The outcome of tibial allograft reconstruction after resection of a tumour is inconsistent and has a high rate of failure. There are few reports on the use of tibial allografts in children with open growth plates. We performed 21 allograft reconstructions (16 osteoarticular, five intercalary) in 19 consecutive patients between seven and 17 years of age. Two had Ewing’s sarcoma, one an adamantinoma and 16 osteosarcoma, one with multifocal disease. Five patients have died; the other 14 were free from disease at the time of follow-up. Six surviving patients (eight allograft reconstructions) continue to have good or excellent function at a mean of 59 months (14 to 132). One patient has poor function at 31 months. The other seven patients have a good or excellent function after additional procedures including exchange of the allograft and resurfacing or revision to an endoprosthesis at a mean of 101 months (43 to 198). The additional operations were performed at a mean of 47 months (20 to 84) after the first reconstruction. With the use of allograft reconstruction in growing children, joints and growth plates may be preserved, at least partially. Although our results remain inconsistent, tibial allograft reconstruction in selected patients may restore complete and durable function of the limb

Aim. There is insufficient evidence to support bony reconstruction of the pubis after a type III internal hemipelvectomy (resection of all or part of the pubis). In this study, we compared surgical complications, postoperative pain, and functional outcome in a series of patients who had undergone a type III internal hemipelvectomy with or without bony reconstruction. Methods. In a retrospective cohort study, 32 patients who had undergone a type III hemipelvectomy with or without allograft reconstruction (n = 15 and n = 17, respectively) were reviewed. The mean follow-up was 6.7 years (SD 3.8) for patients in the reconstruction group and 6.1 years (SD 4.0) for patients in the non-reconstruction group. Functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system and the level of postoperative pain with a visual analogue scale (VAS). Results. The mean MSTS score of the patients was significantly better in patients after reconstruction (26 (SD 1.7) vs 22.7 (SD 2.0); p < 0.001). The mean visual analogue scale score for pain was significantly less in the reconstruction group (2.1 (SD 2) vs 4.2 (SD 2.2); p = 0.016). One infection occurred in each group. Bladder herniation occurred in three patients (17.6%) in the non-reconstruction group but none in the reconstruction group. Five patients (29.4%) in the non-reconstruction group and one (7%) in the reconstruction group had a limp. Graft displacement occurred in two patients in the reconstruction group. Conclusion. We recommend reconstruction of the bony defect after a type III hemipelvectomy: it gives a better functional result, less postoperative pain, and fewer late surgical complications. Cite this article: Bone Joint J 2021;103-B(6):1155–1159

Aims. The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours. Methods. Medical profiles of 13 patients, who between March 2004 and November 2021 underwent osteoarticular ulna allograft reconstruction after the resection of the proximal ulna tumour, were retrospectively reviewed. The outcomes were measured clinically by the assessment of elbow range of motion (ROM), stability, and function, and radiologically by the assessment of allograft-host junction union, recurrence, and joint degeneration. The elbow function was assessed objectively by the Musculoskeletal Tumor Society (MSTS) score and subjectively by the Toronto Extremity Salvage Score (TESS) and Mayo Elbow Performance Score (MEPS) questionnaire. Results. The mean follow-up of patients was 60.3 months (SD 28.5). The mean elbow flexion-extension ROM was 95.8° (SD 21). The mean MSTS of the patients was 84.4 (SD 8.2), the mean TESS was 83.8 (SD 6.7), and the mean MEPS was 79.2 (SD 11.5). All the patients had radiological union at the osteotomy site. Symptomatic osteoarthritic change was observed in three patients (23%), one of whom ended up with elbow joint fusion. Two patients (15.4%) had recurrence during the follow-up period. Surgical complications included two allograft fractures, two plate fractures, three medial instabilities, and two infections. Conclusion. Osteoarticular ulna allograft reconstruction provides acceptable functional outcomes. Despite a high rate of complications, it is still a valuable reconstruction method, particularly in skeletally immature patients who need their distal humerus physis for the rest of hand growth. Cite this article: Bone Jt Open 2024;5(9):749–757

Introduction. Chronic ruptures of the quadriceps tendon after total knee arthroplasty (TKA) are rare but are a devastating complication. The objective of this study was to validate the use of fresh frozen total fresh quadriceps tendon allografts for quadriceps tendon reconstruction. The hypothesis of this work was that the graft was functional in more than 67% of cases, a higher percentage than the results of conventional treatments. Material – methods. We designed a continuous monocentric retrospective study of all patients operated on between 2009 and 2017 for a chronic rupture of the quadriceps tendon after TKA by quadriceps allograft reconstruction. The usual demographic and perioperative data and the rehabilitation protocols followed were collected. Initial and final radiographs were analyzed to measure patellar height variation. The main criterion was the possibility of achieving an active extension of the knee with a quadriceps contraction force greater than or equal to 3/5 or the possibility of lifting the heel off the ground in a sitting position. Results. 29 patients with 33 allografts were included; 3 iterative allografts were performed on ruptures of the initial transplant and 1 patient was grafted on both sides in one step. There were 21 women and 8 men with a mean age of 73 years, and a mean body mass index of 33 kg/m. 2. Ruptures occurred in 22 cases after chronic periprosthetic infection. Walking was allowed immediately in 29 cases, but free mobilization was delayed in 29 cases. Complications affected 22 cases, but the majority of complications were not related to allograft use (including infectious failures and periprosthetic fractures). After a mean follow-up of 52 months, 28 allografts were still in place, and 22 allografts were considered functional. The active quadriceps extension force was rated on average at 3.5/5. The average pre/post-operative patellar height differential was +2 mm. Discussion. This continuous series of 33 allografts is in line with recent publications on the subject. It confirms their negative impact on the functional outcome of the TKA. The complication rate is high but the specific complication rate is not prohibitive. Two thirds of transplants are functional in the long term. Early rehabilitation procedures can be used in these difficult patients with encouraging results. The management of chronic ruptures of the quadriceps tendon after TKA by quadriceps allograft must be part of the current therapeutic options

Extensor mechanism disruption in total knee arthroplasty (TKA) occurs infrequently but often requires surgical intervention. We compared two cohorts undergoing extensor mechanism allograft reconstruction, one group had an extensor mechanism rupture, and the other had a recurrent ankylosed knee. Thirteen consecutive patients with extensor mechanism disruption or ankylosis after TKA were treated. Two different types of extensor mechanism allografts were used: quadriceps tendon-patella-patella tendon-tibial tubercle, and Achilles tendon allograft(Fig1). Demographic factors, diagnosis at extensor failure, Knee Society clinical rating scores, radiographs, and patient satisfaction were recorded. The average time from extensor mechanism disruption to surgery was 6.6 months (range, 1-24 months). At a mean followup of 24 months (range, 6-46 months), all patients were community ambulators. None of the patients showed a postoperative extensor lag. Average postoperative maximum flexion was 97° (90-115°) for the ruptured group and 80° (75-90) for the ankylosed grup. All patients thought their functional status had improved, and 87% were satisfied with the results of the allograft reconstruction (Fig 2, 3, 4, 5). One patient had allograft failure due to recurrent infection after re-revision for sepsis. The total extensor mechanism allograft and Achilles tendon allograft both were successful in the treatment of the failed extensor mechanism and showed promising results for the treatment of the ankylosed knee

