When performing limb salvage operations for malignant bone tumours in skeletally immature patients, it is desirable to reconstruct the limb with a prosthesis that can be lengthened without surgery at appropriate intervals to keep pace with growth of the contra-lateral side. We have developed a prosthesis that can be lengthened non-invasively. The lengthening is achieved on the principle of electromagnetic induction. The purpose of this study was to look at our early experience with the use of the Non Invasive Distal Femoral Expandable Endoprosthesis. A prospective study of 17 skeletally immature patients with osteosarcoma of the distal femur, implanted with the prosthesis, was performed at the Royal National Orthopaedic Hospital, Stanmore. The patients were aged between 9 and 15 years (mean 12.1 years) at the time of surgery. Patients were lengthened at appropriate intervals in outpatient clinics. Patients were functionally evaluated using the Musculoskeletal Tumour Society (MSTS) Scoring System and the Toronto Extremity Severity Score (TESS). Average time from the implantation to the last follow-up was 18.2 months (range 14-30 months). The patients have been lengthened by an average of 25mm (4.25-55mm). The mean amount of knee flexion is 125 degrees. The mean MSTS score is 77% (23/30; range 11-29) and the mean TESS score is 72%. There have been two complications: one patient developed a flexion deformity of 25 degrees at the knee joint and one patient died of disseminated metastatic malignancy. The early results from patients treated using this device have been encouraging. Using this implant avoids multiple surgical procedures and general anaesthesia. This results in low morbidity, cost savings and reduced psychological trauma. We do need additional data regarding the long-term structural integrity of the prosthesis

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant.

A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed.

Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17–86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1).

These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed.

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant.

A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed.

Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17-86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1).

These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed.

Introduction and Objective

Curative resection of proximal humerus tumours is now possible in this era of limb salvage with endoprosthetic replacement considered as the preferred reconstructive option. However, it has also been linked with mechanical and non-mechanical failures such as stem fracture and aseptic loosening. One of the challenges is to ensure that implants will endure the mechanical strain under physiological loading conditions, especially crucial in long surviving patients. The objective is to investigate the effect of varying prosthesis length on the bone and implant stresses in a reconstructed humerus-prosthesis assembly after tumour resection using finite element (FE) modelling.

Debate surrounds the optimum operative treatment of periprosthetic distal femoral fractures (PDFFs) at the level of well fixed femoral components; lateral locking plate fixation (LLP-ORIF) or distal femoral replacement (DFR). To determine which attributed the least peri-operative morbidity and mortality we performed a retrospective cohort study of 60 consecutive unilateral PDFFs of Su types II (40/60) and III (20/60) in patients ≥60 years; 33 underwent LLP-ORIF and 27 underwent DFR. The primary outcome measure was reoperation. Secondary outcomes included perioperative complications and functional mobility status. Kaplan Meier survival analysis was performed. Cox multivariable regression analysis identified risk factors for reoperation after LLP-ORIF.

Mean length of follow-up was 3.8 years (range 1.0–10.4). One-year mortality was 13% (8/60). Reoperation rate was significantly higher following LLP-ORIF: 7/33 vs 0/27, p=0.008. For the endpoint reoperation, five-year survival was better following DFR: 100% compared to 70.8% (51.8 to 89.8 95%CI) (p=0.006). For the endpoint mechanical failure (including radiographic loosening) there was no difference at 5 years: ORIF 74.5% (56.3 to 92.7); DFR 78.2% (52.3 to 100), p=0.182). Reoperation following LLP-ORIF was independently associated with medial comminution: HR 10.7 (1.45 to 79.5, p=0.020). Anatomic reduction was protective against reoperation: HR 0.11(0.013 to 0.96, p=0.046). When inadequately fixed fractures were excluded differences in survival were no longer significant: reoperation (p=0.156); mechanical failure (p=0.453).

Reoperation rates are higher following LLP-ORIF of low PDFFs compared to DFR. Where adequate reduction, proximal fixation and augmentation of medial comminution is used there is no difference in survival between LLP-ORIF and DFR.

Introduction

Computer Tomography (CT) imaging has been limited to beam hardening artefacts until now. Literature has failed to describe sensitivity and specifity for loosening of endoprothesis in CTs, as metal artefacts have always influenced the diagnostic value of CTs.

In recent years a new technology has been developed, the Dual Energy CT. Dual Energy CT scanners simultaneously scan with two tubes at different energy levels, most commonly 100kVp and 140kVp. Furthermore pictures gained from Dual Energy CTs are post-processed with monoenergetic reconstruction, which increases picture quality while further reducing metal artefacts.

This promising technology has increased the diagnostic value preventing more radiation for the patients, for example in detection of kidney stones or to map lung perfusion. In the musculoskeletal imaging it has not been established yet and further clinical investigations are necessary.

Thus the aim of this study is to describe sensitivity and sensibility for endoprothesis loosening of this novel technology.

Purpose: To study the results of treatment of symptomatic non-union with endoprosthesis at the Royal Orthopaedic Hospital

Methods: Between 1987 & 2005, 17patients were treated with massive endoprosthesis for non-union. We performed a retrospective review of these case notes

Results: Mean age at diagnosis was 63years (range 36–86). Location of non-union was distal femur in 9, proximal femur in 4, proximal humerus in 2, proximal tibia in 1, distal humerus in 1. The majority of the patients had received prior multiple operations before endoprosthetic surgery.

Four patients had obvious infection confirmed by histology and/or microbiology prior to surgery. Endoprosthetic Reconstruction was performed as a 1 stage procedure in 13 and as a 2 stage in 4.

Complications occurred in 5 patients. These included recurrence of infection in 1, persistent pain in 1, aseptic loosening in 1, periprosthetic fracture in 1 and a non ST myocardial infarction in 1. At the last follow-up, (mean 5years, range 1–18years) majority of patients achieved good range of motion and good mobility.

Conclusion: We conclude that endoprosthetic replacement is a reasonable option for treatment of end-stage non-union in carefully selected patients. Adequate mobility and function can be achieved in majority of patients following such treatment

Aims

The proximal tibia (PT) is the anatomical site most frequently affected by primary bone tumours after the distal femur. Reconstruction of the PT remains challenging because of the poor soft-tissue cover and the need to reconstruct the extensor mechanism. Reconstructive techniques include implantation of massive endoprosthesis (megaprosthesis), osteoarticular allografts (OAs), or allograft-prosthesis composites (APCs).

Aim

The risk of haematogenic periprosthetic joint infection (PJI) after dental procedures is discussed controversially. To our knowledge, no study has evaluated infections according to the origin of infection based on the natural habitat of the bacteria. We investigated the frequency of positive monomicrobial cultures involving bacteria from oral cavity in patients with suspected PJI compared to bone and joint infections without joint prosthesis.

Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis, for tumour, between 1997 and 2007. The mean age was 46 years, (7–87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3% and the mean TESS was 77.2%.

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7% and a mean TESS of 80.0%.

Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.

Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis for tumour between 1997 and 2007. The mean age was 46 years (7-87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3 % and the mean TESS was 77.2 %.

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7 % and a mean TESS of 80.0%.

Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.

Purpose: We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a 5 year period at our institution.

Introduction: The recent advances in adjuvant and neo-adjuvant therapy in cancer treatment has resulted in improved prognosis of patients with bone metastases. Most patients who have an actual or impending pathological fracture should have operative stabilisation or reconstruction. According to BOA guidelines patients should undergo a single procedure which allows early full weight bearing and lasts the expected lifespan of the patient. The use of modern modular endoprostheses allows these criteria to be met.

