Aims. Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. Methods. The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection. Conclusion. The results of this trial will demonstrate if there is a difference in shoulder pain and function after a subacromial space steroid injection between the anterolateral versus posterior approach in patients with subacromial pain syndrome. This will help to guide treatment for patients with subacromial pain syndrome. Cite this article: Bone Jt Open 2024;5(9):729–735

Aims. The aim of this study was to radiologically evaluate the quality of cement mantle and alignment achieved with a polished tapered cemented femoral stem inserted through the anterior approach and compared with the posterior approach. Methods. A comparative retrospective study of 115 consecutive hybrid total hip arthroplasties or cemented hemiarthroplasties in 110 patients, performed through anterior (n = 58) or posterior approach (n = 57) using a collarless polished taper-slip femoral stem, was conducted. Cement mantle quality and thickness were assessed in both planes. Radiological outcomes were compared between groups. Results. No significant differences were identified between groups in Barrack grade on the anteroposterior (AP) (p = 0.640) or lateral views (p = 0.306), or for alignment on the AP (p = 0.603) or lateral views (p = 0.254). An adequate cement mantle (Barrack A or B) was achieved in 77.6% (anterior group, n = 45) and in 86% (posterior group, n = 49), respectively. Multivariate analysis revealed factors associated with unsatisfactory cement mantle (Barrack C or D) included higher BMI, left side, and Dorr Type C morphology. A mean cement mantle thickness of ≥ 2 mm was achieved in all Gruen zones for both approaches. The mean cement mantle was thicker in zone 7 (p < 0.001) and thinner in zone 9 for the anterior approach (p = 0.032). Incidence of cement mantle defects between groups was similar (6.9% (n = 4) vs 8.8% (n = 5), respectively; p = 0.489). Conclusion. An adequate cement mantle and good alignment can be achieved using a collarless polished tapered femoral component inserted through the anterior approach. Cite this article: Bone Joint J 2021;103-B(7 Supple B):46–52

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

Introduction. Developmental dysplasia of the hip (DDH) can be managed through a variety of different surgical approaches from closed reduction to simple tenotomies of the adductors and through to osteotomies of the femur and pelvis. The rate of redislocation following open reduction for the treatment of DDH may be affected by the number of intraoperative surgeons. Materials and methods. We performed a retrospective cohort analysis of 109 patients who underwent open reduction with or without bony osteotomies as a primary intervention between 2013 and 2023. We measured the number of redislocations and number of operating surgeons (either 1 or 2 operating surgeons) to assess for any correlation. 109 patients were identified and corresponded to 121 primary hip operations, the mean age at operation was 82.2 months (range 6 to 739 months). During the 10-year period 7 hip redislocations were identified. Results. Of the 7 redislocated hips, the rate of redislocation was found to be higher in patients who had undergone surgery via a single surgeon (5 redislocations) compared to the dual surgeon cohort (2 redislocations), though this did not reach statistical significance. Redislocation was more common in female patients and right laterality 7.2% and 8.7% respectively, though this again did not reach statistical significance. Conclusions. We conclude that a single surgeon approach, female gender and right laterality are potential risk factors for redislocation following open reduction. Further investigation utilising a larger sample size would be required to appropriately explore these potential risk factors further

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. Methods. All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders. Results. In total, 3,902 rTSAs were included. A deltopectoral approach was used in 54% (2,099/3,902) and an anterosuperior approach in 46% (1,803/3,902). Overall, the mean age in the cohort was 75 years (50 to 96) and the most common indication for rTSA was cuff tear arthropathy (35%; n = 1,375), followed by osteoarthritis (29%; n = 1,126), acute fracture (13%; n = 517), post-traumatic sequelae (10%; n = 398), and an irreparable cuff rupture (5%; n = 199). The two high-volume centres performed the anterosuperior approach more often compared to the medium- and low-volume centres (p < 0.001). Of the 3,902 rTSAs, 187 were revised (5%), resulting in a five-year survival of 95.4% (95% confidence interval 94.7 to 96.0; 3,137 at risk). The most common reason for revision was a periprosthetic joint infection (35%; n = 65), followed by instability (25%; n = 46) and loosening (25%; n = 46). After correcting for relevant confounders, the revision rate for glenoid loosening, instability, and the overall implant survival did not differ significantly between the two approaches (p = 0.494, p = 0.826, and p = 0.101, respectively). Conclusion. The surgical approach used for rTSA did not influence the overall implant survival or the revision rate for instability or glenoid loosening. Cite this article: Bone Joint J 2023;105-B(9):1000–1006

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

Aims. The most effective surgical approach for total hip arthroplasty (THA) remains controversial. The direct anterior approach may be associated with a reduced risk of dislocation, faster recovery, reduced pain and fewer surgical complications. This systematic review aims to evaluate the current evidence for the use of this approach in THA. Materials and Methods. Following the Cochrane collaboration, an extensive literature search of PubMed, Medline, Embase and OvidSP was conducted. Randomised controlled trials, comparative studies, and cohort studies were included. Outcomes included the length of the incision, blood loss, operating time, length of stay, complications, and gait analysis. Results. A total of 42 studies met the inclusion criteria. Most were of medium to low quality. There was no difference between the direct anterior, anterolateral or posterior approaches with regards to length of stay and gait analysis. Papers comparing the length of the incision found similar lengths compared with the lateral approach, and conflicting results when comparing the direct anterior and posterior approaches. . Most studies found the mean operating time to be significantly longer when the direct anterior approach was used, with a steep learning curve reported by many. Many authors used validated scores including the Harris hip score, and the Western Ontario and McMaster Universities Arthritis Index. These mean scores were better following the use of the direct anterior approach for the first six weeks post-operatively. Subsequently there was no difference between these scores and those for the posterior approach. Conclusion . There is little evidence for improved kinematics or better long-term outcomes following the use of the direct anterior approach for THA. There is a steep learning curve with similar rates of complications, length of stay and outcomes. . Well-designed, multi-centre, prospective randomised controlled trials are required to provide evidence as to whether the direct anterior approach is better than the lateral or posterior approaches when undertaking THA. Cite this article: Bone JointJ 2017;99-B:732–40

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

Aims. The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional THA, and surgical approach on ligament function. Materials and Methods. Eight paired cadaveric hip joints were skeletonized but retained the hip capsule. Capsular ROM restraint during controlled internal rotation (IR) and external rotation (ER) was measured before and after HRA, DM-THA, and conventional THA, with a posterior (right hips) and anterior capsulotomy (left hips). Results. Hip resurfacing provided a near-native ROM with between 5° to 17° increase in IR/ER ROM compared with the native hip for the different positions tested, which was a 9% to 33% increase. DM-THA generated a 9° to 61° (18% to 121%) increase in ROM. Conventional THA generated a 52° to 100° (94% to 199%) increase in ROM. Thus, for conventional THA, the capsule function that exerts a limit on ROM is lost. It is restored to some extent by DM-THA, and almost fully restored by hip resurfacing. In positions of low flexion/extension, the posterior capsulotomy provided more normal function than the anterior, possibly because the capsule was shortened during posterior repair. However, in deep flexion positions, the anterior capsulotomy functioned better. Conclusion. Native head-size and capsular repair preserves capsular function after arthroplasty. The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments. Cite this article: Bone Joint J 2019;101-B:426–434

Aims. Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach. Methods. A comprehensive electronic search and quantitative data analysis from eligible studies were performed. Inclusion criteria were adults with a limb amputation managed with a one- or two-stage osseointegration procedure with follow-up reporting of complications. Results. A total of 19 studies were included: four one-stage, 14 two-stage, and one article with both one- and two-stage groups. Superficial infection was the most common complication (one-stage: 38% vs two-stage: 52%). There was a notable difference in the incidence of osteomyelitis (one-stage: nil vs two-stage: 10%) and implant failure (one-stage: 1% vs two-stage: 9%). Fracture incidence was equivocal (one-stage: 13% vs two-stage: 12%), and comparison of soft-tissue, stoma, and mechanical related complications was not possible. Conclusion. This review suggests that the one-stage approach is favourable compared to the two-stage, because the incidence of complications was slightly lower in the one-stage cohort, with a pertinent difference in the incidence of osteomyelitis and implant failure. Cite this article: Bone Jt Open 2023;4(7):539–550

This technique is a novel superior based muscle sparing approach. Acetabular reaming in all hip approaches requires femoral retraction. This technique is performed through a hole in the lateral femoral cortex without the need to retract the femur. A 5 mm hole is drilled in the lateral femur using a jig attached to the broach handle, similar to a femoral nail. Specialised instruments have been developed, including a broach with a hole going through it at the angle of the neck of the prosthesis, to allow the rotation of the reaming rod whilst protecting the femur. A special C-arm is used to push on the reaming basket. The angle of the acetabulum is directly related to the position of the broach inside the femoral canal and the position of the leg. A specialised instrument allows changing of offset and length without dislocating the hip during trialling. Some instrumentation has been used in surgery but ongoing cadaver work is being performed for proof of concept. The ability to ream through the femur has been proven during surgery. The potential risk to the bone has been assessed using finite analysis as minimal. The stress levels for any diameter maintained within a safety factor >4 compared to the ultimate tensile strength of cortical bone. The described technique allows for transfemoral acetabular reaming without retraction of the femur. It is minimally invasive and simple, requiring minimal assistance. We are incorporating use with a universal robot system as well as developing an electromagnetic navigation system. Assessment of the accuracy of these significantly cheaper systems is ongoing but promising. This approach is as minimally invasive as is possible, safe, requires minimal assistance and has a number of other potential advantages with addition of other new navigation and simple robotic attachments

Primary hip arthroplasty performed through a mini incision ( less than 10 cm) should provide more comfortable postoperative period and faster rehabilitation. After a long period of learning curve ( more than one hundred cases) and development of specific instruments, a prospective comparison between the standard approach technique (38 cases) and mini incision technique (41 cases) was performed. In all cases, the ABG II stem was implanted. It was uncemented in 76% of cases. As it is not randomised, there is a slight difference between the two groups in age (p = 0,03) and body mass index (p = 0,01). The fonctional status was evaluated at the third and seventh post operative days and at the first and second post operative months. Pain relief (EVA score), total peri operative blood loss (OSTHEO study criteria) and radiologic implants positioning are mesured. In this study, there was no major complication. There was one case of phlebitis in both groups. During the evaluation, there was no significant difference in the functional result. The post operative EVA pain score was not different. The mean total peri operative blood loss was 1025 ml in the standard approach group and 1164 ml in the mini incision approach group (p = 0,405). The radiologic evaluation showed no difference in the cup positioning. In the mini incision group, there was few cases of varus positioning of the ABG II stem (21% cases) but it was not significant. Those results demonstrate the safety and the efficacy of the posterior mini incision approach. There is a need for a technical learning curve and a resonably incision sizing adapted for each patient. Under those conditions, we are able to achieve the same quality of implant positioning, which should provide the same long term result

As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction. Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning. We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance. Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension. Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital

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

Aims. The epiphyseal approach to a chondroblastoma of the intercondylar notch of a child’s distal femur does not provide adequate exposure, thereby necessitating the removal of a substantial amount of unaffected bone to expose the lesion. In this study, we compared the functional outcomes, local recurrence, and surgical complications of treating a chondroblastoma of the distal femoral epiphysis by either an intercondylar or an epiphyseal approach. Methods. A total of 30 children with a chondroblastoma of the distal femur who had been treated by intraregional curettage and bone grafting were retrospectively reviewed. An intercondylar approach was used in 16 patients (group A) and an epiphyseal approach in 14 (group B). Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system and Sailhan’s functional criteria. Results. At final follow-up, the mean MSTS score was 29.1 (SD 0.9) in group A and 26.7 (SD 1.5) in group B (p = 0.006). According to Sailhan’s criteria, the knee function was good and fair in 14 (87.5%) and two (12.5%) patients of group A, and eight (57.1%) and six (42.9%) patients of group B, respectively (p = 0.062). The lesion had recurred in one patient (6.2%) in group A and four patients (28.6%) in group B. Limb shortening > 1 cm was recorded in one patient (6.2%) from group A and six patients (42.8%) from group B. Joint degeneration was noted in one patient from group A and three patients from group B. Conclusion. An intercondylar approach to a chondroblastoma of the middle two-quarters of the distal femoral epiphysis results in better outcomes than a medial or lateral epiphyseal approach: specifically, better limb function, a lower rate of recurrence, and a lower rate of physeal damage and joint degeneration. Cite this article: Bone Joint J 2024;106-B(2):195–202

Aims. Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m. 2. ) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m. 2. ) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach. Methods. This retrospective cohort study observes peri- and postoperative outcomes of MO and HW patients who underwent a primary, unilateral THA with the ABMS approach. Data from surgeries performed by three surgeons at a single institution was collected from January 2013 to August 2020 and analyzed using Microsoft Excel and Stata 17.0. Results. This study compares 341 MO to 1,140 HW patients. Anaesthesia, surgery duration, and length of hospital stay was significantly lower in HW patients compared to MO. There was no difference in incidence of pulmonary embolism, periprosthetic fracture, or dislocation between the two groups. The rate of infection in MO patients (1.47%) was significantly higher than HW patients (0.14%). Preoperative patient-reported outcome measures (PROMs) show a significantly higher pain level in MO patients and a significantly lower score in functional abilities. Overall, six-week and one-year postoperative data show higher levels of pain, lower levels of functional improvement, and lower satisfaction scores in the MO group. Conclusion. The comorbidities of obesity are well studied; however, the implications of THA using the ABMS approach have not been studied. Our peri- and postoperative results demonstrate significant improvements in PROMs in MO patients undergoing THA. However, the incidence of deep infection was significantly higher in this group compared with HW patients. Cite this article: Bone Jt Open 2023;4(5):299–305

To propose a modified approach to measuring femoro-epiphyseal acetabular roof (FEAR) index while still abiding by its definition and biomechanical basis, and to compare the reliabilities of the two methods. To propose a classification for medial sourcil edges. We retrospectively reviewed a consecutive series of patients treated with periacetabular osteotomy and/or hip arthroscopy. A modified FEAR index was defined. Lateral center-edge angle, Sharp's angle, Tonnis angle on all hips, as well as FEAR index with original and modified approaches were measured. Intra- and inter-observer reliability were calculated as intraclass correlation coefficients (ICC) for FEAR index with both approaches and other alignments. A classification was proposed to categorize medial sourcil edges. ICC for the two approaches across different sourcil groups were also calculated. After reviewing 411 patients, 49 were finally included. Thirty-two patients (40 hips) were identified as having borderline dysplasia defined by an LCEA of 18 to 25 degrees. Intra-observer ICC for the modified method were good to excellent for borderline hips; poor to excellent for DDH; moderate to excellent for normal hips. As for inter-observer reliability, modified approach outperformed original approach with moderate to good inter-observer reliability (DDH group, ICC=0.636; borderline dysplasia group, ICC=0.813; normal hip group, ICC=0.704). The medial sourcils were classified to 3 groups upon its morphology. Type II(39.0%) and III(43.9%) sourcils were the dominant patterns. The sourcil classification had substantial intra-observer agreement (observer 4, kappa=0.68; observer 1, kappa=0.799) and moderate inter-observer agreement (kappa=0.465). Modified approach to FEAR index possessed greater inter-observer reliability in all medial sourcil patterns. The modified FEAR index has better intra- and inter-observer reliability compared with the original approach. Type II and III sourcils accounts for the majority to which only the modified approach is applicable

