Objectives. Cortical and cancellous bone healing processes appear to be histologically different. They also respond differently to anti-inflammatory agents. We investigated whether the leucocyte composition on days 3 and 5 after cortical and cancellous injuries to bone was different, and compared changes over time using day 3 as the baseline. Methods. Ten-week-old male C56/Bl6J mice were randomized to either cancellous injury in the proximal tibia or cortical injury in the femoral diaphysis. Regenerating tissues were analyzed with flow cytometry at days 3 and 5, using panels with 15 antibodies for common macrophage and lymphocyte markers. The cellular response from day 3 to 5 was compared in order to identify differences in how cancellous and cortical bone healing develop. Results. Between day 3 and 5, the granulocytes increased in the cancellous model, whereas the lymphocytes (T cells, B cells, NK cells) and monocytes (CD11b+, F4/80+, CD206+, CD14+) increased in the cortical model. Conclusion. These results suggest an acute type of inflammation in cancellous bone healing, and a more chronic inflammation in cortical healing. This might explain, in part, why cancellous healing is faster and more resistant to anti-inflammatory drugs than are diaphyseal fractures. Cite this article: L. Tätting, O. Sandberg, M. Bernhardsson, J. Ernerudh, P. Aspenberg. Different composition of leucocytes in cortical and cancellous bone healing in a mouse model. Bone Joint Res 2018;7:620–628. DOI: 10.1302/2046-3758.712.BJR-2017-0366.R2

Cancellous allograft bone chips are commonly used in the reconstruction of defects in bone after removal of benign tumours. We investigated the MRI features of grafted bone chips and their change over time, and compared them with those with recurrent tumour. We retrospectively reviewed 66 post-operative MRIs from 34 patients who had undergone curettage and grafting with cancellous bone chips to fill the defect after excision of a tumour. All grafts showed consistent features at least six months after grafting: homogeneous intermediate or low signal intensities with or without scattered hyperintense foci (speckled hyperintensities) on T1 images; high signal intensities with scattered hypointense foci (speckled hypointensities) on T2 images, and peripheral rim enhancement with or without central heterogeneous enhancements on enhanced images. Incorporation of the graft occurred from the periphery to the centre, and was completed within three years. Recurrent lesions consistently showed the same signal intensities as those of pre-operative MRIs of the primary lesions. There were four misdiagnoses, three of which were chondroid tumours. We identified typical MRI features and clarified the incorporation process of grafted cancellous allograft bone chips. The most important characteristics of recurrent tumours were that they showed the same signal intensities as the primary tumours. It might sometimes be difficult to differentiate grafted cancellous allograft bone chips from a recurrent chondroid tumour. Cite this article: Bone Joint J 2015;97-B:121–8

Objectives. Meropenem may be an important drug in the treatment of open tibial fractures and chronic osteomyelitis. Therefore, the objective of this study was to describe meropenem pharmacokinetics in plasma, subcutaneous adipose tissue (SCT), and cancellous bone using microdialysis in a porcine model. Methods. Six female pigs were assigned to receive 1000 mg of meropenem intravenously over five minutes. Measurements of meropenem were obtained from plasma, SCT, and cancellous bone for eight hours thereafter. Microdialysis was applied for sampling in solid tissues. The meropenem concentrations were determined using ultra-high-performance liquid chromatography. Results. The penetration of meropenem into cancellous bone, expressed as the ratio of plasma to cancellous bone area under the concentration-curve from zero to the last measured value, was incomplete and delayed. The time with concentration above the minimal inhibitory concentration (T. >MIC. ), for an MIC of 0.5 μg/ml, was shorter for cancellous bone in comparison with both plasma and SCT. For MICs above 0.5 μg/ml, T. >MIC. in cancellous bone was only shorter than SCT. Considering an MIC of 4 μg/ml, no animals achieved the target of 40% T. >MIC. in plasma and cancellous bone, while less than 20% achieved it in SCT. Conclusion. The main finding of this study was short T. >MIC. in cancellous bone after intravenous administration of 1000 mg meropenem. Consequently, in order to achieve sufficient tissue concentration in the cases of open tibial fractures and chronic osteomyelitis, supplemental application of meropenem may be necessary. Cite this article: P. Hanberg, A. Lund, K. Søballe, M. Bue. Single-dose pharmacokinetics of meropenem in porcine cancellous bone determined by microdialysis: An animal study. Bone Joint Res 2019;8:342–348. DOI: 10.1302/2046-3758.87.BJR-2018-0308.R1

The compression produced by and the resistance to pullout of the 6.5 mm cannulated Herbert screw were compared with those of ASIF headed screws. The latter were tested with and without washers and in the following sizes: 4.5 mm cortical, 6.5 mm cancellous with a 16 mm threaded segment, and 6.5 mm cancellous with a 32 mm threaded segment. Polyurethane foam was used as a substitute for cancellous bone and ASIF artificial bone for corticocancellous bone. The compression produced by a cancellous lag screw with a washer was significantly greater than that produced by a Herbert screw of equivalent size (p < 0.05). When the screws were tested using the corticocancellous composite the ASIF cancellous screw without a washer produced significantly greater compression (p < 0.05); when used with a washer the difference was highly significant (p < 0.001). The dual pitch Herbert screw is not appropriate for the management of fractures in which compression is of greater importance than the need to avoid prominence of the screw head

We obtained medial and lateral subchondral cancellous bone specimens from ten human postmortem proximal tibiae with early osteoarthritis (OA) and ten normal age- and gender-matched proximal tibiae. The specimens were scanned by micro-CT and the three-dimensional microstructural properties were quantified. Medial OA cancellous bone was significantly thicker and markedly plate-like, but lower in mechanical properties than normal bone. Similar microstructural changes were also observed for the lateral specimens from OA bone, although there had been no sign of cartilage damage. The increased trabecular thickness and density, but relatively decreased connectivity suggest a mechanism of bone remodelling in early OA as a process of filling trabecular cavities. This process leads to a progressive change of trabeculae from rod-like to plate-like, the opposite to that of normal ageing. The decreased mechanical properties of subchondral cancellous bone in OA, which are due to deterioration in architecture and density, indicate poor bone quality

We have tested the axial and torsional stability of femoral components after revision arthroplasty in a cadaver model, using impacted morsellised cancellous graft and cement. Each one of six matched pairs of fresh frozen human femora had either a primary or a revision prosthesis cemented in place. For the ‘revision’ experiments, all cancellous bone was removed from the proximal femur which was then over-reamed to create a smooth-walled cortical shell. An MTS servohydraulic test frame was used to apply axial and torsional loads to each specimen through the prosthetic femoral heads with the femur submerged in isotonic saline solution at 37°C. The mean subsidence was 0.27 ± 0.17 mm for the primary and 0.52 ± 0.30 mm for the revision groups. The difference was statistically significant (p < 0.025), but the mean subsidence was < 1 mm in both groups. The mean maximum torque before failure was 42.9 ± 26.9 N-m for the primary and 34.8± 20.7 N-m for the revision groups. This difference was not statistically significant (p > 0.015). Based on our results we suggest that revision of the femoral component using morsellised cancellous graft followed by cementing with a collarless prosthesis with a polished tapered stem restores the integrity of the proximal femur and provides immediate stability of the implant

Radiopaque solutions and suspensions introduced into cancellous bone in the extremities of the cadaver are rapidly removed into the venous system through regional superficial or deep veins. The experiments described in this communication confirm the simplicity of methods of introduction of fluids into cancellous bone and justify further observations on their clinical application for the technique of phiebography

1. Cancellous bone grafting of the head of the femur in Perthes' disease accelerates reossification and thus shortens the period of treatment. 2. There is no evidence from this series of cases that the final shape of the head is affected for better or for worse by the operation of cancellous chip grafting, by the rate of regeneration of the head after operation or by the stage in the disease process at which the operation is done. 3. No relationship has been found between the shape of the head at the time of operation and its final shape. 4. A larger series of cases is needed to determine the value of bone grafting in Perthes' disease of the hip

We present a prospective study of the treatment of 32 unstable Colles’ fractures by external fixation and cancellous grafting with minimal exposure. We inserted an external fixator between the radius and the second metacarpal, and maintained ligamentotaxis for five weeks. In 27 patients the result was good or excellent, but five fractures healed with malunion. All patients made a satisfactory functional recovery. At a mean follow-up of three years (1 to 5) after injury none had pain in the wrist and all were satisfied with the result. The average grip strength was 95% of normal. Seven patients had algodystrophy with mild impairment of finger movements in four. We conclude that the combination of cancellous grafting and external fixation is effective for the treatment of unstable Colles’ fractures

1. The response of the first regional lymph node to a homograft of fresh iliac cancellous bone inserted subcutaneously into the rabbit's ear three weeks after the introduction of a similar graft from the same donor into the same ear has been investigated in thirty rabbits. Fifteen rabbits which received second-set autografts of cancellous bone have also been studied. 2. The insertion of second-set homografts of fresh marrow-containing cancellous bone evokes an immune secondary response in the lymph nodes draining the grafts. 3. The increase in weight of the first regional lymph nodes on the side receiving second-set homografts is more rapid and of greater magnitude than that of nodes draining first-set homografts of cancellous bone. Second-set autografts evoke weight changes in the draining nodes similar to those in nodes draining first-set autografts of cancellous bone. 4. The histological changes which occur in the lymph nodes draining the second-set homografts (secondary response) are described and compared with those occurring in lymph nodes draining first-set homografts of cancellous bone (primary response). 5. In the primary response the distribution of large and medium lymphoid cells is throughout an activated sector of the cortex of the lymph node (Burwell and Gowland 1961), but in the secondary response these cells are found peripherally within the activated sector of the node. In both the primary and the secondary responses large and medium lymphoid cells are found in the medullary trabeculae of the lymph nodes. 6. The differences between the primary response of lymph nodes draining a tissue homograft (cancellous bone) and the primary response of lymph nodes draining classical antigens, and reported by other workers, are described. 7. Knowledge concerning the inflammatory response in the tissues of the host surrounding homografts of fresh cortical and cancellous bone implanted into animals previously sensitised to tissue from the respective donor is reviewed. 8. The late phase of new bone formation by homografts of fresh cancellous bone is discussed in the light of immunological studies

Previous studies have shown that low-density, rod-like trabecular structures develop in regions of low stress, whereas high-density, plate-like trabecular structures are found in regions of high stress. This phenomenon suggests that there may be a close relationship between the type of trabecular structure and mechanical properties. In this study, 160 cancellous bone specimens were produced from 40 normal human tibiae aged from 16 to 85 years at post-mortem. The specimens underwent micro-CT and the microstructural properties were calculated using unbiased three-dimensional methods. The specimens were tested to determine the mechanical properties and the physical/compositional properties were evaluated. The type of structure together with anisotropy correlated well with Young’s modulus of human tibial cancellous bone. The plate-like structure reflected high mechanical stress and the rod-like structure low mechanical stress. There was a strong correlation between the type of trabecular structure and the bone-volume fraction. The most effective microstructural properties for predicting the mechanical properties of cancellous bone seem to differ with age

1. One hundred and one cases of cancellous chip bone grafting operations for filling of infected bone defects are reviewed. 2. Short-term follow-up showed primary or delayed primary healing in 87 per cent of the cases. 3. Observation after five years revealed a recurrence rate of 20 per cent. The recurrences were successfully overcome by minor procedures except in five patients, who suffer from repeated flare-ups of infection. 4. At the present time, 91 per cent of the lesions are satisfactorily healed with a partial or complete bone graft intact. There have been ten failures. 5. The criteria for successful cancellous chip bone grafting of osteomyelitic cavities are discussed

We report the results of using impacted cancellous allografts and cement for fixation of the femoral component when revision arthroplasty is required in the face of lost bone stock. In 56 hips reviewed after 18 to 49 months there were few complications and a majority of satisfactory results with evidence of incorporation of the graft. Further study and review are necessary, but the use of the method appears to be justified

We have reviewed the results of 30 operations performed on 23 patients with Ficat stage-III or stage-IV osteonecrosis of the femoral head in which autogenous cortical and cancellous bone grafting had been performed through a so-called trapdoor made in the femoral head. At a mean of 56 months (30 to 60) after operation 20 of 24 stage-III hips (83%) had a good or excellent result as determined by the Harris hip-scoring system. Two of six stage-IV hips (33%) had good or excellent results. Eighteen of 21 hips (86%) with a combined necrotic angle of 200° had good or excellent clinical results compared with only four of nine hips (44%) with a combined necrotic angle of more than 200°. Six of the eight hips which had fair or poor results were in patients who had received corticosteroids; five of these six hips had lesions with a combined necrotic angle of greater than 200° or were in a late stage (stage IV). There were no perioperative complications. Our results suggest that the trapdoor procedure with autogenous cancellous and cortical bone grafting can be successful in Ficat and Arlet stage-III osteonecrosis of the hip in patients with small- to medium-sized lesions

We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery

Intermittent treatment with parathyroid hormone (PTH) has an anabolic effect on both intact cancellous and cortical bone. Very little is known about the effect of the administration of PTH on the healing of fractures or the incorporation of orthopaedic implants. We have investigated the spontaneous ingrowth of callus and the formation of bone in a titanium chamber implanted at the medioproximal aspect of the tibial metaphysis of the rat. Four groups of ten male rats weighing approximately 350 g were injected with human PTH (1-34) in a dosage of 0, 15, 60 or 240 μg/kg/day, respectively, for 42 days from the day of implantation of the chamber. During the observation period the chamber became only partly filled with callus and bone and no difference in ingrowth distance into the chamber was found between the groups. The cancellous density was increased by 90%, 132% and 173% in the groups given PTH in a dosage of 15, 60 or 240 μg/kg/day, respectively. There was a linear correlation between bone density and the log PTH doses (r. 2. = 0.6). Our findings suggest that treatment with PTH may have a potential for enhancement of the incorporation of orthopaedic implants as well as a beneficial effect on the healing of fractures when it is given in low dosages

We report a long-term review of 60 acetabular components revised using impacted, morsellised bone allografts and a cemented polyethylene cup. The acetabular defects were cavitary (37) or combined (23). Follow-up was for a mean 11.8 years (10 to 15). Further revision was needed in five hips, two for septic and three for aseptic loosening. The overall survival rate at 11.8 years was 90%; excluding the septic cases it was 94%. Acetabular reconstruction with impacted morsellised cancellous grafts and cement gives satisfactory long-term results

1. Previous immunological studies have shown that homografts of fresh marrow-free iliac bone are only weakly, if at all, antigenic. 2. In view of this finding an attempt was made to produce a foreign bone graft capable of forming new bone as readily as an iliac autograft by the following method. Living cells of high osteogenic potential and of autologous type were introduced into the graft by combining homologous fresh marrow-free iliac bone with the animal's own red marrow to form a fresh composite homograft-autograft of cancellous bone. 3. Such fresh composite homograft-autografts were inserted into a muscular site in Wistar rats and removed for microscopical examination at intervals of one to seven days and at two, six and twelve weeks after transplantation. 4. It is found that bone and marrow together as a fresh composite homograft-autograft form considerably more new bone than do either of the components of the graft transplanted separately. Homografts of fresh marrow-free iliac bone form, in general, a small amount of early phase and late phase new bone. Autografts of red marrow transplanted alone to a muscular site formed new bone in thirteen to thirty experiments (43 per cent). 5. The stimulus to osteogenesis, and the cellular source of osteoblasts, in marrow autografts is discussed in the light of present knowledge. The concept is suggested that after its transplantation there develops in marrow an inductive system leading to osteoblastic differentiation and bone formation. It is proposed that the necrosis of a portion of a marrow graft liberates osteogenic substances which are taken up by primitive wandering cells derived from littoral cells lining the vascular sinusoids of the surviving portions of the marrow which are induced, thereby, to differentiate as osteoblasts. 6. The cellular source of osteoblasts in a fresh composite homograft-autograft of cancellous bone is discussed. It is deduced that the new bone is derived mainly from the contained marrow of the graft, by mechanisms similar to those leading to osteoblastic differentiation in transplanted autografts of marrow. 7. The stimulus to the greater formation of new bone by fresh composite autograft-homografts than by autografts of marrow transplanted alone is discussed. Two explanations are suggested: 1) a more extensive necrosis of marrow in a composite homograft-autograft than in marrow transplanted alone; and 2) an inductive effect of bone upon marrow. 8. The new bone formed by autografts of fresh marrow-containing iliac bone, it is concluded, is derived not only from osteoblasts on the surfaces of the grafted bone but also from primitive wandering cells derived from littoral cells lining the vascular sinusoids of the surviving portions of its marrow. 9. Mechanisms which may play a role in the histogenesis of woven bone are discussed. 10. The significance of the relation of bone and marrow is considered briefly in the light of knowledge concerning the venous patterns of bone and marrow

A technique of subtalar arthrodesis by means of metallic internal stabilisation and autogenous cancellous bone grafting is described. Of forty-eight feet with mobile pes planus treated by this method forty-five gained union after an average of seven and a half weeks in a below-knee weight-bearing plaster, and forty-three had satisfactory correction of the deformity

A boy aged fourteen trapped and tore at its origin a branch of the terminal part of the superficial femoral artery over a cancellous exostosis during extension of the knee from the position of full flexion. Three months later an expanding false aneurysm necessitated arteriography, after which suture of the tear gave a successful result

1. A method of bridging gaps in long bones is described, using cancellous insert grafts supplemented by internal fixation with a metal plate. 2. The experimental work on transplantation of bone is reviewed in so far as it affects the practical problem of bone grafting. 3. Twenty-seven cases have been treated, with no failures. Seven of these are presented as illustrations

1. The antigenicity of cancellous bone has been investigated in ninety-seven rabbits. 2. The immune responses of lymph nodes draining fresh homografts of cancellous bone (Burwell and Gowland 1961b) has been used as a histological indicator of the antigenicity of components of fresh homologous cancellous bone and also of the antigenicity of homologous bone subjected to a variety of physical or chemical treatments. 3. The principal antigenic component of a fresh homograft of iliac cancellous bone is the nucleated cells of the red marrow. 4. Homologous marrow-free cancellous bone does not usually produce cytological evidence of an immune response in the lymph node draining the graft, unless new homograft bone formation occurs. 5. The treatment of marrow-containing cancellous bone by boiling, freezing at - 20 degrees Centigrade, freeze-drying, irradiation or by merthiolate solution impairs the transplantation antigenicity of the tissue as a homograft. 6. The immersion of cancellous bone in a glycerol-serum-Ringer solution which is then slowly cooled to - 79 degrees Centigrade, stored for one week and then rapidly thawed, allows considerable preservation of the antigenicity of the red marrow. 7. Knowledge concerning the antigenicity of fresh and treated homologous bone is discussed. 8. Evidence is presented to show that the large and medium lymphoid cell response of lymph nodes draining homografts is due principally to the T-antigens, rather than H-antigens, of the grafts. 9. The changes which occur in the first regional lymph nodes draining tissue homografts may provide another test system to assess the transplantation antigenicity of foreign tissues or extracts of foreign tissues other than bone

Twenty-nine bone defects caused by chronic osteomyelitis have been treated by radical excision of necrotic bone followed by packing the cavities with cancellous homografts held in position by a fibrin sealant. At follow-up three years after operation all except one had healed, though one case had needed a repeat operation. Good incorporation and remodelling of the grafts was observed even when the osseous bed was severely sclerosed

Twenty-six patients with femoral neck fractures were treated by open reduction, cancellous screw fixation and free fibular grafting. The patients were between 14 and 50 years of age. There were 16 old and 10 fresh fractures. Four patients had radiological signs of avascular necrosis before the treatment was instituted. Bony union was achieved in all patients except one, where the failure occurred because of a technical error. The patients were followed up for at least two years. No new case of avascular necrosis was detected after treatment, and there was clinical and radiological improvement in all four patients with pre-operative avascular necrosis

1. Fifteen cases of bone transplantation for fibrous union of fractures of long bones are described, using boiled minced cancellous bone from cadavers. One transplant became infected but the infection responded to treatment. 2. In one patient with non-union of the shaft of the humerus, bony union was not obtained, but a good functional result obviated further treatment. 3. It is suggested that this relatively simple method of bone transplantation could be used more widely if its potentialities were appreciated more fully

1. A series of 102 cancellous strip grafts for delayed union of long bone fractures has been reviewed. 2. Half of the initial injuries were open. 3. Half of the fractures were butterfly or segmental lesions or were comminuted. 4. After strip grafting 84 per cent of the fractures were united within sixteen weeks, and only four took longer than twenty weeks. 5. Complete failure of union occurred in only one case, a tibial fracture complicated by low-grade pyocyaneus osteomyelitis. 6. A more aggressive attitude to the problem of delayed union is advocated

In order to improve the fixation of the stem in primary Charnley low-friction arthroplasty, the medullary canal was routinely closed off with a cancellous bone block. A prospective study of 611 consecutive arthroplasties were carried out between 1 and 5 1/2 years (average 2 years and 9 months) after operation. There were two cases of radiological loosening of the stem, both of which could have been avoided. Five other patients showed demarcation of the bone-cement junction at the calcar; two of these are considered to be "at risk" of loosening. There was no evidence of radiological loosening of the stem in 604 cases and the method is recommended for routine use in primary total hip arthroplasty

We report the preliminary findings of the use of roentgen stereophotogrammetric analysis to evaluate the early migration of five femoral components after revision for mechanical loosening using impacted cancellous allograft and cement. All hips were examined at one week, four to six months and one year after surgery. All the components subsided by 0.4 to 4.9 mm during the first year. In four hips the prosthetic head was displaced 1.1 to 6.9 mm posteriorly. Fixation of the femoral components was less secure than after primary arthroplasty but the incidence and magnitude of early migration were similar to those after revision with cement alone

1. The antigenicity of homologous cortical and cancellous bone has been investigated in eighty-four rabbits. 2. The primary immune responses which occur in lymph nodes draining homografts of fresh tissues (Burwell and Gowland 1961, 1962) have been used as a histological indicator of the antigenicity of fresh homologous cortical bone freed from soft tissues. 3. The secondary immune responses which occur in lymph nodes draining homografts of fresh marrow-containing iliac bone (Burwell 1962a, b) have been used also as a histological indicator of the antigenicity of homografts of 1) fresh cortical bone freed from soft tissues, 2) fresh marrow-free iliac bone, and 3) mairow-containing iliac bone treated by boiling, freezi ng, freeze-drying and merthiolate solution. 4. It is found that whereas fresh homologous cortical bone fails usually to produce cytological evidence of a primary response in the regional lymph nodes, fresh homologous cortical bone chips inserted into the drainage areas of lymph nodes sensitised previously to donor ..tissue evoke constantly cytological evidence of a secondary response. 5. Fresh homologous marrow-free iliac bone inserted into the drainage areas of lymph nodes sensitised previously to donor tissue does not produce detectable evidence of a secondary response. 6. Homografts of boiled marrow-containing iliac bone do not elicit a secondary response in lymph nodes previously sensitised to donor tissue. 7. Previous work has shown that homografts of frozen (–20 degrees Centigrade) marrow-containing iliac bone do not evoke a primary response in lymph nodes draining such grafts. In the present work it is shown that similar frozen homografts inserted into the drainage areas of lymph nodes previously sensitised to donor tissue evoked a secondary response in three of six lymph nodes. 8. Homografts offreeze-dried marrow-containing iliac bone fail usually to evoke a secondary response in lymph nodes sensitised to donor tissue. 9. Homografts of marrow-containing iliac bone treated by immersion in merthiolate solution before being inserted into the drainage areas of lymph nodes previously sensitised to tissue from the donor elicited a secondary response in three of five lymph nodes. 10. Knowledge concerning the antigenicity offresh and treated homologous bone is discussed in the light of recent work

Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration.

We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts.

Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.

We report the histology of a femur retrieved 3.5 years after a cemented revision of a hip replacement in which impaction allografting had been used to fill two large cortical defects. The allograft chips had largely been replaced by viable cortical bone, and the interface between cement and tissue resembled that seen after primary cemented arthroplasty.

This study presents the clinical and radiological results of 62 consecutive acetabular revisions in 58 patients, at a mean of 16.5 years follow-up (15 to 20). The Kaplan-Meier survivorship for the cup with end-point revisions for any reason, was 79% at 15 years (95% confidence interval (CI); 67 to 91). Excluding two revisions for septic loosening at three and six years, and one revision of a well-fixed cup after 12 years in the course of a femoral revision, the survivorship was 84% at 15 years (95% CI; 73 to 95). At review there were no additional cases of loosening, although seven acetabular reconstructions showed radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.7 cm to 1.0 cm) and a cemented cup, is a reliable technique of reconstruction, when assessed at more than 15 years.

Aims. Fixation of scaphoid nonunion with a volar locking plate and cancellous bone grafting has been shown to be a successful technique in small series. Few mid- or long-term follow-up studies have been reported. The aim of this study was to report the mid-term radiological and functional outcome of plate fixation for scaphoid nonunion. Methods. Patients with a scaphoid nonunion were prospectively enrolled and treated with open reduction using a volar approach, debridement of the nonunion, and fixation using a locking plate and cancellous bone grafting, from the ipsilateral iliac crest. Follow-up included examination, functional assessment using the patient-rated wrist/hand evaluation (PRWHE), and multiplanar reformation CT scans at three-month intervals until union was confirmed. Results. A total of 49 patients with a mean age of 31 years (16 to 74) and a mean duration of nonunion of 3.6 years (0.4 to 16) were included. Postoperatively, the nonunion healed in 47 patients (96%) as shown on CT scans. The mean time to union was 4.2 months (3 to 12). Due to impingement of the plate on the volar rim of the radius and functional limitation, the hardware was removed in 18 patients. At a median follow-up of 38 months in 34 patients, the mean active range of motion (ROM) improved significantly from 89° to 124° (SD 44°; p = 0.003). The mean grip strength improved significantly from 52% to 79% (SD 28%; p < 0.001) of the contralateral side. The mean PRWHE score improved significantly from 66 to 17 points (SD 25; p < 0.001). Conclusion. Locking plate fixation supplemented with autologous cancellous bone grafting is a successful form of treatment for scaphoid nonunion. Functional outcomes improve with the passage of time, and mid-term results are excellent with a significant improvement in ROM, grip strength, and functional outcome as measured by the PRWHE. Cite this article: Bone Joint J 2020;102-B(12):1697–1702

Aims. This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation. Methods. This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements. Results. Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients’ subjective pain score. No peri- or postoperative complications were encountered. Conclusion. Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946–952

Aims. Prompt and sufficient broad-spectrum empirical antibiotic treatment is key to preventing infection following open tibial fractures. Succeeding co-administration, we dynamically assessed the time for which vancomycin and meropenem concentrations were above relevant epidemiological cut-off (ECOFF) minimal inhibitory concentrations (T > MIC) in tibial compartments for the bacteria most frequently encountered in open fractures. Low and high MIC targets were applied: 1 and 4 µg/ml for vancomycin, and 0.125 and 2 µg/ml for meropenem. Methods. Eight pigs received a single dose of 1,000 mg vancomycin and 1,000 mg meropenem simultaneously over 100 minutes and 10 minutes, respectively. Microdialysis catheters were placed for sampling over eight hours in tibial cancellous bone, cortical bone, and adjacent subcutaneous adipose tissue. Venous blood samples were collected as references. Results. Across the targeted ECOFF values, vancomycin displayed longer T > MIC in all the investigated compartments in comparison to meropenem. For both drugs, cortical bone exhibited the shortest T > MIC. For the low MIC targets and across compartments, mean T > MIC ranged between 208 and 449 minutes (46% to 100%) for vancomycin and between 189 and 406 minutes (42% to 90%) for meropenem. For the high MIC targets, mean T > MIC ranged between 30 and 446 minutes (7% to 99%) for vancomycin and between 45 and 181 minutes (10% to 40%) for meropenem. Conclusion. The differences in the T > MIC between the low and high targets illustrate how the interpretation of these results is highly susceptible to the defined MIC target. To encompass any trauma, contamination, or individual tissue differences, a more aggressive dosing approach may be considered to achieve longer T > MIC in all the exposed tissues, and thereby lower the risk of acquiring an infection after open tibial fractures. Cite this article: Bone Joint Res 2022;11(2):112–120

Objectives. Osteophytes are products of active endochondral and intramembranous ossification, and therefore could theoretically provide significant efficacy as bone grafts. In this study, we compared the bone mineralisation effectiveness of osteophytes and cancellous bone, including their effects on secretion of growth factors and anabolic effects on osteoblasts. Methods. Osteophytes and cancellous bone obtained from human patients were transplanted onto the calvaria of severe combined immunodeficient mice, with Calcein administered intra-peritoneally for fluorescent labelling of bone mineralisation. Conditioned media were prepared using osteophytes and cancellous bone, and growth factor concentration and effects of each graft on proliferation, differentiation and migration of osteoblastic cells were assessed using enzyme-linked immunosorbent assays, MTS ((3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium)) assays, quantitative real-time polymerase chain reaction, and migration assays. Results. After six weeks, the area of mineralisation was significantly higher for the transplanted osteophytes than for the cancellous bone (43803 μm. 2. , . sd. 14660 versus 9421 μm. 2. , . sd. 5032, p = 0.0184, one-way analysis of variance). Compared with cancellous bone, the conditioned medium prepared using osteophytes contained a significantly higher amounts of transforming growth factor (TGF)-β1 (471 pg/ml versus 333 pg/ml, p = 0.0001, Wilcoxon rank sum test), bone morphogenetic protein (BMP)-2 (47.75 pg/ml versus 32 pg/ml, p = 0.0214, Wilcoxon rank sum test) and insulin-like growth factor (IGF)-1 (314.5 pg/ml versus 191 pg/ml, p = 0.0418, Wilcoxon rank sum test). The stronger effects of osteophytes towards osteoblasts in terms of a higher proliferation rate, upregulation of gene expression of differentiation markers such as alpha-1 type-1 collagen and alkaline phosphate, and higher migration, compared with cancellous bone, was confirmed. Conclusion. We provide evidence of favourable features of osteophytes for bone mineralisation through a direct effect on osteoblasts. The acceleration in metabolic activity of the osteophyte provides justification for future studies evaluating the clinical use of osteophytes as autologous bone grafts. Cite this article: K. Ishihara, K. Okazaki, T. Akiyama, Y. Akasaki, Y. Nakashima. Characterisation of osteophytes as an autologous bone graft source: An experimental study in vivo and in vitro. Bone Joint Res 2017;6:73–81. DOI: 10.1302/2046-3758.62.BJR-2016-0199.R1

Objectives. Up to 40% of unicompartmental knee arthroplasty (UKA) revisions are performed for unexplained pain which may be caused by elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on bone strain in a cemented fixed-bearing medial UKA using a finite element model (FEM) validated experimentally by digital image correlation (DIC) and acoustic emission (AE). Materials and Methods. A total of ten composite tibias implanted with all-polyethylene (AP) and metal-backed (MB) tibial components were loaded to 2500 N. Cortical strain was measured using DIC and cancellous microdamage using AE. FEMs were created and validated and polyethylene thickness varied from 6 mm to 10 mm. The volume of cancellous bone exposed to < -3000 µε (pathological loading) and < -7000 µε (yield point) minimum principal (compressive) microstrain and > 3000 µε and > 7000 µε maximum principal (tensile) microstrain was computed. Results. Experimental AE data and the FEM volume of cancellous bone with compressive strain < -3000 µε correlated strongly: R = 0.947, R. 2. = 0.847, percentage error 12.5% (p < 0.001). DIC and FEM data correlated: R = 0.838, R. 2. = 0.702, percentage error 4.5% (p < 0.001). FEM strain patterns included MB lateral edge concentrations; AP concentrations at keel, peg and at the region of load application. Cancellous strains were higher in AP implants at all loads: 2.2- (10 mm) to 3.2-times (6 mm) the volume of cancellous bone compressively strained < -7000 µε. Conclusion. AP tibial components display greater volumes of pathologically overstrained cancellous bone than MB implants of the same geometry. Increasing AP thickness does not overcome these pathological forces and comes at the cost of greater bone resection. Cite this article: C. E. H. Scott, M. J. Eaton, R. W. Nutton, F. A. Wade, S. L. Evans, P. Pankaj. Metal-backed versus all-polyethylene unicompartmental knee arthroplasty: Proximal tibial strain in an experimentally validated finite element model. Bone Joint Res 2017;6:22–30. DOI:10.1302/2046-3758.61.BJR-2016-0142.R1

Aims. In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA). Methods. Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1 September 1999 to 31 December 2022 were analyzed. Collared cementless femoral components and cemented components were identified, and the three most commonly used components in each group were analyzed. We identified a total of 11,278 collared cementless components and 47,835 cemented components. Hazard ratios (HRs) from Cox proportional hazards models, adjusting for age and sex, were obtained to compare the revision rates between the groups. Results. From six months postoperatively onwards, patients aged ≥ 75 years undergoing primary THA with primary diagnosis of OA have a lower risk of all-cause revision with collared cementless components than with a polished tapered cemented component (HR 0.78 (95% confidence interval 0.64 to 0.96); p = 0.018). There is no difference in revision rate prior to six months. Conclusion. Patients aged ≥ 75 years with a primary diagnosis of OA have a significantly lower rate of revision with the most common collared cementless femoral component, compared with the most common polished tapered cemented components from six months postoperatively onwards. The lower revision rate is largely due to a reduction in revisions for fracture and infection. Cite this article: Bone Joint J 2024;106-B(3 Supple A):121–129

Aims. To draw a comparison of the pullout strengths of buttress thread, barb thread, and reverse buttress thread bone screws. Methods. Buttress thread, barb thread, and reverse buttress thread bone screws were inserted into synthetic cancellous bone blocks. Five screw-block constructs per group were tested to failure in an axial pullout test. The pullout strengths were calculated and compared. A finite element analysis (FEA) was performed to explore the underlying failure mechanisms. FEA models of the three different screw-bone constructs were developed. A pullout force of 250 N was applied to the screw head with a fixed bone model. The compressive and tensile strain contours of the midsagittal plane of the three bone models were plotted and compared. Results. The barb thread demonstrated the lowest pullout strength (mean 176.16 N (SD 3.10)) among the three thread types. It formed a considerably larger region with high tensile strains and a slightly smaller region with high compressive strains within the surrounding bone structure. The reverse buttress thread demonstrated the highest pullout strength (mean 254.69 N (SD 4.15)) among the three types of thread. It formed a considerably larger region with high compressive strains and a slightly smaller region with high tensile strains within the surrounding bone structure. Conclusion. Bone screws with a reverse buttress thread design will significantly increase the pullout strength. Cite this article: Bone Joint Res 2021;10(2):105–112

Objectives. Elevated proximal tibial bone strain may cause unexplained pain, an important cause of unicompartmental knee arthroplasty (UKA) revision. This study investigates the effect of tibial component alignment in metal-backed (MB) and all-polyethylene (AP) fixed-bearing medial UKAs on bone strain, using an experimentally validated finite element model (FEM). Methods. A previously experimentally validated FEM of a composite tibia implanted with a cemented fixed-bearing UKA (MB and AP) was used. Standard alignment (medial proximal tibial angle 90°, 6° posterior slope), coronal malalignment (3°, 5°, 10° varus; 3°, 5° valgus), and sagittal malalignment (0°, 3°, 6°, 9°, 12°) were analyzed. The primary outcome measure was the volume of compressively overstrained cancellous bone (VOCB) < -3000 µε. The secondary outcome measure was maximum von Mises stress in cortical bone (MSCB) over a medial region of interest. Results. Varus malalignment decreased VOCB but increased MSCB in both implants, more so in the AP implant. Varus malalignment of 10° reduced the VOCB by 10% and 3% in AP and MB implants but increased the MSCB by 14% and 13%, respectively. Valgus malalignment of 5° increased the VOCB by 8% and 4% in AP and MB implants, with reductions in MSCB of 7% and 10%, respectively. Sagittal malalignment displayed negligible effects. Well-aligned AP implants displayed greater VOCB than malaligned MB implants. Conclusion. All-polyethylene implants are more sensitive to coronal plane malalignments than MB implants are; varus malalignment reduced cancellous bone strain but increased anteromedial cortical bone stress. Sagittal plane malalignment has a negligible effect on bone strain. Cite this article: I. Danese, P. Pankaj, C. E. H. Scott. The effect of malalignment on proximal tibial strain in fixed-bearing unicompartmental knee arthroplasty: A comparison between metal-backed and all-polyethylene components using a validated finite element model. Bone Joint Res 2019;8:55–64. DOI: 10.1302/2046-3758.82.BJR-2018-0186.R2

Aims. Flucloxacillin is commonly administered intravenously for perioperative antimicrobial prophylaxis, while oral administration is typical for prophylaxis following smaller traumatic wounds. We assessed the time, for which the free flucloxacillin concentration was maintained above the minimum inhibitory concentration (fT > MIC) for methicillin-susceptible Staphylococcus aureus in soft and bone tissue, after intravenous and oral administration, using microdialysis in a porcine model. Methods. A total of 16 pigs were randomly allocated to either intravenous (Group IV) or oral (Group PO) flucloxacillin 1 g every six hours during a 24-hour period. Microdialysis was used for sampling in cancellous and cortical bone, subcutaneous tissue, and the knee joint. In addition, plasma was sampled. The flucloxacillin fT > MIC was evaluated using a low MIC target (0.5 μg/ml) and a high MIC target (2.0 μg/ml). Results. Intravenous administration resulted in longer fT > MIC (0.5 μg/ml) compared to oral administration, except for cortical bone. In Group IV, all pigs reached a concentration of 0.5 μg/ml in all compartments. The mean fT > MIC (0.5 μg/ml) was 149 minutes (95% confidence interval (CI) 119 to 179; range 68 to 323) in subcutaneous tissue and 61 minutes (95% CI 29 to 94; range 0 to 121) to 106 minutes (95% CI 76 to 136; range 71 to 154) in bone tissue. In Group PO, 0/8 pigs reached a concentration of 0.5 μg/ml in all compartments. For the high MIC target (2.0 μg/ml), fT > MIC was close to zero minutes in both groups across compartments. Conclusion. Although intravenous administration of flucloxacillin 1 g provided higher fT > MIC for the low MIC target compared to oral administration, concentrations were surprisingly low, particularly for bone tissue. Achievement of sufficient bone and soft tissue flucloxacillin concentrations may require a dose increase or continuous administration. Cite this article: Bone Joint Res 2021;10(1):60–67

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts. Cite this article: Bone Joint Open 2020;1-6:198–202

This study was performed to determine whether pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient to achieve bony union and restore alignment in scaphoid nonunion. A total of 65 patients who underwent cancellous bone graft and K-wire fixation were included in this study. The series included 61 men and four women with a mean age of 34 years (15 to 72) and mean delay to surgery of 28.7 months (3 to 240). The patients were divided into an unstable group (A) and stable group (B) depending on the pre-operative radiographs. Unstable nonunion was defined as a lateral intrascaphoid angle > 45°, or a radiolunate angle > 10°. There were 34 cases in group A and 31 cases in group B. Bony union was achieved in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B (p = 0.439). Comparison of the post-operative radiographs between the two groups showed no significant differences in lateral intrascaphoid angle (p = 0.657) and scaphoid length (p = 0.670) and height (p = 0.193). The radiolunate angle was significantly different (p = 0.020) but the mean value in both groups was < 10°. Comparison of the dorsiflexion and palmar flexion of movement of the wrist and the mean Mayo wrist score at the final clinical visit in each group showed no significant difference (p = 0.190, p = 0.587 and p = 0.265, respectively). Cancellous bone graft and K-wire fixation were effective in the treatment of stable and unstable scaphoid nonunion. Cite this article: Bone Joint J 2013;95-B:809–14

As many as 25% to 40% of unicompartmental knee replacement (UKR) revisions are performed for pain, a possible cause of which is proximal tibial strain. The aim of this study was to examine the effect of UKR implant design and material on cortical and cancellous proximal tibial strain in a synthetic bone model. Composite Sawbone tibiae were implanted with cemented UKR components of different designs, either all-polyethylene or metal-backed. The tibiae were subsequently loaded in 500 N increments to 2500 N, unloading between increments. Cortical surface strain was measured using a digital image correlation technique. Cancellous damage was measured using acoustic emission, an engineering technique that detects sonic waves (‘hits’) produced when damage occurs in material. Anteromedial cortical surface strain showed significant differences between implants at 1500 N and 2500 N in the proximal 10 mm only (p < 0.001), with relative strain shielding in metal-backed implants. Acoustic emission showed significant differences in cancellous bone damage between implants at all loads (p = 0.001). All-polyethylene implants displayed 16.6 times the total number of cumulative acoustic emission hits as controls. All-polyethylene implants also displayed more hits than controls at all loads (p < 0.001), more than metal-backed implants at loads ≥ 1500 N (p < 0.001), and greater acoustic emission activity on unloading than controls (p = 0.01), reflecting a lack of implant stiffness. All-polyethylene implants were associated with a significant increase in damage at the microscopic level compared with metal-backed implants, even at low loads. All-polyethylene implants should be used with caution in patients who are likely to impose large loads across their knee joint. . Cite this article: Bone Joint J 2013;95-B:1339–47

We investigated the static and cyclical strength of parallel and angulated locking plate screws using rigid polyurethane foam (0.32 g/cm. 3. ) and bovine cancellous bone blocks. Custom-made stainless steel plates with two conically threaded screw holes with different angulations (parallel, 10° and 20° divergent) and 5 mm self-tapping locking screws underwent pull-out and cyclical pull and bending tests. The bovine cancellous blocks were only subjected to static pull-out testing. We also performed finite element analysis for the static pull-out test of the parallel and 20° configurations. In both the foam model and the bovine cancellous bone we found the significantly highest pull-out force for the parallel constructs. In the finite element analysis there was a 47% more damage in the 20° divergent constructs than in the parallel configuration. Under cyclical loading, the mean number of cycles to failure was significantly higher for the parallel group, followed by the 10° and 20° divergent configurations. In our laboratory setting we clearly showed the biomechanical disadvantage of a diverging locking screw angle under static and cyclical loading

Osteoid osteoma is treated primarily by radiofrequency (RF) ablation. However, there is little information about the distribution of heat in bone during the procedure and its safety. We constructed a model of osteoid osteoma to assess the distribution of heat in bone and to define the margins of safety for ablation. Cavities were drilled in cadaver bovine bones and filled with a liver homogenate to simulate the tumour matrix. Temperature-sensing probes were placed in the bone in a radial fashion away from the cavities. RF ablation was performed 107 times in tumours < 10 mm in diameter (72 of which were in cortical bone, 35 in cancellous bone), and 41 times in cortical bone with models > 10 mm in diameter. Significantly higher temperatures were found in cancellous bone than in cortical bone (p <  0.05). For lesions up to 10 mm in diameter, in both bone types, the temperature varied directly with the size of the tumour (p < 0.05), and inversely with the distance from it. Tumours of > 10 mm in diameter showed a trend similar to those of smaller lesions. No temperature rise was seen beyond 12 mm from the edge of a cortical tumour of any size. Formulae were developed to predict the expected temperature in the bone during ablation. Cite this article: Bone Joint J 2014; 96-B:677–83

Aims. Osteolysis, secondary to local and systemic physiological effects, is a major challenge in total hip arthroplasty (THA). While osteolytic defects are commonly observed in long-term follow-up, how such lesions alter the distribution of stress is unclear. The aim of this study was to quantitatively describe the biomechanical implication of such lesions by performing subject-specific finite-element (FE) analysis on patients with osteolysis after THA. Patients and Methods. A total of 22 hemipelvis FE models were constructed in order to assess the transfer of load in 11 patients with osteolysis around the acetabular component of a THA during slow walking and a fall onto the side. There were nine men and two women. Their mean age was 69 years (55 to 81) at final follow-up. Changes in peak stress values and loads to fracture in the presence of the osteolytic defects were measured. Results. The von Mises stresses were increased in models of those with and those without defects for both loading scenarios. Although some regions showed increases in stress values of up to 100%, there was only a moderate 11.2% increase in von Mises stress in the series as a whole. The site of fracture changed in some models with lowering of the load to fracture by 500 N. The most common site of fracture was the pubic ramus. This was more frequent in models with larger defects. Conclusion. We conclude that cancellous defects cause increases in stress within cortical structures. However, these are likely to lead to a modest decrease in the load to fracture if the defect is large (> 20cm. 3. ) or if the patient is small with thin cortical structures and low bone mineral density. Cite this article: Bone Joint J 2018;100-B:1455–62