Methods and Results: We retrospectively identified all patients diagnosed with metastatic disease to bone between 1999 to 2003. 171 patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 47% of the lesions. 58 patients with bone metastasis to the appendicular skeleton had an endo-prosthetic reconstruction. There were 28 males and 30 females. 11 patients had lesions in the upper extremity and 47 patients had lesions in the lower extremity. Mean age at presentation was 62 years (24 to 88 years). 19 patients are still alive, 34 patients had died and 5 were lost to follow-up. Patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Mean follow-up was 55 months (24 to 78 months). There were 5 wound infections, 1 aseptic loosening, 3 dislocations, 1 subluxation and 1 prosthesis rotated requiring open repositioning. Patients were followed up and evaluated using the Musculoskeletal Society Tumour Score (MSTS) and the Toronto Extremity Salvage Score. The mean MSTS score was 73% (57 to 90%) and TESS was 71% (84 to 95%).

Conclusions: We conclude that endoprosthetic replacement for the treatment of bone metastases in selected cases achieves the aims of restoring function, allowing early weight bearing and alleviating pain. The complication rate is low.

Background

Revision THA presents significant challenges for the surgeon when the proximal femur is deficient or mechanically unreliable. The aim of this study is to assess the clinical and functional results of the use of tumor enndoprosthesis to reconstruct the proximal femur when there is massive bone loss.

Background

Endoprosthetic reconstruction is an established method of treatment for primary bone tumours in children. Traditionally these were implanted with cemented intramedullary fixation. Hydroxyapatite collars at the shoulder of the implant are now standard on all extremity endoprostheses, but older cases were implanted without collars. Uncemented intramedullary fixation with hydroxyapatite collars has also been used in an attempt to reduce the incidence of problems such as aseptic loosening. Currently there are various indications that dictate which method is used.

Introduction: The proximal humerus is one of the common site for neoplasms requiring excision and reconstruction. Out of more than 600 cases of bone tumours operated in the last 12 years, we have managed 33 cases of proximal humerus tumours with custom made megaprosthesis.

Methods: 33 cases of neoplastic involvement of upper end humerus, aged between 18–65 years (mean age 37 years) were operated over a period of 12 years (1995–2007). 23 were males and rest females. The primary lesions were: 19 giant cell tumours; 7 osteosarcoma; 4 chondrosarcoma; 1 metastatic; 2 Round cell sarcoma. The Enneking staging was: 1b(19), IIb(13), III(1). All patients with giant cell tumour had a break of cortex and a soft tissue component necessitating wide surgical excision. Surgery was the primary mode of treatment in all patients and was always undertaken with curative intent. Surgery was supplemented with appropriate chemo- radiotherapy in patients with osteosarcoma/ewing’s sarcoma. Surgical and functional results were evaluated according to MSTS scoring system.

Outcomes: The scoring ranged from 22–27.5%. The hand and elbow function was good in all while the shoulder abduction was always lost. The minimum follow up was 24 months.

Complications included: Superficial infection (1), deep infection (1); Recurrence 2; Improper cementing (2); Neuropraxia [radial nerve] (8); Subluxation of prosthesis head (8); Post radiotherapy skin necrosis and contracture (1); 4 patients died.

Conclusion: Adequate resection of malignant tumours/benign aggressive tumours in the shoulder region gives good oncological & surgical results. For post tumour excision humeral gaps, megaprosthesis is a near ideal choice.

Bipolar hip arthroplasty was introduced to alleviate the problems of hip pain, acetabular protrusion and femoral stem loosening associated with unipolar prosthesis. Earlier generation bipolar endoprosthesis used to cause varus fixation of outer head which led to the unacceptably high incidence of dislocation, component disassembly and fractures of the polyethylene bearing insert. Second generation endoprosthesis with a self centering mechanism were introduced to overcome these problems. This new design incorporates a polar offset by setting the center of rotation of the inner head proximal to the center of rotation of the outer head, which generates a valgus producing moment at the outer cup. There is a controversy whether this mechanism works in vivo, more so in indigenous prosthesis.

A retrospective observational study was done on 37 subjects, which included 21 males and 16 females. The first radiograph was taken with the patient standing and bearing full weight over the endoprosthetic leg and abducting the contra lateral limb as much as possible. The second radiograph was taken with the patient standing neutral and bearing weight on both the legs. Abduction and adduction views were then taken in supine position. The radiographs were analyzed using the method similar to that of Drinker and Murray. The adductive motion from abduction to neutral position is within the range of inner bearing oscillation. Modified Harris Hip Score was used to evaluate the patients clinically. Results were analyzed using Wilcoxon Matched-Pairs Signed-Ranks Test, Students t-test and Karl Pearson correlation statistics.

The mean outer head alignment changed from 42.46 degrees ±13.62 (range 10 to 72 degrees) to 31.93 degrees ± 10.59 (range 8 to 50 degrees) in moving from abduction to neutral position in weight bearing position. The analysis showed that 68.66% of the total motion occurred at the outer bearing in weight bearing position whereas 73.86% of the total motion occurred at the outer bearing in supine position. The difference between distribution of motion between supine and weight bearing position was not found to be statistically different using Wilcoxon Matched-Pairs Signed-Ranks Test (p = 0.3164) and unpaired students t test (p = 0.35). No correlation was found between weight of the patient and time of follow up with outer head alignment and differential distribution of motion.

Self centering mechanism of bipolar endoprosthesis works in vivo under physiological loads and aligns the cup in neutral or valgus position till an average follow up of 10 months. Though the motion occurs at both the bearing surfaces outer bearing motion clearly predominated in both weight bearing as well as supine position.

Problem Wrong positioning of the acetabular cup leads to impingement, luxations and limited ROM. To improve the cup position computer assistant navigation systems had been developed. They are expensive, time consuming and sometimes no easy to handle.

Solution A new concept for the implantation of THP will be introduced: The cup position is not orientated as usual according to the body axis, but according to the stem position. Stem and cup are a closed biomechanical system, cup anteversion and inclination will be positioned according CCD angle and torsion of the stem.

With a new mechanical navigation system for the cup with a special cup probe and guiding system the best position is found intraoperatively according to ROM, impingement, luxation and tension of the muscles.

Results 150 patients had been operated. Optime is extended only 4–6 minutes, dysplasia inlays, impingement and luxations had disappered. The system is easy to handle and to sterilize routinely with the other op.-instruments.

Background: Chronic prosthetic joint infection is a cause of patient morbidity and can be challenging to treat. Surgeons performing revision arthroplasty of the hip and knee are confronted with a growing number of patients with extensive loss of bone stock. The use of a modular endoprosthesis is a possible method of treatment in such patients.

Aim: The purpose of this study was to assess the functional outcomes and the success of a single and two stage revision procedure in eradicating chronic prosthetic joint infection using a femoral endoprosthesis.

Methods: A prospective database was reviewed of 20 patients who underwent a proximal, total or distal femoral endoprosthetic replacement after chronic prosthetic infection. Radiographs performed at the time of latest follow up were evaluated for signs of loosening, osteomyelitis and implant failure. The functional status was assessed using the Short Form (SF)-36 health survey score, Toronto extremity salvage score (TESS) and the Enneking score.

Results: Thirteen patients underwent a single stage revision procedure and seven had been treated with a staged revision. At the latest follow up none of the 13 patients treated with a single stage procedure had evidence of ongoing infection. Of the seven patients who had a staged revision, 3 patients had evidence of ongoing infection. The mean pre operative Enneking score for the entire group was 17.1 points and this improved to 47.5 points post operatively (p< 0.0002). The mean pre operative TESS score for the entire group was 42% and this improved to 59% post operatively (p< 0.005). There was also a statistically significant improvement in all of the components of the SF-36 score.

Conclusion: We believe that the use of a modular endo-prosthesis in the treatment of chronic prosthetic joint infection is a successful and viable option in eradicating infection, preserving the limb and providing a good functional result.

Purpose: To present the results of the use of shoulder prosthesis in multifragmented displaced humeral head fractures. Material-methods: 19 patients with comminuted and severely displaced fractures of the upper humeral epiphysis were treated with shoulder hemiar-throplasty. Their age varied from40 to 81 years (av:71). Seven patients had severely displaced four-part fracture; eight patients had four- part fracture-dislocation and four patients, three-part fracture dislocation with extended damage to humeral head articular surface. In 16 cases the arthroplasty was performed within 10 days, and in three, 6 weeks or more after the injury. The glenoid was not replaced in any of the cases. Results: The follow-up period was 16–84 months (av: 51). None of the patients had been reoperated, and none of the prosthesis was regarded ÒlooseÒ. The clinical assessment was done using the Constant-Murley scale. The score varied from 50 to 89 points, (av: 79). The average score for ÒpainÒ was 13(max 15) and for ÒmobilityÒ29(max 40). Average abduction reached 100 degrees and forward ßexion 110 degrees. At the last examination, 15 out of the 19 patients had returned to the previous social and occupational activities. Conclusions: The shoulder replacement offers satisfactory results in cases with comminuted and badly displaced fractures, but is a technically demanding procedure, and the time interval between injury and operation, strongly affects the result. Long lasting physiotherapy, patient compliance and cooperation are necessary for a satisfactory outcome.

Introduction:

The higher resisting torque against dislocation and the large range of motion due to the enlarged effective head diameter substantiate the use of eccentric dual-mobility cups in case of total hip joint instability [1,2]. As a result of force-dependent self-centering mechanism, an increased movement of the intermediate-component can be expected whose effect on wear propagation is unknown so far. Currently available hip joint simulators are only able to vary the load by the absolute value and not by the direction of resulting force. Therefore, the uniaxial force transmission may lead to a unique and stable alignment of the intermediate-component during testing. The purpose of this numerical study was to evaluate relative movements of the intermediate-component during daily life activities with respect to wear propagation.

Aims: 1. Analysis of indications for THA in young adults with osteoarthrosis, 2. Evaluation of clinical and radiological end results, 3. Investigation of complications after metal-to-metal THA. Material: 75 THAs with metal-tometal cementless endoprosthesis in 75 patients which had been operated between 1997–2002 were retrospectively evaluated. There 50 women and 25 men (mean age: 39 years old). The mean time of follow-up was 2,8 years (form 6 to 48 months). Etiologic factors of osteo-arthrosis in operated hips were: idiopathic arthrosis in 50 hips, CHD in 18 hips, post-traumatic lesions in 3 hips, aseptic necrosis of the femoral capitis. Metal-to-metal THA with the cementless endoprosthesis was made in all evaluated cases with: Alloclassic systeml Ð 66, other systems Ð 9.Methods: The clinical evaluation was performed with Merle dñAbugine score. The radiological evaluation of THA was based on criterion proposed by joined committee of The Hip Society, SICOT and AAOS. Results: The mean postoperative clinical result in the study group is 5,5 p. in Merle dñAbugine score. Radiological result was very good in all hips. Conclusions: The study supports the satisfactory results of the THA with the metal-to-metal cementless endoprosthesis in reconstructive surgery of the hip with degenerative changes in young adults.

Introduction: The results of noncemented press-fit bipolar hip endoprostheses were reviewed in patients with osteonecrosis of the femoral head.

Materials and Methods: Twenty-nine hips in 24 patients with osteonecrosis of the femoral head were studied. The average follow-up period was 12 years and 5 months (range from 9 years 2 months to 17 years 11 months). All hips were classified as stage 3 or 4 (osteonecrosis) before surgery using the classification method of the Japanese Investigation Committee. Acetabular reaming was performed in 5 hips with stage 4 osteonecrosis.

Results: Four prostheses have been revised to a total hip arthroplasty at the time of follow-up examination. The average clinical hip score of Japanese Orthopaedic Association was 88.9 (98–82) with 23 hips rated excellent and good, and 6 hips rated fair. Radiologically, stem subsidence more than 5 mm occurred in 5 hips and stem loosening occurred in 6 hips (21%). Five hips with stage 4 osteonecrosis (3 hips received acetabular reaming, 2 hips in elderly patients with osteoporosis) developed outer head migration more than 4 mm in both superior and axial direction. Osteolytic lesions, seen on 11 hips in the femur and 3 hips in the acetabulum, appeared at an average of 4.2 years postoperatively.

Conclusion: These results suggest that cementless pressfit bipolar endoprosthesis for osteonecrosis demonstrated a high incidence of acetabular protrusio and osteolysis. Cementless THA with a porous coating stem should be recommended for treatment of osteonecrosis of the femoral head.

The aim of this study was to analyze the frequency and reveal the most common reasons of the endoprosthetic instability in patients with malignant bone tumors. From 1992 – 2008, 625/515 patients, endoprosthetic replacement of major joints were performed. The median age of the patients was 30.3 years (13 to 72 years).

Aseptic instability was observed after 3/71(4.2%) humeral joint replacement out of total operations at this location, after 4/80 (5%) hip prosthesis, after 19/133 (14%) proximal tibial prostheses, after 44/299 (14.7%) distal femoral prostheses and after 2/37 (5.4%) total femur replacements.

The retrospective analyses has shown that the reasons of instability were the following: aseptic loosening of the stems of endoprosthesis in 26 cases (24.4%), stem break in 31 (36.1%), endoprosthetic unit destruction in 10 (11.6%), untwistment of fixational screws in 10 (11,6%), migration of hip endoprosthesis components in 2 (2.3%) and endoprosthesis dislocation in 12 (14%). The timing of endoprosthetic instability ranged from 7 days to 12.2 years (average 26.2 months). Statistic analyses was performed in a group of patients with aseptic endoprosthesis instability developed after proximal tibia and distal femur resection.

We conclude that the most frequent reason of aseptic instability was endoprosthetic stem break. The instability rate was actually lower among the patients who had underwent 5–10cm distal tibia resection comparing with the group of 10–15cm bone mass resection (p=0.05). Femoral resection enhanced the instability frequency comparing with proximal tibia resection in the group of 5–10cm bone mass resection (p=0.05).

The aim of this study was to analyze complications and functional outcomes after individual and module endoprosthesis.

From 1993 to 2008 in our clinic 42 patients with bone sarcomas were treated with resection and endoprosthetic reconstruction of large joints. In 29 patients we have applied individual, in 13 patients module prosthesis. We have assessed complications and functional results. For individual prosthesis: pyoseptic complications-4 (9,52%) pts, orthopedic events-9 (21,43%) pts, local recurrences-5 (11,90%); functional results: “excellent”-10,34% (3/29), “good”-48,28% (14/29), “satisfactory”-24,14% (7/29), “non-satisfactory”-17,24% (5/29). For module prosthesis: Only in one patient local recurrence has been observed. Functional results are so: “excellent”-23,1% (3/13), “good”-69,2% (9/13), “satisfactory”-7,7% (1/13), “non-satisfactory”-0.

We conclude that using of module endoprosthesis allows achieving good functional results with low rate postoperative complication.

Infection of total knee replacement (TKR) is considered a devastating complication, which necessitates complete removal and thorough debridement of the site. Usually long term antibiotic treatment and a multitude of surgical interventions within a period of several months are required until a definitive supply can be achieved. Osseous defects are common in such conditions and need to be addressed during re-implantation. Managing removal, debridement, reconstruction and re-implantation within a single operation is the ideal solution, both for the patient and the treating team, but rarely executed due to the fear of re-infection. Allograft bone may be impregnated with high loads of antibiotics using a special incubation technique. The resulting antibiotic bone compound (ABC) provides high and long lasting antibiotic levels at the site of infection and is likely to restore bone stock. We have investigated the results of one-stage exchange of infected TKR using ABC together with uncemented implants.

Between 1998 and 2004 nineteen exchange procedures of infected TKRs were performed in a single stage, all of them without the use of bone cement. After removal of the implants and radical debridement bone voids were filled with ABC using a modified impaction technique. Consequently, new uncemented implants were inserted. We mainly used the revision type of the LCS knee (DePuy, J& J) as long as ligamentary stability was considered sufficient. Otherwise, we used a custom-made uncemented version of the LINK Rotational Endo Model. Joints were drained and closed immediately; rehabilitation did not differ from uninfected revision.

One knee required re-revision because of persisting infection. The remaining 18 patients stayed infect-free for a period between 2 and 8 years after surgery. In two knees loosening was found after one year, once of the tibial and once of the femoral component. Both were found infect-free at the time of re-revision. All could be successfully revised using the same technique again. No adverse side effects could be found. Incorporation appeared as after grafting with unimpregnated bone grafts.

Using antibiotic-impregnated allografts eradication of pathogens, grafting of defects and re-insertion of an uncemented prosthesis may be accomplished in a one-stage procedure. Since the graft gradually is replaced by healthy own bone, improved long-term results may be expected as well as improved conditions in the case of another revision.

Introduction

Primary bone tumours of the distal radius are rare, while it remains the third commonest site for primary lesions and recurrences of Giant Cell Tumours (GCT). The functional demands on the hand make reconstruction of the wrist joint following the excision of distal radius, particularly challenging.

The aim of this study is to evaluate the early results of gleno-humeral reconstruction after tumour excision with a new design of endoprosthesis.

The prosthesis is a fixed fulcrum gleno-humeral replacement consisting of a hydroxyapatite (HA) coated glenoid component with a polyethylene liner and a cemented stem with HA coated collar. Between 1997 and 2000 we inserted the prosthesis into 15 patients with primary bone tumours of the proximal humerus. There were nine males and six females with a mean age of 38 years (range: 8–71 years). Twelve stems were cemented and three uncemented. Two skeletally immature patients had an extendible stem inserted, one subsequently having a successful lengthening procedure. The mean follow-up was 28 months (range: 12–41 years). Functional outcome was assessed using the Musculoskeletal Tumour Society (MTS) scoring system.

There were two early dislocations and one superficial wound infection. Three patients died of their disease and one underwent forequarter amputation for local recurrence. The remaining eleven had satisfactory functional outcomes with a mean MTS score of 81%. Radiologically there has been no evidence of early loosening. Microscopic analysis of the components in the amputated arm showed excellent osseointegration around the HA coated components.

The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding.

Cite this article: Bone Joint J 2023;105-B(8):850–856.

For younger patients many surgeons recommend femoral neck endoprostheses as alternative to stemmed implants in THA. Due to metaphyseal anchorage several advantages are quoted, e.g. preservation of the femoral diaphysis for a revision implant. Determinant factor for long-term implant stability is the load transmission to the bone. Because so far only few information about the load transfer of femoral neck endoprostheses exist, a photoelastic analysis was performed. Aim of the study was the comparison of bony strain pattern before and after implantation of a femoral neck endoprosthesis.

‘Composite-femurs’ (Pacific Research Labs) were used due to of their mechanical characteristics close to human femurs but better reproducibility. Three femurs were coated with photoelastic material. The femurs were loaded prior and post implantation of a femoral neck endoprosthesis type Cigar (ESKA Implants). Test load consisted of the resulting hip joint force and muscle forces (abductors, tractus iliotibialis). Load was applied statically by a universal testing machine and additional weights. Bony strain was measured along the medial, ventral, lateral and dorsal cortex. Statistical analysis of the implant related strain alterations was based on a 99% confidence interval.

The unresected femurs showed an excellent match of bony strain patterns. Implantation of femoral neck endoprostheses caused highly significant strain changes at the trochanteric region. Greatest differences were observed at the lateral cortex. Above the implant’s traction screw former areas of tension changed to compression. Along the medial cortex below the resection plane strain reductions were measured but disappeared at the latest at 40 mm below. No significant changes in strain were detected at the ventral and dorsal cortex.

Implant related bony strain alterations were limited to the trochanteric region of the femur. A marked strain alteration at the lateral trochanteric aspect was measured. Whether this is of clinical importance can not be answered yet.

We aim to report the clinical and radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong HAC coated femoral and acetabular components.

We reviewed 586 consecutive cementless primary THA in 542 patients with a minimum 12-18 year follow-up, performed at one institution between 1986 and 1994. Twenty-eight (32 THA) were lost to follow-up. Clinical outcome was measured using Harris, Charnley and Oxford scores. Quality of life using EuroQol

EQ-5D. Radiographs were systematically analysed.

The mean age was 75.2 years. Dislocation occurred in 12 patients (three recurrent). Re operations were performed in 11 patients (1.9%). Four acetabular and one stem revisions were performed for aseptic loosening. Other re-operations were for infection (two), periprosthetic fractures (two), cup malposition (one), revision of worn liner (two). The mean Harris and Oxford scores were 89 (79–96) and 18.4 (12–32) respectively. The Charnley score was 5.7 for pain, 5.3 for movement and 5.4 for mobility. Acetabular radiolucencies were present in 54 hips (9.7%).

The mean linear polythene wear was 0.06 mm/year. Stable stem by bony ingrowth was identified in all hips excluding one femoral revision case. Mean stem subsidence was 2.2mm (0.30–3.4mm). Radiolucencies were present around 37 (6.6%) stems. EQ- 5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, survival at 12 years was 96.1% for acetabular and 98.3% for femoral components. Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 97.2%.

The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long-term period.

There are results of our first experience treatment 8 patients who underwent endoprosthetic reconstruction of distal radius after excision of malignant tumors. All patients were treated in Sytenko Institute from 2004 to 2008 and had about 5 years follow-up. There are 3 males and 5 females and the median age at diagnosis was 36 (17–55) years. The resection length measured a mean of 8cm and was measure by radiographs, CT and MRI. Each case was malignant Giant cell tumor. There were 5 cases of primary tumor and 3 cases of local tumor relapse. The patients have had chemotherapy, tumor excision and individual custommade endoprosthetic reconstruction. Unfortunately all patients had one-two surgeries before treatment in our Clinic. We used author’s individual custommade endoprosthetsis which was performed from titanium and ceramic spraying. CT-measurement scale was used for preoperative planning and manufacture this distal radius prosthesis.

One patient has had deep soft tissue infection and we were needed to remove prosthesis. One more patient had proximal radius fracture 4 month after surgery and we performed bone plate osteosynthesis. All patients (except one infection case) have satisfactory wrist range of motion and functional result of upper limb from 10 month to 5 years follow-up.

It is proved that surgical procedure of the tumors of distal radius is a useful and main method of the treatment above-stated localization. The individual custommade prosthesis have a good perspectives for upper limb salvage surgery and reconstruction this area, allowing to receive good oncological and functional results.

