Aims. The aim of this study was to present the long-term surgical outcomes, complications, implant survival, and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins. Patients and Methods. A cohort of 50 consecutive patients who underwent the modified Harrington procedure for periacetabular metastasis or haematological malignancy between January 1996 and April 2018 were studied. The median follow-up time for all survivors was 3.2 years (interquartile range 0.9 to 7.6 years). Results. The five-year overall survival rate was 33% for all the patients. However, implant survival rates were 100% and 46% at five and ten years, respectively. Eight patients survived beyond five years. There was no immediate perioperative mortality or complications. A total of 15 late complications occurred in 11 patients (22%). Five patients (10%) required further surgery to treat complications. The most frequent complication was pin breakage without evidence of acetabular loosening (6%). Two patients (4%) underwent revision for aseptic loosening at 6.5 and 8.9 years after surgery. Ambulatory status and pain level were improved in 83% and 89%, respectively. Conclusion. The modified Harrington procedure for acetabular destruction has low complication rates, good functional outcome, and improved pain relief in selected patients. Cite this article: Bone Joint J 2019;101-B:1557–1562

Aim. We present the long-term surgical outcomes, complications, implant survival and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins. Patients and Methods. A cohort of 50 consecutive patients who underwent the modified Harrington procedure along with cemented THA for peri-acetabular metastasis or haematological malignancy between 1990 and April 2018 were studied. The median follow-up time for all patients was 14 years (interquartile range, 9 – 16 years). Results. The 5-year overall survival rate was 33% for all the patients. However, implant survival rates were 100% and 46% at 5 and 10 years respectively. Eight patients survived beyond 5 years. There was no immediate peri-operative mortality or complications. Fifteen late complications occurred in 11 patients (22%). Five (10%) patients required additional surgeries to treat complications. The most frequent complication was pin breakage without evidence of acetabular loosening (6%). Two patients (4%) underwent revision for aseptic loosening at 6.5 and 8.9 years after surgery. Ambulatory status improved in 83%. Conclusions. The modified Harrington procedure for acetabular destruction showed low complication rates, good functional outcome and improved pain relief in selected patients. Long-term results are acceptable in this high risk group of patients. The described procedure using antegrade fully threaded large diameter pins combined with standard arthroplasty showed low rates of complications in this high risk cohort of patients with significant improvement in mobility and pain. This method of reconstruction remains robust for at least 5 years in appropriately selected group of patients

Introduction: The aim of this study is to compare the efficacy of the AO Universal Spine System (AO USS) with Harrington-Luque instrumentation for the treatment of King type II idiopathic scoliosis. Methods/Results: A retrospective analysis was performed on two groups of patients with King II adolescent idiopathic scoliosis. The first group consisted of 40 consecutive patients treated with Harrington-Luque instrumentation between 1990 and 1993. The second group consisted of 25 consecutive patients treated with AO USS instrumentation between 1994 and 1996. The groups were well matched with respect to age, sex and curve severity. Inclusion criteria were patients over the age of 12 years with a King II curve pattern and a Cobb angle of greater than 40°. Half of the patients in each group underwent anterior release prior to posterior fusion. All patients were followed up six monthly for 18 months. The thoracic curve, lumbar curve, kyphosis and lordosis were measured using the Cobb method. The mean pre-operative thoracic and lumbar curves were 62° and 43.9° respectively in the Harrington group and 57.5° and 35.9° in the AO USS group. On average 11.4 levels were fused in the Harrington group compared to 10.9 levels in the AO USS group. The mean post-operative correction of the thoracic curve in the AO USS group of 64% was significantly greater than the 51% achieved in the Harrington group (p< 0.005). At 18 months there was a 7% loss of correction in the Harrington group and 9% in the AO USS group. The correction of lumbar curve of 41% in the Harrington group and 46% in the AO USS group at 18 months was not significantly different. In the sagittal plane the AO USS group had significantly better preservation of the lumbar lordosis but there was no difference in kyphosis correction. Blood loss was similar in both groups. Mean operative time of 132 minutes in the AO USS group was shorter than the mean time of 153 minutes in the Harrington group (p< 0.05). Two hooks in the Harrington group became dislodged and two in the AO group. There were no neurological complications in either group. All the patients in both groups achieved a solid fusion. Conclusion: AO USS is a safe and effective instrumentation system for the treatment of King type II adolescent idiopathic scoliosis. Correction of the thoracic curve is superior to that achieved with Harrington-Luque instrumentation and operative time is shorter. AO USS enables better preservation of the lumbar lordosis than Harrington-Luque. There is no difference in blood loss, complication rate and fusion rates between the two techniques. It has become our instrumentation system of choice for this group of patients

