Single focal grade IV cartilage lesion in the knee has a poor healing capacity. Instead these lesions often progress to severe and generalized osteoarthritis that may result in total knee replacement. Current treatment modalities aim at biological repair and, although theoretically appealing, the newly formed tissue is at the best cartilage-like, often fibrous or fibrocartilaginous. This at the expense of sophisticated laboratory resources, delicate surgery and strict compliance from patients. An alternative may be small implants of biomaterial inserted to replace the damaged cartilage. We investigated the response of the opposing tibia cartilage to a metallic implant inserted at different depth into the surrounding cartilage level. Methods. The medial femoral condyle of both knees of 12 sheep, 70–90kg, 2 year of age and from the same breeder, was operated. A metallic implant with an articulating surface of 316L stainless steel, diameter of 7mm, HA plasma sprayed press-fit peg and a tailored radius and contour to the sheep femoral condyle was placed at the most weight-bearing position. The level of the implant was aimed flush, 0,3 and 0,8 mm below surrounding cartilage. The animals were stabled indoors, allowed to move freely and euthanized after 6 and 12 weeks. Postoperatively the knees were high resolution photographed for macroscopic evaluation. The position and depth of the implant were analysed using a laser scan device. Tibial and femoral condyles specimen were decalcified and slices were prepared for microscopic evaluation. Implant position and cartilage damage was assessed from two independent observers using a macroscopic ICRS score and a modified histologic score according to Mankin. Results. 22 tibia condyles showed a variety of cartilage damage ranging from severe damage down to subchondral bone to an almost pristine condition. There was a strong correlation between implant position and damage to opposing cartilage surface. Mankin score correlated significantly with implant position (p<0.001 regression analysis, r. 2. =.45) as did the ICRS score (p<0.001, regression analysis, r. 2. =.67). Implants sitting proud were associated with poor Mankin score. There was no difference between 6-week and 3-months knees. Conclusion. By precise postoperative measurement we have shown that significant imprecision occur; this has never before been studied. We found a distinct correlation between implant position and cartilage damage. These results suggest that further studies of metallic implants, inserted into cartilage defects with the utmost precision regarding the surrounding cartilage, may be warranted

The Low Contact Stress (LCS) mobile-bearing total knee replacement (TKR) was designed to minimize polyethylene wear, aseptic loosening and osteolysis. However, registry data suggests there is a significantly greater revision rate associated with the LCS TKR.

The primary aim of this study was to assess long-term survivorship of the LCS implant. Secondary aims were to assess survival according to mechanism of failure and identify predictors of revision.

We retrospectively identified 1091 LCS TKRs that were performed between 1993 and 2006. There was incomplete data available 33 who were excluded. The mean age of the cohort was 69 (SD 9.2) years and there were 577 TKRs performed in females and 481 in males. Mean follow up was 14 years (SD 4.3).

There were 59 revisions during the study period: 14 for infection, 18 for instability, and 27 for polyethylene wear. 392 patients died during follow up. All cause survival at 10-year was 95% (95%CI 91.7–98.3) and at 15-year was 93% (95%CI 88.6–97.8). Survival at 10-years according to mechanism of failure was: infection 99% (95%CI 94–100%), instability 98% (95%CI 94–100%), and polyethylene wear 98% (95%CI92–100). Of the 27 with polyethylene wear only 19 had associated osteolysis requiring component revision, the other 8 had simple polyethylene exchanges. Cox regression analysis, adjusting for confounding variables, identified younger age was the only predictor of revision (hazard ratio 0.96, 95%CI 0.94–0.99, p=0.003).

The LCS TKR demonstrates excellent long-term survivorship with a low rate of revision for osteolysis, however the risk is increased in younger patients.

Introduction

We compared standard NexGen Cruciate substituting-flex prosthesis with gender-specific NexGen Cruciate substituting flex prosthesis in patients undergoing bilateral total knee arthroplasty with regard to Coverage of the bone by femoral component, Clinical outcome, Radiographic outcome, Survival and complication rates, with special emphasis on patellofemoral complications.

Objectives

Establishing the diagnosis of implant-associated infections is often difficult, because of variable clinical presentations and lack of uniform diagnostic criteria. Sonication of removed orthopedic devices was shown to have superior sensitivity and specificity for infection. We evaluated the value of microcalorimetry as a quick and reliable tool in the diagnosis of infection in sonication fluid from removed implants.

Hip resurfacing has grown rapidly since its introduction in the United States, as an alternative to total hip replacement in the younger, active patient. Some studies have suggested a steep learning curve and a higher complication rate when compared to THR. Existing studies have originated from the pioneering surgeons, using a specific type of resurfacing implant. The purpose of this study was to look at the experience of a single, non-inventor surgeon with the adoption of hip resurfacing, using 3 different implants.

Introduction

Austin Moore cervicocephalic prostheses have been a therapeutical option for femoral neck fractures in patients with a reduced general condition for many years. Since treatments other than total hip arthroplasties have also been included in National arthroplasty registers during the last decade, adequate reference data for comparative analyses have recently become available.

The treatment for trochanteric femoral fractures is still challenging. Since 2005, we are using 2 new implants: Gamma3™ nail and the PFN-A™.

All patients with a fracture of the trochanteric area were included in an observational study during 3 years.

Objectives were radiographics and clinics (complications) comparaison of these 2 new devices.

We included 426 patients (236 Gamma3™ nails, 190 PFN-A™). We faced the epidemiological data, per and post-operative complications. The tip-apex distance and the position of the cephalic implant were studied.

The 2 implants were well positionned in more than 80%, with no statistic diffferencie. We found a a cut-out rate of 1,4 % and a re-operation rate of 4,9 %. These rates of usual complications are very low in comparaison with litterature. We did not found a statistic difference between these 2 differents nails.

But, we observed 2 unusual complications: for the Gamma3™ nail, a high rate of automatic distal locking failure, and for the PFN-A™, many patients complained of thigh pain resulting from a prominent cephalic blade. These 2 new complications can be avoided by small changes in the operative procedure.

In our mind these 2 implants can be used for treating all patients with trochanteric fracture, but we need other studies to compare these nails with the new generation of sliding plate

Aims

Will Hydroxyapatite hip (HA) arthroplasty associated with ceramic bearings produce uncomplicated function in younger, active patients’ The incidence of aseptic loosening, dislocation and broken implants has been particularly investigated.

Debris disease from plastic debris contributes to aseptic loosening. Hard-Hard bearings should obviate this problem. Metal-metal will release ions which might be deleterious. Experience with metal-metal resurfacing has high lighted problems including pseudo-tumours. Ceramic bearings may fracture but otherwise appear free of complications.

INTRODUCTION. Autologous bone grafts are considered gold standard in the repair of bone defects. However they are limited in supply and are associated with donor site morbidity. This has led to the development of synthetic bone graft substitute (BGS) materials, many of which have been reported as being osteoinductive. The structure of the BGS is important and bone formation has been observed in scaffolds with a macroporous morphology. Smaller pores termed ‘strut porosity’ may also be important for osteoinduction. The aim of this study was to compare the osteoinductive ability of one silicate-substituted calcium phosphate (SiCaP) with differing strut porosities in an ectopic ovine model. Our hypothesis was that SiCaP with greater strut porosity would be more osteoinductive. METHODS. The osteoinduction of SiCaP BGS with two different strut porosities (AF and AF++) was investigated. The materials had an identical chemical composition and morphological structure but differing strut porosity (AF=22.5%, AF++=47%). Implants were inserted into the paraspinal muscles in skeletally mature sheep. Procedures were carried out in compliance with UK Home Office regulations. There were 12 implants in each group. Implants remained in vivo for 8 and 12 weeks and on retrieval were prepared for undecalcified histology. Sections were stained and examined using light microscopy. A line intersection method was used to quantify bone, implant and implant surface/bone contact within seven random regions of interest along each implant. A Mann-Whitney U test was used for statistical analysis where p values < 0.05 were considered significant. RESULTS. Bone formation was observed to be greater in the AF++ group at 8 (AF=0.2%+/−0.15; AF++=0.44%+/−0.12) and significantly higher at 12 weeks (AF=1.33% +/−0.84; AF++=6.17%+/−1.51) (p=0.04). Significantly higher implant surface/bone contact was observed in the AF++ group at 8 (AF=0.67%+/−0.52; AF++=3.30%+/−1.17) (p=0.04) and 12 weeks (AF=3.06%+/−1.89; AF++=21.82%+/−5.59) (p=0.01). The % implant measured was less in the AF++ group at 8 (AF=39.06%+/−1.26; AF++=33.09%+/−2.14) and 12 weeks (AF=36.05% +/−3.55; AF++=30.60%+/−2.29) but this was not significant. Histology revealed bone formation within BGS strut pores measuring < 50um. Endochondral and intramembranous ossification were also observed in both groups. DISCUSSION. The results indicate that higher strut porosity promotes greater osteoinduction in SiCaP materials. This could be attributed to the micropores providing a greater surface area for the action of growth factors and osteoblasts leading to the formation of bone at an earlier time point. Endochondral ossification was an unusual finding as this is usually associated with bone formation secondary to Bone Morphogenetic proteins (BMPs). This suggests that the osteoinductive mechanisms by SiCaP may involve cytokines such as BMPs

