We present a retrospective study of 27 patients treated by callus distraction using a unilateral external fixator of our own design for nonunion with bone loss and shortening of the femur caused by suppurative osteomyelitis. The unilateral external fixator was used either alone or in combination with an intramedullary nail. The mean age of the patients was 13.6 years (8 to 18). The fixator was used alone in 13 patients and with an intramedullary nail in 14. The bone results at a mean follow-up of 88 months (37 to 144) were excellent in 16 patients and good in 11.

The functional results were excellent in 18 patients and good in nine. However, four patients still had draining sinuses at the latest follow-up. A residual deformity greater than 7° was present in seven femora, but this did not adversely affect function or require further treatment.

We reviewed the results of 71 revisions of the acetabular component in total hip replacement, using impaction of bone allograft. The mean follow-up was 7.2 years (1.6 to 9.7). All patients were assessed according to the American Academy of Orthopedic Surgeons (AAOS) classification of bone loss, the amount of bone graft required, thickness of the graft layer, signs of graft incorporation and use of augmentation. A total of 20 acetabular components required re-revision for aseptic loosening, giving an overall survival of 72% (95% CI, 54.4 to 80.5). Of these failures, 14 (70%) had an AAOS type III or IV bone defect. In the failed group, poor radiological and histological graft incorporation was seen. These results suggest that impaction allografting in acetabular revision with severe bone defects may have poorer results than have previously been reported

An experimental sheep model was used for impaction allografting of 12 hemiarthroplasty femoral components placed into two equal-sized groups. In group 1, a 50:50 mixture of ApaPore hydroxyapatite bone-graft substitute and allograft was used. In group 2, ApaPore and allograft were mixed in a 90:10 ratio. Both groups were killed at six months. Ground reaction force results demonstrated no significant differences (p > 0.05) between the two groups at 8, 16 and 24 weeks post-operatively, and all animals remained active. The mean bone turnover rates were significantly greater in group 1, at 0.00206 mm/day, compared to group 2 at 0.0013 mm/day (p < 0.05). The results for the area of new bone formation demonstrated no significant differences (p > 0.05) between the two groups. No significant differences were found between the two groups in thickness of the cement mantle (p > 0.05) and percentage ApaPore-bone contact (p > 0.05).

The results of this animal study demonstrated that a mixture of ApaPore allograft in a 90:10 ratio was comparable to using a 50:50 mixture.

Despite advances in the prevention and treatment of osteoporotic fractures, their prevalence continues to increase. Their operative treatment remains a challenge for the surgeon, often with unpredictable outcomes. This review highlights the current aspects of management of these fractures and focuses on advances in implant design and surgical technique.

During revision total hip replacement using morcellised compacted bone allograft, 16 patients were randomised to receive a graft which had been rinsed in either an ibandronate solution or in saline. Patients were assessed by dual energy x-ray absorptiometry after operation and at 3, 6, 12 and 24 months. A region of interest between the tip of the femoral stem and the distal plastic plug was chosen to measure the changes in bone density over time. The study was double-blinded. In all the control patients the bone density decreased during the first three months and then remained constant at this lower level. A large proportion of the mass of the bone graft was lost. In contrast, all patients with grafts treated with bisphosphonate showed a slight increase in bone density. The difference between the groups was highly significant at all points in time. We conclude that rinsing the graft in a bisphosphonate solution prevents its resorption and may therefore reduce the risk of mechanical failure. The treatment is simple, inexpensive, and appears virtually free of risk

We assessed the outcome of patients with Vancouver type B2 and B3 periprosthetic fractures treated with femoral revision using an uncemented extensively porous-coated implant. A retrospective clinical and radiographic assessment of 22 patients with a mean follow-up of 33.7 months was performed. The mean time from the index procedure to fracture was 10.8 years. There were 17 patients with a satisfactory result. Complications in four patients included subsidence in two, deep sepsis in one, and delayed union in one. Concomitant acetabular revision was required in 19 patients. Uncemented extensively porous-coated femoral stems incorporate distally allowing stable fixation. We found good early survival rates and a low incidence of nonunion using this implant.

This study investigates the use of porous biphasic ceramics as graft extenders in impaction grafting of the femur during revision hip surgery.

Impaction grafting of the femur was performed in four groups of sheep. Group one received pure allograft, group two 50% allograft and 50% BoneSave, group three 50% allograft and 50% BoneSave type 2 and group four 10% allograft and 90% BoneSave as the graft material. Function was assessed using an index of pre- and post-operative peak vertical ground reaction force ratios. Changes in bone mineral density were measured by dual energy X ray absorptiometry (DEXA) scanning. Loosening and subsidence were assessed radiographically and by histological examination of the explanted specimens.

There was no statistically significant difference between the four groups after 18 months of unrestricted functional loading for all outcome measures.

We reviewed 29 patients who had undergone intercalary resection for malignant tumours. Of these, 14 had received segmental allograft reconstruction and 15 extracorporeally-irradiated autograft.

At a mean follow-up of 71 months (24 to 132), 20 were free from disease, five had died and four were alive with pulmonary metastases. Two patients, one with an allograft and one with an irradiated autograft, had a local recurrence. Reconstruction with extracorporeally-irradiated autograft has a significantly lower rate of nonunion (7% vs 43%, p = 0.031) but an insignificantly higher rate of fracture (20% vs 14%, p = 0.535) than that with segmental allograft. Using the Enneking functional evaluation system, the mean postoperative score for the patients without local recurrence was 87% (80% to 96%) and was similar in both groups.

Extracorporeally-irradiated autograft could be an acceptable alternative for reconstruction after intercalary resection, especially in countries where it is difficult to obtain allografts.

Impacted morsellised allografts have been used successfully to address the problem of poor bone stock in revision surgery. However, there are concerns about the transmission of pathogens, the high cost and the shortage of supply of donor bone. Bone-graft extenders, such as tricalcium phosphate (TCP) and hydroxyapatite (HA), have been developed to minimise the use of donor bone. In a human cadaver model we have evaluated the surgical and mechanical feasibility of a TCP/HA bone-graft extender during impaction grafting revision surgery.

A TCP/HA allograft mix increased the risk of producing a fissure in the femur during the impaction procedure, but provided a higher initial mechanical stability when compared with bone graft alone. The implications of the use of this type of graft extender in impaction grafting revision surgery are discussed.

Our aim was to determine if the height of the cup, lateralisation or the abduction angle correlated with functional outcome or survivorship in revision total hip replacement in patients with a previous diagnosis of developmental dysplasia of the hip. A retrospective investigation of 51 patients (63 hips) who had undergone revision total hip replacement was performed. The mean duration of follow-up was 119 months. Forty-one patients (52 hips) were available for both determination of functional outcome and survivorship analysis. Ten patients (11 hips) were only available for survivorship analysis.

The height of the cup was found to have a statistically significant correlation with functional outcome and a high hip centre correlated with a worse outcome score. Patients with a hip centre of less than 3.5 cm above the anatomical level had a statistically better survivorship of the cup than those with centres higher than this. Restoration of the height of the centre of the hip to as near the anatomical position as possible improved functional outcome and survivorship of the cup.

This retrospective study describes the long-term results of core decompression and placement of a non-vascularised bone graft in the management of avascular necrosis of the femoral head. We treated 80 hips in 65 patients, 18 by a cortical tibial autograft and 62 by a fibular allograft. The mean age of the patients was 36 years (sd 13.2). A total of 78 hips were available for evaluation of which pre-operatively six were Ficat-Arlet stage 0, three stage I, 31 stage IIA, 16 stage IIB, 13 stage III and nine stage IV.

A total of 34 hips (44%) were revised at a mean of four years (sd 3.8). Survivorship analysis using a clinical end-point showed a survival rate of 59% five years after surgery. We found a significant difference (p = 0.002) in survivorship, when using a clinical and radiological end-point, between the two grafts, in favour of the tibial autograft. We considered this difference to be the result of the better quality and increased volume of tibial bone compared with that from the trochanteric region used with the fibular allograft.

This is a relatively simple, extra-articular and reproducible procedure. In our view core decompression, removal of the necrotic tissue and packing of the cancellous grafts into the core track are vital parts of the procedure.

Iontophoresis is a novel technique which may be used to facilitate the movement of antibiotics into the substance of bone using an electrical potential applied externally. We have examined the rate of early infection in allografts following application of this technique in clinical practice. A total of 31 patients undergoing revision arthroplasty or surgery for limb salvage received 34 iontophoresed sequential allografts, of which 26 survived for a minimum of two years. The mean serum antibiotic levels after operation were low (gentamicin 0.37 mg/l (0.2 to 0.5); flucloxacillin 1 mg/l (0 to 1) and the levels in the drains were high (gentamicin 40 mg/l (2.5 to 131); flucloxacillin 17 mg/l (1 to 43). There were no early deep infections. Two late infections were presumed to be haemotogenous; 28 of the 34 allografts were retained. In 12 patients with pre-existing proven infection further infection has not occurred at a mean follow-up of 51 months (24 to 82).