Study design: To analyse the long term effect of Harrington Instrumentation and fusion to the lumbar spine in the treatment of idiopathic scoliosis. Objectives: To demonstrate there is a relationship between the strategy used (determination of fusion area) and pain or degenerative changes. Summary of background data: The literature has been fairly controversial in terms of pain and degenerative changes beyond a fusion for idiopathic scoliosis according as the lower level of fusion. This is the first study in which the results are analysed according as the “strategy used” and not the sole level of fusion. Methods: 250 patients operated on by Harrington instrumentation were clinically and radiographically reviewed. Pain was classified (as Moskowitz and Moe). To be included they should have an idiopathic scoliosis, a minimum follow up of 20 years (mean 26, max 36), 37% over 30 years, had to have been under 20 years at the time of surgery, and should have a full set of radiographs. Curves were classified according to our own classification (Salanova et al) 1973–2000 in single structural. Thoracic 114, thoraco-lumbar 21 and double structural thoracic and lumbar, true double major (52), false D.M. (45). The double thoracic was identified with permanent T1 tilt (18). On P.OP standing the lower level of fusion was identified: E.V. (Salanova et al 1973–2000) SV (King) other vertebra. On follow up radiographs standing coronal and sagittal, lumbar coronal and sagittal degenerative changes were evaluated, slipping lateral and sagittal, discopathy over 50% and classified as none, moderate, complete. Results: Mean age at surgery 15 years + 6. Mean age at follow up 49 years. Ten patients were reoperated on for various reasons. Overall results: Pain none 70, episodic 82, frequent 42, permanent 46. Degenerative changes none 155, moderate 62, complete 23. These data were evaluated according to the strategy used; there is a strong statistical relationship between strategy and final results. Our study proves that King’s classification for so-called King II curves is misleading. Conclusion: This study is the most important ever published in terms of patients, methodology, and follow up. It shows that if a clear analysis of curve(s) before surgery is effectuated for determination of fusion area, if for single curves the lower level of fusion is the good one and for double structural the choice between selective thoracic fusion and double fusion is correctly determinated the long term results are not so bad

1. Twelve patients with suspected pseudarthroses in previous spine grafts were subjected to operation. 2. Correction of the curves was produced by Harrington's instrumentation at the sites of pseudarthroses, osteotomies and fractures. 3. A significant increase in stature was produced in all the patients. 4. Harrington's hooks were safely inserted into cavities cut in intact portions of previous grafts. 5. Most patients were able to leave hospital in less than four weeks. 6. Deliberate bending of the Harrington rods has not led to subsequent fracture of the rod. 7. A sliding scoliosis fusion frame is described. It reduces friction during correction and it reduces haemorrhage during surgery

Introduction: In 1962 Harrington published his method of spinal instrumentation in scoliosis treatment. 256 patients have been treated with this instrumentation at the Hospital for Orthopaedic Surgery Stolzalpe in the years of 1968 –1992. Material & Methods: A retrospective study was performed on 74 patients (48 female, 26 male) with a mean follow up time of 22,5 years. A clinical examination, x-ray, spirometry was performed as well as the Oswestry Score and the Visual Analogue Scale test (VAS) to determine the patients confidence and possibilities in activities of daily living (ADL), profession and sports. Also the ROM of the spine, degeneration of the adjacent levels and loss of correction were a subject of interest. Results: All patients were satisfied or very satisfied and there were no severe restrictions in their ADL. 92 % are busy in the normal working process, 61 % do sports without complaints. The mean Oswestry Score was 9 pts (1–12,5) and the average VAS was 1,1 of 10 (0–4), with major problems in sitting and standing. Spirometry was restricted in 33%, movement was limited in side bending in nearly all patients. Conclusion: Although with Harrington’s method no segmental correction was possible and long time casting and orthetic aids were necessary, we found very confident patients without major restrictions in daily life. Similar long term results with modern methods and instruments have to be proven

