The anterolateral ligament (ALL) is considered as an important stabilizer of the knee joint. This ligament prevents anterolateral subluxation of the proximal tibia on the femur when the knee is flexed and internally rotated. Injury of the ALL was not investigated in patients with knee dislocation. The aim of the current research is to study the prevalence and characteristics of ALL injury in dislocated knees. A retrospective review of charts and radiological images was done for patients who underwent multiligamentous knee reconstruction surgery for knee dislocation in our institution from May 2008 to December 2016. Magnetic resonance imaging (MRI) was used to describe the ALL injury. The association of ALL injury with other variables related to the injury and the patient's background features was examined. Forty-eight patients (49 knees) were included. The mean age of the patients was 32.3 ± 10.6 years. High energy trauma was the mechanism of dislocation in 28 (57.1%) knees. Thirty-one knees (63.3%) were classified as knee dislocation (KD) type IV. Forty-five (91.8%) knees had a complete ALL injury and three (6.1%) knees had incomplete ALL injury. Forty (81.6%) knees had a complete ALL injury at the proximal fibres of the ALL, while 23 (46.9%) knees had complete distal ALL injury. None of the 46 (93.9%) knees with lateral collateral ligament (LCL) injury had normal proximal ALL fibres (p = 0.012). Injury to the distal fibres of the ALL, as well as overall ALL injury, were not associated with any other variables (p >0.05). Moreover, all patients with associated tibial plateau fractures (9, 18.4%) had abnormality of the proximal fibres of the ALL (p = 0.033). High grade ALL injury is highly prevalent among dislocated knees. The outcomes of reconstructing the ALL in multiligamentous knee reconstruction surgery should be investigated in future studies

The anterolateral MIS-THA approach can be divided into the Modified Watson-Jones approach (MWJ) performed in the lateral position and the Anterolateral Supine method (ALS) performed in the supine position. Femoral preparation is flexible in stem selection in the MWJ method. On the other hand, the ALS method is more stable for placement on the acetabular implant. Now we introduce novel anterolateral MIS approach named AL60, it makes use of the merits of both MWJ and ALS methods. Technique. The patient is fixed at 30 degrees on the dorsal side from lateral position. That is 60 degrees on the half side from the horizontal plane, and the platform of the operating table is removed just as in the MWJ method. During surgery, the pelvis is fixed by the posterior support, and the stability of the pelvis is very good. Also, if the inclination is accurate at 30 degrees, by holding the holder parallel to the operating table when inserting the cup, the cup is theoretically inserted at Anatomical anteversion 30 degrees. The intraoperative field of view is also visible to the assistant due to the semi-lateral position. Femoral preparation is easier than the MWJ method because the affected limbs have fallen to the dorsal side already. Discussion. Since March 2017 to the end of August 2018, the AL60 method was used for 207 primary THA. There were no dislocations or fractures and any other complications. Full weight bearing was possible from the next day. The AL60 method has stability of the ALS method for acetabular preparation and the operability of the MWJ method for femoral preparation. Therefore, it can be said that new AL60 approach method makes use of the merits of both MWJ and ALS methods

Objectives. The aim of this study was to investigate the biomechanical effect of the anterolateral ligament (ALL), anterior cruciate ligament (ACL), or both ALL and ACL on kinematics under dynamic loading conditions using dynamic simulation subject-specific knee models. Methods. Five subject-specific musculoskeletal models were validated with computationally predicted muscle activation, electromyography data, and previous experimental data to analyze effects of the ALL and ACL on knee kinematics under gait and squat loading conditions. Results. Anterior translation (AT) significantly increased with deficiency of the ACL, ALL, or both structures under gait cycle loading. Internal rotation (IR) significantly increased with deficiency of both the ACL and ALL under gait and squat loading conditions. However, the deficiency of ALL was not significant in the increase of AT, but it was significant in the increase of IR under the squat loading condition. Conclusion. The results of this study confirm that the ALL is an important lateral knee structure for knee joint stability. The ALL is a secondary stabilizer relative to the ACL under simulated gait and squat loading conditions. Cite this article: Bone Joint Res 2019;8:509–517

Aims. The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty. Patients and Methods. A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months. Results. A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups. Conclusion. The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome. Cite this article: Bone Joint J 2019;101-B:793–799

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint. Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances

The aim of the study is to investigate the biomechanical effects on the pelvis of the anterolateral and posterolateral approaches at the time of hip arthroplasty. In particular the study investigates the change in stress distribution, and the change in muscle recruitment pattern following surgery. The study uses an advanced finite element model of the pelvis, in which the role of muscles and ligaments in determining the stress distribution in the pelvis is included. The model is altered for the posterolateral approach by excision of the external rotators. Different levels of gluteal damage for the anterolateral approach are modelled by excising in turn the anterior third, half, and two-thirds of the gluteus medius and minimus. Although attempt is generally made to repair gluteal damage at the time of surgery, it is clear the muscle volume will be compromised immediately after surgery. In support of previous clinical studies indicating an increased risk of limp, and pelvic tilt following the anterolateral approach, significant differences were found in the muscle recruitment pattern following the anterolateral, compared to the posterolateral approach. During single leg stance and walking force transfer to the iliacus and pectineus was observed. Required levels of muscle force, to maintain coronal balance, following the anterolateral approach were found to be close to maximum sustainable levels. In addition significant alteration to the pelvic stress distribution was found following the anterolateral approach. The effects of increasing gluteal damage for the anterolateral approach were progressive, and became more pronounced when more than fifty percent of the gluteus medius and minimus were damaged. Increases in stresses around the acetabulum were observed for the posterolateral, compared to the anterolateral approach. Thus, based on a biomechanical evaluation, the anterolateral approach presents increased risk of limp, and pelvic tilt, in comparison to the posterolateral approach

The anterolateral ligament (ALL) has been recently recognized as a distinct stabilizer for internal rotation in the ACL-deficient knee and it has been hypothesized that ALL reconstruction may play an important role in improving anterolateral instability following ACL reconstruction. Both the gracilis tendon (GT) and a portion of the iliotibial band (ITB) have been suggested as graft materials for ALL reconstruction, however, there is an ongoing debate concerning whether GT or ITB are appropriate grafting materials. Furthermore, there is limited knowledge in how the mechanical properties of these potential grafts compare to the native ALL. Consequently, the aim of this study was to characterize the elastic (Young's modulus and failure load) and viscoelastic (dynamic and static creep) mechanical properties of the ALL and compare these results with the characteristics of the grafting materials (GT and ITB), in order to provide guidance to clinicians with respect to graft material choice. Fourteen fresh-frozen cadaveric knees (85.2±12.2 yr) were obtained. The ALL, ITB, and the distal (GTD) and proximal gracilis tendons (GTP) (bisected at mid portion) were harvested from each donor and tested with a dynamic material testing frame. Prior to testing, the cross-sectional area of each tissue was measured using a casting method and the force required to achieve a min-max stress (1.2–12 MPa) for the testing protocol was calculated (preconditioning (20 cycles, 3–6 MPa), sinusoidal cycle (200 cycles, 1.2–12 MPa), dwell at constant load (100 s, 12 MPa), and load to failure (3%/s)). Kruskall-Wallis tests were used to compare all tissue groups (p<0.05). The Young's modulus of both ALL (181.3±63.9 MPa) and ITB (357.6±94.4 MPa) are significantly lower than GTD (835.4±146.5 MPa) and GTP (725.6±227.1 MPa). In contrast, the failure load of ALL (124.5±40.9 N) was comparable with GTD (452.7±119.3 N) and GTP (433±133.7 N), however, significantly lower than ITB (909.6±194.7 N). Dynamic creep of the ALL (0.5±0.3 mm) and ITB (0.7±0.2 mm) were similar (p>0.05) whereas the GTD (0.26±0.06 mm) and GTP (0.28±0.1 mm) were significantly lower. Static creep progression of the ALL (1.09±0.4 %) was highest across all tissues, while GTD (0.24±0.05 %) and GTP (0.25±0.0.04 %) were lowest and comparable with ITB (0.3±0.07 %) creep progression. Since grafts from the ITB, GTD and GTP were comparable to the ALL only for certain mechanical properties, there was no clear preference for using one over another for ALL reconstruction. Therefore, further studies should be performed in order to evaluate which parameters play a vital role to determine the optimum grafting choice

There have been differing descriptions of the anterolateral structures of the knee, and not all have been named or described clearly. The aim of this study was to provide a clear anatomical interpretation of these structures. We dissected 40 fresh-frozen cadaveric knees to view the relevant anatomy and identified a consistent structure in 33 knees (83%); we termed this the anterolateral ligament of the knee. This structure passes antero-distally from an attachment proximal and posterior to the lateral femoral epicondyle to the margin of the lateral tibial plateau, approximately midway between Gerdy’s tubercle and the head of the fibula. The ligament is superficial to the lateral (fibular) collateral ligament proximally, from which it is distinct, and separate from the capsule of the knee. In the eight knees in which it was measured, we observed that the ligament was isometric from 0° to 60° of flexion of the knee, then slackened when the knee flexed further to 90° and was lengthened by imposing tibial internal rotation. . Cite this article: Bone Joint J 2014;96-B:325–31

Background. The anatomy of the human body has been studied for centuries. Despite this, recent articles have announced the presence of a new knee ligament- the anterolateral ligament. It has been the subject of much discussion and media commentary. Previous anatomical studies indicate its presence, and describe its location, origin, course and insertion. Magnetic resonance imaging (MRI) is the best and most commonly used investigation to assess the ligamentous structure of the knee. To date, most MRI knee reports make no mention of the anterolateral ligament. The aim of this study was to assess for the presence of the anterolateral ligament using MRI, and to describe the structure if visualised. Methods. All right knee MRIs performed on a Siemens Magnetom Espree 1.5 Tesla scanner in Merlin Park Hospital over a 4 year period were retrospectively analysed. Patients born before 1970, or with reported abnormalities were excluded. The normal MRIs were then analysed by a consultant radiologist specialising in musculoskeletal imaging. Measurements on origin, insertion, course and length were noted. Results. 942 right knee MRIs were performed in the time period. 62 were classed as normal, and within the specified age range. 10 were randomly sampled. Of these the ligament was visible on all 10 MRIs, best viewed in the coronal plane. The average length (visible in 8/10) was 28.88mm +/− 5.14mm. The origin (visible in all 10) was 2.25mm +/− 0.39mm. The insertion (visible in 9/10) was 1.93mm +/− 0.424. The mid thickness was 1.87mm +/− 0.2mm. Conclusions. This study indicates that the ALL is a discrete, visible structure on MRI. This furthers the evidence of the presence of the ALL and also provides information that may be beneficial in future studies, and assessment of knee injuries. Level of evidence. 4

Objectives: Total hip arthroplasty by minimal invasive anterolateral exposure is a technique which causes minimal damage on skin, muscles and bone and lead to early recovery. Current study compared the clinical and radiological results of total hip arthroplaties performed with two different exposure- minimal invasive anterolateral (MIA) and standard anterolateral exposure (SA). Methods: Several parameters of total hip arthroplasty patients managed with two different exposures between 2005 and 2008 were evaluated retrospectively from medical records. First group was consisted of total hip arthroplasty patients managed with SA exposure. 26 hip of 25 patients were operated in this cohort. Mean age, follow up and body mass index was 57±12.45 year, 25.23±8.71 months and 32.52±5.77 respectively. Second group was consisted of total hip arthroplasty patients managed with MIA exposure.15 patients were operated in this cohort. Mean age, follow up and body mass index was 68.93±5.51year, 26.07±7.21 months and 28.69±2.72 respectively. Intraoperative, postoperative, total blood loss, operation time, blood transfusions, length of hospital stay were evaluated. Preoperative; postoperative 1,6,12,24 th hours VAS scores and Harris Hip Score (HHS) in preoperative; postoperative 1,6,12 th months and last controls were evaluated. Femoral component position (varus or valgus), inclination of acetabular component and signs of loosening were evaluated from the last follow up radiographies. Results: Intraoperative, postoperative, total blood loss, blood transfusions, length of hospital stay were significantly reduced in MIA group as compared to SA group (p< 0.05). Average operation times were not different (p=0.259). Improving in VAS scores and HHS was significantly better in MIA group (p< 0.001). Postoperative SF-36 scores were significantly higher in both groups as compared to preoperative scores (p< 0.05). No sign of looseing, osteolysis, superficial or deep wound infection were detected in both groups. Conclusion: Total hip arthroplasty by MIA exposure reduces length of hospital stay, leads to better pain control and rehabilitation in early period, causes less blood loss and leads to significant improvement in SF 36 scores. We suggest that after completion of learning curve, total hip arthroplasty by MIA exposure can be performed more effectively and with less complication

Injury to the anterolateral ligament (ALL) has been reported to contribute to high-grade anterolateral laxity following anterior cruciate ligament (ACL) injury. Failure to address ALL injury has been suggested as a cause of persistent rotational laxity following ACL reconstruction. However, lateral meniscus posterior root (LMPR) tears have also has been shown to cause increased internal rotation and anterior translation of the knee. Due to the anatomic relationship of the ALL and the lateral meniscus, we hypothesise that the ALL and lateral meniscus work synergistically, and that a tear to the LMPR will have the same effect on anterolateral laxity as an ALL tear in the ACL deficient knee. Sixteen fresh frozen cadaveric knee specimens were potted into a hip simulator(femur) and a six degree-of-freedom load cell (tibia). Two rigid optical trackers were inserted into the proximal femur and distal tibia, allowing for the motion of the tibia with respect to the femur to be tracked during biomechanical tests. A series of points on the femur and tibia were digitised to create bone coordinate systems that were used to calculate the kinematic variables. Biomechanical testing involved applying a 5Nm internal rotation moment to the tibia while the knee was in full extension and tested sequentially in the following three conditions: i) ACLintact; ii) Partial ACL injury (ACLam) – anteromedial bundle sectioned; iii) Full ACL injury (ACLfull). The specimens were then randomised to either have the ALL sectioned first (ALLsec) followed by the LMPRsec or vice versa. Internal rotation and anterior translation of the tibia with respect to the femur were calculated. A mixed two-way (serial sectioning by ALL section order) repeated measures ANOVA (alpha = 0.05). Compared to the ACLintact condition, internal rotation was found to be 1.78° (p=0.06), 3.74° (p=0.001), and 3.84° (p=0.001) greater following ACLfull, LMPRsec and ALLsec respectively. LMPRsec and the ALLsec resulted in approximately 20 of additional internal rotation (p=0.004 and p=0.01, respectively) compared with the ACL deficient knee (ACLfull). No difference was observed between the ALL and LMPR sectioned states, or whether the ALL was sectioned before or after the LMPR (p=0.160). A trend of increasing anterior translation was observed when the 5Nm internal rotation moment was applied up until the ACL was fully sectioned; however, these differences were not significant (p=0.070). The ALL and LMPR seem to have a synergistic relationship in aiding the ACL in controlling anterolateral rotational laxity. High-grade anterolateral laxity following ACL injury may be attributed to injuries of the ALL and/or the LMPR. We suggest that the lateral meniscus should be thought of as part of the anterolateral capsulomeniscal complex (i.e., LM, ITB, and ALL) that acts as a stabiliser of anterolateral rotation in conjunction with the ACL

Introduction: The anterior and anterolateral approach to the hip traditionally are well described exposures in primary hip arthroplasty with fewer dislocations than the posterior approach. A very debilitating complication associated with the anterolateral approach however is the persistent limp and positive Trendelenburg sign. We discuss our results with respect to abductor function and morphological integrity seen on MRI when using an approach in which we preserve the majority of gluteus medius. Methods: We carried out a prospective study of thirty-nine consecutive total hip replacements performed through a gluteus medius sparing anterolateral approach. The same hip surgeon performed all these between April and October 2004. Gait analysis and Trendelenburg tests were evaluated during clinical follow-up at six weeks and three months. Coronal STIR and T1 weighted MRI sequences of the abductors were performed between four and six weeks and the findings were agreed by the consensus of two radiologists. Results: At three-month follow-up all thirty-nine patients tested Trendelenburg negative. Post-operative radiographs showed satisfactory femoral and acetabular component position. MRI findings showed the gluteus medius tendon to be intact with no shortening on T1. Artefacts were found to be less marked in the higher field strength magnet but more apparent in the STIR weighted sequences. Discussion: We have tried to incorporate the advantages of reduced dislocation rate of the anterolateral approach, whilst avoiding violation of the abductors. The clinical result and radiographic findings we have presented suggest that the described exposure is an effective and safe method of approaching the hip, with minimal disruption of the abductor mechanism. In addition to maintaining the reduced dislocation rate associated with the standard anterolateral approach. Intact abductor function allows for rapid rehabilitation

