3D Printed Acetabular Components for Complex Revision Arthroplasty.

Recent studies have shown high early failure rates with Cup Cage constructs in complex revision surgery for Paprosky 3B acetabular defects. As a result, the use of 3D printed custom-made acetabular components has become more common. In this case series, we present two cases that demonstrate the latest advancement in 3D printed implants for severe acetabular bone loss. The follow up was 3 and 7 years. Neither patient has undergone revision surgery of the acetabular component to date. One patient sustained a femoral peri-prosthetic fracture requiring plate fixation. This case study demonstrates that 3D printed implants have excellent intraoperative and immediate postoperative outcomes in revision surgery for severe acetabular bone defects.

Inferior angle of scapula fractures: a review of literature and evidence-based treatment guidelines.

BACKGROUND: Inferior angle of scapula (IAS) fractures are rare, with very few cases reported. They typically present with pain, loss of shoulder motion, and scapula winging. Operative and nonoperative treatments have been trialed with varying success. The aim of this study was to gather data relating to IAS fractures to develop evidence-based treatment guidelines as none are currently available. METHODS: A search was conducted of the PubMed and Google Scholar databases to identify cases of IAS fractures. Data collected about each case included age and gender of the patient, mechanism of injury, fracture displacement, treatment, and outcome. The authors report 2 additional IAS fracture cases. RESULTS: Ten cases were identified for inclusion in this study, 8 from the literature and 2 described by the authors. Of the 10 cases, 7 described displaced IAS fractures and 3 described undisplaced fractures. All displaced fractures treated nonoperatively resulted in a painful nonunion. All that underwent operative fixation, whether acutely or after failed nonoperative treatment, had resolution of pain and a good functional outcome. All undisplaced fractures were treated nonoperatively; 1 had persisting pain. Surgical exploration identified the fracture fragment attached to serratus anterior in 2 cases and attached to both serratus anterior and latissimus dorsi in 2 cases. DISCUSSION AND CONCLUSIONS: There are limited data available about IAS factures. From the cases reviewed, treatment recommendations include the following: (1) displaced IAS fractures should undergo operative fixation to prevent the development of a painful nonunion; (2) suture repair provides adequate fixation; and (3) undisplaced fractures have a variable outcome when treated nonoperatively.

Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre.

BACKGROUND: A two-stage revision remains the gold standard to eradicate deep infection in total knee arthroplasty. Higher failure rates are associated with a number of factors including poly-microbial infections, multiresistant organisms and previous operations. The aims are to investigate [1] the overall success rate of a two-stage revision for infections in TKA, [2] the outcome of repeat two-stage revisions in recurrent infections and [3] the factors affecting the outcomes of such cases. METHODS: We present the outcomes of a consecutive, retrospective case series of 51 periprosthetic joint infections managed with a two-stage revision knee arthroplasty over a three year period. RESULTS: Forty-six (90%) of 51 were referred from other hospitals. Infection was successfully eradicated in 24 (65%) of 37 patients undergoing an initial two-stage procedure. Following a failed two-stage revision, a repeat two-stage revision was performed in 19 patients eradicating infection in 8 (42%). A third two-stage was performed in five of these patients eradicating infection in three with an average follow-up of 43 months. Multidrug resistance was present in 69%, and 47% of the patients were infected with multiple organisms. All unsuccessful outcomes involved at least one multidrug-resistant organism compared to 43% in the successful cohort (P=0.0002). Serological markers prior to a second-stage procedure were not significantly different between successful and unsuccessful outcome groups. CONCLUSION: Single or multiple two-stage revisions can eradicate infection despite previous failed attempts. In this series, failure is associated with multidrug resistance, previous failed attempts to eradicate infection and a less favourable host response.

Tibial stem tip pain in stemmed revision total knee arthroplasty: treatment with tension band plating.

The use of stemmed modular components in revision total knee arthroplasty has led to increasingly described pain located at the tip of the stem of the implant. This has been described in the literature as being due to the elastic modulus mismatch between the stem tip and the host bone. Current management is re-revision total knee arthroplasty in an attempt to alleviate the mismatch. This case report describes a novel technique using a dynamic compression plate acting as a tension band at the stem tip to successfully treat this condition.

Granuloma debridement and the use of an injectable calcium phosphate bone cement in the treatment of osteolysis in an uncemented total knee replacement.

Polyethylene particulate debris-induced periprosthetic osteolysis is a known complication of knee arthroplasty surgery, and may result in the need for revision surgery. The management of these bony defects can be surgically challenging, and full revisions of well-fixed total knee components can lead to substantial bone loss. We present the case of a 71 year old man who developed knee pain and osteolysis around an uncemented total knee replacement. Due to significant medical comorbidies he was treated by percutaneous cyst granuloma debridement and grafting using an injectable calcium phosphate bone substitute. There were no wound complications, and the patient was allowed to fully weight-bear post-operatively. Histopathology and microbiology of the cyst material confirmed polyethylene granulomata without any evidence of infection. At 6 weeks post-operatively the patient's previous knee pain had resolved, he was able to comfortably fully weight-bear. Preoperative scores (Knee Society Score (KSS) 41, WOMAC score 46.2, and Oxford Knee Score 39) had all improved at the 12-month post-operative review KSS 76, WOMAC 81.7 and Oxford Knee score 21). This is a safe and effective technique with minimal morbidity and may be an appropriate treatment modality when more extensive revision surgery is not possible. The case is discussed with reference to the literature.

Adductor tenotomy: its role in the management of sports-related chronic groin pain.

PATIENTS AND METHODS: Chronic adductor-related groin pain in athletes is debilitating and is often challenging to treat. Little is published on the surgical treatment when conservative measures fail. This single center study reviews the outcomes of 48 patients (68 groins) who underwent percutaneous adductor tenotomy for sports-related chronic groin pain. Questionnaire assessments were made preoperatively and at a minimum follow-up of 25 months. RESULTS: Mean pre-injury Tegner activity scores of 8.8 reduced to 6.1 post-injury and these improved to 7.7 following surgery (p < 0.001). Sixty percent of patients regained or bettered their pre-injury Tegner activity scores after the adductor surgery; however, mean post-surgical Tegner scores still remained lower than pre-injury scores (p < 0.001). No patient had been able to engage in their chosen sport at their full ability pre-operatively, and 40% had been unable to participate in any sporting activity. The mean return to sports was at 18.5 weeks postoperatively, with 54% returning to their pre-injury activity levels, and only 8% still unable to perform athletic activities at latest follow-up. Seventy-three percent patients rated the outcome of their surgery as excellent or very satisfactory, and only three patients would not have wished to undergo the procedure again if symptoms recurred or developed on the opposite side. No patients reported their outcome as worse. A 78.1% mean improvement in function and an 86.5% mean improvement in pain were reported, and these two measures showed statistically significant correlation (p = 0.01). Groin disability scores improved from a mean of 11.8 to 3.9, post-operatively (p < 0.001). Bruising was seen in 37% of procedures, 3 patients developed a scrotal hematoma and 1 patient had a superficial wound infection. One patient developed recurrent symptoms following re-injury 26 months post-surgery, and fully recovered following a further adductor tenotomy. CONCLUSIONS: Adductor tenotomy provides good symptomatic and functional improvement in chronic adductor-related groin pain refractory to conservative treatment.

Chronic asymptomatic dislocation of a total hip replacement: a case report.

INTRODUCTION: Dislocation of a prosthetic hip is the second most common complication after thromboembolic disease in patients undergoing total hip arthroplasty, with an incidence reported as 0.5 to 20%. Although the period of greatest risk for dislocation has been reported to be within the first few months after surgery, late dislocation occurs more commonly then previously thought. CASE PRESENTATION: A 60-year-old man underwent a right Exeter cemented total hip replacement and was subsequently discharged after appropriate follow-up. He next presented 8 years later complaining of pain in the left groin. An anterioposterior radiograph of the pelvis revealed degenerative changes in the left hip and a dislocated right total hip replacement. The dislocated femoral component had formed a neoacetabulum within the ilium, in which it was freely articulating. He remained pain-free on this side, had 5 cm of true leg length shortening with a good range of movement and was very pleased with his hip replacement. He was later placed on the waiting list for a left total hip replacement. CONCLUSION: This case illustrates that a dislocated total hip replacement may occasionally not cause symptoms that cause significant discomfort or reduction in range of movement. The prosthetic femoral head can form a neoacetabulum allowing a full range of pain-free movement. Furthermore it emphasises that with an increased trend to earlier hospital discharge and shorter follow-up, potential complications may be missed. We urge a low index of suspicion for potential complications and suggest that regular review with radiographic follow-up should be made.

MRI after operative reduction with femoral osteotomy in developmental dysplasia of the hip.

The use of MRI scanning has been described after open reduction of the hip in developmental dysplasia of the hip (DDH) to check hip position, but has not previously been reported after open reduction with femoral osteotomy and the use of metalwork. We report a prospective study to determine whether MRI scanning can be used to confirm satisfactory reduction of the hip following surgery for DDH, even in the presence of metalwork in the proximal femur. MRI scans were performed in 12 consecutive children, and all gave diagnostic information indicating satisfactory reduction. Sedation was not required and the mean scanning time was 3 min 45 s. Satisfactory images, the lack of need for sedation, comparable time and cost to CT scanning and most importantly the lack of exposure of the child to ionizing radiation make MRI a most appealing method for imaging. We therefore recommend it as the investigation of choice in this patient group.

Surgical excision of wrist ganglia; literature review and nine-year retrospective study of recurrence and patient satisfaction.

The main options for the treatment of wrist ganglia are reassurance, aspiration, arthroscopic resection and open excision. Variations within each option have been described and the literature is clouded by widespread variability in the results reported. We present the results of our own long-term retrospective study, review the literature and question the surgical risks and demands placed on healthcare resources. A retrospective review of the surgical results of dorsal and volar wrist ganglia excision between January 1998 and March 2005 was undertaken at a single institution. Of the 152 patients in this consecutive series, 117 (77%) patients responded to a telephone questionnaire. The mean length of follow-up in this series of 117 patients was 4.2 years (range 1.5-8.7 years). The overall recurrence rate following excision of all wrist ganglia in this series was 41.8 %. When looking just at volar ganglia, the risk of recurrence is higher at 46.8%. Should the ganglion recur, the risk of developing a moderate to severely tender scar is 34.6% and the risk of developing an unsightly scar is 8.2%. This study questions the effectiveness of surgical excision in the treatment of wrist ganglia when performed by a mixture of surgeons in that the recurrence rates are very similar to the rates seen in studies that merely observe or aspirate wrist ganglia. We propose that for symptomatic ganglia, specialists in hand surgery may be more appropriate at treating such a pathology.