Adolescent idiopathic scoliosis in 152 patients was treated by Luque L-rod instrumentation and early mobilisation without external support. This series was compared with a matched group of 156 patients treated by Harrington instrumentation and immobilised in an underarm jacket for nine months. All the operations in both groups were performed by one surgeon and the patients were followed prospectively for more than two years. Correction of the scoliosis in the frontal plane was similar in both groups. However, the normal sagittal contour was better maintained with Luque rods, especially in the thoracolumbar and lumbar regions, and provided less loss of correction than with Harrington rods. Neither method significantly derotated the scoliosis. All the patients with Luque instrumentation developed a solid fusion despite breakage of the sublaminar wires at one or two levels in 4.9%. There were no major neurological complications with either type of instrumentation

The results of the use of Harrington rods in the treatment of spinal fractures were reviewed. It was found that with burst fractures where the anterior pillar was deficient there was a significant incidence of loss of reduction. Anterior bone supplementation is recommended in these fractures when major loss of height or angulation occurs. Several technical faults were detected which, in most cases, also led to a loss of reduction. Almost all patients with an anatomical reduction were free of pain. There was no correlation between the loss of reduction and the lapse of time before operation, the levels of instrumentation, the length of the fusion, the severity of the initial deformity, the degree of initial correction or the presence or absence of a neurological deficit

One hundred and three patients with scoliosis treated by posterior fusion and Harrington instrumentation are reviewed. The fusion technique described does not require added bone. Walking in a localiser plaster is encouraged as soon as the wound is healed, usually two weeks after operation. The results compare satisfactorily with others published. It is concluded that added bone is not necessary unless neural arch defects are present, and that early walking is advantageous and without risk to the correction

A prospective study to investigate changes in the rib hump or rib deformity after correction of the lateral curvature in adolescent idiopathic scoliosis is reported. The operative treatment for 47 patients was by a Harrington distraction rod and posterior fusion. Before operation and at follow-up, measurements of the Cobb angle, of vertebral rotation, and of the rib deformity were taken. Despite operative correction of the lateral curve, there was a progression of the rib deformity in 64% of the cases after four years. Correction of the lateral curve may thus have no effect on vertebral rotation and cannot be guaranteed to effect a permanent reduction of the rib hump

Objective: To evaluate the long term radiological and clinical outcome after posterior correction of adolescent right thoracic idiopathic scoliosis with Cotrel-Dubousset instrumentation (CDI) and Harrington rod instrumentation (HRI). Design: Retrospective comparative analysis. Subjects: Out of preoperative standing radiographs of 229 patients 30 pairs of female patients, one patient with Harrington rod instrumentation (HRI) and the other with Cotrel-Dubousset instrumentation (CDI), could be identified. Curves within pairs were comparable with regard to curve magnitude (thoracic and lumbar) and level of stable and neutral vertebrae. Follow up examination included a clinical review, long cassette upright PA and lateral radiographs of the spine and two patient outcome questionnaires. Mean follow up time for CDI patients was 128 months and for HRI patients 198 months respectively. Outcome measures: The pain questionnaire according to Moskowitz [. 1. ] was used to assess back pain. A customized questionnaire was used to assess whether patients were satisfied with their postoperative cosmetic appearance. Results: In 92 per cent of the patients L2 was the lowest instrumented vertebra. The thoracic Cobb angle in the HRI group was corrected from 64° to 42° (34%) and in the CDI group from 66° to 24° (58%). Group differences were significant (p=0.004). The lumbar Cobb angle in the HRI group was corrected from 41° to 24° (41%) and in the CDI group from 44° to 21° (52%) respectively. Group differences were significant (p=0.03). The lumbar lordosis below the fusion could be improved postoperatively in CDI patients (L2–L5: 31° to 37°), whereas it remained unchanged in HRI patients (L2–L5: 32°). Group differences were significant (p=0.005). The overall cosmetic appearance was better in the CDI group (CDI 76% excellent and good, HRI 71%, p=0.04). 15% of the CDI patients and 24% of the HRI patients reported frequent low back pain episodes. Group differences were significant (p=0.008). A high correlation between incidence of low back pain and low degrees of lumbar lordosis below the fusion was revealed in HRI patients (p=0.02). Conclusion: With Cotrel-Dubousset instrumentation better correction of the thoracic and lumbar curves in the frontal plane and better restoration of the lumbar lordosis distal the fusion is achievable. The lack of restoration of lumbar lordosis below the fusion in HRI patients may have some impact on the higher incidence of low back pain episodes found in this group. The postoperative cosmetic result was better in patients with Cotrel-Dubousset instrumentation

Objectives

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

Objectives. We investigated the reliability of the cobalt-chromium (CoCr) synovial joint fluid ratio (JFR) in identifying the presence of a severe aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) response and/or suboptimal taper performance (SOTP) following metal-on-metal (MoM) hip arthroplasty. We then examined the possibility that the CoCr JFR may influence the serum partitioning of Co and Cr. Methods. For part A, we included all revision surgeries carried out at our unit with the relevant data, including volumetric wear analysis, joint fluid (JF) Co and Cr concentrations, and ALVAL grade (n = 315). Receiver operating characteristic curves were constructed to assess the reliability of the CoCr JFR in identifying severe ALVAL and/or SOTP. For part B, we included only patients with unilateral prostheses who had given matched serum and whole blood samples for Co and Cr analysis (n = 155). Multiple regression was used to examine the influence of JF concentrations on the serum partitioning of Co and Cr in the blood. Results. A CoCr JFR > 1 showed a specificity of 83% (77% to 88%) and sensitivity of 63% (55% to 70%) for the detection of severe ALVAL and/or SOTP. In patients with CoCr JFRs > 1, the median blood Cr to serum Cr ratio was 0.99, compared with 0.71 in patients with CoCr JFRs < 1 (p < 0.001). Regression analysis demonstrated that the blood Cr to serum Cr value was positively associated with the JF Co concentration (p = 0.011) and inversely related to the JF Cr concentration (p < 0.001). Conclusion. Elevations in CoCr JFRs are associated with adverse biological (severe ALVAL) or tribocorrosive processes (SOTP). Comparison of serum Cr with blood Cr concentrations may be a useful additional clinical tool to help to identify these conditions. Cite this article: D. J. Langton, S. Natu, C. F. Harrington, J. G. Bowsher, A. V. F. Nargol. Is the synovial fluid cobalt-to-chromium ratio related to the serum partitioning of metal debris following metal-on-metal hip arthroplasty? Bone Joint Res 2019;8:146–155. DOI: 10.1302/2046-3758.83.BJR-2018-0049.R1

We reviewed the outcome of patients who had been treated operatively for symptomatic peri-acetabular metastases and present an algorithm to guide treatment. . The records of 81 patients who had been treated operatively for symptomatic peri-acetabular metastases between 1987 and 2010 were identified. There were 27 men and 54 women with a mean age of 61 years (15 to 87). The diagnosis, size of lesion, degree of pelvic continuity, type of reconstruction, World Health Organization performance status, survival time, pain, mobility and complications including implant failure were recorded in each case. The overall patient survivorship at five years was 5%. The longest lived patient survived 16 years from the date of diagnosis. The mean survival was 23 months (< 1 to 16 years) and the median was 15 months. At follow-up 14 patients remained alive. Two cementoplasties failed because of local disease progression. Three Harrington rods broke: one patient needed a subsequent Girdlestone procedure. One ‘ice-cream cone’ prosthesis dislocated and was subsequently revised without further problems. We recommend the ‘ice-cream cone’ for pelvic discontinuity and Harrington rod reconstruction for severe bone loss. Smaller defects can be safely managed using standard revision hip techniques. Cite this article: Bone Joint J 2014;96-B:132–6

Pathological fractures due to metastasis with destruction of the acetabulum and central dislocation of the hip present a difficult surgical challenge. We describe a series using a single technique in which a stable and long-lasting reconstruction was obtained using standard primary hip replacement implants augmented by strong, fully-threaded steel rods with cement and steel mesh, where required. Between 1997 and 2006, 19 patients with a mean age of 66 years (48 to 83) were treated using a modified Harrington technique. Acetabular destruction was graded as Harrington class II in six cases and class III in 13. Reconstruction was achieved using three 6.5 mm rods inserted through a separate incision in the iliac crest followed by augmentation with cement and a conventional cemented Charnley or Exeter primary hip replacement. There were no peri-operative deaths. At the final follow-up (mean 25 months (5 to 110)) one rod had fractured and one construct required revision. Of the 18 patients who did not require revision, 13 had died. The mean time to death was 16 months (5 to 55). The mean follow-up of the five survivors was 31 months (18 to 47). There were no cases of dislocation, deep infection or injury to a nerve, the blood vessels or the bladder