Allograft reconstruction of large defects after resection of malignant tumors is one option besides use of artificial and other biologic material. Allografts allow for a 1:1 reconstruction of the defect, while endoprosthetic reconstruction for its anchorage usually needs resection of more bone or joint structures and thus more loss of growth plates. Tibial allografts used in adults according to the literature and our own experience has been rather diasappointng – while in our experience in children they seem to function better. Patients and Methods: In 6 children with open growth plates 8 reconstructions with massive fresh frozen cry-preserved allografts have been performed. Age at surgery was 7, 8 (2 children), 9, 11 and 13 years. 4 osteoarticular reconstructions were performed (1 distal tibia, 2 proximal tibia), the others were proximal tibia epiphysis sparing reconstructions after transepiphysial proximal tbia resections. Results: All reconstructions between the recipient and allograft fused, except in one patient developing pseud-arthrosis at diaphysial level after irradiation. The joint function in 2 patients with osteoarticular allografts is excellent at 10 and 6 years f/u. One patient with an osteoarticular allograft died after 2 years from metastases, one needed replacement of the allograft because of a fracture at 4 years and at 6 y f/u of the second allograft is scheduled for resurfacing of the knee joint because of cartilage degeneration. In 4 transepiphyseal resectio-nas and reconstructions the joint fuction continues to be excellent at 1 to 5 year f/u. Conclusion: Allograft reconstructions of the tibia in growing children may have better results than in adults. This may be due to better incorporation. They may allow for partial or complete joint sparing and the growth plate of the joint partner . Good results definitely depend on the appropriate indication, choice of allograft and surgical Technique

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting. Cite this article: Bone Joint J 2024;106-B(5):425–429

Introduction: To evaluate the medium-term outcome of patients undergoing revision knee arthroplasty with structural allograft for uncontained defects.

Methods: We followed prospectively 50 patients undergoing 52 revision knee replacements with 66 structural grafts in three institutions. An independent investigator reviewed twenty-nine knees in 27 patients after a mean of 96.9 months.

Results: Twelve knees were re-revised at a mean of 70.7 months. Two of these patients retained their allografts. Eleven patients died with their structural allograft and implants intact and were not awaiting revision at a mean of 93 months.

Failure was defined as an increase of less than 20 points in the modified HSS knee score at the time of the review or the need for an additional operation related to the allograft. Thirteen knees were deemed to be failures giving a 75% success rate. Graft resorption occurred in five patients resulting in implant loosening. Four failed due to infection and non-union between the host bone and allograft was present in two. One patient with both knees grafted failed to gain a 20-point improvement. Survival analysis showed a 72% survival at 10 years. Clinically, the modified HSS score improved from a mean of 32.5 pre-operatively to 75.6 at the time of the review. Radiographic analysis of the surviving grafts showed no severe resorption, one moderate and two mild cases of resorption. Evaluation for loosening revealed one patient with a loose tibial component, while three patients had non-progressive tibial radiolucent lines. All four patients were asymptomatic.

Conclusions: Our results demonstrated encouraging medium-term survival of allografts utilised for revision knee replacement in a group of difficult patients with massive bone loss.

We reviewed 32 deep-frozen irradiated allografts used for the reconstruction of bone defects in 20 knees. They were subdivided into bulk grafts, cortical strut grafts, and morsellised bone. The average follow-up was 4.2 years (2 to 7.2). Radiographs showed union of the allograft to the host in all cases. Two allografts later fractured and three knees required further surgery because of infection. The allografts effectively filled large bone defects around the knee, lessening the need for custom-made and constrained prostheses.

Introduction: The reconstruction of the severely deficient proximal femur is more commonly achieved with a large composite proximal femoral allograft and a prosthesis.

Aim: To review our experience with this technique in 19 revision total hip arthroplasties (18 patients) treated between December 1988 and January 1997.

Cases: There were 15 females and three males. The average age was 56 years (32 to 78 years). The primary diagnoses included osteoarthritis (seven), rheumatoid arthritis (six), congenital dislocation (two), avascular necrosis (one), septic arthritis (one), and ankylosing spondylitis (one). Each underwent an average of three (range: one to 9) previous hip operations. The average time from the previous operation was 10.65 years (0.25 to 25). All hips had significant periprosthetic osteopenia and bone loss on preoperative radiographs. Five had previous infections with two subsequent Girdlestone arthroplasties. Six presented with periprosthetic fractures and loose components.

The hips were approached posteriorly. A step cut was used to secure the host to allograft junction. The femoral component was cemented within the allograft and with a press-fit in the host bone. All but three cases had iliac crest bone graft and/or residual host bone chips added to the host-allograft site. The acetabulum was revised concurrently in 13 (two whole acetabular allografts).

Results: The average period of follow-up was 57.6 months(range: 25 to 127 months). The time taken to heal was estimated radiographically as less than 8.5 months (range: three to 18 months). The average Harris Hip Scores improved from 25.6 to 75.53. One patient complained of persistent pain post-operatively. The complications included proximal migration of the greater trochanter in five, one infection that was converted to a Girdlestone excisional arthroplasty 27 months later, and seven patients with dislocations.

Conclusions: Allograft prosthetic reconstruction of the proximal femur is a durable construct with up to ten years follow-up. This technique preserved host bone while providing additional bone for future reconstruction. There was substantial improvement in function with low complication rates.

Introduction: Osteoarticular allograft represents a reliable option for distal femur reconstruction. The purpose of this study was to describe the technical details and results of distal femur tumor resection and reconstruction with an osteoarticular allograft.

Material and Methods: One hundred and twenty-two patients who received an osteoarticular allograft after distal femur resection were reviewed, with a mean follow-up of 7 years. Key points for successful fixation are allograft selection, absolute stability and satisfactory soft-tissue reconstruction at the time of surgery that allows aggressive rehabilitation. Survival of the allograft was estimated with the Kaplan-Meier method. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up.

Results: Three patients were lost to follow and twenty-three patients died for tumor related reasons without allograft failure. In the remaining 96 allografts, eighteen allografts failed due to 7 infections, 7 local recurrences, 1 massive resorption and 3 fractures. Overall allograft survival was 82% +/− 7.6% (+/− 2 SE) at five and ten years. Those patients who preserved the original allograft had an average functional score of 27 points and a mean radiographic score of 89%, which represents a good and excellent functional and radiographic result.

