Ludloff’s medial approach has never been used for other hip surgeries especially not for THR. 47 patients (26 men/21 women) provided informed consent to participate in the study. The inclusion criterion for the study was the diagnosis of osteoarthritis of the hip joint. The average age at operation was 53.7±10.4years. All patients were provided with a CUT. ®. prosthesis. All patients were examined clinically and X-rayed preoperatively as well as postoperatively at three days, two weeks, six weeks and six months. The functional hip scores according to Harris and the Oxford hip score were obtained preoperatively and at the defined intervals postoperatively. The surgical duration and the intraop-erative as well as the postoperative blood loss were measured for each patient. Abductor muscle function and the number of steps a patient was able to walk without walking aids on a treadmill at a velocity of 5km/h (a maximum of 100steps was measured) were assessed. Multifactorial analyses of variance and Chi-square tests were performed. Based on the numbers available there were no significant differences between the two groups in the distribution of patient age (p=0.604), gender (p=0.654), weight (p=0.180) and height (p=0.295). No significant differences in the calculated Harris score (p=0.723) were found pre-operatively. The amount of steps the patient was able to walk was not different between the approach groups (p=0.636). The total amount of blood loss (intra- + post-OP) was even significantly lower in the medial approach group (p=0.009). Three days post-operatively the leg lengths were assessed. The difference was not statistically significant based on the numbers available (p=0.926). The overall correlation between Harris and Oxford score was significant (r. 2. =0.63, p< 0.001). Three days post-operatively a slight, but significant better Harris (p< 0.001) and Oxford scores (p=0.001) could be observed in the medial approach group. The number of steps the patient was able to walk without help or crutches was significantly higher in the medial approach group (p=0.001). The Trendelenburg sign (p< 0.001) and the limping criterion (p< 0.001) were significantly less in the medial approach group. Two weeks post-operatively the Harris (p=0.001) and the Oxford (p=0.046) scores were significantly better for the medial approach group. The number of steps the patient was able to walk without help or crutches was significantly higher in the medial approach group (p< 0,001). The medial approach is clinically feasible to perform the implantation of a femoral neck prosthesis. The accuracy of the stem implantation reflected in both the leg lengths and the postoperative X-ray alignment was not different between the groups. After six months there was no significant difference between the conventional anterolateral approach and the medial approach in the presented study

Hind foot arthrodesis through traditional lateral approach in patient with severe valgus deformity carries a significant risk of wound breakdowns, infection and the risk of sural nerve damage. It is also difficult to fully correct a severe valgus deformity through the lateral approach. To overcome some these problems a medial approach has been recommended. Few authors have reported good results in a small series of cases. We present a retrospective review of 18 consecutive patients with valgus hind foot deformity who underwent hind foot arthrodesis via a medial approach. There were 10 male and 8 female with an average age of 55 years (range 28–75years). The indications included osteoarthritis in 13; post traumatic OA in 3 and rheumatoid arthritis in 2. The mean pre-op subtalar valgus angle was 32o (range 12 – 49) and mean post op valgus angle was 17 (range 10 – 25). All the wounds healed primarily and there were no incidence of wound breakdown or infection. None of the patients developed neuro-vascular complications. The average time for fusion was 5.6 months (range 3–9). Two patients needed further surgical intervention, one for FHL tethering at the fusion site and one for non-union of subtalar joint in a chronic smoker. The medial approach not only allows a safe and fantastic access to subtalar joint making correction of valgus deformity easier but is also extendable to include talo- navicular and naviculo-cunieform fusion and FDL transfer as additional procedures through the same approach as and when indicated. In conclusion we recommend the medial approach for performing subtalar arthrodesis in valgus hind foot deformities

Introduction: Recent studies suggest that preservation of the calcaneocuboidal joint and a single medial approach may lead to equally good results as a conventional triple arthrodesis for painful malalignment or arthritis of the hindfoot. The theoretical advantage of a single medial approach for subtalar and talonavicular fusion is a lower risk for postoperative wound healing problems. The aim of our study was to assess the capability of the modified triple arthrodesis to correct hindfoot malalignment. Methods: We retrospectively measured radiological parameters in 36 consecutive feet in 34 patients who underwent a modified triple arthrodesis. All operations were done with a single medial incision using rigid internal fixation with screws. Radiological evaluation was done at a mean of 15 months (range 6 to 34) postoperatively. Results: The following angles showed a significant (p< 0.001) improvement: the talonavicular coverage from 23° (range,−51 to 51°) to 10° (range, −13 to 32°), the dorsoplantar talar-first metatarsal angle from 18° (range, −19 to 76°) to 9° (range, −11 to 28°), the lateral talo-calcaneal angle from 38° (range, 14 to 57°) to 28° (range, 12 to 44°), and the lateral talar-first metatarsal angle from −15° (range, −51 to 23°) to −4°(range, −18 to 22°). We encountered neither primary wound healing problems, nor bony nonunion. Conclusions: In our study all radiological parameters improved postoperatively. We therefore believe that this is a safe and effective technique in the management of hindfoot deformity with predictable outcome even in patients with severe malalignment

