ABSTRACT
Aims: Revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) are complex procedures with higher rates of re-revision, complications, and mortality compared to primary TKA and THA. We report the effects of the establishment of a revision arthroplasty network (the East Midlands Specialist Orthopaedic Network; EMSON) on outcomes of rTKA and rTHA. Methods: The revision arthroplasty network was established in January 2015 and covered five hospitals in the Nottinghamshire and Lincolnshire areas of the East Midlands of England. This comprises a collaborative weekly multidisciplinary meeting where upcoming rTKA and rTHA procedures are discussed, and a plan agreed. Using the Hospital Episode Statistics database, revision procedures carried out between April 2011 and March 2018 (allowing two-year follow-up) from the five network hospitals were compared to all other hospitals in England. Age, sex, and mean Hospital Frailty Risk scores were used as covariates. The primary outcome was re-revision surgery within one year of the index revision. Secondary outcomes were re-revision surgery within two years, any complication within one and two years, and median length of hospital stay. Results: A total of 57,621 rTHA and 33,828 rTKA procedures were performed across England, of which 1,485 (2.6%) and 1,028 (3.0%), respectively, were conducted within the network. Re-revision rates within one year for rTHA were 7.3% and 6.0%, and for rTKA were 11.6% and 7.4% pre- and postintervention, respectively, within the network. This compares to a pre-to-post change from 7.4% to 6.8% for rTHA and from 11.7% to 9.7% for rTKA for the rest of England. In comparative interrupted time-series analysis for rTKA there was a significant immediate improvement in one-year re-revision rates for the revision network compared to the rest of England (p = 0.024), but no significant change for rTHA (p = 0.504). For the secondary outcomes studied, there was a significant improvement in trend for one- and two-year complication rates for rTHA for the revision network compared to the rest of England. Conclusion: Re-revision rates for rTKA and complication rates for rTHA improved significantly at one and two years with the introduction of a revision arthroplasty network, when compared to the rest of England. Most of the outcomes studied improved to a greater extent in the network hospitals compared to the rest of England when comparing the pre- and postintervention periods.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Humans , Arthroplasty, Replacement, Knee/methods , Risk Factors , Reoperation , Databases, Factual , Retrospective StudiesABSTRACT
BACKGROUND: The purpose of this study is to determine whether there is a higher dislocation rate when postoperative hip precautions are not used for primary total hip arthroplasty (THA). METHODS: A survey was conducted of the hip precautions used by orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database during the period April 1, 2011 to December 31, 2019 and subsequent dislocations of these prostheses up to June 30, 2020. These were used to determine dislocations within 180 days of primary surgery and emergency readmissions within 30 days of discharge. RESULTS: Records were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total, 1,807 (0.8%) dislocations were recorded within 180 days of surgery. There were 12,416 (5.4%) emergency readmissions within 30 days of surgery. Within hospitals where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant postintervention trend towards fewer dislocations (P < .001). There was also a significant immediate change in median length of stay from 4 to 3 days (P < .001) but no significant trend in the proportion of emergency readmissions within 30 days. CONCLUSION: There is no evidence of an increase in early dislocation or 30-day readmission rates after stopping traditional postoperative hip precautions in primary THA. Potential reductions in length of stay will reduce the risks associated with an extended hospital admission, improve service efficiency, and reduce costs.
Subject(s)
Arthroplasty, Replacement, Hip , Hip Dislocation , Joint Dislocations , Humans , Arthroplasty, Replacement, Hip/adverse effects , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/prevention & control , Patient Readmission , Elective Surgical Procedures , Patient Discharge , Hip Dislocation/epidemiology , Hip Dislocation/etiology , Hip Dislocation/prevention & controlABSTRACT
Unfortunately, the first author name was incorrectly published in the original publication. The complete correct name is given as below.
ABSTRACT
PURPOSE: The aim of this study is to evaluate the true incidence of all clinical negligence claims against spinal surgery performed by orthopaedic spinal surgeons and neurosurgeons in the National Health Service (NHS) in England, including both open and closed claims. METHODS: This study was a retrospective review of 978 clinical negligence claims held by NHS Resolution against spinal surgery cases identified from claims against 'Neurosurgery' and 'Orthopaedic Surgery'. This category included all emergency, trauma and elective work and all open and closed cases without exclusion between April 2012 and April 2017. RESULTS: Clinical negligence claims in spinal surgery were estimated to cost £535.5 million over this five-year period. There is a trend of both increasing volume and estimated costs of claims. The most common causes for claims were 'judgement/timing' (512 claims, 52.35%), 'interpretation of results/clinical picture' (255 claims, 26.07%), 'unsatisfactory outcome to surgery' (192 claims, 19.63%), 'fail to warn/informed consent' (80 claims, 8.13%) and 'never events' including 'wrong site surgery' or 'retained instrument post-operation' (26 claims, 2.66%). A sub-analysis of 3 years including 574 claims revealed the most prevalent pathologies were iatrogenic nerve damage (132 claims, 23.00%), cauda equina syndrome (CES) (131 claims, 22.82%), inadequate decompression (91 claims, 15.85%), iatrogenic cord damage (72 claims, 12.54%), and infection (51 claims, 8.89%). CONCLUSIONS: The volume and costs of clinical negligence claims is threatening the future of spinal surgery. If spinal surgery is to continue to serve the patients who need it, most thorough investigation, implementation and sharing of lessons learned from litigation claims must be systematically carried out. These slides can be retrieved under Electronic Supplementary Material.
Subject(s)
Malpractice , Orthopedic Procedures , Spine/surgery , State Medicine , England , Humans , Malpractice/economics , Malpractice/legislation & jurisprudence , Malpractice/statistics & numerical data , Orthopedic Procedures/economics , Orthopedic Procedures/legislation & jurisprudence , Orthopedic Procedures/statistics & numerical data , Retrospective Studies , State Medicine/economics , State Medicine/legislation & jurisprudence , State Medicine/statistics & numerical dataABSTRACT
OBJECTIVES: Extrathoracic solitary fibrous tumors (ESFTs) are rare low-to-intermediate grade spindle-cell neoplasms of pluripotent fibroblastic or myofibroblastic origin. This review explores prognostic factors in the management of ESFTs and provides guidance on optimal treatment regimens based on the current literature. PATIENTS AND METHODS: Electronic searches were performed using MEDLINE, Embase, and the Cochrane library to identify studies on prognostic factors in the management of ESFTs published between January 1970 and June 2016. The literature search and review process identified 100 articles that were included in this review article. This included both surgical and nonsurgical studies on the management of ESFTs. RESULTS: Surgical excision with wide resection margins forms the mainstay of treatment and provides optimal long-term oncological outcomes. Large tumor size (>5 to 10 cm diameter), inadequate resection margins, malignant histologic features, dedifferentiation, and tumor location within the abdomen/pelvis are associated with adverse oncological outcomes. Radiotherapy may be used for preoperative tumor shrinkage and/or as adjuvant therapy in patients with malignant disease or incomplete surgical margins. Chemotherapy with molecular-targeted therapies has produced promising results and the results of further phase 2 trials are awaited. CONCLUSIONS: Routine long-term follow-up is essential for benign and malignant disease to enable early detection and treatment of recurrent disease.
Subject(s)
Postoperative Complications , Solitary Fibrous Tumors/surgery , Thoracic Neoplasms/surgery , Disease Management , Humans , Prognosis , Solitary Fibrous Tumors/pathology , Thoracic Neoplasms/pathologyABSTRACT
BACKGROUND: Congenital indifference to pain with anhidrosis (CIPA) is a rare hereditary neuropathy, which is associated with defective sensation to noxious stimuli and autonomic dysfunction. The objective of the study was to report on the orthopaedic manifestations of this condition and provide an evidence-based approach for management. METHODS: Retrospective review of 14 consecutive patients with CIPA referred to a single tertiary centre. Mean age of diagnosis was 2.5 years (range 0.5 to 11 years). RESULTS: Patients presented with a range of orthopaedic problems including fractures, infections, growth disturbance, joint subluxation and Charcot joints affecting the limbs and spine. Conservative treatment with closed reduction and cast immobilisation was satisfactory for stress fractures of the lower extremity and Charcot joints. Posterior instrumented correction of scoliosis was associated with a high-risk of infection requiring reoperation for debridement and removal of posterior instrumentation. Growth disturbance leading to leg-length discrepancies were managed with shoe raises and corrective osteotomies. Aspiration and cultures may be used to differentiate between acute fracture and infection. CONCLUSIONS: Preventative treatment strategies with appropriately padded shoe-wear, gait and posture modification, parental education regarding environmental thermoregulation, and behavioural support are essential for improving prognosis and reducing long-term complications.
Subject(s)
Disease Management , Hereditary Sensory and Autonomic Neuropathies/complications , Hereditary Sensory and Autonomic Neuropathies/therapy , Musculoskeletal Diseases/therapy , Child , Child, Preschool , Female , Humans , Infant , Male , Musculoskeletal Diseases/complications , Retrospective StudiesABSTRACT
Custom-made endoprostheses can be linked to existing well-fixed implants in the treatment of complex periprosthetic femoral fractures. By adopting this salvage approach, secure implants can be retained in favour of patients undergoing more tissue disruptive procedures such as total femoral replacements. In this piece, we present a unique case illustrating a salvage strategy for treating a failed cement-linked salvage endoprosthesis, a complex scenario which to our knowledge has never before been reported.
ABSTRACT
The goal of residency programs is to provide an educational venue with graduated responsibility and increasing levels of independence as preparation for entering the unsupervised practice of medicine. Surgical programs are required to both cultivate and convey skills pursuant to three fundamental domains: a sufficient fund of knowledge, technical competence in surgical procedures, and a degree of professionalism to enable ethical independent practice. Never before has the expectation that residency programs provide graduated responsibility in preparation for entering the unsupervised practice of medicine been so clearly articulated as it has by Nasca in the recent Accreditation Council for Graduate Medical Education (ACGME) work-hour guideline revisions. The Royal College of Physicians and Surgeons has provided similar guidance in Canada. Yet, as we progress further into the second decade of work-hour restrictions, it is unclear that we have adequately defined or can recognize the critical end points essential to trainee competency. What is clear is that we must achieve these end points in a manner different from that prior to the introduction of work-hour restrictions. We present the current state of thinking from North America and contrast this with the evolving medical educational process in the United Kingdom.
Subject(s)
Clinical Competence/standards , Internship and Residency/standards , Orthopedics/standards , Accreditation/standards , Canada , Competency-Based Education/standards , Humans , Orthopedics/education , United Kingdom , United StatesABSTRACT
OBJECTIVE: Surgical resection of sacral chordomas offers the best long-term prognosis but has high rates of local recurrence, metastases, and mortality. Most prognostic studies are limited by low patient numbers, variation in treatment, follow-up, and prognostic variables studied. The objective of this study was to identify factors associated with recurrence, metastasis, and survival. METHODS: Retrospective review of 58 patients undergoing sacrectomy for chordoma with a mean age of 63 years (range: 41-80 years) and a mean follow-up of 45.3 months (range: 2-144 months). Data on prognostic variables and outcomes were collected. Forty-two patients underwent a combined anterior and posterior approach and 16 underwent a posterior-only approach. RESULTS: Twenty-six patients (44.8%) died during follow-up. Kaplan-Meier estimates for 5- and 10-year survival were 62% and 26%, respectively. Local recurrence occurred in 32 patients (51.7%) and metastases in 19 (32.7%). Adequacy of resection margins was the most important predictor of disease recurrence, metastases, and survival. Tumors >8 cm were associated with significantly increased risk of metastases and reduced survival (P < 0.05). Dedifferentiated disease and infiltration of the sacroiliac joints and/or adjacent musculature were also associated with reduced survival. Median survival was 23 months for patients with gluteus maximus invasion, 66 months for gluteus maximus and piriformis invasion, 67 months for piriformis invasion, and 90 months for patients with no muscle invasion. CONCLUSIONS: Patients with inadequate resection margins, tumors >8 cm, sacroiliac joint and/or musculature infiltration, and dedifferentiated disease have significantly worse oncologic outcomes. Involvement of gluteus maximus alone confers a higher risk of metastases and local recurrence than involvement of piriformis and gluteus maximus, or piriformis alone.
Subject(s)
Chordoma/surgery , Neurosurgical Procedures/methods , Sacrococcygeal Region/surgery , Spinal Neoplasms/surgery , Adult , Aged , Aged, 80 and over , Female , Follow-Up Studies , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Neoplasm Invasiveness/pathology , Neoplasm Metastasis , Neoplasm Recurrence, Local , Prognosis , Retrospective Studies , Survival AnalysisABSTRACT
BACKGROUND: Aseptic loosening of massive bone tumor implants is a major cause of prosthesis failure. Evidence suggests that an osteointegrated hydroxyapatite (HA)-coated collar would reduce the incidence of aseptic loosening around the cemented intramedullary stem in distal femoral bone tumor prostheses. Because these implants often are used in young patients with a tumor, such treatment might extend the longevity of tumor implants. Questions/purposes We asked whether (1) HA-coated collars were more likely to osteointegrate; (2) HA collars were associated with fewer progressive radiolucent lines around the stem-cement interface; and (3) HA-coated collars were associated with less bone loss at the bone-shoulder implant junction? METHODS: Twenty-two patients were pair-matched to one of two groups--either (1) implants with a HA-coated ingrowth collar (HA Collar Group); or (2) implants without an ingrowth collar (Noncollar Group). Age, sex, and length of followup were similar in both groups. HA-coated collars were developed and used at our institution from 1992 to address the high failure rate attributable to aseptic loosening in patients with massive bone tumor implants. Before this, smooth titanium shafts were used routinely adjacent to bone at the transection site. The minimum followup was 2 years (mean, 7 years; range, 2-12 years). Radiographs obtained throughout the followup period were analyzed and osteointegration at the shaft of the implant quantified. Radiolucent line progression around the cemented stem was semi-quantitatively assessed and cortical bone loss at the bone-shoulder implant junction was measured during the followup period. RESULTS: Comparison of the most recent radiographs showed nine of 11 patients had osteointegrated HA collars, whereas only one patient in the Noncollar Group had osteointegration (p > 0.001). The radiolucent line score quantified around the cemented stem was lower in the HA Collar Group when compared with the Noncollar Group (p = 0.001). Results showed an increase in cortical bone loss at the bone-shoulder implant junction in the Noncollar Group when compared with the HA Collar Group (p < 0.001). CONCLUSIONS: Osteointegration at the implant collar resulted in fewer radiolucent lines adjacent to the intramedullary cemented stem and decreased cortical bone loss immediately adjacent to the transection site. These results suggest that the HA collar may help reduce the risk of aseptic loosening in patients with this type of implant, but longer followup and a larger prospective comparison series are necessary to prove this more definitively.
Subject(s)
Bone Neoplasms/surgery , Chondrosarcoma/surgery , Coated Materials, Biocompatible , Femoral Neoplasms/surgery , Osseointegration , Osteosarcoma/surgery , Prostheses and Implants , Adolescent , Adult , Aged , Durapatite , Female , Humans , Male , Middle Aged , Prosthesis FailureABSTRACT
BACKGROUND: From 1998 to 2008, 1000 skeletally mature patients underwent autologous chondrocyte implantation for an osteochondral defect of the knee. We evaluated the functional outcomes in 827 of 869 patients who had undergone autologous chondrocyte implantation with Chondron or periosteum (ACI-C/ACI-P) or matrix-assisted chondrocyte implantation (MACI) and attempted to identify factors that influenced outcome. METHODS: The age of the patient, the size and site of the osteochondral lesion, previous surgery, and the presence of early osteoarthritis were assessed for their influence on outcomes. Each factor was evaluated in a separate Cox proportional hazards model with use of hazard ratios (HRs), with 95% confidence intervals (CIs), describing the likelihood of failure for that particular factor. Outcomes were assessed with use of the modified Cincinnati score, visual analog scale pain score, and Stanmore functional score. RESULTS: The mean duration of follow-up was 6.2 years (range, two to twelve years). The mean age was thirty-four years (range, fourteen to fifty-six years), with 493 males and 334 females. The average size of the defect was 409 mm2 (range, 64 to 2075 mm2). Four hundred and twenty-one procedures (51%) were performed on the medial femoral condyle; 109 (13%), on the lateral femoral condyle; 200 (24%), on the patella; and fifty (6%), on the trochlea. Kaplan-Meier survival analysis revealed that the unadjusted graft survival rate was 78.2% at five years and 50.7% and ten years for the entire cohort. No difference was found between the survival rates of the ACI-C/ACI-P and MACI techniques (HR = 0.948, 95% CI = 0.738 to 1.219, p = 0.678). There was a significant postoperative improvement in the function and pain scores of all three outcome measures (p < 0.002). Survivorship in the group with a previous cartilage regenerative procedure was inferior to that in patients with a previously untreated lesion, with failure five times more likely in the former group (HR = 4.718, standard error [SE] = 0.742, 95% CI = 3.466 to 6.420, p < 0.001). Degenerative change in any compartment had a significant detrimental effect on survivorship, with survivorship worsening as the osteoarthritis grade increased (Grade 1: HR = 2.077, 95% CI = 1.299 to 3.322, p = 0.002; Grade 2: HR = 3.450, 95% CI = 2.646 to 4.498, p < 0.001; and Grade 3: HR = 3.820, 95% CI = 2.185 to 6.677, p < 0.001). CONCLUSIONS: Our study demonstrated an overall graft survival of 78% at five years and 51% beyond ten years following both autologous chondrocyte implantation techniques. Despite study limitations, our results demonstrate that autologous chondrocyte implantation for the treatment of osteochondral defects of the knee can achieve good results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Subject(s)
Cartilage Diseases/surgery , Chondrocytes/transplantation , Joint Diseases/surgery , Knee Joint/surgery , Adolescent , Adult , Analysis of Variance , Arthralgia/etiology , Autografts , Cartilage, Articular , Female , Graft Survival , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Pain, Postoperative/etiology , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: Dedifferentiated chordomas are rare high-grade malignant spinal tumors for which there is minimal information to help guide treatment. OBJECTIVE: To identify prognostic factors associated with increased risk of local recurrence, metastases, and reduced survival in a cohort of patients undergoing sacrectomy for de novo dedifferentiated sacral chordoma. METHODS: Ten patients undergoing sacrectomy for histologically confirmed dedifferentiated chordoma at a specialist center were reviewed. There were 6 male and 4 female patients with a mean age of 66.7 years (range, 57-80 years) and mean follow-up of 36.7 months (range, 3-98 months). Data on prognostic factors were collected. RESULTS: The commonest presenting symptom was lumbar/gluteal pain. Mean duration of preoperative symptoms was 3.6 months (range, 2-7 months). Local recurrence was seen in 7 patients; metastases occurred in 5 patients. After sacrectomy, 7 patients died at a mean of 41 months (range, 3-98 months). Tumor size >10 cm in diameter, amount of dedifferentiation within the conventional chordoma, sacroiliac joint infiltration, and inadequate resection margins were associated with increased risk of recurrence and reduced survival. Surgical approach, cephalad extent of primary tumor, and adjuvant radiotherapy did not affect oncological outcomes. CONCLUSION: Dedifferentiated chordomas are aggressive malignant tumors with a higher risk of local recurrence, metastases, and early mortality than conventional chordomas. Tumor diameter >10 cm, marginal resection, and sacroiliac joint infiltration may be associated with increased risk of local recurrence and mortality. Those with a smaller burden of dedifferentiated disease (<1 cm) within the primary chordoma have a better prognosis. Patients should be counseled about these risks before surgery and should have regular follow-up for the detection of local recurrence and metastases.
Subject(s)
Chordoma/surgery , Spinal Neoplasms/surgery , Aged , Chordoma/mortality , Female , Humans , Male , Middle Aged , Neoplasm Recurrence, Local/epidemiology , Neoplasm Recurrence, Local/mortality , Neoplasm Recurrence, Local/pathology , Neurosurgical Procedures , Prognosis , Retrospective Studies , Sacrum , Spinal Neoplasms/mortality , Treatment OutcomeABSTRACT
BACKGROUND: Controversies still exist regarding the optimal diagnostic and therapeutic strategies in patients with prosthetic joint infections (PJI). QUESTIONS/PURPOSES: How effective are preoperative and intraoperative cultures in isolating organisms and how do these culture results compare to one another? What are the results of surgical treatment of PJI in the hip and knee in an international, tertiary referral center cohort? PATIENTS AND METHODS: One hundred sixteen patients (N = 59 hip PJI, N = 57 knee PJI) were recruited prospectively to registries at three international, tertiary referral centers between December 2008 to November 2011. Retrospective review of prospective registry data including demographics, microbiology results, and operative reports was performed. RESULTS: Preoperative synovial fluid aspiration yielded an organism in only 45.2% and 44.4% of cases, respectively, for knee and hip PJI. False-negative rates of preoperative aspiration relative to intraoperative culture were 56% and 46% in hip and knee PJI, respectively, with discordance rates of 25% and 21.4%, respectively. Rates of negative intraoperative cultures were 15% in hip PJI and 20.7% in knee PJI. Open debridement with prosthetic retention was the most common initial revision procedure performed (48.3% of hip PJI and 63.8% of knee PJI). This method of revision was successful in 41.3% of hip PJI and 59.4% of knee PJI. Initial failure rates for prosthetic revision was lower than debridement with prosthetic retention but remained substantial in both hip PJI (initial success of one-stage exchange 60% and two-stage exchange 70%) and knee PJI (initial success of one-stage exchange 80% and two-stage exchange 75%). CONCLUSION: Diagnosis and treatment of PJI remains challenging with difficulty in isolating the offending organism and with high rates of prosthetic revision and initial treatment failures. Future advances in organism isolation and international standardization of treatment protocols may improve patient outcomes.
ABSTRACT
OBJECTIVE: Osteoarthritis (OA) is a common debilitating disease that results in degeneration of cartilage and bone in the synovial joints. Subtle changes in the molecular structure of the subchondral bone matrix occur and may be associated with cartilage changes. The aim of this study was to explore whether the abnormal molecular changes observed in the matrix of OA subchondral bone can be identified with Raman spectroscopy. METHODS: Tibial plateaus from patients undergoing total knee replacement for OA (n = 10) were compared with healthy joints from patients undergoing leg amputation (n = 5; sex- and laterality-matched) and with non-OA cadaveric knee specimens (n = 5; age-matched). The samples were analyzed with Raman spectroscopy, peripheral quantitative computed tomography, and chemical analysis to compare changes in defined load-bearing sites in both the medial and lateral compartments. RESULTS: OA subchondral bone matrix changes were detected by Raman spectroscopy. Within each cohort, there was no spectral difference in bone matrix chemistry between the medial and lateral compartments, whereas a significant spectral difference (P < 0.001) was observed between the non-OA and OA specimens. Type I collagen chain ratios were normal in the non-OA specimens but were significantly elevated in the OA specimens. CONCLUSION: In comparing the results of Raman spectroscopy with those obtained by other standard techniques, these findings show, for the first time, that subchondral bone changes, or inherent differences, exist in both the medial and lateral (beneath intact cartilage) compartments of OA knees. The development of Raman spectroscopy as a screening tool, based on molecular-specific modifications in bone, would facilitate the identification of clinical disease, including early molecular changes.
Subject(s)
Bone Matrix/chemistry , Osteoarthritis, Knee/metabolism , Osteoarthritis/metabolism , Spectrum Analysis, Raman , Aged , Aged, 80 and over , Arthroplasty, Replacement, Knee , Bone Density , Bone Matrix/metabolism , Bone Matrix/pathology , Case-Control Studies , Collagen Type I/analysis , Female , Humans , Knee Joint/metabolism , Knee Joint/pathology , Male , Middle Aged , Osteoarthritis/pathology , Osteoarthritis/surgery , Osteoarthritis, Knee/pathology , Osteoarthritis, Knee/surgery , Tibia/metabolism , Tibia/pathologyABSTRACT
Periprosthetic femoral fractures with long stem implants, poor bone stock and loosening pose a considerable surgical challenge. We describe a reconstruction technique using a custom-made mega-prosthesis, cement-linked to the femoral stem of a well-fixed existing implant. Clinical and radiological outcomes were assessed at our tertiary referral centre. There were 15 patients with a periprosthetic femoral fracture: 5 proximal and 10 distal femoral arthroplasties linked to existing femoral stems. The survival rate was 93.3% at a mean follow-up of 5.3 years (0.5-19.3) with 1 revision. We present a salvage technique with good intermediate-term outcomes for highly selected patients with complex periprosthetic femoral fractures, as another option to conventional fixation methods. Specifically, it allows immediate weight bearing and avoids some of the morbidity of total femoral arthroplasty or amputation.
Subject(s)
Arthroplasty, Replacement , Femur/surgery , Joint Diseases/surgery , Joint Prosthesis , Periprosthetic Fractures/surgery , Adult , Aged , Aged, 80 and over , Bone Cements , Cementation , Female , Humans , Male , Middle Aged , Prosthesis Design , ReoperationABSTRACT
BACKGROUND: The objective of this study was to examine the degree of osteointegration into a hydroxyapatite-coated collar and relate this finding to aseptic loosening in patients with a distal femoral replacement used to treat primary bone cancer. Our hypothesis was that the implant collar would increase osteointegration and reduce the rate of aseptic implant loosening. METHODS: Sixty-one patients treated with a primary cemented distal femoral prosthesis between 1992 and 2001 were included in this study. The mean duration of follow-up was 8.5 years (range, two to eighteen years). Extracortical bone growth into the grooved hydroxyapatite-coated collar was quantified radiographically. Histological sections through four hydroxyapatite-coated collars and four implants with no collar, retrieved following amputation due to local recurrence or at autopsy at a mean of 3.5 years (range, 1.4 to 6.1 years) after implantation, were evaluated as well. RESULTS: Five (8%) of the implants were revised because of aseptic loosening, 3% of the implants fractured, and 3% were revised because of infection. Six limbs (10%) required amputation because of local tumor recurrence. On radiographs, osteointegration into the collar was seen to have occurred in 70% of the patients and did not correlate with sex, age, diagnosis, or length of time postoperatively. Histological analysis showed mature lamellar bone within the grooves of the hydroxyapatite-coated collar, and bone was observed in direct contact with the hydroxyapatite coating. Extracortical bone failed to make direct contact with the surface of the implants manufactured without a collar. CONCLUSIONS: The use of cemented distal femoral massive bone tumor prostheses with a hydroxyapatite-coated collar located at the shoulder of the implant was followed by a low (8%) rate of revision due to aseptic loosening. The use of hydroxyapatite grooved collars may lead to osteointegration of the implant shoulder (collar) and may reduce the rate of aseptic loosening.
Subject(s)
Bone Neoplasms/surgery , Femur/surgery , Osseointegration/physiology , Prostheses and Implants , Adolescent , Adult , Aged , Bone Neoplasms/diagnostic imaging , Bone Neoplasms/pathology , Coated Materials, Biocompatible , Durapatite , Female , Femur/diagnostic imaging , Femur/pathology , Follow-Up Studies , Humans , Male , Middle Aged , Prosthesis Implantation , Radiography , Treatment OutcomeABSTRACT
We conducted a prospective single-blinded randomised controlled trial to compare the functional and quality of life outcomes in two groups of patients between 60 and 80 years of age undergoing THR; the first receiving a small head (28-32 mm) metal on polyethylene (MoP) articulation, and the second receiving a large head (44-54 mm) metal on metal (MoM) articulation. We recruited 49 patients and randomised them into one of the two groups (22 MoP and 27 MoM). The results demonstrated no statistical difference in any of the assessed functional outcomes at any follow-up point (p>0.05). There were no dislocations or revisions in either group. Although it has been suggested that large head MoM articulations in THA offer superior stability and function, our results suggest that small head MoP articulations can achieve comparable ROM, function and quality of life at short-term follow-up.
Subject(s)
Arthroplasty, Replacement, Hip , Femur Head , Hip Prosthesis , Aged , Female , Humans , Male , Prospective Studies , Prosthesis Design , Single-Blind Method , Treatment OutcomeABSTRACT
The imaging features and histology of two cases of non-neurogenic intraneural malignancy--an epithelioid sarcoma and myeloma--are described. These cases are important reminders that not all nerve tumours are of neural origin and also show the crucial importance of a robust multidisciplinary approach to achieve the correct diagnosis and management.
Subject(s)
Magnetic Resonance Imaging/methods , Pain/diagnosis , Pain/etiology , Peripheral Nervous System Neoplasms/complications , Peripheral Nervous System Neoplasms/diagnosis , Ultrasonography/methods , Adult , Female , Humans , Male , Middle AgedABSTRACT
PURPOSE: The optimal reconstructive method after resection of malignant bone tumours of the proximal ulna is unknown.We report the outcome of endoprosthetic replacement in a young patient population. METHODS: This was a retrospective review of four patients[three males and one female; mean age 17.5 (range 1131)years] who underwent limb salvage with a proximal ulnar endoprosthetic replacement following excision of malignant bone tumour. Mean follow-up was 85 (range 14194) months. RESULTS: All patients were alive at final follow-up and reported an improvement in pain. One patient required transhumeral amputation for intralesional excision complicating a local recurrence at one month. Two patients developed fixed flexion deformities of the elbow, one of whom required radial-head excision. Mean Musculoskeletal Tumour Society (MSTS)score and Toronto Extremity Salvage Score (TESS) were 27(range 2528) and 81 (7388), respectively. CONCLUSIONS: Custom-made proximal ulna endoprosthetic replacement following resection of malignant bone tumours in young patients provides a stable reconstruction option with satisfactory function and without apparent compromise in patient survival.