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions. There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection. The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants. We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

We aimed to analyse complication rates following medial opening-wedge high tibial osteotomy (OWHTO) for knee OA. A regional retrospective cohort study of all patients who underwent HTO for isolated medial compartment knee OA from 2003–2013. 115 OWHTO were performed. Mean age = 47 (95%CI 46–48). Mean BMI = 29.1 (95%CI 28.1–30.1). Implants used: 72% (n=83) Tomofix, 21% (n=24) Puddu plate, 7% (n=8) Orthofix Grafts used: 30% (n=35) autologous, 35% (n=40) artificial and 35% (n=40) no graft. 25% (n=29) of patients suffered 36 complications. Complications included minor wound infection 9.6%, major wound infection 3.5%, metalwork irritation necessitating plate removal 7%, non-union requiring revision 4.3%, vascular injury 1.7%, compartment syndrome 0.9%, and other minor complications 4%. Apparent higher rates of non-union occurred with the Puddu plate (8.3%) relative to Tomofix (3.6%) but was not statistically significant. No other significant differences existed in complication rates relative to implant type, bone graft used, patient age or BMI. Serious complications following HTO appear rare. The Tomofix has an apparent lower rate of non-union compared to older implants but greater numbers are required to determine significance. There is no significant difference in union rate relative to whether autologous graft, artificial graft or no graft is used

Aims

Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes.

Aims

The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years.

INTRODUCTION. Limb salvage surgery is a common treatment for patients who suffer from bone tumors. In the case of pelvic tumors this creates a challenge for the surgeon and the treatment remains controversial because the oncologic complications like local recurrence, dissemination and orthopaedic ones, like infection, haemorrhage, and mechanical problems of reconstructions Tumors affecting the acetabulum are a challenge for the surgeon because of the impact in the function of the extremity. There are many reconstruction techniques described in the literature like prosthesis, allograft systems, arthrodesis, etc…, but still there is not a gold standard due to the poor functional results at long term follow up, and the associated complications of all techniques. In this study we show the experience in our center on pelvic reconstructions after tumors affecting the acetabulum area (zone II). MATERIAL AND METHODS. We surgically treated 81 pelvic tumors from 1997 to 2009 following the Enneking and Dunham calssification attending to the localization of the tumor: Zone I 38 (iliac bone)Zone II 25 (acetabulum)Zone III 18 (pelvic branches)In zone II tumors we performed pelvic reconstruction in eight cases, with different type of prosthesis. In 5 cases we performed saddle prosthesis (group A) and in 3 cases we performed Coned-Stanmore Implants type prosthesis with sacro-iliac anchorage. The mean follow up of the serie was 3,5 years (1–6 years). In group A the mean follow up was 5 years and in group A and in group B the mean follow up was 1 year due to the recent implantation in our center of Coned type prosthesis for pelvic reconstruction. We evaluated our results with these two types of prosthesis. RESULTS. Oncologic: group A we had a local recurrence of 25% and 25% of the patients died. group B we had no cases of local or systemic recurrence and we didn't registered any death. Functional: In group A the patients showed local pain and difficulty to walk probably due to the change of the center of rotation of the hip and instability of the saddle prosthesis. In group B all patient's followed physical therapy programs without problems and were able to walk with crutches ten months after surgery. Complications:group A we had a 25% of perioperative infection and a 25% of dislocation of the prosthesis. In group B we did not have any of these complications. CONCLUSIONS. Saddle prosthesis mantain the length of the extremity and allow weight bearing but they do not give a good stability. Even if we only have one year follow up with this Coned prosthesis with sacro iliac anchorage we achieved much better functional results and a lower rate of complications

Aim

The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and ‘locking’ plate fixation in the treatment of extra-articular fractures of the distal tibia.

Aims

The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility.

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed.

Cite this article: Bone Joint J 2017;99-B:1125–31

Aims

To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.

Objectives

External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF).