Coronal alignment in total knee arthroplasty: a review.

Total knee arthroplasty (TKA) alignment has recently become a hot topic in the orthopedics arthroplasty literature. Coronal plane alignment especially has gained increasing attention since it is considered a cornerstone for improved clinical outcomes. Various alignment techniques have been described, but none proved to be optimal and there is a lack of general consensus on which alignment provides best results. The aim of this narrative review is to describe the different types of coronal alignments in TKA, correctly defining the main principles and terms.

Percutaneous ultrasound-guided microwave ablation for treatment of hepatocellular carcinomas in dogs: four cases (2019-2020).

OBJECTIVES: To describe ultrasound-guided microwave ablation as a minimally invasive treatment option for primary or metastatic hepatocellular carcinomas. METHODS: Four client-owned dogs underwent percutaneous ultrasound-guided microwave ablation of three primary and one metastatic hepatocellular carcinoma, diagnosed on cytology/histopathology. In each case, multiple ultrasound-guided thermal lesions were created in a 10 to 40 minutes ablation at 30 to 35 W. Real-time monitoring was performed using 10 MHz diagnostic ultrasound transducers. The procedures were performed without complication and CT scans or abdominal ultrasounds were repeated immediately after. Patients were discharged on oral analgesia on the same day or 24 hours later. RESULTS: Hepatocellular carcinomas were successfully ablated, which in some cases resulted in an improvement in clinical signs and laboratory values. The patients were followed up for a time ranging between 39 and 649 days and no evidence of disease progression was found. Three out of four patients are still alive at the time of writing. CLINICAL SIGNIFICANCE: In these four patients, minimally invasive ultrasound-guided microwave ablation was feasible and resulted in no immediate complications. Regular imaging follow-up is recommended after the procedure and further studies on microwave ablation are warranted to establish its effectiveness in dogs with hepatocellular carcinomas.

Microvascular reconstruction of the mandible with medial femoral condylar flap for treatment of mandibular non-union.

Mandibular non-union occurs in 2-9% after open reduction and internal fixation of a mandibular fracture (trauma surgery, orthognathic cases, access osteotomy for oncological purposes). The medial femoral condyle (MFC) has emerged more recently as one of the most versatile donor sites in the treatment of challenging bone reconstruction. This is the first description of MFC for treatment of mandibular non-union. A retrospective chart review was conducted for all patients who underwent reconstruction with a microvascular MFC flap for bone defects of the head and neck area between January 2015 and December 2018 at Careggi Hospital of Florence. Inclusion criteria were patients where the FMC was used for mandibular defects arising due to non-union. Seven patients presented mandibular defects reconstructed by MFC flap and were included in this investigation (two cases of segmental mandible defect due to post-traumatic non-union; two patients of pathological mandibular fracture after prolonged bisphosphonate therapy for osteoporosis; three patients with mandibular continuity loss after failed orthognathic surgeries). At one-year follow-up, all patients had satisfactory occlusion. One-year postoperative CTs revealed full osteointegration of the flaps. In conclusion, the MFC free flap is an attractive option for mandibular reconstruction. Small defects (3-5 cm) in poorly vascularized beds are the ideal target.

Intercalary reconstruction of femur after tumour resection: is a vascularized fibular autograft plus allograft a long-lasting solution?

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. Patients and Methods: A total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mean of 13 months (seven to 26). Results: At final follow-up, the mean Musculoskeletal Tumor Society Score of 22 evaluable patients was 94% (73 to 100). Eight major complications, five fractures (21.7%), and three nonunions (13%) were seen in seven patients (30.4%). Revision-free survival was 72.3% at five, ten, and 15 years, with fracture and nonunion needing surgery as failure endpoints. Overall survival, with removal of allograft or amputation as failure endpoints, was 94.4% at five, ten, and 15 years. Discussion: There were no complications needing surgical revision after five years had elapsed from surgery, suggesting that the mechanical strength of the implant improves with time, thereby decreasing the risk of complications. In young patients with an intercalary bone tumour of the femur, combining a VFG and massive allograft may result in a reconstruction that lasts a lifetime. Cite this article: Bone Joint J 2018;100-B:378-86.

