Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance.

Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores.

A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37)

Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year.

The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures.

Aims

The primary aim was to assess the rate of patient deferral of elective orthopaedic surgery and whether this changed with time during the coronavirus disease 2019 (COVID-19) pandemic. The secondary aim was to explore the reasons why patients wanted to defer surgery and what measures/circumstances would enable them to go forward with surgery.

The pain of arthritic disorders occurs in a social and environmental context. Thus, the pain of arthritis not only can affect the patient, but also the spouse. Numerous investigations have shown that the spouses of individuals with persistent pain report lower levels of marital satisfaction, higher rates of depression and lower quality of life. For the vast majority of patients with osteoarthritis, total hip (THA) or total knee (TKA) arthroplasty results in a significant reduction in pain, emotional distress, disability and a significant improvement in their quality of life and function. Little is currently known about how these recovery-related changes impact on the spouse or the marital relationship.

Patients and their spouses were recruited within one-year following the arthroplasty surgery. Couples participated in a semi-structured interview and were each asked to recall their level of pain on a numerical rating scale from 1 to 10 before and after recovering from surgery, and provide a numerical rating score (10 points) for a set of seven questions pertaining to their level of disability in seven different activities of daily living. In addition, the spouses were asked to list in order of importance the ways in which the surgery of their spouse affected their overall quality of life. In total, 33 couples (66 respondents) answered the survey questionnaire. There were 17 male patients, 16 female patients who underwent 29 THAs and 4 TKAs.

With regard to pain, the spouses estimated their partner's pain, both preoperatively and at the time of the survey, to be at a significantly higher level than the patient's perception (p=0.05). The spouses perceived a greater improvement in family/home responsibilities, recreation and social activities, and in their occupation than that noted by the partner. After the arthroplasty, the spouses indicated that their lives had improved with respect to doing more activities/leisure (70%), because there partner had less suffering (61%), they had more independence/less caregiving (54%), it improved their marital relationship (54%), they had a better social/family life (27%) and they were able to travel (27%).

In addition to the patient, THA and TKA result in a significant improvement in quality of life and marital functioning of the spouse. This should not continue to be unrecognized as a significant benefit of the procedure.

Purpose and background

Lower back pain is a leading cause of disability and a common condition seen by osteopaths. Evidence and advice for the safest lifting posture vary, as do healthcare practitioners' attitudes towards back pain.

The aim of this study was to understand osteopaths' beliefs about safe lifting postures, their attitudes towards back pain, and to compare these findings with published data from physiotherapists and manual handling advisors.

Dislocation is one of the most common complications after revision THA using the posterolateral approach. Although the cause of dislocation after revision THA is multifactorial, the historically high dislocation rates have been shown to be significantly reduced by closing the posterior capsule and by the use of large diameter (36 and 40 mm) femoral heads. The relative importance of each of these strategies on the rate of dislocation remains unknown. We undertook a study to determine if increasing femoral head diameter, in addition to posterior capsule closure would influence the dislocation rate following revision THA.

We retrospectively reviewed 144 patients who underwent a revision THA. We included all patients who underwent revision THA with closure of the posterior capsule and who had at least a 2-year minimum follow-up. We excluded patients undergoing a revision THA for dislocation or multistage revision for infection since these patients would likely have deficient posterior tissues. Forty-eight patients had a 28 mm femoral head, 47 had a 32 mm head and 49 patients had a 36 mm femoral head.

At a minimum follow-up of 2 years, there were 3 dislocations. There were no dislocations in the 28 mm group (0%), 2 in the 32 mm group (4%) and 1 in the 36 mm group (2%). All patients were successfully treated with a closed reduction. No patients had recurrent dislocation. Head size alone was not found to significantly decrease the risk of dislocation (28mm vs 32mm p=0.12; 28mm vs 36mm p=0.27; 32mm vs 36mm p=0.40).

Both large diameter heads and careful attention to surgical technique with posterior capsule closure can decrease the historically high dislocation rate after revision THA when utilizing the posterolateral approach. The additional use of a large diameter head did not have a significant impact on the already low dislocation rate. Capsular closure outweighs the effect of femoral head diameter in preventing dislocation following revision THA through a posterolateral approach.

BACKGROUND

Ideal treatment of displaced femoral neck fragility fractures in the previously ambulatory patient remains controversial. Treating these patients with total hip arthroplasty has improved patient reported outcomes and reduced rates of revision surgery compared to those treated with hemiarthroplasty. However, possible increased risk of dislocation remains a concern with total hip arthroplasty.

