Aims. Loosening of pedicle screws is a major complication of posterior
spinal stabilisation, especially in the osteoporotic spine. Our
aim was to evaluate the effect of
We have developed a hollow perforated cannulated screw. One or more of these was implanted percutaneously in 11 patients with an osteolytic metastasis in the femoral neck and multiple metastases elsewhere. They were supplemented by one or two additional standard 6.5 mm cannulated screws in nine patients. Polymethylmethacrylate bone cement was injected through the screw into the neck of the femur using small syringes, as in vertebroplasty. The mean amount of cement injected was 23.2 ml (17 to 30). Radiotherapy was started on the fourth post-operative day and chemotherapy, on average, was resumed a day later. Good structural stability and satisfactory relief from pain were achieved in all the patients. This technique may be useful in the palliation of metastases in the femoral neck.
The augmentation of fixation with bone cement
is increasingly being used in the treatment of severe osteoporotic fractures.
We investigated the influence of bone quality on the mechanics of
augmentation of plate fixation in a distal femoral fracture model
(AO 33 A3 type). Eight osteoporotic and eight non-osteoporotic femoral
models were randomly assigned to either an augmented or a non-augmented
group. Fixation was performed using a locking compression plate.
In the augmented group additionally 1 ml of bone cement was injected
into the screw hole before insertion of the screw. Biomechanical
testing was performed in axial sinusoidal loading. Augmentation significantly
reduced the cut-out distance in the osteoporotic models by about
67% (non-augmented mean 0.30 mm ( Cite this article:
Aims. Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with
Aims. The purpose of the study was to investigate whether closed intramedullary
(IM) nailing with percutaneous
Aims. The aim of this study was to compare the peak pull-out force
(PPF) of pedicle-lengthening screws (PLS) and traditional pedicle
screws (TPS) using instant and cyclic fatigue testing. Materials and Methods. A total of 60 lumbar vertebrae were divided into six groups:
PLS submitted to instant pull-out and fatigue-resistance testing
(groups A1 and A2, respectively), TPS submitted to instant pull-out
and fatigue-resistance testing (groups B1 and B2, respectively)
and PLS augmented with 2 ml polymethylmethacrylate, submitted to
instant pull-out and fatigue-resistance testing (groups C1 and C2,
respectively). The PPF and normalized PPF (PPFn) for bone mineral density
(BMD) were compared within and between all groups. Results. In all groups, BMD was significantly correlated with PPF (r =
0.83, p < 0.001). The PPFn in A1 was significantly less than
in B1 (p = 0.006) and C1 (p = 0.002). The PPFn of A2 was significantly
less than in B2 (p < 0.001) and C2 (p < 0.001). The PPFn in
A1, B1, and C1 was significantly greater than in A2 (p = 0.002),
B2 (p = 0.027), and C2 (p = 0.003). There were no significant differences
in PPFn between B1 and C1, or between B2 and C2. Conclusion. Pedicle lengthening screws with
We studied the biomechanical behaviour of three sliding fixation devices for trochanteric femoral fractures. These were a titanium alloy sideplate and lag screw, a titanium alloy sideplate and dome plunger with
Giant cell tumours (GCTs) of the proximal femur are rare, and there is no consensus about the best method of filling the defect left by curettage. In this study, we compared the outcome of using a fibular strut allograft and bone cement to reconstruct the bone defect after extended curettage of a GCT of the proximal femur. In a retrospective study, we reviewed 26 patients with a GCT of the proximal femur in whom the bone defect had been filled with either a fibular strut allograft (n = 12) or bone cement (n = 14). Their demographic details and oncological and nononcological complications were retrieved from their medical records. Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) score.Aims
Methods
The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population. This was a multicentre retrospective cohort study including adult patients who presented to 27 NHS hospitals with 539 new PPFs between 1 January 2018 and 31 December 2018. Data collected included: management strategy (operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (reoperation, readmission, and 30-day and 12-month mortality). Descriptive analysis by fracture type was performed, and predictors of PPF management and outcomes were assessed using mixed-effects logistic regression.Aims
Methods