Hydronephrosis and crossing vessels in children: Optimization of diagnostic-therapeutic pathway and analysis of color Doppler ultrasound and magnetic resonance urography diagnostic accuracy.

INTRODUCTION: Ureteropelvic junction obstruction (UPJO) is one of the most frequent urological diseases affecting the pediatric population. It can be due to both intrinsic stenosis of the junction and extrinsic causes such as the presence of crossing vessels (CVs), which can be detected by color Doppler ultrasound (CD-US). Magnetic resonance urography (MRU) is a good alternative, but sedation and infusion of a contrast agent are required. OBJECTIVE: The aim of this study was to analyze the diagnostic accuracy of CD-US and MRU in visualizing CVs in pediatric hydronephrosis, in order to decide the correct diagnostic pathway in the pre-operative phase. MATERIAL AND METHODS: A retrospective review was performed of medical records for all patients who underwent surgical treatment for hydronephrosis from August 2006 to February 2016. Ultrasound and scintigraphy had been performed on all patients. Data about CD-US and MRU were collected. A high-level technology ultrasound scanner and a 1.5 T MR scanner were used. The presence of CVs at surgery was considered the gold standard. Sensitivity, specificity, positive and negative predictive values (NPV) were calculated and reported for both of the imaging techniques. RESULTS: A total of 220 clinical charts were reviewed. Seventy-three CVs were identified at surgery (33.2% of UPJO). The median age was statistically higher in the group with CVs compared to the group without CVs (P < 0.001). The sensitivity and NPV of CD-US in detecting CVs were higher than MRU (sensitivity 93.3% vs. 71.7%, NPV 95.7% vs. 77.6%, respectively). DISCUSSION: According to the data, CD-US had higher sensitivity and NPV than MRU, resulting in superior detection of CVs. It is important for a surgeon to know that a child has a CV, especially in older children in which the incidence of extrinsic UPJO is higher. The main limitation of this study was the presence of incomplete data, due to the retrospectivity. CONCLUSIONS: In the pre-operative phase, the CD-US should be considered as the investigation of choice to detect CVs in children with hydronephrosis (Summary Fig). Moreover, CD-US has lower costs than MRU, and sedation with infusion of contrast agent is unnecessary. For the future, it could be useful to lead a prospective comparison between the two imaging techniques.

Reconstructive techniques for revision and limb salvage surgery in persons with haemophilia.

Haemophilia is an inherited haemorrhagic disease characterized by the lack of coagulative factors associated nowadays mostly to musculoskeletal complications, particularly severe secondary arthritis in specific joints. Recurrent traumatic or spontaneous joint bleeding, induce severe arthropathy at a young age that can be treated only by joint replacement. Total knee or hip arthroplasty in young subjects may fail earlier due to wear or infections and in the haemophilic population, this means bone loss, pseudo tumours and the need of revision or even limb salvage surgery. Modern modular implants and the use of bone graft enriched by tissue engineering techniques such as a concentration of autologous mesenchymal cells or PRP may be helpful to compensate all bone loss and anatomic alterations due to failures of orthopaedic implants. The authors present their experience with this type of surgery and their biological approach to these challenging cases.

Comment on: "A case report of a complete degloving injury of the penile skin".

INTRODUCTION: We recently published an article in the International Journal of Surgical Case Reports titled: "Scrotal dartos-fascio-myo-cutaneous flap for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap". PRESENTATION OF CASE: We propose a comment on a recent article titled "A case report of a complete degloving injury of the penile skin" by Helena Aineskog and Frederik Huss that we read with great interest. DISCUSSION: Genitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Various techniques are available for pe-nile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar. CONCLUSION: Scrotal flap is a single stage procedure that is easy and safe to perform.

Scrotal dartos-fascio-myo-cutaneous flaps for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap.

INTRODUCTION: Genitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Among the surgical procedures requested for aesthetical purposes, circumcision is one of the most popular. Although it can be considered to be a simple surgical practice, it may cause severe complications such as penile skin necrosis. PRESENTATION OF CASE: We report a case of a catastrophic situation after a circumcision performed on a 27-year-old HIV positive man resulted in a drastic reduction in the length of the penile shaft due to extensive skin loss; this was subsequently restored using dartos-fascio-myo-cutaneous flaps. Primary healing occurred in 10days. No infection, dehiscence or flap ischemia were reported. Donor site morbidity was minimal. An adequate aesthetical appearance and satisfactory functional results were obtained. DISCUSSION AND CONCLUSION: Various techniques are available for penile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar. Dartos-fascio-myo-cutaneous flap is a single stage procedure that is easy and safe to perform. It can provide satisfactory cosmetic and functional results, offering a large amount of tissue, with minimal donor site morbidity.

Comparative study of oncoplastic versus non-oncoplastic breast conserving surgery in a group of 211 breast cancer patients.

OBJECTIVE: Breast conserving surgery (BCS) followed by radiotherapy is the standard of care for most patients with early breast cancers; however, the aesthetic outcomes of this procedure is not always desirable. Oncoplastic breast surgery is an innovative approach that aims at the safe and effective treatment of the cancerous lesion while achieving the best possible aesthetic outcome. The aim of this study was to evaluate and compare oncoplastic and non-oncoplastic procedures. PATIENTS AND METHODS: A retrospective observational study was conducted on a group of patients who underwent oncoplastic or non-oncoplastic breast surgery at the Breast Unit of the University of Rome Tor Vergata. RESULTS: Out of 211 patients, 154 (73%) underwent non-oncoplastic surgery, while 61 (27%) underwent an oncoplastic procedure. The percentage of patients requiring re-excision was twice greater for women in the non-oncoplastic group: 12.9% vs. 6.5% in the oncoplastic group. The rate of complications was higher in the oncoplastic group compared to the non-oncoplastic one (4.9% vs. 1.3%). The size of the tumor, the number of the patients receiving post-operative radiation, the interval between surgery and radiotherapy and follow-up were similar between the two groups. CONCLUSIONS: Oncoplastic surgery represents a valid alternative to breast conserving surgery for patients with breast cancer, with only minimal differences in long-term complications and similar results in terms of local recurrence and number of metastasis.

Long Term Results of Epiphyseal Transplant in Distal Radius Reconstruction in Children.

BACKGROUND: Replacement of osseous defect, restoration of joint function, and restoration of longitudinal growth are the 3 main reconstructive issues that need to be addressed when the physis and epiphysis are damaged in a skeletally immature individual. Failure in achieving these objectives leads to severe deformity and functional impairment, which significantly compromises the quality of life of young patients. Because of its biological and morphological characteristics, the proximal fibula epiphyseal transfer has proven to be an excellent option in limb salvage surgery in pediatric oncologic cases meeting all the reconstructive requirements. METHODS: Between 1992-2006, 8 children with a mean age of 7.3 years (range 4-11 years old) diagnosed with malignant bone tumor of the distal radius underwent tumor resection and immediate microsurgical reconstruction of the distal part of the radius with vascularized proximal fibular transfer, which included the physis and a variable length of the diaphysis. The anterior tibial vascular network supplied all of the grafts. One patient died to lung metastasis, 3.5 years after surgery; a second patient was lost at follow-up. The remaining 6 patients were periodically followed up both clinically, measuring range of motion, grip strength and the sensation of the hand, and by means of standard x rays, bone scan and CT scan. RESULTS: The mean follow-up was 13.2 years (range, 8-22 years). All the transfers survived and underwent fusion at the recipient site. In our experience the fibular growth expected after the transplant, ranges between 0.7 and 1.4 cm per year. In this series growth arrest occurred in only one patient after trauma. Serial radiographs and CT scans revealed progressive remodeling over time of the new articular surface. The functional result was rated as excellent in all but the one patient, in whom the distal portion of the ulna had to be resected because of tumor invasion. No major complication occurred at the recipient site. Peroneal nerve palsy occurred at the or site in 3 patients. The palsy was transient in 2 patients, but it persisted in one. No instability of the knee joint was observed. CONCLUSIONS: Our long-term results confirm that a vascularized transfer of the proximal fibula provides a reliable and durable reconstruction of the distal radius in children. Even after 22 years, the reconstructed joint resulted to be free of pain and degenerative changes thus maintaining a nearly normal range of motion. The described procedure is therefore highly recommended in case of distal radius reconstruction in growing children.

Antitumoural activity of viniferin-enriched extracts from Vitis vinifera L. cell cultures.

The aim of this work was to evaluate the effect of stilbenes from different cultivars of Vitis vinifera on tumour proliferation. Extracts were obtained from elicited V. vinifera cell cultures and characterised by HPLC/DAD/MS. Cell growth was evaluated in four human cancer cell lines and in normal human fibroblasts. The cells were exposed to the extracts or to trans-resveratrol, used as reference molecule, for 48 h, at 1-10 µM concentrations of total stilbenoids. All the extracts exhibited antiproliferative activity, mediated by modulation of the cell cycle and induction of cytotoxicity in cancer but not in normal cell lines, and positively correlated with the content in dimeric stilbenoids. The Alphonse Lavallée extract was the most active, and the obtained stilbenoid fraction resulted 8-10 times more active than trans-resveratrol. Extracts from V. vinifera cell cultures could represent new sources of active stilbenoid compounds to be further assayed in in vivo studies for their antitumoural properties.

Agonistic anti-human Fas monoclonal antibody induces fibroblast-like synoviocyte apoptosis in haemophilic arthropathy: potential therapeutic implications.

Haemophilic arthropathy (HA) is characterized by chronic proliferative synovitis leading to cartilage destruction and shares some pathological features with rheumatoid arthritis (RA). Apoptosis has been implicated in RA pathogenesis, and an agonistic anti-Fas monoclonal antibody (mAb) was found to induce RA fibroblast-like synoviocyte (FLS) apoptosis and suppress synovial hyperplasia in animal models of RA. The aim of this study was to evaluate the effect of anti-Fas mAb on HA-FLS. FLS were isolated from knee synovial biopsies from six HA patients, six RA patients and six healthy subjects. The expression of Fas in synovial biopsies was investigated by immunohistochemistry. FLS were stimulated with anti-Fas mAb at different concentrations, alone or in combination with tumour necrosis factor-α (TNF-α) and basic fibroblast growth factor (bFGF). Fas expression in FLS was assessed by Western blot. Cell viability was studied with the WST-1 assay. Active caspase-3 levels were measured using ELISA and Western blot. A strong Fas-immunoreactivity was observed in different cells of HA synovium, including FLS, inflammatory cells and endothelial cells. Fas antigen was constitutively overexpressed in cultured HA-FLS. Anti-Fas mAb had a significant cytotoxicity on HA-FLS in a dose-dependent manner, either alone or in combination with TNF-α and bFGF. These cytotoxic effects were due to the ability of anti-Fas to induce HA-FLS apoptosis, as shown by the increased active caspase-3 levels. Anti-Fas mAb exhibited a more pronounced pro-apoptotic effect on HA-FLS than RA-FLS. Fas antigen is highly expressed on HA-FLS and its stimulation by anti-Fas mAb may be an effective strategy to induce HA-FLS apoptosis.

Gastrocnaemius-propeller extended miocutanous flap: a new chimaeric flap for soft tissue reconstruction of the knee.

PURPOSE: Soft tissue defects involving the anterior aspect of the knee are a frequent finding in a number of pathological conditions. The aim of this article is to describe a new pedicled flap consisting of a conventional medial gastrocnaemius muscle flap associated with a propeller flap based on a perforator of the medial sural artery. MATERIAL AND METHODS: Five males ranging in age between 26 and 72 years underwent a reconstruction of the soft tissue of the knee by means of the described procedure. Three patients sustained complex tissue loss subsequent to high-energy trauma; two losses were due to septic complications after elective knee surgery. RESULTS: Four flaps survived allowing adequate proximal tibial metaphysis and patella coverage. One patient underwent early above-the-knee amputation due to life-threatening septicaemia. DISCUSSION: The described chimaera flap consists of a medial gastrocnaemius flap with a skin paddle that is elevated on a perforator of the medial sural artery and then rotated according to the propeller flaps' principles. It provides effective coverage of large soft tissue defects of the knee. In the authors' experience, the propeller flap portion proved to be particularly useful to cover the patella, while the muscle flap was used to cover the proximal metaphysis of the tibia and fill the dead space if present.

Viscosupplementation in haemophilic arthropathy: a long-term follow-up study.

Haemophilic arthropathy is the most common clinical manifestation of haemophilia, secondary to recurrent haemarthroses and chronic synovitis. Modern bleeding-preventing drugs have limited significantly the incidence of severe arthropathy, and primary approach is usually conservative. Use of intra-articular injections of hyaluronan acid is considered one of the most efficient treatments for early stages of articular degenerative diseases. Assessment of long-term effectiveness of intra-articular administration of hyaluronic acid (HA) in knees, ankles and elbows of patients affected by haemophilic arthropathy was done for 46 patients (10 elbows, 24 knees and 25 ankles) affected by haemophilic arthropathy. They received injections of HA and were evaluated with Visual Analogue Scale, Short Form-36, World Federation of Haemophilia score and Petterson score with a 6-year mean follow-up. Most of the patients showed improvement in pain relief and functional recovery without any complications: only a limited number of patients (8.6%) found poor results, undergoing surgery or other further treatments in the follow-up period for persistent pain or limitation. Viscosupplementation is an effective therapeutic strategy in early stages of haemophilic arthropathy, with no complications and long-term good clinical results.

In-patient rehabilitation in haemophilic subjects with total knee arthroplasty.

Total knee arthroplasty (TKA) is a major orthopaedic surgery intervention, indicated for severe haemophilic arthropathy. The aim of our study was to analyse rehabilitation outcome in haemophilic patients after TKA. A consecutive series of 21 patients (23 knees) was retrospectively evaluated. The mean age was 37 ± 8 years (range 22-55). Physiotherapy treatment was performed twice a day for 5 days week⁻¹, for 3 h day⁻¹. Assessment included knee range of motion (ROM), Visual Analogue Scale (VAS) for pain evaluation, Western Ontario and McMaster University (WOMAC) Score for functional outcome, Medical Research Council Scale (MRC) for quadriceps muscle strength evaluation, incidence of adverse events and a self-reported questionnaire. The patients'data were recorded before surgery (t0), at Rehabilitation Unit admission (t1), before discharge (t2) and at follow-up (t3), 11-48 months after rehabilitation. Western Ontario and McMaster University Score (ref. score: 0-96) was 56.7 ± 12 at t0 and 6.2 ± 6 at t3 (t3 vs. t0: P < 0.001). Visual Analogue Scale (ref. score: 0-10) decreased from 5.0 ± 2 at t1 to 2.1 ± 2 at t2 (t2 vs. t1: P < 0.05) and to 0.1 ± 0 at t3 (t3 vs. t2: P < 0.05). Flexion degrees increased from 43.4 ± 21° at t1 to 80.2 ± 15° at t2 (t2 vs. t1: P < 0.001) and to 95.0 ± 15° at t3 (t3 vs t2: P < 0.05). According to MRC (ref. score: 0-5), quadriceps muscle strength increased from 2.3 ± 0.6 at t1 to 3.6 ± 0.5 at t2 (t2 vs. t1: P < 0.05). Adverse events were found in four patients. Patients' satisfaction on their outcome at follow-up was referred as good by 72% of patients or excellent by 28% of patients. Postsurgical intensive rehabilitation in haemophilic patients resulted effective, safe and feasible.

