Aims

The aim of this study was to evaluate antegrade autologous bone grafting with the preservation of articular cartilage in the treatment of symptomatic osteochondral lesions of the talus with subchondral cysts.

The size and shape of the patella make it suitable for the partial replacement of a femoral or tibial condyle resected for tumour, or destroyed by trauma. It can provide a good articular surface and may give satisfactory knee function. Nineteen cases of patellar grafts are presented, with follow-up from two to nine years. Good consolidation of the graft and fair stability of the joint were obtained; the range of movement was 90 degrees or more in 79% of cases. In contrast with an allograft of a femoral or tibial condyle, the technique described does not need an allograft bank, has a lower risk of infection, and allows better and quicker consolidation and revascularisation of the grafts, as well as a better range of movement at the knee, probably because of the lack of fibrosis from immunological reaction. Merle d'Aubigne's technique, using a patellar graft with a vascular muscle pedicle, is useful only for some cases, requires a longer period of immobilisation and weakens the extensor apparatus. Our series shows that consolidation and revascularisation of a patellar graft can occur in the absence of a pedicle

We review 210 Stanmore knee replacements in 163 patients to assess the survival of the prostheses and the long-term results. The annual rate of failure reached a maximum of 4.6% in the fourth year after operation; thereafter it declined to reach zero by the eighth year. Between two and eight years after operation, 66.3% of the surviving knees were completely free of pain and 30.2% had mild retropatellar pain. Fixed flexion deformities present before operation were completely corrected in 73% of the knees, and varus or valgus deformities were invariably corrected. Stability was always restored to unstable knees and 80.8% of knees flexed to 90 degrees or more after replacement. Aseptic loosening (8.1%), prosthetic infection (4.3%) and femoral fracture (2.9%) led to 8.5% of the prostheses being revised or removed over eight years. Modifications in prosthetic design and operative techniques have been introduced to minimise such complications in the future

We randomised 129 knees which were to be replaced using a standard posterior-cruciate-ligament (PCL)-retaining cemented total knee replacement into two groups. In one the PCL was retained in the normal way and in the other it was resected. They were well matched, with a predominance of women, and a mean age of 67 years. There was no statistically significant difference in the Hospital for Special Surgery scores at a mean of 57 months (56 to 60) between the two groups although 21 patients (24 knees) were lost to follow-up. Relief from pain, correction of deformity, range of movement, stability and strength were comparable in both. Radiological assessment showed femoral rollback in approximately 20% of knees with a slightly higher incidence in the PCL-resected group. There was no significant loosening detected in either group at review at two years. At five years, one knee in the PCL-retained group had been revised because of infection and one patient in each group was awaiting revision for loosening. Our findings have shown no significant difference in the five-year results for a PCL-retaining total knee replacement if the PCL is excised or preserved. This suggests two important points. First, the PCL is not functional in most patients with a total knee replacement even when retained. Secondly, patients with an excised PCL show a good result with a PCL-retaining implant, thereby questioning the need for a posterior stabilised design in such a situation

The results in 102 acetabuloplasties have been assessed in eighty-six patients, with a minimum follow-up of five years. Clinical and radiological assessment was carried out according to a score system very similar to that used in previous studies, and the results were expressed as excellent, good, fair and poor according to the score obtained. Any hip requiring further stabifising procedures was automatically grouped as a failure. Subtrochanteric femoral osteotomy was used when femoral anteversion was excessive. The results revealed that 73 per cent of the hips were satisfactory (excellent or good) overall, but that a steady deterioration was evident when the five-and fifteen-year groups were compared. Few of the hips were regarded as normal on radiological grounds. Homologous bone bank rib was found to be the most satisfactory graft material. Coxa magna was the most common abnormality that was consistent with a good or excellent result. Avascular necrosis of the femoral head was found in only six hips; it was more commonly present in patients subjected to previous operation. Concentric reduction of the femoral head is essential if acetabuloplasty is to maintain stability of the hip

Nine patients underwent arthrodesis of the knee using a customised coupled nail (the Mayday arthrodesis nail), five after infected arthroplasty, one following failed arthrodesis, one for intractable anterior knee pain, one for Charcot instability and one after trauma. Comparison was made with 17 arthrodeses, eight undertaken using external fixation, four with dual compression plates, and five with long Küntscher nails. Union was achieved in all patients (100%) at a mean time of ten months using the customised implant. There were no complications despite early weight-bearing. No further procedures were required. This contrasted with a rate of union of 53% and a complication rate of 76% with alternative techniques. Of this second group, 76% required a further operative procedure. We compared the Mayday arthrodesis nail with other techniques of arthrodesis of the knee. The differences in the need for further surgery and occurrence of complications were statistically significant (p < 0.001), and differences in the rate of nonunion and inpatient stay of less than three weeks were also significant (p < 0.05) using Fisher’s exact test. We conclude that a customised coupled intramedullary nail can give excellent stability allowing early weight-bearing, and results in a high rate of union with minimal postoperative complications

