Background

Excellent results with use of tapered wedged cementless stem have been reported. The purpose of this study was to clarify the indication of tapered wedged cementless stems for patients with poor bone quality.

Aims: Evaluation of: 1/ early clinical and radiographic results of total hip arthroplasty (THA) made by standard lateral direct approach, 2/ early clinical and radiographic results of THA made by minimal lateral approach, 3/ comparison of results of THA in these two groups.

Material and methods: Prospective study of 120 THAs (60 cementless and 60 cement) done in 120 patients due to degenerative changes was made. 60 THAs made by minimal lateral approach consist study group. 60 THAs made by direct lateral approach consist of control group.

Mean age of 120 patients (98 women and 22 men) was 45 y.o. (range: 32–61 y.o.). Follow-up time in study group was from 6 to 12 months (mean: 8,5 months). Follow-up time in control group was from 10 to 16 months (mean: 10,5 months). Mean preoperative functional status of the study group was 44,5p in Harris hip score. Radiographic evaluation of the results was made according to criteria of Joined Committee of The Hip Society, AAOS and SICOT.

Results: Clinical results in 6 months after THA were: 92p. in study group and 88p. in control group. In all 120 cases in both groups radiographic results were very good – there were no differences between control and study group. Incidence of complications were similar in both groups.

Conclusions: THA with minimal invasive approach has proved its value in the treatment of hip degenerative changes as regarding short-time results. Clinical and radiographic results of THA made by standard or minimal invasive approaches are comparable. Successful THA with minimal invasive approach is a matter of excellent operative technique and experience with standard hip approaches, and not special instruments.

Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655

Total hip arthroplasty has been constantly evolving with technological improvements to achieve the best survival rates. Although the new implants are under closer surveillance through processes such as Beyond Compliance, orthopaedic surgeons generally tend to look out for the latest implants with good short-term results and hope for better long-term results for these. We questioned whether such an assumption or bias is valid. We analysed the data of Kaplan-Meier estimates of cumulative revisions of primary hip replacement by fixation, stem/cup brand and bearing combinations from the NJR 19th Annual Report published in September 2022. We performed a univariate linear regression analysis to predict the 10- and 15-year revision rates for these different hip implant combinations from the 3- and 5-year revision rates. Thirty-seven implant combinations had their 15-year revision rates reported and 67 had the 10-year revision rates. The correlation co-efficients were 0.43 and 0.58 for the 3-year and 5-year revision rates against 15-year revision rates. Only 17% of the variance in 15-year revision rates could be predicted by a linear regression model from the 3-year revision rate and 32% from the 5-year revision rate. Corresponding values for the 10-year revision rates were 46% and 67%. 95% prediction intervals for the 15-year revision rate were +/− 3.1% from the 3-year revision rate and +/− 2.8% from the 5-year revision rate. Corresponding values for the 10-year revision rates were +/− 1.3% and +/− 1%. 19 of 37 implant combinations showed 15-year revision rate of more than 4%. Average 3-year and 5-year revision rates for this cohort was 1.0% and 1.42% compared to 1.4% and 1.9% for the rest and the difference was statistically significant. Although average early revision rates showed small but significant difference between the groups with lower and higher 15-year revision rates, the prediction intervals for 15-year revision rates for individual hips based on their 3-year and 5-year revision rates are very wide. Three- and 5-year revision rates for primary total hip replacements are poor predictors of 15-year revision rates

Aims. The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems. Methods. In this case-control study, 25 patients (22 female) at mean age of 78 years (70 to 89) received cemented Exeter short stem (case group). Cases were selected based on Dorr type A femora and matched first by Dorr type A and then age to a control cohort of 21 patients (11 female) at mean age of 74 years (70 to 89) who received with cemented Exeter standard stems (control group). Preoperatively, all patients had primary hip osteoarthritis and no osteoporosis as confirmed by dual X-ray absorptiometry scanning. Patients were followed with radiostereometry for evaluation of stem migration (primary endpoint), evaluation of cement quality, and Oxford Hip Score. Measurements were taken preoperatively, and at three, 12, and 24 months and a minimum five-year follow-up. Results. At three months, subsidence of the short stem -0.87 mm (95% confidence interval (CI) -1.07 to -0.67) was lower compared to the standard stem -1.59 mm (95% CI -1.82 to -1.36; p < 0.001). Both stems continued a similar pattern of subsidence until five-year follow-up. At five-year follow-up, the short stem had subsided mean -1.67 mm (95% CI -1.98 to -1.36) compared to mean -2.67 mm (95% CI -3.03 to -2.32) for the standard stem (p < 0.001). Subsidence was not influenced by preoperative bone quality (osteopenia vs normal) or cement mantle thickness. Conclusion. The standard Exeter stem had more early subsidence compared with the short Exeter stem in patients with Dorr type A femora, but thereafter a similar migration pattern of subsidence until minimum five years follow-up. Both the standard and the short Exeter stems subside. The standard stem subsides more compared to the short stem in Dorr type A femurs. Subsidence of the Exeter stems was not affected by cement mantle thickness. Cite this article: Bone Jt Open 2023;4(7):507–515

Aims. Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT. Methods. We retrospectively analyzed 32 consecutive symptomatic patients with OLT who underwent PACT with minimum one-year follow-up. Standard preoperative radiography and MRI were performed for all patients. Follow-up second-look arthroscopy or MRI was performed with patient consent approximately one-year postoperatively. Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score and International Cartilage Repair Society (ICRS) grades were used to evaluate the quality of the regenerated cartilage. Clinical outcomes were assessed using the pain visual analogue scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Scale (FAOS). Results. All patients had ICRS grade IV cartilage lesions, except for one (ICRS grade III). The paired MOCART scores significantly improved from 42.5 (SD 1.53) to 63.5 (SD 22.60) (p = 0.025) in ten patients. Seven patients agreed to undergo second-look arthroscopy; 5 patients had grade I (normal) ICRS scores and two patients had grade II (nearly normal) ICRS scores. VAS, FFI, and all subscales of FAOS were significantly improved postoperatively (p ≤ 0.003). Conclusion. PACT significantly improved the clinical, radiological, and morphological outcomes of OLT. We consider this to be a safe and effective surgical method based on the short-term clinical results of this study. Cite this article: Bone Jt Open 2023;4(12):942–947

Introduction. Many minimally-invasive approaches have been described in an effort to improve short-term results of total hip arthroplasty (THA), aiming for fast recovery and prevention of dislocation. In our institution, we started to perform THA with SuperPATH approach, including preservation of soft tissue around the hip (James Chow et al. Musculoskelet Med 2011) since July 2014. The purpose of this study is to examine the short-term results of THA using SuperPATH, especially treatment progress of rehabilitation. Materials and methods. We performed a study of 30 patients (30 hips) with osteoarthritis of the hip joint who had a THA with SuperPATH approach. There were 4 men and 26 women with an average age of 71 years, which were followed up for 24 months. Patients were clinically assessed with Merle d'Aubigne score, postoperative hip pain during walking by Numerical Rating Scale (NRS:0–10), complications and treatment progress of rehabilitation in regard to moving and activities of daily living. Implant alignment and stability were radiologically evaluated by annual X-ray and CT acquired two months after surgery. Results. Merle d'Aubigne score was 10.4 (pain:2.9, mobility:4.5 walking ability:3.0) preoperatively and 16.8(pain:5.9, mobility:5.9, walking ability:5.0) at the latest follow-up. NRS showed less than 3 points for more than 50% of the THA patients next day postoperatively. For more than 80%, NRS showed less than 1 point at 7 days after surgery, and most patients acquired the ability of level ground walking for 100 meters independently by 4 days postoperatively, climbing up and down stairs independently by 5 days and wearing/taking off their socks independently by 7 days. There were no dislocation and infection, but intraoperative proximal femoral fracture was found for two cases, which was managed to treat with additional circulating wire intraoperatively. From CT images averaged cup position found to be 39±5 degrees for inclination, and 21±6 degrees for anatomic anteversion, averaged stem anteversion to be 33±9 degrees. No loosening of components was evident. Discussion and Conclusion. Many minimally-invasive approaches have developed, there have been many reports on fast recovery and low incidence of postoperative hip dislocation, however, the risk of complications related to shortage of operative field has been pointed out. In this study, intraoperative proximal femoral fracture occurred for two cases, but the components position seemed excellent and NRS showed less pain postoperatively and most of the patients acquired walking ability in a few days. SuperPATH approach, including pass way from between the Gluteus Medius and the piriformis tendon, can preserve the whole short external rotators and capsule of the hip joint, leading to fast rehabilitation progress. Moreover, this approach may be friendly to the surgeons familiar with the posterior approach because of easily conversion to the conventional posterior approach

Short-stem total hip arthroplasty (THA) has primarily been recommended for young and active patients, mainly due to its bone preserving philosophy. Elderly patients, however, may also benefit of a minimally invasive technique due to the short and curved implant design. The purpose of this study was to compare the clinical and radiological outcomes as well as perioperative complications of a calcar-guided short stem between a young (75 years) population. Data were collected in a total of 5 centers, and 400 short stems were included as part of a prospective multicentre observational study between 2010 and 2014 with a mean follow-up of 49.2 months. Clinical and radiological outcomes were assessed in both groups. Secondary outcomes such as perioperative complications, rates and reasons for stem revision were also investigated. No differences were found for the mean visual analogue scale (VAS) values of rest pain, load pain, and satisfaction. Harris Hip Score (HHS) was found to be slightly better in the young group. Comparing both groups, no statistically significant differences ere found in the radiological parameters that were assessed (stress-shielding, cortical hypertrophy, radiolucency, osteolysis). Aseptic loosening was the main cause of implant failure in younger patients whereas in elderly patients, postoperative periprosthetic fractures due to accidental fall was found to be the main cause for stem revision. These short-term results are encouraging towards the use of a cementless short stem in the geriatric population. According to our findings, advanced age and potentially reduced bone quality should not necessarily be considered as contra-indications for calcar-guided short-stem THA but careful and reasonable selection of the patients is mandatory. Longer follow up is necessary in order to draw safer conclusions

With the increase in the elderly population, there is a dramatic increase in the number of spinal fusions. Spinal fusion is usually performed in cases of primary instability. However it is also performed to prevent iatrogenic instability created during surgical treatment of spinal stenosis in most cases. In literature, up to 75% of adjacent segment disease (ASD) can be seen according to the follow-up time. 1. Although ASD manifests itself with pathologies such as instability, foraminal stenosis, disc herniation or central stenosis. 1,2. There are several reports in the literature regarding lumbar percutaneous transforaminal endoscopic interventions for lumbar foraminal stenosis or disc herniations. However, to the best our knowledge, there is no report about the treatment of central stenosis in ASD. In this study, we aimed to investigate the short-term results of unilateral biportal endoscopic decompressive laminotomy (UBEDL) technique in ASD cases with symptomatic central or lateral recess stenosis. The number of patients participating in the prospective study was 8. The mean follow-up was 6.9 (ranged 6 to 11) months. The mean age of the patients was 68 (5m, 3F). The development of ASD time after fusion was 30.6 months(ranged 19 to 42). Mean fused segments were 3 (ranged 2 to 8). Preoperative instability was present in 2 of the patients which was proven by dynamic lumbar x-rays. Preoperative mean VAS-back score was 7.8, VAS Leg score was 5.6. The preoperative mean JOA (Japanese Orthopaedic Association) score was 11.25. At 6th month follow-up, the mean VAS back score of the patients was 1, and the VAS leg score was 0.5. This improvement was statistically significant (p = 0.11 and 0.016, respectively). The mean JOA score at the 6th month was 22.6 and it was also statistically significant comparing preoperative JOA score(p = 0.011). The preoperative mean dural sac area measured in MR was 0.50 cm2, and it was measured as 2.1 cm. 2. at po 6 months.(p = 0.012). There was no progress in any patient's instability during follow-up. In orthopedic surgery, when implant related problems develop in any region of body (pseudoarthrosis, infection, adjacent fracture, etc.), it is generally treated by using more implants in its final operation. This approach is also widely used in spinal surgery. 3. However, it carries more risk in terms of devoloping ASD, infection or another complications. In the literature, endoscopic procedures have almost always been used in the treatment of ventral pathologies which constitute only 10%. In ASD, disease devolops as characterized by wide facet joint arthrosis and hypertrophied ligamentum flavum in the cranial segment and it is mostly presented both lateral recess and santal stenosis symptoms (39%). In this study, we found that UBEDL provides successful results in the treatment of patients without no more muscle and ligament damage in ASD cases with spinal stenosis. One of the most important advantages of UBE is its ability to access both ventral and dorsal pathologies by minimally invasive endoscopic aproach. I think endoscopic decompression also plays an important role in the absence of additional instability at postoperatively in patients. UBE which has already been described in the literature given successful results in most of the spinal degenerative diseases besides it can also be used in the treatment of ASD. Studies with longer follow-up and higher patient numbers will provide more accurate results

Introduction. Total knee arthroplasty (TKA) is an effective surgical intervention, which alleviates pain and improves function and health-related quality of life in patients with end-stage arthritis of the knee joint. With improvements in anesthesia, general health care, and surgical techniques, this procedure has become widely accepted for use in very elderly patients. However, many elderly patients tend to have compromised function and low reserve capabilities of organs and are therefore likely to develop various complications during the perioperative period. Thus, elderly patients often hesitate to undergo simultaneous bilateral TKA (SBTKA). Our purpose was to report the short-term results and clinical complications of octogenarians undergoing SBTKA. Materials and Methods. Between 2015 and 2016 all patients greater than 80years of age who underwent SBTKA by a single surgeon were retrospectively evaluated demographics, comorbidity, complications, and 30days mortality following SBTKA. Arthroplasty was performed sequentially under general anesthesia by one team led by primary surgeon. After the first knee, the patient's cardiopulmonary status was assessed by anesthesiology to determine whether or not to begin the second side. Cardiopulmonary decompensation, such as significant shifts in heart rate, oxygen saturation or blood pressure, was not showed. Then the second procedure was undertaken. Inclusion criteria of this study was underlying diseases were osteoarthritis. Exclusion criteria were (1) previous knee surgery; (2) underlying diseases were osteonecrosis, rheumatoid arthritis, fracture, and others. Fifty-seven patients with an average age of 82.7years were identified. The results of these procedures were retrospectively compared with those of patients greater than 80years of age of 89 patients unilateral TKA (UTKA) that had been performed by the same surgeon. Results. The study groups did not differ significantly with regard to age, gender, or body mass index. The mean age was 82.7years with a mean body mass index of 25.8 for the SBTKA group, compared with 84.0years with a mean body mass index of 24.9 for the UBTKA group. The length of hospital stay was longer in SBTKA groups. There was no serious complication. No deaths, no pulmonary embolisms and no nerve paralysis occurred within 30days in both groups. There was one wound problem in SBTKA group, compared 10 wound problem in UBTKA group; this difference was significant. Three deliriums occurred in SBTKA group, compared 13 deliriums in UBTKA group; this difference was significant. Minor complications included urinary tract infection, decubitus ulcer, transfusion reaction and ileus were noted seven in SBTKA group, compared in 11 UBTKA group; this difference was not significant. Conclusions. Complications and mortality are not higher for SBTKA compared to UTKA, SBTKA can be a safe and effective option for octogenarians

Introduction. Osteotomy for medial gonarthrosis is most often done as a proximal tibial valgus osteotomy, either as a closing wedge osteotomy (HTO) or as an opening wedge osteotomy including hemicallostasis (HCO). In case of lateral gonarthrosis the osteotomy is done as a proximal tibial varus osteotomy, closing or opening wedge or as a distal femoral varus osteotomy depending on the anatomy of the knee. The early period after osteotomy is influenced by complications to osteotomy. Complications depend on the operative method and localisation of surgery. Short- and long-term results are presented as knee scores or survivorship of high tibial osteotomy. Most often used scores are the HSS-score, NHP-score and the knee scores according to Lysholm and Tegner. Scores from the patient’s perspective are NHP, SF-36. KOOS (Knee Injury and Osteoarthritis Outcome Score) was introduced recently, and only short-term results are available. Results. Osteotomy for medial gonarthrosis. Immediate postoperative results. The closing wedge osteotomy is the golden standard and reported complications are peroneal palsy in 0 – 8%, infection in 1 – 3%, fracture of the tibial plateau and delayed union in 3 – 5% and thromboembolism in 2 – 4%. When the opening wedge method including HCO is used peroneal palsy is extremely seldom, delayed union is reported in 2%, major pin-tract infection in 2 – 20 % and thromboembolism in 2 – 4%. Short-term results. The short-term results are generally good and one to two years after osteotomy excellent and good results are reported in 85 – 97 %. All five partial scales in KOOS with the exception of sports/ recreation function were significantly improved 3 – 4 months postoperatively. Long term results 5 – 20 years after surgery. Evaluations of osteotomies using survivorship of the osteotomy, with conversion to a total knee as the endpoint, show an expected rate of survival of 73–94% at 5 years, 51–85 % at ten years, 39–68 % at 15 years and 30% at 20 years. Analysis of risk factors show that age older than 50 years, presence of lateral tibial thrust and insufficient valgus correction were significantly associated with probability of early failure. Evaluations using knee scores with a mean follow-up time of 5 – 10 years show excellent and good result in 64 – 80%. At follow-up 11– 15 years after surgery the fraction good and excellent knees is 55 – 60% and 16– 20 years after osteotomy a minority of the knees are good or excellent, at most 46%. Stage of arthrosis: Good long-term results are reported for knees with early medial arthrosis with at most obliteration of the medial joint space or just minimal bone attrition. Results after HCO on knees with more advanced gonarthrosis are reported with a short follow-up and the change of osseous correction after osteotomy was less compared to HTO. Only minimal progress of arthrosis after osteotomy is reported in most papers. The results of some studies indicate that the greater the surgical correction, the slower the progress of the medial joint arthrosis. Alignment of the knee:. Most reports find better clinical results and less risk for failure when the osteotomy is corrected to a slight over-correction of the knee alignment. There is however no consensus on the smallest correction needed to change the load on the medial arthrotic compartment. Osteotomy for lateral gonarthrosis. The condition is uncommon and a minority of the papers on osteotomy for gonarthrosis concern osteotomy for lateral gonarthrosis. The aim of osteotomy for lateral gonarthrosis is to achieve a varus alignment of the knee with a joint line obliquity, which after surgery is less than 10 degrees. That affects the method, which is either a proximal tibial osteotomy or a distal femoral osteotomy. Most often the aetiology of the deformity is posttraumatic. Immediate postoperative results. When using the opening wedge osteotomy on tibia transient nerve palsy is reported in 9–50%. Infection is reported in 2% and thromboembolism in 2 – 4%. Pin tract infection when using HCO is reported in 2 – 20%. In a multicenter follow-up distal femoral varus osteotomy 11 complications were recorded in 32 patients (five non unions, three deep infections and three cases with a stiff knee). Short-term results. Short-term results one to two years after surgery are reported excellent and good in 85 – 95%. Results 5 – 15 years. Five to ten years after surgery good and excellent results are reported in 75 − 77%, and in 11 – 15 years after surgery in 50 – 80%. Results are much better in recent reports because of better patient selection and operative technique. The tibial varus osteotomy can be used in knees with less than 12 degrees of valgus. Furthermore the tilting of the tibiofemoral joint line should postoperatively be less than 10 degrees. Otherwise a distal femoral osteotomy should be used. Persistent excessive obliquity of the tibiofemoral joint line predisposes instability with risk of compromising the result. To summarize: Osteotomy is effective in a patient with a medial or a lateral gonarthrosis at most Stage II according to the classification of Ahlbäck, under the age of between 50 and 60 years and of high demands by reason of lifestyle and occupation. Aim at an overcorrection so when the osteotomy is healed you should have a slight overcorrection in valgus in medial gonarthrosis and in varus when you have a lateral gonarthrosis. Furthermore the joint line obliquity should postoperatively be less than 10 degrees. With this selection of patients and with a good surgical technique your patient can expect a probability of having a good knee in about 70 % after ten years. After ten years it is more difficult to make a prognosis for your patients knee