Background. Return to sports after anterior cruciate ligament reconstruction (ACLR) is multifactorial and rotational stability is one of the main concerns. Anterolateral ligament reconstruction (ALLR) has been recommended to enhance rotational stability. Purpose. To assess the effect of ALLR on return to sports. Study Design. Retrospective comparative cohort study;. Level of evidence: III. Methods. A total of 68 patients who underwent ACLR after acute ACL injury between 2015 and 2018 with a follow-up of at least 24 months were enrolled in the study. Patients with isolated ACLR (group ALL(-), n=41) were compared to patients with ACLR+ALLR (group ALL(+), n=27) in regard to subjective knee assessment via Tegner activity scale, Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, Knee Documentation Committee (IKDC) form and Lysholm score. All tests were performed before the surgery, at 6 months and 24 months postoperatively. Results. Mean follow-up was 29.7±2.9 months for group ALL(-) and 31.6±3.0 for ALL(+) (p=0.587). Tegner, ACL-RSI and IKDC scores at last follow-up were significantly better in ALL(+) compared to ALL(-). There were no significant differences in isokinetic extensor strength and single-leg hop test results between the groups. 40 (97.6%) patients in ALL(-) and 27 (100%) in ALL(+) had a grade 2 or 3 pivot shift (p=0.812) preoperatively. Postoperatively, 28 (68.3%) patients in ALL(-) and 25 (92.6%) patients in ALL(+) had a negative pivot shift (p<0.001). 2 (5.9%) patients in ALL(-) and 1 (3.7%) patient in ALL(+) needed ACLR revision due to traumatic re-injury (p=0.165). There was no significant difference in the rate of return to any sports activity (87.8% in ALL(-) vs 88.9% in ALL(+); p=0.532), but ALL(+) showed a higher rate of return to the same level of sports activity (55.6%) than group ALL(-) (31.7%) (p=0.012). Conclusion. ACLR combined with ALLR provided a significantly higher rate of return to the same level sports activity than ACLR alone, probably due to enhanced rotational stability

Purpose. Minimally invasive anterolateral approach (ALA) for total hip arthroplasty (THA) has gained popularity in recent years as better postoperative functional recovery and lower risk of postoperative dislocation are claimed. However, difficulties for femur exposure and intraoperative complications during femoral canal preparation and component placement have been reported. This study analyzes the anatomical factors likely to be related with intraoperative complications and the difficulties of access noted by the surgeons through a modified minimally invasive ALA. The aim is to define the profile for patient at risk of intraoperative complications during minimally invasive ALA. Methods. We retrospectively included 310 consecutive patients (100 males, 210 females) who had primary unilateral THA using the same technique in all cases. The approach was performed between the tensor fascia lata and the gluteus medius and minimus, without incising or detaching muscles and tendons. Posterior translation was combined to external rotation for proximal femur exposure (Fig. 1). All patients were reviewed clinically and radiologically. For the radiological evaluation, all patients underwent pre- and postoperative standing and sitting full-body EOS acquisitions. Pelvic [Sacral slope, Pelvic incidence (PI), Anterior pelvic plane angle] and femoral parameters were measured preoperatively. We assessed all intraoperative and postoperative complications for femoral preparation and implantation. Intraoperative complications included the femoral fractures and difficulties for femoral exposure (limitations for exposure and lateralization of the proximal femur). The patients were divided into two groups: patients with or without intraoperative complications. Results. Ten patients (3.2%) had intraoperative femoral fractures (greater trochanter: 2 cases, calcar: 8 cases). Five fractures required additional wiring. Difficult access to proximal femur was reported in the operative records for 10 other patients (3.2%). There was no difference in diagnosis, age, sex, BMI between the patients with or without intraoperative complications. No significant group differences were found for surgical time, and blood loss. Patients with intraoperative complication, presented a significantly lower pelvic incidence than patients without intraoperative complications (mean PI: 39.4° vs 56.9°, p<0.001). The relative risk of intraoperative complications in patients with low PI (PI<45°) was more than thirteen times (relative risk; 13.3, 95% CI= 8.2 to 21.5. p<0.001) the risk for patients with normal and high PI (PI>45°). Conclusions. Anterolateral approach for THA implantation in lateral decubitus is reported to have anatomical and functional advantages. Nevertheless, the exposure of the femur remains a limitation. This study highlights a significant increased risk in case of low PI less than 45°. This specific anatomical pattern reduces the local working space as the possibility for posterior translation and elevation of the proximal femur is less on a narrow pelvis. This limitation is due to the length and the orientation of the hip abductor and short external rotator muscles related to the relative positions of iliac wing and greater trochanter (Fig. 2). This study points out the importance of pelvic incidence for the detection of anatomically less favourable patients for THA implantation using ALA. For any figures or tables, please contact the authors directly

The anterolateral surgical exposure to the distal tibia for pilon fractures has become more popular. One of the potential benefits over the commonly used anteromedial approach is a reduction in wound complications due to the improved soft tissue coverage of the anterolateral tibia. Minimal data exists regarding the rate of complications with the anterolateral approach. The purpose of this study was to evaluate wound complications in the early postoperative period associated with the use of the anterolateral approach for pilon fractures. Methods: A retrospective review was conducted to identify all operatively treated pilon fractures at our university level 1 trauma center from September 2005 through July 2007. Sixty-eight pilon fractures were identified. All patients were treated with a staged protocol utilizing immediate external fixation followed by delayed open reduction and internal fixation based upon the condition of the soft tissue envelope. Patients who had an anterolateral surgical approach were identified and their medical records were reviewed for the first six weeks postoperatively to determine the rate of wound complications. The endpoint of six weeks was chosen to identify complications related to the surgical exposure alone. Results: Thirty-six of the sixty-eight patients with pilon fractures had an anterolateral surgical exposure. One additional patient had an anterolateral incision performed for revision of a previously treated pilon fracture. 97% of these fractures were AO/OTA 43-C (three C1, nine C2, and twenty-three C3). The median time delay to definitive fixation was 19 days (10–38 days). Sixteen (44.4%) of the fractures were open, ten of which were Gustilo type III (five IIIA, four IIIB, and one IIIC). Eight of the thirty-seven patients had wound complications related to the anterolateral incision within the first six weeks of definitive fixation. Six patients (16%) had minor complications which were successfully treated with dressing changes and oral antibiotics, and two (5%) had major complications, with evidence of deep wound infection that required formal irrigation and debridement. Conclusion: In a case series with a high rate of complex open pilon fractures, open reduction and internal fixation utilizing an anterolateral approach provided good exposure of the distal tibia with a low incidence of early wound complications. Significance: Pilon fractures, especially high energy complex open ones, have a high risk of wound complications. Avoiding complications is the key in managing high energy pilon fractures. This case series provides evidence that the anterolateral approach has a low rate of wound complications in the most complex pilon fractures

We treated 52 patients with impingement of the anterolateral soft tissues of the ankle by arthroscopic debridement. All had a history of single or multiple inversion injuries, without instability. One half had negative stress radiographs (stable group), while the others were positive (unstable group). Their mean age was 31 years and there were 35 men and 17 women. The results were assessed at a mean follow-up of 30 months. Three patients (6%) had a fair result, while 49 (94%) had an excellent or good outcome. No difference was found in the final results between the two groups (p > 0.05). We conclude that anterolateral impingement of the ankle should be considered in a patient with chronic anterolateral pain after an injury, regardless of the stability of the ankle

In 12 patients, we measured the oxygen concentration in the femoral head-neck junction during hip resurfacing through the anterolateral approach. This was compared with previous measurements made for the posterior approach. For the anterolateral approach, the oxygen concentration was found to be highly dependent upon the position of the leg, which was adjusted during surgery to provide exposure to the acetabulum and femoral head. Gross external rotation of the hip gave a significant decrease in oxygenation of the femoral head. Straightening the limb led to recovery in oxygen concentration, indicating that the blood supply was maintained. The oxygen concentration at the end of the procedure was not significantly different from that at the start. The anterolateral approach appears to produce less disruption to the blood flow in the femoral head-neck junction than the posterior approach for patients undergoing hip resurfacing. This may be reflected subsequently in a lower incidence of fracture of the femoral neck and avascular necrosis

Fifty patients who underwent a MacIntosh repair for anterolateral instability of the knee have been reviewed after a mean follow-up of two and a quarter years. The repair abolished a positive anterolateral jerk test in 42 out of 50 knees and at the time of review 37 patients (74 per cent) were involved in some form of active sport, having regained functional and clinical stability. The MacIntosh repair is described in detail and the importance of excluding meniscal lesions as the main cause of instability is emphasised

Aims

The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years.

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2–58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7 %(38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2 – 58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7% (38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

Introduction. Most Japanese patients who receive total hip arthroplasty (THA) are osteoarthritic and 70% have development dysplasia of the hip. Their stature is shorter than average and their sizes (acetabular cup and femoral stem) are smaller. The Taperloc Microplasty (BIOMET) is a short femoral stem. It was launched on July 2012 in Japan (extended on January 2013). It is essentially a shortened version of the Taperloc stem (35mm shorter than the standard stem). Objectives. We aimed to evaluate the outcomes of minimally invasive anterolateral THA using a short stem. Methods. We retrospectively reviewed all 56 patients who underwent THA at our hospitals between July 2013 and April 2015. Of these 28 (50%) were performed with short stems. The surgical approach was antero-lateral in the lateral position. The patients (4 men and 24 women) had a mean age at surgery of 66.5 years (range, 46–85 years). The original diseases were osteoarthritis (25 patients) and osteonecrosis (3 patients). We investigated the system type, size (cup, femoral head, and stem), radiological findings and complications (fracture, infection, deep vein thrombosis, and dislocation). Results. There were no severe complications, such as, infection, deep vein thrombosis, or dislocation. One patient had a femur fracture during operation and was switched to a standard stem. The mean surgery duration was 102 minutes (range, 80–142 minutes) and the mean amount of bleeding during surgery was 254 g (range, 95–720 g). Mean cup size was 51.0 mm (range, 48–60 mm) and stem size is 6 (range, 4–13). Radiological findings showed 2 patients had stem subsidence (within 5mm). One of them had severe osteoporosis and the other patient had leg length discrepancy. Conclusions. Minimally invasive anterolateral THA using a short femoral stem has good clinical and radiological results in Japanese patients. Long-term results should be further observed prospectively

Introduction. In the setting of periprosthetic joint infection, the complete removal of implants and cement can be challenging with well-fixed, cemented implants about the knee. This can get especially complex in the setting of long cemented femoral stems. Osteotomies are well described in the proximal femur and tibia for removal of implants and cement. There is little information available on distal femoral osteotomies to facilitate knee implant and retained cement removal. Methods. We describe a novel anterolateral oblique distal femoral osteotomy for the removal of well-fixed, cemented components during resection knee arthroplasty that preserves vascularity to the osteotomized segment. Cadaveric anatomic vascular injection studies were performed to document vascularity of the osteotomized segment. Clinical examples, and results will be presented. Results. Anatomic vascular studies documented preserved vascularity to the osteotomized segment. In two patients intramedullary infected implant and cement was completely removed. At reimplantation and final followup the osteotomy was radiographically healed, implants well fixed, and no recurrent infections were noted. Conclusions. This osteotomy appears to be useful when removing well fixed, cemented femoral components during periprosthetic infection. Vascularity and union was preserved and obtained in all patients. For figures, tables, or references, please contact authors directly

Introduction. Since2007, we have used CT-based fluoroscopy-matching navigation system (Vector Vision Hip Ver.3.5.2, BrainLAB, Germany) in Total hip arthroplasty. This system completes the registration procedure semi-automatically by matching the contours of fluoroscopic images and touching 3 adequate points to the contours of 3D bone model created in the computer. Registration procedure using fluoroscopic figures has finished before making surgical incision. It needs no elongation time during the operation. The accuracy of navigation system depends on the techniques of registration used for the navigation and secure fixation of the dynamic reference markers. These could be affected by the different type of approaches. The objective of this study was to evaluate the accuracy of CT-based fluoroscopy-matching navigation system in THA and compare the cup position by anterolateral and posteolateral approaches. Material and method. We analysed the acetabular cup in consecutive 132 hips with both intra-operative and post-operative alignment data (based on navigation system and CT evaluation), including 65 cases with anterolateral approach(Modified Watson Jones) (Group AL) and 67 cases with posterolateral approach(Group PL). We aimed the cup angle for THA as following, the inclination: 40 degrees, the anteversion: 20 degrees. Anteversion on the navigation system must be adjusted by the pelvic tilt. Results. The average of the operative time were 84.8 ± 13.5 in group AL and 89.3 ± 15.1 minutes in group PL. There was one dislocation in group AL. There was no other obvious complication (nerve palsy, VTE and Infection) in these two groups. The all cup alignments were within 8 degrees from the preoperative orientation. The differences between the intra- and post-operative measurement of cup inclination were 1.9 ± 1.6 degrees in group AL and 2.1 ± 1.1 degrees in group PL(N.S.). The differences between the intra- and post-operative measurement of cup anteversion were 2.3 ± 1.4 degrees in group AL and 2.2 ± 1.3 degrees in group PL (N.S.). Discussion. CT-based navigation THA is very useful for severe deformity of hip osteoarthritis. We had used CT-based navigation system(landmark matching) since 2003. It needs some technical skills to improve the accuracy of landmark matching. The registration with CT-based fluoroscopy-matching navigation system is much easier and more simple than with landmark matching navigation system. And we found this system provided high accuracy even in severe deformity cases. There was no significant difference with anterolateral and posterolateral approaches by using CT-based fluoroscopy-matching navigation system

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

Background: In order to achieve a minimized need for tissue dissection resulting in a faster rehabilitation, minimally invasive surgery (MIS) in Total Hip Arthroplasty (THA) was developed. In this small incision technique the skin and musle dissection has been reduced with respect to the classical approach. Literature shows ambiguous results comparing the posterolateral minimally incisive with the classical approach. As the anterolateral approach is also a routine procedure, and to test how minimally invasive MIS is, we hypothesized that patients treated with a THA using a posterolateral or anterolateral MIS would experience improved clinical results compared with a standard incision after six weeks and no clinical differences after one year. This was tested in a double-blind randomized controlled trial with the Harris Hip Score (HHS) as a primary endpoint. Methods: One hundred and twenty consecutive primary uncemented THAs were randomized into one of four groups of 30 patients each. Either standard posterolateral or anterolateral approaches (PL- or AL-CLASS), or minimal invasive posterolateral or anterolateral approaches (PL- or AL-MIS) were performed. CLASS incisions were 18 cm. To avoid postoperative bias, MIS incisions were extended at skin level to 18 cm at the end of the procedure. The HHS as well as patient-centered questionnaires (SF-36, WOMAC and OHS) was obtained preoperatively, at six weeks and one year after the index operation. Preoperative data, blood loss, hemoglobin, muscle damage parameters and radiological parameters were analyzed. In order to detect a minimal clinically important difference of five points or more between the MIS or CLASS groups with respect to the Harris Hip Score at the 0.05 alpha level with 80% power, 120 patients were enrolled in the study. Results: Mean incision length of the THAs performed by MIS was 7.8 (SD = 1.6). In the patients of the MIS group a significant increased mean HHS was observed compared with the CLASS (p = 0.03) after six weeks and one year. This difference was caused by the favorable results of the PL-MIS (p = 0.009). Of the three patient-centered questionnaires, the SF-36 results were also favourable in the PL-MIS group after six weeks (p = 0.04). In the MIS group operation time was longer (p < 0.001) and a learning curve was observed based on operation time and complication rate. Peri-operative complications rates were not significantly different between the groups. Blood loss, hemoglobin, muscle damage parameters and radiological parameters also showed no difference. Conclusions: This double-blind, randomized study reveals an improved clinical outcome of the PL-MIS compared with the AL-MIS, PL-CLASS and AL-CLASS after six weeks and one year follow-up with the Harris Hip Score as primary endpoint