The treatment of acetabular metastases with total hip arthroplasty is technically challenging often with significant loss of structural continuity in the medial wall and roof of the acetabulum, as described by Harrington in 1981 as class III defects. Traditionally the acetabular component is stabilised with Harrington rods but the risk of post-operative complications, especially bleeding is significant. We performed 10 consecutive total hip arthroplasties in patients with metastases involving the acetabulum with Harrington class III defects. The first three patients had acetabular reconstruction with a Kerboull cage, (Stryker Howmedica.) The cage was secured using a combination of screw fixation to the ileum and PMMA cement filling voids behind the cage. A polyethylene acetabular cup is then cemented into the cage. There was concern about the superior fixation using this implant and so the remaining 7 patients were treated using the Graft Augmentation Prosthesis (GAP II), (Stryker How-medica.) This is a titanium reconstruction cage with two superior flanges allowing extensive screw fixation onto the ileum. Two patients had very large defects where there was not sufficient support to use this cage alone, so the technique was augmented with Harrington rods. No implants have failed to date. One patient, an 83 year old female, died 23 days post-operatively after suffering a stroke. Two patients died of their disease 95 and 115 days after surgery. The remaining patients continue to have good pain and mobility following surgery as demonstrated by the Oxford hip score. We conclude that in suitable patients with extensive metastatic involvement of the acetabulum, a flanged acetabular reconstruction cage prosthesis is much improved way of providing support for a total hip replacement. This procedure can greatly improve quality of life, and to date we have had no mechanical failures of fixation using this technique

The treatment of massive chronic tears is problematic. The re-tear rate following surgery for extensive cuff tears remains high, and there is little consensus regarding optimum treatment. To investigate the outcome of a cohort of patients who had open repair of an extensive cuff tear using the Leeds Kuff patch as an augment. A retrospective cohort study of consecutive patients with a massive cuff tear who had surgery in our regional elective orthopaedic centre over a two year period from January 2015 to Dec 2016. All patients followed identical rehabilitation protocols, supervised by physiotherapists with an interest in the shoulder. Outcomes assessment was undertaken at a minimum of 12 months by a registrar or physiotherapist who was not part of the treating team. Pre-op data collection included; range of motion, pain score, Oxford shoulder score (OSS), assessment of muscle atrophy on MRI. Data collection was completed in 15 patients. The mean age was 62 yrs (56 – 75). The mean pre-op OSS was 22, improving to a mean of 43. The range of motion and pain score improved. There were no intra-operative complications. One patient required a second surgery for evacuation of a haematoma at 10 days post op. One patient had an obvious re-tear at 4 months. Open rotator cuff repair with synthetic Kuff patch augmentation for chronic degenerative tears appears worthwhile when assessed at 12 months and they continuous to improve even at 18 months. This treatment method may be a useful option for patients > 70 years old.

Aims. Reconstruction of the acetabulum after resection of a periacetabular malignancy is technically challenging and many different techniques have been used with varying success. Our aim was to prepare a systematic review of the literature dealing with these techniques in order to clarify the management, the rate of complications and the outcomes. Patients and Methods. A search of PubMed and MEDLINE was conducted for English language articles published between January 1990 and February 2017 with combinations of key search terms to identify studies dealing with periacetabular resection with reconstruction in patients with a malignancy. Studies in English that reported radiographic or clinical outcomes were included. Data collected from each study included: the number and type of reconstructions, the pathological diagnosis of the lesions, the mean age and follow-up, gender distribution, implant survivorship, complications, functional outcome, and mortality. The results from individual studies were combined for the general analysis, and then grouped according to the type of reconstruction. . Results. A total of 57 studies met the inclusion criteria and included 1700 patients. Most lesions were metastatic (41%), followed by chondrosarcoma (29%), osteosarcoma (10%), Ewing’s sarcoma (7%), and multiple myeloma (2%). The techniques of reconstruction were divided into seven types for analysis: those involving a Harrington reconstruction, a saddle prosthesis, an allograft and allograft prosthesis composite, a pasteurised autograft, a porous tantalum implant, a custom-made prosthesis and a modular hemipelvic reconstruction. The rate of complications was 50%, with infection (14%) and instability (8%) being the most common. Mortality data were available for 1427 patients (84%); 50% had died of disease progression, 23% were alive with disease, and 27% had no evidence of disease at a mean follow-up of 3.4 years (0 to 34). . Conclusion. Both the rate of complications and mortality are high following resection of oncological periacetabular lesions and reconstruction. Many types of reconstruction have been used with unique challenges and complications for each technique. Newer prostheses, including custom-made prostheses and porous tantalum implants and augments, have shown promising early functional and radiographic outcomes. . Cite this article: Bone Joint J 2018;100-B(1 Supple A):22–30