Structural allografts may be used to manage uncontained bone defects in revision total knee replacement (TKR). However, the availability of cadaver grafts is limited in some areas of Asia. The aim of this study was to evaluate the mid-term outcome of the use of femoral head allografts for the reconstruction of uncontained defects in revision TKR, focusing on complications related to the graft.

We retrospectively reviewed 28 patients (30 TKRs) with Anderson Orthopaedic Research Institute (AORI) type 3 bone defects, who underwent revision using femoral head allografts and stemmed components. The mean number of femoral heads used was 1.7 (1 to 3). The allograft–host junctions were packed with cancellous autograft.

At a mean follow-up of 76 months (38 to 136) the mean American Knee Society knee score improved from 37.2 (17 to 60) pre-operatively to 90 (83 to 100) (p < 0.001). The mean function score improved from 26.5 (0 to 50) pre-operatively to 81 (60 to 100) (p < 0.001). All the grafts healed to the host bone. The mean time to healing of the graft was 6.6 months (4 to 16). There have been no complications of collapse of the graft, nonunion, infection or implant loosening. No revision surgery was required.

The use of femoral head allografts in conjunction with a stemmed component and autogenous bone graft in revision TKR in patients with uncontained bone defects resulted in a high rate of healing of the graft with minimal complications and a satisfactory outcome. Longer follow-up is needed to observe the evolution of the graft.

Cite this article: Bone Joint J 2013;95-B:643–8.

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

Aims. Although internal hemipelvectomy is associated with a high incidence of morbidity, especially wound complications, few studies have examined rates of wound complications in these patients or have identified factors associated with the consequences. The present study aimed to: 1) determine the rate of wound and other complications requiring surgery after internal hemipelvectomy; and 2) identify factors that affect the rate of wound complications and can be used to stratify patients by risk of wound complications. Methods. The medical records of 123 patients undergoing internal hemipelvectomy were retrospectively reviewed, with a focus on both overall complications and wound complications. Logistic regression analyses were performed to examine the association between host, tumour, and surgical factors and rates of postoperative wound complications. Results. The overall rate of postoperative complications requiring surgery was 49.6%. Wound complications were observed in 34.1% of patients, hardware-related complications in 13.2%, graft-related complications in 9.1%, and local recurrence in 5.7%. On multivariate analysis, extrapelvic tumour extension (odds ratio (OR) 23.28; 95% confidence interval (CI), 1.97 to 274.67; p = 0.012), both intra- and extrapelvic tumour extension (OR 46.48; 95% CI, 3.50 to 617.77; p = 0.004), blood transfusion ≥ 20 units (OR 50.28; 95% CI, 1.63 to 1550.32; p = 0.025), vascular sacrifice of the internal iliac artery (OR 64.56; 95% CI, 6.33 to 658.43; p < 0.001), and use of a structural allograft (OR, 6.57; 95% CI, 1.70 to 25.34; p = 0.001) were significantly associated with postoperative wound complications. Conclusion. Internal hemipelvectomy is associated with high rates of morbidity, especially wound complications. Several host, tumour, and surgical variables are associated with wound complications. The ability to stratify patients by risk of wound complications can help refine surgical and wound-healing planning and may lead to better outcomes in patients undergoing internal hemipelvectomy. Cite this article: Bone Joint J 2020;102-B(3):280–284

Introduction: Anterior cervical discectomy and inter-body fusion (ACDF) is recognised as an effective surgical treatment for cervical degenerative disc disease. The goals of anterior discectomy, interbody graft placement, and subsequent fusion, are to improve and maintain intervertebral height, establish and maintain physiological cervical lordosis, and achieve arthrodesis so as to eliminate pathological motion. Establishing the most clinically effective and cost effective operative approach to achieve these goals while, at the same time, minimising post-operative complications, is currently an evolving process. One view is that the use of anterior cervical plates reduces graft-related complications, maintains the cervical alignment, and leads to a higher incidence of fusion. In addition, there is evidence to suggest that there is a direct cost benefit of earlier return to pre-operative function and employment. Bone graft: Iliac crest autograft would be regarded as the gold standard source of bone for ACDF. However, donor site complications (due to harvesting autograft) are not insignificant and range from 1% to a sizeable 29%. These complications include iliac crest fracture, infection, persisting pain, neural injury, bowel injury, etc. With the advent of bone banks, allograft has become available and eliminates the problem of graft-harvest related complications. There is a theoretical risk of disease transmission and a corresponding difficulty with patients accepting donated tissue. To date, no HIV cases transmission has occurred from ACDF allograft. There are several studies that demonstrate a significant difference in fusion rates when comparing allograft and autograft. The preponderance of data from the literature supports the conclusion that the use of allograft in ACDF can lead to a higher incidence of graft collapse, pseudarthrosis, and possible subsequent revision surgery. Bishop et al., (Spine 1991 16:726–9): have documented a higher increase in pseudarthrosis rate, graft collapse, and interspace angulation in the allograft group compared to the autograft group. Therefore, the dilemma of allograft being preferred as a basis of eliminating graft harvesting complications, while at the same time being associated with a higher incidence of fusion failure and deformity, have led some surgeons to trial the combination of allograft with anterior plate fixation. Shapiro (J Neurosurg 1966 84:161–5) has reported no incidences of fusion failure, graft collapse, progressive kyphosis, or plate-related complications in 82 consecutive single and multiple level ACDF’s using allograft and anterior plating. Treatment failure: The incidence of the following complications have been reported in the literature. (Graham JJ. Spine 1989 14:1046–50). Pseudarthrosis – 3%–36%. Graft collapse – 3%–14%. Graft extrusion – 0.5%–4%. These figures are regardless of the graft source and are significant. Recent studies show that the combination of graft and anterior plate fixation virtually eliminates the complication of graft extrusion, and also decreases the risk of graft collapse and development of pseudarthrosis. There are also studies that contend that plate fixation can maintain proper lordotic alignment of the spine more effectively than can ACDF without plating. I contend that the use of contemporary cervical plates significantly decreases the rate of fusion failure and graft-related complications without imparting significant implant-related complications. As a result, there is decreased overall risk to the patient. The current type of plates which are available are unicortical with locking systems that substantially decrease the risk of screw loosening or hardware migration

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

Matrix-induced autologous chondrocyte implantation (MACI) is an established technique used to treat osteochondral lesions in the knee. For larger osteochondral lesions (> 5 cm. 2. ) deeper than approximately 8 mm we have combined the use of two MACI membranes with impaction grafting of the subchondral bone. We report our results of 14 patients who underwent the ‘bilayer collagen membrane’ technique (BCMT) with a mean follow-up of 5.2 years (2 to 8). There were 12 men and two women with a mean age of 23.6 years (16 to 40). The mean size of the defect was 7.2 cm. 2. (5.2 to 12 cm. 2. ) and were located on the medial (ten) or lateral (four) femoral condyles. The mean modified Cincinnati knee score improved from 45.1 (22 to 70) pre-operatively to 82.8 (34 to 98) at the most recent review (p < 0.05). The visual analogue pain score improved from 7.3 (4 to 10) to 1.7 (0 to 6) (p < 0.05). Twelve patients were considered to have a good or excellent clinical outcome. One graft failed at six years. The BCMT resulted in excellent functional results and durable repair of large and deep osteochondral lesions without a high incidence of graft-related complications

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

Autologous chondrocyte implantation (ACI) is used widely as a treatment for symptomatic chondral and osteochondral defects of the knee. Variations of the original periosteum-cover technique include the use of porcine-derived type I/type III collagen as a cover (ACI-C) and matrix-induced autologous chondrocyte implantation (MACI) using a collagen bilayer seeded with chondrocytes. We have performed a prospective, randomised comparison of ACI-C and MACI for the treatment of symptomatic chondral defects of the knee in 91 patients, of whom 44 received ACI-C and 47 MACI grafts.

Both treatments resulted in improvement of the clinical score after one year. The mean modified Cincinnati knee score increased by 17.6 in the ACI-C group and 19.6 in the MACI group (p = 0.32). Arthroscopic assessments performed after one year showed a good to excellent International Cartilage Repair Society score in 79.2% of ACI-C and 66.6% of MACI grafts. Hyaline-like cartilage or hyaline-like cartilage with fibrocartilage was found in the biopsies of 43.9% of the ACI-C and 36.4% of the MACI grafts after one year. The rate of hypertrophy of the graft was 9% (4 of 44) in the ACI-C group and 6% (3 of 47) in the MACI group. The frequency of re-operation was 9% in each group.

We conclude that the clinical, arthroscopic and histological outcomes are comparable for both ACI-C and MACI. While MACI is technically attractive, further long-term studies are required before the technique is widely adopted.