Background. It is unclear whether the approach of hemiarthroplasty influence the outcomes in elderly patients with displaced femoral neck fractures. We conducted a randomized controlled trial to compare the direct lateral approach (DL approach) and posterolateral approach (PL approach) for hemiarthroplasty. Methods. This study included patients presenting to our hospital with displaced femoral neck fractures (Garden stage 3 or 4) from August 2010 to August 2011. 59 patients agreed the prospective study. They were randomized between the hemiarthroplasty using DL approach or PL approach. We evaluated and compared the operative time, perioperative blood loss, peri- and post-operative complications, and 5-year survival rates. Results. Thirty-two patients underwent the hemiarthroplasty using DL approach and 27 patients underwent hemiarthroplasty using PL approach. The mean operative time was 91 min in DL group and 77 min in PL group. A significant difference was observed for the mean operative times(p<0.005). The bleeding during surgery was 194 g in DL group and 180 g in PL group. The postoperative blood loss was 268 g in DL group and 264 g in PL group, no significant difference was observed postoperatively. Perioperative and postoperative complications were observed in 8 patients of DL group and 5 patients of the PL group. In DL group, perioperative complications included fracture in 1 patient, whereas postoperative complications included deep vein thrombosis in 7 patients. In PL group, postoperative complications included deep vein thrombosis in 3 patients, deep infection in 1 patient and subluxation of the outerhead in 1 patient. Two patients of DL group and 3patients of PL group suffered second hip fractures within the follow-up period, and 1 patient of PL group suffered periprosthetic fracture and treated conservatively. We identified 28 patients as dead in the follow-up period. The 5-year survival rate of DL group was 51.3% and that of PL group was 44.2%; there were not significantly different between the groups (log-rank test, p = 0.324). Conclusion. The mean operative time was significantly longer in DL groups, but peri- and post-operative complications and the surbival rate were not significantly different between the two groups. Surgical approach might not affect the outcomes of hemiarthroplasty in patients with femoral neck fractures

The majority of papers covering MIS total knee describe a surgical approach where the quads tendon is violated. This presentation describes a modified subvastus approach using MIS technique. The results are compared to the regular subvastus approach. Material and methods: 423 total knee replacements were performed through MIS subvastus approach from November 2002 to February 2004. All cases were performed by the same surgeon. The subvastus approach was modified to allow more quads excursion so the surgery can be performed without dislocating the patella. The data was processed at University of Dundee. The results were compared to the results of 361 cases of standard subvastus approach performed by the same surgeon. Kanasaki et al. (ISTA 2002) has shown that patients who had subvastus approach were able to regain the ability to do a straight leg raising faster than the standard parapateller incision. The results in this paper confirm the same showing that the ability of patients to rehabilitate is not related only to the size of the incision. Having relatively small incisions help in shorten hospital stay but did not make any difference in blood loss. The subvastus approach the only true quad sparing approach and it can be performed through 10 cm incision safely even in heavy patients with severe knee deformity

INTRODUCTION. The majority of papers covering MIS total knee describe a surgical approach where the quads tendon is violated. This presentation describes a modified subvastus approach using MIS technique. The results are compared to the regular subvastus approach. MATERIAL AND METHODS. 423 total knee replacements were performed through MIS subvastus approach from November 2002 to February 2004. All cases were performed by the same surgeon. The subvastus approach was modified to allow more quads excursion so the surgery can be performed without dislocating the patella. The data was processed at University of Dundee. The results were compared to the results of 361 cases of standard subvastus approach performed by the same surgeon. RESULTS. The average skin incision for the MIS group was 10.2 CM. as compared to 18.4 to the standard subvastus. There was no significant difference in the blood loss between the two groups. The progress with rehabilitation was the same in both groups as well. Hospital stay was also the same. DISCUSSION. Kanasaki et al. (ISTA 2002) has shown that patients who had subvastus approach were able to regain the ability to do a straight leg raising faster than the standard parapateller incision. The results in this paper confirm the same showing that the ability of patients to rehabilitate is not related only to the size of the incision. Having relatively small incisions help in shorten hospital stay but did not make any difference in blood loss. CONCLUSION. The subvastus approach is the only true quad sparing approach and it can be performed through 10 cm. incision safely even in heavy patients with severe knee deformity

Introduction. The reconstruction of segmental long bone defects remains one of the holy grails of orthopaedic surgery. The optimal treatment of which remains a topic of great debate. This study aimed to evaluate the outcomes following the management of critical-sized bone defects using a classification-based treatment algorithm. Materials & Methods. A retrospective review of all patients undergoing treatment for segmental diaphyseal defects of long bones at a tertiary-level limb reconstruction unit was performed. The management of the bone defect was standardised as per the classification by Ferreira and Tanwar (2020). Results. A total of 96 patients (mean age 39.8, SD 15.2) with a minimum six months follow-up were included. Most bone defects were the result of open fractures (75/96) with 67% associated with Gustilo-Anderson IIIB injuries. There was a statistical difference in the likelihood of union between treatment strategies with more than 90% of cases undergoing acute shortening and bone transport achieving union and only 72% of cases undergoing the induced membrane technique consolidating (p=0.049). Of those defects that consolidated, there was no difference in the time to bone union between strategies (p=0.308) with an overall median time to union 8.33 months (95% CI 7.4 — 9.2 months). The induced membrane technique was associated with a 40% risk of sepsis. Conclusions. This study reported the outcomes of a standardised approach to the management of critical-sized bone defects. Whilst overall results were supportive of this approach, the outcomes associated with the induced membrane technique require further refinement of its indications in the management of critical-sized bone defects

Background. Disability is an important multifaceted construct. Identifying sources of disability could help optimise patient care. The aim of this study was to test an approach that not only estimates severity of disability, but also identifies the source(s) of this disability. Methods. An online survey was used to collect data from a convenience sample, recruited via email and social media invitations. Two generic measures of disability, the 8-item Universal Disability Index (UDI8) and Groningen Activity Restriction Scale (GARS) were used to estimate the prevalence and severity of disability in this sample. Non-zero UDI8 item responses generated conditional sub-questions, in which participants could attribute their activity limitations to one or more sources (pain, fatigue, worry, mood, and other). This allowed for a decomposition of UDI8 scores into source components. Results. 403 participants enrolled; 334 completed all UDI8 and GARS items. Of these, 85.3% (285/334) reported at least one restricted activity via the UDI8, while 43.4% (145/334) reported some reduced independence via the GARS. Disability severity increased with age until approximately 40 years, after which it decreased gradually. Pain component scores were high in all individuals with higher and lower disability severity, whereas fatigue component scores were highest in individuals reporting higher disability severity. Worry, mood, and other component scores were not high at any level of disability severity. Conclusions. This approach should be used to identify the prevalence, severity and sources of disability in the general population and in specific patient groups. Conflicts of interest. No conflicts of interest. Sources of funding. No funding obtained

Introduction: The development of the ilioinguinal approach by the pioneering work of Letournel in 1965 has transformed the treatment of acetabular fractures. To date, this approach has been well established and few modifications have been described of the original approach. However, this approach is difficult, takes long time for exposure and closure of abdominal layers. The aim of this article is to report a modification of the approach which the authors have found particularly useful. Material and Method: Cadaveric dissection showed that it was easier to detach the inguinal ligament from the anterior superior iliac spine and reflect the anterior abdominal wall as one layer, than by the classical approach through layers of the anterior abdominal wall. Closure was also simpler, in the cadaver, with the entire anterior abdominal wall reattaching satisfactorily by a single transosseous suture. The rest of the approach, including division of iliopectineal fascia and developing the three windows remains the same as in the original approach. Results: To date, three acetabular fractures have been reduced and fixed using this modification. Besides substantially speeding up the exposure and closure, this approach allows superior distal visualization of the anterior column and wall, and the impression of rather less bleeding. No complications developed with the three cases treated through this modified approach, and specifically, there have been no hernias, nor has the lateral femoral cutaneous nerve of the thigh been damaged. Discussion: This small study demonstrates a modification to a classic approach that seems to be both safe and fast We hope that further experience will also show reduction in problems associated with wound healing. Further work in progress may also show that femoral venous flow is less impeded by this approach as retraction is not against the unyielding inguinal ligament

The increased demand for total hip arthroplasty (THA) is having a significant impact on healthcare resources, resulting in increased interest in outpatient care pathways to reduce resource consumption. This study compared costs between patients who underwent outpatient THA using a Direct Anterior (DA) approach compared to a Direct Lateral (DL) approach to understand the effect of surgical approach on resource use. We conducted a prospective randomized controlled trial for DA patients undergoing primary THA. We compared patients in the outpatient arm of the trial to a prospective cohort of outpatient DL approach THAs. We recorded all costs including: equipment, length of stay in hospital, and laboratory or other medical tests. Following discharge, participants also completed a self-reported cost diary recording resource utilization such as emergency department visits or subsequent hospitalizations, tests and procedures, consultations or follow-up, healthcare professional services, rehabilitation, use of pain medications, informal care, productivity losses and out of pocket expenditures. We report costs from both Canadian public health care payer (HCP) and a societal perspective. The HCP perspective includes any direct health costs covered by the publicly funded system. In addition to the health care system costs, the societal perspective also includes additional costs to the patient (e.g. physiotherapy, medication, or assistive devices), as well as any indirect costs such as time off paid employment for patients or caregivers. We included 127 patients in the DA group (66.6 years old) and 51 patients in the DL group (59.4 years old) (p<0.01). There were no statistically significant differences in costs between groups from both the healthcare payer (DA= 7910.19, DL= 7847.17, p=0.80) and societal perspectives (DA= 14657.21, DL= 14581.21, p=0.96). In patients undergoing a successful outpatient hip replacement, surgical approach does not have an effect on cost from in hospital or societal perspectives

Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery

Renal Osteodystrophy is a type of metabolic bone disease characterized by bone mineralization deficiency due to electrolyte and endocrine abnormalities. Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. Treatment involves medical management to resolve the etiology of the underlying renal condition, as well as management (and prevention) of pathological fractures. A 66-year-old female patient, with severe osteoporosis and chronic kidney disease undergoing haemodialysis, has presented with multiple fractures along the years. She was submitted to bilateral proximal femoral nailing as fracture treatment on the left and prophylactically due to pathological bone injury on the right, followed by revision of the left nail with a longer one after varus angulation and fracture distal to the nail extremity. Meanwhile, the patient suffered a pathological fracture of the radial and cubital diaphysis and was submitted to conservative treatment with cast, with consolidation of the fracture. Posteriorly, she re-fractured these bones after a fall and repeated the conservative treatment. Clinical management: There is a multidisciplinary approach to manage the chronic illness of the patient, including medical management to resolve the etiology and consequences of her chronic kidney disease, pain control, conservative or surgical fracture management and prevention of falls. The incidence of chronic renal disease is increasing and the patients with this condition live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Their quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. A multidisciplinary approach is required to treat these patients, controlling their chronic diseases, managing fractures and preventing falls

Introduction. The anterior mini-invasive approach to performing total hip arthroplasty (THA) is associated with less soft tissue damage and a shorter postoperative recovery than other methods. In August 2008, our hospital abandoned the traditional lateral Hardinge approach in favor of this new method. The purpose of this study was to measure changes in short-term clinical and radiological results and complications after the changeover. Methods. We compared the first 100 patients operated after the changeover to the new method (MI group) to the last 100 patients operated using the traditional method (LH group). Clinical and radiological parameters and complications were recorded pre- and postoperatively and the collected data of the two groups were statistically analyzed and compared. Results. There were no statistically significant differences between either group with regard to patient demographics or procedural data, placement of the femur component, postoperative leg discrepancy, prosthesis dislocation, blood transfusion, or postoperative dislocation of the components. The MI group had a significantly shorter hospital stay (p<0.001) and significantly fewer infections (p = 0.007) of the operative site. The LH group had a significantly shorter operative time (p<0.001), less bleeding (p = 0.035), less nerve damage (p = 0.013), and radiologically better positioning of the acetabular component regarding anteversion (p<0.001). Furthermore, a few other recorded surgical complications were more frequent in the MI group, but the difference was not statistically significant. Interpretation. Our results show that the anterior approach correlates with faster postoperative recovery and less soft tissue damage with respect to the lateral approach. Since the changeover, we observed an increase in the overall complications, but in this study this increase was not found to be statistically significant. These complications were not only found in the initial patients operated with the mini-invasive approach, but were homogeneously spread over all 100 patients. Additionally, and perhaps most worrying was the clinically significant increase in intraoperative femur fractures in the MI group. The changeover to the anterior mini-invasive approach, which was the surgeons' initial experience with the MI technique, resulted in a drastic increase in the number of overall complications. A future randomized, prospective study including functional scores and a large body of patients will be imperative to show whether the two different approaches really are equivalent

Total elbow arthroplasty is usually performed through a posterior approach. The management of the triceps tendon insertion include; Triceps division (V-Y Triceps turn down), Detachment of the Triceps insertion either by triceps splitting (Gschwind approach) or triceps reflecting (Bryan-Morrey approach), or by leaving the Triceps insertion intact (Triceps On approach). The ideal approach needs to meet three broad criteria; firstly it should be quick and easy, secondly it should offer excellent exposure and thirdly it should have low morbidity to the Triceps tendon. An approach that is also versatile provides an additional advantage. The purpose of this study was to present and discuss the surgical technique of a “new” posterior approach to the elbow. To biomechanically evaluate and compare the strength of the Triceps tendon repair with the Bryan-Morrey approach (recently demonstrated in a cadaveric study to be the strongest of three methods of management of the Triceps tendon). The Bryan-Morrey and Oxford approach were each performed on fourteen pairs of cadaveric elbows with the two Triceps tendon repairs carried out. The contra-lateral elbow served as the control. The specimens were then mounted on a material testing system and a constant velocity elongation was applied. This new approach demonstrated a significant reduction in operative time as well as providing excellent exposure suitable for multiple indications. Final analysis of the data using % ultimate strength loss (%USL) compared to the control specimens as the ultimate end point showed this new approach is as strong as the Bryan-Morrey approach with %USL of −40% for both approaches

Ideberg-Goss type VI/AO F2(4) glenoid fossa fractures are a rare and complex injury. Although some advocate non-operative management, grossly displaced glenoid fossa fractures in the young patient may warrant fixation. Current approaches still describe difficulty with access of the entirety of the glenoid, particularly the postero-superior quadrant. We present 2 cases of Ideberg-Goss type VI/AO F2(4) glenoid fossa fractures treated with fixation through a novel “Deltoid Takedown” approach, which allows safe access to the whole glenoid with satisfactory clinical results at 5 and 7 years respectively

