic review was to determine the rates of union for vascularized versus non-vascularized grafting techniques in the operative management of scaphoid nonunion. Secondary aims were to determine the effect of the fixation techniques used, the source of grafting, as well as the influence of fracture location (proximal pole) and avascular necrosis (AVN). Methods. A search of PubMed, MEDLINE, and Embase was performed in June 2021 using the Preferred Reporting Items for Systematic Review and Meta-Analyses statement and registered using the PROSPERO International prospective register of systematic reviews. The primary outcome was union rate. Results. There were 78 studies that met the inclusion criteria with a total of 7,671 patients (87.8% male, 12.2% female). The mean age was 27.9 years (SD 3.8) and the mean follow-up was 30.9 months (SD 25.9). The mean union rate was 88.7% (95% confidence interval (CI) 85.0 to 92.5) for non-vascularized grafts versus 87.5% (95% CI 82.8 to 92.2) for vascularized grafts (p = 0.685). Pooled analysis of trial data alone found a mean union rate of 82.4% (95% CI 66.9% to 97.9%) for non-vascularized grafts and 89.4% (95% CI 84.1% to 94.7%) for vascularized grafts (p = 0.780). No significant difference was observed in union rates between any of the fixation techniques used in the studies (p = 0.502). Distal radius and iliac crest graft source had comparable mean union rates (86.9% (95% CI 83.1 to 90.7) vs 87.6% (95% CI 82.2 to 92.9); p = 0.841). Studies that excluded patients with both proximal pole fractures and AVN (n = 14) had a mean union rate of 96.5% (95% CI 94.2 to 98.9) that was significantly greater than the mean union rate of 86.8% (95% CI 83.2 to 90.4) observed in the remaining studies (p < 0.001). Conclusion. Current evidence suggests vascularized bone grafting does not yield significantly superior results to non-vascularized grafting in scaphoid nonunion management. However, potential selection bias lessens the certainty of these findings. The fixation type or source of the graft used was not found to influence union rates either. Sufficiently designed and powered prospective randomized controlled trials in this area are needed. Cite this article: Bone Joint J 2022;104-B(5):549–558

Aims. Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures. Methods. A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout. Results. Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I. 2. = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I. 2. = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable. Conclusion. All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218–228

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. Methods. We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured. Results. Out of 37 ankles, graft incorporation was successful in 30 cases. Among the remaining seven cases, four (10.8%) exhibited cyst re-progression, so secondary bone grafting was needed. After secondary bone grafting, no further progression has been noted, resulting in an overall 91.9% success rate (34 of 37) at a mean follow-up period of 47.5 months (24 to 120). The remaining three cases (8.1%) showed implant loosening, so tibiotalocalcaneal arthrodesis was performed. Functional outcomes were also improved after bone grafting in all variables at the latest follow-up (p < 0.05). The mean incorporation rate of the grafts according to the location of the cysts was 84.8% (55.2% to 96.1%) at the medial malleolus, 65.1% (27.6% to 97.1%) at the tibia, and 81.2% (42.8% to 98.7%) at the talus. Smoking was identified as a significant predisposing factor adversely affecting graft incorporation (p = 0.001). Conclusion. Bone grafting for periprosthetic bone cysts following primary TAA is a reliable procedure with a satisfactory success rate and functional outcomes. Regular follow-up, including CT scan, is important for the detection of cyst re-progression to prevent implant loosening after bone grafting. Cite this article: Bone Joint J 2024;106-B(5):475–481

Aims. This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation. Methods. This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements. Results. Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients’ subjective pain score. No peri- or postoperative complications were encountered. Conclusion. Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946–952

