Results of the cemented Exeter femoral component in patients under the age of 40 : an update at ten to 20 years' follow-up.

AIMS: We carried out a further study of the long-term results of the cemented Exeter femoral component in patients under the age of 40 with a mean follow-up of 13.6 years (10 to 20). PATIENTS AND METHODS: We reviewed our original cohort of 104 cemented Exeter stems in 78 consecutive patients with a mean age of 31 years (16 to 39). Only one patient was lost to radiological follow-up. RESULTS: A total of six patients (eight hips) had died for reasons unrelated to their surgery. There had been one further periprosthetic fracture from a fall and one fractured femoral stem. No revisions for aseptic loosening were undertaken during the whole study period. Overall, 11 hips had progressive radiolucent lines in one or more zones. The Kaplan Meier survival percentages at ten and 17 years were 97.1% (95% confidence interval (CI) 91.3 to 99.1) and 92.1% (95% CI 74.1 to 97.8) with revision for any reason as the endpoint, and 100% at both ten and 17 years with aseptic loosening (95% CI 83.8 to 100) as the endpoint. No additional hips were classified as radiologically loose. CONCLUSION: The Exeter femoral component continues to function satisfactorily in young patients for up to 17 years after surgery. Cite this article: Bone Joint J 2017;99-B:192-8.

Aneurysmal bone cyst: the role of cryosurgery as local adjuvant treatment.

BACKGROUND: Aneurysmal bone cysts (ABCs) are most often treated with intralesional surgery (curettage) and additional bone grafting. There is debate on whether or not to use adjuvant therapy to decrease the local recurrence rate. This study is done to assess the outcome of curettage and cryosurgery as a treatment of ABC. METHODS: We analyzed 80 consecutive cases of ABC treated with curettage and cryosurgery. Patients were followed minimal 24 months after surgery (average 55 months, range 24-122 months) with physical examination and radiographs. Functional outcome was evaluated using the musculoskeletal tumor society score (MSTS). RESULTS: The 80 patients were all treated with curettage and cryosurgery. Additional bone grafting was used in 73 patients, osteosynthesis in 12 and spondylodesis in 1 patient. Four local recurrences were found in this study, a recurrence rate of 5%. All local recurrences were treated successfully with curettage and cryosurgery again 7-33 months after the initial surgery. Postoperative one fracture, one wound infection, and three transient nerve palsy occurred. The average MSTS score was 29.2 at follow-up. CONCLUSIONS: The use of cryosurgery as adjuvant therapy results in a lower local recurrence rate when compared to other publications for the treatment of ABC and excellent functional results.

Acetabular revision with impacted morsellised cancellous bone grafting and a cemented acetabular component: a 20- to 25-year follow-up.

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.

Survival of massive allografts in segmental oncological bone defect reconstructions.

Reconstructions of large segmental bone defects after resection of bone tumours with massive structural allografts have a high number of reported complications including fracture, infection and non-union. Our goal is to report the survival and complications of massive allografts in our patients. A total of 32 patients were evaluated for fracture, infection, non-union rate and survival of their massive allograft reconstructions. The average follow-up for this group was five years and three months. The total fracture rate was 13% with a total infection rate of 16%. We found a low union rate of 25%. The total survival of the allografts was 80.8% (+/- 18.7%) after five years. We found a five-year allograft survival of 80.8% which is comparable with other studies.

The medium-term results of the cemented Exeter femoral component in patients under 40 years of age.

We evaluated the outcome of 104 consecutive primary cemented Exeter femoral components in 78 patients (34 men, 44 women) under the age of 40 years who underwent total hip replacement between October 1993 and May 2004. The mean age at operation was 31 years (16 to 39). No hip was lost to follow-up, but three patients (four hips) died. None of the deaths were related to the surgery. At a mean follow-up of 6.2 years (2 to 13), three femoral components had been revised for septic loosening. Using Kaplan-Meier survival analysis, the seven-year survival of the component with revision for any reason as the endpoint was 95.8% (95% confidence interval 86.67 to 98.7). The seven-year survival with aseptic femoral loosening as the endpoint was 100% (95% confidence interval 100). The cemented Exeter femoral component in patients under the age of 40 shows promising medium-term results. As it is available in a wide range of sizes and offsets, we could address all types of anatomical variation in this series without the need for custom-made components.

Oncological and functional results of cryosurgical therapy of enchondromas and chondrosarcomas grade 1.

BACKGROUND AND OBJECTIVES: Cryosurgery using liquid nitrogen is used as adjuvant treatment after intralesional resection of bone tumours to induce cell death. It is applied to enlarge the oncological margins of resection and to reduce the local recurrence rate. The objective of this study is to analyze the oncological and functional results. METHODS: We studied the oncological and functional results of curettage and cryosurgery in 123 patients with 130 tumors. There were 75 enchondromas and 55 chondrosarcomas grade 1. The minimal follow-up period for all patients was 2 years (range 24-119 months). RESULTS: During follow-up one local recurrence of an active enchondroma and one local recurrence of an aggressive enchondroma occurred. They were treated with curettage and cryosurgery again. Both patients were disease-free at minimum of 3 years follow-up. No local recurrences after treatment of chondrosarcoma grade 1 were seen. Functional scores, according to the MSTS scoring system, showed an average score of 28 points (94%) at 2 years follow-up. Post-operative fractures were seen in 18 patients (14%). CONCLUSIONS: Curettage and cryosurgery for enchondroma and chondrosarcoma grade 1 has excellent oncological and functional results. The post-operative management has been adjusted to reduce the number of fractures.

[Choice of hip prosthesis in patients younger than 50 years]. / Keuze van heupprothese voor patiënten jonger dan 50 jaar.

There is no agreement about the most ideal type of hip prosthesis to be used in patients younger than 50 years. The most commonly used hip prostheses in patients younger than 50 years are uncemented or resurfacing prostheses and to a lesser extent cemented prostheses. A good result of a hip prosthesis can be defined as follows: 10 years after surgery more than 90% of the prostheses should be still in situ during endpoint revision for any reason. No trials are available comparing cemented, uncemented or resurfacing hip prostheses. Studies are available of cemented hip prostheses in patients younger than 50 years that prove that more than 90% of the hips are still in situ after 50 years. There are no studies available of uncemented or resurfacing hip prostheses in younger patients that prove that after to years of follow-up 90% or more of the prostheses are still in situ. The Scandinavian hip registers show that the highest rate of prostheses still in situ after 10 years is achieved by cemented hip prostheses.

[Favourable long-term results from cemented total hip arthroplasty combined with acetabular bone impaction grafting in patients under the age of 50]. / Goede langetermijnresultaten van een gecementeerde totaleheupprothese in combinatie met een acetabulumreconstructie met geïmpacteerde botsnippers bij patiënten jonger dan 50 jaar.

OBJECTIVE: Determination of long-term results of hip replacements in patients who, at the time of operation, were under the age of 50. Procedures whereby an existing acetabulum defect was filled with bone chips that were impacted into a strong layer, after which a cemented total hip prosthesis was implanted. DESIGN: Descriptive. METHOD: Prospectively collected data from patients who were under the age of 50, and had undergone a hip replacement operation at our hospital between 1 July 1979 and 31 December 1987 were analysed. Data were collected up to 31 December 2002. The main outcome was time to revision. Survival was calculated by the Kaplan-Meier method. RESULTS: The study group consisted of 25 patients, 17 women and 8 men with 29 prosthetic hips. The average age at operation was 37.6 years (range: 20-49). Follow-up time was 15-23 years (median: 18.7 years). 1 patient (1 hip) was lost to follow-up. 3 patients (4 hips) died within 15 years after the operation; none of them had undergone revision. 4 revisions had been performed: I septic loosening (14 years p.o.) and 3 aseptic loosenings (6, 15, 20 years p.o.). The cumulative survival with the end-point 'revision for any reason' was 96% (95% CI: 88-100) at to years and 88% (95% CI: 74-100) at 20 years; after exclusion of the septic loosening the survival at 20 years was 92% (95% CI: 80-100). CONCLUSION: Hip replacement including a reconstruction technique for an acetabulum defect in patients under the age of 50 was regarded as successful if after 10 years, at least 90% of the prostheses were still in situ.

