Objectives. Periprosthetic femoral fractures (PFFs) have a higher incidence with cementless stems. The highest incidence among various cementless stem types was observed with double-wedged stems. Short stems have been introduced as a bone-preserving alternative with a higher incidence of PFF in some studies. The purpose of this study was a direct load-to-failure comparison of a double-wedged cementless stem and a short cementless stem in a cadaveric fracture model. Methods. Eight hips from four human cadaveric specimens (age mean 76 years (60 to 89)) and eight fourth-generation composite femurs were used. None of the cadaveric specimens had compromised quality (mean T value 0.4 (-1.0 to 5.7)). Each specimen from a pair randomly received either a double-wedged stem or a short stem. A materials testing machine was used for lateral load-to-failure test of up to a maximal load of 5000 N. Results. Mean load at failure of the double-wedged stem was 2540 N (1845 to 2995) and 1867 N (1135 to 2345) for the short stem (p < 0.001). All specimens showed the same fracture pattern, consistent with a Vancouver B2 fracture. The double-wedged stem was able to sustain a higher load than its short-stemmed counterpart in all cases. Failure force was not correlated to the bone mineral density (p = 0.718). Conclusion. Short stems have a significantly lower primary load at failure compared with double-wedged stems in both cadaveric and composite specimens. Surgeons should consider this biomechanical property when deciding on the use of short femoral stem. Cite this article: A. Klasan, M. Bäumlein, P. Dworschak, C. Bliemel, T. Neri, M. D. Schofer, T. J. Heyse. Short stems have lower load at failure than double-wedged stems in a cadaveric cementless fracture model. Bone Joint Res 2019;8:489–494. DOI: 10.1302/2046-3758.810.BJR-2019-0051.R1

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

Aims. Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. Methods. We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs. Results. Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym. 2. , 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time. Conclusion. Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):594–601

Aims. When performing revision total hip arthroplasty using diaphyseal-engaging titanium tapered stems (TTS), the recommended 3 to 4 cm of stem-cortical diaphyseal contact may not be available. In challenging cases such as these with only 2 cm of contact, can sufficient axial stability be achieved and what is the benefit of a prophylactic cable? This study sought to determine, first, whether a prophylactic cable allows for sufficient axial stability when the contact length is 2 cm, and second, if differing TTS taper angles (2° vs 3.5°) impact these results. Methods. A biomechanical matched-pair cadaveric study was designed using six matched pairs of human fresh cadaveric femora prepared so that 2 cm of diaphyseal bone engaged with 2° (right femora) or 3.5° (left femora) TTS. Before impaction, three matched pairs received a single 100 lb-tensioned prophylactic beaded cable; the remaining three matched pairs received no cable adjuncts. Specimens underwent stepwise axial loading to 2600 N or until failure, defined as stem subsidence > 5 mm. Results. All specimens without cable adjuncts (6/6 femora) failed during axial testing, while all specimens with a prophylactic cable (6/6) successfully resisted axial load, regardless of taper angle. In total, four of the failed specimens experienced proximal longitudinal fractures, three of which occurred with the higher 3.5° TTS. One fracture occurred in a 3.5° TTS with a prophylactic cable yet passed axial testing, subsiding < 5 mm. Among specimens with a prophylactic cable, the 3.5° TTS resulted in lower mean subsidence (0.5 mm (SD 0.8)) compared with the 2° TTS (2.4 mm (SD 1.8)). Conclusion. A single prophylactic beaded cable dramatically improved initial axial stability when stem-cortex contact length was 2 cm. All implants failed secondary to fracture or subsidence > 5 mm when a prophylactic cable was not used. A higher taper angle appears to decrease the magnitude of subsidence but increased the fracture risk. The fracture risk was mitigated by the use of a prophylactic cable. Cite this article: Bone Jt Open 2023;4(7):472–477

Aims. Research on hip biomechanics has analyzed femoroacetabular contact pressures and forces in distinct hip conditions, with different procedures, and used diverse loading and testing conditions. The aim of this scoping review was to identify and summarize the available evidence in the literature for hip contact pressures and force in cadaver and in vivo studies, and how joint loading, labral status, and femoral and acetabular morphology can affect these biomechanical parameters. Methods. We used the PRISMA extension for scoping reviews for this literature search in three databases. After screening, 16 studies were included for the final analysis. Results. The studies assessed different hip conditions like labrum status, the biomechanical effect of the cam, femoral version, acetabular coverage, and the effect of rim trimming. The testing and loading conditions were also quite diverse, and this disparity limits direct comparisons between the different researches. With normal anatomy the mean contact pressures ranged from 1.54 to 4.4 MPa, and the average peak contact pressures ranged from 2 to 9.3 MPa. Labral tear or resection showed an increase in contact pressures that diminished after repair or reconstruction of the labrum. Complete cam resection also decreased the contact pressure, and acetabular rim resection of 6 mm increased the contact pressure at the acetabular base. Conclusion. To date there is no standardized methodology to access hip contact biomechanics in hip arthroscopy, or with the preservation of the periarticular soft-tissues. A tendency towards improved biomechanics (lower contact pressures) was seen with labral repair and reconstruction techniques as well as with cam correction. Cite this article: Bone Joint Res 2023;12(12):712–721

Introduction and Objective. Scapholunate instability is the most common cause of carpal instability. When this instability is left untreated, the mechanical relationship between the carpal bones is permanently disrupted, resulting in progressive degenerative changes in the radiocarpal and midcarpal joints. Different tenodesis methods are used in the treatment of acute or early chronic reducible scapholunate instability, where arthritis has not developed yet and the scapholunate ligament cannot be repaired. Although it has been reported that pain is reduced in the early follow up in clinical studies with these methods, radiological results differ between studies. The deterioration of these radiological parameters is associated with wrist osteoarthritis as previously stated. Therefore, more studies are needed to determine the tenodesis method that will improve the wrist biomechanics better and will last longer. In our study, two new tenodesis methods, spiral antipronation tenodesis, and anatomic front and back reconstruction (ANAFAB) were radiologically compared with triple ligament tenodesis (TLT), in the cadaver wrists. Materials and Methods. The study was carried out on a total of 16 fresh frozen cadaver wrists. Samples were randomly allocated to the groups treated with 3 different scapholunate instability treatment methods. These are TLT (n: 6), spiral antipronation tenodesis (n: 5) and ANAFAB tenodesis (n: 5) groups. In all samples SLIL, DCSS, STT, DIC, RSC and LRL ligaments were cut in the same way to create scapholunate instability. Wrist CT scans were taken on the samples in 4 different states, in intact, after the ligaments were cut, after the reconstruction and after the movement cycle. In all of these 4 states, wrist CTs were taken in 6 different wrist positions. For every state and every position through tomography images; Scapholunate (SL) distance, Scapholunate (SL) angle, Radioscaphoid (RS) angle, Radiolunate (RL) angle, Capitolunate (CL) angle, Dorsal scaphoid translation (Dt) measurements were made. Results. Scapholunate distances means were different between intact and cut states only in neutral and clenched fist positions for all groups (p values <0.001). Mean differences were similar between the groups (p > 0.100). In neutral position, for SL center distance, mean difference between cut and reconstruction states were not different between the groups (p=0.497) but it was noted that only TLT group could not restore to the intact state. In neutral position, for SL angle, compared with the cut state, TLT and ANAFAB significantly reduced the angle (TLT: 20° (p=0.005), ANAFAB: 28° (p<0.001)) whereas antipronation tenodesis could not (13°, p=0.080). In clenched fist position, for SL angle, compared with the intact state, only ANAFAB group restored the angle, TLT and antipronation groups were significantly worse than the intact state (TLT: p<0.001, antipronation: p=0.001). In clenched fist position, for RL angle, compared with the intact state, ANAFAB and TLT groups restored the angle but antipronation group was significantly worse than the intact state (p<0.001). In neutral position, for RS angle, compared with the cut state, only ANAFAB significantly reduced the angle (11°, p<0.001) whereas TLT and antipronation groups could not (TLT: 6° (p=0.567), antipronasyon: 4° (p=0.128). Conclusions. In the presence of severe scapholunate instability in which a several number of secondary stabilizers are injured, the ANAFAB tenodesis method may be preferred to the classical method, TLT tenodesis. The results of spiral antipronation tenodesis were not better than the TLT

