Introduction

We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy.

Introduction

The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator.

Background

Finite element (FE) models are frequently used in biomechanics to predict the behaviour of new implant designs. To increase the stability after severe bone loss tibial components with long stems are used in revision total knee replacements (TKR). A clinically reported complication after revision surgery is the occurrence of pain in the stem-end region. The aim of this analysis was the development of a validated FE-model of a fully cemented implant and to evaluate the effect of different tibial stem orientations.

There has been an unprecedented increase in total knee replacement in recent years. The UK national joint registry recorded over 80,000 total knee replacements per year with a generally successful outcome. Improvements in modern knee replacement designs and surgical techniques has resulted in more and more young and active patients having knee replacements. Their more active lifestyles and increased life expectancy is also leading to a rise in revision knee surgery. The most common reason for revision knee replacement is for loosening as a result of wear and/or bone resorption. Revision knee tibial components typically use long stems to increase the stability in the presence of the proximal bone loss associated with implant removal and loosening. The stem design has been cited as a possible cause of the clinically reported pain at the stem end region. The aim of this study was to experimentally validate a finite element (FE) model and the analysis different load conditions and stem orientations in a stemmed tibial component. CT-scans of a composite tibia (Sawbones) were utilized to form a multi-body solid consisting of cortical bone and cancellous bone with an intramedullary canal. A fully cemented tibial component (Stryker) was virtually implanted in the composite tibia with the stem-end centred in the cancellous bone. The tibial compartment loads were distributed with a 60:40 (Medial: Lateral) and 80:20 ratio to simulate a normal and varus type knee. Several stem-end positions were developed with the modification of the tibias proximal resection angle. An experimental study using strain gauges applied to the same composite tibia was used to compare the results with the FE-model. The model was validated with the strain gauged experimental test specimens demonstrating a similar pattern and magnitude of predicted strains. The simulation of different stem-end orientations revealed an increase in strain to the posterior cortex below the stem-end with the stem in direct contact to the posterior cortical bone. A tibial stem fully surrounded by cancellous bone demonstrated a small increase to the proximal strains. The simulation of a varus aligned knee with a 80:20 (Medial: Lateral) load distribution shifted strain overall to the medial side and revealed a large increase of strain to the posterior-medial in the proximity of the stem-end. The intensification of the load on one side of the tibial plateau, associated with a varus aligned knee, developed the largest increase in strain beneath the stem-end region and is possibly a factor in the reported pain after surgery. The stem in close proximity to the posterior cortical bone is also a possible contributing factor to pain due to the increase of strain in the vicinity of the stem-end.

Introduction

Traditional applied loading of the knee joint in experimental testing of RTKR components is usually confined to replicating the tibiofemoral joint alone. The second joint in the knee, the patellofemoral joint, can experience forces of up to 9.7 times body weight during normal daily living activities (Schindler and Scott 2011). It follows that with such high forces being transferred, particularly in high flexion situations such as stair climbing, it may be important to also represent the patellofemoral joint in all knee component testing.

This research aimed to assess the inclusion of the patellofemoral joint during in vitro testing of RTKR components by comparing tibial strain distribution in two experimental rigs. The first rig included the traditional tibiofemoral joint loading design. The second rig incorporated a combination of both joints to more accurately replicate physiological loading. Five implanted tibia specimens were tested on both rigs following the application of strain gauge rosettes to provide cortical strain data through the bone as an indication of the load transfer pattern. This investigation aimed to highlight the importance of the applied loading technique for pre-clinical testing and research of knee replacement components to guide future design and improve patient outcomes.

Total knee replacement (TKR) is an established treatment for end stage joint disease of the knee. Trabecular metal is one of the design experiments seeking to improve the bone-implant interface and wear patterns in order to increase the longevity of primary joint replacements and reduce the revision burden. Uncemented implants retain bone stock, reduce third body wear, and require a shorter operative time. Although only 4% of knee replacements currently being implanted are uncemented TKRs, there has been considerable recent interest in uncemented designs with a hope of improving the survival time of primary implants. National Joint Registry data has been less favourable of uncemented designs thus far. We report our experience with these comparative implants and present our functional and radiological mid-term results.

Trabecular metal is made of tantalum. It has an interconnecting 3-dimensional lattice structure which is 80% porous. It closely resembles the microstructural architecture of cancellous bone. Bone grows into the porous structure creating a strong bond between bone and implant. In this design, the tibial pegs are seated in a peripheral position, in denser cancellous bone when compared with a central peg. Tantalum offers an appropriate modulus of elasticity, reducing the likelihood of component lift-off and stress shielding.

Over a 4.5 year period, between April 2007 and December 2011, 132 knees in 127 patients with a diagnosis of end stage osteoarthritis, underwent TKR at a single hospital (CMH), performed by a single surgeon (JH). All surgeries were performed with a thigh tourniquet, medial parapatellar approach, antibiotic and VTE prophylaxis, patellar resurfacing, and rapid recovery rehabilitation. 86 cemented TKRs in 78 patients (mean age 76 years), and 66 uncemented TKRs in 49 patients (mean age 68 years). All components were standard NexGen (Zimmer) implants. Follow-up was a mean of 40 months (range 6–87 months).

We analysed the patient postoperative routine standing and recumbent anterior-posterior and lateral radiographs using the knee society TKA scoring system. All linear measurements were made using a PACS viewing system and analysed by 2 of the authors independently. There was no significant radiological lucent lines, and no single KSS > 4. Patients completed Oxford Knee Scores and Knee Society Scoring questionnaires to evaluate their functional outcomes. The mean OKS was 41, and KSS 89. In this period there were revisions in 3 cemented prostheses and 2 uncemented prostheses. 2 revisions were for infection, 2 for peri-prosthetic fracture following trauma, and 1 for unexplained pain.

The uncemented TKR performs equally as well as its cemented counterpart in our experience, both clinically and radiologically, at mid-term follow-up of up to 7 years (mean 3.3 years).

Introduction

The human body is a complex and continually adapting organism. It is theorised that the morphology of the proximal femur is closely related to that of the distal femur. Patients that have abnormal anatomy in the proximal femur, such as a high femoral neck anteversion angle, may have abnormal anatomy in the distal femur to overcome proximal differences. This phenomenon is of key interest when performing Total Hip Replacement (THR) or Total Knee Replacement (TKR) surgery. The current design and placement of existing hip and knee implants does not account for any correlation between the anatomical parameters of the proximal and distal femur, where bone anatomy may have adapted to compromise for abnormalities.

A preliminary study of 21 patients has been carried out to assess the relationship between the proximal and distal femur. The difficulties in defining and measuring key anatomical parameters on the femur have been widely discussed in the literature [1] due to its complex three dimensional geometry. Using CT scans of healthy octogenarians, it was possible to mark key anatomical landmarks which could be used to define various anatomical axes throughout the femur. Correlation analyses could then be carried out on these parameters to assess the relationship between proximal and distal femur morphology.

The purpose of this study was to examine clinical outcomes of capsular plication using subjective outcome measures and objective clinical examination with emphasis on range of motion. Data of consecutive patients (twenty-five at six months and twenty at twelve months) who required arthroscopic stabilization over a period of three years were retrospectively reviewed. At six and twelve month post-operatively, the disease specific outcome measure, ASES, and relative Constant, showed significant changes in quality of life. There was no loss of external rotation at 0° and 90° of external rotation at one year post-operatively.

The purpose of this study was firstly to assess the effectiveness of capsular plication, in the treatment of instability related pathology, using subjective outcome measures and secondly to look specifically at the effect of this procedure on range of motion.

Suture capsular plication has been advocated as a less invasive technique to reduce symptomatic capsular laxity with less morbidity than traditional open techniques. There is, however, little evidence that this procedure has the same clinical effectiveness as open capsular shift procedures.

Arthroscopic capsular plication improves quality of life (QOL) in patients suffering from shoulder instability without significantly restricting external rotation.

Data of consecutive patients who required arthroscopic stabilization over a period of three years were retrospectively reviewed. Three outcome measures were used; one disease-specific and two shoulder specific measures:

the American Shoulder & Elbow Surgeons standardized shoulder assessment form and,

Analysis involved a paired T test between the means of each outcome measure pre and post-surgery.

Twenty-five patients had complete pre-op and six- month post-op data. Twenty subjects had complete pre-op and twelve- month post-op data. At six month post-operatively, the disease specific outcome, relative Constant, and ASES showed significant improvement in QOL scores (P< 0.000, 0.006, and, 0.004 respectively). At twelve- month post surgery, change in all measures remained statistically significant. There was no loss of range of motion in external rotation at 0° or 90° of abduction between initial and follow up assessments in the clinic.

Funding: This study was supported by the research funds of the Orthopedic & Arthritic Institute, Sunnybrook and Women’s College Health Sciences Centre.

Tissues from five patients who underwent revision operations for failed total hip replacements were found to contain large quantities of particulate titanium. In four cases this metal must have come from titanium alloy screws used to fix the acetabular component; in the fifth case it may also have originated from a titanium alloy femoral head. Monoclonal antibody labelling showed abundant macrophages and T-lymphocytes, in the absence of B-lymphocytes, suggesting sensitisation to titanium. Skin patch testing with dilute solutions of titanium salts gave negative results in all five patients. However, two of them had a positive skin test to a titanium-containing ointment.