Ultrasound detects joint damage and bleeding in haemophilic arthropathy: a proposal of a score.

Haemarthrosis triggers haemophilic arthropathy (HA) because bleeding starts synovitis immediately, damages cartilage and leads to loss of function and disability. The aim of our study was to investigate the capacity of ultrasonography (US) in detecting bleeding and joint damage in HA. The joints of 62 patients (pts) with haemophilia A or haemophilia B were consecutively evaluated and scored (score ranging from 0 to 21) for effusion (E), bone remodelling (BR), cartilage damage (CD), synovial hypertrophy (SH), haemosiderin (H), osteophytes (O), haemarthrosis (Hae), erosion (Er) and fibrotic septa (FS) with US. X-rays [Pettersson Score (PXS)] were performed in 61 patients and clinical evaluation [World Federation Haemophiliac orthopaedic score (WFHO)] was performed in all patients. A total of 20 healthy subjects and 20 patients affected by Rheumatoid Arthritis (RA) were used as controls. Power Doppler US (PDUS) was performed in all patients on the knee, ankle and elbow joints. A total of 83 joints were studied (50 knees; 12 elbows and 21 ankles). US showed effusion in 57 joint, bone remodelling in 62, cartilage damage in 64, synovial hypertrophy in 45, haemosiderin in 39, osteophytes in 30, haemarthrosis in 24, erosion in 5 and fibrotic septa in 3. The X-rays score showed remodelling in 47 joints, narrowing joint space in 44, displacement/angulation in 39, osteoporosis in 42, subchondral irregularity in 44, subchondral cyst formation in 37, osteophytes in 36 and erosions in 25. The US score in healthy subjects was always ≤ 5 (range 0 to 4). In haemophiliacs, 34 of 83 joints showed US score ≤ 5, and 49 US score > 5. Joints with US score ≤ 5 had a low PXS (SRCC = 0.375, P < 0.01) and joints with US score > 5 showed a high PXS (SRCC = 0.440, P < 0.01). A significant correlation between US score and PXS for bone remodelling [Spearman's rho Correlation Coefficient (SRCC) = 0.429, P < 0.01] and for osteophytes (SRCC = 0.308, P < 0.05) was found. The correlation between the US score and number of bleedings in 83 joints was very significant (SRCC = 0.375, P < 0.01). A total of 24 bleeding joints were identified and verified with aspiration of haematic fluid. US may detect bone and cartilage alterations and synovitis. Indeed, PDUS identified bleeding also in asymptomatic joints and was able to show different entity of haemarthrosis. US may be a feasible and reliable tool to evaluate joint modifications in HA.

Local perforator flaps in soft tissue reconstruction of the upper limb.

