The April 2012 Hip & Pelvis Roundup³⁶⁰ looks at osteoporotic hip fractures, retrotrochanteric pain, fibrin adhesive and reattachment of articular cartilage, autologous bone marrow mononuclear cells and avascular necrosis, bearing surfaces, stability after THR, digital templating, pelvic tilt after THR, custom-made sockets for DDH, and dogs and THR

As many as 25% to 40% of unicompartmental knee replacement (UKR) revisions are performed for pain, a possible cause of which is proximal tibial strain. The aim of this study was to examine the effect of UKR implant design and material on cortical and cancellous proximal tibial strain in a synthetic bone model. Composite Sawbone tibiae were implanted with cemented UKR components of different designs, either all-polyethylene or metal-backed. The tibiae were subsequently loaded in 500 N increments to 2500 N, unloading between increments. Cortical surface strain was measured using a digital image correlation technique. Cancellous damage was measured using acoustic emission, an engineering technique that detects sonic waves (‘hits’) produced when damage occurs in material.

Anteromedial cortical surface strain showed significant differences between implants at 1500 N and 2500 N in the proximal 10 mm only (p < 0.001), with relative strain shielding in metal-backed implants. Acoustic emission showed significant differences in cancellous bone damage between implants at all loads (p = 0.001). All-polyethylene implants displayed 16.6 times the total number of cumulative acoustic emission hits as controls. All-polyethylene implants also displayed more hits than controls at all loads (p < 0.001), more than metal-backed implants at loads ≥ 1500 N (p < 0.001), and greater acoustic emission activity on unloading than controls (p = 0.01), reflecting a lack of implant stiffness. All-polyethylene implants were associated with a significant increase in damage at the microscopic level compared with metal-backed implants, even at low loads. All-polyethylene implants should be used with caution in patients who are likely to impose large loads across their knee joint.

Cite this article: Bone Joint J 2013;95-B:1339–47.

We undertook a randomised prospective follow-up study of changes in peri-prosthetic bone mineral density (BMD) after hip resurfacing and compared them with the results after total hip replacement. A total of 59 patients were allocated to receive a hip resurfacing (n = 29) or an uncemented distally fixed total hip replacement (n = 30). The BMD was prospectively determined in four separate regions of interest of the femoral neck and in the calcar region corresponding to Gruen zone 7 for the hip resurfacing group and compared only to the calcar region in the total hip replacement group. Standardised measurements were performed pre-operatively and after three, six and 12 months. The groups were well matched in terms of gender distribution and mean age.

The mean BMD in the calcar region increased after one year to 105.2% of baseline levels in the resurfaced group compared with a significant decrease to 82.1% in the total hip replacement group (p < 0.001) by 12 months. For the resurfaced group, there was a decrease in bone density in all four regions of the femoral neck at three months which did not reach statistical significance and was followed by recovery to baseline levels after 12 months.

Hip resurfacing did indeed preserve BMD in the inferior femoral neck. In contrast, a decrease in the mean BMD in Gruen zone 7 followed uncemented distally fixed total hip replacement. Long term follow-up studies are necessary to see whether this benefit in preservation of BMD will be clinically relevant at future revision surgery.

We implanted titanium and carbon fibre-reinforced plastic (CFRP) femoral prostheses of the same dimensions into five prosthetic femora. An abductor jig was attached and a 1 kN load applied. This was repeated with five control femora. Digital image correlation was used to give a detailed two-dimensional strain map of the medial cortex of the proximal femur. Both implants caused stress shielding around the calcar. Distally, the titanium implant showed stress shielding, whereas the CFRP prosthesis did not produce a strain pattern which was statistically different from the controls. There was a reduction in strain beyond the tip of both the implants.

This investigation indicates that use of the CFRP stem should avoid stress shielding in total hip replacement.

Corticosteroids are prescribed for the treatment of many medical conditions and their adverse effects on bone, including steroid-associated osteoporosis and osteonecrosis, are well documented. Core decompression is performed to treat osteonecrosis, but the results are variable. As steroids may affect bone turnover, this study was designed to investigate bone healing within a bone tunnel after core decompression in an experimental model of steroid-associated osteonecrosis. A total of five 28-week-old New Zealand rabbits were used to establish a model of steroid-induced osteonecrosis and another five rabbits served as controls. Two weeks after the induction of osteonecrosis, core decompression was performed by creating a bone tunnel 3 mm in diameter in both distal femora of each rabbit in both the experimental osteonecrosis and control groups. An in vivo micro-CT scanner was used to monitor healing within the bone tunnel at four, eight and 12 weeks postoperatively. At week 12, the animals were killed for histological and biomechanical analysis.