Abstract. Optimal acetabular component position in Total Hip Arthroplasty is vital for avoiding complications such as dislocation and impingement, Transverse acetabular ligament (TAL) have been shown to be a reliable landmark to guide optimum acetabular cup position. Reports of iliopsoas impingement caused by acetabular components exist. The Psoas fossa (PF) is not a well-regarded landmark for Component positioning. Our aim was to assess the relationship of the TAL and PF in relation to Acetabular Component positioning. A total of 22 cadavers were implanted on 4 occasions with the an uncemented acetabular component. Measurements were taken between the inner edge of TAL and the base of the acetabular component and the distance between the lower end of the PF and the most medial end of TAL. The distance between the edge of the acetabular component and TAL was a mean of 1.6cm (range 1.4–18cm). The distance between the medial end of TAL and the lowest part of PF was a mean of 1.cm (range 1,3–1.8cm) It was evident that the edge of PF was not aligned with TAL. Optimal acetabular component position is vital to the longevity and outcome following THA. TAL provides a landmark to guide acetabular component position. However we feel the PF is a better landmark to allow appropriate positioning of the acetabular component inside edge of the acetabulum inside the bone without exposure of the component rim and thus preventing iliopsoas impingement at the psoas notch and resultant groin pain

Aim. To quantify the micro-motion at the fracture gap in a tibial fracture model stabilised with an external fixator. Method. A surrogate model of a tibia and a cadaver leg were fractured and stabilised using a two-ring hexapod external fixator. They were tested initially under static loading and then subjected to vibration. Results. The overall stiffness of the cadaver leg was significantly higher than the surrogate model under static loading. This resulted in a significantly higher facture movement in the surrogate model. In the surrogate model there was no significant difference between the displacement applied via the vibrating platform and the fracture movement at the fracture gap. The fracture movement was however found to be statistically lower during vibration in the cadaver leg. Discussion. The significant difference in stiffness seen between the surrogate and cadaveric model is likely due to multiple factors such as the presence of soft tissues and fibula, including the biomechanical differences between the frame constructs. The fracture movement seen at 200N loading in the cadaveric leg was approximately 1mm which corresponds to partial weight bearing and a displacement shown to promote callus formation. During vibration however, the movements were far less suggesting that micromotion would be insufficient to promote healing. It may be proposed that soft tissues can alter the overall stiffness and fracture movement recorded in biomechanical studies investigating the effect of various devices or therapies

Introduction. Roentgen stereophotogrammetric analysis (RSA) is currently the gold standard to measure early prosthetic migration which can predict aseptic loosening. However, RSA has some limitations such as the need for perioperative placed markers and exposure to X-radiation during follow up. Therefore, this study evaluates if low field MRI could be an alternative for RSA. Low field MRI was chosen because it is less hampered by metal artifacts of the prosthesis than high field MRI. Methods. 3D models of both the tibial component of a total knee prosthesis (Genesis II, Smith and Nephew) and the porcine tibia were made. The tibial component was implanted in the tibial bone. Consequently, 17 acquisitions with the low field MRI scanner (Esaote G-scan 0.25T) in transverse direction with a 2D PD weighted metal artifact reducing sequence PD-XMAR (TE/TR 10/1020ms, slice thickness 3mm, FOV 180×180×120 mm³, matrix size 224×224) were made. The first five acquisitions were made without repositioning the cadaver, the second twelve after slightly repositioning the cadaver within limits that are expected to be encountered in a clinical setting. Hence, in these 17 acquisitions no prosthetic-bone motions were induced. The scans were segmented and registered with Mimics. Virtual translation and rotation of the prosthesis with respect to the bone between two scans were calculated using a Procrustes algorithm. The first five scans without repositioning were used to calculate the measurement error, the following twelve to calculate the precision of low field MRI to measure prosthetic migration. Results were expressed as the maximum total point motion, mean error and 95% CI and expressed in boxplots. Results. The error of the method to measure the prosthetic position without repositioning has a mean translation between 0.09 and 0.22mm with a 95%CI between 0.30 and 0.46mm. The mean rotation was between 0.02° and 0.11° with a 95%CI between 0.18° and 0.32° with a MTPM of 0.45mm. The precision of low field MRI to measure migration with repositioning has a mean translation between 0.02 and 0.12mm with a 95%CI between 1.16mm and 1.86mm. The mean rotation was between 0.01° and 0.15° with a 95%CI between 1.78° and 3.26° with a MTPM of 2.35mm. The overall registration error was largest in the distal-proximal direction. Discussion. At the moment the low field MRI technique is not as accurate as this gold standard RSA. The accuracy of RSA varies between 0.05 and 0.5 mm for translation and 0.15 ° to 1.15 ° for rotation (95% confidence intervals). However, results are comparable with markerless RSA studies. The largest measurement error was found in the distal-proximal direction, which can be explained by the through-plane resolution of 3 mm, which is larger than the in-plane resolution of 0.8×0.8 mm². Future research should focus on improving resolution in the distal-proximal direction which would improve the precision. Moreover, an actual migration study should be performed to proof the true value of this low field MRI base markerless and X-radiation free alternative to measure prosthetic migration

Abstract. Background. Optimal acetabular component position in Total Hip Arthroplasty is vital for avoiding complications such as dislocation, impingement, abductor muscle strength and range of motion. Transverse acetabular ligament (TAL) and posterior labrum have been shown to be a reliable landmark to guide optimum acetabular cup position. There have been reports of iliopsoas impingement caused by both cemented and uncemented acetabular components. Acetabular component mal-positioning and oversizing of acetabular component are associated with iliopsoas impingement. The Psoas fossa (PF) is not a well-regarded landmark to help with Acetabular Component positioning. Our aim was to assess the relationship of the TAL and PF in relation to Acetabular Component positioning. Methods. A total of 12 cadavers were implanted with the an uncemented acetabular component, their position was initially aligned to TAL. Following optimal seating of the acetabular component the distance of the rim of the shell from the PF was noted. The Acetabular component was then repositioned inside the PF to prevent exposure of the rim of the Acetabular component. This study was performed at Smith & Nephew wet lab in Watford. Results. Out of the twelve acetabular components that were implanted parallel to the TAL, all had the acetabular rim very close or outside to the psoas notch with a potential to cause iliopsoas impingement. Alteration of the acetabular component position was necessary in all cadavers to inside the PF to prevent iliopsoas impingement. It was evident that the edge of PF was not aligned with TAL. Conclusion. Optimal acetabular component position is vital to the longevity and outcome following THA. TAL provides a landmark to guide acetabular component position. We feel the PF is a better landmark to allow appropriate positioning of the acetabular component inside bone without exposure of the component rim and thus preventing iliopsoas impingement at the psoas notch. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. To assess the accuracy of patient-specific instruments (PSIs) versus standard manual technique and the precision of computer-assisted planning and PSI-guided osteotomies in pelvic tumour resection. Methods. CT scans were obtained from five female cadaveric pelvises. Five osteotomies were designed using Mimics software: sacroiliac, biplanar supra-acetabular, two parallel iliopubic and ischial. For cases of the left hemipelvis, PSIs were designed to guide standard oscillating saw osteotomies and later manufactured using 3D printing. Osteotomies were performed using the standard manual technique in cases of the right hemipelvis. Post-resection CT scans were quantitatively analysed. Student’s t-test and Mann–Whitney U test were used. Results. Compared with the manual technique, PSI-guided osteotomies improved accuracy by a mean 9.6 mm (p < 0.008) in the sacroiliac osteotomies, 6.2 mm (p < 0.008) and 5.8 mm (p < 0.032) in the biplanar supra-acetabular, 3 mm (p < 0.016) in the ischial and 2.2 mm (p < 0.032) and 2.6 mm (p < 0.008) in the parallel iliopubic osteotomies, with a mean linear deviation of 4.9 mm (p < 0.001) for all osteotomies. Of the manual osteotomies, 53% (n = 16) had a linear deviation > 5 mm and 27% (n = 8) were > 10 mm. In the PSI cases, deviations were 10% (n = 3) and 0 % (n = 0), respectively. For angular deviation from pre-operative plans, we observed a mean improvement of 7.06° (p < 0.001) in pitch and 2.94° (p < 0.001) in roll, comparing PSI and the standard manual technique. Conclusion. In an experimental study, computer-assisted planning and PSIs improved accuracy in pelvic tumour resections, bringing osteotomy results closer to the parameters set in pre-operative planning, as compared with standard manual techniques. Cite this article: A. Sallent, M. Vicente, M. M. Reverté, A. Lopez, A. Rodríguez-Baeza, M. Pérez-Domínguez, R. Velez. How 3D patient-specific instruments improve accuracy of pelvic bone tumour resection in a cadaveric study. Bone Joint Res 2017;6:577–583. DOI: 10.1302/2046-3758.610.BJR-2017-0094.R1

Aims. Accurate placement of acetabular and femoral stem components in total hip arthroplasty (THA) is an important factor in the success of the procedure. A variety of free hand or navigated techniques is reported. Survivorship and complications have been shown to be directly related to implant position during THA. The aim of this cadaver study was to assess the accuracy of the placement of the components in THA using patient specific instruments (PSI) in combination with a 3D planning software and the direct anterior approach. Method. Patient specific instruments (PSI) were developed to guide the surgeon during THA that were 3D printed with their bone models following a 3D software planning protocol (LPH software V2.5.1, Onefit-Medical, Eos Imaging Company, Besancon, France). Acetabular guides: cup, offset and straight reamer handle and impactor, femoral- and chisel guides were used in each THA (Fig. 1). To define anatomic bone landmarks and to generate a 3D model of each hip joint CT scans were performed preoperatively. The planning of component position was done by one surgeon (AZ) preop. Surgery was performed by two experienced surgeons (AZ, SD) on cadaver specimen with 4 hips in two separate series. A total of 8 hip replacements were evaluated pre- and postoperatively using CT-scans of each hip joint to compare planned to achieved results. Mechanical simulations of the guides were carried out to verify that there were no conflicts between the different instruments. To meet the ISO standard 16061: 2015 the compatibility of the instruments with the guides has been checked. Parameters were evaluated in 3D pelvic and femoral planes: center cup position, inclination angle, anteversion angle, cutting height and plan orientation, anteversion angle, flexion/extension angle, varus/valgus angle, anatomical and functional leg length, offset. Acceptance criteria: postop. parameters evaluated must not have a deviation of more than 5 degrees, 2,5 mm according to preop. planning. For every THA the test protocol has been completely realized. Results. The difference between the preop. and postop. measures in the first series of 4 hips revealed 2 outliers because of fractures of the acetabulum in 2 cases, related to bad cadaver quality. In the second series we found satisfactory results comparing the planned preop and postop component position (Fig. 2). For example difference of leg length showed a mean absolute of 1,58 mm, standard deviation 1,21 mm (min 0,62; max 3,34 mm). Offset revealed a mean absolute of 1,62 mm, standard deviation 0,57 mm (min 1,06; max 2,14 mm) concerning the difference between preop. planning and result postop. Conclusion. Accurate and safe placement of total hip components in THA, both acetabular cup and stem, performing the direct anterior approach can be achieved using a 3D preoperative planning along with patient specific instruments. The results of the cadaver study tests are promising and that is to be proven in the clinical setting and by application in the future

Osteoarthritic (OA) changes to the bone morphology of the proximal tibia may exhibit load transfer patterns during total knee arthroplasty not predicted in models based on normal tibias. Prior work highlighted increased bone density in transverse sections of OA knees in the proximal-most 10mm tibial cancellous bone. Little is known about coronal plane differences, which could help inform load transfer from the tibial plateau to the tibial metaphysis. Therefore, we compared the cancellous bone density in OA and cadaveric (non-OA) subjects along a common coronal plane. This study included nine OA patients (five women, average age 59.1 ± 9.4 years) and 18 cadaver subjects (four women, average age 39.5 ± 14.4 years). Patients (eight with medial OA and one with lateral OA) received pre-operative CT scans as standard-of-care for a unicompartmental knee replacement. Cadavers were scanned at our institution and had no history of OA which was confirmed by gross inspection during dissection. 3D reconstructions of each proximal tibia were made and an ellipse was drawn on the medial and lateral plateau using a previously published method. A coronal section (Figure 1) to standardize the cohort was created using the medial ellipse center, lateral ellipse center, and the tibial shaft center 71.5mm from the tibial spine. On this section, profile lines were drawn from the medial and lateral ellipse centers, with data collected from the first subchondral bone pixel to a length of 20mm. The Hounsfield Units (HU) along each profile line was recorded for each tibia; a representative graphical distribution is shown in Figure 2. The Area Under the Curve (AUC) was calculated for the medial and lateral sides, which loosely described the stiffness profile through the region of interest. To determine differences between the medial and lateral subchondral bone density, the ratio AUC[medial] / AUC[lateral] was compared between the OA and cadaver cohorts using a two-sample t-test. Data from the sole lateral OA patient was mirror-imaged to be included in the OA cohort. The majority of the OA patients appeared to have higher subchondral bone density on the affected side. Figure 3 compares the medial and laterals sides of each group using the AUC ratio method described above. For the cadaver group the AUC was 1.2 +/− 0.22, with a median of 1.1 [0.9 1.6], smaller than the mean AUC for the OA group, which was 1.4 +/− 0.39, with a median of 1.6 [0.93 2.1]. The p-value was 0.06. The increased density observed in OA patients is consistent with asymmetric loading towards the affected plateau, resulting in localized remodeling of cancellous bone from the epiphysis to metaphysis. From the coronal plane, bone was often observed in OA patients bridging the medial plateau to the metaphyseal cortex. Although the cadaver subjects were normal from history and gross inspection, some subjects exhibited early bone density changes consistent with OA. Future work looks to review more OA scans, extend the work to the distal femur, and convert the HU values to bone elastic moduli for use in finite element modelling

Summary Statement. We measured scapulothoracic motions during humeral abduction with different humeral rotations in healthy subjects and whole cadaver models and clarified that humeral rotation significantly influenced scapular kinematics. Introduction. Scapular dyskinesis has been observed in various shoulder disorders such as impingement syndrome or rotator cuff tears. However, the relationship between scapular kinematics and humeral positions remains unclear. We hypothesised that humeral rotation would influence scapular motions during humeral abduction and measured scapular motion relative to the thorax in the healthy subjects and whole cadavers. Methods. Healthy Subjects: Twenty-four shoulders of twelve healthy subjects without shoulder disorders were enrolled. Three electromagnetic sensors were attached on the skin over the sternum, scapula and humerus. Scapular motions during scapular plane abduction (abduction) were measured. The measurements were performed with four hand positions, palm up, thumb up, palm down and thumb down. The elbow was kept extended in all measurements. Each measurement took 5 seconds and repeated three times. Cadavers: Twelve shoulders from 6 fresh whole cadavers were used. A cadaver was set in sitting position on a wooden chair without interrupting scapular motions. Electromagnetic sensors were attached on the thorax, scapula and humerus rigidly with transcortical pins. The elbow was kept in extended position by holding the forearm and the arm was moved passively. The measurements were performed during scapular plane abduction and scapular kinematics were measured in four hand positions, 1: thumb up, 2; palm up, 3; palm down, 4; thumb down as well as the healthy subjects. Each measurement took 5 seconds and repeated three times. Data Analysis: The coordinate system and rotation angles of the thorax, scapula and humerus were decided following ISB recommendation. A one-way analysis of variance was used to test the differences in 4 arm positions. Dunnet's multiple post hoc tests were used to identify the difference between thumb up model (neutral rotation) and other three arm positions. Results. Scapular posterior tilt increased during palm up abduction (healthy subjects −2.0° to 0.1°, cadaver −3.2° to −1.4° at 120° of abduction). During thumb-down abduction, scapular posterior tilt decreased (healthy subjects −4.1° to −8.0° at 110° of abduction, cadaver −3.2° to −8.6° at 120° of abduction) and scapular upward rotation increased (healthy subjects 21.0° to 26.1° at 110° of abduction, cadaver 25.3° to 31.1° at 120° of abduction). Thumb down abduction demonstrated no significant difference from thumb up position. Discussion. Scapular motions measured in healthy subjects and cadaver models showed similar patterns indicating that surface markers on the healthy subjects could track scapular motions successfully as bone markers in cadaver models. Humeral external rotation increased scapular posterior tilt and humeral internal rotation increased scapular anterior tilt and upward rotation. This suggests that position of the greater and lesser tuberosity and tension of the joint capsule caused scapular tilt and scapular upward rotation. Kinematic changes caused by humeral rotations were observed in earlier phase of abduction in healthy subjects than in cadaver models. This suggests that healthy subjects set scapular position beforehand not to increase subacromial pressure. Conclusion. Humeral rotation significantly influenced scapular kinematics. Assessment for these patterns is important for evaluation of shoulder pathology associated with abnormal scapular kinematics

We introduce a novel active tensioning system that can be used for dynamic gap-based implant planning as well as for assessment of final soft tissue balance during implant trialing. We report on the concept development and preliminary findings observed during early feasibility testing in cadavers with two prototype systems. System description. The active spacer (fig 1) consists of a motorized actuator unit with integrated force sensors, independently actuated medial and lateral upper arms, and a set of modular attachments for replicating the range of tibial baseplate and insert trial sizes. The spacer can be controlled in either force or position (gap) control and is integrated into the OMNIBotics. TM. Robotic-assisted TKA platform (OMNI, MA, USA). Cadaver Study. Two design iterations were evaluated on eleven cadaver specimens by seven orthopaedic surgeons in three separate cadaver labs. The active spacer was used in a tibial-first technique to apply loads and measure gaps prior to and after femoral resections. To determine the range of forces applied on the spacer during a varus/valgus assessment procedure, each surgeon performed a varus/valgus stress test and peak medial and lateral forces were measured. Surgeons also rated the feel of the stability of the knee at 50N and 80N of preload using the following scale: 1 – too loose; 2 – slightly loose; 3 – ideal; 4 slightly tight; 5 – too tight. Final balanced was assessed with the spacer and with manual trial components. Results. Overall the prototype system successfully met the functional requirements for applying controlled tension during ligament balancing, and user feedback on usability and feasibility for use in TKA was highly positive. Peak forces measured during blinded stability assessments were significantly imbalanced from medial to lateral and exhibited a wide range across users (range: 70N – 310N, table 1). Each surgeon rated 50N of tension as feeling “slightly loose” and 80N as feeling “ideal” in extension. “Ideal” soft tissue balance was achieved in the last three knees tested using the second design iteration, as rated by the surgeons with final trial components in place. Discussion. Our preliminary cadaver results have established the initial feasibility of the active spacer concept for applying tension during ligament balancing and implant planning. Our initial results also suggest that performing a varus/valgus assessment without force readings can lead to imbalanced mediolateral load application. This may be due to factors such as hand dominance and pulling in varus versus pushing in valgus. There was also considerable inter-surgeon variability in the peak forces applied. An advantage of computer-controlled ligament tensioning and force sensing is ability to standardize applied mediolateral forces across patients and surgeons. In the assessment of the ‘ideal' static ligament tension in extension a force of 80N was preferred over 50N, which is in the range of forces applied by others during ligament balancing. What is the ideal patient specific force to apply remains a topic of future research. Our next steps will be to further evaluate use of the system in the context of virtual trialing

Introduction. The objective of this study was to determine if a synthetic bone substitute would provide results similar to bone from osteoporotic femoral heads during in vitro testing with orthopaedic implants. If the synthetic material could produce results similar to those of the osteoporotic bone, it could reduce or eliminate the need for testing of implants on bone. Methods. Pushout studies were performed with the dynamic hip screw (DHS) and the DHS Blade in both cadaveric femoral heads and artificial bone substitutes in the form of polyurethane foam blocks of different density. The pushout studies were performed as a means of comparing the force displacement curves produced by each implant within each material. Results. The results demonstrated that test material with a density of 0.16 g/cm. 3. (block A) produced qualitatively similar force displacement curves for the DHS and qualitatively and quantitatively similar force displacement curves for the DHS Blade, whereas the test material with a density of 0.08 g/cm. 3. (block B) did not produce results that were predictive of those recorded within the osteoporotic cadaveric femoral heads. Conclusion. This study demonstrates that synthetic material with a density of 0.16 g/cm. 3. can provide a good substitute for cadaveric osteoporotic femoral heads in the testing of implants. However we do recognise that no synthetic material can be considered as a definitive substitute for bone, therefore studies performed with artificial bone substrates may need to be validated by further testing with a small bone sample in order to produce conclusive results

Introduction. Knee instability, stiffness, and soft-tissue imbalance are causes of aseptic revision and patient dissatisfaction following total knee arthroplasty (TKA). Surgical techniques that ensure optimal ligament balance throughout the range of motion may help reduce TKA revision for instability and improve outcomes. We evaluated a novel tibial-cut first gap balancing technique where a computer-controlled tensioner is used to dynamically apply a varying degree of distraction force in real-time as the knee is taken through a range of motion. Femoral bone cuts can then be planned while visualizing the predicted knee implant laxity throughout the arc of flexion. Surgical Technique Description. After registering the mechanical axes and morphology of the tibia and femur using computer navigation, the tibial resection was performed and a robotic tensioning tool was inserted into the knee prior to cutting the femur. The tool was programmed to apply equal loads in the medial and lateral compartments of the knee, but to dynamically vary the distraction force in each compartment as the knee is flexed with a higher force being applied in extension and a progressively lower force applied though mid-flexion up to 90° of flexion. The tension and predictive femoral gaps between the tibial cut and the femoral component in real-time was determined based on the planned 3D position and size of the femoral implant and the acquired pre-resection gaps (figure 1). Femoral resections were then performed using a robotic cutting guide and the trial components were inserted. Methods. The technique was evaluated by three experienced knee arthroplasty surgeons on 4 cadaver knees (3 torso-to-toe specimens, Pre-operative deformity range: 4° varus − 6° valgus; Extension lag: 0° – 13°; BMI 23.4 – 32.6; Age 68 – 85yr). An applied targeted load of 80N in extension and 50N in flexion was used in each of the four knees. These force values were determined in a prior cadaver study aimed at determining what magnitude of applied load corresponded to an optimally rated knee tension and stability. The femoral component was planned in each of the four knees to have symmetric gaps at 0° and 90° of flexion. The overall balance of the knee was assessed clinically by each surgeon using a varus/valgus stress test with the trial components inserted. No soft-tissue releases were performed other than a standard medial release during initial exposure of the knee. The following scale was used to rate the final knee stability achieved: 1 – too loose; 2 – slightly loose; 3 – ideal; 4 slightly tight; 5 – too tight. Results. ‘Ideal' balance was achieved in three out of the four knees tested (table 1). In two of the four knees the final inserted thickness selected was 1mm thicker than the planned insert thickness. Conclusions. Our preliminary cadaver results suggest that it is possible to achieve a balanced knee by incorporating dynamic ligament tensioning and gap data throughout flexion into the femoral planning process using a robotic tensioning tool. For figures/tables, please contact authors directly.

Objectives. The purpose of this study was to develop an accurate, reliable and easily applicable method for determining the anatomical location of the joint line during revision knee arthroplasty. Methods. The transepicondylar width (TEW), the perpendicular distance between the medial and lateral epicondyles and the distal articular surfaces (DMAD, DLAD) and the distance between the medial and lateral epicondyles and the posterior articular surfaces (PMAD, DLAD) were measured in 40 knees from 20 formalin-fixed adult cadavers (11 male and nine female; mean age at death 56.9 years, . sd. 9.4; 34 to 69). The ratios of the DMAD, PMAD, DLAD and PLAD to TEW were calculated. Results. The mean TEW, DMAD, PMAD, DLAD and PLAD were 82.76 mm (standard deviation (. sd. ) 7.74), 28.95 mm (. sd. 3.3), 28.57 mm (. sd. 3), 23.97 mm (. sd. 3.27) and 24.42 mm (. sd. 3.14), respectively. The ratios between the TEW and the articular distances (DMAD/TEW, DLAD/TEW, PMAD/TEW and PLAD/TEW) were calculated and their means were 0.35 (. sd. 0.02), 0.34 (. sd. 0.02), 0.28 (. sd. 0.03) and 0.29 (. sd. 0.03), respectively. Conclusion. This method provides a simple, reproducible and reliable technique enabling accurate anatomical joint line restoration during revision total knee arthroplasty. Cite this article: B. Ozkurt, T. Sen, D. Cankaya, S. Kendir, K. Basarır, Y. Tabak. The medial and lateral epicondyle as a reliable landmark for intra-operative joint line determination in revision knee arthroplasty. Bone Joint Res 2016;5:280–286. DOI: 10.1302/2046-3758.57.BJR-2016-0002.R1

Because ankle inversion trauma can result in persistent isolated subtalar joint instability and can contribute to chronic lateral ankle instability, optimization of subtalar joint ligament injury diagnosis and treatment is essential. 12 fresh-frozen cadaver lower extremities were used. The cradle was a component of a gimbal system that allowed unrestricted inversion/eversion and anterior-posterior and medial-lateral translation of the subtalar joint. The bearing system to which the tibia/fibula were attached allowed unconstrained internal/external rotation and superior-inferior translation. 4N-m inversion/ eversion and internal/external rotational moments and translational forces of 67N were applied. All measurements were performed sequentially in neutral, 10° dorsiflexion and 20° plantarflexion, and were repeated as the cervical, calcaneofibular, and interosseous ligaments were consecutively sectioned in all possible different orders. In neutral position, inversion increased after sectioning of the cervical (3.7°), interosseous (0.8°), and calcaneofibular (1.9°) ligaments individually. Combined sectioning of all three ligaments showed an increase in inversion of 8.3°, 8.5° and 1.4° in the neutral, plantarflexed, and dorsiflexed positions, respectively, compared to the intact ankle. External rotation also increased in neutral position after sectioning the cervical ligament (2.0°). Combined sectioning of all ligaments showed an increase in external rotation of 3.6° and 5.4° for neutral and dorsiflexion, respectively. This is the first comprehensive biomechanical cadaver study of the contributions of the cervical, calcaneofibular, and interosseous ligaments to stabilization of the subtalar joint. The surgeon may refer to the findings in both diagnosing and planning treatment of problematic subtalar joint instability

Aims

One of the main causes of tibial revision surgery for total knee arthroplasty is aseptic loosening. Therefore, stable fixation between the tibial component and the cement, and between the tibial component and the bone, is essential. A factor that could influence the implant stability is the implant design, with its different variations. In an existing implant system, the tibial component was modified by adding cement pockets. The aim of this experimental in vitro study was to investigate whether additional cement pockets on the underside of the tibial component could improve implant stability. The relative motion between implant and bone, the maximum pull-out force, the tibial cement mantle, and a possible path from the bone marrow to the metal-cement interface were determined.