Introduction. We describe a minimally invasive technique that permits intra-focal bone graft of non-union sites with minimal disturbance of soft tissues and vascularity, and present the results of this technique. Materials and Methods. 10 patients with established tibia fracture non-union were judged suitable for the technique, and were treated in our limb reconstruction unit between January 1995 to June 2007. Eight patients were male, 2 were females with a mean age of 37.4 years (27–64). Five fractures were in the distal tibia and five were diaphyseal fractures. Five fractures were as a result of high velocity and 6 fractures were open. Average number of previous operations were 3 (range 1–7). Time lapse between injury to trephine grafting procedure was mean of 34 (6–168 months). 5 patients had a sedentary job, 2 were labourers and 2 were not working. There were 5 smokers and 2 obese patients. Six cases were of infected non-unions. Operative technique. Under general anaesthesia, the graft(s) was first obtained from the iliac crest using a guide wire centred trephine. A stab incision was made at the non-union site under image control. A core was taken across the non-union, taking care to breach both bone fragments. A trephine core was rolled in Bone Morphogenetic Protein (BMP-7). This was then introduced through the trephine in to the non-union site and pushed with the plunger into the defect created by the cylindrical plug taken from the site. After this, the trocar with the stylet in place was gradually withdrawn with small oscillating motions to fill in the path of the trocar. This was repeated about 3–4 times at the non-union site. The stab wound were closed with interrupted Nylon. Results. 10 patients underwent treatment for complex non-union after initial operation (average number 3) at the referring centre. Treatment in a circular fixator ranged from 10–33 months (20.7 months) with reapplication in 2 patients. Average number of procedures were 4 (range 1–7). Trephine grafting was performed in all cases; BMP was used in 4 cases along with iliac crest bone graft. All patients attained clinical and radiological union with CT confirmation required in 2 patients. 4 patients with sedentary job returned to work, manual workers returned to low demand occupation. Conclusion. The technique described is a safe and effective treatment method for this complex problem with limited donor site morbidity and avoids prolonged hospital stay

The technique for removal of bone ingrown extensively coated devices involves cutting the stem below the metaphyseal portion of the stem, followed by removal of the proximal stem and trephine removal of the cylindrical distal portion of the stem. This can be done with or without an extended trochanteric osteotomy (ETO). When the proximal portion of the stem is not bone ingrown (extensive proximal osteolysis, or the stem is broken) or the metaphyseal bone is easily accessed (there is no collar) the stem can be cut through a bone window. In all other cases an ETO at the level where the stem becomes a cylinder is required to disrupt the metaphyseal bone prosthesis interface, cut the stem and extract the proximal portion of the stem. Glassman described the techniques for removal of cementless stems in 1992. Forty-two loose stems were easily removed, 11 fibrous stable implants were removed with thin osteotomes, and 11 bone ingrown, canal filling, extensively coated stems were removed with trephines. In no cases was reconstruction precluded by stem removal. The critical tools required included manufacturer specific removal tools, high speed burs, thin osteotomes, universal extraction device for connection to the neck, and multiple trephines. More recently, Kancherla reported the use of trephines to remove 36 porous coated stems. Eighty-six percent of cases were bone ingrown after removal, however complications included an extruded trephine causing a femoral fracture and two periprosthetic fractures thought to be secondary to trephine induced osteonecrosis. The authors recommend bypassing the most distally trephined bone by a minimum of 4cm. Trephines are very helpful for removing distally fixed stems. Multiple trephines need to be irrigated and changed frequently to avoid dull cutting teeth which can lead to bone necrosis