Limb salvage has become the most important treatment for patients with malignant bone tumors of the lower limb. Reconstruction with endoprosthesis of the proximal femur and distal femur and proximal tibia is now the most common solution. The data of 180 consecutive patients with malignant bone tumors of the lower limbtreated between 4/1987 and 11/1998 were reviewed. The average follow up is of four years.

129 patients had surgery for primary bone sarcoma, six for aggressive GCT and 45 for metastatic carcinoma. 63 patients were reoperated for different complications. The main complications were: local recurrences in 10 patients, infection in 12 patients and mechanical complications in 35 patients. 28 patients were operated two times and 24 patients more than two times.

14 patients have undergone amputation: six because of local recurrences, four because of infection, and two for post-surgical ischemia.

Eight of the 12 infections occurred after a re-operation.

35 patients had mechanical complications: 14 patients were reoperated to replace the polyethylene bushings in of the first model of HMRTS prosthesis (Howmedica), five patients had ruptures of the femoral stem, three patients suffered mobilization of the tibial stem and two of the femoral stem, six patients required a patella prostheses for local pain.

Two patients had acetabulum wear and three had hip dislocation.

In our experience endoprosthesis reconstruction after resection of bone tumors of the lower limb is a feasible procedure for limb salvage. We must consider that more than 30% of these patients will be re-operated for different complications and that 50% of infections occours after a new surgical procedure.

From 1992 on 2008, 615/515 patients underwent primary or revisional endoprosthetic replacement of major joints. In 51 patients (31 men & 20 women) modular system MUTARS (Implantcast, Germany) has been used. The median age was 23.3 years (15 to 52 years).

MUTARS modular endoprosthesis has been used in 10 patients with deep infection of endoprosthetic bed as a revisional endoprosthetic replacement: 1 Total endoprosthetic replacement of femur, 5 Total knee joint replacement (2 for distal femoral defect and 3 for proximal tibial defect). In 3(27%) patients, we used newly patented silver ion coated MUTARS either after two stage treatment for infection of endoprosthetic bed or as a prophylaxis of endoprosthetic infection.

In 1 patient (23 yrs), with 12cm limb length shortening, we used extensible MUTARS as a revisional endoprosthetic replacement.

The following complications we observed: Instability of endoprosthesis – 3/51 (5.9%), deep endoprosthetic bed infection – 4/51 (7.8%).

In comparison group, when using custom-made endoprosthesis, the frequency of infectious complications have made 60/574 (10.5 %), and instability of implants was observed in 79/574 (13.8 %) cases.

Transition of using modular systems for primary and revisional endoprosthesis allows to reduce the level of instability from 13.8 % to 5.9 %. The quantity of infectious complications is also not great as in comparison with control group. For revisional endoprosthetic replacement, we think, the given modular system is optimal, for correcting limb length deficiency and restoration of basic function at patients. Use of silver ion coated modular implants is a promising method for treating deep endoprosthetic bed infection.

The purpose of this study was to compare the outcome, complications and survival of the three most commonly used surgical reconstructions of the proximal humerus in adult patients after trans-articular tumour resection.

We are reporting our case series of lumbar total disc endoprostheses. Oswestry and SF-36 scores were obtained from patients preoperatively and postoperatively for discs in situ for six, twelve and twenty-four months. Oswestry scores improved from fifty-three to thirty-two at six months (N=34); fifty-five to thirty-one at twelve months (N=28); and fifty-two to twenty-five at twenty-four months (N=17). SF-36 scores improved from thirty to fifty-four (physical) and forty to sixty-two (mental) at six months; twenty-nine to fifty-five (physical) and thirty-eight to sixty-three (mental) at twelve months; and twenty-nine to sixty-two (physical) and forty-one to sixty-seven (mental) at twenty-four months.

We report our results using the Charité III Endprosthesis in the treatment of degenerative disc disease.

Short term outcome for patients having undergone total disk arthroplasty support cautious optimism for continued implantation. Continued close follow-up is essential

Total disk arthroplasty for the treatment of degenerative disc disease is increasing in popularity. Expected FDA approval of several implants make accurate functional outcome reports essential to guide practice.

Disc replacements in situ for six months (N=34) improved in Oswestry scores from fifty-three to thirty-two. SF-36 physical scores for the same cohort improved from a mean of thirty to fifty-four and mental scores from forty to sixty-two. At one year (N=28), Oswestry scores improved from fifty-five to thirty-one. SF-36 physical scores improved from twenty-nine to fifty-five, and mental scores from thirty-eight to sixty-three. At two years (N=17), Oswestry scores improved from fifty-two to twenty-five. SF-36 physical scores improved from twenty-nine to sixty-two, and mental scores from forty-one to sixty-seven.

Using very narrow indications for application of this technique we have implanted fifty-one total disc arthroplasties. Cohorts were analyzed for outcome based on duration in situ of the implant. Through careful follow-up we have identified the following trends based on validated objective outcome measures including the Oswestry low back index and the Short Form 36. These outcome measures in addition to data reported separately demonstrating clear maintenance of interdiscal lumbar range of motion allow for cautious optimism regarding the continued application of total disc arthroplasty.

Aim: The purpose of this report was to analyse the clinical and survivorship results and revision rates of Bichat III uncemented total hip arthroplasty in a community hospital setting. Poor results are rarely published what may have effect on the results of meta-analyses done on hip replacement surgery. At the time of selecting the prosthesis there were no reports published on this particular model. Methods: Between 1987 and 1990 þftyþve patients (57 hips) were operated using the Bichat III endoprosthesis. The prosthesis has a ßuted, anatomic and non-porous Ti femur, and a threaded nonporous acetabular cup. There were 25 male and 30 female patients. Mean age of the male patients was 62 (40–75) and that for the female 61 years (43–82). The indication for operation was primary arthrosis in 45, posttraumatic arthrosis in 5, LPC in 2 cases, and rheumatoid arthritis, AVN and CHD one each. All the operations were made using the Hardingen approach. For the survivorship analysis the patients were traced from the Finnish Arthroplasty Register and Kaplan-Meir survival was calculated for all the 57 patients with the 95% Cl. Those not revised until 31st December 2001 were called for clinical and radiological examination. The mean follow-up time was 12,7 years (11,4–14,2). Results: During the follow-up 16 patients died (28%), and revision was done on 21 patients (37%) after a mean follow-up time of 7,2 years (3,6–11,3). Seventeen patients arrived to the clinical follow-up; of those only 10 cases were without any radiological signs of loosening. For all the patients re-examined the Mayo Clinics Hip Score was 50.8 in average ((5–75), and that for those with radiological signs of loosening 46,3 (16–71). The survivorship calculated at ten years was 57,0% (95%Cl 42,5–71,6; 22 hips at risk). Typical features at revision were total loosening of both components, marked metallosis and breakage of the polyethylene liner. Conclusions: Our results are in accordance with other reports with uncemented, non-porous coated components, as well as with those of the screw þxed acetabular cups. Also the reports from other Nordic arthroplasty registers speak favour of the non-acceptable results with such concepts of THA. Publication of also the negative results of THA may decrease risk of sc. publication bias. We conclude that until now there is sufþcient evidence that porous coating on both components of hip endoprosthesis is crucial for reliable þxation of uncemented components. Prosthesis selection should be made on a well documented basis and trials should be made in arthroplasty centers and on a prospective and randomized basis.

Aims: To study the utility of a computer assisted orthopaedic surgery (CAOS) wireless system (navigator) in Total Knee Arthroplasty (TKA). Methods: Randomised prospective study. A sample of 40 TKA patients was randomised in two groups: CAOS was used in 20 of them. In the other group standard technique with manual alignment was performed. Femoral angle (formed between the femoral mechanical axis and the femoral component), tibial angle (formed between the tibial mechanical axis and the tibial platform) and femorotibial angle (formed between femoral and tibial mechanical axes) were measured from Computed Tomography Surviews taken in the immediate postoperative period. Results: In the standard group (without navigator) the femoral angle mean was 91.7° (ranged 90 to 94°). Tibial angle mean was 90.2° (87°–95°) and femorotibial angle mean was 175.9° (172°–180°) showing a slight prevalence of varus deviation of the extremity mechanical axis. In the group with navigator the femoral angle mean was 90.2∞ (87–93°), tibial angle mean 89.6°(85°–93°) and femorotibial angle mean 179.2° (177°–182°). There were statistically significant differences between groups for the femoral angle (p=0.001), and the femorotibial angle (p < 0.001). An ideal femorotibial angle (180±3°) was achieved for all the patients of the CAOS group but only 9 patients of the standard technique group reached this objective (p< 0.001). Conclusions: The use of CAOS for TKA favors the implant placement in a position nearer to the ideal mechanical axis.

Several methods have been used for proximal humeral reconstruction following tumour resection. None of these modalities allow the patient to regain his normal shoulder range of motion. Moreover, every modality has its advantages and disadvantages.

The aim of this study was to compare the functional outcome of 2 reconstructive modalities that we are using in our institution for proximal humeral reconstruction; endoprosthesis and shoulder arthrodesis using a vascularised autograft This study included 48 patients diagnosed with malignant or benign aggressive tumours that required resection of their proximal humerus. They were divided into 2 groups according to the method of reconstruction. Group 1 included 22 patients with an average age of 20 years were reconstructed by shoulder arthrodesis using a free vascularised fibular graft (6) or a pedicled scapular crest graft (16). Group 2 included 26 patients with an average age of 26 years were reconstructed with an endoprosthesis.

In group 1 the average follow up period was 88 months (range 12 to 184 months). The average functional outcome (according to the MSTS scoring system) was 25 points (range 19 – 28). The average abduction and forward flexion range of motion (scapulothoracic) was 40 degrees (range 20 -60). Complications included failed fixation (2), non union (1), infection (1) and temporary radial nerve palsy (2). In group 2 the average follow up period was 36 months (range 12 – 110). The average functional outcome was 24 points (range 20 – 27). The average abduction and forward flexion range of motion was 40 (range 30 –70). Complications included sublaxation (2), loosening (1) and infection (1).

Reconstruction of the proximal humerus by arthrodesis or endoprosthesis yield similar functional outcome. Although endoprosthesis is a much more expensive modality, it does not provide any superior functional outcome over shoulder arthrodesis.

Aim: To report the clinical and radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong Hydroxyapatite ceramic (HAC) coated femoral and acetabular components

Methods: We reviewed 586 consecutive cementless primary THA using HAC coated components in 542 patients, with a minimum 12-year follow-up to 18 years, performed at one institution between 1986 and 1994. Twenty eight (32 THA) were lost prior to 12-year follow-up, leaving 514 patients (554 THA) available for study. Threaded cups were used in 64% and press-fit cups with screws in the rest. Fully HAC coated stems were used in all patients. The clinical outcome was measured using Harris, Charnley and Oxford hip scores. Anterior thigh pain was quantified on a visual analogue scale (VAS) and quality of life using EuroQol EQ-5D. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis and stress shielding. Polythene wear was digitally measured. The radiographic stability of the femoral component was determined by Enghs criteria

Results: The mean age was 75.2 yrs. Dislocation occurred in 12 patients (3 recurrent). Re operations were performed in 11 patients (1.9%). Four acetabular and one stem revisions were performed for aseptic loosening. Other re-operations were for infection (2), periprosthetic fractures (2), cup malposition (1), revision of worn liner (2). The mean Harris and Oxford scores were 89 (79–96) and 18.4 (12–32) respectively. The Charnley score was 5.7 (5–6) for pain, 5.3 (4–6) for movement and 5.4 (4–6) for mobility. Migration of acetabular component was seen in 4 hips. Acetabular radiolucencies were present in 54 hips (9.7%). The mean linear polythene wear was 0.06mm/year. Stable stem by bony ingrowth was identified in all hips excluding one femoral revision case. Mean stem subsidence was 2.2mm (0.30–3.4mm). Radiolucencies were present around 37 (6.6%) stems. Mean EQ- 5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, the probability of survival at 12 years was 96.1% for acetabular and 98.3% for femoral components. Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 97.2%.

Conclusion: The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long term period.

Frequent imaging after a completed multimodal therapy of osteosarcoma is recommended by therapy optimization studies to detect local or systemic tumor recurrence. Considering the low rates of local recurrence, regular local imaging has to be questioned.

150 patients with osteosarcoma were treated in our department between 1991 and 2005. The median age of patients with osteosarcoma was 17 years with a range of 4 – 79 years and a female:male ratio of 1:1.1. The primary tumors of 147 patients were treated surgically, while 3 patients refused to be operated. After a wide resection, a tumor endoprosthesis was implanted in 103 (70.1%) of the 147 patients, 16 (10.9%) patients underwent a Borggreve rotationplasty, a resection and biological reconstruction was implemented in 10 (6.8%) patients, while further 18 (12.2%) patients were amputated. The median follow up was 95 months.

Local recurrences appeared in 2 (1.4%) patients which had been treated with a hemipelvectomy. After implantation of a tumor endoprosthesis, local recurrences were not observed. Postoperative complications observed after the implantation of a tumor endoprosthesis included infections (n=14; 13.6%), loosening, fractures and wearing of endoprotheses (n=7; 4.8%), luxation (n=1; 0.7%) as well as traumatic shaft fractures of involved bones (n=5; 3.4%). All complications included specific symptoms and were diagnosed outside the routine follow up.

In conclusion, local radiological imaging after resection of an osteosarcoma and reconstruction with a tumor endoprosthesis as a routine examination should be questioned, however it is definitely indicated in patients with specific symptoms.

Aim: To study the remodelling of cortical bone around the passive growing component of an expandable endoprosthesis.

Introduction: When inserting the passive component of an expandable prosthesis a polyethylene sleeve is commonly used. The sleeve migrates towards the lateral cortex and causes a cortical reaction and hence the use of the sleeve has been discarded recently. This study quantifies the amount of cortical reaction and degree of cortical drift in patients that had sleeves and those that did not.

Material And Methods: We reviewed X-rays and case notes of all patients that had an expandable endoprosthesis in a 20 year period. The thickness of medial and lateral cortices of the tibial diaphysis was measured at 6 months and on the last follow up radiograph. The distance from the edge of the sleeve (or prosthesis) from the cortical edge was also compared. Retrieved components also had their histology reviewed.

Results: The sleeve shifted laterally on average by 2mm (range 0.5 – 3mm) and touched the cortex. This was associated with an increase in lateral cortical thickness by 2.27mm (range 1 – 3mm). When the sleeve was used the prosthesis was inserted in the mid-line. When the sleeve was not used the tibial component tended to be inserted in valgus.

Conclusions: The presence of a sleeve is associated with a cortical reaction and the sleeve tends to migrate laterally. The clinical implications of this and the evolution of the design will be discussed in the meeting.

Aims

Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA).

This case highlights the close association between osteo-fibrous dysplasia (OFD) and adamantinoma, drawing attention to the role for more radical treatment options when treating OFD. We discuss the advancements in joint-sparing endoprostheses using bicortical fixation. Finally we describe a unique biomedical design allowing for manufacture of an end cap to allow amputation through a custom made joint-sparing proximal tibial replacement as opposed to an above knee amputation.

A 37 year old presented 7 years ago having sustained a pathological fracture of her tibia. Subsequent biopsy revealed OFD, curettage with bone graft was performed. She later developed recurrence, two percutaneous biopsies confirmed OFD. 6 years following her initial diagnosis she was referred to RNOH with further recurrence, a biopsy at this stage revealed a de-differentiated adamantinoma. A joint-sparing proximal tibial replacement was performed and adjuvant chemotherapy administered, she remained well for one year. Recurrence was noted at the distal bone-prosthesis interface, histology revealed a high grade dedifferentiated osteosarcoma, limb preservation was not deemed possible and an amputation was performed through the prosthesis. The proximal tibial device was uncoupled leaving a residual 7 cms insitu, a small custom made end cap was attached to the remaining prosthesis and a myocutaneous flap fashioned over it, this ultimately enabled the patient to mobilise well with a below–knee orthotic device.

This case highlights the need for more radical surgery when treating cases of OFD and the relationship between OFD and adamantinoma. It also introduces a joint-sparing proximal tibial device for use in proximal tibial tumours that do not invade the proximal tibial metaphysis. The biomechanical design solution has given us the unique option of preserving the knee joint allowing the patient a below knee amputation whereas previously an above knee amputation would have been performed thereby significantly reducing her functional outcome.

Aims

Instability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability.

Aims

We aimed to examine the long-term mechanical survivorship, describe the modes of all-cause failure, and identify risk factors for mechanical failure of all-polyethylene tibial components in endoprosthetic reconstruction.

Aims

Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique.

Aims

The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses.

Objectives

Enhanced micromotions between the implant and surrounding bone can impair osseointegration, resulting in fibrous encapsulation and aseptic loosening of the implant. Since the effect of micromotions on human bone cells is sparsely investigated, an in vitro system, which allows application of micromotions on bone cells and subsequent investigation of bone cell activity, was developed.

Aims

Following the resection of an extensive amount of bone in the treatment of a tumour, the residual segment may be insufficient to accept a standard length intramedullary cemented stem. Short-stemmed endoprostheses conceivably have an increased risk of aseptic loosening. Extra-cortical plates have been added to minimise this risk by supplementing fixation. The aim of this study was to investigate the survivorship of short-stemmed endoprostheses and extra-cortical plates.

Aims

The aims of this retrospective study were to report the feasibility of using 3D-printing technology for patients with a pelvic tumour who underwent reconstruction.

Aims

Massive endoprostheses rely on extra-cortical bone bridging (ECBB) to enhance fixation. The aim of this study was to investigate the role of selective laser sintered (SLS) porous collars in augmenting the osseointegration of these prostheses.

Aims

The aim of this study was to establish what happens to patients in the long term after endoprosthetic replacement for a primary malignant tumour of bone.

Peri-acetabular tumour resections and their subsequent reconstruction are among the most challenging procedures in orthopaedic oncology. Despite the fact that a number of different pelvic endoprostheses have been introduced, rates of complication remain high and long-term results are mostly lacking.

In this retrospective study, we aimed to evaluate the outcome of reconstructing a peri-acetabular defect with a pedestal cup endoprosthesis after a type 2 or type 2/3 internal hemipelvectomy.

A total of 19 patients (11M:8F) with a mean age of 48 years (14 to 72) were included, most of whom had been treated for a primary bone tumour (n = 16) between 2003 and 2009. After a mean follow-up of 39 months (28 days to 8.7 years) seven patients had died. After a mean follow-up of 7.9 years (4.3 to 10.5), 12 patients were alive, of whom 11 were disease-free. Complications occurred in 15 patients. Three had recurrent dislocations and three experienced aseptic loosening. There were no mechanical failures. Infection occurred in nine patients, six of whom required removal of the prosthesis. Two patients underwent hindquarter amputation for local recurrence.

The implant survival rate at five years was 50% for all reasons, and 61% for non-oncological reasons. The mean Musculoskeletal Tumor Society score at final follow-up was 49% (13 to 87).

Based on these poor results, we advise caution if using the pedestal cup for reconstruction of a peri-acetabular tumour resection.

Cite this article: Bone Joint J 2014;96-B:1706–12.

The purpose of this study was to assess whether the use of a joint-sparing technique such as curettage and grafting was successful in eradicating giant cell tumours of the proximal femur, or whether an alternative strategy was more appropriate.

Between 1974 and 2012, 24 patients with a giant cell tumour of the proximal femur were treated primarily at our hospital. Treatment was either joint sparing or joint replacing. Joint-sparing treatment was undertaken in ten patients by curettage with or without adjunctive bone graft. Joint replacement was by total hip replacement in nine patients and endoprosthetic replacement in five. All 11 patients who presented with a pathological fracture were treated by replacement.

Local recurrence occurred in five patients (21%): two were treated by hip replacement, three by curettage and none with an endoprosthesis. Of the ten patients treated initially by curettage, six had a successful outcome without local recurrence and required no further surgery. Three eventually needed a hip replacement for local recurrence and one an endoprosthetic replacement for mechanical failure. Thus 18 patients had the affected joint replaced and only six (25%) retained their native joint. Overall, 60% of patients without a pathological fracture who were treated with curettage had a successful outcome.

Cite this article: Bone Joint J 2014;96-B:127–31.

Objectives

Guidelines for the management of patients with metastatic bone disease (MBD) have been available to the orthopaedic community for more than a decade, with little improvement in service provision to this increasingly large patient group. Improvements in adjuvant and neo-adjuvant treatments have increased both the number and overall survival of patients living with MBD. As a consequence the incidence of complications of MBD presenting to surgeons has increased and is set to increase further. The British Orthopaedic Oncology Society (BOOS) are to publish more revised detailed guidelines on what represents ‘best practice’ in managing patients with MBD. This article is designed to coincide with and publicise new BOOS guidelines and once again champion the cause of patients with MBD.

Reducing wear of endoprosthetic implants is still an important goal in order to increase the life time of the implant. Endoprosthesis failure can be caused by many different mechanisms, such as abrasive wear, corrosion, fretting or foreign body reactions due to wear accumulation. Especially, modular junctions exhibit high wear rates and corrosion due to micromotions at the connection of the individual components. The wear generation of cobalt-chromium-molybdenum alloys (CoCrMo) is strongly influenced by the microstructure. Therefore, the aim of this work is to investigate the subsurface phase transformation by deep rolling manufacturing processes in combination with a “sub-zero” cooling strategy. We analyzed the influence on the phase structure and the mechanical properties of wrought CoCr28Mo6 alloy (ISO 5832-12) by a deep rolling manufacturing process at various temperatures (+25°C,-10°C,-35°C) and different normal forces (700N and 1400N). Surface (S. a. ,S. z. ) and subsurface characteristics (residual stress) as well as biological behavior were investigated for a potential implant application. We showed that the microstructure of CoCr28Mo6 wrought alloy changes depending on applied force and temperature. The face centered cubic (fcc) phase could be transformed to a harder hexagonal-close-packed (hcp) phase structure in the subsurface. The surface could be smoothed (up to S. a. = 0.387 µm±0.185 µm) and hardened (≥ 700 HV 0.1) at the same time. The residual stress was increased by more than 600% (n=3). As a readout for metabolic activity of MonoMac (MM6) and osteosarcoma (SaOS-2) cells a WST assay (n=3) was used. The cells showed no significant negative effect of the sub-zero manufacturing process. We showed that deep rolling in combination with an innovative cooling strategy for the manufacturing process has a great potential to improve the mechanical properties of CoCr28Mo6 wrought alloy, by subsurface hardening and phase transformation for implant applications

The implantation of endoprosthesis is a routine procedure in orthopaedics. Endoprosthesis are mainly manufactured from ceramics, polymers, metals or metal alloys. To ensure longevity of the implants they should be as biocompatible as possible and ideally have antibacterial properties, to avoid periprosthetic joint infections (PJI). Various antibacterial implant materials have been proposed, but have so far only been used sporadically in patients. PJI is one of the main risk factors for revision surgeries. The aim of the study was to identify novel implant coatings that both exhibit antibacterial properties whilst having optimal biocompatibility. Six different novel implant coatings and surface modifications (EBM TiAl6V4, strontium, TiCuN, TiNbN, gentamicin phosphate (GP), gentamicin phosphate+cationic polymer (GP+CP)) were compared to standard CoCrMo-alloy. The coatings were further characterized with regard to the surface roughness. E. coli and S. capitis were cultured on the modified surfaces to investigate the antibacterial properties. To quantify bacterial proliferation the optical density (OD) was measured and viability was determined using colony forming units (CFU). Murine bone marrow derived macrophages (BMMs) were cultured on the surfaces and differentiated into osteoblasts to quantify the mineralisation using the alizarin red assay. All novel coatings showed reduced bacterial proliferation and viability compared to standard CoCrMo-alloy. A significant reduction was observed for GP and GP+CP coated samples compared to CoCrMo (OD. GP,E.coli. = 0.18±0.4; OD. GP+CP,E.coli. = 0.13±0.3; p≤0.0002; N≥7-8). An increase in osteoblast-mediated mineralisation was observed on all surfaces tested compared to CoCrMo. Furthermore, GP and GP+CP coated samples showed a statistically significant increase (M. GP. = 0.21±0.1; M. GP+CP. = 0.25±0.2; p<0.0001; N≥3-6). The preliminary data indicates that the gentamicin containing surfaces have the most effective antibacterial property and the highest osseointegrative capacity. The use of antibiotic coatings on prostheses could reduce the risk of PJI while being applied on osseointegrative implant surfaces

Aims

We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton.

Aims

Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

Purpose; To show that Distal Femoral Endoprosthetic Replacement for metastatic disease can be performed with relatively few complications and allows good pain control and mobilisation for otherwise severely compromised patients. Method; This is a retrospective study, using the oncology database, patient records and local correspondence, looking at 23 patients with distal femoral metastases who had limb salvage with a Distal Femoral Endoprosthesis (DF EPR). Results; There were 10 males (43%) and 13 females (57%), mean age 65 (38–84). 13 (57%) had Renal, 6 (26%) Breast and 5 other primaries identified. Five had additional metastases. 8 (35%) had pathological fractures. The mean time for diagnosis of mets was 67 months ranging from 0 (i.e. at the time of primary tumour) to 30 years since the original diagnosis. 15 patients had surgery alone. 3 patients were lost to follow up. 15 patients have diseased at a mean of 26 months (4–58) post op. There was one intra-op and four post-op complications. The majority of the patients were satisfied post op with regards to pain and mobility. The generally unfavourable prognosis and perceived risks have led surgeons to palliate, stabilise in situ or amputate for distal femoral metastases despite recognised morbidity and life style restrictions. We conclude that DF EPR should be considered as a limb salvage option in patients with distal femoral mets

Purpose of Study: To assess the safety of our practice of Bilateral Simultaneous Total Knee Replacements. Methods: We retrospectively reviewed 202 patients (404 knees) who underwent bilateral simultaneous total knee replacements using the DePuy PFC Sigma Cruciate Sacrificing Endoprosthesis between January 2000 and January 2006. There were 103 males and 99 females with an average age of 71.3 years (range 41–90 years) included. Indication for surgery was Osteoarthritis in 190 patients and Rheumatoid Arthritis in 12 patients. All patients were reviewed at 6 weeks, 1 year and then yearly post surgery. Results: The average hospital stay was 12.4 days (range 5–38 days) with 6 patients needing HDUadmission post surgery. The average observed blood loss in the drains post surgery was 1200ml (700–2600ml) with an average drop in Haemoglobin of 4.1%, 71% of patients needed a blood transfusion post surgery. Two patients (0.99%) developed a deep vein thrombosis and 2 patients (0.99%) developed a pulmonary embolus.3 (1.48%) deaths were encountered in the immediate post operative period (within 30 days of surgery) and 6 (2.9%) patients suffered a myocardial infarct post surgery.14 (6.9%) patients developed a superficial wound infection of which 10(4.9%) needed a formal washout. 8(3.96%)knees needed a manipulation under anaesthesia for a poor range of movement, and 2(.99%) needed revision total knee replacement for infection. Conclusion: Bilateral simultaneous total knee replacement is a safe procedure in our experience Complication rates observed comparable to published literature on the subject

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

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The aim of this study was to describe the use of 3D-printed sacral endoprostheses to reconstruct the pelvic ring and re-establish spinopelvic stability after total en bloc sacrectomy (TES) and to review its outcome.

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The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma.

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The aim of this study was to identify any progression between benign osteofibrous dysplasia (OFD), OFD-like adamantinoma and malignant adamantinoma, and to investigate the rates of local recurrence, metastases and survival, in order to develop treatment algorithms for each.

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Few studies dealing with chondrosarcoma of the pelvis are currently available. Different data about the overall survival and prognostic factors have been published but without a detailed analysis of surgery-related complications. We aimed to analyse the outcome of a series of pelvic chondrosarcomas treated at a single institution, with particular attention to the prognostic factors. Based on a competing risk model, our objective was to identify risk factors for the development of complications.

We investigated the functional outcome in patients who underwent reverse shoulder replacement (RSR) after removal of a tumour of the proximal humerus. A total of 16 patients (ten women and six men) underwent this procedure between 1998 and 2011 in our hospital. Five patients died and one was lost to follow-up. Ten patients were available for review at a mean follow-up of 46 months (12 to 136). Eight patients had a primary and two patients a secondary bone tumour.

At final follow up the mean range of active movement was: abduction 78° (30° to 150°); flexion 98° (45° to 180°); external rotation 32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity Salvage Score was 70% (30% to 91%). Two patients had a superficial infection and one had a deep infection and underwent a two-stage revision procedure. In two patients there was loosening of the RSR; one dislocated twice. All patients had some degree of atrophy or pseudo-atrophy of the deltoid muscle.

Use of a RSR in patients with a tumour of the proximal humerus gives acceptable results.

Cite this article: Bone Joint J 2013;95-B:1551–5.

Aims

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.

Aims

We present an audit comparing our level I major trauma centre’s data for a cohort of patients with hip fractures in the National Hip Fracture Database (NHFD) with locally held data on these patients.

We retrospectively studied local recurrence of giant cell tumour in long bones following treatment with curettage and cementing in 137 patients. The median follow-up time was 60 months (3 to 166). A total of 19 patients (14%) had at least one local recurrence, the first was diagnosed at a median of 17 months (3 to 29) after treatment of the primary tumour. There were 13 patients with a total of 15 local recurrences who were successfully treated by further curettage and cementing. Two patients with a second local recurrence were consequently treated twice. At the last follow-up, at a median of 53 months (3 to 128) after the most recent operation, all patients were free from disease and had good function.

We concluded that local recurrence of giant cell tumour after curettage and cementing in long bones can generally be successfully treated with further curettage and cementing, with only a minor risk of increased morbidity. This suggests that more extensive surgery for the primary tumour in an attempt to obtain wide margins is not the method of choice, since it leaves the patient with higher morbidity with no significant gain with respect to cure of the disease.

Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%).

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18).

Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.