Intramedullary nailing of metaphyseal fractures may be associated with deformity as a result of instability after fixation. Our aim was to evaluate the clinical use of Poller screws (blocking screws) as a supplement to stability after fixation with statically locked intramedullary nails of small diameter. We studied, prospectively, 21 tibial fractures, 10 in the proximal third and 11 in the distal third in 20 patients after the insertion of Poller screws over a mean period of 18.5 months (12 to 29). All fractures had united. Healing was evident radiologically at a mean of 5.4 ± 2.1 months (3 to 12) with a mean varus-valgus alignment of −1.0° (−5 to 3) and mean antecurvatum-recurvatum alignment of 1.6° (−6 to 11). The mean loss of reduction between placement of the initial Poller screw and follow-up was 0.5° in the frontal plane and 0.4° in the sagittal plane. There were no complications related to the Poller screw. The clinical outcome, according to the Karström-Olerud score, was not influenced by previous or concomitant injuries in 18 patients and was judged as excellent in three (17%), good in seven (39%), satisfactory in six (33%), fair in one (6%), and poor in one (6%)

A clay containing hydroxyapatite (HA) was developed for use as a filling material between an uncemented implant and bone. It consists of 55% HA granules greater than 0.1 mm in size with a homogeneous pore distribution and a porosity of 35% to 48% in a saline solution of sodium alginate (6%). Ti-6A1-4V alloy rods with smooth surfaces were implanted into the distal medullary canal of one osteotomised tibia of 32 Japanese white rabbits. Sixteen rods were inserted with HA clay and 16 without the clay to act as a control group. Six of each group were killed at one week and ten at 12 weeks postoperatively. The pull-out strength of the implants with HA clay was significantly greater at 12 weeks (p < 0.05), as was the percentage of the area of the new bone (p < 0.05). The study suggests that HA clay has an osteoconductive property, allowing adequate bone fixation across a gap at an early stage. The use of HA clay to enhance the early stability of uncemented components may help to improve the functional outcome of total joint arthroplasty

The stabilising effects on the glenohumeral joint of each of the rotator-cuff muscles and of the biceps were studied with the arm in abduction and external rotation in 13 cadaver shoulders. The muscles were loaded one at a time with forces proportional to their cross-sectional areas. We recorded the positions of the humeral head before and after the application to the humerus of an anterior force of 1.5 kg. When the capsule was intact, the anterior displacement with the subscapularis loaded was significantly larger than with the other muscles loaded (p = 0.0009). With the capsule vented, the displacement with the biceps loaded was significantly smaller than that with the subscapularis loaded (p = 0.0052). After creating an imitation Bankart lesion, the displacement with the biceps loaded was significantly less than with any of the rotator-cuff muscles loaded (p = 0.0132). We conclude that in the intact shoulder, the subscapularis is the least important anterior stabiliser, and that the biceps becomes more important than the rotator-cuff muscles as stability from the capsuloligamentous structure decreases. Strengthening of the biceps as well as the rotator-cuff muscles should be part of the rehabilitation programme for anterior shoulder instability

We reviewed 249 consecutive Charnley primary low-friction arthroplasties in 191 patients performed by one surgeon using a transtrochanteric approach at a minimum follow-up of ten years. Of these, 37 hips in 32 patients showed osteolysis and were compared with 41 hips in 37 matched patients with no osteolysis. We assessed in each case the wear rate, stability of the prosthesis, acetabular angle, socket angle, thickness of the acetabular and femoral cement mantle, canal flare index, femoral score, stem alignment, implant:canal ratio and stem:canal ratio. We found that a high rate of wear, component instability and osteolysis were associated. Osteolysis was three times more common in men than in women. Factors which reduced osteolysis were cement mantles of 6 mm at the acetabulum and of 3 mm in all zones of the femur, a stem:canal ratio of 60% to 70% and an implant:canal ratio of over 99%. The overall incidence of osteolysis was 14.9% but when these technical criteria were met, the incidence was 5.2%. This suggests that careful technique can dramatically reduce the risk of this complication

We treated 90 patients with an isolated injury to the anterior cruciate ligament (ACL) by reconstruction using a patellar tendon autograft and interference screw fixation. Of these, 82 (91%) were available for review at 24 months. Two grafts and two contralateral ACLs had ruptured during sport and there was one case of atraumatic graft resorption. Using the assessment of the International Knee Documentation Committee (IKDC), 86% of the remaining patients were normal or nearly normal. The median Lysholm knee score was 95/100 and 84% of patients were participating in moderate to strenuous activity. All had grade-0 or grade-1 Lachman, pivot-shift and anterior-drawer tests. Measurement with the KT1000 arthrometer gave a side-to-side difference of < 3 mm of anterior tibial displacement in 90%. Sixty-six radiographs were IKDC grade A and one was grade B. Pain on kneeling was present in 31% and graft site pain in 44%. At 24 months after operation all patients had excellent knee stability, a high rate of return to sport and minimal radiological evidence of degenerative change. Our series therefore represents a basis for comparison of results using other techniques and after more severe injuries

This systematic review examines the current literature regarding surgical techniques for restoring articular cartilage in the hip, from the older microfracture techniques involving perforation to the subchondral bone, to adaptations of this technique using nanofractures and scaffolds. This review discusses the autologous and allograft transfer systems and the autologous matrix-induced chondrogenesis (AMIC) technique, as well as a summary of the previously discussed techniques, which could become common practice for restoring articular cartilage, thus reducing the need for total hip arthroplasty. Using the British Medical Journal Grading of Recommendations, Assessment, Development and Evaluation (BMJ GRADE) system and Grade system. Comparison of the studies discussed shows that microfracture has the greatest quantity and quality of research, whereas the newer AMIC technique requires more research, but shows promise.

Cite this article: W. E. Hotham, A. Malviya. A systematic review of surgical methods to restore articular cartilage in the hip. Bone Joint Res 2018;7:336–342. DOI: 10.1302/2046-3758.75.BJR-2017-0331.

We have reviewed 29 patients (30 hips) who had undergone revision total hip arthroplasty using a Freeman metal-backed acetabular component and acetabular impaction allografting. The mean follow-up was for 15.3 years (12 to 17). Five patients (5 hips) died with the prosthesis in situ and four (4 hips) were lost to follow-up. Twelve hips had failed and in the remaining nine there were minor symptoms. The mean time to failure requiring further surgery was nine years. Excluding patients who were lost to follow-up or had died, 72% of the hips were radiologically loose at the last review. The commonest pattern in those requiring revision was failure of the reinforcement ring in adduction with remodelling of the medial wall. Of the nine patients who had not undergone revision, one with bilateral replacements had no current radiographs and only three of the remaining seven replacements had no radiological signs of loosening. The short-term results for this technique have been reported to be satisfactory, but in the long term they are not. The factors associated with failure include the design of the prosthesis, which has been implicated in disappointing long-term results when used in primary arthroplasty, but not with the frequency of failure found in this series. It seems that the reliance on peripheral screw fixation over a bed of allograft without bridging the graft does not provide sufficient stability to allow incorporation of the graft

1. The results of three forms of treatment (mobilisation, immobilisation for six weeks, and suture with immobilisation for six weeks) for ruptures of the lateral ligament of the ankle have been compared in previously uninjured asymptomatic patients. 2. Only suture and immobilisation ensured final mechanical stability of the ankle as assessed by stress radiography. Unstable ankles were found after both mobilisation and immobilisation, but in these groups no ankle finally displayed more than 8 degrees of relative talar tilt. 3. The mean duration of disability in patients who finally became symptom-free was: after mobilisation, twelve weeks; after immobilisation, twenty-two weeks; and after suture and immobilisation, twenty-six weeks. 4. One year after injury 58 per cent of patients treated by mobilisation, 53 per cent of patients treated by immobilisation, but only 25 per cent of patients treated by suture and immobilisation, had become perfectly symptom-free. 5. For these reasons, and because simple sprains are satisfactorily treated by mobilisation, it is suggested that mobilisation may be the treatment of choice for most, perhaps all, ruptures of the lateral ligament of the ankle

Arthroplasty, with normal or nearly normal reposition, is possible in most old congenital dislocations of the hip in young adults. Reposition is possible even in very high dislocation, but it is difficult or impossible in aged patients and when arthritic changes have taken place. The reduction equalises the length of the extremities in unilateral cases, but makes operation on both sides necessary in bilateral cases. Post-operative complications may be largely avoided by a good technique and careful post-operative treatment. Stability is good, and consequently the limp is generally reduced. Mobility is as a rule sufficient, though often less than before operation when the hip was normally or excessively mobile. Pain is very often relieved or greatly reduced, but walking is generally limited. Even if the radiographic appearance of the hip is almost normal, the functional result may be imperfect. This assessment is probably pessimistic, for two reasons: first, patients operated on are still improving; second, the improved technique of the later operations should give better results. Nevertheless, arthroplasty with reduction should be proposed to patients only suffering severe functional disability

1. Trochanteric fractures are classified, with special emphasis on the stability or instability of the fracture. The importance of the cortical buttress of bone on the inner side of the femoral neck and shaft is stressed. 2. Three series of cases are presented: a) one hundred and one cases treated conservatively in hospital; b) twenty-five cases sent home by reason of lack of hospital beds; c) twenty-two cases treated by fixation with a Capener-Neufeld nail-plate. 3. From consideration of these three series, and from study of similar series of cases reported in the literature, it is suggested that routine operative treatment of trochanteric fractures has the advantages of greater comfort and mobility of the patient, lowered mortality, and economy of hospital beds. 4. Certain features of the operation of internal fixation by the Capener-Neufeld nail-plate are discussed. A director, for more efficient insertion of the nail-plate, is described. 5. The importance of early mobility after operation is emphasized. Only a small proportion of Patients can be allowed early weight-bearing but almost all can be got up in a chair, and most can be taught to get about with crutches, without weight-bearing on the fractured limb, within a few days of operation

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically. The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001). The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux

Aims

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.

Aims

The outcome of total knee arthroplasty (TKA) is not always satisfactory. The purpose of this study was to identify satisfaction and biomechanical features characterising the gait of patients who had undergone TKA with either an anatomical single radius design or a medial pivot design. We hypothesised that the latter would provide superior function.