Clinical assessment of elbow deformity in children at present is mainly based on physical examination and plain X-ray images, which may be inaccurate if the elbow is not in fully supination; furthermore, the rotational deformity is even harder to be determined by such methods. Morrey suggested that the axis of rotation of the elbow joint can be simplified to a single axis. Based on such assumption, we are proposing a method to assess elbow deformity using rotational axis of the joint, and an optimized calculation algorithm is presented. The rotation axis of elbow in respective to the upper arm can be obtained from the motion tract of markers placed at the forearm. Cadaver study was done, in which three skeletal motion trackers were placed over both the anterior aspect of humerus, as well as distal ulna. Osteotomy was created at the supracondylar region of humerus through lateral approach, and the bone fragments were stabilized with a set of external skeletal fixator, leaving the soft tissue intact. The amount of deformity was created manually by adjusting the position of the distal fragment via skeletal fixator. Ultrasound 3D motion tracking system from Zebris® was used in this study, and the program was developed under the Matlab environment. Cycles of passive elbow flexion/extension motion were carried out for each set of deformity. The data were initially transformed to humerus coordinate, and since the upper arm was not absolutely stationary, its influence on the measured position of ulna was adjusted. With this adjusted data, a best fit plane that would include most of the ulna positions (MU) within a minimal distance was obtained. The rotation axis was calculated as the normal vector to this plane, and the carrying angle could subsequently be assessed according to the relationship between this axis and the x-axis on the xy-plane as well as on the xz-plane. Fresh frozen cadaver study was conducted in the Medical Simulation Center at Tzu-Chi University. After adjustment of the raw data to eliminate the influence of humerus motion, the ulna motion could be narrowed down from a band of 10mm to 3mm, with a significant smaller standard deviation. The rotation axis was obtained by the normal vector to the best fit plane. Two different approaches were attempted to find the plane. In the first method, the plane was obtained via least square method from the adjusted ulna positions, and the second method found the plane via RANSAC method. Calculations were repeated several times for each method, and the results showed a variation of 5 degrees in the first method and about 2 degrees in the second method. Rotational axis can be used to define the 3-dimensional deformity of elbow joint; however, it is difficult to obtain such axis accurately due to hypermobility and multi-directional motion of the shoulder joint. In this study, we have developed another method to assess the elbow deformity using motion analysis system instead of the conventional image studies, and this may be applicable clinically if the facility becomes more accessible in the future. (This research was supported by the project TCRD-TPE-99-30 granted by the Buddhist Tzu-Chi General Hospital, Taipei Branch)

Total elbow arthroplasty (TEA) usage is increasing owing to expanded surgical indications, better implant designs, and improved long-term survival. Correct humeral implant positioning has been shown to diminish stem loading in vitro, and radiographic loosening in in the long-term. Replication of the native elbow centre of rotation is thought to restore normal muscle moment arms and has been suggested to improve elbow strength and function. While much of the focus has been on humeral component positioning, little is known about the effect of positioning of the ulnar stem on post-operative range of motion and clinical outcomes. The purpose of this study is to determine the effect of the sagittal alignment and positioning of the humeral and ulnar components on the functional outcomes after TEA. Between 2003 and 2016, 173 semi-constrained TEAs (Wright-Tornier Latitude/Latitude EV, Memphis, TN, USA) were performed at our institution, and our preliminary analysis includes 46 elbows in 41 patients (39 female, 7 male). Patients were excluded if they had severe elbow deformity precluding reliable measurement, experienced a major complication related to an ipsilateral upper limb procedure, or underwent revision TEA. For each elbow, saggital alignment was compared pre- and post-operatively. A best fit circle of the trochlea and capitellum was drawn, with its centre representing the rotation axis. Ninety degree tangent lines from the intramedullary axes of the ulna and humerus, and from the olecranon tip to the centre of rotation were drawn and measured relative to the rotation axis, representing the ulna posterior offset, humerus offset, and ulna proximal offset, respectively. In addition, we measured the ulna stem angle (angle subtended by the implant and the intramedullary axis of the ulna), as well as radial neck offset (the length of a 90o tangent line from the intramedullary axis of the radial neck and the centre of rotation) in patients with retained or replaced radial heads. Our primary outcome measure was the quickDASH score recorded at the latest follow-up for each patient. Our secondary outcome measures were postoperative flexion, extension, pronation and supination measured at the same timepoints. Each variable was tested for linear correlation with the primary and secondary outcome measures using the Pearson two-tailed test. At an average follow-up of 6.8 years (range 2–14 years), there was a strong positive correlation between anterior radial neck offset and the quickDASH (r=0.60, p=0.001). There was also a weak negative correlation between the posterior offset of the ulnar component and the qDASH (r=0.39, p=0.031), and a moderate positive correlation between the change in humeral offset and elbow supination (r=0.41, p=0.044). The ulna proximal offset and ulna stem angle were not correlated with either the primary, or secondary outcome measures. When performing primary TEA with radial head retention, or replacement, care should be taken to ensure that the ulnar component is correctly positioned such that intramedullary axis of the radial neck lines up with the centre of elbow rotation, as this strongly correlates with better function and less pain after surgery