Discussion and conclusion: Osteoarticular allograft is a successful procedure for reconstruction of the distal femur. Adequate preoperative planning, careful surgical technique and aggressive rehabilitation lead to excellent function and low complication rate.

Low-grade surface tumours of bone may theoretically be treated by hemicortical resection, retaining part of the circumference of the cortex. An inlay allograft may be used to reconstruct the defect. Since 1988 we have performed 22 hemicortical procedures in selected patients with low-grade parosteal osteosarcoma (6), peripheral chondrosarcoma (6) and adamantinoma (10).

Restricted medullary involvement was not a contraindication for this procedure.

There was no evidence of local recurrence or distant metastasis at a mean follow-up of 64 months (27 to 135). Wide resection margins were obtained in 19 patients. All allografts incorporated completely and there were no fractures or infections. Fractures of the remaining hemicortex occurred in six patients and were managed successfully by casts or by osteosynthesis. The functional results were excellent or good in all except one patient.

Hemicortical procedures for selected cases of low-grade surface tumours give excellent oncological and functional outcomes. There was complete remodelling and fewer complications when compared with larger intercalary procedures. The surgery is technically demanding but gives good clinical results.

Purpose: Revision total knee arthroplasty (RTKA) is particularly difficult and results more variable than primary total knee arthroplasty due to the added problem of bone loss. Massive bone allografts have been proposed to restore bone stock and mechanical conditions as close to the physiological situation as possible. The purpose of this retrospective analysis was to assess clinical and radiological results after knee reconstruction with massive allografts in patients undergoing revision total knee arthroplasty.

Materials and method: This series included 14 patients who underwent a revision procedure between February 1990 and August 1998 for RTKA with segmentary bone loss and bone defects. This group included seven patients with mechanical failure and seven others with septic loosening. Reconstruction was achieved with a massive allograft sealed around a long stem cemented implant. The composite assembly was impacted into the patient’s bony segment. The allografts were used to reconstruct the distal femur in nine cases, the proximal tibia in one, and both in the others. The IKS score and radiographic homogenisation of the host-graft junction were assessment criteria.

Results: Mean follow-up was 50 months (24–110). Mean IKS score was significantly improved from 43 (11–70) pre-operatively to 75 (40–100) at last follow-up (Wilcoxon test, p = 0.002). At last follow-up, the flexion-extension amplitude was 91±10°. Radiographic integration of the allografts was achieved in 14 out of 18 grafts. Three allografts were resorbed leading to fracture with subsequent implant failure and a new revision in two. There were no infections.

Discussion and conclusion: Bone grafts may be a solution to the difficult problem of bone loss during RTKA. Massive grafts combined with long stem implants have given encouraging early and mid-term results. The duration of these results is under evaluation.

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients.

Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed.

Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery.

No septic complications occurred.

One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series.

Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score and a wrist-specific functional score (PRWE).

The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed.

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients.

Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed.

Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery.

No septic complications occurred.

One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series.

Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score, a wrist-specific functional score (PRWE) and a comprehensive evaluation of upper arm function score (DASH).

The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed.

Several stems have been used for revision of total hip replacement (THR). Moreover, management of proximal femoral bone loss at the time of revision THR remains one of the challenges for hip surgeons. Recently, impaction bone grafting has been suggested to resolve this problem, but it is a demanding technique that results in frequent complications. We have used the Wagner self-locking stem with cancellous chip allograft for reconstruction of proximal femoral bone defect during revision surgery since 1992. This study evaluated the midterm results of using Wagner revision stem with bone allograft for femoral revision of THR. We could evaluate forty-one femoral revisions performed between 1992 and 2005 using Wagner revision stem with bone allograft. All patients had been followed for a minimum of three years with a mean follow-up of 8.6 years. Preoperative radiological femoral bone defects were assessed and classified by Gustillo’s classification. Subsidence of the stem was measured on radiograms taken immediately after revision surgery and again at the latest follow-up. Femoral component fixation was graded as radiographic ingrowth, fibrous stable, or unstable according to the criteria described by Engh et al. The incidence of surgical complications was examined. Allografts were assessed for incorporation into host bone as evidenced by trabecular bridging of the host-graft interface. A clear reduction in density or breakdown of the allograft was defined as bone resorption. Kaplan-Meier survival analysis was performed. The end point was revision because of mechanical loosening of the stem. Bone defects were classified as: 10 hips type I, 20 hips type II, and 7 hips type III and 4 hips were a periprosthetic fracture. Subsidence was measured at the time of last follow-up in six hips (3, 3, 12, 16, 21, 30 mm). At the latest follow-up 37 of 41 stems were stable. Allograft incorporation could clearly be observed in the proximal femoral bone defects of 31 stems. Three stems were defined as showing bone resorption. Surgical complications included 11 intraoperative fractures, two femoral shafts were perforated during reaming, one dislocation postoperatively, and 3 greater trochanter pseudoarthroses. There was one deep infection, and these cases were excluded from survivorship analysis. One unstable stem and one stem with infection had to be revised. Kaplan-Meier survival was 97.1 % at 10 years. Wagner self-locking stem with allograft for reconstruction for proximal femoral bone defect in revision surgery is a beneficial procedure. However, because there is a high incidence of intraoperative fractures, surgery should be performed carefully

Several techniques have been described to reconstruct a mobile wrist joint after resection of the distal radius for tumour. We reviewed our experience of using an osteo-articular allograft to do this in 17 patients with a mean follow-up of 58.9 months (28 to 119).

The mean range of movement at the wrist was 56° flexion, 58° extension, 84° supination and 80° pronation. The mean ISOLS-MSTS score was 86% (63% to 97%) and the mean patient-rated wrist evaluation score was 16.5 (3 to 34). There was no local recurrence or distant metastases. The procedure failed in one patient with a fracture of the graft and an arthrodesis was finally required. Union was achieved at the host-graft interface in all except two cases. No patient reported more than modest non-disabling pain and six reported no pain at all. Radiographs showed early degenerative changes at the radiocarpal joint in every patient.

A functional pain-free wrist can be restored with an osteo-articular allograft after resection of the distal radius for bone tumour, thereby avoiding the donor site morbidity associated with an autograft. These results may deteriorate with time.

Introduction: Treatment of acetabular defects can be difficult, especially in case of roof destruction. Since 9 years, we use a variant of Paprosky’s technique which consists in rebuilding the roof by structural allograft and acetabular reinforcement ring. The purpose of this study is to present this technique and the follow up results.

Patients: This retrospective study concerns 21 patients (23 hips) with severe acetabular bone loss (8 cases of stage 2 and 15 cases of stage 3 of Paprosky): 4 septical and 19 aseptical loosening. Between 1998 and 2005, all patients were operated with the same surgical technique using an allogeneic structural allograft (femoral head or distal femur) and an acetabular reinforcement ring (20 of KERBOULL, 3 of GANZ) associated with a cemented PE cup.

