Non-traumatic osteonecrosis of the femoral head
is a potentially devastating condition, the prevalence of which
is increasing. Many joint-preserving forms of treatment, both medical
and surgical, have been developed in an attempt to slow or reverse
its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is
available for the many forms of treatment considering the variation
in the demographics of the patients, the methodology and the outcomes
in the studies that have been published, so that it can be used
effectively. The purpose of this review, therefore, was to provide an up-to-date,
evidence-based guide to the management, both non-operative and operative,
of non-traumatic osteonecrosis of the femoral head. Cite this article:
The aims of this study were to analyse the long-term outcome
of vascularised fibular graft (VFG) reconstruction after tumour
resection and to evaluate the usefulness of the method. We retrospectively reviewed 49 patients who had undergone resection
of a sarcoma and reconstruction using a VFG between 1988 and 2015.
Their mean follow-up was 98 months (5 to 317). Reconstruction was
with an osteochondral graft (n = 13), intercalary graft (n = 12),
inlay graft (n = 4), or resection arthrodesis (n = 20). We analysed
the oncological and functional outcome, and the rate of bony union
and complications.Aims
Patients and Methods
The aim of the study was to compare measures of the quality of
life (QOL) after resection of a chordoma of the mobile spine with
the national averages in the United States and to assess which factors
influenced the QOL, symptoms of anxiety and depression, and coping
with pain post-operatively in these patients. A total of 48 consecutive patients who underwent resection of
a primary or recurrent chordoma of the mobile spine between 2000
and 2015 were included. A total of 34 patients completed a survey
at least 12 months post-operatively. The primary outcome was the
EuroQol-5 Dimensions (EQ-5D-3L) questionnaire. Secondary outcomes were
the Patient-Reported Outcome Measurement Information System (PROMIS)
anxiety, depression and pain interference questionnaires. Data which
were recorded included the indication for surgery, the region of
the tumour, the number of levels resected, the status of the surgical
margins, re-operations, complications, neurological deficit, length
of stay in hospital and rate of re-admission.Aims
Patients and Methods
Chronic conditions of the wrist may be difficult to manage because
pain and psychiatric conditions are correlated with abnormal function
of the hand. Additionally, intra-articular inflammatory cytokines
may cause pain. We aimed to validate the measurement of inflammatory cytokines
in these conditions and identify features associated with symptoms. The study included 38 patients (18 men, 20 women, mean age 43
years) with a chronic condition of the wrist who underwent arthroscopy.
Before surgery, the Self-Rating Depression Scale (SDS), Hand20 questionnaire
and a visual analogue scale (VAS) for pain were used. Cytokine and
chemokine levels in the synovial fluid of the wrist were measured
using enzyme-linked immunosorbent assays and correlations between
the levels with pain were analysed. Gene expression profiles of
the synovial membranes were assessed using quantitative polymerase
chain reaction.Aims
Patients and Methods
Aims. This retrospective cohort study compared the results of vascularised
and non-vascularised anterior sliding tibial grafts for the treatment
of osteoarthritis (OA)of the ankle secondary to osteonecrosis of
the talus. . Patients and Methods. We reviewed the clinical and radiological outcomes of 27 patients
who underwent arthrodesis with either vascularised or non-vascularised
(conventional) grafts, comparing the outcomes (clinical scores,
proportion with successful union and time to union) between the
two groups. The clinical outcome was assessed using the Mazur and
American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot
scores. The mean follow-up was 35 months (24 to 68). Results. The mean outcome scores increased significantly in both groups.
In the vascularised graft group, the mean Mazur score improved from
36.9 to 74.6 and the mean AOFAS scale improved from 49.6 to 80.1. . In the conventional arthrodesis group, the mean Mazur score improved
from 35.5 to 65 and the mean AOFAS scale from 49.2 to 67.6. . Complete fusion was achieved in 13 patients (76%) in the vascularised
group, but only four (40%) in the conventional group. The clinical
outcomes and proportion achieving union were significantly better
in the vascularised group compared with the conventional arthrodesis
group, although time to union was similar in the two groups. Take home message:
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:
The December 2014 Oncology Roundup360 looks at: metaphyseal and diaphyseal osteosarcoma subtly different beasts; sports and endoprosthetic reconstruction of the knee; is curettage without tissue diagnosis sensible in cartilaginous tumours?; autoclaved autograft in bone tumour reconstruction; vascularised graft a step too far in bone defects?; interdigitated neoadjuvant chemoradiotherapy in high-grade sarcoma; predicting life expectancy in patients with painful metastasis; and osteolytic lesions of the hands and feet.
Resection of a primary sarcoma of the diaphysis
of a long bone creates a large defect. The biological options for reconstruction
include the use of a vascularised and non-vascularised fibular autograft. The purpose of the present study was to compare these methods
of reconstruction. Between 1985 and 2007, 53 patients (26 male and 27 female) underwent
biological reconstruction of a diaphyseal defect after resection
of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4).
Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised
fibular autograft. Either method could have been used for any patient in
the study. The mean follow-up was 52 months (12 to 259). Oncological,
surgical and functional outcome were evaluated. Kaplan–Meier analysis
was performed for graft survival with major complication as the
end point. At final follow-up, eight patients had died of disease. Primary
union was achieved in 40 patients (75%); 22 (42%) with a vascularised
fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A
total of 32 patients (60%) required revision surgery. Kaplan–Meier
analysis revealed a mean survival without complication of 36 months
(0.06 to 107.3, . sd. 9) for the vascularised group and 88
months (0.33 to 163.9, . sd. 16) for the non-vascularised
group (p = 0.035). . Both groups seem to be reliable biological methods of reconstructing
a diaphyseal bone defect.
This preliminary study evaluates a combination
of bone morphogenetic protein (BMP)-7 and non-vascularised autologous
fibular grafting (AFG) for the treatment of osteonecrosis of the
femoral head. BMP-7/AFG combination was applied in seven pre-collapse femoral
heads (five Steinberg stage II, two stage III) in six patients.
Pre- and post-operative evaluation included clinical (Harris hip
score (HHS), visual analogue scale (VAS) for pain) and radiological
assessment (radiographs, quantitative CT) at a mean follow-up of
4 years (2 to 5.5). A marked improvement of function (mean HHS increase of 49.2)
and decrease of pain level (mean VAS decrease of 5) as well as retention
of the sphericity of the femoral head was noted in five hips at
the latest follow-up, while signs of consolidation were apparent
from the third post-operative month. One patient (two hips) required
bilateral total hip replacement at one year post-operatively. In
the series as a whole, quantitative-CT evaluation revealed similar densities
between affected and normal bone. Heterotopic ossification was observed
in four hips, without compromise of the clinical outcome. In this limited series AFG/BMP-7 combination proved a safe and
effective method for the treatment of femoral head osteonecrosis,
leading to early consolidation of the AFG and preventing collapse
in five of seven hips, while the operative time and post-operative
rehabilitation period were much shorter compared with free vascularised fibular
grafts. Cite this article:
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
The June 2013 Hip &
Pelvis Roundup360 looks at: failure in metal-on-metal arthroplasty; minimal hip approaches; whether bisphosphonates improve femoral bone stock following arthroplasty; whether more fat means more operative time; surgical infection; vascularised fibular graft for osteonecrosis; subclinical SUFE; and dentists, hips and antibiotics.
The October 2012 Oncology Roundup360 looks at: the causes of primary bone tumours; adjuvant chemotherapy in the longer term; vascularised fibular grafts to salvage massive femoral allografts; a new look at old risks; reconstruction with excised irradiated bone; predicting chemosensitivity in osteosarcoma ; and chemotherapy, osteoporosis and the risk of fracture.
The June 2012 Children’s orthopaedics Roundup360 looks at; open reduction for DDH; growing rod instrumentation for scoliosis; acute patellar dislocation; management of the relapsed clubfoot; clubfoot in Iran; laughing gas and fracture manipulation; vascularised periosteal fibular grafting for nonunion; slipped upper femoral epiphysis; intramedullary leg lengthening and orthopaedic imaging and defensive medicine.
We retrospectively reviewed 101 consecutive patients
with 114 femoral tumours treated by massive bone allograft at our
institution between 1986 and 2005. There were 49 females and 52
males with a mean age of 20 years (4 to 74). At a median follow-up
of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed.
The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and
failure of fixation were studied. The most adverse factor on the
outcome was the use of intramedullary nails, followed by post-operative
chemotherapy, resection length >
17 cm and age >
18 years at the
time of intervention. The simultaneous use of a vascularised fibular
graft to protect the allograft from mechanical complications improved
the outcome, but the use of intramedullary cementing was not as
successful. In order to improve the strength of the reconstruction and to
advance the biology of host–graft integration, we suggest avoiding
the use of intramedullary nails and titanium plates, but instead
using stainless steel plates, as these gave better results. The
use of a supplementary vascularised fibular graft should be strongly
considered in adult patients with resection >
17 cm and in those
who require post-operative chemotherapy.
Congenital pseudarthrosis of the tibia remains one of the most difficult orthopaedic problems. We describe early excision and the use of the Masquelet technique to reconstruct the bone defect in a child aged 14 months. Consolidation sufficient for complete weight-bearing was achieved by seven weeks. After two and a half years, the child was asymptomatic with a fully reconstructed tibia and no leg-length discrepancy.
Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%). Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18). Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.
We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3). Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results.
We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.
