Introduction Maquet views are a well established method of determining the axial alignment of the lower limb in the coronal plane and their use in the assessment of total knee replacement is widespread. It is an awkward investigation for both patient and radiographer and we compared them to the information that can be obtained using the new generation of Helical CT scanners.

Results We prospectively studied a cohort of 60 patents undergoing TKR. As part of their routine post-operative follow-up they had a standard series of AP and Lateral radiographs (performed under fluoroscopic control) in addition to the Maquet views and a CT scan of their lower limbs. All plain films were performed at the same hospital by the same group of radiographers, while all CTs were performed on the same scanner using a predetermined protocol, and post processing performed by the same individual. Maquet views gave a good assessment of coronal alignment but were also shown to have a much high interobserver error than CT. Maquet views took on average three times longer for the radiographers to perform than CT, were often repeated as technically demanding, and patients (especially the elderly and infirm) often found it difficult and uncomfortable to comply with the required positioning. CT views on each patient (which incorporated standard slices and a scanogram) took a few minutes of time in the scanner allowing a quick throughput when patients arrived in clinic. Patients were supine, a position they all found easy to adopt, and radiographers reported that they found them less difficult to perform. The femoral and tibial axes were easily determined, and rotation easily assessed from the femoral epicondyles, negating the projection errors due to malrotation that may compromise the accuracy of Maquet views. Radiation dosage for the CT is higher than a single Maquet view, but these are often repeated due to poor exposure, increasing the dosage above that of CT.

Conclusions We have used a spiral CT protocol with much success and feel that its greater accuracy, coupled with the information gained on sagittal alignment and component rotation means that the older Maquet view has now been superceded. We also feel that the amount of information recorded by a single investigation may prove invaluable in subsequent investigation of pain or suspected loosening, and very helpful in planning any required revision.

Scarf osteotomy improves hallux valgus and can be used for deformities with large intermetatarsal angles. It is designed to minimise shortening of the first ray. The aim of this radiographic analysis was to assess the outcome of patients undergoing Scarf osteotomy at the Royal Cornwall Hospital.

The initial 18 consecutive cases performed by the senior author were analysed using the guidelines recommended by the American Foot and Ankle Society. Standardised anterior-posterior radiographs of the foot were compared pre-operatively and at 6 weeks postoperatively. Measurements of the intermetatarsal angle (IMA), hallux valgus angle (HVA), joint congruency angle (JCA), distal metatarsal articular angle (DMAA), sesamoid position and metatarsal length were used to assess any improvement.

The results showed a significant median reduction of the IMA of 70, HVA of 180, JCA of 50, and the DMAA of 30 (all p values < 0.001). The medial sesamoid position in relation to the first metatarsal also improved from a mean value of 2.28 to 1 using the American Foot and Ankle Society grading system. There was no shortening of metatarsal length as measured using the Hardy and Clapham method.

This study shows that the radiographic outcome of Scarf osteotomy at the Royal Cornwall Hospital compares favourably with that found in the literature. It provides effective correction of moderate to large intermetatarsal angles.

We describe the radiographic measurement of the angle of tilt of the patella and relate it to malalignment of the extensor mechanism. The tilt angle is defined as the angle subtended by a line joining the medial and lateral edges of the patella and the horizontal. The radiograph (Merchant type) is taken with the foot pointing up, the lower edge of the film parallel to the ground, and the knee at 30 degrees flexion. The mean tilt angle of a group of patients with signs and symptoms suggesting patellofemoral malalignment was 12 degrees (+/- 6 degrees); in a similar group of control subjects it was 2 degrees (+/- 2 degrees) (p < 0.01). Tilting of 5 degrees was taken to be the limit of normal. For the detection of patellar malalignment, the tilt angle was almost as specific as the congruence angle (92% v 99%) but more sensitive (85% v 25%) and more accurate (89% v 62%).

INTRODUCTION

Femur is one of the bones in humans that exhibit ethnic, racial, and gender difference. Several basic and clinical studies were conducted to explore these variations. Clinical anthropological studies have dealt with the compatibility of femoral prostheses and osteosythesis and materials with the femur. If there is a misalignment between the Total Knee Arthroplasy (TKA) femoral comportment installation position, Range of Motion (ROM) failure and several problems may arise. The aim of this study was to evaluate anterior bowing of the Japanese femur and to assess the adequacy of TKA femoral comportment installation position.

Background

We occasionally come across cortical atrophy of the femur with cemented collarless polished triple-taper stem, a short time after the operation. This study aimed to estimate the radiographs of cemented collarless polished triple-taper stem taken at three, six, twelve, and twenty-four months after the initial operation.

Introduction

In total knee arthroplasty extramedullary tibial guides could not to be as accurate as requested in obtaining proper alignment perpendicular to the mechanical axis. The aim of this study was to determine the accuracy of an accelerometer-based system (KneeAlign 2; OrthAlign Inc, Aliso Viejo, California) as evaluated by post-op X-rays analysis.

Avascular necrosis of the femoral head (AVN) is associated with collapse of the femoral head and arthritic degeneration of the joint. The combination of an implant inserted into the femoral head that provides mechanical support and bone grafting to promote bone formation may offer a possible joint-preserving solution1. Seventeen such procedures were performed between November 2012 and March 2014 during an IRB approved clinical trial. Thirteen out of 18 patients remained unrevised at a minimum of 12 months; the results of radiographic and histological analysis of four revisions are presented.

The investigational device (Figure 1) was developed as a joint preserving treatment for AVN with a clinical grade of IIC or less according to the ARCO grading system2.

The device consisted of a braided spherical Nitinol cage with a Titanium / Nitinol orientation feature. It was implanted using fluoroscopic navigation into a spherical cavity cut into the femoral head via an 11mm diameter access tunnel. Once deployed, the implant was filled with a lightly impacted mixture of autologous bone graft and bone marrow soaked Conduit TCP (DePuy CMW, Blackpool, UK). The implant's purpose was to provide mechanical support to the weakened subchondral surface while the bone graft mixture re-integrated with the host bone.

The retrieved femoral heads were trimmed to leave approximately 3mm of bone around the implant, dehydrated, embedded in methacrylate resin, sectioned and thinned into 50–70µm coronal slices for histological analysis. The following observations were made (Figure 2):

Case 1 (Female, age 70, ARCO IIB, revised after 2 days): The patient was revised for spontaneous sub-trochanteric fracture secondary to osteoporosis. Contact between the native bone and bone graft was observed. Marrow elements and repair tissue were visible within the pores in the graft (Figure 2a).

Case 2 (Male, age 67, ARCO IIIC, revised after 82 days): Two wires were broken but retained within the braided structure. A radiolucent gap caused by the presence of fibrous tissue between the graft mixture and native bone was evident suggesting that the implant was unable to prevent progression in this case.

Case 3 (Female, age 70, ARCO IIC, revised after 482 days): The cavity penetrated the subchondral surface; at revision the implant was found to have breached the articular cartilage. There was partial separation of the proximal osteonecrotic fragment and no evidence of graft revascularisation or remodelling within the implant.

Case 4 (Male, age 42, ARCO IIC, revised after 469 days): There was no indication of bone graft re-integration. Collapse of the necrotic bone and deformation of the implant was diagnosed from 1 year follow-up x-rays.

The thickness of the cement mantle surrounding total hip replacements has been used to predict the incidence of aseptic loosening. However little work has been done regarding the significance of the cement mantle distal to the tip of the femoral prosthesis. Results are reported of a radiographic audit study analyzing the thickness of the distal cement column in primary total hip replacement.

In this study the thickness of cement distal to the tip of the femoral prosthesis was measured from 80 post-op AP radiographs taken over a period of 5 months using both the PACS system and plain film x-rays. The mean thickness was 2cm (max 8cm) (min −1.8cm) with a std dev of 1.7cm.

This study demonstrated the wide variation in the thickness of the distal cement column achieved by surgeons. It also highlighted the fact that while 2–5mm is the generally accepted optimal cement mantle surrounding the femoral prosthesis, there is little guidance from the literature with regards the optimal thickness of the cement mantle distal to the tip of the femoral prosthesis. Further work requires to be undertaken to determine the optimal thickness of cement in this area, as well as changes in local surgical practice to ensure the optimal thickness of cement distally is consistently achieved. A re-audit of this work after alterations of surgical technique is desirable.

Background

We occasionally came across cortical atrophy of femurs with cemented collarless polished triple-taper stem in a short term period. This study aimed to estimate radiographs of cemented collarless polished triple-taper stem taken 6 months after the initial operation.

Introduction: An intra-medullary cement restrictor is an integral part of modern cementing technique in total hip arthroplasty. Failure of the restrictor to contain cement, flawed surgical technique or dislocation of the restrictor during pressurisation can all result in a deficient cement mantle. A radiographic analysis of hip replacements using a biodegradable restrictor was undertaken to determine the incidence of restrictor failure, the influence of femoral canal morphology on restrictor failure and to describe the cement mantle quality in successful and failed distal cement restriction.

Methods: x-rays from 299 consecutive hip replacements using the amberflex restrictor were analysed. The cortical index, canal-calcar ratio and femoral type, according to Dorr, were recorded. 3 modes of restrictor failure were identified:

Cement leakage –cement was seen to have escaped past the cement restrictor

Results: 84 cases of restrictor failure were observed – 44 dislocations, 24 leakages and 16 penetrations. The mode of failure was not correlated with femoral type, cortical index or canal-calcar ratio. A strong association was found between restrictor failure and grades c and d cement mantles using the chi squared test. A correlation between cortical index, canal-calcar ratio and femoral type was not observed.

Discussion: The ability of a cement restrictor to occlude the femoral canal and resist pressurisation is very important if a good quality cement mantle is to be achieved. Technical error was likely to be an important factor in many of the observed cases of restrictor failure, especially penetrative failure. Surgical technique is more important than femoral morphology in determining the successful use of this restrictor.

Purpose:

Acetabular bone loss during revision total hip arthroplasty (THA) poses a challenge for reconstruction as segmental and extensive cavitary defects require structural support to achieve prosthesis stability. Trabecular metal (TM) acetabular augments structurally support hemispherical cups. Positive short-term results have been encouraging, but mid- to long-term results are largely unknown. The purpose of this study was to determine the continued efficacy of TM augments in THA revisions with significant pelvic bone loss.

Introduction: Drilling of the femoral bone tunnel in anterior cruciate ligament reconstruction may be performed in a transtibial drilling technique or via the anteromedial portal.

Purpose: To determine the accuracy of the radiographic bone tunnel position using either a transtibial or anteromedial drilling technique.

Materials & methods: The postoperative lateral radiographs of 100 patients after anterior cruciate ligament reconstruction were reviewed. In each patient, the femoral bone tunnel was created either through the tibial tunnel or via the anteromedial standard arthroscopy portal. The resulting position of the femoral tunnel was evaluated according to reference values reported by Aglietti (65 % of the cortical femoral A-P distance along Blumenstaat’s line), Amis (60 % of the A-P diameter of the posterior lateral femoral condyle parallel to Blumensaat’s line), and Harner (80 % of the A-P length of Blumensaat’s line). The mean deviation of the radiographic tunnel position from the referenced values was statistically evaluated.

Results: Radiographic bone tunnel positions with transtibial drilling were 62.42 ± 8.36, %, 54.53 ± 8.43 %, and 75.84 ± 9.56 % according to Aglietti, Amis, and Harner, respectively. Bone tunnel positions with anteromedial drilling were 65.46 ± 5.29 %, 59.59 ± 4.18 %, and 79.93 ± 4.24 %, respectively. The mean deviation from the reference values was significantly higher when comparing transtibial to anteromedial drilling. Transtibial drilling resulted in a significantly more anterior bone tunnel position.

Conclusion: Precise bone tunnel placement is a prerequisite for proper postoperative knee function and stability. The results of this study indicate that the accuracy of femoral bone tunnel placement through the anteromedial arthroscopy portal was superior to transtibial drilling. It may therefrore be concluded that drilling the femoral tunnel through the anteromedial portal is recommended when using fixation techniques not depending upon placement of a transtibial guide.

We analyzed the radiographic results of patients treated surgically for flatfoot deformity and who underwent medial cuneiform opening wedge osteotomy as part of the operative procedure. The aim of this study was to confirm the utility of the cuneiform osteotomy as part of the correction of hindfoot and ankle deformity. All patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. We measured standardized and validated radiographic parameters on pre and post-operative weight bearing radiographs of the foot. All radiographs were assessed using the digital imaging software package (Siemens). The following measurements were used: lateral talus-1st metatarsal angle; medial cuneiform to floor distance (mm), talar declination angle, calcaneal-talar angle, calcaneal pitch angle, 1st metatarsal declination angle, talonavicular coverage angle, and anteroposterior talus-1st metatarsal angle. Other variables including concomitant surgical procedures, healing of the osteotomy, malunion, and adjacent joint arthritis were also noted. There were 86 patients with a mean age of 36 years (range 9–80). 15 patients had bilateral surgery. The aetiology of the deformity was flexible flat-foot in 48, rupture of the posterior tibial tendon in 41, rigid flatfoot deformity with a fixed forefoot supination deformity in 7, and fixed forefoot varus with metatarsus elevatus in 5. In addition to an opening wedge medial cuneiform osteotomy, a lateral column lengthening calcaneus osteotomy was performed in 80, a gastrocnemius recession in 76, a supramalleolar osteotomy in 2, a triple arthrodesis in 4, a subtalar arthroerisis in 13, excision of an accessory navicular in 6, a tendon transfer in 15 and medial-slide calcaneal osteotomy in 8 patients. The mean lateral talus-1st metatarsal angle improved from 23° to 1°; the mean medial cuneiform to floor distance improved from 20mm to 34mm; the mean talar declination angle improved from 39° to 27°; the mean calcaneal-talar angle improved from 64° to 55°; the calcaneal pitch angle improved from 14° to 23°; the mean 1st metatarsal declination angle improved from 17° to 26°; the mean talonavicular coverage angle improved from 45° to 18°; and the mean anteroposterior talus-1st metatarsal angle improved from 19° to 0° Radiographical analysis confirms that the medial cuneiform opening wedge osteotomy is a reliable and valuable surgical tool in the correction of the forefoot which is associated with flatfoot deformity and that arthrodesis of the 1st metatarsocuneiform joint may not be required to obtain correction of the elevated 1st metatarsal.

The ABG stem (Anatomique Benoist Girard, How-medica) was realized of titanium alloy (TA6V) and it was designed to provide anchoring only at the femour’s metaphyseal portion. The long-term stability is achived by osteointegration of the implant at the metaphyseal region, which is coated with hydroxyapatite (HA) crystals. The plasma-sprayed HA coating has a tickness of 60 μm for the stem.

The current study presents radiographic outcomes of more than one hundred primary uncemented HA stems with a long-term follow-up. One hundred and eleven ABG hip arthroplasties were evaluated with a mean follow-up of 9.8 years. The radiographical findings have been classified observing Engh’s stability criteria according to Gruen’s subdivision of the periprosthetic femoral zones.

Dividing the hips into two different groups (in the first one the prosthesis implanted 11, 12 or 13 years ago and in the second one the prosthesis with a maximum age of 10 years) it’s possible to see as in the first group the radiolucent lines are quite reduced. Among the older prosthesis the percentage of radiolucent lines is 3.1% in zones 3 and 5 and 18.8% in zone 4. For what concerns the younger ones the percentage are 10.1% (zone 3), 21.5% (zone 4) and 15.2% (zone 5).

We believe that there is a load transfer from the metaphyseal to the metadiaphyseal portion of the femur without a worsening of the clinical outcomes. The absence of reactive lines and lucencies around the proximal HA-coated portion of the stem supports an excellent circumferential bony ingrowth in the metaphyseal area of the proximal femur. According to these percentages we can say that there’s less presence of radiolucency in the oldest prosthesis and it could be possible to argue that radiolucent lines tend to reduce along the time. This is probably due to the increase of the strength of the stem anchorage.

Introduction

The advantages of the direct anterior approach (DAA) for total hip arthroplasty include the preservation of external rotators and hip abductors thus leading to quicker recovery times. To our knowledge, there is no objective method in the literature to predict the level of difficulty for femoral exposure through the DAA. It would be beneficial to the surgeon learning the DAA to assess difficulty pre-operatively to avoid prolonged operative times. The purpose of this study was to develop a predictive model of femoral exposure difficulty in the DAA using a combination of demographic data and radiographic measurements.

Introduction: The progression of the collapse is influenced by the extent and location of the necrotic focus of the necrotic femoral head. The authors studied the extent of the necrotic focus on the joint surface by conventional antero-posterior radiographs in neutral position, and antero-posterior radiographs at the 45 degrees flexion position. The differences of the lesions in these two types of radiographs were analyzed.

Materials and Methods: The conventional antero-posterior radiographs of the neutral position, and the antero-posterior radiographs at the 45 degrees flexion positions in 115 hip joints of 86 patients with non-traumatic osteonecrosis of the femoral head were obtained for this study. These 115 hips showed extensive lesions and could be divided into two groups: Type C-1 or C-2 by classification of the Specific Disease Investigation Committee under the auspices of the Japanese Ministry of Health Labor and Welfare. Type C1 lesions occupy more than the medial 2/3 of the femoral head and C2 lesions extend laterally to the acetabular edge.

Results: At the neutral position, Type C-1 lesions were noted in 42 joints (36%). In these 42 hips, 13 showed Type C-1 (30%) at the 45 degrees flexion position. In contrast, 29 joints (70%) were Type C-2. Type C-2 lesions in 73 joints (64%) were shown in the neutral position. In these 73 hips, Type C-2 lesions were disclosed on 69 joints (95%) in the 45 degrees flexion position and Type C-1 was noted on 4 hips (5%).

Conclusions: Based on these results, the authors propose that location of the lesion on the joint surface varies with different hip positions.

Degenerate chondral surfaces can be assessed in many ways, but arthroscopy is often performed without proper categorisation, mapping, zoning or sizing of lesions. Progression of disease in un-resurfaced compartments is well-recognised to occur, but is only one of several failure mechanism in partial knee replacement.

A validated ‘Functional Zone’ mapping method was used to document articular surface damage in 250 sequential cases of knee arthroscopy in patients over the age of 40. Size, shape, location and severity of each chondral lesion were noted using the Outerbridge classification. Analysis determined rates of involvement of particular compartments and assessed potential for partial replacement or local treatment and also to consider the risk of future progression. Radiographs including antero-posterior standing, postero-anterior flexion views (Rosenberg), lateral and skyline views were graded (Kellgren and Lawrence) and compared with the arthroscopic findings.

Our results showed that out of the 210 knees with Grade 3 or greater damage 13.3% of knees showed ‘isolated’ medial disease of Outerbridge Grade 3 or worse. Isolated lateral disease was noted in 1.4%, patello-femoral disease in 24.3%, bi-compartmental (Medial/PFJ) disease in 30.9% with tibio-femoral and tri-compartmental disease seen in 15.2%. The combination of lateral and patello-femoral disease was seen in 14.8%. Provided that Grade 1 and 2 changes (which were found in other compartments in high percentages) were ignored and ACL status considered, this information seemed to indicate that at the time these procedures were performed, 13.3% of cases were suitable for a medial uni-compartmental device, with sub-analysis of lesion sizes indicating that 17 out of 28 cases (60.7%) were suitable for a localised resurfacing. Lateral uni-compartmental replacement seemed suitable for only 1.4%, patello-femoral replacement in 24.3%, bi-compartmental in 30.9% and total knee replacement in 30%. The mean age for partial resurfacing was 53years and 59 years for total joint replacements.

Radiological analysis found that the antero-posterior standing views had only 66% sensitivity and 73% specificity for the presence of Grade 3 changes or worse in the medial compartment in comparison with Rosenberg views having a sensitivity of 73% and a specificity of 83%. Skyline views had a sensitivity of 56% and 100% specificity.

This study indicates that a large proportion of cases may be suited to local and limited resurfacing. Cases suitable for Patello-femoral and Bi-compartmental replacements were very common, but with the patella-femoral joint's tendency to be more forgiving in terms of symptoms, meaning that indications for uni-compartmental replacement might well be much higher than the arthroscopic findings suggested. On the other hand, the presence of high levels of Grade 1 and 2 changes in other compartments seems to indicate a need for caution particularly in younger patients. This study also indicates a need for better methods of assessing local cartilage health such as enhanced MRI scanning or spectroscopy.

Purpose: Hinged knee prostheses are mainly used for reconstruction after major tumour resection. Aseptic loosening is the main problem with these implants. One of the solutions proposed to reduce the rate of loosening is to add a hydroxyapatite collar on the shaft stems. This work was conducted to study bone ingrowth with a new hinged implant with a hydroxyapatite collar at the junction between the zone of resection and the shaft.

Material and methods: Twenty-nine massive prostheses with a hydroxyapatite collar were implanted between 1998 and 2001. Nine patients were excluded from the analysis because follow-up was less than two years. This retrospective analysis thus compared twenty massive prostheses with twenty matched hinged GUEPAR prostheses without a collar. Bony ingrowth was measured on plain x-rays (two orthogonal views) at 6, 12, 24, and 36 months. Filling of the gap between the bone and the implant was also assessed. Signs of loosening were noted.

Results: Mean bony ingrowth in implants with a hydroxyapatite collar was 6.58 mm at 6 months 9.84 mm at 12 months, 12.3 mm at 24 months and 13.25 mm at 36 months. Mean bony ingrowth in the implants without a hydroxyapatite collar was 1.65 mm at 6 months, 3.31 mm at 12 months, 4.8 mm at 24 months and 4.35 mm at 36 months. In the implants with a collar, gap filling was partial in five cases and total in 15. In implants without a collar, there was no gap filling in eight cases, partial filling in two cases and total filling in fifteen cases.

Discussion: Prostheses with a hydroxyapatite collar enable better radiological bony ingrowth than observed in implants without a hydroxyapatite collar. Gap filling is better for prostheses with a collar. There was no case of loosening at last follow-up for implants with a hydroxyapatite collar.

Conclusion: In light of these results, shaft anchorage appears to be better with implants with a hydrosyapatite collar. Confirmation of improvement in clinical outcome and lower rate of aseptic loosening will require longer follow-up.

Purpose: Uncertain position of the acetabular implant has been the cause of dysfunction in certain cases of total hip arthroplasty (THA). Classical computed tomographic analysis of anteversion has certain limitations. Integrated reconstruction of positions at risk allows a better diagnostic approach.

Material and methods: We studied 46 THA because of posterior malposition (n=17, anterior subluxation in the standing position in twelve, and true dislocation in five) and anterior malposition (n=29, posterior subluxation in sixteen and true dislocation in thirteen). Two groups of 70 naïve hips and a group of 56 THA with no functional problem served as controls. The position of the acetabulum was studied on optimised computed tomography slices reconstructing the planes of analysis for the standing, sitting and reclining positions. The reference planes for the slices was given by the sacral tilt angle measured on the lateral views of the patient in the corresponding positions. The optimised computed tomographic measurements of anteversion were compared with the classical measures. None of the patients had abnormal femoral anteversion and/or an oblique pelvis and/or leg length discrepancy greater than 10 mm. The frontal inclination of the acetabular implants was 40°–50°.

Results: In the naïve hips, acetabular anteversion varied: 19.2 with the conventional method, 15.7 in the standing position and 31 in the sitting position. In the THA controls, anteversion measurements differed: 21.3 with the conventional method, 21.4 in the standing position and 35.8 in the sitting position. In the THA with a posterior malposition, 18/29 could not be explained by the conventional measurement, but the optimised measurement enabled an understanding in 17 hips (defective anteversion in the sitting position).

Discussion: Changes in pelvis orientation between the sitting and standing positions modifies real anteversion of the cup. In particular, subjects with THA tend to have a spontaneous posterior tilt of the pelvis related to trunk ageing. This element should be taken into account for the analysis of both major and minor THA dysfunction.

Introduction: In cases of small and middle size osteonecrosis on conventional antero-posterior (AP) radiographs, we studied the extent of the lesion on AP radiographs at the 45 degrees flexion position for lesions of the anterior area of the femoral head.

Materials and Methods: Classification of Japanese organizing committee was applied for the extent of the lesion on joint surface. Type A lesions occupy the medial one-third or less; Type B, the medial two-thirds or less; Type C-1 occupies more than the medial two-thirds; and Type C-2 extends laterally to the acetabular edge at the neutral position on conventional AP radiographs. Thirty-three hips (25 patients) with small or middle size lesions (Type A;11, Type B;22) were studied. On AP radiographs taken at the 45 degrees flexion position, the extent of the lesion was studied in 33 hips.

Results: Seven of 11 hips of Type A on neutral position showed Type A lesions. For the remaining 4 hips, 2 were Type B, 2 were on Type C-1 at 45 degrees flexion position. For 22 hips with Type B on neutral position, 6 were Type B, 12 were Type C-1, 4 were Type C-2 found at the 45 degrees flexion position.

Discussion: AP radiographs at the 45 degrees flexion position revealed more extensive necrotic area in cases of small and middle size lesions comparing with the neutral position. This finding may be related to progression of the disease.

Purpose: The purpose of this work was to study the radiological outcome more than seven years after implantation of 89 anatomic non-cemented femoral stems with hydroxyapatite coating around the metaphyseal circumference.

Material: These 81 patients underwent primary arthroplasty (89 hips) between 1991 and 1994 for joint degeneration or necrosis: 48 men and 33 women, mean age 59 years (range 41–78). The inclusion criteria for this study were physical examination and complete radiographic work-up in the second half of 2001. Mean follow-up was nine years (range 7–10).

Methods: All x-rays were analysed by four independent surgeons who used the Engh and Massin criteria. The evaluators, who had not participated in patient care, made their assessment on the basis of the last follow-up clinical report and x-rays. They search for radiographic evidence of stem stability and bony integration as well as signs of osteolysis using the Gruen criteria.

Results: At last follow-up only one femoral stem was painful, but stable. This stem was revised at seven years. Six cups had been changed due to polyethylene wear with iliac osteolysis but without femoral participation. There were no other reoperations. Polyethylene wear was observed in about one-half the hips (44 hips) and was considered severe (1–2 mm) in nine cases. There were no lucent lines nor reactive lines in the metaphyseal area (zones 1 and 7) but 16% of the hips presented reactive lines along the lower, smooth, part of the stem. Endosteal ossification was observed in zones 2 and 6 in 72% of the hips, and less often (13%) in zones 9 and 13. Five hips (5.6%) exhibited bony growth at the tip of the stem producing a thickening in zone 5; these were the only cases with cortical thickening excepting the revised stem (thickening in zones 2 and 6). There was no case of cortical narrowing. Calcar atrophy was observed in 42 hips (47%) with five showing a “drop” aspect. Four hips exhibited osteolysis of the proximal femur in zone 1A, but there were no images of distal osteolysis of the femur.

Discussion: This independent analysis of 89 x-ray files demonstrated that endosteal growth is frequent in the isthmic region. The radiological tolerance was good for this stem (no cortical changes) but there were modifications of the calcar which were difficult; it could be speculated that certain of these modifications might correspond to localised osteolysis at the lowest part of the joint, migration point of polyethyene debris. The role of hydroxyapatite in the observed absence of distal osteolysis is noteworthy.

Conclusion: At nine years follow-up, the absence of osteolysis of the distal femur despite usual polyethylene wear allows the conclusion that hydoxyapatite coating of the metaphyseal circumference creates an effective barrier against wear debris.

Conservative management of talipes equinovarus has a good effect on adductus deformity of the forefoot, whereas equinus deformity cannot usually be treated well conservatively. However, adductus is the most common recurrent deformity after operations. The aim of the study was to use radiological analysis to explore the reasons that lead to recurrent adductus.

In 86.7% of the cases, either a correction was evaluated as radiologically inadequate but seemed to be good physically, or compensation for an operative over-correction resulted in recurrent adductus some years later. In spite of adequate correction from both a physical and radiological view, recurrent adductus developed in 13.3% of the cases. In our opinion, these recurrences were due to persistent muscle imbalance.

In our department, 458 children were operated on for clubfoot from 1982 to 1997. The patients involved in this study were those managed by medial and posterior soft tissue release after an ineffective six to nine month period of conservative treatment that was started when they were one to two weeks old. Children treated previously in another hospital were excluded from the study. We controlled 228 feet and 42 cases of recurrent adductus were found 2 to 16 years (mean 6.8) after the operations. The radiographs were examined at the end of ineffective conservative treatment, during the early postoperative days, and finally at the follow-up. The anteroposterior talocalcaneal (ATC) angle, the talometatarsal (TM) angle and the naviculometatarsal (NM) angle were measured in all of the radiographs. Based on the measured angles, three main groups of patients were formed.

Recurrent adductus in 24 feet (Group A) was caused by inadequate operative corrections, including inappropriate correction of either the hind foot (reduced ATC angle) or the forefoot (reduced NM angle), or both. Although the talocalcaneal and talometatarsal positions were normal in early postoperative radiographs, adductus developed again two to five years later in seven cases (Group B). In these cases, we think that persistent muscle imbalance was responsible for the recurrent deformity.

In 11 feet the ATC angles were in normal range or increased (Group C). These adductus deformities were caused by either an overcorrected talocalcaneal position resulting in compensatory metatarsal varus or medial subluxation of the talonavicular joint, which had been only partially compensated by the lateral deviation of the 1st ray.

Different resurfacing implants offer different kinds of positioning instruments. As it is of outmost importance to position the components within rather narrow limits to diminish the risk of femoral notching or impingement we decided to measure the position achieved in 72 hips resurfaced with the Durom^® resurfacing hip and instruments.

There were 38 males and 27 females with 72 hips (7 bilateral). The indication was OA in 51 cases, RA in 12 and ON in 2. We compared 2 groups, 26 hips operated with an antero-lateral approach (A) and 46 with a postero-lateral approach (B).

The acetabular cup anteversion angle was 22±11° in group A and 15±9° in group B. The abduction angle was 38±9 ° in group A and 44±7° in group B. The acetabular gap was 2±1 mm, resp. 2±2 mm. The stem-shaft angle was 140±5° resp. 141±6°. Retroverted cups averaged 7±4°.

The difference between pre- and postoperative acetabular size was 3 mm in group A (mostly RA patients) and 5 mm in group B (mostly OA patients).

Conclusions: We have obtained a fairly good implant position. The only significant differences between the two groups were decreased acetabular cup abduction angle compared to the preoperative angle in the antero-lateral group, but increased angle in the postero-lateral group, and that less acetabular bone was removed in the antero-lateral group (patients with RA included) compared to the postero-lateral group.

Aims

Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity.

Aims

The stability of cementless acetabular components is an important factor for surgical planning in the treatment of patients with pelvic osteolysis after total hip arthroplasty (THA). However, the methods for determining the stability of the acetabular component from pre-operative radiographs remain controversial. Our aim was to develop a scoring system to help in the assessment of the stability of the acetabular component under these circumstances.

Several factors have been implicated in unsatisfactory results after total hip replacement (THR). We examined whether femoral offset, as measured on digitised post-operative radiographs, was associated with pain after THR. The routine post-operative radiographs of 362 patients (230 women and 132 men, mean age 70.0 years (35.2 to 90.5)) who received primary unilateral THRs of varying designs were measured after calibration. The femoral offset was calculated using the known dimensions of the implants to control for femoral rotation. Femoral offset was categorised into three groups: normal offset (within 5 mm of the height-adjusted femoral offset), low offset and high offset. We determined the associations to the absolute final score and the improvement in the mean Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain subscale scores at three, six, 12 and 24 months, adjusting for confounding variables.

The amount of femoral offset was associated with the mean WOMAC pain subscale score at all points of follow-up, with the low-offset group reporting less WOMAC pain than the normal or high-offset groups (six months: 7.01 (sd 11.69) vs 12.26 (sd 15.10) vs 13.10 (sd 16.20), p = 0.006; 12 months: 6.55 (sd 11.09) vs 9.73 (sd 13.76) vs 13.46 (sd 18.39), p = 0.010; 24 months: 5.84 (sd 10.23) vs 9.60 (sd 14.43) vs 13.12 (sd 17.43), p = 0.004). When adjusting for confounding variables, including age and gender, the greatest improvement was seen in the low-offset group, with the normal-offset group demonstrating more improvement than the high-offset group.

Cite this article: Bone Joint J 2014;96-B:36–42.

Inter- and intra-observer variation has been noted in the analysis of radiographic examinations with regard to experience of surgeons, and the monitors used for conducting the evaluations. The aim of this study is to evaluate inter/intra observer variation in the measurement of mechanical alignment from long-leg radiographs.

40 patients from the elective waiting list for TKA underwent long leg radiographs pre-operatively and 6 months post-operatively (total of 80 radiographs). The x-rays were analysed by 5 observers ranging in experience from medical student to head orthopaedic surgeon. Two observers re-analysed their results 6 months later to determine intraobserver correlation, and one observer re-measured the alignment on a different monitor. These measurements were all conducted blindly and none of the observers had access to the others’ results.

80 radiographs were analysed in total, 40 pre-op and 40 post-op. The mechanical alignment was analysed using Pearson's correlation (r = 0 no agreement, r = 1 perfect agreement) and revealed that experience as an orthopaedic surgeon has little effect on the measurement of mechanical alignment from long leg radiograph. The results for the different monitor analysis were also analysed using Pearson's correlation of long leg alignment. Monitor quality does seem to affect the correlation between alignment measurements when reviewing both intra and inter observer correlation on different computer monitors.

Surgical experience has little impact on the measurement of alignment on long leg radiographs. Of greater concern is that monitors of different resolution can affect measurement of mechanical alignment. As there might be a range of monitors in use in different institutions, and also in outpatient clinics to surgical theatres, close attention should be paid to the implications of these results.

The aim of this studdy was to examine the effect of cementless surface replacement shoulder arthroplasty (CSRA) on proximal humeral anatomy in eroded shoulder joints.

AP radiographs of 39 shoulders in 37 patients that underwent CSRA for arthritis were examined for geometry of the glenohumeral joint with correction for the magnification of our apparatus. Thirty-two were hemiarthroplasties and seven were total shoulder replacements (TSR). Average age was 70 years (range: 29–88 years). Mean clinical and radiological follow-up was 38 month (range: 24–72 months) and 16 months (range: 10–65 months) respectively. We measured reliable values on the proximal humerus and the lateral glenohumeral offset (LGHO) relative to the coracoid base. Preoperative and last follow-up Constant scores were recorded.

Based on anatomical data with respect to humeral head radius there was a mean 6mm preoperative loss in LGHO (95% CI 3.6–8.8, p< 0.01). The mean value of 53mm increased postoperatively to 59mm and was 57mm at last follow-up. The mean changes were an increase of 6mm (95% CI 4.4–8.5, p< 0.01) and then a decrease of 2mm (95% CI 0.1–5.4, p=0.04) respectively. The lever arm, measured from the greater tuberosity to the centre of instant rotation, increased a mean 5mm post-operatively (95% CI 3.8–6.4, p< 0.01) with no significant fall at last follow-up. Humeral head size and medial offset relative to shaft width increased by 13% and 30% respectively. The humeral head centre moved superiorly relative to the glenoid a mean 2mm after operation (95% CI −0.2–3.5, p=0.08) and a further 1mm at last follow-up (95% CI −0.1–3.0, p=0.07). Forward flexion and abduction improved from 66′ and 58′ preoperatively to 124′ and 112′ postoperatively, with age/ sex-adjusted Constant scores increasing by 53 (95% CI 43.0–64.4, p< 0.01) from a mean 25 preoperatively to 79 at last follow-up.

For hemiarthroplasty the LGHO increased by 9% and for TSR by 24%, with greater increases in flexion and abduction in the latter group.

The Copeland CSRA is centred on the native humeral neck for head version and offset. This preserves maximal bone stock and avoids the need for modularity which some modern stemmed prostheses use to reconcile differences between proximal shaft and humeral head anatomy. The inherent limitation is the requirement for preservation of sufficient humeral head to permit resurfacing. In this group with fairly marked degrees of joint erosion the CSRA, using autogenous bone graft and prostheses of variable width, achieved statistically and clinically significant increases in the lever arm. The improved biomechanics and soft tissue tension correlated to a good clinical outcome with no evidence of significant early subsidence.

Introduction: A prospective randomized study of artifical disc replacement vs. lumbar fusion for one-level disc pathology with 2 year minimum follow-up was completed in compliance with a U.S. FDA protocol.

Methods: A total of 15 investigational sites enrolled 375 subjects with a randomization in a 2:1 ratio. Of the 375, 205 were randomized to receive the Charité artificial disc, and 99 were randomized to receive anterior lumbar interbody fusion with BAK cages. An additional group of 71 patients received the Charité disc as “training cases” prior to beginning randomization. Clinical outcome measures included VAS, Oswestry Disability Index, and SF-36 Healthy Surveys. A total of 6,900 radiographs were digitized throughout the 24 month treatment interval. The 276 disc replacement patients were allocated into one of three groups based on radiographic technical paramenters-- Group I – Ideal, defined as Charité disc placement within 3 mm of ideal in both planes. Coronal plane = AP radiograph = midline or within 3 mm of midline. Mid-Sagittal plane = Lateral radiograph = 2mm posterior to middle of vertebral body or within 3mm of this axis. Group II —Suboptimal (not ideal) and Group III – Poor.

Results: The Charité prosthesis was significantly more effective than BAK in restoring the height of the collapsed disk space (p < 0.001). In Charité cases, the mean initial disc space height at the L5-S1 operative level was 5.2 mm +/− 1.44 (Std Dev) and increased to a mean of 13.5 mm +/− 1.18 (Std Dev). For BAK, the initial disc space height was 5.9.mm +/− 1.74 and increased to an immediate post-operative disk space height of 11.9 mm +/− 2.07. There was less subsidence with the Charite disk replacement than the BAK control at 2 years (p < 0.001). Of the 276 subject radiographs analysed with Charité disc replacement, 83% were classified as Group I, 11% as Group II, and 6% as Group III.

The mean Oswestry Disability Index scores at 2 years correlated with technical accuracy in placement of the prosthesis: Group I – 24.1; Group II – 30.3; and Group III – 36.3 (p < .05). The Mean VAS scores at 2 years correlated with technical accuracy in placement of the prosthesis: Group I – 28.3; Group II – 35.4; and Group III – 48.4 (p = 0.016). The mean flexion/extension range of motion and prosthesis function also correlated with device placement: Group I – 7.12 +/− 4.06 degrees; Group II – 7.47 +/− 4.41 degrees; and Group III – 3.15 +/− 3.51 degrees (p = 0.003).

