Aims

The surgical target for optimal implant positioning in robotic-assisted total knee arthroplasty remains the subject of ongoing discussion. One of the proposed targets is to recreate the knee’s functional behaviour as per its pre-diseased state. The aim of this study was to optimize implant positioning, starting from mechanical alignment (MA), toward restoring the pre-diseased status, including ligament strain and kinematic patterns, in a patient population.

Aims

Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary intramedullary fixation within the ilium combined with a monoflange for rotational stability, was anticipated to overcome this obstacle. The aim of this study was to evaluate the design with regard to functional outcome, complications, and acetabular reconstruction.

The February 2024 Oncology Roundup³⁶⁰ looks at: Does primary tumour resection improve survival for patients with sarcomas of the pelvis with metastasis at diagnosis?; Proximal femur replacements for an oncologic indication offer a durable endoprosthetic reconstruction option: a 40-year experience; The importance of awaiting biopsy results in solitary pathological proximal femoral fractures: do we need to biopsy solitary pathological fractures?; Effect of radiotherapy on local recurrence, distant metastasis, and overall survival in 1,200 extremity soft-tissue sarcoma patients; What to choose in bone tumour resections? Patient-specific instrumentation versus surgical navigation; Optimal timing of re-excision in synovial sarcoma patients: immediate intervention versus waiting for local recurrence; Survival differences of patients with resected extraskeletal osteosarcoma receiving two different (neo) adjuvant chemotherapy regimens; Solitary versus multiple bone metastases in the appendicular skeleton: should the surgical treatment be different?.

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Aims. The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection. Methods. From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients. Results. Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively. Conclusion. The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747–757

INTRODUCTION. Lumbar total disc replacement (TDR) is an alternative treatment to avoid fusion related adverse events, specifically adjacent segment disease. New generation of elastomeric non-articulating devices have been developed to more effectively replicate the shock absorption and flexural stiffness of native disc. This study reports 5 years clinical and radiographic outcomes, range of motion and position of the center of rotation after a viscoelastic TDR. Material and methods. This prospective observational cohort study included 61 consecutive patients with monosegmental TDR. We selected patients with intermediate functional activity according to Baecke score. Hybrid constructs had been excluded. Only cases with complete clinical and radiological follow-up at 3, 6, 12, 24 and 60 months were included. Mean age at the time of surgery was 42.8 +7.7 years-old (27–60) and mean BMI was 24.2 kg/m² +3.4 (18–33). TDR level was L5-S1 in 39 cases and L4-L5 in 22 cases. The clinical evaluation was based on Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI) score, Short Form-36 (SF36) including physical component summary (PCS) and mental component summary (MCS) and General Health Questionnaire GHQ28. The radiological outcomes were range of motion and position of the center of rotation at the index and the adjacent levels and the adjacent disc height changes. Results. There was a significant improvement in VAS (3.3±2.5 versus 6.6±1.7, p<0.001), in ODI (20±17.9 versus 51.2±14.6, p<0.001), GHQ28 (52.6±15.5 versus 64.2±15.6, p<0.001), SF 36 PCS (58.8±4.8 versus 32.4±3.4, p<0.001) and SF 36 MCS(60.7±6 versus 42.3±3.4, p<0.001). Additional surgeries were performed in 5 cases. 3 additional procedures were initially planified in the surgical program: one adjacent L3-L5 ligamentoplasty above a L5S1 TDR and two L5S1 TDR cases had additional laminectomies. Fusion at the index level was secondary performed in 2 L4L5 TDR cases but the secondary posterior fusion did not bring improvement. In the 56 remaining patients none experienced facet joint pain. One patient with sacroiliac pain needed local injections. Radiological outcomes were studied on 56 cases (exclusion of 5 cases with additional surgeries). The mean location centers of the index level and adjacent discs were comparable to those previously published in asymptomatic patients. According to the definition of Ziegler, all of our cases remained grade 0 for disc height (within 25% of normal). Discussion. The silent block design of LP-ESP provides an interesting specificity. It could be the key factor that makes the difference regarding facets problems and instability reported with other implants experimentally or clinically. Unfortunately no other comparative TDR series are available yet in the literature. Conclusion. This series reports significant improvement in mid-term follow up after TDR which is consistent with previously published studies but with a lower rate of revision surgery and no adjacent level disease pathologies. The radiographic assessment of the patients demonstrated the quality of functional reconstruction of the lumbar spine after LP ESP viscoelastic disc replacement

Aims

We present a retrospective review of patients treated with extracorporeally irradiated allografts for primary and secondary bone tumours with the mid- and long-term survivorship and the functional and radiographic outcomes.

Introduction. Since 1989 we have been using custom lateral-flare stems. Using this stem, its lateral flare can produce high proximal fit and less fit in distal part. Applying this automatic designing software to the average femoral geometries, we can make off the shelf high proximal fit stem (Revelation ®). Putting the off the shelf stem, the original center of the femoral heads were well reproduced. But in DDH cases, severe deformities around hip sometimes make complicated difficulty for better functional reconstruction. They are high hip center such as Crowe II-IV, shortening of the femoral neck, high anteversion etc. DDH cases are well known to have higher anteversion than non DDH cases. There would be no definite explanations for it. The high anteversion would not always be harmful for the preoperative patients. But in some cases, osteophytes are observed at posterior side of the femoral head which make another sphere with different centre. We can guess that the patient's biomechanics had not been matched with the original anteversion. Then posterior osteophytes can correct inappropriate anteversion (self-reduction.) (Fig.1) In those patients, reduction of the anteversion by putting stems twisted into the canal or using modular stems are sometimes done by the surgeons' decision. Younger DDH cases can also be treated with THA, because of the complicated deformities or biomechanical disorders. Short stems are expected to reduce operative invasion and stress shielding then can reserve bone quality and quantity. From these point of view to improve the understanding of the characteristics of the DDH anteversion, and design a DDH oriented short stem could be one of good solution for those cases. Method. For the better understanding of the high anteversion 57 femora (mean anteversion: 34.4 deg.) were analyzed slice by slice. The direction of femoral head centre, lesser trochanter (LTR), linea aspera (aspera) just below LTR, aspera in the middle of the femur and aspera between the last 2 sections. All of the directions were assessed from PC line. To clarify the meaning of the head osteophytes, 35 operated cases were analyzed the extent of the head osteophytes. According to the results, a DDH oriented short stem was designed. Results. Even with the different anteversion, femoral head centres and LTRs were located within limited angle (51.4 +/−7.9 deg.) But aspera just below the LTR had no relation to the LTR direction, but always kept within limited angle (102.0 +/− 4.5) to the PC line. This means that DDH cases have proximal femurs of normal shape. But they are only twisted around the level just below the LTR. From this result, stems for DDH cases can have the same shape with normal stem inside the canal. The posterior osteophytes had reduced 4.6+/− 3.0 degree in average independently to the extent of anteversion. There was no tendency that higher anteversion cases have higher self-reduction angle. the stems were give the same shape inside the canal with stems for non DDH cases but its femoral head center was located with 5 degrees less anteversion

Reconstructing mandibular and maxillary bone defects with free vascularized bone flaps requires to take into account the aesthetic and functional requirements to consider subsequent placement of dental implants. It implies a three-dimensional conformation of the bone fragment. This is usually done by making osteotomies on the bone harvested. The aim of our study was to evaluate the interest of virtual planning and 3D printing using free software and a consumer printer in this indication. Invesalius® software (Technology of Information Renato Archer Center, Campinas, Brazil) was used to build virtual models from the patients' CT scan imaging data. The surgical procedure was planned using Meshmixer® (Autodesk, San Rafael, United States). Meshlab® software (Visual Computing Lab, Pisa, Italy) was used to design cutting guides for the flap harvest and modelling. 3D printing of these guides with a consumer printer (Ultimaker 2® Ultimaker B.V., Geldermalsen, the Netherlands) allowed the transfer of the planning to the operating room. Three patients requiring mandibular reconstruction underwent an iliac crest free flap, a fibula free flap and a scapula free flap, and could benefit from this technique. In each case, the bone resection was performed virtually and the positioning of the bone available at the donor site was simulated on screen. This allowed to anticipate the position and orientation of the cutting planes on the bone flap. From the anatomy of the donor site and the cutting planes, harvest templates and cutting guides could be designed by computer. Planning the conformation of the bone flap to the recipient site has allowed an anatomical, aesthetic and functional reconstruction of the bone defect. Surgeon-made virtual planning and “low cost” 3D printing helps harvest the bone flap and position and orient the osteotomies to adapt it to the defect. They provide, both the patient and the surgeon, reduced operative time and better anticipation of the result, particularly in the context of the maxillofacial reconstruction. Compared to commercially available custom-made devices, this technique allows the manufacture of the guides without delay and at a cheap price

This pilot study reports the clinical outcomes of a combination of partial subscapularis tendon transfer and small-head hemiarthroplasty in patients with rotatator cuff arthropathy. A total of 30 patients (30 shoulders; eight men and 22 women) with a mean age of 74 years (55 to 84) were assessed at a mean follow-up of 31 months (24 to 60). The inclusion criteria were painful cuff tear arthropathy with normal deltoid function and a non-degenerative subscapularis muscle and tendon and a preserved teres minor.