The aim of this study was to present the long-term surgical outcomes, complications, implant survival, and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins. A cohort of 50 consecutive patients who underwent the modified Harrington procedure for periacetabular metastasis or haematological malignancy between January 1996 and April 2018 were studied. The median follow-up time for all survivors was 3.2 years (interquartile range 0.9 to 7.6 years).Aims
Patients and Methods
We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis. The study utilized data from the Swedish Hip Arthroplasty Register (SHAR) and information from patient records. We included all primary total hip arthroplasties (THAs) performed in Sweden since 1979, and undergoing further surgery due to Vancouver type B periprosthetic femoral fracture between 2001 and 2011. The primary outcome measure was any further reoperation between 2001 and 2013. Cross-referencing with the National Patient Register was performed in two stages, in order to identify all surgical procedures not recorded on the SHAR.Aims
Patients and Methods
The aim of this study was to evaluate the clinical and radiological outcomes of locking plate fixation, with and without an associated fibular strut allograft, for the treatment of displaced proximal humeral fractures in elderly osteoporotic patients. We undertook a retrospective comparison of two methods of fixation, using a locking plate without an associated fibular strut allograft (LP group) and with a fibular allograft (FA group) for the treatment of these fractures. The outcome was assessed for 52 patients in the LP group and 45 in the FA group, with a mean age of 74.3 years (52 to 89), at a mean follow-up of 14.2 months (12 to 19). The clinical results were evaluated using a visual analogue scale (VAS) score for pain, the Constant score, the American Shoulder and Elbow Surgeons (ASES) score, and the range of movement. Radiological results were evaluated using the neck-shaft angle (NSA) and humeral head height (HHH).Aims
Patients and Methods
Intercalary allografts following resection of a primary diaphyseal
tumour have high rates of complications and failures. At our institution
intercalary allografts are augmented with intramedullary cement
and fixed using compression plating. Our aim was to evaluate their
long-term outcomes. A total of 46 patients underwent reconstruction with an intercalary
allograft between 1989 and 2014. The patients had a mean age of
32.8 years (14 to 77). The most common diagnoses were osteosarcoma
(n = 16) and chondrosarcoma (n = 9). The location of the tumours
was in the femur in 21, the tibia in 16 and the humerus in nine. Function
was assessed using the Musculoskeletal Tumor Society (MSTS) scoring
system and the Toronto Extremity Salvage Score (TESS). The survival
of the graft and the overall survival were assessed using the Kaplan-Meier method.Aims
Patients and Methods
Fractures of the distal femur can be challenging to manage and
are on the increase in the elderly osteoporotic population. Management
with casting or bracing can unacceptably limit a patient’s ability
to bear weight, but historically, operative fixation has been associated
with a high rate of re-operation. In this study, we describe the outcomes
of fixation using modern implants within a strategy of early return
to function. All patients treated at our centre with lateral distal femoral
locking plates (LDFLP) between 2009 and 2014 were identified. Fracture
classification and operative information including weight-bearing
status, rates of union, re-operation, failure of implants and mortality
rate, were recorded.Aims
Patients and Methods
Pelvic reconstruction after the resection of a tumour around
the acetabulum is a challenging procedure due to the complex anatomy
and biomechanics. Several pelvic endoprostheses have been introduced,
but the rates of complication remain high. Our aim was to review
the use of a stemmed acetabular pedestal cup in the management of
these patients. The study involved 48 patients who underwent periacetabular reconstruction
using a stemmed pedestal cup (Schoellner cup; Zimmer Biomet Inc.,
Warsaw, Indiana) between 2000 and 2013. The indications for treatment included
a primary bone tumour in 27 patients and metastatic disease in 21
patients. The mean age of the patients at the time of surgery was
52 years (16 to 83).Aims
Patients and Methods
Patients with multiple myeloma (MM) develop deposits in the spine
which may lead to vertebral compression fractures (VCFs). Our aim
was to establish which spinopelvic parameters are associated with
the greatest disability in patients with spinal myeloma and VCFs. We performed a retrospective cross-sectional review of 148 consecutive
patients (87 male, 61 female) with spinal myeloma and analysed correlations
between spinopelvic parameters and patient-reported outcome scores.
The mean age of the patients was 65.5 years (37 to 91) and the mean
number of vertebrae involved was 3.7 (1 to 15).Aims
Patients and Methods
Surgical intervention in patients with bone metastases from breast
cancer is dependent on the estimated survival of the patient. The
purpose of this paper was to identify factors that would predict
survival so that specific decisions could be made in terms of surgical
(or non-surgical) management. The records of 113 consecutive patients (112 women) with metastatic
breast cancer were analysed for clinical, radiological, serological
and surgical outcomes. Their median age was 61 years (interquartile
range 29 to 90) and the median duration of follow-up was 1.6 years
(standard deviation (Aims
Methods
Many tumors metastasise to bone, therefore, pathologic
fracture and impending pathologic fractures are common reasons for
orthopedic consultation. Having effective treatment strategies is
important to avoid complications, and relieve pain and preserve
function. Thorough pre-operative evaluation is recommended for medical
optimization and to ensure that the lesion is in fact a metastasis
and not a primary bone malignancy. For impending fractures, various scoring
systems have been proposed to determine the risk of fracture, and
therefore the need for prophylactic stabilisation. Lower score lesions
can often be treated with radiation, while more problematic lesions
may require internal fixation. Intramedullary fixation is generally
preferred due to favorable biomechanics. Arthroplasty may be required
for lesions with massive bony destruction where internal fixation
attempts are likely to fail. Radiation may also be useful postoperatively
to minimise construct failure due to tumor progression.
The aims of this study were to evaluate the clinical and radiological
outcomes of instrumented posterolateral fusion (PLF) performed in
patients with rheumatoid arthritis (RA). A total of 40 patients with RA and 134 patients without RA underwent
instrumented PLF for spinal stenosis between January 2003 and December
2011. The two groups were matched for age, gender, bone mineral
density, the history of smoking and diabetes, and number of fusion
segments. The clinical outcomes measures included the visual analogue scale
(VAS) and the Korean Oswestry Disability Index (KODI), scored before
surgery, one year and two years after surgery. Radiological outcomes
were evaluated for problems of fixation, nonunion, and adjacent
segment disease (ASD). The mean follow-up was 36.4 months in the RA
group and 39.1 months in the non-RA group.Aims
Methods
Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised. Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.
The aim of this study was to quantify the stability
of fracture-implant complex in fractures after fixation. A total
of 15 patients with an undisplaced fracture of the femoral neck,
treated with either a dynamic hip screw or three cannulated hip
screws, and 16 patients with an AO31-A2 trochanteric fracture treated
with a dynamic hip screw or a Gamma Nail, were included. Radiostereometric
analysis was used at six weeks, four months and 12 months post-operatively
to evaluate shortening and rotation. Migration could be assessed in ten patients with a fracture of
the femoral neck and seven with a trochanteric fracture. By four
months post-operatively, a mean shortening of 5.4 mm (-0.04 to 16.1)
had occurred in the fracture of the femoral neck group and 5.0 mm
(-0.13 to 12.9) in the trochanteric fracture group. A wide range
of rotation occurred in both types of fracture. Right-sided trochanteric
fractures seem more rotationally stable than left-sided fractures. This prospective study shows that migration at the fracture site
occurs continuously during the first four post-operative months,
after which stabilisation occurs. This information may allow the
early recognition of patients at risk of failure of fixation. Cite this article:
We set out to determine the impact of surgery on quality of life and function in patients who had undergone surgery for symptomatic peri-acetabular metastases. From a prospective database we retrospectively reviewed 46 consecutive patients who had been treated operatively between June 2003 and June 2009. The mean age of the patients was 56.4 years (20 to 73) and the mean post-operative follow-up was 19.2 months (4 to 70). Functional evaluation and quality-of-life assessments were performed. At the most recent follow-up, 26 patients (56.5%) were alive. Their median survival time was 25.0 months. Ten major postoperative complications had occurred in eight patients (17.4%). The mean post-operative Musculoskeletal Tumor Society score (MSTS 93) was 56.3% (6.7% to 90.0%). Improvement in the Eastern Cooperative Oncology Group (ECOG) performance status was seen in 32 patients (69.6%). On the European Organisation for Research and Treatment of Cancer core quality-of-life questionnaire (QLQ-C30) measure of global health status there was a statistically significant improvement from the patients’ pre-operative status (42.8 ( Surgery for patients with peri-acetabular metastases reduces pain and improves their quality of life, and has a low rate of surgical complications.
Bone loss secondary to primary or metastatic lesions of the proximal humerus remains a challenging surgical problem. Options include preservation of the joint with stabilisation using internal fixation or resection of the tumour with prosthetic replacement. Resection of the proximal humerus often includes the greater tuberosity and adjacent diaphysis, which may result in poor function secondary to loss of the rotator cuff and/or deltoid function. Preservation of the joint with internal fixation may reduce the time in hospital and peri-operative morbidity compared with joint replacement, and result in a better functional outcome. We included 32 patients with pathological fractures of the proximal humerus in this study. Functional and radiological assessments were performed. At a mean follow-up of 17.6 months (8 to 61) there was no radiological evidence of failure of fixation. The mean revised musculoskeletal Tumour Society functional score was 94.6% (86% to 99%). There was recurrent tumour requiring further surgery in four patients (12.5%). Of the 22 patients who were employed prior to presentation all returned to work without restrictions. The use of a locking plate combined with augmentation with cement extends the indications for salvage of the proximal humerus with good function in patients with pathological and impending pathological fractures.
In this retrospective study we evaluated the
proficiency of shelf autograft in the restoration of bone stock
as part of primary total hip replacement (THR) for hip dysplasia,
and in the results of revision arthroplasty after failure of the primary
arthroplasty. Of 146 dysplastic hips treated by THR and a shelf
graft, 43 were revised at an average of 156 months, 34 of which
were suitable for this study (seven hips were excluded because of
insufficient bone-stock data and two hips were excluded because
allograft was used in the primary THR). The acetabular bone stock
of the hips was assessed during revision surgery. The mean implant–bone
contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%)
at the time of the revision, which was a significant improvement
(p <
0.001). At primary THR all hips had had a segmental acetabular
defect >
30%, whereas only five (15%) had significant segmental
bone defects requiring structural support at the time of revision.
In 15 hips (44%) no bone graft or metal augments were used during
revision. A total of 30 hips were eligible for the survival study. At a
mean follow-up of 103 months (27 to 228), two aseptic and two septic
failures had occurred. Kaplan-Meier survival analysis of the revision
procedures demonstrated a ten-year survival rate of 93.3% (95% confidence
interval (CI) 78 to 107) with clinical or radiological failure as
the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for
non-revised cases at final follow-up. Our results indicate that the use of shelf autografts during
THR for dysplastic hips restores bone stock, contributing to the
favourable survival of the revision arthroplasty should the primary
procedure fail. Cite this article:
Bone defects are occasionally encountered during
primary total knee replacement (TKR) and cause difficulty in establishing
a stable well-aligned bone-implant interface. Between March 1999
and November 2005, 59 knees in 43 patients underwent primary TKR
with a metal block augmentation for tibial bone deficiency. In all,
six patients (eight knees) died less than four years post-operatively,
and four patients (five knees) were lost to follow-up leaving 46 knees
in 33 patients available for review at a mean of 78.6 months (62
to 129). The clinical results obtained, including range of movement,
American Knee Society and Oxford knee scores, and the Western Ontario
and McMaster Universities osteoarthritis index, were good to excellent,
with no failures. Radiolucent lines at the block-cement-bone interface
were noted in five knees (11%) during the first post-operative year,
but these did not progress. Modular rectangular metal augmentation for tibial bone deficiency
is a useful option. No deterioration of the block-prosthesis or
block-cement-bone interface was seen at minimum of five years follow-up.
