Background. There is doubt regarding resection compared to curettage for pelvic metastases. Previous studies have reported that curettage is associated with decreased survival compared with wide resection, and have justified a radical surgical approach to achieve pain palliation and tumor control. Aim. To evaluate the role of wide en bloc resection compared to curettage/marginal resection for patients with pelvic metastases. The rationale was that wide resection does not improve survival even in patients with solitary pelvic metastases. Method. Between 1985 and 2009, 21 patients (6 women, 15 men; age, 34–76 years) were treated for pelvic metastases. Histology included thyroid carcinoma in 5 patients, bladder carcinoma in 4 patients, renal and endometrium in 2 cases each and colon, ovarium, cerebral and lung carcinoma in 1 case each; the primary tumor was undiagnosed in 4 patients. Three patients had sacral and 1 patient had sacroiliac joint metastasis. According to Enneking's classification of the anatomical site involved, 5 patients had type I, 1 patient had type II, 6 patients had type III, 1 patient had type I and II, and 4 patients had type II and III pelvic metastasis. Metastatic disease was localized in the pelvic ring in 15 patients and multifocal in 6 patients. Eight patients had surgical treatment only; 13 patients had surgical treatment in addition to radiation therapy (2 patients), chemotherapy (1 patient), embolization (3 patients), or combined adjuvant treatments (7 patients). 21 patients with pelvic metastases were treated with wide resection (12 patients) and curettage/marginal resection (9 patients) and adjuvants. Sixteen patients had solitary pelvic metastases. Reconstruction of the hip joint was performed in three patients. Results. At a mean of 27.6 months (range, 2–152 months), the overall survival to death and local recurrence was 15% at 66 months and 47% at 26 months, respectively. Survival to death of patients treated with wide en bloc resection was 18% at 46 months compared to 62% at 12months of patients treated with curettage/marginal resection; no difference in survival to death between wide en bloc resection and curettage/marginal resection was observed (p=0.570). Survival to local recurrence of patients treated with wide en bloc resection was 67% at 24 months compared to 26% at 24 months of patients treated with curettage/marginal resection; this was also not statistically significant (p=0.0683). One patient treated with wide en bloc resection for a solitary pelvic bone metastasis had a postoperative complication. Conclusion. This series showed that neither the combination of surgical and adjuvant treatments nor the type of surgical resection were statistically significant parameters for local recurrence. We found no difference in survival to death or local recurrence 1 with wide en bloc resection compared to curettage or marginal resection, even in patients with solitary pelvic metastases

Introduction. Primary malign tumors and solitary metastatic lesions of the thoracic and thoracolumbar spine are indications for radical en bloc resections. Extracompartimental tumor infiltration makes the achievement of adequate oncological resection more difficult and requires an extension of the resection margins. We present a retrospective clinical study of patients that underwent chest wall resection in combination with vertebrectomy due to sarcomas and solitary metastases for assessing the clinical outcome especially focusing on onco-surgical results. Method. From 01/2002 to 01/2009 20 patients (female/male: 8/12; mean age: 52 (range of age: 27–76yrs)) underwent a combined en bloc resection of chest wall and vertebrectomy for solitary primary spinal sarcoma and metastatic lesions. The median follow-up was 20,5 (3–80) months. Histological analysis revealed 17 primary tumors and 3 solitary metastatic lesions. In the group of primary tumors 10 sarcomas, 1 giant cell tumor, 2 PNET, 1 histiocytoma, 1 aggressiv fibrous dysplasia, 1 pancoast tumor and 1 plasmocytoma were histologically documented. We included 1 rectal carcinoma, 1 breast cancer metastases and 1 renal cell carcinoma. All patients underwent a chestwall resection en bloc with multilevel (1/2/3/4 segments: n=4/6/6/4) hemi (n=7) or total vertebrectomy (n=13) with subsequent defect reconstruction. Reconstruction of the spinal defect following total resections was accomplished by combined dorsal stabilization and carbon cage interposition. The chest wall defects were closed with a goretex ® -patch. One patient also received a musculocutaneus latissimus dorsi flap. Results. The surgical margins were R0 in 19 (wide in 14, marginal in 5) and one R1 resection. Marginal/R1 resections were due to extracompartimental sarcoma invasion (spinal canal) and dural involvement. In these patients postoperative radiotherapy was performed. Surgical complications requiring revision occurred in 1 patient due to injury of the ductus thoracicus and persisting chylothorax. Temporary subileus or mild pneumonia appeared in 3 patients. No superficial/deep infection or neurological deficits (except those related to oncologically required dissection of thoracic nerve roots) were observed. At follow up 2 patients died due to the disease after 7,5 months. Local recurrences were seen in 3 patients at median 24 months (13–43). Pulmonary metastases necessitating polychemotherapy were seen in 7 patients after median 17 months (7–44). Conclusion. Despite the only midterm follow up, the combined en bloc resection of chest wall and multilevel en bloc spondylectomy/hemivertebrectomy is a challenging but safe and effective technique in order to achieve adequate margins and local control in selected with spinal sarcomas extending to the dorsolateral chest wall

Aim. To analyse our results after en-block resection of aggressive GCT during 20 years period. Methods. We review 86 patients with skeletal GCT during the last 20 years, from 1990 until 2009, retrospectively. In the cases of latent and active type, extended curettage and bone graft or cement were our treatment of choice, while in aggressive ones we performed en block resection and reconstruction by fibular autograft (e.g. in distal part of radius) or fusion/hinge joint prosthesis (e.g. in GCT around the knee joint). We describe the recurrences, metastases and complications according to treatment. Results. There was no recurrence in 18 cases of en block resection and segmental bone defects were reconstructed with fibular autograft (5), joint fusion (4) and hinge joint arthroplasty (9). We had 2 cases of pulmonary metastasis that underwent resection of the metastasis. In one case, internal fixation failed and the graft broke; thus revision was performed. The rest 68 cases underwent extended curettage and bone graft (51) or cement (17). We had 7 cases of recurrence, 6 treated with repeated curettage and bone cement and one with en lock resection. No death or major complication was reported. Conclusions. In comparison of en block resection with extended curretage, the recurrence rate is greater with the latter; however it results in good control of the disease with less morbidity. In recent years, the invention of hinge knee prosthesis has increased the quality of patients' life in whom we could not preserve the involved joint

Aim. Bone metastases of the upper limb are a frequent complication of primary tumors. The aim of this study is to evaluate treatment and functional results of patients with prosthetic reconstruction of the proximal humerus. Method. Between 1975 and 2007, 67 patients were treated by resection of humeral metastasis and reconstruction with prosthesis. Cemented modular prostheses of the proximal humerus were implanted in 59 cases (all MRS Bioimpianti® prostheses), uncemented prostheses in 2 (HMRS® Stryker), 4 elbow Coonrad-Morrey prostheses (in 2 cases with bone allograft), 1 elbow custom-made cemented and 1 intercalary prosthesis (Osteobridge Merete®). Sites of primary tumors: kidney (23), lung (13), bone and unknow (7 each), liver and breast (3 each), bladder, endometrium, thyroid, soft tissues and nervous tissues (2 each), ovarium (1). Complications were evaluated and univariate analysis with actuarial Kaplan-Meier curves of implant survival was performed. Functional results were assessed with the MSTS system. Results. At mean follow-up 27 months oncologic outcome showed 7 patients NED (mean time 7 yrs.), 57 DOD, 3 lost to follow-up. Complications were deep infection (2 cases, 3%) and loosening (1 case, 1.5%) causing failure requiring revision. Functional results were good or excellent in 93% of patients, with average score of 71%. Conclusion. Resection of metastatic lesion is indicated: 1) for patients with solitary metastases and long free interval from treatment of primary cancer, 2) for patients with meta-epiphyseal metastases not amenable to durable internal fixation even in presence multiple metastases. Indications of resections are increasing, due to prolonged survival with newer medical treatments. Different reconstructive techniques are available, depending on type of resection and soft tissues removal. Cemented prostheses are mostly used, since cemented fixation is not affected by radiotherapy. Although prognosis was poor, prosthetic reconstructions of the humerus provided satisfactory results

Introduction. Although various reports analyzed “en-bloc” excision of sacral tumors, there are still technical problems to improve protection of nerve roots, preserve surrounding structures and reduce intraoperative bleeding, maintaining the oncologic result. We present a new technique for sacral resection, with short term preliminary results, derived with modification from Osaka technique. Methods. Seven patients were resected for their sacrococcygeal chordoma with the followed described technique. Two patients had previous surgery elsewhere. The sacrum is exposed by a posterior midline incision and complete soft-tissue dissection. Lateral osteotomies were performed through the sacral foramina using a threadwire saw and Kerrison rongeurs, to avoid sacral roots damage. After proximal osteotomy, the sacrum is laterally elevated and mobilized to allow dissection of presacral structures. Mean surgical time was 5 hours (range: 3 to 8). Mean blood loss was 3640 ml. Results. Level of resection was S1 in 2 pts, S2 in 4 pts, S3 in 1. Margins were wide in 6 patients and marginal in one. At a mean follow-up of 2 years, six patients were disease-free, one had a local recurrence. No complications were showed. Conclusion. This technique allows wide margins with roots preservation and reduction of complications and operative time. Indications for posterior approach only can be extended to resection proximal to S3, when there is minimal pelvic invasion and none or partial involvement of sacroiliac joints. However, the long term benefits of this technique need to be evaluated

Introduction. The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?. Material and methods. In an amount of 35 consecutive patients who were taken in charge for an elbow dislocation 26 were included in this retrospective study, 13 of them had the association of a dislocation and a fracture of the radial head. In all 13 cases the radial head was considered as inadequate with a conservative treatment and was resected. The patients were assessed clinically according to the American Shoulder and Elbow Surgeons score (ASES) and the Mayo elbow performance index with a mean follow-up of 13 years (ranging from 5 to 15). The degenerative changes were assessed on plan × rays and an additional axial view according to the 4 stages described by Morrey. Results. No redislocation occurred. According to the Broberg/Morrey index 92% of the patients were considered as having a good result. They returned to work with no hindering. Signs of osteoarthritis grade 1 or 2 were observed and were clinically well tolerated. There was no difference for this item between the patients who conserved their radial head and those who sustained a resection. All patients were satisfied although they were protecting their joint against overuse while working. Discussion. The studies about the use of prosthesis of the radial head offer similar functional results. Degenerative changes on the trochleo ulnar joint are identical in all type of treatment. In order to prevent stiffness in the elbow joint an early post operative rehabilitation is recommended, it justifies a surgical stabilization associated with the use of an adapted dynamic splint. Conclusion. In case of elbow dislocation with a fracture of the radial head when its preservation is impossible, the resection without any prosthetic replacement remains a reasonable option if associated with a repair of the medial collateral ligament. At long term the functional results are still good with mild signs of osteoarthritis eliminating ipso facto the problem of an implant survivorship

A systematic literature review of distraction osteogenesis (DO) for the primary reconstruction of bone defects following resection of primary malignant tumours of long bones (PMTLB) is presented. Fewer than 50 cases were identified. Most reports relate to benign tumours or secondary reconstructive procedures. The outcomes of our own series of 7 patients is also presented (4 tibiae, 3 femora). All patients had isolated bone lesions without metastases and were assessed through the hospital sarcoma board. Mean follow-up was 59 months (17–144). Mean age was 42 years. Final histologic diagnoses were 3 chondrosarcoma, 2 malignant fibrous histiocytoma, 1 adamantinoma and 1 malignant intraosseous nerve sheath tumour. Mean bone defect after resection was 13.1cm (10–17) and bone transport was the reconstruction method in all. There was one local recurrence of tumour six months post-resection, necessitating amputation. Mean frame index for remaining cases was 30.9 days/cm (15.7–41.6). Complications included pin infection, docking site non-union, premature corticotomy union, soft-tissue infection and minor varus deformity. Six cases remain tumour-free with united, well-aligned bones and good long-term function. We conclude DO provides an effective biologic reconstruction option in select cases of PMTLB

Background. Osteoarthritis of basal joint of the thumb represents one of the commonest degenerative diseases of the hand and wrist region. Depending on the severity of clinical symptoms surgical treatment is often recommended. Resection arthroplasty of the CMC joint with tendon interposition can be regarded as the gold standard. The aim of our study is to compare the Burton Pellegrini technique with a new modified technique of resection arthroplasty with interposition of local capsule tissue. Materials and Methods. We retrospectively evaluated 2 groups of patients. Two Consultant Surgeons took part in the study, one for each group, with each consultant performing trapeziectomies using only one of the techiniques for all his patients. The first group underwent trapeziectomy and local capsule interposition. It consists of 26 patients with a female/male ratio of 20/6, an average age of 64 years (range 53–88), an average follow up of 3.15 years (range 9–1) and a left/right ratio of 16/10. The second group underwent a standard Burton Pellegrini including flexor tendon interposition. It consists of 13 patients with a female/male ratio of 5/8, an average age of 68 years (range 58–85), an average follow up of 4.46 years (range 9–1) and a left/right ratio of 5/8. The outcomes were compared using the Michigan Hand Outcomes Questionnaire. A 2-tailed independent samples t-test was used for the statistical analysis of our data. Results. We found that there is significant difference between the two procedures only on the ability of working in present, t = 2.153 and p = 0.038. However, there is no significant difference between the other parameters we examined: overall hand function, t = 0.237 and p = 0.814; activities of daily living using the operated hand, t = 0.194 and p = 0.847; activities of daily living using both hands, t = 0.184 and p = 0.855; overall activities of daily living, t = 0.204 and p = 0.839; pain, t = 0.123 and p = 0.903; aesthetics, t = 1.063 and p = 0.295; satisfaction, t = 0.628 and p = 0.534; total score, t = 0.509 and p = 0.613. Furthermore, the overall score for the two procedures suggests that there is no significant difference between them. Conclusions. The new modified procedure is simpler and quicker than the traditional operation and avoids the morbidity of tendon harvesting. The overall outcome score for the two operations is equal, suggesting that there is no advantage to the more complex procedure. We have shown a difference between the two procedures in post op working ability, being better in the group with local capsule interposition

Aims

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

Patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma have been recently established. However, little is known regarding what patient factors affect these outcomes. This is the first and largest prospective study to determine which patient factors influence surgical outcome following Morton's neuroma excision. Over a seven-year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Patient demographics were recorded in addition to co-morbidities, deprivation, associated neuroma excision and other forefoot surgery. Obesity, deprivation and revision surgery proved to statistically worsen MOXFQ outcomes post-operatively (p=0.005, p=0.002 and p=0.004 respectively). Deprivation significantly worsened the mental component of the SF12 (p=0.043) and depression the physical component (p=0.026). No difference in outcome was identified for age, sex, time from diagnosis to surgery, multiple neuroma excision and other forefoot surgeries. 23.5percnt; of deprived patients were dissatisfied with their surgery compared to 7percnt; of the remaining cohort. Patient reported outcomes following resection of symptomatic Morton's neuroma are shown to be less favourable in those patients who display characteristics of obesity, depression, deprivation and in those who undertake revision neuroma resection. Surgery can be safely delayed, as time to surgery from diagnosis bears no impact on clinical outcome

Aim. Aim of this study was to review surgical treatment of femural metastases, comparing nailing versus resection and prosthetic reconstruction. Method. Between 1975 and 2008 110 patients were surgically treated for metastatic disease of the femur. Prostheses were implanted in 57 cases (16 HMRS® Stryker, 38 MRP® Bioimpianti, 2 Osteobridge® and 1 GMRS®). In 53 patients femoral nailing was performed with different types of locked nails (32 Gamma, 14 Grosse-Kempft and 6 T2-Stryker®). Sites of primary tumor were breast (33 cases), kidney (18), lung (17), undifferentiated carcinoma (14), g.i. (8), bladder and prostate (5 each), endometrium and thyroid (3 each), skin (2), pheochromocytoma and pancreas (1 each). Indications to nails were given in patients with femoral metastasis and poor prognosis: multiple metastases, short free interval, unfavourable histotype, poor general conditions. Resection and prosthesis was preferred for patients with solitary metastasis, long free interval, favourable histotype, good general conditions or in whenever the extent of the lesion was not amenable to a durable internal fixation. Complications were analysed. Univariate analysis by Kaplan-Meier curves of implant and oncological survival was performed. Functional results were assessed with MSTS system. Results. Outcome showed: 23 AWD at mean 52 months, 57 DWD at mean 9 months, 30 lost to follow up. Survival in patients treated with femoral nailing was about 10% at 5 years versus 20% for patients treated with resection. Patients with resections had a better survival curve at 2 years. Complications were: infections (4/110, 3.7%), aseptic loosening (1/110, 1%). Statistical analysis showed a significantly better survival for patients resected versus those treated by internal fixation (p=0.0214). Multivariate analysis indicated that pathologic fracture is the only significant adverse prognostic factor (p=0.006). Conclusion. Internal fixation is indicated in patients with multiple metastases and poor prognosis. When expected survival is longer and there is a solitary metastasis a resection is preferable. Indications of resections are progressively increasing due to newer medical treatment giving longer survival to metastatic patients

Background. Giant cell tumours of bone (GCT) are benign bone tumours with a locally aggressive character. Local recurrence is considered the main complication of surgical treatment and is described in up to 50% of patients. Intralesional curettage with the use of adjuvants like phenol or polymethylmetacrylate (PMMA) is recommended as initial treatment, significantly decreasing the risk of recurrence. However, risk factors for local recurrence in skeletal GCT have not yet been firmly established and a golden standard for local therapy remains controversial. Objective. The identification of risk factors predisposing for an increased risk of local recurrence. In addition, different surgical techniques are compared to identify the optimal surgical approach for the identified risk factors. Methods. In a retrospective study all 215 patients with bone GCT treated between 1964 and 2009 in one centre were included, of which 193 were suitable for analysis. All patients had minimal follow-up of 12 months (mean 115; range 12–445). Using a Kaplan Meier survival analysis recurrence free survival rates were calculated. Cox-regression was used to determine the influence of different types of therapy, the use of adjuvants, and various patient and tumour characteristics. Results. The mean local recurrence rate for all patients was 35.2% (n=68, 95%CI: 28.3–42.1). Recurrence rate after wide resection was 0.17 (n=6, 95%CI: 0.04–0.29), after curettage with adjuvants 0.32 (n=42, 95%CI 0.24–0.41) and after curettage alone 0.74 (n=20, 95%CI: 0.57–0.91, p < 0.001). Soft tissue extension (Hazard Ratio: 3.8, p < 0.001), localisation in radius and ulna (HR: 2.6, p=0.013), and surgical experience (HR: 2.2, p=0.022) were identified as significant general risk factors for local recurrence. For intralesional resection, Campanacci grade III (HR: 3.9, p=0.019) and location in axial skeleton (HR: 3.3, p=0.016) additionally significantly increased this risk. Comparing treatments our data showed that curettage followed by adjuvants was superior to curettage alone (p < 0.004), and the application of both phenol and PMMA did not present a significantly better outcome than curettage and PMMA alone (HR: 1.07, p=0.881). Conclusion. Of all possible risk factors only soft tissue extension, localisation in radius and ulna and non-radical resections significantly influenced the risk of local recurrence for all treatments. In addition, we found that high-grade tumours and localisation in the axial skeleton were additional risk factors for local recurrence after intralesional surgery. Although wide resection increases patient morbidity, it can be the therapy of choice in high risk patients. Intralesional therapy can be advised for low recurrence risk patients using curettage and PMMA only, whereas our study could not confirm the predicted effect of phenol as an additional adjuvant

Objective. High grade hallux rigidus is a forefoot deformity characterized by a limitation of dorsiflexion of the first toe associated with pain, and severe damage of the first metatarsophalangeal joint. Most authors recommended resection arthroplasty or arthrodesis of the first metatarsophalangeal joint. The aim of this study was to present the results of our series of 42 consecutive cases of severe hallux rigidus treated by resection of the first metatarsal head and implant of a poly D-L lactic (PDLLA) bioreabsorbable spacer to promote the interposition of fibrous tissue to preserve the range of motion of the joint. Material and methods. Forty-two feet in 27 patients affected by high grade hallux rigidus were included in the study. Surgical treatment consisted of resection of the first metatarsal head and positioning of a poly D-L lactic acid (PDLLA) bioreabsorbable implant. Post-operative care consisted in gauze bandage of the forefoot, and immediate weight-bearing with talus shoes for 3 weeks. All patients were clinically and radiographically evaluated preoperatively and checked at a mean 6 (5–7) year follow-up. Results. No intraoperative complication occurred. No sinus formation were observed. All implants resulted well tolerated by the patients. Mean AOFAS score was 42±14 preoperatively and 81±9 postoperatively. Mean preoperative metatarsophalangeal joint ROM was 27±17 degrees and mean postoperative metatarsophalangeal joint ROM was 75±8 degrees. Conclusions. First metatarsophalangeal joint arthroplasty using bioreabsorbable implant demonstrated to be an effective surgical option for treatment of high grade hallux rigidus, thank to its ability to promote fibrous tissue formation during its reabsorption

Aims

Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture.

Introduction. While clinically successful for decades, CR TKA is persistently compromised by inconsistent PCL function. Problems of mid-flexion instability, incomplete knee flexion, erratic kinematic behavior and posterior instability, not seen with PS devices, raise concerns about the consistency of the technique, and the devices used. Most TKA systems offer at least 2 different geometries of tibial inserts to address this clinical problem. We hypothesize these problems are a result of compromise of PCL anatomy. To avoid compromise to the PCL 3 steps are required: 1) The slope of tibial resection must be less than 5°; 2) the depth of tibial resection must be based off the insertion footprint of the PCL, not the deficiencies of the tibial articular surface; and 3) the tibial insert must be modified to allow intraoperative balancing of the PCL. Results. The CR Slope ™ implants and technique (Exactech) (“Posterior Cruciate Referencing Technique (PCRT)”) reflect this philosophy and have allowed consistent surgical intervention without PCL release and without multiple inserts. We present data identifying, the footprint, and the instrument and technique modifications that allow for predictable identification of the depth and angle of resection. At 2 years post implantation in the first 100 patients implanted, the study group has demonstrated similar operative time, LOS and Oxford knee scores (OKS), while ROM averaged 5° greater, and time to achieved flexion was decreased. Conclusion. The PCRT offers a new conceptual and clinical approach to predictable CR TKA

Objectives. Deep bone and joint infections (DBJI) are directly intertwined with health, demographic change towards an elderly population, and wellbeing. The elderly human population is more prone to acquire infections, and the consequences such as pain, reduced quality of life, morbidity, absence from work and premature retirement due to disability place significant burdens on already strained healthcare systems and societal budgets. DBJIs are less responsive to systemic antibiotics because of poor vascular perfusion in necrotic bone, large bone defects and persistent biofilm-based infection. Emerging bacterial resistance poses a major threat and new innovative treatment modalities are urgently needed to curb its current trajectory. Materials and Methods. We present a new biphasic ceramic bone substitute consisting of hydroxyapatite and calcium sulphate for local antibiotic delivery in combination with bone regeneration. Gentamicin release was measured in four setups: 1) in vitro elution in Ringer’s solution; 2) local elution in patients treated for trochanteric hip fractures or uncemented hip revisions; 3) local elution in patients treated with a bone tumour resection; and 4) local elution in patients treated surgically for chronic corticomedullary osteomyelitis. Results. The release pattern in vitro was comparable with the obtained release in the patient studies. No recurrence was detected in the osteomyelitis group at latest follow-up (minimum 1.5 years). Conclusions. This new biphasic bone substitute containing antibiotics provides safe prevention of bone infections in a range of clinical situations. The in vitro test method predicts the in vivo performance and makes it a reliable tool in the development of future antibiotic-eluting bone-regenerating materials. Cite this article: M. Stravinskas, P. Horstmann, J. Ferguson, W. Hettwer, M. Nilsson, S. Tarasevicius, M. M. Petersen, M. A. McNally, L. Lidgren. Pharmacokinetics of gentamicin eluted from a regenerating bone graft substitute: In vitro and clinical release studies. Bone Joint Res 2016;5:427–435. DOI: 10.1302/2046-3758.59.BJR-2016-0108.R1

We hypothesised that an independent Notch Trial is essential on the same lines as other Component Trials-Femoral, Tibial and Patellar - in posterior stabilised total knee arthroplasty. Therefore we evolved Notch Trial to visually ascertain the adequacy of intercondylar resection and eliminate the possibility of femoral intercondylar fractures. We undertook a retrospective study to evaluate Notch Trial by the frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection by using the detachable box part of the trial femoral component, assess occurrence of distal femoral intercondylar fractures and demonstrate Notch Trial in posterior stabilised total knee replacement. We studied 206 patients, 113 females and 93 males, who underwent consecutive primary posterior stabilised total knee replacements applying Notch Trial between 2000 and 2008 in a District General Hospital under our team. Outcome Measurements were 1) frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection and 2) occurrence of distal femoral intercondylar fractures intraoperatively or on postoperative radiographs. We had to remove the osteophytes and file the cut surfaces in 183 (88.88%) of patients after Notch Trial. We had no distal femoral intercondylar fractures intraoperatively or on postoperative radiographs. Notch Trial allows the surgeon to directly visualise and ascertain the adequacy and precise fit of femoral notch cut with cam part of femoral component to ensure a press fit femoral component in condylar posterior cruciate substituting total knee replacement. Notch Trial prior to Femoral Component Trial effectively pre-empts intraoperative distal femoral intercondylar fractures. We recommend that Notch Trial should become part of the protocol for cruciate substituting total knee replacement and implants of all companies should have the option of a detachable box component for Notch Trial

The reconstruction of lower limb defects after oncological reconstructions is still a problem in limb salvage surgery. Large bony defects need to be treated with sound and durable reconstructions. During recent decades, the life expectancy of patients affected with cancer has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution. From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures were relatively high. We should consider that in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure. However the new design of morse tapers have annulled these problems