Outcome was assessed using the University of California Los Angeles score, the Japanese Orthopaedic Association score, and the Oxford Shoulder Score. Radiographic measurements included the centre of rotation distance and the length of the deltoid.

All clinical scores were significantly improved post-operatively. The active flexion and external rotation improved significantly at the most recent follow-up (p < 0.035). Although the mean centre of rotation distance changed significantly (p < 0.001), the mean length of the deltoid did not change significantly from the pre-operative value (p = 0.29). The change in the length of the deltoid with < 100° flexion was significantly less than that with > 100° (p < 0.001).

Progressive erosion of the glenoid was seen in four patients. No patient required revision or further surgery.

A combination of partial subscapularis tendon transfer and small-head hemiarthroplasty effectively restored function and relieved pain in patients with rotator cuff arthropathy.

Cite this article: 2015;97-B:1090–5.

To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing’s sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively. We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing’s sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27). This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates. Cite this article: Bone Joint J 2013;95-B:1410–16

Introduction. Failed operated intertrochanteric fractures (with screw cutout, joint penetration, varus collapse, nonunion, or femoral head avascular necrosis) pose treatment dilemmas. The ideal approach is re-osteosynthesis with autologous bone grafting. When the femoral head is unsalvageable, conversion to a prosthetic hip replacement is necessary. Materials/Methods. Thirty-seven patients with failed dynamic hip screw fixation (and unsalvageable femoral heads) were treated with cementless hip arthroplasty (13 underwent Bipolar Arthroplasty, 24 had Total Hip Arthroplasty) over a 5-year period (Dec 2005 to Nov 2010). Seven needed a modified trochanteric split, and the rest were managed by standard anterolateral approach. Abductor mechanism was reconstructed using strong nonabsorbable sutures (ethibond 5) or stainless steel wires. The calcar was partially reconstructed using remnant femoral head and cerclage wiring in a few cases. Results. Clinico-radiological assessment was done at three, six, 12 months and yearly thereafter over an average 36 months (range, three to 60 months). Stem loosening, lysis, subsidence and trochanteric union were studied. At last follow-up, one patient had died, and there were two instances each of stem subsidence and trochanteric nonunion. Clinical results using Harris hip scores were good or excellent. Conclusion. Management of nonsalvageable femoral heads after failed intertrochanteric fracture fixation is possible with cementless hip arthroplasty. Successful outcomes depend on functional abductor reconstruction, fracture and femoral shaft penetration prevention. Autograft, allograft or head/neck replacement components are necessary sometimes

The current indications for functional restoration of extension of the knee following quadriceps resection or loss require reappraisal. The contribution of pedicled and free functional muscle transfer is likely to be over-emphasised in many studies, with good functional outcomes predominantly reported only in the context of cases with residual quadriceps function. In cases with total quadriceps resection or loss, all forms of reconstruction perform poorly. Furthermore, in smaller resections with loss of two or fewer components of the quadriceps, minimal impairment of function occurs in the absence of functional reconstruction, suggesting that functional restoration may not be warranted. Thus there is a paradox in the current approach to quadriceps reconstruction, in that small resections are likely to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and rationale for reconstructing functional extension of the knee after quadriceps resection or loss. A classification based on current evidence is suggested that emphasises more clearly the indications and rationale for functional transfers

Prior to the 1970s, almost all bone sarcomas were treated by amputation. The first distal femoral resection and reconstruction was performed in 1973 by Dr Kenneth C Francis at the Memorial Sloan-Kettering Cancer Centre in New York. Since that time, limb-sparing surgery for primary sarcoma has become the mainstay of sarcoma surgery throughout the world. Initially, the use of mega-prostheses of increasing complexity, involving all the major long bones and both pelvic and shoulder girdles, was popularised. In the early 1980s, wide use of massive allograft reconstructions became widespread in both Europe and in multiple centres in the USA and UK. Since that time, increasing complexity in the design of prostheses has allowed for increasing functional reconstructions to occur, but the use of allograft has become less popular due to the development of late graft failures of patients survive past ten years. Fracture rates approaching 50% at 10 years are reported, and thus, other forms of reconstruction are being sought. Techniques of leg lengthening, and bone docking procedures to replace segmental bone loss to tumour are now employed, but the use of biological vascularised reconstructions are becoming more common as patient survivorship increases with children surviving their disease. The use of vascularised fibular graft, composite grafts and re-implantation of extra-corporeally irradiated bone segments are becoming more popular. The improvement in survivorship brought about the use of chemotherapy is producing a population of patients with at least a 65% ten year survivorship, and as many of these patients are children, limb salvage procedures have to survive for many decades. The use of growing prostheses for children have been available for some 25 years, first commencing in Stanmore, UK, with mechanical lengthening prostheses. Non-invasive electro-magnetic induction coil mechanisms are now available to produce leg lengthening, with out the need for open surgery. Whilst many of these techniques have great success, the area of soft tissue attachment to metallic prostheses has not been solved, and reattachment of muscles is of great importance, of course, for return of function. There are great problems in the shoulder joints where sacrifice of rotator cuff muscles is necessary in obtaining adequate disease clearance at the time of primary resection, and a stable shoulder construct, with good movement, has yet to emerge. Similar areas of great difficultly remain the peri-acetabular and sacro-iliac resections in the pelvis. Perhaps the real future of the art of limb salvage will be in the reconstruction of failed major joint replacements where there is great loss of bone stock, and already massive tumour prostheses are providing a salvage pathway for failed standard joint replacement. The final future for limb salvage, however, may not rest with increasing surgical complexity and innovation, but with the development of molecular biology and specific targeted treatments, according to the cytogenetics of a particular tumour. We are on the threshold of yet another quantum change in the approach to cancer management; just as chemotherapy brought a tremendous change in the 1970s, molecular biology is the frontier to make much of the current limb salvage surgery that is performed redundant

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°. The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved

We report our early experience with a new peri-acetabular reconstruction endoprosthesis used for pelvic reconstruction after tumour resection. The outcome of 21 patients who underwent limb salvage following type II pelvic resection and reconstruction using the peri-acetabular reconstruction prosthesis between 2000 and 2006 was retrospectively reviewed. This prosthesis was designed to use the remaining part of the ilium to support a horizontally placed acetabular component secured with internal fixation and bone cement. Into this device a constrained acetabular liner is positioned which is articulates with a conventional femoral component to which a modular extension and modular head are attached. The mean follow-up was 20.5 months (1 to 77). The most common complications were deep infection, superficial wound infections, and dislocation. The mean musculoskeletal tumor society functional outcome score for the survivors was 20.1(11 to 27).

We recommend the use of the peri-acetabular reconstruction prosthesis for reconstruction of large defects after type II pelvic resection, as this design has a greater inherent stability over other available prostheses.

Despite extensive experience with prosthetic replacement for the reconstruction of limbs following juxta-articular resection of tumours, there are few reports of prosthetic replacement of the distal radius. We present two cases of massive bone defects of the distal radius in which alumina ceramic prosthetic replacements were used. We evaluated the patients more than ten years after the procedure. Both patients had degenerative changes to the wrist. This, however, was not associated with pain or decreased function, and both had returned to their previous occupation after surgery.

When a patient has a massive defect of the distal radius, reconstruction using a ceramic prosthesis is a reasonable alternative to using autograft. This method of treatment results in little pain, a moderate range of movement and satisfactory function.

The multiplicity of factors that influence the clinical evolution of discopathies, determine a great diversity in its presentation. The barely known genetic predisposition, the individual morphological aspects, the age and sex, the associated co-morbidities as well as the patient environment define in its all an individual context that influences decisively the treatment for each patient. On the other hand, the identification in each case of the different stages of the multilevel DDD, causes doubts regarding the involvement of each segment in the respective clinical condition. To singly identify all sources of pain, and not only each painful level, is the main challenge poised to the spine surgeon when defining the treatment strategy. The diagnosis aggressiveness must be proportional to its doubts, and the discography, the disco-scanner and the facet blocks are fundamental when the conventional clinical investigation is inconclusive. The use of minimal invasive techniques such as IDET or Coblation can be considerate as alternatives, especially in the early stages of single-level DDD. The nucleoplasthy – nuclear prosthesis- is an interesting alternative in the intermediate stages of the discogenic pain DDD, as well as in the predominant facet pain or in the foraminal dynamic stenosis is the dynamic stabilization. Those are techniques with controversial results and which liability in some cases is yet to be proven. Last, the use of different techniques in different levels in the context of multi-level DDD – ex: fusion + disc replacement; disc replacement + dynamic stabilization with or without decompression procedures in the spinal canal- must be rigorously considered according to the specific dysfunction of each segment and considering the anatomical and functional reconstruction of the spine