Purpose: We describe our management of the valgus knee including release of tight lateral structures using a medial approach. Method: Controversy surrounds which approach to use when undertaking a total knee replacement (TKR) in a fixed valgus knee. Poor patellar tracking is associated with this deformity and often rectified by a lateral retinacular release. Those favoring the lateral approach feel, although more demanding, it gives direct access to the tight lateral structures and avoids excessive devas-cularization to the patella, which may be associated with a lateral release and a medial arthrotomy. Two hundred and eight consented patients (24.2%) were identified from 860 primary knee arthroplasties carried out over a 33-month period by a single surgeon. An LCS mobile bearing prosthesis was used in all cases. The mean valgus deformity measured 12.1 degrees (range 1–38). Fifty four percent of patients had a deformity of greater than 10 degrees. The patella was not resurfaced in any patient. Results: Forty-four patients (21%) required no soft tissue release. The mean deformity was 6 degrees (range 2–13). Of the remaining 164 patients, 142 (87%) had a posterolateral capsule release, 17 (10%) posterolateral capsule and iliotibial band release, 4 (2.4%) posterolateral and direct posterior capsule release and 1 (0.6%) a lateral collateral ligament slide for fixed valgus deformity. The mean valgus deformity increased with each additional release required. Of note 61 (29.3%) patients required a lateral patellar release for patellar maltracking. No patellar complications were noted. Mean patellar tilt was 1.1 degrees (sd=0.6 degrees) and mean patellar congruency 98% (sd=0.7%). Conclusion: Using a medial approach in the valgus knee is technically less demanding than a lateral approach, can be used in any primary knee irrespective of the type of deformity and can restore patellar alignment without compromising viability at least in cases where the patella is not resurfaced

Purpose of the study: Transadductor approaches to the hip joint have been described in the spastic child. Ludl-off as well as Ferguson pass behind the short adductor and the pectineus, a narrow route with a risk of injuring the obturator nerve. We describe a simple minimally invasive approach. Material and method: The incision is made with the hip in the flexion, external rotation, abduction, from the pubic insertion of the long adductor following along the mass of the muscle for 6 to 8 cm. The aponeurosis of the long adductor is cut just deep enough to see the muscle fibres. Careful finger dissection of the muscle sheath common to the three anterior adductor muscles leads directly to the lesser trochanter. Two forceps are inserted on either side of the lesser trochanter, exposing the lesser trochanter and the tendon of the iliopsoas muscle. Dissection of the iliopsoas muscle held aside (follow the tendon on its lateral aspect leading to the vessels). An angled spreader is positioned between the anterior aspect of the capsule and the medial border of the tendon, displacing the tendon laterally and exposing the capsule. Extra-articular exposure of the capsule with a rugine to displace the posterior medial circumflex pedicle. Longitudinal incision of the capsule continued along the inter-trochanteric line to the peri-acetabular region. The medial as well as the anterior aspect of the neck can be visualized by rotating the hip. The inferior and anterior portion of the head is visible: the iliopubic branch and the entire superior and medial wall of the acetabulum can be exposed. Results: We performed 29 medial approaches. Nine for periprostheic pain, four for fresh fracture of the femoral head during posterior dislocation, four for old fractures of the femoral head during posterior dislocation, three for chondromatosis, three for tumours of the femoral head or the acetabulum, six for retractile periarthritis without arthroplasty. Hip arthroplasty (7) or not (6), median pain could be induced by the presence of retractile periarthritis with presence of synovial adherences to the femoral neck penetrating into the joint space; release relieved pain in 11/13. Conclusion: The medial approach to the hip joint is a useful orthopaedic technique with a rapid learning curve

Background: Deformity of the femoral head after open reduction for developmental dislocation of the hip (DDH) influences the outcome of pelvic osteotomy as a final correction for residual dysplasia to prevent secondary osteoarthritis. The purpose of this study was to review long-term outcomes after open reduction using a medial approach for DDH. The correlation between age at the time of operation and femoral head deformity at skeletal maturity was specifically evaluated. Methods: Forty-two hips in 40 patients with more than 10 years of follow-up were assessed radiologically. The mean age at the time of surgery was 14.3 (range, 6–31) months, and the postoperative follow-up period ranged from 10 to 27 (mean, 15.8) years. The round and enlargement indices of the femoral head were measured on follow-up radiographs to evaluate deformity and enlargement of the femoral head at skeletal maturity. Results: Severin classification was I and II in 16 hips; III, IV, and V in 23; and II at the final follow-up in the 3 hips treated by osteotomy less than 10 years after open reduction. Mean round index at follow-up was 58.3 ± 8.3 (range, 47–79); it showed correlation with age at the time of operation (r = 0.68, p < 0.001). Mean enlargement index at follow-up was 113.4 ± 11.8 (range, 93–137) and showed no correlation with age at the time of operation (r = 0.009, p = 0.96). Conclusions: At more than 10 years’ follow-up, the occurrence of deformity of the femoral head correlated with increased age at the time of operation. Indications for use of a medial approach in the correction of DDH in older patients must take into account the risk of subsequent femoral head deformity at skeletal maturity

We present our experience with a medial approach for triple arthrodesis for correction of severe rigid hindfoot deformity in patients who were at risk for wound complications with a standard lateral approach. Between 1995 and 2002, we treated 17 patients with a rigid hindfoot valgus deformity, and for whom a triple arthrodesis was planned, using a single medial incision. The indication for surgery was pain refractory to shoe wear, orthotic and brace modifications. The severity of the hindfoot deformity itself was not sufficient an indication for this procedure, since during the same time period, 157 triple arthrodesis procedures were performed using a two incision technique, many of which were associated with severe hindfoot varus or valgus deformities. The medial incision was indicated specifically for patients who were at risk for wound complications following correction of the hindfoot valgus deformity due to stretching of the lateral skin. There were 15 patients with rheumatoid arthritis (RA), and two patients who had deformity of the hind-foot following a crush injury associated with scarring of the lateral skin over the sinus tarsi. In addition to standard weight bearing radiographs of the foot and ankle, non-invasive vascular studies were performed in 5/17 patients pre-operatively who on clinical examination were considered to have peripheral vascular disease. Immunosuppressant medication(s) were not discontinued prior to surgery for the patients with RA, and were renewed once wound healing occurred. The surgery was performed in a standard manner for each patient, with an extensile medial incision, the use of a laminar spreader to facilitate exposure and joint debridement, and removal of appropriate bone wedges to improve correction. Cannulated partially threaded 5.0 mm (for the talonavicular and calcaneocuboid joints) and 6.5 mm (for the subtalar joint) screws were used in each patient. All 17 patients were examined a mean of 4.5 years following surgery (range 2.5–8), and the examination focused on the success of arthrodesis, the presence of ankle arthritis, as well as hindfoot deformity. Other outcome parameters were not specifically examined since these patients had multiple additional lower limb deformities, as well as arthritides of the foot and ankle unrelated to the performance of the triple arthrodesis. The correction obtained was compared with preoperative radiographs. There were no wound healing complications in any patient. Arthrodesis was obtained in 16/17 patients. In one patient with RA, a non-union of the calcaneocuboid joint was noted radiographically, but had been present for 6 years, and was asymptomatic. There was no loss of correction, however hindfoot valgus was present in three patients, caused by arthritis of the ankle associated with valgus tibiotalar deformity. Two additional patients had since undergone a total ankle replacement for correction of arthritis not associated with deformity, and one had undergone an ankle arthrodesis 2 years following the triple arthrodesis for correction of severe arthritis as well as tibiotalar deformity. On the anteroposterior foot radiograph, the talus-first metatarsal angle improved from a mean of 26 degrees (range 15–45), to a mean of 5 degrees (range 0–15). The talocalcaneal angle was not measured, since reproducible preoperative measurements could not be obtained. The axial talocalcaneal angle was not measured. The medial approach to triple arthrodesis is a reliable procedure, and can be used with a predictable outcome in patients who are at risk for wound healing complications for correction of hindfoot valgus deformity