Background. The increasing desire to protect the periarticular structures led the need of a Tissue Sparing Surgery. The accesses most widely used are the direct-lateral approach and the postero-lateral one, both with patient in lateral decubitus. Aim: This accesses require however an incision of tendons and muscles even in their minimally invasive technique, so we looked for an approach that would wholly protect the periarticular structures and allow us not to revise our experience in patient positioning, preparation of the operating field and surgeon's position during surgery. Our intent was to leave the acquired knowledge unchanged and to preserve unaltered the anatomical landmarks that we had previously identified and consolidated for the correct positioning of the components. Methods. We have used this approach in more than 180 cases of primary hip arthroplasty. Clinical control includes: Oxford Hip Score, VAS and X-Ray. Results. OHS mean:44, range 37-48. On X-Ray no signs of components migration, radioucent lines or osteolysis. We didn't have dislocations or other complications. Discussion. The only approach that safeguard really the periarticular structures is the anterior one (Smith-Petersen), which actually is performed placing the patient in supine decubitus, with obvious difficulties in preparing the operating field and a complete change of the anatomical landmarks. We have combined the advantages of the anterior access with the ones linked to the lateral decubitus. The rewards of this new approach are: easiest preparation of the operating field, no special bed or supports are required, the inferior limb can be easly moved, it is a real tissue sparing approach, good acetabular exposition, surgeon placed traditionally on the posterior side of the patient during the acetabular time. Conclusion. We have encoded all the steps of this approach that we have called the Anterior Lateral Decubitus Intermuscolar (ALDI) approach

The Posterior and Lateral approaches are most commonly used for Total Hip Arthroplasty (THA) in the United Kingdom (UK). Fewer than 5% of UK surgeons routinely use the Direct Anterior Approach (DAA). DAA THA is increasing, particularly among surgeons who have learned the technique during overseas fellowships. Whether DAA offers long-term clinical benefit is unclear. We undertook a retrospective analysis of prospectively collected 10-year, multi-surgeon, multi-centre implant surveillance study data for matched cohorts of patients whose operations were undertaken by either the DAA or posterior approach. All operations were undertaken using uncemented femoral and acetabular components. The implants were different for the two surgical approaches. We report the pre-operative, and post operative six-month, two-year, five-year and 10-year Oxford Hip Score (OHS) and 10-year revision rates. 125 patients underwent DAA THA; these patients were matched against those undergoing the posterior approach through propensity score matching for age, gender and body mass index. The 10-year revision rate for DAA THA was 3.2% (4/125) and 2.4% (3/125) for posterior THA. The difference in revision rate was not statistically significant. Both DAA and Posterior THA pre-operative OHS were comparable at 19.85 and 19.12 respectively. At the six-month time point, there was an OHS improvement of 20.89 points for DAA and 18.82 points for Posterior THA and this was statistically significant (P-Value <0.001). At the two, five and 10-year time-points the OHS and OHS improvement from the pre-operative review were comparable. At the 10-year time point post-op the OHS for DAA THA was 42.63, 42.10 for posterior THA and the mean improvement from pre-op to 10-years post op was 22.78 and 22.98 respectively. There was no statistical difference when comparing the OHS or the OHS mean improvements at the two, five and 10-year point. Whilst there was greater improvement and statistical significance during the initial six month time period, as time went on there was no statistically significant difference between the outcome measures or revision rates for the two approaches

In this work, we propose a new quantitative way of evaluating acute compartment syndrome (ACS) by dynamic mechanical assessment of soft tissue changes. First, we have developed an animal model of ACS to replicate the physiological changes during the condition. Secondly, we have developed a mechanical assessment tool for quantitative pre-clinical assessment of ACS. Our hand-held indentation device provides an accurate method for investigations into the local dynamic mechanical properties of soft tissue and for in-situ non-invasive assessment and monitoring of ACS. Our compartment syndrome model was developed on the cranial tibial and the peroneus tertius muscles of a pig's leg (postmortem). The compartment syndrome pressure values were obtained by injecting blood from the bone through the muscle. To enable ACS assessment by a hand-held indentation device we combined three main components: a load cell, a linear actuator and a 3-axis accelerometer. Dynamic tests were performed at a frequency of 0.5 Hz and by applying an amplitude of 0.5 mm. Another method used to observe the differences in the mechanical properties inside the leg was a 3D Digital Image Correlation (3D-DIC). Videos were taken from two different positions of the pig's leg at different pressure values: 0 mmHg, 15 mmHg and 40 mmHg. Two strains along the x axis (Exx) and y axis (Eyy) were measured. Between the two pressure cases (15 mmHg and 40 mmHg) a clear deformation of the model is visible. In fact, the bigger the pressure, the more visible the increase in strain is. In our animal model, local muscle pressures reached values higher than 40 mmHg, which correlate with observed human physiology in ACS. In our presentation we will share our dynamic indentation results on this model to demonstrate the sensitivity of our measurement techniques. Compartment syndrome is recognised as needing improved clinical management tools. Our approach provides both a model that reflects physiological behaviour of ACS, and a method for in-situ non-invasive assessment and monitoring

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

Aims. To compare the functional outcome, health-related quality of life (HRQoL), and satisfaction of patients who underwent primary total hip arthroplasty (THA) and a single debridement, antibiotics and implant retention (DAIR) procedure for deep infection, using either the transgluteal or the posterior surgical approach for both procedures. Methods. The study was registered at clinicaltrials.gov (ID: NCT03161990) on 15 May 2017. Patients treated with a single DAIR procedure for deep infection through the same operative approach as their primary THA (either the transgluteal or the posterior approach) were identified in the Norwegian Arthroplasty Register and given a questionnaire. Median follow-up after DAIR by questionnaire was 5.5 years in the transgluteal group (n = 87) and 2.5 years in the posterior approach group (n = 102). Results. Patients in the posterior approach group were less likely to limp after the DAIR procedure (17% vs 36% limped all the time; p = 0.005), had a higher mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (80 vs 71; p = 0.013), and were more likely to achieve a patient acceptable symptom state for the WOMAC function score (76% vs 55%; p = 0.002). In a multivariable analysis, the point estimate for the increase in WOMAC function score using the posterior approach was 10.2 (95% CI 3.1 to 17.2; p = 0.005), which is above the minimal clinically important improvement. The patients in the posterior approach group also reported better mean HRQoL scores and were more likely to be satisfied with their hip arthroplasty (77% vs 55%; p = 0.001). Conclusion. In patients treated with a single, successful DAIR procedure for deep infection of a primary THA, the use of the posterior approach in both primary surgery and DAIR was associated with less limping, better functional outcome, better HRQoL, and higher patient satisfaction compared with cases where both were performed using the transgluteal approach. The observed differences in functional outcome and patient satisfaction were clinically relevant. Cite this article: Bone Joint J 2020;102-B(12):1662–1669

Aims. Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA. Methods. A prospective continuous cohort study was conducted on patients undergoing operation for FNF using DMC by DAA or PLA. Functional outcome was evaluated using the Harris Hip Score (HHS) and Parker score at three months and one year. Perioperative complications were recorded, and radiological component positioning evaluated. Results. There were 50 patients in the DAA group and 54 in the PLA group. The mean HHS was 85.5 (SD 8.8) for the DAA group and 81.8 (SD 11.9) for the PLA group (p = 0.064). In all, 35 patients in the DAA group and 40 in the PLA group returned to their pre-fracture Parker score (p = 0.641) in both groups. No statistically significant differences between groups were found at one year regarding these two scores (p = 0.062 and p = 0.723, respectively). The DAA was associated with more intraoperative complications (p = 0.013). There was one dislocation in each group, and four revisions for DAA and one for PLA, but this difference was not statistically significant. There were also no significant differences regarding blood loss, length of stay, or operating time. Conclusion. In DMC-THA for FNF, DAA did not achieve better functional results than PLA, either at three months or at one year. Moreover, DAA presented an increased risk of intra-operative complications. Cite this article: Bone Joint J 2024;106-B(5 Supple B):133–138

Aims. Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. Methods. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up. Results. Immediate postoperative radiological Matta’s reduction accuracy showed anatomical reduction (0 to 1 mm) in 23 cases (67.6%), satisfactory (2 to 3 mm) in nine (26.4%), and unsatisfactory (> 3 mm) in two (6%). Merle d’Aubigné score at the end of one year was calculated to be excellent in 18 cases (52.9%), good in 11 (32.3%), fair in three (8.8%), and poor in two (5.9%). Matta’s radiological grading at the end of one year was calculated to be excellent in 16 cases (47%), good in nine (26.4%), six in fair (17.6%), and three in poor (8.8%). Merle d’Aubigné score at latest follow-up deteriorated by one point in some cases, but the grading remained the same; Matta’s radiological grading at latest follow-up also remained unchanged. Conclusion. Stabilization of posterior column through AIP by medial surface plate along the sciatic notch gives good stability to posterior column, and at the same time can avoid morbidity of the additional lateral window. Cite this article: Bone Jt Open 2024;5(2):147–153

Aims. The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA). Methods. This was a retrospective single surgeon study comparing the first 100 consecutive DSA THA patients with a matched group of patients using a standard PLA. Case notes were examined for patient demographics, length of hospital stay, operating time, intra- and postoperative complications, pain score, satisfaction score, and Oxford Hip Score (OHS). Leg length discrepancy and component positioning were measured from postoperative plain radiographs. Results. The DSA patients had a shorter length of hospital stay (mean 2.09 days (SD 1.20) DSA vs 2.74 days (SD 1.17) PLA; p < 0.001) and shorter time to discharge from the inpatient physiotherapy teams (mean 1.44 days (SD 1.17) DSA vs 1.93 days (SD 0.96) PLA; p < 0.001). There were no differences in operating time (p = 0.505), pain levels up to postoperative day 1 (p = 0.106 to p =0.242), OHS (p = 0.594 to p = 0.815), satisfaction levels (p = 0.066 to p = 0.299), stem alignment (p = 0.240), acetabular component inclination (p < 0.001) and anteversion (p < 0.001), or leg length discrepancy (p = 0.134). Conclusion. While the DSA appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, a randomized controlled trial with functional outcomes in the postoperative phase is needed to evaluate this surgical approach formally. Cite this article: Bone Joint J 2021;103-B(3):500–506

Orthopaedic surgeons vary in their surgical approaches to total knee arthroplasty. The aim of this investigation was to compare outcomes after two different surgical approaches. The study was a prospective single-centre longitudinal randomized controlled trial. A sub-vastus approach was compared with a medial para-patellar approach. Participating surgeons elected to randomize their patients to one of the two types of approach. Outcomes included the Knee Society (KS) Clinical Rating System, WOMAC Osteoarthritis Index, SF-36, and EuroQol (measured at 1, 6, 12 and 52 weeks post-operatively compared to baseline) complications, surgeon rated ease of exposure, and proportion of patients who had a lateral release. Two hundred and thirty one patients were randomized to the two approaches. One hundred and sixteen patients were randomized to the sub-vastus approach. At one week compared to baseline, range of motion, KS global, KS knee, and KS pain scores were significantly better in the sub-vastus group. At six weeks, the medial para-patellar group tended to have better outcomes, but not statistically significantly. At fifty-two weeks compared to baseline, the WOMAC global and pain scores, the SF36 physical function and role-physical scores, and the EuroQol utility and pain score were significantly better in the sub-vastus group. Surgeons reported the ease of exposure in the sub-vastus group was significantly worse on average. This trial is the largest of its kind to date, and the first, so far as we are aware, to compare clinical outcomes of different surgical approaches at one year post-operatively. The sub-vastus approach to total knee arthroplasty was more effective than a medial para-patellar approach at both one week and fifty-two weeks post-operatively in patients whose surgeons considered either approach would be suitable. However, surgeons reported worse ease of exposure in the sub-vastus group

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

Introduction: Minimal invasive surgery (MIS) seems to be part of future orthopaedic solutions. Currently, most approaches for the Bernese periacetabular osteotomy (PAO) are characterized by relatively extensive incisions, dissection and detachment of muscles. We have developed a new MIS approach for the Bernese PAO. The purposes were to reduce patient morbidity and to improve the cosmetic result following surgery without negatively influencing the achieved reorientation of the acetabular articular surface. In this study we present the surgical technique, results and compare them to the ilioinguinal (II) approach. Methods: The new MIS technique is a trans-sartorial approach using a three inch skin incision. Previously the II approach was used. From 1999–2006 a total of 215 patients with acetabular dysplasia were operated by the same surgeon in two successive time periods with the II (97) and the trans-sartorial (118) approaches. No supplemental surgery was performed. The two approaches are retrospectively compared regarding perioperative measures, transfusion requirements, complications and the achieved reorientation of the acetabular articular surface. Data are compared by Kruskal-Wallis Test and are presented as median and interquartile range. Results: The trans-sartorial approach significantly reduced days of admission (8 days (7–9) vs. 10 days (8–13), p< 0.0001), duration of surgery (70 min (60–75) vs. 100 min (82.5–120), p< 0.0001), perioperative blood loss (200ml (150–350) vs. 450ml (325–700), p< 0.0001) and the percentage of patients receiving blood transfusion (18.6 % vs. 3.4%). Of severe neurovascular, infectious and technical complications none occurred in the trans-sartorial group and 3 cases of arterial thrombosis were seen in the II group. The achieved reorientation measured by the CE-angle postoperatively had median values of 31° (25–36) in the II group and 33° (29–36) in the trans-sartorial group, p=0.016. The postoperative AI-angles were 10° (2–14) and 3° (0–7) in the II and trans-sartorial groups respectively, p< 0.0001. Discussion: Our shift to the trans-sartorial approach was rewarding as the duration of surgery, perioperative blood loss and transfusion requirements were reduced. The new MIS technique is safe and improves the cosmetic result without negative influence on the achieved reorientation of the acetabular articular surface

The purpose of this study was to investigate the influence of surgical approach on femoral stem version in THA. This was a retrospective database review of 830 THAs in 830 patients that had both preoperative and postoperative CT scans. All patients underwent staged bilateral THAs and received CT-based 3D planning on both sides. Stem version was measured in the second CT-scan and compared to the native neck axis measured in the first CT-scan, using the posterior condyles as the reference for both. Cases were performed by 104 surgeons using either a direct anterior (DAA, n=303) or posterior (PA, n=527) approach and one of four stem designs: quadrangular taper, calcar-guided short stem, flat taper and fit-and-fill. Sub-analyses investigated changes in version for low (≤5°), neutral (5–25°) and high (≥25°) native version subgroups and for the different implant types. Native version was not different between approaches (DAA = 12.6°, PA = 13.6°, p = 0.16). Overall, DAA stems were more anteverted relative to the native neck axis vs PA stems (5.9° vs 1.4°, p<0.001). This trend persisted in hips with high native version (3.2° vs -5.3°, p<0.01) and neutral native version (5.3° vs 1.3°, p<0.001), but did not reach significance in the low native version subgroup (8.9° vs 5.9°, p=0.13). Quadrangular taper, calcar-guided, and flat taper stem types had significantly more anteversion than native for DAA, while no differences were found for PA. Stems implanted with a direct anterior approach had more anteversion than those implanted with a posterior approach. The smaller surgical field, soft tissue tension and lack of a “tibial” vertical reference frame may contribute to this finding

Introduction. Lower limb open fractures are severe injuries, with a joint orthoplastic approach for management recommended by BOAST. An initial audit highlighted a discrepancy in time to definitive wound coverage between the Queen Elizabeth University Hospital (QEUH), which at the time was not an orthoplastic centre, and the Glasgow Royal Infirmary (GRI) which was. Our aim was to perform a secondary audit to identify if the introduction of an orthoplastic service at the QEUH led to a reduction in time to definitive wound coverage. Materials and Methods. Forty-six patients with open lower limb fractures treated at the QEUH in 2019 following introduction of the orthoplastic service were identified. Management including time to antibiotics and wound coverage, and rates of complication were compared with previous audit data. Results. Days to washout was similar between the second cohort of QEUH patients and the first (p=0.522), as was days to definitive management without plastics input (p=0.143). When plastics input was required, there was a reduction in days to wound coverage in the second cohort of QEUH patients compared to the first (3 days vs 8.5 days; p=0.002), and a similar time if compared to the GRI cohort (p=0.778). Conclusions. Time to definitive wound coverage was reduced in those that required plastics input in the second cohort of QEUH patients, with a similar time to that of the original GRI cohort. The QEUH now displays improved concordance with the BOAST guidelines, with definite wound coverage on average occurring within 72 hours

Dislocation after total hip arthroplasty in individuals treated for acute hip fracture is up to 10 times more frequent than in elective patients. Whilst approach plays a role, the effect of head sizes in conventional THA and dual mobility cups (DMC) is less studied in fracture cases. The total dislocation rate at 1-year and 3-year revision rates were recorded in this observational study on 8,031 patients with acute hip fracture, treated with a THA 2005–2014. Swedish Arthroplasty Register data were linked with the National Patient Register. Cox multivariable regression models were fitted to calculate adjusted hazard ratios stratified by approach and head size. The cumulative risk of dislocation during year 1 was 2.7% (95% CI 2.2–3.2) with lateral approach and 8.3% (7.3–9.3) with posterior approach (KM estimates). In the posterior approach group DMC was associated with a lower risk of dislocation compared to cTHA=32mm (HR=0.21; 0.07–0.68), whilst a head size <32mm carried a higher risk (HR=1.47; 1.10–1.98). These differences were no longer visible when revision in general was used as outcome. Neither of the implant designs influenced the dislocation risk when direct lateral approach was used. Male gender and severe comorbidity increased the risk. DMC with lateral approach was associated with a reduced risk of revision in general (HR=0.36; 0.13–0.99). Head size did not influence the revision risk. When aiming to reduce the risk of any dislocation, lateral approach – regardless of cup/head design – is referable. If, for any reason, posterior approach is used, DMC is associated with the lowest risk of dislocation. This is not reflected in analysing revision in general as outcome. An interpretation could be that there are different thresholds for dislocation prompting revision

In osteoarthritis, chondrocytes acquire a hypertrophic phenotype that contributes to matrix degradation. Inflammation is proposed as trigger for the shift to a hypertrophic phenotype. Using in vitro culture of human chondrocytes and cartilage explants we could not find evidence for a role of inflammatory signalling activation. We found, however, that tissue repair macrophages may contribute to the onset of hypertrophy (doi: 10.1177/19476035211021907) Intra-articularly injected triamcinolone acetonide to inhibit inflammation in a murine model of collagenase-induced osteoarthritis, increased synovial macrophage numbers and osteophytosis, confirming the role of macrophages in chondrocyte hypertrophy occurring in osteophyte formation (doi: 10.1111/bph.15780). In search of targets to inhibit chondrocyte hypertrophy, we combined existing microarray data of different cartilage layers of murine growth plate and murine articular cartilage after induction of collagenase-induced osteoarthritis. We identified common differentially expressed genes and selected those known to be associated to inflammation. This revealed EPHA2, a tyrosine kinase receptor, as a new target. Using in silico, in vitro and in vivo models we demonstrated that inhibition of EPHA2 might be a promising treatment for osteoarthritis. Recently, single cell RNA-seq. has revealed detailed information about different populations of chondrocytes in articular cartilage during osteoarthritis. We re-analysed a published scRNA-seq data set of healthy and osteoarthritic cartilage to obtain the differentially expressed genes in the population of hypertrophic chondrocytes compared to the other chondrocytes, applied pathway analyses and then used drug databases to search for upstream inhibitors of these pathways. This drug repurposing approach led to the selection of 6 drugs that were screened and tested using several in vitro models with human chondrocytes and cartilage explants. In this lecture I will present this sequence of studies to highlight different approaches and models that can be used in the quest for a disease modifying drug for osteoarthritis

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 anterolateral approach to those resulting from the posterior approach. Methods: In 22 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted supero-laterally 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 antero-lateral approach. Results: During the operation patterns were similar for both groups, except following joint relocation and soft tissue reconstruction; oxygen concentration recovered significantly in the anterolateral group only. The posterior approach resulted in significantly lower (p< 0.01) oxygen concentration at the end of the procedure (22%, SD 31) than the antero-lateral approach (123%, SD 99). Discussion and Conclusion: The anterolateral approach disrupts the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches

Low back pain affects 80% of the population with half of cases attributed to intervertebral disc (IVD) degeneration. However, the majority of treatments focus on pain management, with none targeting the underlying pathophysiological causes. PCRX-201 presents a novel gene therapy approach that addresses this issue. PCRX-201 codes for interleukin-1 receptor antagonist (IL-1Ra), the natural inhibitor of the pro-inflammatory cytokine IL-1, which orchestrates the catabolic degeneration of the IVD. Our objective here is to determine the ability of PCRX-201 to infect human nucleus pulposus (NP) cells and tissue to increase the production of IL-1Ra and assess downstream effects on catabolic protein production. Degenerate human NP cells and tissue explants were infected with PCRX-201 at 0 or 3000 multiplicities of infection (MOI) and subsequently cultured for 5 days in monolayer (n=7), 21 days in alginate beads (n=6) and 14 days in tissue explants (n=5). Cell culture supernatant was collected throughout culture duration and downstream targets associated with pain and degeneration were assessed using ELISA. IL-1Ra production was increased in NP cells and tissue infected with PCRX-201. The production of downstream catabolic proteins such as IL-1β, IL-6, MMP3, ADAMTS4 and VEGF was decreased in both 3D-cultured NP cells and tissue explants. Here, we have demonstrated that a novel gene therapy, PCRX-201, is able to infect and increase the production of IL-1Ra in degenerate NP cells and tissue in vitro. The increase of IL-1Ra also resulted in a decrease in the production of a number of pro-inflammatory and catabolic proteins, suggesting PCRX-201 enables the inhibition of IL-1-driven IVD degeneration. At present, no treatments for IVD degeneration target the underlying pathology. The ability of FX201 to elicit anti-catabolic responses is promising and warrants further investigation in vitro and in vivo, to determine the efficacy of this exciting, novel gene therapy

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

Since 1989 we have treated most rotationally or vertically unstable pelvic fractures operatively. An anterior extra peritoneal approach has been used to achieve access to all parts of the anterior ring. This can be combined with the lateral approach on the iliac wing or with posterior approach for the SI and sacral lesions. The extra peritoneal midline approach is created through a 10–15 cm long midline incision beginning from the symphysis. The rectus muscles are not detached. Blunt preparation along the superior ramus gives more space laterally and reveals the obturator foramen. The corona mortis vessels are ligated. The iliac vessels, femoral nerve and the psoas muscle can be gentle elevated with a long hook. The eminential area, linea terminalis as well as the quadrilateral space are then visualised. All essential fragments can be reduced and fixed with plates and screws. Our study of 101 patients with an unstable pelvic ring (68 rotationally and vertically unstable injuries, 21 lateral compression injuries and 12 open book injuries) showed excellent or good reduction in 88, fair in 11 and poor in 2 cases. The overall functional results were excellent or good in 83, fair in 13 and poor in 5 patients. The correlation between anatomical reduction and good functional result was clear. Our experience and new data strongly support the use of ORIF in Type C pelvic ring injuries, in Type B- open book injuries, and in markedly displaced Type-B lateral compression injuries. Good reduction and a reliable stability can be achieved. Moreover, short postoperative morbidity and hospital stay as well as full weight bearing after 4 to 8 weeks resulted after adopting ORIF in pelvic fractures. External fixation is still used by us as a temporary bleeding control device before the final operative treatment when the bleeding is considered significant

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

Abstract. The lateral ligaments of the ankle composed of the anterior talofibular (ATFL), calcaneofibular (CFL) and posterior talofibular ligaments (PTFL), are amongst the most commonly injured ligaments of the human body. Although treatment methods have been explored exhaustively, healing outcomes remain poor with high rates of re-injury, chronic ankle instability and pain persisting. The introduction and application of tissue engineering methods may target poor healing outcomes and eliminate long-term complications, improving the overall quality of life of affected individuals. For any surgical procedure or tissue-engineered replacement to be successful, a comprehensive understanding of the complete anatomy of the native structure is essential. Knowledge of the dimensions of ligament footprints is vitally important for surgeons as it guides the placement of bone tunnels during repair. It is also imperative in tissue-engineered design as the creation of a successful replacement relies on a thorough understanding of the native anatomy and microanatomical structure. Several studies explore techniques to describe ligament footprints around the body, with limited studies describing in-depth footprint dimensions of the ATFL, CFL and PTFL. Techniques currently used to measure ligament footprints are complex and require resources which may not be readily available, therefore a new methodology may prove beneficial. Objectives. This study explores the application of a novel technique to assess the footprint of ankle ligaments through a straightforward inking method. This method aims to enhance surgical technique and contribute to the development of a tissue-engineered analogue based on real anatomical morphometric data. Methods. Cadaveric dissection of the ATFL, CFL and PTFL was performed on 12 unpaired fresh frozen ankles adhering to regulations of the Human Tissue (Scotland) Act. The ankle complex with attaching ligaments was immersed in methylene blue. Dissection of the proximal and distal entheses of each ligament was carried out to reveal the unstained ligament footprint. Images of each ligament footprint were taken, and the area, length and width of each footprint were assessed digitally. Results. The collective area of the proximal entheses of the ATFL, CFL and PTFL measures 142.11 ± 12.41mm2. The mean areas of the superior (SB) and inferior band (IB) of the distal enthesis of the ATFL measured 41.72 ± 5.01mm2 and 26.66 ± 3.12mm2 respectively. The footprint of the distal enthesis of the CFL measured 146.07 ± 14.05mm2, while the footprint of the distal PTFL measured 126.26 ± 8.88mm2. The proximal footprint of the ATFL, CFL and PTFL measured 11.06 ± 0.69mm, 7.87 ± 0.43mm and 10.52 ± 0.63mm in length and 8.66 ± 0.50mm, 9.10 ± 0.92mm and 14.41 ± 1.30mm in width on average. The distal footprint of the ATFL (SB), ATFL (IB), CFL and PTFL measured 10.92 ± 0.81 mm, 8.46 ± 0.46mm, 13.98 ± 0.93mm and 11.25 ± 0.95mm in length and 7.76 ± 0.59mm, 7.51 ± 0.64mm, 18.98 ± 1.15mm and 24.80 ± 1.25mm in width on average. Conclusions. This methodology provides an effective approach in the identification of the footprint of the lateral ligaments of the ankle to enhance surgical precision and accuracy in tissue-engineered design. 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

Proponents of the direct anterior approach (DAA) for hip arthroplasty (THA) claim lower postoperative pain compared to the posterolateral approach (PA); however, whether that theoretical advantage results in lower opioid consumption is unclear. We sought to investigate the relationship between the DAA and PA on total 90-day predicted opioid consumption in a large cohort. Retrospective analysis identified 2,304 DAA and 6,288 PA primary THAs in patients >18 years old from February 2019 to April 2022. Ninety-day postoperative total morphine milligram equivalent (MME); in-hospital administration, discharge prescriptions, and refills within 90 days were compared between DAA and PA cohorts. Nearest-neighbor matching was performed controlling for age, sex, BMI, ASA, and periarticular injection to evaluate opioid consumption patterns for DAA and PA. Quantile regression was employed to predict the median (50th percentile) MME prescribed by surgical approach. After matching, DAA and PA demonstrated similar median total 90-day prescribed MME (p = 0.008). After adjusting for patient and surgical factors, quantile regression predicted a similar median total 90-day prescribed MME for DAA and PA (243.5 versus 242.7; p = 0.78). While approach did not demonstrate a significant relationship for predicted 90-day MME, other factors including age, sex, BMI, length of stay, peripheral anesthesia, periarticular injection, and white or Caucasian race demonstrated a significant relationship with predicted 90-day MME (p <0.0001). While we identified several risk factors for increased in-hospital and 90-day post-operative opioid consumption, a comparison between DAA and PA did not demonstrate significantly different opioid prescribing patterns

Objectives. Articular cartilage damage is a primary outcome of pre-clinical and clinical studies evaluating meniscal and cartilage repair or replacement techniques. Recent studies have quantitatively characterized India Ink stained cartilage damage through light reflectance and the application of local or global thresholds. We develop a method for the quantitative characterisation of inked cartilage damage with improved generalisation capability, and compare its performance to the threshold-based baseline approach against gold standard labels. Methods. The Trainable WEKA Segmentation (TWS) tool (Arganda-Carreras et al., 2017) available in Fiji (Rueden et al., 2017) was used to train two separate Random Forest classifiers to automatically segment cartilage damage on ink stained cadaveric ovine stifle joints. Gold standard labels were manually annotated for the training, validation and test datasets for each of the femoral and tibial classifiers. Each dataset included a sample of medial and lateral femoral condyles and tibial plateaus from various stifle joints, selected to ensure no overlap across datasets according to ovine identifier. Training was performed on the training data with the TWS tool using edge, texture and noise reduction filters selected for their suitability and performance. The two trained classifiers were then applied to the validation data to output damage probability maps, on which a threshold value was calibrated. Model predictions on the unseen test set were evaluated against the gold standard labels using the Dice Similarity Coefficient (DSC) – an overlap-based metric, and compared with results for the baseline global threshold approach applied in Fiji as shown in Figures 1 and 2. Results. Test set results for the global threshold approach against gold standard labels were 45.0% DSC for the femoral condyle and 32.0% DSC for the tibial plateau. Results for the developed TWS classifiers on the same unseen test data were 79.0% and 72.7% DSC, showing absolute gains of 34.0% and 40.7% DSC over the global threshold baseline for the femoral and tibial classifiers. The trained TWS classifiers were then applied to an external set of unlabelled images of ink stained femoral condyles and tibial plateaus. Model results on sample images shown in Figure 3 further highlight the generalisation capability of the developed models. The most prominent classification features were Hessian filters (32.9%), Entropy (19.4%), Gaussian blur (10.1%), Gabor filters (6.3%) and Sobel filters (6.0%), with all other features contributing less than 6%. Conclusions. Our findings show that the developed segmentation method more accurately quantifies cartilage damage and provides improved generalisation capability over a range of input variations such as inconsistent orientation and lighting conditions. The developed model enables the use of articular cartilage damage as a reliable and quantitative outcome measure in studies involving large datasets, with reduced requirements for complex pre-processing and specialised equipment. For any figures or tables, please contact the authors directly

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

Aim. Culture-based conventional methods are still the gold standard to identify microorganisms in hip and knee PJIs diagnosis. However, such approach presents some limitations due to prior antimicrobial treatment or the presence of unusual and fastidious organisms. Molecular techniques, in particular specific real-time and broad-range polymerase chain reaction (PCR), are available for diagnostic use in a suspected PJI. However, limited data is available on their sensitivity and specificity. This study aimed to evaluate the performance of a rapid and simple Investigational Use Only (IUO) version of the BioFire® JI multiplex PCR panel when compared to traditional microbiological procedures. Method. Fifty-eight native synovial fluid samples were recovered from 49 patients (female n=26; male =23) who underwent one or multiple septic or aseptic revision arthroplasties of the hip (n=12) and knee (n=46). The JI panel methodology was used either on specimens freshly collected (n=6) or stored at −80°C in our Musculoskeletal Biobank (n=52). The JI panel performance was evaluated by comparison with culture reference methods. Patient's medical records were retrieved from our institutional arthroplasty registry as well as our prospectively maintained PJI infection database. Results. The JI panel identified additional microorganisms in 3/39 (7.7%) positive cases, and a different microorganism in 1/39 (2.6%) sample. Out of 9/58 (15.5%) culture negative samples, two (22%) were positively detected by the JI panel. In total 49/58 (84%) native synovial fluid specimens were positive by culture methods, versus 39/58 (81.2%) with the JI panel. Ten samples are currently under investigation for confirmatory results. Out of 39 positive detections with the JI panel, 35 (89.7%) were concordant with the identified microorganism (n=29 same species; n=6 same genus). The combined information from the JI panel results and clinical records revealed the existence of 6/58 (10.3%) PJIs’ cases which would have required a different antibiotic therapeutic approach. Conclusions. The work presented, provides additional value for the clinical use of the JI panel to the improvement of PJI management in terms of rapid and successful treatment decisions, patient outcome, and healthcare costs. This technique shows high sensitivity to detect PJIs specific microorganisms in both fresh as well frozen native synovial fluid samples, thus emphasizing its use for retrospective studies analysis

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

Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results. All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion. Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities

The aim of this study was to analyze and compare clinical, radiological and mortality outcomes of patients who underwent cemented hip hemiarthroplasty for displaced neck of femur fractures using a SPAIRE technique when compared to a pair-matched control cohort who underwent the same procedure using the direct lateral approach. A retrospective review of patients who underwent cemented hip hemiarthroplasty for displaced neck of femur fractures by a single surgeon using a SPAIRE technique over a two-year period between July 2019 and July 2021 was performed. These were subsequently pair matched in a 5:1 ratio for age, gender, ASA grade and residential status with a control group who underwent cemented hip hemiarthroplasty by 4 other surgeons using a direct lateral approach. The study included a total of 240 patients (40 and 200 pairmatched to SPAIRE and control groups respectively), with a mean age of 81.0 ± 8.2 years (63–99) and a mean follow-up of 12 ± 3 months (3–30). Overall, there was no significant difference in any of the radiological or mortality outcome scores assessed between the SPAIRE and control groups (p > 0.05 for all). There was a significantly lower number of patients in the SPAIRE group who dropped a level of mobility from their pre-injury baseline at 30-days post-operatively (8.1% versus 31.6%; p = 0.003). However, this appeared to have resolved at 120-day follow-up with no significant differences between the groups in terms of those acquiring a new baseline mobility at 120-days post-operatively (2.7% versus 13.2%, p = 0.09). In cases of cemented hip hemiarthroplasty for displaced intracapsular neck of femur fractures, the SPAIRE technique appears to offer patients an earlier return to levels of baseline pre-injury mobility when compared to a direct lateral approach

Introduction. While additional resources associated with direct anterior (DA) approach total hip arthroplasty (THA) such as fluoroscopy, staff, and special tables are well recognized, time consumption is not well studied. The purpose of this study was to analyze anesthesia and surgical time in DA and posterior approach THA in a large healthcare system across multiple facilities and surgeons. Methods. 3,155 unilateral primary THAs performed via DA or posterior approaches between 1/1/2017 and 06/30/2019 at nine hospitals and ambulatory surgery centers (ASC) in a large metropolitan healthcare system were retrospectively reviewed. All surgeons were experienced and beyond learning curves. 247 cases were excluded to eliminate confounds. Operating room (OR) in and out times and surgical times were collected via EMR electronic and manual data extraction with verification. Multivariate statistical analyses were utilized with p<0.05 significant. Results. 1261 DA approach (43%) and 1647 posterior approach (57%) THAs were analyzed. Mean total OR time, including anesthesia and positioning, was greatest for hospital-based DA THAs (146 mins), followed by hospital posterior approach THAs (126.4 mins), ASC-based DA THAs (118.1 mins) and ASC posterior THAs (90.1 mins) (p<0.001). In multivariate analysis, compared to the optimal ASC posterior approach group, the total OR time predictive model added 31 minutes per ASC DA THA, 33 minutes per hospital posterior THA, and 56 minutes for hospital DA THA (p<0.001). Similar predictive effect was observed for surgical time, which added 18 minutes per ASC-based DA THA, 22 minutes for hospital posterior THA and 29 minutes for hospital DA THA (p<0.001). Conclusion. In the COVID era, efficiency should be enhanced to maximize patient access for elective procedures and facilitate the healthcare system financial recovery. Despite equivocal clinical results, DA approach THA consumes substantially more OR time when compared to the posterior approach in both the hospital and ASC setting

Abstract. Background. Anterior cruciate ligament (ACL) injuries with coinciding posterolateral tibial plateau (PLTP) depression fractures are rare. According to the most up to date literature, addressing the PLTP is crucial in preventing failure of the ACL. However, the surgical management of these injuries pose a great challenge to orthopaedic surgeons, given the anatomical location of the depressed PTP fragment. We report a case of a 17-year-old patient presenting to our department with this injury and describe a novel fixation method, that has not been described in the literature. Surgical Technique. A standard 2-portal arthroscopy is used to visualise the fractures. The PLTP is addressed first. With the combined use of arthroscopy and fluoroscopy, a guide pin is triangulated from the anteromedial aspect of the tibia, towards the depressed plateau fragment. Once the guide pin is approximately 1cm from the centre of the fragment, it is over-drilled with a cannulated drill, and simultaneously bluntly punched up to its original anatomical location. Bone graft is then used to fill the void, supported by two subchondral screws. Both fluoroscopy and arthroscopy are used to confirm adequacy of fixation. Finally, the tibial spine avulsion fracture is repaired arthroscopically using the standard suture bridging technique. Conclusion. We describe a novel, one-stage, minimally invasive approach that addresses both the ACL injury and PLTP fracture. We highlight the advantages of utilising this approach and functional outcomes

Periprosthetic femur fracture (PFF) is a major complication following total hip arthroplasty (THA) that carries significant morbidity, mortality, and economic burden. Currently, uncemented stems are highly preferred in primary THA, but have been associated with higher risk of PFF compared to cemented stems. The use of collared stems in uncemented primary THA has shown promise in reducing PFF rates postoperatively. This retrospective study included 2,294 uncemented primary THAs using the posterior approach performed by two attending surgeons from January 2016 to December 2022. Both surgeons switched from a collarless femoral stem design to a collared design in May 2020. Data was collected regarding stem design, frequency of PFF, and requirement for revision surgery. Periprosthetic fractures were identified and confirmed using medical records and/or radiographic imaging. Fracture rates and percentages between collared and collarless stems were then analyzed. A Fisher's Exact Test was performed to determine if there was a significant association between collared and collarless stem use on PFF rates. A total of 2,294 uncemented primary THAs performed by 2 surgeons were eligible for analysis. 903 (39.4%) patients received a collared stem, and 1,391 (60.6%) patients received a collarless stem. In total, 14 (0.6%) PFFs occurred over the study period. There was 1 fracture (0.1%) out of 903 collared stems, and 13 fractures (0.9%) out of 1,391 collarless stems (p = 0.012). Collared stems were associated with a significant decrease in PFF rate when compared to collarless stems in uncemented primary THA. Future studies are encouraged to continue to investigate PFF and other complication rates with the use of a collared stem design

Range of Motion (ROM) assessments are routinely used during joint replacement to evaluate joint stability before, during and after surgery to ensure the effective restoration of patient biomechanics. This study aimed to quantify axial torque in the femur during ROM assessment in total hip arthroplasty to define performance criteria against which hip instruments can be verified. Longer term, this information may provide the ability to quantitatively assess joint stability, extending to quantitation of bone preparation and quality. Joint loads measured with strain-gaged instruments in five cadaveric femurs prepared using posterior approach were analysed. Variables such as surgeon-evaluator, trial offset and specimen leg and weight were used to define 13 individual setups and paired with surgeon appraisal of joint tension for each setup. Peak torque loads were then identified for specific motions within the ROM assessment. The largest torque measured in most setups was observed during maximum extension and external rotation of the joint, with a peak torque of 13Nm recorded in a specimen weighing 98kg. The largest torque range (19.4Nm) was also recorded in this specimen. Other motions within the trial reduction showed clear peaks in applied torque but with lower magnitude. Relationships between peak torque, torque range and specimen weight produced an R2 value greater than 0.65. The data indicated that key influencers of torsional loads during ROM were patient weight, joint tension and limb motion. This correlation with patient weight should be further investigated and highlights the need for population representation during cadaveric evaluation. Although this study considered a small sample size, consistent patterns were seen across several users and specimens. Follow-up studies should aim to increase the number of surgeon-evaluators and further vary specimen size and weight. Consideration should also be given to alternative surgical approaches such as the Direct Anterior Approach

Aims. Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications. Methods. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Results. Fifty-eight intra-articular calcaneal fractures (fifty-three patients including five bilateral, mean age = 46.91 years) were included. Forty-nine patients were injured as a result of a fall from a height (92.4%). Mean time from presentation to surgery was 3.23 days (range 0–21). Mean Maryland Foot score was found to be 77.6 (+/− 16.22) in forty-five patients. Five patients (9.4%) had wound complications; two superficial (3.7%) and three deep (5.6%). Conclusion. Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management

Aim of this work is to critically analyze the current mandatory trend to adapt femoral cementless implant shape as to allow their use through mini-invasive anterior hip approach (MIS-AA). During decades, designers of cementless stems tried to adapt implant shapes to patient anatomy, that led to various classification systems (straight, curved, anatomic, etc …). Another way to classify cementless stems is according to their longevity, outcome quality and long-term results. This is the goal of the Orthopaedic Data Evaluation Panel (ODEP) that provided in 2017 an approved list of prostheses that meet at least the NICE 10y revision rate standard. In the last available ODEP 2020 issue, the best rating (13y experience “13”, with strong evidence “A” and < 6.5% rev rate “∗”) was achieved by only 10 cementless implant: Mallory-Head®, Taperloc®, Bimetric®, Accolade®, SL-Alloclassic®, Corail®, CLS Spotorno®, Furlong®, Synergy® & Versys Fibermetal®. All 10 are Ti straight tapers with large metaphyseal morphology in particular in Gruen Zone I. All these 10 ODEP 13A∗ cementless stems can universally be implanted through postero-lateral (PL), MIS-PL, lateral & conventional anterior approaches, but not safely through MIS-AA. Conversely, only new short and curved stems can be inserted safely through MIS-AA. Indeed, surgeons who promote MIS-AA cannot routinely use those successful femoral implants classified ODEP 13A∗. Obviously, surgical approach determines the choice of femoral component. Surgeons who promote MIAA can only bet/hope that these new short curved implants with currently very few clinical evidence will reach the same success and longevity that ODEP 13A∗ conventional straight tapers. Only future long-term studies will address that concern

Aim of this study was the development of a dynamic FE-framework to identify worst-case size combinations and kinematics in a virtual wear simulator setup covering five daily activities and high, dynamic loads. Two cruciate sacrificing knee designs (D1 & D2) were tested physically on a wear-testing machine prior the model development using a high demanding, daily activity protocol (HDA) [1]. A simplified FE-setup was generated, reduced to the 3D geometries of the assembly whereas the representation of the mechanical wear simulator conditions and the load transmission was achieved by joint elements. Inertial and other time-related effects of the physical situation were compensated by a system of spring- and damper elements. Using a time-series signal optimization approach on the anterior-posterior translation and the internal-external rotation results for each activity, 38 variable parameters were varied in between pre-defined limits in a semiautomatic workflow. For each design, two consecutive cycles of a single activity were analysed and the results of the second cycle were used for the optimization. Based on the determined values, a single set of averaged parameter settings was identified that covers all activity cycles sufficiently. A total of 1010 dynamic analyses were carried out in order to find a sharable set of parameter values. In this study, an efficient simulation workflow for design evaluation was developed. Therefore, a HDA wear-testing machine was simplified to boundary conditions and stabilizing elements, using a single set of parameters for all activities. The calculated kinematics were in a comparable range to the machine output. Further applications of the method were found in systematic analyses of entire implant systems to achieve consistent kinematics over the size compatibility range in the design process of new implant systems

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

Aims. Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT). Methods. Data was retrospectively analyzed from a single centre. In all, 29 consecutive joints prior to the implementation of an infection MDT in November 2016 were compared with 29 consecutive joints subsequent to the MDT conception. All individuals who underwent a debridement antibiotics and implant retention (DAIR) procedure, a one-stage revision, or a two-stage revision for an acute or chronic PJI in this time period were included. The definition of successfully treated PJI was based on the Delphi international multidisciplinary consensus. Results. There were no statistically significant differences in patient demographics or comorbidities between the groups. There was also no significant difference in length of overall hospital stay (p = 0.530). The time taken for formal microbiology advice was significantly shorter in the post MDT group (p = 0.0001). There was a significant difference in failure rates between the two groups (p = 0.001), with 12 individuals (41.38%) pre-MDT requiring further revision surgery compared with one individual (6.67%) post-MDT inception. Conclusion. Our standardized multidisciplinary approach for periprosthetic knee and hip joint infection shows a significant reduction in failure rates following revision surgery. Following implementation of our MDT, our success rate in treating PJI is 96.55%, higher than what current literature suggests. We advocate the role of a specialist infection MDT in the management of patients with a PJI to allow an individualized patient-centred approach and care plan, thereby reducing postoperative complications and failure rates. Cite this article: Bone Jt Open 2021;2(7):509–514

Precision health aims to develop personalised and proactive strategies for predicting, preventing, and treating complex diseases such as osteoarthritis (OA). Due to OA heterogeneity, which makes developing effective treatments challenging, identifying patients at risk for accelerated disease progression is essential for efficient clinical trial design and new treatment target discovery and development. To create a reliable and interpretable precision health tool that predicts rapid knee OA progression over a 2-year period from baseline patient characteristics using an advanced automated machine learning (autoML) framework, “Autoprognosis 2.0”. All available 2-year follow-up periods of 600 patients from the FNIH OA Biomarker Consortium were analysed using “Autoprognosis 2.0” in two separate approaches, with distinct definitions of clinical outcomes: multi-class predictions (categorising disease progression into pain and/or radiographic progression) and binary predictions. Models were developed using a training set of 1352 instances and all available variables (including clinical, X-ray, MRI, and biochemical features), and validated through both stratified 10-fold cross-validation and hold-out validation on a testing set of 339 instances. Model performance was assessed using multiple evaluation metrics. Interpretability analyses were carried out to identify important predictors of progression. Our final models yielded higher accuracy scores for multi-class predictions (AUC-ROC: 0.858, 95% CI: 0.856-0.860) compared to binary predictions (AUC-ROC: 0.717, 95% CI: 0.712-0.722). Important predictors of rapid disease progression included WOMAC scores and MRI features. Additionally, accurate ML models were developed for predicting OA progression in a subgroup of patients aged 65 or younger. This study presents a reliable and interpretable precision health tool for predicting rapid knee OA progression. Our models provide accurate predictions and, importantly, allow specific predictors of rapid disease progression to be identified. Furthermore, the transparency and explainability of our methods may facilitate their acceptance by clinicians and patients, enabling effective translation to clinical practice

Bone regeneration is a complex but very well organized process in which the immune system has a decisive role. The adaptive immune system and its experience level (percentage of effector and memory T cells) has been proven to influence the healing cascade especially in the early healing phases. This opens the possibility of an early intervention to enhance bone healing during the primary clinical treatment. Patients stratified for possible delayed bone healing could benefit from immunomodulatory treatment approaches. In pre-clinical studies cells and signaling molecules have been identified that could represent promising candidates to help patients in need

Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons. Pseudarthrosis, cage migration, subsidence or infection can occur, with subsequent failed surgery, persistent pain and patient’ bad quality of life. The goal of revision fusion surgery is to correct any previous technical errors avoiding surgical complications. The most safe and effective way is to choose a naive approach to the disc. Therefore, the anterior approach represents a suitable technique as a salvage operation. The aim of this study is to underline the technical advantages of the anterior retroperitoneal approach as a salvage procedure in failed PLIF/TLIF analyzing a series of 32 consecutive patients. Materials and Methods. We performed a retrospective analysis of patients’ data in patients who underwent ALIF as a salvage procedure after failed PLIF/TLIF between April 2014 to December 2019. We recorded all peri-operative data. In all patients the index level was exposed with a minimally invasive anterior retroperitoneal approach. Results. Thirty-two patients (average age: 46.4 years, median age 46.5, ranging from 21 to 74 years hold- 16 male and 16 female) underwent salvage ALIF procedure after failed PLIF/TLIF were included in the study. A minimally invasive anterior retroperitoneal approach to the lumbar spine was performed in all patients. In 6 cases (18.7%) (2 infection and 4 pseudarthrosis after stand-alone IF) only anterior revision surgery was performed. A posterior approach was necessary in 26 cases (81.3%). In most of cases (26/32, 81%) the posterior instrumentation was overpowered by the anterior cage without a previous revision. Three (9%) intraoperative minor complications after anterior approach were recorded: 1 dural tear, 1 ALIF cage subsidence and 1 small peritoneal tear. None vascular injuries occurred. Most of patients (90.6%) experienced an improvement of their clinical condition and at the last follow-up no mechanical complication occurred. Conclusions. According to our results, we can suggest that a favourable clinical outcome can firstly depend from technical reasons an then from radiological results. The removal of the mobilized cage, the accurate endplate and disc space preparation and the cage implant eliminate the primary source of pain reducing significantly the axial pain, helping to realise an optimal bony surface for fusion and enhancing primary stability. The powerful disc distraction given by the anterior approach allows inserting large and lordotic cages improving the optimal segmental lordosis restoration

Abstract. Introduction. Precision health aims to develop personalised and proactive strategies for predicting, preventing, and treating complex diseases such as osteoarthritis (OA), a degenerative joint disease affecting over 300 million people worldwide. Due to OA heterogeneity, which makes developing effective treatments challenging, identifying patients at risk for accelerated disease progression is essential for efficient clinical trial design and new treatment target discovery and development. Objectives. This study aims to create a trustworthy and interpretable precision health tool that predicts rapid knee OA progression based on baseline patient characteristics using an advanced automated machine learning (autoML) framework, “Autoprognosis 2.0”. Methods. All available 2-year follow-up periods of 600 patients from the FNIH OA Biomarker Consortium were analysed using “Autoprognosis 2.0” in two separate approaches, with distinct definitions of clinical outcomes: multi-class predictions (categorising patients into non-progressors, pain-only progressors, radiographic-only progressors, and both pain and radiographic progressors) and binary predictions (categorising patients into non-progressors and progressors). Models were developed using a training set of 1352 instances and all available variables (including clinical, X-ray, MRI, and biochemical features), and validated through both stratified 10-fold cross-validation and hold-out validation on a testing set of 339 instances. Model performance was assessed using multiple evaluation metrics, such as AUC-ROC, AUC-PRC, F1-score, precision, and recall. Additionally, interpretability analyses were carried out to identify important predictors of rapid disease progression. Results. Our final models yielded high accuracy scores for both multi-class predictions (AUC-ROC: 0.858, 95% CI: 0.856–0.860; AUC-PRC: 0.675, 95% CI: 0.671–0.679; F1-score: 0.560, 95% CI: 0.554–0.566) and binary predictions (AUC-ROC: 0.717, 95% CI: 0.712–0.722; AUC-PRC: 0.620, 95% CI: 0.616–0.624; F1-score: 0.676, 95% CI: 0.673–0679). Important predictors of rapid disease progression included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and MRI features. Our models were further successfully validated using a hold-out dataset, which was previously omitted from model development and training (AUC-ROC: 0.877 for multi-class predictions; AUC-ROC: 0.746 for binary predictions). Additionally, accurate ML models were developed for predicting OA progression in a subgroup of patients aged 65 or younger (AUC-ROC: 0.862, 95% CI: 0.861–0.863 for multi-class predictions; AUC-ROC: 0.736, 95% CI: 0.734–0.738 for binary predictions). Conclusions. This study presents a reliable and interpretable precision health tool for predicting rapid knee OA progression using “Autoprognosis 2.0”. Our models provide accurate predictions and offer insights into important predictors of rapid disease progression. Furthermore, the transparency and interpretability of our methods may facilitate their acceptance by clinicians and patients, enabling effective utilisation in clinical practice. Future work should focus on refining these models by increasing the sample size, integrating additional features, and using independent datasets for external validation. 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

Aims. Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening. Methods. In all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment. Results. The mean Harris Hip Score at the latest follow-up was 79.2 (68 to 90). There was significant improvement in the coronal pelvic obliquity from 16.6. o. (SD 7.9. o. ) to 1.8. o. (SD 2.4. o. ; p < 0.001). Radiographs of all ten hips showed stable prostheses with no signs of loosening or migration, regardless of whether paralytic or non-paralytic hip was replaced. No complications, including dislocation or infection related to the surgery, were observed in any patient. The subtrochanteric shortening osteotomy done in two patients had united by nine months. Conclusion. Simultaneous correction of soft tissue contractures is necessary for obtaining a stable hip with balanced pelvis while treating hip arthritis by THA in patients with PPRP and fixed pelvic obliquity. Cite this article: Bone Jt Open 2021;2(9):696–704

With the success of the medial parapatellar approach (MPA) to total knee arthroplasty (TKA), current research is aimed at reducing iatrogenic microneurovascular and soft tissues damage to the knee. In an effort to avoid disruption to the medial structures of the knee, we propose a novel quadriceps-sparing, subvastus lateralis approach (SLA) to TKA. The aim of the present study is to compare if a SLA can provide adequate exposure of the internal compartment of the knee while reducing soft tissue damage, compared to the MPA. Less disruption of these tissues could translate to better patient outcomes, such as reduced post-operative pain, increased range of motion, reduced instances of patellar maltracking or necrosis, and a shorter recovery time. To determine if adequate exposure could be achieved, the length of the skin incision and perimeter of surgical exposure was compared amongst 22 paired fresh-frozen cadaveric lower limbs (five females/six males) which underwent TKA using the SLA or MPA approach. Additionally, subjective observations which included the percent of visibility of the femoral condyles and tibial plateau, as well as the patellar tracking, were noted in order to qualify adequate exposure. All procedures were conducted by the same surgeon. Subsequently, to determine the extent of soft tissue damage associated with the approaches, an observational assessment of the dynamic and static structures of the knee was performed, in addition to an examination of the microneurovascular structures involved. Dynamic and static structures were assessed by measuring the extent of muscular and ligamentus damage during gross dissection of the internal compartment of the knee. Microneurovascular involvement was evaluated through a microscopic histological examination of the tissue harvested adjacent to the capsular incision. Comparison of the mean exposure perimeter and length of incision was not significantly different between the SLA and the MPA (p>0.05). In fact, on average, the SLA facilitated a 5 mm larger exposure perimeter to the internal compartment, with an 8 mm smaller incision, compared to the MPA, additional investigation is required to assert the clinical implications of these findings. Preliminary analysis of the total visibility of the femoral condyles were comparable between the SLA and MPA, though the tibial plateau visibility appears slightly reduced in the SLA. Analyses of differences in soft tissue damage are in progress. Adequate exposure to the internal compartment of the knee can be achieved using an incision of similar length when the SLA to TKA is performed, compared to the standard MPA. Future studies should evaluate the versatility of the SLA through an examination of specimens with a known degree of knee deformity (valgus or varus)

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

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

Aim. Bone and joint infections (BJIs) are serious infections requiring early optimized antimicrobial therapy. BJIs can be polymicrobial or caused by fastidious bacteria, and the patient may have received antibiotics prior to sampling, which may decrease the sensitivity of culture-based diagnosis. Furthermore, culture-based diagnosis can take up to 14 days. Molecular approaches can be useful to overcome these concerns. The BioFire® system performs syndromic multiplex PCR in 1 hour, with only a few minutes of sample preparation. The BioFire® Joint Infection (JI) panel (BF-JI), recently FDA-cleared, detects both Gram-positive (n=15) and Gram-negative bacteria (n=14), Candida, and eight antibiotic resistance genes directly from synovial fluids. The aim of this study was to evaluate its performance in acute JIs in real-life conditions. Method. BF-JI was performed on synovial fluid from patients with clinical suspicion of acute JI, either septic arthritis or periprosthetic JI, in 6 French centers. The results of BF-JI were compared with the results of culture of synovial fluid and other concomitantly collected osteoarticular samples obtained in routine testing in the clinical microbiology laboratory. Results. From July 2021 to May 2022, 319 patients (including 10 children < 5y and 136 periprosthetic infections) had been included in the study. The BF-JI test was invalid for one patient (not retested). Among the 318 remaining patients, overall concordance with comparative microbiology methods was 88% (280/318): 131 samples were negative with both BF-JI and culture, and 149 samples were positive with the same microorganisms using complementary techniques. In 33 cases (10.4%), BF-JI was negative while culture was positive: 18 microorganisms were not targeted by BF-JI (including Staphylococcus epidermidis, n=10, and Cutibacterium acnes, n=2); 15 microorganisms targeted by BF-JI were obtained in culture but not by the molecular test (false-negative 4.7%). In 20 cases, BF-JI was positive while culture was not: 12 patients had received antibiotics before sampling, and 7 cases involved fragile and fastidious bacteria (Kingella kingae, n=5; Neisseria gonorrhoeae, n=2). In 6 cases, both BF-JI and culture were positive, but no yielding the same bacteria (polymicrobial specimens). Conclusions. In acute JIs, the BF-JI panel shows a good concordance with culture for the microorganisms targeted by the panel. Therefore, this molecular tool may have a place in microbiological diagnosis of acute JIs in order to confirm JI faster than culture. Moreover, it allows easy detection of difficult-to-culture bacteria. Acknowledgements. study was supported by bioMérieux, who provided all reagents

Purpose. Various approaches have been reported for the total hip replacement (THR). In recent years, a muscle sparing approach with low postoperative muscle weakness and low dislocation risk has been frequently selected. However, such surgery has a learning curve. Thus, at the time of switching from the conventional approach to such approaches, invasion or infection risk may increase with the operation time extension. The purpose of this study is to clarify the change of invasiveness or latent infection rate with the change in approach in order to select the cases safely at the beginning of introducing a new approach in THR. Methods. In facility A, THR was performed with Dall's approach (Dall), but 1 surgeon changed Dall to anterolateral modified Watson-Jones approach (OCM) and another surgeon changed Dall to direct anterior approach (DAA). In facility B, all 3 surgeons changed posterolateral (PL) approach to OCM. The subjects are 150 cases in total, including the each last 25 cases operated with the conventional approach and the each first 25 cases operated with a new approach (Dall to OCM: 25 + 25, Dall to DAA: 25 + 25, PL to OCM: 25 +25 cases). And, differences in operative time, intraoperative bleeding volume, postoperative hospital stay, and postoperative hemoglobin, white blood cell count, lymphocyte count, creatine kinase (CK), C-reactive protein (CRP) were investigated. Results. The average age of subjects was 64 years (31–87 years old), and there were 27 male subjects and 123 female subjects. In the change from Dall to OCM, only the postoperative hospital stay decreased significantly. In the change from Dall to DAA, the length of hospital stay and postoperative CRP significantly decreased, but the intraoperative bleeding volume increased. In the change from PL to OCM, the operation time, postoperative CRP and CK decreased, but postoperative Hb decreased. Cases with lymphocytes less than 1000/µL or less than 10% after surgery on day 4 are latent infection cases, and in such cases the operation time was significantly longer, the postoperative Hb was significantly lower, and the postoperative CK was significantly higher. However, such cases were not significantly increased by the change of operation approach. Conclusion. Introduction of the muscle sparing approach improved many items on surgical invasion, but some items deteriorated especially at the beginning of a new approach. In the early stages of introduction of the new approach, choosing cases without obesity and without lots of muscle volume may reduce latent infection

Economic data, clinical outcome studies, and anatomical studies continue to support the Superior Hip Approach as a preferred approach for improved safety, maximal tissue preservation, rapid recovery, and minimised cost. Clinical studies show exceedingly low rates of all major complications including femur fracture, dislocation, and nerve injury. Economic data from Q1 2013 to Q2 2016 demonstrate that CMS-insured patients treated by the Superior Hip Approach have the lowest cost of all patients treated in Massachusetts by an average of more than $7,000 over 90 days. The data show that the patients treated by the Superior Hip Approach have lower cost than any other surgical technique. Matched-pair bioskills dissections demonstrate far better preservation of the hip joint capsule and short external rotators than the anterior approach. Design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ prior to femoral neck osteotomy; Excision of the femoral head, thereby avoiding surgical dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intra-operative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Conclusion. In contrast to the results of the Superior Approach, the anterior approach continues to show difficulties with wound problems, infection, intra- and post-operative fracture, and failure of femoral component osseointegration and even dislocation. Evidence continues to demonstrate that the Superior Hip Approach has advantages over all other surgical approaches to the hip

The optimal approach for total hip arthroplasty (THA) remains controversial. We present the results of the Direct Superior Approach (DSA), an improved variation of the posterior approach with high levels of stability, patient-reported functional outcomes, and satisfaction. This is a single-surgeon prospective series. All patients undergoing THA between 2010 and 2015 via the DSA were included. Complication data was collected by interrogation of the Scottish Arthroplasty Project national joint registry. Pre and one-year post-operative Oxford Hip Score (OHS), Euroqol-5D (EQ-5D), and patient satisfaction questionnaires were collected. 659 patients received a THA via the DSA during the study period. Average age was 61.8 years (range 16.4–93.3). Analysis of registry data revealed no cases of dislocation, 5 cases of venous thromboembolism (0.75%), and 5 cases of deep infection (0.75%). 586 patients (88.9%) underwent their surgery in the National Health Service, and post-operative outcomes were available for 337 of these patients (57.5% follow-up) at one year. Average improvement in OHS and EQ-5D was 20 (range −14 – 48) and 0.39 (−0.697–1.2) respectively. 311 patients (92.3%) were satisfied. This description of the DSA is accessible to all surgeons, confers excellent stability with no dislocations, and is associated with excellent post-operative functional outcomes and patient satisfaction

Introduction. The hip hemiarthroplasty in posterior approach is a common surgical procedure at the femoral neck fractures in the elderly patients. However, the postoperative hip precautions to avoid the risk of dislocations are impeditive for early recovery after surgery. We used MIS posterior approach lately known as conjoined tendon preserving posterior (CPP) approach, considering its enhancement of joint stability, and examined the intraoperative and postoperative complications, retrospectively. Methods. We performed hip hemiarthroplasty using CPP approach in 30 patients, and hip hemiarthroplasty using conventional posterior approach in 30 patients, and both group using lateral position with the conventional posterior skin incision. The conjoined tendon (periformis, obturator internus, and superior/inferior gemellus tendon) was preserved and the obturator externus tendon was incised in CPP approach without any hip precautions postoperatively. The conjoined tendon was incised in conventional approach using hip abduction pillow postoperatively. Results. There was no difference between CPP approach group and conventional approach group in the mean age of patients (81.8 years, and 80.3 years, respectively), and in the mean operative time (68.8 minutes, and 64.9 minutes, respectively). In 4 cases of CPP approach, the avulsion fracture at femoral attachment of the conjoined tendon occured during hip reduction manoeuvres. No dislocations occured in both groups in the follow-up period (2 years). Discussion. Lately, the number of hip surgery in muscle sparing approach is increasing. However, in general, MIS approach induces the intraoperative complications, and requires the skillful procedure. The hip reduction manoeuvres would be more difficult in the CPP approach, than in conventional posterior approach, because the preserved conjoined tendon would inhibit hip reduction, considering those avulsion fractures of the femoral attachment. Nevertheless, CPP approach did not require no extended time compared to conventional approach, and no postoperative hip precautions. Due to these results, CPP approach could be a good MIS procedure including early recovery after surgery based on the enhancement of joint stability, excluding the difficulties in hip reduction manoeuvres. We could not show the difference in dislocation rate between two groups, because of small numbers. We are planning to increase the number of patients in the future study

Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study. From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH. A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012). The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation

The Superior Hip Approach allows for safe reconstruction of the hip while maximizing preservation of the surrounding soft tissues. The procedure involves an incision in the hip joint capsule posterior to the gluteus medius and minimus and anterior to the short external rotators. The technique involves preparation of the femur in-situ through the superior femoral neck and then excision of the femoral head, which avoids the attendant soft tissue dissection or injury associated with dislocation of the native hip. After component implantation, the capsule is closed anatomically. Two separate studies have demonstrated that over a 90-day period, patients whose hips were replaced using this technique consumed the least amount of cost of any patients treated by hip arthroplasty in the Commonwealth of Massachusetts. One study assessed all hips replaced in patients insured by Medicare over a four-year period. In this study, patients treated by the Superior Hip Approach were less costly by an average of more than $7,000 over 90 days. A second study assessed all hips replaced in patients insured by a large private insurer. This study showed again that patients treated by the Superior Hip Approach were the lowest cost patients. Notable, the cost on average was $23,500 less per procedure compared to the most well-known medical care organization in the state or roughly half the cost. Lower cost was due to both lower inpatient cost and reduced utilization of post-acute care resources. Since reduced resource utilization is a direct measure of accelerated recovery, these economic data combine with clinical outcomes and anatomical studies that document that the Superior Hip Approach is a reliable technique for achieving optimal results following THA

Introduction and Objective. Interest for direct anterior approach (DAA) in hip hemiarthroplasty (HHA) has greatly increased in recent years, however which is the best surgical approach in hip replacement treating femoral neck fractures (FNFs) is already unclear. The aim of this study is to perform a radiographic and perioperative complications analysis by comparing the direct anterior approach (DAA) with the direct lateral approach (DLA) in patients treated with hemiarthroplasty for FNFs. Materials and Methods. Patients with FNFs surgically treated between 2016–2020 with HHA were enrolled. The radiographical outcomes of DAA and DLA are compared. Several peri-operative and post-operative variables were evaluated: mean surgery time, complications as periprosthetic fractures or episodes of dislocation, the average of post-operative diaphyseal filling of the stem (Canal Fill Index, CFI), the extent of heterotopic ossification (HO) (simplified Broker classification) and metadiaphiseal bone loss (Paprosky classification) within one year from surgery. Results. 86 patients underwent HHA by DAA and 80 patients by DLA. The two groups are qualitatively comparable. No statistically significate differences were showed in all variables analyzed (p>0.05). The average of surgical time of DAA were 61 minutes compared to 67 of DLA. No differences were showed in the post-operative CFI (DAA 0.71 ± 6.1; DLA 0.76 ± 13.5), the extent of the HO (DAA 79.07% low; DLA 75% low) and metadiaphiseal bone loss (DAA Grade I 91.86%; DLA Grade I 93.75%). Regarding perioperative complications, we have discovered only one periprosthetic fracture each group. Although there was no statistically significant difference, we highlighted a higher number of dislocations in the group of DLA (2 episodes vs no one). Conclusions. In this study we have shown that the DAA is an adequate surgical choice comparing with the classical DLA for FNFs treated with HHA. The analysis of our radiographic parameters and perioperative complications have not shown a significant difference between the two surgical approach. This study is limited by a purely radiographic analysis without addition of clinical parameters

Keywords. Complete Abductor Detachament, Direct Lateral Approach, Abductor Insuffenciency, Hip Arthroplasty. Backgroung. Approach of Total hip replacement (THR) is a very important part of the surgery, the approach dictates the postoperative complications. Lateral approach is one of the most commonly used approaches. The initial lateral approach relied on bony (trochanteric) osteotomy which was later modified to tendon detachment, there are many versions of the lateral approach but the main goal is to detach the hip abductors mechanism to gain access to the underlying joint. One of the modifications is to completely detach the abductors tendon, this offers superior exposure compared to the traditional partial detachment (Hardinge) approach. Objectives. We aimed to perform the first study comparing the complications rate following complete detachment of hip abductors to the documented complications rate of the traditional approach. Study Design & Methods. Retrospective study to evaluate the rate of approach specific complications following complete abductor detachment approach, we included s all patients who had THR using this approach 8–18 months ago. The study group comprised of 44 patients of different age groups and genders. Patients were reviewed to assess gait abnormality, abductor weakness with Trendlenberg test, lateral trochanteric pain (LTP) and heterotopic ossification (H.O). Results. Out of the 44 patients in our study group 20 patients had abductor weakness with positive Trendelnberg test (45.5%) while the reported percentage of abductor weakness following the traditional approach is 4–20%.7 patients (15%) were dissatisfied with the postoperative gait. LTP was reported in 5 patients (11%) compared to 4.9% associated with standard lateral approach. In our series 9 (20.4%) patients had H.O which is within the acceptable range (up to 25%). Conclusions. Complete abductor detachment approach offers better exposure and quicker alternative to the traditional lateral approach of the hip (Hardinge) but on the other hand it has relatively higher complication rate

Gait analysis is an indispensable tool for scientific assessment and treatment of individuals whose ability to walk is impaired. The high cost of installation and operation are a major limitation for wide-spread use in clinical routine. Advances in Artificial Intelligence (AI) could significantly reduce the required instrumentation. A mobile phone could be all equipment necessary for 3D gait analysis. MediaPipe Pose provided by Google Research is such a Machine Learning approach for human body tracking from monocular RGB video frames that is detecting 3D-landmarks of the human body. Aim of this study was to analyze the accuracy of gait phase detection based on the joint landmarks identified by the AI system. Motion data from 10 healthy volunteers walking on a treadmill with a fixed speed of 4.5km/h (Callis, Sprintex, Germany) was sampled with a mobile phone (iPhone SE 2nd Generation, Apple). The video was processed with Mediapipe Pose (Version 0.9.1.0) using custom python software. Gait phases (Initial Contact - IC and Toe Off - TO) were detected from the angular velocities of the lower legs. For the determination of ground truth, the movement was simultaneously recorded with the AS-200 System (LaiTronic GmbH, Innsbruck, Austria). The number of detected strides, the error in IC detection and stance phase duration was calculated. In total, 1692 strides were detected from the reference system during the trials from which the AI-system identified 679 strides. The absolute mean error (AME) in IC detection was 39.3 ± 36.6 ms while the AME for stance duration was 187.6 ± 140 ms. Landmark detection is a challenging task for the AI-system as can clearly be seen be the rate of only 40% detected strides. As mentioned by Fadillioglu et al., error in TO-detection is higher than in IC-detection

Total hip arthroplasty (THA) has been cited as one of the most successful surgical procedures performed today. However, as hip surgeons, we desire constantly improving outcomes for THA patients with more favorable complication rates. At the same time, patients desire hip pain relief and return to function with as little interruption of life as possible. The expectation of patients has changed; they have more physical demands for strength and flexibility, and aspire to achieve more in their recreational pursuits. Additionally, health care system constraints require the THA episode of care to become more efficient as the number of procedures increases with time. These factors, over the past fifteen years, have led to a search for improved surgical approaches and peri-operative pain and rehabilitation protocols for primary THA. The orthopaedic community has seen improved pain control, length of stay, and reduction in complications with changes in practice and protocols. However, the choice of surgical approach has provided significant controversy in the orthopaedic literature. In the 2000s, the mini-posterior approach (MPA) was demonstrated as the superior tissue sparing approach. More recently, there has been a suggestion that the direct anterior approach (DAA) leads to less muscle damage, and improved functional outcomes. A recent prospective randomised trial has shown a number of early deficits of the posterior approach when compared to the direct anterior approach. The posterior approach resulted in patients taking an additional 5 days to discontinue a walker, discontinue all gait aids, discontinue narcotics, ascend stairs with a gait aid, and to walk 6 blocks. Patients receiving the posterior approach required more morphine equivalents in the hospital, and had higher VAS pain scores in the hospital than the direct anterior approach. Interestingly, activity monitoring at two weeks post-operatively also favored DAA with posterior approach patients walking 1600 steps less per day than DAA patients. There has been little difference in the radiographic outcomes or complications between approaches in prospective randomised trials. A number of randomised clinical trials have demonstrated that both the direct anterior and posterior approach provided excellent early post-operative recovery with a low complication rate. DAA patients have objectively faster recovery with slightly shorter times to achieve milestones of function, with similar radiographic and clinical outcomes at longer-term outcomes, with a similar complication rate

Aims. To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between the two groups. Methods. Based on specific eligibility criteria, 120 adults (median age 37.5 years (interquartile range (18 to 61)) and 84% males (n = 101)) diagnosed with an acute displaced mid-shaft fracture were recruited, and randomized to either the operative (n = 60) or nonoperative (n = 60) treatment group. This randomized controlled, partially blinded trial followed patients for 12 months following initial treatment. Functionality was assessed by the Constant score (CS) (assessor blinded to treatment) and Disability of the Arm, Shoulder and Hand (DASH) score. Clinical and radiological evaluation, and review of patient files for complications and reoperations, were added as secondary outcomes. Results. At 12 months, 87.5% of patients (n = 105) were available for analysis. The two groups were well balanced based on demographic and fracture-related characteristics. At six weeks of follow-up a significant difference in DASH score (p < 0.001) was found in favour of operative treatment. The functionality at 12 months of follow-up based on CS and DASH was excellent in both groups (CS > 90 points and DASH < 10 points) with no significant difference (p = 0.277 for DASH and p = 0.184 for CS) between the two groups. The risk of symptomatic nonunion was significantly higher in the nonoperative group (p = 0.014), with a relative risk of 9.47 (95% confidence interval (CI) 1.26 to 71.53) in this group compared to the operative group. The number-needed-to-treat to avoid one symptomatic nonunion was 6.2. Initial treatment and age were factors significantly associated with nonunion in a logistic analysis. There were 26% in both groups (n = 14 in operative group and n = 15 in nonoperative group) who required secondary surgery, with most indications in the nonoperative group mandatory due to nonunion compared to most relative indications in the operative group requiring intervention due to implant irritation. Conclusion. Superiority was not identified with either an all-operative or all-nonoperative approach. The functionality at short term (within six weeks) seems igreater following operative treatment but was not found at one year. The risk of nonunion is significantly higher with nonoperative treatment. However, an all-operative approach to lower the nonunion risk may result in unnecessary surgery and is not recommended. Cite this article: Bone Joint J 2021;103-B(4):762–768

Aims. The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. Patients and Methods. A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter. Results. Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased. Conclusion. The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116–122

The future of work brings several challenges and opportunities for occupational health and safety on three major drivers: the rapid progress of technological innovation; demographic changes, in particular ageing of the workforce and migration; and changes in the labour market, especially owing to new ways of per-forming jobs. Innovation technologies are leading to an overall transformation of industrial processes that offer huge developmental perspectives in the world of work and opportunities for society. In the field of prevention of musculoskeletal disorders, relevant progresses have been made in the clinical setting and in the context of care, also in relation to the ageing society. In the near future, the adaptation of workstations and the implementation of sensors and enabling technologies (collaborative robots and exoskeletons) will offer, together with the innovations in the clinic and orthopaedic surgery, a significant contribution to the reduction of risks from biomechanical overload, as well as support interventions to increase work ability and reduce the impact of disability. However, the potential risk scenarios for health and safety in the workplace, along with the progress in occupational health research, lead to the need for creating an inte-grated system of skills and approaches to adopt a Prevention through Design perspective. This requires designing and conceiving processes taking into consideration occupational risk prevention and guarantee-ing the return to work in a multidisciplinary and integrated perspective

Aims. This study aimed to develop a virtual clinic for the purpose of reducing face-to-face orthopaedic consultations. Patients and Methods. Anonymized experts (hip and knee arthroplasty patients, surgeons, physiotherapists, radiologists, and arthroplasty practitioners) gave feedback via a Delphi Consensus Technique. This consisted of an iterative sequence of online surveys, during which virtual documents, made up of a patient-reported questionnaire, standardized radiology report, and decision-guiding algorithm, were modified until consensus was achieved. We tested the patient-reported questionnaire on seven patients in orthopaedic clinics using a ‘think-aloud’ process to capture difficulties with its completion. Results. A patient-reported 13-item questionnaire was developed covering pain, mobility, and activity. The radiology report included up to ten items (e.g. progressive periprosthetic bone loss) depending on the type of arthroplasty. The algorithm concludes in one of three outcomes: review at surgeon’s discretion (three to 12 months); see at next available clinic; or long-term follow-up/discharge. Conclusion. The virtual clinic approach with attendant documents achieved consensus by orthopaedic experts, radiologists, and patients. The robust development and testing of this standardized virtual clinic provided a sound platform for organizations in the United Kingdom to adopt a virtual clinic approach for follow-up of hip and knee arthroplasty patients. Cite this article: Bone Joint J 2019;101-B:951–959

Aim

Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers.

Primary bone tumors are rare, complex and highly heterogeneous. Its diagnostic and treatment are a challenge for the multidisciplinary team. Developments on tumor biomarkers, immunohistochemistry, histology, molecular, bioinformatics, and genetics are fundamental for an early diagnosis and identification of prognostic factors. The personalized medicine allows an effective patient tailored treatment. The bone biopsy is essential for diagnosis. Treatment may include systemic therapy and local therapy. Frequently, a limb salvage surgery includes wide resection and reconstruction with endoprosthesis, biological or composites. The risk for local recurrence and distant metastases depends on the primary tumor and treatment response.

Cancer patients are living longer and bone metastases are increasing. Bone is the third most frequently location for distant lesions. Bone metastases are associated to pain, pathological fractures, functional impairment, and neurological deficits. It impacts survival and patient quality of life. The treatment of metastatic disease is a challenge due to its complexity and heterogeneity, vascularization, reduced size and limited access. It requires a multidisciplinary treatment and depending on different factors it is palliative or curative-like treatment. For multiple bone metastases it is important to relief pain and increases function in order to provide the best quality of life and expect to prolong survival. Advances in nanotechnology, bioinformatics, and genomics, will increase biomarkers for early detection, prognosis, and targeted treatment effectiveness. We are taking the leap forward in precision medicine and personalized care.

Background. Subvastus approach for Total Knee Arthropalsty (TKA) allows a faster recovery. It is traditionally not utilized for revision surgeries because of difficulty in exposure of the knee and eversion of the patella. It is considered to have limited indications. We hypothesized that revision TKA should not really pose a problem as the exposure gained is adequate with added advantage of preserving the extensor mechanism, thereby allowing faster functional recovery. We present an analysis of the use of subvastus approach for revision TKAs. Materials and methods. 50 patients (50 knees) 37 females + 13 males with mean age 68 years underwent revision total knee arthroplasty (TKA) by subvastus approach between January 2006 to January 2013. All patients were prospectively evaluated by pre- and postoperative Knee Society and function score. The average follow-up was 24 months (range from 1 to 3 years) with minimum 1 year follow-up. The indications for revisions were aseptic loosening (20 knees), infection (12 knees), instability (12 knees) and peri-prosthetic fractures (6 knees). Constrained condylar prosthesis (43 knees), hinged prosthesis (6 knees) and custom made prosthesis (1 knee) were fixed using the subvastus approach. Infected knees underwent one or two staged revisions. Results. The approach provided adequate exposure in all revisions. The average Knee Society score improved from 42 to 83 and the function score from 48 to 65. The complications included medial collateral ligament injury (one case), patellar tendon avulsion (one case) and mal-tracking patella (one case). Average hospital stay was 4 days. Average blood lose was 400 ml. Conclusion. Our results compare favourably with other reported series on revision TKA. The subvastus approach can be considered for revision TKAs

Introduction. Early functional recovery following total hip arthroplasty (THA) has the potential to increase patient satisfaction and reduce resource utilization. The direct anterior approach (DA) has been shown to provide earlier recovery compared to the direct lateral (DL) approach based on functional tests and outcome scores. There are limited studies that objectively evaluate functional recovery comparing the two approaches in the early post-operative period. Activity trackers have emerged as a valid tool to objectively quantify physical activity levels and potentially better assess functional status compared to commonly reported functional questionnaires. The purpose of this study is to measure physical activity levels in patients undergoing THA with the DA approach and compare these to THA with the direct lateral approach in the immediate postoperative period. Methods. In a tertiary academic center we prospectively enrolled patients with primary OA that were eligible for a primary THA undergoing either the DA or the DL approach using the same prosthesis. Patients with comorbidities precluding them from ambulation, diagnoses of AVN or RA or undergoing bilateral THA were excluded. The number of steps walked per day were measured using wristband activity tracking technology for one week preoperatively, the first 2 weeks postoperatively and for 1 week leading up to their 6-week follow-up appointment. The University of California, Los Angeles (UCLA) activity score was also collected at the same two time points. Demographics were analyzed with descriptive statistics. A non-parametric Mann Whitney U test was used to determine whether a difference in physical activity levels exist between the DA and DL approach groups in the first 2 weeks and 6 weeks postoperatively. Results. One hundred and thirty-nine patients with primary OA were enrolled. Seventeen were withdrawn prior to beginning the study (7 – patient requested, 5 – could not work the activity tracker, 5 – health issues). Following enrolment 29 patients were withdrawn due to lack of data available for analysis. There were 53 patients in the DA group and 40 patients in the DL group. Patient demographics including age and gender were similar in both groups. Body mass index was higher in the DL group (32.4 ± 6.9) compared to the DA group (28.2 ± 3.9) (p=0.001). There was no difference in the average steps taken per day or the UCLA score between the two groups preoperatively. The UCLA score and the overall average steps walked collected at 2 weeks postoperatively were significantly higher in the DA group compared to the DL group (median 4(1–6) vs. 3(2–6), p<0.001 and median 1641(329 – 8678) vs. 890(87 – 4347), p<0.001) respectively. When each postoperative day was evaluated individually, the DA group had a greater number of steps per day for the entire two weeks. At 6 weeks, the average number of steps taken by the DA group (median 4734 (1703 – 16605) () were greater than those taken by the DL group (median 3534 (462–8665) ± 2263) (p=0.007). A similar finding was demonstrated for the UCLA with the DA having greater self-reported activity levels (median 6 vs. 4, p<0.001). Discussion/Conclusions. The DA approach provided faster functional recovery in the immediate postoperative period compared to the DL approach as measured by a wristband activity tracker. DA approach patients walked a greater number of steps at both 2 weeks and 6 weeks. Further examination regarding the economic implications of the improved early function from the perspective of the patient, caregiver, and care payer is indicated

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

The aim of this study was to evaluate the time of return to play of elite basketball and voleyball players (both grouped together as jumper) with Haglund deformity after surgical resection of the prominence in the postero-superolateral aspect of the calcaneum. Haglund deformity is a prominence in the postero superolateral aspect of the calcaneum, causing a painful bursitis, which may be difficult to treat by non-operative techniques. In this study, we evaluated the duration that is needed to reach a level that a player perform regularly in a competition. This study consists of players operated by the same surgeon with same technique from 2011 to 2019. Twenty eight feet of 22 patients underwent resection of Haglund deformity with lateral approach and the outcome was analysed using AOFAS Ankle-Hind Foot Scale for hindfoot and time to restart a full range regular training was reported. All players received one dose (5–6 cc) platelet rich fibrin to attachement site of Achilles tendon peroperatively just after decompression of prominence. The mean AOFAS score at the follow up was 90/100, at the end of first year and the majority of players returned to play at 4th to 8th month of follow-up. Only two players with deformity of three feet could start to perform after one year. We conclude that minimal invasive approach ostectomy is an effective treatment for players suffering from Haglund deformity and the results were from good to excellent. However, the player should be well informed that the recovery and returning to play can take a longer time than they expect

Aims. We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. Patients and Methods. A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, . sd. 12.3) and 28.8 kg/m. 2. (13.3 to 57.6, . sd. 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. Results. There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. Conclusion. We found a higher rate of PJI in DA versus NA approaches. Infection prevention protocols such as use of aspirin, dilute povidone-iodine lavage, vancomycin powder, and Gram-negative coverage may have been positively associated with diminished PJI rates observed for all approaches over time. Cite this article: Bone Joint J 2019;101-B(6 Supple B):2–8

Dual mobility cups (DMC) reduce the risk of dislocation in femoral neck fractures (FNF). Direct anterior approach (DAA), historically promoted for better stability, has been developed in recent years for better functional results. The aim of this study was to compare the early functional results of DMC in FNF by DAA versus posterolateral approach (PLA). A prospective study was conducted on a continuous series of patients who received DMC for FNF by DAA or PLA. The primary endpoint was Harris Hip Score and Parker score assessed at the first follow-up visit. Intraoperative complications were collected during hospitalization. One year clinical results and all cause revision rate were also collected. Radiographic data of cup positioning and limb length were evaluated. Fifty-two patients were included in the DAA group and 54 in the PLA group. Two patients were lost to follow-up. The mean age was 72.8 years. There was no significant difference in HHS or Parker score at 3 and 12 months follow up (p=0.6, p= 0.75). DAA was associated with more intraoperative complications with 4 fractures and 1 femoral nerve deficit (p=0.018). There were 3 revisions in the DAA group (1 infection, 1 dislocation, 1 peri prosthetic fracture) and 1 in the PLA group (infection), which was not statistically significant (p=0.34). Cup anteversion was 6° greater and inclination 9° lesser in DAA group (p=0.028, p<0.01). Results suggest that DAA does not provide any early functional benefit in THA-DMC for FNF compared to PLA. It could lead to more intraoperative complications and a higher revision rate. DAA requires an experienced surgeon and careful patient selection

Osteoclasts (OCs) are multinucleated cells that play a pivotal role in skeletal development and bone remodeling. Abnormal activation of OCs contributes to the development of bone-related diseases, such as osteoporosis, bone metastasis and osteoarthritis. Restoring the normal function of OCs is crucial for bone homeostasis. Recently, RNA therapeutics emerged as a new field of research for osteoarticular diseases.

The aim of this study is to use non-coding RNAs (ncRNAs) to molecularly engineer OCs and modulate their function. Specifically, we investigated the role of the microRNAs (namely miR-16) and long ncRNAs (namely DLEU1) in OCs differentiation and fusion.

DLEU1/DLEU2 region, located at chromosome 13q14, also encodes miR-15 and miR-16. Our results show that levels of these ncRNA transcripts are differently expressed at distinct stages of the OCs differentiation. Specifically, silencing of DLEU1 by small interfering RNAs (siDLEU1) and overexpression of miR-16 by synthetic miRNA mimics (miR-16-mimics) led to a significant reduction in the number of OCs formed per field (OC/field), both at day 5 and 9 of the differentiation stage. Importantly, time-lapse analysis, used to track OCs behavior, revealed a significant decrease in fusion events after transfection with siDLEU1 or miR-16-mimics and an alteration in the fusion mode and partners. Next, we investigated the migration profile of these OCs, and the results show that only miR-16-mimics-OCs, but not siDLEU-OCs, have a lower percentage of immobile cells and an increase in cells with mobile regime, compared with controls. No differences in cell shape were found. Moreover, mass-spectrometry quantitative proteomic analysis revealed independent effects of siDLEU1 and miR-16-mimics at the protein levels. Importantly, DLEU1 and miR-16 act by distinct processes and pathways.

Collectively, our findings support the ncRNAs DLEU1 and miR-16 as therapeutic targets to modulate early stages of OCs differentiation and, consequently, to impair OC fusion, advancing ncRNA-therapeutics for bone-related diseases.

Acknowledgements: Authors would like to thank to AO CMF / AO Foundation (AOCMFS-21-23A). SRM and MIA are supported by FCT (SFRH/BD/147229/2019 and BiotechHealth Program; CEECINST/00091/2018/CP1500/CT0011, respectively).

Aim

To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics.

Introduction. There is growing evidence that patients with lumbar spine fusion are at greater risk for postoperative dislocation following total hip arthroplasty. The purpose of this study is to review one author's experience with the modified direct lateral approach in patients with prior or subsequent lumbar spine fusion and total hip arthroplasty. Methods. Our IRB approved clinical database was queried for all primary total hip arthroplasties performed by the senior author from 1/1/2004 to 12/31/2016. All were performed via a modified direct lateral approach. Of these 1902 hips (1656 patients), 59 were identified in our medical records as patients who had a prior spine fusion or a spine fusion following THA. The extent of fusion was identified and reported. Radiographs were reviewed for acetabular position (abduction and anteversion) and leg length discrepancies. Records were reviewed and patients were contacted to determine if there were dislocations. Results. Of the 59 patients with concomitant spine fusion and total hip arthroplasty, 47 had the fusion prior to THA and 12 following THA. All patients were seen in the office or contacted by phone for a mean follow up of 5.8 years (2 to 15 years)(3 deceased, 3 lost). The direct lateral approach was used in all cases and in no cases was a dual mobility, lipped liner, or constrained component used. Head size ranged from 32 to 40. There were no postoperative dislocations in any of these patients. Acetabular position was a mean 43.6 degrees abduction (range 30–50), and a mean anteversion of 23.7 degrees (range 17 – 34). Average postoperative LLD was 2.8mm long on operated side (range −2mm to + 12mm). Spine fusion extent was a mean 2.1 levels (range 1 – 9) with 15 that included the sacrum/pelvis. Discussion. As surgeons have become aware of the elevated risk of hip dislocation associated with spine fusion/stiffness, several approaches have been proposed to address this risk. Our findings suggest that using the modified direct lateral approach for primary total hip arthroplasty significantly reduces the risk of such a complication. For any tables or figures, please contact the authors directly