Between 2003 and 2007, 99 knees in 77 patients
underwent opening wedge high tibial osteotomy. We evaluated the effect
of initial stable fixation combined with an artificial bone substitute
on the mid- to long-term outcome after medial opening-wedge high
tibial osteotomy (HTO) for medial compartmental osteoarthritis or
spontaneous osteonecrosis of the knee in 78 knees in 64 patients
available for review at a minimum of five years (mean age 68 years;
49 to 82). The mean follow-up was 6.5 years (5 to 10). The mean
Knee Society knee score and function score improved from 49.6 ( Opening-wedge HTO using a stable plate fixation system combined
with a bone substitute is a reliable procedure that provides excellent
results. Although this treatment might seem challenging for older
patients, our results strongly suggest that the results are equally
good. Cite this article:
This study reports on the first 150 consecutive
Oxford cementless unicompartmental knee arthroplasties (UKA) performed
in an independent centre (126 patients). All eligible patients had
functional scores (Oxford knee score and high activity arthroplasty
score) recorded pre-operatively and at two- and five-years of follow-up. Fluoroscopically
aligned radiographs were taken at five years and analysed for any
evidence of radiolucent lines (RLLs), subsidence or loosening. The
mean age of the cohort was 63.6 years (39 to 86) with 81 (53.1%)
males. Excellent functional scores were maintained at five years
and there were no progressive RLLs demonstrated on radiographs.
Two patients underwent revision to a total knee arthroplasty giving
a revision rate of 0.23/100 (95% confidence interval 0.03 to 0.84)
component years with overall component survivorship of 98.7% at
five years. There were a further four patients who underwent further
surgery on the same knee, two underwent bearing exchanges for dislocation
and two underwent lateral UKAs for disease progression. This was
a marked improvement from other UKAs reported in New Zealand Joint
Registry data and supports the designing centre’s early results. Cite this article:
A total of 20 patients with a depressed fracture
of the lateral tibial plateau (Schatzker II or III) who would undergo open
reduction and internal fixation were randomised to have the metaphyseal
void in the bone filled with either porous titanium granules or
autograft bone. Radiographs were undertaken within one week, after
six weeks, three months, six months, and after 12 months. The primary outcome measure was recurrent depression of the joint
surface: a secondary outcome was the duration of surgery. The risk of recurrent depression of the joint surface was lower
(p <
0.001) and the operating time less (p <
0.002) when titanium
granules were used. The indication is that it is therefore beneficial to use porous
titanium granules than autograft bone to fill the void created by
reducing a depressed fracture of the lateral tibial plateau. There
is no donor site morbidity, the operating time is shorter and the
risk of recurrent depression of the articular surface is less. Cite this article:
A common situation presenting to the orthopaedic
surgeon today is a worn acetabular liner with substantial acetabular
and pelvic osteolysis. The surgeon has many options for dealing
with osteolytic defects. These include allograft, calcium based
substitutes, demineralised bone matrix, or combinations of these
options with or without addition of platelet rich plasma. To date
there are no clinical studies to determine the efficacy of using
bone-stimulating materials in osteolytic defects at the time of
revision surgery and there are surprisingly few studies demonstrating
the clinical efficacy of these treatment options. Even when radiographs
appear to demonstrate incorporation of graft material CT studies
have shown that incorporation is incomplete. The surgeon, in choosing
a graft material for a surgical procedure must take into account
the efficacy, safety, cost and convenience of that material. Cite this article:
We report the clinical and radiographic outcomes
of 208 consecutive femoral revision arthroplasties performed in 202
patients (119 women, 83 men) between March 1991 and December 2007
using the X-change Femoral Revision System, fresh-frozen morcellised
allograft and a cemented polished Exeter stem. All patients were
followed prospectively. The mean age of the patients at revision
was 65 years (30 to 86). At final review in December 2013 a total
of 130 patients with 135 reconstructions (64.9%) were alive and
had a non re-revised femoral component after a mean follow-up of
10.6 years (4.7 to 20.9). One patient was lost to follow-up at six
years, and their data were included up to this point.
