Modern total shoulder arthroplasty seeks to produce a construct that reproduces the kinematics and stability of the native glenohumeral joint. The latest 4th generation implants are modular, adaptable, and capable of use as either anatomic or reverse shoulder arthroplasty components. During surgery, these implants are “universal”; post-operatively, they are “convertible”.

Recent work has demonstrated that reverse shoulder arthroplasty components may indeed be the emerging standard of care for most (if not all) shoulder arthroplasty indications.

As this new frontier develops, the use of a convertible/universal implant creates the flexibility to individually choose the best surgical option for each patient.

Reverse total shoulder arthroplasty (TSA) has demonstrated success in restoring active elevation for patients with rotator cuff dysfunction (with or without arthritis). However, recovery of active external rotation after reverse TSA has demonstrated variable success. Transfer of the latissimus dorsi has shown promise in restoring active external rotation in those patients with profound external rotation deficits.

The combined latissimus transfer and reverse TSA procedure is intra-operatively challenging and fraught with post-operative complications. Technical details and precise indications are necessary to produce the best chance of success with this operation.

Stemless shoulder arthroplasty implants for the proximal humerus provide cementless metaphyseal prosthetic fixation. A near-perfect anatomic restoration of the proximal humeral articular surface is possible with this canal-sparing design—avoiding the risks associated with humeral stems and preserving bone for later revision.

When compared with proximal humeral resurfacing, stemless arthroplasty avoids the potential technical errors that may lead to oversized implants, abnormal shift of the glenohumeral joint center of rotation, and excessive strain on the native rotator cuff.

While canal-sparing stemless implants represent a new concept in shoulder arthroplasty without mid- and long-term results, the failures associated with resurfacing humeral arthroplasty have been documented in the literature. Unlike a stemless component, use of a resurfacing technique (and hence preservation of the humeral head) makes glenoid prosthetic implantation challenging and often impossible.

While the definition of “stiffness” after shoulder arthroplasty remains controversial, loss of range of motion in the post-arthroplasty setting can be a disabling functional complication. Fortunately, the incidence of post-operative loss of both active and passive range of motion is relatively less common following shoulder replacement procedures. Certain pre-operative diagnoses (proximal humeral fracture, capsulorraphy arthropathy, revision arthroplasty) are associated with post-operative soft tissue contractures. Certain medical comorbidities (diabetes, inflammatory arthropathy) are associated with periarticular capsular adhesions at the intracellular level.

Management of the “stiff” shoulder arthroplasty must account for several confounding variables:

Appropriateness of diagnosis leading to arthroplasty

Techniques for management include soft tissue contracture release (manipulation, arthroscopic, open) and component revision.

The classic Hill-Sachs lesion is a compression or impression fracture of the humeral head in occurrence with anterior glenohumeral instability. The true incidence is unknown but clearly increases with recurrent instability episodes. Recent peer-reviewed literature has highlighted the importance of addressing “significant” humeral and glenoid bone defects in the management of glenohumeral instability. Quantification of the “significance” of a Hill-Sachs lesion with regard to location, size, and depth in relation to the glenoid has helped guide indications for surgical management.

Options for managing Hill-Sachs lesions include both humeral-sided techniques (soft tissue, bone, and/or prosthetic techniques) and also glenoid-sided techniques (bone transfers to increase glenoid width). The majority of significant acute or chronic Hill-Sachs lesions can be effectively managed without prosthetic replacement.

Is a prosthetic surface replacement ever indicated for the management of Hill-Sachs lesions? The peer-reviewed literature is sparse with the outcomes of this treatment, and significant consideration must be given to both the age of the patient and the need for such management when other effective non-prosthetic options exist. In a patient with more than half of the humeral head involved after instability episodes (perhaps seizure or polytrauma patients), metallic surface replacement arthroplasty may be an option that could require less involved post-operative care while restoring range of motion and stability.

Background

High functional aspirations and an active ageing population equate to a growing number of patients awaiting hip arthroplasty demanding superior biomechanical function. The purpose of this study was to compare the biomechanics of top walking speed between two commonly used hip arthroplasty procedures to determine if a performance advantage existed.

Aims

To investigate (1) The relationship between macroscopic grading and durability of cartilage repair following collagen-covered autologous chondrocyte implantation (ACI-C) in the knee; (2) The influence of histology on durability of cartilage repair; (3) The relationship between macroscopic appearance and histology of repair tissue.