Introduction: To access efficacy of our protocol for treatment of displaced Gartland type 3 supracondylar fracture humerus in children by giving a small incision medially to identify correct entry point of medial wire and to save the ulnar nerve. This incision is extendable for open reduction if required and have no effect on morbidity. Methods: All Patients with displaced Gartland type 3 supracondylar fractures of humerus admitted from October 1997 to October 2003 were included into this study. They were all treated by closed or open reduction through medial approach and fixed with medial and lateral cross K-wires within 12 hours of admission. Results: There were 43 children with a mean age of 7.2 years at presentation. Follow up time averaged 48 months (range 12–84 months). No patient had iatrogenic ulnar nerve injury. The postoperative mean value of Bauman’s angle in affected elbow was 76.7° with +/− 1.0° and 74.8° with +/− 0.6° on the unaffected elbow. All patients showed satisfactory results according to Flynn’s criteria. Discussion: Cross K-wires give reliable results; a small medial incision is cosmetically more acceptable, provides an excellent view for correct entry point of the wire after visualising ulnar nerve with added advantage of extension if fracture required open reduction

Objectives. There are several reports clarifying successful results following open reduction using Ludloff’s medial approach for congenital (CDH) or developmental dislocation of the hip (DDH). This study aimed to reveal the long-term post-operative course until the period of hip-joint maturity after the conventional surgical treatments. Methods. A long-term follow-up beyond the age of hip-joint maturity was performed for 115 hips in 103 patients who underwent open reduction using Ludloff’s medial approach in our hospital. The mean age at surgery was 8.5 months (2 to 26) and the mean follow-up was 20.3 years (15 to 28). The radiological condition at full growth of the hip joint was evaluated by Severin’s classification. Results. All 115 hips successfully attained reduction after surgery; however, 74 hips (64.3%) required corrective surgery at a mean age of 2.6 years (one to six). According to Severin’s classification, 69 hips (60.0%) were classified as group I or II, which were considered to represent acceptable results. A total of 39 hips (33.9%) were group III and the remaining seven hips (6.1%) group IV. As to re-operation, 20 of 21 patients who underwent surgical reduction after 12 months of age required additional corrective surgeries during the growth period as the hip joint tended to subluxate gradually. Conclusion. Open reduction using Ludloff’s medial approach accomplished successful joint reduction for persistent CDH or DDH, but this surgical treatment was only appropriate before the ambulating stage. Cite this article: Bone Joint Res 2014;3:1–6

Objectives. The approach in total knee arthroplasty (TKA) with severe valgus deformity is controversial. The lateral parapatellar approach has been proposed for several years, but surgical technique of this approach was unusual and difficult. Therefore, we have consistently been selected medial parapatellar approach (MPP) for all cases. In this study, we investigated the short term results of TKA for severe valgus deformity with MPP about clinical and radiographic assessment. Methods. Seven knees in seven cases of severe valgus knees with stand femorotibial angle (FTA) less than 160 degrees were enrolled. Osteoarthritis were 6 cases, hemophilic arthropathy was 1 case and no rheumatoid arthritis case. There were 6 female and 1 male, and mean age was 63.6 years (41–75 years). Duration of follow up ranged 3 months to 22.5 months, with mean of 10.9 months. We compared alignment on standing radiograph, range of motion (ROM), the Japanese Orthopaedic Association (the JOA) score for osteoarthritic knee pre/postoperatively, and examined post operative complication retrospectively. Results. Significant changes of the range of motion pre- and postoperation were not obtained. The mean JOA score improved 50.0 preoperatively to 76.7 postoperatively. The mean stand FTA was corrected 149 degrees preoperatively to 174 degrees postoperatively (p0.001). Postoperative complications occurred in two cases. Aseptic loosening of tibial component due to pyoderma gangrenosum was one case, and peroneal nerve palsy was another. In the former case, revision TKA with varus-valgus constrained prosthesis were performed after a year from primary surgery. In the latter case, weakness of the extensor hallucis longus muscle was fully recovered 4 months later. Conclusion. The medial parapatellar approach was beneficial for TKA of severe valgus knee over the short term

Purpose. To compare the early medial open approach (MO) with the anterior approach (AO) performed after the appearance of the ossific nucleus for DDH that has failed closed reduction or presented late. Methods. We present the experience of 2 UK surgeons with prospectively gathered data for MO (26 hips) compared with that of a third surgeon in the same unit for the AO (21 hips) in 41 children under 24 months of age at index surgery. Femoral head osteonecrosis (FHO) risk was predicted using the height-to-width index of Bruce et al, measured at 12–18 months post reduction, and graded with the Kalamchi and MacEwen classification where follow-up exceeded 3 years. Acetabular index (AI) was measured at or close to 2 years post reduction. Results. Age at time of surgery averaged 11.2 months (3.1–24) for the MO group and 17.8 months (12–24) for the AO group. Average follow-up was 4.3 years (13 months to 12 years). FHO was evident or strongly predicted in 2/26 hips (7.7%) in the MO group and 2/21 (9.5%) in the AO group. AI improved by 8.8° (4–12°) and 7.9° (6–10°) respectively at 2 years post reduction (p>0.05). One case of early recurrent dislocation in the MO group required revision surgery via an anterior approach. The height to width index cut-off value of 0.357 at 12–18 months post reduction accurately predicted FHO risk in cases with longer follow-up. Conclusions. The medial open approach was not associated with a higher risk of FHO compared to a protocol of waiting for the appearance of the ossific nucleus before proceeding to reduction via an anterior approach. There was no significant difference in acetabular remodeling in the first two postoperative years between the protocols despite earlier reduction in the MO group

Orthopaedic surgeons vary in their surgical approaches to total knee arthroplasty. The aim of this investigation was to compare outcomes after two different surgical approaches. The study was a prospective single-centre longitudinal randomized controlled trial. A sub-vastus approach was compared with a medial para-patellar approach. Participating surgeons elected to randomize their patients to one of the two types of approach. Outcomes included the Knee Society (KS) Clinical Rating System, WOMAC Osteoarthritis Index, SF-36, and EuroQol (measured at 1, 6, 12 and 52 weeks post-operatively compared to baseline) complications, surgeon rated ease of exposure, and proportion of patients who had a lateral release. Two hundred and thirty one patients were randomized to the two approaches. One hundred and sixteen patients were randomized to the sub-vastus approach. At one week compared to baseline, range of motion, KS global, KS knee, and KS pain scores were significantly better in the sub-vastus group. At six weeks, the medial para-patellar group tended to have better outcomes, but not statistically significantly. At fifty-two weeks compared to baseline, the WOMAC global and pain scores, the SF36 physical function and role-physical scores, and the EuroQol utility and pain score were significantly better in the sub-vastus group. Surgeons reported the ease of exposure in the sub-vastus group was significantly worse on average. This trial is the largest of its kind to date, and the first, so far as we are aware, to compare clinical outcomes of different surgical approaches at one year post-operatively. The sub-vastus approach to total knee arthroplasty was more effective than a medial para-patellar approach at both one week and fifty-two weeks post-operatively in patients whose surgeons considered either approach would be suitable. However, surgeons reported worse ease of exposure in the sub-vastus group

Aims: To compare the vastus muscle-splitting approach and the classical medial parapatellar in total knee replacement. Methods: Prospective clinical and radiographic study in 50 cemented cruciate-retaining prostheses (Interax, Stryker-Howmedica-Osteonics): midvastus approach in 25 and parapatellar medial in 25. Results: There were no differences (p> 0.05) in postoperative femoro-tibial or patelar tilt angles, duration of surgery, drainage bleeding, Hemoglobine and Hematocrite at postoperative day 3, units of blood transfused, complications, hospital stay, range of motion, and score of the American Knee Society at 1, 6, 12 or 24 months. However, the midvastus approach showed less intraoperative lateral retinacular releases, more patients were able to get independent terminal knee extension at postoperative day 5, and the range of motion at discharge was higher (p< 0.05). Conclusions: The midvastus splitting approach can reduce the need to perform lateral retinacular releases, with advantages in the early postoperative range of motion and knee extension ability.