Introduction. Ankle arthrodesis is a common treatment for destroyed ankle arthrosis with sacrificing the range of motion. On the other hand, total ankle arthroplasty (TAA) is an operation that should develop as a method keeping or improving range of motion (ROM); however, loosening and sinking of the implant have been reported in especially constrained designs of the implant. The concept of FINE TAA is the mobile bearing system (Nakashima Medical Co., Ltd, Okayama Japan) that can reduce stress concentration to implants. The purpose of this study is to evaluate the short-term results of FINE TAA. Objectives and Methods. We performed FINE TAA for osteoarthritis (OA) (2 ankles of 2 patients) and rheumatoid arthritis (RA) (4 ankles of 3 patients). All patients were female. The mean age of the patients was 71.4 years old at the operation. The mean follow-up period was 32.6 (range, 18–55) months. All patients were assessed for Japan Orthopedic Association (JOA) score and ROM in plantar flexion and dorsiflexion at the point of pre-operation and final follow-up. We evaluated radiolucent line, subsidence, and alignment of implants at the latest follow-up. Results. JOA score improved from 34.8 to 72.2 on average. ROM improved from 4.0 ± 5.5 º to 7.0 ± 4.5 º on average in plantar flexion and from 21.0 ± 17.0 º to 31.0 ± 16.0 º in dorsiflexion. One case underwent an ankle arthrodesis because of the implant loosening. This failed case was very obese (70 kg of body weight, 31.0 of Body Mass Index) and her activity was relatively high. One ankle showed radiolucent line around the components with no symptoms. The alignment of implants was slightly varus and anteversion (the mean values of alpha angle was 88.0 ± 1.2º, beta angle was 84.0 ± 9.2º, and gamma angle was 2.1 ± 0.2º). Discussion. The ankle joint is highly loaded up to five times body weight on small surface of contact area during walking. Therefore, the poor results have been published after TAA with using fixed-bearing 2-component prostheses compared to ankle arthrodesis. On the other hand, FINE TAA was designed as 3-component mobile bearing system that can reduce stress concentration compared to conventional TAA. We experienced implant failure in one obese case but short-term results of other cases were acceptable. Good clinical results can be expected with FINE TAA except for the obese case. We should pay careful attention to the surgical indication. Conclusion. Our short term results of FINE TAA were acceptable except for one obese case. We should evaluate further mid- and long- clinical results

Introduction. Acetabular revision surgery is challenging due to severe bone defects. Burch-Schneider anti-protrusion cages (BS cage: Zimmer-Biomet) is one of the options for acetabular revision, however higher dislocation rate was reported. A computed tomography (CT)-based navigation system indicates us the planned direction for implantation of a cemented acetabular cup during surgery. A large diameter femoral head is also expected to reduce the dislocation rate. The purpose of this study is to investigate short-term results of BS cage in acetabular revision surgery combined with the CT-based navigation system and the use of large diameter femoral head. Methods. Sixteen hips of fifteen patients who underwent revision THA using allografts and BS cage between September 2013 and December 2017 were included in this study with the follow-up of 2.7 (0.1–5.0) years. There were 12 women and three men with a mean age of 78.6 years (range, 59–61 years). The cause of acetabular revision was aseptic loosening in all hips. The failed acetabular cup was carefully removed, and acetabular bone defect was graded using the Paprosky classification. Structural allografts were morselized and packed for all medial or contained defects. In some cases, solid allograft was implanted for segmental defects. BS cage was molded to optimize stability and congruity to the acetabulum and fixed with 6.5 mm titanium screws to the iliac bone. The inferior flange was slotted into the ischium. The upside-down trial cup was attached to a straight handle cup positioner with instrumental tracker (Figure 1) and placed on the rim of the BS cage to confirm the direction of the target angle for cement cup implantation under the CT-based navigation system (Stryker). After removing the cement spacer around the X3 RimFit cup (Stryker) onto the BS cage for available maximum large femoral head, the cement cup was implanted with confirming the direction of targeting angle. Japanese Orthopedic Association score (JOA score) of the hip was used for clinical assessment. Implant position, loosening, and consolidation of allograft were assessed using anterior and lateral radiographies of the pelvis. Results. Fifteen hips had a Paprosky IIIB defect, and one hip had a pelvic discontinuity. JOA score significantly improved postoperatively. No radiolucent lines and no displacement of BS cage could be found in 9 of 15 hips. Consolidation of allografts above the protrusion cage was observed in these patients. Displacement of BS cage (>5mm) was observed in 6 hips and displacement was stopped with allograft consolidation in 5 of 6 hips. The other patient showed lateral displacement of BS cage and underwent revision surgery. Average cup inclination and anteversion angles were 37.7±5.0 degree and 24.6±7.2 degree, respectively. 12 of 16 patients were included in Lewinnek's safe zone. One patient with 32 mm diameter of the femoral head had dislocation at 17 days postoperatively. All patients who received ≥36mm diameter of femoral head showed no dislocation. Conclusions. CT-based navigation system and the use of large femoral head may influence the prevention of dislocation in the acetabular revision surgery with BS cage for severe acetabular bone defects

Introduction. In our institution, we started to perform THA with SuperPATH approach, including preservation of soft tissue around the hip (James Chow et al. Musculoskelet Med 2011) since July 2014, aiming for fast recovery and prevention of hip dislocation. For minimally-invasive approaches, however, there have been a few reports on malalignment of the implants related to shortage of operative field. The purpose of this study is to examine the short-term results of THA using SuperPATH, especially implant alignment. Materials and methods. We performed a study of 45 patients (45 hips) with osteoarthritis of the hip joint who had a THA with SuperPATH approach. There were 8 men and 37 women with an average age of 73 years, which were minimally 24 months followed. Dynasty Bioform cup and Profemur Z stem (Microport Orthopaedics) were used for all cases. Patients were clinically assessed with Merle d'Aubigne score and complications. Implant alignment and stability were radiologically evaluated by annual X-ray and CT acquired two months after surgery. Results. Merle d'Aubigne score was 10.2 (pain:2.8, mobility:4.4 walking ability:3.0) preoperatively and 16.6(pain:5.8, mobility:5.8, walking ability:5.0) at the latest follow-up. There were no dislocation and infection, but intraoperative proximal femoral fracture was found for two cases, which was managed to treat with additional circulating wire intraoperatively. Latest follow-up X-ray image showed 95% of the stem A-P alignment to be within 2 degrees and 5% to be more than 2 degrees and less than 5 degrees, while 44% of the stem lateral alignment to be within 2 degrees, 47% to be more than 2 degrees and less than 5 degrees, and 8% to be more than 5 degrees. From CT images averaged cup position found to be 40±5 degrees for inclination, and 19±5 degrees for anatomic anteversion, averaged stem anteversion to be 33±9 degrees. Annual X-ray evaluation showed no radiolucent line and less than Grade 2 stress-shielding (Engh classification) around the implants for all cases. One case had more than 5mm subsidence of the stem in early postoperative period, but not progressively subsided. No loosening of components was evident. Discussion and Conclusion. Many minimally-invasive approaches have developed, there have been many reports on fast recovery and low incidence of postoperative hip dislocation, however, the risk of complications or malalignment related to shortage of operative field has been pointed out. In this study, intraoperative proximal femoral fracture occurred for two cases. Also, though there were no loosening and the components position seemed excellent but lateral view of the X-ray showed 8% to be more than 5 degrees tilting alignment, resulting from femoral broaching required before femoral neck resection. SuperPATH approach, including pass way from between the Gluteus Medius and the piriformis tendon, can preserve the whole short external rotators and capsule of the hip joint, leading to fast recovery and low incidence of postoperative dislocation. Moreover, this approach may be friendly to the surgeons familiar with the posterior approach because of easily conversion to the conventional posterior approach

Purpose. There is a large gap between UKA and TKA in terms of tissue preservation including bone stock and knee ligament. We have recently introduced bicompartmental UKA (Bi-UKA) to fill the gap and achieve more “physiological” knee than TKA. In this study, we report the short-term results of Bi-UKA. Subjects and Methods. Thirty knees in twenty-nine osteoarthritis patients who underwent Bi-UKA from December 2010 to December 2013 (6 males and 23 females, average age of 75) were clinically and radiologically evaluated with an average observation period of 19 months. The operative indications were (1)confirmed diagnosis of medial and lateral osteoarthritis or osteonecrosis with preserved status of patellofemoral joint; (2)range of knee flexion greater than 110°; (3)flexion contracture less than 20°; (4)clinically stable knee in the frontal and sagittal plane; (5)correctable knee deformity with fine knee congruency. In all cases, fixed type UKA was implanted through a tibia dependent cut using a spacer block. Zimmer Uni and TRIBRID UKA (Kyocera Medical Corporation) were implanted in 18 and 12 cases, respectively. Results. The mean JOA score improved significantly from 57 points preoperatively to 89 points postoperatively. With regard to ROM, the mean extension significantly improved from −6° to −1° (p<0.001), and the mean flexion was almost unchanged from 134° to 139°. Six knees achieved maximum flexion angles of more than 150°. The mean leg alignment was unchanged from 174.5° to 175.2°, although there were five knees in which alignment was corrected by more than 10° after the surgery. All implant alingnments were reasonably acceptable and particularly, the gaps of setting angle between medial and lateral components were quite small in lateral view radiograph. A only major postoperative complication we have experienced was a periprosthetic tibia fracture, which had been successfully treated with screw fixation. Discussion. Bi-UKA is a bone- and ligament-sparing procedure that may provide better knee function and patient satisfaction than does TKA. Complicated surgical procedure, relationship of placement position between medial and lateral prostheses, ligament balancing, and longer-term results remain subjects to be resolved. However, tibia dependent cut technique using spacer block was quite useful to improve the accuracy of implants positioning during Bi-UKA procedure. Our short-term results of Bi-UKA were well acceptable although there were a few complaints or complications. We would like to confirm the usefulness of this procedure and further establish the best indication by increasing the number of patients in the future

