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 After this, the trocar with the stylet in place was gradually withdrawn with small oscillating motions to fill in the path of the trocar.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

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

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

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

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

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

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal tissue is a rare disease. An early and accurate diagnosis is often difficult because of the indolent clinical course and difficulty of isolating pathogens. Our goal was to determine the clinical features of musculoskeletal NTM infection and to present the treatment outcomes. A total of 29 patients (nine females, 20 males between 34 and 85 years old, mean age 61.7 years; 34 to 85) with NTM infection of the musculoskeletal system between 1998 to 2011 were identified and their treatment retrospectively analysed. Microbiological studies demonstrated NTM in 29 patients: the isolates were Mycobacterium intracellulare in six patients, M. fortuitum in three, M. abscessus in two and M. marinum in one. In the remaining patients we failed to identify the species. The involved sites were the hand/wrist in nine patients the knee in five patients, spine in four patients, foot in two patients, elbow in two patients, shoulder in one, ankle in two patients, leg in three patients and multiple in one patient. The mean interval between the appearance of symptoms and diagnosis was 20.8 months (1.5 to 180). All patients underwent surgical treatment and antimicrobial medication according to our protocol for chronic musculoskeletal infection: 20 patients had NTM-specific medication and nine had conventional antimicrobial therapy. At the final follow-up 22 patients were cured, three failed to respond to treatment and four were lost to follow-up. Identifying these diseases due the initial non-specific presentation can be difficult. Treatment consists of surgical intervention and adequate antimicrobial therapy, which can result in satisfactory outcomes.

Cite this article: Bone Joint J 2014;96-B:1561–5.