Method: Review included a clinical and X-ray evaluation (analysis of the refocusing of the hip, the positioning and the stability of implants and the graft incorporation).

Results: Mean duration of follow-up is 3,5 years [1–8,3]. Preoperative PMA score rised from 6,6 [0–12] to 15,8 [12–18] in postoperative. There was no peroperative complication. After surgery, 2 cases of early hip dislocation required PE block; 2 cases of sepsis were treated, one by washing and one by a surgical revision. In 60% of cases, immediate total weight bearing was allowed.

The immediate postoperative X-rays showed that the rotation center of the hip was 5,2 mm [0–10] far from the ideal rotation center (26% of cases: 0 mm) and the PE cup was implanted with a lateral inclination of 42,5° [30–55]. In postoperative X-ray follow up, one case of acetabular aseptic loosening was found which didn’t need hip revision. In all other cases no modification of implants position neither of hip rotation center was noted. In 79% of cases, we had total graft incorporation; in 17% of cases, an non evolutive radiolucent area between graft and bone and in 4% of cases (loosening) a graft migration.

Conclusion: The use of a structural allograft combined with acetabular reinforcement ring allows hip reconstruction in severe acetabular bone loss with good medium term results.

Postoperative knee stability is critical in determining the success after reconstruction; however, only posterior and anterior stability is assessed. Therefore, this study investigates medial and lateral rotational knee laxity changes after partial and complete PCL tear and after PCL allograft reconstruction. The extending Lachman test assessed knee instability in six fresh-frozen human cadaveric knees. Tibia rotation was measured for the native knee, after partial PCLT (pPCLT), after full PCLT (fPCLT), and then after PCLR tensioned at 30° and 90°. In addition, tests were performed for the medial and lateral sides. The tibia was pulled with 130N using a digital force gauge. A compression load of 50N was applied to the joint on the universal testing machine (MTS Systems) to induce contact. Three-dimensional tibial rotation was measured using a motion capture system (Optotrak). On average, the tibia rotation increased by 33%-42% after partial PCL tear, and by 62%-75% after full PCL tear when compared to the intact case. After PCL reconstruction, the medial tibia rotation decreased by 33% and 37% compared to the fPCL tear in the case that the allograft was tensioned at 30° and 90° of flexion, respectively. Similarly, lateral tibial rotation decreased by 15% and 2% for allograft tensioned at 30° and 90° of flexion respectively, compared to the full tear. Rotational decreases were statistically significant (p<0.005) at the lateral pulling after tensioning the allograft at 90°. PCLR with the graft tensioned at 30° and 90° both reduced medial knee laxity after PCLT. These results suggest that while both tensioning angles restored medial knee stability, tensioning the Achilles graft at 30° of knee flexion was more effective in restoring lateral knee stability throughout the range of motion from full extension to 90° flexion, offering a closer biomechanical resemblance to native knee function

Aims. We retrospectively report our experience of managing 30 patients with a primary malignant tumour of the distal tibia; 25 were treated by limb salvage surgery and five by amputation. We compared the clinical outcomes of following the use of different methods of reconstruction. Patients and Methods. There were 19 male and 11 female patients. The mean age of the patients was 19 years (6 to 59) and the mean follow-up was 5.1 years (1.25 to 12.58). Massive allograft was used in 11 patients, and autograft was used in 14 patients. The time to union, the survival time of the reconstruction, complication rate, and functional outcomes following the different surgical techniques were compared. The overall patient survival was also recorded. Results. Out of 14 patients treated with an autograft, 12 (86%) achieved union at both the proximal and distal junctions. The time to union at both junctions of the autograft was significantly shorter than in those treated with an allograft (11.1 vs 17.2 months, p = 0.02; 9.5 vs 16.2 months, p = 0.04). The complication rate of allograft reconstruction was 55%. The five patients treated with an amputation did not have a complication. Out of the 25 patients who were treated with limb salvage, three (12%) developed local recurrence and underwent amputation. The mean functional Musculoskeletal Tumor Society (MSTS) score after autograft reconstruction was higher than after allograft reconstruction (81% vs 67%; p = 0.06), and similar to that after amputation (81% vs 82%; p = 0.82). The two- and five-year overall rates of survival were 83% and 70%, respectively. Conclusions. This consecutive case series supports the safety of limb salvage and the effectiveness of biological reconstruction after the resection of a primary tumour of the distal tibia. Autograft might be a preferable option. In some circumstances, below-knee amputation remains a valid option

Introduction. A deficient abductor mechanism leads to significant morbidity and few studies have been published describing methods for reconstruction or repair. This study reports the reconstruction of hip abductor deficiency using human allograft. Methods. All patients were identified as having deficient abductor mechanisms following total hip arthroplasty through radiographic assessment, MRI, clinical examination and intra-operative exploration. All patients underwent hip abductor reconstruction using a variety of human allografts including proximal humeral, tensor fascia lata, quadriceps and patellar tendon. The type of allograft reconstruction used was customized to each patient, all being attached to proximal femur, allograft bone adjacent to host bone, with cerclage wires. If a mid-substance muscle rupture was identified an allograft tendon to host tendon reconstruction was performed. Results. Allograft reconstruction was performed in 15 patients over 18 months. One patient had an abductor deficiency after a primary total hip. All patients had an abductor lurch gait and positive Trendelenburg test preoperatively. Manual muscle strength testing showed significant weakness with a mean MRC grade of 3+/5. Peri-trochanteric pain was cited as a significant complaint in > 80 % of patients. Proximal humeral allografts, with rotator cuff, were used in 8 patients, 5 had tensor fascia lata and the remainder had patella with attached tendon allograft. The majority of patients had a reduction in pain and 8/15 (53%) increased their abductor strength by almost a full grade. A reduced lurch was observed in 10 (66%) patients and one patient re-dislocated after a failed revision for instability. Conclusion. To our knowledge, this is the largest reported series of allograft reconstruction for a deficient abductor mechanism following hip arthroplasty. A viable solution is demonstrated, with promising early results for a difficult problem, utilizing a straightforward technique with low morbidity