Total hip arthroplasty has become one of the most successful orthopaedic procedures with long-term survival rate. An ever-increasing acceptance of the potential longevity of THA systems has contributed to an increasing incidence of THA in younger and more active patients. Nowadays, especially in younger patients, cementless THA is the favored method worldwide. Since the first cementless THA in late 1970s, many implant designs and modifications have been made. Despite excellent long-term results for traditional straight cementless stems, periprosthetic fractures or gluteal insufficiency are still a concern. For instance, as reported in a meta-analysis by Masonis and Bourne, the incidence of gluteal insufficiency after THA varies between 4% and 22%. In contrast, the flattened lateral profile of the SP-CL. ®. anatomical cementless stem can protect the greater trochanter during the use of cancellous bone compressors and can avoid gluteal insufficiency after THA. Another benefit of this stem design is the rotational stability and the natural load transfer due to the anatomical concept. In this context, we report our experiences using the SP-CL. ®. anatomical cementless stem. The study group consists of 1452 THA cases (850 male, 602 female) with an average age of 62 years (range 25–76 years). After a mean follow-up of 20 months, in seven cases (0.5%) a stem exchange was necessitated. The reason for stem revision was periprosthetic fracture in 4 cases (0.3%) and periprosthetic joint infection in three cases (0.2%). In five patients, hip dislocation and in four patients migration of the stem occurred. However, stem exchange was not required in those cases. In conclusion, the SP-CL. ®. anatomical cementless stem has excellent short-term results

Introduction. MERA Quest Knee System (Quest Knee) is a posterior cruciate ligament–retaining prosthesis considering the anatomical features and lifestyles of the Japanese. As for the anatomical features, we reduced the size of prosthesis and set a smaller interval of sizes because Japanese knees are smaller and flatter than those of Caucasians. As for the lifestyles, we evaluated in vivo patellar tracking during deep knee flexion and the condylar geometry in the axial plane of magnetic resonance imaging. It was found that the patella sank deeply into the intercondylar notch and that the articular surface of the lateral condyle began to curve steeply. We adopted this shape and engraved the lateral condyle deep to reduce the pressure of the patellofemoral joint and to get better range of motion (ROM). For the contact pressure rise in the femorotibial joint by engraving the lateral condyle, the insert was suited to the shape of the femoral component. Furthermore, we increased the thickness of the posterior flange of the femoral component and changed the posterior radius of curvature gradually, and this shape allowed the flexion of 155°. We have used Quest Knee for clinical applications from October 2009. We studied the short-term results of Quest Knee. Methods. Between June 2010 and July 2013, the same senior surgeon performed 59 consecutive primary operations with Quest Knee. Forty patients (44 knees) were women, and 14 patients (15 knees) were men. The mean patient age was 72.5 years (range, 59–89 years). All were osteoarthritis knees. Coronal deformity was varus in 58 knees and valgus in one knee. All operations were performed with a measured resection technique, and all patellae were resurfaced. Clinical evaluations were assessed using the Japanese Orthopaedic Association knee rating score (JOA score), and clinical ROM and standing femorotibial angle (FTA) were measured. Additionally, three-dimensional motion analysis of the patellar component during squatting was performed by the image matching method with image correlations. Results. The mean follow-up period was 17.4 months (range, 6–43 months). The JOA score at preoperative and follow-up were 57.5 ± 10.1 and 87.5 ± 5.6 points, respectively (P < 0.0001) (Fig. 1). The ROM at preoperative and follow-up were 127.4 ± 11.1 and 126.2 ± 9.0° (P = 0.47) (Fig. 2). The mean FTA at preoperative and follow-up were 184.2 and 172.3°. With regard to the three-dimensional motion analysis, the patella showed lateral shift during squatting (Fig. 3). Discussion. As for the patellofemoral contact pressure at flexion in total knee arthroplasty, a biomechanical study has reported that the pressures of posterior cruciate ligament–retaining and posterior-stabilized knees were 3.2 and 2.8 times as much as the body weight. This report suggests that the reduction of the pressure of the patellofemoral joint during deep knee flexion results in better ROM. We suppose that Quest Knee reduced the pressure, led the patella to the lateral side, and achieved better ROM. Conclusions. Short-term results of Quest Knee were good. More detailed studies are needed to get better function and long-term durability

Introduction. Osteochondral defects of the knee may occur following patella dislocation or following direct trauma or twisting injuries to the knee in adolescents. Often a diagnostic and therapeutic challenge, if these lesions are left, posttraumatic osteoarthritis may occur. This retrospective single centre study presents the short-term results following operative fixation of osteochondral fragments of the knee using Omnitech ® screws. Method. All skeletally immature patients presenting with an osteochondral fracture of their femur or patella confirmed on xray and MRI were identified. Arthroscopic evaluation of the osteochondral defect was performed followed by open reduction and internal fixation of the osteochondral fragment using Omnitech ® screws. A standard postoperative rehabilitation protocol was followed. Patients were evaluated at follow-up using a Knee Injury and Osteoarthritis Outcome Score (KOOS). Results. Eight patients were identified. The mean age at time of injury was 15 years (range 14–16) for two girls and 14.4 years (range 13–16) for six boys. The lateral femoral condyle was involved in six cases and patella in two cases. At mean follow up of 14 months (range 1–38) there was no revision for failure and no postoperative complications. The KOOS score (out of 100) at final follow up was subdivided as follows; Pain, 93 (range 81–100), other symptoms, 77 (range 36–100), function in daily living (ADL), 97 (range 84–100), function in sport and recreation, 84 (range 55–100) and knee related quality of life, 79 (range 44–100). Discussion. The short-term results of using Omnitech® screws are promising. Subchondral screw placement with adequate compression of the osteochondral fragment is achievable with Omnitech ® screws. Seven patients are back to their pre-injury sporting activity and one patient is currently undergoing postoperative rehabilitation, one month following surgery

Reconstruction of massive acetabular bone defects in primary and revision THA is challenging for reconstructive joint surgeons. The use of porous metal augments is one of the options. The advantages of porous metal augments are easy to use, modularity and lack of resorption. We investigated the radiological results of porous metal augments used for massive acetabular bone defects in primary and revision THA. Forty-one hips in forty patients had porous metal augments between 2011 and 2016. Thirty of the procedures were revision arthroplasties and 11 were primary procedures (Crowe type III in 5 hips, Crowe type IV in 3, septic hip sequalae in 2 and RA in one). Four of the revisions were second-stage reimplantation after infection. The Paprosky classification for revision was 2B in 4 hips, 2C in one, 3A in 3 and 3B in 22. Regenerex augments were used in 39 hips and trabecular metal augments were used in 2. Thirty-six cups were cemented and 5 cups were uncemented. Mean follow-up was 37.6 months (range, 1–82). Radiographic findings of osteointegration between host bone and the porous metal augments were assessed. The presence or absence of radiolucent lines between cement or cup/host bone and augment/host bone interface was noted. Two revisions were performed due to infection, one month and 66 months after operation. The other implants were stable without any complications. Osteointegration between host bone and the porous metal augments were recognized in 36 hips. Radiolucent lines between cement/host bone interface, less than 1 mm in width, were visualized in 2 hips. Porous metal augments are convenient and our short-term results showed excellent radiological results for massive acetabular bone defects in primary and revision THA

The advent of modern anatomic shoulder arthroplasty occurred in the 1990's with the revelation that the humeral head dimensions had a fixed ratio between the head diameter and height. As surgeons moved from the concept of balancing soft tissue tension by using variable neck lengths for a given humeral head diameter, a flawed concept based on lower extremity reconstruction, improvements in range of motion and function were immediately observed. Long term outcome has validated this guiding principle for anatomic shoulder replacement with improved longevity of implants, improved patient and surgeon expectations and satisfaction with results. Once the ideal humeral head prosthesis is identified, and its position prepared, the surgeon must use a method to fix the position of the head that is correct in three dimensions and has the security to withstand patient activities and provide maximal longevity. Based again on lower extremity concepts, long stems were the standard of care, initially with cement, and now, almost universally without cement for a primary shoulder replacement. The incredibly low revision rates for humeral stem aseptic loosening shifted much of the attempted innovation to the challenges on the glenoid side of the reconstruction. However, glenoid problems including revision surgery, infections, periprosthetic fractures, and other complications often required the removal of the humeral stem. And, in many cases, the overall results of the procedure and the patient's long-term outcome was affected by the difficulty in removing the stem, leading surgeons to compromise the revision procedure, avoid revision surgery, or add to the overall morbidity with humeral fractures and substantial bone loss. With improved technology, including bone ingrowth methods, better matching of the proximal stem geometry to the humerus, and an understanding that the center of rotation (torque) on the humeral component is at the level of the humeral osteotomy, shorter stems and stemless humeral components were developed, now more than 10 years ago, primarily in Europe. With more than a decade of experience, our European colleagues have shown us that stemless humeral component replacement with a device that has both cortical and cancellous fixation is as effective as a stemmed device, easier to implant as well as revise when needed. The short-term results of the cancellous fixation stemless devices are acceptable, but longer follow-up is needed. Currently, the most widely used humeral components in the USA are short stem components, although the recent FDA approval of numerous stemless devices has initiated a shift from short stems to stemless devices. The truth is, short stem devices have a firm position in the USA surgeons' armamentarium today due to regulatory restrictions. A decade ago, without a predicate on the market, it was not conceivable that a stemless device that was already gaining popularity in Europe would be able to get 510K approval, and therefore would require a lengthy and expensive FDA IDE process. However, shorter stems had already been approved in the USA, as long as the stem length was 7 centimeters, matching the market predicate. Now, in 2018, based on evidence and outcomes, stemless humeral components should be the first choice when treating primary osteoarthritis of the glenohumeral joint. Short stem or longer stem devices should be reserved for those cases where stemless fixation is not possible, which is less than 10% of patients with primary OA of the shoulder