Vertebral compression fractures are the most prevalent complication of osteoporosis and percutaneous vertebroplasty (PVP) has emerged as a promising addition to the methods of treating the debilitating pain they may cause. Since PVP was first reported in the literature in 1987, more than 600 clinical papers have been published on the subject. Most report excellent improvements in pain relief and quality of life. However, these papers have been based mostly on uncontrolled cohort studies with a wide variety of inclusion and exclusion criteria. In 2009, two high-profile randomised controlled trials were published in the
There are three basic concepts that are important to the biomechanics of pedicle screw-based instrumentation. First, the outer diameter of the screw determines pullout strength, while the inner diameter determines fatigue strength. Secondly, when inserting a pedicle screw, the dorsal cortex of the spine should not be violated and the screws on each side should converge and be of good length. Thirdly, fixation can be augmented in cases of severe osteoporosis or revision. A trajectory parallel or caudal to the superior endplate can minimise breakage of the screw from repeated axial loading. Straight insertion of the pedicle screw in the mid-sagittal plane provides the strongest stability. Rotational stability can be improved by adding transverse connectors. The indications for their use include anterior column instability, and the correction of rotational deformity.
We have reviewed 54 patients who had undergone 61 total hip replacements using bulk femoral autografts to augment a congenitally dysplastic acetabulum. There were 52 women and two men with a mean age of 42.4 years (29 to 76) at the time of the index operation. A variety of different prostheses was used: 28 (45.9%) were cemented and 33 (54.1%) uncemented. The graft technique remained unchanged throughout the series. Follow-up was at a mean of 8.3 years (3 to 20). The Hospital for Special Surgery hip score improved from a mean of 10.7 (4 to 18) pre-operatively to a mean of 35 (28 to 38) at follow-up. The position of the acetabular component was anatomical in 37 hips (60.7%), displaced less than 1 cm in 20 (32.7%) and displaced more than 1 cm in four (6.6%). Its cover was between 50% and 75% in 34 hips (55.7%) and less than 50% in 25 (41%). In two cases (3.3%), it was more than 75%. There was no graft resorption in 36 hips (59%), mild resorption in 21 (34%) and severe resorption in four (6%). Six hips (9.8%) were revised for aseptic loosening. The overall rate of loosening and revision was 14.8%. Overall survival at 8.3 years was 93.4%. The only significant factor which predicted failure was the implantation of the acetabular component more than 1 cm from the anatomical centre of rotation of the hip.
The management of bone loss in revision replacement of the knee remains a challenge despite an array of options available to the surgeon. Bone loss may occur as a result of the original disease, the design of the prosthesis, the mechanism of failure or technical error at initial surgery. The aim of revision surgery is to relieve pain and improve function while addressing the mechanism of failure in order to reconstruct a stable platform with transfer of load to the host bone. Methods of reconstruction include the use of cement, modular metal augmentation of prostheses, custom-made, tumour-type or hinged implants and bone grafting. The published results of the surgical techniques are summarised and a guide for the management of bone defects in revision surgery of the knee is presented.
We report the clinical and radiographic outcome of a consecutive series of 138 hydroxyapatite-coated total knee replacements with a mean follow-up of 11 years (10 to 13). The patients were entered into a prospective study and all living patients (76 knees) were evaluated. The Hospital for Special Surgery knee score was obtained for comparison with the pre-operative situation. No patient was lost to follow-up. Radiographic assessment revealed no loosening. Seven prostheses have been revised, giving a cumulative survival rate of 93% at 13 years. We believe this to be the longest follow-up report available for an hydroxyapatite-coated knee replacement and the first for this design of Insall-Burstein II knee.
Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective.
We undertook a multicentre, prospective study of a series of 112 unstable trochanteric fractures in order to evaluate if internal fixation with a sliding screw device combined with augmentation using a calcium phosphate degradable cement (Norian SRS) could improve the clinical, functional and radiological outcome when compared with fractures treated with a sliding screw device alone. Pain, activities of daily living, health status (SF-36), the strength of the hip abductor muscles and radiological outcome were analysed. Six weeks after surgery, the patients in the augmented group had significantly lower global and functional pain scores (p <
0.003), less pain after walking 50 feet (p <
0.01), and a better return to the activities of daily living (p <
0.05). At follow-up at six weeks and six months, those in the augmented group showed a significant improvement compared with the control group in the SF-36 score. No other significant differences were found between the groups. We conclude that augmentation with calcium phosphate cement in unstable trochanteric fractures provides a modest reduction in pain and a slight improvement in the quality of life during the course of healing when compared with conventional fixation with a sliding screw device alone.
