A new method of vascularised tibial grafting
has been developed for the treatment of avascular necrosis (AVN)
of the talus and secondary osteoarthritis (OA) of the ankle. We
used 40 cadavers to identify the vascular anatomy of the distal
tibia in order to establish how to elevate a vascularised tibial
graft safely. Between 2008 and 2012, eight patients (three male,
five female, mean age 50 years; 26 to 68) with isolated AVN of the
talus and 12 patients (four male, eight female, mean age 58 years;
23 to 76) with secondary OA underwent vascularised bone grafting
from the distal tibia either to revascularise the talus or for arthrodesis.
The radiological and clinical outcomes were evaluated at a mean
follow-up of 31 months (24 to 62). The peri-malleolar arterial arch
was confirmed in the cadaveric study. A vascularised bone graft
could be elevated safely using the peri-malleolar pedicle. The clinical
outcomes for the group with AVN of the talus assessed with the mean
Mazur ankle grading scores, improved significantly from 39 points
(21 to 48) pre-operatively to 81 points (73 to 90) at the final
follow-up (p = 0.01). In all eight revascularisations, bone healing
was obtained without progression to talar collapse, and union was
established in 11 of 12 vascularised arthrodeses at a mean follow-up
of 34 months (24 to 58). MRI showed revascularisation of the talus
in all patients. We conclude that a vascularised tibial graft can be used both
for revascularisation of the talus and for the arthrodesis of the
ankle in patients with OA secondary to AVN of the talus. Cite this article:
Although the technique of autogenous acetabular bone grafting has been widely used to augment containment of the acetabulum in total hip arthroplasty (THA) for developmental dysplasia, the role of this technique in improving long-term results remains controversial. We present the long-term results of cemented THA with acetabular bone grafting in 112 patients (133 hips) in order to clarify the factors which affect the outcome. The mean follow-up was for 12.3 years (8 to 24). Kaplan-Meier survivorship analysis predicted a rate of survival of the acetabular component at 15 years of 96% (95% confidence interval (CI) 92 to 99) with revision for aseptic loosening as the endpoint, and of 75% (95% CI 65 to 85) when radiological loosening was used. Parametric survivorship analysis using the Cox proportional-hazards model indicated that trochanteric nonunion, lateral placement of the socket, and delayed trabecular reorientation of the bone graft were risk factors for loosening of the acetabular component. Our findings have shown that autologous acetabular bone grafting is of value for long-term success provided that the risk factors are reduced.
We have developed a new drug delivery system using porous apatite-wollastonite glass ceramic (A-W GC) to treat osteomyelitis. A-W GC (porosity, 70% and 20% to 30%), or porous hydroxyapatite (HA) blocks (porosity 35% to 48%) used as controls, were soaked in mixtures of two antibiotics, isepamicin sulphate (ISP) and cefmetazole (CMZ) under high vacuum. We evaluated the release concentrations of the antibiotics from the blocks. The bactericidal concentration of ISP from A-W GC was maintained for more than 42 days, but that from HA decreased to below the detection limit after 28 days. The concentrations of CMZ from both materials were lower than those of ISP. An in vivo study using rabbit femora showed that an osseous concentration of ISP was maintained at eight weeks after implantation. Osteoconduction of the A-W GC block was good. Four patients with infected hip arthroplasties and one with osteomyelitis of the tibia have been treated with the new delivery system with excellent results.