Introduction and Objective. Osteoarthritis of the knee joint is common in old age population in every part of world. Pain is the major source of disability in patients with osteoarthritis of the knee joint. Subchondral bone marrow is richly innervated with nociceptive pain fibers and may be a source of pain in patients with symptomatic degenerative joint disease. Current therapy for managing bone marrow oedema is core decompression (CD), combining core decompression and injection of hydroxyapatite cement or autologus chondrocyte supplementtion. But all of this work has been done in femoral head and authors documented good result with minimal complication. There are various studies in literature suggesting treatment to repair BME by restoring support and relieving abnormal stresses with accepted internal fixation and bone stimulating surgical techniques in relieving knee OA pain. In this study, we present efficacy of knee arthroscopy with adjunctive core decompression and supplementation with structural scaffold to improve self-rated visual analog scale (VAS) pain scores, rate of conversion to arthroplasty, and patient satisfaction levels. Materials and Methods. The study included patients aged between 40 and 75 years old, with pain in the knee for at least six months, associated with high-signal MRI lesion on T2 sequences, on the tibia or femur. Trephine was used as the bone decompression instrument. Trephine has a diameter of 8–10 mm and operation with trephine requires that a cortical incision window be made prior to decompression treatment, thus necessitating strict disinfection. This procedure was done under spinal anesthesia. After diagnostic arthroscopy, decompression was done under C –ARM in desired area on MRI. After decompression, defect was filled with Poly ester urea's scaffold impregnated with BMAC. Results. Patients were assessed using the visual analog pain scale and the KOOS score, one week before surgery and one, three, six, 12, and 24 weeks after the procedure. MRI images were analyzed Lesions were mapped and measured in the axial, coronal, and sagittal views to plan the injection site and the trajectory of the cannula used for the procedure. Radiographs using anteroposterior, profile, and Rosenberg views of the knee and lower limb were performed to classify the lesion according to the Kellgren-Lawrence classification and to assess lower limb alignment. Evaluation using the KOOS showed a mean total score in the preoperative period of 38.44 points and of 60.7, 59.08, 56.92, 64.40, and 71.36 points at one, three, six, 12, and 24 weeks after surgery, respectively. In the VAS assessment, mean was 7.8 points preoperatively and 2.8, 2.6, 2.5, 1.3, and 0.5 points in the same periods. Conclusions. Hence it can be Concluded that this new innovative technique has provided significant improvements in the parameters of pain and functional capacity in the short-term assessment

The technique for removal of bone ingrown extensively coated devices involves cutting the stem below the metaphyseal portion of the stem, followed by removal of the proximal stem and trephine removal of the cylindrical distal portion of the stem. This can be done with or without an extended trochanteric osteotomy (ETO). When the proximal portion of the stem is not bone ingrown (extensive proximal osteolysis, or the stem is broken) or the metaphyseal bone is easily accessed (there is no collar) the stem can be cut through a bone window. In all other cases an ETO at the level where the stem becomes a cylinder is required to disrupt the metaphyseal bone prosthesis interface, cut the stem and extract the proximal portion of the stem. Glassman described the techniques for removal of cementless stems in 1992. Forty-two loose stems were easily removed, 11 fibrous stable implants were removed with thin osteotomes, and 11 bone ingrown, canal filling, extensively coated stems were removed with trephines. In no cases was reconstruction precluded by stem removal. The critical tools required included manufacturer specific removal tools, high speed burs, thin osteotomes, universal extraction device for connection to the neck, and multiple trephines. More recently, Kancherla reported the use of trephines to remove 36 porous coated stems. Eighty-six percent of cases were bone ingrown after removal, however, complications included an extruded trephine causing a femoral fracture and two periprosthetic fractures thought to be secondary to trephine induced osteonecrosis. The authors recommend bypassing the most distally trephined bone by a minimum of 4 cm. Trephines are very helpful for removing distally fixed stems. Multiple trephines need to be irrigated and changed frequently to avoid dull cutting teeth which can lead to bone necrosis