Purpose: The purpose of our retrospective analysis was to describe results of arthroscopic treatment of painful ankle instability without clinical or radiological laxity. Material and methods: Eighteen patients, mean age 27 years (seven men and nine women) were operated on by the same surgeon between 1999 and 2000. Sixteen patients (90%) were reviewed by an independent investigator at 20±4 months. Fifteen patients were athletes, ten at the competition level, and five had amateur sports activities. The accident caused forced inversion in 15/16 cases, during sports activities in 85.5% of the cases. Mean age at injury was 17±6 years. Mean time between the accident and arthroscopy was eight years. All patients had pain in the anterolateral region associated with effusion in 50% and apprehension or instability for daily life activities. Standard x-rays were normal in fourteen patients (87.5%). Comparative stress images did not demonstrate pathological laxity. Complementary imaging (MRI, CT scan, arthroscan, ultrasonography) was obtained in six patients with 50% negative results. Arthroscopy revealed anterior tissue interposition (antero lateral in thirteen patients (81%) and anteromedial and anterolateral in three) which was removed with the shaver. Joint cartilage was intact in fifteen patients (81.25%). Results: At last follow-up, functional outcome was good in all patients who had all resumed their sports activities. Subjectively, six patients felt they had normal function, seven nearly normal function and three abnormal function (81% satisfied or very satisfied). Six patients were symptom free even during intense physical activity. Eight patients reported some difficulties for strenuous exercise and two for moderate exercise. Joint motion was normal in ten patients and 5° dorsal flexion deficit was observed in six. There were no recurrent sprains. The x-ray was normal and identical to the initial image in 87.5% of the patients. Globally, 87.5% of the patients had good or excellent outcome. Two patients had fair or poor outcome. Discussion: Diagnosis of anterolateral ankle conflict can be established in patients with a compatible history and a typical clinical presentation with normal x-rays. Arthroscopic treatment can remove tissue interposition allowing good functional results and total recovery of sports activities. Complementary MRI or arthroscan have little specificity and poor sensitivity

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient

Recent National Institute for Health and Care Excellence (NICE) guidance has advised against the continued use of the Thompson implant when performing hip hemiarthroplasty and recommended surgeons consider using the anterolateral surgical approach over a posterior approach. Our objective was to review outcomes from a consecutive series of Thompson hip hemiarthroplasty procedures performed in our unit and to identify any factors predicting the risk of complications. 807 Thompson hip hemiarthroplasty cases performed between April 2008 and November 2013 were reviewed. 721 (89.3%) were cemented and 86 (10.7%) uncemented. 575 (71.3%) were performed in female patients. The anterolateral approach was performed in 753 (93.3%) and the posterior approach with enhanced soft tissue repair in 54 (6.7%). Overall, there were 23 dislocations (2.9%). Dislocation following the posterior approach occurred in 13.0% (7 of 54) in comparison to 2.1% (16 of 753) with the anterolateral approach (odds ratio (OR) 8.5 (95% CI 2.8 to 26.3) p < 0.001). Surgeon grade and patient history of cognitive impairment did not have a significant impact on dislocation rate. Patients were discharged home in 459 cases (56.9%), to a care home or other hospital in 273 cases (33.8%). 51.8% (338 of 653) returned home within 30 days. 75 died during their admission (9.3%). 30-day mortality was 7.1% and 1-year mortality was 16.6%. Intraoperative fracture occurred in 15 cases (1.9%) of which 14 were cemented. Superficial or deep infection occurred in 33 cases (4.1%). We recommend against the continued use of the posterior approach in hip hemiarthroplasty, as enhanced soft tissue repair did not reduce dislocation rates to an acceptable level. Our findings, however, demonstrate satisfactory results for patients treated with the Thompson hip hemiarthroplasty performed through an anterolateral approach. We suggest that the continued use of the Thompson implant in a carefully selected patient cohort is justifiable

Purpose: The purpose of this study was to evaluate the clinical effectiveness and outcomes of the ‘abductor sparing’ MIS Anterolateral approach (MIS Watson Jones/G3) in comparison to the MIS Direct Lateral and MIS Posterolateral approaches in primary total hip arthroplasty. Method: A multicentre, prospective, randomized controlled trial was designed to evaluate for the superiority of the new MIS Anterolateral approach (MIS Watson Jones/ G3). The sample size calculation was performed for alpha .05, power .90, to evaluate for effect size 0.5 in WOMAC using repeated measures analyses with baseline WOMAC as covariate. A total of 156 patients consented to participate in the trial and patients were assigned to MIS Antero-lateral approach or alternate MIS approach (MIS Direct Lateral or MIS Posterolateral). Patients were subjected to standardized anaesthetic and perioperative management protocols and were evaluated at standardized intervals to evaluate endpoints of early recovery (3 months) as well as endpoints of 12 and 24 months respectively. The primary outcome of interest was WOMAC, however secondary outcomes included SF-36, as well as parameters of health resource utilization and complications. Univariate and multivariate analyses were perfomed. Results: Patient groups were found to be similar at baseline with regards to demographics and baseline quality of life outcomes (p> .05). Multivariate and repeated measures analyses demonstrated no superiority of the MIS Anterolateral approach on outcomes of WOMAC and other quality of life measures in comparison to MIS Direct Lateral and MIS Posterolateral approaches (p> .05). Health care resource utlization was also similar with length of stay, blood transfusion requirements and complications (p> .05). Conclusion: Our multicentre, prospective, randomized clinical trial demonstrates that the MIS Anterolateral approach is not superior to alternate MIS surgical approaches when evaluating outcomes of quality of life, complications, and health resource utilization. Surgeons should consider these outcomes, complications, and other relevant advantages and disadvantages of select surgical approaches when deciding on a technique for use in their orthopaedic practice

Our previous reports on the pathological anatomy and operative treatment of intra-articular fractures of the calcaneum failed to take account of the fracture pattern anterior to the posterior facet of the subtalar joint. We have reviewed our experience of 63 operative cases and have studied fractures with axial and coronal CT scans reconstructed onto plastic model bones. A constant anterolateral fragment exists, which is displaced by an extended lateral approach to the fracture. If it is unrecognised and unreduced, union in a displaced position may limit hindfoot eversion and disrupt the calcaneocuboid joint. We describe techniques for reduction and fixation of the fragment

Of a total of 905 patients with fracture or fracture-dislocation of the thoracolumbar spine admitted from 1969 to 1982, a neurological deficit was present in 334 (37%). All unstable injuries were initially treated by reduction and posterior fusion. In 79 of these patients, an anterolateral decompression was undertaken later because of persistent neurological deficit and radiographic demonstration of encroachment on the spinal canal. One patient died of pulmonary embolism; 78 were reviewed after a mean period of four years. Of these 78 patients 18 made a complete neurological recovery while 53 appeared to have benefited from the procedure; 25 remained unchanged. The best results were obtained in burst fractures at thoracolumbar and lumbar levels when a solitary detached fragment of a vertebral body had been displaced into the spinal canal. These results indicate that anterolateral decompression of the spinal canal should be considered, after careful evaluation, for certain injuries of the spine in which there is severe neural involvement

Introduction: Avascular necrosis of the femoral head may play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches. Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and March 2006 by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. There were an equal number of procedures for each approach. 1.5 gms of intravenous cefuroxime was administered following caspsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime. The average time taken to prepare the femur and take samples was 8.5 minutes. Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 – 19.1) compared to the posterior approach (mean 5.6mg/kg; CI 3.5 – 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable. Discussion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure

The purpose of this experimental study was to elucidate the accuracy of neck-cut PSG setting, and femoral component implantation using neck-cut PSG in the THA through the anterolateral-approach relative to the preoperative planning goals, and to determine the usefulness of PSG compared with the procedure without PSG. A total of 32 hips from 16 fresh Caucasian cadaveric samples were used and classified into 4 groups: cementless anatomical stem implantation with wide-base-contact PSG (AWP: 8 hips, Fig.2); (2) cementless anatomical stem implantation with narrow-base-contact PSG (ANP: 8 hips, Fig.2); (3) cementless anatomical stem implantation without PSG (Control: 8 hips); and (4) cementless taper-wedge stem implantation with wide-base-contact PSG (TWP: 8 hips). The absolute error of PSG setting in the sagittal plane of the AWP group was significantly less than that of the ANP (p=0.003).THA with wide-base- contact PSG resulted in better alignment of the femoral component than THA without PSG or with narrow- base-contact PSG. Although the neck-cut PSG did not control the sagittal alignment of taper-wedge stem, the neck-cut PSG was effective to realise the preoperative coronal alignment and medial height for THA via the anterolateral approach regardless of the femoral component type. For figures and tables, please contact authors directly

Aims: The purpose of this study was to compare the hip abductor strength in patients undergoing total hip replacement via anterolateral (Müller) or posterolateral (Gibson) approach. Methods: Biomechanical studies were performed prospectively on a group of 80 patients who underwent hip arthroplasty via the anterolateral (48 cases) or posterolateral approach (32 cases). There were 61 females and 19 males with an average age of 57 years (range 37 – 78 years). The isometric abductor strength was measured with the kinetic communicator device preoperatively and 6, 12 and 24 weeks postoperatively. Results: Hip abductor strength improved postoperatively in both groups. The posterolateral surgical approach was associated with statistically significant higher abductor strength values. Conclusions: Posterolateral approach significantly increases the isometric abductor strength in relation to the anterolateral approach

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°. The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved

The Dall approach is a modified anterolateral approach with osteotomy of the anterior part of the greater trochanter. This approach relatively preserves the soft tissue tension during total hip arthroplasty (THA). We insert the stem and select a ball neck size so as to have a stable hip which will not dislocate easily during the trial reduction. The aim of this study is to evaluate the adequacy of this method, to measure leg length discrepancy and offset discrepancy at postoperative radiographs. We selected patients for inclusion in this study from those who have more than a 120 degree of affected hip flection angle, the opposite hip is almost normal with a low leg length discrepancy (primary OA, osteonecrosis, Crowe 1 secondary OA, femoral neck fracture). All THA were performed with cement fixation using an alignment guide to ensure accurate acetabular positioning. The ball head's diameter used were all 26mm. From September 2011 to October 2013, 22 patients met inclusion criteria among 103 THA. The mean age for 22 subjects was 66.6±12 years. The mean flexion angle of preoperative hip joints was 127.2±6.1 degrees. The cup inclination was 43.8° ± 3.5°. Anteversion was 11.8°±6°. The mean preoperative leg length discrepancy was 5.8mm±6.3mm. The mean postoperative leg length discrepancy was 0.7±3.5mm. The mean postoperative offset discrepancy was 0.7±6.6mm. There were no dislocations in this series of 103 cases. Discussion. Dislocation and leg length discrepancies are major complications following a total hip arthroplasty. A good range of motion of the preoperative hip joint is considered a high risk dislocation factor. The Dall approach with minimal release of soft tissue related to a tension of hip joint offers maximal stability and the ability to accurately restore leg length

Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. In this study we identify structures are risk during this approach. Method. Thirteen unpaired adult lower limbs were used for this study. Thirteen, 16-hole synthes®LCP anterolateral distal tibial plates were percutaneously inserted according to the manufacturer instructions and confirmed by xray. Dissection was performed around the plate to examine the relation of nerves and soft tissue. Results. The neurovascular bundle was under the plate in one case. Over the horizontal limb of the plate, typically the superficial peroneal nerve had a variable course over all four screw holes. The anterior tibial artery coursed over hole number 3 and the Extensor hallucis longistendon was positioned over hole 3 or 4. The Anterior tibialis tendon skirted hole 4 in 12 cases. Over the vertical limb of the plate, the neurovascular bundle coursed over holes, 5 to 7, the superficial peroneal nerve over holes 5 to 7. Discussion. Meticulous attention is required when placing an anterolateral distal tibia plate using a MIPO technique. We recommend a larger initial incision to avoid entanglement of the superficial peroneal nerve under the plate. Over the anterior aspect of the tibia, an open technique with adequate neurovascular structure and tendon protection is necessary due to the variability of structure coursing over the plate. A bridging technique for placement of proximal locking screw should be made through a mini open incision and this is safe to do so proximally over holes 12 to 16. Caution is advised during placement of screws percutaneously from holes 1 to 12 however the neurovascular bundle courses commonly over holes 5 to 7. These landmarks also apply to the use of shorter anterolateral distal tibial plates

We reviewed 64 anterolateral decompressions performed on 63 patients with tuberculosis of the dorsal spine (D. 1. to L. 1. ). The mean age of the patients was 35 years (9 to 73) with no gender preponderance. All patients had severe paraplegia (two cases grade III, 61 cases grade IV). The mean number of vertebral bodies affected was 2.6; the mean pre-treatment kyphosis was 24.8° (7 to 84). An average of 2.9 ribs were removed in the course of 64 procedures. The mean time taken at surgery was 2.45 hours when two ribs were removed and 3.15 hours when three ribs were removed. Twelve patients (19%) showed signs of neurological recovery within seven days, 33 patients (52%) within one month and 12 patients (19%) after two months; but six patients (10%) showed no neurological recovery. Forty patients were followed up for more than two years. In 34 (85%) of these patients there was no significant change in the kyphotic deformity; two patients (5%) showed an increase of more than 20°

Aim. The objective of this study was to evaluate the intermediate term clinical and radiological results of a new short stem hip implant. Methods. In 20 consecutive patients suffering from osteoarthritis with 25 affected hip joints (five cases were bilateral), the clinical and radiological results of 25 hip arthroplasties performed in one hospital between October 2009 and May 2014 through a minimally invasive anterolateral approach using a cementless short stem prosthesis type Aida and a cementless cup type Ecofit with a ceramic on ceramic pairing were evaluated prospectively. The median age of patients at time of surgery was 60 years (range, 42–71 years), 15 male (4 were bilateral) and 5 female patients (one was bilateral) were included in the study. The median clinical follow up was 30 months (range, 2–88 months), and the median radiological follow up was 30 months (range, 2–88 months). Results. Harris Hip Score improved from a median preoperative value of 53 to a median postoperative value of 96 (range, 73–100) at follow up. 22 hips (88%) showed an excellent postoperative Harris Hip Score, 2 hips (8%) a good postoperative Harris Hip Score, and one hip (4%) a fair postoperative Harris Hip Score. Only two patients complained of postoperative thigh pain. Regarding patient satisfaction, 15 patients (60%) were very satisfied, 10 patients (40%) were satisfied. None was unsatisfied. Radiological analysis showed that 19 stems (76%) were with stable bony ingrowth, two cases (8%) showed stable fibrous ingrowth. Four cases need further follow up for proper evaluation of stem fixation.(See Figures 1,2,3). Conclusion. The intermediate term survival of this new short stem is very promising, and achieving the goals of a standard hip arthroplasty. For any figures or tables, please contact the authors directly

Introduction. Migration of the trial femoral head is a rarely occurring complication of total hip arthroplasty (THA) performed using the anterolateral approach (ALA). This migration of the trial femoral head under the rectus femoris is extremely risky because of the anatomical situation. Analyzing the morphological character of a case of migration may help us to avoid this risk. Objective. We analyzed the three-dimensional bone morphology using computed tomography (CT) scan images to investigate the physiological characteristics of five migration cases. Methods. We examined 108 patients (21 men, 87 women, 113 hips) who underwent THA via the ALA. The average patient age was 62.9 (range: 30–87) years and average body mass index was 24.4 (range: 18.0–36.0) kg/m2. The exclusion criteria were dysplastic coxarthroses greater than Crowe type II, previous fractures, previous hip operations, and muscle disease. Three-dimensional models of the pelvis and femur were made using ZedHip software® (Lexi, Tokyo, Japan). The anterior superior iliac spine on the affected side (A) and contralateral side (A’), anterior inferior iliac spine (I), and greater trochanter tip (G) were noted in these models. The distances A–I, I–G, and A–G and the angle formed by AA’ and AI were measured (Figure 1, 2). Each hip was classified by the presence (group M) or absence (group N) of migration during surgery. A Fisher's exact probability test, Student's t-test, and Welch's t-test were used to compare the two groups, and p-values less than 0.05 were considered significant. Results. In 5 of the 113 hips, the trial femoral heads migrated under the rectus femoris and were removed safely. No significant differences were found between the gender, height, weight, or BMI of the groups. The average A–I distance was 32.3±3.0 mm (mean±SD) in group M and 39.4±10.4 mm in group N; I–G was 52.2±8.2 mm in group M and 59.7±10.6 mm in group N; and A–G was 64.3±10.3 mm in group M and 76.3±12.3 mm in group N. The average angle formed by AA’ and AI was 50.5±5.8°. Significant differences between the two groups were found for the distances A–I and A–G. Conclusions. In 4.4% of cases, the trial femoral heads migrated under the rectus femoris, which creates a risk for serious complications because major nerve and blood vessels are located nearby. The tendency for migration was expected to be related to the balance between soft tissues. In this study, we found that migration tends to occur in patients with shorter distances between A and I, and A and G. The trial head should be dislocated more carefully in those patients

Background. Percutaneous vertebroplasty (PVP) is a well established procedure with respect to improved pain and function following vertebral compression fracture. Currently, there is no consensus on the optimal cement distribution within a treated vertebral body. The aim of this study was to determine the influence of two distinct patterns of cement distribution following PVP on patient reported outcome measures up to 1 year post procedure. Methods. A retrospective study was undertaken of 42 patients consecutively undergoing PVP of up to 3 levels by a sole operator. Immediate post-procedural CT scans were analysed with VOXAR MPR software to determine cement distribution in each treated vertebrae as one of two defined patterns -“anterolateral” or “diffuse”. Patients completed an EQ-5D questionnaire pre-procedure and at 1, 2, 6 and 12 months from the procedure. Results. A 97% follow up rate of questionnaire completion was achieved for 30 patients. There were 58 treated levels with PVP performed at all levels between T6 and L5. Twelve patients had an anterolateral fill pattern and 18 patients had a diffuse fill pattern. Statistically significant improvement occurred in in all EQ-5D domains except self care at almost all timepoints in the study group. In the anterolateral group, pain was significantly improved at 1 week, 2months, 6 months and 1 year compared with only at 1 year in the diffuse group. Conclusion. PVP leads to immediate and sustained improvement in quality of life. Lateral cement placement leads to greater pain relief in the short term compared with diffuse cement filling. Conflicts of Interest. None. Source of Funding. None. This abstract has not been previously published in whole or in part; nor has it been presented previously at a national meeting

Purpose of the study: The purpose of this study was to assess traumatic damage to muscles using biological markers. Two approaches were evaluated: a modified Hardinge approach (anterior hemimyotomy) and a reduced anterolateral approach (Rottinger). Material and method: This was a multicentric prospective study conducted in three centres in 2008. The first 50 patients in each centre were included. Total creatinine phosphokinase (CPK) and serum myoglobulin levels were used to evaluate muscle damage. Blood samples were taken ten hours after surgery for myoglobulaeia and at one and two postoperative days for CPK. Student’s t test was used for the statistical analysis. Results: There was no statistically significant difference in serum myoglobulin levels 10 hours postoperatively (p=0.25) or for CPK level at day 1 (p=0.098) and day 2 (p=0.105). Objective clinical recovery (Postel-Merle-d’Aubigné, Harris) and function (WOMAC and SF-12) were better at six weeks with the reduced anterolateral approach. Discussion: These findings show that muscle aggression after mini-incision is to the same order as with the standard approach. The damage is however different: section for the Hardinge type approaches, stretching and contusion for the mini-incisions. Conclusion: Use of biological markers specific for muscle tissue appears to be a simple way of quantifying muscle damage. However, adjunction of an imaging technique (MRI) might provide a more precise assessment of muscle injury

Purpose of the study: Survival of a total hip arthroplasty (THA) mainly depends on the choice of the implant and the quality of the implantation. Use of minimally invasive approaches remains a subject of controversy due to the uncertain implant position and questions concerning increased perioperative complications. The purpose of this work was to assess these two elements in a consecutive series of patients who underwent THA implanted via the minimally invasive anterolateral approach described by Rottinger. Materials and Methods: This was a consecutive series of 130 patients (84 female, 46 male, mean age 69 years, age range 46–91) operated by the same surgeon. Mean follow-up was twelve months (range 6 – 24 months). The clinical parameters studied were: the pre–and post-operative Postel-Merle-d’Aubigné (PMA) score, mean operative time, presence of perioperative surgical complications. Radiographic parameters studied were lucent lines (De Lee and Gruen), homogeneous cementing of the femoral piece, axial position of the femoral implant, angle of acetabular inclination, acetabular anteversion (Hassan), and any leg length discrepancy. Results: Intraoperative complications were: one intraoperative mobilisation of a press-fit cup, one trochanter fracture. Postoperatively, the rate of dislocation was 2.3%. In 3.8% of the patients developed skin lesions or a local haematoma but none with infection. Mean operative time was 107 minutes (range 80–210). Mean postoperative PMA score was 17.4 versus 12.4 preoperatively. Patients were able to walk without limping 3.3 months postoperatively (range 0.5–12 months). Mean cup inclination and anteversion were 46.1° (28–60°) and 12.3° (0–35°) respectively. Leg length discrepancy was +4.8mm on average (operated side). Femoral alignment was ±3° relative to the femoral axis in 83% of hips. Homogeneous cementing of the femoral stem was noted in 84%. There was a learning curve with an 11% complication rate for the first twenty hips versus 4% for the remainder of the hips in this series. Discussion: In our hands, the minimally invasive anterolateral approach described by Rottinger enables proper reproducible THA implantation. The rate of intraoperative complications is low. There is a learning curve which was an estimated twenty cases in our series. This method has become our first-intention option for implantation of THA

As much as there is interest in mini-invasive surgery (MIS) total hip arthroplasty (THA), there is controversy ranging from a more advantageous to a potentially dangerous alternative to classic THA. The purpose of this study is to compare the results of 130 cementless, standard stem navigated primary THA with data collected retrospectively from 2005 to 2010 (64 classic Hardinge approach (HAL) and 66 MIS intermuscular anterolateral approach by the senior surgeon). Data include: operative time, perioperative bleeding, length of surgery, hospital stay, patient's satisfaction and pain perception. The alignment values at six months to a maximum of 60 months provided necessary statistical information for clinical and radiological comparison of the two groups. Significant differences were found between the two groups with MIS being superior with respect to less surgical time (p = 0.029) and achieving quicker rehab goals with shorter hospital stay (p <0.001). Pain perception was less in MIS group with a higher satisfaction score (p <0.001). Although both groups have the potential of nerve injury to tensor fascia muscle, it's only the classic HAL that jeopardises the glutei nerve supply. MIS approach to navigated THA seems to be an acceptable alternative with some advantages to Classic HAL

This single incision, anterolateral intermuscular approach (AL-IM) utilises the interval between gluteus medius and tensor fascia lata. The aims of the study were to compare the quality of life, satisfaction and complications of this approach with two of the most commonly used limited incision transmuscular (TM) approaches, namely the mini-posterior (P-TM) and the mini-direct lateral (L-TM). One hundred and ninety-nine patients receiving MIS THA surgical procedures were evaluated prospectively (63 AL-IM, 68 P-TM and 68 L-TM). The outcome variables were WOMAC function, pain, stiffness, SF-12 (physical & mental), Oxford-12, satisfaction and radiological outcome. Parametric and non-parametric analyses were performed. There were no significant differences between groups in baseline characteristics including age, sex, BMI, co-morbidity, or pre-op WOMAC, SF-12, Oxford-12 (p> 0.05). However, the AL-IM group was associated with superior outcomes (p< 0.05) in WOMAC function, WOMAC pain, global WOMAC, Oxford-12 and SF-12 physical component. In the short term the AL-IM approach provides significant improvements in quality of life scores over other limited incision approaches. It provides minimal soft tissue disruption and maintains the abductor musculature and posterior soft tissue envelope, with similar complications and radiological outcomes

Introduction: Compartment syndrome is one of the most devastating complications in orthopaedic trauma cases. The aim of this study is to investigate whether the intra-compartmental pressure changes rise and stay above the dangerous limits during percutaneous bridge plating of tibial shaft fractures necessitating fascial release or not. Patients and Methods: Between January 2007 and April 2009 17 isolated tibial fractures of the 17 patients were treated with percutaneous bridge plating technique by a single orthopaedic trauma surgeon. During the operation before, during and after the plating leg compartmental pressures were measured by using invasive blood pressure monitor. Demographic, trauma and fracture related data were also recorded. Analyses were performed by using SPSS 13. Findings: Mean age was 32 (19–55) years. Mean of ISS was 14 (10–27). Plating was performed at a mean of 3,3 (1–6) days after the trauma. Means of difference between systolic and diastolic blood pressure and leg anterior compartment pressures just before the plate insertion were 42 and 25,5 (16–32) mmHg respectively. During plating compartmental pressures rose to a mean of 51,5 mmHg (p=0,001) and dropped to 50 mmHg 10 minutes after implantation. Mean delta P was – 7 mmHg for the leg antertior compartment ten minutes after plating. No correlation was found between the blood pressure differences; ISS; age; type of anesthesia and delta P (r< 0,1 and p> 0,05). Although there is a trend of having decreased delta P with earlier surgery difference was not significant (r=0,18; p=0,058). Conclusion: Anterolateral percutaneous bridge plating of tibial shaft fractures significantly increases intracom-partmental pressures. Physician should carefully judge the risk of compartment syndrome in each patient separately and should not hesitate to perform percutaneous fascial release intraoperatively

Introduction: This single incision, anterolateral intermuscular approach (AL-IM) utilizes the interval between gluteus medius and tensor fascia lata. The aims of the study were to compare the quality of life, satisfaction and complications of this approach with two of the most commonly used limited incision transmuscular (TM) approaches, namely the mini-posterior (P-TM) and the mini-direct lateral (L-TM). Methods: 199 patients receiving MIS THA surgical procedures were evaluated prospectively (63 AL-IM, 68 P-TM and 68 L-TM). The outcome variables were WOMAC function, pain, stiffness, SF-12 (physical & mental), Oxford-12, satisfaction and radiological outcome. Parametric and non-parametric analyses were performed. Results: There were no significant differences between groups in baseline characteristics including age, sex, BMI, co-morbidity, or pre-op WOMAC, SF-12, Oxford-12 (p> .05). However, the AL-IM group was associated with superior outcomes (p< .05) in WOMAC function, WOMAC pain, global WOMAC, Oxford-12 and SF-12 physical component. Conclusion: In the short term the AL-IM approach provides significant improvements in quality of life scores over other limited incision approaches. It provides minimal soft tissue disruption and maintains the abductor musculature and posterior soft tissue envelope, with similar complications and radiological outcomes

Introduction: Total hip arthroplasty preformed with the use of minimal incision surgery has received tremendous attention recently. Various surgical approaches have been introduced to minimize surgical trauma to the soft tissues. The mini invasive Modified Watson-Jones approach have been selected to decrease the perioperative complications associated with other mini invasive approaches that has been described. The anterolateral mini incision is a new innovative approach using the intramuscular plan between the gluteus medius and the tensor fascia lata. This intermuscular interval through a small incision provides good exposure and preserves muscle integrity. Moreover, preserving the muscle integrity provides a very stable joint after implantation such that no restrictions is giving to the patient during the rehabilitation period. Materials and Methods: Between July 2004 to September 2005, we used this approach on 60 sequential patients. Fifty patients were enrolled in this prospective study. Patients were evaluated preoperatively, immediately postoperatively, and at 3-month and 6 month follow-up according to operating time, intraoperative blood loss, subcutaneous drains blood loss, post op pain control drugs requirements, short form 36 patient questionnaire (SF-36) scores and the Harris Hip Score (HHS). 4 patients had previous THA on the contralteral side. Results: The average operation time was 137min (range 90–200min), there were no dislocations, the mean post operation blood transfusion requirements was 1.64, the mean subcutaneous drains blood loss was 241.9ml (range 20–620ml), there was significant improvement in function, pain, SF-36 and Harris Hip Score (HHS) at the 3-month and 6-month follow-up examination. The average length of the incision was under 12cm. We had one reoperation due to deep infection. All four patients with bilateral THA preferred their last operation due to lack of post operative restrictions and due to shorter recovery of muscle strength. Conclusion: We think that using mini invasive Modified Watson-Jones approach in total hip replacement surgeries is a preferable option. There are several advantages of using this approach compared with the more traditional techniques. Such a technique should help reduce morbidity and complication rates for those patients undergoing a total hip replacement

In fall 2004 we started with minimal invasive hip surgery at our clinic. Our requirements: Use of our standard implant system (Bicon threaded cup and Zweymüller stem), fast realization of the minimal invasive procedure through the continuation of the used, anterolateral Watson-Jones approach, modified for this technique, retaining the supine position with unchanged orientation concerning the positioning of the implant parts. Our expectations: Reduction in operative trauma through lower blood loss with less post-operative pain, less limping especially during the first weeks, less trochanter pain through the preservation of the gluteal muscle tendons, fewer posterior dislocations by preservation of the dorsal capsule, and a better cosmetic result. The patient is placed in supine position on the standard OR table with the option of tilting the legs down. The contralateral leg lies on a leg holder in extended position, flexed by approx. 20 degrees. This allows to bring the leg in hyperextension (without hyperlordosis of the lumbar spine), adduction and external rotation during broaching the femur. The main criterion of the minimal invasivness is the preservation of the gluteal tendons and not primarily the reduction of the length of the skin incision. An extensive capsular release with partial dissection of the rectus tendon for exposure of the acetabulum is necessary. For the stem implantation a notching of the piriformis can be necessary in addition to this. During the stem preparation the soft tissues should not influence the axial entrance of the rasps into the femoral canal otherwise there is a danger of a dorsolateral perforation. Right-left-lateral-double-offset rasps and the use of manipulation rasps as trial prostheses have worked satisfactorily. Retrospective analyses of numerous peri- and post-operative data were accomplished, as well as radiological evaluations regarding the optimal position of the implanted joints, and compared with a conventional control group. After a learning curve the OP duration was the same in both groups. The development of the haemoglobin and hematocrit levels were identical, 1/3 of the patients needed blood subsitution (autologous or stored blood). 90% of the analysed postoperative x-rays in standing position showed equal bilateral leg length corresponding to the preoperative planning, the planned offset was achieved in 93%. Deviations of the remaining were without clinical relevance. The complication rate was 2,5%. Conclusions: The anterolaterale approach in supine position is standardised for the minimal invasive THR. The compliance with the developed implantation technique is a requirement for the optimal positioning of the prosthesis and to avoid complications. The subjective patient assessments, especially of those who experienced both methods, are impressive

Introduction: The minimally invasive posterior approach has become a standard for total hip replacement (THR) but the interest for the other minimally invasive approaches has not waned in any way. We carried out a prospective and comparative study in order to analyse the interest of the anterolateral minimal invasive (ALMI) approach in comparaison to a minimally invasive posterior (MIP) approach for THR. Material and method: We carried out a prospective and comparative study. A group of 35 primaries THR with large head using the ALMI approach, as described by Bertin and Röttinger, was compared to a group of 43 primaries THR performed through the MIP approach. The groups were not significantly different with respect to age, sex, bony mass index, ASA score, Charnley class, diagnoses and preoperative Womac index and PMA score. The preoperative Harris hip score was significantly lower in ALMI group. Early functional results have been evaluated thanks to Womac index and modified Harris hip score at 6 weeks, 3 and 6 months. A p value < 0.05 has been considered as significant. Results: The duration of surgical procedure was longer and the calculated blood loss more important in ALMI group (respectively p=0.045 and p=0.07). The preoperative complications were significantly more frequent in this group with 4 greater trochanter fractures, 3 false routes, 1 calcar fracture, and 2 metal back bascules versus one femoral fracture in MIP group. Other postoperative data (implant positioning, morphine consumption, length of hospital stay, type of discharge) were comparable. The early functional results at 6 weeks, 3 and 6 months were also comparable. No other complication has been noted during the first 6 months in the two groups. Discussion and Conclusion: The ALMI approach uses the intermuscular interval between the tensor fascia lata and the gluteus medius. It leaves intact the abductors muscles and the posterior capsule and short external rotators. The early clinical results are excellent despite of the initial complications related to the initial learning curve for this approach and the use of the large head with metal-on-metal bearing. The stability of the arthroplasty and the absence of muscular damage should permit to accelerate the postoperative rehabilitation in parallel with less preoperative complications after the initial learning curve

Introduction: Chronic anterolateral instabilitiy of the ankle joint is a combination of mechanical and functional instability. Various surgical procedures are well known. Many of them are peroneus brevis tenodesis techniques. We demonstrate our modified surgical procedure (Peroneus-brevis-shift technique) as well as report results from 2 to 17 years post operatively, as short-, mid-, and long-term results. OP-technique: The intact peronaeus brevis tendon is shifted and sutured fronto-lateral of the malleolus lateralis in neutral polsition of the foot. Postoperatively full weight bearing without a blaster is allowed, a splint for 3 weeks is recommended. Patients and Methods: From 11/86 to 12/04 91 patients (95 feet) were treated with our modified peroneus brevis tenodesis augmentation. Preoperatively all patients were treated conservatively without success. Following surgical treatment all patients under went a standardised post operative treatment protocol. In this retrospective study 73 patients (81,1%) resp. 77 feet (81%) with a meantime follow up of 9.3 ± 4.7yrs were available for evaluation. Patients were evaluated using the following means, clinical examination (AOFAS ankle-hindfood scale of H. Kitaoka), function score (Karlsson and Peterson), instability score (Good et al), radiological examination (according to Van Dijk et al), and dynamometric testing. All clinical and radiological tests were done on the treated and non treated sides (control group). We evaluated the results of our clinical testing as well as biplanar stress radiographs, using the TELOS device (15kp), with regards to talar shift and talar tilt. Dynamometric examination of both feet was performed and force descrepencies between the operated and non-operated sides was eveluated with regards to eversion force. Statistical testing were performed concerning short-, mid-, and long-term Results: (Kruskal-Wallis-tests and chi-squared-tests). All p-values < 0.0015625 were considered as statistically significant. The critical boundary results from the correction for multiplicity due to the number of tests (32 tests were performed, 0,05/32=0.0015625). Results: Short- (2–5yrs), mid- (6–10yrs) and long-term (11–17yrs) results showed no statistically significant differences in any clinical or radiological testing between the treated and control side. Discussion: In many cases of chronic lateral instability of the ankle also a strain of the lateral talocalcaneal joint is seen. Most tenodesis techniques are showing the well known biomechanical disadvantages more or less. Our peroneusbrevis-shift technique (PBS-technique) offers a simple and safe surgical technique, a short learning curve and early weightbearing stability. It leads in 93% to excellent and good longterm results

Purpose: The interest in minimally invasive surgery (MIS) for total hip arthroplasty has not waned in anyway (THA). Different surgical approaches have been used to do MIS-THA. The purpose of this study was to compare the outcome of the THA using the minimally invasive postero-lateral approach (MIS-PL) and minimally invasive antero-lateral approach (MIS-AL).

Patients and Methods: Fifty randomly assigned patients with MIS-PL and 32 patients with MIS-AL were included in the study. There were no significant differences in age, sex, diagnosis, JOA score or body mass index in each group. The operation time, length of incision, blood loss, implant position, muscle recovery and complication were observed.

Results: Total blood loss and pain was significantly less in patients undergoing THA via MIS postero-lateral approach. In addition, the MIS-PL had improved recovery of muscle strength (hip flexion and abduction) which was statistically significant. Median cup inclination was 42.3 degrees (MIS-AL) and 41.7 degrees (MIS-PL). Median cup anteversion was 18.3 degrees (MIS-AL) and 15.9 degrees (MIS-PL), respectively. Roentgenographic evaluation of femoral component positioning showed no significant difference. Other postoperative data (length of hospital stay, operation time, complication) were comparable.

Conclusion: The MIS antero-lateral approach have often been selected to decrease the risk of dislocation, but this approach needs to release the one third of the gluteus medius from the greater trochanter. MIS postero-lateral approach caused less pain and improve recovery time, postero-lateral approach is more suitable for minimally invasive total hip arthroplasty.

Exposure of the hip by osteotomy of the anterior part of the greater trochanter is described. This maintains the continuity of the tendinous junction between the anterior half of gluteus medius and the vastus lateralis and preserves intact the insertion of gluteus minimus into the anterior surface of the trochanter. The nerve supply to these muscles is not compromised and good abductor function is retained. The approach can be extracapsular or intracapsular. Reattachment of the osteotomised fragment is simple, and upward displacement after operation, as sometimes seen after complete osteotomy of the greater trochanter, cannot occur.

Introduction: There is an increased risk of revision for aseptic loosening with a transgluteal approach as described in the Swedish Hip Register. Femoral component malpositioning is itself associated with a poor outcome. A cuff of posteriorly situated glutei during the direct lateral approach may result in levering the proximal stem anteriorly and the tip of the stem posteriorly and does not allow the entry point of the stem to be placed posteriorly at the level of neck resection resulting in possible malpositioning.

The purpose of this study was to determine whether there is a significant difference in femoral component alignment when the posterior and direct lateral approaches are compared.

Materials and methods: Forty patients underwent an direct lateral approach and forty a posterior approach (n = 80). Inclusion criteria included primary hip arthroplasty using a cemented Exeter femoral component. At 6 weeks a standard AP and a modified lateral radiograph were taken. Measurements were taken from digitized radiographs as follows:

1. AP radiograph

Component alignment was defined as A – B and C – D.

Results: A–B was 0.71 for the modified direct lateral approach and 2.56 for the posterior approach. C–D was 1.47 for the direct lateral approach and 1.21 for the posterior approach. This difference was not statistically different using paired t tests as p > 0.05(P=0.69) for lateral views measurements.

Discussion: This study demonstrates that there is no significant difference between direct lateral and posterior approaches as far as femoral component alignment is concerned. The increased revision rate noted by the Swedish Hip Register when a transgluteal approach is likely to be multifactorial, but not likely to be due to femoral component malalignment.

Purpose of the study: The survival of a total hip arthroplasty (THA) depends mainly on the choice of the implant and the quality of the implantation. Mini-incisions have been criticised because of the increased risk of complications and the uncertainty concerning implant position. The main objective of this work was to assess this later feature.

Material and method: This was a prospective series of consecutive patients attending different centres from January 2008 to January 2009 comparing 100 THA implanted via the reduced Watson-Jones approach (2 centres) and 520 THA implanted in a third centre via the anterior hemimyotomy. Objective assessment (PMA, Harris) and early functional outcome (WOMAC, SF12), biological aggression (myoglobinaemia, CPK, blood loss), complications, and scanographic position of the implants were analysed.

Results: For the mini-Watson-Jones arthroplasties, there was a longer operative time (p< 0.0001), smaller scar, less consumption of analgesics the first postoperative day (p=0.003), and better objective and functional recovery at six weeks (PMA: p < 0.0001; Harris: p = 0.004; WOMAC: p < 0.0001; SF12: p = 0.007). Conversely, there was no significant difference for intraoperative or postoperative blood loss, intraoperative and early postoperative complications, elevation of serum muscle markers, or duration of hospital stay. Regarding implant position, significantly greater acetabular and cumulated anteversion was observed with the mini-incision (p=0.03 and p=0.002 respectively). Nevertheless, the proportion of well positioned implants (Lewinnek criteria) was not significantly different.

Discussion: This series confirms the contribution of the mini-incision to more rapid recovery. We did not find any difference in implant malposition related to approach. The first analyses did however show that the position of the implants is more reproducible with the conventional approach.

Aims. It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively. Methods. Two consecutive groups of patients whose operations were performed by the senior author were compared. The anterolateral capsule was resected in the first group of 430 patients between January 2012 and December 2014, and preserved and anatomically closed in the second group of 450 patients between July 2015 and December 2017. There were no other technical changes between the two groups. Patient characteristics, the Charlson Comorbidity Index (CCI), and surgical data were collected from our database. PROM questionnaires, consisting of the Oxford Hip Score (OHS) and Core Outcome Measures Index (COMI-Hip), were collected two years postoperatively. Data were analyzed with generalized multiple regression analysis. Results. The characteristics, CCI, operating time, and length of stay were similar in both groups. There was significantly less blood loss in the capsular preservation group (p = 0.037). The revision rate (n = 3, (0.6%) in the resected group, and 1 (0.2%) in the preserved group) did not differ significantly (p = 0.295). Once adjusted for demographic and surgical factors, the preserved group had significantly worse PROMs: + 0.24 COMI-Hip (p < 0.001) and -1.6 OHS points (p = 0.017). However, the effect sizes were much smaller than the minimal clinically important differences (MCIDs) of 0.95 and 5, respectively). The date of surgery (influencing, for instance, the surgeon’s age) was not a significant factor. Conclusion. Based on the MCID, the lower PROMs in the capsular preservation group do not seem to have clinical relevance. They do not, however, confirm the expected benefit of capsular preservation reported for the posterolateral approach. Cite this article: Bone Joint J 2022;104-B(7):826–832

The surgical care of extra-articular distal tibial fractures remains controversial. This study looks at the radiological outcomes of distal tibial fractures treated with either a direct medial or anterolateral plate, with or without plating of the fibula, to assess the outcome and complications associated with these 2 approaches. This is a retrospective review of 80 patients with distal tibial extra-articular fractures, treated with an open reduction and plating, between 2008 and 2019 at Glasgow Royal Infirmary. Case notes and x-rays were reviewed. Of those tibial fractures fixed with only a medial plate, 78% united (28/36), 5% (2/36) had a non-union and 17% (6/36) a malunion. In the group treated with a combination of medial tibial and fibular plating, the figures were; 71% (15/21), 19% (4/21) and 10% (2/21). However, in the group treated with anterolateral plating of the tibia alone, only 53% (8/15) united, with a 20% (3/15) non-union and 13% (2/15) malunion rate. Additionally in this group, there were 2 patients (13%) with loss of fracture reduction within the first two months of fracture fixation, requiring revision surgery. Interestingly, of the 8 patients treated with anterolateral tibial and fibular plating, 88% (7/8) showed full union and only one (12%) had a non-union, with no malunions is this group. It would appear that medial tibial and a combination of medial tibial and fibular plating, have superior outcomes compared to anterolateral plating. Results suggest, if anterolateral plating is done, this should be augmented by fixation of the fibular fracture as well

Aims. The aim of our study was to investigate the effect of asymmetric crosslinked polyethylene liner use on the risk of revision of cementless and hybrid total hip arthroplasties (THAs). Methods. We undertook a registry study combining the National Joint Registry dataset with polyethylene manufacturing characteristics as supplied by the manufacturers. The primary endpoint was revision for any reason. We performed further analyses on other reasons including instability, aseptic loosening, wear, and liner dissociation. The primary analytic approach was Cox proportional hazard regression. Results. A total of 213,146 THAs were included in the analysis. Overall, 2,997 revisions were recorded, 1,569 in THAs with a flat liner and 1,428 in THAs using an asymmetric liner. Flat liner THAs had a higher risk of revision for any reason than asymmetric liner THAs when implanted through a Hardinge/anterolateral approach (hazard ratio (HR) 1.169, 95% confidence interval (CI) 1.022 to 1.337) and through a posterior approach (HR 1.122, 95% CI 1.108 to 1.346). There was no increased risk of revision for aseptic loosening when asymmetric liners were used for any surgical approach. A separate analysis of the three most frequently used crosslinked polyethylene liners was in agreement with this finding. When analyzing THAs with flat liners only, THAs implanted through a Hardinge/anterolateral approach were associated with a reduced risk of revision for instability compared to posterior approach THAs (HR 0.561 (95% CI 0.446 to 0.706)). When analyzing THAs with an asymmetric liner, there was no significant difference in the risk of revision for instability between the two approaches (HR 0.838 (95% CI 0.633 to 1.110)). Conclusion. For THAs implanted through the posterior approach, the use of asymmetric liners reduces the risk of revision for instability and revision for any reason. In THAs implanted through a Hardinge/anterolateral approach, the use of an asymmetric liner was associated with a reduced risk of revision. The effect on revision for instability was less pronounced than in the posterior approach. Cite this article: Bone Joint J 2021;103-B(9):1479–1487

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 incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years. Methods. From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors. Results. The mean follow-up period was 70.2 months (36 to 191). There were 146 AFFs (99.3%) in female patients and the mean age was 71.6 years (48 to 89). The AFFs were located in the subtrochanter and shaft in 52 cases (35.4%) and 95 (64.6%), respectively. The preoperative mean anterior/lateral femoral bowing angles were 10.5° (SD 5.7°)/6.1° (SD 6.2°). The postoperative mean anterior/lateral bowing values were changed by 8.7° (SD 5.4°)/4.6° (SD 5.9°). Bisphosphonates had been used contemporarily in 115 AFFs (78.2%) for a mean of 52.4 months (1 to 204; SD 45.5) preoperatively. Nailing was performed in 133 AFFs (90.5%), and union was obtained at a mean of 23.6 weeks (7 to 85). Delayed union occurred in 41 (27.9%), and nonunion occurred in 13 (8.8%). Contralateral AFF occurred in 79 patients (53.7%), and the use of a bisphosphonate significantly influenced the occurrence of contralateral AFFs (p = 0.019). Peri-implant fractures occurred in a total of 13 patients (8.8%), and a significant increase was observed in cases with plating (p = 0.021) and high grade of postoperative anterolateral bowing (p = 0.044). Conclusion. The use of a bisphosphonate was found to be a risk factor for contralateral AFF, and high-grade postoperative anterolateral bowing and plate fixation significantly increased the occurrence of peri-implant fractures. Long-term follow-up studies on the bilaterality of AFFs and peri-implant fractures are warranted. Cite this article: Bone Joint J 2021;103-B(11):1648–1655

Aims. The purpose of this study was to explore the correlation between femoral torsion and morphology of the distal femoral condyle in patients with trochlear dysplasia and lateral patellar instability. Methods. A total of 90 patients (64 female, 26 male; mean age 22.1 years (SD 7.2)) with lateral patellar dislocation and trochlear dysplasia who were awaiting surgical treatment between January 2015 and June 2019 were retrospectively analyzed. All patients underwent CT scans of the lower limb to assess the femoral torsion and morphology of the distal femur. The femoral torsion at various levels was assessed using the a) femoral anteversion angle (FAA), b) proximal and distal anteversion angle, c) angle of the proximal femoral axis-anatomical epicondylar axis (PFA-AEA), and d) angle of the AEA–posterior condylar line (AEA-PCL). Representative measurements of distal condylar length were taken and parameters using the ratios of the bianterior condyle, biposterior condyle, bicondyle, anterolateral condyle, and anteromedial condyle were calculated and correlated with reference to the AEA, using the Pearson Correlation coefficient. Results. The femoral torsion had a strong correlation with distal condylar morphology. The FAA was significantly correlated with the ratio of the bianterior condyle (r = 0.355; p = 0.009), the AEA-PCL angle (r = 0.340; p = 0.001) and the ratio of the anterolateral condyle and lateral condyle (ALC-LC) (r = 0.309; p = 0.014). The PFA-AEA angle was also significantly correlated with the ratio of the bianterior condyle (r = 0.319; p = 0.008), the AEA-PCL angle (r = 0.231; p = 0.031), and the ratio of ALC-LC (r = 0.261; p = 0.034). In addition, the bianterior condyle ratio showed a significant correlation with the biposterior condyle ratio (r = -0.324; p = 0.027) and the AEA-PCL angle (r = 0.342; p = 0.021). Conclusion. Increased femoral torsion correlated with a prominent anterolateral condyle and a shorter posterolateral condyle compared with the medial condyle. The deformities of the anterior and posterior condyles are combined deformities rather than being isolated and individual deformities in patients with trochlear dysplasia and patella instability. Cite this article: Bone Joint J 2020;102-B(7):868–873

The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

Chondral defects in the knee have cartilage biomechanical differences due to defect size and orientation. This study examines how the tibiofemoral contact pressure is affected by increasing full-thickness chondral defect size on the medial and lateral condyle at full extension. Isolated full-thickness, square chondral defects increasing from 0.09cm. 2. to 1.0cm. 2. were created sequentially on the medial and lateral femoral condyles of six human cadaveric knees with intact ligaments and menisci. Chondral defects were created 1.0cm from the femoral notch posteriorly. The knees were fixed to a uniaxial load frame and loaded from 0N to 600N at full extension. Contact pressures between the femoral and tibial condyles were measured using pressure mapping sensors. The peak contact pressure was defined as the highest value in the 2.54mm. 2. area around the defect. The location of the peak contact pressure was determined relative to the centre of the defect. Peak contact pressure was significantly different between (4.30MPa) 0.09cm. 2. and (6.91MPa) 1.0cm. 2. defects (p=0.04) on the medial condyle. On the lateral condyle, post-hoc analysis showed differences in contact pressures between (3.63MPa) 0.09cm. 2. and (5.81MPa) 1.0cm. 2. defect sizes (p=0.02). The location of the stress point shifted from being posteromedial (67% of knees) to anterolateral (83%) after reaching a 0.49cm. 2. defect size (p < 0.01) in the medial condyle. Conversely, the location of the peak contact pressure point moved from being anterolateral (50%) to a posterolateral (67%) location in defect sizes greater than 0.49cm. 2. (p < 0.01). Changes in contact area redistribution and cartilage stress from 0.49cm. 2. to 1.0cm. 2. impact adjacent cartilage integrity. The location of the maximum stress point also varied with larger defects. This study suggests that size cutoffs exist earlier in the natural history of chondral defects, as small as 0.49cm. 2. , than previously studied, suggesting a lower threshold for intervention

