Introduction. Ankle fusion presents a difficult problem in the presence of infection, inadequate soft tissue, poor bone stock and deformity. Nonunion and infection remains a problem even with internal fixation. Ilizarov frame provides an elegant solution to the problem with stable remote fixation while allowing lengthening, deformity correction and weight bearing. Patients and methods. Twenty-one consecutive patients were studied. The mean age at onset of disease was 52 years (range 4-70). Mean duration of the problem was 59.9 months (6-372). Aetiology included traumatic arthritis in 5, traumatic arthritis with osteomyelitis in 1, failed ankle fusion in 8, septic arthritis in 1, infected ankle fracture nonunion in 1, avascular necrosis of talus in 1, congenital deformity in 3 and failed ankle arthroplasty in 1. 15 patients had deformity of the ankle at the time of presentation. 15 of the 21 patients had either clinical or radiological evidence of infection. Treatment principles involved local excision, deformity correction with good alignment and soft tissue management. Static Compression was achieved with an Ilizarov frame while dynamic fixation was performed in 3 cases for lengthening. Antibiotics treatment was continued until union in the infected cases. On achieving union the frame was removed and a below knee cast was applied for 4 weeks. Results. Fusion was achieved in all cases at an average time of 5 months. One patient had below knee amputation for chronic pain. There was no recurrence of infection. Complications included pin site infection, lateral impingement, drug reaction and hind-foot pain. The results were assessed in terms of SF36 and Modified foot and ankle score. Conclusion. The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems

As there are many reports describing avascular reactions to metal debris (ARMD) after Metal-on-Metal Hip Arthroplasty (MoMHA), the use of MoMHA, especially hip resurfacing, is decreasing worldwide. In cases of ARMD or a rise of metal ion blood levels, revision is commended even in pain free patients with a well integrated implant. The revision of a well integrated implant will cause bone loss. As most of the patients with a hip resurfacing are young and a good bone stock is desirable for further revision surgeries, the purpose of this study was to evaluate the stability of a cemented polyethylene cup in a metal hip resurfacing cup. Two different hip resurfacing systems were investigated in this study (ASR™, DePuy Orthopaedics, Leatherhead, UK; Cormet™, Corin Group, Cirencester, UK).

Six different groups were formed according to the treatment and preparation of the cement-cup-interface (table 1). Before instilling cement in groups 1, 3, 5 the surface, which was contaminated with blood, was cleaned just using a gauze bandage. In groups 2, 4, 6 saline, polyhexanid and a gauze were used to clean the surface prior to the cement application. In group one and two the polyethylene cup (PE) was cemented either into Cormet™ or ASR™, just the ASR™ was further investigated in group three to six. A monoaxial load was applied while the cup was fixed with 45 degrees inclination (group 1–4) and 90 degrees inclination (group 5, 6: rotatory stability) and the failure torque was measured. In contrast to group 1 and 2, the cement penetrated the peripheral groove of the ASR™ in groups 3–6. The mean failure torque of five tests for each group was compared between the groups and the implants.

The ASR™ showed mean failure torque of 0.1 Nm in group one, of 0.14 Nm in group two, of 56.9 Nm in group three, of 61.5 Nm in group four, of 2.96 Nm in group five and of 3.04 Nm in group six. The mean failure torque of the Cormet™ was 0.14 Nm both in groups one and two (table 2). In groups 1–6 there were no significant differences between the different preparations of the interface. Furthermore, in groups 1 and 2 there were no significant differences between the Cormet™ and the ASR™. The mean failure torque of group 4 was significant increased compared to group 3 (p=0.008).

We saw an early failure of the cement fixation due to the smooth surface of the Cormet™ and the ASR™ components in groups 1, 2, 5, 6. In contrast to other hip resurfacing cups the ASR™ has a peripheral groove, which was not cemented except in groups 3 and 4 and therefore the lever-out failure torque was significant increased in these groups. Nevertheless, the groove did not provide stability of the cement-PE compound in case of rotatory movements. In conclusion we do not recommend the use of these methods in clinical routine. The complete removal of hip resurfacing components seems to be the most reasonable procedure.

Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age.

The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery.