The quality of reconstruction of soft tissue defects in the upper extremity, resulting either from traumatic injury or tumor excision, has relevant implications both from functional and aesthetic standpoints. Various local and free flaps with more or less consistent donor-site morbidity have been described in the past. The recent introduction of the perforator-based flap concept, has led to an evolution in upper extremity reconstruction, optimizing results at the recipient site whilst minimizing damage to the donor site and, performing this in the simplest way possible. In this study between 2001 and 2008, 31 patients having post-traumatic or post-tumor excision soft tissue defects of the upper limb, were treated using local perforator flaps raised according to two different modalities: "pedicled fasciocutaneous" and "transposition fasciocutaneous/cutaneous". Complete and stable coverage of the soft tissue losses was obtained in all cases with an inconspicuous, only aesthetic, donor-site defect. Superficial or partial necrosis of the tip of the flap, due to venous congestion, was observed in 2 cases of "pedicled fasciocutaneous flap". An additional surgical procedure was required in only one of these cases. In our series all 9 patients who had a transposition flap, underwent routinely a preoperative echo color Doppler investigation to identify the main perforators. In only one case did the Doppler investigation fail to accurately locate the perforator. Local perforator flaps allow the coverage of medium size defects in the upper extremity, can be raised with a relatively simple surgical technique, have a high success rate and good aesthetic results without functional impairment. In the light of this they can be considered among the surgical choices to resurface complex soft tissue defects of the upper extremity. Preoperative identification of the perforators in case of "transposition flaps" greatly facilitates the operation. In our experience echo color Doppler investigations provided reliable results.

Biological reconstruction after resection of bone tumours around the knee: long-term follow-up.

We reviewed 25 patients who had undergone resection of a primary bone sarcoma which extended to within 5 cm of the knee with reconstruction by a combination of a free vascularised fibular graft and a massive allograft bone shell. The distal femur was affected in four patients and the proximal tibia in 21. Their mean age at the time of operation was 19.7 years (5 to 52) and the mean follow-up period 140 months (28 to 213). Three vascularised transfers failed. The mean time to union of the fibula was 5.6 months (3 to 10) and of the allograft 19.6 months (10 to 34). Full weight-bearing was allowed at a mean of 21.4 months (14 to 36). The mean functional score at final follow-up was 27.4 (18 to 30) using a modified 30-point Musculoskeletal Tumour Society rating system. The overall limb-salvage rate was 88%. The results of our study suggest that the combined use of a vascularised fibular graft and allograft is of value as a limb-salvage procedure for intercalary reconstruction after resection of bone tumours around the knee, especially in skeletally immature patients.

Total knee arthroplasty after complex tibial plateau fractures.

Total knee arthroplasty following complex fractures of the tibial plateau is considered a challenge for orthopaedic surgeons and clinical outcomes may vary. A total of 29 total knee replacements were performed after a tibial plateau fracture: 25 patients (16 women, 9 men; average age: 57 years; mean follow-up: 92 months) were available. We had two significative complications: one partial avulsion of the patellar tendon, conservatively treated by bracing, and one case of deep venous thromboembolism, managed with low molecular weight heparin. In two cases (8%) there was a failure of the implant; nine cases were excellent, nine good, four fair and one poor. A percentage of patients with previous complex proximal tibia fractures had an increased rate of postoperative complications due to anatomical deformity, functional deficiency and post-traumatic arthritis and required solutions similar to revision surgery. Total knee arthroplasty is a suitable solution for the treatment of these challenging cases: compared to primary knee replacement, final KSS score is generally lower, but improvement is similar due to poorer pre-operative scores.

A ten-year follow-up of the Reflection cementless acetabular component.

We reviewed the long-term results at ten to 12 years of 118 total hip replacements in 109 patients using a second-generation hemispherical cementless acetabular component (Reflection) designed to address the problem of backside wear. Five patients (five hips) died and six patients (seven hips) were lost to follow-up. The remaining 98 patients (106 hips) had a mean age of 62.9 years (34.0 to 86.2) A rate of revision for aseptic loosening of 0.9%, and predictable results were found with respect to radiological evidence of fixation, lack of pain, walking ability, range of movement and function. One component was revised for aseptic loosening, and of the 101 hips (95.2%) that did not have a revision, minor osteolytic lesions of the pelvis were seen in six (5.9%). Kaplan-Meier survival analysis for the total cohort of 118 hips revealed a 96.4% survival at both ten (95% confidence interval 90 to 98) and 12 years (95% confidence interval 86 to 98).