Introduction. A total knee arthroplasty (TKA) is the standard of care treatment for end-stage osteoarthritis (OA) of the knee. Over the last decade, we have observed a change in TKA patient population to include younger patients. This cohort tends to be more active and thus places more stress on the implanted prothesis. Bone cement has historically been used to establish fixation between the implant and host bone, resulting in two interfaces where loosening may occur. Uncemented fixation methods provide a promising alternative to cemented fixation. While vulnerable during the early post-operative period, cementless implants may be better suited to long-term stability in younger patient cohorts. It is currently unknown whether the surgical technique used to implant the cementless prostheses impacts the longevity of the implant. Two different surgical techniques are commonly used by surgeons and may result in different load distribution across the joint, which will affect bone ingrowth. The overall objective of the study is to assess implant migration and in vivo kinematics following cementless TKA. Methods. Thirty-nine patients undergoing a primary unilateral TKA as a result of OA were recruited prior to surgery and randomized to a surgical technique based on surgeon referral. In the gap balancing surgical technique (GB) soft tissues releases are made to restore neutral limb alignment followed by bone cuts (resection) to balance the joint space in flexion and extension. In the measured resection surgical technique (MR) bone cuts are first made based on anatomical landmarks and soft tissue releases are subsequently conducted with implant components in-situ. Patients returned 2 weeks, 6 weeks, 12 weeks, 24 weeks, and 52 weeks following surgery for radiographic evaluation. Kinematics were assessed 52 weeks post-operatively. Results. No significant difference was observed between groups in maximum total point motion (MTPM) at any time point during the first post-operative year. MTPM of both the tibial and femoral component did not significantly change between the six month and one year follow up visits for both the GB (6 mths=0.67 ±0.34mm, 1 yr=0.65 ±0.52, p=0.71) and MR (6 mths= 0.79 ±0.53mm, 1 yr= 0.82 ±0.43mm, p=0.56) cohorts. MTPM for both components over the follow up period is displayed in Figure 1. No significant difference was observed in contact location or pattern on the medial condyle during deep flexion (Figure 2A). A significant difference (p=0.01) was observed, however, between surgical techniques in the lateral contact location at full extension (Figure 2B). No significant difference was observed in the magnitude of AP excursion for both the medial and lateral condyles within and between groups. Conclusion. Surgical technique did not impact the MTPM of an uncemented TKA design during the first post-operative year. By the six month post-operative period tibial and femoral MTPM plateaus indicating that osseointegration between the host bone and implanted components has occurred. Kinematic evaluation indicates contact locations anterior to the midline of the sagittal plane, paradoxical anterior translation, and a lateral pivot point, regardless of surgical technique

Introduction. Osteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods. Methodology. After the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct. Results. Three children ages 5,8 and 13 underwent the procedure. Five coxa vara femurs have undergone this technique with follow-up out to 62 months (41–85 months) from surgery. Improvements in the femoral neck shaft angle (FNSA) were av. 18. o. (10–38. o. ) with pre-op coxa vara FNSA av. 99. o. (range 87–114. o. ) and final FNSA 117. o. (105–125. o. ). Hilgenreiner's epiphyseal angle was improved by av. 29. o. (2–58. o. ). However only one hip was restored to <25. o. In the initial technique employed for 3 hips, the plates were left short in the neck to avoid damaging the physis. This resulted in 2 of 3 hips fracturing through the femoral neck above the plate at approximately 1 year. There were revisions of the 3 hips to longer plates to prevent intra-capsular stress riser. All osteotomies united and both intracapsular fractures healed. No further fractures have occurred within the protected femurs and no other repeat operations have been required. Conclusions. Surgical correction of the OI coxa vara hip is complex. Bone mineral density, multiplanar deformity, a desire to maintain physeal growth and protection of the whole bone all play a role in the surgeon's decision making process. Following modifications, this technique demonstrates a novel method in planning and control of multiplanar proximal femoral deformity, resulting in restoration of the FNSA to a more appropriate anatomical alignment, preventing long bone fracture and improved femoral verticalization in the medium term follow-up

Introduction. While total hip arthroplasty is considered to be one of the most cost-effective medical interventions, the total cost of care for a population patients treated by THR can present a significant burden on the payer, whether it be an employer, private insurer or government. Data on the true cost of care has rarely been made available to the treating physician. Such lack of information makes comprehensive management difficult. Bundled payment models of care require knowledge of all costs associated with the care of our patients and opens new opportunity for analysis to improve management and outcomes. The current study assess the influence of surgical technique on total cost of care for total hip arthroplasty. Methods. Payment data for 341 patients who underwent total hip arthroplasty at a single institution from June 1. st. , 2011 to October 31. st. , 2014 were analyzed. Each procedure was performed using either the superior, anterior, or posterior exposure. The superior exposure was performed with femoral head excision and without dislocation of the hip. The data were analyzed for total cost, inpatient cost, inpatient physician cost, readmission cost, skilled nursing facility cost, and home healthcare agency cost among the different approaches. Results. The superior hip approach for total hip arthroplasty results in a significant total cost savings over a 90-day episode of care when compared to both the anterior and posterior exposure techniques. It reduced overall costs by approximately $2,000 and $7,000 per case versus the other groups respectively. The superior approach also demonstrated savings in inpatient and skilled nursing facility cost when compared to the other groups. Conclusions. Surgical technique can have a profound influence on the total cost of care for hip arthroplasty patients. The current study demonstrates that the posterior exposure resulted in the largest consumption of resources post-operatively as measured by total cost of care and that the superior exposure resulted in the least consumption of resources among the three surgical exposures assessed. The study suggests that while we focus on many aspects of improvement in the overall episode of care for our patients, that focus on surgical technique may be worthwhile

Introduction. Because of concerns regarding excessive wear and short-term failures attributed to the metal-on-metal bearings, the use of metal-on-metal hip resurfacing arthroplasty (MOMHRA) has been greatly reduced since 2008, despite great mid-term results for well-designed implants and in certain patient populations. The true cause of excessive wear was then unknown. Therefore, identification of true risk factors for the procedure became paramount to refine indications and improve survivorship outcomes. Methods. Over the last 10 years, a systematic search of the US national library of Medicine and National institutes of health with the key words “metal-on-metal” and hip resurfacing” was conducted and returned 2186 items. Of these items, 862 were deemed relevant to our research purposes and entered in our center's reference database from which this review was performed. Results. Edge loading is the main culprit for high wear and high serum Co and Cr ion concentrations because it disrupts the fluid film lubrication of the device. Computation of the contact patch to rim distance (CPR), an estimate of the joint's functional coverage, is the best predictor of potential edge loading and excessive wear. Both in vivo and in vitro studies show that the wear of well-designed and well-positioned MOM bearings diminishes over time with continued use, an advantage only featured by MOM bearings. Systemic wear-related complications and hypersensitivity to metal once thought to be common are in fact rare occurrences. In addition, metal-related revisions only represent a small portion of the various modes of failure encountered with well-designed HRA. In our series of 1321 hips with only 0.5% lost to follow-up, 11 patients underwent revision surgery for excessive wear or adverse local tissue reaction. All but 2 had mal-positioned acetabular components (CPR distance <10mm). One of these 2 patients had serum cobalt and chromium levels of 13 and 9 µg/L respectively, despite a CPR distance of 18.3 mm, while the other showed a peri-prosthetic fluid collection estimated at 111cc on MRI. Component aseptic loosening (acetabular or femoral) remains, as is also the case for total hip arthroplasty (THA), the leading indication for revision surgery, even though substantial progress has been reported to reduce its incidence. Femoral neck fractures and loosening are associated with the surgeon's learning curve which can be avoided with proper training. The survivorship of the femoral component in our series after implementation of surgical technique changes is 99.2% at 10 years for an overall survivorship of 95.5%. A diagnosis of DDH is associated with a higher failure rate, particularly from socket loosening, while women without risk factors have a survivorship of 98.6% at 15 years. Conclusion. HRA has often been, but should not be associated with the results of large head metal-on-metal THA which often present with a different set of failure mechanisms. Now that most of the risk factors for HRA have been identified, and solutions found, a balanced perspective of its results is needed because the long-term data available validate the low wear of MOM bearings which was predicted in the early hip simulator studies. Considering the tremendous progress made in surgical technique and the advanced tribological knowledge acquired with the last 20 years of investigations related to MOM HRA, all the conditions are present to make this procedure a success for lifetime durability as shown in our series where 44 patients (54 hips) have died without a revision at a mean follow-up time of 9.7 years (range, 1.8 to 19.7). For HRA, when devices with adequate coverage and clearance of the ball by the socket are used, severe developmental dysplasia and inadequate surgical technique are responsible for most failures at 10 to 15 years of follow-up. It is our opinion that the advantages of HRA over THA (such as absence of thigh pain, a low dislocation rate, no taper corrosion, and the preservation of proximal femoral bone mineral density and the ability to maintain high activity levels without penalty) now outweigh the risks of using a MOM bearing

Introduction. To achieve well aligned and balanced knee is essential for the post-operative outcome in total knee arthroplasty (TKA). Gap balancing technique can adjust the bone cut depending on the soft tissue balance in addition to soft tissue releases. Therefore, gap balancing technique would be more advantageous in soft tissue balance comparing to measured resection technique (MRT) in which soft tissue balancing relayed on soft tissue releases alone. Nevertheless, the influence of surgical technique on the post-operative knee stability has not been fully investigated. Objective. We introduced a new surgical technique (medial gap technique: MGT) according to modified gap technique regarding medial knee stability as important. The intra-operative soft tissue balance and post-operative knee stability were compared between MGT and MRT in posterior-stabilized (PS) TKA for varus type osteoarthritic knees. Materials & Methods. Sixty varus type osteoarthritis knees were involved in this study. PS type TKAs (NexGen LPS flexR) were performed using MGT in 30 knees (MGT group) and MRT in 30 knees (MRT group). The extension gap was made in the same manners in both groups. Both femoral and tibial bone cuts were perpendicular to the mechanical axis. Medial soft tissue releases were limited until the spacer block with the thickness corresponding to the resected lateral tibial condyle could be inserted. After extension gap was prepared, OFR-tensorR was used to assess soft tissue balance (center gap, varus angle) at extension and flexion prior to posterior femoral condyle bone resection. Both differences of the center gap and varus angle between at extension and flexion were calculated and used for size selection and external rotation angle of femoral component in MGT. The final joint component gaps were evaluated using OFR-tensorR with both femoral trial in place and patello-femoral joint reduced at 0, 10, 30, 45, 60, 90, 120 and 135 degrees of flexion. Quantitative stress radiographies were performed at 1 month, 6 months and 1 year post-operatively to assess joint stability. Joint opening distance (mm) at both medial and lateral joint compartment were measured with knee extension and flexion. Each parameter was compared between MGT and MRT group using unpaired t-test (p<0.05). Results. Pre-operative factors showed no significant differences between 2 groups. The joint component gaps were significantly larger in MRT group from 45 to 135 degrees of flexion (Fig.1). The joint opening at the lateral compartment was significantly larger than medial at both knee extension and flexion in both groups. The joint openings were significantly larger bilaterally in MRT group comparing to MGT group at both extension and flexion (Fig.2, 3). Discussions. Medial instability has been reported as a possible reason for the persistent knee pain after TKA in the varus knees. We proposed a new surgical technique (MGT) not to deteriorate medial stability and allow lateral looseness in TKA. Post-operative knee stability was superior in MGT group comparing to MRT group from one month to one year after surgery. The difference of the intra-operative soft tissue balance might play an important role on the post-operative knee stability

Poor soft tissue balance in total knee arthroplasty (TKA) is one of the most primary causes of dissatisfaction and reduced joint longevity, which are associated with postoperative instability and early implant failure. 1. Therefore, surgical techniques, including mechanical instruments and 3-D guided navigation systems, in TKA aim to achieve optimum soft tissue balancing in the knee to improve postoperative outcome. 2. Patella-in-Place balancing (PIPB) is a novel technique which aims to restore native collateral ligament behaviour by preserving the original state without any release. Moreover, reduction of the joint laxity compensates for the loss of the visco-elastic properties of the cartilage and meniscus. Following its clinical success, we aimed to evaluate the impact of the PIPB technique on collateral ligament strain and laxity behaviour, with the hypothesis that PIPB would restore strains in the collateral ligaments. 3. . Eight fresh-frozen cadaveric legs were obtained (KU Leuven, Belgium, H019 2015-11-04) and CT images were acquired while rigid marker frames were affixed into the femur, and tibia for testing. After carefully removing the soft tissues around the knee joint, while preserving the joint capsule, ligaments, and tendons, digital extensometers (MTS, Minnesota, USA) were attached along the length of the superficial medial collateral ligament (MCL) and lateral collateral ligament (LCL). A handheld digital dynamometer (Mark-10, Copiague, USA) was used to apply an abduction or adduction moment of 10 Nm at fixed knee flexion angles of 0°, 30°, 60° and 90°. A motion capture system (Vicon Motion Systems, UK) was used to record the trajectories of the rigid marker frames while synchronized strain data was collected for MCL/LCL. All motion protocols were applied following TKA was performed using PIPB with a cruciate retaining implant (Stryker Triathlon, MI, USA). Furthermore, tibiofemoral kinematics were calculated. 4. and combined with the strain data. Postoperative tibial varus/valgus stresses and collateral ligament strains were compared to the native condition using the Wilcoxon Signed-Rank Test (p<0.05). Postoperative tibial valgus laxity was lower than the native condition for all flexion angles. Moreover, tibial valgus of TKA was significantly different than the native condition, except for 0° (p=0.32). Although, tibial varus laxity of TKA was lower than the native at all angles, significant difference was only found at 0° (p=0.03) and 90° (p=0.02). No significant differences were observed in postoperative collateral ligament strains, as compared to the native condition, for all flexion angles, except for MCL strain at 30° (p=0.02) and 60° (p=0.01). Results from this experimental study supported our hypotheses, barring MCL strain in mid-flexion, which might be associated with the implant design. Restored collateral ligament strains with reduced joint laxity, demonstrated by the PIPB technique in TKA in vitro, could potentially restore natural joint kinematics, thereby improving patient outcomes. In conclusion, to further prove the success of PIPB, further biomechanical studies are required to evaluate the success rate of PIPB technique in different implant designs

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.

Purpose: To introduce our new surgical technique for better correction of scoliosis and rib hump deformity. Surgical technique: The technique consists of rib mobilization (RM) and hook rotation maneuver (HRM). RM is to release costo-vertebral connection bilaterally from T5 to T10 to mobilize ribs obtaining more flexibility of the spine. HRM is to rotate convex side hooks on transverse process ventrally pushing down the ribs, thus giving derotational force while compression force is applied. Subjects: Forty-six idiopathic cases with minimum 1 year follow-up were reviewed. The average F-up period is 15.1m( 12 – 24). The average age at surgery was 20.1 y(12–57). Conventional multiple hooks, screws, wires and rod system was used. Results: The average Cobb angle was 56.0 ( 40 – 93) degrees. The average rib hump was 22.5 mm in height and 13.9 degrees by scoliometer. At 3 w post-op, 6 m post-op, and at F-up, the average Cobb angle was 13.0 (77.9%), 15.6 (73.4%), and 16.0 (72.6%, 43 – 100%)) respectively. The average rib hump at 6m post-op and at F-up was 9.7 mm in height and 6.8 degrees, and 10.3mm and 6.4 degrees respectively. The hump index at thoracic level was 5.49 pre-op, 3.73 at 6m and 4.25 at F-up. Conclusion: Our new technique improved the correction of not only scoliosis but also thoracic hump significantly. The derotational force by HRM is weaker than direct derotation by pedicle screw. However, it is undoubtedly a safer and less expensive technique than thoracic pedicle screw, providing significant correction of rib hump

INTRODUCTION. Evolving payment models create new opportunities for assessment of patient care based on total cost over a defined period of time. These models allow for analyses of economic data that was previously unavailable and well beyond our familiar studies which typically include length of stay, surgical complications, and post-operative clinical and radiographic assessments. In the United States, the new Federal program entitled TheBundled Payment for Care Initiative created new opportunities for the assessment of surgical interventions. The purpose of the reported study was to assess the total reimbursement for care as a function of surgical technique in primary total hip arthroplasty (THA). METHODS. The total reimbursement for services performed following primary THA for patients insured by Medicare was analyzed for a group of patients at a single institution during the fiscal years of 2013 and 2014. The population included data on 356 patients who had surgery performed by seven surgeons who used the same pre-operative education, OR, PACU, PT, nursing, and case management. A total of 38 “pre-selected” patients underwent THA by an anterior exposure, 219 had surgery performed by a posterior exposure, and 99 had surgery performed by the superior exposure utilizing mechanical surgical navigation (HipXpert System, Surgical Planning Associates, Boston, MA). Reimbursement for all in-patient and out-patient services performed over the initial 90-day period from sugeical admission was compared across surgical techniques. Reimbursement includes the sum of all payments including the hospital, physicians, skilled nursing facilities, home care, out-patient care, and readmission. RESULTS. The authors previously reported that primary THA cases performed using the superior approach have shorter average length of stay, a lower complication rate, higher percentage of acetabular components within the “safe zone” when compared to the other approaches and higer rate of patients discharged directly to home. An average reimbursement of $24,848 for THA performed using posterior exposure, $21,446 for the selected anterior exposure, and $20,268 for the superior exposure with navigation. The cost of care for treatment by the superior exposure with navigation was statistically significantly less than the posterior exposure (p<0.001) but not significantly less than the selected anterior exposure patients (p=0.287). Medicare in-patient reimbursements for patients treated by the superior exposure with mechanical surgical navigation was significantly less than the selected anterior exposure group (p<0.002) and the posterior exposure group (p<0.001). Overall, 84% of patients with the superior exposure were discharged directly to home versus 69% in the selected anterior group and 60% in the posterior group thus minimizing the out-patient Medicare cost burden in THA performed using the superior exposure over the other techniques. CONCLUSION. The current study demonstrates the influence of surgical technique on the direct reimbursement for the continuum of care, indicative of incurred costs, across the first 90-day post-operative period. The superior exposure combined with surgical navigation demonstrates the potential for significantly reduced total cost burden in Medicare patients when compared to two of the most common surgical approaches used for primary THA

Introduction. The use of screws is frequent for additional fixation, however, since some disadvantages have been reported a cup press-fit is desirable, although this can not always be obtained. Cup primary intraoperative fixation in uncemented total hip replacement (THR) depends on sex, acetabular shape, and surgical technique. We analyzed different factors related to primary bone fixation of five different designs in patients only diagnosed with osteoarthritis, excluding severe congenital hip disease and inflammatory arthritis, and their clinical and radiological outcome. Materials y Methods. 791 hips operated in our Institution between 2002 and 2012 were included for the analysis. All cases were operated with the same press-fit technique, and screws were used according to the pull-out test. Two screws were used if there was any movement after the mentioned manoeuvres. Acetabular and femoral radiological shapes were classified according to Dorr et al. We analyzed radiological postoperative cup position for acetabular abduction angle, the horizontal distance and the vertical distance. Cup anteversion was evaluated according to Widmer and the hip rotation centre according to Ranawat. Results. Screws were required in 155 hips (19.6%) and were more frequently used in women and patients with a type A acetabulum (p<0.001, p=0.021, respectively). There were no differences among the different cups evaluated. The need for screws was more frequent in hips with a smaller version of the cup and with a distance greater than 2 mm to the approximate femoral head centre from the centre of the prosthetic femoral head (p=0.022, 0.012, respectively). Adjusted multivariate analysis revealed that female patients (p<0.001, Odds Ratio (OR): 2.063; 95% Confidence Interval (CI) 1.409–3.020), cups with a smaller version (p=0.012, OR: 0.966, 95% CI 0.94–0.992), and a greater distance to the rotation hip center (p<0.005, OR: 1.695; 95% CI 1.173–2.450) had a higher risk for screw use. No hips needed revision for aseptic loosening. Conclusions. Cup press-fit depends on gender and surgical technique in hips without significant acetabular abnormalities or inflammatory arthritis. Contemporary uncemented cups provide similar primary fixation and mid-term outcome

Introduction. Two principal targets are dominating the spectrum of goals in total knee arthroplasty: first of all the orthopedic surgeon aims at achieving an optimal pain-free postoperative kinematic motion close to the individual physiologic range of the individual patient and secondly he aims for a concurrent high ligament stability within the entire range of movement in order to establish stability for all activities of daily living. This study presents a modified surgical procedure for total knee replacement which is ligament-controlled in order to put both component into the “ligamentous frame” of the patients individual kinematics. Methods. The posterior femero-condylar index (PFC-I) is defined as being the posterior condylar offset divided by the distal antero-posterior diameter on a lateral radiograph. After careful preoperative planning the positions and orientations of the osteotomies is controlled intraoperatively via ligamentous guidance. Anterior and distal femoral osteotomy are planned on antero-posterior and lateral radiographs considering intramedular and mechanical axes as well as the orientation of the posterior condyles. Osteotomies are carried out in a stepwise fashion, starting with the anterior femoral osteotomy followed by the distal femoral osteotomy as planned. Then the extension gap is finalized by tensioning the ligaments and “top-down” referencing the level of the tibial osteotomy. After rotating the femur into the 90°-flexion position the flexion gap is finalized by referencing the level of the posterior condyle osteotomy in a “bottom-up” fashion to the tibial osteotomy. Hence, this technique determines the size of the femoral component with the last osteotomy. It likewise respects the new, ACL-lacking ligamentous framework and it drives the prosthetic components to fit into the new ligamentous envelope to follow the modified kinematics. Results. More than 130 patients have been operated on using this surgical technique, 104 of them have been followed-up after a minimum of one year: age 73+/−9, m/f 37/67, 71% had a varus, 29% a valgus-deformity. In all patients a subvastus approach was applied, 12 from medial, 92 from lateral. Mean flexion reached 122°+/−7.4 and a 120°-flexion or more was achieved by 86% of the patients. All patients reveived a LCS total knee prosthesis with either a rotating or an antero-posterior gliding inlay. No fixed tibial inlays were used. Antero-posterior translation of the APG-insert was 13 to 16mm immediately postoperatively whereas after one year it decreased to 4 to 10mm. We succeeded in reconstructing the posterior femero-condylar index (PFC-I) and found a linear correlation of 0.98 +/−0.06 of pre- to postoperative PFC-I. Conclusion. This PCL-retaining surgical technique respects the new, ACL-lacking kinematics in total knee replacement. The anterior and distal femoral osteotomies are femur-axis-controlled while the extension and flexion gaps are ligament-controlled. The size of the femoral component is regarded as a variable within the procedure and is only determined while performing the last osteotomy, i.e. the posterior condylar osteotomy. This technique is suitable for both PCL-retaining and also for PCL–sacrificing techniques

Introduction: Blount’s disease is an idiopathic, non-physiological form of genu varum. Deformity usually occurs in the proximal tibia with progressive varus, but also with valgus in the distal femur. Treatment in the infantile stage includes observation or bracing, and surgery for acute marked proximal tibial varus. Recurrence is common with conventional surgery after the age of four. Method: A new surgical technique is proposed as definitive treatment of this condition which includes an arthrogram to visualise the knee joint, acute elevation of the varus aligned medial tibia plateau with second plane correction of posterior slope deformity, lengthening and derotation of the tibia by application of a Taylor spatial frame, application of an 8 plate on the distal femur to correct valgus deformity and finally proximal tibial and fibular epiphysiodesis to prevent recurrence. Results: Five patients with Blount’s disease had this definitive corrective procedure performed at a mean age of 9.8. Radiographs and CT scans taken pre-operatively demonstrated marked medial plateau varus deformity and increased posterior slope. Surgery was performed by the senior author. Follow-up X-rays demonstrated satisfactory alignment, length and rotation of the lower limb. Conclusions: This new surgical technique allows correction of all deformities of Blount’s disease at one operation and maintains alignment, length and rotation clinically and radiologically at follow-up

Autologous cancellous bone graft is the gold standard in large bone defect repair. However, studies using autologous bone grafting in rats are rare and donor sites as well as harvesting techniques vary. The aim of this study was to determine the feasibility of autologous cancellous bone graft harvest from 5 different anatomical sites in rats and compare their suitability as donor sites for autologous bone graft.

13 freshly euthanised rats were used to describe the surgical approaches for autologous bone graft harvest from the humerus, iliac crest, femur, tibia and tail vertebrae (n=4), determine the cancellous bone volume and microstructure of those five donor sites using µCT (n=5), and compare their cancellous bone collected qualitatively by looking at cell outgrowth and osteogenic differentiation using an ALP assay and Alizarin Red S staining (n=4).

It was feasible to harvest cancellous bone graft from all 5 anatomical sites with the humerus and tail being more surgically challenging. The microstructural analysis showed a significantly lower bone volume fraction, bone mineral density, and trabecular thickness of the humerus and iliac crest compared to the femur, tibia, and tail vertebrae. The harvested volume did not differ between the donor sites. All donor sites apart from the femur yielded primary osteogenic cells confirmed by the presence of ALP and Alizarin Red S stain. Bone samples from the iliac crest showed the most consistent outgrowth of osteoprogenitor cells.

The tibia and iliac crest may be the most favourable donor sites considering the surgical approach. However, due to the differences in microstructure of the cancellous bone and the consistency of outgrowth of osteoprogenitor cells, the donor sites may have different healing properties, that need further investigation in an in vivo study.

Total knee replacement (TKA) surgery is an excellent and well-proven procedure for the treatment of end stage arthritis of the knee. Many refinements have taken place over time in an attempt to improve the components, wear qualities of the polyethylene, and the surgical technique to improve accuracy of component positioning, reduce patient pain, improve postoperative range of motion, ultimately improve results and to prolong the time until revision surgery may occur. This study examines the results of a gap balancing surgical technique in which components were implanted that had a posterior cruciate substituting design. This technique is performed with exacting alignment and balancing of the flexion and extension gaps prior to implantation of the knee components. The follow up is at a minimum of ten years. 515 consecutive knee replacements were followed prospectively for a minimum of ten years. The average age at surgery was 70 years, 73% of patients were female, with an average BMI of 31. All patients carried a diagnosis of osteoarthritis and a cemented, posterior stabilized design TKA (Balanced Knee System, Ortho Development) was implanted. All cases were performed by one of two experienced joint replacement surgeons. The surgical technique demanded flexion and extension gap balancing as well as soft tissue balancing prior to finishing cuts being performed on the femoral side (See figures 1 and 2). Polyethylene spacers come in 1 millimeter increments. 28% of patients died postoperatively at an average of 7.4 years. These patients were older on average at the time of index surgery (76.6 years). None had undergone revision surgery. Of the remaining patients Knee Society scores (39 preop to 91 post op at ten years), function scores and range of motion all improved significantly. What's more, these results were not diminished at ten years. There were no component failures and less than 1% radiographic progressive lucent lines. Eleven revision surgeries (2.1 %) were performed with 2 acute superficial wound revisions, 3 late infections, one patellar tendon disruption from a fall at 7 years (BMI 45.7), 2 complete revisions performed elsewhere for unsatisfactory results, and 3 spacer exchanges for perception of postoperative laxity. For the current study we also examined subgroups of the morbidly obese, octogenarians, and those with a preoperative valgus deformity of greater than 15%. At follow-up these subgroups fared very well with the exception of the heaviest BMI's being limited in range of motion because of soft tissue impingement. Results suggest that this balancing technique gives excellent results with few complications at ten year evaluation. We believe that careful attention to bony and soft tissue balancing and equalization of gaps in flexion and in extension will prove beneficial for TKA longevity in even longer-term evaluation. Figures 1 and 2 demonstrate gap balancing blocks and alignment rods in extension and in flexion

Introduction. The direct anterior approach (DAA) for total hip arthroplasty (THA) has gained popularity in recent years. Potential advantages over other surgical approaches include less postoperative pain, fewer postoperative precautions, and quicker early recovery. It is most commonly performed in the supine position with traction tables or table mounted bone hooks to facilitate exposure. In this study, we describe a reproducible surgical technique for DAA THA in the lateral decubitus position with use of standard THA equipment and report on our results and learning curve. Methods. A prospectively collected hip repository was queried for all primary THA DAA performed in the lateral position by a single surgeon over a 4-year period from the surgeon's first case utilizing the technique. Retrospective chart review was performed to identify complications and revisions. Modified Harris Hip Score (mHHS) was collected pre-operatively and again at 1-year post-operative. Radiographic parameters including were measured on the 1-year postoperative radiographs. Results. Three hundred forty-one hips were identified in patients over 18 years of age with 337 hips meeting our inclusion/exclusion criteria. A total of 257 hips (76%) had a minimum of 1-year follow-up. 212 of 225 hips (94%) with available mHHS data achieved MCID, defined as mHHS change of > 8. Mean surgical time was 88 ± 16 minutes. Radiographic evaluation demonstrated reproducible results with mean radiographic side to side leg length discrepancy of 2.6 ± 5.9mm and femoral offset difference of 0.2 ± 4.9mm. Among patients with adequate postoperative radiographs, 234 of 243 (96%) had acetabular component positions within Lewinnick's safe zone. 3 hips (0.9%) required revision THA within the first year postoperatively. There were no dislocations and there was no learning curve detected in terms of operative time, blood loss, complication rate or acetabular component position. Discussion. Critics of DAA THA cite its long learning curve with increased risk of complications as an argument against its widespread use. In this study, we have described a safe and efficient technique for performing THA via the DAA in the familiar lateral decubitus with the use of a standard operating table, positioning devices and THA instrumentation. Our results demonstrate excellent acetabular component placement and low rates of complications within the first postoperative year. Conclusion. DAA THA can be performed safely and efficiently in the lateral decubitus position without a specialized table or instrumentation. Surgeon familiarity with patient position and instruments using the technique presented here may be associated with a shorter procedural learning curve

Introduction: Distal radius metaphyseal fractures in children are not uncommon, but when they occur proximal to the insertion of the pronator quadratus muscle, reduction and maintenance of reduction can be challenging. The deforming forces at the fracture site result in pronation and shortening of the distal fragment. Manual manipulation of this fracture often results in tearing of the dorsal periosteum and hence renders this fracture highly unstable. Aim: We present a novel easily reproducible mini-open surgical technique and functionally and radiologically evaluate a series of eleven patients who have undergone this technique. Materials and Methods: The surgical technique consists of a mini-open intrafocal image intensifier guided reduction technique with percutaneous k-wiring fixation. Five males and six females with an average age of 8.8 years (range 5 to 13 years), who sustained a pronator quadratus distal radius fracture and subsequently underwent this surgical technique from 2005 to 2007, were evaluated both radiologically in terms of radial length, radial tilt and volar tilt compared with the contralateral limb and functionally using the Mayo Modified wrist score and the patient related wrist evaluation questionnaire. Results: Patients were followed up for an average of 18 months (range 2–31 months). All patients achieved clinical and radiological union. No patient required remanipulation for loss of reduction. Radiological outcome measures similar to contralateral limb with good functional scores. No complications were noted. All patients returned to preoperative level of function. Conclusion: This minimally invasive technique has been shown to be technically easy, reliable and reproducible with excellent results and low risk of displacement compared to other techniques used to treat this potentially challenging fracture

Purpose of the study: Coxofemoral conflicts can sometimes lead to early degenerative disease in young patients. Hip arthroscopy is a less invasive alternative which can remove all of the coxofemoral conflicts. Like open surgery, a purely arthroscopic technique enables all the necessary corrections, even involving the rim. Arthroscopy has provides promising short- and mid-term results. The purpose of this work was to present the surgical technique, its drawbacks and complications, and present suggestions for improvement. Material and methods: Fifty-one patients, mean age 31 years (range 15–54 years) underwent purely arthroscopic treatment of coxofemoral conflicts between February 2001 and November 2003. Prospective follow-up was at least six months. The type of conflict and the corresponding corrections were noted. The Pre- and postoperative WOMAC scores were used for clinical assessment. Complications were noted as well as means for avoiding them. Results: The operative technique, the potential dangers, and suggestions for successful arthroscopy are presented. The clinical outcome with at least six months follow-up was: hip R/L: 21/31. Head and acetabular correction: 46 cases. Head correction alone (head/neck offset): 5 cases. Preoperative WOMAC score: 59/100 (15–99). Postoperative WOMAC score: 85/100 (49–99). Complications: spontaneously resolutive hematoma (n=2), transient (48h) irritation of the lateral femoral cutaneous nerve (n=1). Discussion: Purely arthroscopic correction of a coxofemoral conflict is as safe as the open surgical technique. The arthroscopic method provides very promising short- and mid-term results with no major complications. The lower morbidity with this technique enables ambulatory treatment with shorter recovery time

Background A further two changes to the technique of primary Total Hip Arthroplasty (THA) have recently been advocated, computer assisted surgery and access by mini incision(s). These add to the potential different ways the surgeon can perform THA and are still in an early evolutionary stage. However, they add further fuel to the question, what is the best technique for THA ?. Method We considered the procedure of THA and broke it down into the main component stages. We then assessed the various possible different options for each different stage from the literature and a survey of 14 Orthopaedic Surgeons (6 consultants, 2 associate specialists and 6 trainees). Results We calculate that THA can be performed by at least 1.08 x 10. 11. different unique techniques. We were unable to find any consensus on the best technique for THA. Conclusions This massive diversity causes problems with informed consent, research and training. NICE and NJR have issues regarding choice of implant but we believe the choice of surgical technique for THA can play an even more important role in outcome

Introduction. Total hip replacement (THR) is one of the most successful orthopedic surgeries performed today. Long term success of THR has been well established, but there remains significant room to improve early outcomes (e.g. pain, length of hospital stay, readmissions). The surgical technique is a key variable affecting these early outcomes. The objective of the current study was to evaluate outcomes for over 1,000 consecutive THRs using the supercapsular percutaneously-assisted total hip (SuperPath) approach. Patients and Methods. Between September 2008 and April 2015, one surgeon performed 1,074 consecutive primary THRs using the SuperPath surgical technique. All THRs were performed without local anesthesia, patient controlled analgesia (PCA), or postoperative hip precautions. Surgical outcomes including operative time, blood loss, incision length, length of stay (LOS), and complications were collected as part of this IRB approved study. Harris Hip Scores (HHS) and UCLA scores were obtained preoperatively and at 6 and 12 months postoperatively. Results. The mean operative time, blood loss, incision length, and LOS were 75 minutes (range, 40–141), 150 mL (range, 50–900), 7.4 cm (range, 5–12), and 1.4 days, respectively. In total there were 29 complications including: 6 (0.5%) periprosthetic fractures; 4 (0.3%) thromboembolisms; 3 (0.2%) subsidence; 2 (0.1%) heterotropic ossifications; and 1 (0.09%) dislocation. There were no instances of infection or neurovascular injury. Mean HHS improved from 45.4 preoperatively to 89.9 and 87.2 at 6 and 12 months, respectively. Mean UCLA scores improved from 3.9 preoperatively to 5.5 and 5.6 at 6 and 12 months, respectively. Conclusions. These results from over 1,000 consecutive THRs using the SuperPath technique demonstrate this technique is safe and reliable, with results similar or better than those reported for other THR surgical techniques. There was a low rate of complications with an even distribution and no bias to early cases

Introduction: Between June 2005 and September 2007, ten male athletes underwent repair of the pectoralis major tendon using a new double row surgical technique whereby employing three bone anchors to produce a large foot print of the pectoralis major tendon. Here, we present our new surgical technique for the repair of the pectoralis major tendon with the results. Patients: The mean age was 33.9 years (23–46 years) and the average follow up was 20.3 months (12–39). The mean time between surgery and the original injury was 11.6 weeks (1–48 weeks). We used the visual analogue scale for determining the level of satisfaction with regards to cosmesis and pain. Also, the patients were asked them about their subjective loss of strength. Results: Eight patients were in pain prior to surgery and all patients were unsatisfied with the appearance of their chest. The average loss of strength was 75% pre-operatively. At the final follow up, none of the patients complained of any pain while pushing things away from their body; nine patients had no pain on moving their arm across the chest whilst one patient reported mild pain. Nine were satisfied with the appearance and the average regain in strength was around 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst our patients. Hence, we conclude that satisfactory results can be achieved with this new technique