The technique for removal of bone ingrown extensively coated devices involves cutting the stem below the metaphyseal portion of the stem, followed by removal of the proximal stem and trephine removal of the cylindrical distal portion of the stem. This can be done with or without an extended trochanteric osteotomy (ETO). When the proximal portion of the stem is not bone ingrown (extensive proximal osteolysis, or the stem is broken) or the metaphyseal bone is easily accessed (there is no collar) the stem can be cut through a bone window. In all other cases an ETO at the level where the stem becomes a cylinder is required to disrupt the metaphyseal bone prosthesis interface, cut the stem and extract the proximal portion of the stem. Glassman described the techniques for removal of cementless stems in 1992. 42 loose stems were easily removed, 11 fibrous stable implants were removed with thin osteotomes, and 11 bone ingrown, canal filling, extensively coated stems were removed with trephines. In no cases was reconstruction precluded by stem removal. The critical tools required included manufacturer specific removal tools, high speed burs, thin osteotomes, universal extraction device for connection to the neck, and multiple trephines. More recently, Kancherla reported the use of trephines to remove 36 porous coated stems. 86% of cases were bone ingrown after removal, however, complications included an extruded trephine causing a femoral fracture and two periprosthetic fractures thought to be secondary to trephine induced osteonecrosis. The authors recommend bypassing the most distally trephined bone by a minimum of 4cm. Trephines are very helpful for removing distally fixed stems. Multiple trephines need to be irrigated and changed frequently to avoid dull cutting teeth which can lead to bone necrosis

Cutting rodent's bone ends and irrigation of the medullary canal is the common method used for cells collection in allogenic transplantation, however it does not yield sufficient cells for autologous transplantation. The aim of this experiment was to establish and validate a method for bone marrow collection for autologous MSCs transplantation. Two collection methods were examined: 1) Transection of the bone ends and irrigation of the medullary canal, 2) Trephining of the bone with a hypodermic needle without aspiration. Then cell harvesting was compared in the idealised laboratory situation and under simulated surgery. First, two lower limbs were harvested from the same rat cadaver for comparison, bone marrow in one limb was collected by cutting the femoral head and the distal tibia and irrigation of the canal through drilled holes at the distal end of the femur and proximal end of the tibia. Other limb, hypodermic needle was used as a trephining tool into the medullary canal multiple times without applying negative pressure and rinsed from inside and outside. Second, bone marrow was harvested from another rat's cadaver in the surgery room to simulate the conditions needed for autologous transplantation. The number of cells from irrigation method was 1.28*106 cells, whereas that from trephining method reached 17*106. The number cells from the bone marrow harvested in the surgery room was found 29.6*106. We report a novel technique for harvesting cells for autologous cell therapy from only one limb. A significantly larger number of cells from bone marrow could be collected using the needle trephining method. There is no negative effect on the viability of cells after bone marrow harvesting in the surgery room

Menisci are crucial structures for knee homeostasis: they provide increase of congruence between the articular surfaces of the distal femur and tibial plateau, bear loading, shock absorption, lubrication, and proprioception. After a meniscal lesion, the golden rule, now, is to save as much meniscus as possible: only the meniscus tissue which is identified as unrepairable should be excised and meniscal sutures find more and more indications. Several different methods have been proposed to improve meniscal healing. They include very basic techniques, such as needling, abrasion, trephination and gluing, or more complex methods, such as synovial flaps, meniscal wrapping, or the application of fibrin clots. Basic research of meniscal substitutes has also become very active in the last decades. The features needed for a meniscal scaffold are: promotion of cell migration, it should be biomimetic and biocompatible, it should resist forces applied and transmitted by the knee, it should slowly biodegrade and should be easy to handle and implant. Several materials have been tested, that can be divided into synthetic and biological. The first have the advantage to be manufactured with the desired shapes and sizes and with precise porosity dimension and biomechanical characteristics. To date, the most common polymers are polylactic acid (PGA); poly-(L)-lactic acid (PLLA); poly- (lactic-co-glycolic acid) (PLGA); polyurethane (PU); polyester carbon and polycaprolactone (PCL). The possible complications, more common in synthetic than natural polymers are poor cell adhesion and the possibility of developing a foreign body reaction or aseptic inflammation, leading to alter the joint architecture and consequently to worsen the functional outcomes. The biological materials that have been used over time are the periosteal tissue, the perichondrium, the small intestine submucosa (SIS), acellular porcine meniscal tissue, bacterial cellulose. Although these have a very high biocompatibility, some components are not suitable for tissue engineering as their conformation and mechanical properties cannot be modified. Collagen or proteoglycans are excellent candidates for meniscal engineering, as they maintain a high biocompatibility, they allow for the modification of the porosity texture and size and the adaptation to the patient meniscus shape. On the other hand, they have poor biomechanical characteristics and a more rapid degradation rate, compared to others, which could interfere with the complete replacement by the host tissue. An interesting alternative is represented by hydrogel scaffolds. Their semi-liquid nature allows for the generation of scaffolds with very precise geometries obtained from diagnostic images (i.e. MRI). Promising results have been reported with alginate and polyvinyl alcohol (PVA). Furthermore, hydrogel scaffolds can be enriched with growth factors, platelet-rich plasma (PRP) and Bone Marrow Aspirate Concentrate (BMAC). In recent years, several researchers have developed meniscal scaffolds combining different biomaterials, to optimize the mechanical and biological characteristics of each polymer. For example, biological polymers such as chitosan, collagen and gelatin allow for excellent cellular interactions, on the contrary synthetic polymers guarantee better biomechanical properties and greater reliability in the degradation time. Three-dimensional (3D) printing is a very interesting method for meniscus repair because it allows for a patient-specific customization of the scaffolds. The optimal scaffold should be characterized by many biophysical and biochemical properties as well as bioactivity to ensure an ECM-like microenvironment for cell survival and differentiation and restoration of the anatomical and mechanical properties of the native meniscus. The new technological advances in recent years, such as 3D bioprinting and mesenchymal stem cells management will probably lead to an acceleration in the design, development, and validation of new and effective meniscal substitutes

The parameters to be considered in the selection of a cartilage repair strategy are: the diameter of the chondral defect; the depth of the bone defect; the location of the defect (weight bearing); alignment. A chondral defect less than 3 cm in diameter can be managed by surface treatment such as microfracture, autologous chondrocyte transplantation, mosaicplasty, or periosteal grafting. An osteochondral defect less than 3 cm in diameter and less than 1 cm in depth can be managed by autologous chondrocyte transplantation, mosaicplasty or periosteal grafting. An osteochondral defect greater than 3 cm in diameter and 1 cm in depth is best managed by an osteochondral allograft. If there is an associated knee deformity, then an osteotomy should also be performed with all of the aforementioned procedures. In our series of osteochondral allografts for large post-traumatic knee defects realignment osteotomy is performed about 60% of the time in order to off load the transplant. To correct varus we realign the proximal tibia with an opening wedge osteotomy. To correct valgus, we realign the distal femur with a closing wedge osteotomy. Our results with osteochondral allografts for the large osteochondral defects of the knee have been excellent in 85% of patients at an average follow-up of 10 years. The Kaplan-Meier survivorship at 15 years is 72%. At an average follow-up of 22 years in 58 patients with distal femoral osteochondral allograft, 13 have been revised (22%). The 15-year survivorship was 84%. The results for the hip are early. To date we have performed this procedure on 16 patients. Surgical dislocation of the hip is carried out via a trochanteric osteotomy and the defect defined and trephined out. A press-fit fresh osteochondral allograft is inserted using the trephine technique. We have published our early results on a series of 8 patients with 5 good to excellent results, 1 fair result and 2 failures

Cartilage repair strategies have been applied successfully to the knee, but only recently and with limited experience to the hip. The indications for these strategies have been well defined for the knee and are defined by the diameter and depth of the defects that are mainly post traumatic and degenerative. Viscosupplementation is an intra-articular therapy that theoretically restores the protective effects of hyaluronic acid. This therapy has been widely used for osteoarthritis of the knee with some early preliminary promising results for osteoarthritis of the hip. Microfracture can be performed arthroscopically or as part of an open procedure. This procedure is indicated for smaller lesions less than 3cm in diameter and 1cm in depth. Widely used in the knee, the results in the hip are limited but promising. The repair tissue is however fibrocartilage. Autologous chondrocyte transplantation can yield hyaline like repair cartilage with good mid- to long-term results in the knee. The indications are chondral defects greater than 3cm in diameter or osteochondral defects less than 1cm in depth. Its use in the hip has been limited with only a few published papers. The procedure requires two stages. The first stage which involves harvesting the cartilage can be done arthroscopically, and the second stage which involves transplantation of the cultured chondrocytes can be done arthroscopically or open. Larger lesions greater than 3cm in diameter and 1cm in depth, can be managed by osteochondral allografts. The published mid- to long-term results for the knee have been encouraging. The results for the hip are early. To date we have performed this procedure on 16 patients. Surgical dislocation of the hip is carried out via a trochanteric osteotomy and the defect defined and trephined out. A press-fit fresh osteochondral allograft is inserted using the trephine technique. We have published our early results on a series of 8 patients with 5 good to excellent results, 1 fair results and 2 failures

Study Design: A retrospective case note review. Objective: To report on the accuracy of the Harlow-Wood bone biopsy trephine used via a percutaneous approach to obtain tissue from vertebral lesions. Methods: 82 patients undergoing this procedure in either the University Hospital Nottingham or Leicester Royal Infirmary between 1995 and 2003 were included in the study. Data was collected regarding the provisional diagnosis, MRI diagnosis and final diagnosis based on micro-biological and histological reports. Outcome Measures: Microbiological and histological reports were reviewed to determine the pathological nature of each biopsy. If the biopsy returned a positive diagnosis, or if the biopsy confirmed normal vertebral microbiology and histology in a patient who was subsequently disease-free, then the biopsy was deemed to have provided a diagnosis. Results: The technique provided a diagnosis in 88% of cases, with a sensitivity of 87% and specificity of 100%. Where the provisional diagnosis was of a neoplastic lesion (n = 48), the diagnosis rate was 88%. Where the provisional diagnosis was of an infective lesion (n = 26), the diagnosis rate was 89%. Where the provisional diagnosis was uncertain (n = 8), the diagnosis rate was 88%. Conclusions: Percutaneous biopsy of vertebral lesions using the Harlow-Wood bone trephine under fluoroscopic guidance can be performed safely and efficaciously. The high accuracy and sensitivity of this closed percutaneous technique, particularly in infective lesions, allows a timely diagnosis and subsequent early commencement of appropriate treatment

Purpose: Massive endoprostheses have become the mainstay of treatment for reconstruction after resection of primary bone tumours. The Kotz Modular Femoral Tibial Replacement (KMFTR, Kotz prosthesis, Stryker Inc.) system has been one of the most widely utilized uncemented modular systems. Although this prosthesis has excellent bone ingrowth characteristics and a low aseptic loosening rate, we have identified a significant incidence of mechanical failure and breakage of the prosthesis. The purpose of this investigation is to review the outcomes after prosthetic revision for a broken Kotz prosthesis. Method: A retrospective review was undertaken of our institutional database from the years 1989, when we first utilized the Kotz prosthesis, until present. We identified all patients who had undergone a revision of the prosthesis for mechanical failure or prosthetic breakage. Periprosthetic fractures and revisions for polyethylene bushing wear were excluded. Results: 119 distal femoral, 55 proximal tibial and 47 proximal femoral Kotz endoprostheses (221 in total) have been implanted in our center since 1989. There were 21 revisions (9.5% of total prostheses) for mechanical failure. Of these, 16 were in the distal femur, four in the proximal tibia and one in the proximal femur. Mechanical failures occurred at a mean of 77 months (range 24–170). Of the 21 metal failures, 8 stems broke at the junction of the stem and body, 8 fractured through screw holes in the stem, 3 fractured the derotation lug, one fractured the tibial housing and one lateral side-plate failed. Of these failures only three implants had associated definite loosening and two of these three were cemented. Broken stems initially required extraction whilst preserving as much of the longitudinal and transverse bone stock as possible in order to facilitate osseo-mechanical integration of the revision prosthesis. This was accomplished using trephines to core the ingrown broken stem out of the bone. Over the last 20 years, the 16 broken stems have been revised in 5 patients to larger Kotz uncemented stems, 2 to cemented GMRS stems with an adaptor to the KMFTR system, 3 to Restoration uncemented revision hip stems with a custom adaptor to the KMFTR system, 2 to custom GMRS uncemented stems with an adaptor to the KMFTR system, and 4 to total femurs. All except one patient was alive with no evidence of disease. Post-revision, 14 patients had TESS, MSTS87, MSTS93 scores of 80.5, 25.5 and 70 respectively. Conclusion: Despite very low aseptic loosening rates, mechanical failure of the Kotz prosthesis continues to be a significant clinical problem even several years after implantation. Fatigue failure often leads to the difficult scenario of removing a well-ingrown uncemented stem. Our data illustrates that these prostheses can often be successfully revised by trephining out the broken stem and inserting new uncemented stems. Functional outcome continues to be good and is comparable to pre-revision levels

The well-fixed femoral stem can be challenging to remove. Removal of an extensively osteointegrated cementless stem requires disruption of the entire implant-bone interface while a well-fixed cemented stem requires complete removal of all adherent cement from the underlying cortical bone in both the metaphysis and diaphysis of the femur. In these situations, access to those areas of the femur distal to the metaphyseal flare that are beyond the reach of osteotomes and high speed burrs is necessary. This typically requires use of an extended femoral osteotomy (ETO). The ETO should be carefully planned so that it extends distal enough to allow for access to the end of the stem or cement column and still allow for stable fixation of a new implant. Too short of an ETO increases the risk of femoral perforation by straight burrs, trephines or cement removal instruments that cannot negotiate the bowed femoral canal to access the end of the cement column or end of the stem without risk of perforation. The ETO should also be long enough to allow for fixation with at least 2 cerclage cables. An ETO that is too distal makes implant and cement removal easier, but may not allow for sufficient fixation of a new revision femoral stem. After insertion of the revision stem, the osteotomy is reduced back around the stem and secured in place with cerclage cables

The battle of revision TKA is won or lost with safe, effective, and minimally bony-destructive implant removal, protecting all ligamentous stabilisers of the knee and, most importantly, the extensor mechanism. For exposure, incisions should be long and generous to allow adequate access. A standard medial parapatellar capsular arthrotomy is preferred. A synovectomy is performed followed by debridement of all scar tissue, especially in the medial and lateral gutters. All peripatellar scar tissue is excised followed by release of scar tissue within the patellar tendon, allowing for displacement or everting of the patella. As patellar tendon avulsion at any time of knee surgery yields disastrous results, the surgeon should be continuously evaluating the patellar tendon integrity, especially while displacing/everting the patella and bringing the knee into flexion. If displacement/eversion is difficult, consider rectis-snip, V-Y quadricepsplasty, or tibial tubercle osteotomy. The long-held requisite for patellar eversion prior to component removal is inaccurate. In most cases simple lateral patellar subluxation will provide adequate exposure. If a modular tibial system is involved, removal of the tibial polyethylene will decompress the knee, allowing for easier access to patellar, femoral, and tibial components. For patellar component removal, first identify the border of the patella, then carefully clean and debride the interface, preferably with electrocautery. If the tibial component is cemented all-polyethylene, remove using an oscillating saw at the prosthetic-bone interface. Debride the remaining cement with hand tools, ultrasonic tools, or burrs. Remove the remaining peg using a low-speed burr. If the tibial component is metal-backed, then utilise a thin saw blade or reciprocating saw to negotiate the undersurface of the component between the pegs. If pegs are peripherally located, cut with a diamond disc circular cutting tool. Use a trephine to remove the pegs. For femoral component removal, identify the prosthetic-bone/prosthetic-cement interface then remove soft tissue from the interface, preferably with electrocautery. Disrupt the interface around all aspects of the component, using any of following: Gigli saw for cementless components only, micro saw, standard oscillating saw, reciprocating saw, a series of thin osteotomes, or ultrasonic equipment. If the femoral component is stemmed, remove the component in two segments using an appropriate screwdriver to remove the screw locking the stem to the component. Remove the femoral component with a retrodriver or femoral component extractor. Debride cement with hand tools or burr, using care to avoid bone fracture. If a stem is present, then remove with the appropriate extraction device. If “mismatch” exists, where femoral (or likewise, tibial) boss is smaller in diameter than the stem, creating a cement block prohibiting stem removal, remove the cement with hand tools or burr. If the stem is cemented, use hand tools, ultrasonic tools, or a burr to debride the cement. Curette and clean the canals. For tibial component removal, disrupt the prosthetic-cement/prosthetic-bone interface using an oscillating or reciprocating saw. Gently remove the tibial component with a retrodriver or tibial extractor. If stem extensions are utilised, disengage and debride all proximal cement prior to removing the stem. If stem is present, then remove stem with appropriate extraction device. If stem is grit-blasted and well-fixed, create 8mm burr holes 1.5 to 2.5cm distal to tibial tray on medial aspect and a small divot using burr, then drive implant proximally with Anspach punch. Alternatively, a tibial tubercle osteotomy may be performed. If the stem is cemented, use hand tools, ultrasonic tools or burr to debride cement

Background. Fractures of the femoral component are well reported complications that present a challenging task in revision total hip arthroplasty. Albeit being uncommon, with an incidence of 0.23–11%, the consequences can be devastating. Its extraction being a demanding undertaking that is potentially detrimental to the remaining host bone. Several techniques have been described to address this complex issue prior to revision: drilling of the exposed part of the femoral stem and attaching a threaded extraction device, surface undercutting with an extraction device wedged in, femoral trephine techniques, creation of a femoral cortical window, an extended femoral osteotomy procedure, as well as extraction by means of retrograde nail impaction. Here we present the modified technique we employed in the revision of a failed cementless extensively porous coated femoral component that had fractured at the neck-stem interface. Technique. The proximal femoral component was visualized and an orthopedic burr and a femoral osteotome employed surrounding the component. Utilizing a Midas Rex® MR7 drill with its metal cutting attachment, a circular recess was created in the shoulder of the femoral component. This facilitated the application of the distal end of a universal slap hammer. The component was retrieved successfully with no associated bone loss negating the need for a femoral osteotomy. Discussion. Revision hip arthroplasty is a perplexing field where unpredictable prosthetic failures require innovation to tackle the unique problems encountered. Our method allows a safe and efficient alternative in retrieving femoral components with no associated complications

Aims

Therapeutic agents that prevent chondrocyte loss, extracellular matrix (ECM) degradation, and osteoarthritis (OA) progression are required. The expression level of epidermal growth factor (EGF)-like repeats and discoidin I-like domains-containing protein 3 (EDIL3) in damaged human cartilage is significantly higher than in undamaged cartilage. However, the effect of EDIL3 on cartilage is still unknown.

The recognition, investigation and management of osteoid osteoma has been well documented. Treatment can either be medical or surgical, studies have shown both options to have almost equal long term outcomes. However only surgical treatment involving complete excision of the lesion allows for confirmatory tissue diagnosis of osteoid osteoma especially important in cases where symptoms and signs are atypical. Several methods of surgical treatment with varying degrees of success have been described in literature. Here we describe a surgical techniques for the treatment of osteoid osteoma which enables removal of the lesion in a precise manner using a precision bone graft trephine with minimal excision of bone. This technique will be very useful in the excision of lesions in areas in which excessive excision of bone can lead to an unstable bony structure which can predispose to fracture. To our knowledge this surgical technique in the management of osteoid osteoma has not been described in the literature

Between 1994 and 2002, 81 patients underwent ulnohumeral arthroplasty for elbow arthritis at our institution. All patients were sent a questionnaire with a request to attend for a clinical evaluation. Forty replied and 34 attended for clinical examination, 6 females and 34 males with an average age of 63 years (32-80) and a mean follow-up of 6 years (2-10). There were 22 (55%) patients with primary osteoarthritis, 14 (35%) with osteoarthritis secondary to trauma, two patients with rheumatoid arthritis and one patient each with arthrogryphosis multiplex congenital and post-septic arthritis of the elbow. Using the VAS (0-10), the pain score was seen to improve from a mean pre-operative score of 8 (6-10) to 4 (0-9). 21 patients (50%) were on minimal or no analgesia and 31 (75%) patients felt they would have the surgery again for the same problem. The arc of motion as regards flexion/extension was found to increase by 19% while prono-supination was found to increase by 30%. There was one patient each with superficial infection, anterior interosseous nerve neuropathy and myositic ossificans while two patients had triceps rupture. Radiological examination showed that in 12 cases the trephine hole was partially obliterated while in 4 cases it was completely obliterated. This could not be correlated clinically. Patients with loose bodies seemed to do better in the post-operative phase. Ulnohumeral arthroplasty has a role in the management of the arthritic elbow as it provides pain relief in the post-operative period; however, the improvement in the range of movement is limited particularly as regards the arc of extension

The purpose of the study was to assess the incorporation of defatted, and deproteinated bovine cancellous bone in a sheep bone graft model. Cylindrical defects were created in the femoral condyles of 12 sheep using custom-made trephines. The defect was filled with a cylinder of prepared bovine bone. The removed cylinder of bone was implanted into a defect created in the opposite femoral condlyle. Fluorochrome bone labels were administered over an 8-week period and the sheep sacrificed at 10 weeks. Undecalcified thin bone sections were viewed with a fluorescent microscope. ln one sheep there was a technical problem leading to unsatisfactory histology. All other sheep showed similar histology. The autograft incorporated rapidly with the graft showing a rim of reactive bone and the graft itself showing rapid laying down of new bone on its surface. The xenograft showed a similar reactive rim of new bone with deposition of new bone throughout the graft and resorption of the graft material. This study demonstrates that specially prepared bovine cancellous bone can act as a scaffold for the depostion of new bone in a sheep model. The role of this material in humans is to be evaluated

Sutures are the strongest and the only time proven technique for meniscal repair. Sutures are safe and without surprises as long as the peroneal and the saphenus nerves are protected and avoided. Sutures can be placed via arthrotomy or under arthroscopic view. In pure suture techniques a sling holds the meniscus parts together or refixes the meniscus to the capsule. The orientation of the sling can be vertical, horizontal or oblique, but should always either catch the circumferential fibre bundles of the meniscal tissue or part of the densely woven meniscal surface. Suture related techniques make use of a thread but do not strive to form a sling. The earliest of these was the knot-end technique, the latest one is the Fastfix? repair. Either absorbable or non-absorbable material has been recommended but most would favour non-absorbable threads of 0 or 1–0 USP sizes. Depending on the course of the needle inside-out, outside-in and all-inside techniques have been described. For repair of intrasubstance tears the sutures have to be supplemented by measures to enhance healing as trephination of the meniscal periphery or addition of a fibrin clot to the repair side. There are regions of the menisci that are close to impossible to reach for the suture cannulas. For these it seems better to do a non-suture reconstruction with some of the innovative devices compared to leaving them alone or do meniscectomy instead of repair. Hybrid meniscal rapair, combining the advantages of sutures and new repair devices are in frequent use

Background. The Kotz Modular Femoral Tibial Replacement system has been one of the most widely utilised uncemented modular systems for bone and joint reconstruction after tumour resection. We have identified a significant incidence of mechanical failure and breakage of the prosthesis. The purpose of this investigation is to review the modes of implant failure and the outcomes after prosthetic revision for a broken Kotz prosthesis. Methods. Over 20 years there were 121 distal femoral, 55 proximal tibial, 47 proximal femoral and 12 total femoral replacements performed. Results. Out of 180 currently living patients there were 27 implant fractures in 23 patients (13%) with 22 distal femoral and five proximal tibial implant failures. Mechanical failures occurred at a mean of 77 months (range 24-170). There were 21 stem fractures. Five fractured at the derotation lug and one fractured the tibial housing. Lug fracture is an unreported mode of failure of these implants. The implant design selected for revision was very much dependent on when the fractured implant was revised. Eleven patients had new KMFTR stems inserted; 4 Restoration stems (one of which was cemented), 3 GMRS stems (one of which was cemented), two total femora and one Compress (Biomet) implants have been utilised, all with custom adaptors between the stem and the KMFTR system. There were 12 complications (44%), seven infections, three implant re-fractures, one vascular insufficiency necessitating amputation and one per-prosthetic fracture. The mean pre-implant fracture and post-revision TESS scores were 80.9 (Range 54.2-98.3) and 79.1 (50-96.7). The MSTS87 pre- and post- scores were 26.8 (14-33) and 26.1 (15-33) respectively. The MSTS93 also demonstrated no differences in the pre-fracture and post-revision scores with 75.4 (50-93) and 74.8 (40-100). Conclusion. Our data illustrate that these prostheses can often be successfully revised by trephining out the broken stem and inserting new uncemented stems. Functional outcome continues to be good and is comparable to pre-revision levels, despite a 44% complication rate