4 years of follow-up study on 27 patients who had biological reverse total shoulder replacement 12 patients who had Bio-RSA by using Tonier Aequalis reversed implants with bone graft extracted from the head of humerus before humeral shaft was prepared. The average age of this group of patients is 77. The average pre-operative shoulder abduction on the affected side is 52 degrees and forward flexion of 90 degrees. Indication for surgery in all those cases are due to cuff tear. The average post-operative abduction is 90 degrees and forward flexion of 97 degrees. The average follow-up period is 9 months with a range from 4 to 18 months. Two patients from this group failed to make an improvement in the range of their shoulder movements post-operatively. 15 underwent Bio-RSA by using Delta XTEND reverse shoulder system without bone graft. The average age of this group of patients is 73. The average pre-operative shoulder abduction is 35 degrees and forward flexion of 37 degrees. Indication for surgery again in most of the cases is due to cuff tear, except one case was due to proximal humeral fracture. The average post-operative abduction is 96 degrees and forward flexion of 101 degrees. The average follow-up period is 19 months with a range of 4–42 months. Only one patient failed to make an improvement post-operatively. This is the patient who had Bio-RSA due to a proximal humeral fracture. 6 patients out of this group also had previous resurfacing which has failed in comparison to the bone graft group which none had previous resurfacing surgery. Conclusion. Overall, the average post-operative range of movements in both groups is not very significant different. Bio-RSA without bone graft seems to make a larger improvement when compared with per-operative range of motion. Howver, whether a much longer follow-up period and younger patients have an impact on the outcome is debatable

Aims. Rates of reverse total shoulder arthroplasty (rTSA) continue to grow. Glenoid bone loss and deformity remains a technical challenge to the surgeon and may reduce improvements in patients’ outcomes. However, there is no consensus as to the optimal surgical technique to best reconstruct these patients’ anatomy. This review aims to compare the outcomes of glenoid bone grafting versus augmented glenoid prostheses in the management of glenoid bone loss in primary reverse total shoulder arthroplasty. Methods. This systematic review and meta-analysis evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We performed searches of Medline (Ovid), Embase (Ovid), and PubMed from their dates of inception to January 2022. From included studies, we analyzed data for preoperative and postoperative range of motion (ROM), patient-reported functional outcomes, and complication rates. Results. A total of 13 studies (919 shoulders) were included in the analysis. The mean age of patients at initial evaluation was 72.2 years (42 to 87), with a mean follow-up time of 40.7 months (24 to 120). Nine studies with 292 rTSAs evaluated the use of bone graft and five studies with 627 rTSAs evaluated the use of augmented glenoid baseplates. One study was analyzed in both groups. Both techniques demonstrated improvement in patient-reported outcome measures and ROM assessment, with augmented prostheses outperforming bone grafting on improvements in the American Shoulder and Elbow Surgeons Score. There was a higher complication rate (8.9% vs 3.5%; p < 0.001) and revision rate among the bone grafting group compared with the patients who were treated with augmented prostheses (2.4% vs 0.6%; p = 0.022). Conclusion. This review provides strong evidence that both bone graft and augmented glenoid baseplate techniques to address glenoid bone loss give excellent ROM and functional outcomes in primary rTSA. The use of augmented base plates may confer fewer complications and revisions. Cite this article: Bone Joint J 2022;104-B(12):1334–1342

Aims. Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects. Methods. We performed a retrospective review at a single institution of patients undergoing revision THA by a single surgeon. We identified 49 consecutive patients with large acetabular defects where the biphasic BGS was applied, with no other products added to the BGS. After placement of metallic acetabular implants, the BGS was injected into the remaining bone defects surrounding the new implants. Patients were followed and monitored for functional outcome scores, implant fixation, radiological graft site remodelling, and revision failures. Results. Mean follow-up was 39.5 months (36 to 71), with a significant improvement in post-revision function compared to preoperative function. Graft site remodelling was rated radiologically as moderate in 31 hips (63%) and strong in 12 hips (24%). There were no cases of complete graft site dissolution. No acetabular loosening was identified. None of the patients developed clinically significant heterotopic ossification. There were twelve reoperations: six patients developed post-revision infections, three experienced dislocations, two sustained periprosthetic femur fractures, and one subject had femoral component aseptic loosening. Conclusion. Our series reports bone defect restoration with the sole use of a biphasic injectable BGS in the periacetabular region. We did not observe significant graft dissolution. We emphasize that successful graft site remodelling requires meticulous recipient site preparation. Cite this article: Bone Jt Open 2022;3(12):991–997

Objective. To determine differences in fracture stability and functional outcome between synthetic bone graft and allograft/autograft with internal fixation of tibia plateau metaphyseal defects. Patient & Methods. Between 2007- 2008, 84 consecutive cases of internal fixation of tibia plateaux were identified from our theater logbook. 29 patients required additional autologous, allogenic bone graft, or synthetic bone graft substitute to ensure fracture stability. 5 patients were excluded due to lost to follow up leaving a cohort of 24 patients. Hydroxyapatite calcium carbonate synthetic bone graft was utilised in 14 patients (6 male and 8 female). Allograft/autograft were utilised in the remaining 10 patients (6 male and 4 female). All 24 patients had closed fractures, classified using the AO and Schatzker classification. Roentograms at presentation, post-operatively and regular follow-up till 12 months were analysed for maintenance of reduction, early and late subsidence of the articular surface. Functional outcomes such as knee range of movement and WOMAC Knee scores were compared between groups. Results. There was no significant statistical difference between groups for post-operative joint reduction, long term subsidence, and WOMAC scores. The degree of subsidence was not related to age or fracture severity. Maintenance of knee flexion was found to be better in the allograft/autograft group (p=0.015) when compared between groups. Multivariate analysis compared graft type, fracture severity, postoperative reduction, subsidence rate, range of movement and WOMAC score. The only finding was a statistical significant (p=0.025) association with the graft type and range of movement. Conclusion. Allograft/autograft may allow better recovery of long-term flexion, possibly due to reduced inflammatory response compared with synthetic bone graft. However, all other parameters such as maintenance of joint reduction and subjective outcome measures were comparable with the use of hydroxyapatite calcium carbonate bone graft. This study shows that synthetic bone graft is a suitable option in fixation of unstable tibia plateau fractures, avoiding risk of viral disease transmission with allograft and donor site morbidity associated with autograft

Introduction. The purpose of this study was to analyse the efficacy and complications associated with the use of Calcium Sulphate synthetic bone graft in a paediatric population. There are no published articles on the use in children. Materials & Methods. A retrospective review was undertaken of the notes, microbiology, and X-Rays of 17 cases (in 15 patients) of calcium sulphate use in paediatric patients. As well as patient demographic data, data collected included indication, use of additional agents (antibiotics), return to theatre, and wound complications. Major complications were also assessed for. Results. There were 17 cases, in 15 patients, in our case series where calcium sulphate synthetic bone graft was used. The average patient age was 12.0 years (range 5 years – 17 years). Indications for use included likely infection (12), possible infection (3), and 2 elective finger cases (enchondroma and osteotomy). The humerus was the most common target site (5), followed by the femur (4), tibia (3), calcaneum (2), finger (2) and metatarsal (1) also included. There were positive intra-operative microbiology samples for eleven cases (Staphylococcus aureus and Staphylococcus epidermidis). Antibiotics were used in all cases except the elective finger surgery, and choice ranged between vancomycin, gentamicin, or a combination of both. Two patients required return to theatre for management of ongoing deep infection, although one case was later deemed to be non-infective osteomyelitis. Seven patients had undergone debridements prior to the definitive one with calcium sulphate (5 without Calcium Sulphate, 2 with Calcium Sulphate). Three patients experienced wound issues in the form of discharge/leakage, all were managed with dressings and did not require return to theatre. Conclusions. Calcium Sulphate synthetic bone graft, with addition of antibiotics, is an efficacious treatment in the paediatric population and is not associated with any major complications. Wound discharge should be observed for, and patients/parents warned about this, but only as per the adult population

Aims. The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF. Methods. The medical records from 136 patients (65 male, 71 female) with a mean age of 52.7 years (14 to 80) who underwent TES were retrospectively reviewed. The mean follow-up period was 101 months (36 to 232). Analyzed factors included incidence of IF, age, sex, BMI, history of chemotherapy or radiotherapy, tumour histology (primary or metastasis; benign or malignant), surgical approach (posterior or combined), tumour location (thoracic or lumbar; junctional or non-junctional), number of resected vertebrae (single or multilevel), anterior resection line (disc-to-disc or intravertebra), type of bone graft (autograft or frozen autograft), cage subsidence (CS), and local alignment (LA). A survival analysis of the instrumentation was performed, and relationships between IF and other factors were investigated using the Cox regression model. Results. A total of 44 patients (32.4%) developed IF at a median of 31 months (interquartile range 23 to 74) following TES. Most IFs were rod fractures preceded by a mean CS of 6.1 mm (2 to 18) and LA kyphotic enhancement of 10.8° (-1 to 36). IF-free survival rates were 75.8% at five years and 56.9% at ten years. The interval from TES to IF peaked at two to three years postoperatively and continued to occur over a period of time thereafter; the early IF-developing group had greater CS at one month postoperatively (CS1M) and more lumbar TES. CS1M ≥ 3 mm and sole use of frozen autografts were identified as independent risk factors for IF. Conclusion. IF is a common complication following TES. We have demonstrated that robust spinal reconstruction preventing CS, and high-quality bone grafting are necessary for successful reconstruction. Cite this article: Bone Joint J 2023;105-B(2):172–179

The continual cycle of bone formation and resorption is carried out by osteoblasts, osteocytes, and osteoclasts under the direction of the bone-signaling pathway. In certain situations the host cycle of bone repair is insufficient and requires the assistance of bone grafts and their substitutes. The fundamental properties of a bone graft are osteoconduction, osteoinduction, osteogenesis, and structural support. Options for bone grafting include autogenous and allograft bone and the various isolated or combined substitutes of calcium sulphate, calcium phosphate, tricalcium phosphate, and coralline hydroxyapatite. Not all bone grafts will have the same properties. As a result, understanding the requirements of the clinical situation and specific properties of the various types of bone grafts is necessary to identify the ideal graft. We present a review of the bone repair process and properties of bone grafts and their substitutes to help guide the clinician in the decision making process. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):6–9

Problems associated with allograft are well known. The addition of hydroxyapatite (HA) to allograft has various mechanical advantages, especially within revision arthroplasty. The mixing of bone and HA results in mechanical properties different from the individual parts. However, at present the changes in material properties the mix have not been fully investigated and the optimum mixing ratio not characterized. A compressive uniaxial chamber was used to investigate the change in mechanical properties occurring with the addition of HA in varying proportions to morcellised bone graft (MBG). Materials and methods. MBG was prepared using femoral heads donated from patients undergoing total hip replacement surgery using a bone mill in a standard manner. Non porous HA (npHA) was prepared using a precipitation method of Calcium Carbonate and Orthophosphoric acid. The porous HA, (pHA) is a 60% macroporosity HA commercially prepared. Chamber. The uniaxial compression chamber was a 30mm diameter, steel chamber. Holes were drilled to allow fluid drainage. Loads were applied using a 10 kN load cell. Specimens were prepared in the volumetric proportions pure HA, pure MBG, 2:1, 1:1, 1:2 ratio of MBG to HA. The samples were subjected to compressive forces of incrementally increasing loads of up to 2 KN for 60 cycles. The sample was then allowed to creep under a stress of 2 kN. MBG was also tested up to forces of 7 kN. The mechanical parameters that were examined were the stiffness of the sample at the 60th cycle, (Ec60), and creep. Statistical analysis. The different bone: HA mixes were compared by Mann Whitney U tests. The parameters analysed were the Ec60 and creep for the different mixes. All samples were also compared to MBG compacted with higher forces. Results. Apparent stiffness. The Ec60 of the MBG increased with increasing axial stress. The Ec60 of the different proportions of MBG and both npHA and pHA lay between the values of the MBG and HA individually and were significantly different from one another (p<0.05). MBG:npHA were significantly stiffer than the comparative mixes of MBG:pHA. (p<0.05). Creep rate. With increasing axial stress the creep rate for pure MBG decreased up to a precycling stress of 4 MPa. Subsequent increases in stress had no significant effect. Pure npHA and all of the mixes of MBG:npHA demonstrated significantly less creep than the comparable mixes of MBG:pHA (p=0.01). Applicability of results. The increase in apparent stiffness associated with an increase in the volume fraction of HA is accompanied by a concomitant decrease in the creep rate. Comparison of the mechanical response of the MBG at the high precycling stresses (4 - 7 MPa) to the mechanical response of the MBG:HA mixes at 3 MPa demonstrated an overlap in the mechanical response of the pure MBG at high stress and both the MBG:npHA and MBG: pHA mixes. Conclusions. Greater proportions of HA in the mix led to improvement in the mechanical response without the need for increased force of impaction. These improvements can be quantified by using a uniaxial compression test. The results raise the interesting possibility of tailoring bone graft mixtures to specific patient requirements dependent upon their weight and the quality of their bone stock

