The proximal tibia (PT) is the anatomical site most frequently affected by primary bone tumours after the distal femur. Reconstruction of the PT remains challenging because of the poor soft-tissue cover and the need to reconstruct the extensor mechanism. Reconstructive techniques include implantation of massive endoprosthesis (megaprosthesis), osteoarticular allografts (OAs), or allograft-prosthesis composites (APCs). This was a retrospective analysis of clinical data relating to patients who underwent proximal tibial arthroplasty in our regional bone tumour centre from 2010 to 2018.Aims
Methods
In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.Aims
Methods
The NHS generates 4–5% of the nation's total carbon emissions and over 500,000 tonnes of waste annually. Up to one-third of waste from orthopaedic procedures are recyclable, with large joint arthroplasties producing more than other subspecialties. However, there is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. This study aimed to analyse the environmental impact and sustainable initiatives undertaken within orthopaedic surgery. A systematic review was performed according to PRISMA guidelines. The systematic search was conducted through EMBASE, Medline, and PubMed libraries.Abstract
Introduction
Methodology
Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery. Retrospective review of osseointegration frequency, pattern, and timing to a specific HA-coated collar on massive endoprostheses used in revision surgery at our tertiary referral centre between 2010 to 2017 was undertaken. Osseointegration was radiologically classified on cases with a minimum follow-up of six months.Aims
Methods
For cementless implants, stability is initially attained by an interference fit into the bone and osteo-integration may be encouraged by coating the implant with bioactive substances. Blood based autologous glue provides an easy, cost-effective way of obtaining high concentrations of growth factors for tissue healing and regeneration with the intention of spraying it onto the implant surface during surgery. The aim of this study was to incorporate nucleated cells from autologous bone marrow (BM) aspirate into gels made from the patient’s own blood, and to investigate the effects of incorporating three different concentrations of platelet rich plasma (PRP) on the proliferation and viability of the cells in the gel. The autologous blood glue (ABG) that constituted 1.25, 2.5, and 5 times concentration PRP were made with and without equal volumes of BM nucleated cells. Proliferation, morphology, and viability of the cells in the glue was measured at days 7 and 14 and compared to cells seeded in fibrin glue.Aims
Methods
Limb salvage in bone tumour patients replaces the bone with massive segmental prostheses where achieving bone integration at the shoulder of the implant through extracortical bone growth has been shown to prevent loosening. This study investigates the effect of multidrug chemotherapy on extracortical bone growth and early radiological signs of aseptic loosening in patients with massive distal femoral prostheses. A retrospective radiological analysis was performed on adult patients with distal femoral arthroplasties. In all, 16 patients were included in the chemotherapy group with 18 patients in the non-chemotherapy control group. Annual radiographs were analyzed for three years postoperatively. Dimensions of the bony pedicle, osseointegration of the hydroxyapatite (HA) collar surface, bone resorption at the implant shoulder, and radiolucent line (RLL) formation around the cemented component were analyzed.Aims
Methods
THR is one of the most frequently performed operations nationally. A large number of prostheses are available, and the procedure is therefore associated with variation in practice and outcomes. NICE guidelines aim to standardise best practice, and are informed by separate, independent bodies, such as the NJR and ODEP, which monitor data about the implants used and their performance. This study aims to determine whether clinical practice and component use has changed since the publication of NJR data. NJR reports from 2006–2014 were analysed, with record made of the different prostheses used in THR, noting ODEP ratings of components used. Analysis was also performed by component type (i.e. cemented and cementless stems and cups), and combinations of components, according to their frequency of use in a given year. The Kruksal-Wallis test was used for statistical analysis.Introduction
Methods
Pigmented Villonodular Synovitis (PVNS) is a rare inflammatory disorder of the synovium, bursa and tendon sheath. The objective of this study was to evaluate the long-term outcomes and morbidity associated with operative management of PVNS of the hand. Histological databases were retrospectively interrogated. All patients between 2003–2008 with confirmed PVNS of the hand were included in the study.Introduction:
Methods:
Endoprosthetic replacement of the proximal femur is common in the management of bone tumours and failed revision arthroplasty. This study seeks to compare those patients undergoing acetabular resurfacing at the time of femoral replacement with those patients where the native acetabulum was preserved. All proximal femoral replacements from 2004 to 2009 with a five year follow up were included. Case files were interrogated to identify those that had either revision surgery or dislocation of the hip.Introduction:
Methods:
Distal femoral replacement is recognised as the optimum treatment for malignant distal femoral tumours. Aseptic loosening is known to be a major cause for failure in these implants. Studies have indicated that the HA coated collar promotes osteointegration and bony in growth. This study compares long term aseptic loosening in implants with HA coated collars to those without in the immature skeleton. To assess the effect of HA coated collars on aseptic loosening in extendable distal femoral replacement prosthesis in the immature skeleton.Introduction:
Objectives:
Osteoarthritis is associated with changes to the matrix composition of subchondral bone. Raman spectroscopy has the potential to detect in vivo the molecular changes in osteoarthritic subchondral bone. The objectives were to determine the levels of mineralisation, carbonate accumulation and bone remodelling in osteoarthritic subchondral bone, which we defined as within 3mm of articular cartilage. This was compared to the proximal-compartment (10mm distal to articular cartilage) and the head-neck junction. Five osteoarthritic (average age: 76 years) and five normal cadaveric femoral heads (average age: 72 years) were scanned using peripheral quantitative computed tomography and then sectioned coronally. Raman spectroscopy was then used to scan the femoral heads. All scans were done in the plane of the longitudinal axis of the diaphysis. Cores were subsequently extracted and sodium dodecyl sulphate polyacrylamide gel electrophoresis performed to determine the levels of homotrimeric collagen. The phosphate-to-amide I ratio, from the Raman spectra, in osteoarthritic subchondral bone was significantly greater than controls (p=0.023). Within osteoarthritic specimens, the phosphate-to-amide I ratio increased proximally. The density in osteoarthritic subchondral bone was 89mg/cm3 higher than controls (p=0.022), and 494mg/cm3 higher than the osteoarthritic proximal-compartment (p<0.001). Moreover, carbonate substitution into the apatite crystals decreased in osteoarthritic specimens. The carbonate-to-amide I ratio was highest in osteoarthritic subchondral bone. Furthermore, the median α1-to-α2-chain ratio in osteoarthritic specimens was 2:1. The changes found in subchondral bone are important in the pathogenesis of osteoarthritis. This study shows that Raman spectroscopy can detect differences between osteoarthritic specimens and controls, further supporting its potential use in diagnosing bone disorders.
Osteoarthritis (OA) is a common, debilitating joint disease involving degeneration of cartilage and bone. It has been suggested that subtle changes in the molecular structure of subchondral bone may precede cartilaginous changes in the osteoarthritic joint. To explore these changes Raman spectroscopy was employed as a diagnostic tool. Raman spectroscopy measures inelastic scattered laser light produced when photons interact with chemical materials. Resultant changes in wavelength form spectra relative to the chemical composition of the given sample: with bone this includes the mineral and matrix components, unlike conventional X-rays. The aim of our study is to explore the hypothesis: Changes in matrix composition of osteoarthritic subchondral bone can be detected with Raman spectroscopy. pQCT and Raman spectroscopy were employed to determine the bone mineral density (BMD) and bone quality, respectively. Ten medial compartment OA and five control (non-OA) tibial plateaus were interrogated and analysis performed to compare OA to control, and medial to lateral compartments. The subchondral bone of the medial OA compartments had higher BMD (p=0.05) and thickness compared to lateral and control samples. Spectral analysis revealed there is no difference between the medial and lateral compartments within either cohort. However, there is a statistically significant (p=0.02) spectral difference between the OA and control specimens. The detection of bone matrix changes in osteoarthritis using Raman spectroscopy contributes to the understanding of the biochemical signature of subchondral bone across diseased and control tibial plateaus. This technique has potential to shed light on the role of bone in osteoarthritis.
Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis, for tumour, between 1997 and 2007. The mean age was 46 years, (7–87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3% and the mean TESS was 77.2%. Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7% and a mean TESS of 80.0%. Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.
It is known that excessive varus alignment of the femoral stem in total hip replacement (THR) creates a sub-optimal biomechanical environment which is associated with increased rates of revision surgery and component wear. Little is known regarding the effect of femoral stem alignment on patient functional outcome. A retrospective study of patients undergoing primary THR at the RNOH. Alignment of the femoral stem component in-situ was measured subjectively by a consultant musculoskeletal radiologist in both coronal and sagittal planes using post-operative anterior-posterior and lateral pelvic radiographs. Each THR was grouped into valgus, minor-valgus, neutral, minor-varus or varus coronal plane alignment and posterior, minor-posterior, neutral, minor-anterior or anterior sagittal plane alignment. Patient reported functional outcome was assessed by Oxford Hip Score (OHS) and WOMAC questionnaires after a minimum follow-up of 11 months. Maximum range of passive hip flexion, abduction, adduction, external and internal rotation were measured in clinic. A factorial linear regression model was used to analyse data.Background
Methods
The surgical treatment of bone tumours can result in large perioperative blood loss due to their large sizes and hypervascularity. Preoperative embolisation has been successfully used to downgrade vascularity, thus reducing perioperative blood loss and its associated complications. Prior to embolization era, blood loss as high as 18,500mL have been reported peri-opratively. Twenty-six patients with a variety of bone tumours (average size 10.5×7.5×5.5cm), who underwent pre-operative embolisation between 2005 and 2009, were retrospectively studied. The group comprised of 17 females and 9 males. Their mean age was 38 years old. All patients underwent surgical resection within 48 hours of embolization. Mean blood loss was 796mL and required on average 1.1units of blood. We experienced no complications. Pre-operative arterial embolisation of large, richly vascular bone tumours in anatomically difficult positions, is a safe and effective method of downstaging vascularity and reducing blood loss.
