Cartilage repair in terms of replacement, or
regeneration of damaged or diseased articular cartilage with functional tissue,
is the ‘holy grail’ of joint surgery. A wide spectrum of strategies
for cartilage repair currently exists and several of these techniques
have been reported to be associated with successful clinical outcomes
for appropriately selected indications. However, based on respective
advantages, disadvantages, and limitations, no single strategy, or
even combination of strategies, provides surgeons with viable options
for attaining successful long-term outcomes in the majority of patients.
As such, development of novel techniques and optimisation of current techniques
need to be, and are, the focus of a great deal of research from
the basic science level to clinical trials. Translational research
that bridges scientific discoveries to clinical application involves
the use of animal models in order to assess safety and efficacy
for regulatory approval for human use. This review article provides
an overview of animal models for cartilage repair. Cite this article:
We report the outcome of 84 nonunions involving
long bones which were treated with rhBMP-7, in 84 patients (60 men:
24 women) with a mean age 46 years (18 to 81) between 2003 and 2011.
The patients had undergone a mean of three previous operations (one
to 11) for nonunion which had been present for a mean of 17 months
(4 months to 20 years). The nonunions involved the lower limb in
71 patients and the remainder involved the upper limb. A total of 30
nonunions were septic. Treatment was considered successful when
the nonunion healed without additional procedures. The relationship
between successful union and the time to union was investigated
and various factors including age and gender, the nature of the
nonunion (location, size, type, chronicity, previous procedures,
infection, the condition of the soft tissues) and type of index
procedure (revision of fixation, type of graft, amount of rhBMP-7) were
analysed. The improvement of the patients’ quality of life was estimated
using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further
procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate
logistic regression analysis of the factors affecting union suggested
that only infection significantly affected the rate of union
(p = 0.004).Time to union was only affected by the number of previous
failed procedures
(p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and
mental score, respectively, was noted within the first post-operative
year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion
and improved quality of life in about 80% of patients. Aseptic nonunions
were much more likely to unite than septic ones. The number of previous
failed operations significantly delayed the time to union. Cite this article:
The current indications for functional restoration
of extension of the knee following quadriceps resection or loss require
reappraisal. The contribution of pedicled and free functional muscle
transfer is likely to be over-emphasised in many studies, with good
functional outcomes predominantly reported only in the context of
cases with residual quadriceps function. In cases with total quadriceps
resection or loss, all forms of reconstruction perform poorly. Furthermore,
in smaller resections with loss of two or fewer components of the
quadriceps, minimal impairment of function occurs in the absence
of functional reconstruction, suggesting that functional restoration
may not be warranted. Thus there is a paradox in the current approach
to quadriceps reconstruction, in that small resections are likely
to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and
rationale for reconstructing functional extension of the knee after
quadriceps resection or loss. A classification based on current
evidence is suggested that emphasises more clearly the indications
and rationale for functional transfers.
Clinical studies of patients with bone sarcomas have been challenged
by insufficient numbers at individual centres to draw valid conclusions.
Our objective was to assess the feasibility of conducting a definitive
multi-centre randomised controlled trial (RCT) to determine whether
a five-day regimen of post-operative antibiotics, in comparison
to a
24-hour regimen, decreases surgical site infections in patients
undergoing endoprosthetic reconstruction for lower extremity primary
bone tumours. We performed a pilot international multi-centre RCT. We used
central randomisation to conceal treatment allocation and sham antibiotics
to blind participants, surgeons, and data collectors. We determined
feasibility by measuring patient enrolment, completeness of follow-up,
and protocol deviations for the antibiotic regimens. Objective
Methods
Dislocation of the shoulder may occur during
seizures in epileptics and other patients who have convulsions. Following
the initial injury, recurrent instability is common owing to a tendency
to develop large bony abnormalities of the humeral head and glenoid
and a susceptibility to further seizures. Assessment is difficult
and diagnosis may be missed, resulting in chronic locked dislocations
with protracted morbidity. Many patients have medical comorbidities,
and successful treatment requires a multidisciplinary approach addressing
the underlying seizure disorder in addition to the shoulder pathology.
The use of bony augmentation procedures may have improved the outcomes
after surgical intervention, but currently there is no evidence-based
consensus to guide treatment. This review outlines the epidemiology
and pathoanatomy of seizure-related instability, summarising the
currently-favoured options for treatment, and their results.
In 1999, we developed a technique for biological
reconstruction after excision of a bone tumour, which involved using
autografts of the bone containing the tumour treated with liquid
nitrogen. We have previously reported the use of this technique
in 28 patients at a mean follow up of 27 months (10 to 54). In this study, we included 72 patients who underwent reconstruction
using this technique. A total of 33 patients died and three were
lost to follow-up, at a mean of 23 months (2 to 56) post-operatively,
leaving 36 patients available for a assessment at a mean of 101
months 16 to 163) post-operatively. The methods of reconstruction included
an osteo-articular graft in 16, an intercalary in 13 and, a composite
graft with prosthesis in seven. Post-operative function was excellent in 26 patients (72.2%),
good in seven (19.4%), and fair in three (8.3%) according to the
functional evaluation system of Enneking. No recurrent tumour occurred
within the grafts. The autografts survived in 29 patients (80.6%),
and the rates of survival at five and ten years were 86.1% and 80.6
%, respectively. Seven of 16 osteo-articular grafts (44%) failed
because of fracture or infection, but all the composite and intercalary
grafts survived. The long-term outcomes of frozen autografting, particularly using
composite and intercalary grafts, are satisfactory and thus represent
a good method of treatment for patients with a sarcoma of bone or
soft tissue. Cite this article:
We report our early experience with the use of
a new prosthesis, the Modular Hemipelvic Prosthesis II, for reconstruction
of the hemipelvis after resection of a primary malignant peri-acetabular
tumour involving the sacroiliac joint. We retrospectively reviewed the outcome of 17 patients who had
undergone resection of a pelvic tumour and reconstruction with this
prosthesis between July 2002 and July 2010. One patient had a type I+II+III+IV resection (ilium + peri-acetabulum
+ pubis/ischium + sacrum) and 16 had a type I+II+IV resection (ilium
+ acetabulum + sacrum). The outcome was assessed at a mean follow-up
of 33 months (15 to 59). One patient was alive with disease, 11
were alive without disease and five had died of disease. The overall
five-year survival rate was 62.4%. Six patients had a local recurrence.
The mean Musculoskeletal Tumour Society score was 58% (33 to 77).
Deep infection occurred in two patients, problems with wound healing
in five and dislocation in one. For patients with a primary malignant peri-acetabular sarcoma
involving the sacroiliac joint, we believe that this new prosthesis
is a viable option for reconstruction of the bony defect left following
resection of the tumour. It results in a satisfactory functional
outcome with an acceptable rate of complications. Cite this article:
Revision knee arthroplasty presents a number
of challenges, not least of which is obtaining solid primary fixation
of implants into host bone. Three anatomical zones exist within
both femur and tibia which can be used to support revision implants.
These consist of the joint surface or epiphysis, the metaphysis
and the diaphysis. The methods by which fixation in each zone can
be obtained are discussed. The authors suggest that solid fixation
should be obtained in at least two of the three zones and emphasise
the importance of pre-operative planning and implant selection. Cite this article:
The December 2013 Shoulder &
Elbow Roundup360 looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions
Pelvic discontinuity represents a rare but challenging
problem for orthopaedic surgeons. It is most commonly encountered
during revision total hip replacement, but can also result from
an iatrogentic acetabular fracture during hip replacement. The general
principles in management of pelvic discontinuity include restoration
of the continuity between the ilium and the ischium, typically with
some form of plating. Bone grafting is frequently required to restore
pelvic bone stock. The acetabular component is then impacted, typically
using an uncemented, trabecular metal component. Fixation with multiple
supplemental screws is performed. For larger defects, a so-called
‘cup–cage’ reconstruction, or a custom triflange implant may be
required. Pre-operative CT scanning can greatly assist in planning
and evaluating the remaining bone stock available for bony ingrowth.
Generally, good results have been reported for constructs that restore
stability to the pelvis and allow some form of biologic ingrowth. Cite this article:
The December 2013 Hip &
Pelvis Roundup360 looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting
Ankle replacements have improved significantly since the first reported attempt at resurfacing of the talar dome in 1962. We are now at a stage where ankle replacement offers a viable option in the treatment of end-stage ankle arthritis. As the procedure becomes more successful, it is important to reflect and review the current surgical outcomes. This allows us to guide our patients in the treatment of end-stage ankle arthritis. What is the better surgical treatment – arthrodesis or replacement?
The purpose of this prospective study was to
evaluate the long-term clinical and radiological outcomes of revision of
the femoral component of a total hip replacement using impaction
bone grafting. Femoral revision with an impacted allograft was performed
on 29 patients (31 hips). In all, 21 hips (68%) had grade III or
IV femoral defects according to the Endo-Klinik classification.
A total of 11 patients (12 hips) died before the ten-year follow-up
period. Of the remaining patients, 18 patients (19 hips) were followed
for 10 to 15 years; three further patients died during this time.
None of the 31 stems underwent further revision of their stem. However,
four stems showed extensive subsidence (>
15 mm). One of these patients
had a femoral fracture that required fixation. Three other patients
had a femoral fracture, two of which required fixation and the other
was treated conservatively. Patients with a femoral fracture and/or
severe subsidence had significantly more grade IV defects (six of
seven hips; p = 0.004). One patient needed a closed reduction for
dislocation. Impaction allografting in revision hip surgery gives good long-term
results for femora with grades I, II and III Endo-Klinik-classified
defects. Extensive subsidence and femoral fractures were seen mainly
in patients with grade IV damaged femora.
Based on the first implementation of mixing antibiotics
into bone cement in the 1970s, the Endo-Klinik has used one stage
exchange for prosthetic joint infection (PJI) in over 85% of cases.
Looking carefully at current literature and guidelines for PJI treatment,
there is no clear evidence that a two stage procedure has a higher
success rate than a one-stage approach. A cemented one-stage exchange
potentially offers certain advantages, mainly based on the need
for only one operative procedure, reduced antibiotics and hospitalisation time.
In order to fulfill a one-stage approach, there are obligatory pre-,
peri- and post-operative details that need to be meticulously respected,
and are described in detail. Essential pre-operative diagnostic
testing is based on the joint aspiration with an exact identification
of any bacteria. The presence of a positive bacterial culture and
respective antibiogram are essential, to specify the antibiotics
to be loaded to the bone cement, which allows a high local antibiotic
elution directly at the surgical side. A specific antibiotic treatment
plan is generated by a microbiologist. The surgical success relies
on the complete removal of all pre-existing hardware, including
cement and restrictors and an aggressive and complete debridement
of any infected soft tissues and bone material. Post-operative systemic
antibiotic administration is usually completed after only ten to
14 days. Cite this article:
We describe the results of 81 consecutive revision
total hip replacements with impaction grafting in 79 patients using
a collared polished chrome–cobalt stem, customised in length according
to the extent of distal bone loss. Our hypothesis was that the features
of this stem would reduce the rate of femoral fracture and subsidence
of the stem. The mean follow-up was 12 years (8 to 15). No intra-operative
fracture or significant subsidence occurred. Only one patient suffered
a post-operative diaphyseal fracture, which was associated with
a fall. All but one femur showed incorporation of the graft. No
revision for aseptic loosening was recorded. The rate of survival of the femoral component at 12 years, using
further femoral revision as the endpoint, was 100% (95% confidence
interval (CI) 95.9 to 100), and at nine years using re-operation
for any reason as the endpoint, was 94.6% (95% CI 92.0 to 97.2). These results suggest that a customised cemented polished stem
individually adapted to the extent of bone loss and with a collar
may reduce subsidence and the rate of fracture while maintaining
the durability of the fixation.
Implant-associated infection is a major source
of morbidity in orthopaedic surgery. There has been extensive research
into the development of materials that prevent biofilm formation,
and hence, reduce the risk of infection. Silver nanoparticle technology
is receiving much interest in the field of orthopaedics for its
antimicrobial properties, and the results of studies to date are
encouraging. Antimicrobial effects have been seen when silver nanoparticles are
used in trauma implants, tumour prostheses, bone cement, and also
when combined with hydroxyapatite coatings. Although there are promising
results with Cite this article:
The purpose of this study was to evaluate A total of 60 Sprague-Dawley rats (125 g to 149 g) were implanted
subcutaneously with SWCNT/PLAGA composites (10 mg SWCNT and 1gm
PLAGA 12 mm diameter two-dimensional disks), and at two, four, eight
and 12 weeks post-implantation were compared with control (Sham)
and PLAGA (five rats per group/point in time). Rats were observed
for signs of morbidity, overt toxicity, weight gain and food consumption,
while haematology, urinalysis and histopathology were completed
when the animals were killed.Objectives
Methods
Revision total hip arthroplasty (THA) is challenging
when there is severe loss of bone in the proximal femur. The purpose
of this study was to evaluate the clinical and radiographic outcomes
of revision THA in patients with severe proximal femoral bone loss
treated with a fluted, tapered, modular femoral component. Between
January 1998 and December 2004, 92 revision THAs were performed
in 92 patients using a single fluted, tapered, modular femoral stem
design. Pre-operative diagnoses included aseptic loosening, infection
and peri-prosthetic fracture. Bone loss was categorised pre-operatively
as Paprosky types III-IV, or Vancouver B3 in patients with a peri-prosthetic
fracture. The mean clinical follow-up was 6.4 years (2 to 12). A
total of 47 patients had peri-operative complications, 27 of whom
required further surgery. However, most of these further operations
involved retention of a well-fixed femoral stem, and 88/92 femoral
components (97%) remained Revision THA in patients with extensive proximal femoral bone
loss using the Link MP fluted, tapered, modular stem led to a high
rate of osseointegration of the stem at mid-term follow-up. Cite this article:
The purpose of this study was to evaluate the
clinical results of a newly designed prosthesis to replace the body
of the talus in patients with aseptic necrosis. Between 1999 and
2006, 22 tali in 22 patients were replaced with a ceramic prosthesis.
A total of eight patients were treated with the first-generation
prosthesis, incorporating a peg to fix into the retained neck and
head of the talus, and the remaining 14 were treated with the second-generation prosthesis,
which does not have the peg. The clinical results were assessed
by the American Orthopaedic Foot and Ankle Society ankle/hindfoot
scale. The mean follow-up was 98 months (18 to 174). The clinical results
of the first-generation prostheses were excellent in three patients,
good in one, fair in three and poor in one. There were, however,
radiological signs of loosening, prompting a change in design. The
clinical results of the second-generation prostheses were excellent
in three patients, good in five, fair in four and poor in two, with
more favourable radiological appearances. Revision was required
using a total talar implant in four patients, two in each group. Although the second-generation prosthesis produced better results,
we cannot recommend the use of a talar body prosthesis. We now recommend
the use of a total talar implant in these patients.
Stems may improve fixation and stability of components
during revision total knee replacement. However, the choice between
cemented and cementless stems is not a clear one. Cemented stems
offer several advantages in terms of versatility, mechanical stability, surgical
technique and clinical outcome over their cementless counterpart. Cite this article: