Aims. In UK there are around 76,000 hip fractures occur each year 10% to 15% of which are undisplaced intracapsular. There is considerable debate whether internal fixation is the most appropriate treatment for undisplaced fractures in older patients. This study describes cannulated hip screws survivorship analysis for patients aged ≥ 60 years with undisplaced intra-capsular fractures. Methods. This was a retrospective cohort study of consecutive patients aged ≥ 60 years who had cannulated screws fixation for Garden I and II fractures in a teaching hospital between March 2013 and March 2016. The primary outcome was further same-side hip surgery. Descriptive statistics were used and Kaplan-Meier estimates calculated for implant survival. Results. A total of 114 operations were performed on 112 patients with a mean age of 80.2 years (SD 8.9). The 30-day and one-year mortality were 1% (n = 1) and 13% (n = 15), respectively. Median follow-up was 6.6 years (interquartile range 6.0 to 7.3). Kaplan-Meier estimates showed a survivorship of 95% at one year and 90% at five years (95% confidence interval 84% to 95%) for cannulated screws. Nine patients underwent further hip surgery: four revision to total hip arthroplasty, one revision to hemiarthroplasty, three removals of screws, and one haematoma washout. Posterior tilt was assessable in 106 patients; subsequent surgery was required in two of the six patients identified with a posterior angle > 20° (p = 0.035 vs angle < 20°). Of the 100 patients with angle < 20°, five-year survivorship was 91%, with seven patients requiring further surgery. Conclusion. This study of cannulated hip screw fixation for undisplaced fractures in patients aged ≥ 60 years reveals a construct survivorship without further operation of 90% at five years. Cannulated screws can be considered a safe reliable treatment option for Garden I and II fractures. Caution should be taken if posterior tilt angle on lateral view exceeds 20°, due to a higher failure rate and reoperation, and considered for similar management to Garden III and IV injuries. Cite this article: Bone Jt Open 2022;3(3):182–188

Slipped upper femoral epiphysis (SUFE) is an uncommon condition with potentially severe complications including avascular necrosis (AVN) and chondrolysis. Children with a ‘slip’ are at a significantly higher risk of a contralateral slip. Controversy remains as to when to undertake prophylactic pinning. The primary aim of this study was to assess the Posterior Sloping Angle (PSA, as described by Barrios et al in 2005) as a predictor for contralateral slip in a large, multi ethnic cohort. All consecutive patients treated for SUFE presenting to Waikato Hospital between January 2000 and December 2009 were identified via medical coding. Patients without radiographs and those with bilateral slips on presentation were excluded. Clinical records were reviewed to document demographic data, slip characteristics and follow up outcomes. Radiographic analysis of the PSA in the unaffected hip was performed by a single author. Statistical analysis was performed using a student's t-test with Microsoft Excel 2003. 182 patients were identified, 50 were excluded [26 bilateral slips, 24 no radiograph available] to total a study population of 132 patients. 93 patients were male [72%]. Mean age was 11.8 years [6.2–15.6 years]. 72% were of Maori ethnicity and 26% were of New Zealand European descent. 90 patients [69%] had a unilateral slip, 42 [32%] had a contralateral slip. 48% were not followed until physeal closure and 50% did not attend at least one scheduled appointment Mean PSA of those with a unilateral slip was 10.8° [2–21°]. Patients who subsequently developed a contralateral slip had a statistically significantly higher mean PSA of 17.2° [6–36°] [p<0.0001]. Children with a contralateral slip were significantly younger 11.1 years than those with a unilateral slip 12.2 years (p<0.0001). No significant differences in PSA were found between Maori and NZ European children. If a PSA of 14° was used as an indication for prophylactic fixation in this population 35/42 [83.3%] of contralateral slips would have been prevented. 19/90 hips would have been pinned unnecessarily. The number needed to treat demonstrates that 1.79 hips are prophylactically pinned to prevent one slip in this population. This large retrospective cohort study demonstrates that a PSA of 14° in an unaffected hip after one sided SUFE could warrant prophylactic pinning in an unaffected hip to prevent subsequent slip and the complications associated with this, potentially protecting a population that can be difficult to follow up

This study aimed to describe the morphology of the coracoid process and determine the frequency of commonly observed patterns. The second purpose was to determine the location of inferior tunnel exit with superior based tunnel drilling and the superior tunnel exit with inferior based tunnel drilling. A sample of 100 dry scapulae for the morphology aspect and 52 cadaveric embalmed shoulders for tunnel drilling were used. The coracoid process was described qualitatively and categorized into 6 different shapes. A transcoracoid tunnel was drilled at the centre of the base. Twenty-six shoulders were used for the superior-inferior tunnel drilling approach and 26 for the inferior-superior tunnel drilling approach. The distances to the margins of the coracoid process, from both the entry and exit points of the tunnel, were measured. Eight coracoid processes were of convex shape, 31 of hooked shape, 18 of irregular shape, 18 of narrow shape, 25 of straight shape, and 13 of wide shape. The mean difference for the distances between superior entry and inferior exit from the apex was Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation 3.65+3.51mm (p=0.002); 1.57+2.27mm for the lateral border (p=0.40) and 5.53+3.45mm for the medial border (p=0.001). The mean difference for the distances between inferior entry and superior exit from the apex was 16.95+3.11mm (p=0.0001); 6.51+3.2mm for the lateral border (p=0.40) and 1.03+2.32 mm for the medial border (p=0.045). The most common coracoid process shape observed was a hooked pattern. Both superior to inferior and inferior to superior tunnel drilling directed the tunnel from a more anterior and medial entry to a posterior-lateral exit. Superior to inferior drilling resulted in a more posteriorly angled tunnel. With inferior to superior tunnel drilling cortical breaks were observed at the inferior and medial margin of the tunnel

The aim of this study is to analyse the radiological outcomes and predictors of avascular necrosis following 2-hole DHS in Garden I and II neck of femur fractures in patients more than 60 years with a minimum follow up of one year. We retrospectively reviewed 51 consecutive patients aged more than 60 years who underwent DHS fixation for Garden I and II fractures. Demographics, fracture classification, time to surgery, pre-operative AMTS, preoperative posterior tilt angle, quality of reduction, pre and post-operative haemoglobin(hb), creatinine and comorbidities were analysed for correlation with AVN using Chi-Square test, Independent Sample and paired t test. There were 40 (78.4%) females and the mean age of the cohort was 77 years. 28 and 23 were Garden I and II NOF fractures respectively. Union was observed in all our patients except one(kappa =1). 12/51(23.5%) developed AVN of the femoral head. Statistically significant higher incidence of AVN was noted in patients with a pre-op tilt angle > 200 (p = 0.006). The mean drop in Hb was higher in patients who developed AVN (21.5 g/L) versus the non-AVN group (15.9 g/L) (p = 0.001). There was no difference in AVN rates with respect to laterality, mean time to surgery, pre-op AMTS and Charlson comorbidity index. 4/52 (7.6%) had re-operations (one hardware prominence, two conversions to arthroplasty, one fixation failure during the immediate post-op period). The 30-day and one year mortality rates were 1.9 % and 11.7 % respectively. 2-hole DHS fixation in undisplaced NOF fractures has excellent union rates. A pre-operative posterior tilt angle of >200 and a greater difference in pre and post operative haemoglobin were found to correlate positively with the progression to AVN . No correlation was observed between AVN and time to surgery, laterality, quality of reduction and comorbidities

Abstract. Background. The aim of this study is to analyse the radiological outcomes and predictors of avascular necrosis following 2-hole DHS in Garden I and II neck of femur fractures in patients >60 years with a minimum follow up of one year. Methods. We retrospectively reviewed 51 consecutive patients >60 years who underwent DHS fixation for Garden I and II fractures. Demographics, fracture classification, time to surgery, pre-operative AMTS, preoperative posterior tilt angle, quality of reduction, pre and post-operative haemoglobin (hb), creatinine and comorbidities were analysed. Results. There were 40 (78.4%) females and the mean age was 77 years. 28 and 23 were Garden I and II NOF fractures respectively. Union was observed in all our patients except one. 12/51(23.5%) developed AVN of the femoral head. Statistically significant higher incidence of AVN was noted in patients with a pre-op tilt angle > 20. 0. (p = 0.006). The mean drop in Hb was higher in patients who developed AVN (21.5 g/L) versus the non-AVN group (15.9 g/L) (p = 0.001). There was no difference in AVN with respect to laterality, mean time to surgery, pre-operative AMTS and Charlson comorbidity index. 4/52 (7.6%) had re-operations. The 30-day and one year mortality were 1.9 % and 11.7 % respectively. Conclusion. In our series a preoperative posterior tilt angle of >20. 0. and a drop in haemoglobin were found to correlate with the progression to AVN. No correlation was observed between AVN and time to surgery, laterality, quality of reduction and comorbidities

Aims. The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs. Methods. Patients aged younger than 55 years diagnosed with ONFH after FNF were retrospectively reviewed. Overall, 65 hips (38 males and 27 females; mean age 32.6 years (SD 12.2)) met the inclusion criteria. Patients with stage 1 or 4 ONFH, as per the Association Research Circulation Osseous classification, were excluded. The ratios of anterior and posterior viable areas and necrotic areas of the femoral head to the articular surface were calculated by setting the femoral head centre as the reference point. The PTA was measured using Palm’s method. The association between the PTA and viable or necrotic areas of the femoral head was assessed using Spearman’s rank correlation analysis (median PTA 6.0° (interquartile range 3 to 11.5)). Results. We identified a negative correlation between PTA and anterior viable areas (rho −0.477; p = 0.001), and no correlation between PTA and necrotic (rho 0.229; p = 0.067) or posterior viable areas (rho 0.204; p = 0.132). Conclusion. Our results suggest that residual posterior tilt after FNF could affect the anteroposterior localization of necrosis. Cite this article: Bone Jt Open 2024;5(5):394–400

Aim. To investigate the effect of the eight plate position in sagittal plane on tibial slope in temporary epiphysiodesis technique applied to the proximal tibia and whether there is a rebound effect after removing the plate. Method. Forty New Zealand rabbits (6 weeks old) were divided into four groups. In all groups, two 1.3 mm mini plates and cortical screws implantation were placed on both medial and lateral side of the proximal epiphysis of the right tibia. In Group 1 and 3, the plates were placed on anterior of the proximal tibial anatomical axis in the sagittal plane, and placed posteriorly in Group 2 and 4. The left tibia was examined as control in all groups. Group 1 and Group 2 were sacrificed after four week-follow-up. In Group 3 and Group 4, the implants were removed four weeks after index surgery and the rabbits were followed four more weeks to investigate the rebound effect. The tibial slope was measured on lateral X-rays every two weeks. Both medial and lateral plateau slopes were evaluated on photos of the dissected tibia. Results. In Group 1, right MTPA (medial tibial plateau angle) and left MTPA, right LTPA (lateral tibial plateau angle) and left LTPA, and right 4wTPPA (the tibial proximal posterior angle at 4th week) and left 4wTPPA values were compared with each other. There was a significant difference in MTPA, LTPA, and 4wTPPA in Group 1 (p: 0.003, 0.006, 0.004). In Group 1, the medial and lateral slope significantly decreased after 4 weeks. There was no significant difference in MTPA, LTP and 4wTPPA measurements in Group 2 (p= 0.719, 0.306, 0.446, respectively). In Group 2, the slope did not change in four weeks. There was a significant difference in MTPA, LTPA, 4wTPPA, and 8wTPPA (tibial proximal posterior angle at 8th week) in Group 3 (p= 0.005, 0.002, <0.001, <0.001, respectively). In Group 3, the slope decreased at 4th week and remained stabile during the next four week-follow up and no rebound effect was observed. There was no significant difference in MTPA, LTPA, 4wTPPA, and 8wTPPA measurements in Group 4 (p= 0.791, 0.116, 0.232, 0.924), respectively. In group 4, slope did not change at 4th week of index surgery and no rebound effect was observed in the next four week-follow up. Conclusion. If eight plates were placed on anterior of lateral proximal tibia axis on both medial and lateral side, the tibial slope would reduce, and remain stabile after implant removal. Care should be taken to place the plates on the line of proximal tibial axis in sagittal plane in temporary epiphysiodesis technique performed due to angular knee deformities. Changing the slope due to plate placement can be used as a secondary gain for patients who will benefit from slope change, such as adolescent ACL surgery

Abstract. Introduction. Changes in posterior tibial slope (PTS) and patellar height (PH) following proximal tibial osteotomies have been a recent focus for knee surgeons. Increased PTS and decreased PH following medial opening wedge high tibial osteotomy (MOWHTO) have been repeatedly reported in the literature. However, this has been disputed in more recent biomechanical studies. Methodology. A total of 62 cases who underwent MOWHTO were included. Surgery was performed using a dedicated step-by-step protocol focusing on the risks of unintentional slope changes. Clinically, all patients were evaluated preoperatively and at 2 years follow-up with the KOOS scores and UCLA physical activity scale. Preoperative and postoperative radiographic lower limb alignment parameters were measured on full-length lower limb radiographs, including (HKA), (MPTA), (mLDFA), proximal posterior tibial angle (PPTA), (JLCA) and(JLO). PH measurements were assessed on radiographs. Results. There was a significant change in the coronal plane alignment; the mMPTA changed from 84.38° to 90.39°, and the HKA changed from 172.19° to 180.15° (Both P < 0.0001). There was no significant change in the PTS as evidenced by a postoperative PPTA of 80.56 ° from a preoperative of 80.36°. And no significant change in the PH with all the indices; preoperative Caton Deschamps, Insall Salvati, and Schröter indices measured 0.95, 1.03, and 1.56, respectively. In comparison to postoperative measures of 0.93, 1.03, and 1.54, respectively. Conclusion. MOWHTO does not change the PTS or PH when accurate preoperative planning and precise intraoperative freehand technique are adopted. Involuntary modification of these anatomic parameters should be considered surgical errors

Acetabular retroversion is a recognised cause of hip impingement. Pelvic tilt influences acetabular orientation and is known to change in different functional positions. While previously reported in patients with developmental dysplasia of the hip, positional changes in pelvic tilt have not been studied in patients with acetabular retroversion. We retrospectively analysed supine and standing AP pelvic radiographs in 22 patients with preoperative radiographs and 47 with post-operative radiographs treated for symptomatic acetabular retroversion. Measurements were made for acetabular index (AI), lateral centre-edge angle (LCEA), crossover index, ischial spine sign, and posterior wall sign. The change in pelvic tilt angle was measured both by the Sacro-Femoral-Pubic (SFP) angle and the Pubic Symphysis to Sacro-iliac (PS-SI) Index. In the supine position, the mean calculated pelvic tilt angle (by SFP) was 1.05° which changed on standing to a pelvic tilt of 8.64°. A significant increase in posterior pelvic tilt angle from supine to standing of 7.59° (SFP angle) and 5.89° (PS –SI index) was calculated (p<0.001;paired t-test). There was a good correlation in pelvic tilt change between measurements using SFP angle and PS-SI index (rho .901 in pre-op group, rho .815 in post-op group). Signs of retroversion were significantly reduced in standing x-rays compared to supine: Crossover index (0.16 vs 0.38; p<0.001) crossover sign (19/28 vs 28/28 hips; p<0.001), ischial spine sign (10/28 hips vs 26/28 hips; p<0.001) and posterior wall sign (12/28 vs 24/28 hips; p<0.001). Posterior pelvic tilt increased from supine to standing in patients with symptomatic acetabular retroversion, in keeping with previous studies of pelvic tilt change in patients with hip dysplasia. The features of acetabular retroversion were much less evident on standing radiographs. The low pelvic tilt angle in the supine position is implicated in the appearance of acetabular retroversion in the supine position. Patients presenting with symptoms of hip impingement should be assessed by supine and standing pelvic radiographs so as not to miss signs of retroversion and to assist with optimising acetabular correction at the time of surgery

Introduction and Objective. The geometry of the proximal tibia and distal femur is intimately linked with the biomechanics of the knee and it is to be considered in total knee arthroplasty (TKA) component positioning. The aim of the present study was to evaluate the proximal tibial torsion in relation to the flexion-extension axis of the knee in healthy and pathological cohort affected by knee osteoarthritis (OA). Materials and Methods. We retrospectively analyzed computed tomography scans of OA knee of 59 patients prior to TKA and non-arthritic knee of 39 patients as control. Posterior condylar angle (PCA), femoral tibial torsion (TEAs-PTC and TEAs-PTT), proximal tibial torsion (PTC-PTT and PCAx-PTC) and distance between tibial tuberosity and the trochlear groove (TT-TG) were measured. Results. No differences were found for gender, age, TG-TT and PCAn angles. Statistically significant differences were found for all the other angles considered. Significant relation was found between Tibial Torsion and TEA-PTT angles, between PCAx-PTC and TEA-PTC, between TEA-PTT and TEA-PTC and between PCAx-PTC and TEA-PTT. All measures, except TG-TT and PCAn angles, showed high validity (AUC > 75%) in detecting OA, with TEA-PTT displaying the highest validity with an AUC of 94.38%. Conclusions. This is the first study to find significant differences in terms of proximal tibia geometry and anatomy between non arthritic and OA knees. It is conceivable that such anatomy could be implicated in the development of OA. Based on our data, the TEAs is a valid reference for correct positioning of tibial component in TKA. Indeed, setting the tibial component parallel to TEAs makes the prosthetic knee more similar to the native non-arthritic knee

Acetabular retroversion is a recognised cause of hip impingement. Pelvic tilt influences acetabular orientation and is known to change in different functional positions. While previously reported in patients with developmental dysplasia of the hip, positional changes in pelvic tilt have not been studied in patients with acetabular retroversion. We retrospectively analysed supine and standing AP pelvic radiographs in 22 patients with preoperative radiographs and 47 with post-operative radiographs treated for symptomatic acetabular retroversion. Measurements were made for acetabular index (AI), lateral centre-edge angle (LCEA), crossover index, ischial spine sign, and posterior wall sign. The change in pelvic tilt angle was measured both by the Sacro-Femoral-Pubic (SFP) angle and the Pubic Symphysis to Sacro-iliac (PS-SI) Index. In the supine position, the mean calculated pelvic tilt angle (by SFP) was 1.05° which changed on standing to a pelvic tilt of 8.64°. A significant increase in posterior pelvic tilt angle from supine to standing of 7.59° (SFP angle) and 5.89° (PS –SI index) was calculated (p<0.001;paired t-test). The mean pelvic tilt change of 6.51° measured on post-operative Xrays was not significantly different (p=.650). There was a good correlation in pelvic tilt change between measurements using SFP angle and PS-SI index (rho .901 in pre-op group, rho .815 in post-op group). Signs of retroversion were significantly reduced in standing x-rays compared to supine: Crossover index (0.16 vs 0.38; p<0.001) crossover sign (19/28 vs 28/28 hips; p<0.001), ischial spine sign (10/28 hips vs 26/28 hips; p<0.001) and posterior wall sign (12/28 vs 24/28 hips; p<0.001). Posterior pelvic tilt increased from supine to standing in patients with symptomatic acetabular retroversion, in keeping with previous studies of pelvic tilt change in patients with hip dysplasia. The features of acetabular retroversion were much less evident on standing radiographs. The low pelvic tilt angle in the supine position is implicated in the appearance of acetabular retroversion in the supine position. Patients presenting with symptoms of hip impingement should be assessed by supine and standing pelvic radiographs so as not to miss signs of retroversion and to assist with optimising acetabular correction at the time of surgery

Introduction and Objectives: Sinding-Larsen-Johansson (SLJ) syndrome is a frequent entity in which there is pain on the anterior aspect of the patella in young athletes. Its etiopathogenesis is not well defined and it is considered a traction apophysitis. Our objective was to analyze the association of SLJ syndrome with the presentation of elevated patella. Materials and Methods: We carried out a prospective study of 15 knees with evident clinical and radiological signs of SLJ syndrome and another 15 knees without any previous pathological condition. We used X-rays to measure the Caton-Deschamps index, the modified Insall index, and the posterior angle of inclination of the proximal surface of the tibia; we also took clinical measurements of the popliteal angle. Results: We studied 15 knees in 14 patients. The percentage of males was 85.7% and the mean age of appearance of this pathological condition was 10.86 years (+/− 1.61) Analysis of the data shows that there were no significant differences (p> 0.5) between the groups in relation to the Caton index and the modified Insall index. In relation to the measurements of the popliteal angle of damaged knees, we did find significant differences (mean value: 32.50 d.t.:8.90) with reference to the control group (mean value: 17.67 (+/−. 8.21), and the same was true for the measurements of the posterior inclination angle (mean value: 10.47 (+/− 2.82) in comparison with the knees of the control cases (mean value: 8.33 (+/− 1,40). Discussion and Conclusions: In conclusion, we found a statistically significant relationship between SLJ syndrome and shortening of the hamstring and increase in the posterior angle of inclination of the tibia

The pourpose of this study was to investigate the variability of the posterior condylar angle and the whiteside’s angle to establish if three degrees of external rotation of the femoral component produce the correct rotational alignment, in varus knee. 33 patients (33 knee) affected by varus osteoarthritic knee (5°–30°)underwent a preoperative CT scan examination of the knee and the hip. On the axial views, we have evaluated the femoral anteversion, the posterior condylar angle and the whitesiede’s angle. The mean femoral anteversion angle was 5.5°±13.7° (−24°;33°). The mean posterior condylar angle was 6.1°±2.5° (1°;14°). The mean intraobserver error was 0.9°. In 60.6% of the cases the angle was greater than 5°. The mean Witheside’s angle was 6°±3.5° (1°;16.5°). The mean intraobserver error was 0.8°. In 51.5% of the cases the angle was greater than 5°. Both the posterior condylar angle and the Whiteside’s angle showed values almost double than three degrees proposed as standard rotation for the femoral component. The method of three degrees standard of external rotation lead to relative internal rotation of the femoral component in TKR also for varus knee

Patello-femoral tracking and polyethylene wear are strongly dependent on rotational alignment of the components in total knee arthroplasty. In the current literature four methods to obtain correct axial femoral alignment are reported: the transepicondylar axis method, Whiteside’s method, the tibial axis method and 3° external rotation of posterior condyles method. Because of its simplicity the last of these is the most popular method used at present. But it is also the most accurate? The purpose of this study was to investigate the accuracy of the 3° external rotation method, comparing it to the transepicondylar axis and the White-side’s A-P line. We performed a CT scan examination of the hip and the knee of 40 patients scheduled to undergo a total knee arthroplasty. Seven cases of valgus deformity were excluded from the study, leaving 34 cases. The mean age was 72.4 and the left knee was involved in 23 cases. The mean height was 159 cm and the mean weight was 76.6 kg. The mean varus deformity was 14° (min 5° – max 30°). CT scan was conducted using a Picker PQCT machine. Two axial images were obtained in all the patients: one of the femoral neck and one of the knee with good visualisation of the posterior aspect of the condyles of the femur and epicondyles. We measured the following angles: the femoral anteversion angle (between the femoral neck line and the posterior condylar line), the posterior condylar angle (between the posterior condylar line and the transepicondylar axis) and the Whiteside’s angle (between the posterior condylar line and the perpendicular line to the White-side’s A-P line). The mean femoral anteversion angle was 5.5°± 13.7° (min -24°; max 33°). The mean posterior condylar angle was 6.1°± 2.5° (min 1°; max 14°). In 20 cases (60.6%) the posterior condylar angle was greater than 5°. The mean Whiteside’s angle was 6°±3.5° (min 1°; max 16.5°). In 17 cases (51.5%) it was greater than 5°. Both the posterior condylar angle and the White-side’s angle showed average values, which doubled the 3° proposed as standard for external rotational alignment of the femoral component, with maximum values of 14° and 16.5° respectively. More than 50% of the cases showed a posterior condylar angle grater than 5°. The two methods (transepicondylar and Whiteside’s line) are complementary. The posterior condylar axis and the Whiteside’s line were not altered by severe varus deformity or femoral neck retro- or anteversion. The 3° external rotation of the posterior condyle line is not recommended as a standard procedure to determine the degree of external rotation of the femoral component in total knee arthroplasty

Introduction. A femoral rotational alignment is one of the essential factors, affecting the postoperative knee balance and patellofemoral tracking in total knee arthroplasty (TKA). To obtain an adequate alignment, the femoral component must be implanted parallel to the surgical epicondylar axis (SEA). We have developed “a superimposable Computed Tomography (CT) scan-based template”, in which the SEA is drawn on a distal femoral cross section of the CT image at the assumed bone resection level, to determine the precise SEA. Therefore, the objective of this study was to evaluate the accuracy of the rotational alignment of the femoral component positioned with the superimposed template in TKA. Patients and methods. Twenty-six consecutive TKA patients, including 4 females with bilateral TKAs were enrolled. To prepare a template, all knees received CT scans with a 2.5 mm slice thickness preoperatively. Serial three slices of the CT images, in which the medial epicondyle and/or lateral epicondyle were visible, were selected. Then, these images were merged into a single image onto which the SEA was drawn. Thereafter, another serial two CT images, which were taken at approximately 9 mm proximal from the femoral condyles, were also selected, and the earlier drawn SEA was traced onto each of these pictures. These pictures with the SEA were then printed out onto transparent sheets to be used as potential “templates” (Fig. 1-a). In the TKA, the distal femur was resected with the modified measured resection technique. Then, one template, whichever of the two potential templates, was closer to the actual shape, was selected and its SEA was duplicated onto the distal femoral surface (Fig. 1-b). Following that, the distal femur was resected parallel to this SEA. The rotational alignment of the femoral component was evaluated with CT scan postoperatively. For convention, an external rotation of the femoral component from the SEA was given a positive numerical value, and an internal rotation was given a negative numerical value. Results. The subjects were 4 knees in 4 males and 26 knees in 22 females. A mean age (for 30 knees) at the operation was 76.7 ± 6.1 years (range from 66.4 to 88.3). The posterior condylar angle was −0.27 ± 1.43, and the outlier, more than 3 degrees, was 1 case. Discussion. Conventionally, the SEA is palpated intraoperatively, however, the sulcus of the medial condyle sometimes cannot be identified precisely in osteoarthritic degeneration at the medial condyle. Also, the SEA is determined from the posterior condylar axis (PCA) by calculating the posterior condylar angle, which is between the SEA and the PCA, with the measurements from the preoperative CT scan. However, the residual cartilage thickness is not considered in this method, and thus, the SEA is possible to be inaccurate. The simple technology of our template allowed us to determine the SEA directly on the femoral surface, without any influence from bone degeneration. The femoral components could be implanted accurately, and therefore, the superimposed template was considered to improve TKA outcomes with the accurate SEA

Introduction. Instability, loosening, and patellofemoral pain belong to the main causes for revision of total knee arthroplasty (TKA). Currently, the diagnostic pathway requires various diagnostic techniques such as x-rays, CT or SPECT-CT to reveal the original cause for the failed knee prosthesis, but increase radiation exposure and fail to show soft-tissue structures around TKA. There is a growing demand for a diagnostic tool that is able to simultaneously visualize soft tissue structures, bone, and TKA without radiation exposure. MRI is capable of visualising all the structures in the knee although it is still disturbed by susceptibility artefacts caused by the metal implant. Low-field MRI (0.25T) results in less metal artefacts and offers the ability to visualize the knee in weight-bearing condition. Therefore, the aim of this study is to investigate the possibilities of low field MRI to image, the patellofemoral joint and the prosthesis to evaluate the knee joint in patients with and without complaints after TKA. Method. Ten patients, eight satisfied and two unsatisfied with their primary TKA, (NexGen posterior stabilized, BiometZimmer) were included. The patients were scanned in sagittal, coronal, and transversal direction on a low field MRI scanner (G-scan Brio, 0.25T, Esaote SpA, Italy) in weight-bearing and non-weight-bearing conditions with T1, T2 and PD-weighted metal artefact reducing sequences (TE/TR 12–72/1160–7060, slice thickness 4.0mm, FOV 260×260×120m. 3. , matrix size 224×216). Scans were analysed by two observers for:. - Patellofemoral joint: Caton-Descamps index and Tibial Tuberosity-Trochlear Groove (TT-TG) distance. - Prosthesis malalignment: femoral component rotation using the posterior condylar angle (PCA) and tibial rotation using the Berger angle. Significance of differences in parameters between weight-bearing and non-weight-bearing were calculated with the Wilcoxon rank test. To assess the reliability the inter and intra observer reliability was calculated with a two-way random effects model intra class correlation coefficient (ICC). The two unsatisfied patients underwent revision arthroplasty and intra-operative findings were compared with MRI findings. Results. In the satisfied group, a significant difference was found between TT-TG distance in non-weight-bearing and weight-bearing condition (p=0.018), with a good interrater reliability ICC=0.89. Furthermore, differences between weight-bearing and non-weight-bearing were found for the CD ratio, however, not significant (p=0.093), with a good interrater reliability ICC=0.89. The Berger angle could be measured with an excellent interrater reliability (ICC=0.94). The PCA was hard to assess with a poor interrater reliability (ICC=0.48). For one unsatisfied patient a deviation was found for tibial component rotation, according to the perioperative findings as, ‘malposition of the tibial component’. For the other unsatisfied patient revision surgery was performed due to aseptic loosening in which the MRI showed a notable amount of synovitis. Conclusion. It is possible to image the patellofemoral joint and knee prosthesis with low field MRI. Patellofemoral measurements and tibial component rotation measurements can reliably be performed. For the two patients with complaints MRI findings were consistent with intra-operative findings. Further research should focus on a larger group of patients with complaints after TKA to verify the diagnostic capacity of low field MRI for peri-prosthetic knee problems. For any figures or tables, please contact authors directly

The in vivo kinematics of squatting after total hip arthroplasty (THA) has remained unclear. The purpose of the present study was to elucidate range of motion (ROM) of the hip joint and the incidence of prosthetic impingement during heels-down squatting after THA. 23 primary cementless THAs using a computed tomography-based navigation system (CT-HIP, Stryker Navigation, Freiberg, Germany) were investigated using fluoroscopy. An acetabular component with concavities around the rim (TriAD HA PSL, Stryker Orthopaedics, Mahwah, NJ) and a femoral component with reduced neck geometry (CentPiller, Stryker Orthopaedics), which provided a large oscillation angle, were used. The femoral head size was 28mm (8 hips), 32mm (10 hips), and 36mm (5 hips). Post-operative analysis was performed within 6 months in 6 hips, and at 6 months to 2 years in 17 hips. Successive hip motion during heels-down squatting was recorded as serial digital radiographic images in a DICOM format using a flat panel detector. The coordinate system of the acetabular and femoral components based on the neutral standing position was defined. The images of the hip joint were matched to three-dimensional computer aided design models of the acetabular and femoral components using a two-dimensional to three-dimensional (2D/3D) registration technique. In the previous computer simulation study of THA, the root mean square errors of rotation was less than 1.3°, and that of translation was less than 2.3 mm. We estimated changes in the relative angle of the femoral component to the acetabular component, which represented the hip ROM, and investigated the incidence of prosthetic impingement during squatting. We also estimated changes in the flexion angle of the acetabular component, which represented the pelvic posterior tilting angle (PA), and the flexion angle of the femoral component, which represented the femoral flexion angle (FA). The contribution of the PA to the FA at maximum squatting was evaluated as the pelvic posterior tilting ratio (PA/FA). In addition, when both components were positioned most closely during squatting, we estimated the minimum angle (MA) up to theoretical prosthetic impingement. No prosthetic impingement occurred in any hips. The maximum hip flexion ROM was mean 92.7° (SD; 15.7°, range; 55.1°–119.1°) and was not always consisted with the maximum squatting. The maximum pelvic posterior tilting angle (PA) was mean 27.3° (SD; 11.0°, range; 5.5°–46.5°). The pelvis began to tilt posteriorly at 50°–70° of the hip flexion ROM. The maximum femoral flexion angle (FA) was mean 118.9° (SD; 10.4°, range; 86.4°–136.7°). At the maximum squatting, the ratio of the pelvic posterior tilting angle to the femoral flexion angle (pelvic posterior tilting ratio, PA/FA) was mean 22.9% (SD; 10.4%, range; 3.8%–45.7%). The minimum angle up to the theoretical prosthetic impingement was mean 22.7° (SD; 7.5°, range; 10.0°–37.9°). The maximum hip flexion of ROM in 36 mm head cases was larger than that in 32 mm or 28 mm head cases, while the minimum angle up to the prosthetic impingement in 36 mm head cases was also larger than that in 32 mm or 28 mm head cases. Three-dimensional assessment of dynamic squatting motion after THA using the 2D/3D registration technique enabled us to elucidate hip ROM, and to assess the prosthetic impingement, the contribution of the pelvic posterior tilting, and the minimum angle up to theoretical prosthetic impingement during squatting

Aim. The aim of this study is to evaluate the effect of three-dimensional (3D) simulation with 3D planning software ZedKnee® (ZK) in total knee arthroplasty (TKA). Materials and methods. The participants in this study were all TKA patients whose operations were simulated by using ZK. The alignment of all components was evaluated with the ZK valuation software in postoperative computer tomography. Thirty patients (43 knees) met the inclusion criteria. 6 patients were male and 24 patients were female. The mean age of the 30 patients was 72 years old. Diagnoses for surgery were: osteoarthritis- 40 knees, rheumatoid arthritis- 2 knees and osteonecrosis- 1 knee. TKA was performed using the measured resection technique. The distal femur axis where the intramedullary rod would be inserted was drawn manually on the 3D image. Then, the angle between the distal femoral axis and the mechanical axis was measured. The rotational angles of the femoral components were determined from the automatically calculated angle between the posterior condylar axis and the surgical epicondylar axis (SEA) by using ZK. The ZK data used during the operation was the posterior condylar angle, the angle between the distal femoral axis and the mechanical axis and implant size. Results. The angle in coronal plane between the 3D mechanical axis and the distal femoral axis in preoperative planning ranged between 3 degrees and 11 degrees, mean 6.7 (SD 2.2) degrees. The postoperative femoral component alignment was on average 0.7 (SD 1.3) degrees in varus. Outlier of more than 3 degrees in coronal alignment was recognized in 3 cases (7%). The mean posterior condylar angle in preoperative planning was 3.8 (SD 1) degrees. The postoperative femoral component alignment was on average 1.5 (SD 1.6) degrees in external rotation to surgical epicondylar axis. Outlier of more than 3 degrees in rotational alignment was recognized in 6 cases (14%). The concordance rate between the preoperative planning size and the intraoperative selective size was 91%. Discussion. Some errors may be observed in the preoperative TKA X-ray planning, because of the rotational position of the femur while having the X-ray taken or angle of the X-ray beam. Kanekasu et al reported the measurement of the condylar twist angle during the X-ray and it was relatively correct compared with the measurement during CT. Max 1.9 degrees error occurred in the measurements using X-rays. It appeared that preoperative planning using CTs was more accurate than using X-rays. Conclusion. Femoral components with 3D simulation using ZK were fixed perpendicularly against the mechanical axis and parallel to the surgical epicondylar axis with high accuracy. We considered that the ZK 3D simulation in TKA is useful for the accurate alignment of femoral components

Background. Finding the anatomical landmarks used for correct femoral rotational alignment can be difficult. The Posterior Condylar Line (PCL) is probably the easiest to find during surgery. The aim of this study was to analyze if a predetermined fixed angle referencing of the PCL could help obtain good femoral alignment in TKA patients. Methods. 2637 CT scans used for preoperative planning and creation of patient-specific instrumentation (PSI) were used to analyze the Posterior Condylar Angle (PCA) between the Surgical Epicondylar Axis (SEA) and the PCL. Results. The mean PCA was 3.99° +/− 1.35° of external rotation. A significant relation was found between more external rotation and more varus of the tibia and more valgus of the femur. In 132 patients bilateral CT's were available and 94 (71%) had rotation within 1° of the opposite side. 96% of patients would receive the right amount of external rotation with 6°. On 105 (4%) CT's external rotation between 7° to 11° was measured and 77 (73%) of those were in varus or neutral alignment. Conclusions. After substracting a correction of 1° for cartilage remnants, a posterior condylar angle of 5° external rotation is proposed which should cover 96% of the population. For 4% of patients, both varus and valgus knees, 5° of external rotation will not be sufficient. The epicondylar axis should be explored during surgery, determined with patient-specific instruments, or a balancer should be used for this group

Introduction. Implant malalignment is an important predictor of prosthetic failure following total knee arthroplasty (TKA). The purpose of this study was to determine the incidence of outliers for common alignment targets and the impact of surgeon volume and experience on the accuracy of implant alignment with current generation manual instrumentation. Methods. This study was a retrospective, multi-center, radiographic analysis of 1675 consecutive primary uncomplicated TKAs from seven surgeons at three academic and state-funded centers in the US and UK. Surgeons were categorized as “high-volume” (≥50 TKAs/year) and “high-experience” (≥5 years post-fellowship). Femorotibial, tibial varus/valgus, and posterior tibial slope angles were digitally measured using postoperative radiographs. Femorotibial (<2° or >8° valgus), tibial (> ±3° deviation from the neutral axis), and tibial slope (<0° or >7° of flexion for cruciate retaining, <0° or >5° of flexion for posterior stabilized) angle outliers were identified. The proportion of outliers among surgeons in each subgroup was compared. Results. When comparing high-and low-volume surgeons, the proportion of femorotibial (12% vs. 19%, p <0.0001), posterior slope (17% vs. 28%, p <0.0001), and total outliers (12% vs. 19%, p <0.0001) was significantly lower in the high-volume group. Furthermore, the proportion of knees with well-aligned implants in all three measurements (69% vs. 53%, p <0.0001) was significantly higher in the high-volume group. When comparing high-and low-experience surgeons, the proportion of femorotibial (14% vs. 17%, p = 0.046), tibial (9% vs. 6%, p = 0.030), posterior slope (19% vs. 26%, p <0.0001), and total outliers (14% vs. 17%, p = 0.006) was higher in the low-volume group. Furthermore, the proportion of knees with well-aligned implants in all three measurements (64% vs. 58%, p = 0.008) was significantly higher in the high-experience group. Conclusions. Low surgeon volume and experience predispose to implant malalignment following TKA, with surgical volume bearing a greater influence on alignment accuracy. Even among high volume, high experience surgeons, outliers in at least one standard alignment target occur in over 30% of cases with current standard instrumentation