Abstract. MAGnetic Expansion Control (MAGEC) rods are used in the surgical treatment of children with early onset scoliosis. The magnetically controlled lengthening mechanism enables rod distractions without the need for repeated invasive surgery. The CE certification of these devices was suspended in March 2021 due, primarily, to performance evidence gaps in the documents provided by the manufacturer to regulators and notified bodies. MAGEC rods are therefore not permitted for use in countries requiring CE marking. This was a survey of 18 MAGEC rod surgeons in the UK about their perception of the impact of the CE suspension on the clinical management of their patients. Unsurprisingly, virtually all perceived a negative impact, reflecting the complexity of this patient group. Reassuringly, these surgeons are highly experienced in alternative treatment methods. Cite this article: Bone Jt Open 2022;3(2):155–157

Aims. This study aims to enhance understanding of clinical and radiological consequences and involved mechanisms that led to corrosion of the Precice Stryde (Stryde) intramedullary lengthening nail in the post market surveillance era of the device. Between 2018 and 2021 more than 2,000 Stryde nails have been implanted worldwide. However, the outcome of treatment with the Stryde system is insufficiently reported. Methods. This is a retrospective single-centre study analyzing outcome of 57 consecutive lengthening procedures performed with the Stryde nail at the authors’ institution from February 2019 until November 2020. Macro- and microscopic metallographic analysis of four retrieved nails was conducted. To investigate observed corrosion at telescoping junction, scanning electron microscopy (SEM) and energy dispersive x-ray spectroscopy (EDX) were performed. Results. Adjacent to the nail’s telescoping junction, osteolytic changes were observed in bi-planar radiographs of 20/57 segments (35%) after a mean of 9.5 months (95% confidence interval 7.2 to 11.9) after surgery. A total of 8/20 patients with osseous alterations (40%) reported rest and ambulation pain of the lengthened segment during consolidation. So far, 24 Stryde nails were retrieved and in 20 (83%) macroscopic corrosion was observed at the nail’s telescoping junction. Before implant removal 11/20 radiographs (55%) of lengthened segments with these 20 nails revealed osteolysis. Implant retrieval analysis by means of SEM showed pitting and crevice corrosion. EDX detected chromium as the main metallic element of corrosion. Conclusion. Patients are exposed to the risk of implant-related osteolysis of unclear short- and long-term clinical consequences. The authors advocate in favour of an early implant removal after osseous consolidation. Cite this article: Bone Joint Res 2021;10(7):425–436

Objectives. Bioresorbable orthopaedic devices with calcium phosphate (CaP) fillers are commercially available on the assumption that increased calcium (Ca) locally drives new bone formation, but the clinical benefits are unknown. Electron beam (EB) irradiation of polymer devices has been shown to enhance the release of Ca. The aims of this study were to: 1) establish the biological safety of EB surface-modified bioresorbable devices; 2) test the release kinetics of CaP from a polymer device; and 3) establish any subsequent beneficial effects on bone repair in vivo. Methods. ActivaScrew Interference (Bioretec Ltd, Tampere, Finland) and poly(L-lactide-co-glycolide) (PLGA) orthopaedic screws containing 10 wt% β-tricalcium phosphate (β-TCP) underwent EB treatment. In vitro degradation over 36 weeks was investigated by recording mass loss, pH change, and Ca release. Implant performance was investigated in vivo over 36 weeks using a lapine femoral condyle model. Bone growth and osteoclast activity were assessed by histology and enzyme histochemistry. Results. Calcium release doubled in the EB-treated group before returning to a level seen in untreated samples at 28 weeks. Extensive bone growth was observed around the perimeter of all implant types, along with limited osteoclastic activity. No statistically significant differences between comparative groups was identified. Conclusion. The higher than normal dose of EB used for surface modification did not adversely affect tissue response around implants in vivo. Surprisingly, incorporation of β-TCP and the subsequent accelerated release of Ca had no significant effect on in vivo implant performance, calling into question the clinical evidence base for these commercially available devices. Cite this article: I. Palmer, S. A. Clarke, F. J Buchanan. Enhanced release of calcium phosphate additives from bioresorbable orthopaedic devices using irradiation technology is non-beneficial in a rabbit model: An animal study. Bone Joint Res 2019;8:266–274. DOI: 10.1302/2046-3758.86.BJR-2018-0224.R2

We split 100 porcine flexor tendons into five groups of 20 tendons for repair. Three groups were repaired using the Pennington modified Kessler technique, the cruciate or the Savage technique, one using one new device per tendon and the other with two new devices per tendon. Half of the tendons received supplemental circumferential Silfverskiöld type B cross-stitch. The repairs were loaded to failure and a record made of their bulk, the force required to produce a 3 mm gap, the maximum force applied before failure and the stiffness. When only one device was used repairs were equivalent to the Pennington modified Kessler for all parameters except the force to produce a 3 mm gap when supplemented with a circumferential repair, which was equivalent to the cruciate. When two devices were used the repair strength was equivalent to the cruciate repair, and when the two-device repair was supplemented with a circumferential suture the force to produce a 3 mm gap was equivalent to that of the Savage six-strand technique

Patient warming significantly decreases the risk of surgical site infection. Recently there have been concerns that forced air warming may interfere with unidirectional airflow, potentially posing an increased risk of infection. Our null hypothesis was that forced air and radiant warming devices do not increase the temperature and the number of particles over the surgical site when compared with no warming device. A forced air warming device was compared with a radiant warming device and no warming device as a control. The temperature and number of particles were measured over the surgical site. The theatre was prepared as for a routine lower-limb arthroplasty operation, and the same volunteer was used throughout the study. Forced air warming resulted in a significant mean increase in the temperature (1.1°C vs 0.4°C, p < 0.0001) and number of particles (1038.2 vs 274.8, p = 0.0087) over the surgical site when compared with radiant warming, which raises concern as bacteria are known to require particles for transport

Objectives. Platelet-rich fibrin matrix (PRFM) has been proved to enhance tenocyte proliferation but has mixed results when used during rotator cuff repair. The optimal PRFM preparation protocol should be determined before clinical application. To screen the best PRFM to each individual’s tenocytes effectively, small-diameter culture wells should be used to increase variables. The gelling effect of PRFM will occur when small-diameter culture wells are used. A co-culture device should be designed to avoid this effect. Methods. Tenocytes harvested during rotator cuff repair and blood from a healthy volunteer were used. Tenocytes were seeded in 96-, 24-, 12-, and six-well plates and co-culture devices. Appropriate volumes of PRFM, according to the surface area of each culture well, were treated with tenocytes for seven days. The co-culture device was designed to avoid the gelling effect that occurred in the small-diameter culture well. Cell proliferation was analyzed by water soluble tetrazolium-1 (WST-1) bioassay. Results. The relative quantification (condition/control) of WST-1 assay on day seven revealed a significant decrease in tenocyte proliferation in small-diameter culture wells (96 and 24 wells) due to the gelling effect. PRFM in large-diameter culture wells (12 and six wells) and co-culture systems induced a significant increase in tenocyte proliferation compared with the control group. The gelling effect of PRFM was avoided by the co-culture device. Conclusion. When PRFM and tenocytes are cultured in small-diameter culture wells, the gelling effect will occur and make screening of personalized best-fit PRFM difficult. This effect can be avoided with the co-culture device. Cite this article: C-H. Chiu, P. Chen, W-L. Yeh, A. C-Y. Chen, Y-S. Chan, K-Y. Hsu, K-F. Lei. The gelling effect of platelet-rich fibrin matrix when exposed to human tenocytes from the rotator cuff in small-diameter culture wells and the design of a co-culture device to overcome this phenomenon. Bone Joint Res 2019;8:216–223. DOI: 10.1302/2046-3758.85.BJR-2018-0258.R1

Aims. This study aims to evaluate a new home medical stretching device called the Self Treatment Assisted Knee (STAK) tool to treat knee arthrofibrosis. Methods. 35 patients post-major knee surgery with arthrofibrosis and mean range of movement (ROM) of 68° were recruited. Both the STAK intervention and control group received standard physiotherapy for eight weeks, with the intervention group additionally using the STAK at home. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at all timepoints. An acceptability and home exercise questionnaire capturing adherence was recorded after each of the interventions. Results. Compared to the control group, the STAK intervention group made significant gains in mean ROM (30° versus 8°, p < 0.0005), WOMAC (19 points versus 3, p < 0.0005), and OKS (8 points versus 3, p < 0.0005). The improvements in the STAK group were maintained at long-term follow-up. No patients suffered any complications relating to the STAK, and 96% of patients found the STAK tool ‘perfectly acceptable’. Conclusion. The STAK tool is effective in increasing ROM and reducing pain and stiffness. Patients find it acceptable and adherence to treatment was high. This study indicates that the STAK tool would be of benefit in clinical practice and may offer a new, cost-effective treatment for arthrofibrosis. Cite this article: Bone Joint Open 2020;1-8:465–473

We retrospectively reviewed 40 hips in 36 patients who had undergone acetabular reconstruction using a titanium Kerboull-type acetabular reinforcement device with bone allografts between May 2001 and April 2006. Impacted bone allografts were used for the management of American Academy of Orthopaedic Surgeons Type II defects in 17 hips, and bulk bone allografts together with impacted allografts were used for the management of Type III defects in 23 hips. A total of five hips showed radiological failure at a mean follow-up of 6.7 years (4.5 to 9.3), two of which were infected. The mean pre-operative Merle d’Aubigné score was 10 (5 to 15) vs 13.6 (9 to 18) at the latest follow-up. The Kaplan-Meier survival rate at ten years, calculated using radiological failure or revision of the acetabular component for any reason as the endpoint, was 87% (95% confidence interval 76.3 to 97.7). A separate experimental analysis of the mechanical properties of the device and the load-displacement properties of bone grafts showed that a structurally hard allograft resected from femoral heads of patients with osteoarthritis should be preferentially used in any type of defect. If impacted bone allografts were used, a bone graft thickness of < 25 mm was acceptable in Type II defects. This clinical study indicates that revision total hip replacement using the Kerboull-type acetabular reinforcement device with bone allografts yielded satisfactory mid-term results

The optimal characteristics of pneumatic compression for mechanical prophylaxis of thromboembolism after total knee arthroplasty (TKA) are not known. Our study compared two methods of calf compression, with the hypothesis that the device which provided a larger increase in peak venous velocity would produce a lower rate of thromboembolism. We performed a prospective, randomised study on 423 patients (472 knees). Duplex ultrasonography was carried out by experienced technicians who were blinded to the device used. Overall, 206 patients (232 knees) used a rapid inflation, asymmetrical compression (RIAC) device and 217 (240 knees) a sequential circumferential compression device (SCD). The rate of venous thromboembolism was 6.9% with the RIAC device compared with 15% for the SCD device (p = 0.007). The incidence of thrombi with unilateral primary TKA was 8.4% for the RIAC compared with 16.8% for the SCD device (p = 0.03). In 47 patients with a bilateral TKA, the incidence of thrombi was 4% for the RIAC compared with 22.7% for the SCD device (p = 0.05 per knee). There was a low rate of mortality and pulmonary embolism when using mechanical prophylaxis for thromboembolism after TKA. Our findings show that the use of rapid inflation, asymmetrical calf compression gave a significantly lower rate of thromboembolism

Pain, swelling and inflammation are expected during the recovery from total knee arthroplasty (TKA) surgery. The severity of these factors and how a patient copes with them may determine the ultimate outcome of a TKA. Cryotherapy and compression are frequently used modalities to mitigate these commonly experienced sequelae. However, their effect on range of motion, functional testing, and narcotic consumption has not been well-studied. A prospective, multi-center, randomised trial was conducted to evaluate the effect of a cryopneumatic device on post-operative TKA recovery. Patients were randomised to treatment with a cryopneumatic device or ice with static compression. A total of 280 patients were enrolled at 11 international sites. Both treatments were initiated within three hours post-operation and used at least four times per day for two weeks. The cryopneumatic device was titrated for cooling and pressure by the patient to their comfort level. Patients were evaluated by physical therapists blinded to the treatment arm. Range of motion (ROM), knee girth, six minute walk test (6MWT) and timed up and go test (TUG) were measured pre-operatively, two- and six-weeks post-operatively. A visual analog pain score and narcotic consumption was also measured post-operatively. At two weeks post-operatively, both the treatment and control groups had diminished ROM and function compared to pre-operatively. Both groups had increased knee girth compared to pre- operatively. There was no significant difference in ROM, 6MWT, TUG, or knee girth between the 2 groups. We did find a significantly lower amount of narcotic consumption (509 mg morphine equivalents) in the treatment group compared with the control group (680 mg morphine equivalents) at up to two weeks postop, when the cryopneumatic device was being used (p < 0.05). Between two and six weeks, there was no difference in the total amount of narcotics consumed between the two groups. At six weeks, there was a trend toward a greater distance walked in the 6MWT in the treatment group (29.4 meters versus 7.9 meters, p = 0.13). There was a significant difference in the satisfaction scores of patients with their cooling regimen, with greater satisfaction in the treatment group (p < 0.0001). There was no difference in ROM, TUG, VAS, or knee girth at six weeks. There was no difference in adverse events or compliance between the two groups. A cryopneumatic device used after TKA appeared to decrease the need for narcotic medication from hospital discharge to 2 weeks post-operatively. There was also a trend toward a greater distance walked in the 6MWT. Patient satisfaction with the cryopneumatic cooling regimen was significantly higher than with the control treatment.

Aims. Local antibiotics are used in the surgical management of foot infection in diabetic patients. This systematic review analyzes the available evidence of the use of local antibiotic delivery systems as an adjunct to surgery. Materials and Methods. Databases were searched to identify eligible studies and 13 were identified for inclusion. Results. Overall, the quality of the studies was poor. A single trial suggested that wound healing is quicker when a gentamicin-impregnated collagen sponge was implanted at time of surgery, with no difference in length of stay or rate of amputation. Results from studies with high risk of bias indicated no change in wound healing when a gentamicin-impregnated sponge was implanted during transmetatarsal amputation, but a reduction in the incidence of wound breakdown (8% vs 25%, not statistically significant) was identified. A significant cost reduction was identified when using an antimicrobial gel to deliver antibiotics and anti-biofilm agents (quorum-sensing inhibitors) compared with routine dressings and systemic antibiotics. Analyses of case series identified 485 patients who were treated using local antibiotic delivery devices. The rates of wound healing, re-operation, and mortality were comparable to those that have been previously reported for the routine management of these infections. Conclusion. There is a lack of good-quality evidence to support the use of local antibiotic delivery devices in the treatment of foot infections in patients with diabetes. Cite this article: Bone Joint J 2018;100-B:1409–15

Implant-associated infection is a major source of morbidity in orthopaedic surgery. There has been extensive research into the development of materials that prevent biofilm formation, and hence, reduce the risk of infection. Silver nanoparticle technology is receiving much interest in the field of orthopaedics for its antimicrobial properties, and the results of studies to date are encouraging. Antimicrobial effects have been seen when silver nanoparticles are used in trauma implants, tumour prostheses, bone cement, and also when combined with hydroxyapatite coatings. Although there are promising results with in vitro and in vivo studies, the number of clinical studies remains small. Future studies will be required to explore further the possible side effects associated with silver nanoparticles, to ensure their use in an effective and biocompatible manner. Here we present a review of the current literature relating to the production of nanosilver for medical use, and its orthopaedic applications.

Cite this article: Bone Joint J 2015; 97-B:582–9.

Objectives. Secondary fracture healing is strongly influenced by the stiffness of the bone-fixator system. Biomechanical tests are extensively used to investigate stiffness and strength of fixation devices. The stiffness values reported in the literature for locked plating, however, vary by three orders of magnitude. The aim of this study was to examine the influence that the method of restraint and load application has on the stiffness produced, the strain distribution within the bone, and the stresses in the implant for locking plate constructs. Methods. Synthetic composite bones were used to evaluate experimentally the influence of four different methods of loading and restraining specimens, all used in recent previous studies. Two plate types and three screw arrangements were also evaluated for each loading scenario. Computational models were also developed and validated using the experimental tests. Results. The method of loading was found to affect the gap stiffness strongly (by up to six times) but also the magnitude of the plate stress and the location and magnitude of strains at the bone-screw interface. Conclusions. This study demonstrates that the method of loading is responsible for much of the difference in reported stiffness values in the literature. It also shows that previous contradictory findings, such as the influence of working length and very large differences in failure loads, can be readily explained by the choice of loading condition. Cite this article: A. MacLeod, A. H. R. W. Simpson, P. Pankaj. Experimental and numerical investigation into the influence of loading conditions in biomechanical testing of locking plate fracture fixation devices. Bone Joint Res 2018;7:111–120. DOI: 10.1302/2046-3758.71.BJR-2017-0074.R2

We retrospectively evaluated 42 hips which had undergone acetabular reconstruction using the Kerboull acetabular reinforcement device between September 1994 and December 1998. We used autogenous bone chips from the ilium and ceramic particle morsellised grafts, even in large acetabular bone defects, in the early stages of the study. Thereafter, femoral head allograft was used as bulk graft in patients with large acetabular defects. Ceramic blocks and the patients’ contralateral femoral head were also used as bulk graft. The mean follow-up period was 8.7 years (4.3 to 12). Survivorship analysis was performed using radiological failure of the acetabular component, irrespective of whether it was revised, or not, as the end-point. The survival rate of the morsellised graft group (25 hips) and the bulk graft group (17 hips) at ten years was 53% (95% confidence interval (CI) 42.5% to 63.5%) and 82% (95% CI 72.4% to 91.6%), respectively. The mid-term results of revision total hip replacement with the Kerboull device were better when bulk graft was used in any size of bone defect

Aims. The purpose of this current multicentre study is to analyse the presence of alpha-defensin proteins in synovial fluid using the Synovasure lateral flow device and to determine its diagnostic reliability and accuracy compared with the prosthetic joint infection (PJI) criteria produced by the Musculoskeletal Infection Society (MSIS). Patients and Methods. A cohort of 121 patients comprising 85 total knee arthroplasties and 36 total hip arthroplasties was prospectively evaluated between May 2015 and June 2016 in three different orthopaedic centres. The tests were performed on patients with a chronically painful prosthesis undergoing a joint aspiration in a diagnostic pathway or during revision surgery. Results. Based on the MSIS criteria, 34 patients (28%) would have had a PJI, and 87 patients had no PJI. Testing with the lateral flow device had a sensitivity of 97.1% (95% confidence intervals (CI) 84.5 to 99.9) and a specificity of 96.6% (95% CI 90.3 to 99.2). The positive predictive value was 91.7% (95% CI 77.7% to 98.3), and the negative predictive value was 98.8% (95% CI 93.6 to 99.9). Receiver operator characteristics analysis demonstrated an area under the curve for the Synovasure test of 0.97 (95% CI 0.93 to 1.00). Conclusion. Our findings suggest that the Synovasure test has an excellent diagnostic performance to confirm or reject the diagnosis of a PJI. The results are promising for the care of the painful or problematic knee and hip joint arthroplasty and the test should be considered as part of the diagnostic toolbox for PJIs. Cite this article: Bone Joint J 2017;99-B:1176–82

Aims. The purpose of this retrospective study was to evaluate the minimum five-year outcome of revision total hip arthroplasty (THA) using the Kerboull acetabular reinforcement device (KARD) in patients with Paprosky type III acetabular defects and destruction of the inferior margin of the acetabulum. Patients and Methods. We identified 36 patients (37 hips) who underwent revision THA under these circumstances using the KARD, fresh frozen allograft femoral heads, and reconstruction of the inferior margin of the acetabulum. The Merle d’Aubigné system was used for clinical assessment. Serial anteroposterior pelvic radiographs were used to assess migration of the acetabular component. Results. At a mean follow-up of 8.2 years (5 to 19.3), the mean Merle d’Aubigné score increased from 12.5 (5 to 18) preoperatively to 16.5 (10 to 18) (p < 0.0001). The survival rate at ten years was 95.3% (. sd. 4.5; 95% confidence interval (CI) 86.4 to 100) and 76.5% (. sd. 9.9, 95% CI 57.0 to 95.9) using aseptic loosening and radiological loosening as the endpoints, respectively. Conclusion. These results show that the use of the KARD with reconstruction of the inferior margin of the acetabulum in revision THA is associated with acceptable clinical results and survival at mid-term follow-up with, however, a high rate of migration of the acetabular component of 21.6%. Cite this article: Bone Joint J 2018;100-B:725–32

Posterior spinal instrumentation with the placement of intrapedicular implants has become an important technique. We have designed a hand-held target device to facilitate the open or percutaneous location and penetration of the thoracolumbar pedicles. A cylindrical pin guide incorporates two metal rings and can be moved under image intensifier control until the rings are superimposed to show correct alignment. The radiation dosage for the surgeon is minimal; the device allowed accurate placement of 106 consecutive pedicle screws