Traditionally, open reduction and internal fixation (ORIF) and hemiarthroplasty (HA) have been the surgical treatments of choice for displaced proximal humerus fractures (PHF) despite high rates of fixation failure and tuberosity nonunion, especially in the elderly population with poor bone quality. Recently, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) as a treatment option in both acute fractures, as well as a salvage procedure for fracture sequelae (i.e., malunion, nonunion, fixation failure, tuberosity non-union). Despite the growing enthusiasm it remains unknown whether functional outcomes after RTSA as a salvage procedure are similar to those following acute RTSA. As a result, the purpose of this systematic review was to compare functional outcomes after RTSA as a primary versus salvage procedure for displaced PHF in the elderly. A literature search of the electronic databases EMBASE, MEDLINE, and PubMed was conducted to identify all studies comparing RTSA as a primary treatment for displaced PHF and as a salvage procedure for failed initial management. Only studies with a minimum follow-up of two years were included. Data pertaining to range of motion, patient reported outcome measures and complications were extracted from eligible studies and entered into a meta-analysis software package (RevMan version 5.1, The Cochrane Collaboration) for pooled analysis. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of eligible studies. The search identified four studies consisting of 200 patients with a mean age of 73.3 years and a mean follow-up of 3.2 years. There were a total of 76 patients (75% female) who underwent acute RTSA following displaced PHF, while 124 patients (77% female) required salvage RTSA for failure of initial treatment. Primary RTSA was found to have significantly higher American Shoulder and Elbow (ASES) (P = 0.04), Constant (P = 0.01) and University of California at Los Angeles (UCLA) (P = 0.0004) scores compared to salvage RTSA. Forward flexion (P = 0.001) and external rotation (P< 0.0001) were significantly greater amongst those undergoing RTSA acutely versus as a salvage procedure. The odds of having a complication (e.g., infection, dislocation, fracture) were 76% lower amongst those who had primary RTSA compared to salvage RTSA (P = 0.02). The overall quality of eligible studies was moderate to high. Based on the current available evidence, elderly patients with displaced PHF have significantly greater range of motion, higher patient reported outcomes and lower risk of complications with primary RTSA compared to those undergoing RTSA as a salvage procedure. Additional prospective studies are warranted to confirm these findings

Introduction. Orthopaedic rehabilitation of adolescences and young adults with high dislocation of the femur is rather challenging. The role of palliative salvage procedures is controversial enough in the cohort of patients. Materials and Methods. Treatment outcomes of 10 patients with congenital hip dislocation were analyzed. Mean age at intervention was 17,8 years (15–22). The grade of dislocation were assessed according to Eftekhar: type C − 2, type D − 8. The mean baseline shortening was 4.7±0.36 cm. All subjects underwent PSO with the Ilizarov method. Another osteotomy for lengthening and realignment was produced at the boundary of the upper and middle third of the femur. The mean time in the Ilizarov frame was 5.3 months. Results. The mean follow-up was 2.6±.1 years (range, 15 to 32 years). Limb shortening of 1 cm to 1. 1. /. 2. cm was observed in four cases. Functional outcomes according to d'Aubigne-Postel were: Pain 4,4±0,15 points. ROM − 4,1±0,3 points. Walking ability − 4,5±0,2 points. Two cases had good results (15–17 points), and seven patients had fair outcomes (12–14 points). A poor result (7 points) was recorded in one female patient 28 years after PSO followed by THA. Conclusions. Hip reconstruction with the Ilizarov method can be used in specific clinical situations as an alternative salvage procedure to delay THR in young patients with high dislocation of the femur

Treatment for hip displacement in children and youth with cerebral palsy (CP) is dependent upon when the problem is detected. Hip surveillance aims to identify hip displacement early through systematic screening and, together with timely orthopaedic intervention, can eliminate the need for salvage hip procedures. Here we report the impact on surgical practice of 1) hip surveillance program advocacy and knowledge translation efforts and 2) initial population-based program implementation. A retrospective review was completed of all children with CP undergoing surgery for hip displacement at a provincial tertiary pediatric hospital in the years 2004 to 2018. Date and type of surgery, age at surgery, Gross Motor Function Classification System (GMFCS) level, and pre-operative migration percentages (MP) were collected. Surgeries were categorized as soft-tissue release, reconstructive, and salvage procedures. Results were collected for three time periods: historical (September 2004- June 2010), hip surveillance advocacy and knowledge translation (July 2010- August 2015), and post provincial hip surveillance program implementation (September 2015 – December 2018). A total of 261 surgeries on 321 hips were reviewed. The rate of salvage procedures dropped from 29% (24) of surgeries performed in the historical period to 12% (14) during the period that included targeted hip surveillance knowledge translation and development of provincial guidelines. Since implementation of the surveillance program, salvage procedures have accounted for 7% (4) of interventions performed; all of these were in patients new to the province or existing patients. During the three study periods, reconstructive surgeries accounted for 64%, 81%, and 80% of the interventions performed. The mean initial MP at time of reconstructive surgery has decreased from 66% (SD 20%) in the historical time period to 57% (SD 25%) and 57% (SD 22%) in the subsequent time periods. There were a greater number of children at GMFCS levels III and IV in the two more recent time periods suggesting surveillance may assist in identifying children at these levels of impairment. The rate of soft-tissue surgeries was low during all time periods with the number trending higher since program implementation (7%, 7%, 10%). Knowledge translation and use of standardized surveillance guidelines can have a significant impact on the prevalence of salvage hip surgeries. Centers should utilize existing surveillance guidelines and educate key stakeholders about the importance of hip surveillance in the absence of a formal hip surveillance program

Introduction. Reconstruction of large defect of tibia following infection is considered as one of the most difficult problem facing the orthopaedic surgeon. Amputation with modern prosthetic fitting is a salvage procedure to treat big defects, which gives a functional result with unpredictable psychological impact. Materials & Methods. Between January 2000 and January 2021, 56 patients (30 males and 26 females) with big defects following infection and post traumatic injury of the tibia were treated. The mean age of the patients at the time of surgery was 20.5 years (4–24 years). The fibula was mobilized medially to fill the defect and was fixed with Ilizarov fixator. The average size of the defects reconstructed was 18.5 cm (17–20 cm). Results. The average time for complete union was 8.6 months (range, 5–9 months). At final follow-up all patients had fully united. We found leg length discrepancy in 52 patients and that was corrected by re-lengthening of the solid new regenerate bone. Conclusions. The Ilizarov method has been shown to be an effective method of treating Tibialization of fibula for reconstruction of big tibial defects

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures

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

Background. Bacteriophages are natural viruses of interest in the field of PJI. A paper previously reported the PhagoDAIR procedure (use of phages during DAIR) in three patients with PJI for whom explantation was not desirable. As the need to isolate the pathogen before surgery to perform phage susceptibility testing is a strong hindrance for the development of this procedure, we developed post-operative phage injections using ultrasound, in patients infected with S. aureus and/or P. aeruginosa who were eligible for the PhagoDAIR procedure, but for whom phages were not available at the time of surgery. Materials/Methods. We performed a single center, exploratory, prospective cohort study including patients with knee PJI who received phage therapy with ultrasound after performance of a DAIR or a partial prosthesis exchange. All patients had PJI requiring conservative surgery and suppressive antimicrobial therapy (SAT) as salvage procedure. Each case was discussed in multidisciplinary meetings in agreement with French health authority, based on the clinical presentation, and the phage susceptibility testing. The cocktail of highly concentrate active phages (5 mL; about 10. e. 9 PFU/mL) was extemporaneous prepared and administered three times directly into the joint using sonography (1 injection per week during 3 weeks) during the postoperative period, before switching antibiotics to SAT. Results. Seven patients received phages under sonography after the DAIR, and one after a partial exchange (mean age 71 years). All had resection prosthesis or constrained knee prosthesis. Among these seven patients, three were infected with S. aureus (including one MRSA), two were infected with P. aeruginosa (one was a multidrug-resistant isolate), one was infected with both S. aureus and P. aeruginosa and the last one was infected with MRSA, S. epidermidis and Corynebacterium spp.. All patients received a cocktail of active phages provided by Pherecydes Pharma targeting S. aureus or P. aeruginosa. No adverse event was recorded during or after the local injections. All patients were switched to SAT after a primary postoperative antimicrobial therapy of three months. Under SAT, the patient with S. epidermidis co-infection developed a relapse due to the S. epidermidis. With a mean follow-up of 13 months after surgery (from 9 to 24 months), the outcome was favorable for all patients without any sign of infection; none of them had abnormal pain, joint effusion or loosening. Conclusions. Postoperative administration of phages using sonography is a potentially useful procedure in patients with complex PJI for whom a conservative approach is desirable

Aim. External fixator knee arthrodesis is a salvage procedure mainly used in cases of end-stage infected total knee replacement (iTKR). A stable fixation combined with bone-ends compression is basic to achieve knee fusion in such a scenario but providing enough stability can be challenging in the presence of severe bone loss after multiple previous procedures. Compared with monoplanar configuration, a biplanar frame achieves improved coronal stiffness, while providing the advantages of good access to the wound and allowance of early ambulation. Our primary hypothesis stated that a biplanar frame would achieve higher and quicker fusion rate than a monolateral configuration. Method. We conducted a retrospective cohort study examining patients managed with biplanar external fixator knee fusion due to non-revisable iTKR between 2014 and 2018. We compared this group of patients with a historical cohort-control patient who had been previously published by our unit in 2013, since we switched from a monoplanar to a biplanar configuration for the management of this kind of complex end-stage iTKR. Primary end-points were fusion rate, time to achieve bone fusion and infection eradication rate. Limb-length discrepancy, pain level, patient satisfaction, and health-related quality of life were also evaluated. Results. A total of 29 cases were finally included; 8 patients were managed with a bilateral external fixator and 21 patients were managed with a monoplanar external fixator. In the biplanar configuration group, infection was eradicated in 100% of the patients, and fusion was achieved in all cases after 5.24 months on average. In comparison, in the monolateral configuration group, infection was eradicated in 18 (86%) out of 21, whereas fusion was achieved in 17 (81%) of the patients after a mean of 10.3 months (range, 4–16). Such difference was statistically significant (p<0.05). In both groups, postoperative pain was mild (VAS score 2,25 and 3,4, respectively) and patients expressed a high degree of satisfaction once fusion was achieved. Conclusions. External fixation knee fusion is a useful limb-salvage procedure in end-stage cases of knee PJI. According to our data, the use of a biplanar configuration allows us to reduce in half (10.3 vs 5.2 months, p<0.05) the time needed to achieve the solid bone fusion in such a complex scenario. In this cohort of previously multi-operated patients, the satisfaction is high, and the level of pain is low if a solid bone fusion free of infection is achieved

Knee arthrodesis is a potencial salvage procedure for limb preservation in patients with multiple failures of Total Knee Arthroplasty (TKA) with massive bone loss and extensor mechanism deficiency. The purpose of the study is to evaluate the outcome of bridging knee arthrodesis using a modular and non cemented intramedullary nail in patients with septic failure Total Knee Arthroplasty. Between 2005 and 2013 (9 years), 15 patients (13 female and 2 male) with mean age 71.1 years (range 41 to 85) were treated at our Institution with septic two- stage knee arthrodesis using a modular and non- cemented intramedullary nail after multiple failures of septic Total Knee Arthroplasty. Mean follow- up was 70.1 months (24 to 108 months) with a minimum follow- up of 24 months. We evaluated the erradication of infection clinically and with normalization of laboratory parameters (ESR and CRP), limb length discrepancies and complications (periimplant fractures, amputation rates, wound healing disturbances) and the subjective evaluation of the patients after knee arthrodesis. We reported 11 cases of resolution of the infection (73.3 %), with good tolerance of the implant and a mean limb length discrepancies of 15 mm. Of these, 8 patients had been monitored over 5 years without recurrence of the infection. The mean number of previous operations was 4.9 (range 2 to 9). Two patients (13.3 %) required multiples surgical debridements for uncontrolled sepsis and finally underwent knee amputation. Coagulase- negative Staphylococci (SCN) were the most commom pathogen (53.3 %) followed by polimicrobian infections (26.7 %). One patient continues suppressive antibiotic treatment and 1 patient was treated with a one- stage custom- made arthrodesis nail exchange. Bridging knee arthrodesis using a modular and non- cemented intramedullary nail is a salvage procedure with acceptable results in terms of erradication of infection after septic faliure Total Knee Arthroplasty with restoration of limb length discrepancy. Despite these satisfactory results it is not without serious complications such as knee amputation

Aim. To evaluate clinical outcomes for patients with osteomyelitis at a major trauma centre limb reconstruction unit. Method. We prospectively evaluated 137 patients on the limb reconstruction database with long bone osteomyelitis. Data on initial diagnosis, management (bone resection, use of external fixation, dead space and soft tissue management), microbiology and 2-year outcomes were collated. 11 patients' data was incomplete and 9 underwent primary amputations; these were excluded from microbiology data analysis. The patient data was categorised into microbiological culture negative or culture positive groups. Inter-group comparisons were made to evaluate two-year outcomes and percentage failure rate. Results. Forty percent (55/137) of patients presented with infected non-union, 20% (27/137) infected fractures, 19% (26/137) chronic osteomyelitis without implants and 14% (19/137) had infected metalwork. Removal of metalwork, reaming and debridement were the most frequently performed procedures, often in combination. 3% of patients failed treatment and had persistent infected non-union. The most common microorganisms identified in the culture positive group were Staphylococcus aureus (47.6%), Coagulase Negative Staphylococcus species (11.9%) and Enterobacter cloacae (11.9%), however multiple organism growth was more common than single organism growth, 53% and 47% respectively. 8% of culture negative patients had histological evidence of infection on biopsy. Conclusions. The 2-year failure rate (persistent infective non-union) was higher in the culture negative group (8%) than the culture positive group (1%). The higher failure rate may be secondary to lack of organisms isolated and available sensitivities from deep tissue samples. In 9 cases patient preference led to primary amputation over limb salvage procedures, without further infection. Our work highlights the array of factors contributing to outcome in this patient group. The incidence of micro-organisms commonly encountered in this cohort will provide further evidence to support choice of antibiotic for empirical therapy especially in cases which are culture negative. Finally, there are many challenges in achieving adequate outcomes in patients with long bone infections thus the need for a multidisciplinary team approach in this patient cohort is invaluable. Routine histology testing may be beneficial as this may highlight infective processes in culture negative patents thereby allowing optimization of patient management

The moderator will lead a structured panel discussion that explores how to manage challenges commonly found in the multiply revised knee. Topics covered will include: (1) Exposure in the multiply operated knee (when to use quad snip, tibial tubercle osteotomy, other techniques); (2) Implant removal: Tips for removing stemmed implants; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (4) Level of constraint (when to use posterior stabilised, constrained condylar, and hinge) and management of instability in multiply operated knees; (5) Preferred management of infection in the multiply operated knee; (6) The extensor mechanism: Preferred deficient patellar bone management; Preferred extensor mechanism deficiency management; (7) When is it time to convert to a salvage procedure (i.e. fusion, resection arthroplasty, amputation)?; (8) Post-operative management: wound management; knee range of motion

Aim. The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality. Method. This is a single-center retrospective review of routine hospital data from 21 patients (15 men, 6 women, median age 65 [range, 21 to 87] years) undergoing IMN arthrodesis of the hindfoot for post-traumatic infections between January 1st, 2012 and March 15, 2018. We observed four bimalleolar, eight trimalleolar, three pilon fractures, and six distal lower leg fractures. Six and three patients had sustained second- and third degree open fractures, respectively. Early- and late-onset surgical infections were observed in 8 and 13 cases. Four participants had diabetes mellitus, two arterial occlusive disease, and four had both. Six patients were smokers. Results. Intraoperative cultures before implanting the nail revealed staphylococcus aureus in 12, staphylococcus epidermidis in five, and enterococcus faecalis in eight cases. After a median follow-up of 21 months, infection was considered cured in 19 / 21 subjects (90%, 95% confidence interval 70 – 99%). Soft tissue comminution required coverage with a suralis flap in five patients, and with a latissimus dorsi flap in another three. Mesh graft was necessary in 8 / 21 reconstructions. Conclusions. Tibiotalocalcaneal fusion by IMN is an effective salvage procedure for post-traumatic ankle infections. Arthrodesis and definitive wound closure or plastic flap coverage can be performed as single-stage surgery. By resecting the prominent distal fibula, lateral soft tissue defects can be managed more easily. The small sample size prohibited a more detailed analysis of exposure variables, but 8 / 13 patients in this cohort had at least one known risk factor for infection and prolonged healing

Salvage Total Hip Arthroplasty (THA) presents a viable solution following failed treatment of a hip fracture. Several studies have suggested higher complication rate including high dislocation rate associated with salvage THA. The present study evaluates the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of a hip fracture and comparison made to Primary THA in osteoarthritis (OA). Between 1992 and 2007, 53 patients with a mean age of seventy years were treated with THA after the failed treatment of a hip fracture under the care of a single surgeon. The indication for conversion arthroplasty was Avascular necrosis head – 24(45.3%), screw cut out – 6 (11.3%), non-union – 2(3.8%), Displaced fracture – 2(3.8%), Secondary OA – 19 (35.8%). The implants retrieved were Cannulated screws – 3, Sliding plate and screw – 46, Spline plate – 2, Smith Petersons nail – 1, Martin Plate – 1. This group of patients were matched for age, sex, side, and ASA grading with a group of 59 patients who underwent THA for primary osteoarthritis (THA-OA group). Posterior approach was used in all cases. Four patients (7.5%) required grafting of cup and 21 patients (39.6%) required soft tissue release. The average blood loss was 555 ml, mean duration of surgery was 85.5 min, average inpatient stay was 6.7 days. Cemented THA was used in 43 patients and Cementless THA in 10 patients. At one year follow up there were no dislocations, one patient had an undisplaced femoral fracture treated in Spica. Three patients had broken screws; one patient with shortening > 1 inch. There was one revision for deep infection. The mean Harris Hip Score (HHS) improved from 28.4 to 82.5 at one year, while the Oxford Hip score (OHS) improved from 50.9 to 21.9 (Old system). When the scores were compared to the THA-OA group there was no difference in the oxford hip scores and the the mean one year HHS in the THA-OA group was slightly higher than the group with salvage THA, but the difference was not statistically significant. Hip arthroplasty is an effective salvage procedure in patients with prior surgery for hip fracture. Most patients have good pain relief and functional improvement. Despite the operative challenges, remarkably few serious orthopaedic complications were associated with this procedure in the present study

The moderator will lead a structured panel discussion that explores how to manage challenges commonly found in the multiply revised knee. Topics covered will include: (1) Exposure in the multiply operated knee (when to use quad snip, tibial tubercle osteotomy, other techniques); (2) Level of constraint (when to use posterior stabilised, constrained condylar, and hinge) and management of instability in multiply operated knees; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (4) Preferred management of infection in the multiply operated knee; (5) When is it time to convert to a salvage procedure (i.e. fusion, resection arthroplasty, amputation)?

The Failed Femoral Neck Fracture. For the young patient: Attempt to preserve patient's own femoral head. Clinical results reasonably good even if there are patches of avascular necrosis. Preferred methods of salvage: valgus-producing intertrochanteric femoral osteotomy: puts the nonunion under compression. Other treatment option: Meyer's vascularised pedicle graft. For the older patient: Most reliable treatment is prosthetic replacement. Decision to use hemiarthroplasty (such as bipolar) or THA based on quality of articular cartilage, perceived risk of instability problem. In most patients THA provides higher likelihood of excellent pain relief. Specific technical issues: (1) hardware removal: usually remove after hip has first been dislocated (to reduce risk of femur fracture); (2) Hip stability: consider methods to reduce dislocation risk: larger diameter heads/dual mobility/anteriorly-based approaches; (3) Acetabular bone quality: poor because it is not sclerotic from previous arthritis; caution when impacting a pressfit cup; low threshold to augment fixation with screws; don't overdo reaming; just expose the bleeding subchondral bone. A reasonable alternative is a cemented cup. The Failed Intertrochanteric Hip Fracture. For the young patient: Attempt to salvage hip joint with nonunion takedown, autogenous bone grafting and internal fixation. For the older patient: Decision to preserve patient's own hip with internal fixation versus salvage with hip arthroplasty should be individualised based on patient circumstances, fracture pattern, bone quality. THA is an effective salvage procedure for this problem in older patients. If prosthetic replacement is chosen special considerations include:. THA vs. hemiarthroplasty: hemiarthroplasty better stability; THA more reliable pain relief. Removal of hardware: be prepared to remove broken screws in intramedullary canal. Management of bone loss: bone loss to level of lesser trochanter common. Often requires a calcar replacement implant. Proximal calcar build-up size dictated by bone loss. Length of stem: desirable to bypass screw holes from previous fixation, if possible. Stem fixation: cemented or uncemented fixation depending on surgeon preference, bone quality. If uncemented, consider diaphyseal fixation. Greater trochanter: often a separate piece, be prepared to fix with wires or cable grip. Residual trochanteric healing, hardware problems not rare after THA

The moderator will lead a structured panel discussion that explores how to manage challenges commonly found in the multiply revised knee. Topics covered will include: (1) Exposure in the multiply operated knee (when to use quad snip, tibial tubercle osteotomy, other techniques); (2) Implant removal: Tips for removing stemmed implants; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (4) Level of constraint (when to use posterior stabilised, constrained condylar, and hinge) and management of instability in multiply operated knees; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (5) Preferred management of infection in the multiply operated knee; (6) The extensor mechanism: Preferred deficient patellar bone management; Preferred extensor mechanism deficiency management; (7) When is it time to convert to a salvage procedure (i.e. fusion, resection arthroplasty, amputation)?; (8) Post-operative management: wound management; knee range of motion

Patients with neuromuscular disease and imbalance present a particularly challenging clinical situation for the orthopaedic hip surgeon. The cause of the neuromuscular imbalance may be intrinsic or extrinsic. Intrinsic disorders include those in which the hip is in development, such as cerebral palsy, polio, CVA, and other spinal cord injuries and disease. This can result in subluxation and dislocation of the hip in growing children, and subsequent pain, and difficulty in sitting and perineal care. Extrinsic factors involve previously stable hips and play a secondary role in the development of osteoarthritis and contractures in later life. Examples of extrinsic factors are Parkinson's disease, dyskinesis, athetosis, and multiple sclerosis. Goals of treatment in adults with pain and dysfunction in the setting of neuromuscular imbalance are to treat contractures and to perform salvage procedures to improve function and eliminate pain. Treatment of patients with neuromuscular imbalance may include resection arthroplasty (Girdlestone), arthrodesis, or total hip arthroplasty. Resection arthroplasty is typically reserved for patients that are non-ambulatory, or hips that are felt to be so unstable that arthroplasty would definitely fail due to instability. In modern times arthrodesis has limited use as it negatively impacts function and self-care in patients with neuromuscular disorders. Total hip arthroplasty has the ability to treat pain, relieve contractures, and provide improved function. Due to the increased risk of instability, special considerations must be made during primary total hip arthroplasty in this patient cohort. Risk of instability may be addressed by surgical approach, head size, or use of alternative bearing constructs. Posterior approach may have increased risk of posterior dislocation in this patient group, particularly if a posterior capsular repair is not possible due to the flexion contractures and sitting position in many patients. Surgeons familiar with the approaches may utilise the anterolateral or direct anterior approach judicially. Release of the adductors may be performed in conjunction with primary total hip arthroplasty to help with post-operative range of motion and to decrease risk of instability. In a standard bearing, the selected head size should be the largest that can be utilised for the particular cup size. Rigorous testing of intra-operative impingement, component rotation, and instability is required. If instability cannot be adequately addressed by a standard bearing, the next option is a dual mobility bearing. Multiple studies have shown improved stability with the use of these bearings, but they are also at risk for instability, intraprosthetic dislocation, and fretting and corrosion of the modular connections. Another option is a constrained liner. However, this results in reduced range of motion, and an increased risk for mechanical complications of the construct. The use of a constrained liner in a primary situation should be limited to the most severe instability cases, and the patient should be counseled with the associated risks. If total hip arthroplasty results in repeated instability, revision surgery or Girdlestone arthroplasty may be considered