Discussion: The surgical technical accuracy of Charité artificial disc placement correlated with clinical outcome, range of motion, and device functionality at 2 years. The Charité Lumbar Disk replacement proved to be a successful alternative to traditional lumbar fusion in every parameter. The results from this U.S. Investigational study confirm that proper placement of the Charité artificial disc improves clinical and radiological outcomes.

Short cementless femoral stems are increasingly popular as they allow for less dissection for insertion. Use of such stems with the anterior approach (AA) may be associated with considerable per-operative fracture risk. This study's primary aim was to evaluate whether patient-specific femoral- and pelvic- morphology and surgical technique, influence per-operative fracture risk. In doing so, we aimed to describe important anatomical thresholds alerting surgeons. This is a single-center, multi-surgeon retrospective, case-control matched study. Of 1145 primary THAs with a short, cementless stem inserted via the AA, 39 periprosthetic fractures (3.4%) were identified. These were matched for factors known to increase fracture risk (age, gender, BMI, side, Dorr classification, stem offset and indication for surgery) with 78 THAs that did not sustain a fracture. Radiographic analysis was performed using validated software to measure femoral- (canal flare index [CFI], morphological cortical index [MCI], calcar-calcar ratio [CCR]) and pelvic- (Ilium-ischial ratio [IIR], ilium overhang, and ASIS to greater trochanter distance) morphologies and surgical technique (% canal fill). Multivariate and Receiver-Operator Curve (ROC) analysis was performed to identify predictors of fracture. Femoral factors that differed included CFI (3.7±0.6 vs 2.9±0.4, p3.17 and II ratio>3 (OR:29.2 95%CI: 9.5–89.9, p<0.001). Patient-specific anatomical parameters are important predictors of fracture-risk. When considering the use of short stems via the AA, careful radiographic analysis would help identify those at risk in order to consider alternative stem options

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

Abstract. Objective. Up to 20% of patients can remain dissatisfied following TKR. A proportion of TKRs will need early revision with aseptic loosening the most common. The ATTUNE TKR was introduced in 2011 as successor to its predicate design The PFC Sigma (DePuy Synthes, Warsaw, In). However, following reports of early failures of the tibial component there have been ongoing concerns of increased loosening rates with the ATTUNE TKR. In 2017 a redesigned tibial baseplate (S+) was introduced, which included cement pockets and an increased surface roughness to improve cement bonding. Given the concerns of early tibial loosening with the ATTUNE knee system, this study aimed to compare revision rates and those specific to aseptic loosening of the ATTUNE implant in comparison to an established predicate as well as other implant designs used in a high-volume arthroplasty centre. Methods. The Attune TKR was introduced to our unit in December 2011. Prior to this we routinely used a predicate design with an excellent long-term track record (PFC Sigma) which remains in use. In addition, other designs were available and used as per surgeon preference. Using a prospectively maintained database, we identified 10,202 patients who underwent primary cemented TKR at our institution between 01/04/2003–31/03/2022 with a minimum of 1 year follow-up (Mean 8.4years, range 1–20years): 1) 2406 with ATTUNE TKR (of which 557 were S+) 2) 4652 with PFC TKR 3) 3154 with other cemented designs. All implants were cemented using high viscosity cement. The primary outcome measures were all-cause revision, revision for aseptic loosening, and revision for tibial loosening. Kaplan-Meier survival analysis and Cox regression models were used to compare the primary outcomes between groups. Matched cohorts were selected from the ATTUNE subsets (original and S+) and PFC groups using the nearest neighbor method for radiographic analysis. Radiographs were assessed to compare the presence of radiolucent lines in the Attune S+, standard Attune, and PFC implants. Results. At a mean of 8.4 years follow-up, 308 implants underwent revision equating to 3.58 revisions per 1000 implant-years. The lowest risk of revision was noted in the ATTUNE cohort with 2.98 per 1000-implant-years where the PFC and All Other Implant groups were 3.15 and 4.4 respectively. Aseptic loosing was the most common cause for revision across all cemented implants with 76% (65/88) of involving loosening of the tibia. Survival analysis comparing the ATTUNE cohort to the PFC and All Other Cemented Implant cohorts showed no significant differences for: all-cause revision, aseptic loosening, or tibial loosening (p=0.15,0.77,0.47). Radiolucent lines were detected in 4.6%, 5.8%, and 5.0% of the ATTUNE S+, standard ATTUNE, and PFC groups respectively. These differences were not significant. Conclusion. This study represents the largest non-registry review of the original and S+ ATTUNE TKR in comparison to its predicate design as well as other cemented implants. There appears to be no significant increased revision rate for all-cause revision or aseptic loosening. Radiographic analysis also showed no significant difference in peri-implant radiolucency. It appears that concerns of early loosening may be unfounded. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Short cementless femoral stems are increasingly popular as they allow for less dissection for insertion. Use of such stems with the anterior approach (AA) may be associated with considerable per-operative fracture risk. This study's primary aim was to evaluate whether patient-specific femoral- and pelvic- morphology and surgical technique, influence per-operative fracture risk. In doing so, we aimed to describe important anatomical thresholds alerting surgeons. This is a single-centre, multi-surgeon retrospective, case-control matched study. Of 1145 primary THAs with a short, cementless stem inserted via the AA, 39 periprosthetic fractures (3.4%) were identified. These were matched for factors known to increase fracture risk (age, gender, BMI, side, Dorr classification, stem offset and indication for surgery) with 78 THAs that did not sustain a fracture. Radiographic analysis was performed using validated software to measure femoral- (canal flare index [CFI], morphological cortical index [MCI], calcar-calcar ratio [CCR]) and pelvic- (Ilium-ischial ratio [IIR], ilium overhang, and ASIS to greater trochanter distance) morphologies and surgical technique (% canal fill). Multivariate and Receiver-Operator Curve (ROC) analysis was performed to identify predictors of fracture. Femoral factors that differed included CFI (3.7±0.6 vs 2.9±0.4, p<0.001) and CCR (0.5±0.1 vs 0.4±0.1, p=0.006). The mean IIR was higher in fracture cases (3.3±0.6 vs 3.0±0.5, p<0.001). % Canal fill was reduced in fracture cases (82.8±7.6 vs 86.7±6.8, p=0.007). Multivariate analysis and ROC analyses revealed a threshold CFI of 3.17 was predictive of fracture (sensitivity:84.6% / specificity:75.6%). Fracture risk was 29 times higher when patients had CFI>3.17 and II ratio>3 (OR:29.2 95%CI: 9.5–89.9, p<0.001). Patient-specific anatomical parameters are important predictors of fracture-risk. When considering the use of short stems via the AA, careful radiographic analysis would help identify those at risk in order to consider alternative stem options

Modifiable factors contributing to stiffness include alignment, implant size, implant position and rotation, and soft tissue tightness or laxity. Less modifiable factors include genetics as in predisposition to inflammation and fibrosis, aberrations in perception and experience of emotional pain, and preoperative range of motion. We reviewed 559 knees undergoing revision between 2007 and 2014, selecting out patients with a diagnosis of stiffness and greater than one-year follow-up. Stiffness was defined as greater than 15 degrees of flexion contracture or less than 75 degrees of flexion or less than 90 degrees of active motion and a chief complaint of limited motion and pain. Radiographic analysis used a set of matched controls with greater than 90 degrees and full extension prior to surgery and were further matched by age, gender, BMI. Flexion contracture changed from an average of 9.7 to an average of 2.3 degrees, flexion changed from an average of 81 to an average of 94 degrees, active motion changed from an average of 72 to an average of 92 degrees, pain scores improved from 44 to 72 points, and Knee Society function scores improved from an average of 49 to an average of 70 points. There were four failures for stiffness, two knees underwent additional manipulation, gaining an average of 10 degrees; and two knees were revised. Radiographic analysis demonstrated stiffness to be strongly correlated to anterior condylar offset ratio and to patellar displacement by multivariant regression analysis, suggesting that overstuffing the patellofemoral joint by anteriorization of the femoral component is associated with stiffness. Using modern revision techniques, revision for stiffness creates reliable improvements in pain, Knee Society clinical and functional scores, and motion

Periprosthetic fractures (PPF) of the femur following total hip arthroplasty represent a significant complication with a rising incidence. The commonest subtype is Vancouver B2 type, for which revision to a long uncemented tapered fluted stem is a widely accepted management. In this study we compare this procedure to the less commonly performed cement-in-cement revision. All patients undergoing surgical intervention for a Vancouver B2 femoral PPF in a cemented stem from 2008 – 2018 were identified. We collated patient age, gender, ASA score, BMI, operative time, blood transfusion requirement, change in haemoglobin (Hb) level, length of hospital stay and last Oxford Hip Score (OHS). Radiographic analysis was performed to assess time to fracture union and leg length discrepancy. Complications and survivorship of implant and patients were recorded. 43 uncemented and 29 cement-in-cement revisions were identified. There was no difference in patient demographics between groups. A significantly shorter operative time was found in the cement-in-cement group, but there was no difference in transfusion requirement, Hb change, or length of hospital stay. OHS was comparable between groups. A non-significant increase in overall complication rates was found in the revision uncemented group, with a significantly higher dislocation rate. Time of union was comparable and there were no non-unions in the cement-in-cement group. A greater degree of stem subsidence was found in the uncemented group. There was no difference in any revision surgery required in either group. Three patients in the uncemented group died in the perioperative period, compared to none in the cement-in-cement group. With appropriate patient selection, both cement-in-cement and long uncemented tapered stem revision represent appropriate treatment options for Vancouver B2 fractures

Trabecular metal (TM) augments are designed to support an uncemented socket in revision surgery when adequate rim fit is not possible. We have used TM augments in an alternative arrangement, to contain segmental defects to facilitate impaction bone grafting (IBG) and cementation of a cemented socket. However, there is a paucity of literature supporting the use of this technique. We present one of the largest studies to date, reporting early outcomes of patients from a tertiary centre. A single-centre retrospective analytical study of prospectively collected data was performed on patients who had undergone complex acetabular reconstruction using TM augments, IBG and a cemented cup. All patients operated between 2015 and 2019 were included. We identified 105 patients with a mean age of 74yrs. The mean follow-up was 2.3 years(1–5.5yrs). Our primary outcome measure was all-cause revision of the construct. The secondary outcome measures were, Oxford hip score (OHS), radiographic evidence of cup migration/loosening and post-op complications. Eighty-four out of 105 patients belonged to Paprosky grade IIb, IIc or IIIa. Kaplan-Meier survivorship for all-cause revision was 96.36% (CI, 90.58–100.00) at 2 years with 3 failures. Two were due to early infection which required two-stage re-revision. The third was due to post-operative acetabular fracture which was then re-revised with TM augment, bone graft and large uncemented cup. Pre-op and post-op matched OHS scores were available for 60 hips(57%) with a mean improvement of 13 points. Radiographic analysis showed graft incorporation in all cases with no evidence of cup loosening. The mean vertical cup migration was 0.5mm (Range −5 to 7mm). No other complications were recorded. This study shows that reconstruction of large acetabular defects during revision THA using a combination of TM augments to contain the acetabulum along with IBG to preserve the bone stock and a cemented socket is a reliable and safe technique with low revision rates and satisfactory clinical and radiographic results. Long term studies are needed to assess the possibility of preservation and regeneration of bone stock

Background. Calcium sulfate and phosphate have a long clinical history of use as bone-void fillers (BVF) with established biocompatibility and resorption profiles. It has been widely reported that the addition of ‘impurity’ elements such as Silicon, Strontium and Zinc to calcium phosphate is advantageous, resulting in an improved bone healing response. Methods. This study examined the in vivo response of two formulations of calcium sulfate, as 3mm diameter hemispherical beads, in critical sized defects created in cancellous bone of distal femur and proximal tibia (10mm diameter × 13mm depth) in adult sheep; beads prepared from recrystallised pharmaceutical grade calcium sulfate (RPCS, Stimulan, Biocomposites Ltd, UK) and a lower purity medical grade material containing 1% strontium (SrCS). The animals were sacrificed at 3, 6 and 12 weeks post implantation and the surgical sites analysed using microCT and decalcified histology. Results. Radiographic analysis showed a slower resorption for SrCS compared to RPCS. Radiographic analysis for both materials confirmed little residual beads at three weeks post implantation. Radiographs at sacrifice confirmed no adverse reactions at any sites at 3, 6 and 12 weeks. Radiographic data alone was not adequate to determine the status of the bone formation and the implant resorption at the implant site. Histological analysis confirmed little or no adverse tissue reactions to either material. However, RPCS outperformed the modified material in terms of new bone formation at all time points post implantation. At 3 weeks histology for RPCS confirmed that residual beads were still visible with active new bone growth appearing to penetrate centripetally into the defect with some resorption of the implant material. By 6 weeks significant new bone was present throughout the defect. In comparison, absorption of the modified material was slower, and penetration of new bone into the defect was less progressed. Conclusions. The rapid bone regenerative ability of the recrystallised pharmaceutical grade calcium sulfate was demonstrated. The presence of 1% Strontium impurity acted to delay implant absorption and bone healing in this model

Introduction. Initial post-operative implant instability leads to impaired osseointegration, one of the most common reasons for aseptic loosening and revision surgery. In this study, we developed a novel murine model of implant instability and demonstrated the anabolic effect of immediate and delayed intermittent Parathyroid Hormone (iPTH) treatment in the setting of instability-induced osseointegration failure. Methods. 3D-printed titanium implants were inserted in an oversized drill-hole in the tibia of C57Bl/6 mice (n=54). After implantation, the mice were randomly divided in 3 treatment groups (control: PBS-vehicle; iPTH; delayed iPTH). Radiographic analysis was performed to confirm signs of implant loosening. Peri-implant tissue formation was assessed through histology. Osseointegration was assessed through µCT and biomechanical pullout testing. Results. Immediate iPTH treatment reduced radiolucencies and induced a distinct pedestal sign distal to the implant stem (white arrow Fig 1A). The PBS treated mice had fibrous tissue implant encapsulation, whereas new mineralized tissue and no fibrous tissue was observed with immediate iPTH treatment (Fig 1E). Delayed iPTH treatment was also able to exhibit significant peri-implant bone mineralization, osteoblasts, angiogenesis, and a reduction of fibrous tissue (Fig 2A-B). iPTH treatment increased the force required to pull out the implant significantly from 8.41 ± 8.15N in the PBS group to 21.49 ± 10.45N and 23.68 ± 8.99N, in the immediate and delayed iPTH treatment groups, respectively (Fig 2D). PBS vehicle resulted in a bone volume/trabecular volume (BV/TV) of 0.23 ± 0.03, while immediate and delayed iPTH treatment increased BV/TV significantly to 0.46 ± 0.07 and 0.34 ± 0.10, respectively (Fig 2E). Conclusion. Immediate iPTH treatment prevents peri-implant fibrous tissue formation and enhances peri-implant bone formation in our murine model of mechanical instability. Delayed iPTH treatment was able to resolve the peri-implant fibrous tissue and stimulate bone formation. This study potentially addresses a leading cause of aseptic loosening by demonstrating that initial implant instability can be rescued by iPTH even with delayed start of treatment. For any figures or tables, please contact authors directly

Introduction. Revision total knee arthroplasty (TKA) is becoming increasingly common in the United States as the population ages and larger numbers of primary TKA are performed in younger individuals. Cemented or uncemented tibial stems are frequently used in revision cases. Decreased clinical outcomes and patient satisfaction have been described for revision TKA. This study aims to determine if the presence of overall pain and tibial pain at the end of the stem differs between cemented and uncemented tibial stems in revision TKA. Methods. This was a retrospective cohort study comparing patients who underwent revision TKA utilizing cemented or uncemented tibial stems in a 15-year period at a single institution with at least two-year follow-up. Exclusion criteria included age under 18, isolated revisions of the femoral component or polyethylene exchanges, lack of preoperative or postoperative imaging, insufficient operative or implant records available for electronic chart review, revision procedures performed at outside facilities, patients who were deceased at the time of survey administration, refusal to participate in the study, and failure to return the mailed survey or respond to a telephone follow-up questionnaire. Radiographic analysis included calculation of the percentage of the tibial canal filled with the implant, as well as measurement of the diameter of the tibial stem. Radiographs were also reviewed for evidence of cavitary defects, pedestal formation, radiolucent lines, and periprosthetic fractures. Mailed surveys addressing overall pain, tibial pain, and satisfaction were analyzed using Fisher's exact test and the independent sample t-test. Logistic regression was used to adjust for age, gender, and preoperative bone loss. Results. A total of 110 patients were included (63 cemented and 47 uncemented stems). No statistically significant differences in stem length, operative side, or indications for revision were found. The uncemented group had a significantly higher percent canal fill (p < 0.0001). Tibial pain at the end of the stem was present in 25.3% of cemented stems and 25.5% of uncemented stems (p = 1.00). There was a trend towards more overall pain in the uncemented cohort, but this did not reach statistical significance. Only 74.6% of cemented patients and 78.7% of uncemented patients were satisfied following revision TKA (p = 0.66). Conclusion. The data supports our hypothesis that there are no differences in end-of-stem pain or overall pain between cemented and uncemented tibial stems in revision TKA. High rates of dissatisfaction were noted in both cohorts postoperatively, consistent with previous literature. Patient factors likely play a large role in the presence of postoperative pain. These factors should be further evaluated in future studies in an effort to reduce pain and improve patient satisfaction

Introduction. Porous metaphyseal cones are increasingly used for fixation in revision total knee arthroplasty (RTKA). Both cemented shorter length stems and longer diaphyseal engaging stems are currently utilized with metaphyseal cones with no clear evidence of superiority. The purpose of this study was to evaluate our experience with 3D printed titanium metaphyseal cones with both short cemented and longer cementless stems from a clinical and radiographic perspective. Methods. In total 136 3D printed titanium metaphyseal cones were implanted. The mean patient age was 63 and 48% were female. The mean BMI was 33 and the mean ASA class was 2.5. There were 42 femoral cones in which 28 cemented and 14 cementless stems were utilized. There were 94 tibial cones in which 67 cemented and 27 cementless stems were utilized. The choice for stem fixation was surgeon dependent and in general cones were utilized for AORI type 2 and 3 bone defects on the femur and tibia. The most common fixation scenario was short cemented stems on both the femur and tibia followed by cemented stem fixation on the tibia and cementless fixation on the femur. Clinical data such as revision, complication, and PRO was collected at last follow-up (minimum follow-up 1 year). Radiographic analysis included cone bony ingrowth and coronal and sagittal alignment on long-standing radiographs. Descriptive statistics were used to compare demographics between patients who had malalignment (HKA beyond +/− 3 degrees and flexion/extension beyond +/− 3 degrees). Adjusted logistic regression models were run to assess malalignment risk by stem type. Results. Patient reported outcomes demonstrated modest improvements with Pre-op KOOS improving from 44 pre-op to 59 post -op and PF-CAT improving from 33 to 37 post-op. PROMIS pain scores decreased significantly from 54 to 44 post-op. 36% of patients had malalignment in either the coronal or sagittal plane. Patients with malalignment were more likely to be female (66.7% vs 40.4%, p-value=0.02). After adjusting for age, sex and BMI, there was a significantly increased risk for coronal plane malalignment when both the femur and tibia had cementless compared to cemented stems (odds ratio=5.54, 95%CI=1.15, 26.80). There was no significantly increased risk when comparing patients with mixed stems to patients with cemented stems. Sagittal plane malalignment was more common with short cemented stems although both coronal plane and sagittal plane malalignment with either stem type was not associated with inferior clinical outcome. Overall cone survivorship was excellent with only two cones removed for infection. Conclusion. Metaphyseal titanium cones provide reliable fixation in revision TKA. However, PROs in this complex patient population show only modest improvement consistent with other variables such as co-morbidities and poor baseline physical function. Small cone inner diameter may adversely influence cementless stem position leading to coronal plane malalignment. Short cemented stems are subject to greater sagittal plane malalignment with no apparent influence on clinical outcome

INTRODUCTION. The Woodpecker pneumatic broaching system facilitates femoral preparation to achieve optimal primary fixation of the stem in direct anterior hip replacement using a standard operating table. The high-frequency axial impulses of the device reduce excess bone tension, intraoperative femoral fractures and overall operating time. The Woodpecker device provides uniformity and enhanced control while broaching, optimizing cortical contact between the femur and implant and thereby maximizing prosthetic axial stability and longevity. This study aims to describe a single surgeon's experience using the Woodpecker pneumatic broaching system in 649 cases of direct anterior approach (DAA) total hip arthroplasties to determine the device's safety and efficacy. METHODOLOGY. All consecutive patients undergoing elective anterior bikini total hip arthroplasties (THA) performed by a single surgeon between July 2013 and June 2018 were included. Patients undergoing a THA with the use of the Woodpecker device through a different surgical approach, revision THA or arthroplasties for a fractured neck of femur were excluded (n=219). The pneumatic device was used for broaching the femoral canal in all cases. Pre-operative and post-operative Harris Hip Scores (HHS) and post-operative radiographs were analyzed to identify femoral fractures and femoral component positioning at 6 weeks, 6 months and 12 months post-operative. Any intra-operative or post-operative surgical complications and component survivorship until most recent follow up were recorded in the clinical notes. RESULTS. A total of 649 patients (L THA=317, R THA=328 and bilateral=2) with a mean age of 69 (range 46–91yrs) and mean BMI of 28.3 (range = 18.4–44.0) underwent a DAA THA using a Woodpecker device were included in the study. Of these patients, 521 (80%) underwent uncemented and 128 (20%) underwent cemented femoral components. The time taken to broach the femur using Woodpecker broaching this system averaged 2.8 minutes (1.4 to 7.5 minutes) in both cemented and uncemented cases. In 91% of cases the templated broach size was achieved with the remaining 9% within +/− 1 size of the planned template. Radiographic analysis revealed 67.3% of the stems placed in 0–1.82 degrees of varus and 32.7% placed in 0–1.4 degrees of valgus. Average HHS were 24.4 pre-operatively, with drastic improvements shown at 6 weeks (80.95), 6 months (91.91) and 12 months (94.18) after surgery. Intraoperative femoral fractures occurred in three patients (0.4%) during trial reduction, a further three patients had periprosthetic post-operative fractures (0.4%) from falls, two patients had stem subsidence (0.3%) and a further two patients had wound infections (0.3%). At the most recent follow up, the survivorship of the acetabular component was 99.7% and the femoral component was 99.1%, with mean follow up of 2.9 years (0.5 to 5 years). No intraoperative or post-operative complications could be directly attributed to the Woodpecker broaching system. CONCLUSION. The pneumatic Woodpecker device is a safe and effective alternative tool in minimally invasive direct anterior hip replacement surgery for femoral broaching performed on a standard operating table. The skill and experience of the surgeon must be taken into consideration when utilizing new surgical devices

Aims. Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years. Materials and Methods. We performed a retrospective review of a consecutive series of DM THA performed between 2010 and 2014 at our institution (Hospital for Special Surgery, New York, New York) by a single, high-volume orthopaedic surgeon employing a single prosthesis design (Anatomic Dual Mobility (ADM) Stryker, Mahwah, New Jersey). Patient medical records and radiographs were reviewed to confirm the type of implant used, to identify any preoperative risk factors for dislocation, and any complications. Radiographic analysis was performed to assess for signs of osteolysis or remodelling of the acetabulum. Results. There were 151 patients who met the classification of high-risk according to the inclusion criteria and received DM THA during the study period. Mean age was 82 years old (73 to 95) and 114 patients (77.5%) were female. Mean follow-up was 3.6 years (1.9 to 6.1), with five patients lost to follow-up and one patient who died (for a reason unrelated to the index procedure). One patient (0.66%) sustained an intraprosthetic dislocation; there were no other dislocations. Conclusion. At mid-term follow-up, the use of a DM bearing for primary THA in patients at high risk of dislocation provided a stable reconstruction option with excellent radiographic results. Longer follow-up is needed to confirm the durability of these reconstructions

We used a canine intercalary bone defect model to determine the effects of recombinant human osteogenic protein 1 (rhOP-1) on allograft incorporation. The allograft was treated with an implant made up of rhOP-1 and type I collagen or with type I collagen alone. Radiographic analysis showed an increased volume of periosteal callus in both test groups compared with the control group at weeks 4, 6, 8 and 10. Mechanical testing after 12 weeks revealed increased maximal torque and stiffness in the rhOP-1 treated groups compared with the control group. These results indicate a benefit from the use of an rhOP-1 implant in the healing of bone allografts. The effect was independent of the position of the implant. There may be a beneficial clinical application for this treatment

Purpose. To evaluate the radiographic long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. Materials and methods. Among 28 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 9 years 6 months to 14 years 5 months (mean, 12, 5 years). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis. Results. Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 5 mm) and 1 stem showed moderate subsidence (about 10 mm) in the cement. But there was no mechanical failure and subsidence at the composit-femur interface. Evidence of cortical and trabecular remodeling were observed in all cases. No radiolucent line or osteolysis were found in the follow-up period. There were 4 proximal femoral cracks and 1 distal femoral splitting during operation. Conclusion. The result of cemented stem revision with the use of impacted cancellous allograft was good long-terand femoral bone stock deficiency may be reconstructed successfully

Introduction: The Birmingham Hip resurfacing was commercially introduced in 1997 and early originating centre series show good functional outcomes. Concerns have been raised over the longevity, functional outcomes and metal ion release from the implants. There are no series of medium term results from an independent district general hospital reported in the literature. We present a prospective series of 100 patients with mean 5 year follow up from a district general hospital. Each patient underwent yearly clinical, hip scoring, and regular radiographic evaluation. Radiographic analysis was undertaken using Harris’, Hodgkinson’s and Amstutz’s criteria, evaluation of component position, neck narrowing and migration using diagnostic PACS workstations with standardised scaled images. Results: Between June 2001 and Feb 2004 100 Birmingham Hip replacements were performed by two consultant surgeons (MP, AA). Mean follow up is 61.2 months (range 38–76 months). Harris hip scores (fig 1) improved from 46 pre-operatively to 90 post-operatively and no significant change over the next five years. There were no revisions in this period. Obese patients (BMI> 30) had a significantly (p< 0.03) lower post operative functional score as compared normal patients. No other factors were significant for outcome. Component position was satisfactory in 93% of cases. Radiographic analysis showed no cups, or stems were definitely loose. Radiolucent lines were present in 8/100 acetabular and 3/100 femoral components, osteolytic lesions were seen in three acetabular components. Mean neck narrowing was 9mm. No patients show any radiographic evidence of avascular necrosis. Conclusion This independent series shows the results of the Birmingham hip resurfacing are reproducible and comparable to those reported in the originating centre. The Birmingham hip resurfacing gives excellent clinical results, and there is no early evidence of radiographic failure. The high rate of neck narrowing gives us cause for concern and we would recommend regular radiographic follow up

Background. In the late 1980's Michael Freeman conceived the idea that knee replacement would most closely replicate the natural knee joint, if the medial Tibio-Femoral articulation was configured as a “ball-in-socket”. Over the last three decades, medial rotation and medial pivot designs have proved successful in clinical use. Freeman's final iteration of the medial ball-in-socket concept was the Medial Sphere knee. We report the three-year survivorship, clinical outcomes, patient reported outcome measures (PROMs) and radiographic analysis of this implant in a multi-centre, multi-surgeon, prospective observational study. Methods. Patients awaiting total knee replacement were recruited by four centres. They had no medical contraindication to surgery, were able to provide informed consent and were available for follow-up. Primary outcome was implant survival at six months, one, two, three and five years. Secondary outcomes were patient reported outcome measures: Oxford Knee Score (OKS), Euroqol (EQ-5D), International Knee Society Score (IKSS), IKSS Functional score and Health State score, complications and radiographic outcomes. Radiographic analysis was undertaken using the TraumaCad software and data analysis was undertaken using SPSS. Results. To date, 328 female and 202 male patients with a mean age 66.9 years and mean body mass index 30.0 were recruited. Three year Kaplan-Meier survivorship analysis of cumulative failure showed an implant survival of 99.46% (95% confidence interval 100 – 96.74), when deaths and withdrawals were treated as censored data. Twelve patients withdrew (2.26%), seven died (1.32%) and two knees were revised (0.38%). The mean EQ5D, Health State Scores, OKS, IKSS & IKSS Function scores at three years improved significantly from pre- operative scores (Health State Score: 9.91 (65.59 pre-op to 75.50); OKS: 18.82 (19.90 pre-op to 38.72); IKSS: 39.87 (44.39 pre-op to 92.09); IKSS Function Score: 35.03 (49.42 pre-op to 84.45). The mean improvement of EQ5D at three years was: 0.34 (0.48 pre-op to 0.82). Discussion. Survival of the GMK Sphere to three years in this study was over 99%. Risk of revision compares favourably with UK National Joint Registry (NJR) data. The improvements that are seen in patient reported outcome measures reflect an enhancement in patient function and quality of life. Conclusion. At three years follow-up, the implant demonstrates satisfactory survival and outcomes. Patient matching and evaluation of more cases, at more time points will allow outcome comparison with other implant options

Introduction. Trabecular Titanium is a biomaterial characterized by a regular three-dimensional hexagonal cell structure imitating trabecular bone morphology. Components are built via Electron Beam Melting technology in aone- step additive manufacturing process. This biomaterial combines the proven mechanical properties of Titanium with the elastic modulus provided by its cellular solid structure (Regis 2015 MRS Bulletin). Several in vitro studies reported promising outcomes on its osteoinductive and osteoconductive properties: Trabecular Titanium showed to significantly affect osteoblast attachment and proliferation while inhibiting osteoclastogenesis (Gastaldi 2010 J Biomed Mater Res A, Sollazzo 2011 ISRN Mater Sci); human adipose stem cells were able to adhere, proliferate and differentiate into an osteoblast-like phenotype in absence of osteogenic factors (Benazzo 2014 J Biomed Mater Res A). Furthermore, in vivo histological and histomorphometric analysis in a sheep model indicated that it provided bone in-growth in cancellous (+68%) and cortical bone (+87%) (Devine 2012 JBJS). A multicentre prospective study was performed to assess mid-term outcomes of acetabular cups in Trabecular Titanium after Total Hip Arthroplasty (THA). Methods. 89 patients (91 hips) underwent primary cementless THA. There were 46 (52%) men and 43 (48%) women, with a median (IQR) age and BMI of 67 (57–70) years and 26 (24–29) kg/m2, respectively. Diagnosis was mostly primary osteoarthritis in 80 (88%) cases. Radiographic and clinical evaluations (Harris Hip Score [HHS], SF-36) were performed preoperatively and at 7 days, 3, 6, 12, 24 and 60 months. Bone Mineral Density (BMD) was determined by dual-emission X-ray absorptiometry (DEXA) according to DeLee &Charnley 3 Regions of Interest (ROI) postoperatively at the same time-points using as baseline the measureat 1 week. Statistical analysis was carried out using Wilcoxon test. Results. Median (IQR) HHS and SF-36 improved significantly from 48 (39–61) and 49 (37–62) preoperatively to 99 (96–100) and 76 (60–85) at 60 mo. (p≤0.0001). Radiographic analysis showed evident signs of bone remodelling and biological fixation, with presence of superolateral and inferomedial bone buttress, and radial trabeculae in ROI I/II. All cups resulted radiographically stable without any radiolucent lines. The macro-porous structure of this biomaterial generates a high coefficient of friction (Marin 2012 Hip Int), promoting a firm mechanical interlocking at the implant-bone interface which could be already observed in the operating room. BMD initially declined from baseline at 7 days to 6 months. Then, BMD slightly increased or stabilized in all ROIs up to 24 months, while showing evidence of partial decline over time with increasing patient' age at 60 months, although without any clinical significance in terms of patients health status or implant stability. Statistical significant correlations in terms of bone remodeling were observed between groups of patients on the basis of gender and age (p≤0.05). No revision or implant failure was reported. Conclusions. All patients reported significant improvements in quality of life, pain relief and functional recovery. Radiographic evaluation confirmed good implant stability at 60 months. These outcomes corroborate the evidence reported on these cups by orthopaedic registries and literature (Perticarini 2015 BMC Musculoskelet Disord; Bistolfi 2014 Min Ortop)

Background. Peri-prosthetic humerus fractures are relatively uncommon occurrences that can be difficult to manage non-operatively. Locking plate technology has enhanced the surgical management of these fractures. We describe an osteosynthesis technique utilizing a locking plate with eccentrically placed screw holes to place “skive screws” in the proximal end of the plate to achieve fixation around the stem of the implant. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with this skive screw technique from May 2011 to September 2014. Seven patients presented with postoperative type B peri-prosthetic humerus fractures. Average follow-up was 24 months. Radiographic analysis was performed on most recent postoperative imaging. Clinical outcomes were assessed using VAS pain, ASES total score, ASES functional score, SST, SANE, range of motion and strength. Results. At an average of follow-up of 24 months, all patients demonstrated fracture healing. Functional outcomes were limited with only two patients achieving forward elevation above 90 degrees and average ASES Function score was 27.5. Pain relief was nearly uniform with an average VAS Pain score of 0.5 (Figure 1). Conclusions. Peri-prosthetic humeral shaft fractures can be successfully treated with hybrid fixation technique using a locking plate with eccentric holes that facilitate placement of proximal “skive screws”. Using this technique, a 100% union rate was observed with excellent pain relief

It is a well-known fact that total knee arthroplasty is a soft tissue operation. Soft tissue balancing is the key to success in total knee arthroplasty. It is paramount importance to preserve the maximal amount of bone on both the femur and tibial side. In Indian scenario, majority of the patients present relatively late with varus or valgus deformity. Adding to this problem is poor bone quality due to osteoporosis. Our technique of Posterior cruciate ligament (PCL) retaining TKA with tibial end plate resection facilitates soft tissue balancing, preserves PCL and maximizes bone preservation on both tibial and femoral side achieving good results in minimum seven year follow up. We retrospectively analyzed seven year outcomes of 120 knees (110 patients), mean age was 65 years (range 55 to 75 years), who received contemporary cruciate-retaining prostheses with tibial end plate resection technique. The diagnosis was osteoarthritis in 96%, Rheumatoid arthritis in 2% and posttraumatic arthritis in 2% cases. There were more number of flexible varus knees as compared to flexible valgus knees. All the patients were followed up for minimum of 84 months with average follow up of 96 months. They were followed up at 3mths, 6mths, 1,3,5,7,9 and 10 years. The functional assessment was done using knee society knee and function scores. Radiographic analysis was done to rule out subsidence and aseptic loosening. The statistical significance was assessed using chi square test. Survival analysis was done using the Kaplan Meier analysis with revision taken as the endpoint. The average ROM was 100 degrees preoperatively and 120 degrees at last follow-up. The average knee society knee score improved from 45 points preoperatively to 90 points at last follow-up. The average knee society functional score improved from 48 points preoperatively to 84 points at last follow-up (p<0.05). Radiolucency was observed in 20 knees but all except four were non-progressive lesions smaller than 2 mm. None of the implants were revised for subsidence or aseptic loosening of tibial component. The technique of PCL retaining total knee arthroplasty with tibial end plate resection in arthritic knees with flexible varus or valgus deformity yields good functional outcome in medium term follow up with relatively low incidence of subsidence of the tibial implant. This technique appears promising for total knee arthroplasty in osteoporotic bones where retaining the strong subchondral bone increases the longevity of the implant

Purpose. This studyevaluated the results of the acetabular medial wall osteotomy to reconstruct the acetabulum in dysplastic hip during total hip athroplasty. Materials and Methods. A total of 30 hips of 30 patients who underwent THA between March 1999 and October 2002 were clinically and radiogically evaluated. The average age at the time of operation was 46.5 years (range: 17 to 73 years), and the mean follow-up period was 5 years (range: 5.3 to 8.7 years). 26 cases, a cementless hemispherical acetabular cup and 4 cases, reinforced ring were inserted in the true acetabulum. Only 2 hips needed structural bone graft. Results. The average Harris hip score improved from 56.3 points preoperatively to 93.2 points at the last follow up. Radiographic analysis revealed no aseptic loosening or radiolucent line, and showed stable bony fixation at the true acetabulum. The mean thickness of the medial acetabular wall postoperative was 20.5 mm. Bone union of the medial wall observed at a mean of four months post-operatively. Conclusion. The acetabular medial wall osteotomy can provide the integrity of acetabular medial wall while achieving enhanced acetabular coverage and more normal hip biomechanics

Introduction. The first highly crosslinked and melted polyethylene acetabular component for use in total hip arthroplasty was implanted in 1998 and femoral heads larger than 32mm in diameter introduced 2004. The purpose of this study was to re-assemble a previous multi-center patient cohort in order to evaluate the radiographic and wear analysis of patients receiving this form of highly crosslinked polyethylene articulating against large diameter femoral heads at a minimum of 10 years follow-up. Methods. Two centers contributed patients to this ongoing clinical study. Inclusion criteria for patients was: primary THR; femoral heads greater than 32mm; minimum 10 year follow-up. 69 hips have been enrolled with an average follow-up of 11.2 years (10–15), 32 females (50%). Wear analysis was performed using the Martell Hip Analysis software. Radiographic grading was performed on the longest follow-up AP hip films. The extent of radiolucency in each zone greater than 0.5mm in thickness was recorded along with the presence of sclerotic lines and osteolysis. Results. Wear analysis: Using the average of the slopes of the individual regression lines, the wear rate was 0.004±0.094mm/yr. Using the early to latest film method, the wear rate was 0.035±0.076mm/yr. Radiographic analysis: Acetabular side: the greatest incidence of radiolucency occurred in zone 1 at 27%; sclerotic lines had a less than 2% incidence in any of the 3 zones; there was no identified osteolysis. Femoral side: the highest incidence of radiolucencies was in zones 1 and 3, 7% and 4%; sclerotic lines were rare in any zone, maximum in zone 3, 4%; there was no identified osteolysis. Conclusion. The wear of this form of irradiated and melted highly crosslinked polyethylene remained at levels lower than the detection limit of the software at minimum 10 year follow-up and there was no identified osteolysis

Introduction. The first highly crosslinked and melted polyethylene acetabular component for use in total hip arthroplasty was implanted in 1998. Numerous publications have reported reduced wear rates and a reduction in particle induced peri-prosthetic osteolysis at short to mid-term follow-up. The purpose of this study was to re-assemble a previous multi-center patient cohort in order to evaluate the radiographic and wear analysis of patients receiving this form of highly crosslinked polyethylene articulating against 32mm femoral heads or less at a minimum of 13 years follow-up. Methods. Inclusion criteria for patients was a primary THR with femoral heads 32mm or less and a minimum 13 year follow-up. 139 hips have been enrolled with an average follow-up of 13.7 years (13–16), 80 females (57%). Wear analysis was performed using the Martell Hip Analysis software. Radiographic grading was performed on the longest follow-up AP hip films. The extent of radiolucency in each zone greater than 0.5mm in thickness was recorded along with the presence of sclerotic lines and osteolysis. Results. Wear analysis: Using the average of the slopes of the individual regression lines, the wear rate was 0.006±0.033mm/yr. Using the early to latest film method, the wear rate was 0.003±0.056mm/yr. Radiographic analysis: Acetabular side: the greatest incidence of radiolucency occurred in zone 1 at 21%; sclerotic lines had a less than 2% incidence in any of the 3 zones; there was no identified osteolysis. Femoral side: the incidence of radiolucencies was limited to zone 1, 2%; sclerotic lines were rare in any zone, maximum in zone 3, 4%; there was no identified osteolysis. Conclusion. The wear of this form of irradiated and melted highly crosslinked polyethylene remained at levels lower than the detection limit of the software at minimum 13 year follow-up and there was no identified osteolysis

Instability after total hip arthroplasty is the most common indication for revision arthroplasty and can be difficult to treat. The purpose of this study is to evaluate the outcomes associated with the use of a constrained acetabular component as a treatment for instability after hip arthroplasty. We reviewed the clinical and radiographic outcomes of 149 arthroplasties, that had been performed with use of a single design of constrained acetabular component between 2007 and 2012 at a single institution. Patient demographics and case specific data were collected The Mann-Whitney U test was used to assess continuous variables. Categorical variables were examined using the Chi-square test and Fisher's exact test when appropriate. Survival probability was calculated using the Kaplan-Meier method. The mean age at time of index surgery was 70 years, 65% were female, and mean BMI was 26.3. The average number of previous surgeries was 3.6. The constrained liner was cemented into a well-fixed cup in 40 hips (20%). In eighty-two (55%) hips the constrained component was implanted for the treatment of recurrent instability, and in sixty-seven (45%) hips it was implanted because the hips demonstrate instability during revision surgery. At an average duration of follow-up of 4.2 (2–7) years the overall revision rate was 10.6 % The constrained acetabular device eliminated or prevented hip instability in all patients except five; 3.3% had a new dislocation and six (4.0%) had failure of the retentive ring. Three revisions (2%) were performed for deep infection, and 2 (1.3%) for acetabular component loosening. Radiographic analysis revealed a non-progressive radiolucent line around the cup in 19 hips (12.7%). When stratified by patient age, survivorship for patients less than 65 years of age versus those greater than 65 years was similar. This study correlates with results of other papers in the literature looking at outcome of constrained tripolar type sockets. The focal constraint socket with a metal ring type design has a much greater failure rate (9–29%). Constrained liners remain an excellent option for hip instability in early to mid- term follow up

Introduction. Potential implant and technique related factors to improve patellofemoral (PF) kinematics in total knee arthroplasty (TKA) are design of trochlear geometry and patella, restoration of posterior offset, patellar tilt and avoid overstuffing. The primary aim of this prospective, matched pair study was to assess the radiographic features of PF kinematics with an anatomic patella. Material and Methods. Between July 2012 and May 2013, 49 consecutive posterior stabilized cemented Attune TKAs (Depuy Synthes Warsaw Indiana) were matched to the 49 PFC Sigma (Depuy) based on age, gender, and body mass index (BMI). All surgeries were performed via medial parapatellar approach with patellar resurfacing. Radiographic analysis was performed prospectively with minimum 1-year follow-up and included overall limb alignment, anterior offset, posterior offset, joint line, patellar thickness, patellar tilt and patellar displacement by two independent observers. Results. We found significant improvement in all post-operative radiographies parameters from prior to surgery, however, there was no significance between the two groups (Table 1). Posterior offset and joint line were restored in all cases and no overstuffing of the PF joint was seen. Discussion. At minimum one-year follow-up, anatomical patella has excellent safety and efficacy with restoration of the PF kinematics. Metalized design of the Attune anatomic patella component allows better contact with trochlear groove and improves tilt with lateralization of the patella

Introduction. Anterior knee pain (AKP) is a recognized cause of patient's dissatisfaction after total knee arthroplasty. Potential implant/technique related contributors to AKP are patellofemoral maltracking, trochlear geometry, femoral malrotation, patellar tilt and overstuffing. The primary aim of this prospective, matched pair study was to assess the safety, efficacy and performance of an anatomic patella and its effect on AKP in in a matched pair analysis. Material and Methods. Between July 2012 and May 2013, 55 consecutive posterior stabilized cemented Attune TKAs (Depuy) were matched to the PFC Sigma group based on age, gender, and body mass index (BMI). All surgeries were performed via medial parapatellar approach with patellar resurfacing. Clinical and radiographic analysis was performed prospectively with minimum 6 month follow-up. Radiographic measurements included overall limb alignment, anterior offset, posterior offset, joint line, patellar thickness, patellar tilt and patellar displacement by two independent observers. Results. The mean functional outcomes were similar in both groups. AKP incidence between Attune and PFC was statistically insignificant (3.6% and 3.8%). Radiographic analysis revealed no mal-alignment, or osteolysis. No complications such as infection, patellar fracture, subluxation or dislocations were observed. Discussion. Attune knee design demonstrates excellent short-term safety and efficacy. At minimum 6-month follow-up, anatomical patella with shows less AKP than single radius patella design. Longer follow-up is required to assess functional outcome this design

Introduction. Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate. Methods. 22 feet were identified from the senior authors flatfoot reconstructions over a 3 year period (Jan 2013 to Dec 2015). 9 feet underwent a spring ligament reconstruction. The control group were 13 feet treated with standard tibialis posterior reconstruction surgery. Follow up ranged from 8 to 49 months. Functional assessment comprised VAS heath and pain scales, EQ-5D and MOXFQ scores. Radiographic analysis was performed for standardised parameters. Results. Each group contained two bilateral procedures. The spring ligament patients had a mean age of 43, BMI of 29 and a male to female ratio of 4;1 There were no statistical differences between groups starting point functional scores or pre-operative radiological deformity. Post-operatively there was a statistically significant improvement of all domains and overall MOXFQ, EQ5d and VAS in the spring ligament patients. There was a statistically significant improvement in all radiological parameters with all patients being returned to normal. Functional scores were not significantly better than the control group [MOXFQ components, Control vs spring ligament group, Pain: 42 vs 45 (p=0.71), Walking: 50 vs 56 (p=0.43), Social: 35 vs 39 (p=0.72), EQ-5D: 0.64 vs 0.70 (p=0.72)]. Spring ligament reconstruction produced statistically better deformity correction for 4 of 5 measured radiological parameters (p< 0.05). Conclusion. Our new method of spring ligament reconstruction restores normal anatomy. In comparison to traditional procedures our method provides equivalent functional results and improved deformity correction

Background. The use of robotics in joint arthroplasty was initiated in 1992 with the introduction of the ROBODOC® Surgical Assistant device for planning and active robotic preparation of the femoral canal in THA. From 1993–1996, an FDA trial was undertaken using pin-based fiduciary markers to register the CT to the robot coordinate system. From 2000–2006, a second FDA trial was initiated using a point-to-surface matching “pinless” registration system. Combined, these two studies offer the first long-term follow-up of robot-assisted THA using an active robotic system for preparation of the femoral canal during THA. Methods. Due to the support of an open implant architecture, patients were implanted with either the Depuy AML, Howmedica Osteoloc, or Zimmer VerSys FMT. Combining patients from the two studies, 86 THA's were performed in 63 patients using the active robotic system. Of these 63 patients, 7 were confirmed to have died and 5 have been lost to follow-up, 2 declined to participate due to infirmity, 37 are still recruiting, and 12 are currently enrolled (16 hips). Data collected included: Harris Hip Scale, HSQ-12, WOMAC, UCLA Activity Score, VAS Pain Score as well as radiographic analysis. The demographics at follow-up were:. Results. There were no revisions of the femoral component for aseptic reasons. Of the 16 hips enrolled, only two have required reoperation for head and liner change. Clinical results are given below:. Radiographic analysis found that peri-acetabular osteolysis was present in 12.5% of hips, AP femoral osteolysis was found in 18.8% of hips, above and lateral femoral osteolysis was found in 6.3% of cases. Conclusions. The use of active robotics for preparation of the femoral canal in THA appears safe and effective at a long-term follow-up of 14 years. The clinical results are comparable to or better than other long term studies of cementless femoral stem prostheses in terms of Harris Hip score (Aldinger et al 2003) and WOMAC Pain, Stiffness, and Physical Function score (Popischill and Knahr 2005). Patient recruitment is still ongoing

Background/Purpose. Total hip arthroplasties (THAs) with ceramic bearings are widely performed in young, active patients and thus, long-term outcome in these population is important. Moreover, clinical implication of noise, in which most studies focused on ‘squeaking’, remains controversial and one of concerns unsolved associated with the use of ceramic bearings. However, there is little literature regarding the long-term outcomes after THAs using these contemporary ceramic bearings in young patients. Therefore, we performed a long-term study with a minimum follow-up of . 1. 5 years after THAs using contemporary ceramic bearings in young patients with osteonecrosis of the femoral head (ONFH) less than fifty. Materials and Methods. Among sixty patients (71 hips) with a mean age of 39.1 years, 7 patients (7 hips) died and 4 patients (4 hips) were lost before 15-year follow-up. The remaining 60 hips were included in this study with an average follow-up period of 16.3 years (range, 15 to 18). All patients underwent cementless THA using a prosthesis of identical design and a 28-mm third-generation alumina head by single surgeon. The clinical evaluations included the modified Harris hip score (HHS), history of dislocation and noise around the hip joint: Noise was classified into squeaking, clicking, grinding and popping and evaluated at each follow-up. Snapping was excluded through physical examination or ultrasonography. Radiographic analysis was performed regarding notching on the neck of femoral component, loosening and osteolysis. Ceramic fracture and survivorship free from revision were also evaluated. Results. The mean Harris hip score improved from 55.3 to 95.5 points (range, 83 to 100) at the time of the final follow-up. Seventeen patients (34.7%) reported noise around the hip joint: “squeaking” in one and “clicking” in 16 patients. Notching on the neck of femoral component suggesting impingement between neck and ceramic liner was demonstrated in 9 hips (15%) at average of 6.9 years postoperatively and located at 2 to 3.5 mm distal to edge of ceramic head. Although no chip fracture of ceramic ‘liner’ occurred, notching was associated with “clicking” sound (p<0.01). One patient who reported clicking sound underwent a revision THA because of ceramic ‘head’ fracture. Loosening, osteolysis or dislocation was not observed in any hip and survivorship free from revision at 5 years was 98%. Conclusion. Cementless THAs using 28-mm contemporary alumina ceramic head demonstrated excellent long-term outcome in young, active patients with ONFH. Despite this encouraging result, however, we remain concerned about ‘clicking’ sound, because we did observe it associated with notching on the neck of stem. Acknowledgement. This work was supported by Institute for Information & communications Technology Promotion (IITP) grant funded by the Korea government (MSIP) (#B0101-14-1081)

Bone infection occurring after fractures or orthopedic surgery can progress to the chronic stage and lead to poor results of treatment. Optimal treatment of chronic osteomyelitis are stabilization the fracture, biological recovery of bone defects and destroy bacterial infection. Traditional methods of treatment are systemic administration of antibiotics and surgical treatment of active infection focus. Systemic antibiotics are part of the standard therapy after surgical treatment of infected bone, but their effectiveness is limited due to malnutrition and low absorption at the site of infection. Moreover, long-term treatment and higher doses are associated with serious side effects. The aim of this investigation was to study the results of the complex treatment of patients with chronic osteomyelitis using biodegradable nanomaterials “PerOssal” as antibiotic delivery system. The study was performed at Regional center traumatology and orthopedics, Karaganda, Kazakhstan. A total 20 patient with post-traumatic/post-operative osteomyelitis were included in this open-label, prospective study. Bacteriological examination was taken with the determination of culture and sensitivity test preoperatively, during and postoperatively. After radical surgical debridement and ultrasound cavitation, the bone cavity was full filled with Perosal which can be loaded with different antibiotics depending from the antibiotic sensitivity test. Postoperative wound is completely was sutured. Systemic antibiotic treatment are allowed. The course of infection was monitored by determination leukocyte count and blood sedimentation rate; blood samples were taken befor, 24 hours after surgery, and on days 3, 7, 10, 14. Wound healing was assessed on days 2, 3, 7, 10, and at the time of removal of sutures. Resorption of implanted beads and bone reconstruction were evaluated by X-ray at after operation and at approximately one, three and six months after implantation. A total of 20 patients (mean age 38,1 (26 to 53), 14 male, 6 female) were treated with Perossal pellets (AAP, Germany) from October 2013 to April 2015. Mean leukocyte counts and blood sedimentation rate were within the normal laboratory range and did not indicate infectious complications during the first 21 days after surgery. Primary wound healing occurred in 18 patients and secondary wound healing in two patients. There were two cases of re-infection during the course of the study, one of them related to an incomplete eradication of infected tissue and multidrug-resistant strain occurring during the course of the study, the other is occurred that patient non-compliance. Radiographic analysis six months after surgery showed progressive resorption of the implanted pellets, but only 10 cases have decreasing size of defects on X-ray. This study in adult patients with chronic post-traumatic/post-operative osteomyelitis demonstrated that these biodegradable bone filler pellets which can be loaded with different antibiotics are a clinically useful local antibiotic delivery system and bone substitute which can be used as an alternative to other anti-infective implants. The implantation of the pellets was safety and well tolerated in all patients. This composite can provide adequate protection against bacterial infection during the first weeks after implantation and to support the bone healing process

Structural bone allografts are a viable option in reconstructing massive bone defects in patients following musculoskeletal (MSK) tumour resection and revision hip/knee replacements. To decrease infection risk, bone allografts are often sterilised with gamma-irradiation, which consequently degrades the bone collagen connectivity and makes the bone brittle. Clinically, irradiated bone allografts fracture at rates twice that of fresh non-irradiated allografts. Our lab has developed a method that protects the bone collagen connectivity through ribose pre-treatment while still undergoing gamma-irradiation. Biomechanical testing of bone pretreated with our method provided 60–70% protection of toughness and 100% protection of strength otherwise lost with conventional irradiation. This study aimed to determine if the ribose-treated bone allografts are biocompatible with host bone. The New Zealand White rabbit (NZWr) radius segmental defect model was used, in which 15-mm critically-sized defects were created. Bone allografts were first harvested from the radial diaphysis of donor female NZWr, and treated to create 3 graft types: C=untreated controls, I=conventionally-irradiated (33 kGy), R=our ribose pretreated + irradiation method. Recipient female NZWr (n=24) were then evenly randomised into the 3 graft groups. Allografts were surgically fixed with a 0.8-mm Kirschner wire. Post-operative X-rays were taken at 2, 6, and 12 weeks, with bony healing assessed by a blinded MSK radiologist using an established radiographic scoring system. The reconstructed radii were retrieved at 12 weeks and analysed using bone histomorphometry and microCT. Kruskal-Wallis and Mann-Whitney tests were utilised to compare groups, with statistical significance when p<0.05. Radiographic analysis revealed no differences in periosteal reaction and degree of osteotomy site union between the groups at any time point. Less cortical remodeling was observed in R and I grafts compared to untreated controls at 6 weeks (p=0.004), but was no longer evident by 12 weeks. Radiographic union was achieved in all groups by 12 weeks. Histologic and microCT analysis further confirmed union at the graft-host bone interface, with the presence of mineralising callus and osteoid. Histomorphometry also showed the bridging external callus originated from host bone periosteum and a distinct cement line between allograft and host bone was present at the union site. Previous studies have shown that the presence of non-enzymatic glycation end products in bone can impair fracture healing. However, these studies investigated bony healing in the setting of diabetic states. Our findings showed that under normal conditions, ribose pretreated grafts healed at rates similar to controls via mechanisms also seen in retrieved human allografts clinically in use. These findings that grafts pretreated with our method are biocompatible with host bone in the rabbit help to further advance this technology for clinical trials

Introduction. Cement in cement revision with preservation of the original cement mantle has become an attractive and commonly practised technique in revision hip surgery. Since introducing this technique to our unit we have used two types of polished tapered stem. We report the clinical and radiological outcomes for cement in cement femoral revisions performed using these prostheses. Materials and Methods. All patients who underwent femoral cement in cement revision with a smooth tapered stem between 2005 –2013 were assessed. Data collected included indication for revision surgery and components used. All patients were followed up annually. Outcomes recorded were radiographic analysis, clinical outcome scores (Oxford Hip Score, WOMAC and SF-12) and complications, including requirement for further revision surgery. Median follow-up was 5 years (range 1 – 8 years). 116 revision procedures utilising cement in cement femoral revision were performed in the 8 year study period (68 females, 48 males, and mean age of 69 years). The femoral component was a C-stem AMT (Depuy) in 59 cases and Exeter stem (Stryker) in 57 cases. Results. Radiographic analysis demonstrated no progressive radiolucencies around the femoral component in any patient and no evidence of stem loosening at most recent review. Median Oxford Hip Score increased from 15 to 32, WOMAC from 22 to 38, and SF-12 from 25 to 32. Two patients had a further revision procedure for recurrent dislocation and 1 patient for infection. Two patients had a peri-prosthetic fracture at 4 years following initial revision surgery. There were 2 femoral stem fractures (occurring at 3 and 4 years post revision, both occurring in Exeter stems). Conclusion. Our results report cement in cement revision of the femoral component provides promising mid-term radiographic and clinical results. No femoral stems required revision for aseptic loosening. Stem fracture however occurred in 2 cases suggesting stem design is crucial for this technique

Introduction. Wear and osteolysis are major contributors which limit the durability of total hip arthroplasty (THA) and ultimately cause it to fail. Efforts were made to decrease the wear by highly cross-linked polyethylene (HXLPE) and using ceramic bearings. The purpose of this study is to analyze the five year performance of large sized (32mm and 36mm) ceramic and metal heads on X3 HXLPE (Stryker, Mahwah, NJ). Materials and Method. From Jan 2006 to June 2008, 81 consecutive patients with minimum 5 year radiographic and clinical followup were identified from out institutional prospective database. 51 non-cemented THA (45 patients) had ceramic on HXLPE (CoX3) group and 30 hips (29 patients) had metal on HXLPE (MoX3) group. Mean age was 36 ± 8 years (36–76) and 50 ± 9 years (51–86) in ceramic and metal group, respectively. Wear rates were measured on an anteroposterior weight-bearing pelvis radiographs using the computer-assisted Roman software. Results. The mean WOMAC, PAQ, HSS and UCLA scores for CoX3 and MoX3 groups at final follow-up were 13.2 ± 17.3, 10.1 ± 14.4, 36.4 ± 5.3 and 5.9 ± 1.8 and 16.5 ± 17.8, 17.1 ± 17.2, 31.6 ± 10.5 and 5.3 ± 1.6, respectively. At the final follow up, the mean wear rates were 0.022 ± 0.06 mm/yr and 0.022 ± 0.05 mm/yr for CoX3 and MoX3 groups, respectively. This was not statistically significant (p=0.8). When negative values were considered zero, wear rates for CoX3 and MoX3 groups were 0.037 ± 0.04 mm/yr and 0.033 ± 0.04 mm/yr, respectively (p=0.6). Radiographic analysis does not reveal any incidence of osteolysis or loosening in both groups. Discussion and Conclusion. The five year wear rate of large diameter metal and ceramic femoral heads on HXLPE bearing demonstrated excellent similar wear rates. Longer follow-ups are required to assess superiority of one bearing over another

Photodynamic therapy (PDT) uses the strong cytotoxicity of singlet oxygen and hyperthermia produced by irradiating excitation light on a photosensitizer. The phototoxic effects of indocyanine green (ICG) and near-infrared light (NIR) have been studied in different types of cancer cells. Plasma proteins bind strongly to ICG, followed by rapid clearance by the liver, resulting in no tumor-selective accumulation after systemic administration. Kimura et al. have proposed using a novel nanoparticle labeled with ICG (ICG-lactosome) that has tumor selective accumulation owing to enhanced permeability and retention (EPR) effect. In this study, we investigated the efficacy of PDT using ICG-lactosome and NIR for a bone metastatic mouse model of breast cancer. Cells from the human breast cancer cell line, MDA-MB-231 were injected into the right tibia of 26 anesthetized BALB/C nu/nu mice at a concentration. The mice were then randomly divided into three groups: the PDT group (n = 9), the laser (laser irradiation only) group (n = 9), and the control group (n = 8). PDT was performed thrice (7, 21, 35 days after cell inoculation) following ICG-lactosome administration via the tail vein 24 hours before irradiation. The mice were percutaneously irradiated with an 810-nm medical diode laser for 10 min. In the laser group, mice were irradiated following saline administration 24 hours before irradiation. Radiographic analysis was performed for 49 days after cell inoculation. The area of osteolytic lesion was quantified. The right hind legs of 3 mice were amputated 24 hours after the third treatment. Histological analysis was performed using hematoxylin-eosin staining and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining of sagittal sections. The data was analyzed using Tukey-Kramer post-hoc test. P-value of <0.05 was considered significant. X-ray on day 49 of the three groups are considered. The area of osteolytic lesion in the PDT group (7.9 ± 1.2 mm. 2. : mean ± SD) was significantly smaller than that of the control (11.4 ± 1.4 mm. 2. ) and laser (11.9 ± 1.2 mm. 2. ) groups. In histological findings, we observed many TUNEL-positive cells in the metastatic tissue 24 hours after PDT. In the control and laser groups, TUNEL-positive cells were occasionally observed. We have previously reported the effect of ICG-lactosome-enhanced PDT on the cytotoxicity of human breast cancer cells in vitroand on the delay of paralysis in a rat spinal metastasis model. In this study, we demonstrated the inhibitory effect of ICG-lactosome-enhanced PDT on bone destruction caused by human breast cancer cells in vivo. This PDT induced apoptosis and necrosis in the tumor cells. Intralesional resection is often performed for spinal metastases in an emergency. The residual tumor may regrow and cause neurological deficits. We believe that ICG-lactosome-enhanced PDT can decrease the rate of local recurrence through reduction of the residual tumor. PDT with ICG-lactosome and NIR had an inhibitory effect on the growth of bone metastasis of a human breast cancer

Aim. To assess the clinical outcome at 1 year of 30 cases of primary TKA performed with PMCB. Method. Data was collected prospectively pre-operatively on over 100 primary TKA's performed with PMCB. Of these cases, 30 have reached a point of 1 year follow-up. Validated outcome measures including American Knee Society score, Oxford Knee Score and WOMAC were completed pre-operatively and at 1 year. Radiographic analysis of alignment was performed. Results. Oxford score improved from 16 to 38. WOMAC score improved from 40 to 17. AKS total score improved from 85 to 172. All improvements were statistically significant. No cases were aligned at >+/−3 degrees from neutral alignment. Conclusion. Our first 30 cases to reach 1 year follow-up using PMCB have shown excellent improvement in clinical scores and good radiographic alignment. NO DISCLOSURES

Purpose:. Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation. Amputation osteoplasty is a technique described by Ertl to enhance rehabilitation after trans-tibial amputation. The purpose of the present study was to evaluate the results of the original Ertl procedure in skeletally immature patients, and to assess whether use of this procedure would result in a diminished incidence of bony overgrowth. Methods:. Four consecutive patients (five amputations) treated between January 2005 and June 2008 were reviewed. Clinical evaluation consisted of completion of the prosthesis evaluation questionnaire (PEQ) and physical examination. Radiographic analysis was performed to evaluate bone-bridge healing, bone overgrowth and the medial proximal tibial angle (MPTA). Results:. The best mean PEQ result in the Question section was 91.8 (Range 74–100) for ‘Well being’ and the worst mean score was 66.6 (Range 50–78) for the sub-section ‘Residual limb health’. Examination of the residual limbs revealed no bursae were present and all knees were stable with full range of movement. All bony bridges united at an average age of 1.7 months (Range 1–2). One case required stump revision for bony overgrowth, and one case developed asymptomatic mild genu varum. Conclusions:. In this series, the original Ertl osteomyoplasty shows good functional and prosthetic use with only one bony overgrowth requiring revision surgery

Introduction. Revision TKA can be a difficult and complex procedure. Bone quality is commonly compromised and stem fixation is required in many cases to provide stability of the prosthetic construct. However, utilization of diaphyseal engaging stems adds complexity to the case and can present technical challenges to the surgeon. Press fit metaphyseal sleeves can provide stable fixation of the construct without the need for stems and allows for biologic ingrowth of the prosthesis. Metaphyseal sleeves simplify the revision procedure by avoiding the need to prepare the diaphysis for stems, alleviating the need for offset stems and decreasing the risk of intra-operative complications. The ability to obtain biologic fixation in the young patient is also appealing. This study reports on the author's mid-term experience with this novel technique. Methods. Between May 2007 and June 2009 the author performed 17 revisions TKA that utilized press-fit metaphyseal sleeves without stems on either the tibial side of the joint, the femoral side of the joint or both. Twenty six sleeves were implanted altogether (13 tibial, 13 femoral). Patients were limited to touch down weight bearing for 6 weeks post-operatively. The patients were followed prospectively with clinical and radiographic follow-up at routine intervals. Results. Average clinical and radiographic F/U for the cohort was 57 months (range 30 – 77). Fourteen of seventeen patients had a minimum of 4 years F/U. Average age at the time of surgery was 58 years (range 46–72) and average BMI was 32.4. Indications for the index revision included nine knees with aseptic loosening and / or osteolysis, two knees for septic loosening, two knees for instability and 4 knees for pain / stiffness or other causes. ROM at pre-op and latest F/U averaged 2–108 deg and 0–117 deg respectively. Knee Society Scores at pre-op and latest F/U averaged 35 and 86 respectively (range 57–100). Survivorship analysis revealed 25 of 26 sleeves (96%) to still be in situ at latest F/U. One tibial sleeve was revised at 30 months for septic loosening. Radiographic analysis revealed 22 of the remaining 25 sleeves (88%) to be ingrown. Two tibial sleeves and one femoral sleeve exhibit stable fibrous fixation and are asymptomatic. Conclusions. Press-fit metaphyseal sleeves utilized without stems appear to provide excellent stability of the revision TKA construct at mid-term F/U. Biologic fixation appears to be present in the majority of cases. This ability to obtain reliable osseointegration of the revision construct is appealing, especially in the younger revision patient. The sleeves have proven easy to use and there have been no intra-operative complications. This technique appears to provide a simple, but robust alternative when compared to revision TKA with stems in appropriate cases. Further F/U of this cohort is necessary to evaluate long term results

Background. Tapered cementless femoral components have been used in total hip arthroplasty (THA) constructs for more than 20 years. The Synergy femoral component was introduced in 1996 as a second generation titanium proximally porous-coated tapered stem with dual offsets to better restore femoral offset at THA (Figure 1). The purpose of this study was to evaluate the outcome of the authors' experience using the Synergy stem at minimum 15 years of follow-up. Material and methods. We retrospectively reviewed a consecutive series of 102 patients (112 hips) who underwent surgery between November 1996 and October 1998 for primary THA using cementless Synergy stem with a minimum 15-years follow-up. The mean age at the time of surgery was 61 years, and the mean duration of follow-up was 16.3 years. Seventeen patients were lost at FU (8 died before the 15 years mark, 8 changed residency, 1 not willing to be seen) with no problems related to the replaced hip. Ninety-four hips in 85 patients were available for clinical and radiologic analysis. Clinical results of the 94 THAs with more than 15 years of follow-up were assessed preoperatively and postoperatively at 5, 10 and 15 years by means of standard evaluation tools: SF12, WOMAC and Harris Hip Score. Thigh pain frequency and intensity were also recorded. Radiographic analysis (Figure 2) was focused on stem alignment, bone ingrowth, radiolucent lines presence, width and progression, stress-shielding and heterotopic ossification (HTO). Student paired test and Kaplan-Meier survival analysis were used for statistical analysis. Results. All clinical evaluation tools showed at 5-year FU, 10-year FU and at latest FU (15–17 years) a statistically significant improvement compared to the preoperative scores. We observed a not constant thigh pain in 5 hips (4.75%). Nine stems were revised due to polyethylene wear (3 cases), late periprosthetic fracture (2 cases), infection (2 cases), subsidence (1 case) and instability (1 case). Stem related revision was a case of subsidence, related to occult intraoperative calcar crack and early revised (within 1 year); cumulative stem-related survival rate at 15 years was 99%. Alignment was varus in 5 cases and valgus in 1. Bone in-growth was observed in 93 hips (98%). Radiolucent lines were uncommon, non progressive, less than 2 mm, in Gruen zones 2 and 6. Stress-shielding was present as cortical reaction in 5 femurs in Gruen zones 3 and 5. Fifteen cases of HTO (grade I and II in 12 case and grade III in 3 cases) were observed. Conclusions. The Synergy stem demonstrated excellent clinical and radiographic results at 15–17 years FU in 85 patients. Survivorship (with stem revision as end point) was 99% at 15 years. Thigh pain was uncommon and the level of activity and autonomy is excellent. Radiographically bone ingrowth is evident in all stems and radiolucent lines are “benign” with no aseptic loosening

Introduction. The metal-backed patella was originally designed to address shortcomings found with cemented, all-polyethylene patellae. However, complications relating to an all-polyethylene patella were reported to account for up to half of all knee revisions. At the same time, good fixation with bone ingrowth was observed in both titanium and cobalt chromium porous-coated patellae. The advantages provided by using a metal-backed patella, such as uniform load sharing, decreased polyethylene deformation, and potential for biological fixation, may be unjustly outweighed by the fear of patellar component failure; high rates of failure have not been inherent to all metal-backed patella designs. Over the past decade, we have used a metal-backed patella design with excellent results that may be due largely to the design features of the component. Also, we believe there are certain selection criteria that should be strictly adhered to when implanting metal-backed patellae. Correct selection criteria and improved component design strongly indicate the use of press-fit metal-backed patellae. Methods. This single-center study was designed to conduct clinical and independent radiographic review of primary metal-backed, press-fit patella patients with a minimum five-year follow-up. Potential patients were recruited from a group of existing metal-backed patella patients within the principal investigator's medical practice. All patients recruited for this study were required to have undergone primary knee replacement surgery at least five years prior to clinical and radiographic evaluation. Patients were included if they had a diagnosis of noninflammatory degenerative joint disease. Patients with a BMI >40 were excluded from this study. Radiographic analysis was conducted by an independent reviewer according to the current Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Any radiographs that the reviewer deemed questionable were shown to a second independent orthopaedic surgeon for review, comment, and validation of observations. Kaplan-Meier survivorship was determined for all metal-backed patellae. For survival analysis, only knees with radiographic data were included (74 knees). KSS, WOMAC, and SF-36 scores were calculated also. Results. Seventy-four patients (88 knees) were enrolled in the study, 31 women (41.2%) and 43 men (58.1%). At the time of surgery, the average age was 59.7 years (range, 40–86 years), and the average BMI was 30.6 (range, 19.1–39.6). The breakdown of patients who completed the study and those who were lost to follow-up is shown in Table 1. One metal-backed patella was revised at 49 months for loosening at the bone/implant interface. Survivorship of the metal-backed patellae at minimum five-year follow-up was estimated to be 93.95% with bounds of 73.61% and 98.74%. No radiolucencies greater than 1 mm were observed in any radiographs (Fig. 1), with the exception of the one revision case. Conclusion. Our experience with this metal-backed patella design has been excellent. Failure does not occur due to dissociation of the plastic. As the porous coating is almost under constant compression, biological fixation is assured in most instances, as confirmed by our minimum five-year radiological results. Improved component design and adherence to the correct patient selection criteria absolutely indicate the use of press-fit metal-backed patellae

Introduction:. Although cementless total hip arthroplasty (THA) is well accepted, the optimal femoral component design remains unknown. Among early complications, loosening and periprosthetic fracture persist and are related to implant design. The purpose of this study is to compare the anatomic fit and early subsidence of two different stem designs: a modern, short taper-wedge design and a traditional fit-and-fill design. Methods:. A retrospective cohort study of 129 consecutive cementless THAs using two different femoral stems was performed. A modern taper-wedge stem was used in 65 hips and a traditional proximal fit-and-fill stem was used in 64 hips. Radiographic analysis was performed at preoperative, immediate postoperative and 1-month postoperative intervals. The radiographic parameters of bone morphology via the canal-flare index, implant subsidence at 1 month, sagittal alignment, and the “anatomic fit” metrics of canal fill and associated gaps were measured and recorded. Results:. There were no differences between groups in patient demographics (p > 0.4), and in bone morphology via the canal-flare index (p = 0.6) with numbers available. The mean subsidence was less in the taper-wedge design at 0.27 mm compared to 1.1 mm in the fit-and-fill stem (p < 0.0001). Subsidence greater than 2 mm occurred in 26 of 64 fit-and-fill stems (41%) compared to 1 of 65 taper-wedge implants (1.5%). The percentage fill at all levels measured was greater in the taper-wedge design (p < 0.0001). The taper-wedge design was inserted a mean of 2.7° sagittal extension compared to 0.4° in the fit-and-fill design (p < 0.0001). Conclusion:. Despite being shorter in length, the taper-wedge design demonstrates greater axial stability and less subsidence compared to a traditional fit-and-fill stem. The optimized proximal femoral fit inherent in this anatomic-based taper-wedge design is likely responsible for the minimal subsidence. The clinical implication of greater extension in the sagittal plane is unknown and longer-term clinical follow up is warranted

We retrospectively reviewed 54 patients (92 hips) who underwent cementless total hip arthroplasty for bony ankylosis in ankylosing spondylitis between September 1988 and 2002. Clinical assessment was done at follow-up, which envisages assessment of the pain, function, deformities and range of motion using the Harris Hip Score. Radiographic analysis was done. Kaplan-Meier survivorship analysis was done at 5 and 8.5 years using the revision for the removal of femoral component, acetabular component or both due to any cause as the end point. The mean age of the patients was 25.5 years. The mean duration of follow up was 8.5 years. The average preoperative Harris Hip Score of 49.5 improved to 82.6 post operatively. Post operatively 10 hips had mild to moderate pain. Anterior dislocation occurred in four hips (4.3 %) and sciatic nerve palsy in one hip. Heterotopic ossification was seen in 12 patients, reankylosis rate was 0%. Thirteen arthroplasties were revised due to aseptic loosening. Kaplan-Meier survivorship analysis with revision as end point revealed 98.8% survival at 5 years and 85.8% survival at 8.5 years 11 follow up. Cementless THA in osseous ankylosis in ankylosing spondylitis is a worthwhile surgical intervention in bony ankylosis. Newfound mobility, manoeuvrability and improved ability to sit comfortably were the outcomes, which alleviated the patients’ daunted morale. However, the technically demanding nature of the procedure should not be underestimated

Ninety-seven revisions of total hip replacements are reviewed with a median time of observation of 47 months. Satisfactory pain relief was obtained in 86%. There were six complete failures which were reduced to three by further surgery. One hip became infected and was excised. In 12 cases the revisions were complicated by peroperative fractures and in five by dislocations. Radiographic analysis disclosed a high percentage of periarticular ossification and 25 cases of radiographic loosening of the femoral implant

INTRODUCTION. Acetabular cup orientation is an important element of Total Hip arthroplasty (THA). The purpose of this retrospective case-control study was to compare variability of acetabular cup placement between THA performed via Direct Anterior Approach (DAA) with fluoroscopy in supine position and posterior approach (PA) in lateral position without use of fluoroscopy. METHODS. Radiographic and clinical records of THAs performed by a single, high volume arthroplasty surgeon at one institution were reviewed. Patients with similar design of uncemented acetabular cup, femoral component and bearing surface were included to form two groups. PA group consisted of 300 THAs performed from May 2006 to June 2009. DAA group consisted of 300 THAs performed from Oct 2009 to Oct 2011 excluding first 100 cases to eliminate the influence of learning curve. Radiographic analysis was done by two independent blinded observers to determine cup inclination and anteversion (Liaw et al) on standardized, 6 week postoperative, standing anteroposterior pelvic radiographs using Picture Archiving and Communication System software (PACS). RESULTS. Both groups were comparable in terms of age, sex and BMI. Mean inclination in both groups was similar; PA (41.2 degrees; range, 23 to 63) and DAA (40.36 degrees; range, 29 to 51). Mean anteversion was lower in DAA group (13.29 degrees; range, 6.2 to 32) as compared to PA group (24 degrees; range, 2.3 to 48.8). Variances for cup inclination (49.7 PA vs 19.1 DAA) and anteversion (75.1 PA vs 16.1 DAA) were significantly lower in the DAA group as compared to the PA group as per the F- test for equality of variances (p = 0.001). DISCUSSION. Acetabular cup placement in PA relies predominantly on internal landmarks. Utilization of fluoroscopy with supine position during DAA THA helps in intraoperative assessment of cup orientation and making adjustments for pelvic tilt, thus resulting in decreased variability

To document the medium term results of the use of a fluted tapered titanium femoral stem in revision total hip arthroplasty. 70 patients undergoing total hip revision using a tapered grit blasted titanium modular stem were reviewed at a mean follow up time of 47 months. No bone graqfts were used. Femoral defects were classified according to Pak and Paprosky and the femoral bone quality was assessed with the Bohm and Bischel system. Clinical function was assessed by the Oxford Hip Score. Radiographic analysis was performed in all cases. The results of the use of this prosthesis compares favourably with other revision stems. The Oxford Hip Scores compare favourably with the results for revisions recorded in the New Zealand National Joint Register (24.3) Although technically demanding this stem offers a very satisfactory solution for revision of total hips in most circumstances

Introduction: The removal of well-fixed cementless acetabular components can be challenging and may lead to tremendous bone loss. The options for a well-fixed, mal-positioned cup include cup revision, face-changing liners, or eccentrically cementing a liner in a more appropriate position. This study reviews our experience with a technique of eccentrically cemented acetabular liners in wellfixed, malpositioned cementless acetabular components. Methods: From 2002 to 2004, 30 patients underwent acetabular revisions with eccentrically cemented liners into well-fixed, malpositioned acetabular components. The range of malpositioning included excessive abduction, extreme anteversion, retroversion, and neutral cup position. The cemented liners were downsized by 2–4 mm to provide an acceptable cement mantle and were positioned more appropriately in terms of both abduction angle and anteversion. Results: Mean follow-up was 4 years (3–5). Liners were reoriented for the following reasons 7 excessive abduction, 8 extreme anteversion, 10 neutral and retroversion, and 5 combined inappropriate version and abduction. One liner loosened at 18 months and required cup revision. The other 29 functioned well with no dislocations. Radiographic analysis demonstrated no loosening in 29 cups at a mean of 4 years (3–5). Conclusion: Eccentrically cemented liners into well fixed, malpositioned acetabular components in a reasonable option that has promising short-term results

Introduction:. Subsidence of cementless femoral stems in total hip arthroplasty (THA) has been associated with poor initial fixation and subsequent risk of aspectic loosening. There is limited literature on how subsidence of cementless, proximally porous coated, tapered wedge femoral stems impacts the patient clinically. The aim of our study was to assess whether subsidence with these stems is associated with a decline in clinical function. Method:. A review of a prospectively collected database of THAs performed by a single surgeon at one institution using two cementless, tapered wedge stem designs from January 2006 to June 2010 was performed. Radiographic analysis using Picture Archiving and Communications System (PACS) was used to identify patients with greater than 1.5 mm of subsidence, and to document osseointegration. Preoperative and postoperative pain and Harris hip scores were recorded; and analyzed to identify if the clinical recovery pattern of the subsidence versus no subsidence groups differed. Protected weight bearing was recommended to all patients with subsidence. Results:. 264 hips were reviewed clinically and radiographically at a mean follow-up of 29 months. 10 hips had subsidence greater than 1.5 mm at last follow up. There were 6 males and 3 females with a mean age of 62.1 years in the subsidence group. Subsidence was noted at the 6 week visits in all 10 patients. Mean Harris Hip scores and pain scores were significantly diminished at 6 weeks in the subsidence group (Mean 67.6) as compared to the none subsidence group (82.2) (Figure 1). The two groups had similar scores preoperatively, at 1 year and 2 years postoperatively. In the subsidence group 9 of 10 hips had no further progression of subsidence, and showed radiographic evidence of osseointegration. Persistent thigh pain was noted in 2 patients in the subsidence group. One underwent successful femoral revision for failure of osseointegration and the other continues to have pain with radiographic signs of osseointegration. All 254 hips in the control group had evidence of osseointegration. Conclusion:. Subsidence of tapered wedge stems which occurs at the 6 week mark may be associated with a transient decline in clinical function. Early modification in the rehabilitation regimen may help improve clinical outcome scores in these patients

To evaluate the radiographic mid-to long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. Among 27 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 36 months to 10 years, 3 months (mean, 76.6 months). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis. Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 0.005m) and 1 stem showed moderate subsidence (about 0.008m) in the cement. But there was no mechanical failure and subsidence at the composite-femur interface. Evidence of cortical and trabecular remodeling were observed in all cases. No radiolucent line or osteolysis were found in the follow-up period. There were 4 proximal femoral cracks and 1 distal femoral splitting during operation. The result of cemented stem revision with the use of impacted cancellous allograft was good mid-to long-term. And femoral bone stock deficiency may be reconstructed successfully

Introduction. To report the short to medium term results of acetabular reconstruction using reinforcement/reconstruction ring, morcellised femoral head allograft and cemented metal on metal cup. Methods. Single centre retrospective study of 6 consecutive patients who underwent acetabular reconstruction for revision hip surgery. The acetabulum was reconstructed using morcellised femoral head allograft and reinforcement or reconstruction ring fixed with screws. The Birmingham cup – designed for cementless fixation, was cemented into the ring in all cases. The uncemented Echelon stem with metal on metal modular head was used for reconstructing the femur. Data from our previous in-vitro study had shown good pull out strength of a cemented Birmingham cup. Results. There were 2 men and 4 women with a mean age of 75 years(57-83). Revision was performed for aseptic loosening in 2, septic loosening in 2 and peri-prosthetic fracture with loosening in 2 patients. All patients were reviewed clinically and radiographically at a mean of 36 months follow-up(range 24 - 42 months). Revision was not necessary in any patient for failure of acetabular or femoral fixation. However, 1 patient had revision to a proximal femoral replacement and constrained cup for recurrent infection and osteomyelitis at 24 months. This patient was excluded from the final analysis. The mean Harris hip score at last follow up was 79(range 70-89). Radiographic analysis revealed good graft incorporation and no signs of loosening or cup/ring migration. No dislocations or metal ion problems were recorded in this series. Conclusions. To the best our knowledge, this is the first series using cemented metal on metal cups within a reinforcement/reconstruction ring for revision hip arthroplasty. Excellent cemented fixation of the cup, manufactured for cementless fixation, was obtained at surgery with no evidence of loosening, and no dislocations at minimum 24 months follow up

Background. Minimally invasive surgery is being widely used in the field of total hip arthroplasty (THA). The advantages of the direct anterior approach (DAA), which is used in minimally invasive surgery, include low dislocation rate, quick recovery with less pain, and accuracy of prosthesis placement. However, minimally invasive surgery can result in more complications related to the learning curve. The aim of this study was to evaluate the learning curve of DAA-THA performed by a senior resident. Methods. Thirty-three consecutive patients (33 hips) who underwent primary THA were enrolled in this study. All operations were performed by a senior resident using DAA in the supine position without the traction table. The surgeon started using DAA exclusively for all cases of primary THA after being trained in this approach for 6 months. Operative time, intraoperative blood loss, complications, and accuracy of prosthesis placement were investigated. Results. The mean intraoperative blood loss was 524 mL (range, 130–1650 m L). The mean operative time was 60 min (range, 41–80 min). Radiographic analysis showed an average acetabular anteversion angle of 17.0±3.3°, abduction angle of 37.8±4.3°, and stem alignment of 0±0.8°. Thirty-two (97%) of 33 cups were placed within the Lewinnek's safe zone. The overall complication rate was 12% (4 of 33 hips), including 1 proximal femoral fracture (salvaged with circumferential wiring), 1 temporary femoral nerve palsy (completely recovered in 2 weeks), 1 stem subsidence (5 mm), and 1 cup migration. Three of these complications were occurred in the first 10 cases. No revision surgery was required, No postoperative dislocation occurred. Conclusion. We investigated the learning curve of DAA-THA performed by a senior resident. We considered the first 10 cases as the learning curve, but concluded that with adequate training this procedure can be performed safely and effectively without increasing the risk of complications

The ABG I cementless hip prosthesis has demonstrated unacceptably high rates of wear and osteolysis in our patients. We performed a retrospective study of 97 hips implanted between 1992 and 1998. Radiographic analysis revealed high rates of wear of the polyethylene liner with marked periacetabular osteolysis. Clinical examination indicated that many of these patients were initially asymptomatic. Wear-related problems have required ten hips to be revised and a furher 13 are awaiting revision. This gives a failure rate of 24% at a mean follow-up of 69 months. Contributing factors are likely to include poor wear characteristics of the polyethylene liners which were gamma irradiated in air, and increased wear debris caused by a poor fit of the polyethylene liner within the shell. We believe that all ABG I implants should be immediately reviewed and remain under careful, long-term follow-up

Aim: To assess mid to long-term functional and symptomatic outcome after internal fixation of the distal radius. Methods: All patients operated upon between June 2004 and October 2007 were retrospectively assessed using the ‘Disabilities of arm, shoulder and hand’ (DASH, range 0–100), and Mayo wrist (range 0–100) functional scoring systems. Fractures were classified according to the AO system. All patients were treated in one unit by the same group of surgeons using standard accepted techniques. Revision operations and patients treated at greater than four weeks after injury were excluded. Radiographic analysis of time to union was also performed. Results: 201 patients underwent surgical fixation of which, 183 patients were contactable for follow up (9% loss). Only these patients were included in the study. Mean age was 62.5 years. Mean follow up time was 30 months. Mean time to surgery was eight days. 74% had good/excellent Mayo and 75% good/excellent DASH scores. 2% of patients had a poor outcome with both scores. 28 % reported no functional or symptomatic deficit. There was a 14% overall complication rate (6% major). Mean time to union was 8.39 weeks. Time to union increased with advancing AO grade. There was no significant difference in scores with regard to postoperative immobilisation, time to surgery, time to follow up, patient age, surgeon grade or fracture type. Conclusion: This is one of the largest series of its type and the results compare favourably with other published operative and non-operative treatment modalities. This is a safe, reproducible technique with excellent functional outcome and is recommended as the treatment of choice when surgery is indicated for these fractures

Bone stock loss is a major challenge to the revision hip surgeon. Impaction grafting is frequently the preferred option for the surgeon when faced with bone stock deficiency. This retrospective study assesses a consecutive series of patients who underwent revision hip replacement with femoral impaction grafting during the period 1994–2001. Radiographic measurement for stem subsidence was carried out by 2 independent observers on pre-operative and post-operative radiographs at 6 months, 1 year, 18 months and 2 years following surgery. Graft incorporation and trabecular remodelling were also subjectively assessed. Irradiated bone allograft was used in all cases. Sixty-nine hips were reviewed. Radiographic analysis revealed graft incorporation in 38% of cases. However, there was no evidence of trabecular remodelling. Moderate subsidence (5–10 mm) occurred in 10 cases (14.5%), and massive subsidence (> 10 mm) occurred in 5 cases (7.2%). The survivorship with re-revision or need for further surgery as the end point was 92.8% at an average of 28 months. The results obtained in this study are less favourable than other reported studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling reported in other series raises concerns that irradiated bone graft may be a significant factor in the post-operative progress

Aim: To determine the Inter & Intra-observer Agreement in Assessment & Classiþcation of Non-unions of fractures based on Radiological appearance. Methods: X-rays of 100 adult patients with established non-union (NU) were selected by random sampling, excluding cases with poor quality x-rays. Common denominators of various classiþcation/assessment systems were selected for study. Observers were selected in 3 categories (2 in each): Senior Limb Reconstruction specialist, Musculoskeletal Radiologists & senior trainees. 6 weeks were allowed between the 2 sets of observations. Data was analysed by calculating kappa coefþcients (95% CI) Results: Radiologists were unable to comment on vascularity. Conclusion: Agreement in common denominators except hypertrophic/atrophic NU is poor. Radiographic analysis of non-union remains poor indicating the need for further study to see whether identiþable diagnostic, therapeutic & prognostic features exist

Aim: The differential diagnosis between chondroma and grade I chondrosarcoma still represents a challenge. There are always cases in which a perfect diagnosis can’t be done for sure. This cases are defined in literature with different synonyms such as: borderline chondrosarcoma, grade 0 chondrosarcoma, atypical enchondroma or in situ chondrosarcoma. Enchondroma are benign lesions that do not require a surgical treatment. Low grade chondrosarcoma is a malignant tumour that can recur and also if in a low percentage of cases can metastasize. Methods: The Authors reviewed 22 cases of chondrosarcoma of the limbs for clinical, radiographycal and histological features. Results: Pain was present in 80% of cases of low grade chondrosarcoma, while was absent in enchondroma. Radiographic analysis was not significative. Bone scan was often positive in low grade chondrosarcoma as in enchondroma. Histology demonstrated a permeative pattern in chondrosarcoma with infiltration of the bone trabeculae. Conclusions: Only the complete evaluation of the patient resulted in a correct diagnosis. Follow-up of patients confirmed our findings

Introduction. Acetabular component position is an important determinant of stability, wear and impingement following total hip arthroplasty (THA). Its optimum position and size in direct anterior approach (DAA) THA has not been clearly described in previous studies. Our aim was to study the evolution of the same with reference to stability and impingement as a part of a single surgeon's learning curve. Methods. Clinical and radiographic records of first 300 consecutive DAA THAs performed by a single surgeon from April 2009 to April 2011 were reviewed from a prospective database at a single center. Radiographic analysis was done by two observers to determine acetabular inclination and anteversion on 6 week postoperative standing radiographs. Native femoral head size, measured on preoperative radiographs after adjusting for magnification, was used to calculate the native acetabular cup size. The study population was divided into three groups; Group A– 1. st. 100 DAA THA cases, Group B – 2. nd. 100 and Group C – 3. rd. 100 corresponding to the use of intraoperative anterior stability assessment (Group B and C) and change in the cup size strategy (Group C). The incidence of instability and psoas impingement (PI) –related groin pain at 2 year follow-up was determined for the three groups. Statistical analysis was done to see if there were differences in these clinical and radiographic outcome measures in the three groups. Results. Mean values for abduction were similar in all the groups. Mean anteversion was significantly lower in Group B [12.5° (± 3.3°)] and C [13.6 °(± 2.3°)] as compared to group A [24.3°(± 7.5°)]. The difference between the implanted cup size and calculated native cup size was significantly higher in Group A [5.2(± 2.1) mm] and group B [5.8 (± 2.60 mm] as compared to group C [1.4 (± 1.4) mm] (Figure 1). There were 2 anterior dislocations in group A with none in the other groups. The incidence of PI-related groin pain was higher in group B (12%) as compared to group A (2%) and group C (2%). For PI related groin pain, an arthroscopic psoas release was performed in 3 patients and cup revision in 1 patient. Discussion. For optimum anterior stability, the target cup anteversion is lower in the DAA. Increasing the cup size makes the use of large heads possible. However, the implanted cup size should be as close to the native cup size with DAA THA to avoid anterior overhang (psoas impingement) or posterior overhang (cup-neck impingement and anterior instability)

Introduction. Taper corrosion at modular junctions can cause a spectrum of adverse local tissue reactions (ALTR) in the periprosthetic soft tissues in patients who have undergone total hip arthroplasty (THA). Because these reactions are usually painful, taper corrosion has become part of the differential diagnosis of hip pain following THA. However these destructive lesions may not always cause pain, and can occasionally result in other atypical presentations. The purpose of this study is to describe a cohort of patients presenting with late and recurrent instability following THA due to underlying ALTR and taper corrosion. Methods. This is a multicenter retrospective case series of fourteen patients presenting with late instability secondary to ALTR and corrosion at the modular head-neck taper. The cohort included nine women and five men with a mean age of 66.8 years (range, 49 to 74). All patients had a metal (CoCr)-on-polyethylene bearing surface, but had a range of CoCr and Ti-alloy stem designs from three different manufacturers. Seven patients had 28 mm heads, while the rest had 32–40 mm heads. Patients experienced a mean of 3.4 dislocations (range, 2 to 6) at an average of 5.2 years (range, 0.4 to 17.0) following their index surgery. Although most reported some degree of discomfort around the hip, instability was the primary presenting symptom in all fourteen patients, and four were otherwise completely asymptomatic. Serum metal levels demonstrated a greater elevation of cobalt (mean 3.13 ng/mL) than chromium (mean 2.33 ng/mL). Preoperative infection workup including serum inflammatory markers and a hip aspiration documented the absence of sepsis. Results. Radiographic analysis demonstrated cups were well positioned, with a mean abduction angle of 43.2° (range, 40° to 48°) and mean anteversion angle of 19.5° (range, 16° to 26°). Hips were revised at a mean of 7.4 years (range, 2.4 to 19.4) following their index surgery. At the time of revision, ALTR was encountered in every case, with extensive tissue necrosis and abductor damage or insufficiency in the majority. The modular head-neck junction demonstrated visible corrosion seen as fretting, surface damage, and deposition of a black, flaky material. Constrained liners were placed in all patients. Conclusions. Although ALTR resulting from modular taper corrosion typically presents with hip pain, some patients can present with recurrent instability in the absence of other significant symptoms. Recurrent instability in the setting of otherwise well-positioned components and without another obvious cause should raise concern for ALTR as a potential underlying etiology

This multicenter study compared computer-navigated TKA using either MIS or conventional surgical technique, using a CR fixed bearing knee, Stryker Navigation system and dedicated MIS instrumentation. It was hypothesized that patients would benefit from the MIS technique by shorter recovery periods, less blood loss, faster wound healing and improved mobility during early rehabilitation. A prospective multicentre double-blind controlled trial included 69 patients matched for age, gender, BMI (MIS n=36, CONV n=33). Assessments at pre-op, 1 week, 3 and 6 months post-op included surgery time, bloodloss, range of motion, Knee Society Score (KSS) and WOMAC, Chair rise test and quadriceps strength. Radiographic analysis included radiographs for lucencies and CAT scans for alignment,. Four patients were lost to follow-up. The MIS group had significantly more prolonged surgery time and blood loss at 24 hours p<0.05. At 6 months mean flexion values for MIS (106,7°±12,91) and CONV 105,92 ±11,58) with no significant differences in flexion ROM between both groups at any time point. KSS scores showed a significant improvement (p<0,01) over time in both groups but no statistical significance between groups. WOMAC score also improved significantly (p<0,01) over time in both groups without reaching statistical significance. A significant decrease of anterior knee pain score was observed over time with no significant difference between both groups. Quadriceps strength recovery was not significant between groups but trended toward faster recovery in the MIS group. X-rays showed stable implants with no progressive radiolucent lines in all patients. The hypothesis that patients benefit from the MIS technique in the short term was not confirmed by the results of this study. The MIS surgery technique resulted in more blood loss intra-op and in the first 24hours post op as well as an elongated surgery time. The MIS surgery technique also failed to generate clear advantages in clinical or functional outcome that persisted over time

BMPs, among which BMP-7 or OP-1, unlike several growth factors involved in new bone formation, are the only proteins able to start the whole process. That is BMPs are the only factors with osteoinduction ability. Contrary to other growth factors, BMPs on the market are drugs. RhOP-1, carried by collagen type 1, is the first osteo-inductive drug approved in the world for the clinical usage: in long-bone non-unions in US, Australia and Canada and in tibia non-unions, recalcitrant to autograft, in Europe (Osigraft). We report data related to a retrospective observation on some patients treated in Italy with rhOP-1. 90 patients (66 with long-bone non-union diagnosis, 8 with delayed union, 7 with bone defect /bone cyst and the remaining with other pathologies) are reported, and efficacy results are showed on 60 patients with follow-up > 6 months. Radiographic analysis shows that rhOP-1 is effective in 86,6% of patients. Unions have been reported in 34,8% at 4–5 months, and in 69,1% at 6–8 months. Failure: 8/60 (13,4%). No adverse event has been reported. These data are similar to those reported in literature in randomised and not randomised studies

Acetabular revision in patients with bone deficiency is often difficult because of the poor quality and quantity of the acetabular bone stock. The purpose of this study was to evaluate the midterm clinical and radiographic outcomes of acetabular revision with use of an impaction bone-grafting technique and a cemented polyethylene cup. Results: thirty consecutive acetabular revisions were performed with impaction bone-grafting and use of a cemented cup in twenty-eight patients with bone deficiency. The average age at the revision was sixty-eight years. The minimum duration of follow-up of all reconstructions that were still functioning or that were followed until the time of death was three years (mean, 8.1 years; range, three to fifteen years). The acetabular bone defects were classified as cavitary in fifteen hips and as combined segmental-cavitary in fifteen hips according to AAOS classification. One hip had a repeat revision. Radiographic analysis that had not been revised showed loosening in four hips. All these four hips were treated by bulk bone graft covering more than 50% of cups. Kaplan-Meier analysis demonstrated a prosthetic survival rate, with aseptic loosening as the end point, of 72% at fourteen years and, with revision as the endpoint, of 100% at ten years and 83% at fourteen years. Impaction bone-grafting was an excellent option to manage acetabular revision surgery. However, excessive bulk bonegraft should not be used

