Background Currently, the two most commonly used options for the revision of femoral components in North America are: cylindrical, nonmodular, cobalt-chromium stems and tapered, fluted, modular, titanium (TFMT) stems. Previous reports have cited high failure rates with cylindrical cobalt chrome stems in large femoral defects but the longer term survival of the fluted stems is unknown. Questions/PurposesWe examined the 5-to 10-year survival of TFMT stems implanted for severe femoral defects. Methods We reviewed all 65 patients with severe proximal bone defects revised with the TMFT stem between January 2000 and 2006. Ten were lost to followup and seven were dead, leaving 48 patients for followup at 5 to 10 years (mean, 84 months; range, 60-120 months). All patients completed five quality-of-life (QOL) questionnaires. Radiographs were evaluated for loosening, subsidence, and preservation of proximal host bone stock.

Surgical stabilization of humeral shaft nonunions can be difficult to achieve if severe osteopenia or loss of bone stock is present. We present a technique whereby a 4.5-mm standard dynamic compression plate is used in conjunction with a humeral cortical allograft strut and bone grafting to stabilize humeral shaft nonunions complicated by severe bone loss. Six patients with established nonunion of the humeral shaft underwent this technique. Union was achieved at an average of 3.4 months (range 2-6 months). Our method using onlay allograft struts can provide an effective alternative in the management of humeral shaft nonunion complicated by severe osteopenia of various etiologies.

Periprosthetic fracture of the proximal femur involving the lesser trochanter (the Vancouver type A(LT)) is an uncommon occurrence. As it is basically an avulsion fracture of the attachment of the iliopsoas, it does not destabilize the stem and can be treated nonsurgically. In contrast, there is a so-called type "new B2" periprosthetic fracture of the lesser trochanter, which includes a segment of the proximal medial femoral cortex. This is usually seen within 6 weeks of the index procedure, typically following insertion of a tapered, cementless stem within a demineralized femur. This may be due to an unrecognized intraoperative fracture that subsequently displaced under load, or it may occur soon after, during rehabilitation. It is important to distinguish this fracture from the type A(LT), because it is associated with destabilization of the stem and requires early reintervention. The principles of treatment depend on the timing of the fracture and the size of the medial fracture fragment. If recognized intraoperatively as a nonpropagated cortical crack, then extraction of the broach or stem followed by cerclage cable fixation and reinsertion of the stem is adequate in most cases, with protected weight bearing for 6 weeks. If diagnosed postoperatively, or if the fracture fragment is larger, then management with a stem that gains fixation distal to the fracture is required. This distinction between the pseudo type A(LT) and the type "new B2" is important to recognize if appropriate treatment is to be prescribed and a satisfactory outcome is to be assured.

Infection after a primary total-joint replacement can be devastating. If the infecting organism is meth-icillin resistant, the chance of successful eradication of the infection is considerably decreased. What is more concerning is that these organisms are becoming increasingly common in periprosthetic joint infection. We have reviewed the literature and have outlined the effectiveness of single- and two-stage treatment regimens for this difficult problem. We have also looked at the screening and decolonisation methods that have been implemented in an attempt to decrease the risk of surgical site infections. Lastly, we outline our recommendations on how we should tackle this emerging and difficult problem that is affecting the orthopaedic world.

A fracture of the femoral shaft after hip arthroplasty is a relatively rare complication. However, the incidence of periprosthestic femoral fractures increases dramatically in patients with established osteopenia or a loss of bone stock. In cases involving periprosthetic femoral fractures around stable implants, cortical allograft strut fixation has emerged as a very attractive treatment option. Cortical allograft struts provide considerable strength and stability while actually increasing the femoral bone stock. Several studies have demonstrated the success of using cortical allograft struts for the treatment of fractures around an implant with union rates ranging from 89% to 100%. 1-3 However, certain complications accompany cortical allograft fixation including extensive periosteal stripping, the potential for disease transmission, and the progressive weakening of the allograft struts as incorporation progresses. 4,5 Perhaps the most serious complication after the use of a cortical strut allograft is deep infection. Numerous studies have examined the use of cortical allografts in revision hip arthroplasty, for reconstruction of large bone defects, and treating periprosthetic fractures, with a significant variation in the rates of postoperative infection. In many cases the origin of the infection is unknown with an abundance of potential sources including contamination of the allograft or hardware either pre-or perioperatively, postoperative wound infection, or systemic bacteremia.We present an unusual case of bilateral femoral shaft fractures sustained by a 35-year-old man with a history of ankylosing spondylitis. The fracture of the left femur was a periprosthetic fracture fixed with a broad 4.5-mm dynamic compression plate in conjunction with two cortical allograft struts. He subsequently developed a deep infection of the left femur that continued to persist after 12 months of antibiotic therapy and two separate irrigation and debridement procedures. The cause of infections related to allograft fixation of periprosthetic femoral fractures is discussed. CASE REPORTA 35-year-old man sustained bilateral femoral shaft fractures after being thrown from his motorized wheelchair when attempting to ascend a steep ramp. He had a 20-year history of severe ankylosing spondylitis with complete vertebral column fusion (except occiput-C1 and C1-C2 articulations), bilateral hip joint fusion, and a fused right shoulder. Before admission he had been confined to a motorized wheelchair for all activities and transfers. The patient had undergone numerous operations including bilateral total knee arthroplasties and a left hip arthroplasty all approximately 15 years earlier. He also had autofusion of his right hip. Before his fall, the patient did not have a problem symptomatically with respect to his knees or hips. Given his history of severe ankylosing spondylitis and his inability to ambulate, his fractures were initially treated nonoperatively at another center.On examination, after 2 months of failed nonoperative treatment, ...