The aim of this study was to investigate if the rotational axis of normal human shoulders moves during flexion in the sagittal plane. Twenty four shoulders were measured in twelve normal volunteers, aged 25-42, height range 1.65-1.88 m and weight range 63–120 Kg. Each subject had surface markers placed on their iliac crests, mastoid processes and upper arms. Joint movement was video recorded as shoulders were actively flexed and extended in the sagittal plane. For each joint, a typical flexion sweep was selected and replayed into a computerised imaging system, where still frames were captured at 20 degree intervals from 20 to 120 degrees. These images were analysed to extract the co-ordinates of each marker. The coordinates were then processed to determine the Instant Centres of Rotation (ICR) for each angle of flexion. These ICR’s were then plotted to derive the Rotational Axis Pathway (RAP) for each shoulder joint. The results indicate that throughout the flexion arc, the rotational axis is located in the region of the humeral head. At the start of the arc the rotational axis is in the anterio-superior part of the shoulder joint. As the shoulder flexes forward the rotational axis moves posteriorly following a curved pathway. In 18 cases the RAPs moved posterio-inferiorly and in six cases the RAPs moved posterio-superiorly. The pathways can be quantified in terms of their curved pathway lengths and the displacements of their end points from their start points. In the case of the 18 posterio-inferior pathways, the mean pathway length was 98.3 mm (SD=31.5) and the mean posterior/inferior displacements were 59.6 mm (SD=34.7) and 43.2 mm (SD=24.6) respectively. In the case of the 6 posterior-superior pathways, the mean pathway length was 109.4 mm (SD=40.2) and the mean posterior/ superior displacements were 94.7 mm (SD=43.9) & 20.9 mm (SD=11.1) respectively. The variation in inferior-superior displacement of the axis may be due to normal variations in scapula movement during forward flexion. This investigation indicates that in normal subjects, the rotational axis moves posteriorly during flexion

Abstract. Objectives. Catastrophic neck injuries in rugby tackling are rare (2 per 100,000 players per year) with 38% of these injuries occurring in the tackle. The aim of this study was to determine the primary mechanism of cervical spine injury during rugby tackling and to highlight the effect of tackling technique on intervertebral joint loads. Methods. In vivo and in vitro experimental data were integrated to generate realistic computer simulations representative of misdirected tackles. MRI images were used to inform the creation of a musculoskeletal model. In vivo kinematics and neck muscle excitations were collected during lab-based staged tackling of the player. Impact forces were collected in vitro using an instrumented anthropometric test device during experimental simulations of rugby collisions. Experimental kinematics and muscle excitations were prescribed to the model and impact forces applied to seven skull locations (three cranial and four lateral). To examine the effects of technique on intervertebral joint loads the model's neck angle was altered in steps of 5° about each rotational axis resulting in a total of 1,623 experimentally informed simulations of misdirected tackles. Results. Neck flexion angles and cranial impact locations had the largest effects on maximal compression, anterior shear and flexion moment loads. During posterior cranial impacts compression forces and flexion moments increased from 1500 to 3200 N and 30 to 60 Nm respectively between neck angles of 30° extension and 30° flexion. This was more evident at the C5-C6 and C6-C7 joints. Anterior shear loads remained stable throughout neck angle ranges however during anterior impacts they were directed posteriorly when the neck was flexed. Conclusions. The combination of estimated joint loads in the lower cervical spine support buckling as the primary injury mechanism of anterior bilateral facet dislocations observed in misdirected rugby tackles and highlights the importance of adopting a correct tackling technique. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aim: The aim of this investigation was to determine how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation. Materials & Methods: Ulna to radial deviation was assessed in 30 normal wrists in 15 normal subjects aged 19 to 32. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metacarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation. Results: The mean range of movement was 47 degrees (SD 8). In full ulna deviation the wrist rotational axis was in the region of the lunate/capitate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 22 mm (SD 14). In 17 wrists the distal displacement was accompanied by mean displacement towards the ulna of 13 mm (SD 8). In 13 wrists the distal displacement was accompanied by a mean displacement towards the radius of 7 mm (SD 5). Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 type of carpal movement. i.e. Column movers and row movers [Craigen & Stanley]