The anterolateral and direct anterior approaches to total hip replacement have been applied in the femoral neck fracture population to minimize dislocation rates. However, the anterolateral approach has been associated with abductor injury and increased rates of heterotopic ossification while the anterior approach has been associated with peri-prosthetic femur fracture, lateral femoral cutaneous nerve injury, and wound complications. The Supercapsular Percutaneously Assisted (SuperPATH) approach was developed to minimize disruption of the capsule and short-external rotators in an effort to reduce the risk of dislocation and assist in quicker recovery in the elective hip arthroplasty setting. To achieve this, the SuperPATH technique allows the femur to be prepared in situ and the acetabulum to be reamed percutaneously once the femoral head is removed.

This study investigates the post-operative time to ambulation, length of stay, discharge destination, and early dislocation rate of previously ambulatory patients with a displaced femoral neck fragility fracture that were treated with a total hip arthroplasty via the SuperPATH technique.

BACKGROUND

The need for post-operative manipulation under anesthesia (MUA) for stiffness after primary total knee arthroplasty is a frustrating complication that can lead to suboptimal outcomes if range-of-motion to a functional level is not regained. Implant morphology and kinematics, PCL imbalance, and soft-tissue balancing can all contribute to post-operative stiffness. Utilization of total knee arthroplasty components that replicate the native knee's medial ball and socket kinematics may lead to easier maintenance of flexion post-operatively compared to conventional components.

INTRODUCTION

The direct anterior approach to THR has become an increasingly popular minimally-invasive technique in an effort to minimize dislocation risk, facility early recovery, and diminish soft tissue injury. However, it has been associated with unique complications including intraoperative femur fracture, cutaneous nerve palsy, stem subsidence, and wound healing complications. These risk of these complications have been documented to be more likely in the surgeon's early experience with the approach. The minimally-invasive Supercapsular Percutaneous-Assisted (SuperPATH) technique was developed to minimize capsular and short-external rotator injury, minimize dislocation risk, and provide an easier transition from the standard posterior approach.

Introduction

Orientation of the acetabular component in total hip arthroplasty has been shown to influence component wear, stability, and impingement. Freehand placement of the component can lead to widely variable radiographic outcomes. Accurate abduction, in particular, can be difficult in the lateral decubitus position due to limited ability to appreciate and control positional obliquity of the pelvis. A CT-based mechanical navigation device has been shown to decrease cup placement error. This is an independent report of a single-surgeon's radiographic results using the device to control cup abduction.

Introduction

While clinically successful for decades, CR TKA is persistently compromised by inconsistent PCL function. Problems of mid-flexion instability, incomplete knee flexion, erratic kinematic behavior and posterior instability, not seen with PS devices, raise concerns about the consistency of the technique, and the devices used. Most TKA systems offer at least 2 different geometries of tibial inserts to address this clinical problem.

We hypothesize these problems are a result of compromise of PCL anatomy. To avoid compromise to the PCL 3 steps are required: 1) The slope of tibial resection must be less than 5°; 2) the depth of tibial resection must be based off the insertion footprint of the PCL, not the deficiencies of the tibial articular surface; and 3) the tibial insert must be modified to allow intraoperative balancing of the PCL.

Introduction

There are approximately 1.2 million patients using orthotics in the UK costing the NHS in excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with orthotics prescribed and to investigate the reasons behind patient dissatisfaction.

Background: Non-operative treatment for plantar fasciitis varies widely and includes the use of night ankle-foot orthoses (AFO’s). Some studies have shown that this is more effective in the initial management of plantar fasciitis than anti-inflammatory therapy. During sleep the foot and ankle tend to assume a plantarflexed position, which results in tightness of the calf muscle group, accounting for the stiffness and pain experienced by patients as they take their first weight bearing steps in the morning. However, when the foot and ankle are kept in a dorsiflexed stretched position at night, stress relaxation occurs and the plantar fascia relaxes.

Aim: Compliance with night AFO’s that dorsiflex the foot/ankle has always been a problem. This study compares the effectiveness of a posterior AFO, which dorsiflexes the foot, with an anterior AFO, which maintains the foot in plantigrade, asking whether it is absolutely necessary to dorsiflex the foot and ankle during the night to avoid early morning pain and stiffness, or whether it is it sufficient just to maintain the foot in plantigrade.

Methods: 18 participants were recruited on a voluntary basis and at random from among those patients referred to the Orthotics department with plantar fasciitis to be provided with a night orthosis. The inclusion criterion was that the diagnosis was purely plantar fasciitis with no secondary diagnosis, symptoms or complications. Each participant was given a questionnaire to fill in; this evaluated how satisfied the participants were with the orthosis with regards to comfort, ease of use and appearance, and whether the pain in the foot was reduced and at what stage was it reduced. The two types of AFO’s used in this study were:

A posterior AFO that holds the foot in dorsiflexion. The amount of dorsiflexion could be adjusted.

Results: 67% of the participants confirmed that morning pain and stiffness was less after wearing the AFO; this included 78% of those that wore the anterior AFO and 56% of those that used the posterior orthosis. 56% of all participants reported that the orthoses were uncomfortable and disrupted sleep. The most uncomfortable was the posterior AFO (89%), as opposed to the anterior one (22%). Both types of orthoses were reported to be relatively easy to don and doff (89% anterior AFO and 78% posterior AFO). On a scale of 1 to 10, the participants were asked to grade the pain before starting the orthosis treatment regime, after 6 weeks of wearing the AFO and again 6 weeks later. On average, the anterior AFO reduced the pain from 7 to 2.1, while the posterior orthosis only reduced the pain from 8.1 to 6.7.

Conclusion: In general, plantar fasciitis night AFO’s are poorly tolerated orthoses, however, their use can be justified in that the pain levels are reduced. The anterior AFO seems to be more effective in achieving this, without dorsiflexing the foot/ankle beyond plantigrade. Thus, one could argue that there is no need to dorsiflex to achieve the goal. However, further investigation is necessary with a larger patient cohort.

We introduce a new technique called the “Posterior Cruciate Referencing Technique” (PCRT), a specific combination of surgical technique, devices and instrumentation. Careful anatomic preservation of the posterior cruciate ligament (PCL) based upon a specific reference point off the tibia allows for use of sloped tibial components to achieve consistent functional behavior of the PCL. We discuss the preclinical design and development leading to availability of this device, and subsequent early clinical experience with this approach.

Posterior cruciate ligament (PCL) retention in total knee arthroplasty (CR-TKA) has been a feature of certain styles of TKA since the inception of predictable TKA in the early 1970s. It has been adapted and promoted as advantageous for a number of real and theoretical benefits. In reality, however, PCL retention has proven inconsistent when applied across a broad range of surgical environments. A number of adaptations in surgical technique, device modification and instrumentation have been developed to try to improve the predictability of the surgical intervention and subsequent postoperative performance. It is our belief that currently recommended surgical techniques can lead to inconsistencies in surgical judgment and consequently performance of CR devices because they inadvertently compromise the anatomy and hence functional performance of the PCL. A study by Shannon et al showed that, during CR-TKA, the PCL was either partially or completely removed as a result of the tibial cut in two out of three cases [1]. Unlike the long held and validated approach of ligament releases for fixed New Technique for Functional Posterior Cruciate Retention in TKA varus and valgus deformity that, along with alignment, allow successful long 45 term outcomes, ligament release of the PCL to balance the knee in flexion, whether by bone cuts or physical release, may compromise its overall function and explain kinematic differences in expected versus observed performance. Our hypothesis is that devices, surgical techniques and instruments designed around anatomical and functional preservation of the PCL would promote a reproducible surgical approach and consistent clinical performance of a CR-TKA. This manuscript provides the rationale for development of a new technique called the “Posterior Cruciate Referencing Technique” (PCRT), a combination of technique, instruments and devices specifically designed to preserve the PCL anatomy and take advantage of the functional performance of the PCL. We discuss the anatomical, radiographic, kinematic and mechanical testing approach that suggests that this is a safe and effective approach for primary CR-TKA.

Conclusion: This manuscript presents a body of work that elucidates specific issues of implant design and technical implantation that may have led to inadvertent compromise of function of the PCL during CR-TKA. We believe that such compromises may explain the inconsistent kinematic behavior of these devices in the hands of surgeons who use them, and may result in clinical outcomes that were unintended. We have provided the rationale for a new technique of implantation the Posterior-Cruciate Referencing Technique (PCRT) -which mates specific referencing approaches of the PCL and tibial resection, with implants, to address PCL functional New Technique for Functional Posterior Cruciate Retention in TKA behavior. We have provided laboratory, pre-clinical and early clinical evaluations that suggest that this will prove a safe and effective approach to CR-TKA.

Purpose: The treatment and prognosis of labral tears secondary to femoroacetabular impingement depends on the severity of the labral injury and whether or not there is concomitant injury and delamination of the adjacent articular cartilage. At present, there is no simple and reproducible technique to determine if there is delamination of the adjacent articular cartilage. We undertook a study to determine if the preoperative presence of a previously undescribed radiographic finding, a “delamination cyst”, correlated with delamination of the articular cartilage at the time of hip arthroscopy.

Method: The preoperative radiographs of 125 consecutive hip arthroscopies in which a labral tear was identified intraoperatively were retrospectively reviewed.. In each case an anteroposterior (AP) pelvis and AP, lateral and frog lateral hip radiographs were evaluated for the presence of delamination cysts, perilabral cysts, abnormalities of the femur and acetabulum, as well as arthritic changes. A “delamination cyst” was defined as a subchondral cyst either directly adjacent to a perilabral cyst, or in relation to a subchondral crack in the anterolateral portion of the acetabulum. These findings were then compared and correlated to the intraoperative arthroscopic findings.

Results: We identified 16 patients with delamination cysts on radiographs and 15 patients with delamination of the acetabulum on arthroscopy. A strong correlation was found between the preoperative radiographic presence of a delamination cyst and acetabular delamination at the time of arthroscopy – sensitivity of 93.3%, specificity of 98.8%, positive predictive value of 93% and a negative predictive value of 99% (p=0.034). No other radiographic findings were associated with the status of the articular cartilage.

Conclusion: A “delamination cyst” is a previously undescribed and novel radiographic sign that can accurately predict preoperatively which patients with labral tears have associated acetabular cartilage delamination or chondral damage. Delamination cysts can be easily identified on plain radiographs without performing any special imaging or invasive infiltrations. Identifying these cysts preoperatively can aid the surgeon in selecting the appropriate surgical procedure and help predict the patient’s prognosis following the planned surgical procedure.

This is the first study to determine if closure of the posterior capsule during revision total hip arthroplasty (THA) results in a reduction in the historically high dislocation rate. Seventy-nine consecutive patients undergoing revision THA with a posterolateral approach and closure of the posterior hip capsule were retrospectively reviewed. At a mean follow-up of fifty-seven months (range twenty-four to one hundred and twenty months), there were only two dislocations (2.5%). The historically high dislocation rates with the posterolateral approach in revision THA, can be significantly decreased with posterior capsular closure from approximately 15% to 2.5%.

To determine if closure of the posterior capsule during revision total hip arthroplasty results in a reduction in the historically high dislocation rate.

The dislocation rate after revision THA with a posterior approach can be minimized by repairing the posterior capsule and rotators.

The historically high dislocation rates with the pos-terolateral approach in revision THA, can be significantly decreased with posterior capsular closure from approximately 15% to 2.5%.

A retrospective study was carried out to review seventy-nine consecutive revision THAs. In all cases, the surgery was done by a single surgeon using the posterolateral approach. In every case, the posterior capsule was meticulously repaired at the end of the procedure. All patients had a minimum two- year follow-up and no patients were lost to follow up.

At a mean follow-up of fifty-seven months (range twenty-four to one hundred and twenty months), there were only two dislocations (2.5%). Both dislocations occurred early postoperatively were anterior. One occurred in a high risk case- a proximal femoral replacement with a trochanteric osteotomy, high hip center and skirted head. The other was due to a technical error, with the cup being excessively anteverted. There were no late dislocations or subluxations.

The dislocation rate after revision THA with a posterior approach can be minimized by balancing soft tissues, correct implant alignment and repairing the posterior capsule and rotators.

Introduction: The clinical effectiveness of spinal bracing for the conservative treatment of adolescent idiopathic scoliosis is still not fully understood. Cohort studies on clinical effectiveness fail to adequately measure and control for confounding variables including spine flexibility, curve type, magnitude and maturity, distribution of corrective forces and compliance. This paper presents intermediate findings from a longitudinal study to objectively measure brace wear patterns and compliance in users of custom fitted TLSOs in the UK. Braces are fitted with data logging devices to measure temperature and humidity at the skin/brace interface. Previously reported measures of compliance have been in adolescents wearing Boston Braces using questionnaires, strap tension, interface pressure and skin temperature. They have shown compliance reported by the user can significantly over estimate actual compliance.

Methods and results: 20 patients are being studied over 18 months. TLSOs are fitted with data logging devices to measure temperature and humidity at the skin/brace interface. They are discrete sensors inserted into a pocket formed on the posterior of the brace. Measurements are recorded at 16 minute intervals and data downloaded every three to four months. Results clearly demonstrate compliance and daily wear routines. Temperature and humidity at the skin/brace interface during periods of wear are 35°C and > 80%RH respectively. Compliance ranges from 60–98%. Users who stick rigidly to their regime only remove their brace in the evening. Where poorer compliance is evident, the brace is worn sporadically during the day and evening, and worn full time at night.

Conclusion: Measurement of temperature and humidity at the skin/brace interface clearly demonstrates compliance and daily wear routines. Compliance varies from 60–98%. Where poor compliance is an issue it is intended to re-interview these individuals and obtain more detailed information about the reasons why they failed to use the brace.