Introduction. Dislocation after primary total hip arthroplasty (THA) is a devastating and frequent postoperative complication. Many risk factors for dislocation have been identified, however, thus far there has been no consensus whether inflammatory arthritis is a risk factor for dislocation or not. We carried out a prospective study assessing the prevalence of dislocation within 2 years after primary total hip arthroplasty for osteoarthrosis and inflammatory arthritis. Patients and Methods. Between 1996 and 1999 312 patients (342 hips) with either a primary or a posttraumatic osteoarthrosis (OA group) and 59 patients (69 hips) with rheumatoid arthritis or other forms of inflammatory arthritis (IA group) were operated. One single type of prosthesis was implanted (EPF-PLUS. ®. cup and SL-PLUS. ®. stem) using an anterior approach. All dislocations in the two years following surgery were recorded. Both diagnostic groups were compared for known risk factors such as old age, female gender, prior hip surgery, and experience of the surgeon. Radiographs were examined for avulsion fractures of the tip of the trochanter and signs of loosening. The abduction and anteversion angles of the acetabular component were measured. Statistical analysis was performed with the Chi-square test and Student’s t-test. Results. The dislocation rate for inflammatory arthritis patients was significantly greater than that in patients with osteoarthrosis: 10. 1% (7 hips) in the IA group, 2. 9% (10 hips) in the OA group (p = 0. 006). There were no other differences in risk factors favouring dislocation in the IA group, such as old age, female gender, prior hip surgery, experience of the surgeon, trochanteric fractures or malposition of the prosthetic components. All dislocations in the IA group were posterior and occurred without any kind of trauma. In contrast, nearly half of the dislocations in the OA group were anterior and two were of traumatic origin. Discussion. Taking into account the fact that there are no differences in known risk factors for dislocation between our two groups and no differences in complication rate, except for dislocation, we can say that inflammatory arthritis has to be considered an independent risk-factor for dislocation after primary total hip arthroplasty. It may be that inferior quality of the (pseudo) capsule and the muscles stabilising the hip joint due to inflammatory arthritis leads to inadequate soft tissue tension. Another factor can be the concomitant impairments in rheumatoid patients, such as impairments of the upper extremity, ipsilateral knee or contralateral hip, leading to hyperflexion in the operated hip causing a posterior dislocation without trauma

Introduction. Total hip arthroplasty (THA) is the only successful treatment for patients in whom the hip joint is destroyed by inflammatory arthritis. Due to the effects of both the disease and its treatment elevated rates of complications and of aseptic loosening have been described. Whether with modern uncemented hip prostheses the results can be improved is not fully known. Therefore, we decided to carry out a prospective study. Material and methods. At the introduction of a new press-fit acetabular component a prospective study on the results of uncemented THA was started. From 1995 to 1999 85 primary THAs were carried out in 72 patients (57 women, 15 men) suffering from inflammatory arthritis. Diagnosis: RA 76, adult-onset Still 4, JIA 3, miscellaneous 2. Mean age at operation was 60 years (SD 15. 9). Clinically, the Harris Hip Score was used for evaluation. Radiographically, the Larsen classification was used and at follow-up radiolucencies and signs of migration were registered. The implants used in this study were the EPF-PLUS® acetabular component and the SL-PLUS® femoral component (PLUS Endoprothetik AG, Rotkreuz-CH). The EPF-PLUS® acetabular component is a novel modular press-fit cup. Its shell has a triple radius profile on cross-section, thereby creating a gradual lowering of the polar part of the cup. This produces a small gap of about 2 mm. between the acetabulum and the pole of the cup. Therefore, forces are mainly transmitted to the peripheral part of the acetabulum, leading to an enhanced primary stability. Originally, the shell had a gritblasted surface for osseointegration. Since 1996, the outer surface of the cup has been coated with a ground layer of pure titanium and a superficial layer of a crystalline hydroxyapatite (Ti-HA). The gritblasted version was used in 14 hips (1995–1996), the Ti-HA coated version in 71 hips. In 68 hips the cup was implanted by press-fit fixation, in 17 screws were added. Results. Larsen classification was as follows: 0-1: 6; 3: 17; 4: 60; 5: 2. At follow-up, 5 patients (6 THAs) were deceased. Deep infection required revision in one hip. Another revision was carried out for recurrent dislocations. One grit-blasted cup developed late subsidence and was revised almost 4 years postoperatively. One Ti-HA coated cup failed early due to severe acetabular bone loss. Finally, one femoral component developed a varus tilt and became symptomatic 2 years after implantation, requiring revision. In all 62 patients with 74 THAs in follow-up cup and stem are functioning well, both clinically and radiographically. Harris Hip Score increased from 36. 6 (SD 17. 7) to 87. 9 (SD 11. 8). Discussion. The medium-term results of the EPF®-PLUS cup show that its primary stability is good and that, as the polar gap rapidly disappears, osseointegration is secure. Only severe acetabular deficiency appears to be a contra-indication for this implant. Also, the SL-PLUS® stem performs well in inflammatory arthritis

Introduction. Multiple factors contributing to an elevated risk for dislocation after total hip arthroplasty (THA) have been identified. Patient-related risk factors that have been identified are prior hip surgery, old age and female gender. However, there have been no prospective reports whether inflammatory arthritis (IA) is an independent risk factor. Material and methods. From January 1996 to December 1999 427 primary total hip arthroplasties were carried out using one type of uncemented prosthesis: a hydroxyapatite coated EPF-PLUS. ®. cup and a SL-PLUS. ®. stem (PLUS Endoprothetik AG, Rotkreuz-CH). A 28 mm. ball head was used in every hip. To evaluate whether IA is a risk factor for dislocation the incidence and cause of early (< 2 year post-surgery) dislocation in IA hips was compared with those carried out for osteoarthrosis (OA). There were 341 THAs in 311 patients with OA and 69 THAs in 59 patients with IA (mainly rheumatoid arthritis) included in this study. The remaining 17 THAs were for various other reasons and excluded from this study. Statistical analysis of the dichotomous variables was carried out by the chi-square test and the Fisher’s exact test, Student’s t-test was used for the analysis of continuous variables. Results and discussion. Both groups were comparable with respect to the following risk factors: gender, approach (either straight-lateral or anterolateral), position of the acetabular component and experience of the surgeon. Mean age was lower in the IA group than in the OA group: 61. 0 vs 68. 1 years. Furthermore, the incidence of prior hip surgery was higher in the OA group. The incidence of dislocation was 7 out of 69 (10. 1%) in IA hips and 10 out of 341 (2. 9%) in OA hips (p=0. 006). All dislocations in IA where posterior, in OA 5 were posterior and 4 were anterior (1 unknown). No other mechanical factors leading to an increased instability of the hip in IA, such as trochanteric fractures, could be identified. Due to the relatively small numbers a statistical difference in the direction of dislocation could be identified (p= 0. 088). So, IA has to be considered as an independent risk factor for dislocation after THA. Both the polyarticular impairments and the lower quality of the soft tissues in IA could explain this elevated risk. To reduce the incidence of dislocation in IA it therefore seems advisable to pay detailed attention the soft tissues and the position of the prosthetic components in IA at the time of surgery. Also, consideration should be given to the use of an acetabular component with an elevated rim

Aims. Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis. Methods. We identified 418 hips (350 patients) with a primary diagnosis of inflammatory arthritis who underwent primary THA with HXLPE liners from January 2000 to December 2017. Of these hips, 68% had rheumatoid arthritis (n = 286), 13% ankylosing spondylitis (n = 53), 7% juvenile rheumatoid arthritis (n = 29), 6% psoriatic arthritis (n = 24), 5% systemic lupus erythematosus (n = 23), and 1% scleroderma (n = 3). Mean age was 58 years (SD 14.8), 66.3% were female (n = 277), and mean BMI was 29 kg/m. 2. (SD 7). Uncemented femoral components were used in 77% of cases (n = 320). Uncemented acetabular components were used in all patients. Competing risk analysis was used accounting for death. Mean follow-up was 4.5 years (2 to 18). Results. The ten-year cumulative incidence of any revision was 3%, and was highest in psoriatic arthritis patients (16%). The most common indications for the 15 revisions were dislocations (n = 8) and periprosthetic joint infections (PJI; n = 4, all on disease-modifying antirheumatic drugs (DMARDs)). The ten-year cumulative incidence of reoperation was 6.1%, with the most common indications being wound infections (six cases, four on DMARDs) and postoperative periprosthetic femur fractures (two cases, both uncemented femoral components). The ten-year cumulative incidence of complications not requiring reoperation was 13.1%, with the most common being intraoperative periprosthetic femur fracture (15 cases, 14 uncemented femoral components; p = 0.13). Radiological evidence of early femoral component subsidence was observed in six cases (all uncemented). Only one femoral component ultimately developed aseptic loosening. Harris Hip Scores substantially improved (p < 0.001). Conclusion. Contemporary primary THAs with HXLPE in patients with inflammatory arthritis had excellent survivorship and good functional outcomes regardless of fixation method. Dislocation, PJI, and periprosthetic fracture were the most common complications in this cohort with inflammatory arthritis. Cite this article: Bone Joint J 2023;105-B(7):768–774

Metal on metal hip resurfacing was introduced in 1992 by Derek McMinn initially using an all cementless device and then an all cemented device. A hybrid resurfacing with a cemented femoral component and a cementless acetabular component was introduced in 1994. The manufacturer of the hybrid hip resurfacing was changed in 1996. Since 1997 the Birmingham hip resurfacing has been in continuous use. The device is approved by NICE (National Institute for Clinical Excellence) for use within the NHS in patients with Osteoarthritis of the hip. The device is not yet approved for use in patients with Rheumatoid Arthritis and other types of inflammatory arthritis. There are concerns regarding bone quality in rheumatoid patients, which may result in a high incidence of component loosening or femoral neck fracture. Conventional total hip replacement is a successful procedure in inflammatory arthritis however with modern treatments producing increased activity levels there are concerns about polyethylene wear. The author has performed metal on metal hip resurfacing in patients with inflammatory arthritis over the past 12 years. A total of 170 patients have been operated on with 198 resurfacings. 33% of patients have a diagnosis of some type of inflammatory arthritis. The outcomes have been assessed using Oxford hip scores and long term clinical and radiological review. Our results indicate that there is a minimal risk of femoral neck fracture and a minimal risk of component loosening when the device is used with this approach in patients with inflammatory arthritis

Aims. The purpose of this study was to validate our hypothesis that centrifugation may eliminate false-positive leucocyte esterase (LE) strip test results caused by autoimmune diseases in the diagnosis of knee infection. Methods. Between January 2016 and May 2019, 83 cases, including 33 cases of septic arthritis and 50 cases of aseptic arthritis, were enrolled in this study. To further validate our hypothesis, another 34 cases of inflammatory arthritis from the Department of Rheumatology of our institution were also included. After aspiration, one drop of synovial fluid was applied to LE strips before and after centrifugation. The results were recorded after approximately three minutes according to the different colour grades on the colour chart. The differences of LE results between each cohort were analyzed. Results. Before centrifugation, 46% (23/50) of the LE strip tests in the aseptic arthritis group were false-positives. Most of the false-positive results were due to inflammatory arthritis; after centrifugation, 78.3% (18/23) of the tests yielded negative results. Similar results were observed in cases from the Department of Rheumatology. The sensitivity of the centrifuged LE strip test was 0.818 (0.639 to 0.924), which is still an acceptable level compared with the uncentrifuged results, which yielded a sensitivity of 0.909 (0.745 to 0.976). However, the specificity was increased from 0.540 (0.395 to 0.679) to 0.900 (0.774 to 0.963) after centrifugation. Conclusion. Although inflammatory arthritis can yield a false-positive LE strip test result in the diagnosis of knee infection, centrifugation may eliminate these false-positive results. Cite this article: Bone Joint Res. 2020;9(5):236–241

We report a consecutive series of 16 revision total knee arthroplasties using the Total Condylar III system in 14 patients with inflammatory arthritis which were performed between 1994 and 2000. There were 11 women and three men with a mean age of 59 years (36 to 78). The patients were followed up for 74 months (44 to 122). The mean pre-operative Knee Society score of 37 points (0 to 77) improved to 88 (61 to 100) at follow-up (t-test, p < 0.001) indicating very good overall results. The mean range of flexion improved from 62° (0° to 120°) to 98° (0° to 145°) (t-test, p < 0.05) allowing the patients to stand from a sitting position. The mean Knee Society pain score improved from 22 (10 to 45) to 44 (20 to 50) (t-test, p < 0.05). No knee had definite loosening, although five showed asymptomatic radiolucent lines. Complications were seen in three cases, comprising patellar pain, patellar fracture and infection. These results suggest that the Total Condylar III system can be used successfully in revision total knee arthroplasty in inflammatory arthritis

Introduction: Hip Resurfacing has always been an attractive concept for the treatment of hip arthritis in young patients. Excellent early and medium-term results have been reported with the Birmingham Hip Resurfacing (BHR) device in single and multi-surgeon all-diagnoses and OA series. In the present report we present the results of BHR in inflammatory arthritis. Methods: This is a single-surgeon consecutive series. There were 15 consecutive hips (12 patients) including 2 women (2 hips) with ankylosing spondylitis (AS) operated at a mean age of 41.7 years (range 29.5 to 54.3 years). Fortytwo hips (31 patients) with seronegative or rheumatoid (RA) arthritis treated with a BHR at a mean age of 40 (13 to 64) years and a follow-up of 2 to 9 (mean 5.9) years were also studied. One patient died 5 years later. Revision for any reason was the end-point and unrevised patients were assessed with Oxford hip scores and reviewed clinico-radiologically with AP and lateral radiographs. Results: In the RA group there was one failure from femoral neck fracture two months after operation giving a failure rate of 2.4%. There were no failures in this cohort at a follow-up of 1.8 to 8.8 (mean 4.9) years. As a combined group the failure rate of BHRs in inflammatory arthritis is 1.75% and the cumulative survivorship at 9 years is 98.2% (figure). Discussion: The good results of Birmingham Hip Resurfacing in inflammatory arthritis in this relatively young cohort of patients make this a viable treatment option for these patients. Selection of patients with a reason-able bone quality and adherence to precise operative technique are vital to the success of this procedure

Introduction. Serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and synovial fluid white blood cell (WBC) count and differential are effective in diagnosing periprosthetic joint infection (PPJI); however their utility in patients with inflammatory arthritis is unknown. The purpose of this study is to determine the utility of these tests in patients with inflammatory arthritis. Methods. 934 Consecutive revision hip and knee arthroplasties were prospectively evaluated for PPJI. 202 Cases were excluded due to acute post-operative or hematogenous infection. 690 Patients had non-inflammatory and 42 had inflammatory arthritis. Receiver operating characteristic (ROC) curves were used to establish optimal ESR, CRP, WBC, and % neutrophil values for diagnosis of PPJI, and the area under the curve (AUC) was calculated to determine the overall accuracy. Results. The optimal thresholds for predicting PPJI were ESR 30mm/hr, CRP 17mg/L, WBC 2667, and differential 75% neutrophils in inflammatory arthritis, and ESR 32mm/hr, CRP 15mg/L, WBC 4000, and 78% neutrophils in non-inflammatory arthritis. The efficacy of these tests was similar in both populations (AUC for inflammatory ESR=86.2%, CRP=86.2%, WBC=93.8, 93.6% neutrophils; AUC for non-inflammatory ESR=85.2%, CRP=90.2%, WBC=94.5, 95% neutrophils); there was no significant difference between groups (ESR p = 0.861, CRP p= 0.549, WBC p=0.8315, % neutrophils p=0.7021). The rate of PPJI was significantly higher in patients with inflammatory (33.3%) than non-inflammatory (18.8%) arthritis (p-value=0.013). Conclusions. These results suggest that the ESR and CRP are useful in diagnosing PPJI in patients with inflammatory as well as non-inflammatory arthritis with similar optimal cut-off values

Introduction. Total knee replacement has been well-established form of treatment both for osteoarthritis and inflammatory arthritis. Both cemented and uncemented TKR have been used successfully. Since 1977 low contact stress (LCS) mobile bearing knee replacement has been in extensive use. Most of the intermediate and long term results reported are in osteoarthritis1–7. Though there are several studies reporting short term performance of TKR in rheumatoid arthritis8–19 there have been rare reports31 of intermediate to long-term performance of LCS uncemented TKR in rheumatoid arthritis. Methods. Retrospective, non-randomised and consecutive study. Case notes and radiological assessment done. Kaplan meyer survival analysis used. Radiological assessment between initial and final xrays done using T test statistics. Assessement done by two independent observer. Results. 108 knees in 67 patients are collected. 21 patients with 36 knees have died. Only 65 knees in 42 patients had both case notes and xrays which are included in this study. Of this 11 knees in 7 patients were dead. All 65 knees in 42 patients are sero-positive rheumatoid arthritis. Pre-operative bone loss was seen only in 4 knees. Bone loss was in the medial side in 3 knees (4,5 and 8mm respectively) and lateral in 1 knee (1 cm). None of these bone loss needed bone grafting or any special procedures. There was no subsidence in any of the 65 knees. Survival of uncemented LCS TKR in inflammatory arthritis patients is 100%. Aseptic failure is 0%. No infective failure. There is no significant change in the implant position. This is the longest follow for uncemented TKR in inflammatory arthritis ever reported in the literature. Conclusion and Discussion. In conclusion, our study has uniformity, as a single surgeon performed/supervised with senior trainees all the operations and all patients received the same level of post-operative care. Survival of LCS uncemented TKR in inflammatory arthritis patients is 100% up to 15years. This is the longest follow up in this patient population ever reported in the literature. Our study shows excellent survival and comparable to other cemented TKRs in this patient population reported in the literature. This study proves contrary to the general belief that uncemented TKR do poor in inflammatory arthritis due to osteoporotic bone

Aims: Patient-related risk factors of dislocation after total hip arthroplasty (THA) that have been identified are previous hip surgery, old age and female gender. However, there have been no prospective reports whether inflammatory arthritis (IA) is an independent risk factor. Methods: Prospective evaluation of the incidence of early (< 2 year post-surgery) dislocation in a consecutive series of primary THA. From January 1996 to December 1999 341 THAs in 311 patients with osteoarthrosis (OA) and 69 THAs in 59 patients with IA (mainly rheumatoid arthritis) were included in this study. One type of prosthesis having a 28 mm. ball head was implanted in every hip through an anterior appoach. Results: Both groups were comparable with respect to the following risk factors: gender, position of the acetabular component and experience of the surgeon. Average age was lower in the IA group than in the OA group: 61.0 vs 68.1 years. Furthermore, the incidence of previous hip surgery was higher in the OA group. Despite the presence of these risk factors in the OA group, the incidence of dislocation was higher in IA than in OA: 10.1% vs. 2.9% (p=0.006). All dislocations in IA where posterior, in OA 5 were posterior and 4 were anterior (1 unknown). No other mechanical factors leading to an increased instability of the hip in IA, such as trochanteric fractures, could be identified. Conclusions: Inflammatory arthritis is an independent risk factor of dislocation after THA. Both the polyarticular impairments and the lower quality of the soft tissues in IA could explain this increased risk

We divided 309 patients with an inflammatory arthritis who had undergone primary elbow replacement using the Souter-Strathclyde implant into two groups according to their age. The mean follow-up in the older group (mean age 64 years) was 7.3 years while in the younger patients (mean age 42 years) it was 12 years. Survivorship for three different failure end-points (revision, revision because of aseptic loosening of the humeral component, and gross loosening of the humeral implant), was compared in both groups. Our findings showed that there was no significant difference in the incidence of loosening when young rheumatoid patients were compared with an older age group

The purpose of this study is to assess the improvement in pain and function of the ankle when arthrodiastasis is used for end stage juvenile idiopathic arthritis [JIA] in the paediatric population. All patients treated with ankle arthrodiastasis, 2009–2013 were studied. Clinical, radiological and survivorship data were examined. The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) and Parents (OxAFQ-P), along with the American Orthopaedic Foot and Ankle Society (AOFAS) Clinical rating system for Ankle-Hindfoot were recorded pre-operatively and at 6 months. Eight patients (9 ankles) with severe tibiotalar JIA, refractory to medical management were treated. Average age at surgery was 14.5 years (range 8–19). Average length of arthrodiastasis was 3.5 months. Length of follow-up averaged 13 months (range 5–28 months). All scores showed an improvement at 6 months. OxAFQ-C scores (out of 60) improved on average from 23 to 43. OxAFQ-P scores also improved from19 to 39. The largest improvement was found for the physical subsection. AOFAS Ankle-Hindfoot score (out of 100) averaged 34 pre-op and 74 at 6 months. Pain scored out of 10 decreased from an average of 7.4 to 4.3 at 6 months. All patients and parents were satisfied with the surgery and would have the procedure performed again. Radiological studies demonstrated cartilage regeneration, joint restoration and deformity correction with arthrodiastasis. Survivorship was good (75%) at 36 months, but 2 patients (3 ankles) had subsequent surgery in the adult sector for progression of disease despite initial improvement following arthrodiastasis. This case series demonstrates the efficacy of ankle arthrodiastasis as a surgical option in severe end-stage ankle inflammatory arthritis in paediatric patients in the short to midterm. It improved functional scores and pain scores which should delay the need for more radical joint fusion or replacement procedures in this challenging surgical condition

Introduction. Synovectomy in children with juvenile rheumatoid arthritis (JRA) and psoriatic arthritis (PSA) is still subject of controversial discussion. Our results of arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease are presented. Material. From 1989–1997 27 synovectomies were performed in 27 children with inflammatory arthritis (15 JRA, 12 PSA). Average age at surgery was 12. 5 y (2. 9–17. 8 y). Mean follow-up was 4. 9 years. Methods. Onset of disease and conservative therapy was documented. Each patient was physically and radiologically examined preoperatively and 24 children postoperatively (mean follow-up 4. 9 years). For arthroscopic shaver-assisted synovectomy of the knee we used minimum 4 portals and normally 6 portals (2 anterior, 2 suprapatellar and 2 posterior portals). In addition to the physical examination we used a special clinical score (Laurin 1974). We compared the pre- and postoperative limits of active and passive knee movement. We performed sonographs and radiographs of the infected joint. Radiography was classified following the Larsen-Scale. Patient and parents gave their opinion whether the operation was successful. Before surgery all children had intensive drug and physical therapy for 8–62 months (42 month). In the course of conservative treatment, knees had local joint treatment with triamcinolonhex-acetomid (THA), normally for three times before surgery. Preoperative X-rays showed Larsen stage I in 3 knee joints and Larsen stage 0 in the other knees. Results. In 85% of the children, we found good or excellent surgical outcome. 2 joints achieved fair and 2 joints poor outcome. Concerning subjective outcome 22 (82%) children had been very satisfied (56%) or satisfied (26%). 25 of the children’s parents would agree in the same surgical procedure again. In 6 knee joints we found recurrent synovitis. 2 of these knee joints were reoperated (30 and 22 month postoperatively with satisfying result), the other 4 joints were treated with THA i. a.. The 2 reoperations were regarded as poor result. We had no postoperative complications and the normal hospitalisation was 15 days. Prior to surgery, 12 knee joints had an average deficit of active knee extension of 10° (5–20°). Postoperatively, no extension deficit was found anymore in 25 of the knees. Compared to the contralateral knees, a flexion deficit of 10° (5–15°) was obtained postoperatively. At sonography, no joint effusion could be revealed. Postoperative X-rays showed no progression in Larsen stage. Outcome in children with oligoarthritis was better than in those with polyarthritic disease. Discussion. Early arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease is, in case of failure of conservative treatment, a useful method of treatment. We propose early synovectomy of the knee joint as an essential part of the treatment scheme for children with inflammatory joint disease

The management of radial head fractures complicated by ligamentous disruption remains a matter of controversy. The use of a silicone radial head implant to provide temporary stability is thought to help to protect the ligaments during healing. The reported complications of long-term implantation of a silicone replacement include fracture, dislocation, synovitis, lymphadenitis and subchondral resorption. We now report one case in which an inflammatory process resulted in generalised cartilage degeneration. This has not previously been noted.

Aims. Insufficient treatment response in rheumatoid arthritis (RA) patients requires novel treatment strategies to halt disease progression. The potential benefit of combination of cytokine-inhibitors in RA is still unclear and needs further investigation. To explore the impact of combined deficiency of two major cytokines, namely interleukin (IL)-1 and IL-6, in this study double deficient mice for IL-1αβ and IL-6 were investigated in different tumour necrosis factor (TNF)-driven inflammatory bone disorders, namely peripheral arthritis and sacroiliitis, as well as systemic bone loss. Methods. Disease course, histopathological features of arthritis, and micro-CT (µCT) bone analysis of local and systemic bone loss were assessed in 15-week-old IL1-/-IL6-/-hTNFtg in comparison to IL1-/-hTNFtg, IL6-/-hTNFtg, and hTNFtg mice. µCT bone analysis of single deficient and wild-type mice was also performed. Results. Combined deficiency of IL-1/IL-6 markedly ameliorated TNF-mediated arthritis and bilateral sacroiliitis, but without additive benefits compared to single IL-1 deficiency. This finding confirms the important role of IL-1 and the marginal role of IL-6 in TNF-driven pathways of local joint damage, but questions the efficacy of potential combinatorial therapies of IL-1 and IL-6 in treatment of RA. In contrast, combined deficiency of IL-1/IL-6 led to an additive protective effect on TNF-driven systemic bone loss compared to single IL-1 and IL-6 deficiency. This finding clearly indicates a common contribution of both IL-1 and IL-6 in TNF-driven systemic bone loss, and points to a discrepancy of cytokine dependency in local and systemic TNF-driven mechanisms of inflammatory arthritis. Conclusion. Combinatorial treatments in RA might provide different benefits to inflammatory local arthritis and systemic comorbidities. Cite this article: Bone Joint Res 2022;11(7):484–493

Aim of study

The thrust plate prosthesis is an implantat with metaphyseal fixation at the proximal femur, which leaves the diaphyseal bone untouched. Therefore this implant preferably is employed in younger patients. It is dependent on a good bone quality in the proximal femur. Because bone quality is reduced in patients with polyarthritis, this kind of endoprosthesis may have a higher failer rate than conventional stemmed endoprostheses in these patients. Therefore in patients with polyarthritis even short- end midterm results of the thrust plate prosthesis should be analyzed.

Material and Methods

47 thrust plate prostheses were implanted in 42 patients with polyarthritis (29 with rheumatoid arthritis, 6 with juvenile chronic arthritis and 7 patients with spondarthritis) and followed prospectively. The average age at the operation was 40. 8 ± 10. 7 years. Each patient was clinically and radiologically examined preoperative, 3 and 6 months after the operation and at the end of each postoperative year. The mean follow-up was 26. 1 ± 10. 7 months. The clinical findings were evaluated using the Harris-Hip-Score. Radiologically 8 different zones at the thrust plate prosthesis were analyzed for radiolucencies.

Results

During the first year the Harris-Hip-Score rose continuously from the preoperative average of 42. 4 ± 6. 5 points to 78. 8 ± 10. 3 points 3 months postoperatively, 82. 3 ± 9. 8 points 6 months postoperatively, and 86. 8 ± 10. 1 points 1 year after the operation. The following examinations showed Harris-Hip-Scores at the same level. 5 patients (5 joints, 10. 6%) had to undergo a revision of the thrust plate prosthesis due to aseptic loosening in 3 cases and septic loosening in 2 cases. 6 prostheses (12. 6 %) showed radiolucencies, mostly below the thrust plate in zone 1 and 2. 2 of these prostheses were certainly radiologically loose which raised the failure rate to 7 of 47 (14. 8 %).

Conclusion

The thrust plate prosthesis improves function and pain in patients with polyarthritis to a satisfactory degree. Concerning the failure rate this type seems to yield slightly worse results than cementless stemmed endoprostheses in the same patient group. Due to the preservation of the diaphysial bone of the femur and the possibility of an unproblematic change to a stemmed endoprosthesis the thrust plate prosthesis keeps its indication in younger patients with polyarthritis.

Aims: To evaluate the results of a novel modular press-þt acetabular cup in primary total hip arthroplasty (THA) for osteoarthrosis (OA) and inßammatory arthritis (IA). Methods: From February 1996 to June 1999 in 324 patients (249 women, 75 men) 355 THA using a novel cup has been carried out. The shell is non-hemispherical on cross-section and has a hydroxyapatite coating on porous titanium for osseointegration. Diagnosis was: osteoarthrosis (OA) 236, developmental dysplasia (DDH) 21, post-traumatic arthrosis 27, avascular necrosis 6, IA 65 Ð mainly rheumatoid arthritis (RA). Average age at operation was 65.8 years. The patients were studied prospectively using Harris Hip Score (HHS), by measuring any radiolucency around the cup and by looking for signs of migration. Results: Median follow-up was 4.5 years. At follow-up, 21 patients had deceased. Revision for deep infection was carried out in 5 hips (3 low-grade infections). No septic loosening occurred with low-grade infection. Recurrent dislocations required revision of 1 cup and exchange of 2 inserts. Only 1 cup in a RA patient with severe superior bone loss became unstable after a fall 4 months postoperatively. Survival with aseptic loosening of the cup as endpoint was 1 in OA and 0.98 in IA. In all 290 patients with 318 THA in follow-up the cup was functioning well, both clinically and radiographically. HHS increased from 44.5 to 90.3. Conclusion: Press-þt þxation using a modern acetabular component is an excellent treatment option in primary total hip arthroplasty for all diagnostic groups.

Rheumatoid arthritis (RA) is an autoimmune disease that involves T and B cells and their reciprocal immune interactions with proinflammatory cytokines. T cells, an essential part of the immune system, play an important role in RA. T helper 1 (Th1) cells induce interferon-γ (IFN-γ), tumour necrosis factor-α (TNF-α), and interleukin (IL)-2, which are proinflammatory cytokines, leading to cartilage destruction and bone erosion. Th2 cells primarily secrete IL-4, IL-5, and IL-13, which exert anti-inflammatory and anti-osteoclastogenic effects in inflammatory arthritis models. IL-22 secreted by Th17 cells promotes the proliferation of synovial fibroblasts through induction of the chemokine C-C chemokine ligand 2 (CCL2). T follicular helper (Tfh) cells produce IL-21, which is key for B cell stimulation by the C-X-C chemokine receptor 5 (CXCR5) and coexpression with programmed cell death-1 (PD-1) and/or inducible T cell costimulator (ICOS). PD-1 inhibits T cell proliferation and cytokine production. In addition, there are many immunomodulatory agents that promote or inhibit the immunomodulatory role of T helper cells in RA to alleviate disease progression. These findings help to elucidate the aetiology and treatment of RA and point us toward the next steps. Cite this article: Bone Joint Res 2022;11(7):426–438

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

The April 2024 Wrist & Hand Roundup³⁶⁰ looks at: Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial; Postoperative scaphoid alignment, smoking, and avascular necrosis determine outcomes; Grip strength signals broader health concerns in females with distal radius fractures; Clearing the smoke: how smoking status influences recovery from open carpal tunnel release surgery; Age matters: assessing the likelihood of corrective surgery after distal radius fractures; Is pronator quadratus muscle repair required after anterior plate fixation for distal radius fractures?; Efficacy of total wrist arthroplasty: a comparative analysis of inflammatory and non-inflammatory arthritis outcomes; A comprehensive review of the one-bone forearm as a salvage technique.

Aims. The lack of disease-modifying treatments for osteoarthritis (OA) is linked to a shortage of suitable biomarkers. This study combines multi-molecule synovial fluid analysis with machine learning to produce an accurate diagnostic biomarker model for end-stage knee OA (esOA). Methods. Synovial fluid (SF) from patients with esOA, non-OA knee injury, and inflammatory knee arthritis were analyzed for 35 potential markers using immunoassays. Partial least square discriminant analysis (PLS-DA) was used to derive a biomarker model for cohort classification. The ability of the biomarker model to diagnose esOA was validated by identical wide-spectrum SF analysis of a test cohort of ten patients with esOA. Results. PLS-DA produced a streamlined biomarker model with excellent sensitivity (95%), specificity (98.4%), and reliability (97.4%). The eight-biomarker model produced a fingerprint for esOA comprising type IIA procollagen N-terminal propeptide (PIIANP), tissue inhibitor of metalloproteinase (TIMP)-1, a disintegrin and metalloproteinase with thrombospondin motifs 4 (ADAMTS-4), monocyte chemoattractant protein (MCP)-1, interferon-γ-inducible protein-10 (IP-10), and transforming growth factor (TGF)-β3. Receiver operating characteristic (ROC) analysis demonstrated excellent discriminatory accuracy: area under the curve (AUC) being 0.970 for esOA, 0.957 for knee injury, and 1 for inflammatory arthritis. All ten validation test patients were classified correctly as esOA (accuracy 100%; reliability 100%) by the biomarker model. Conclusion. SF analysis coupled with machine learning produced a partially validated biomarker model with cohort-specific fingerprints that accurately and reliably discriminated esOA from knee injury and inflammatory arthritis with almost 100% efficacy. The presented findings and approach represent a new biomarker concept and potential diagnostic tool to stage disease in therapy trials and monitor the efficacy of such interventions. Cite this article: Bone Joint Res 2020;9(9):623–632

Aims. Total wrist arthrodesis (TWA) produces a spectrum of outcomes. We investigated this by reviewing 77 consecutive TWA performed for inflammatory and post-traumatic arthropathies, wrist instability and as a salvage procedure. . Patients and Methods. All operations were performed by a single surgeon using a specifically designed pre-contoured dorsally applied non-locking wrist arthrodesis plate at a single centre. . Results. Median post-operative Buck-Gramcko Lohman (BGL), Disabilities of the Arm, Shoulder and Hand and Patient Rated Wrist Evaluation scores at six years (interquartile range (IQR) 3 to 11) were 9 (IQR = 6 to 10), 19 (IQR = 7 to 45) and 13 (IQR = 1 to 31) respectively. Polyarticular inflammatory arthritis and female gender were associated with poorer patient-reported outcomes, although the effect of gender was partly explained by higher rates of inflammatory disease among women. Return to work was negatively influenced by workers’ compensation and non-inflammatory wrist pathology. There was no difference in complication rates for inflammatory and non-inflammatory indications. . Take home message: Polyarticular inflammatory arthritis is a risk factor for adverse patient-reported outcomes in TWA. Furthermore, when compared with patients without inflammatory arthritis, dorsally applied pre-contoured plates can be used for wrist arthrodesis in patients with inflammatory arthritis without an increased risk of complications. Cite this article: Bone Joint J 2016;98-B:647–53

Aims. Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature. Materials and Methods. A systematic review using the search terms “reverse shoulder”, “reverse total shoulder”, or “inverted shoulder” was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design. Results. The review included 90 articles out of 686 identified after exclusions. The incidence rate of acromial and/or scapular spine fractures was 2.8% (253/9048 RSAs). The fracture rate was similar for primary and revision RSA (2.8% vs 2.1%; p = 0.4). Acromial fractures were most common after RSA for inflammatory arthritis (10.9%) and massive rotator cuff tears (3.8%). The incidence was lowest in RSA for post-traumatic arthritis (2.1%) and acute proximal humerus fractures (0%). Lateralized glenosphere design had a significantly higher rate of acromial fractures compared with medial glenosphere designs. Conclusion. Based on current English literature, acromial and/or scapular spine fractures occur at a rate of 2.8% after RSA. The incidence is slightly more common after primary compared with revision arthroplasty. Also, higher rates of acromial fractures are reported in RSA performed for inflammatory arthritis and in the lateralized glenoid design. Cite this article: Bone Joint J 2019;101-B:627–634

This study aimed to evaluate the month-to-month prevalence of antibiotic dispensation in the 12 months before and after total knee arthroplasty (TKA) and total hip arthroplasty (THA) and to identify factors associated with antibiotic dispensation in the month immediately following the surgical procedure. In total, 4,115 THAs and TKAs performed between April 2013 and June 2019 from a state-wide arthroplasty referral centre were analysed. A cross-sectional study used data from an institutional arthroplasty registry, which was linked probabilistically to administrative dispensing data from the Australian Pharmaceutical Benefits Scheme. Multivariable logistic regression was carried out to identify patient and surgical risk factors for oral antibiotic dispensation. Oral antibiotics were dispensed in 18.3% of patients following primary TKA and 12.0% of patients following THA in the 30 days following discharge. During the year after discharge, 66.7% of TKA patients and 58.2% of THA patients were dispensed an antibiotic at some point. Patients with poor preoperative health status were more likely to have antibiotics dispensed in the month following THA or TKA. Older age, undergoing TKA rather than THA, obesity, inflammatory arthritis, and experiencing an in-hospital wound-related or other infectious complications were associated with increased antibiotic dispensation in the 30 days following discharge. A high rate of antibiotic dispensation in the 30 days following THA and TKA has been observed. Although resource constraints may limit routine wound review for all patients by a surgeon, a select cohort may benefit from timely specialist review postoperatively. Several risk factors identified in this study may aid in identifying appropriate candidates for such changes to follow-up care

Introduction. This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales. Methods. Patients were recruited from 11 centres in the United Kingdom between June 2016 and November 2019. Demographic, radiographic, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Foot Ankle Questionnaire and Euroquol 5D-5L) were collected preoperatively, at 6 months, 1 year and 2 years and 5 years. The average age was 67.8 (range 23.9 to 88.5) and average BMI 29.3 (18.9 to 48.0). The COFAS grading system was used to stratify deformity. There were 261 (51.9%) COFAS Type 1, 122 (24.2%) COFAS Type 2, 31 (6.2%) COFAS 3 and 89 (17.7%) COFAS type 4. 38 patients (7.6%) presented with inflammatory arthritis. 99 (19.7%) implantations utilised patient specific instrumentation. Complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts and/or subsidence. Results. The mean follow up was 34.2 months (range 24–64). 15 patients have died, 8 withdrawn and 3 lost to follow up. 8 implants (1.6%) have been revised. According to the Glazebrook classification there were low grade complications in 6.6%, medium grade in 1.4% and high grade in 1.6%. There have been an additional 13 non revision re-operations (2.6%) at the latest follow up. There was a significant (p < 0.01) improvement across all functional outcome scores at a minimum of 2yr follow up. Discussion and conclusion. This large cohort has shown a low early revision rate and high functional outcomes with a low-profile fixed bearing prosthesis

Higher uric acid levels or hyperuricemia is a product of more uric acid production, dysfunctional renal excretion, or a combination of both leading to deposition of urate crystals in the joints and kidneys and has been strongly linked with the development of gout, that is, acute inflammatory arthritis. Uric acid levels have been suggested to depend on multiple factors including lifestyle, diet, alcohol consumption, etc. As these are risk parameters for hyperuricemia and since lifestyle choices vary amongst different Indian communities, we sought to study the prevalence of hyperuricemia in these communities. Also, large-scale data (in terms of gender, age, lifestyle, community) on the prevalence of hyperuricemia in subjects amongst different community populations, Hindu, Muslim, Sikh, and Christian was generated. In a retrospective study conducted at Dr. D. Y. Patil School of Medicine & Research Centre, Navi Mumbai from April 2018 to May 2021, information was gathered from four major communities on a range of indicators including serum uric acid levels followed by a thorough multilevel logistic analysis. We evaluated uric acid levels in 10,378 patients of four different communities. Outcomes were assessed biochemically as well as clinically based on the levels of serum uric acid. The mean serum uric acid levels were highest in Sikhs (7.6 mg%, n=732) followed by Christians (7.3 mg%, n=892) and then by Hindus (5.9 mg%, n=6846) and Muslims (5.6 mg%, n=1908). About 83.7% of Christians consumed meat in a non-vegetarian diet followed by 45.7% Muslims. Percentage of Christians who binge drink were highest whereas percentage of Sikh people in the heavy drinkers’ category were 5.2%. Further, 9.5% Hindus were current smokers followed by 7.8% Sikhs who smoked at present. Overall, our study of 10,378 patients demonstrated that the serum uric acid levels varied from one Indian community to another due to varying external factors like diet, age, lifestyle, and addictions. Thus, lifestyle modification in communities with higher serum uric acid levels is highly advocated and this may reduce the healthcare burden of gouty arthritis in these communities

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 – 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 - 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Aims. This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes. Methods. Patients were recruited from 11 specialist centres between June 2016 and November 2019. Demographic, radiological, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Questionnaire, and EuroQol five-dimension five-level score) were collected preoperatively, at six months, one year, and two years. The Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system was used to stratify deformity. Early and late complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts, and/or subsidence. Results. In all, 500 patients reached six-month follow-up, 420 reached one-year follow-up, and 188 reached two-year follow-up. The mean age was 67.8 years (23.9 to 88.5). A total of 38 patients (7.5%) presented with inflammatory arthritis. A total of 101 (20.0%) of implantations used patient-specific instrumentation; 167 patients (33.1%) underwent an additional procedure at the time of surgery. A total of seven patients died of unrelated causes, two withdrew, and one was lost to follow-up. The mean follow-up was 16.2 months (6 to 36). There was a significant improvement from baseline across all functional outcome scores at six months, one, and two years. There was no significant difference in outcomes with the use of patient-specific instrumentation, type of arthritis, or COFAS type. Five (1.0%) implants were revised. The overall complication rate was 8.8%. The non-revision reoperation rate was 1.4%. The 30-day readmission rate was 1.2% and the one-year mortality 0.74%. Conclusion. The early experience and complications reported in this study support the current use of the INFINITY TAA as a safe and effective implant in the treatment of end-stage ankle arthritis. Cite this article: Bone Joint J 2021;103-B(7):1270–1276

Cementless stem designs in total hip arthroplasty differ in relation to geometry and area of fixation. We utilised radiostereometric analysis (RSA) to evaluate the 2-year migration of a novel, short, proximally coated femoral stem. 30 participants undergoing primary total hip replacement for any cause (rheumatoid or inflammatory arthritis, osteoarthritis) were prospectively recruited in this study. Osteoporotic patients and cases of suspected infection were excluded. All patients received a short blade stem, proximally coated with a reduced lateral shoulder and narrow triple taper geometry to minimise bone removal. RSA radiographs were performed post-operatively and at 6 weeks, 6 months, 1- and 2 years. The Harris Hip Score (HHS), Oxford Hip Score (OHS) and EQ-5D were collected at baseline and at 2 years post-operatively. The stability of implants and complications were captured during each follow-up visit. A total of 14 female and 16 male patients were recruited with a mean age of 64.8 (range 47 to 75). At two years the mean subsidence of the stem was 0.34 mm (SD 0.62) and the total migration 0.74 mm (SD 0.60). The mean medial translation at two years was 0.059 (0.24) and the mean anterior translation 0.12 (0.59) respectively. Baseline PROM scores improved significantly at 2-years from pre-operatively (median and interquartile range): HHS from 33 (18.25) to 92 (19), EQ5D from 0.5 (0.35) to 0.94 (0.17), OHS from 21 (18.25) to 42 (4.25). P-value for all comparisons was <0.001. 2-year follow up data revealed no complications. There were no stem revisions in study participants and no heterotopic ossifications were identified on radiographs. 2-year migration results of a cementless, short blade, proximally coated tapered femoral stem using RSA, showed the stem exhibits a predictable migration pattern and achieves initial stability. This is highly likely to translate to mid and long-term stability, which needs to be corroborated by long-term outcome studies. Furthermore, participants demonstrated excellent clinical, patient reported and radiological outcomes after 2 years of follow up to support expansion in the use of this prosthesis

Introduction: etiology of late infection after arthroplasty can be difficult to establish. Histology is the gold standard for infection in patients without inflammatory arthritis but diagnosis in inflammatory arthritis depends on culture (Atkins et al). Real-time PCR offers a rapid and direct assessment for staphylococci and enterococci infection but has not been widely assessed. The aims of this study were. to develop the Roche lightcycler Staphylococcal and Enterococcal PCR kits to facilitate diagnosis of hip and knee prosthetic infections. To analyse results together with bacteriological and histological findings. Methods: uplicate, multiple tissue samples were taken (with separate sterile instruments) at the 1. st. stage of revision after informed consent. One set were cultured and results interpreted by the Oxford criteria. The second set were extracted using the Qiagen DNA kit, purified (in-house method) and tested using the Roche lightcycler kits. Results:53 patients undergoing 2 stage revision for suspected infection were recruited.15 (28.3%) had negative histology and no inflammatory arthritis; 3 with single positive cultures and negative PCR – considered contaminants. 29 patients had non-inflammatory arthritis. 14/18 (77.8%) with positive cultures had staphylococci +/or enterococci isolated and 10 PCR results correlated. The other 11 patients had negative cultures. 9 patients had inflammatory arthritis. Six were culture negative and of the other three, 2 were positive for staphylococci on culture with 1 positive by PCR. Discussion: Negative staphylococcal PCR correlates with the isolation of staphylococci from only one sample. This agrees with the Oxford criteria that such samples may be considered contaminants. Additional positives detected by staphylococcal PCR alone are rare. Enterococcal PCR confirmed culture positivity in 2/3 patients. An additional 5 positive PCR’s were obtained from patients’ culture negative for enterococci. It is not clear if these are false positives or more sensitive detection of enterococcal isolation

Study Objective: To determine the proportion of patients proceeding to elective total knee arthroplasty with pre-operative anaemia. Background: Over 60,000 primary total knee replacements are performed in England and Wales each year. Blood transfusion can be associated with serious complications. A pre-operative haemoglobin of less than 12 g/dl increases the likelihood of blood transfusion in the peri-operative period by threefold [. 1. ]. Published BOA guidelines recommend patients with pre-operative haemoglobins of 12 g/dl or below in males or 11 g/dl or below in females should have their anaemia investigated and treated prior to total knee arthroplasty. Methods: Patients having elective total knee arthroplasty at our hospital over three-months formed the study population. Data were collected on age, sex, pre- and postoperative haemoglobin, transfusion requirements in the peri-operative period, and whether the patient had inflammatory arthritis. Patients were classified according to the recommended BOA guidelines for deferring elective surgery using pre-operative haemoglobin levels. Post-operative haemoglobin drop was also calculated. Results: Fifteen patients (7%) out of 212 had pre-operative haemoglobins below guideline thresholds. The age range of these patients was 59–84 yr. Nine patients were female. Pre-operative haemoglobin ranged from 9.2–12.0 g/dl. Post-operative haemoglobin drop ranged from 0.5–4.3 g/dl. Six patients received blood transfusion in the peri-operative period (maximum of three units). One patient had a diagnosis of inflammatory arthritis. Discussion: Pre-operative anaemia is common in patients having elective total knee arthroplasty. In this study most anaemic patients did not have anaemias attributable to inflammatory arthritis. Using cell salvage techniques did not prevent peri-operative blood transfusion in anaemic patients. Conclusion: Anaemic patients wanting arthroplasty in favour of surgical deferral and treatment of their anaemia must be made fully aware of the serious complications associated with blood transfusions

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis

Osteoarthritis (OA) is a joint degenerative disease leading to chronic pain and disability, thus resulting in a major socioeconomic health burden. OA, which has long been believed to be a cartilage disease, is now considered a whole-joint disorder affecting various anatomical structures, including subchondral bone. Hyaluronic Acid (HA) is commonly used as intra-articular viscosupplementation therapy for its mechanical features and biological effects. Bisphosphonates (BPs) are antiresorptive agents inhibiting recruitment and maturation of osteoclast precursors and activity of mature osteoclasts in the bone. Pre-clinical evidences in the literature, show that intra-articular BPs could impact on OA progression, slowing down or reversing it. The combination of HA biological and mechanical role and Alendronate (ALD) antiresorptive effect could be an interesting strategy for OA treatment. This study describes the synthesis and characterization of FID-134, a new chemical derivative of HA conjugated with ALD by means of a covalent bond, cleavable in physiological condition. FID-134 was synthesized starting from 500 kDa HA: chemical structure and functionalization degree with ALD were investigated by NMR and ICP-OES. Kinetics of ALD release from FID-134 was determined in TRIS buffer at 37°C and compared to a simple mixture of HA+ALD. 20mg/mL formulations of FID-134 and HA+ALD were investigated for viscoelastic properties, in absence and presence of Ca. 2+. ions. The cytotoxicity of FID-134 and free ALD were tested on Saos-2 osteoblasts (ATCC HTB-85) and on primary bovine chondrocytes (PBC) at day 1, 3 and 7. The efficacy of FID-134 was assessed in an inflammatory arthritis in vitro model, where bovine cartilage biopsies were exposed to IL-1β/OSM (10ng/mL) for 3 weeks; at the same time, cartilage explants were treated with FID-134. Collagen release in the surnatants was quantified and compared to controls. FID-134 structure was confirmed by NMR and the 20% mol/mol functionalization degree was determined by ICP-OES. Only about 50% of total bound ALD was released from FID-134 within 7 days, resulting slower compared to HA+ALD mixture. In presence of Ca. 2+. ions, viscoelastic properties of FID-134 dramatically improved, while HA+ALD formulation remained unaffected. The cytotoxicity of ALD was evident at 100 μM on Saos-2 and PBC after 3 days, while no cytotoxicity was observed at 7 days with FID-134. In the cartilage explant model, a strong collagen release was detected in inflammatory conditions after 3 weeks; this tendency was reversed, and collagen release halved when FID-134 was added to the biopsies. The synthesized HA-ALD adduct, FID-134, opens the door for a new approach for OA treatment. The results suggest that FID-134 could be beneficial in cartilage degradation and in restoration of subchondral bone function. Finally, local administration and controlled BP release would likely overcome the drawbacks of ALD oral administration, such as unspecific features and long-term toxic side effects

Restoration of ankle alignment is thought to be critical in total ankle arthroplasty (TAA) outcomes, but previous research is primarily focused on coronal alignment. The purpose of this study was to investigate the sagittal alignment of the talar component. The talar component inclination, measured by the previously-described gamma angle, was hypothesized to be predictive of TAA outcomes. A retrospective review of the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was performed on all TAA cases at a single center over a 11-year period utilizing one of two modern implant designs. Cases without postoperative x-rays taken between 6 and 12 weeks were excluded. The gamma angle was measured by two independent orthopaedic surgeons twice each and standard descriptive statistics was done in addition to a survival analysis. The postoperative gamma angles were analyzed against several definitions of TAA failure and patient-reported outcome measures from the COFAS database by an expert biostatistician. 109 TAA cases satisfied inclusion and exclusion criteria. An elevated postoperative gamma angle higher than 22 degrees was associated with talar component subsidence, defined as a change in gamma angle of 5 degrees or more between postoperative and last available followup radiographs. This finding was true when adjusting for age, gender, body mass index (BMI), and inflammatory arthritis status. All measured angles were found to have good inter- and intraobserver reliability. Surgeons should take care to not excessively dorsiflex the talar cuts during TAA surgery. The gamma angle is a simple and reliable radiographic measurement to predict long-term outcomes of TAA and can help surgeons counsel their patients postoperatively

Introduction. The use of screws is frequent for additional fixation, however, since some disadvantages have been reported a cup press-fit is desirable, although this can not always be obtained. Cup primary intraoperative fixation in uncemented total hip replacement (THR) depends on sex, acetabular shape, and surgical technique. We analyzed different factors related to primary bone fixation of five different designs in patients only diagnosed with osteoarthritis, excluding severe congenital hip disease and inflammatory arthritis, and their clinical and radiological outcome. Materials y Methods. 791 hips operated in our Institution between 2002 and 2012 were included for the analysis. All cases were operated with the same press-fit technique, and screws were used according to the pull-out test. Two screws were used if there was any movement after the mentioned manoeuvres. Acetabular and femoral radiological shapes were classified according to Dorr et al. We analyzed radiological postoperative cup position for acetabular abduction angle, the horizontal distance and the vertical distance. Cup anteversion was evaluated according to Widmer and the hip rotation centre according to Ranawat. Results. Screws were required in 155 hips (19.6%) and were more frequently used in women and patients with a type A acetabulum (p<0.001, p=0.021, respectively). There were no differences among the different cups evaluated. The need for screws was more frequent in hips with a smaller version of the cup and with a distance greater than 2 mm to the approximate femoral head centre from the centre of the prosthetic femoral head (p=0.022, 0.012, respectively). Adjusted multivariate analysis revealed that female patients (p<0.001, Odds Ratio (OR): 2.063; 95% Confidence Interval (CI) 1.409–3.020), cups with a smaller version (p=0.012, OR: 0.966, 95% CI 0.94–0.992), and a greater distance to the rotation hip center (p<0.005, OR: 1.695; 95% CI 1.173–2.450) had a higher risk for screw use. No hips needed revision for aseptic loosening. Conclusions. Cup press-fit depends on gender and surgical technique in hips without significant acetabular abnormalities or inflammatory arthritis. Contemporary uncemented cups provide similar primary fixation and mid-term outcome

We report the outcome at a minimum of 10 years follow-up for 80 polished tapered stems performed in 53 patients less than 35-years-old with a high risk profile for aseptic loosening. Forty-six prosthesis were inserted for inflammatory hip arthritis and 34 for avascular necrosis. The mean age at surgery was 28 years in the inflammatory arthritis (17–35) and 27 years in the avascular necrosis (15–35) patients. At a mean follow-up of 14.5 years in the inflammatory arthritis group and 14 years in the avascular necrosis group respectively, survivorship of the 80 stems with revision of the femoral component for any reason as an endpoint was 100 % (95 % CI). Re-operation was because of failure of four metal-backed cups, 3 all polyethylene cups and one cementless cup. None of the stems were radiographically loose. All but two femoral components subsided within the cement mantle to a mean of 1.2 mm (0 tot 2.5) at final follow-up. Periarticular osteolysis was noted in 4 femurs in zone 7. This finding was associated with polyethylene wear and was only seen in those hips that needed revision for a metal backed cup loosening. Our findings show that the polished tapered stem has excellent medium-term results when implanted in young patients with high risk factors for aseptic loosening

Background. Stress fracture of the acromium and scapular spine is a common complication following reverse total shoulder arthroplasty (RSA), with a reported incidence of 3.1%–11%. There is some evidence associating osteoporosis with increased risk of acromial stress fractures, but little else is known about the causes of acromial stress fractures after RSA. This study aims to define better preoperative factors, including demographics, comorbidities, and diagnoses, which predispose patients to postoperative acromial stress fractures. Methods. We retrospectively identified patients who underwent primary or revision RSA for any indication between January 2013 and December 2018 by two surgeons at two separate hospitals. Stress fractures of the acromion were identified on plain radiographs or computed tomography, when necessary. Patient demographics, comorbidities, and surgical indications were compared between patients with and without acromial stress fractures. Results. A total of 1,488 arthroplasties were identified and met the inclusion criteria. Of the study sample, 54 patients were diagnosed with a postoperative acromial stress fracture, an incidence of 3.6%. Patients in the stress fracture cohort were significantly more likely to have preoperative rotator cuff pathology (p<0.001), be of female gender (p<0.001), older (p=0.002), and osteoporotic (p<0.001; Table I). Thyroid disease (p=0.045) and inflammatory or rheumatoid arthritis (p=0.02) were also more frequent among patients with acromial stress fractures (Table I). No other comorbidities, including obesity (p=0.21) and diabetes (p=0.58), correlated significantly with postoperative acromial stress fracture (Table I). Conclusions. Old age, female gender, diagnosed osteoporosis, inflammatory arthritis, thyroid disease, and preoperative rotator cuff deficiency may all be risk factors for postoperative acromial stress fractures. Given that rotator cuff pathology is among the predominant indications for RSA, further research is required to determine the etiology and biomechanical basis for acromial stress fractures. For any figures or tables, please contact the authors directly

Introduction. Bone mineral density (BMD) is correlated with component migration and aseptic loosening after total knee arthroplasty (TKA). Older implant designs have demonstrated BMD loss up to 23% in the first 6 months after TKA, and continued to BMD decline at an average of 5% per year for as long as 2 years after TKA. The impact of component design and fixation method on BMD loss after TKA in modern implant designs has not been fully elucidated. The purpose of this study is to determine the effect of tibial tray thickness and fixation method (cemented versus cementless) on BMD loss patterns of the proximal tibia in two different modern TKA implant systems. Methods. A prospective, nonrandomized, single center study of patients undergoing primary TKA by one of two surgeons was performed with four study cohorts: cemented DePuy Attune, cementless DePuy Attune, cemented Stryker Triathlon, cementless Stryker Triathlon. Target sample size was 80, with 20 per cohort based on adhoc power analysis. Exclusion criteria included: age over 75, BMI >40, inflammatory arthritis, previous knee surgery involving the femur, tibia or tibial bone, and diagnosis of osteopenia/osteoporosis. Implant fixation type was based on surgeon intraoperative assessment of patient bone quality. Demographic data was collected preoperatively. Dual Energy X-ray Absorptiometry (DEXA) Bone Density Monitoring was performed at 6 weeks and one year postoperatively. Bone mineral density was calculated from the DEXA scans for 4 zones for the tibia relative to the keel or central peg: anterior, posterior, medial and lateral. Results were reported as BMD at 1 year postoperatively as a percentage of BMD at 6 weeks postoperatively. Results. 81 knees with complete DEXA studies at 6 weeks and 1 year postoperatively were available for analysis. The mean (SD) age at the time of surgery was 65.4 years (6.1), with 39 men and 42 women and a mean (SD) BMI of 31.2 kg/m. 2. (4.7). The patients who received cementless implants were significantly younger with a mean (SD) age of 62.1 (6.0) than those who received cemented implants with a mean age of 69.1 (3.7) (p < 0.05). There was no difference in age between implant type (p > 0.05). There was no difference in BMI or gender distribution between implant types or fixation type (p > 0.05). There was no significant difference in mean BMD loss between 6 weeks and 1 year postoperatively between the cemented and cementless Triathlon in any zone, between the cemented Triathlon and Attune in any zone, the cementless Triathlon and Attune in any zone, and the cemented and cementless attune in the lateral, anterior and posterior proximal tibia (p > 0.05). There was significantly more BMD loss seen in the medial tibia in the cemented (BMD at 1 year 88% of BMD at 6 weeks) than cementless (BMD at 1 year 103% of BMD at 6 weeks) Attune (p = 0.043). Conclusion. BMD loss at 1 year postoperatively versus 6 weeks postoperatively after TKA with two modern implant designs is not significantly affected by tibial tray thickness. BMD loss was unaffected by fixation type for the Stryker Triathlon, but was significant less for the cementless DePuy Attune than the cemented version

Reverse shoulder arthroplasty (RSA) has an increasing effective use in the treatment of patients with a variety of diagnoses, including rotator cuff deficiency, inflammatory arthritis, or failed shoulder prostheses. Glenoid bone loss is not uncommonly encountered in these cases due to the significant wear. Severe bone loss can compromise glenoid baseplate positioning and fixation, consequently increasing the risk for early component loosening, instability, and scapular notching. To manage severe glenoid bone deficiencies, bone grafts are commonly used. Although, many studies report outcome of bone grafting in revision RSA, the literature on humeral head autograft for glenoid bone loss in primary RSA is less robust. The purpose of this study is to evaluate the clinical and radiographic outcomes of primary RSA with humeral head autograft for glenoid bone loss at our institution. Institutional review board approval was obtained to retrospectively review the records of 22 consecutive primary RTSA surgeries in 21 patients with humeral head autograft for glenoid bone loss between January 2008 and December 2016. Five patients died during follow-up, three were unable to be contacted and one refused to participate, leaving a final study cohort of 12 patients with 13 shoulders that underwent RSA. All patients had a clinical evaluation including detailed ROM and clinical evaluation using the American Shoulder and Elbow Surgeons (ASES) Score, Constant Score, Western Ontario Osteoarthritis of the Shoulder Index (WOOS), and Short Form-12 (SF-12) questionnaires. Preoperative and postoperative plain radiographs and CT scans were assessed for component position, loosening, scapular notching, as well as graft incorporation, resorption, or collapse. There were 6 males and 6 females, with an average age of 74 ± 6.8 years. The average BMI was 31.7 ± 5.3, and the median ASA score was 3. Average follow-up was 3.4 ± 1.1 years. The average postoperative range of motion measurements for the operative arm are: flexion = 120 ± 37, abduction = 106 ± 23, external rotation = 14 ± 12, internal rotation at 90 degrees of abduction = 49 ± 7, external rotation at 90 degrees of abduction = 50 ± 28. Average functional scores are: ASES: 76.9 ± 19.2, WOOS: 456 ± 347, SF12 physical: 34.2 ± 8.2, SF12 mental: 54.1 ± 10.2, Constant Score: 64.6 ± 14. No evidence of hardware loosening or evidence of bone graft resorption were encountered. On CT, the average of pre operative B-angle was 79.3 ± 9.3 while the pre operative reverse shoulder angle was 101.4 ± 28. Glenoid retroversion average on CT was 13.3 ± 16.6. Post operative baseplate inclination average was 82 ± 7.4 while the baseplate version 7.8 ±10. The operative technique was able to achieve up to 30 degrees of inclination correction and up to 50 degrees of version correction. In conclusion, primary reverse shoulder arthroplasty with humeral head autograft for glenoid bone loss provides excellent ROM and functional outcomes at mid-term follow-up. This technique has a high rate of bone incorporation and small risk of bone resorption at mid term follow up

First Metatarsophalangeal joint fusion has been successfully used to treat Hallux rigidus. We have attempted to evaluate commonly used methods of fixation and joint preparation. To the best of our knowledge, this is the single largest comparative study on first MTPJ fusion. We aimed to evaluate the radiological union and revision rates. We included 409 consecutive MTPJ fusions performed in 385 patients. We collected demographic, comorbidities and complication data. We evaluated the radiographs for the status of the union. Logistic regression was used to calculate the Odds ratio (OR) of non-union for the collected variables. Our union rate was 91.4% (34/409). 29.4% of our non-unions were symptomatic (10/34). Hallux valgus showed a statistically significant relation to non-union (Odds ratio 9.33, p-value 0.017). Other potential contributing factors like sex (OR1.9, p-value 0.44), diabetes (OR 0, p-value 0.99), steroid use (OR 2.07, p-value 0.44), inflammatory arthritis (OR 0, p-value 0.99) and smoking (OR 2.69, p-value 0.34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR 0, p-value 0.99), plate (OR 3.6, p-value 0.187) or cannulated screws (OR 0.09, p-value 0.06) showed no correlation with non-union. We compared two techniques of joint preparation and found no significant difference in union rates (Chi-Square 1.0426, p-value 0.30). Our crude cost comparison showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plate. Only Hallux Valgus had a statistically significant relation to non-union. Solid screw could be economically the most viable option and a valid alternative

Metal on metal hip resurfacing is increasing in popularity for the young, active patient. We present the results of a consecutive series from a single surgeon over a ten year period; 295 hip resurfacings (McMinn and Cormet; Corin, Cirencester, UK) with a minimum follow up of 2 years and a mean follow up of 4 years. There were 173 males with a mean age of 53.4 years and 121 females with a mean age of 50.3 years. Forty-six patients underwent bilateral resurfacings. All resurfacings were performed through a posterior approach. The aetiology in this group was primary OA in 75.9%, inflammatory arthritis in 6.1%, DDH in 6.1%, AVN in 4.7%, trauma in 4.7%, Perthes in 1.7% and SUFE in 0.7%. Patients were reviewed clinically and radiographically on an annual basis. Follow-up was available on 93% of patients. 94.2% of hips have survived and the mean Harris Hip Score is 87.5. Females had a higher failure rate (10.7%) than males (2.3%). There was no clear trend between patient age and failure rate. The highest failure rate (33.3%) was seen in patients with DDH whilst only 4.5% of patients with OA failed. One patient with AVN failed but no failures occurred in patients with inflammatory arthritis, trauma, Perthes or SUFE. Failures occurred due to cup loosening (2.0%), neck fractures (1.7%), head loosening (1.0%), head collapse (0.3%), infection (0.3%) and pain (0.3%). The five patients who suffered neck fractures were symptomatic within 3 months of surgery. We remain cautiously optimistic about the medium term results of hip resurfacing. Careful patient selection is important and caution should be taken in females and patients with DDH

Between 1986 and 1994, 13 patients with mobile painful arthritic elbows were treated by distraction interposition arthroplasty using fascia lata. The mean period of follow-up was 63 months. An elbow distractor/fixator was applied for three to four weeks to separate the articular surfaces and to protect the fascial graft. Nine of the 13 patients (69%) had satisfactory relief from pain; eight (62%) had an excellent or good result by the objective criteria of the Mayo Elbow Performance score. Four have required revision to total elbow arthroplasty at a mean of 30 months with good results to date. Instability of the elbow, both before and after surgery, was found to be associated with unsatisfactory results. The rate of success when the procedure was performed for inflammatory arthritis was similar to that for post-traumatic arthritis, about 67%. Eight complications occurred in six patients, all in the group with post-traumatic arthritis. Two of these required further surgical procedures such as transposition of the ulnar nerve or repair of hernia of the fascia lata. Although less reliable than prosthetic replacement, distraction interposition arthroplasty is a useful option in the treatment of young, high-demand patients with arthritis of the elbow. It is rarely indicated in the presence of generalised inflammatory arthritis, but may be of value in those patients in whom the disease is limited primarily to the elbow

To evaluate how much tendon may be safely excised in insertional Achilles tendonitis without predisposing the patient to Achilles tendon rupture. Insertional Achilles tendonitis commonly affects runners and is frequently managed by general orthopaedic surgeons. Most patients may be managed non-operatively but those who do not respond to conservative measures may require excision of the diseased tendon. Currently, there are no clinical studies indicating how much of the tendon may be excised without predisposing the patient to Achilles tendon rupture. This chart review reports on 52 heels treated surgically for this condition and followed for a minimum of 6 months post-operatively. When less than 50% of the tendon was excised (49 heels) patients were immediately mobilised free of a cast. There were two failures using this regimen. One patient had inflammatory arthritis and was taking significant immunosuppressive therapy. The second patient was keen for simultaneous bilateral procedures. In retrospect the senior surgeon acknowledges that this was somewhat enthusiastic as even with the most compliant of patients true partial weight-bearing in such a situation is extremely difficult. This review supports biomechanical data which demonstrates up to 50% of the tendon may be safely resected. We suggest that it is not necessary to immobilise all patients in a cast following surgery for insertional Achilles tendonitis when less than 50% of the tendon is excised. We recommend that patients with inflammatory arthritis or recent immunosuppressive therapy and those in whom greater than 50% of the tendon has been excised should be immobilised in a cast for six weeks. We do not recommend that simultaneous bilateral procedures are performed

We report the ten-year survival of a cemented total knee replacement (TKR) in patients aged < 55 years at the time of surgery, and compare the functional outcome with that of patients aged > 55 years. The data were collected prospectively and analysed using Kaplan-Meier survival statistics, with revision for any reason, or death, as the endpoint. A total of 203 patients aged < 55 years were identified. Four had moved out of the area and were excluded, leaving a total of 221 TKRs in 199 patients for analysis (101 men and 98 women, mean age 50.6 years (28 to 55)); 171 patients had osteoarthritis and 28 had inflammatory arthritis. Four patients required revision and four died. The ten-year survival using revision as the endpoint was 98.2% (95% confidence interval 94.6 to 99.4). Based on the Oxford knee scores at five and ten years, the rate of dissatisfaction was 18% and 21%, respectively. This was no worse in the patients aged < 55 years than in patients aged > 55 years. These results demonstrate that the cemented PFC Sigma knee has an excellent survival rate in patients aged < 55 ten years post-operatively, with clinical outcomes similar to those of an older group. We conclude that TKR should not be withheld from patients on the basis of age

Survivorship analysis was performed on 479 Link V-Type cementless threaded acetabular cups on 310 cases with inflammatory arthritis, 138 cases with osteoarthritis and 31 cases with dysplastic hip. The average follow-up was 8. 6 ± 3. 2 years. The same analysis was performed on a modified cup with a smaller primary coil (type ”Bad Bramstedt”). This analysis had a mean follow-up period of 4. 5 ± 0. 7 years in 110 cases, including 49 with inflammatory arthritis, 49 with osteoarthritis and 12 with dysplastic hip. In a second approach 264 Link V-cups with a mean follow-up period of 8. 2 ± 2. 7 years and 59 modified cups with a mean follow-up period of 4. 6 ± 0. 7 years were radiologically examined for radiolucent lines according to Delee and Charnley and cup migration with regard to the method of Nunn et al. The cumulative survival rate for the former Link V-Type acetabular cup was 94. 5% after 5 years, 88. 1% after 10 years and 71. 2% after 15 years. The ”Bad Bramstedt” cup showed a 5 year survivorship rate of 97. 9%. Migration greater than 3 mm or tilting of the cup greater than 5 degrees was seen in 73% of the former type and in 39% of the modified cup. Radiolucent lines greater than 2 mm and detectable in two zones appeared in 6. 4% of the former Link V-Type and in 1. 7% of the ”Bad Bramstedt” cup design. Significant influence on cup migration was found in primary implant positioning and time elapsed. Due to the high rates of migration of the two implant designs and the frequent late aseptic loosening of the former Link V-Type acetabular component these two types of threaded cups were abandoned in favor of cementless press-fit cups

Not all degenerative knees need a total knee replacement. Over the last few decades we have shifted our surgical treatment of end-stage osteoarthritis (OA) of the knee to a “compartmental approach” resulting in approximately half of end-stage OA knees receiving a partial knee replacement. Of these an emerging procedure is isolated lateral compartment replacement with the indications being isolated bone-on-bone osteoarthritis or avascular necrosis of the lateral compartment of the knee. Associated significant patellofemoral disease and inflammatory arthritis are contraindications. The purpose of this study is to present the indications, surgical technique, and early outcome of lateral partial knees from our institution. From Aug 2011 until June 2017 we have performed 3,548 knee arthroplasties. Of these 147 were fixed bearing lateral partial knee replacements via a lateral parapatellar approach (4%), 1,481 medial partial knee replacements (42%), and 1,920 total knee replacements (54%). The average age was 66 years old and 76% were female. Average follow-up in the lateral partials was 1.3 years (range 0.5 years to 6 years). Knee Society Scores improved from 41 (pre-op) to 86 points (post-op). Range of motion improved from 6 – 113 degrees (pre-op) to 0 – 123 degrees (post-op). No knees were revised to a TKA. One knee required I&D for traumatic wound dehiscence. This is the largest single center series of lateral partial knee replacements. We have observed this cohort to have more female patients and gain additional range of motion compared to our historic cohorts of TKA's. Longer-term follow-up is needed for determination of implant and unreplaced compartment survivorship. We believe the lateral partial knee replacement to be a viable option for isolated lateral compartment disease in approximately 4% of patients

Introduction. Total knee arthroplasty (TKA) is a successful treatment for degenerative end stage knee arthritis. Younger patients who undergo TKA may face multiple revisions during their lifetime due to aseptic loosening, infection, and instability. The purpose of this study was to compare the early complication rates and revision free survivorship between age groups undergoing TKA in a nationwide database. Methods. The PearlDiver national insurance database was queried from 2007–2015 for all patients who underwent primary TKA. Kaplan-Meier Curve survival analysis and log rank test were performed to evaluate revision rates between age groups (<40, 40–49, 50–59, 60–69, 70–79, 80–89, and ≥90 years). Complication rates were compared to rates in the age 60–79 group using multiple logistic regressions controlling for baseline demographics and comorbidities. Results. There were 114,698 patients included in the analysis. Patients under age 40 years had higher rates of diabetes mellitus, inflammatory arthritis, drug abuse, and smoking status compared to the rest of the cohort (p<0.001). After controlling for baseline comorbidities using multiple logistic regressions, patients under age 40 and those age 40–49 had an increased rate of early mechanical complications (OR 2.84, p=0.01 and 2.95, p<0.001 respectively). 90-day readmission rates were significantly higher in the under age 40 group (OR 1.63, p=0.03). Revision free survivorship at 5 years was significantly worse in patients less than 60 years of age (77.2% in age <40 group, 88.9% in age 40–49 group, and 91.7% in age 50–59 group, p<0.01). Conclusions. Young patients under 40 years of age had a higher risk of early revision after TKA with 77% revision free survivorship at 5 years. Additionally, these patients have an increased risk of mechanical complications and readmission at 90 days. These outcomes may be used to shape preoperative counseling for the young patient

Short uncemented humeral stems can preserve humeral bone stock and facilitate revision surgery but may be prone to malalignment or loosening, especially when used in reverse total shoulder replacement (TSR). We undertook a retrospective review of 44 patients with a mean age of 76 years (59 to 92) who underwent primary reverse TSR with a short uncemented humeral stem. There were 29 females. The indications for joint replacement included cuff tear associated arthropathy (33), avascular necrosis (six), post-traumatic arthritis (two), and inflammatory arthritis (three). At a mean follow-up of 27 months (24 to 40), pain was rated as mild or none in 43 shoulders (97.7%). The mean active elevation improved from 54° . (sd. 20°) to 142° (. sd . 25°) and the mean active external rotation from 14° (. sd. 13°) to 45° (. sd. 9°). The outcome, as assessed by the modified Neer score, was excellent in 27 (61.3%), satisfactory in 15 (34.1%), and unsatisfactory in two shoulders (4.5%). Stems were well-positioned, without evidence of significant valgus or varus malalignment in 42 TSRs (95.5%). There was no radiological evidence of loosening of the humeral stem in any patient; 13 TSRs (29.5%) had evidence of proximal humeral remodelling and scapular notching was noted in three (6.8%). Cite this article: Bone Joint J 2014;96-B:526–9

Aims. This study presents the long-term survivorship, risk factors for prosthesis survival, and an assessment of the long-term effects of changes in surgical technique in a large series of patients treated by metal-on-metal (MoM) hip resurfacing arthroplasty (HRA). Patients and Methods. Between November 1996 and January 2012, 1074 patients (1321 hips) underwent HRA using the Conserve Plus Hip Resurfacing System. There were 787 men (73%) and 287 women (27%) with a mean age of 51 years (14 to 83). The underlying pathology was osteoarthritis (OA) in 1003 (75.9%), developmental dysplasia of the hip (DDH) in 136 (10.3%), avascular necrosis in 98 (7.4%), and other conditions, including inflammatory arthritis, in 84 (6.4%). Results. The mean follow-up time was 10.5 years (1 to 20). Using revision for any reason as the endpoint, the overall survivorship at 15 years was 89.4% (95% confidence interval (CI) 86.8 to 91.4). There was a substantial increase between the first and second generation of surgical technique (86.6% vs 90.1%; p = 0.05). Men with idiopathic OA had a 15-year survivorship of 94.5% and women, 82.2% (p = 0.001); gender was not a risk factor after stratification by component size and aetiology. Using revision for excessive wear (ion levels > 7 µg/l associated with symptoms or adverse local tissue reactions) as the endpoint, the 15-year survivorship was 98.5%. Risk factors for revision for all modes of failure were an underlying pathology of hip dysplasia, a contact patch to rim (CPR) distance of 7 mm or less, an age at surgery of 55 years or less, and a femoral component size of 46 mm or less. Specific risk factors for aseptic failure of the femoral component were early surgical technique, a cementless metaphyseal stem, and a body mass index of 24 kg/m. 2. or less. Conclusion. HRA is a viable concept; metal-on-metal bearings are well suited for this procedure when a well-designed device is properly implanted. The best results were obtained in men with OA, but survivorship was better for other underlying pathologies and for women after changes were made to the technique of implantation. Lifetime durability is a possible outcome for many patients despite a high level of activity. Cite this article: Bone Joint J 2018;100-B:1424–33

The AAOS clinical practice guideline for diagnosis of periprosthetic joint infection (PJI) and the MSIS definition of PJI were both “game changers” in terms of diagnosing PJI and the reporting of outcomes for research. However, the introduction of new diagnostic modalities, including biomarkers, prompted a re-look at the diagnostic criteria for PJI. Further there was a desire to develop an evidence-based, validated algorithm for the diagnosis of PJI. This multi-institutional study led by Dr. Jay Parvizi examined revision total joint arthroplasty patients from three academic institutions. For development of the algorithm, infected and aseptic cohorts were defined. PJI cases were defined using only the major criteria from the Musculoskeletal Infection Society (MSIS) definition (n=684). Aseptic cases underwent revision for a non-infective indication and did not show evidence of PJI or undergo a reoperation for any reason within 2 years (n=820). Risk factors, clinical findings, serum and synovial markers as well as intraoperative findings were assessed. A stepwise approach using random forest analysis and multivariate regression was used to generate relative weights for each of the various variables assessed at each stage to create an algorithm for diagnosing PJI using the 3 most important tests from each step. The algorithm was formally validated on a separate cohort of 422 patients, 222 who were treated with a 2-stage exchange for PJI who subsequently failed secondary to PJI within one year and 200 patients who underwent revision surgery for an aseptic diagnosis and had no evidence of PJI within two years and did not undergo a reoperation for any reason. The first step in evaluating PJI should include a physical examination to identify a sinus tract, followed by serum testing for C-reactive protein (cut-off value 1mg/dl), D-dimer (cut-off value 860ng/mL) and/or erythrocyte sedimentation rate (cut-off value 30mm/hr) in that order of importance. If at least one of these are elevated, or if there is a high clinical suspicion, joint aspiration should be performed, sending the fluid obtained for a synovial fluid white blood-cell (cut-off value 3,000 wbc/uL) or leukocyte esterase strip testing, polymorphonuclear percentage (cut-off value 80%) and culture. Alpha defensin did not show added benefit as a routine diagnostic test. Major diagnostic criteria are the same whereby the presence of a sinus tract or (2) positive cultures showing the same organism defines PJI. Special care should be taken in cases of ALTR (failed metal-on-metal bearing), crystalline deposition disease, inflammatory arthritis flares or slow growing organisms. In the rare cases where no fluid is obtained at the time of an attempted aspiration and revision surgery is not planned, then this is the rare scenario where nuclear imaging (my preference is an indium labeled white blood cell scan) or a biopsy can be performed. The updated definition of PJI demonstrated a higher sensitivity of 97.7% when compared to the MSIS criteria (79.3%) and the ICM definition (86.9%), with a similar specificity of 99.5%. However, just over 2% of patients examined do fall into the “inconclusive” category. The proposed diagnostic algorithm demonstrated a high overall sensitivity (96.9%) and specificity (99.5%)

BACKGROUND. We conducted this study to determine if the pre-surgical patient specific instrumented planning based on Computed tomography scans can accurately predict each of the femoral and tibial resections. The technique helps in optimization of component positioning and hence overall alignment thereby reducing errors. This makes it less invasive, more efficient and cost effective. The surgical plan in combination with the cutting guides determine the resection thickness, component size, femoral rotation and femoral and tibial component alignment. Several clinical studies have shown that PSI is safe, accurate and reproducible in primary TKA. Accurate preparation of the femoral and tibial surfaces will determine alignment and component positioning and this in turn reflects on function and longevity. METHODS. The study was conducted prospectively between May 2016 and December 2017 in our institution. Patients admitted over a period of these twenty months were included in the study. Patients with primary or secondary osteoarthritis (OA) and inflammatory arthritis who were suitable to undergo patient-specific TKA were included in the study. Patients with conventional instrumented TKR and those with significant deformities requiring constrain including valgus or varus of greater than 20 degrees with incompetent lateral or medial collateral ligaments were excluded from the study along with revisions of partial knee to TKA using PSI blocks. Prophecy® Preoperative Navigation 3D printed Guides were used for the Evolution Medial Pivot knee replacement system (. Microport Orthopaedics (Arlington, TN 38002, USA)). in all cases. The operating surgeon measured all the resections made (4 femoral and 2 tibial) using vernier calipers intraoperatively. These measurements were then compared with the preoperative CT predicted bone resection surgical planning. The senior author (IN) also designed markings on the tibial cutting blocks to improve accurate placement on the tibia and further markings on the femoral cutting blocks to ensure accurate positioning and rotational alignment improving accuracy of the cuts and femoral rotation. Further markings by senior surgeon (IN) on the pre-operative plans included tibial rotational plans in relation to the tibial tubercle. RESULTS. A total of 3618 readings were calculated from 201 knees (105 right and 96 left). There were 112 females and 76 males, and the average age was 67.72 years (44 to 90 years) and average BMI 32.3 (25.1 to 42.3). The surgical time ranged from 46 to 102 minutes with a mean operating time of 62 minutes. All Femoral and Tibial blocks sat accurately on the bony surfaces before being pinned. 94% of all collected resection readings were below the error margin of ≤1.5 mm of which 90% showed resection error of ≤1mm. Mean error of different resections were ≤0.60 mm (P ≤ 0.0001). In 24% of measurements there were no errors or deviations from the templated resection (0.0 mm). CONCLUSION. The 3D printed cutting blocks with slots for jigs accurately predict bone resections in PSI total knee arthroplasty which would directly affect component positioning and hence longevity and function

The aim of this study was to review the early outcome of the Femoro-Patella Vialla (FPV) joint replacement. A total of 48 consecutive FPVs were implanted between December 2007 and June 2011. Case-note analysis was performed to evaluate the indications, operative histology, operative findings, post-operative complications and reasons for revision. The mean age of the patients was 63.3 years (48.2 to 81.0) and the mean follow-up was 25.0 months (6.1 to 48.9). Revision was performed in seven (14.6%) at a mean of 21.7 months, and there was one re-revision. Persistent pain was observed in three further patients who remain unrevised. The reasons for revision were pain due to progressive tibiofemoral disease in five, inflammatory arthritis in one, and patellar fracture following trauma in one. No failures were related to the implant or the technique. Trochlear dysplasia was associated with a significantly lower rate of revision (5.9% vs 35.7%, p = 0.017) and a lower incidence of revision or persistent pain (11.8% vs 42.9%, p = 0.045). . Focal patellofemoral osteoarthritis secondary to trochlear dysplasia should be considered the best indication for patellofemoral replacement. Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease should be part of the pre-operative assessment, especially for the non-dysplastic knee. Cite this article: Bone Joint J 2013;95-B:793–7

Since 2005, the author has performed nearly 1000 Oxford medial unicompartmental arthroplasties (UKA) using a mobile bearing. The indications are 1) Isolated medial compartment osteoarthritis with ‘bone-on-bone’ contact, which has failed prior conservative treatment, 2) Medial femoral condyle avascular necrosis or spontaneous osteonecrosis, which has failed prior conservative treatment. Patients are recommended for UKA only if the following anatomic requirements are met: 1) Intact ACL, 2) Full thickness articular cartilage wear limited to the anterior half of the medial tibial plateau, 3) Unaffected lateral compartment cartilage, 4) Unaffected patellar cartilage on the lateral facet, 5) Less than 10 degrees of flexion deformity, 6) Over 100 degrees of knee flexion, and 7) Varus deformity not exceeding 15 degrees. Exclusion criteria for surgery are BMI of more than 30, prior high tibial osteotomy, and inflammatory arthritis. All cases were performed with a tourniquet inflated using a minimally-invasive incision with a quadriceps-sparing approach. Both femoral and tibial components were cemented. Most patients were discharged home the next morning; bilaterals usually stayed a day longer. We have previously described our results and the factors determining alignment. In a more recent study, we have compared the coronal post-operative limb alignment and knee joint line obliquity after medial UKA with a clinically and radiologically (less than Grade 2 medial OA) normal contralateral lower limb. In our series, we have had 1 revision for aseptic loosening of both components, conversion to TKRs in a patient with bilateral UKAs who developed rheumatoid arthritis 3 years later, and 9 meniscal dislocations. There have been no cases of wound infections and thromboembolism. We have reviewed our patients with a minimum 10-year follow-up which will be presented. The vast majority of our patients have been generally very satisfied with the results. Our study shows that most patients (who have no disease in the contralateral knee) regain their ‘natural’ alignment and joint line obliquity comparable to their contralateral limb. Over the past few years our percentage of UKAs has been steadily rising to about a third of our knee cases. UKA serves as a definitive procedure in the elderly. We see it as a suitable procedure in middle-aged patients who want an operation that provides a quick recovery, full function and range of motion, and near-normal kinematics, with the understanding that they have a small chance of conversion to a total knee arthroplasty in the future

Introduction. Traditional treatment for end-stage ankle arthritis has been ankle arthrodesis, however ankle arthroplasty is becoming an accepted alternative. The Zenith Ankle (Corin, UK) is 3rd generation implant with a mobile bearing design. In the NJR 2016 report, the Zenith was the commonest ankle prosthesis implanted in the UK. However, compared to other ankle implants, there's little published data on its performance and survival. The aim of this study was to analyse outcome in a consecutive series from a non-designer centre. Method. We conducted a retrospective review of a consecutive series of 118 Zenith Ankle replacements implanted in our Unit (December 2010 to May 2016). Data was collected from our National Joint Registry entries, research databases, patient notes, PACS and PROMS. Results. Average age was 68.2 years (range 46–46 years; 75M:43F; 97 Osteoarthritis, 20 inflammatory arthritis, 1 haemophilia). Results show a 95.8% survivorship at average 3.5 years follow up (range 0.6–6.3 years). 5 patients (4.2%) required revision. Average pre- and post-op MOXFQ scores were 85.0/100 and 32/100 respectively with improvements in VAS from 7.0/10 to 3.6/10, with an average range of movement of 20.4 degrees. Overall satisfaction rate was 89%. There were 65 complications in 55 patients, but only 7.7% of these led to detrimental effects on the implant. The commonest were malleolar fracture (14.4%), wound problems (13.6%) and superficial infection (12.7%), medial gutter pain (10.2%). There were no cases of deep infection. Five patients required revision (all were revised to revision arthroplasty), for component loosening, or pain and stiffness. Conclusions. This is largest non-designer centre series examining the outcomes of the Zenith implant. Survival figures for this implant are comparable to NJR averages (6.8% revision at 5 years), with high levels of patient functional outcome and satisfaction. The data highlights the risks associated with this procedure

Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of malnutrition (albumin, transferrin or total lymphocyte count) were extremely common. Specifically, 53% of patients who presented for treatment of a chronic infection had at least one marker for malnutrition, compared to 33% in the group of patients undergoing revision for an aseptic reason. Malnutrition was found to be an independent risk factor for septic failure (p < 0.001 and OR 2.1). Interestingly, malnutrition was most common among patients of normal weight but was also common among obese patients (so-called “paradoxical” malnutrition). What was more disturbing, however, was that of those patients undergoing an aseptic revision, serum markers of malnutrition were associated with a 6× risk of acute post-operative infection complicating the patient's aseptic revision. We have confirmed this association using the NSQIP database where hypoalbuminemia was associated with a higher risk of infection, pneumonia and readmission. At our center, we also have studied the use of dilute betadine at the end of the case, prior to wound closure, in an attempt to decrease the load of bacteria in the wound. In a retrospective review the prevalence of acute post-operative infection was reduced from just under 1% (18/1862) to 0.15% (1 of 688; p = 0.04). It is critical that the betadine utilised be STERILE and the dilution we use is 0.35% made by diluting 17.5cc of 10% povidone-iodine paint in 500cc of normal saline

There are a variety of potential causes of shoulder arthritis in young patients including osteoarthritis, inflammatory arthritis, post-traumatic arthritis, and avascular necrosis. However, the primary etiology in my practice is related to complications of instability surgery or labral repair: thermal or anchor/suture related chondrolysis. The outcomes of arthroscopic debridement have been disappointing in patients with shoulder arthritis with worse results with increasing severity of articular cartilage changes. Among all joint arthroplasty procedures, patients who undergo shoulder arthroplasty have the youngest average age. Results of hemiarthroplasty (HA) have been approximately 75% to 80% compared to 90% with total shoulder arthroplasty (TSA). The largest series in the literature on shoulder arthroplasty in young patients is Schoch et al. They reviewed the results of 56 hemiarthroplasties and 19 TSA performed in patients less than 50 years old with a minimum 20-year follow-up or follow-up until reoperation. Both HA and TSA resulted in significant improvements in pain scores (p<0.001), abduction (p<0.01), and external rotation (p=0.02). Eighty-one percent of shoulders were rated much better or better than pre-operatively. Unsatisfactory ratings in HA were due to reoperations in 25 (glenoid arthrosis in 16) and limited motion, pain, or dissatisfaction in 11. Unsatisfactory ratings in TSA were due to reoperations in 6 (component loosening in 4) and limited motion in 5. Estimated 20-year survival was 75.6% (confidence interval, 65.9–86.5) for HAs and 83.2% (confidence interval, 70.5–97.8) for TSAs

Objectives. C-reactive protein(CRP) Used as screening test for acute periprosthetic joint infection has high sensitivity and low specificity. So there are many reasons except acute infection after total knee arthroplasty to elevate CRP level but it is unclear what reasons exactly were concerned. We therefore performed this study to determine the Causes of elevated CRP level in the early-postoperative period after primary total knee arthroplasty. Methods. Between 2005 and 2013, 502 patients undergone primary total knee arthroplasty were included. We excluded patients performed total knee arthroplasty with inflammatory arthritis and revision total knee arthroplasty, We measured the serial CRP levels in the all cases and then found cases with CRP level show elevation-depression-elevation pattern(bimodal graph) or >23.5mg/dl. We analyzed causes of elevated CRP level of that. Results. 66 patients represented bimodal pattern CRP graph. Elevation caused by periprosthetic infection were 16, Deep vein thrombosis were 10, Gastrointestinal problem were 8, urogenital cause were 10, respiratory infection was 10 and Unknown causes were 11. Conclusions. We had to know that Elevated CRP level after total knee arthroplasty can be caused by various general conditions including deep vein thrombosis can be a one of the origin elevating CRP & gastrointestinal problem, urogenital problem, respiratory infection

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No significant difference was found between the two groups

Minimizing the risk of periprosthetic joint infection (PJI) is of interest to all surgeons performing hip and knee arthroplasty. Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of malnutrition (albumin, transferrin or total lymphocyte count) were extremely common in the revision population. Specifically, among patients who presented for treatment of a chronic infection, 53% (67 of 126) had at least one marker for malnutrition. The prevalence of serological markers of malnutrition was lower (33%) in the group of patients undergoing revision for an aseptic reason suggesting that malnutrition was a risk factor for septic failure (p < 0.001 and OR 2.1). Interestingly, malnutrition was most common among patients of normal weight but was also common among obese patients (so-called “paradoxical” malnutrition). What was more disturbing, however, that of those patients undergoing an aseptic revision, serum markers of malnutrition were associated with a 6x risk of acute postoperative infection complicating the patient's aseptic revision. At our center, we also have studied the use of dilute betadine at the end of the case, prior to wound closure, in an attempt to decrease the load of bacteria in the wound. In a retrospective review the prevalence of acute postoperative infection was reduced from just under 1% (18/1862) to 0.15% (1 of 688; p = 0.04). It is critical that the betadine utilised be STERILE and the dilution we use is 0.35% made by diluting 17.5cc of 10% povidone-iodine paint in 500cc of normal saline. Although this is a retrospective review, it does suggest a benefit and we have not seen any problems associated with its use

Aims

There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA).

Aims

Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations.

Introduction. A common problem for patients receiving total knee arthroplasty (TKA) is postoperative functional impairment of the joint. This is minimized in bicruciate-retaining (ACL preserving) knee replacements, due to the important role of the anterior cruciate ligament (ACL) in normal kinematic patterns of the knee. We explore ACL sparing TKA by estimating the fraction of osteoarthritic TKA patients with a compatible ACL (assessed intraoperatively), while also examining potential preoperative indicators of ACL status. Method. We retrospectively examined 498 patients with a primary diagnosis of osteoarthritis who underwent a TKA by one surgeon between September 2013 and March 2015. Exclusion criteria included a prior TKA, a unicompartmental knee replacement, or inflammatory arthritis. Extensive preoperative data (within four months of surgery) for each patient was collected (anatomical alignment, extension, flexion, range of motion (ROM), Lachman test, and BMI) in addition to de-identified demographic data. The intraoperative assessment of ACL status (normal/functionally intact, compromised/deficient, or absent) was then obtained from our local database and compared with the preoperative data. IRB exemption was obtained to retrospectively collect data. Results. Intraoperative assessment of ACL status found 73.5% normal ACL, 12.9% compromised ACL, and 13.6% absent ACL. A significant demographic predictor of ACL status was gender (female - more likely intact, male - more likely absent; χ2 = 12.43, P<0.002). Patients with an intact ACL were also shown to have significantly better preoperative extension (χ2=14.83, P<0.022), flexion (F. 2, 469. = 9.93, P < 0.001), and ROM (F. 2, 469. = 9.38, P < 0.001) than those with a compromised ACL. We had a very small number of positive Lachman test results, and therefore could not draw any valid conclusion for preoperative predictive ability of the test. There was no significant difference in age, ethnicity, BMI or preoperative alignment between ACL status groups. Conclusion. Our study found 73.5% of 498 osteoarthritic TKA patients have an intact ACL. The strongest preoperative indicators of ACL status were gender, flexion, and ROM. Taken together, our results highlight a significant percentage of patients who are potential candidates for a bicruciate-retaining TKA

It is important to remember that osteoarthritis is a noninflammatory condition that can affect 1, 2 or all 3 compartments of the knee. Moreover, this disease is a continuum from very mild to very severe involvement of the soft tissue, articular cartilage and bone. For this reason, a variety of nonsurgical and surgical options are indicated. The rheumatologist and/or orthopedist must understand the stage of the disease and fit that both to the pathology, age, activity level, and functional needs of the patient. For that reason, each of the options discussed today have an indication. The important issue about tricompartmental replacement is that we have improved technology and technique and the indications of today are broader than those of 20 years ago. Hopefully, they will continue to evolve both in terms of materials and instruments. The American Rheumatologic Association (ARA) has stated that joint replacement has been the major improvement in the care of the arthritic patient. The tricompartmental solution is the treatment of choice in patients with inflammatory arthritis such as rheumatoid arthritis as well as the solution in osteoarthritic patients with tricompartmental disease. There is an indication for osteotomy, unicompartmental replacement and perhaps patellofemoral replacement. I think the next frontier will be to find disease modifying osteoarthritic drugs (DMOADS) that will provide disease intervention as the DMARDs have done in rheumatoid arthritis. Moreover, cartilage repair combined with osteotomy will hopefully allow us to prevent progression of this disease

Intraoperative fractures during primary total hip arthroplasty (THA) can occur on either the acetabular or the femoral side. A range of risk factors including smaller incision surgery, uncemented components, prior surgery, female sex, osteoporosis, and inflammatory arthritis have been identified. Acetabular fractures are rare but when they do occur often are underrecognised. It is not uncommon for intraoperative acetabular fractures to be discovered only postoperatively. Intraoperative acetabular fractures are associated with cementless implants and a number of identified anatomic risk factors. Factors related to surgical technique, including excessive under-reaming, excessive medialization with aggressive reaming, and implant designs such as an elliptical cup design are associated with higher risk. Treatment of acetabular fractures is dependent on whether they are diagnosed intraoperatively or postoperatively. When discovered intraoperatively, supplemental fixation should be added in the form of additional screw fixation, placing a pelvic plate, or using an acetabular reconstruction cage and morselised allografts. Acetabular reamings, obtained during preparation of the acetabulum, can be used for local bone graft. The goal should be stability of both the fracture and acetabular cup. Postoperatively, weight bearing and mobilization protocols may require modification, with many surgeons choosing a period of toe-touch weight-bearing in such cases. Acetabular fractures found postoperatively require the surgeon to make a judgement on the relative stability of the implant and the fracture to determine if immediate revision surgery or protected weight-bearing alone is appropriate. On the femoral side intraoperative fractures can occur around the greater trochanter, the calcar, or in the diaphysis. Fractures of the greater trochanter are problematic because of their tendency to displace due to the attachment of the abductors and the strong force they apply. Tension band wiring techniques will work for many greater trochanteric fractures while a trochanteric plate may be occasionally called for. With either form of fixation strong consideration should be given to 6–8 weeks of protected weight bearing postoperatively. Short longitudinal cracks in the medial calcar region are not rare with uncemented implants. Calcar fractures that do not extend below the lesser trochanter can often be managed with a single cerclage cable. Calcar fractures extending below the lesser trochanter should be scrutinised with additional intraoperative xrays; longer longitudinal cracks can be managed with 2 cables while more complex fractures that exit the diaphysis demand a change to a distally fixed implant and formal fracture reduction. Distal diaphyseal fractures are relatively uncommon in the primary setting, but not rare in the revision setting. When recognised intraoperatively, distal diaphyseal fractures can be treated effectively with cerclage cables. Distal diaphyseal longitudinal cracks noted postoperatively do not typically mandate a return to the OR and instead can be managed with 8 weeks of protected weight bearing

As an alternative to ankle replacement, ankle arthrodesis remains a mainstay in the treatment of end-stage arthritis. Arthroscopic techniques for ankle arthrodesis have more recently been developed, although there has been limited research exploring the cost of arthroscopic (AAA) versus open ankle arthrodesis (OAA), and comparing ankle fusions to replacement (TAA). We hypothesise that resource use after AAA will be lower than that after OAA, and both will be lower than TAA. We performed a retrospective review of a prospectively collected database. The COFAS database was used to identify patients with >2 years of follow up who have undergone AAA, OAA or Hintegra TAA at St Paul's Hospital between 2003–2010. Ninety patients with TAA, 52 with AAA and 56 with OAA met our inclusion criteria. The following data were documented: patient demographics (age, gender, presence of diabetes, inflammatory arthritis or any smoking history), factors related to the index surgery (type of surgery, OR time, length of stay) and factors relating to the post-operative course (number of post-operative clinic visits, OR time for re-operations, length of stay for additional hospital admissions). In terms of the index surgery, AAA required less initial OR time compared to either OAA or TAA. Initial length of hospital stay was significantly longer for both TAA and OAA, compared to AAA. Patients attended more follow-up visits after TAA or OAA compared to after AAA. In terms of additional OR time required, no significant differences were found among the groups. The most common reason for re-operation was infection or wound breakdown (38% of re-operations), followed by removal of hardware (15%). TAA also required significantly more additional days in hospital compared to either OAA or AAA. For all significant comparisons, p < 0.05. For each primary TAA, on average an additional one hour of surgery, three days in hospital and seven clinic visits were required on top of the cost factored for the primary arthroplasty. For each primary AAA, an additional four clinic visits, 23 minutes of revision surgery and one day in hospital were required. For each primary OAA, an average additional five clinic visits, three minutes of OR time, and 0.2 days of additional hospital stay occurred during follow up. Using several measures of resource use, we find that arthroscopic ankle fusions compare favourably to both ankle replacements and open ankle fusions. We also show that resource utilisation measurements can be a useful surrogate for complications, and that resource utilisation can demonstrate the practical implications of complications for patients, surgeons and health care resources

Since 2005, the author has performed 422 Oxford medial unicompartmental arthroplasties (UKA) using a mobile bearing. There were 263 females and 119 males, (40 patients had bilateral UKAs) with a mean age of 62 years. The indications were: Isolated medial compartment osteoarthritis with ‘bone-on-bone’ contact, which had failed prior conservative treatment; Medial femoral condyle avascular necrosis or spontaneous osteonecrosis, which had failed prior conservative treatment. Patients were recommended UKA only if the following anatomic requirements were met: Intact ACL, Full thickness articular cartilage wear limited to the anterior half of the medial tibial plateau, Unaffected lateral compartment cartilage, Unaffected patellar cartilage on the lateral facet, Less than 10 degrees of flexion deformity, Over 100 degrees of knee flexion, Varus deformity not exceeding 15 degrees. Exclusion criteria for surgery were BMI of more than 30, prior high tibial osteotomy, and inflammatory arthritis. All cases were performed with a tourniquet inflated using a minimally-invasive incision with a quadriceps-sparing approach. Both femoral and tibial components were cemented. Rehabilitation consisted of teaching the patients 6 exercises to regain strength and range of motion, and weight-bearing as tolerated with a cane began from the evening of surgery. Most patients were discharged home the next morning; bilaterals usually stayed a day longer. We have previously described our results and the factors determining alignment. In a more recent study we have compared the coronal postoperative limb alignment and knee joint line obliquity after medial UKA with a clinically and radiologically (less than Grade 2 medial OA) normal contralateral lower limb. In our series of 423 cases, we have had 1 revision for aseptic loosening of both components, and 4 meniscal dislocations. There have been no cases of wound infections and thromboembolism. We are currently undertaking a review of the 2–10 year follow-up of our cases. The vast majority of our patients have been generally very satisfied with the results. Our study shows that most patients (who have no disease in the contralateral knee) regain their ‘natural’ alignment and joint line obliquity comparable to their contralateral limb. Over the past few years our percentage of UKAs has been steadily rising. UKA serves as a definitive procedure in the elderly. We see it as a suitable procedure in middle-aged patients who want an operation that provides a quick recovery, full function and range of motion, and near-normal kinematics, with the understanding that they have a small chance of conversion to a total knee arthroplasty in the future

Acetabular protrusio is defined radiographically as migration of the femoral head medial to Kohler's line (a line from the lateral border of the obturator foramen to the medial border of the sciatic notch). Protrusio can develop in association with metabolic bone diseases such as osteogenesis imperfecta, Marfan's Syndrome, and Paget's disease, inflammatory arthritis or osteoarthritis, tumors, or result from prior trauma. Acetabular protrusio can cause limited hip motion due to impingement of the femoral neck against the acetabular rim. When protrusio develops in association with osteoarthritis, coxa vara is often also present. Surgical treatment of acetabular protrusio during total hip arthroplasty should lateralise the center of the hip to its anatomic position. This typically can be achieved with use of a larger, slightly oversized, rim fit cementless acetabular component and medial morselised femoral head bone autograft. In cases with more severe deformity, a reconstruction cage may be required. Alternatively a medialised acetabular shell can be used with a lateralised liner. If coxa vara is also present, standard femoral component position (approximately 1cm above the lesser trochanter) can result in an increase in leg length. Careful pre-operative templating should be performed and may require more distal placement of the femoral component to avoid overlengthening the limb

Aims

When a total ankle arthroplasty (TAA) fails, it can be converted to a fusion or a revision arthroplasty. Despite the increasing numbers of TAAs being undertaken, there is little information in the literature about the management of patients undergoing fusion following a failed TAA. The primary aim of this study was to analyze the survival of fusions following a failed TAA using a large dataset from the National Joint Registry (NJR).

Aims

This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

Orthopaedic reconstruction procedures to combat osteoarthritis, inflammatory arthritis, metabolic bone disease and other musculoskeletal disorders have increased dramatically, resulting in high demand on the advancement of bone implant technology. In the past, joint replacement operations were commonly performed primarily on elderly patients, in view of the prosthesis survivorship. With the advances in surgical techniques and prosthesis technology, younger patients are undergoing surgeries for both local tissue defects and joint replacements. This patient group is now more active and functionally more demanding after surgery. Today, implanted prostheses need to be more durable (load-bearing), they need to better match the patient's original biomechanics and be able to survive longer. Additive manufacturing (AM) provides new possibilities to further combat the problem of stress-shielding and promote better bone remodelling/ingrowth and thus long term fixation. This can be accomplished by matching the varying strain response (stiffness) of trabecular or subchondral bone locally at joints. The purpose of this research is therefore to determine whether a porous structure can be produced that can match the required behaviour and properties of trabecular bone regardless of skeletal location and can it be incorporated into a long-term implant. A stochastic structure visually similar to trabecular bone was designed and optimised for AM (Figure 1) and produced over a range of porosities in multiple materials, Stainless Steel 316, Titanium (Grade 23 – Ti6Al4V ELI) and Commercially Pure Titanium (Grade 2) using a Renishaw AM250 metal additive manufacturing system. Over 150 cylindrical specimens were produced per material and subjected to a compression test to determine the specimens' Elastic Modulus (Stiffness) and Compressive Yield Strength. Micro-CT scans and gravimetric analysis were also performed to determine and validate the specimens' porosity. Results were then graphed on a Strength vs. Stiffness Ashby plot (Figure 2) comparing the values to those of trabecular bone in the tibia and femur. It was found that AM can produce porous structures with an elastic modulus as low as 100 MPa up to 2.7 GPa (the highest stiffness investigated in this study). Titanium structures with a stiffness <500MPa had compressive strengths towards the bottom range of similar stiffness trabecular bone. Between 500 MPa − 1 GPa Titanium AM porous structures match the compressive strength of equivalent stiffness trabecular bone and from 1 GPa − 2 GPa the Ti structures exceed the strength of equivalent stiffness trabecular bone up to ∼2.5 times and consequently increase by a power law. These results show that AM can produce structures with similar stiffness to trabecular bone over a range of skeletal locations whilst matching or exceeding the compressive strength of bone. The results have not yet taken into account fatigue life with the fatigue life of these types of structures tending to be between 0.1 – 0.4 of their compressive strength. This means that a titanium porous structure would need to be 2.5 – 10 times stiffer or stronger than the portion of trabecular bone it is replacing. This data is highly encouraging for AM manufactured, bone stiffness matched implant technology

Minimizing the risk of periprosthetic joint infection (PJI) is of interest to all surgeons performing hip and knee arthroplasty. Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of malnutrition (albumin, transferrin or total lymphocyte count) were extremely common in the revision population. Specifically, among patients who presented for treatment of a chronic infection, 53% (67 of 126) had at least one marker for malnutrition. The prevalence of serological markers of malnutrition was lower (33%) in the group of patients undergoing revision for an aseptic reason suggesting that malnutrition was a risk factor for septic failure (p < 0.001 and OR 2.1). Interestingly, malnutrition was most common among patients of normal weight but was also common among obese patients (so-called “paradoxical” malnutrition). What was more disturbing, however, that of those patients undergoing an aseptic revision, serum markers of malnutrition were associated with a 6× risk of acute post-operative infection complicating the patient's aseptic revision. At our center, we also have studied the use of dilute betadine at the end of the case, prior to wound closure, in an attempt to decrease the load of bacteria in the wound. In a retrospective review the prevalence of acute post-operative infection was reduced from just under 1% (18/1862) to 0.15% (1 of 688; p = 0.04). It is critical that the betadine utilised be STERILE and the dilution we use is 0.35% made by diluting 17.5 cc of 10% povidone-iodine paint in 500 cc of normal saline. Although this is a retrospective review, it does suggest a benefit and we have not seen any problems associated with its use

Resurfacing the patella is performed the majority of the time in the United States and in many regions it is considered standard practice. In many countries, however, the patella is left un-resurfaced an equal amount of the time or even rarely ever resurfaced. Patella resurfacing is not a simple or benign procedure. There are numerous negative sequelae of resurfacing including loosening, fragmentation, avascular necrosis, lateral facet pain, stress fracture, acute fracture, late fracture, and restricted motion. In a study by Berend, Ritter, et al, failures of the patella component were reported 4.2% of the time at an average of only 2.6 years. A study was undertaken at Washington University in recent years to determine rather more clinical problems were observed following total knee replacement with or without patella resurfacing. Records were maintained on all problem total knees cases with well localised anterior knee pain. The referral area for this clinic is St. Louis which is among the largest American cities, with the highest percentage of total knees that are performed without patella resurfacing. During 4 years of referrals of total knee patients with anterior knee pain, 47 cases were identified of which 36 had a resurfaced patella and 11 had a non-resurfaced patella. Eight of 36 resurfaced patellae underwent surgery while only 2 of 11 non-resurfaced patellae underwent subsequent surgery. More than 3 times as many painful total knees that were referred for evaluation had already had their patella resurfaced. In spite of the fact that approximately equal number of total knees were performed in this area without patella resurfacing, far more patients presented to clinic with painful total knee in which the patella had been resurfaced. The numerous pathologies requiring a treatment following patella resurfacing included patella loosening, fragmentation of the patella, avascular necrosis patella, late stress fracture, lateral facet pain, oblique resurfacing, and too thick of a patellar composite. In a large multi-center randomised clinical trial at 5 years from the United Kingdom in over 1700 knees from 34 centers and 116 surgeons, there was no difference in the Oxford Score, SF-12, EQ-5D, or need for further surgery or complications. The authors concluded, “We see no difference in any score, if there is a difference, it is too small to be of any clinical significance”. In a prospective of randomised clinical trial performed at Tulane University over 20 years ago, no differences were observed in knee score, a functional patella questionnaire, or the incidence of anterior knee pain between resurfaced and un-resurfaced patellae at time intervals of 2–4 years, 5–7 years, or greater than 10 years. Beyond 10 years the knee scores of total knee patients with a resurfaced patella had declined significantly greater than those with a non-resurfaced patella. There are numerous advantages of not resurfacing the patella including less surgical time, less expense, a lower risk of “major” complications (especially late complications), and if symptoms develop in an un-resurfaced patella, it is an easier salvage situation with more options available. A small percentage of total knee patients will be symptomatic whether or not their patella is resurfaced. Not resurfacing the patella retains more options and has fewer complications. The major determinant of clinical result and the presence of anterior knee pain after knee replacement is surgical technique and component design not whether or not the patella is resurfaced. Patella resurfacing is occasionally necessary for patients with inflammatory arthritis, a deformed or maltracking patella, or symptoms and pathology that are virtually restricted to the patellofemoral joint. For the vast majority of patients, however, patella resurfacing is not necessary

Acetabular protrusio occurs from migration of the femoral head medial to Kohler's line. This occurs in inflammatory arthritis, osteoarthritis with coxa vara deformities, previous acetabular fracture, and in metabolic bone diseases such as osteomalacia, Paget's disease, Marfan's syndrome, and osteogenesis imperfecta. Total hip replacement in this situation is difficult due to the requirement to place the acetabular component opening at the level of the normal rim or the patient will be at risk for component-on-component or bone-on-bone impingement, resulting in dislocation or component loosening. The deficient medial wall doesn't resist cup subsidence and the deficient peripheral rim may provide poor initial cup stability. Many management options have been described including using cement, bulk bone graft, and particulate graft to support the cup medially, and use of a reinforcement ring cage to provide better rim support. Gates reported on a series of 36 primary total hip replacements with acetabular protrusio treated with cemented cups and medial particulate autograft with a mean follow-up of 12.8 years with 6 definitively loose, 3 probably loose, and 22 possibly loose. The technique that provides initial porous cup stability and potential for long-term biological fixation is preferred. Mullaji and Shetty reported 90% good and excellent results and no loosening or migration at a mean 4.2 years in 30 primary total hips with acetabular protrusio treated with oversized porous cups for rim support and medial particulate bone grafting. Forty percent of their cases had protrusio greater than 15 mm medial to Kohler's line. Hansen and Ries also reported no revisions using this same technique in 19 revision total hips with an average follow-up of 2.8 years. However, they emphasised that this technique should only be used if the peripheral rim is intact, and if inadequate, to use a reconstruction cage. In revision total hips with large medial acetabular defects this is more likely to be the case. However, use of a reconstruction cage doesn't provide biological fixation. Ilyas reported a 15.1% loosening rate using cages for revisions with medial defects at a follow-up of 6 years. I have alternatively used a porous protrusio shell when rim support is poor and the medial defect is greater than 10 mm. The technique is to perform a cylindrical peripheral ream and a medial hemispherical ream. This provides greater host bone to shell contact for stability and greater biological fixation, and fills much of the medial defect. I used this technique in 43 cases with an average follow-up of 3.7 years. There were no revisions, no apparent cup migrations, and no progressive component bone radiolucencies. For primary total hips with protrusio, when good rim support can be achieved with a few millimeters of peripheral over-ream, a standard porous cup and medial particulate autografting is preferred. However, in many primary cases with greater than 10 mm of protrusio, the peripheral rim may be significantly stress shielded and thus, may have poor rim support unless the rim is significantly over-reamed. Because of my excellent results using protrusio shells in revision cases, I will consider also using a protrusio shell in primary total hips in elderly patients with >10 mm of protrusio. I have experience in 10 primary cases with an average follow-up of 4.1 years. One failed for infection. The other 9 have been successful with no apparent cup migration and no progressive component bone radiolucencies

Aims

To investigate the optimal thresholds and diagnostic efficacy of commonly used serological and synovial fluid detection indexes for diagnosing periprosthetic joint infection (PJI) in patients who have rheumatoid arthritis (RA).

We set out to demonstrate the 10-year survivorship of the PFC sigma TKA in a young patient group. Demographic and clinical outcome data were collected prospectively at 6 months, 18 months, 3 years, 5 years and 8–10 years post surgery. The data were analysed using Kaplan Meier survival statistics with end point being regarded as death or revision for any reason. 203 patients were found to be < 55 years at the time of surgery. Four patients required revision and four patients died. Another four patients moved away from the region and were excluded from the study. A total of 224 knees in 199 patients (101 male and 98 females.) 168 patients had a diagnosis of Osteoarthritis and 28 with inflammatory arthritis. Average age 50.6 years range 28–55 years (median 51). Ten-year survivorship in terms of revision 98.2% at ten years 95% confidence interval. Our results demonstrate that the PFC Sigma knee has an excellent survival rate in young patients over the first 10 years. TKR should not be withheld from patients on the basis of age

We set out to demonstrate the 10-year survivorship of the PFC sigma TKA in a young patient group. Demographic and clinical outcome data were collected prospectively at 6 months, 18 months, 3 years, 5 years and 8-10 years post surgery. The data were analysed using Kaplan Meier survival statistics with end point being regarded as death or revision for any reason. 203 patients were found to be ≤55 years at the time of surgery. Four patients required revision and four patients died. Another four patients moved away from the region and were excluded from the study. A total of 224 knees in 199 patients (101 male and 98 females.) 168 patients had a diagnosis of Osteoarthritis and 28 with inflammatory arthritis. Average age 50.6 years range 28-55 years (median 51). Ten-year survivorship in terms of revision 98.2% at ten years 95% confidence interval. Our results demonstrate that the PFC Sigma knee has an excellent survival rate in young patients over the first 10 years. TKR should not be withheld from patients on the basis of age

This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed.

Cite this article: Bone Joint J 2022;104-B(12):1329–1333.

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

Aims

Knee osteoarthritis (OA) involves a variety of tissues in the joint. Gene expression profiles in different tissues are of great importance in order to understand OA.

Resurfacing the patella is performed the majority of the time in the US and in many regions it is considered standard practice. In many countries, however, the patella is left unresurfaced an equal amount of the time or even rarely ever resurfaced. Patella resurfacing is not a simple or benign procedure. There are numerous negative sequelae of resurfacing including loosening, fragmentation, avascular necrosis, lateral facet pain, stress fracture, acute fracture, late fracture, and restricted motion. In a study by Berend, Ritter, et al, failures of the patella component were reported 4.2% of the time at an average of only 2.6 years. A study was undertaken at Washington University in recent years to determine whether more clinical problems were observed following total knee replacement with or without patella resurfacing. Records were maintained on all problem total knees cases with well localised anterior knee pain. The referral area for this clinic is St. Louis which is among the largest American cities, with the highest percentage of total knees that are performed without patella resurfacing. During 4 years of referrals of total knee patients with anterior knee pain, 47 cases were identified of which 36 had a resurfaced patella and 11 had a non-resurfaced patella. Eight of 36 resurfaced patellae underwent surgery while only 2 of 11 non-resurfaced patellae underwent subsequent surgery. More than 3 times as many painful total knees that were referred for evaluation had already had their patella resurfaced. In spite of the fact that approximately equal number of total knees were performed in this area without patella resurfacing, far more patients presented to clinic with painful total knee in which the patella had been resurfaced. The numerous pathologies requiring a treatment following patella resurfacing included patella loosening, fragmentation of the patella, avascular necrosis patella, late stress fracture, lateral facet pain, oblique resurfacing, and too thick of a patellar composite. In a large multi-center randomised clinical trial at 5 years from the United Kingdom in over 1700 knees from 34 centers and 116 surgeons, there was no difference in the Oxford Score, SF-12, EQ-5D, or need for further surgery or complications. The authors concluded, “We see no difference in any score, if there is a difference, it is too small to be of any clinical significance”. In a prospective randomised clinical trial performed at Tulane University over 20 years ago, no differences were observed in knee score, a functional patella questionnaire, or the incidence of anterior knee pain between resurfaced and unresurfaced patellae at time intervals of 2–4 years, 5–7 years, or greater than 10 years. Beyond 10 years the knee scores of total knee patients with a resurfaced patella had declined significantly greater than those with a non-resurfaced patella. There are numerous advantages of not resurfacing the patella including less surgical time, less expense, a lower risk of “major” complications (especially late complications), and if symptoms develop in an unresurfaced patella, it is an easier salvage situation with more options available. A small percentage of total knee patients will be symptomatic whether or not their patella is resurfaced. Not resurfacing the patella retains more options and has fewer complications. The major determinant of clinical result and the presence of anterior knee pain after knee replacement is surgical technique and component design not whether or not the patella is resurfaced. Patella resurfacing is occasionally necessary for patients with inflammatory arthritis, a deformed or maltracking patella, or symptoms and pathology that are virtually restricted to the patellofemoral joint. For the vast majority of patients, however, patella resurfacing is not necessary

Enhanced appreciation of normal knee kinematics and the inability to replicate these in the replaced total knee has led to increased enthusiasm for partial knee arthroplasty by some. These arthroplasties more closely replicate normal kinematics since they inherently preserve the anterior cruciate ligament (ACL). Indications for medial UKA are: anteromedial osteoarthritis with an intact ACL, posterior cruciate ligament, and medial collateral ligament (MCL), full thickness cartilage loss, and correctable deformity demonstrated radiographically with valgus stress view; full thickness cartilage laterally with no central ulcer; <15 degrees of flexion contracture, < 15 degrees varus and > 90 degrees flexion. The state of the patellofemoral joint, chondrocalcinosis, obesity, age and activity level are NOT contraindications to medial mobile-bearing UKA. The only certain contraindications are the presence of inflammatory arthritis or a history of previous high tibial osteotomy (HTO). Advantages of medial UKA are that it preserves undamaged structures, it is a minimally invasive technique with low incidence of perioperative morbidity, preservation of the cruciate mechanism results in more “normal” kinematics versus TKA, it normalises contact forces and pressures in the patellofemoral joint, and it provides better range of motion than TKA. Furthermore, medial UKA results in better function than TKA in gait studies, with demanding activities, such as climbing stairs, having a better “feel”. Pain relief with medial UKA is equivalent or better than TKA, and morbidity and mortality are decreased compared with TKA, as well as venous thromboembolism. Recommended preoperative imaging studies consist of plain radiographs with the following views obtained: standing AP, PA flexed, lateral, Merchant or axial, and valgus stress. There are several surgical perils associated with performing medial UKA. First, in regard to patient selection, avoid medial UKA in patients with residual hyaline cartilage – the joint must be bone on bone. Second, perform a conservative tibial resection with respect to depth to prevent tibial collapse as well as excessive overload of weakened bone, and avoid excessive posterior slope. Perform the tibial resection coplanar with tibial spine/ACL insertion to maximise tibial coverage. Avoid overcorrection of deformity. Do not perform a medial release. Balance flexion/extension gaps meticulously. For mobile-bearing designs, remove all impinging osteophytes. Over 55 published studies report results with mobile-bearing medial UKA, with survival ranging 63.2–100% at mean follow-up ranging from 1 to 17.2 years

Aims

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry.

Favourable long-term results have been reported with the standard Exeter cemented stem. We report our experience with a version for use in smaller femora, the Exeter 35.5 mm stem. Although, also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem. Between August 1988 and August 2003, 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 years (18 to 86), with 73 patients under the age of 50 years. The diagnosis was osteoarthritis in 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in three, secondary to Perthes disease in two and avascular necrosis of the hip in one patient. The fate of every implant is known. At a median follow-up of 8 years (5 to 19), survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Fifteen cases (7.8%) underwent further surgery 11 for acetabular revision, one for stem fracture and three others. Although, smaller than a standard Exeter Universal polished tapered cemented stem—with a shorter, slimmer taper—the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients

Aims

This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI).

OBJECTIVE. To evaluate the results of results of total knee replacement (TKA) in stiff and Ankylosed knees. A retrospective study was done to evaluate the results of total knee arthroplasty performed on 110 knees in 69 patients with spontaneously Ankylosed knees. The reasons of ankylosis was previous infection (pyogenic and tuberculous), inflammatory arthritis (rheumatoid arthritis, Juvenile rheumatoid arthritis, ankylosing spondylitis) and post –traumatic. The age at operation ranged from 30 to 65 years (average 42.8 years). Preoperative arc of movement was between 0 degrees and 20 degrees (average, 14 degrees). The difficulties encountered in surgical exposure were managed by using various extensile exposure techniques. Quadriceps snip was used in all case to avoid patellar avulsion. Follow-up ranged from 5 to 17 years (average, 9 years). The average postoperative arc of movement at final follow-up was 75.8 degrees, with a significant average gain of 61 degrees at final follow up. The average preoperative Hospital for Special Surgery Knee Score was 60 which improved to 75 at the final follow up. The average extensor lag was 8 degrees (range 0- 20 degrees). Complications included skin edge necrosis (35%), pyogenic infection in 3 patients, and a quadriceps tendon rupture in 1 patient. 4 knees were revised on account of component loosening. Conclusions. Total knee arthroplasty in Ankylosed knees does achieve correction of deformity with gain in range of motion leading to improved quality of life. Meticulous surgical technique is required to prevent complications. We believe that TKA in Ankylosed knees is a viable option

Introduction. Ankle replacement is now common in the UK. In a tertiary referral NHS practice, between 1997–2011 we implanted two types of cementless mobile bearing total ankle replacements (TAR). Methods. We reviewed our operative database and electronic patient records and confirmed the number of prosthesis with our theatre records. All case notes and radiographs were reviewed. Failure was taken as revision, and patients were censored due to death or loss to follow-up. The survivorship was calculated using a life table (the Kaplan-Meier method), with 95% confidence intervals. Results. We found a total of 358 NHS patients had a TAR from Jan 1997 to April 2012 total ankle replacements; the mean follow up was 76 months. The principle indications for surgery included primary OA (n=146) and inflammatory arthritis in (n=79). Overall survival was 90.9% (94–84) at 10 years. A complication requiring revision developed in 42 ankles and 36 were revised or fused. Thirty-two TAR's underwent further hind foot fusions which were not attributed as a failure of the prosthesis. We arthroscoped 6 TAR's for hetrotrophic calcification. When we separated the implants we found the STAR (implanted from 1997–2004) had a 5-year survival of 95.2% (98–91) and the Mobility (implanted from 2004–11) of 92.6% (96–88). We found early failures (within 2 years of implantation) were higher within 2 years of introduction of TAR and on changing our prosthesis. Conclusion. In a study of TAR undertaken at one centre principally by an experienced surgeon and team, we have shown a learning curve. Cementless mobile bearing total ankle replacements (TAR) conducted on a routine basis with careful patient selection has a 90.9% survivorship over a 10-year period. The difference in survival for two implants is not statistically significant

Introduction: Hot swollen knee joints are a common presentation in clinical practice. It has wide differential diagnoses, the most serious being septic arthritis. Delayed or inadequate treatment leads to joint damage. Arthroscopic lavage should be planned appropriately after proper clinical assessment and investigation. Other differential diagnoses like crystal arthritis, reactive arthritis, monoarticular inflammatory arthritis should be considered. Patients and Methods: This retrospective audit involved 44 patients who had arthroscopic knee lavage for suspected septic arthritis from January 2005 to May 2007. Analysis included the aspects of adequate backup supportive evidence for the procedure, the time from diagnosis to operation and postoperative antibiotic regime. Results: There were 29 males and 15 females with age group ranging from 11 to 91 yrs. Fever was present in 15 patients(34%), preoperative joint aspiration done in 22(50%), peri-operatively pus found in 11(25%). 13 patients(29.5%) had procedure done within 6hrs, causal organism identified in 25%. Follow-up ranged upto 12 months without persistence or reactivation. Discussion: Arthroscopic lavage is a useful adjunct in treatment of septic arthritis of knees but proper patient selection with systematic approach considering other possible differential diagnoses is important for avoiding unnecessary operations

Methods. There were 106 men and 94 women (mean age 65 years; 22 - 85). 69 patients had inflammatory arthritis and 131 osteo-arthritis. 27 patients (13 B-P, 14 STAR) had a pre-operative varus/valgus deformity greater than or equal to 20 degrees. Mean follow-up was 48 months (36-72). Results. Ten patients had died from unrelated cause with satisfactory final outcome assessment. Thirteen ankles (4 STAR, 9 B-P) required revision surgery. The causes of failure were: early deep infection (1 STAR), recurrent deformity (1 STAR, 4BP) aseptic loosening (1STAR, 4 BP), implant failure (1STAR, 1 BP). Six revised ankles (5BP, 1STAR) had pre-operative varus/valgus deformity of 20 degrees or more. AOFAS score for pain improved from 0 to 35 and for function from 30 to 43. There was no difference between the two groups. Pre-operative range of movement was predictive of the final range of movement. Radiographic assessment showed that 30 patients (17BP, 13 STAR) had recurrent deformity (edge loading) as shown by the UHMWPE insert no longer articulating congruently with the metallic components. 14 ankles (8BP, 6 STAR) from this group had pre-operative deformity of 20 degrees or more. Conclusion. Patients with severe pre-operative deformity had a significant evidence of edge loading and failure resulting in revision surgery. BP replacements failed more frequently than STAR replacements but most BP failures were in ankles with severe pre-operative deformity

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The complication rates in the early and delayed treatment group were 13% and 29% respectively. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No statistically significant difference was found between the two groups. We conclude that total elbow replacement provides a preditable and reproducible outcome in terms of pain relief and functional range of movement in elderly osteoporotic patients with difficult distal humerus fractures

Objective: To study the incidence of joint replacement procedure, arthrodesis, and synovectomy among patients with chronic inflammatory joint disease during the period 1994 to 2004. Methods: Data from the Norwegian Arthroplasty Register was used to find the number of joint replacement procedures performed in Norway 1994 – 2004. The incidences of arthrodeses and synovectomies were obtained from the Norwegian Patient Register. Incidence rates were calculated based on age, year, and gender specific population rates for the Norwegian population, obtained from Statistics Norway. Results: There were 8268 primary joint replacements, 3554 arthrodeses, and 5012 synovectomies performed in patients with inflammatory arthritis (IA) during the study period. A reduction in joint replacement procedures and synovectomies took place during the period 1994 to 2004, in patients with IA. For the oldest patients (80 years and older), no such trend was found. During the same time period, the incidence of joint replacements due to osteoarthritis increased. A significant reduction in the incidence of arthrodesis procedures was also found for the total study group, but not for the different subgroups. Conclusion: The incidence of joint replacements and synovectomies among patients with chronic inflammatory joint disease decreased from 1994 to 2004. This may be the result of improved medical treatment of these patients

This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures; cryotherapy following total knee arthroplasty; and physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents.

Introduction. The Signature system has been hailed as a new way to perform arthroplasty of the knee. It combines the accuracy in restoring mechanical axes of navigation with the convenience and familiarity of classical surgical techniques. With this comes the expectation that they should produce better functional results. In the literature, thus far, there is little data to corroborate this. The aim of this paper is to compare the early functional outcomes of this with the cemented AGC knee replacement system. Methods. Since April 2010, based on requirement, 25 patients underwent Signature knee replacements during this period for symptomatic degenerative or inflammatory arthritis with varying levels of deformity. Oxford functional scores were taken pre-operatively, at 6 weeks, 3 months and 6 months. These were then matched to an equal number of patients that had undergone an AGC knee replacement by the same surgeon. They were matched by pre-operative functional Oxford scores, age and gender. Results. The mean age for our patients was 63.4 years at the time of surgery. The mean follow-up period was 6.9 months. There have been no revision procedures required or complications in either group so far. The mean pre-operative Oxford score was 44.4, 26.3, 25 and 19 pre-operatively, at 6 weeks, 3 months and 6 months respectively for the Signature knee group. No link was seen between pre-operative function and post-operative scores. The AGC group has had comparable results thus far at scores 43.2, 28.4, 20.1 and 19.7 respectively. More results are to follow. Conclusions. To our knowledge this is one of the earliest reports of functional results following the new technique of knee mechanical axis restoration for arthroplasty surgery. The system showed comparable results at similar post-operative time periods with the conventionally performed AGC knee replacement system

Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.

Cite this article: Bone Joint J 2023;105-B(3):227–229.

The Rotaglide+ knee arthroplasty was introduced in 2000 as a successor to the Nuffield and Rotaglide knees. Both prosthesis were used in our unit and data was collected prospectively on sex, diagnosis, range of motion, pain score and American knee association score (AKSS). All operations were done under the care of one Surgical team (BBM) using the same instrumentation and the same pathway. Between 1987 and 2000 444 primary Nuffield were performed. 278 primary Rotaglide+ knees between 2000 and 2006. 65% of Nuffields implanted were in female candidates and 55% in the Rotaglide+. 75% of Nuffields were performed for Osteoarthritis, 69% in the Rotaglide+, this reflects the authors growing interest in inflammatory arthritis. Pre-operative functional range of motion and pain scores were similar. Both series showed a significant and sustained improvement in pain score, and walking time. Similar improvement was seen in range of motion. Comparison of the two series showed the Nuffield knee scored better on AKSS at year’s one and two and on pain score at year one but other than this outcomes were similar for both series. Revision rate in the Nuffield series is 9% at 25 years and in the Rotaglide+ series 4% at 8 years. This compares favourably with other published knee series’. Despite being introduced as an improved design the Rotaglide+ fails to demonstrate any improvement in function and pain compared to its predecessor the Nuffield knee. Knee surgeons need to maintain a healthy cynicism of manufacturers ‘improved’ implants

Survivorship of the standard Exeter Universal cemented stem with revision of the femoral component for aseptic loosening as the endpoint has been reported as 100% at 12 years. A version for use in smaller femora, the Exeter 35.5 mm stem, was introduced in 1988. Although also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem. Between August 1988 and August 2003 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 (18 to 86) years with 73 patients under the age of 50 years. The diagnosis was osteoarthritis 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in 3, secondary to Perthes disease in 2 and avascular necrosis of the hip in 1 patient. The fate of every implant is known. At a median follow-up of 8 (5 to 19) years survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. 15 cases (7.8%) underwent further surgery – 11 for acetabular revision, 1 for stem fracture and 3 others. Although smaller than a standard Exeter Universal polished tapered cemented stem, with a shorter, slimmer taper, the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients

Background. Stability of total knee arthroplasty (TKA) is dependent on correct and precise rotation of the femoral component. Multiple differing surgical techniques are currently utilized to perform total knee arthroplasty. Accurate implant position have been cited as the most important factors of successful TKA. There are two techniques of achieving soft gap balancing in TKA; a measured resection technique and a balanced gap technique. Debate still exists on the choice of surgical technique to achieve the optimal soft tissue balance with opinions divided between the measured resection technique and the gap balance technique. In the measured resection technique, the bone resection depends on size of the prosthesis and is referenced to fixed anatomical landmarks. This technique however may have accompanying problems in imbalanced patients. Prediction of gap balancing technique, tries to overcome these fallacies. Our aim in this study was twofold: 1) To describe our methodology of ROBOTIC TKA using prediction of gap balancing technique. 2) To analyze the clinico-radiological outcome our technique comparison of meseaured resection ROBOTIC TKA after 1year. Methods. Patients that underwent primary TKA using a robotic system were included for this study. Only patients with a diagnosis of primary degenerative osteoarthritis with varus deformity and flexion deformity of were included in this study. Patients with valgus deformity, secondary arthritis, inflammatory arthritis, and severe varus/flexion deformity were excluded. Three hundred ten patients (319 knees) who underwent ROBOTIC TKA using measured resection technique from 2004 – 2009. Two hundred twenty (212 knees) who underwent ROBOTIC TKA using prediction of gap balancing technique from 2010 – 2012. Clinical outcomes including KS and WOMAC scores, and ranges of motion and radiological outcomes including mechanical axis, prosthesis alignments, flexion varus/valgus stabilities were compared after 1year. Results. Leg mechanical axes were significantly different at follow-up 1year versus preoperative values, the mean axes in the Robotic-TKA with measured resection technique and Robotic-TKA with prediction of gap balancing technique improved from 9.6±5.0° of varus to 0.5±1.9° of varus, and from 10.6±5.5° to 0.4±1.3° of varus (p<0.001), respectively. However, no significant intergroup differences were found between mechanical axis or coronal alignments of femoral or tibial prostheses (pï¼ï¿½0.05). Mean varus laxities at 90° of knee flexion in measured resection and gap prediction technique group were 6.4° and 5.3°, respectively, and valgus laxities were 6.2 and 5.2 degrees, respectively, with statistical significance (p=0.045 and 0.032, respectively). KS knee and function scores and WOMAC scores were significantly improved at follow-up 1year (pï¼ï¿½0.05). However, no significant difference was found between the Robotic-TKA with measured resection technique and Robotic-TKA with prediction of gap balancing technique for any clinical outcome parameter at follow-up 1year (pï¼ï¿½0.05). Conclusions. Robotic assisted TKA using measured resection or gap prediction technique provide adequate and practically identical levels of flexion stability at 90° of knee flexion with accurate leg and prosthesis alignment. But, Robotic TKA using measured resection technique have less than flexion stability compared with gap prediction technique with statistical significance after follow-up 1year

In June 1999 we instituted a prospective, randomised, double blind study to determine whether in the use of the Profix® total knee replacement system the addition of screws improved the fixation of the tibial base plate. There were 145 arthroplasties in 137 patients, 77% of them female. Their mean age was 66 years. In 86% of the patients there was osteoarthritis and in 14% an inflammatory arthritis. On a random basis, supplementary screws were inserted through the base plate into the tibia in 49% of arthroplasties and the remaining 51% were not fixed. In both groups the postoperative femoral angle measured 95% and at 12-month evaluation the tibial angle measured 89°, giving a total valgus angle of 6°. To date no tibial base plates have come loose. It is felt that the large central titanium peg plays a major role in assisting fixation of the base plate to the tibia and that supplementary screws are unnecessary. There is a small cost saving when screws are not used. We postulate that one may in the future minimise polyethylene debris tracking and osteolysis