Purpose

We report on minimum 2 year follow-up results of 71 patients randomised to autologous chondrocyte implantation (ACI) using porcine-derived collagen membrane as a cover (ACI-C) and matrix-induced autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the knee.

Introduction: Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. We performed two separate studies:

1) observational study to analyse surgeon’s and anaesthetist’s attitude to transfusion

Method: 500 orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty.

200 patients (88 THR, 99 TKR, 13 hip resurfacing) were evaluated. Blood Hb, hand grip strength and vigour scores using fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. POMS and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia.

Results: In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below Hb of 8g/dL. Mean transfusion threshold in surgeons was 8.3g/dL compared to 7.9g/dL for anaesthetists (p< 0.01). 97% of surgeons transfused two or more units compared to 78% anaesthetists (p< 0.01). This threshold Hb increased if patient was symptomatic (surgeons 9.3g/dL, anaesthetists 8.8g/dL, p< 0.05), or if known to have pre-existing ischaemic heart disease (surgeons 9.0g/dL, anaesthetists 9.2g/dL, p< 0.05).

A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09).

A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or duration of in-patient physiotherapy (p=0.20).

A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02).

Conclusion: Haemoglobin level below 9g/dL is the most common ‘trigger’ for blood transfusion. Surgeons tend to be more aggressive in their attitude to transfusion. A fall in Hb of more than 4 g/dL has a detrimental effect on post-operative rehabilitation. Pre-operative grip strength measurements are valuable in predicting the rehabilitation potential of patients undergoing lower limb arthroplasty.

Aim: To report the clinical and histological outcome of autologous chondrocyte implantation (ACI) using two techniques -collagen covered ACI or ACI-C and matrix carried ACI or MACI- over eight year period.

Patients and methods: One hundred and seventy one patients (61 ACI-C and 110 MACI) who underwent ACI were followed-up prospectively using both objective and patient reported clinical outcome measures. Biopsy of the repair tissue was performed in 115 patients.

The mean clinical follow-up was 39.4 months (13mths to 8 years) and the mean timing of biopsy was 14.8 months. The mean age at the time of surgery was 32 years (15 to 55 years). The site of defect was as follows: medial femoral condyle-95, lateral femoral condyle-25, trochlea-7, patella 27 and multiple sites- 12. The mean proportion of viable cells available for implantation was 96.3 % (range: 86 to 100) and the mean number of multiplication of cells during culture was 90 (range: 9 to 667).

Results: 79 % of patients had an improvement in clinical outcome, 5 % of patients had no difference and 16 % had deterioration in clinical outcome. Short Form 36 (SF-36) health survey assessments demonstrated significant improvements in both mental and physical component scores (p< 0.001). The number of patients who demonstrated hyaline-like, mixture of hyaline-like and fibrocartilage, fibrocartilagenous and fibrous tissue histology were 32, 22, 59 and 2 respectively.

The most favourable sites were lateral femoral condyle and trochlea where as the least favourable site was patella. There was no correlation between the mental score of patients and the final clinical result. Improvement in functional score was significantly higher among those who had a higher pre-operative function (p< 0.001). There were 7 patients who had previously failed micro-fracture and all of them obtained significant improvements in pain and function. Those who had a higher proportion of viable cells after cell culture demonstrated a tendency towards better outcome, but failed to reach statistical significance (p=0.14). There was no correlation between the number of cell multiplications at the time of cell culture and final clinical outcome (p=0.65). There was no significant difference in clinical outcome between the ACI- C and MACI techniques of ACI (p> 0.05).

Conclusion: Autologous chondrocyte implantation is a useful procedure for patients with symptomatic chondral defects of the knee and produces significant improvement in both objective and patient reported clinical outcome scores in up to 79 % of patients.

Aims: To investigate

the influence of histology on durability of cartilage repair following collagen-covered autologous chon-drocyte implantation (ACI-C) in the knee.

Patients and methods: The modified Cincinnati scores (MCRS) of eighty-six patients were evaluated prospectively at one year and at the latest follow-up (mean follow-up = 4.7yrs. Range = 4 to 7 years). Biopsies of their cartilage repair site were stained with Haema-toxylin and Eosin and some with Safranin O and the neo-cartilage was graded as hyaline-like (n=32), mixed fibro-hyaline (n=19) and fibro-cartilagenous tissue (n=35). Macroscopic grading of the repair tissue using the international cartilage repair society grading system (ICRS) was available for fifty-six patients in this study cohort. Statistical analyses were performed to investigate the significance of histology and ICRS grading on MCRS at 1 year and at the latest follow-up.

Results: The MCRS of all three histology groups were comparable at one year evaluation (p=0.34). However, their clinical scores at the latest follow-up showed a significantly superior result for those with hyaline-like repair tissue when compared to those with mixed fibro-hyaline and fibro-cartilagenous repair (p=0.05).

There was no correlation between the ICRS grading and MCRS either at one year (p=0.12) or at the latest follow-up (p=0.16). Also, the ICRS grading of the repair tissue did not correlate with its histological type (p=0.12).

Conclusion: We conclude that any form of cartilage repair gives good clinical outcome at one year. At four years and beyond, hyaline-like repair tissue produces a more favourable clinical outcome. Macroscopic evaluation using the ICRS grading system does not reflect the clinical outcome or its durability or the histological type of repair tissue.

Purpose: We report on minimum 2 year follow-up results of 71 patients randomised to autologous chon-drocyte implantation (ACI) using porcine-derived collagen membrane as a cover (ACI-C) and matrix-induced autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the knee.

Introduction: ACI is used widely as a treatment for symptomatic chondral and osteochondral defects of the knee. Variations of the original periosteum-cover technique include the use of porcine-derived type I/type III collagen as a cover (ACI-C) and matrix-induced autolo-gous chondrocyte implantation (MACI) using a collagen bilayer seeded with chondrocytes.

Results: 71 patients with a mean age of 33 years (15–48) were randomised to undergo either an ACI-C or a MACI. 37 had ACI-C and 34 MACI. The mean size of the defect was 5.0cm2. Mean duration of symptoms was 104.4 months (9–456). Mean follow-up was 33.5 months (24–45). Functional assessment using the modified Cincinnati knee score, the Bentley functional rating score and the visual analogue score was carried out. Assessment using the modified Cincinnati knee score showed a good to excellent result in 57.1% of patients followed up at 2 years, and 65.2% at 3 years in the ACI-C group; and 63.6% of patients at 2 years, and 64% at 3 years in the MACI group. Arthroscopic assessments showed a good to excellent International Cartilage Repair Society score in 81.8% of ACI-C grafts (22 patients) and 50% of MACI grafts (6 patients). Fisher’s exact test showed a p value of p=0.35 (not statistically significant). Hyaline-like cartilage or hyaline-like cartilage with fibrocartilage was found in biopsies of 56.3% of the ACI-C grafts (9 out of 16 patients) and 30% of the MACI grafts (3 out of 10 patients) after 2 years. Fisher’s exact test showed a p value of p=0.25 (not statistically significant).

Conclusion: At this stage of the trial we conclude that the clinical, arthroscopic and histological outcomes are comparable for both ACI-C and MACI.

Introduction and Aims: Allogenic blood transfusion is often required in lower-limb arthroplasty. The aims of this study were (1) to analyze the influence of anaemia on post-operative fatigue, hand grip strength, duration of in-patient physiotherapy and post-operative morbidity score (POMS) and (2) to investigate for prognostic factors to predict functional recovery following primary arthroplasty of the lower limb.

Patients and methods: This study was approved by the regional ethics committee. Two hundred patients (88 THR, 99 TKR and 13 hip resurfacing) were evaluated in this prospective trial. Blood haemoglobin concentration (Hb), hand grip strength and vigour scores using a validated fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. Postoperative morbidity score (POMS) and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia.

Results: A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09).

A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or required duration of in-patient physiotherapy (p=0.20).

A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02).

Conclusion: We conclude that a fall in Hb of more than 4 g/dL has a detrimental effect on post-operative rehabilitation. Pre-operative grip strength measurements are valuable in predicting the rehabilitation potential of patients undergoing lower limb arthroplasty.

Aim: The aim of this study was to correlate the histology of cartilage repair site with long term clinical function.

Materials and methods: We have analyzed the clinical results of a cohort of patients who had collagen-covered autologous chondrocyte implantations performed since 1998. Our hypothesis was that the hyaline cartilage repair does influence the clinical outcome.

The modified Cincinnati scores (MCRS) of eighty-six patients were evaluated prospectively at one year and at the latest follow-up following ACI-C (mean follow-up= 4.7 years. Range= 4 to 7 years). All these patients underwent biopsies of their cartilage repair site performed at variable periods between six months and five years following ACI-C (mean=22.2 months). The neo-cartilage was graded as hyaline (n=32), mixed fibrohyaline (n=19), fibrocartilagenous (n=35) and fibrous (n=0).

Results: The clinical results showed that at one year, the percentage of patients with excellent and good results was 84.4, 89.5 and 74.3 respectively for those with hyaline, mixed fibro-hyaline and fibro-cartilagenous histology respectively. Their mean MCRS were 70.8, 72.4 and 66.2 respectively. This difference was not statistically significant (p=0.34).

However, their clinical scores at the latest follow-up demonstrated a significantly superior result for those with hyaline repair tissue when compared to those with mixed fibro-hyaline and fibro-cartilagenous repair tissue (p=0.05). The percentage of patients with excellent and good results for those with hyaline, mixed fibro-hyaline and fibro-cartilagenous repair was 75, 42 and 68.6 respectively. Their mean MCRS were 70.6, 56.8 and 63.9 respectively.

Conclusion: This study demonstrates that any form of cartilage repair would give good clinical outcome at one year. At four years and beyond, it appears that patients with hyaline repair tissue tend to show a more favourable clinical outcome whereas those who demonstrated mixed fibrohyaline and fibrocartilagenous repair would show less favourable clinical results.

Functional evaluations using the Harris hip scoring system and the delayed Trendelenberg test were performed on fifty randomly selected patients who had undergone cemented primary CPT total hip replacements (Zimmer UK) at least 12 months previously using Hardinge approach. The prosthesis used increases offset with femoral stem diameter but did not allow separate correction of neck offset.

Patients were grouped according to whether hip offset had been accurately reconstructed, increased or decreased. Their functional outcomes were compared. There was no significant difference (p value 0.57) in the final functional outcome between the three groups. Reconstruction of the hip using a standard cemented CPT prosthesis produced considerable variation in the reconstructed hip arthroplasty offset. This resulted in no functionally significant effect.

Accurate reconstruction of the hip joint offset in total hip arthroplasty may therefore not be as important in the early functional outcome as recently advocated.

Introduction and aims: Increasingly the accurate reconstruction of the hip in total hip arthroplasty is planned using pre-operative pelvic radiographs. The accuracy of reconstruction is assessed using post-operative pelvic radiographs. This study defines significant variations in the offset, hip joint centre and femoral head centre-trochanteric height relations in normal radiographs.

Method: One hundred standard normal pelvic radiographs were examined based on a defined criterion. The medial offset, the vertical height of hip joint centre with reference to the ischial tuberosity and the femoral head centre-trochanterc height relation were measured for both hips. The differences in measurements were evaluated to determine the normal variation in offset and the hip joint centre. The relationship of the femoral head centre to the tip of the greater trochanter was determined.

Results: On average, the right hip and left hip differed by 2.54mm in their offset .The standard deviation of differences was 2.31. Therefore the offset of one hip will predict the offset of the other hip to within 4.62mm, with 95% accuracy. If the reconstructed hip has an offset to within + 4.62 to – 4.62mm of the contra lateral side, then the offset should be considered to be reconstructed as normal. The average difference in height of the hip joint centres of right hip from left hip with reference to bi-ischial line was found to be 3.49mm. The standard deviation of differences was 3.15. Therefore the hip joint centre height measured in one hip will predict the hip joint centre height of the opposite hip to within 6.3mm with 95% accuracy. Thus the hip joint centre height of one hip may differ from the opposite hip by 6.3mm in normal individuals. The tip of greater trochanter was on average 8mm higher than the centre of rotation of the femoral head. The greater trochanter was not at the same level as the femoral head centre as commonly believed.

Conclusion: This study demonstrates considerable variation in the medial offset and the hip joint centre location on pelvic wall. The femur head centre is lower than commonly assumed. These factors should be taken into account when pre-operative planning using pelvic radiographs and assessing the quality of the post-operative reconstruction.