Our previous work presented at BHS revealed a reduced risk of revision for all reasons in THAs using lipped (asymmetric) liners. Some audience members felt that this finding may be due to unaccounted confounders and the hip surgery community remains sceptical. A fully adjusted Cox model was built after exploratory Kaplan-Meier analyses. The following surgical approaches were included in the analysis: Posterior, Hardinge/anterolateral, Other. The variables included in the final Cox model included: Gender, liner asymmetry, age, head composition, stem fixation method, head diameter, indication for implantation and surgical approach. An additional analysis of the 3 most commonly used polyethylene liners with both a flat and asymmetric version was performed. In the fully adjusted Cox model, the use of a flat liner was associated with increased risk of revision for instability (HR: 1.79, 95%CI: 1.52–2.10) and increased risk of revision for all reasons (HR 1.195, 95%CI: 1.104 – 1.293) when compared to THAs utilising flat liners. This finding was upheld in the product specific analysis. When utilising flat liners, the Hardinge/anterolateral approach was associated with a reduced risk of revision for instability compared to the posterior approach (HR 0.56, 95%CI: 0.446 to 0.706). When an asymmetric liner was used, there was no significant difference in the risk of revision for instability between the Hardinge/anterolateral approach and the posterior approach (HR 0.838, 95%CI: 0.633 – 1.110). The use of polyethylene-based bearings gives the surgeon the option to use asymmetric liners. The reduced risk of revision in THAs with asymmetric liners was seen in the analysis of the complete dataset and in the product specific analysis. Our results demonstrate that the posterior approach, when used with asymmetric XLPE liners, is not associated with a higher risk of revision for instability as historical data suggested

Aims. Rotational acetabular osteotomy (RAO) has been reported to be effective in improving symptoms and preventing osteoarthritis (OA) progression in patients with mild to severe develomental dysplasia of the hip (DDH). However, some patients develop secondary OA even when the preoperative joint space is normal; determining who will progress to OA is difficult. We evaluated whether the preoperative cartilage condition may predict OA progression following surgery using T2 mapping MRI. Methods. We reviewed 61 hips with early-stage OA in 61 patients who underwent RAO for DDH. They underwent preoperative and five-year postoperative radiological analysis of the hip. Those with a joint space narrowing of more than 1 mm were considered to have 'OA progression'. Preoperative assessment of articular cartilage was also performed using 3T MRI with the T2 mapping technique. The region of interest was defined as the weightbearing portion of the acetabulum and femoral head. Results. There were 16 patients with postoperative OA progression. The T2 values of the centre to the anterolateral region of the acetabulum and femoral head in the OA progression cases were significantly higher than those in patients without OA progression. The preoperative T2 values in those regions were positively correlated with the narrowed joint space width. The receiver operating characteristic analysis revealed that the T2 value of the central portion in the acetabulum provided excellent discrimination, with OA progression patients having an area under the curve of 0.858. Furthermore, logistic regression analysis showed T2 values of the centre to the acetabulum’s anterolateral portion as independent predictors of subsequent OA progression (p < 0.001). Conclusion. This was the first study to evaluate the relationship between intra-articular degeneration using T2 mapping MRI and postoperative OA progression. Our findings suggest that preoperative T2 values of the hip can be better prognostic factors for OA progression than radiological measures following RAO. Cite this article: Bone Joint J 2021;103-B(9):1472–1478

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured. . The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups. Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols. Cite this article: Bone Joint J 2014;96-B:406–13

Abstract. INTRODUCTION. To preserve knee function and reduce degenerative, meniscal tears should be repaired where possible. Meniscal wrapping with collagen matrices has shown promising clinical outcome (AAOS meniscal algorithm), however there is limited basic science to support this. AIM. to model the contact pressures on the human tibial plateau beneath a (1) a repaired radial meniscal tear and (2) a wrapped and repaired radial meniscal tear. METHODOLOGY. Complete anterolateral radial tears were formed across 4 lateral human menisci, before repairing with ‘rip-stop’ H sutures using 2mm Arthrex Meniscal Suture tape. This was then repeated with the addition of a ChondroGide collagen matrix wrapping. From this experimental setup a finite element (FE) analysis model was construted. FE models of the two techniques (i) suture alone and (ii) suture and collagen-matrix wrap, were then modelled; bone was linear elastic, articular cartilage was a hyperelastic Yeoh model, and a linear elastic and transversely isotropic material model for the meniscus. The contact areas of the articulating surfaces, meniscus kinematics, and stress distribution around the repair were compared between the two systems. RESULTS. Meniscal suture-tape repair had higher local stresses and strains (σ_max=51 MPa ε_max=25%) around the repair compared to with Collagen wrapping (σ_max=36.6MPa ε_max=15%). Radial displacement and pressure on the meniscal contact surfaces were higher in the suture only repair. CONCLUSION. Collagen-matrix wrapping strengthens the repair, reducing local peak stresses and strains around the suture-tape. This could reduce the chance of suture-tape pull-out and subsequent repair failure

The Pivot-shift test is a clinical test for knee instability for patinets with Anterior cruciate ligament (ACL), however the test has low inter-observer reliability. Dynamic radiostereometry (dRSA) imaging is a highly precise method for objective evaluation of joint kinematics. The purpose of the study was to quantify precise knee kinematics during Pivot-shift test by use of the non-invasive dynamic RSA imaging. Eight human donor legs with hemipelvis were evaluated. Ligament lesion intervention of the ACL was performed during arthroscopy and anterolateral ligament (ALL) section was performed as a capsular incision. Pivot-shift test examination was recorded with dRSA on ligament intact knees, ACL-deficient knees and ACL+ALL-deficient knees. A Pivot-shift pattern was identifyable after ligament lesion as a change in tibial posterior drawer velocity from 7.8 mm/s in ligament intact knees, to 30.4 mm/s after ACL lesion, to 35.1 mm/s after combined ACL-ALL lesion. The anterior-posterior drawer excursion increased from 2.8 mm in ligament intact knees, to 7.2 mm after ACL lesion, to 7.6 mm after combined lesion. Furthermore a change in tibial rotation was found, with increasing external rotation at the end of the pivot-shift motion going from intact to ACL+ALL-deficient knees. This experimental study demonstrates the feasibility of RSA to objectively quantify the kinematic instability patterns of the knee during the Pivot-shift test. The dynamic parameters found through RSA displayed the kinematic changes from ACL to combined ACL-ALL ligament lesion

In this study, we evaluated the labrum tear using radial sequence 3D Multiple Echo Recombined Gradient Echo (MERGE) MRI without arthrography based on modified Czerny's classification, comparing with actual arthroscopic findings. A total of 61 hips including 27 hips of femoroacetabular impingement (FAI), 19 hips of borderline development dysplasia of the hip (BDDH) and 15 hips of early stage osteoarthritis (OA) were enrolled this retrospective study. MRI findings evaluated in each three regions of interest; anterior region, anterolateral region, and lateral region. The cases with severe degeneration that is not concordant with any original Czerny's classification is defined as stage4. We compared MRI findings with arthroscopic findings and calculated the sensitivity, specificity, and likelihood ratio in terms of the existence of labrum tear. MRI findings revealed labrum tear more frequently in anterolateral than lateral (p<0.001). Especially in FAI group, labrum tear was more frequently observed by MRI in anterolateral than lateral (p=0.006). In comparison with MRI findings and arthroscopic findings, the sensitivity was 97%, specificity was 79% and likelihood ratio was 4.59 as average of all regions in terms of the existence of labrum tear. In each region, sensitivity and specificity was 97% and 50% in anterior, 97% and 100% specificity in anterolateral, 94% and 81% in lateral, respectively. Thus, MERGE MRI revealed excellent sensitivity and specificity for diagnosis of labrum tear, especially in anterolateral region. The cases with severely degenerated labrum were classified as newly defined stage 4, which was recognized frequently in OA cases

Several studies have evaluated the risk of peroneal nerve (PN) injuries in all-inside lateral meniscal repair using standard knee magnetic resonance imaging (MRI) with the 30 degrees flexed knee position which is different from the knee position during actual arthroscopic lateral meniscal repair. The point of concern is “Can the risk of PN injury using standard knee MRIs be accurately determined”. To evaluate and compare the risk of PN injury in all-inside lateral meniscal repair in relation to both borders of the popliteus tendon (PT) using MRIs of the two knee positions in the same patients. Using axial MRI studies with standard knee MRIs and figure-of-4 with joint fluid dilatation actual arthroscopic lateral meniscal repair position MRIs, direct lines were drawn simulating a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the PT. The distance from the tip of each line to the PN was measured. If a line touched or passed the PN, a potential risk of iatrogenic injury was noted and a new line was drawn from the same portal to the border of the PN. The danger area was measured from the first line to the new direct line along the joint capsule. In 28 adult patients, the closest distances from each line to the PN in standard knee MRI images were significantly shorter than arthroscopic position MRI images (all p-values < 0.05). All danger areas assessed in the actual arthroscopic position MRIs were included within the danger areas as assessed by the standard knee MRIs. We found that the standard knee MRIs can be used to determine the risk of peroneal nerve injury in arthroscopic lateral meniscal repair, although the risks are slightly overestimated

Finite element analysis (FEA) has been applied for the biomechanical analysis of acetabular dysplasia, but not for biomechanical studies of periacetabular osteotomy (PAO) or those performing analysis taking into consideration the severity of acetabular dysplasia. This study aimed to perform biomechanical evaluation of changes in stress distribution following PAO and to determine the effect of the severity of developmental dysplasia of the hip (DDH) using three-dimensional FEA. A normal model was designed with a 25° center-edge (CE) angle and a 25° vertical-center-anterior margin (VCA) angle. DDH models were designed with CE and VCA angles each of 10, 0, or −10°. Post-PAO models were created by separating each DDH model and rotating the acetabular bone fragment in the anterolateral direction so that the femoral head was covered by the acetabular bone fragment, with CE and VCA angles each at 25°. Compared to the normal hip joint model, the DDH models showed stress concentration in the acetabular edge and contacting femoral head, and higher stress values; stress increased with decreasing CE and VCA angles. Compared to the DDH models, the post-PAO models showed near-normal patterns of stress distribution in the acetabulum and femoral head, with stress concentration areas shifted from the lateral to medial sides. Stress dispersion was especially apparent in the severe acetabular dysplasia models. PAO provided greater decreases in the maximum values of von Mises stress in the load-bearing area of the acetabulum and femoral head when applied to the DDH models of higher degrees of severity, although the values increased with increasing severity of DDH. PAO is expected to provide biomechanical improvement of the hip joint, although the results also suggest a limitation in the applicability of PAO for the patients with severe acetabular dysplasia

Introduction. Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach. Methods. The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach, following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. The talus was disarticulated and high resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid with a perpendicular surgical blade was documented. ImageJ software was used to calculate the surface area exposed with each approach. Results. The mean percentage area of talar dome available through the transligamentous approach was 77.3 % (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1,2, 3,5 & 6 with partial access to Zones 4,8 & 9. Conclusion. The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zone 4 and Zone 7, the posteromedial corner

Hip abductor tears(AT) have long been under-recognized, under-reported and under-treated. There is a paucity of data on the prevalence, morphology and associated factors. Patients with “rotator cuff tears of the hip” that are recognized and repaired during total hip arthroplasty(THA) report comparable outcomes to patients with intact abductor tendons at THA. The study was a retrospective review of 997 primary THA done by a single surgeon from 2012–2022. Incidental findings of AT identified during the anterolateral approach to the hip were documented with patient name, gender, age and diagnosis. The extent and size of the tears of the Gluteus medius and Minimus were recorded. Xrays and MRI's were collected for the 140 patients who had AT and matched 1:1 with respect to age and gender against 140 patients that had documented good muscle quality and integrity. Radiographic measurements (Neck shaft angle, inter-teardrop distance, Pelvis width, trochanteric width and irregularities, bodyweight moment arm and abductor moment arm) were compared between the 2 groups in an effort to determine if any radiographic feature would predict AT. The prevalence of AT were 14%. Females had statistically more tears than males(18vs10%), while patients over the age of 70y had statistically more tears overall(19,7vs10,4%), but also more Gluteus Medius tears specifically(13,9vs5,3%). Radiographic measurements did not statistically differ between the tear and control group, except for the presence of trochanteric irregularities. MRI's showed that 50% of AT were missed and subsequently identified during surgery. Abductor tears are still underrecognized and undertreated during THA which can results in inferior outcomes. The surgeon should have an high index of suspicion in elderly females with trochanteric irregularities and although an MRI for every patient won't be feasible, one should always be prepared and equipped to repair the abductor tendons during THA

Abstract. Introduction. Anterolateral procedures can reduce the risk of re-rupture after ACL reconstruction in high risk patients however, this effectiveness has never been evaluated in elite athletes. The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis in reducing revision rates in ACL reconstructions in elite athletes. Methodology. A consecutive cohort of elite athletes between 2005 and 2018 undergoing ACLR reconstruction with or without modified Lemaire lateral extra-articular tenodesis were analysed. A minimum of 2 years of follow-up was required. The association between the use of LET and ACL graft failure was evaluated with univariate and multivariate logistic regression models. Results. 455 elite athletes (83% male; 22.5±4.7 years) underwent primary ACL reconstruction with (n=117) or without (n=338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACL reconstruction reduced the risk of graft failure by 2.8 times with 16.5 athletes needing to be treated with LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (RR=0.325; p=.029) as compared to ACL reconstruction alone after controlling for age at ACL reconstruction and gender. Including graft type in the model did not significantly change the risk profile. Conclusion. The addition of LET in elite athletes undergoing primary ACL reconstruction reduced the risk of undergoing revision by 2.8 times

There is controversy regarding the effect of different approaches on recovery after THR. Collecting detailed relevant data with satisfactory compliance is difficult. Our retrospective observational multi-center study aimed to find out if the data collected via a remote coaching app can be used to monitor the speed of recovery after THR using the anterolateral (ALA), posterior (PA) and the direct anterior approach (DAA). 771 patients undergoing THR from 13 centers using the moveUP platform were identified. 239 had ALA, 345 DAA and 42 PA. There was no significant difference between the groups in the sex of patients or in preoperative HOOS Scores. There was however a significantly lower age in the DAA (64,1y) compared to ALA (66,9y), and a significantly lower Oxford Hip Score in the DAA (23,9) compared to PA(27,7). Step count measured by an activity tracker, pain killer and NSAID use was monitored via the app. We recorded when patients started driving following surgery, stopped using crutches, and their HOOS and Oxford hip scores at 6 weeks. Overall compliance with data request was 80%. Patients achieved their preoperative activity level after 25.8, 17,7 and 23.3 days, started driving a car after 33.6, 30.3 and 31.7 days, stopped painkillers after 27.5, 20.2 and 22.5 days, NSAID after 30.3, 25.7, and 24.7 days for ALA, DAA and PA respectively. Painkillers were stopped and preoperative activity levels were achieved significantly earlier favoring DAA over ALA. Similarly, crutches were abandoned significantly earlier (39.9, 29.7 and 24.4 days for ALA, DAA and PA respectively) favoring DAA and PA over ALA. HOOS scores and Oxford Hip scores improved significantly in all 3 groups at 6 weeks, without any statistically significant difference between groups in either Oxford Hip or HOOS subscores. No final conclusion can be drawn as to the superiority of either approach in this study but the remote coaching platform allowed the collection of detailed data which can be used to advise patients individually, manage expectations, improve outcomes and identify areas for further research

Introduction. Total hip arthroplasty (THA) is indicated in independently mobile patients sustaining displaced intracapsular hip fractures. Studies presently suggest that the anterolateral approach is preferable to the posterior approach due to a perceived reduced risk of reoperations and dislocations. However, these observations come from small studies with short follow-up. We assessed whether surgical approach in THA performed for hip fractures effects outcomes. Patients and Methods. A retrospective observational study was performed using data collected prospectively by the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. All primary stemmed THAs implanted for hip fractures between 2003–2015 were eligible for inclusion (n=19,432). The two surgical approach groups (posterior versus anterolateral) were propensity-score matched for multiple potential patient and surgical confounding factors (n=14,536, with 7,268/group). Outcomes (implant survival, patient survival, intraoperative complications) were compared between the approach groups using regression analysis. Results. Five-year implant survival rates were similar between posterior and anterolateral approaches (97.3% vs. 97.4%; sub-hazard ratio (SHR)=1.15 (95% CI 0.93–1.42)). Five-year implant survival rates free from revision for dislocation (SHR=1.28 (CI=0.89–1.84)) and free from revision for periprosthetic fracture (SHR=1.03 (CI=0.68–1.56)) were also comparable. Thirty-day patient survival was significantly higher with a posterior approach (99.5% vs. 98.8%; hazard ratio (HR)=0.44 (CI=0.30–0.64)), which persisted at 1-year (HR=0.73 (CI=0.64–0.84)) and 5-years (HR=0.87 (CI=0.81–0.94)). The posterior approach had a lower risk of intraoperative complications (odds ratio=0.59 (CI=0.45–0.78)). Discussion. This is the largest study assessing the influence of surgical approach on outcomes following THA performed for hip fractures. In THA for hip fractures, the posterior approach had a similar risk of revision, and a lower risk of mortality and intraoperative complications compared with the anterolateral approach. Conclusion. We propose that the posterior approach is safer than the anterolateral approach when performing THA for hip fractures and should be preferred where possible

Introduction. Snapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome. Materials & Methods. A systematic review looking at published surgical management of snapping hip was performed according to PRISMA guidelines. PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Library databases were searched for “((Snapping hip OR Iliotibial band syndrome OR ITB syndrome) AND (Management OR treatment))”. Adult and paediatric published studies were included as few results were found on paediatric snapping hip alone. Results. 1548 studies were screened by 2 independent reviewers. 8 studies were included with a total of 134 cases, with an age range of 14–71 years. Surgical management ranged from arthroscopic, open or ultrasound guided release of the ITB, as well as gluteal muscle releases. Common outcome measures showed statistically significant improvement pre- and post-operatively in visual analogue pain score (VAPS) and the Harris Hip Score (HHS). VAPS improved from an average of 6.77 to 0.3 (t-test p value <0.0001) and the HHS improved from an average of 62.6 to 89.4 (t-test p value <0.0001). Conclusions. Although good surgical outcomes have been reported, no study has reported on the effect of rotational profile of the lower limbs and snapping hip syndrome. We present the case of a 13-year-old female with snapping hip syndrome and trochanteric pain. Ultrasound confirmed external snapping hip with normal soft tissue morphology and radiographs confirmed no structural abnormalities. Following extensive physiotherapy and little improvement, she presented again aged 17 with concurrent anterior knee pain, patella mal-tracking and an asymmetrical out-toeing gait. CT rotational profile showed 2° of femoral neck retroversion and excessive external tibial torsion of 52°. Consequently, during her gait cycle, in order to correct her increased foot progression angle, the hip has to internally rotate approximately 35–40°, putting the greater trochanter in an anterolateral position in stance phase. This causes the ITB to snap over her abnormally positioned greater trochanter. Therefore, to correct rotational limb alignment, a proximal tibial de-rotation osteotomy was performed with 25° internal rotation correction. Post-operatively the patient recovered well, HHS score improved from 52.5 to 93.75 and her snapping hip has resolved. This study highlights the importance of relevant assessment and investigation of lower limb rotational profile when exploring causes of external snapping hip, especially where ultrasound and radiographs show no significant pathology

Aims. Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Methods. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. Results. The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. Conclusion. The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J 2021;103-B(6):1160–1167

Femoroacetabular impingement (FAI) – enlarged, aspherical femoral head deformity (cam-type) or retroversion/overcoverage of the acetabulum (pincer-type) – is a leading cause for early hip osteoarthritis. Although anteverting/reverse periacetabular osteotomy (PAO) to address FAI aims to preserve the native hip and restore joint function, it is still unclear how it affects joint mobility and stability. This in vitro cadaveric study examined the effects of surgical anteverting PAO on range of motion and capsular mechanics in hips with acetabular retroversion. Twelve cadaveric hips (n = 12, m:f = 9:3; age = 41 ± 9 years; BMI = 23 ± 4 kg/m2) were included in this study. Each hip was CT imaged and indicated acetabular retroversion (i.e., crossover sign, posterior wall sign, ischial wall sign, retroversion index > 20%, axial plane acetabular version < 15°); and showed no other abnormalities on CT data. Each hip was denuded to the bone-and-capsule and mounted onto a 6-DOF robot tester (TX90, Stäubli), equipped with a universal force-torque sensor (Omega85, ATI). The robot positioned each hip in five sagittal angles: Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°; and performed hip internal-external rotations and abduction-adduction motions to 5 Nm in each position. After the intact stage was tested, each hip underwent an anteverting PAO, anteverting the acetabulum and securing the fragment with long bone screws. The capsular ligaments were preserved during the surgery and each hip was retested postoperatively in the robot. Postoperative CT imaging confirmed that the acetabular fragment was properly positioned with adequate version and head coverage. Paired sample t-tests compared the differences in range of motion before and after PAO (CI = 95%; SPSS v.24, IBM). Preoperatively, the intact hips with acetabular retroversion demonstrated constrained internal-external rotations and abduction-adduction motions. The PAO reoriented the acetabular fragment and medialized the hip joint centre, which tightened the iliofemoral ligament and slackenend the pubofemoral ligament. Postoperatively, internal rotation increased in the deep hip flexion positions of Flexion 60° (∆IR = +7°, p = 0.001) and Flexion 90° (∆IR = +8°, p = 0.001); while also demonstrating marginal decreases in external rotation in all positions. In addition, adduction increased in the deep flexion positions of Flexion 60° (∆ADD = +11°, p = 0.002) and Flexion 90° (∆ADD = +12°, p = 0.001); but also showed marginal increases in abduction in all positions. The anteverting PAO restored anterosuperior acetabular clearance and increased internal rotation (28–33%) and adduction motions (29–31%) in deep hip flexion. Restricted movements and positive impingement tests typically experienced in these positions with acetabular retroversion are associated with clinical symptoms of FAI (i.e., FADIR). However, PAO altered capsular tensions by further tightening the anterolateral hip capsule which resulted in a limited external rotation and a stiffer and tighter hip. Capsular tightness may still be secondary to acetabular retroversion, thus capsular management may be warranted for larger corrections or rotational osteotomies. In efforts to optimize surgical management and clinical outcomes, anteverting PAO is a viable option to address FAI due to acetabular retroversion or overcoverage

Adequate perpendicular access to the posterolateral talar dome for osteochondral defect repair is difficult to achieve and a number of different surgical approaches have been described. This cadaveric study examined the exposure available from various approaches to help guide pre-operative surgical planning. Four surgical approaches were performed in a step-wise manner on 9 Thiel-embalmed cadavers; anterolateral approach with arthrotomy, anterolateral approach with anterior talo-fibular ligament (ATFL) release, anterolateral approach with antero-lateral tibial osteotomy, and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly which allowed perpendicular access with a 2mm k-wire to the lateral surface of the talar dome was measured from the anterior aspect of the talar dome. The mean antero-posterior diameter of the lateral talar domes included in this study was 45.1mm. An anterolateral approach to the ankle with arthrotomy provided a mean exposure of the anterior 1/3rd of the lateral talar dome. ATFL release increased this to 43.2%. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy. Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome and is recommended for lesions affecting the posterior half of the lateral talar dome

There is an increased risk of fracture following osteoplasty of the femoral neck for cam-type femoroacetabular impingement (FAI). Resection of up to 30% of the anterolateral head–neck junction has previously been considered to be safe, however, iatrogenic fractures have been reported with resections within these limits. We re-evaluated the amount of safe resection at the anterolateral femoral head–neck junction using a biomechanically consistent model. In total, 28 composite bones were studied in four groups: control, 10% resection, 20% resection and 30% resection. An axial load was applied to the adducted and flexed femur. Peak load, deflection at time of fracture and energy to fracture were assessed using comparison groups. There was a marked difference in the mean peak load to fracture between the control group and the 10% resection group (p < 0.001). The control group also tolerated significantly more deflection before failure (p < 0.04). The mean peak load (p = 0.172), deflection (p = 0.547), and energy to fracture (p = 0.306) did not differ significantly between the 10%, 20%, and 30% resection groups. . Any resection of the anterolateral quadrant of the femoral head–neck junction for FAI significantly reduces the load-bearing capacity of the proximal femur. After initial resection of cortical bone, there is no further relevant loss of stability regardless of the amount of trabecular bone resected. Based on our findings we recommend any patients who undergo anterolateral femoral head–neck junction osteoplasty should be advised to modify their post-operative routine until cortical remodelling occurs to minimise the subsequent fracture risk. Cite this article: Bone Joint J 2015;97-B:1214–19

The direct lateral (or anterolateral) approaches to the hip for revision THA involve detachment of the anterior aspect of the gluteus medius from the trochanter along with a contiguous sleeve of the vastus lateralis. Anterior retraction of this flap of gluteus medius and vastus lateralis and simultaneous posterior retraction of the femur creates an interval for division of gluteus minimus and deeper capsular tissues and exposure of the joint. To enhance reattachment of this flap of the anterior portion of the gluteus medius and vastus lateralis back to the trochanter, an oblique wafer of bone can be elevated along with the muscle off of the anterolateral portion of the trochanter. This bony wafer prevents suture pull out when large nonabsorbable sutures are used around or through the fragment and passed into the bone of the trochanteric bed for reattachment during closure. To prevent excessive splitting proximally into the gluteus medius muscle (and resulting damage to the superior gluteal nerve), it is often helpful to extend the muscle split further distally down into the vastus lateralis. This combined with careful elevation of the gluteal muscles off of the ilium (instead of splitting them) helps provide excellent and safe exposure of the entire rim of the acetabulum and access to the supracetabular region for bone grafting, acetabular augment placement and even fixation of the flanges of a cage. A simple method for posterior column plating via the anterolateral approach involves contouring of the distal end of the plate around the base of the ischium at the inferior edge of the socket. When an extended osteotomy of the femur is needed to correct deformity, remove a well-fixed implant or cement, the “extensile” variation of this same surgical approach involves a Wagner style (lateral to medial) osteotomy of the greater trochanter and proximal femur. The anterior portion of the femur after it is osteotomised is elevated as a separate segment while maintaining the soft tissue attachments to the bone as much as possible to aid osteotomy healing. After implant or cement removal, this approach gives excellent direct access to the distal femur for placement of a long stem revision femoral component without bone-implant conflict proximally because of the bow of the femur. The anterolateral approach (and extensile variants detailed above) can be used routinely and safely in the full range of revision THA procedures, or it can be employed selectively, if desired, in cases at increased risk for dislocation

Aims. The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications. Methods. Between September 2014 and July 2017, 25 patients with symptomatic osteochondritis of the talus and an osteochondral fragment, who were treated using bone peg fixation, were analyzed retrospectively. All were available for complete follow-up at a mean 22 of months (12 to 35). There were 15 males and ten females with a mean age of 19.6 years (11 to 34). The clinical results were evaluated using a visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and at the final follow-up. The radiological results were evaluated using classification described by Hepple et al based on the MRI findings, the location of the lesion, the size of the osteochondral fragment, and the postoperative healing of the lesion. Results. The mean VAS and AOFAS score improved significantly from 6.3 (4 to 8) and 70.6 (44 to 78) preoperatively to 1.6 (0 to 5) and 91.1 (77 to 100) at the final follow-up, respectively (p < 0.001). The classification on MRI was stage 2a in nine patients, stage 3 in 14, and stage 4 in two. The lesion was located on the posteromedial aspect of the dome of the talus in 19 patients, the anterolateral aspect in five, and the centrolateral aspect in one. The mean size of the fragment was 11.2 mm (5 to 20) horizontally, 10.4 mm (7 to 18) vertically, and 5.2 mm (3 to 10) deep, respectively. The postoperative healing state was good in 19 patients and fair in six. Conclusion. Bone peg fixation for osteochondral lesions of the talus showed satisfactory clinical and radiographic results, without complications. This technique could be a good form of treatment for patients with this condition who have an osteochondral fragment. Cite this article: Bone Joint J 2020;102-B(10):1349–1353

Aim. Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years. Method. One-hundred sixty-seven patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 49 patients. Of these, seven presented with extensor apparatus deficiency. Results. One patient underwent primary arthrodesis and six patients underwent autologous reconstruction of the extensor apparatus. The principle to reconstruct missing tissue ‘like with like’ was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and three patients received a pedicled medial sural artery perforator gastrocnemius flap, of which one with Achilles tendon. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo knee arthrodesis because of recurrent infection and one patient was lost to follow-up. In parts, results have been published under doi: 10.7150/jbji.47018. Conclusions. A treatment concept and its rationale, based on a single-centre experience, is presented. It differentiates between various types of soft-tissue defects and shows reconstructive options following the concept to reconstruct ‘like with like’. Despite good results 1 year postoperatively, PJI of the knee with extensor apparatus deficiency remains a dreaded combination with a poor long-term outcome

A complete cement mantle is important for the longevity of a total hip replacement. In the minimally-invasive direct anterior approach used at the Innsbruck University hospital, the femoral component has to be inserted into the femoral canal by an angulated movement. In a cadaver study, the quality and the extent of the cement mantle surrounding 13 Exeter femoral components implanted straight through a standard anterolateral transgluteal approach were compared with those of 13 similar femoral components implanted in an angulated fashion through a direct anterior approach. A third-generation cementing technique was used. The inner and outer contours of the cement mantles was traced from CT scans and the thickness and cross-sectional area determined. In no case was the cement mantle incomplete. The total mean thickness of the cement mantle was 3.62 mm (95% confidence interval 3.59 to 3.65). The mean thickness in the group using the minimally-invasive approach was 0.16 mm less than that in the anterolateral group. The distribution of the thickness was similar in the two groups. The mean thickness was less on the anteromedial and anterolateral aspect than on the posterior aspect of the femur. There is no evidence that the angulated introduction of Exeter femoral components in the direct anterior approach in cadavers compromises the quality, extent or thickness of the cement mantle

Aims. Of growing concern in arthroplasty is the emergence of atypical infections, particularly Cutibacterium (formerly Propionibacterium) sp. infections. Currently, the dermal colonization rate of Cutibacterium about the hip is unknown. Therefore, the aim of this study was to investigate colonization rates of Cutibacterium sp. at locations approximating anterior and posterolateral approaches to the hip joint. Methods. For this non-randomized non-blinded study, 101 adult patients scheduled for hip or knee surgery were recruited. For each, four 3 mm dermal punch biopsies were collected after administration of anaesthesia, but prior to antibiotics. Prebiopsy skin preparation consisted of a standardized preoperative 2% chlorhexidine skin cleansing protocol and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two skin samples 10 cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10 cm apart were collected from a lateral skin incision (suitable for posterior, direct-lateral, or anterolateral approaches). Samples were cultured for two weeks using a protocol optimized for Cutibacterium. Results. A total of 23 out of 404 cultures (collected from 101 patients) were positive for a microorganism, with a total of 22 patients having a positive culture (22%). Overall, 15 of the cultures in 14 patients were positive for Cutibacterium sp. (65%), of which Cutibacterium acnes comprised the majority (n = 13; 87%). Other isolated microorganisms include coagulase-negative Staphylococcus (n = 6), Clostridium (n = 1), and Corynebacterium (n = 1). Of all positive cultures, 15 were obtained from the anterior location (65%), of which seven (60%) were from the most proximal biopsy location. However, these findings were not statistically significant (anterior vs lateral, p = 0.076; proximal vs distal, p =0.238). Conclusion. Approximately 14% (14/101) of the patients demonstrated a positive Cutibacterium colonization about the hip, the majority anteriorly. Given the high colonization rate of Cutibacterium, alternative skin preparations for total hip arthroplasty should be considered. Cite this article: Bone Joint J 2020;102-B(7 Supple B):52–56

Introduction and Objective. Heterotopic ossification is the formation of extraskeletal mineralized tissue commonly associated with either trauma or surgery. While several mouse models have been developed to better characterize the pathologic progression of HO, no model currently exists to study HO of the hip, the most common location of acquired HO in patients. Owing to the unique biological mechanisms underpinning the formation of HO in different tissues, we sought to develop a model to study the post-surgical HO of the hip. Materials and Methods. Wild-type mice C57BL/6J mice were used to study the procedure outcomes, while Pdgfra-CreERT2;mT/mG and Scx-GFP reporter animals were used for the lineage tracing experiments (total n=16 animals, male, 12 weeks old). An anterolateral approach to the hip was performed. Briefly, a 2 cm incision was made centered on the great trochanter and directed proximal to the iliac crest and distally over the lateral shaft of the femur. The joint was then reached following the intermuscular plane between the rectus femoris and gluteus medius muscles. After the joint was exposed, the articular cartilage was removed using a micropower drill with a 1.2 mm reamer. The medius gluteus and superficial fascia were then re-approximated with Vicryl 5-0 suture (Ethicon Inc, Somerville, NJ) and skin was then closed with Ethilon 5-0 suture (Ethicon Inc). Live high resolution XR imaging was performed every 2 wks to assess the skeletal tissues (Faxitron Bioptics, Tucson, AZ). The images were then scored using the Brooker classification. Ex-vivo microCT was conducted using a Skyscan 1275 scanner (Bruker-MicroCT, Kontich, Belgium). 3D reconstruction and analysis was performed using Dragonfly (ORS Inc., Montreal, Canada). For the histological analysis of specimens, Hematoxylin and Eosin (H&E), modified Goldner's Trichrome (GMT) stainings were performed. Reporter activity was assessed using fluorescent imaging. Results. Substantial periarticular heterotopic bone was seen in all cases. A periosteal reaction and an initial formation of calcified tissue within the soft tissue was apparent starting from 4 wks after surgery. By XR, progressive bone formation was observed within the periosteum and intermuscular planes during the subsequent 8 weeks. Stage 1 HO was observed in 12.5% of cases, stage 2 in 62.5% of cases, and stage 3 HO in 25% of cases. 3D microCT reconstructions of the treated hip joints demonstrated significant de novo heterotopic bone in several location which phenocopy human disease. Heterotopic bone was observed in an intracapsular location, periosteal location involving the iliac bone and proximal femur, and intermuscular locations. Histological analyses further confirmed these findings. To assess the cells which gave rise to HO in this model, an inducible PDGFRα and constitutive Scx-GFP reporter mice were used. A dramatic increase in mGFP reporter activity was noted PDGFRα within the HO injury site, including in areas of new cartilage and bone formation. Scx-associated reporter activity increased in the soft tissue and periosteal periacetabular areas of injured hips. Conclusions. HO has a diverse set of pathologies, of which joint associated HO after elective surgery is the most common. Here, we present the first mouse model of hip dislocation and acetabular reaming that mimics elements of human periarticular HO. The diverse locations of HO after acetabular reaming (intracapsular, intermuscular and periosteal) suggests the activation of different and specific HO program after surgery. Such a field effect would be consistent with local trauma and inflammation, which is a well-studied contributor to HO genesis. Not surprisingly, joint-associated HO significantly derives from PDGFRα-expressing cells, which has been shown to similarly give rise to intramuscular and intratendinous HO

Introduction. Osteomyelitis (OM) is a challenging condition to diagnose and treat. The multidisciplinary team (MDT) approach is used in managing complex diseases such as cancer and diabetes. The Hull Regional Bone Infection MDT team was established to provide coordinated care for patients suspected to have OM. This study reviews the orthoplastic treatment and outcomes of patients with non-periprosthetic OM. Materials and Methods. Retrospective review of patients presenting to the MDT team who had orthoplastic intervention with debridement and flap coverage between 1/6/2014 - 30/11/2018. We describe our MDT approach of assessment, planning for surgical intervention and antibiotic protocol. Data was obtained from electronic and paper patient records, and PACS. Results. Twenty-nine patients were identified (75.9% male). Mean age was 52.7 (23–82). Median duration of symptoms at surgery was 10 months (IQR 4.0–34.3). Cierny-Mader (CM) Host Type B. (L). (41.4%), type B. (S). (34.5%), and type B. (S+L). (17.2%). Twenty-four patients (82.8%) were CM anatomical class IV. Twenty-four patients (82.8%) had single-stage surgical treatment. Twenty-one patients received 23 free flaps. Anterolateral thigh flap (9/23) and gracilis muscle flap (7/23) were most commonly used. Tibialis anterior flap was the most commonly used local flap. Stimulan was used in 65.5%. Staphylococcus aureus was seen in 60% of patients. Mean follow-up time was 21 months (1–62). There were 2 (6.9%) OM recurrence. Both patients were CM anatomical class IV. Conclusions. Our study showed that our MDT management of patients with OM can achieve a low recurrence rate despite a high proportion of patients with severe OM. We recommend considering an MDT approach for these complex OM patients

Objectives. Indocyanine green (ICG) fluorescence angiography is an emerging technique that can provide detailed anatomical information during surgery. The purpose of this study is to determine whether ICG fluorescence angiography can be used to evaluate the blood flow of the rotator cuff tendon in the clinical setting. Methods. Twenty-six patients were evaluated from October 2016 to December 2017. The participants were categorized into three groups based on their diagnoses: the rotator cuff tear group; normal rotator cuff group; and adhesive capsulitis group. After establishing a posterior standard viewing portal, intravenous administration of ICG at 0.2 mg/kg body weight was performed, and fluorescence images were recorded. The time from injection of the drug to the beginning of enhancement of the observed area was measured. The hypovascular area in the rotator cuff was evaluated, and the ratio of the hypovascular area to the anterolateral area of the rotator cuff tendon was calculated (hypovascular area ratio). Results. ICG fluorescence angiography allowed for visualization of blood flow in the rotator cuff in all groups. The adhesive capsulitis group showed significantly earlier enhancement than the other groups. Furthermore, the adhesive capsulitis group had a significantly smaller hypovascular area ratio than the other groups. Conclusion. ICG fluorescence angiography allowed for evaluation of real-time blood flow of the rotator cuff in arthroscopic shoulder surgery. The techniques of ICG fluorescence angiography are simple and easy to observe, observer reliability is high, and it has utility for evaluating blood flow during surgery. Cite this article: N. Doi, T. Izaki, S. Miyake, T. Shibata, T. Ishimatsu, Y. Shibata, T. Yamamoto. Intraoperative evaluation of blood flow for soft tissues in orthopaedic surgery using indocyanine green fluorescence angiography: A pilot study. Bone Joint Res 2019;8:118–125. DOI: 10.1302/2046-3758.83.BJR-2018-0151.R1

Aims. A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications. Patients and Methods. The electronic medical records of all patients who underwent primary elective THA at a single large-volume arthroplasty centre, between 2011 and 2016, with at least two years of follow-up, were reviewed. After exclusion, 3574 consecutive patients were included in the study. There were 1571 men (44.0%) and 2003 women (56.0%). Their mean age and body mass index (BMI) was 63.0 years (. sd. 11.8) and 29.1 kg/m. 2. (. sd. 6.1), respectively. Data gathered included the age of the patient, BMI, the American Society of Anesthesiologists (ASA) score, estimated blood loss (EBL), length of stay (LOS), operating time, the presence of intra- or postoperative complications, type of complication, and the surgical approach. The approaches used during the study were posterior, anterior, direct lateral, anterolateral, and the northern approach. The complications that were recorded included prolonged wound drainage without infection, superficial infection, deep infection, dislocation, aseptic loosening, and periprosthetic fracture. Finally, the need for re-operation was recorded. Means were compared using analysis of variance (ANOVA) and Student’s t-tests where appropriate and proportions were compared using the chi-squared test. Results. A total of 248 patients had 263 complications related to the surgery, with an incidence of 6.94%. The anterior approach had the highest incidence of complications (8.5% (113/1329)) and the posterior approach had the lowest, at 5.85% (97/1657; p = 0.006). Most complications were due to deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%). The rate of dislocation was 0.84% (14/1657) with the posterior approach and 1.28% (17/1329) with the anterior approach (p = 0.32). Conclusion. Overall, THA has a relatively low complication rate. However, the surgical approach plays a role in the incidence of complications. We found that the posterior approach had a significantly lower overall complication rate compared with the anterior approach, with an equal dislocation rate. Periprosthetic fracture and surgical site infection contributed most to the early complication rates. Cite this article: Bone Joint J 2019;101-B:646–651

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. . The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

The posterior approach to the hip avoids violating abductors and has presumed functional advantages. The anterolateral approach risks abductor damage, but has reportedly lower dislocation rate. To determine effects of surgical approach on function and dislocation after primary and revision THR 3274 primary THRs and 66 first time revision THRs were investigated from the arthroplasty database (2000–2008). 2682 (82%) primary THRs were via anterolateral approach, 592 (18%) by posterior. Post primary dislocation rate was 50/2682 (1.9%) for anterolateral and 26/592 (4.4%) for posterior. Posterior approach had significantly better Harris Hip Scores: 91 vs 88 (P = 0.000) and function: 40 vs 37 (P = 0.000). Of the 66 revisions THRs, 30 were anterolateral and 36 posterior. Dislocation rates were 2/30 (6.7%) and 4/36 (11.1%) respectively. There was no significant difference in Harris Hip Score or Harris Hip Function 1 year after revision based on revision surgery approach. However there was a significant difference in Harris Hip Function 1 year after revision based on the approach for primary surgery (Anterolateral 30 vs Posterior 37, P=0.008) and a similar trend in Harris Hip Score (Anterolateral 79 vs Posterior 85, P = 0.198) and patients who had posterior approach for both primary and revision had the best scores overall. The clinical relevance of the modest, but statistically significant difference in Harris hip score after primary THR is unclear. That primary approach has an impact on function after revision suggests the posterior approach should be considered in younger patients likely to require revision in the future

Abstract. Objectives. Three-dimensional visualisation of sonographic callus has the potential to improve the accuracy and accessibility of ultrasound evaluation of fracture healing. The aim of this study was to establish a reliable method for producing three-dimensional reconstruction of sonographic callus. Methods. A prospective cohort of ten patients with a closed tibial shaft fracture managed with intramedullary nailing were recruited and underwent ultrasound scanning at 2-, 6- and 12-weeks post-surgery. Ultrasound B-mode capture was performed using infrared tracking technology to map each image to a three-dimensional lattice. Using echo intensity, semi-automated mapping was performed by two independent reviewers to produce an anatomic three-dimensional representation of the fracture. Agreement on the presence of sonographic bridging callus on three-dimensional reconstructions was assessed using the kappa coefficient. Results. Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus at ≥1 cortex on the three-dimensional reconstruction; when present all united. Compared to radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8%-sensitive and 100%-specific to predict union). At twelve weeks, nine patients had bridging callus at ≥1 cortex on three-dimensional reconstruction and all united (100%-sensitive and 100%-specific to predict union). Compared to radiographs, seven of the nine patients that united had bridging callus. Three-dimensional reconstruction of the anteromedial and anterolateral tibial surface was achieved in all patients, and detection of sonographic bridging callus on the three-dimensional reconstruction demonstrated substantial inter-observer agreement (kappa=0.78, 95% confidence interval 0.29–1.0, p=0.011). Conclusions. Three-dimensional fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to identify impaired healing at an early stage in fracture management. 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

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. We compared the changes in femoral head oxygenation resulting from the posterior approach to those resulting from the anterolateral approach and the trochanteric flip approach. Methods: In 37 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted superolaterally in the femoral head via the femoral neck following division of the fascia lata. Inter-operative X-ray confirmed correct electrode placement. Baseline oxygen concentration levels were recorded immediately after electrode insertion. All results were expressed relative to this baseline, which was considered as 100% relative oxygen concentration. Oxygen levels were monitored continuously throughout the operation. 10 patients underwent surgery through the posterior approach, 12 patients through the anterolateral approach and 15 through the trochanteric flip approach. Results: A similar pattern of intra-operative reduction in femoral oxygen concentration was observed for all reviewed approaches. The average change in oxygen concentration during surgery through the trochanteric flip approach was found to be significantly less than through posterior (p< 0.02) and anterolateral (p< 0.02) approaches. Oxygen concentration following joint relocation and soft tissue reconstruction recovered significantly in the anterolateral and trochanteric flip group only. The posterior approach resulted in significantly lower oxygen concentration at the end of the procedure (22%, SD 31) than the anterolateral approach (123%, SD 99; p< 0.05) and the trochanteric flip approach (89%, SD 62, p< 0.02). Discussion and Conclusion: The anterolateral and trochanteric flip approaches disrupt the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The most consistent intra-operative oxygen levels were observed during surgery through the trochanteric flip approach. Oxygen concentration during the anterolateral approach was found to be highly dependent upon leg position. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches

Introduction. There is little information available to surgeons regarding how the lateral soft-tissue structures prevent instability in knees implanted with total knee arthroplasty (TKA). The aim of this study was to quantify the lateral soft-tissue contributions to stability following cruciate retaining (CR) TKA. Methods. Nine cadaveric knees with CR TKA implants (PFC Sigma; DePuy Synthes Joint Reconstruction) were tested in a robotic system (Fig. 1) at full extension, 30°, 60°, and 90° flexion angles. ±90 N anterior-posterior force, ±8 Nm varus-valgus and ±5 Nm internal-external torque were applied at each flexion angle. The anterolateral structures (ALS, including the iliotibial band, anterolateral ligament and anterolateral capsule), the lateral collateral ligament (LCL), the popliteus tendon complex (Pop T) and the posterior cruciate ligament (PCL) were then sequentially transected. After each transection the kinematics obtained from the original loads were replayed, and the decrease in force / moment equated to the relative contributions of each soft-tissue to stabilising the applied loads. Results. In the CR TKA knee, the LCL was found to be the primary restraint to varus laxity (Fig. 2, an average 56% across all flexion angles), and was significant in internal-external rotational stability (28% and 26% respectively) and anterior drawer (16%). The ALS restrained 25% of internal rotation (Fig. 3), whilst the PCL was significant in posterior drawer only at 60° and 90° flexion. The Pop T was not found to be significant in any tests. Conclusion. This study has for the first time delineated the relative contributions of lateral structures to stability in the implanted knee. It was confirmed that the LCL is the major lateral structure in CR TKA stability throughout the arc of flexion. In the event of LCL deficiency, stability of the knee may only be restored by either changing to a more constrained implant or performing a reconstruction of the ligament. Furthermore, care should be taken when releasing the LCL to correct a valgus deformity as it may result in a combined rotational laxity pattern that cannot be overcome by the other passive lateral structures or the PCL. For figures, please contact authors directly

Aims. To assess the accuracy of posterior and anterolateral methods of injection into the subacromial space (SAS) of the shoulder. Patients and methods. Ethical approval was obtained and 50 patients (23 women and 27 men) with mean age of 64.5 years (42-87 years) and clinical diagnosis of subacromial impingement were recruited. Patients with old or recent shoulder fracture, bleeding disorders, and allergy to iodine were excluded. All injections were given by the consultant or an experienced registrar after obtaining informed consent. Patients were randomised into posterior and anterolateral groups and the method of injection was revealed by opening sealed envelopes just before the injection. A combination of 3mls 0.5% bupivacaine and 2mls of radiographic dye (Niopam) was injected in the subacromial space (SAS) using either anterolateral (n-22) and posterior approaches (28). AP and lateral radiographs of shoulder were taken after injection and were reported by a Consultant Radiologist blinded to the method of injection. Visual analogue scale (VAS) and Constant-Murley shoulder score was used to assess pain and function respectively. Both scores were determined before and 30 minutes after the injection. Results. 22 injections (78.5%) were accurately placed in SAS with the posterior approach and in 14 patients (63.6%) with anterolateral approach. This difference was statistically significant (P< 0.05). Only patients who received injection accurately in SAS with either method had a reduction in pain of an average of 4 points on VAS, and improvement in the Constant score of average 14 points. Conclusions. The posterior approach of SAS injection is more accurate than anterolateral approach. Injections that are correctly placed in the SAS lead to better reduction of pain and improvement in the Constant score

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries