Introduction and Aims: Difficult primary and revision total knee arthroplasty (TKA) with constrained knee systems is becoming more common. Modular systems are critical to success. A review of 457 consecutive cases with a single knee system for difficult primary and revision TKA provides an algorithm for good results. Method: Between July 1992 and December 2000, 457 consecutive TKA were performed at a single institution using a posterior-stabilised constrained (PSC) system. Ninety-seven cases were primary with ligamentous instability and 360 were revision cases with bone loss and instability. Sixty-two patients died during follow-up, seven were lost to follow-up. Results: Follow-up averaged 2.5 years. Pre-operative Knee Society (KSS) and Hospital for Special Surgery (HSS) scores averaged 47.3 and 60.0 respectively, and improved to 79.0 and 75.0 (p< 0.001). Range of motion improved significantly (p< 0.001). Incidence of manipulation was 9.4 percent. Infection necessitated debridement in 4.6 percent of cases. Extensor mechanism complications occurred in 2.2 percent. Excision of the patellar component without reinsertion was highest risk. There was a 2.2 percent aseptic loosening rate and 3.0 percent failure for instability. Conclusion: The authors describe an algorithm for long-term success using a PSC modular knee system based upon critical review of radiographic and clinical outcomes. Methods for achieving stability and fixation affect results. Appropriate augmentation for femoral and tibial deficits re-establishes the joint line and provides excellent range of motion. A step-wise approach to the patella provides durable results. Predictors of success including alignment, the joint line, managing bone loss, fixation, and extensor mechanism are reviewed

Introduction: Atypical femoral geometry and bone stock loss may make fitting a press-fit, traditional one-piece stem difficult, if not impossible. Modularity that permits independent fitting of the diaphysis, metaphysis, length, offset, and version may greatly facilitate reconstruction and ultimate clinical performance.

Method: We prospectively evaluated the early clinical results of Exactech’s AcuMatch®^□ M-series prosthesis, a novel three-piece modular femoral stem. One hundred and twenty-seven were implanted in 114 patients. Ninety-one of these were primaries and 36 were revisions. The patients were followed prospectively and evaluated pre-operatively and at ≥2-year post-operatively.

Results: Harris hip score for primaries was 37 pre-operatively and 87 at last follow-up. Harris hip score for revision group was 35 pre-operatively and 84 at last follow-up. Four dislocations occurred and one prosthesis fractured in a 330-pound patient with deficient abductors. One prosthesis has been removed, due to sepsis in the primary group.

Conclusion: Through atraumatic milling of the bone and insertion of the implants, a minimal amount of intra-operative complications resulted. Ultimate restoration of hip biomechanics and soft tissue tension resulted in good clinical outcome with a very low dislocation rate.

Introduction: atypical femoral geometry and bone stock loss may make þtting a press þt traditional one-piece stem difþcult, if not impossible. modularity that permits independent þtting of the diaphysis, metaphysis, length, offset, and version may greatly facilitate reconstruction and ultimate clinical performance. Materials and methods: we prospectively evaluated the early clinical results of exactechñs acumatch? m-series prosthesis, a novel three-piece modular femoral stem. eighty-two were implanted in 80 patients. þfty-three of these were primaries and 29 were revisions. the patients were followed prospectively and evaluated with harris hip scores, range of motion, and complications pre-operatively and at ≥ 1-year post-operatively. Results: Harris hip score for primaries was 37 preoperatively and 84 at last follow-up. Harris hip score for revision group was 37 preopera-tively and 79 at last follow-up. Only one dislocation occurred in the 82 cases, in a patient who was revised for recurrent dislocation with deþcient abductors. There were three minor undisplaced calcar fractures in the primary group that did not alter the clinical outcome and in no case did the prosthesis penetrate the diaphysis. One prosthesis has been removed, and this was due to sepsis in the primary group. Conclusion: Through atraumatic milling of the bone and insertion of the implants, a minimal amount of intra-operative complications resulted. Ultimate restoration of hip biomechanics and soft tissue tension resulted in good clinical outcome with a very low dislocation rate.

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella.

Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes.

When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):30–9.

Aim. In surgeries on patients with advanced ligament instabilities or severe bone defects modern-generation of rotating hinged knee prostheses are one of the main options. The objective of our study is to evaluate the mid-term functional results and complications of several surgeries using this form of prosthesis. Material and Method. The rotating hinged knee prosthesis (RHKP) was applied to 208 knees of 204 patients in primary surgeries between September 2009 and December 2017, the minimum followup was 15 months (mean, 65 months; range, 15–115 months). Of the total number of female patients there were 152 (74.5%), men − 52 (25.5%). The average age of the patients was 64,6 years (from 32 to 85). The main indications for using RHKP were severe varus deformity with flexion contracture in 107 knees (51,4%), severe valgus deformity (from 20 to 50 degrees) in 54 knees (26,0 %), severe ligamentous deficiencies in 24 knees (11,5%) and ankylosis in the flexion position in 23 cases (11,1%). Patients were evaluated clinically (Knee Society score) and radiographically (positions of components, signs of loosening, bone loss). Results. The average Knee Society Knee Scores, and Knee Society Functional Scores were 27, and 18, respectively, before the surgery; and 86, and 77 in the final post-surgery follow-ups. In addition, the average range of motion increased from the pre-operative level of 46 to 104 degrees at the final evaluation. Four patients (2%) had various complications after the surgery : two patients had deep infection, in one case took place fracture of the hinge mechanism and in one - post-operative rupture of the patellar tendon. Conclusions. Primary knee arthroplasty using RKHP can be successful in cases with advanced ligament instability or severe bone defects. Modern-generation of the kinematic rotating-hinge total knee prostheses allow to achieve in difficult primary cases the same consistently good results as commonly used constructions in standard situations

This prospective study presents the ten-year (5 to 16) clinical and radiological results of 55 primary total hip replacements (THR) using a cementless modular femoral component (S-ROM). All patients had a significant anatomical abnormality which rendered the primary THR difficult. The mean Harris hip score was 36 (12 to 72) pre-operatively, 83 (44 to 100) at five years, and 85 (45 to 99) at ten years. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and short-form (SF)-12 scores were recorded from the year 2000. The mean SF-12 score at five years after surgery was 45.24 (22.74 to 56.58) for the physical component and 54.14 (29.20 to 66.61) for the mental component. By ten years the SF-12 scores were 42.86 (21.59 to 58.95) and 51.03 (33.78 to 61.40), respectively. The mean WOMAC score at five years post-operatively was 25 (0 to 59), and at ten years was 27 (2 to 70). No femoral components were radiologically loose, although five had osteolysis in Gruen zone 1, three had osteolysis in zone 7, and two showed osteolysis in both zones 1 and 7. No osteolysis was observed around or distal to the prosthetic sleeve. No femoral components were revised, although three hips underwent an acetabular revision and two required a liner exchange. At a mean of ten years’ follow-up the S-ROM femoral component implanted for an anatomically difficult primary THR has excellent clinical and radiological results

We reviewed retrospectively 45 patients (46 procedures) with bladder exstrophy treated by bilateral oblique pelvic osteotomy in conjunction with genitourinary repair. The operative technique and post-operative management with or without external fixation are described. A total of 21 patients attended a special follow-up clinic and 24 were interviewed by telephone. The mean follow-up time was 57 months (24 to 108). Of the 45 patients, 42 reported no pain or functional disability, although six had a waddling gait and two had marked external rotation of the hip. Complications included three cases of infection and loosening of the external fixator requiring early removal with no deleterious effect. Mid-line closure failed in one neonate managed in plaster. This patient underwent a successful revision procedure several months later using repeat osteotomies and external fixation. The percentage pubic approximation was measured on anteroposterior radiographs pre-operatively, post-operatively and at final follow-up. The mean approximation was 37% (12% to 76%). It varied markedly with age and was better when external fixation was used. The wide range reflects the inability of the anterior segment to develop naturally in spite of close approximation at operation. We conclude that bilateral oblique pelvic osteotomy with or without external fixation is useful in the management of difficult primary closure in bladder exstrophy, failed primary closure and secondary reconstruction

A series of 167 patients with Charnley-type total hip replacements were studied retrospectively to determine the incidence of trochanteric non-union, the degree of postoperative trochanteric displacement, and the relation between these two complications. The power in the hip abductor muscles, measured with a load-cell device, was significantly reduced if the trochanteric fragment had displaced proximally by more than 3 cm; 12% of those studied fell into this group and, as a consequence, had a poorer result. It was concluded that displacement of the trochanter was of greater importance than bony union in determining function in the replaced hip. Because these unwanted problems may compromise an otherwise successful operation, it is suggested tentatively that trochanteric osteotomy should be abandoned except for difficult primary operations or for revision procedures

Objective: To assess the early results of the TC3 total knee prosthesis, a modular system with stems and augments, in difficult primary and revision knee arthroplasties. Method: 13 index procedures were undertaken for gross varus or valgus deformities with severe ligamentous incompetence and/or major bone defects. 18 procedures were revision arthroplasties, 7 being undertaken for sepsis. 29 knees underwent full clinical and radiological review, using the Hospital for Special Surgery Score (HSS) and the Knee Society Score. One patient was interviewed by phone with recent radiological follow-up. One patient died of unrelated causes. Results: All patients were very pleased with the outcome of surgery. The mean pre-operative alignment for primary arthroplastles was 280 of varus and 320 valgus. The mean post-operative alignment was 70 valgus. The mean post-operative HSS was 72.4 for primary procedures and 72.7 for revision surgery. The mean Knee Society Knee Score was 77.9 for primary and 75.1 for revision surgery, and the mean function score was 60.8 for primary and 49.4 for revision surgery. The latter reflects the elderly age, multiple joint involvement and constitutional status (including rheumatoid arthritis) of many of these patients. Conclusion: The TC3 knee system affords an excellent modular option to compensate for bone defects and ligamentous incompetence, achieving restoration of the joint line and satisfactory function in a very disabled group of patients

Objective: To assess the early results of the TC3 knee prosthesis, a modular system with stems and augments, in difficult primary and revision knee arthroplasties. Method: 13 index procedures were undertaken for gross varus or valgus deformities with severe ligamentous incompetence and/or major bone defects. 18 procedures were revision arthroplasties, 7 being undertaken for sepsis. 28 knees underwent full clinical and radiological review at a mean of 25.8 months post-operatively, using the Hospital for Special Surgery Score and the Knee Society Score. 2 patients were interviewed by phone with recent radiological follow-up. One patient had died from unrelated causes. Results: All patients were very pleased with the outcome of surgery. The mean pre-operative alignment for the primary arthroplasties was 28° for the varus and 32° for the valgus knees. The mean postoperative alignment was 7°. The mean Hospital for Special Surgery score was 72.4 for primary arthroplasties and 72.7 for revision surgery. The mean Knee Society Knee Score was 79.8 and 75.1 respectively, and the mean Functional Score was 60.8 and 49.4 respectively. The latter reflects the elderly age, multiple joint involvement and constitutional status (including rheumatoid arthritis) of many of these patients. 4 patients experienced retropatellar pain. One patient with severe rheumatoid developed sepsis of the revision implant. Difficulties with tibial tray lateralisation and stem fixation will be discussed. Conclusion: The TC3 knee system affords an excellent modular option to compensate for bone defects and ligamentous incompetence, achieving restoration of the joint line and satisfactory function

Introduction: In many cases of massive rotator cuff tears, especially in cases of revision repairs the shoulder surgeon is facing a technical and biological challenge. The loss of collagenous material in the tendon, coupled with poor quality of the remaining rotator cuff, makes obtaining a mechanically strong repair difficult. Primary closure of such defects may result in excessive tissue tension, which may further increase the chance of failure. Purpose: The objective of this study is to determine the feasibility of using xenogeneic small intestine submucosa (SIS) as a biomaterial to reinforce repair of massive rotator cuff tears. Clinical Material and Methods: Nine patients ranging in age from 52 to 74 with massive rotator cuff tears were selected for the study. Selection of these patients was based upon the quality of remaining rotator cuff tendon tissue at the time of the repair. Seven cases after failed repair of massive rotator cuff tear and two cases of long standing neglected rotator cuff tears in patients with weight bearing shoulders (bilateral below the knees amputation and incomplete paraplegia after anterior poliomyelitis) were selected for this study. In all patients first the tear was repaired by well-known techniques: tendon to tendon, tendon to bone through bone tunnels or using suture anchors. After the repair was accomplished, the poor quality tissue obtained was reinforced by a patch of Restore Orthobiologic Soft Tissue Implant (DePuy, Johnson & Johnson). The Restore Implant is a xenograft obtained of ten layers of porcine small intestine submucosa, it is biocompatible, infection resistant, possess predictable mechanical properties, and, perhaps most significantly, induce a host connective and epithelial tissue response that results in regeneration of specialized connective tissues. Results: Follow-up ranging between 6 to 22 month excellent and good results were observed in eight cases (88%), whereas in the patient aged 74, the cuff repair failed again (after two previous failures). In the eight successful cases an almost normal painfree active range of movements was observed three month after surgery. Conclusions: The results confirm the usefulness of the SIS graft material in the patients having questionable quality cuff tissue remaining after repair. Use of the Restore soft tissue implant could possibly be utilized to strengthen the repair, as well as the inside ingrowth of the tendon, leading to a successful repair of the rotator cuff

Squamous cell carcinoma arising within bone is a rare lesion and is only seen essentially in the jaw and skull bones. Review of the medical literature showed that malignant change has been described in epidermoid cyst particularly in neurosurgical and orthodontic literature. However, no cases have been described in long bones as yet. Diagnosis of these tumours based on radiology and histology can be difficult and primary tumour elsewhere must be excluded. Here , a case of well differentiated squamous cell carcinoma arising from apparently a pre-existing intra-osseous epidermoid cyst in the distal tibia of a 45-year-old woman is reported. Initially treated with curettage and impact bone graft, then subsequently when the histopathology confirmed the above diagnosis, below knee amputation was performed. The differential diagnosis from other bone tumours with epithelial differentiation such as adamantinoma is discussed. This represents a rare primary neoplasm of bone of unknown histogenesis and also warns us to always try to get a histological diagnosis of what could look like clinically and radiologically a benign cyst

We studied the effect of trochanteric osteotomy in 192 total hip replacements in 140 patients with congenital hip disease. There was bony union in 158 hips (82%), fibrous union in 29 (15%) and nonunion in five (3%). The rate of union had a statistically significant relationship with the position of reattachment of the trochanter, which depended greatly on the pre-operative diagnosis. The pre-operative Trendelenburg gait substantially improved in all three disease types (dysplasia, low and high dislocation) and all four categories of reattachment position. A persistent Trendelenburg gait post-operatively was noticed mostly in patients with defective union (fibrous or nonunion). Acetabular and femoral loosening had a statistically significant relationship with defective union and the position of reattachment of the trochanter.

These results suggest that the complications of trochanteric osteotomy in total hip replacement for patients with congenital hip disease are less important than the benefits of this surgical approach.

This paper reviews the current knowledge relating to the management of adult patients with congenital hip disease. Orthopaedic surgeons who treat these patients with a total hip replacement should be familiar with the arguments concerning its terminology, be able to recognise the different anatomical abnormalities and to undertake thorough pre-operative planning in order to replace the hip using an appropriate surgical technique and the correct implants and be able to anticipate the clinical outcome and the complications.

We report the results of 62 hips in 62 patients (17 males, 45 females) with mean age of 62.4 years (37 to 81), who underwent revision of the acetabular component of a total hip replacement due to aseptic loosening between May 2003 and November 2007. All hips had a Paprosky type IIIa acetabular defect. Acetabular revision was undertaken using a Procotyl E cementless oblong implant with modular side plates and a hook combined with impaction allografting.

At a mean follow-up of 60.5 months (36 to 94) with no patients lost to follow-up and one died due to unrelated illness, the complication rate was 38.7%. Complications included aseptic loosening (19 hips), deep infection (3 hips), broken hook and side plate (one hip) and a femoral nerve palsy (one hip). Further revision of the acetabular component was required in 18 hips (29.0%) and a further four hips (6.4%) are currently loose and awaiting revision.

We observed unacceptably high rates of complication and failure in our group of patients and cannot recommend this implant or technique.

Injury to the common peroneal nerve was present in 14 of 55 patients (25%) with dislocation of the knee. All underwent ligament reconstruction. The most common presenting direction of the dislocation was anterior or anteromedial with associated disruption of both cruciate ligaments and the posterolateral structures of the knee. Palsy of the common peroneal nerve was present in 14 of 34 (41%) of these patients. Complete rupture of the nerve was seen in four patients and a lesion in continuity in ten.

Three patients with lesions in continuity, but with less than 7 cm of the nerve involved, had complete recovery within six to 18 months. In the remaining seven with more extensive lesions, two regained no motor function, and one had only MRC grade-2 function. Four patients regained some weak dorsiflexion or eversion (MRC grade 3 or 4). Some sensory recovery occurred in all seven of these patients, but was incomplete. In summary, complete recovery occurred in three (21%) and partial recovery of useful motor function in four (29%). In the other seven (50%) no useful motor or sensory function returned.

Massive endoprostheses using a cemented intramedullary stem are widely used to allow early resumption of activity after surgery for tumours. The survival of the prosthesis varies with the anatomical site, the type of prosthesis and the mode of fixation. Revision surgery is required in many cases because of aseptic loosening. Insertion of a second cemented endoprosthesis may be difficult because of the poor quality of the remaining bone, and loosening recurs quickly.

We describe a series of 14 patients with triplate fixation in difficult revision or joint-sparing tumour surgery with a minimum follow-up of four years. The triplate design incorporated well within a remodelled cortex to achieve osseomechanical integration with all patients regaining their original level of function within five months.

Our preliminary results suggest that this technique may provide an easy, biomechanically friendly alternative to insertion of a further device with an intramedullary stem, which has a shorter lifespan in revision or joint-sparing tumour surgery. A short segment of bone remaining after resection of a tumour will not accept an intramedullary stem, but may be soundly fixed using this method.