Altered phase-transitions in tibialis anterior and medial gastrocnemius during walking after limbsaving surgery.

OBJECTIVE: In normal gait onset activity in tibialis anterior at end stance is closely linked to reduction in activity in medial gastrocnemius. Is a similar transition also present in patients undergoing limb-saving surgery? METHODS: Nineteen subjects after limb-saving surgery of the lower extremity and ten age-matched controls were compared. Patients walked on a treadmill at their preferred speed. Bipolar surface EMG activity was recorded from the tibialis anterior and the medial gastrocnemius. RESULTS: Patients showed asymmetry in gait. In controls a close tibialis anterior and medial gastrocnemius connection was seen. The close link between ipsilateral tibialis anterior and medial gastrocnemius was absent in patients. Instead, a link was found between tibialis anterior onset in the affected and medial gastrocnemius onset in the non-affected leg. CONCLUSIONS: This finding suggests that two control mechanisms can be seen: a contralateral connection between tibialis and gastrocnemius and a less important ipsilateral connection. This means that automated phase switching in patients does not rely primarily on ipsilateral mechanisms but that instead the onset of the ipsilateral swing is linked to the moment of load acceptance by the contralateral leg These results are strikingly similar to those obtained in simulated limping by normal subjects. SIGNIFICANCE: Patients after limbsaving surgery have a clinically significant problem that creates aberrant gait patterns. This study provides new information about linking of ankle dorsiflexors and plantarflexors, as well as reporting the uncoupling of this mechanism in these patients after major surgery.

Displacement of the medial meniscus within the passive motion characteristics of the human knee joint: an RSA study in human cadaver knees.

The objective of this study was to validate an in vitro human cadaver knee-joint model for the evaluation of the meniscal movement during knee-joint flexion. The question was whether our model showed comparable meniscal displacements to those found in earlier meniscal movement studies in vivo. Furthermore, we determined the influence of tibial torque on the meniscal displacement during knee-joint flexion. Three tantalum beads were inserted in the medial meniscus of six human-cadaver joints. The knee joints were placed and loaded in a loading apparatus, and the movements of the beads were determined by means of RSA during knee-joint flexion and extension with and without internal tibial (IT) and external tibial (ET) torque. During flexion without tibial torque, all menisci moved in posterior and lateral direction. The anterior horn showed significantly greater excursions than the posterior horn in both posterior and lateral direction. Internal tibial torque caused an anterior displacement of the pathway on the tibial plateau. External tibial torque caused a posterior displacement of the pathway. External tibial torque restricted the meniscal displacement during the first 30 degrees of knee-joint flexion. The displacements of the meniscus in this experiment were similar to the displacements described in the in vivo MRI studies. Furthermore, the application of tibial torque confirmed the relative immobility of the posterior horn of the meniscus. During external tibial torque, the posterior displacement of the pathway on the tibial plateau during the first 30 degrees of flexion might be restricted by the attached knee-joint capsule or the femoral condyle. This model revealed representative meniscal displacements during simple knee-joint flexion and also during the outer limits of passive knee-joint motion.

Chemotherapy affects the pattern of failure after shear loading of the proximal tibial growth plate.

INTRODUCTION: Tibial bones are shorter and less resistant to shear forces after treatment with doxorubicin, methotrexate, or cisplatin. We investigated the pattern of failure after shear loading of the proximal tibial growth plate in rats treated with these chemotherapeutic agents. MATERIALS AND METHODS: Male Wistar rats from the age of 4 weeks were given doxorubicin intravenously at 15 mg/m2 body surface area (BSA), methotrexate 60 mg/m2 BSA, or cisplatin 7.5 mg/m2 BSA. There was one nontreated control group fed ad libitum an d a diet control group for each drug-treated group. At the age of 13 weeks the tibial bones were dissected. The proximal growth plate was shear loaded to failure in the posteroanterior direction. The pattern of failure through the growth plate was examined. RESULTS: In rats fed ad libitum the failure pattern ran mainly through the transitional zone between proliferating and hypertrophic chondrocytes, but the pattern of failure showed considerable variability. The pattern in rats treated with methotrexate or cisplatin and that in their diet controls were comparable. In rats treated with doxorubicin the fracture ran mainly through the trabecular zone. CONCLUSIONS: Doxorubicin affects the pattern of failure after shear loading of the proximal tibial growth plate, but methotrexate and cisplatin do not. Special attention should be paid to epiphyseal injuries in children treated with doxorubicin.

Acetabular revision with impacted morsellised cancellous bone grafting and a cemented cup. A 15- to 20-year follow-up.

This study presents the clinical and radiological results of 62 consecutive acetabular revisions in 58 patients, at a mean of 16.5 years follow-up (15 to 20). The Kaplan-Meier survivorship for the cup with end-point revisions for any reason, was 79% at 15 years (95% confidence interval (CI); 67 to 91). Excluding two revisions for septic loosening at three and six years, and one revision of a well-fixed cup after 12 years in the course of a femoral revision, the survivorship was 84% at 15 years (95% CI; 73 to 95). At review there were no additional cases of loosening, although seven acetabular reconstructions showed radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.7 cm to 1.0 cm) and a cemented cup, is a reliable technique of reconstruction, when assessed at more than 15 years.

The management of clear cell sarcoma.

Clear cell sarcoma is a rare soft tissue tumour, constituting approximately 1% of all soft tissue sarcomas. Prognosis is reported to be poor due to the great propensity to metastasise regionally and distantly. In this paper, we report the surgical experience of two university hospitals. Both disease-free and overall survival after resection of clear cell sarcoma in this limited study were excellent, which may be explained by relatively small tumour size in seven out of eight patients and adjuvant radiation treatment. The current treatment for clear cell sarcoma is wide local tumour excision, with adjuvant radiation therapy for resection margins of less than 1 mm.

A porous polymer scaffold for meniscal lesion repair--a study in dogs.

Meniscal lesions often occur in the avascular area of the meniscus with little chance of spontaneous repair. An access channel in the meniscal tissue can function as an entrance for ingrowing repair tissue from the vascular periphery of the meniscus to the lesion in the avascular zone which again induced healing of the lesion. Implantation of a porous polymer in a full-thickness access channel induced healing. However, a better integration between meniscal tissue and the implant might be achieved with the combination of the newly developed porous polymers and a modified surgical technique. This might improve meniscal lesion healing and the repair of the access channel with neo-meniscal tissue. Longitudinal lesions were created in the avascular part of 24 canine lateral menisci and a partial-thickness access channel was formed to connect the lesion with the meniscal periphery. In 12 menisci, the access channel was left empty (control group), while in the remaining 12 menisci the polymer implant was sutured into the access channel. Repair of the longitudinal lesions was achieved with and without polymer implantation in the partial-thickness access channel. Polymer implants induced fibrous ingrowth with cartilaginous areas, which resembled neo-meniscal tissue. Implantation did not prevent articular cartilage degeneration.

Presence and mechanism of knee articular cartilage degeneration after meniscal reconstruction in dogs.

OBJECTIVE: Partial meniscectomy is the golden standard for treating a bucket-handle tear in the meniscus of the knee, but it inevitably leads to articular cartilage degeneration. Surgical creation of an access channel between the lesion and the vascularized synovial lining is intended to induce ingrowth of repair tissue and thus avoid degeneration of articular cartilage. DESIGN: The presence and mechanism of cartilage degeneration were evaluated in 24 canine menisci after a longitudinal lesion and access channel had been created in the avascular part of the meniscus. In 12 menisci the channel was implanted with a porous polymer scaffold, while the remaining 12 were left empty. Evaluation was performed using routine histology and antibodies directed against denatured type II collagen (Col2-3/4M). RESULTS: Articular degeneration was apparent in the polymer implant group and the empty channel group. This consisted of fibrillation, loss of chondrocytes and decreased proteoglycan content. Areas of fibrillated cartilage always showed positive labeling with the collagen degradation antibody Col2-3/4M. Collagen degradation was also visible in non-fibrillated areas. The upper zone of the cartilage showed swelling especially in the implant group, with empty cell lacunae and moderate levels of Col2-3/4M antibody labeling. DISCUSSION: This reconstruction technique cannot be considered superior to partial meniscectomy. We propose that degradation of the collagen type II network is a result of cartilage fibrillation and vice versa.

Chondrosarcoma of bone: functional outcome and quality of life.

BACKGROUND AND OBJECTIVES: Outcome studies of chondrosarcoma have so far only reported oncological and functional results. Quality-of-life assessment becomes more important because more long-term survival after treatment of malignant diseases occur. The objective of this study is to analyze functional outcome and quality of life. METHODS: Functional evaluation of the patients was carried out according to the MSTS functional scoring system. For assessment of quality of life, questionnaires were used. RESULTS: Response of the questionnaires sent to 45 disease-free patients was 84%. The mean functional score of these 38 patients was 74% (20-100%). Best functional results were seen after bone graft reconstruction and curettage and cryosurgery with reconstruction. Quality-of-life analysis revealed a mean global health status of 75 (66-84). Furthermore, 24% of the patients experienced severe fatigue. Patients reported more problems with regard to physical functioning and sleep in comparison with healthy controls. No correlation was found between global health status scores and functional scores. CONCLUSIONS: Functional scores depend on the type of treatment with best results after curettage and cryosurgery. Quality-of-life analysis reveals problems on several domains, including fatigue, physical functioning and sleep.

Bone grafting of cryosurgically treated bone defects: experiments in goats.

It is hypothesized that cryosurgically treated bone defects are inappropriate host sites for cancellous bone grafting. The influence of autologous cancellous bone grafting on the healing of cryosurgically treated gap defects of long bones was investigated. A unilateral in vivo experiment was done to study bone strength and graft incorporation in the goat. The lining of a cylindrical defect of the femoral diaphysis was treated with a closed liquid nitrogen cryoprobe in 62 goats. Thirty-one animals received an impacted, morselized, cancellous bone graft harvested from the sternum. The other 31 animals served as controls. At 0, 4, 7, 10, 13, 16, and 26 weeks animals were euthanized and the femurs were evaluated for torsional strength, computed tomography, and histologic assessment. Specimens with a bone graft showed no significant increase in torsional strength with time compared to the controls. In all goats euthanized at 10 weeks or later, the graft was resorbed. The amount of bone apposition at the site of the cryosurgical lesion and the time at which the defect was bridged were similar in both groups. Autologous cancellous bone grafting does not accelerate healing of cryosurgically treated, stable, diaphyseal defects in the goat.

Cemented total hip arthroplasty with impacted morcellized bone-grafts to restore acetabular bone defects in congenital hip dysplasia.

We evaluated the results of 27 acetabular reconstructions in 21 patients with secondary osteoarthritis resulting from congenital dysplasia of the hip in which the acetabular bone defects were restored with impacted morcellized bone-grafts in combination with a cemented cup. At an average follow-up of 7 years, 7 months (range, 5-15 years), 2 hips were revised. One cup was revised after 27 months for sciatic nerve problems; the other hip was revised for aseptic loosening of the cup at 12 years' follow-up. The cumulative survival of the acetabular reconstruction was 96.3% at 5- and 10-year intervals. Additionally, 2 hips (7.7%) showed stable radiolucent lines in zone III without migration of the cup. None of the cemented stems were revised. The bone impaction grafting technique is a safe and attractive method to restore bone deficiencies in dysplastic hips.