Re-operation for any reason was performed in 33 hips (15.9%), in
13 of which the femoral component was re-revised (6.3%). The mean
pre-operative Harris hip score was 52 (19 to 95) (n = 73) and improved
to 80 (22 to 100) (n = 161) by the last follow-up. Kaplan–Meier
survival with femoral re-revision for any reason as the endpoint
was 94.9% (95% confidence intervals (CI) 90.2 to 97.4) at ten years;
with femoral re-revision for aseptic loosening as the endpoint it was
99.4% (95% CI 95.7 to 99.9); with femoral re-operation for any reason
as the endpoint it was 84.5% (95% CI 78.3 to 89.1); and with subsidence ≥ 5
mm it was 87.3% (95% CI 80.5 to 91.8). Femoral revision with the
use of impaction allograft bone grafting and a cemented polished
stem results in a satisfying survival rate at a mean of ten years’ follow-up. Cite this article:
This systematic review of the literature summarises
the clinical experience with ceramic-on-ceramic hip bearings over
the past 40 years and discusses the concerns that exist in relation
to the bearing combination. Loosening, fracture, liner chipping
on insertion, liner canting and dissociation, edge-loading and squeaking
have all been reported, and the relationship between these issues
and implant design and surgical technique is investigated. New design
concepts are introduced and analysed with respect to previous clinical
experience.
Hip fracture is a global public health problem.
The National Hip Fracture Database provides a framework for service evaluation
in this group of patients in the United Kingdom, but does not collect
patient-reported outcome data and is unable to provide meaningful
data about the recovery of quality of life. We report one-year patient-reported outcomes of a prospective
cohort of patients treated at a single major trauma centre in the
United Kingdom who sustained a hip fracture between January 2012
and March 2014. There was an initial marked decline in quality of life from baseline
measured using the EuroQol 5 Dimensions score (EQ-5D). It was followed
by a significant improvement to 120 days for all patients. Although
their quality of life improved during the year after the fracture,
it was still significantly lower than before injury irrespective
of age group or cognitive impairment (mean reduction EQ-5D 0.22;
95% confidence interval (CI) 0.17 to 0.26). There was strong evidence
that quality of life was lower for patients with cognitive impairment.
There was a mean reduction in EQ-5D of 0.28 (95% CI 0.22 to 0.35)
in patients <
80 years of age. This difference was consistent
(and fixed) throughout follow-up. Quality of life does not improve
significantly during recovery from hip fracture in patients over
80 years of age (p = 0.928). Secondary measures of function showed
similar trends. Hip fracture marks a step down in the quality of life of a patient:
it accounts for approximately 0.22 disability adjusted life years
in the first year after fracture. This is equivalent to serious
neurological conditions for which extensive funding for research
and treatment is made available. Cite this article:
Third-body wear is believed to be one trigger for adverse results
with metal-on-metal (MOM) bearings. Impingement and subluxation
may release metal particles from MOM replacements. We therefore
challenged MOM bearings with relevant debris types of cobalt–chrome
alloy (CoCr), titanium alloy (Ti6Al4V) and polymethylmethacrylate
bone cement (PMMA). Cement flakes (PMMA), CoCr and Ti6Al4V particles (size range
5 µm to 400 µm) were run in a MOM wear simulation. Debris allotments
(5 mg) were inserted at ten intervals during the five million cycle
(5 Mc) test. Objectives
Methods
Peri-acetabular tumour resections and their subsequent
reconstruction are among the most challenging procedures in orthopaedic
oncology. Despite the fact that a number of different pelvic endoprostheses
have been introduced, rates of complication remain high and long-term
results are mostly lacking. In this retrospective study, we aimed to evaluate the outcome
of reconstructing a peri-acetabular defect with a pedestal cup endoprosthesis
after a type 2 or type 2/3 internal hemipelvectomy. A total of 19 patients (11M:8F) with a mean age of 48 years (14
to 72) were included, most of whom had been treated for a primary
bone tumour (n = 16) between 2003 and 2009. After a mean follow-up
of 39 months (28 days to 8.7 years) seven patients had died. After
a mean follow-up of 7.9 years (4.3 to 10.5), 12 patients were alive,
of whom 11 were disease-free. Complications occurred in 15 patients.
Three had recurrent dislocations and three experienced aseptic loosening.
There were no mechanical failures. Infection occurred in nine patients,
six of whom required removal of the prosthesis. Two patients underwent
hindquarter amputation for local recurrence. The implant survival rate at five years was 50% for all reasons,
and 61% for non-oncological reasons. The mean Musculoskeletal Tumor
Society score at final follow-up was 49% (13 to 87). Based on these poor results, we advise caution if using the pedestal
cup for reconstruction of a peri-acetabular tumour resection. Cite this article:
In the UK we have many surgeon inventors – surgeons who innovate and create new ways of doing things, who invent operations, who design new instruments to facilitate surgery or design new implants for using in patients. However truly successful surgeon inventors are a rare breed and they need to develop additional knowledge and skills during their career in order to push forward their devices and innovations. This article reviews my own experiences as a surgeon inventor and the highs and lows over the whole of my surgical career.
The most common reasons for revision of unicompartmental
knee arthroplasty (UKA) are loosening and pain. Cementless components
may reduce the revision rate. The aim of this study was to compare
the fixation and clinical outcome of cementless and cemented Oxford
UKAs. A total of 43 patients were randomised to receive either a cemented
or a cementless Oxford UKA and were followed for two years with
radiostereometric analysis (RSA), radiographs aligned with the bone–implant
interfaces and clinical scores. The femoral components migrated significantly during the first
year (mean 0.2 mm) but not during the second. There was no significant
difference in the extent of migration between cemented and cementless
femoral components in either the first or the second year. In the
first year the cementless tibial components subsided significantly
more than the cemented components (mean 0.28 mm ( As second-year migration is predictive of subsequent loosening,
and as radiolucency is suggestive of reduced implant–bone contact,
these data suggest that fixation of the cementless components is
at least as good as, if not better than, that of cemented devices. Cite this article:
Metallosis is a rare cause of failure after total knee replacement and has only previously been reported when there has been abnormal metal-on-metal contact. We describe 14 patients (15 knees) whose total knee replacement required revision for a new type of early failure caused by extensive metallosis. A modification of a cementless rotating platform implant, which had previously had excellent long-term survival, had been used in each case. The change was in the form of a new porous-beaded surface on the femoral component to induce cementless fixation, which had been used successfully in the fixation of acetabular and tibial components. This modification appeared to have resulted in metallosis due to abrasive two-body wear. The component has subsequently been recalled and is no longer in use. The presentation, investigation, and findings at revision are described and a possible aetiology and its implications are discussed.
Acetabular bone loss is a challenging problem
facing the revision total hip replacement surgeon. Reconstruction
of the acetabulum depends on the presence of anterosuperior and
posteroinferior pelvic column support for component fixation and
stability. The Paprosky classification is most commonly used when
determining the location and degree of acetabular bone loss. Augments
serve the function of either providing primary construct stability
or supplementary fixation. When a pelvic discontinuity is encountered we advocate the use
of an acetabular distraction technique with a jumbo cup and modular
porous metal acetabular augments for the treatment of severe acetabular
bone loss and associated chronic pelvic discontinuity. Cite this article:
Medial open-wedge high tibial osteotomy has been gaining popularity in recent years, but adequate supporting material is required in the osteotomy gap for early weight-bearing and rapid union. The purpose of this study was to investigate whether the implantation of a polycaprolactone-tricalcium phosphate composite scaffold wedge would enhance healing of the osteotomy in a micro pig model. We carried out open-wedge high tibial osteotomies in 12 micro pigs aged from 12 to 16 months. A scaffold wedge was inserted into six of the osteotomies while the other six were left open. Bone healing was evaluated after three and six months using plain radiographs, CT scans, measurement of the bone mineral density and histological examination. Complete bone union was obtained at six months in both groups. There was no collapse at the osteotomy site, loss of correction or failure of fixation in either group. Staining with haematoxylin and eosin demonstrated that there was infiltration of new bone tissue into the macropores and along the periphery of the implanted scaffold in the scaffold group. The CT scans and measurement of the bone mineral density showed that at six months specimens in the scaffold group had a higher bone mineral density than in the control group, although the implantation of the polycaprolactone-tricalcium phosphate composite scaffold wedge did not enhance healing of the osteotomy.
There is little in the literature on the level
of participation in sports which patients undertake after total
hip replacement (THR). Our aims in this study were to determine
first, the level of sporting activity, second, the predictive factors
for returning to sporting activity, and third, the correlation between
participation in sports and satisfaction after THR. We retrospectively
identified 815 patients who had undergone THR between 1995 and 2005. All
were asked to complete a self-administered questionnaire regarding
their sporting activity. A total of 571 patients (71%) met the inclusion
criteria and completed the evaluation. At a mean follow-up of 9.8
years ( In conclusion, we found that most patients participate in sporting
activity after THR, regardless of the advice of their surgeon, and
that there is a correlation between the level of participation and
pre-operative function, motivation, duration of symptoms and post-operative
satisfaction. Cite this article:
The inherent challenges of total hip replacement
(THR) in children include the choice of implant for the often atypical
anatomical morphology, its fixation to an immature growing skeleton
and the bearing surface employed to achieve a successful long-term
result. We report the medium-term results of 52 consecutive uncemented
THRs undertaken in
35 paediatric patients with juvenile idiopathic arthritis. The mean
age at the time of surgery was 14.4 years (10 to 16). The median
follow-up was 10.5 years (6 to 15). During the study period 13 THRs
underwent revision surgery. With revision as an endpoint, subgroup
analysis revealed 100% survival of the 23 ceramic-on-ceramic THRs
and 55% (16 of 29) of the metal- or ceramic-on-polyethylene. This
resulted in 94% (95% CI 77.8 to 98.4) survivorship of the femoral
component and 62% (95% CI 41.0 to 78.0) of the acetabular component.
Revision of the acetabular component for wear and osteolysis were
the most common reasons for failure accounting for 11 of the 13
revisions. The success seen in patients with a ceramic-on-ceramic articulation
seems to indicate that this implant strategy has the potential to
make a major difference to the long-term outcome in this difficult
group of patients.
There is little information about the management
of peri-prosthetic fracture of the humerus after total shoulder replacement
(TSR). This is a retrospective review of 22 patients who underwent
a revision of their original shoulder replacement for peri-prosthetic
fracture of the humerus with bone loss and/or loose components.
There were 20 women and two men with a mean age of 75 years (61
to 90) and a mean follow-up 42 months (12 to 91): 16 of these had
undergone a previous revision TSR. Of the 22 patients, 12 were treated
with a long-stemmed humeral component that bypassed the fracture.
All their fractures united after a mean of 27 weeks (13 to 94).
Eight patients underwent resection of the proximal humerus with
endoprosthetic replacement to the level of the fracture. Two patients
were managed with a clam-shell prosthesis that retained the original
components. The mean Oxford shoulder score (OSS) of the original
TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean
OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival
using re-intervention for any reason as the endpoint was 91% (95%
confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at
one and five years, respectively. There were two revisions for dislocation of the humeral head,
one open reduction for modular humeral component dissociation, one
internal fixation for nonunion, one trimming of a prominent screw
and one re-cementation for aseptic loosening complicated by infection,
ultimately requiring excision arthroplasty. Two patients sustained
nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated
with bone loss and/or loose components is a salvage procedure that
can provide a stable platform for elbow and hand function. Good
rates of union can be achieved using a stem that bypasses the fracture.
There is a high rate of complications and function is not as good as
with the original replacement.
We reviewed our initial seven-year experience
with a non-invasive extendible prosthesis in 34 children with primary bone
tumours. The distal femur was replaced in 25 cases, total femur
in five, proximal femur in one and proximal tibia in three. The
mean follow-up was 44 months (15 to 86) and 27 patients (79%) remain
alive. The prostheses were lengthened by an electromagnetic induction
mechanism in an outpatient setting and a mean extension of 32 mm
(4 to 80) was achieved without anaesthesia. There were lengthening
complications in two children: failed lengthening in one and the
formation of scar tissue in the other. Deep infection developed
in six patients (18%) and local recurrence in three. A total of
11 patients required further surgery to the leg. Amputation was
necessary in five patients (20%) and a two-stage revision in another.
There were no cases of loosening, but two patients had implant breakage
and required revision. The mean Musculoskeletal Tumor Society functional
score was 85% (60% to 100%) at last known follow-up. These early
results demonstrate that the non-invasive extendible prosthesis
allows successful lengthening without surgical intervention, but
the high incidence of infection is a cause for concern.