Aim: The carpal bone arrangement can be described as a matrix of two rows and three columns. There a various theories as to how the bones within the matrix move during ulna to radial deviation. One theory suggests that there are two types of wrist movement, namely Row & Column. 1. . The aim of this study was to investigation how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation. Materials and Methods: Ulna to radial deviation was assessed in 50 normal wrists in 25 normal subjects aged 19 to 57. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metcarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation. Results: The mean range of movement was 45 degrees (SD 7). In full ulna deviation the wrist rotational axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5). Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement. i.e. Column movers and row movers. 1.

The aim of this study was to investigate how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation. Fifty normal wrists in 25 subjects were assessed with a Polhemus Fastrak (TM) magnetic tracking system. The subjects, aged 19 to 57, placed their palms on a flat wooded stool. Sensors were attached over their 3rd metcarpal and distal radius. The sensors then recorded movement from ulna to radial deviation. The translational and rotational measurement accuracies were 1 mm and 1 degree respectively. The mean range of movement was 45 degrees (SD 7). In ulna deviation the axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by a mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5). The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement proposed by Craigen and Stanley (J. Hand Surg, 20B, 165–170, 1995)

To develop a useful surgical navigation system, accurate determination of bone coordinates and thorough understanding of the knee kinematics are important. In this study, we have verified our algorithm for determination of bone coordinates in a cadaver study using skeletal markers, and at the same time, we also attempted to obtain a better understanding of the knee kinematics. The research was performed at the Medical Simulation Center of Tzu Chi University. Optical measurement system (Polaris® Vicra®, Northern Digital Inc.) was used, and reflective skeletal markers were placed over the iliac crest, femur shaft, and tibia shaft of the same limb. Two methods were used to determine the hip center; one is by circumduction of the femur, assuming it pivoted at the hip center. The other method was to partially expose the head of femur through anterior hip arthrotomy, and to calculate the centre of head from the surface coordinates obtained with a probe. The coordinate system of femur was established by direct probing the bony landmarks of distal femur through arthrotomy of knee joint, including the medial and lateral epicondyle, and the Whiteside line. The tibial axis was determined by the centre of tibia plateau localised via direct probing, and the centre of ankle joint calculated by the midpoint between bilateral malleoli. Repeated passive flexion and extension of knee joint was performed, and the mechanical axis as well as the rotation axis were calculated during knee motion. A very small amount of motion was detected from the iliac crest, and all the data were adjusted at first. There was a discrepancy of about 16.7mm between the two methods in finding the hip centre, and the position found by the first method was located more proximally. When comparing the epicondylar axis to the rotation axis of the tibia around knee joint, there was a difference of 2.46 degrees. The total range of motion for the knee joint measured in this study was 0∼144 degrees. The mechanical axis was found changing in an exponential pattern from 0 degrees to undetermined at 90 degrees of flexion, and then returned to zero again. Taking the value of 5 degrees as an acceptable range of error, the calculated mechanical axis exceeded this value when knee flexion angle was between 60∼120 degrees. The discrepancy between the hip centres calculated from the two methods suggested that the pivoting point of the femur head during hip motion might not be at the center of femur head, and the former location seemed closer to the surface of head at the weight bearing site. Under such circumstances, the mechanical axis obtained through circumduction of the thigh might be 1∼2 degrees different from that obtained through the actual center of femur head. During knee flexion, the mechanical axis also changed gradually, and this could be due to laxity of knee joint, or due to intrinsic valgus/varus alignment. However, the value became unreliable when the knee was at a flexion angle of 60∼120 degrees, and this should be taken into account during navigation surgery

Objectives. There remains a lack of data on the reliability of methods to estimate tibial coverage achieved during total knee replacement. In order to address this gap, the intra- and interobserver reliability of a three-dimensional (3D) digital templating method was assessed with one symmetric and one asymmetric prosthesis design. Methods. A total of 120 template procedures were performed according to specific rotational and over-hang criteria by three observers at time zero and again two weeks later. Total and sub-region coverage were calculated and the reliability of the templating and measurement method was evaluated. Results. Excellent intra- and interobserver reliability was observed for total coverage, when minimal component overhang (intraclass correlation coefficient (ICC) = 0.87) or no component overhang (ICC = 0.92) was permitted, regardless of rotational restrictions. Conclusions. Measurement of tibial coverage can be reliable using the templating method described even if the rotational axis selected still has a minor influence

In this study, we attempt to explore the differences between anatomical and non-anatomical tibial baseplates in terms of rotation and coverage. To achieve this, we divided 80 dry bones into groups, and examined them using anatomical and non-anatomical baseplates. The results of the study showed that anatomical baseplates provided better coverage and also yielded better results according to the rotational assessment. Surgeons make rotational mistakes by non-anatomic base plates, when trying to achieve best coverage. Anatomic base plates warrant better coverage according to non-anatomic base plates when both are placed at the same rotational axis. It is more possible to adjust size and rotation correctly with the anatomic tibial components

Total hip replacement in Germany has been performed in 227293 cases in 2015 and tendency is increasing. Although it is a standard intervention, freehand positioning of cup protheses has frequently poor accuracy. Image-based and image-free navigation systems improve the accuracy but most of them provide target positions as alphanumeric values on large-size screens beneath the patient site. In this case the surgeon always has to move his head frequently to change his eye-focus between incision and display to capture the target values. Already published studies using e.g. IPod-based displays or LED ring displays, show the chance for improvement by alternative approaches. Therefore, we propose a novel solution for an instrument-mounted small display in order to visualise intuitive instructions for instrument guidance directly in the viewing area of the surgeon. For this purpose a solution consisting of a MicroView OLED display with integrated Arduino microcontroller, equipped with a Bluetooth interface as well as a battery has been developed. We have used an optical tracking system and our custom-designed navigation software to track surgical instruments equipped with reference bodies to acquire the input for the mini-display. The first implementation of the display is adapted to total hip replacement and focuses on assistance while reaming the acetabulum. In this case the reamer has to be centred to the middle point of the acetabular rim circle and its rotation axis must be aligned to the acetabular centre axis by Hakki. By means of these references the actual deviations between instrument and target pose are calculated and indicated. The display contains a cross-hair indicator for current position, two bubble level bars for angular deviation and a square in square indicator for depth control. All display parts are furnished with an adaptive variable scale. Highest possible resolution is 0.5 degrees angular, 1 millimeter for position and depth resolution is set to 2 mm. Compared to existing approaches for instrument-mounted displays, the small display of our solution offers high flexibility to adjust the mounting position such that it is best visible for the surgeon while not constraining instrument handling. Despite the small size, the proposed visualisation symbols provide all information for instrument positioning in an intuitive way

Aims

Custom triflange acetabular components (CTACs) play an important role in reconstructive orthopaedic surgery, particularly in revision total hip arthroplasty (rTHA) and pelvic tumour resection procedures. Accurate CTAC positioning is essential to successful surgical outcomes. While prior studies have explored CTAC positioning in rTHA, research focusing on tumour cases and implant flange positioning precision remains limited. Additionally, the impact of intraoperative navigation on positioning accuracy warrants further investigation. This study assesses CTAC positioning accuracy in tumour resection and rTHA cases, focusing on the differences between preoperative planning and postoperative implant positions.

Utilisation of unicondylar knee arthroplasty (UKA) has been limited due in part to high revision rates. Only 8% of knee arthroplasty surgeries completed in England and Wales are UKAs. It is reported that the revision rate at 9 years for Total Knee Arthroplasty (TKA) was 3% compared to 12% for UKAs. In the last decade semi active robots have been developed to be used for UKA procedures. These systems allow the surgeon to plan the size and orientation of the tibial and femoral component to match the patient's specific anatomy and to optimise the balancing the soft tissue of the joint. The robotic assistive devices allow the surgeon to execute their plan accurately removing only ‘planned’ bone from the predefined area. This study investigates the accuracy of an imageless navigation system with robotic control for UKA, reporting the errors between the ‘planned’ limb and component alignment with the post-operative limb and component alignment using weight bearing long leg radiographs. We prospectively collected radiographic data on 92 patients who received medial UKA using an imageless robotic assisted device across 4 centres (4 surgeons). This system is CT free, so relies on accurate registration of intra-operative knee kinematic and anatomic landmarks to determine the mechanical and rotational axis systems of the lower limb. The surface of the condylar is based on a virtual model of the knee created intra-operatively by ‘painting’ the surface with the tip of a tracked, calibrated probe. The burring mechanism is robotically controlled to prepare the bone surface and remove the predefined volume of bone. The study shows the 89% of the patients' post-operative alignment recorded by the system was within 30 of the planned coronal mechanical axis alignment. The RMS error was 1.980. The RMS errors between the robotic system's implant plan and the post-operative radiographic implant position was; femoral coronal alignment (FCA) 2.6o, tibial coronal alignment (TCA) 2.9o and tibial slope (TS) 2.9o. In conclusion, the imageless robotic surgical system for UKA accurately prepared the bone surface of the tibia and femur which resulted in low errors when comparing planned and achieved component placement. This resulted in a high level of accuracy in the planned coronal mechanical axis alignment compared to that measured on post-operative radiographs

Aims

A functional anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) has been assumed to be required for patients undergoing unicompartmental knee arthroplasty (UKA). However, this assumption has not been thoroughly tested. Therefore, this study aimed to assess the biomechanical effects exerted by cruciate ligament-deficient knees with medial UKAs regarding different posterior tibial slopes.

To evaluate the impact of a knee prosthesis on the soft-tissue envelope or knee kinematics, cadaveric lower extremities are often mounted in a custom test rig, e.g. Oxford knee rig. Using such test rig, the knee is tested while performing a squatting motion. However, such motion is of limited daily-life relevance and clinical practices has shown that squatting commonly causes problems for knee patients. As a result, a new test rig was developed that allows a random, controlled movement of the ankle relative to the hip in the sagittal plane. Mounting the specimen in the test rig, restricts five degrees of freedom (DOF) at the hip; only the rotation in the sagittal plane is not restrained (Figure 1). On the other hand, at the ankle, only two degrees of freedom are restrained, namely the movement in the sagittal plane. The ankle has thus three rotational degrees of freedom, all rotation axis intersect in a single point: the center of the ankle. In addition, the out-of-plane translational movement of the ankle remains free. This is achieved by means of a linear bearing. The other translational degrees of freedom, in the sagittal plane, are controlled by two actuators. As a result, the knee has five degrees of freedom left; flexion-extension is controlled. This represents typical closed chain applications, such as cycling. In a first step, the knee kinematics have been evaluated under un-loaded conditions (no quadriceps or hamstring forces applied). To evaluate the knee kinematics, an infrared camera system (OptiTrack, NaturalPoint Inc, USA) is used. Therefore, three infrared markers are placed on the femur and tibia respectively. In addition, markers are placed on the test rig itself, to evaluate the accuracy of the applied motion. All markers are tracked using eight infrared cameras. At the ankle, a 2D circular motion with a radius of 100 mm was applied. Based on the 3D motion analysis, it was demonstrated that the control system has an accuracy of ± 0.5 mm. The evaluation of the knee kinematics in accordance to Grood and Suntay (J. of Biomechanical Engineering, 1983), additionally requires the evaluation of the knee anatomy. To that extent, the cadaveric specimen has been visualized using a CT scan, with the infrared markers in place. From these CT images, a 3D reconstruction has been created (Mimics, Materialise, Belgium). Subsequently, custom software has been developed that combines the CT data with the motion analysis data (Matlab, The MathWorks Inc., USA). As a result, knee motion is visualized in 3D (Figure 2.a) and clinical relevant kinematic parameters can be derived (Figure 2.b). In conclusion, the presented test rig and analysis framework is ready to evaluate more complex knee kinematics with reasonable accuracy and stability of the control loops. Future research will however primarily focus on the evaluation and validation of the impact of forces applied onto the specimen

INTRODUCTION. Wear, aseptic loosening, dislocation, corrosion and prosthetic joint infection (PJI) are major factors leading to revision of THA. The effect of using ceramic components to address these issues was investigated to determine their behaviour and potential benefit. METHODS. a) Wear determination in off-normal conditions. A series of CoC articulations (32mm) was evaluated using a hip simulator (ISO 14242) up to 4 million cycles in presence of fine alumina particles (48mg/ml). Wear was measured gravimetrically. b) Friction moment determination. Friction moments were measured in a hip simulator with 25% newborn calf serum as lubricant. CoC, CoPE, MoPE, MoXLPE and CoXLPE with articulating diameters ranging between 28 and 40mm were used. The cup was inclined to a constant angle of 33° and rotated ±20° sinusoidally around a horizontal axis at 1Hz. Peak friction moments were measured around the cup rotation axis during a constant joint force period of 1700N between 200 and 210 seconds. c) Infections. Four databases were analysed and additionally data from registers and literature were reviewed to determine the risk of revision for prosthetic joint infection (PJI) dependence on the bearing. Only data for cementless THA were used. Several studies also included analysis of several confounding factors like age at surgery, BMI, pathology, etc. using Cox multivariate analysis. RESULTS. a) Wear determination in off-normal conditions. Loading the test medium with alumina particles didn't produces detectable wear. Opaque areas appeared only after 3 million load cycles, but the wear-rate remained within the gravimetric measurement detection limit (about 0.1–0.2mg) indicating the still extremely low wear-rate of the tested couplings. b) Friction moment determination. The highest moments were measured for metal heads; the lowest for CoC bearings. 40mm CoC bearing showed a similar friction moment like 28mm bearings when coupled with a XLPE liner. c) Infections. The rate of revisions for PJI for 500'749 patients from various studies was in the range of 0.2 to 1.1%. Age at surgery and BMI did not influence septic loosening, while the bearing did; sometimes significant. The trend was identical for all seven sources and ceramic components resulted in a lower incidence of revisions for up to 60%. CONCLUSION. The wear of CoC articulations is extremely low even in a heavily contaminated environment with fine hard particles. Such high scratch resistance makes CoC the preferable revision solution in THA. Friction moments with CoC are the lowest, even with large diameter bearings. The low friction moments of ceramics lower the stresses at the modular and also bone interface and can affect the outcome of THA. Revisions due to infection seem to be also dependent on the bearing couple with a positive influence of ceramic components. Although due to the complex reasons for infections only a trend, CoP and CoC has been identified to mitigate the risk of PJI

The kinematic alignment (KA) approach to total knee arthroplasty (TKA) has recently increased in popularity. Accordingly, a number of derivatives have arisen and have caused confusion. Clarification is therefore needed for a better understanding of KA-TKA. Calipered (or true, pure) KA is performed by cutting the bone parallel to the articular surface, compensating for cartilage wear. In soft-tissue respecting KA, the tibial cutting surface is decided parallel to the femoral cutting surface (or trial component) with in-line traction. These approaches are categorized as unrestricted KA because there is no consideration of leg alignment or component orientation. Restricted KA is an approach where the periarthritic joint surface is replicated within a safe range, due to concerns about extreme alignments that have been considered ‘alignment outliers’ in the neutral mechanical alignment approach. More recently, functional alignment and inverse kinematic alignment have been advocated, where bone cuts are made following intraoperative planning, using intraoperative measurements acquired with computer assistance to fulfill good coordination of soft-tissue balance and alignment. The KA-TKA approach aims to restore the patients’ own harmony of three knee elements (morphology, soft-tissue balance, and alignment) and eventually the patients’ own kinematics. The respective approaches start from different points corresponding to one of the elements, yet each aim for the same goal, although the existing implants and techniques have not yet perfectly fulfilled that goal.

We have performed two-component total ankle arthroplasty (TNK ankle) since 1991 and reported good clinical results. However, in vivo kinematics of this implant are not well understood. The purpose of this study was to measure three-dimensional kinematics of total ankle arthroplasty during non-weightbearing and weightbearing activities. Forty-seven patients with a mean age of 71 years were enrolled. Preoperative diagnosis was osteoarthritis in 36 patients and rheumatoid arthritis in 11 patients, and the mean followup was 50 months. Radiographs were taken during nonweightbearing maximal dorsiflexion and plantarflexion, and weightbearing maximal dorsiflexion and plantarflexion. Three-dimensional kinematics were determined using 3D-2D model registration techniques. Anatomic coordinate systems were embedded in the tibial and talar implant models, and they were projected onto the radiographic image. Three-dimensional positions and orientations of the implants were determined by matching the silhouette of the models with the silhouette of the image. From non-weightbearing dorsiflexion to plantarflexion, the talar implant showed 18.1, 0.3, and 1.2 degrees of plantarflexion, inversion, and internal rotation respectively. It also translated 0.8mm posteriorly. There was not significant difference between non-weightbearing and weightbearing kinematics except for the plantarflexion angle (p = 0.007). Posterior hinging, in which tibiotalar contact was seen at only the posterior edge of the talar implant, was observed in 16 patients at either non-weightbearing or weightbearing plantarflexion. There was significantly larger plantarflexion in patients with posterior hinging than patients without hinging (p < 0.001). Nine patients showed anterior hinging at maximum dorsiflexion, and 11 patients showed talar lift-off at maximum plantarflexion. More than half of the patients showed anterior or posterior edge contact, which might cause excessive contact stress and lead to implant failure in the longer term. This phenomenon is due to the difference in rotation axis between the natural ankle and the implant ankle arthroplasty

The aim of this study was to evaluate the rotational axis of the tibia and the association of its axis to tibial coronal alignment after TKR. TKRs were performed using navigated mobile bearing system (40 knees), conventional mobile bearing (48 knees) and conventional fixed bearing (40 knees) and preoperative and postoperative CT scans were assessed using 3D image reconstruction-analysis program. The tibial AP axis which was defined as the line connecting the middle of the PCL and the medial edge of the patellar tendon attachment was measured relative to the AP axis of distal femur preoperatively and postoperatively, as well as the coronal angle of the tibia and posterior slope. The tibial coronal alignments in navigation, postoperative plain radiograph and CT were compared. The AP axis of the tibia was in 2.10° internally rotated position relative to the AP axis of the femur preoperatively and 3.54° postoperatively (range, 19.5° internal rotation to 16.8° external rotation). The coronal angle of the tibia was 0.46° varus on plain radiograph, 0.72° varus on CT, 0.37° valgus in navigation (p=0.005). Posterior slope was 2.53° on plain radiograph and 0.67° in navigation (p< 0.001). There was no correlation between postoperative rotational position of the tibia relative to the femur and the difference in the tibial coronal angle between navigation data and CT. The proposed anteroposterior axis of the tibia centered between 0 to 5 degrees internally rotated position relative to the femur but showed wide range of deviation. The rotation angle of the tibial cutting in navigated TKR did not influence on the postoperative measurement discrepancy between navigation and CT

The presence of an unremovable cemented tibial nail presents a unique challenge for limb salvage reconstructions utilizing a rotating hinge knee. All manufacturers’ designs except Link America incorporate a vertically-oriented rotational channel in the proximal tibia to provide the housing for a rotational axis stem. Such channel placement may be impossible in patients with pre-existing tibial hardware that obliterates the proximal tibial intramedullary canal. The Link America design utilizes a superiorly-projecting rotational stem that articulates with a housing located on the rotational yoke component; however it requires an intramedullary tibial stem for component stabilization. Thus all currently available rotating hinge knees require placement of a stem or a stem equivalent into the tibial intramedullary canal. We describe a limb salvage case employing a Link America rotating hinge knee with a tibial component incorporating a custom hollow stem in a patient with an unremovable centralized, straight, cemented tibial nail. This reconstruction was required following an intra-articular fracture of a successfully incorporated massive proximal tibial osteoarticular allograft. The allograft had been implanted seven years previously following resection of a proximal tibia osteosarcoma. This custom device allowed a relatively simple limb salvage reconstruction with good results and only a two day hospital stay. This custom hollow-stemmed device allowed limb salvage in a situation that otherwise would have required either an amputation or resection of a healed tibial allograft that had successfully incorporated, replacing approximately 50% of the length of the tibia shaft. While rarely required, such an implant can allow a relatively simple and straight-forward functional salvage of an extremity in those patients whose only other choices for limb salvage include much more extensive bone resections and complex reconstructions. The potential for subsequent articular level failure should be considered whenever utilizing an osteoarticular allograft. A cemented, retrograde inserted, intramedullary nail can provide reliable internal fixation of such an allograft. If such fixation is selected, a straight intramedullary nail (as in this case) should be utilized, so that the intramedullary device is centered in the proximal tibia. This will allow for future revision to a total knee with a hollow stemmed tibial component should the need arise