Biphasic calcium phosphate (BCP) with a characteristic needle-shaped submicron surface topography (MagnetOs) has attracted much attention due to its unique bone-forming ability which is essential for repairing critical-size bone defects such as those found in the posterolateral spine. Previous in vitro and ex-vivo data performed by van Dijk LA and Yuan H demonstrated that these specific surface characteristics drive a favorable response from the innate immune system. This study aimed to evaluate and compare the in vivo performance of three commercially-available synthetic bone grafts, (1) i-FACTOR Putty. ®. , (2) OssDsign. ®. Catalyst Putty and (3) FIBERGRAFT. ®. BG Matrix, with that of a novel synthetic bone graft in a clinically-relevant instrumented sheep posterolateral lumbar spine fusion (PLF) model. The novel synthetic bone graft comprised of BCP granules with a needle-shaped submicron surface topography (MagnetOs) embedded in a highly porous and fibrillar collagen matrix (MagnetOs Flex Matrix). Four synthetic bone grafts were implanted as standalone in an instrumented sheep PLF model for 12 weeks (n=3 bilateral levels per group; levels L2/3 & L4/5), after which spinal fusion was determined by manual palpation, radiograph and µCT imaging (based on the Lenke scale), range-of-motion mechanical testing, and histological and histomorphological evaluation. Radiographic fusion assessment determined bilateral robust bone bridging (Lenke scale A) in 3/3 levels for MagnetOs Flex Matrix compared to 1/3 for all other groups. For µCT, bilateral fusion (Lenke scale A) was found in 2/3 levels for MagnetOs Flex Matrix, compared to 0/3 for i-FACTOR Putty. ®. , 1/3 for OssDsign. ®. Catalyst Putty and 0/3 for FIBERGRAFT. ®. BG Matrix. Fusion assessment for MagnetOs Flex Matrix was further substantiated by histology which revealed significant graft resorption complemented by abundant bone tissue and continuous bony bridging between vertebral transverse processes resulting in bilateral spinal fusion in 3/3 implants. These results show that MagnetOs Flex Matrix achieved better fusion rates compared to three commercially-available synthetic bone grafts when used as a standalone in a clinically-relevant instrumented sheep PLF model

Aims. The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results. Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion. The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction. Cite this article: Bone Joint J 2024;106-B(6):613–622

Aims. Bone stock restoration of acetabular bone defects using impaction bone grafting (IBG) in total hip arthroplasty may facilitate future re-revision in the event of failure of the reconstruction. We hypothesized that the acetabular bone defect during re-revision surgery after IBG was smaller than during the previous revision surgery. The clinical and radiological results of re-revisions with repeated use of IBG were also analyzed. Methods. In a series of 382 acetabular revisions using IBG and a cemented component, 45 hips (45 patients) that had failed due to aseptic loosening were re-revised between 1992 and 2016. Acetabular bone defects graded according to Paprosky during the first and the re-revision surgery were compared. Clinical and radiological findings were analyzed over time. Survival analysis was performed using a competing risk analysis. Results. Intraoperative bone defect during the initial revision included 19 Paprosky type IIIA and 29 Paprosky type IIIB hips; at re-revision, seven hips were Paprosky type II, 27 type IIIA and 11 were type IIIB (p = 0.020). The mean preoperative Harris Hip Score was 45.4 (SD 6.4), becoming 80.7 (SD 12.7) at the final follow-up. In all, 12 hips showed radiological migration of the acetabular component, and three required further revision surgery. The nine-year cumulative failure incidence (nine patients at risk) of the acetabular component for further revision surgery was 9.6% (95% confidence interval (CI) 2.9 to 21.0) for any cause, and 7.5% (95% CI 1.9 to 18.5) for aseptic loosening. Hips with a greater hip height had a higher risk for radiological migration (odds ratio 1.09, 95% CI 1.02 to 1.17; p = 0.008). Conclusion. Bone stock restoration can be obtained using IBG in revision hip surgery. This technique is also useful in re-revision surgery; however, a better surgical technique including a closer distance to hip rotation centre could decrease the risk of radiological migration of the acetabular component. A longer follow-up is required to assess potential fixation deterioration. Cite this article: Bone Joint J 2021;103-B(3):492–499

Aims. The epiphyseal approach to a chondroblastoma of the intercondylar notch of a child’s distal femur does not provide adequate exposure, thereby necessitating the removal of a substantial amount of unaffected bone to expose the lesion. In this study, we compared the functional outcomes, local recurrence, and surgical complications of treating a chondroblastoma of the distal femoral epiphysis by either an intercondylar or an epiphyseal approach. Methods. A total of 30 children with a chondroblastoma of the distal femur who had been treated by intraregional curettage and bone grafting were retrospectively reviewed. An intercondylar approach was used in 16 patients (group A) and an epiphyseal approach in 14 (group B). Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system and Sailhan’s functional criteria. Results. At final follow-up, the mean MSTS score was 29.1 (SD 0.9) in group A and 26.7 (SD 1.5) in group B (p = 0.006). According to Sailhan’s criteria, the knee function was good and fair in 14 (87.5%) and two (12.5%) patients of group A, and eight (57.1%) and six (42.9%) patients of group B, respectively (p = 0.062). The lesion had recurred in one patient (6.2%) in group A and four patients (28.6%) in group B. Limb shortening > 1 cm was recorded in one patient (6.2%) from group A and six patients (42.8%) from group B. Joint degeneration was noted in one patient from group A and three patients from group B. Conclusion. An intercondylar approach to a chondroblastoma of the middle two-quarters of the distal femoral epiphysis results in better outcomes than a medial or lateral epiphyseal approach: specifically, better limb function, a lower rate of recurrence, and a lower rate of physeal damage and joint degeneration. Cite this article: Bone Joint J 2024;106-B(2):195–202

Aims. Glenoid bone loss is a significant problem in the management of shoulder instability. The threshold at which the bone loss is considered “critical” requiring bony reconstruction has steadily dropped and is now approximately 15%. This necessitates accurate measurement in order that the correct operation is performed. CT scanning is the most commonly used modality and there are a number of techniques described to measure the bone loss however few have been validated. The aim of this study was to assess the accuracy of the most commonly used techniques for measuring glenoid bone loss on CT. Methods. Anatomically accurate models with known glenoid diameter and degree of bone loss were used to determine the mathematical and statistical accuracy of six of the most commonly described techniques (relative diameter, linear ipsilateral circle of best fit (COBF), linear contralateral COBF, Pico, Sugaya, and circle line methods). The models were prepared at 13.8%, 17.6%, and 22.9% bone loss. Sequential CT scans were taken and randomized. Blinded reviewers made repeated measurements using the different techniques with a threshold for theoretical bone grafting set at 15%. Results. At 13.8%, only the Pico technique measured under the threshold. At 17.6% and 22.9% bone loss all techniques measured above the threshold. The Pico technique was 97.1% accurate, but had a high false-negative rate and poor sensitivity underestimating the need for grafting. The Sugaya technique had 100% specificity but 25% of the measurements were incorrectly above the threshold. A contralateral COBF underestimates the area by 16% and the diameter by 5 to 7%. Conclusion. No one method stands out as being truly accurate and clinicians need to be aware of the limitations of their chosen technique. They are not interchangeable, and caution must be used when reading the literature as comparisons are not reliable. Cite this article: Bone Jt Open 2023;4(7):478–489

Aims. The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique. Methods. We updated the outcomes of our previous study, based on 208 consecutive revisions using IBG and the X-change femoral revision system in combination with a cemented polished stem, performed in our tertiary care institute between 1991 and 2007. Kaplan-Meier survival analyses were used to determine the survival rate of the revisions with endpoint revision for any reason and aseptic loosening. Secondary outcomes were radiological loosening and patient-reported outcome measures. Results. Mean age at revision total hip arthroplasty (THA) was 64.9 years (30 to 86). The most prevalent diagnosis for the femoral revision was aseptic loosening. At review in May 2021, 81 patients (85 hips) were still alive and 118 patients (120 hips; 58%) had died. Three patients (3 hips; 1%) were lost to follow-up at 11, 15, and 16 years after surgery, respectively. Data of all deceased and lost patients were included until final follow-up. The mean follow-up was 13.4 years (0 to 28). During the follow-up, 22 re-revisions were performed. The most common reason for re-revision was infection (n = 12; 54%). The survival with endpoint re-revision for any reason was 86% (95% confidence interval (CI) 79 to 91) at 20 years and 74% (95% CI 43 to 89) at 25 years after surgery. The survival for endpoint re-revision for aseptic loosening was 97% (95% CI 91 to 99) after both 20 and 25 years. Conclusion. We conclude that femoral IBG is a valuable technique that can reconstitute femoral bone loss in the long term. After 25 years of follow-up, few re-revisions for aseptic loosening were required. Also, the overall revision rate is very acceptable at a long follow-up. This technique is especially attractive for younger patients facing femoral revisions with extensive bone loss. Cite this article: Bone Joint J 2022;104-B(9):1039–1046

Aims. To evaluate whether low-intensity pulsed ultrasound (LIPUS) accelerates bone healing at osteotomy sites and promotes functional recovery after open-wedge high tibial osteotomy (OWHTO). Methods. Overall, 90 patients who underwent OWHTO without bone grafting were enrolled in this nonrandomized retrospective study, and 45 patients treated with LIPUS were compared with 45 patients without LIPUS treatment in terms of bone healing and functional recovery postoperatively. Clinical evaluations, including the pain visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score, were performed preoperatively as well as six weeks and three, six, and 12 months postoperatively. The progression rate of gap filling was evaluated using anteroposterior radiographs at six weeks and three, six, and 12 months postoperatively. Results. The pain VAS and JOA scores significantly improved after OWHTO in both groups. Although the LIPUS group had better pain scores at six weeks and three months postoperatively, there were no significant differences in JOA score between the groups. The lateral hinge united at six weeks postoperatively in 34 (75.6%) knees in the control group and in 33 (73.3%) knees in the LIPUS group. The progression rates of gap filling in the LIPUS group were 8.0%, 15.0%, 27.2%, and 46.0% at six weeks and three, six, and 12 months postoperatively, respectively, whereas in the control group at the same time points they were 7.7%, 15.2%, 26.3%, and 44.0%, respectively. There were no significant differences in the progression rate of gap filling between the groups. Conclusion. The present study demonstrated that LIPUS did not promote bone healing and functional recovery after OWHTO with a locking plate. The routine use of LIPUS after OWHTO was not recommended from the results of our study. Cite this article: Bone Jt Open 2022;3(11):885–893

Aims. The underlying natural history of suspected scaphoid fractures (SSFs) is unclear and assumed poor. There is an urgent requirement to develop the literature around SSFs to quantify the actual prevalence of intervention following SSF. Defining the risk of intervention following SSF may influence the need for widespread surveillance and screening of SSF injuries, and could influence medicolegal actions around missed scaphoid fractures. Methods. Data on SSF were retrospectively gathered from virtual fracture clinics (VFCs) across a large Scottish Health Board over a four-year period, from 1 January 2018 to 31 December 2021. The Bluespier Electronic Patient Record System identified any surgical procedure being undertaken in relation to a scaphoid injury over the same time period. Isolating patients who underwent surgical intervention for SSF was performed by cross-referencing the unique patient Community Health Index number for patients who underwent these scaphoid procedures with those seen at VFCs for SSF over this four-year period. Results. In total, 1,739 patients were identified as having had a SSF. Five patients (0.28%) underwent early open reduction and internal fixation (ORIF). One patient (0.06%) developed a nonunion and underwent ORIF with bone grafting. All six patients undergoing surgery were male (p = 0.005). The overall rate of intervention following a SSF was 0.35%. The early intervention rate in those undergoing primary MRI was one (0.36%), compared with three in those without (0.27%) (p > 0.576). Conclusion. Surgical intervention was rare following a SSF and was not required in females. A primary MRI policy did not appear to be associated with any change in primary or secondary intervention. These data are the first and largest in recent literature to quantify the prevalence of surgical intervention following a SSF, and may be used to guide surveillance and screening pathways as well as define medicolegal risk involved in missing a true fracture in SSFs. Cite this article: Bone Jt Open 2024;5(4):312–316