1. The effect of immobilisation on bone formation has been investigated in the rat. As chlortetracycline has the property of being deposited preferentially in areas of newly deposited bone, its uptake can be used as a reflection of osseous formation. 2. One hind limb of albino rats was immobilised either by section of the second, third and fourth lumbar nerve trunks or by section of tendo calcaneus and ligamentum patellae. The incorporation of chlortetracycline was determined quantitatively in the femur and tibia of both hind limbs at intervals after immobilisation. 3. Tetracycline uptake is expressed in terms of bone weight, this being most important in order to obtain correct values. 4. A comparison between the tetracycline uptake and the weight of the bones gives information about the rate of bone destruction. 5. In animals immobilised by nerve section three phases can be distinguished: a first phase with diminished bone formation, a second with increased formation and increased destruction and a third phase with diminished bone formation. Both mechanisms, decreased formation and increased destruction, are therefore important in the production of immobilisation osteoporosis; their relative importance depending upon the duration of the immobilisation. 6. In animals immobilised by tendon section the mechanical function becomes restored in the second week as a result of healing: this explains the rapid compensation for the initial loss of weight of the bones accompanied by a marked increase in tetracycline uptake. 7. These results are discussed and compared with information in the literature. Variations in bone formation and destruction rates with time could explain the varied results reported by other authors.
The surgical treatment of tuberculosis (TB) of the spine consists
of debridement and reconstruction of the anterior column. Loss of
correction is the most significant challenge. Our aim was to report
the outcome of single-stage posterior surgery using bone allografts
in the management of this condition. The study involved 24 patients with thoracolumbar TB who underwent
single-stage posterior spinal surgery with a cortical bone allograft
for anterior column reconstruction and posterior instrumentation
between 2008 and 2015. A unilateral approach was used for 21 patients
with active TB, and a bilateral approach with decompression and closing-opening
wedge osteotomy was used for three patients with healed TB.Aims
Patients and Methods
Cancellous allograft bone chips are commonly
used in the reconstruction of defects in bone after removal of benign tumours.
We investigated the MRI features of grafted bone chips and their
change over time, and compared them with those with recurrent tumour.
We retrospectively reviewed 66 post-operative MRIs from 34 patients
who had undergone curettage and grafting with cancellous bone chips
to fill the defect after excision of a tumour. All grafts showed
consistent features at least six months after grafting: homogeneous
intermediate or low signal intensities with or without scattered
hyperintense foci (speckled hyperintensities) on T1 images; high
signal intensities with scattered hypointense foci (speckled hypointensities)
on T2 images, and peripheral rim enhancement with or without central
heterogeneous enhancements on enhanced images.
We describe a new technique of reconstruction of the deficient acetabulum in cementless total hip arthroplasty. The outer iliac table just above the deficient acetabulum is osteotomised and slid downwards. We have termed this an iliac sliding graft. Between October 1997 and November 2001, cementless total hip arthroplasty with an iliac sliding graft was performed on 19 patients (19 hips) with acetabular dysplasia. The mean follow-up was 3.4 years (2 to 6). The mean pre-operative Harris hip score was 45.1 which improved significantly to 85.3 at the time of the final follow-up. No patient had post-operative abductor dysfunction.
There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring. This study was a single-centre noninferiority randomized controlled trial. Infants aged under six months whose hips were reduced and centred in the harness at initiation of treatment (stable dysplastic or subluxable), or initially decentred (subluxated or dislocated) but reduced and centred within four weeks of PH treatment, were randomized to our current standard US monitoring protocol (every clinic visit) or to a limited-frequency US protocol (US only at end of treatment). Groups were compared based on α angle and femoral head coverage at the end of PH treatment, acetabular indices, and International Hip Dysplasia Institute (IHDI) grade on one-year follow-up radiographs.Aims
Methods
Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified.
Femoral impaction bone allografting has been developed as a means of restoring bone stock in revision total hip replacement. We report the results of 75 consecutive patients (75 hips) with a mean age of 68 years (35 to 87) who underwent impaction grafting using the Exeter collarless, polished, tapered femoral stem between 1992 and 1998. The mean follow-up period was 10.5 years (6.3 to 14.1). The median pre-operative bone defect score was 3 (interquartile range (IQR) 2 to 3) using the Endo-Klinik classification. The median subsidence at one year post-operatively was 2 mm (IQR 1 to 3). At the final review the median Harris hip score was 80.6 (IQR 67.6 to 88.9) and the median subsidence 2 mm (IQR 1 to 4).
Neglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or avascular necrosis (AVN). We treated 52 cases by open reduction, fixation by compression screw and a free fibular graft. The mean delay between injury and operation was 5.1 months. Of 40 fractures assessed at a mean of 58.8 months (24 to 153), 38 were found to be united and two, owing to surgical errors, were not. Seven of eight heads which were avascular before operation revascularised without collapse, while seven others developed AVN after the procedure. At the last follow-up considerable collapse was apparent in five femoral heads, and 11 hips had developed coxa vara. The fibular graft had fractured in four cases. The hip had been penetrated by the screw in six cases and by the graft in three. Hip function was excellent in seven patients, good in 21 and fair in seven. Five patients had poor results.
Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics. Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system.Aims
Methods
Interleukin (IL)-1β is one of the major pathogenic regulators during the pathological development of intervertebral disc degeneration (IDD). However, effective treatment options for IDD are limited. Suramin is used to treat African sleeping sickness. This study aimed to investigate the pharmacological effects of suramin on mitigating IDD and to characterize the underlying mechanism. Porcine nucleus pulposus (NP) cells were treated with vehicle, 10 ng/ml IL-1β, 10 μM suramin, or 10 μM suramin plus IL-1β. The expression levels of catabolic and anabolic proteins, proinflammatory cytokines, mitogen-activated protein kinase (MAPK), and nuclear factor (NF)-κB-related signalling molecules were assessed by Western blotting, quantitative real-time polymerase chain reaction (qRT-PCR), and immunofluorescence analysis. Flow cytometry was applied to detect apoptotic cells. The ex vivo effects of suramin were examined using IDD organ culture and differentiation was analyzed by Safranin O-Fast green and Alcian blue staining.Aims
Methods
This study aims to evaluate a new home medical stretching device called the Self Treatment Assisted Knee (STAK) tool to treat knee arthrofibrosis. 35 patients post-major knee surgery with arthrofibrosis and mean range of movement (ROM) of 68° were recruited. Both the STAK intervention and control group received standard physiotherapy for eight weeks, with the intervention group additionally using the STAK at home. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at all timepoints. An acceptability and home exercise questionnaire capturing adherence was recorded after each of the interventions.Aims
Methods
Bioresorbable orthopaedic devices with calcium phosphate (CaP) fillers are commercially available on the assumption that increased calcium (Ca) locally drives new bone formation, but the clinical benefits are unknown. Electron beam (EB) irradiation of polymer devices has been shown to enhance the release of Ca. The aims of this study were to: 1) establish the biological safety of EB surface-modified bioresorbable devices; 2) test the release kinetics of CaP from a polymer device; and 3) establish any subsequent beneficial effects on bone repair ActivaScrew Interference (Bioretec Ltd, Tampere, Finland) and poly(L-lactide-co-glycolide) (PLGA) orthopaedic screws containing 10 wt% β-tricalcium phosphate (β-TCP) underwent EB treatment. Objectives
Methods
Loosening is a well-known complication in the fixation of fractures using devices such as locking plates or unilateral fixators. It is believed that high strains in the bone at the bone-screw interface can initiate loosening, which can result in infection, and further loosening. Here, we present a new theory of loosening of implants. The time-dependent response of bone subjected to loads results in interfacial deformations in the bone which accumulate with cyclical loading and thus accentuates loosening. We used an ‘ideal’ bone-screw system, in which the screw is subjected to cyclical lateral loads and trabecular bone is modelled as non-linear viscoelastic and non-linear viscoelastic-viscoplastic material, based on recent experiments, which we conducted.Aims
Methods
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 study involved seven men and five women; their mean age was
35.9 years (14 to 70). All lesions included full-thickness articular
cartilage extending through subchondral bone and were associated
with subchondral cysts. Medial lesions were exposed through an oblique
medial malleolar osteotomy, and one lateral lesion was exposed by
expanding an anterolateral arthroscopic portal. After refreshing
the subchondral cyst, it was grafted with autologous cancellous
bone from the distal tibial metaphysis. The fragments of cartilage
were fixed with 5-0 nylon sutures to the surrounding cartilage.
Function was assessed at a mean follow-up of 25.3 months (15 to
50), using the American Orthopaedic Foot and Ankle Society (AOFAS)
ankle-hindfoot outcome score. The radiological outcome was assessed
using MRI and CT scans.Aims
Patients and Methods
The purpose of this retrospective study was to differentiate
between the MRI features of normal post-operative change and those
of residual or recurrent disease after intralesional treatment of
an atypical cartilage tumour (ACT)/grade I chondrosarcoma. We reviewed the case notes, radiology and histology of 75 patients,
who had been treated for an ACT/grade I chondrosarcoma by curettage,
phenolisation and bone allografting between 1994 and 2005. The first
post-operative Gd-enhanced MRI scan was carried out within one year
of surgery. Patients had a minimum of two scans and a mean follow-up
of 72 months (13 to 169). Further surgery was undertaken in cases
of suspected recurrence.Aims
Patients and Methods
Femoral impaction bone grafting was first developed in 1987 using
morselised cancellous bone graft impacted into the femoral canal
in combination with a cemented, tapered, polished stem. We describe
the evolution of this technique and instrumentation since that time. Between 1987 and 2005, 705 revision total hip arthroplasties
(56 bilateral) were performed with femoral impaction grafting using
a cemented femoral stem. All surviving patients were prospectively
followed for a mean of 14.7 years (9.8 to 28.3) with no loss to
follow-up. By the time of the final review, 404 patients had died.Aims
Patients and Methods
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.
We present the results of 62 consecutive acetabular
revisions using impaction bone grafting and a cemented polyethylene
acetabular component in 58 patients (13 men and 45 women) after
a mean follow-up of 27 years (25 to 30). All patients were prospectively
followed. The mean age at revision was 59.2 years (23 to 82). We performed Kaplan–Meier (KM) analysis and also a Competing
Risk (CR) analysis because with long-term follow-up, the presence
of a competing event (i.e. death) prevents the occurrence of the
endpoint of re-revision. A total of 48 patients (52 hips) had died or had been re-revised
at final review in March 2011. None of the deaths were related to
the surgery. The mean Harris hip score of the ten surviving hips
in ten patients was 76 points (45 to 99). The KM survivorship at 25 years for the endpoint ‘re-revision
for any reason’ was 58.0% (95% confidence interval (CI) 38 to 73)
and for ‘re-revision for aseptic loosening’ 72.1% (95% CI 51 to
85). With the CR analysis we calculated the KM analysis overestimates
the failure rate with respectively 74% and 93% for these endpoints.
The current study shows that acetabular impaction bone grafting
revisions provide good clinical results at over 25 years. Cite this article:
Bone allografts can be used in any kind of surgery involving bone from minor defects to major bone loss after tumour resection. This review describes the various types of bone grafts and the current knowledge on bone allografts, from procurement and preparation to implantation. The surgical conditions for optimising the incorporation of bone are outlined, and surgeon expectations from a bone allograft discussed.
We hypothesised that cells obtained via a Reamer–Irrigator–Aspirator
(RIA) system retain substantial osteogenic potential and are at
least equivalent to graft harvested from the iliac crest. Graft
was harvested using the RIA in 25 patients (mean age 37.6 years
(18 to 68)) and from the iliac crest in 21 patients (mean age 44.6
years (24 to 78)), after which ≥ 1 g of bony particulate graft material
was processed from each. Initial cell viability was assessed using Trypan
blue exclusion, and initial fluorescence-activated cell sorting
(FACS) analysis for cell lineage was performed. After culturing
the cells, repeat FACS analysis for cell lineage was performed and
enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin
red staining to determine osteogenic potential. Cells obtained via
RIA or from the iliac crest were viable and matured into mesenchymal
stem cells, as shown by staining for the specific mesenchymal antigens
CD90 and CD105. For samples from both RIA and the iliac crest there
was a statistically significant increase in bone production (both
p <
0.001), as demonstrated by osteocalcin production after induction. Medullary autograft cells harvested using RIA are viable and
osteogenic. Cell viability and osteogenic potential were similar
between bone grafts obtained from both the RIA system and the iliac
crest. Cite this article:
Structural allografts may be used to manage uncontained
bone defects in revision total knee replacement (TKR). However,
the availability of cadaver grafts is limited in some areas of Asia.
The aim of this study was to evaluate the mid-term outcome of the
use of femoral head allografts for the reconstruction of uncontained
defects in revision TKR, focusing on complications related to the
graft. We retrospectively reviewed 28 patients (30 TKRs) with Anderson
Orthopaedic Research Institute (AORI) type 3 bone defects, who underwent
revision using femoral head allografts and stemmed components. The
mean number of femoral heads used was 1.7 (1 to 3). The allograft–host
junctions were packed with cancellous autograft. At a mean follow-up of 76 months (38 to 136) the mean American
Knee Society knee score improved from 37.2 (17 to 60) pre-operatively
to 90 (83 to 100) (p <
0.001). The mean function score improved
from 26.5 (0 to 50) pre-operatively to 81 (60 to 100) (p <
0.001).
All the grafts healed to the host bone. The mean time to healing
of the graft was 6.6 months
(4 to 16). There have been no complications of collapse of the graft,
nonunion, infection or implant loosening. No revision surgery was
required. The use of femoral head allografts in conjunction with a stemmed
component and autogenous bone graft in revision TKR in patients
with uncontained bone defects resulted in a high rate of healing
of the graft with minimal complications and a satisfactory outcome.
Longer follow-up is needed to observe the evolution of the graft. Cite this article:
We report the results of 62 hips in 62 patients
(17 males, 45 females) with mean age of 62.4Â years (37 to 81), who underwent
revision of the acetabular component of a total hip replacement
due to aseptic loosening between May 2003 and November 2007. All
hips had a Paprosky type IIIa acetabular defect. Acetabular revision
was undertaken using a Procotyl E cementless oblong implant with
modular side plates and a hook combined with impaction allografting. At a mean follow-up of 60.5 months (36 to 94) with no patients
lost to follow-up and one died due to unrelated illness, the complication
rate was 38.7%. Complications included aseptic loosening (19 hips),
deep infection (3 hips), broken hook and side plate (one hip) and
a femoral nerve palsy (one hip). Further revision of the acetabular component
was required in 18 hips (29.0%) and a further four hips (6.4%) are
currently loose and awaiting revision. We observed unacceptably high rates of complication and failure
in our group of patients and cannot recommend this implant or technique.
Osteoporosis is common and the health and financial
cost of fragility fractures is considerable. The burden of cardiovascular
disease has been reduced dramatically by identifying and targeting
those most at risk. A similar approach is potentially possible in
the context of fragility fractures. The World Health Organization
created and endorsed the use of FRAX, a fracture risk assessment
tool, which uses selected risk factors to calculate a quantitative,
patient-specific, ten-year risk of sustaining a fragility fracture.
Treatment can thus be based on this as well as on measured bone
mineral density. It may also be used to determine at-risk individuals,
who should undergo bone densitometry. FRAX has been incorporated
into the national osteoporosis guidelines of countries in the Americas,
Europe, the Far East and Australasia. The United Kingdom National
Institute for Health and Clinical Excellence also advocates its
use in their guidance on the assessment of the risk of fragility
fracture, and it may become an important tool to combat the health
challenges posed by fragility fractures.
The clinical and radiological results of 50 consecutive acetabular reconstructions in 48 patients using impaction grafting have been retrospectively reviewed. A 1:1 mixture of frozen, ground irradiated bone graft and Apapore 60, a synthetic bone graft substitute, was used in all cases. There were 13 complex primary and 37 revision procedures with a mean follow-up of five years (3.4 to 7.6). The clinical survival rate was 100%, with improvements in the mean Harris Hip Scores for pain and function. Radiologically, 30 acetabular grafts showed evidence of incorporation, ten had radiolucent lines and two acetabular components migrated initially before stabilising. Acetabular reconstruction in both primary and revision surgery using a 1:1 mixture of frozen, ground, irriadiated bone and Apapore 60 appears to be a reliable method of managing acetabular defects. Longer follow-up will be required to establish whether this technique is as effective as using fresh-frozen allograft.
We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery.
We studied 11 patients (14 elbows) with gross rheumatoid deformity of the elbow, treated by total arthroplasty using the Kudo type-5 unlinked prosthesis, and who were evaluated between five and 11 years after operation. Massive bone defects were augmented by autogenous bone grafts. There were no major complications such as infection, subluxation or loosening. In most elbows relief from pain and stability were achieved. The results, according to the Mayo Elbow Performance Score, were excellent in eight, good in five and fair in one. In most elbows there was minimal or no resorption of the grafted bone. There were no radiolucent lines around the stems of the cementless components. This study shows that even highly unstable rheumatoid elbows can be replaced successfully using an unlinked prosthesis, with augmentation by grafting for major defects of bone.
Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of Orthopaedic Surgeons classification at a mean of 31.4 months (14 to 51) after surgery. At the latest follow-up, the mean Harris hip score was 69.9 points (13.5 to 97.1) in group A and 71.0 points (11.5 to 96.5) in group B. Each hip showed evidence of trabeculation and incorporation of the allograft with no acetabular loosening. These results suggest that the use of an acetabular reinforcement ring and a living composite of sterile allograft and autologous marrow appears to be a method of reconstructing acetabular deficiencies which gives comparable results to current forms of treatment.
We stably transfected early passage chondrocytes with an anti-apoptotic Bcl-2 gene We conclude that NO-induced chondrocyte death involves a mechanism which appears to be subject to regulation by an anti-apoptotic Bcl-2 gene. Therefore, Bcl-2 gene therapy may prove to be of therapeutic value in protecting human articular chondrocytes.
Bone allografts can store and release high levels of vancomycin. We present our results of a two-stage treatment for infected hip arthroplasty with acetabular and femoral impaction grafting using vancomycin-loaded allografts. We treated 29 patients (30 hips) by removal of the implants, meticulous debridement, parenteral antibiotic therapy and second-stage reconstruction using vancomycin-supplemented impacted bone allografts and a standard cemented Charnley femoral component. The mean follow-up was 32.4 months (24 to 60). Infection control was obtained in 29 cases (re-infection rate of 3.3%; 95% confidence interval 0.08 to 17) without evidence of progressive radiolucent lines, demarcation or graft resorption. One patient had a further infection ten months after revision caused by a different pathogen. Associated post-operative complications were one traumatic periprosthetic fracture at 14 months, a single dislocation in two hips and four displacements of the greater trochanter. Vancomycin-supplemented allografts restored bone stock and provided sound fixation with a low incidence of further infection.