Massive irreparable rotator cuff tears often lead to superior migration of the humeral head, which can markedly impair glenohumeral kinematics and function. Although treatments currently exist for treating such pathology, no clear choice exists for the middle-aged patient demographic. Therefore, a metallic subacromial implant was developed for the purpose of restoring normal glenohumeral kinematics and function. The objective of this study was to determine this implant's ability in restoring normal humeral head position. It was hypothesized that (1) the implant would restore near normal humeral head position and (2) the implant shape could be optimized to improve restoration of the normal humeral head position. A titanium implant was designed and 3D printed. It consisted of four design variables that varied in both implant thickness (5mm and 8mm) and curvature of the humeral articulating surface (high constraint and low constraint. To assess these different designs, these implants were sequentially assessed in a cadaver-based biomechanical testing protocol. Eight cadaver specimens (64 ± 13 years old) were loaded at 0, 30, and 60 degrees of glenohumeral abduction using a previously developed shoulder simulator. An 80N load was equally distributed across all three deltoid heads while a 10N load was applied to each rotator cuff muscle. Testing states included a fully intact rotator cuff state, a posterosuperior massive rotator cuff tear state (cuff deficient state), and the four implant designs. An optical tracking system (Northern Digital, Ontario, Canada) was used to record the translation of the humeral head relative to the glenoid in both superior-inferior and anterior-posterior directions. Superior-Inferior Translation. The creation of a posterosuperior massive rotator cuff tear resulted in significant superior translation of the humeral head relative to the intact cuff state (P=0.016). No significant differences were observed between each implant design and the intact cuff state as all implants decreased the superior migration of the humeral head that was observed in the cuff deficient state. On average, the 5mm low and high constraint implant models were most effective at restoring normal humeral head position to that of the intact cuff state (-1.3 ± 2.0mm, P=0.223; and −1.5 ± 2.3mm, P=0.928 respectively). Anterior-Posterior Translation. No significant differences were observed across all test states for anterior-posterior translation of the humeral head. The cuff deficient on average resulted in posterior translation of the humeral head, however, this was not statistically significant (P=0.128). Both low and high constraint implant designs were found to be most effective at restoring humeral head position to that of the intact cuff state, on average resulting in a small anterior offset (5mm high constraint: 2.0 ± 4.7mm, P=1.000; 8mm high constraint: 1.6 ± 4.9mm, P=1.000). The 5mm high constraint implant was most effective in restoring normal humeral head position in both the superior-inferior and anterior-posterior directions. The results from this study suggest the implant may be an effective treatment for restoring normal glenohumeral kinematics and function in patients with massive irreparable rotator cuff tears. Future studies are needed to address the mechanical efficiency related to arm abduction which is a significant issue related to patient outcomes

The management of patients with massive irreparable rotator cuff tears (RCT) has traditionally proved challenging. This prospective study was undertaken with the aim to assess the overall functional outcome following the use of human dermal allograft in the reconstruction of massive irreparable RCT. 15 patients were included in the study, having a median age of 63 years. All patients underwent open reconstruction of massive irreparable RCT. None of the selected patients had evidence of significant gleno-humeral arthritis. All patients were evaluated pre- and post- operatively by the treating surgeon, and followed up for 12 months. The same physiotherapy protocol was prescribed for all patients. Initial and follow-up assessments were done at regular intervals using the Oxford and quick-DASH scoring systems. A very high patient satisfaction rate, with substantial improvement in pain and function was noted. There was substantial improvement in Oxford shoulder score from a mean of 23.3 to 8.7 (p<0.01), and a similar improvement in mean quick-DASH score from 50.3 to 23.0 (p<0.01). Of the 15 patients, 11 had an improvement of >10 in Oxford score, with these reporting a score of <10 after 12 months. None of the patients had any significant complications because of the surgery, and none had a deterioration in Oxford score from their pre-operative status. We found that Human dermal allograft is a very effective tool in the repair of massive irreparable RCT, with excellent follow-up results after one year

Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and tendon transfers are used. This study presents clinical and radiological outcomes of muscle advancement technique for repair of mRCT. Sixty-one patients (mean age 57±6, 77% males and 23% females) (66 shoulders) underwent all-arthroscopic rotator cuff repair that included supraspinatus and infraspinatus subperiosteal dissection off scapular bony fossae, lateral advancement of tendon laminae, and tension-free double-layer Lasso Loop repair to footprint. Pre-and post-operative range of motion (ROM), cuff strength, VAS, Constant, ASES, and UCLA scores were assessed. Radiologic assessment included modified Patte and Goutallier classifications. All patients had MRI at 6 months to evaluate healing and integrity of repair was assessed using Sugaya classification with Sugaya 4 and 5 considered retears. Advanced fatty degeneration (Goutallier 3-4) was present in 44% and 20% of supraspinatus and infraspinatus. Tendon retraction was to the level of or medial to glenoid in 22%, and just lateral in 66%. 50.8% mRCT extended to teres minor. Subscapularis was partially torn (Lafosse 1-3) in 46% and completely torn (Lafosse 4-5) in 20%. At mean follow-up (52.4 weeks), a significant increase in ROM, Relative Cuff Strength (from 57% to 90% compared to contralateral side), VAS (from 4 ±2.5 to 1±1.7), Constant (50±17.8 to 74 ±13.0), ASES (52 ±17.5 to 87 ±14.9), and UCLA (16± 4.9 to 30 ±4.9) scores were noted. There were six retears (10%), one failure due to P. acnes infection. 93% returned to pre-injury work and 89% of cases returned to pre-injury sport. Satisfaction rate was 96%. Muscle advancement technique for mRCT is a viable option with low retear rates, restoration of ROM, strength, and excellent functional outcomes

Aims. To evaluate the place of the massive prostheses in the most complex periprosthetic infections cases (PJis). Method. Between 2011 and 2017, 516 hip and knee revisions for periprosthetic infections had been performed in our hospital by the same senior surgeon. We report a prospective series of 58 patients treated between 2011 and the end of 2017. 26 males and 32 females with on average 69,4 years old (38–86). Infection involved TKA in 39 cases (26 TKA revisions, 11 primary TKA), THA in 18 cases (10 revisions, 7 primary THA), a femoral pseudoarthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used one stage procedures in 38 cases (14 hips, 23 knees, 1 shoulder) and 20 two stages surgeries (16 knees and 4 hips). Additional technics used with massive prostheses, all for TKA PJis: 4 massive extensor systemallografts performed two times in a one stage procedure, two local flaps (medial gastronecmienmuscle). Two perioperative hyperbaric procedures used to limit the risks of wound complications. Results. The average follow-up is 38 months (12–62 months). The rate of sucess to treat the infection at this follow-up is 89,7 %. We report our feedback of the different massive components uses and the qualities/defaults we noted. The most frequent complication was skin events like wound swelling and delayed cicatrisations in 13 cases. 3 cases of one stages needed a complementary debridement in the three weeks after the surgery with always a good local and infectious evolution. This series report 5 failures of two stages TKA revisions. In 4 cases, the initial local soft tissues conditions were compromised. Conclusions. The use of massive prostheses to treat PJIs is a good option for the complex cases. It can be a good alternative of knee arthrodesis. These components must be used, preferentially for oldest patients, in cases of extreme bone loss or extensed osteitis to secure the bone debridement and the quality of the reconstruction. In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. The two stages procedure is a secondary option, particularly when softtissues status is compromised before or after the debridement, and mostly for the knees

Aim. To evaluate the results and complications of bone transport in the treatment of massive tibial bone defects, using the Ilizarov method. Methods. 15 patients underwent bone transport using the Ilizarov technique to treat massive tibial bone defects. The average age of the patients was 8.7 years (3–24 years) and the mean bone defect was 10.8 cms. Following a latent period of 1 week, distraction of the transport doughnut was commenced at 1mm/24 hours in 4 quarterly turns. A docking procedure was performed in 7 cases which involved freshening of the bone ends and autogenous bone grafting from the iliac crest. Following docking the fixator was removed once the regenerate had consolidated. Results. The fixators were removed after a mean 12.3 months (range 8–21 months). 1 patient required adjustment of the frame under anaesthetic due to translation of the docking doughnut and poor alignment. All patients had at least one superficial pin site infection successfully treated with oral antibiotics. Deep infection at the docking site was seen in 1 patient needing debridement and split skin grafting. There were no neuro-vascular complications. 1 patient had a recurvatum deformity at the regenerate due to early frame removal. There were no early fractures. Re-fracture of the docking site occurred in one patient, 17 months after the removal of the original frame. This needed open reduction and internal fixation. Non union at the docking site was seen in 3 patients, needing open reduction, internal fixation with bone grafting (1 case) and excision of non-union and compression with a further frame (2 cases). Conclusion. Massive bone transport in the tibia is an orthopaedic challenge. This paper highlights the complications of this procedure. It confirms the viability of this method but emphasises careful counselling of both the patient and parents prior to the commencement of such difficult treatment

To evaluate the value of the use of massive prostheses in periprosthetic infections both in one stage and two stages procedures. Between 2008 and 2014, 236 revisions for PJI had been performed in our hospital by the same surgeon. For the most complex cases, we decided to introduce megaprostheses in our practice in 2011. We report a prospective series of 33 infected patients treated between 2011 and the end of 2014, 14 male and 19 female with on average 67.9 years old (38–85) Infection involved TKA in 22 cases (17 TKA revisions, 4 primary TKA), THA in 9 cases (6 revisions, 3 primary THA), a femoral pseudo-arthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used a total femoral component for two patients: the first one for a hip PJI with extended diaphyseal bone loss and multiples sinus tracks, and the second one for a massive infected knee prosthesis used in a knee reconstruction for liposarcoma. We used one stage procedures in 20 cases (8 hips, 12 knees, 1 shoulder) and two stages in 13 cases (12 knees and 1 hip). Additional technics included 3 massive extensor system allografts, two local flaps. Perioperative hyperbaric treatment was used for 2 patients. The average follow up is 19.8 months (6–48 months). The most frequent complications were wound swelling and delayed healing in 8 cases;). In 3 cases of one stage surgery a complementary debridement was necessary in the three weeks after the surgery with always a good local and infectious evolution. VAC therapy was used in four cases with good results. We report one early postoperative dead. In summary, the use of massive prostheses in PJI is a good option for complex cases. It can be a good alternative to knee arthrodesis. These components must be used preferentially for older patients, in cases of extreme bone loss or extensive osteomyelitis to secure the bone debridement and the quality of the reconstruction. In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. We believe the two stages surgery is a secondary option, particularly when soft tissues status is compromised before or after the debridement, and mostly for the knees. The longevity of the implantation must be evaluate by a long term follow up

Aim. To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap. Method. This is a prospective cohort of 43 patients (24 male, 19 female) with average age of 62 years. The primary indication of surgery was pain. Patients with massive rotator cuff tear involving supraspinatus and infraspinatus, showing retraction and fatty infiltration in MRI were selected. Few (8/43) were with failed surgical treatment and rest had conservative treatment failed. They underwent rotator cuff repair during Feb 1999 to Jan 2004. The long head of the triceps was detached from the olecranon, rotated 180 degrees from its pivot point with its major vascular pedicle under the deltoid and acromion through the posterior capsule and attached to the greater tuberosity and any remnant of remaining cuff. All patients were assessed pre-operatively, at 3, 6 and 12 months post-operatively clinically and also using UCLA pain and functional score for shoulder. Shoulder range of motion was assessed before and after the surgery. 24 patients had minimum of 1 year and 19 had 2 year minimum follow-up. Results. The mean total UCLA score of 9.7 pre-operatively improved to 27.8 (p<0.0001) following the operation. The mean pre-operative UCLA pain score 2.2 improved to 7.8 post-operatively (p<0.001). The UCLA functional score improved from a pre-operative average of 3.4 to 8.2 (p<0.0001) following the operation. There was significant improvement in forward elevation, external and internal rotation but not abduction. There was no weakness in elbow extension. Complications: 3 superficial infections, 1 ulnar neuritis (resolved in 6 weeks), 1 olecranon bursitis (resolved in 3 months). Conclusion. Long head triceps tendon transfer is an effective technique to alleviate pain and improve functions in patients with massive rotator cuff tear, specially in difficult group of patients with limited options

Massive tears of the supraspinatus of the rotator cuff lead to painful loss of movement. The literature supports repair of these tears for young healthy individuals, however they present a surgical challenge with historically poor results from both athroscopic and standard open techniques. Prof Bunker has developed a surgical technique for massive rotator cuff tears with a Grammont Osteotomy of the spine of the acromion, when standard surgical techniques will not allow the necessary exposure: the so called “Full Monty”. Patients were entered in to a prospective study to obtain the functional benefit of this procedure. Each patient had a pre-operative American Shoulder Elbow Score (ASES) Oxford Shoulder score (OSS), pain score, range of movement. Post-operatively these measures were repeated along with a patient questionnaire on function and satisfaction. The mean American Shoulder score (ASS) preoperatively was 7 (out of a possible 30) and improved postoperatively to 23(P = 0.00011). The improvement in the Oxford Shoulder Score was 22 (out of a possible 48) preoperatively to 43 postoperatively (0.0001) and 80% patients stated their treatment was “successful”. We believe this a successful surgical option for a patient with “massive” rotator cuff tear that is not amenable to standard surgical techniques

Aim. To determine the benefit of dissolvable Balloon Arthroplasy in managing patients with massive irreparable rotator cuff tears (RCT). Methods. This is prospective pilot study carried out adhering to the local approval process. Patients having massive cuff tear with pain or functional limitation were seen by consultants and MRI confirmed the diagnosis. The patients were explained of ‘all available’ treatment options and information leaflet about the new procedure balloon arthroplasty, provided. Patients were seen after 4 weeks in a dedicated clinic to find out if they were willing to participate. Patients were seen by a physiotherapist pre and post-operatively at 6 weeks then at 3, 6 and 12months in addition to medical follow-ups, using VAS, Oxford Shoulder, Constant and SF36 scores. All procedures were carried out by consultant shoulder surgeons and where the cuff was reparable or contraindications identified were excluded. Results. Of the 25 recruited 4 were lost for follow up. 17 of the remaining 21 completed 12 month follow up, and the remaining completed their 6 month follow up. Male to female ratio was 2:1 and no surgical complications were noted. Two patients required an inverse shoulder arthroplasty. Improvements were noted in the SF36, VAS and OSS. Conclusion. The balloon arthroplasty seems to offer benefit for a group of patients who are unfit or not keen on major surgery to offer pain relief possibly function. Recommendations cannot be made due to the study but suggest a multicentre study

Background:. The purpose of this study was to compare the biomechanical effects of the trapezius transfer and the latissimus dorsi transfer in a cadaveric model of a massive posterosuperior rotator cuff tear. Methods:. Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane with anatomically based muscle loading. Humeral rotational range of motion and the amount of humeral rotation due to muscle loading were measured. Glenohumeral kinematics and joint reaction forces were measured throughout the range of motion. After testing in the intact condition, the supraspinatus and infraspinatus were resected, simulating a massive rotator cuff tear. The lower trapezius transfer was then performed. Three muscle loading conditions for the trapezius (12N, 24N, 36N) were applied to simulate a lengthened graph as a result of excessive creep, a properly tensioned graph exerting a force proportional to the cross-sectional area of the inferior trapezius, and an over-constrained graph respectively. Next the latissimus dorsi transfer was performed and tested with one muscle loading condition 24N. A repeated-measures analysis of variance was used for statistical analysis. Results:. The amount of internal rotation due to muscle loading increased with massive cuff tear at 0°, 30°, 60° abduction (p < 0.05), and was restored with the latissimus transfer at 0° abduction and the trapezius transfer at all abduction angles. (Figure 1) The cuff tear decreased glenohumeral joint compressive force, which was restored with the trapezius transfer at all positions; however, the latissimus transfer failed to restore the intact compressive force (p < 0.05). (Figure 2) At neutral rotation and 0° abduction, there was an increase in the anteriorly directed force for the rotator cuff tear and latissimus transfer conditions, that was restored to intact values by the trapezius transfer (p < 0.05). (Figure 3) At maximum internal rotation and 0° of abduction, the apex of humeral head shifted superiorly and laterally after massive cuff tear (p < 0.05); this abnormal shift was more closely restored to intact values by the trapezius transfer than the latissimus transfer in directions (p < 0.05). Conclusion:. The trapezius transfer for massive cuff tear restores native glenohumeral forces better than the latissimus transfer by recruiting an exogenous force across the glenohumeral joint. However, the increase in compressive force seen with the trapezius transfer may be problematic in patients with osteoarthritis. Clinical studies to evaluate the results of the trapezius transfer are warranted

Background. Revision THA presents significant challenges for the surgeon when the proximal femur is deficient or mechanically unreliable. The aim of this study is to assess the clinical and functional results of the use of tumor enndoprosthesis to reconstruct the proximal femur when there is massive bone loss. Patients and Methods. A prospective study was conducted involving 10 cases. The follow up of the cases ranged from 12 months to 30 months with a mean period of an average of 23months. The indications for revision surgery were aseptic loosening in 9 cases and septic loosening in one case Harris hip score was used for pre and postoperative clinical evaluation of the patients. Results. At the latest follow up the Harris Hip scores improved from a preoperative average of 16 (range, 3-47), to a postoperative average of 75.6 (range, 66-94). The complications that we encountered in the study included one case of superficial wound infection, another case developed sciatic nerve palsy postoperatively. No other complications were reported. Conclusion. Revision hip replacement in proximally compromised femurs presents a significant surgical challenge. When there is massive proximal femoral bone loss proximal fitting revision stems do not achieve adequate fixation hence the use of tumor prosthesis is indicated

Introduction. Aseptic loosening is the most common mode of failure of massive endoprostheses. Introduction of Hydroxyapatite coated collars have reduced the incidence of aseptic loosening. However bone growth is not always seen on these collars. Objectives. The aims of our study were to determine the extent of osseous integration of Hydroxyapatite coated collars, attempt a grading system for bone growth and to determine the effect of diagnosis, surgical technique and adjuvant therapy on bone growth. Methods. We reviewed the records and radiographs of 58 patients who had a massive endoprosthesis implanted by two surgeons in our unit over the last five years. Revision surgeries were recorded separately. Bone growth was graded 1–4 based on appearance in antero-posterior and lateral radiographs. Results. Three groups were identified. Group 1-Resections for primary bone tumours (33 patients), Group 2-resections for metastatic bone disease (22 patients) and Group 3- Resections for non tumour indications (3 patients). Overall, 60% of patients had grade 1, 12% had grade 2, 19% had grade 3 and 9% had grade 4 osteointegration. Grade 3 or 4 Collar osteointegration was found in 37% of patients in Group 1, 9% in group 2 and 67% in group 3. 5% of patients with grade 1 integration, 100% patients with grade 2 integration and none of the patients with grade 3 or 4 integration underwent revision for aseptic loosening. Appearance or widening of a gap between the resected bone end and the collar indicated loosening and impending revision. Proximal humeral replacements had the lowest rate of osteointegration (12%). Adjuvant therapy did not affect osteointegration. Conclusion. Osteointegration of collars is seen more often after resection of primary bone tumours. The role of collars in metastatic tumour surgery is questionable. Our radiographic grading system of bone growth predicted aseptic loosening

Massive uncontained glenoid defects are a difficult surgical problem requiring reconstruction in the setting of either primary or revision total shoulder arthroplasty. Our aim is to present a new one-stage technique that has been developed in our institution for glenoid reconstruction in the setting of massive uncontained glenoid bone loss. We utilise a modified delto-pectoral approach to perform our dual biology allograft autograft glenoid reconstruction. The native glenoid and proximal femoral allograft are prepared and shaped to create a precisely matched contact surface, which permits axial compression to secure fixation. The surface of the glenoid is lateralised to at least the level of the coracoid. The central cancellous femoral allograft is removed and impaction autografting is performed prior to implantation of a glenoid base plate with 25-mm long centre peg. Two screws are inserted into the best quality native scapular bone available to ensure compression. A reverse shoulder arthroplasty is implanted. We have performed our dual-biology reconstruction of the glenoid in combination with reverse total shoulder arthroplasty in 8 patients to date. The technique has been performed in the setting of massive uncontained glenoid defects without prostheses as well as in revisions from failed hemiarthroplasties and total shoulder arthroplasties. Our post-operative follow-up is now up to 32 months. CT scanning as early as 6 months demonstrates incorporation of the graft. There has been no evidence of loosening. None of our cases have been complicated by infection or peri-prosthetic fracture and there have been no dislocations. One patient sustained an acromial stress fracture at 9 months post-operatively after lifting a 100-pound gas cylinder. This was diagnosed on bone scan, had no impact on the construct and was managed in a sling for comfort. Another patient has developed Nerot grade I notching which substantially in all patients, with an average improvement of 6.6 on a 10-point scale. Our dual biology allograft-autograft reconstruction is a useful and elegant technique in the setting of massive uncontained defects of the glenoid, which permits the implantation of a reverse total shoulder arthroplasty. We believe this technique to be reproducible and uses materials that are both readily available and familiar

Reverse shoulder arthroplasty (RSA) was released into the United States market in 2004 for the indication of Rotator Cuff Tear Arthropathy. Since that time the indications have widened and now include massive rotator cuff tears that are not deemed to be surgically repairable. This diagnosis includes patients that are considered young in terms of shoulder replacement surgery. These patients do not have the radiographic changes of arthropathy, but most have undergone multiple surgical procedures in the past to attempt to repair the rotator cuff deficiency. These younger patients have a different post-op expectation than the patient with advanced arthropathy over the age of 70. The complication rate seen in this younger patient population is higher than seen in the older population undergoing RSA. The post-operative survey for satisfaction is also considerably lower in the younger population group. RSA for massive rotator cuff tears in a younger population under the age of 65 years gives a lower patient satisfaction result and a higher complication rate than age-matched patients older than 65 years. Although this is still the best procedure available for this difficult diagnosis, patients younger than 65 years should be consulted as to what their expectations are post-operatively. Pain relief is still the main reason to undergo an RSA

Purpose. Chronic massive rotator cuff tears are challenging to repair completely because of the development of tendon retraction with inelasticity, muscle atrophy and fatty infiltration. The objective of this study was to investigate the clinical outcome and MRI findings after arthroscopic superior capsule reconstruction (ASCR) for symptomatic irreparable rotator cuff tears. Methods. From 2011 to 2013, 12 shoulders in 12 consecutive patients (mean, 70.8 years) with irreparable massive rotator cuff tears underwent ASCR using fascia lata. We used suture anchors to attach the graft medially to the glenoid superior tubercle and laterally to the greater tuberosity as same technique by Mihata et al. We added side-to-side sutures between the graft and infraspinatus tendon and between the graft and residual anterior supraspinatus/subscapularis tendon to improve force coupling. Physical examination, clinical rating system, and magnetic resonance imaging (MRI) were performed before surgery; at 6 and 12 months after surgery; and 6 months thereafter. Average follow-up was 19.1 months (12 to 28 months) after surgery. We assessed patients preoperatively by using the scoring systems of the shoulder index of the American Shoulder and Elbow Surgeons (ASES), the Japanese Orthopaedic Association, and the University of California, Los Angeles. Results. Mean active elevation increased from 59° to 111° significantly and external rotation increased from 28 to 33. The average preoperative scores were 16.0 points by ASES, 48.0 points by JOA, and 10.8 points by UCLA. Average clinical outcome scores all improved significantly after ASCR at the final follow-up (ASES, 73.3 points; JOA, 73.7 points; UCLA, 22.7 points). There was surgical complication as infection. Although infection was controlled by arthroscopic irrigation, the transplanted tendon was absorbed, and preoperative conditions did not functionally improve. Five patients had graft tear during follow-up. Postoperative active range of motion in the healed patients was significantly greater than in the unhealed patients who had graft tears. Conclusions. ASCR restored superior glenohumeral stability and function of the shoulder joint with irreparable rotator cuff tears compared to preoperative function in the cases without postoperative complications. However ratio of graft tears were 50% and clinical results of these cases were not improved sufficiently

Massive irreparable rotator cuff tears (MIRCTs) represent a difficult situation especially in painful and pseudoparalytic patients. A new technique, consisting of an arthroscopic implantation of an inflatable biodegradable “balloon”, serving as a temporary subacromial spacer, has been introduced recently for MIRCTs. The purpose of this paper is: 1) to present the efficacy and safety results of patients treated with the balloon; 2) to show that these results are maintained over time, after balloon degradation; 3) to compare these results to published results of other procedures available for MIRCTs. This paper presents the first group of 22 patients (females/males 13/8, one bilateral), treated in a single-surgeon, prospective and on-going series of 97 shoulders operated with the balloon, since September 2010. The mean age is 69.3 (52–86) and the average follow-up 52.5 months. The balloon is inserted arthroscopically and inflated with saline. The procedure is simple with a short operative time (10–20 min). It can also supplement partial repairs, especially of the subscapularis, as well as repairable massive tears with bad tissue quality. The balloon is not used in severe cuff tear arthropathy or complete insufficiency of the external rotators. Final outcome scores, Constant (CS) and UCLA scores are obtained at least three years after complete balloon degradation (which occurs within 12 months), and are also compared to those of other treatments available for MIRCTs. No device related safety issues were observed in this group. Good results, including rapid pain relief and restoration of active motion, which maintained over time, are obtained in 85% of the patients. The CS has improved significantly (average preop/postop: pain 2.9/12.7; ADL 6.8/17.4; ROM 22.8/36.6; strength 3.1/5.6; TOTAL 35.8/72.3; NORMATIVE 42.7/86.4). The UCLA score has also improved significantly (preop/postop: pain 1.9/8.6; function 3.9/8.6; active flexion 3.5/4.5; strength in flexion 2.4/3.4; satisfaction 0/4.5; TOTAL 11.2/29.8). Pseudoparalysis is reversed (average preop/postop flexion 86°/156.8°). The CS and UCLA score for the balloon are superior compared to published results of debridement, biceps tenotomy/tenodesis, partial repair, tuberoplasty and latissimus dorsi transfer. CS (86.4/63.8), CS pain (12.7/11.9) and flexion (156.8/128.0) are also better for the balloon compared to the reverse prosthesis. The balloon is indicated for MIRCTs, as well as reparable massive tears with a high risk of retear. The implantation is a straightforward and short procedure, which has excellent safety profile and positive effect on painful MIRCTs including pseudoparalysis. The balloon provides significant improvement in the CS and UCLA score that persists way beyond its degradation. The balloon patients' shoulder function is superior to the other available treatment options. Additional studies are needed to further confirm the effectiveness of the balloon as a first line treatment for MIRCTs

Introduction. The burden of peri-prosthetic joint infection (PJI) following hip and knee surgery is increasing. Endoprosthetic replacement (EPR) is an option for management of massive bone loss resulting from infection around failed lower limb implants. Aims. To determine clinical outcome of EPRs for treatment of PJI around the hip and knee joint. Methods. This was a retrospective consecutive case-series of hip and knee EPRs between 2007–2014 in our tertiary unit for the treatment of PJI following complex arthroplasty or fracture fixation. Data recorded included indication for EPR (infected primary/revision arthroplasty, infected non-union/failed osteosynthesis, gross bone loss following native joint infection), number of previous surgeries, and organism identified. Outcome measures included PJI eradication rate (with failure defined as EPR revision, amputation, or being on life-long suppressive antibiotics), complications, implant survival, mortality, and functional outcome (Oxford Hip/Knee Score; OHS/OKS). Results. 58 EPRs (32 knee and 26 hip) were performed with a mean age of 68 years (range: 35–92). The mean number of previous surgeries prior to EPR was 3.4 (range: 1–10). At mean follow-up of 3.5 years, 11 (19%) patients were deceased. EPR was implanted as a two-stage procedure in 76% of cases. Plastic surgical involvement and flap coverage was necessary in 11 cases. Polymicrobial growth was detected in 40% of cases, followed by Coagulase-negative staphylococci (26%). The overall complication rate was 40%. Recurrence of infection post-EPR occurred in 14 patients (24%); 5 were treated with Debridement, Antibiotics and Implant Retention (DAIR), 3 with revision, 1 with above-knee amputation and the remaining 6 remained on long-term suppressive antibiotics. PJI eradication was achieved in 44 (76%) cases (69% knees and 85% hips). Of the remaining 14 cases, 9 remain on long-term antibiotics. The complication rate was similar in knees (41%) and hips (38%). PJI eradication was more successful in hips (85%) compared to knees (69%). To date, 6 EPRs have been revised (10%). The overall 5-year implant survivorship was 83% (95% CI: 68–98%). The mean OHS was 25 (range 7–39.) and the mean OKS was 20 (range 6–43), the best possible score being 48. Conclusions. This mid-term study provides further support for the use of massive endoprostheses in the eradication of PJI in complex, previously multiply revised cases with subsequent limb salvage (in all but one case). We describe PJI eradication rate of 76% with acceptable functional outcomes. This eradication rate is comparable to that following treatment of PJI associated with standard arthroplasty

In North America, and for the most part globally, a cementless acetabular component with adjuvant screw fixation is the preferred technique for revision total hip arthroplasty. However, there are situations that involve massive pelvic bone loss that preclude the use of a cementless cup alone. Options include: . i). Enhanced fixation components and augments. ii). Specialised constructs (cup/cage). iii). Structural allografts. iv). Bone graft substitutes. Complex acetabular revisions present the arthroplasty surgeon with challenges that require an approach with more than one solution for all scenarios. While structural allografts have recently fallen out of favour with the increasing use of enhanced fixation components, there would still appear to be a role in the case in which bone stock restoration is a primary goal. The role of bone graft substitutes remains unclear, with supportive basic science data, but limited clinical experience to date. An algorithm will be discussed to assist in prioritising the multiple goals of acetabular reconstruction and one stock restoration

One cementless cup which had porous outer surface with Apatite-Wollastonite glass ceramic (AWGC) coating, was revised 13 years after primary THA because of massive osteolysis expanded to medial iliac wall along the screws. While many retrieved studies of hydroxyapatite-coated cup have been reported, there has been no report on the retrieved cup with AWGC coating. The purpose of this study was to describe this rare case in detail, confirm the bone ingrowth to the porous cup, and discuss on the effectiveness of porous surface with AWGC coating. Case. The patient was a 64 old woman and complained of chronic mild pain around her left groin region. X-ray examination revealed that osteolysis had been expanding around the screws and extended proximally. The revision surgery was performed for the massive osteolysis through Hardinge antero-lateral approach. The retrieved implants included a cementless cup made of titanium alloy (QPOC cup, Japan Medical Materirals Inc.(JMM) Osaka, Japan), the outer surface of which was plasma-sprayed with titanium for porous formation and coated with AWGC in the deep layer. It was found that the polyethylene liner was destructed partially in the supero-lateral portion, but the cup was well fixed to the bone. The bone-attached area was found to be dispersed over the porous surface of the hemispherical cup. Histological examination revealed that matured bony tissue intruded into the porous surface of the cup, and contacted to bone directly, which was also demonstrated in the back-scattered electron image. It was also demonstrated that there were residual silicon (Si) rich regions on the porous surface by the SEM-EDX analysis, which indicated that constituents of AWGC still remained on the surface. On the other hand, the results of elementary analyses in the Si rich regions varied among the sections, which probably indicated that the extent of degradation and absorption of AWGC varied among the sections. AWGC was one of the bioactive ceramics and reported to have an ability to bond to bone earlier than hydroxyapatite (HA). In the present case, though massive osteolysis occurred with aggressive wear, it did not expand on the porous surface, and rather progressed along the smooth surface of the screws. Considering that there are many clinical studies reporting poor clinical results of HA-coated smooth cups, bioactive ceramic coating may function well and bring superior clinical results when combined with porous coated substrate. In our study, though the cause of massive polyethylene wear and intrapelvic giant osteolysis could not be revealed, the porous cup with AW-GC bottom coating was well fixed and gained bone-ingrowth at the porous surface under osteolytic conditions, which may demonstrate the long-term durability of this surface treatment

Aim. To introduce and promote a new technic and a new component using the 3D technology in the extreme acetabular revisions. Method. Since 2012, 13 patients, nine women and four men, were treated, 12 for a chronic complex PJI and one for an aseptic loosening. The average age was 75 years old (60 -90 years), the average follow-up 18,6 months (7–36 months). The revisions were bipolar in 12 cases and unipolar in one case for the oldest patient. For the septic cases, we performed 7 one stage procedure and 5 two stages. The femoral components were in 7 cases a modular stem, in 5 cases a massive component and a total femur. All these massive components were combined with a cemented double cup. The bone loss was evaluated with the AAOS, the Praposky and the Saleh classifications. A preoperative and postoperative Oxford score was used. Results. The bone loss are major; 9 stades III, 4 IV for the AAOS classification, 7 III A, 6 III B for the Praposky and 3 III, 6 IV, 4 V for the Saleh classification. The classifications weren't change by the component removal. 10 components were implanted without using cement. For the three cemented implants, the bone loss interested the columns and the roof. An acetabular disruption isn't a contrindication of an uncemented option. We report one early failure, in relation with no surgical postoperative complications. A good preoperative anchorage had never failed in the follow-up. The preoperative Oxford score was on average 8,9 (4–15) and the postoperative 33,6 (16–44). We report one early failure f a two stage procedure. Two patients underwent a recovery for partial change with no custom made implant involvement. In doing so, we have found that these cement less implants were well integrated and stable two months after the implantation. The most significant events are skin complications always after an extensive debridement, treated systematically by an iterative debridement. None of these complications appear to be related to the use of these implants. Conclusions. It's the first series which reports the use of the powder technology for a custom made component. In our series, it interests specific situations; elderly patients failing conventional medico-surgical strategies in complex functional and PJI. First results are really promising. This technology simplifies the complex acetabular reconstructions. It's a key point for the immediate postoperative functional management and to limit complications