Introduction: The occurrence of bony ankylosis in ankylosing spondylitis (AS) is not precisely known. Bony ankylosis, especially in stiff spine may present several exclusive challenges in its management. The current study is an endeavor to evaluate the clinical and the radiological results of cementless THA in patients with bony ankylosis of hip due to ankylosing spondylitis. Materials and Methods: We retrospectively reviewed 54 patients (92 hips) who underwent cementless total hip arthroplasty for bony ankylosis in ankylosing spondylitis between September 1988 and 2002. Clinical assessment was done at follow-up, which envisages assessment of the pain, function, deformities and range of motion using the Harris Hip Score. Radiographic analysis was done. Kaplan-Meier survivorship analysis was done at 5 and 8.5 years using the revision for the removal of femoral component, acetabular component or both due to any cause as the end point. Results: The mean age of the patients was 25.5 years. The mean duration of follow up was 8.5 years. The average preoperative Harris Hip Score of 49.5 improved to 82.6 post operatively. Post operatively 10 hips had mild to moderate pain. Anterior dislocation occurred in four hips (4.3 %) and sciatic nerve palsy in one hip. Heterotopic ossification was seen in 12 patients, reankylosis rate was 0%. Thirteen arthroplasties were revised due to aseptic loosening. Kaplan-Meier survivorship analysis with revision as end point revealed 98.8% survival at 5 years and 85.8% survival at 8.5 years 11 follow up. Discussion: Cementless THA in osseous ankylosis in ankylosing spondylitis is a worthwhile surgical intervention in bony ankylosis. Newfound mobility, maneuverability and improved ability to sit comfortably were the outcomes, which alleviated the patients’ daunted morale. However, the technically demanding nature of the procedure should not be underestimated

Purpose. To define the orthopaedic problems associated with pseudoachondroplasia (PSACH) and their functional impact. Methods. We reviewed the medical records of 12 consecutive patients presenting to our unit. Radiographic analysis of deformity included assessment of mechanical axis and dysplasia at hip, knee and ankle measured by acetabular index (AI), Reimer's migration percentage (MP), neck-shaft angle, distal lateral femoral (aDFLA) and proximal (mMPTA) and distal tibial angles. The paediatric/adolescent PODCI questionnaires and the SF36 were used to assess quality of life issues. Results. 12 patients (9 female) were reviewed at median age 18yrs (range 12-43yrs). Most symptoms related to walking tolerance, joint discomfort and deformity: 9 patients had genu varum, 7 tibial torsion, 2 patella instability and 3 significant low back pain. All patients had hip dysplasia. 10 had medial displacement of the mechanical axis, with a mean mDFLA 105 deg (88 -128) and mMPTA 75deg (51-90). 2 patients have been treated only with growth hormone; 10 patients have undergone a total of 9 distal femoral, 19 proximal tibial and 2 supramalleolar osteotomies. 6 procedures were performed using an external fixator. 7 limb segments have been treated by guided growth and in all these cases alignment has improved. One patient has had bilateral hip arthroplasties (age 29), a second patient has had bilateral patellectomies. These 10 patients have undergone a mean 3.8 operative procedures on a mean 2.4 occasions. Patients scored less well than their peer groups in all domains of the PODCI assessment. All have maintained some independent mobility. Conclusions. PSACH is a severe skeletal dysplasia with deformity at all levels of the lower limb affecting patient satisfaction and quality of life. Knee deformities are those which most frequently require surgical intervention. Significance. The genetic defect in PSACH differs from that in achondroplasia, joint degeneration is more common and maintenance of limb alignment is essential

Most common current surgical treatment options for cuff tear arthropathy (CTA) are hemiarthroplasty and reverse total shoulder replacement. At our unit we have been using Reverse Total shoulder replacement (TSR) for CTA patients since 2001. We present our results of Reverse TSR in 64 patients (single surgeon) with a mean follow up of 2 years (Range 1 to 8 years). There were 45 males and 19 females in the study with a mean age of 70 years. Preoperative and postoperative Constant scores were collected by a team of specialist shoulder physiotherapists. Preoperatively plain radiographs were used to evaluate the severity of arthritis and bone stock availability. 90% patients showed an improvement in the Constant score post operatively. The mean improvement in Constant score was 25 points. The mean Pain Score (max 15) improved from 6.3 to 11.8; the mean ADL Score (max 20) improved from 6.8 to 12.3; the mean Range of Motion score (max 40) improved from 10.8 to 20.2; but the mean Power Score (max 25) only improved from 0.9 to 4.9. The differences in improvement were statistically significant in each category. A total 6 patients (10%) required 10 revision surgeries for various reasons. Two patients dislocated anteriorly who were treated by open reduction. Two patients required revision of the glenoid component due to loosening after a mean of 2 years. One patient required revision of the humeral component with strut grafting secondary to severe osteolysis. Only one patient required revision of both humeral and glenoid components secondary to malpositioning. Three patients died for reasons unconnected with their shoulder problems and surgery. Radiographic analysis at the latest follow up (mean 24 months) showed inferior glenoid notching in 40% cases. Heterotrophic ossification was not seen in our series. We conclude that reverse TSR is a viable option for treatment of cuff tear arthropathy however glenoid loosening and scapular notching remains an issue

We assessed the functional outcome of fractures of the os calcis a minimum of twenty- four months following injury. Eighty-three patients with 85 fractures were assessed a minimum of two years following fracture of the os calcis, using a validated functional outcome measure designed specifically for fractures of the os calcis, and an EQ5D. Radiographic analysis of all fractures was performed to attempt to correlate outcome scores with the fracture pattern. Sixty per cent of the questionnaires were returned completed. Forty percent of the fractures were treated surgically, the remainder with a period of weight relief, followed by physiotherapy and graded weight-bearing. The majority of patients reported a mild hind foot pain (8/10 on a VAS), and all reported some difficulties with walking on uneven terrain. There was no appreciable difference in the outcomes comparing patients treated by open reduction and internal fixation and those treated non-operatively. This study demonstrates a surprisingly high patient satisfaction rate following fractures of the os calcis whether they are treated operatively or non-operatively. Patients seemed to have compensated for any altered function very well. We were not able to identify specific fracture patterns that were associated with poorer outcomes

Purpose: To determine if use of CAS in TKA improves postoperative mechanical axis alignment and component position as compared to use of standard surgical instrumentation. Method: 200 patients were prospectively randomized to TKA utilizing CAS navigation vs. standard surgical technique. Two surgeons performed all procedures utilizing a subvastus approach, the BrainLab navigation system and posterior cruciate substituting implants. Postoperative mechanical axis alignment was measured on full length standing radiographs and component placement on CT (Perth protocol). Two independent raters measured radiographic angles. The variation in mechanical axis measures were compared between the two treatment groups using a two-sided permutation test. Results: Surgery has been completed on all 200 patients with patient demographics similar among the two treatment groups. Median tourniquet time was increased in the navigation group (82 mins versus 57 mins, p < 0.001). Radiographic analysis of the first 100 patients showed the standard deviation of the post-operative mechanical axis measurements to be 22% lower in the navigation group than the standard surgical instrumentation group (2.4 vs. 3.0), marginally significant (p = 0.055). Optimal mechanical axis alignment (to within 3 degrees or less) was achieved in 75% of patients with navigation and in 68% of patients with standard surgical instrumentation. Analysis of all 200 pts will be completed shortly as well as results of component placement based on postoperative CT. Conclusion: Based on analysis of the first 100 patients, use of CAS in TKA marginally statistically improved mechanical axis alignment precision compared to standard surgical technique

Purpose: We report a series of 117 consecutive metal-on-metal Birmingham Hip Resurfacings in 105 patients with a minimum of 5 year follow up. Method: Patients were followed up both clinically and radiographically for a minimum of 5 years following implantation. Revision of either the femoral or acetabular component during the study period is defined as failure. Results: We followed up 114 of 117 hips (97%). We had 4 failures giving us survivorship at 5 years of 97% (95% confidence interval (CI) 94–100). The mean follow up was 72 months and the mean age at implantation 54.5 years old. The mean Oxford Hip Score fell from 41.6 preoperatively to 15.3 postoperatively (p< 0.0001). The mean Harris Hip Score at 5 year follow up was 96.4. The UCLA Activity Scale rose from 3.93 preoperatively to 7.54 postoperatively (p< 0.001). Radiographic analysis revealed neck thinning in 12 patients (10%) and we define a method of measuring this. The average stem shaft angle in our cohort was 130 degrees and the average cup angle was 36 degrees. Heterotropic ossification was present in 17 hips (15%). Conclusion: This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients. It is the first study with a minimum 5 year follow up outside the originating centre

Intraosseous ganglia are typically found in the epiphyses of long bones with the two most common locations being the femoral head and medial malleolus. Almost a fifth of cases reported are found in the carpal bones where the ganglion may be an infrequent cause of chronic wrist pain. Persistence and severity of symptoms rather than radiological findings determine the need for further management. Curettage and bone grafting has been performed for patients with constant symptoms that have severely restricted occupational or recreational activities. Clinically the patients improve but in up to forty percent symptoms persist affecting function. The authors describe an arthroscopic assisted technique of debridement and bone graft used to treat eight patients with intraosseous ganglions of the lunate. All patients returned to work within four months with significant improvement in function and substantial reductions in pain scores. The modified Green scores increased 33.8 points from 51.2 to 85.0 points (p=0.03) by one year postoperatively. Radiographic analysis showed trabeculation within the lunate at an average of 13.8 months following surgery. The technique is safe, with minimal morbidity and no re-operations

Navigation technology is a new tool which can help surgeons to a more accurate hip component implantation and a better reproducibility of the procedure. The purpose of this study was to compare conventional and navigated technique and a new developed straight hip stem for uncemented primary total hip replacement. The results of two consecutive implantation series of 42 patients (non navigated) and 42 patients (navigated) were analysed for implant positioning and short term complications. Non navigated components were implanted through conventional incision (15 cm), navigated component by minimal invasive surgery (5 cm). All surgeries were performed through Hardinge approach and by a single senior surgeon. Radiographic analysis of cup position showed a significant improvement with reduced radiological inclination (53° non navigated/44° navigated, p< 0.001) and higher anteversion (7° non navigated/12° navigated, p< 0.001). The mean postoperative limb length difference was 6.2 mm (SD 9.0, non navigated) and 4.4 mm (SD 6.4, navigated). Intraoperative and early postoperative complications were not different. No dislocation occurred in both groups. There was one intraoperative trochanter fracture which was not revised (non navigated) and one revision because of a periprosthetic fracture caused by fall down during rehabilitation (navigated). We conclude that acetabular implant positioning can be significantly improved by the use of navigated surgery technique even in minimal invasive surgery condition. The data for postoperative limb length difference was still similar but within the expected range in both groups. Navigation technology seems essential for minimal invasive surgical procedure yielding help and security to the surgeon. The effect of improved cup positioning on mid and long term results for both groups have to be further investigated

Introduction. Medial unicompartmental knee arthroplasty (UKA) for isolated medial knee arthritis is a highly successful and efficacious procedure. However, UKA is technically more challenging than total knee arthroplasty (TKA). Research has shown that surgical technical errors may lead to high early failure rates. Haptic robotic systems have recently been developed with the goal of improving accuracy, reducing complications, and improving overall outcomes. There is little research comparing robotic-assisted UKA to standard UKA. The goal of this study was to compare clinical and radiographic data for matched cohorts who received robotic-arm assisted UKA or standard instrumentation UKA. Methods. We performed a non-randomized, retrospective review of 30 robotic-arm assisted UKA and 32 manual UKA performed by single fellowship-trained joint arthroplasty surgeon (SKK) over 2.5 years. All procedures completed through a medial parapatellar approach. All components were cemented. All tibial components were a metal-backed onlay design. Average follow-up was 10.1 months (range 5–36). A full clinical/hospital chart review of demographic, intra- and post-operative measures was performed. Radiographic analysis of pre- and post-op images evaluating sagital and coronal alignment, and component positioning was performed by single observer (DCH), using OsiriX imaging system (Pixmeo; Geneva, Switzerland). Radiographs were available for analysis in 28 robotic-assisted and 30 manual patients. Statistical analysis was performed using SPSS v. 20. Comparison between group means was performed as well as calculation of variance in component placement within groups. Results. No demographic differences were seen between groups. Operative time was significantly longer in robotic-assisted UKA compared to the manual group. Minimal clinical post-op differences between groups. The robotic group showed some early advantage in ambulation/ROM during inpatient stay. This ROM difference reversed at 2 weeks post-op. Continued medial-sided knee pain was reported more commonly in robotic group. Radiographic results showed no difference between groups in pre-op mechanical alignment. The robotic group was significantly more accurate at recreating femoral axis. Accuracy in recreation of tibial slope/ was similar between groups. Accuracy of the tibial component in the coronal plane was not significantly different between groups. The robotic group did have significantly larger variance in coronal alignment of the tibial component. Medial overhang of tibial component was significantly greater and more variable in the manual group. Non-significant decrease in resection depth found in robotic group. Conclusion. There were minimal clinical and radiographic differences between techniques. Clinically, both cohorts did very well. Radiographically, both groups had quite accurate placement of components, with the most obvious difference being the increased tibial component overhang in the manual group. Overall, our data suggests that the purported benefits of robotic UKA may be obviated in the hands of a surgeon with training and experience in manual UKA implantation

Introduction. Total hip arthroplasty (THR) is one of the most successful procedures performed today. Uncemented acetabular components have by and large replaced cemented cups. As such, optimal fixation, bony ingrowth with longevity, and safety is highly demanded. In this study, we look at the safety and efficacy of the Stryker® Trident PSL™ acetabular component based on radiographic and clinical analysis. Materials and Methods. We looked at 860 consecutive patients between 2003 and 2007. Of these, 231 consecutive patients had a minimum 5 year follow up. All cases were for degenerative joint disease (DJD), except 2 for dysplasia, 1 for avascular necrosis (AVN), 1 femoral neck nonunion. Average Hospital for Special Surgery (HSS) hip scores at final follow up were recorded. Radiographic analysis included classification based on Delee and Charnley's zones 1–3. Osseointegration was assessed based on presence of SIRCAB (stress induced reactive cortical hypertrophy of bone), demarcation around the implant, stress shielding, presence of radial trabeculae, absence of radiolucency, type of bearing, presence of preoperative protrusion, violation of Kohler's line. EBRA software was used to assess acetabular inclination and version. Results. Of 231 hip replacements analyzed, 114 were male, 117 were female. The average age was 63 (range 33–87); height was 67.5 inches; BMI was 27; 3 patients had a preoperative diagnosis of DDH, 2 had AVN, 1 femoral neck nonunion, and 1 case of rheumatoid arthritis (RA), with the remainder of patients diagnosed with DJD. cup abduction angle was 41.7° with average of 17.4° of anteversion. Average HSS functional score was excellent at latest follow up was 34, with most patients not relying on any assistive devices; There were no revisions performed due to mechanical failures or due to failure to osseointegrate. Complications include 1 infection (0.43%); and 4 dislocations (1.73%). Osseointegration was measured by separating the acetabulum into DeLee and Charnley zones and assessed by analyzing:. a). stress induced hypertrophic reaction of cortical bone (SIHRCaB): zone 1 (75.8%), zone 2 (11.7%), zone 3 (51.9%). b). Radial trabeculae: zone 1 (94.8%), zone 2 (93.5%), zone 3 (92.6%). c). Absence of radiolucency: zone 1 (96.1%), zone 2 (97%), zone 3 (96.1%). No association of bearing surfaces to survivorship was noted as metal femoral heads were used in 72.7% of cases while a ceramic bearing was used in 25.1%. Conclusion. The Trident PSL acetabular component was examined in a large, consecutive series by a single surgeon with a minimum 5–9 year follow up. We have demonstrated excellent radiographic osseointegration at latest follow up with no mechanical failures, high survivorship, and excellent clinical outcome scores. It continues to be a reliable option for primary acetabular reconstruction

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown aetiology. In RA, inflammation and pain are initial symptoms followed by bone and cartilage destruction. Proinflammatory cytokines play a significant role in the initiation and progress of inflammation and tissue destruction. Sensory neuropeptide substance P (SP) participates not only in nociception but also in pro-inflammatory processes by enhancing vasodilatation and recruitment of inflammatory cells. Ubiquitin proteasome system (UPS) activates a transcription factor, NF-κB which regulates the synthesis of proinflammatory mediators like cytokines; however its role in regulating pro inflammatory sensory neuropeptides is unknown. A number of proteasome inhibitors have been shown to down regulate the activity of NF-κB and hence reduce inflammation. In the present study, the effect of proteasome inhibitor (MG 132) on the severity of arthritis and pain was observed along with the expression of SP-positive nerve fibres in the ankle joint in a chronic inflammatory model of rat adjuvant arthritis. Histology and mechanical pain tests showed a significant reduction in inflammation and pain in ankle joint by daily administration of proteasome inhibitor MG132 at the dose of 1mg/kg body weight compared to untreated groups. Radiographic analysis of ankle joints indicated a reduction in soft tissue swelling and joint destruction in the treatment group. A marked reduction in the NF-κB activity was observed by EMSA. Furthermore, proteasome inhibition resulted in the normalization of up regulated neuronal response occurred during inflammation by significantly reducing the expression of SP-positive fibres in the ankle joint as demonstrated by immunohistochemistry. Our data provide the evidence that proteasome inhibitor MG132 can reduce severity of arthritis and reverse inflammatory pain behaviour by influencing the peripheral sensory nervous system. The drugs targeting UPS can be developed for treatment of chronic inflammatory joint disorders

Aim: The purpose of this study was to report our experience mid to long-term results of hybrid cement fixation in revision total knee arthroplasty. Methods: Patients who underwent revision total knee arthroplasty using a hybrid cement technique (press-fit diaphyseal fixation and cemented metaphyseal fixation) with a titanium fluted revision knee implant were reviewed. There were 127 patients. Mean age at surgery was 71 years (range 41–94 years). There were 56 males and 71 females. Mean follow-up was 5 years (range, 2–12 years). A Kaplan-Meier survivorship analysis using an end-point of revision surgery or radiographic loosening was employed to determine probability of survival at 5 and 10 years. Results: 127 patients (135 knees), 31 patients (36 knees) died and 2 patients (2 knees) were lost to follow-up. Six patients (six knees) were revised at a mean of 3.5 years (range 1–8 yrs). Of the 6 revisions, two were for re-infection, two were for (MCL) instability, and two were for aseptic loosening. Mean Knee Society clinical and functional scores were 86 and 55 points, respectively. The mean range of motion was 108 degrees. End of stem pain was not reported in this group of patients. Kaplan-Meier survivorship analysis revealed a probability of survival free of revision for aseptic loosening of 98% at 12 years. Discussion: The results of this study suggest that the use of a hybrid cement technique in revision knee arthroplasty can provide good mid to long-term results. Radiographic analysis has shown continued satisfactory appearances regardless of constraint, stem size and augments. Our experience has shown that the survivorship of a hybrid fixation technique for revision knee arthroplasty is comparable to reported long-term survivorship of cemented revision knee arthroplasty