Introduction

A deficient abductor mechanism leads to significant morbidity and few studies have been published describing methods for reconstruction or repair. This study reports the reconstruction of hip abductor deficiency using human allograft.

Introduction

Revision hip arthroplasty with massive proximal femoral bone loss remains challenging. Whilst several surgical techniques have been described, few have reported long term supporting data. A proximal femoral allograft (PFA) may be used to reconstitute bone stock in the multiply revised femur with segmental bone loss of greater than 8 cm. This study reports the outcome of largest case series of PFA used in revision hip arthroplasty.

Purpose

The literature indicates that the tibial component in total knee arthroplasty (TKA) should be placed in internal rotation not exceeding 18 to the line connecting the geometrical center of the proximal tibia and the middle of the tibial tuberosity. These landmarks may not be easily identifiable intraoperatively. Moreover, an angle of 18 is difficult to measure with the naked eye.

Purpose

The purpose of this study was to determine the functional outcome, imaging and complications of conversion of hip fusion to uncemented total hip replacement.

Purpose

Case logs have been utilized as a means of assessing residents surgical exposure and involvement in cases. It can be argued that the degree of involvement in operative cases is as important as absolute number of cases logged. A log which contains accurate information on actual participation in surgical cases in addition to self reported competency, is a powerful tool in obtaining a true reflection of surgical experience. Thus a prerequisite for a valuable log is the ability to perform an accurate self-assessment. Numerous studies have shown mixed results when examining residents ability to perform self-assessment on varying tasks. The purpose of the study was to examine the correlation between residents self-assessment and staff surgeons evaluation of surgical involvement and competence in performing primary hip and knee arthroplasty surgery.

Purpose

Surgical training is based on an apprenticeship model. This training can be divided broadly into three main categories: practical skills, knowledge and decision making. The operating room is the nexus of a large part of surgical teaching. The supervising surgeon imparts both practical teaching as well as didactic information to the trainee during surgical procedures. A large amount of decision making skills are also acquired in the OR. Indeed, a large part of the surgical teams time is spent in the operating room which makes it an ideal educational environment.

Bench model training is one teaching modality whereby the novice surgeon is taught surgical skills on life-like models. This practice enhances and accelerates the ability of the trainee to acquire fundamental, technical and surgical skills in the operating room. Whether bench model training provides an advantage on the ability of the trainee to acquire knowledge and decision making skills is unknown. Based on the motor learning theories, it is hypothesized that bench-model training will allow junior residents to be more interactive than trainees lacking similar active hands-on training. In this study, we examined whether bench model training provides an advantage on the ability of the trainee to acquire knowledge and decision making skills.

The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three.

Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating.

An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone.

Primary total hip arthroplasty in patients with osteoarthrosis secondary to developmental hip dysplasia is often more complex due to anterolateral acetabular bone deficiency. Femoral head (shelf) autograft provides a non-immunogenic, osteoconductive lateral support with the potential for enhanced bone stock should revision surgery be required. The technique has been shown in other series to give reliable early results but may be complicated by graft revascularisation and collapse. As yet, no study has assessed shelf grafts long term or quantified the need for further bone graft at revision surgery.

This study aims to assess initial graft union rate; quantify long term graft resorption and; quantify the need for further bone graft in the patients requiring revision surgery.

A retrospective analysis of a single surgeon's series of 31 THR in 25 patients was conducted. Post-operative, biplanar radiographic analysis was performed at 3 and 6 months and annually thereafter for a mean of 14 years (range 8-18). Grafts were assessed for union, resorption and displacement. Intra-operative necessity for bone graft at revision surgery was recorded.

Union, osseous 93%, fibrous 7%. No grafts displaced. In 71% less than one-third of the graft resorbed, in 29% one-third to one-half resorbed and in no grafts did greater than a half resorb. Of 10 patients revised, 2 required bone graft for inadequate bone stock.

Femoral head autograft allows effective acetabular coverage with excellent rates of union, minimal graft resorption in the long term and improves bone stock in revision surgery.

We report the use of porous metal acetabular revision shells in the treatment of contained bone loss. The outcomes of 53 patients with ≤ 50% acetabular bleeding host bone contact were compared with a control group of 49 patients with > 50% to 85% bleeding host bone contact. All patients were treated with the same type of trabecular metal acetabular revision shell. The mean age at revision was 62.4 years (42 to 80) and the mean follow-up of both groups was 72.4 months (60 to 102). Clinical, radiological and functional outcomes were assessed. There were four (7.5%) mechanical failures in the ≤ 50% host bone contact group and no failures in the > 50% host bone contact group (p = 0.068). Out of both groups combined there were four infections (3.9%) and five recurrent dislocations (4.9%) with a stable acetabular component construct that were revised to a constrained liner. Given the complexity of the reconstructive challenge, porous metal revision acetabular shells show acceptable failure rates at five to ten years’ follow-up in the setting of significant contained bone defects. This favourable outcome might be due to the improved initial stability achieved by a high coefficient of friction between the acetabular implant and the host bone, and the high porosity, which affords good bone ingrowth.

Purpose: To evaluate fellowship trainee and supervisor perceptions on the relative importance of core cognitive and procedural competencies in spine subspecialty fellowship training.

Method: A questionnaire was designed through synthesis and amalgamation of two previous surveys designed by other authors. This questionnaire was reviewed for content by spine surgery experts (Canadian Spine Society Education Committee). The questionnaire was administered (online and paper) to fellow trainees and supervisors across Canada and data was collected over a 3-month period. It consisted of 40 MCQ items grouped into 13 broad cognitive skills categories, as well as 29 technical/procedural items. Data was analyzed using qualitative and descriptive statistics (e.g. average mean scores, standard deviations, t-tests).

Results: The response rate was 91%, with 15 of 17 fellow trainees and 47 of 51 supervisors completing the survey. Twelve of the 13 core cognitive skill categories were rated as being important to acquire by the end of fellowship. Trainees were not comfortable performing, and requested additional training in 8 of 29 spine surgery technical skill items. Specifically, additional training was believed to be required for intradural procedures (e.g. syringomyelia, intradural neoplasms) and other less common, technically demanding, procedures (e.g. transoral odontoidectomy, anterior thoracic discectomy). Significant differences (p< 0.05) existed in perceptions of importance for specific cognitive and technical skills based on previous residency training (orthopaedic or neurosurgical). No such differences were found when comparing responses of the fellow trainees and their supervisors.

Conclusion: This study demonstrates that fellowship trainees and supervisors have similar perceptions on the relative importance of specific core cognitive and procedural competencies required in achieving successful spine fellowship training. Furthermore, background specialty training (orthopaedic or neurosurgical) influences the perceptions of both fellow trainees and supervisors regarding the importance of specific cognitive and technical skills deemed necessary for successful training.

Introduction: The objective for this study was to assess the long term results for minor column allograft used in revision hip arthroplasty.

Methods: We prospectively included patients undergoing acetabular cup revision using minor column allograft with a minimum of 5 years follow-up. Minor column allograft was used in uncontained acetabular bone defects of sizes between 30% and 50% of the acetabulum. Acetabular failures requiring re-revisions at any time after surgery were included. Acetabular failure for any cause requiring re-revision surgery was used as end-point. Graft failure was considered when re-revision required the concurrent use of structural bone graft, metal augments or excision arthroplasty for any cause.

Results: There were 65 cases that met the study criteria. We included 5 deaths with a mean follow-up of 11.9 years (6.8–14.8) and 10 losses to follow-up after a mean follow-up of 11.7 years (5.3–17.4). Twenty eight acetabulum failed, with 14 occurring before 5 years at a mean of 1.8 years (0.1–4.8) and 14 occurring after 5 years at a mean of 12.2 years (5.6–23.2). Causes included aseptic loosening (23), infection (2), dislocation (1), graft non-union (1) and cup fracture (1). Fourteen grafts failed, with 8 occurring before 5 years at a mean of 1.2 years (0.5–4) and 6 occurring after 5 years at a mean of 11.3 years (6–23.2) after surgery. The mean improvement in modified Harris Hip Scores was 32.3 at 1 year and 32.6 at last follow-up assessment. The cup survivorship was 56.9 % and graft survivorship 78.5 % at a mean follow-up of 16.3 years (5.3–24.8).

Discussion: Metal augments have been used in revision arthroplasty for low demand patients but we recommend the use of minor column allografts in higher demand patients who are more likely to require further revision surgery.

Purpose: The literature regarding the outcome of total knee arthroplasty following distal femoral varus osteotomy is limited. The largest published series to date of eleven such patients suggested that medio-lateral constrained implants are commonly required as ligament balancing is difficult. This study presents mid-term outcomes of patients treated with total knee arthroplasty following distal femoral varus osteotomy at a single center.

Method: Twenty-two consecutive distal femoral varus osteotomies (21 patients) converted to total knee arthroplasties were reviewed at a mean follow-up of five years (range, two to 14 years). The mean duration between osteotomy and conversion to arthroplasty was 12 years (range, three to 21 years). In 14 patients (15 knees) the underlying etiology for the femoral osteotomy was primary knee osteoarthritis with valgus deformity, while in seven patients the procedure was performed to unload a fresh osteochondral allograft of either the lateral tibia (five patients) or femur (two patients). It is the authors’ routine to use posterior stabilized implants were used in all total knee arthroplasty surgeries. Femoral stems were used in six knees in which the bone quality was clinically determined by the surgeon to be sufficiently deficient to predispose to periprosthetic fractures, while the remaining sixteen knees were treated with unstemmed components. Modified knee society scores were used to evaluate the clinical outcomes preoperatively and at most recent follow-up.

Results: The mean knee society knee and function scores in surviving knees improved from 50 points (range, 10 to 75 points) and 50 points (range, 30 to 70 points) pre-operatively, to 91 points (range, 67 to 100 points) and 64 points (range, 50 to 70 points) at final follow-up, respectively. The mean arc of motion improved from 94 degrees (range, 70 to 115 degrees) to 114 degrees (range, 90 to 130 degrees). Two patients underwent revision arthroplasty for polyethylene wear and component loosening at eight and 11 years following the index arthroplasty, respectively. There were no fractures, infections or wound complications.

Conclusion: Total knee arthroplasty following distal femoral varus osteotomy reliably decreases pain and improves knee function. Standard posterior stabilized components provide satisfactory stability after appropriate ligamentous balancing, without the need for stemmed or highly constrained components in the majority of patients.

Purpose: Preoperative planning forces the surgeon to understand the “fracture personality” and devise an operative plan. In our experience, trainees have difficulty in preparing for complex acetabular cases; these fractures are among the most difficult fractures to conceptualize and teach. As a result, these fractures are poorly understood as demonstrated by low interobserver agreement between trainees in the classification of acetabular fractures. We sought to determine whether the use of visou-haptic technology would help trainees to appreciate the “personality” of an Associated-Both-Column (ABC)fracture more accurately than trainees taught by conventional instruction.

Method: Thirty senior medical students and PGY1 residents, were randomized into two groups. The control group studied an ABC fracture with the aid of a textbook excerpt and a 3D CT reconstruction of the fracture. The intervention group was given the same instructional materials, and a visuo-haptic CT model of the fracture. All other learning variables, including time on task were standardized. Participants were evaluated on their accuracy in drawing the fracture lines on a model pelvis.

Results: There was no significant difference in gender, visuo-spatial ability, and training level between groups. The participants taught with the visuo-haptic model recalled an additional 26% anatomic relationships (p< 0.01) compared with the control group.

Conclusion: These findings suggest that in addition to the benefits observed in the learning of motor skills, visuo-haptic input may improve the understanding of spatial relationships. This technology may be a useful adjunct for teaching anatomy, as well as preoperative planning.

Purpose: Single anesthetic bilateral total knee arthroplasty (SABTKA) is a controversial procedure with a questionable safety profile. The purpose of this study was to determine if specific, individual preoperative medical co-morbidities can predict perioperative complications in patients undergoing SABTKA.

Method: The records of all SABTKA performed between 1997 and 2007 at 1 large community hospital and 1 academic, university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities (cardiovascular disease, COPD, diabetes, and hypertension), and perioperative complications for 156 patients were collected and analyzed using logistic multivariate regression analysis. Comparison was made to an age, gender, and co-morbidity matched cohort of patients treated with unilateral TKA.

Results: In the SABTKA group only 11% of patients had a preoperative history of cardiovascular disease yet 89% of all post operative myocardial infarctions (MI) occurred in this population (p< 0.001, Odds Ratio 57.8). Cardiovascular disease also predicted need for admission to ICU (p< 0.001, Odds Ratio 50.8), and number of days spent in the ICU (p< 0.001). In those patients without preoperative cardiovascular disease or COPD the rate of MI was only 0.64%. All differences were significant when compared to the matched unilateral TKA cohort. Age, gender, diabetes, and hypertension did not predict perioperative complications in the SABTKA cohort.

Conclusion: The literature indicates there are certain populations of patients at higher risk for perioperative complications after SABTKA. This study clearly identifies a subpopulation of patients that have cardiovascular disease and are at an unacceptably high risk of perioperative MI. Cardiovascular disease should likely be considered an absolute contraindication to SABTKA.

Purpose: Acetabular component revision in the context of large, contained bone defects with less than 50% host-bone-contact traditionally required roof reinforcement or antiprotrusio cages. Trabecular Metal (TM) cups (Zimmer, Warsaw, Indiana) may offer a viable treatment alternative. The objective of this study was to evaluate the clinical and radiological outcome of this mode of treatment.

Method: Fifty-four hip revision acetabular arthroplasty procedures performed with TM cups for contained defects offering ≤50% contact with native bone were prospectively followed. Average follow-up was 45 months (range 24–71). All patients were clinically and radiographically evaluated for evidence of loosening or failure.

Results: Contact with bleeding host bone ranged from 0 to 50% (average 23%). At latest follow up 43 (79.6%) arthroplasties had excellent or good results, 8 (14.8%) cases had medium or fair results and 3 cases (5.6%) had poor results. Two cups failed and had to be revised. Two additional cups had radiological evidence of probable loosening. Overall preliminary survivorship of the revision acetabulae was 96%. Complications included 4 dislocations and 1 sciatic nerve palsy.

Conclusion: Treatment of cavitary defects with less than 50% host-bone contact with using TM cups, without structural support by augments or structural bone grafts, is a viable option.

Purpose: Pelvic discontinuity associated with bone loss is a complex challenge in acetabular revision surgery. Reconstruction with anti protrusion cages, Trabecular Metal (Zimmer, Warsaw, Indiana) cups and morselized bone (Cup-Cage) constructs is a relatively new technique used by the authors for the past 6 years. The purpose of the study was to examine the clinical outcome of these patients.

Method: Thirty-two consecutive acetabular revision reconstructions in 30 patients with pelvic discontinuity and bone loss treated by cup cage technique between January 2003 and September 2007 were reviewed. Average clinical and radiological follow up was 38.5 ± 19 months (range 12 – 68, median 34.5). Failure was defined as component migration > 5mm.

Results: In 29 (90.6%) patients there was no clinical or radiographic evidence indicative of loosening at latest follow up. Harris Hip Scores improved significantly (p< 0.001) from 46.6 ± 10.4 to 78.7 ± 10.4 at 2 year follow up. In 3 patients the construct migrated at 1 year post surgery. One construct was revised to anti protrusion cage with a structural graft while the other was revised to a large Trabecular Metal cup. The third patient is scheduled for revision. Complications included 2 dislocations, 1 infection and 1 partial peroneal nerve palsy. Two patients died due to unrelated reasons at 1 and 3 years post surgery, respectively.

Conclusion: Treatment of pelvic discontinuity by Cup-Cage construct is a reliable option based on preliminary results which suggest restoration of the pelvic mechanical stability. However, patients should be followed closely in order to detect cup migration until satisfactory bony ingrowth into the cup takes place.

Objectives: Fresh osteochondral allografts are well-established treatment for patients who have posttraumatic osteochondral defects over 3cm in diameter and 1cm in depth of the knee. The objective of our study was to investigate the long-term outcome of these grafts and how long they may delay need for arthroplasty in patients with mal-united tibial plateau fractures.

Method: A prospective cohort study of patients who had received fresh osteochondral allografts of the tibial plateau was conducted. 118 patients were identified and survivor ship analysis was performed using conversion to total knee arthroplasty as the end point for graft failure. The Modified Hospital for Knee Surgery Scoring System (MHKSS) was used to clinically assess each patient who had more than five years of follow up. Radiographs were assessed for mechanical axis as well as using the Tonis grade for degenerative change.

Results: 29 of 118 (25%) experienced graft failure and underwent conversion to total knee arthroplasty, at a mean of 12 years (range 3–23) after the index procedure. The remaining 52 patients with a successful graft, and follow up over five years, had a mean MHKSS score of 83 (range 49–100) with a mean follow up of 11.7 years (range 5–34). Kaplan-Meier survivorship analysis of all 118 patients showed that graft survivorship was 94% at 5 years (std err 2.7), 83% at 10 years (std err 4.6), 62% at 15 years (std err 7.4) and 45% at 20 years (std err 8.5). Factors that predicted a successful graft were, using a meniscal allograft in conjunction with the osteochondral graft, and a lateral tibial plateau defect. The age at the time of surgery was no different between the patients that had a successful graft or those that failed.

Conclusion: Fresh osteochondral allografting works well in providing long term treatments for patients with tibial plateau damage. The concurrent use of meniscal allografts is also recommended.

Purpose: Fresh osteochondral allograft (FOCA) transplantation has been an effective treatment option with promising long-term clinical outcomes for focal post-traumatic or intra-articular lesions in the knee for young, active individuals. The goal of this study was to assess the osteochondral allograft to characterize the histopathologic features of early and late graft failure, as well as prolonged graft survival.

Method: We examined histological features of thirtyfive fresh osteochondral allograft specimens retrieved at the time of subsequent graft revision, osteotomies or total knee arthroplasty.

Results: The graft survival time in our samples ranged from one to twenty-five years based on their time to reoperation. Histological features of early graft failures were lack of chondrocyte viability, loss of matrix cationic staining, and features of mechanical instability. Histological features of late graft failures were fracture through the graft, active and incomplete remodelling of the graft bone by the host bone, and resorption of the graft tissue by synovial inflammatory activity at graft edges. Histological features associated with long-term allograft survival included viable chondrocytes, functional preservation of matrix, and complete replacement of the graft bone with the host bone. These long-term histological findings correlate clinically with excellent Oxford Knee Scores (mean 17.5) in age-matched cohorts with allograft transplants surviving 20 (mean 20.9) years or longer.

Conclusion: Given chondrocyte viability, long-term allograft survival depends on graft stability by rigid fixation of host bone to graft bone. With the stable osseous graft base, the hyaline cartilage portion of the allograft can survive and function for 25 years or more.

Pelvic discontinuity with associated bone loss is a complex challenge in acetabular revision surgery. Reconstruction using ilio-ischial cages combined with trabecular metal acetabular components and morsellised bone (the component-cage technique) is a relatively new method of treatment.

We reviewed a consecutive series of 26 cases of acetabular revision reconstructions in 24 patients with pelvic discontinuity who had been treated by the component-cage technique. The mean follow-up was 44.6 months (24 to 68). Failure was defined as migration of a component of > 5 mm.

In 23 hips (88.5%) there was no clinical or radiological evidence of loosening at the last follow-up. The mean Harris hip score improved significantly from 46.6 points (29.5 to 68.5) to 76.6 points (55.5 to 92.0) at two years (p < 0.001). In three hips (11.5%) the construct had migrated at one year after operation. The complications included two dislocations, one infection and one partial palsy of the peroneal nerve.

Our findings indicate that treatment of pelvic discontinuity using the component-cage construct is a reliable option.

The purpose of this study was to ascertain the radiographic results of the modified extended trochanteric sliding osteotomy (ETSO), performed by the senior author. The main feature of the ETSO is preservation of the posterior 1cm of greater trochanter and its attached external rotators. Results with this particular osteotomy for revision hip arthroplasty have not been previously reported.

We reviewed forty-eight ETSOs in forty-six patients that underwent revision hip arthroplasty from March 2000 to March 2006. Nineteen osteotomies were for femoral revision alone, and twenty-nine osteotomies were performed for femoral and acetabular revision. All but six (12.5%) had cortical strut augmentation of the osteotomy. The length of the osteotomy, the length of distal fit, the number of wires used were recorded and their relation to union of the osteotomy and femoral stem loosening were investigated.

The rate of ETSO union in this study was 91.3%. Four osteotomies were not united and this was associated with femoral stem subsidence and loosening requiring femoral stem revision in three cases. The rate of femoral stem loosening requiring revision was 8.3%. The length of the osteotomy did not correlate with femoral stem loosening, but a distal fit of less than 9cm was highly significant(p=0.001) with regards to loosening. The use of cortical struts was not protective against osteotomy non-union or femoral stem loosening. Osteotomy union was shown to be dependant on a well fixed (p< 0.0001) and stable stem (p< 0.0001). Three patients dislocated postoperatively (6.5%), and only one of these required revision surgery.

The modified extended trochanteric osteotomy has a low rate of dislocation and a reliable rate of union. We have shown that a well fixed and stable stem is critical to successfully obtaining union of the osteotomy.