Aims. To assess complications and failure mechanisms of osteoarticular allograft reconstructions for primary bone tumours. Patients and Methods. We retrospectively evaluated 38 patients (28 men, 74%) who were treated at our institution with osteoarticular allograft reconstruction between 1989 and 2010. Median age was 19 years (interquartile range 14 to 32). Median follow-up was 19.5 years (95% confidence interval (CI) 13.0 to 26.1) when 26 patients (68%) were alive. In addition, we systematically searched the literature for clinical studies on osteoarticular allografts, finding 31 studies suitable for analysis. Results of papers that reported on one site exclusively were pooled for comparison. Results. A total of 20 patients (53%) experienced graft failure, including 15 due to mechanical complications (39%) and three (9%) due to infection. In the systematic review, 514 reconstructions were analysed (distal femur, n = 184, 36%; proximal tibia, n = 136, 26%; distal radius, n = 99, 19%; proximal humerus, n = 95, 18%). Overall rates of failure, fracture and infection were 27%, 20%, and 10% respectively. With the distal femur as the reference, fractures were more common in the humerus (odds ratio (OR) 4.1, 95% CI 2.2 to 7.7) and tibia (OR 2.2, 95% CI 1.3 to 4.4); infections occurred more often in the tibia (OR 2.2, 95% CI 1.3 to 4.4) and less often in the radius (OR 0.1, 95% CI 0.0 to 0.8). Conclusion. Osteoarticular allograft reconstructions are associated with high rates of mechanical complications. Although comparative studies with alternative techniques are scarce, the risk of mechanical failure in our opinion does not justify routine employment of osteoarticular allografts for reconstruction of large joints after tumour resection. Cite this article: Bone Joint J 2017;99-B:522–30

Chronic extensor mechanism insufficiency around TKA is a very challenging pathology to treat. An insufficient extensor mechanism negatively affects implant survival and patient outcomes. There are several risk factors for extensor mechanism disruption and the surgeon should be aware and avoid these problems in the perioperative period. In appropriately selected patients, reconstruction of the extensor mechanism is a valid option. Whole extensor mechanism and Achilles tendon allograft reconstruction of the deficient extensor mechanism have been proposed with good early published results. These reconstructions, however, are expensive and with time may stretch and lead to recurrence of an extensor lag. An alternative to allograft, is the use of Marlex mesh as popularised by Browne and Hanssen. This technique uses a knitted monofilament polypropylene mesh that is secured to the patient's native lateral tissue and covered by an appropriately dissected and distalised vastus medialis muscle. The technique can be used for both patellar and quadriceps tendon deficiencies and can be done with or without implant revision and is currently the treatment of choice at the presenter's institution. The surgeon should be aware of the complexity and limitations of these three reconstructive techniques

INTRODUCTION. Allograft reconstruction after resection of primary bone sarcomas has a non-union rate of approximately 20%. Achieving a wide surface area of contact between host and allograft bone is one of the most important factors to help reduce the non-union rate. We developed a novel technique of haptic robot-assisted surgery to reconstruct bone defects left after primary bone sarcoma resection with structural allograft. METHODS. Using a sawbone distal femur joint-sparing hemimetaphyseal resection/reconstruction model, an identical bone defect was created in six sawbone distal femur specimens. A tumor-fellowship trained orthopedic surgeon reconstructed the defect using a simulated sawbone allograft femur. First, a standard, ‘all-manual’ technique was used to cut and prepare the allograft to best fit the defect. Then, using an identical sawbone copy of the allograft, the novel haptic-robot technique was used to prepare the allograft to best fit the defect. All specimens were scanned via CT. Using a separately validated technique, the surface area of contact between host and allograft was measured for both (1) the all-manual reconstruction and (2) the robot-assisted reconstruction. All contact surface areas were normalized by dividing absolute contact area by the available surface area on the exposed cut surface of host bone. RESULTS. The mean area of contact between host and allograft bone was 24% (of the available host surface area) for the all-manual group and 76% for the haptic robot-assisted group (p=0.004). CONCLUSIONS. This is the first report to our knowledge of using haptic robot technology to assist in structural bone allograft reconstruction of defects left after primary bone tumor resection. The findings strongly indicate that this technology has the potential to be of substantial clinical benefit. Further studies are warranted

Pupose: The purpose of this study was to analyze the outcome of proximal tibia osteoarticular allografts after tumor resections. Material amd Methods: We performed a retrospective study over 58 patients in which a proximal tibia allograft reconstruction was undertaken. All patients were followed for a minimum of 5 years and allografts survival from the date of implantation to the date of revision or the time of the latest follow-up was determined with the use of the Kaplan-Meier method. In all patients, the patellar tendon from the host was reattached by suturing to overlapped donor flaps. Patients were clinically evaluated with the MSTS score system. Results: The global rate of allograft survival was 65% +/− 12% (+/− 2 SE) at five and ten years, with no significant difference between patients who received chemotherapy and those who did not. Allografts needed to be removed in twenty patients due to 12 infection, 4 local recurrences and 4 fractures. Active knee extension was restored in all patients with an average functional score of 26.3 points. Discussion: Survival analysis showed that 65% of proximal tibia osteoarticular allograft reconstructions remain stable at five and ten years. Patellar tendon reconstruction with allogeneic tissue in proximal tibia allograft restores active knee extension with an excellent functional result. Despite the incidence of complications, proximal tibia osteoarticular allografts continue to be a very valuable reconstructive procedure for large defects after resection of bone tumors

The August 2012 Oncology Roundup. 360. looks at: prolonged symptom duration; peri-operative mortality and above-knee amputation; giant cell tumour of the spine; surgical resection for Ewing’s sarcoma; intercalary allograft reconstruction of the femur for tumour defects; and an induced membrane technique for large bone defects

Purpose. The management of moderate to large engaging Hill-Sachs lesions is controversial and surgical options include remplissage, allograft reconstruction, and partial resurfacing arthroplasty. Few in-vitro studies have quantified their biomechanical characteristics and none have made direct comparisons. The purpose of this study was to compare joint stability and range of motion (ROM) among these procedures using an in-vitro shoulder simulator. It was hypothesized that all procedures would prevent defect engagement, but allograft and partial resurfacing would most accurately restore intact biomechanics; while remplissage would provide the greatest stabilization, possibly at the expense of motion. Method. Eight cadaveric shoulders were tested on an active in-vitro shoulder simulator. Each specimen underwent testing in 11 conditions: intact, Bankart lesion, Bankart repair, and two unrepaired Hill-Sachs lesions (30% & 45%) which were then treated with each of the three techniques. Anterior joint stability, ROM in extension and internal-external rotation, and glenohumeral engagement were assessed. Stability was quantified as resistance, in N/mm, to an anteriorly applied load of 70N. Results. Remplissage significantly increased joint stiffness compared to both defects (6.43.8 N/mm, p=0.01) and the allograft and partial resurfacing (p <= 0.04). No technique significantly surpassed the stability of the intact state (p>0.05). In adduction, the remplissage significantly reduced internal-external rotation compared to both defects (p <= 0.01), but only the 30% repair caused a significant change compared to the intact state (14.511.3 N/mm, p=0.05). In abduction, all repairs reduced rotation ROM compared to the Hill-Sachs defect (>= 8.24o, p <= 0.04), but none with respect to the intact condition (p >= 0.05). Remplissage had significantly less extension than either resurfacing procedure (>= 15.4o, p <= 0.02) and resulted in a greater reduction in extension ROM for 45% defects compared to 30% defects (11.918.91, p=0.06). All unrepaired lesions engaged during extension. None of the remplissage or allograft reconstructions engaged, however, 75% of partial resurfacing arthroplasties partially engaged. Conclusion. This study is the first biomechanical evaluation to directly compare three surgical procedures for engaging Hill-Sachs lesions. Each procedure enhanced stability; however, the enhancement provided by the resurfacing repairs more closely resembled the intact state. Remplissage of the 30% and the 45% defects improved stability and eliminated glenohumeral engagement but caused significant and progressive reductions in ROM. In comparison, both the allograft and partial resurfacing procedures re-established ranges of motion approaching those of the intact joint; however, the partial resurfacing could not fully prevent engagement. These findings indicate that the effects of each technique are not equivalent and further clinical and biomechanical studies are required

Various arthroscopic techniques using differing graft materials have been described and present a potential alternative to arthroplasty for rotator cuff arthropathy. We describe the short-term outcomes of allograft reconstruction, having evolved of our surgical technique from graft interposition to superior capsule reconstruction (SCR). All patients with an irreparable tear, in the absence of clinical and radiograph evidence of osteoarthritis, who underwent an allograft (Graft Jacket. TM. ) reconstruction with either an arthroscopic interposition or SCR technique within our institution were included. A retrospective case note analysis was performed to ascertain perioperative details including total operating and consumable implant costs. 15 patients were in the interposition group, mean age 66 years (48–77). Mean postoperative follow-up time was 17 months (1.9 −27.8). The mean OSS improved from 30.6 to 35.7 (p<0.05). Additionally, mean pain scores out of 10 improved from 7.7 to 1.5 (p<0.01). Mean satisfaction for the surgery was 7.8 out of 10. Complications included 2 re-ruptures (13.3%), 1 infection (6.7%) and 1 case of no improvement (6.7%). In the SCR group, there were 10 patients, mean age 64.5 (56– 68 years). Half of these patients had previous rotator cuff surgery. Mean postoperative follow-up time was 8.7 months (1.9 – 16.3). The mean OSS improved from 24 to 32.9 (p<0.01). Similarly, pain scores decreased from 7.9 to 3.5 (p<0.01). Mean satisfaction was 7.2. Complications included 1 case of no improvement (10%) resulting in a reverse TSR and 1 re-rupture (10%). A formal, prospective comparison trial is advocated to determine if SCR is superior

Purpose: Local resection with or without irradiation is the primary treatment modality of soft tissue sarcomas. Adequate surgical margin is required for local tumour control and avoiding local recurrence. Adjacent bone should be included into the resection plan if the tumour is in the close proximity of the bone or cortical and medullary tumour invasion was present. Reconstruction method depends on the location. Methods: 25 patient (10 female, 15 male) with soft tissue sarcomas received local wide excision including adjacent bone between 1995–2007. Histological types were 3 MPNSTM, 3MFH, 10 Synovial sarcoma, 2 liposarcoma, 4 angiosarcoma, 2 fibrosarcoma, 1 Leiomyosarcoma. Localisations were 5 glutea, 9 thigh, 5 cruris, 1 forearm, 5 foot. In 8 patients with proximal bone resection including the joint surface prosthetic reconstruction were aplied. 6 Patients with intercalary resections required allograft reconstruction with I.M nail, 2 patients required autoclaved graft, 1 patient needed tricortical iliac autograft. 8 patients in the gluteal region required iliac and sacral resections without any bony reconstruction. 25 patient received irradiation. 16 of them had neoadjuant chemotherapy also. Results: At mean 64 mo.s follow up (min11–max159). Mean age was 44, 5 (min 18–max 71). Oncologically 17 patients were NED, 1 AWD, 7 DOD (2 with local recurrence). Regarding complications 7 patients developed local recurrence, 2 patient developed infection, 2 patient had developed wound healing. 5 of 7 local recurrences were amputated. 2 of them died of the disease. 2 local recurrences could be re-resected. Delayed wound healing and infection occured in the patients received preoperative chemotherapy and irradiation. Conclusion: If a large soft tissue sarcoma is in the close proximity of an adjacent bone or had cortical or medullary invasion, adjacent bone must be included in the resection plan so that a wide margin could be achieved. Reconstruction of the created bone defect in the weight bearing bone close to a major joint should be prosthetic reconstruction. Allograft reconstruction is recommended in the foot and upper extrimity. A thorough preoperative plan with appropriate imaging should be done and local resection should be performed precisely to achieve satisfactory wide margin which influences the both local and systemic outcome

Aims

Osteoarticular reconstruction of the distal femur in childhood has the advantage of preserving the tibial physis. However, due to the small size of the distal femur, matching the host bone with an osteoarticular allograft is challenging. In this study, we compared the outcomes and complications of a resurfaced allograft-prosthesis composite (rAPC) with those of an osteoarticular allograft to reconstruct the distal femur in children.

We undertook a retrospective review of 33 patients who underwent total femoral endoprosthetic replacement as limb salvage following excision of a malignant bone tumour. In 22 patients this was performed as a primary procedure following total femoral resection for malignant disease. Revision to a total femoral replacement was required in 11 patients following failed segmental endoprosthetic or allograft reconstruction. There were 33 patients with primary malignant tumours, and three had metastatic lesions. The mean age of the patients was 31 years (5 to 68). The mean follow-up was 4.2 years (9 months to 16.4 years). At five years the survival of the implants was 100%, with removal as the endpoint and 56% where the endpoint was another surgical intervention. At five years the patient survival was 32%. Complications included dislocation of the hip in six patients (18%), local recurrence in three (9%), peri-prosthetic fracture in two and infection in one. One patient subsequently developed pulmonary metastases. There were no cases of aseptic loosening or amputation. Four patients required a change of bushings. The mean Musculoskeletal Tumour Society functional outcome score was 67%, the mean Harris Hip Score was 70, and the mean Oxford Knee Score was 34. Total femoral endoprosthetic replacement can provide good functional outcome without compromising patient survival, and in selected cases provides an effective alternative to amputation

The purpose of this study was to assess the outcome of 15 patients (mean age 13.6 years (7 to 25)) with a primary sarcoma of the tibial diaphysis who had undergone excision of the affected segment that was then irradiated (90 Gy) and reimplanted with an ipsilateral vascularised fibular graft within it. The mean follow-up was 57 months (22 to 99). The mean time to full weight-bearing was 23 weeks (9 to 57) and to complete radiological union 42.1 weeks (33 to 55). Of the 15 patients, seven required a further operation, four to obtain skin cover. The mean Musculoskeletal Society Tumor Society functional score at final follow-up was 27 out of 30 once union was complete. The functional results were comparable with those of allograft reconstruction and had a similar rate of complication. We believe this to be a satisfactory method of biological reconstruction of the tibial diaphysis in selected patients

Aims: Massive allografts have been widely employed to replace skeletal defects after bone tumour resection. They have major advantages but the major concern is the long term behaviour of the implant. The aim of the present study was to evaluate the incidence of complications in allograft reconstruction and to describe the new techniques to decrease their rate. Methods: The present series includes 68 patients with 70 massive allografts operated from 1996 to 2002. 35 were males and 35 females with an average age of 31 years (4–79). The massive allograft was used as osteoarticular reconstruction in 28 cases, composite in 28, intercalary in 10, knee arthrodesis reconstruction in 3 and scapular replacement in one case. In 7 cases a vascularized fibula was associated. The femur was involved in 23 cases, the humerus in 16 and the tibia in 17, the pelvis in 7, the radius in 3, the scapula in 2 and patella and a finger in 1 case. Results: Infection rate on 68 cases was 6% (4 cases). All infections healed after surgical revision. Two patients were lost at fu and 10 patients have less than 12 months of fu. The 58 patients left have an average fu of 34 months (12–71). Among these patients 45% had one or more complications treated surgically and 2/3 of the cases healed. Non union rate was 12% and fracture rate 5%. Conclusion: Allograft reconstruction showed a high rate of complications. Almost half of the patients (45%) presented one or more complications which required surgery in 40% of cases. Aggressive antibiotic perioperative regimen and adequate soft tissue coverage of the graft may reduce the risk of infections. Biologic augmentation with vascularized grafts, bone marrow and/or growth factors may reduce non union rate. Cement filling of the graft and composite implant (with prosthesis association) have been introduced in order to decrease the risk of diaphyseal and articular fractures

Objective: The purpose of this study was to evaluate the effectiveness of surgical reconstruction of posttraumatic deformity. Posttraumatic kyphosis (PTK) causes pain, neurological deficit, sagittal imbalance, progressive deformity, cosmetic and functional deterioration. Its treatment is cause of controversy and technically demanding. There are few reviews in the literature about the results of its surgical treatment. Methods: From 1995 to 2002 twenty-one patients suffering from posttraumatic thoracolumbar kyphosis were operated. The average follow-up was 3.9 years (range 6 – 1 years). The average age was 38 years (range 23–62): 13 female and 8 male. All patients complained about vertebral pain, 16 located at the apex of the deformity, 2 patients in the lumbar area and 3 patients referred also pain above the lesion. Three patients had irradiated circumferential pain and 4 patients mild neurological deficit. Two patients showed sexual dysfunction. In one patient only anterior approach with allograft reconstruction and anterior plate fixation was performed. In 17 patients simultaneous or staged approach with posterior release, anterior discectomy and allograft reconstruction and posterior compressed instrumentation was performed. In three patients a posterior closing wedge osteotomy was performed. Results: Postoperative pain decreased from 7.5 to 2.8 (VAS). Functional status: preoperative 42.3 % and postoperative 13.8% (Oswestry score). There was no hardware failure. All cases showed solid fusion without significant loss of correction. The average corrected kyphosis was 27.3°. All patients were satisfied with their cosmetic result. No cavity drainage was performed in 2 patients with syringomielia. 1 of 4 patients with neurological deficit did not improve. Two patients had thoracic neuropathic postoperative pain; one of them needed pain clinic treatment until remission. One case had superficial infection. One patient showed a Chylous leakage. Discussion: Only few works analyze the results of surgical treatment of PTK. The controvesrsy between anterior-aposterior surgery versus posterior closing wedge osteotomy depens of classification of posttraumatic spinal deformities based on three criteria: the region involved, the neurological status and the presence of any sagittal or frontal plane deformities outsides the local kyphosis. Conclusions: Our results suggest that the double approach with anterior allograft and posterior instrumentation shows clinical and radiological efficacy for sagittal posttraumatic deformity. In spite of surgical risk, there have been few complications with a high rate of patient satisfaction

The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a suboptimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. For most patients, antibiotics alone are not an acceptable method of treatment, and surgery is necessary. The standard of care for established infection is two stage revision with antibiotic loaded cement during the interval period and parental antibiotic therapy for six weeks. Single stage revision may have economic and functional advantages, however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors. Our protocol has included single stage revision using antibiotic loaded cement in both THA and TKA. This was only undertaken when sensitive organisms were identified pre-operatively by aspiration and appropriate antibiotics were available to use in cement. Patients with immunocompromise, multiple infecting organisms or recurrent infection were excluded. Patients with extensive bone loss that required allograft reconstruction or where a cementless femoral component was necessary were also excluded. Our algorithm was validated first in the hip and extended to infected TKA in 2004. This protocol has now been applied in over 100 TKA revisions for infection between 2004 and 2009. Our single stage revision rate is now over 25%. We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two stage revision cases. Whilst our indications are arbitrary and not based on specific biomarkers, we present excellent results for selective single stage exchange. A minimum three year follow-up suggests that these patients have shorter hospital stays, higher satisfaction rates and better knee scores. An ongoing evaluation is in place. One stage revision arthroplasty for infection offers potential clinical and economic advantages in selected patients

Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Cite this article: Bone Joint J 2023;105-B(5):474–480.

We reviewed 29 patients who had undergone intercalary resection for malignant tumours. Of these, 14 had received segmental allograft reconstruction and 15 extracorporeally-irradiated autograft. At a mean follow-up of 71 months (24 to 132), 20 were free from disease, five had died and four were alive with pulmonary metastases. Two patients, one with an allograft and one with an irradiated autograft, had a local recurrence. Reconstruction with extracorporeally-irradiated autograft has a significantly lower rate of nonunion (7% vs 43%, p = 0.031) but an insignificantly higher rate of fracture (20% vs 14%, p = 0.535) than that with segmental allograft. Using the Enneking functional evaluation system, the mean postoperative score for the patients without local recurrence was 87% (80% to 96%) and was similar in both groups. Extracorporeally-irradiated autograft could be an acceptable alternative for reconstruction after intercalary resection, especially in countries where it is difficult to obtain allografts

The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a suboptimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. For most patients, antibiotics alone are not an acceptable method of treatment, and surgery is necessary. The standard of care for established infection is two-stage revision with antibiotic loaded cement during the interval period and parental antibiotic therapy for six weeks. Single stage revision may have economic and functional advantages however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors. Our protocol has included single stage revision using antibiotic loaded cement in both THA and TKA. This was only undertaken when sensitive organisms were identified pre-operatively by aspiration and appropriate antibiotics were available to use in cement. Patients with immunocompromise, multiple infecting organisms or recurrent infection were excluded. Patients with extensive bone loss that required allograft reconstruction or where a cementless femoral component was necessary were also excluded. Our algorithm was validated first in the hip and extended to infected TKA in 2004. This protocol has now been applied in over 100 TKA revisions for infection between 2004 and 2009. Our single stage revision rate is now over 25%. We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two-stage revision cases. Whilst our indications are arbitrary and not based on specific biomarkers, we present excellent results for selective single stage exchange. A minimum three-year follow-up suggests that these patients have shorter hospital stays, higher satisfaction rates and better knee scores. An ongoing evaluation is in place. One-stage revision arthroplasty for infection offers potential clinical and economic advantages in selected patients

Aims

The standard of surgical treatment for lower limb neoplasms had been characterized by highly interventional techniques, leading to severe kinetic impairment of the patients and incidences of phantom pain. Rotationplasty had arisen as a potent limb salvage treatment option for young cancer patients with lower limb bone tumours, but its impact on the gait through comparative studies still remains unclear several years after the introduction of the procedure. The aim of this study is to assess the effect of rotationplasty on gait parameters measured by gait analysis compared to healthy individuals.

Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours.

Cite this article: Bone Joint J 2022;104-B(12):1284–1291.

Aims

Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm.

Aims

Ilium is the most common site of pelvic Ewing’s sarcoma (ES). Resection of the ilium and iliosacral joint causes pelvic disruption. However, the outcomes of resection and reconstruction are not well described. In this study, we report patients’ outcomes after resection of the ilium and iliosacral ES and reconstruction with a tibial strut allograft.

Aims

The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol.

Aims

Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS).

Aims

The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula.

Acetabular reconstruction of extensive bone defect is troublesome in revision total hip arthroplasty (rTHA). Kerboull or Kerboull type reinforcement acetabular device with allobone grafting has been applied since 1996. Clinical results of the procedure were evaluated. Patients. One hundred and ninety-two consecutive revision total hip arthroplasties were performed with allograft bone supported by the Kerboull or Kerboull type reinforcement acetabular device from 1996 to 2009. There were 23 men and 169 women. Kerboull plates were applied to 18 patients, and Kerboull type plates to 174. The mean follow up of the whole series was 8 years (4–18years). Surgical Technique. The superior bone defect was reconstructed principally by a large bulky allo block with plate system. Medial bone defect was reconstructed by adequate bone chips and/or sliced bone plates. After temporally fixation of bulky bone block with two 2.0mm K-wires, it was remodeled by reaming to fit the gap between host bone and plate, followed by fixation to the iliac bone by screws. Finally, residual space of the defect between host bone and the fixed plated was filled up with morselized cancellous bones, bone chips, and/or wedged bony fragments with impaction. This method was sufficiently applicable to AAOS Typeâ�, II, and III bone defects. In case of AAOS Typeâ�£, the procedure was also available after repairing discontinuation between distal and proximal bones by reconstrusion plate or allografting with tibial bone plates or sliced femoral head. Results. Nine patients (4.7%) required revision surgery (infection 5, breakage 3, and malalignment 1). The plate breakage was observed in 8 joints (4.2%). Three patients had no symptoms after the breakage. Three required revision, but the other cases were carefully observed without additional surgical intervention. Ten-year survival rate by Kaplan-Meier method was 96.6% when the endpoint was set revision by asceptic loosning. Conclusions. This study indicated that acetabular allograft reconstructions reinforced by Kerboull or Kerboull type acetabular device were able to recover bone stock with anatomic reconstruction of femoral head center, thus providing satisfactory clinical results in middle term period

Aims

Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery.

Aims

Giant cell tumour of bone (GCTB) is a locally aggressive lesion that is difficult to treat as salvaging the joint can be associated with a high rate of local recurrence (LR). We evaluated the risk factors for tumour relapse after treatment of a GCTB of the limbs.

Aims

Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture.

There is a difference between “functional instability” of a total knee arthroplasty (TKA) and a case of “TKA instability”. For example a TKA with a peri-prosthetic fracture is unstable, but would not be considered a “case of instability”. The concept of “stability” for a TKA means that the reconstructed joint can maintain its structure and permit normal motion and activities under physiologic loads. The relationship between stability and alignment is that stability maintains alignment. Instability means that there are numerous alignments and almost always the worst one for the loading condition. In the native knee, “instability” is synonymous with ligament injury. If this were true in TKA, then it would be reasonable to treat every “unstable TKA” with a constrained implant. But that is NOT the case. If the key to successful revision of a problem TKA is understanding (and correcting) the specific cause of the problem, then deep understanding of why the TKA is unstable is essential. A case of true “instability” then, is the loss of structural integrity under load as the result of problems with soft tissue stabilizing structures and/or the size or position of components. It is rare that ligament injury alone is the sole cause of instability (valgus instability invariably involves valgus alignment; varus instability usually means some varus alignment and compromised lateral soft tissues). There will be forces (structures) that create instability and forces (structures) that stabilise. There are three categories of instability: Varus-valgus or coronal: Assuming that the skeleton, implant and fixation are intact. These are usually cases that involve ligament compromise, but the usual cause is CORONAL ALIGNMENT, and this must be corrected. The ligament problem is best solved with mechanical constraint. Gait disturbances that increase the functional alignment problems (hip abductor lurch causing a valgus moment at the knee, scoliosis) may require attention of additional compensation with re-alignment. Plane of motion: Both fixed flexion contractures and recurvatum may result in buckling. The first by exhaustion of the quadriceps (consider doing quadriceps “lunges” with every step) and the second because recurvatum is usually a compensation for extensor insufficiency. The prototype for understanding recurvatum has always been polio. This is perhaps one of the most difficult types of instability to treat. The glib answer has been a hinged prosthesis with an extensor stop but there are profound mechanical reasons why this is flawed thinking. The patient with recurvatum instability due to neurologic compromise of the extensor should be offered an arthrodesis, which they will likely decline. The simpler problem of recurvatum secondary to a patellectomy will benefit from an allograft reconstruction of the patella using a modified technique. A common occurrence is obesity with patellofemoral pain, that the patient has managed with a “patellar avoidance” or “hyperextension gait”. Plane of motion instability is a problem of the EXTENSOR MECHANISM DEFICIENCY. Flexion instability. This results from a flexion gap that is larger than the extension gap, where a polyethylene insert has been selected that permits full extension but leaves the flexion gap unstable. These patients achieve remarkable flexion easily and early, but have difficulties with pain and instability on stairs, with recurrent (non-bloody) effusions and peri-articular tenderness. Revision surgery is necessary. Flexion instability may also occur with posterior stabilised prostheses. So-called “mid-flexion” instability is a contentious concept, poorly understood and as yet, not a reported cause for revision surgery distinct from “FLEXION INSTABILITY”. Flexion instability is a problem of GAP BALANCE