Abstract. Aim. To study and compare the rise of Inflammatory markers post TKR operated by Medial parapatellar approach with tourniquet (MP) and by Subvastus approach used without tourniquet. (SV). Materials and Methods. 100 patients were operated for a TKR by two experienced Arthroplasty surgeons utilising either the MP approach or the SV approach. (50 knees each). The groups were well matched as regards age, degree of deformity, obesity, pre-op knee scores and co-morbidities. The patients were managed peri-operatively in an identical manner .5 inflammatory markers viz: IL-6, AST, LDH, CRP and ESR were measured pre-operatively and at 12, 24,48 and 72 hours postoperatively. Additionally, the patients' VAS score at these intervals and Morbidity Index was determined. Results. All the 5 inflammatory markers increased post surgery in both groups. However, the rise of 4 out of the 5 inflammatory markers i(IL-6, AST, CRP, ESR) in the MP group was statistically significantly higher than in the SV group. The LDH values were similar in the two groups. The VAS scores were better in the SV group and the Morbidity Index showed a higher degree of morbidity in the MP group. Discussion. Surgical technique and approach can influence the rise of Inflammatory markers post TKR. Conclusion. The Subvastus tourniquetless approach reliably produces a lesser degree of rise in inflammatory markers post TKR than the medial parapatellar approach used with tourniquet. The subvastus approach should be utilised more to improve the immediate post-operative results following a TKR

Distal femur fractures (DFF) are common, especially in the elderly and high energy trauma patients. Lateral locked osteosynthesis constructs have been widely used, however non-union and implant failures are not uncommon. Recent literature advocates for the liberal use of supplemental medial plating to augment lateral locked constructs. However, there is a lack of proprietary medial plate options, with some authors supporting the use of repurposing expensive anatomic pre-contoured plates. The aim of this study was to investigate the feasibility of a readily available cost-effective medial implant option. A retrospective analysis from January 2014 to June 2022 was performed on DFF (primary or revision) managed with supplemental medial plating with a Large Fragment Locking Compression Plate (LCP) T-Plate (~$240 AUD) via a medial sub-vastus approach. The T-plate was contoured and placed superior to the medial condyle. A combination of 4.5mm cortical, 5mm locking and/or 6.5mm cancellous screws were used, with oblique screw trajectories towards the distal lateral cortex of the lateral condyle. All extra-articular fractures and revision fixation cases were allowed to weight bear immediately. The primary outcome was union rate. This technique was utilised on sixteen patients; 3 acute, 13 revisions; mean age 52 years (range 16-85), 81% male, 5 open fractures. The union rate was 100%, with a median time to union of 29 weeks (IQR 18-46). The mean follow-up was 15 months. There were two complications: a deep infection requiring two debridements and a prominent screw requiring removal. The mean range of motion was 1–108. o. . Supplemental medial plating of DFF with a Large Fragment LCP T-Plate is a feasible, safe, and economical option for both acute fixation and revisions. Further validation on a larger scale is warranted, along with considerations to developing a specific implant in line with these principles

Introduction and Objective. Distal femoral fractures are commonly treated with a straight plate fixed to the lateral aspects of both proximal and distal fragments. However, the lateral approach may not always be desirable due to persisting soft-tissue or additional vascular injury necessitating a medial approach. These problems may be overcome by pre-contouring the plate in helically shaped fashion, allowing its distal part to be fixed to the medial aspect of the femoral condyle. The objective of this study was to investigate the biomechanical competence of medial femoral helical plating versus conventional straight lateral plating in an artificial distal femoral fracture model. Materials and Methods. Twelve left artificial femora were instrumented with a 15-hole Locking Compression Plate – Distal Femur (LCP-DF) plate, using either conventional lateral plating technique with the plate left non-contoured, or the medial helical plating technique by pre-contouring the plate to a 180° helical shape and fixing its distal end to the medial femoral condyle (n=6). An unstable extraarticular distal femoral fracture was subsequently simulated by means of an osteotomy gap. All specimens were tested under quasi-static and progressively increasing cyclic axial und torsional loading until failure. Interfragmentary movements were monitored by means of optical motion tracking. Results. Initial axial stiffness was significantly higher for helical (185.6±50.1 N/mm) versus straight (56.0±14.4) plating, p<0.01. However, initial torsional stiffness in internal and external rotation remained not significantly different between the two fixation techniques (helical plating:1.59±0.17 Nm/° and 1.52±0.13 Nm/°; straight plating: 1.50±0.12 Nm/° and 1.43±0.13Nm/°), p≥0.21. Helical plating was associated with significantly higher initial interfragmentary movements under 500 N static compression compared to straight plating in terms of flexion (2.76±1.02° versus 0.87±0.77°) and shear displacement under 6 Nm static rotation in internal (1.23±0.28° versus 0.40±0.42°) and external (1.21±0.40° versus 0.57±0.33°) rotation, p≤0.01. In addition, helical plating demonstrated significantly lower initial varus/valgus deformation than straight plating (4.08±1.49° versus 6.60±0.47°), p<0.01. Within the first 10000 cycles of dynamic loading, helical plating revealed significantly bigger flexural movements and significantly lower varus/valgus deformation versus straight plating, p=0.02. No significant differences were observed between the two fixation techniques in terms of axial and shear displacement, p≥0.76. Cycles to failure was significantly higher for helical plating (13752±1518) compared to straight plating (9727±836), p<0.01. Conclusions. Although helical plating using a pre-contoured LCP-DF was associated with higher shear and flexion movements, it demonstrated improved initial axial stability and resistance against varus/valgus deformation compared to straight lateral plating. Moreover, helical plate constructs demonstrated significantly improved endurance to failure, which may be attributed to the less progressively increasing lever bending moment arm inherent to this novel fixation technique. From a biomechanical perspective, helical plating may be considered as a valid alternative fixation technique to standard straight lateral plating of unstable distal femoral fractures

Introduction: The double-hindfoot arthrodesis (subtalar and midtarsal joints) is traditionally performed through a lateral surgical approach associated or not with a medial approach. The main goal of this procedure is to correct severe deformities of the hindfoot in varus or in valgus. In this study we report a series of 19 double-hin-foot arthrodeses through a single medial approach. Methods and Materials: 19 double arthrodeses (subtalar and talonavicular joint) were performed on 16 patients, 8 males and 8 females with a mean age at surgery of 58.3 years (range 27–72). The indications were: 12 pes planovalgus and 7 cavus foot. 9 deformities were fixed (3 in valgus and 6 in varus). The chosen surgical technique was always identical using a medial approach and performed by a single dedicated orthopaedic foot and ankle surgeon (JLB), followed by an osteotomy of the insertion of the Tibialis posterior muscle to the Navicular bone, distraction and avivement of the articular surface done without bone resection, reduction of the talus on the calcaneus, fixation of the talonavicular joint with titanium staples (Pareos®) and of the subtalar joint with two 6.5 mm canulated cancellous screws (Unima®). On five occasions (in 3 pes planovalgus and in 2 cavus foot) arthrodesis of the calcaneocuboid joint was carried out through a mini lateral approach due to painful arthritic lesions. Results: The average follow up was 16.5 months (range 6–40). Consolidation was always achieved. In the subgroup with pes planovalgus: the mean Kitaoka score increased from 44 to 75, the axis of the hind-foot decreased from 21° to 11° in valgus, Djian’s angle decreased from 142° to 134.4°, the slope of the calcaneus increased from 17° to 19.4°. Two failures of the associated medial ligament reparation have led to a secondary complementary arthrodesis of the talo-crural joint. In the subgroup with cavus foot: the mean Kitaoka score increased from 16 to 67. The axis of the hindfoot decreased from 13° in varus to 0.6° in valgus. Djians’s angle increased from 117° to 127.4°, the slope of the calcaneus ranges from 21.3° to 21.5°. Discussion: The double-hindfoot arthrodesis via a medial approach permits the fusion without developing nonunion (in comparison with 20% non-union of triple arthrodesis reported in the literature). Double arthrodesis via a medial approach provide a significant correction of the fixed deformities without resorting to bone grafts. Not classically used in cavus foot, it has permitted the correction of the cavo varus deformity without complications of the surgical wound and by extending the approach, a double elevating osteotomy of the metatarsal bases was performed when necessary

Dual plating of the medial and lateral distal femur has been proposed to reduce angular malunion and hardware failure secondary to delayed union or nonunion. This strategy improves the strength and alignment of the construct, but it may compromise the vascularity of the distal femur paradoxically impairing healing. This study investigates the effect of dual plating versus single plating on the perfusion of the distal femur. Ten matched pairs of fresh-frozen cadaveric lower extremities were assigned to either isolated lateral plating or dual plating of a single limb. The contralateral lower extremity was used as a matched control. A distal femoral locking plate was applied to the lateral side of ten legs using a standard sub-vastus approach. Five femurs had an additional 3.5mm reconstruction plate applied to the medial aspect of the distal femur using a medial sub-vastus approach. The superficial femoral artery and the profunda femoris were cannulated at the level of the femoral head. Gadolinium MRI contrast solution (3:1 gadolinium to saline ration) was injected through the arterial cannula. High resolution fat-suppressed 3D gradient echo sequences were completed both with and without gadolinium contrast. Intra-osseous contributions were quantified within a standardized region of interest (ROI) using customized IDL 6.4 software (Exelis, Boulder, CO). Perfusion of the distal femur was assessed in six different zones. The signal intensity on MRI was then quantified in the distal femur and comparison was made between the experimental plated limb and the contralateral, control limb. Following completion of the MRI protocol, the specimens were injected with latex medium and the extra-osseous vasculature was dissected. Quantitative MRI revealed that application of the lateral distal femoral locking plate reduced the perfusion of the distal femur by 21.7%. Within the dual plating group there was a reduction in perfusion by 24%. There was no significant difference in the perfusion between the isolated lateral plate and the dual plating groups. There were no regional differences in perfusion between the epiphyseal, metaphyseal or meta-diaphyseal regions. Specimen dissection in both plating groups revealed complete destruction of any periosteal vessels that ran underneath either the medial or lateral plates. Multiple small vessels enter the posterior condyles off both superior medial and lateral geniculate arteries and were preserved in all specimens. Furthermore, there was retrograde flow to the distal most aspect of the condyles medially and laterally via the inferior geniculate arteries. The medial vascular pedicle was proximal to the medial plate in all the dual plated specimens and was not disrupted by the medial sub-vastus approach in any specimens. Fixation of the distal femur via a lateral sub-vastus approach and application of a lateral locking plate results in a 21% reduction in perfusion to the distal femur. The addition of a medial 3.5mm reconstruction plate does not significantly compromise the vascularity of the distal femur. The majority of the vascular insult secondary to open reduction, internal fixation of the distal femur occurs with application of the lateral locking plate

Aims. Meniscal injuries are common and often induce knee pain requiring surgical intervention. To develop effective strategies for meniscus regeneration, we hypothesized that a minced meniscus embedded in an atelocollagen gel, a firm gel-like material, may enhance meniscus regeneration through cell migration and proliferation in the gel. Hence, the objective of this study was to investigate cell migration and proliferation in atelocollagen gels seeded with autologous meniscus fragments in vitro and examine the therapeutic potential of this combination in an in vivo rabbit model of massive meniscus defect. Methods. A total of 34 Japanese white rabbits (divided into defect and atelocollagen groups) were used to produce the massive meniscus defect model through a medial patellar approach. Cell migration and proliferation were evaluated using immunohistochemistry. Furthermore, histological evaluation of the sections was performed, and a modified Pauli’s scoring system was used for the quantitative evaluation of the regenerated meniscus. Results. In vitro immunohistochemistry revealed that the meniscus cells migrated from the minced meniscus and proliferated in the gel. Furthermore, histological analysis suggested that the minced meniscus embedded in the atelocollagen gel produced tissue resembling the native meniscus in vivo. The minced meniscus group also had a higher Pauli’s score compared to the defect and atelocollagen groups. Conclusion. Our data show that cells in minced meniscus can proliferate, and that implantation of the minced meniscus within atelocollagen induces meniscus regeneration, thus suggesting a novel therapeutic alternative for meniscus tears. Cite this article: Bone Joint Res 2021;10(4):269–276

To compare outcome between the medial and posterior approaches for the surgical treatment of supracondy-lar fractures when performed by two experienced surgeons. A retrospective analysis of 45 children, mean age of 5.5 years (2.5-11 years), treated for closed Wilkins IIB/III supracondylar fractures without vascular deficit between January 1999 and December 2004. Twenty-one and twenty-four children were treated using the medial and posterior approaches respectively. The medial approach is quicker but technically demanding. The posterior approach is easier but cuts through the intact posterior structures. In both groups the fracture was stabilised using crossed K-wires and the arm was immobilised in an above elbow backslab for 3 to 4 weeks. Follow-up was at 3 to 4 weeks, 3, 6, and 9 months, and at 1 year. The results were assessed clinically using Flynn’s classification and radiologically using the metaphyseal-diaphyseal and humerocapitellar angles. There was no post-operative infection or redisplace-ment. Clinically, the medial approach gave 18 excellent, 2 good, and one fair result, and the posterior approach gave 21 excellent, 2 good, and one fair result (P> 0.50). Radiologically, the medial approach gave 18 excellent and 3 good results, and the posterior approach gave 20 excellent and 4 good results (P> 0.50). We found no significant difference in outcome between the two approaches, both giving mostly excellent long term results. Each approach has its known merits and drawbacks. This type of fracture needs an experienced surgeon comfortable with his preferred approach