The position of the hip-joint centre of rotation (HJC) within the pelvis is known to influence functional outcome of total hip replacement (THR). Superior, lateral and posterior relocations of the HJC from anatomical position have been shown to be associated with greater joint reaction forces and a higher incidence of aseptic loosening. In biomechanical models, the maximum force, moment-generating capacity and the range of motion of the major hip muscle groups have been shown to be sensitive to HJC displacement. This clinical study investigated the effect of HJC displacement and acetabular cup inclination angle on functional performance in patients undergoing primary THR. Retrospective study of primary THR patients at the RNOH. HJC displacement from anatomical position in horizontal and vertical planes was measured relative to radiological landmarks using post-operative, calibrated, anterior-posterior pelvic radiographs. Acetabular cup inclination angle was measured relative to the inter-teardrop line. Maximum range of passive hip flexion, abduction, adduction, external and internal rotation were measured in clinic. Patient reported functional outcome was assessed by Oxford Hip Score (OHS) and WOMAC questionnaires. Data analysed using a linear regression model.Background
Methods
It is known that excessive varus alignment of the femoral stem in total hip replacement (THR) creates a sub-optimal biomechanical environment which is associated with increased rates of revision surgery and component wear. Little is known regarding the effect of femoral stem alignment on patient functional outcome. Retrospective study of primary THR patients at the RNOH. Alignment of the femoral stem component in-situ was measured subjectively by a consultant musculoskeletal radiologist in both coronal and sagittal planes using post-operative anterior-posterior and lateral pelvic radiographs. Each THR was grouped into valgus, minor-valgus, neutral, minor-varus or varus coronal plane alignment and posterior, minor-posterior, neutral, minor-anterior or anterior sagittal plane alignment. Patient reported functional outcome was assessed by Oxford Hip Score (OHS) and WOMAC questionnaires. Data analysed using a linear regression model. 90 THRs were studied in 87 patients (55 Female). Mean age at THR=62 (22-86). Mean follow-up=17 months (11-39 months). Median OHS=16, WOMAC=8. Coronal plane alignment of the femoral stem was not associated with any change in OHS (p>0.05) or WOMAC score (p>0.05). Sagittal plane alignment of the femoral stem was not associated with any change in OHS (p>0.05) or WOMAC score (p>0.05).Methods
Results
Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis for tumour between 1997 and 2007. The mean age was 46 years (7-87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3 % and the mean TESS was 77.2 %. Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7 % and a mean TESS of 80.0%. Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.
High Tibial Osteotomy (HTO) is a recognised method of correction for knee joint malalignment and unicom-partmental osteoarthritis. Long-term results of this technique have been reported and are favourable. Good results have also been reported with Autologous Chondrocyte Implantation (ACI-C, MACI). Malalignment, if present, should be corrected when ACI is performed. Although results have been reported for either procedure separately, the outcomes of combined HTO-ACI remain unreported. The aim of this study was to evaluate functional outcome in patients undergoing combined HTO-ACI procedures. Twenty three patients undergoing a combined ACI-HTO procedure were identified retrospectively from a larger trial of patients undergoing ACI for symptomatic chondral defects. The mean age of the patients was 36 (28 – 49). The mean follow-up was 54 months (12 – 108) and mean defect size was 689mm2 (range 350 – 1200). Nine patients had ACI-C and HTO, the remainder having MACI and HTO. Pre and post-operative assessment was carried out using the Visual Analogue Score (VAS), the Bentley Functional Rating Score and the Modified Cincinnati Rating System. The Mean VAS score improved from 7.4 (4 – 10) pre-operatively to 2.9 (0 – 6) post-operatively at the latest follow-up (p<
0.0001). The Bentley Functional Rating Score improved from 2.9 (2 – 4) to 1.8 (0 – 4), which was statistically significant (p<
0.0001). The Modified Cincinnati Rating System improved from 35.2 (20 – 49) pre-operatively to 68.7 (46 – 85) post-operatively (p<
0.0001). Fourteen patients underwent biopsy of the graft site at a mean of 13.7 months: 21% of biopsies were hyaline-like cartilage, 36% were mixed hyaline/fibrocartilage, 29 % were fibrocartilage and 14% were fibrous tissue. Combining high tibial osteotomy with autologous chondrocyte implantation is an effective method of decreasing pain and increasing function in the short term. Further evaluation of this procedure is required.