In the osteonecrosis group all measurements of bone healing and maturation were lower compared with the control group. Impaired osteogenesis and remodelling within the bone tunnel was demonstrated in the steroid-induced osteonecrosis, accompanied by inferior mechanical properties of the bone.

We have confirmed impaired bone healing in a model of bone defects in rabbits with pulsed administration of corticosteroids. This finding may be important in the development of strategies for treatment to improve the prognosis of fracture healing or the repair of bone defects in patients receiving steroid treatment.

The pathophysiology of intervertebral disc degeneration has been extensively studied. Various factors have been suggested as influencing its aetiology, including mechanical factors, such as compressive loading, shear stress and vibration, as well as ageing, genetic, systemic and toxic factors, which can lead to degeneration of the disc through biochemical reactions. How are these factors linked? What is their individual importance? There is no clear evidence indicating whether ageing in the presence of repetitive injury or repetitive injury in the absence of ageing plays a greater role in the degenerative process. Mechanical factors can trigger biochemical reactions which, in turn, may promote the normal biological changes of ageing, which can also be accelerated by genetic factors. Degradation of the molecular structure of the disc during ageing renders it more susceptible to superimposed mechanical injuries.

This review supports the theory that degeneration of the disc has a complex multifactorial aetiology. Which factors initiate the events in the degenerative cascade is a question that remains unanswered, but most evidence points to an age-related process influenced primarily by mechanical and genetic factors.

In a longitudinal case-control study, we followed 81 subjects with dysplasia of the hip and 136 control subjects without dysplasia for ten years assessing radiological evidence of degeneration of the hip at admission and follow-up. There were no cases of subluxation in the group with dysplasia. Neither subjects with dysplasia nor controls had radiological signs of ongoing degenerative disease at admission. The primary radiological discriminator of degeneration of the hip was a change in the minimum joint space width over time. There were no significant differences between these with dysplasia and controls in regard to age, body mass index or occupational exposure to daily repeated lifting at admission.

We found no significant differences in the reduction of the joint space width at follow-up between subjects with dysplasia and the control subjects nor in self-reported pain in the hip. The association of subluxation and/or associated acetabular labral tears with dysplasia of the hip may be a conditional factor for the development of premature osteoarthritis in mildly to moderately dysplastic hips.

Using a modern cementing technique, we implanted 22 stereolithographic polymeric replicas of the Charnley-Kerboul stem in 11 pairs of human cadaver femora. On one side, the replicas were cemented line-to-line with the largest broach. On the other, one-size undersized replicas were used (radial difference, 0.89 mm sd 0.13).

CT analysis showed that the line-to-line stems without distal centralisers were at least as well aligned and centered as undersized stems with a centraliser, but were surrounded by less cement and presented more areas of thin (< 2 mm) or deficient (< 1 mm) cement. These areas were located predominantly at the corners and in the middle and distal thirds of the stem. Nevertheless, in line-to-line stems, penetration of cement into cancellous bone resulted in a mean thickness of cement of 3.1 mm (sd 0.6) and only 6.2% of deficient and 26.4% of thin cement. In over 90% of these areas, the cement was directly supported by cortical bone or cortical bone with less than 1 mm of cancellous bone interposed.

When Charnley-Kerboul stems are cemented line-to-line, good clinical results are observed because cement-deficient areas are limited and are frequently supported by cortical bone.

The June 2013 Knee Roundup³⁶⁰ looks at: iodine washout: chondrotoxic or antiseptic?; stem tip pain following revision knee replacements; metalwork removal prior to TKR; astroturf and ACL rupture; Robert Jones dressings; if thicker gloves safer; and the long leg radiograph: is it still the gold standard?

Correct positioning and alignment of components during primary total knee replacement (TKR) is widely accepted to be an important predictor of patient satisfaction and implant durability. This retrospective study reports the effect of the post-operative mechanical axis of the lower limb in the coronal plane on implant survival following primary TKR.

A total of 501 TKRs in 396 patients were divided into an aligned group with a neutral mechanical axis (± 3°) and a malaligned group where the mechanical axis deviated from neutral by > 3°. At 15 years’ follow-up, 33 of 458 (7.2%) TKRs were revised for aseptic loosening. Kaplan-Meier survival analysis showed a weak tendency towards improved survival with restoration of a neutral mechanical axis, but this did not reach statistical significance (p = 0.47).

We found that the relationship between survival of a primary TKR and mechanical axis alignment is weaker than that described in a number of previous reports.