Aims. The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel ‘Hub and Spoke’ Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model. Methods. Patients with idiopathic CTEV were seen in their local hospitals (‘Spokes’) for initial diagnosis and casting, followed by referral to the tertiary hospital (‘Hub’) for tenotomy. Non-idiopathic CTEV was managed solely by the Hub. Primary and secondary outcomes were achieving primary correction, and complication rates resulting in early transfer to the Hub, respectively. Consecutive data were prospectively collected and compared between patients allocated to Hub or Spokes. Mann-Whitney U test, Wilcoxon signed-rank test, or chi-squared tests were used for analysis (alpha-priori = 0.05, two-tailed significance). Results. Between 1 March 2020 and 31 March 2023, 92 patients (139 feet) were treated at the service (Hub 50%, n = 46; Spokes 50%, n = 46), of whom nine were non-idiopathic. All patients (n = 92), regardless of allocation, ultimately achieved primary correction, with idiopathic patients at the Hub requiring fewer casts than the Spokes (mean 4.0 (SD 1.4) vs 6.9 (SD 4.4); p < 0.001). Overall, 60.9% of Spokes’ patients (n = 28/46) required transfer to the Hub due to complications (cast slips Hub n = 2; Spokes n = 17; p < 0.001). These patients ultimately achieved full correction at the Hub. Conclusion. The Shared Care model was found to be feasible in terms of providing primary correction to all patients, with results comparable to other published services. Complication rates were higher at the Spokes, although these were correctable. Future research is needed to assess long-term outcomes, parents’ satisfaction, and cost-effectiveness. Cite this article: Bone Jt Open 2023;4(11):865–872

Aims

The aim of this study was to report the meaningful values of the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS) in patients undergoing primary knee arthroplasty (KA).

Aims

Studies of infant hip development to date have been limited by considering only the changes in appearance of a single ultrasound slice (Graf’s standard plane). We used 3D ultrasound (3DUS) to establish maturation curves of normal infant hip development, quantifying variation by age, sex, side, and anteroposterior location in the hip.

Aims. Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability. Methods. Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired t-tests or Wilcoxon signed-rank tests were used to assess the outcome using the Veterans RAND 12 (VR-12) physical and VR-12 mental scores, the Harris Hip Score (HHS) pain and function, and the Hip disability and Osteoarthritis Outcome score for Joint Replacement (HOOS, JR). Results. The median follow-up was 3.1 years (interquartile range 2.0 to 5.1). The one-year cumulative incidence of recurrent dislocation after revision was 8.7%, which increased to 18.8% at five years and 31.9% at ten years postoperatively. In multivariable analysis, a high American Society of Anesthesiologists (ASA) grade (hazard ratio (HR) 2.72 (95% confidence interval (CI) 1.13 to 6.60)), BMI between 25 and 30 kg/m. 2. (HR 4.31 (95% CI 1.52 to 12.27)), the use of specialized liners (HR 5.39 (95% CI 1.97 to 14.79) to 10.55 (95% CI 2.27 to 49.15)), lumbopelvic stiffness (HR 6.03 (95% CI 1.80 to 20.23)), and postoperative abductor weakness (HR 7.48 (95% CI 2.34 to 23.91)) were significant risk factors for recurrent dislocation. Increasing the size of the acetabular component by > 1 mm significantly decreased the risk of dislocation (HR 0.89 (95% CI 0.82 to 0.96)). The VR-12 physical and HHS (pain and function) scores improved significantly at mid term. Conclusion. Patients requiring revision THA for instability are at risk of recurrent dislocation. Higher ASA grades, being overweight, a previous lumbopelvic fusion, the use of specialized liners, and postoperative abductor weakness are significant risk factors. Cite this article: Bone Joint J 2024;106-B(5 Supple B):105–111

Objectives. Whilst gait speed is variable between healthy and injured adults, the extent to which speed alone alters the 3D in vivo knee kinematics has not been fully described. The purpose of this prospective study was to understand better the spatiotemporal and 3D knee kinematic changes induced by slow compared with normal self-selected walking speeds within young healthy adults. Methods. A total of 26 men and 25 women (18 to 35 years old) participated in this study. Participants walked on a treadmill with the KneeKG system at a slow imposed speed (2 km/hr) for three trials, then at a self-selected comfortable walking speed for another three trials. Paired t-tests, Wilcoxon signed-rank tests, Mann-Whitney U tests and Spearman’s rank correlation coefficients were conducted using Stata/IC 14 to compare kinematics of slow versus self-selected walking speed. Results. Both cadence and step length were reduced during slow gait compared with normal gait. Slow walking reduced flexion during standing (10.6° compared with 13.7°; p < 0.0001), and flexion range of movement (ROM) (53.1° compared with 57.3°; p < 0.0001). Slow walking also induced less adduction ROM (8.3° compared with 10.0°; p < 0.0001), rotation ROM (11.4. °. compared with 13.6. °. ; p < 0.0001), and anteroposterior translation ROM (8.5 mm compared with 10.1 mm; p < 0.0001). Conclusion. The reduced spatiotemporal measures, reduced flexion during stance, and knee ROM in all planes induced by slow walking demonstrate a stiff knee gait, similar to that previously demonstrated in osteoarthritis. Further research is required to determine if these characteristics induced in healthy knees by slow walking provide a valid model of osteoarthritic gait. Cite this article: N. Mannering, T. Young, T. Spelman, P. F. Choong. Three-dimensional knee kinematic analysis during treadmill gait: Slow imposed speed versus normal self-selected speed. Bone Joint Res 2017;6:514–521. DOI: 10.1302/2046-3758.68.BJR-2016-0296.R1

Abstract. Objectives. Exploring the relationship of gait function pre and post total knee replacement (TKR) in two groups of patients. Methods. Three-dimensional gait analysis was performed at Cardiff University, UK, and Karolinska University Hospital, Sweden, on 29 and 25 non-pathological (NP) volunteers, and 39 and 28 patients with end-stage knee osteoarthritis (OA), respectively. Patients were assessed pre and one-year post-TKR. Data reduction was performed via Principal Component (PC) analysis on twenty-four kinematic and kinetic waveforms in both NP and pre/post-TKR. Cardiff's and Karolinska's cohorts were analysed separately. The Cardiff Classifier, a classification system based on the Dempster-Shafer theory, was trained with the first 3 PCs of each variable for each cohort. The Classifier classifies each participant by assigning them a belief in NP, belief in OA (BOA) and belief in uncertainty, based on their biomechanical features. The correlation between patient's BOA values (range: 0–1, 0 indicates null BOA and 1 high BOA) pre and post-TKR was tested through Spearman's correlation coefficient in each cohort. The related-samples Wilcoxon signed-rank test (α=0.05) determined the significant changes in BOA in each cohort of patients. The Mann-Whitney U test (α=0.05) was run to explore differences between the patients’ cohorts. Results. There were no significant differences between patients’ cohorts in median age (p=0.096), height (p=0.673), weight (p=0.064) or KOOS sub-scores pre or post-TKR (p-value ranged 0.069 to 0.955) but Cardiff's patients had a significantly higher BMI (p=0.047). There was a significant, median decrease of 0.12 and 0.19 in the BOA pre to post TKR (p<0.001) in Cardiff's and Karolinska's patients, respectively. There was a statistically significant, strong positive correlation between the BOA pre and post-TKR (Cardiff:r. s. =0.706, p<0.001; Karolinska:r. s. =0.669, p<0.001). Conclusions. In two distinct cohorts of patients, having a more compromised gait function in end-stage knee OA was correlated with poorer gait function post-TKR

Rotator cuff repair has excellent clinical outcomes but continues to be a challenge when it comes to large and massive tears as well as revision procedures. Reported symptomatic retear rates are still too high to be acceptable. The purpose of the present study was to evaluate the effectiveness of a combination of augmentation techniques consisting of microfractures of the greater tuberosity, extracellular matrix (ECM) patch graft and subsequent platelet concentrate (PC) subacromial injections in revision rotator cuff repair. The study was designed as a retrospective comparative study on prospectively collected data from a consecutive cohort of patients. All patients who underwent arthroscopic revision rotator cuff repair for symptomatic failure of previous posterosuperior rotator cuff repair were considered eligible for the study. Symptomatic failure had been diagnosed according to clinical examination and confirmed by magnetic resonance imaging (MRI). Structural integrity had been assessed on MRI and classified according to Sugaya classification. Only patients affected by stage IV-V were considered eligible. Tear reparability was confirmed during arthroscopy. Only patients with a minimum 2 years follow-up were included. Patients were divided in two groups. In group 1 (control group) a standard arthroscopic revision and microfractures of the greater tuberosity were performed; in group 2 (experimental group), microfractures of the greater tuberosity and a ECM patch graft were used to enhance tendon repair, followed by postoperative PC injections. Minimum follow-up was 12 months. Primary outcome was the Constant-Murley score (CMS) normalized for age and gender. Subjective outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score in its short version (Quick-DASH). Tendon integrity was assessed with MRI at 6 months after surgery. Comparison between groups for all discrete variables at baseline and at follow-up was carried out with the Student's t-test for normally distributed data, otherwise Mann-Whitney U-test was used. Within-group differences (baseline vs follow-up) for discrete variables were analyzed by paired t-test, or by Wilcoxon signed-rank test in case of data with non-normal distribution. Differences for categorical variables were assessed by chi-squared test. Significance was considered for p values < 0.05. Forty patients were included in the study (20 patients for each group). The mean follow-up was 13 ± 1.6 months. No patients were lost at the follow up. Comparison between groups did not show significant differences for baseline characteristics. At follow-up, mean CMS was 80.7 ± 16.6 points in group 1 and 91.5 ± 11.5 points in group 2 (p= 0.022). Mean DASH score was 28.6 ± 21.6 points in group 1 and 20.1 ± 17.4 points in group 2 (p= 0.178). Post-operative MRI showed 6 healed shoulders in Group 1 and 16 healed shoulders in Group 2 (p<0.004). No postoperative complications were reported in both groups. The combination of microfractures of the greater tuberosity, ECM patch graft, and subsequent PC subacromial injections is an effective strategy in improving tendon healing rate

While knee osteoarthritis (OA) is now recognized as a complex disease affecting the whole joint, not just the cartilages, there remains a paucity of data regarding the interactions between knee components. One relationship of particular interest is between the spatial variations in cartilage thickness (CTh) and subchondral bone mineral density (BMD). Indeed, bone and cartilage are two mechanosensitive tissues that interact as a functional unit and there is evidence of a biomechanical coupling between both tissues. Particularly, a recent in vivo study has shown a positive relationship in non-OA knees with thicker cartilage where bone is denser, and an alteration of this relationship in OA knees. These observations support the concept of an osteochondral unit and warrant additional research to assess the influence of bone depth. Therefore, this study aimed to characterize the relationship between spatial variations in CTh and BMD measured at various depths below the bone surface. CT-arthrography of 20 non-OA tibias and 20 severe medial-compartment OA tibias were segmented to build 3D mesh models of the bones and cartilages. Each individual tibia model was registered to a reference tibia, allowing to calculate BMD maps at 1, 3, 5 and 10mm below the bone-cartilage interface in the medial compartment. Pearson correlations between CTh maps and the four BMD maps were then calculated for each knee. Lastly, differences in correlation coefficients between successive bone layers were assessed using Wilcoxon signed-rank tests. In both OA and non-OA tibias, the correlation coefficients were higher with the BMD measured in the 1mm layer, and followed a pattern of statistically significant decrease with bone layers of increasing depth (p < 0.021). In non-OA tibias, the median relationship was positive with a strong effect size in the 1, 3 and 5mm layers, while in OA tibias the median relationship was positive only in the 1mm layer and with a medium effect size. In the OA tibias, the median relationship was negative with a weak effect size in the 3 and 5mm layers, and it was negative with a medium effect size in the 10mm layer. In conclusion, the results of the present study support the value of considering bone and cartilage as a unit, and more generally support OA pathophysiology models based on relationships among knee properties

The purpose of this study was to compare the outcomes of arthroscopic unilateral surgery and simultaneous bilateral surgery for posterior ankle impingement syndrome (PAIS) in athletes and to evaluate the usefulness of simultaneous bilateral surgery. A total 48 hindfeet of 41 athletes (14 hindfeet of 14 males, 34 hindfeet of 27 females) who underwent arthroscopic surgery for PAIS were studied. Japanese society for surgery of the foot (JSSF) score and visual analogue scale (VAS) were compared before and after surgery, using Wilcoxon signed-rank test. The operation time and the time to return to sports activity were compared in 10 hindfeet of 5 patients who underwent simultaneous bilateral surgery and 38 hindfeet of 36 patients who underwent unilateral surgery, using Wilcoxon rank sum test. Classic ballet was the most common type of sport that caused PAIS (59%, 24/41 athletes). Soccer (10%, 4/41 athletes), baseball (10%, 4/41 athletes), badminton (5%, 2/41 athletes), volleyball (5%, 2/41 athletes), and athletics (5%, 2/41 athletes) followed. The JSSF score improved significantly from 72.7 preoperatively to 98.9 postoperatively in unilateral surgery, and significantly improved from 75.2 preoperatively to 99.0 postoperatively in simultaneous bilateral surgery. VAS significantly decreased from 64.7 preoperatively to 4.8 postoperatively in unilateral surgery, and significantly decreased from 72.7 preoperatively to 1.0 postoperatively in simultaneous bilateral surgery. The operating time was 53.7 minutes on average for unilateral surgery and 101.0 minutes for simultaneous bilateral surgery, significantly longer in bilateral simultaneous surgery. The mean time to return to sports activity was 4.8 weeks for unilateral surgery and 9.6 weeks for simultaneous bilateral surgery, significantly longer in simultaneous bilateral surgery. Both unilateral and simultaneous bilateral surgeries for PAIS in athletes were useful. It should be noted that the operating time and the time to return to sports will be longer. However, considering the 2 times hospitalizations and 2 times surgeries, simultaneous bilateral surgery is one of the treatment options for PAIS

Aims. Our first aim was to determine whether there are significant changes in the level of metal ions in the blood at mid-term follow-up, in patients with an Articular Surface Replacement (ASR) arthroplasty. Secondly, we sought to identify risk factors for any increases. Patients and Methods. The study involved 435 patients who underwent unilateral, metal-on-metal (MoM) hip resurfacing (HRA) or total hip arthroplasty (THA). These patients all had one measurement of the level of metal ions in the blood before seven years had passed post-operatively (early evaluation) and one after seven years had passed post-operatively (mid-term evaluation). Changes in ion levels were tested using a Wilcoxon signed-rank test. We identified subgroups at the highest risk of increase using a multivariable linear logistic regression model. Results. There were significant increases in the levels of metal ions for patients who underwent both MoM HRA (Chromium (Cr): 0.5 parts per billion (ppb); Cobalt (Co): 1.1 ppb) and MoM THA (Cr: 0.5 ppb; Co: 0.7 ppb). In a multivariable model considering MoM HRAs, the change in the levels of metal ions was influenced by female gender (Co: Odds Ratio (OR) 1.42; p = 0.002 and Cr: OR 1.08; p = 0.006). The change was found to be irrespective of the initial level for the MoM HRAs, whereas there was a negative relationship between the initial level and the change in the level for those with a MoM THA (Co: OR -0.43; p <  0.001 and Cr: OR -0.14; p = 0.033). Conclusion. The levels of metal ions in the blood increase significantly over the period until mid-term follow-up in patients with both a MoM HRA and those with a MoM THA. We recommend that the levels of metal ions be measured most frequently for women with a MoM HRA. While those with a MoM THA appear to stabilise at a certain level, the accuracy of this trend is not yet clear. Vigilant follow-up is still recommended. . Cite this article: Bone Joint J 2017;99-B(4 Supple B):33–40

Introduction. The purpose of this study was to demonstrate the feasibility of passively collecting objective data from a commercially available smartphone-based care management platform (sbCMP) and robotic assisted total knee arthroplasty (raTKA). Methods. Secondary data analysis was performed using de-identified data from a commercial database that collected metrics from a sbCMP combined with intraoperative data collection from raTKA. Patients were included in this analysis if they underwent unilateral raTKA between July 2020 and February 2021, and were prescribed the sbCMP (n=131). The population consisted of 76 females and 55 males, with a mean age of 64 years (range, 43 – 81). Pre-operative through six-week post-operative data included step counts from the sbCMP, as well as administration of the KOOS JR. Intraoperative data included surgical times, the hip-knee-ankle angle (HKA), and medial and lateral laxity assessments from the robotic assessment. Data are presented using descriptive statistics. Comparisons were performed using a paired samples t-test, or Wilcoxon Signed-rank test, with significance assessed at p<0.05. A minimal detectable change (MDC) in the KOOS JR score was considered ½ standard deviation of the preoperative values. Results. KOOS JR scores improved from a preoperative mean of 51.5 ± 11.5 to a 6-week postoperative mean of 64 ± 10.04 (p<0.001). An MDC of 5.75 units was achieved. Step counts decreased initially and returned to preoperative values by week 6 (Figure 1, p=0.196). When evaluating time requirements from landmarking to completed surgical cuts, the median surgical time was 40.2 minutes (IQR, 29.4 – 52.0). The median absolute deformity for HKA preoperatively was 6.9 degrees (IQR, 4.1 – 10.1) and the final intraoperative median HKA was 0.9 degrees (IQR, 0.1 – 3, p<0.001). There was a difference in medial and lateral joint laxity in flexion and extension at the initial intraoperative evaluation (p<0.01). At the final evaluation there was no difference in medial and lateral joint laxity in extension (p=0.239); however, a slight difference in flexion was noted (p=0.001). Given the median values of 1.2mm (0.8 – 2.4) medially vs. 1.4mm (0.9 – 3) laterally, this difference is not likely clinically relevant. Patients who had <1 mm of medial laxity in flexion had significantly fewer step counts at week 6 post-operatively (p=0.035). There was no difference in KOOS JR scores associated with tightness (p>0.05). Discussion. The use of passively collected objective measures in a commercial database across the episode of care was feasible and demonstrated associations between intraoperative and post-operative metrics. To our knowledge, this is the first integrated data collection and reporting platform to report on these measures in a commercial population. Future research is needed in order to understand the benefit of displaying these metrics, as well as the role of variations in alignment and gap balance on function. Conclusions. Contemporary data platforms may be used to improve the understanding of individual recovery paths through real-time passive data collection throughout the episode of care. For any figures or tables, please contact the authors directly

Objectives. Osteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible. The aim of the present study was to biomechanically compare retrograde intramedullary fixation of the superior pubic ramus using either one large- or two small-diameter screws. Materials and Methods. A total of 12 human cadaveric hemipelvises were analysed in a matched pair study design. Bone mineral density of the specimens was 68 mgHA/cm. 3. (standard deviation (. sd). 52). The anterior pelvic ring fracture was fixed with either one 7.3 mm cannulated screw (Group 1) or two 3.5 mm pelvic cortex screws (Group 2). Progressively increasing cyclic axial loading was applied through the acetabulum. Relative movements in terms of interfragmentary displacement and gap angle at the fracture site were evaluated by means of optical movement tracking. The Wilcoxon signed-rank test was applied to identify significant differences between the groups. Results. Initial axial construct stiffness was not significantly different between the groups (p = 0.463). Interfragmentary displacement and gap angle at the fracture site were also not statistically significantly different between the groups throughout the evaluated cycles (p ⩾ 0.249). Similarly, cycles to failure were not statistically different between Group 1 (8438, . sd. 6968) and Group 2 (10 213, . sd. 10 334), p = 0.379. Failure mode in both groups was characterised by screw cutting through the cancellous bone. Conclusion. From a biomechanical point of view, pubic ramus stabilisation with either one large or two small fragment screw osteosynthesis is comparable in osteoporotic bone. However, the two-screw fixation technique is less demanding as the smaller screws deflect at the cortical margins. Cite this article: Y. P. Acklin, I. Zderic, S. Grechenig, R. G. Richards, P. Schmitz, B. Gueorguiev. Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density? Bone Joint Res 2017;6:8–13. DOI: 10.1302/2046-3758.61.BJR-2016-0261

Poor soft tissue balance in total knee arthroplasty (TKA) is one of the most primary causes of dissatisfaction and reduced joint longevity, which are associated with postoperative instability and early implant failure. 1. Therefore, surgical techniques, including mechanical instruments and 3-D guided navigation systems, in TKA aim to achieve optimum soft tissue balancing in the knee to improve postoperative outcome. 2. Patella-in-Place balancing (PIPB) is a novel technique which aims to restore native collateral ligament behaviour by preserving the original state without any release. Moreover, reduction of the joint laxity compensates for the loss of the visco-elastic properties of the cartilage and meniscus. Following its clinical success, we aimed to evaluate the impact of the PIPB technique on collateral ligament strain and laxity behaviour, with the hypothesis that PIPB would restore strains in the collateral ligaments. 3. . Eight fresh-frozen cadaveric legs were obtained (KU Leuven, Belgium, H019 2015-11-04) and CT images were acquired while rigid marker frames were affixed into the femur, and tibia for testing. After carefully removing the soft tissues around the knee joint, while preserving the joint capsule, ligaments, and tendons, digital extensometers (MTS, Minnesota, USA) were attached along the length of the superficial medial collateral ligament (MCL) and lateral collateral ligament (LCL). A handheld digital dynamometer (Mark-10, Copiague, USA) was used to apply an abduction or adduction moment of 10 Nm at fixed knee flexion angles of 0°, 30°, 60° and 90°. A motion capture system (Vicon Motion Systems, UK) was used to record the trajectories of the rigid marker frames while synchronized strain data was collected for MCL/LCL. All motion protocols were applied following TKA was performed using PIPB with a cruciate retaining implant (Stryker Triathlon, MI, USA). Furthermore, tibiofemoral kinematics were calculated. 4. and combined with the strain data. Postoperative tibial varus/valgus stresses and collateral ligament strains were compared to the native condition using the Wilcoxon Signed-Rank Test (p<0.05). Postoperative tibial valgus laxity was lower than the native condition for all flexion angles. Moreover, tibial valgus of TKA was significantly different than the native condition, except for 0° (p=0.32). Although, tibial varus laxity of TKA was lower than the native at all angles, significant difference was only found at 0° (p=0.03) and 90° (p=0.02). No significant differences were observed in postoperative collateral ligament strains, as compared to the native condition, for all flexion angles, except for MCL strain at 30° (p=0.02) and 60° (p=0.01). Results from this experimental study supported our hypotheses, barring MCL strain in mid-flexion, which might be associated with the implant design. Restored collateral ligament strains with reduced joint laxity, demonstrated by the PIPB technique in TKA in vitro, could potentially restore natural joint kinematics, thereby improving patient outcomes. In conclusion, to further prove the success of PIPB, further biomechanical studies are required to evaluate the success rate of PIPB technique in different implant designs

Background. In the setting of a “dry” aspiration, saline lavage is commonly used to obtain a sample for analysis. The purpose of this study is to prospectively determine the impact of saline lavage on synovial fluid markers in revision arthroplasty. Methods. 79 patients undergoing revision hip (19) and knee (60) arthroplasty were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry-tap (“pre-lavage”) followed by subsequent injection with 20 mL of normal saline and re-aspiration (“post-lavage”). Pre and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared. Statistical analyses utilized the Wilcoxon signed-rank test. Results. Nine patients met modified MSIS criteria for prosthetic joint infection (PJI). Pre and post-lavage %PMN were similar in septic patients (90.1% vs. 88.2%, p=0.40 for septic). Pre and post-lavage WBC counts were different in both cohorts (69,432 vs. 6,547 WBCs, p=0.008 for septic; 1,850 vs. 449 WBCs for aseptic, p<0.001). Using a pre-lavage cutoff of >80% PMN, the post-lavage aspirate correctly identified 84.6% of true positives (sensitivity) and 98.5% of true negatives (specificity). Using a pre-lavage cutoff of >3000 WBCs, the post-lavage aspirate correctly identified only 38.1% of true positives (sensitivity). As the synovial fluid WBC count increased, the correlation between pre and post-lavage %PMN was stronger (mean difference of 7.0% PMN in WBC <3000 vs. mean difference −2.9% PMN in WBC >3000, p=0.002). Of seven positive pre-lavage fluid cultures, 4 remained positive post-lavage. Conclusion. While saline lavage aspiration significantly lowers the synovial WBC count, the %PMN is well maintained, particularly at WBC counts >3000. Our findings suggest that in the setting of a dry tap where saline lavage is required to obtain a sample, the %PMN has reasonable sensitivity and specificity for the detection of PJI. For figures, tables, or references, please contact authors directly

Musculoskeletal ultrasound (MSK-US) can have many uses for orthopaedic surgeons, such as assisting in clinical diagnosis for muscle, tendon and ligament injuries, providing direct guidance for joint injections, or assessing the adequacy of a reduction in the emergency department. However, proficiency in sonography is not a requirement for Royal College certification, and orthopaedic trainees are rarely exposed to this modality. The purpose of this project was to assess the usefulness in clinical education of a newly implemented MSK-US course in an orthopaedic surgery program. A MSK-US course for orthopaedic surgery residents was developed by an interdisciplinary team involving a paediatric orthopaedic surgeon, an emergency physician with a fellowship in point-of-care ultrasonography, and an orthopaedic surgery resident. Online videos were created to be viewed by residents prior to a half-day long practical course. The online portion covered the basics of ultrasonography, as well as the normal and abnormal appearance of musculoskeletal structures, while the practical portion applied those principles to the examination, injection, and aspiration of joints, and ultrasound-guided fracture reduction. An online survey covering the level of training of the resident and their previous use of ultrasound (total hours) was filled by the participants prior to the course. Resident's knowledge acquisition was measured with a written pre-course, same-day post-course and six-month follow-up tests. Residents were also scored on a practical shoulder examination immediately after the course and at six-month follow-up. An online survey was also sent to evaluate residents' satisfaction with different aspects of the course (NAS). Change in test scores were calculated using an ANOVA and a Wilcoxon signed-rank test. Ten orthopaedic surgery residents underwent the MSK-US curriculum. Pre-course interest to MSK-US was moderate (65%) and prior exposure was low (1.5 hours mean total experience). MSK-US has been previously mostly observed in the emergency department and sports orthopaedic clinic. Satisfaction with the online curriculum, hands-on practice session and general quality of the course were high (8.78, 8.70 and 8.60/10 respectively). Written test scores improved significantly from 50.7 ± 17% to 84 ± 10.7% immediately after the course (p < 0 .001) and suffered no significant drop at six months (score 75 ± 8.7%, p=0.303). Average post-course practical exam score was 78.8 ± 3.1% and decreased to 66.2 ± 11.3% at six months (p=0.012). Residents significantly improved their subjective comfort level with all aspects of ultrasound use at six months (p=0.007–0.018) but did not significantly increase clinical usage frequency. A MSK-US curriculum was successfully developed and implemented using an interdisciplinary approach. The course was rated high quality and succeeded in improving the residents' knowledge, skills, and comfort with MSK-US. This improvement was maintained at six months on the written test, but did not result in higher frequency of use by the residents

Patellofemoral pain syndrome (PFPS) is a common knee disorder in active individuals. Movement dysfunction of valgus positioning at the knee during weight-bearing is frequently seen in PFPS. A single-leg squat (SLS) is a test commonly used in physiotherapy to assess for movement dysfunction. Kinesio-Tape (KT) is gaining in popularity in treating PFPS and claims to alter muscle recruitment and motor control, however evidence is weak. Objective: To evaluate the effect of KT applied to the quadriceps on muscle activity with electromyography (EMG) of the rectus femoris, vastus lateralis and vastus medialis oblique and motor control via the frontal plane projection angle (FPPA) using 2-dimensional video analysis. A convenience sample of healthy females were recruited and performed 5 single-leg squats with and without KT. EMG of the quadriceps was recorded and dynamic valgus assessed via the FPPA using Dartfish video analysis software. Eccentric and concentric EMG data was recorded and the FPPA measured in single-leg stance and the depth of the squat. Institutional ethical approval was obtained for the study. 16 active females were assessed (mean age 28.94 +6.58 years). Wilcoxon signed-rank tests found no significant change in eccentric or concentric EMG of the quadriceps (%MVC) with KT compared to without (p values 0.35–0.86). Paired-sample t-tests found no significant difference in FPPA between conditions in single-leg stance (p=1.00) or the depth of the squat (p=0.871). KT did not affect EMG activity of the quadriceps or the FPPA in a SLS when applied to the quadriceps of healthy females, questioning proposed effects of KT on normal muscle tissue. Further research is required into the efficacy of using KT in physiotherapy

Purpose. The purpose of this study was to evaluate the short to mid-term results after hemiarthroplasty with extended head prosthesis (CTA head) for patients with cuff tear arthopathy. Hypothesis. Favorable pain reduction would be obtained after hemiarthroplasty with the extended head design. Methods. From June 2005 to Apr 2012, 20 shoulders in 18 patients (mean age 75.6 years-old; 8 famales, 10 males) with cuff tear arthopathy (14, Seebauer 1A; 4, 1B; 1, IIA; 1, IIB) were treated with a hemiarthroplasty with an extended head design (14, CTA head, DePuy; 6, SMR, Lima, figure 1). Minimum follow up was 2 years. Patients were evaluated based on range of motion, the modified UCLA score, and complications. Data were analyzed by means of Wilcoxon signed-rank test. Results. There was no complication related to the implant during this study period (mean follow-up, 3.7 years). There was no infection, hardware loosening, or evidence of progressive acroimion wear. The UCLA score improved from 12.6 to 26.3 at final follow-up (p < 0.01), especially the pain score in the UCLA score improved from 2.8 to 7.6 (p < 0.01). Forward elevation increased slightly from 94° to 118° (p < 0.05), and, external rotation increased from 22.5° to 25.3°. No clinical improvement was observed in the Seebauer IIA patient. Overall, 85% of patients expressed an overall satisfaction with their surgery. Discussion and conclusion. Pain was significantly relieved in the majority of cases. The findings of this study indicate that favorable pain reduction could be obtained after hemiarthroplasty with the extended head design for patients with a cuff tear arthopathy without the superior humeral escape. A low complication rate could be expected for this procedure

Introduction. Revision Total Hip Arthroplasties (THA) have a significantly higher failure rate than primary THA's and the most common cause is aseptic loosening of the cup. To reduce this incidence of loosening various porous metal implants with a rough surface and a porous architecture have been developed which are said to increase early osteointegration. However, for successful osteointegration a minimal micromotion between the implant and the host bone (primary stability) is beneficial. It has not been previously determined if the primary stability for the new Gription® titanium cup differs from that of the old Porocoat® titanium cup. Material and Methods. In 10 cadaveric pelvises, divided into 20 hemipelvises, bilateral THA's were performed by an experienced surgeon (RGB) following the implant manufacturer's instructions and with the original surgical instruments provided by the company. In randomized fashion the well established Porocoat® titanium implant was implanted on one side of each each hemipelvis whereas on the corresponding opposite side the modified implant with a Gription® coating was inserted. Radiographs were taken to confirm satisfactory operative results. Subsequently, the hemipelvis and cups were placed in a biomechanical testing machine and subjected to physiological cyclic loading. Three-dimensonal loading corresponded to 30% of the load experienced in normal gait was imposed reflecting the limited weight bearing generally prescribed postoperatively. The dynamic testing took place in a multi-axial testing machine for 1000 cycles. Relative motion and micromotion were quantified using an optical measurement device (Pontos, GOM mbh, Braunschweig, Germany). Statistical evaluation was performed using the Wilcoxon signed-rank test. Results and conclusion. The standard Porocoat® titanium cups showed a mean relative motion with respect to the host bone of 54.74µm (Range 26.04 – 127.06µm), while the porous Gription® titanium cup displayed a relative motion with respect to the host bone of 49.77µm (Range 24.69 – 128.37µm). The Wilcoxon test did not reveal a significant difference between the two surfaces. The in-vitro biomechanical evaluation of both acetabular cups under a physiologic loading scenario showed no significant difference with regard to primary stability. Both the extensively tried and clinically successful Porocoat® titanium cup and the newer Gription® coated cup showed very little micromotion and both implants should therefore allow good osteointegration

Objectives. Delayed gadolinium enhanced MRI of cartilage (dGEMRIC) is a novel MRI-based technique with intravenous contrast agent that allows an objective quantification of biochemical cartilage properties. It enables a ‘monitoring' of the loss of cartilage glycosaminoglycan content which ultimately leads to osteoarthritis. Data regarding the longitudinal change of cartilage property after joint preserving hip surgery is sparse. We asked (1) if and how the dGEMRIC-index changes in patients undergoing open/arthroscopic treatment of femoroacetabular impingement (FAI) one year postoperatively compared to a control group of patients with non-operative treatment; (2) and if a change correlates with the clinical short term outcome. Methods. IRB-approved prospective comparative longitudinal study of two groups involving a total of 61 hips in 55 symptomatic patients with FAI. The ‘operative' group consisted of patients that underwent open/arthroscopic treatment of their pathomorphology. The ‘non-operative' group consisted of conservatively treated patients. Groups were comparable for preoperative radiographic arthritis (Tönnis score), preoperative HOOS- and WOMAC-scores and baseline dGEMRIC indices. All patients eligible for evaluation had preoperative radiographs and dGEMRIC scans at baseline and repeated dGEMRIC scans using the same scanner and protocol. (1) dGEMRIC indices of femoral and acetabular cartilage were assessed separately on the initial and follow-up dGEMRIC scans. Radial images were reformatted from a 3D T1 map for measurements. Regions of interest were placed manually peripherally and centrally within the cartilage based on anatomical landmarks at the 12 ‘hour' position of the clcok-face with the help of radial high-resolution PD-weighted MR images. (2) Patient-reported outcome was evaluated at baseline and at 1 year follow-up: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Hip disability and Osteoarthritis Outcome Score (HOOS). Statistical analysis included Student's t-Tests, Mann-Whitney U-tests and Wilcoxon signed-rank tests (p<0.05). Results. On the acetabular side, the dGEMRIC index decreased significantly (p<0.05) in 17/20 (85%) zones respectively in 21/24 (88%) of femoral zones in the operated group [Fig. 1]. In the non-operative group, no acetabular zone and 2/24 (8%) femoral zones presented with a significant drop [Fig. 2]. After one year the WOMAC and the HOOS scores significantly improved (58±42 to 33±42; p= 0.007 respectively 63±16 to 74±18; p= 0.028) for the operative group, while there was no change (55±45 to 48±50; p= 0.825 respectively 63±14 to 66±19; p= 0.816) for the non-operative group. Discussion. Interestingly joint-preserving surgery for FAI led to a decline in biochemical cartilage properties on MRI at a one year follow-up despite the significant improvement of patient outcome. This short-term phenomenon was described after periacetabular osteotomy for correction of hip dysplasia in literature with a normalization of the dGEMRIC values at 2 years

We conducted a randomized controlled trial (RCT) to investigate if iodine impregnated incision drapes (IIID) increases bacterial recolonization rates compared to no drape use under conditions of simulated total knee arthroplasty (TKA) surgery. Background: To prevent surgical site infection (SSI), one of the important issues is managing the patient´s own skin flora. Many prophylactic initiatives have been suggested, including the use of IIID. IIID has been debated for many years and was deemed ineffective in preventing SSI in a recent systematic review [1], while some evidence suggests a potential increase in postoperative infection risk, as a result of IIID use [2]. IIID is sparsely investigated in orthopaedic surgery. An increase in the number of viable bacteria in the surgical field of an arthroplasty operation has a potential to increase the risk of SSI in an otherwise elective and clean procedure [3]. 20 patients scheduled for TKA were recruited. Each patient had one knee randomized for draping with IIID [4] while the contralateral knee was left bare, thus the patients acted as their own controls. Operating theater settings with laminar airflow and standard perioperative procedures were simulated. Sampling was performed with the cup-scrup technique [5] using appropriate neutralizers. Samples were collected from the skin of each knee prior to disinfection and on 2 occasions after skin-preparation, 75 minutes apart. Bacterial quantities were estimated by spread plating with 48-hour aerobic incubation. Outcome was measured as colony forming units per square centimeter of skin. We used Wilcoxon signed-rank test for comparative analysis within and between knees. Following skin-disinfection we found no significant difference in bacterial quantities between the intervention and the control knee (p = 0.388). Neither did we see any difference in bacterial quantities between the two groups after 75 minutes of simulated surgery (p = 0.367). When analyzed within the intervention and control group, bacterial quantities had not significantly increased at the end of surgery when compared to baseline, thus no recolonization was detected (p = 0.665 and 0.609, respectively). Iodine impregnated incision drapes did not increase bacterial recolonization rates in simulated TKA surgery. Thus, the results of this RCT study does not support the hypothesis that iodine impregnated incision drapes promotes bacterial recolonization and postoperative infection risk

Total Elbow Arthroplasty (TEA) is a procedure to treat a number of conditions including rheumatoid arthritis (RA), post-traumatic arthritis, and osteoarthritis. To date, there has been minimal literature published on the Latitude since its release in 2001. There is one study reporting outcomes from the Latitude, a German study published in 2010. The purpose of this study was to analyse outcomes from primary Latitude TEAs. We performed a retrospective case series of 23 TEAs performed on 20 patients. 6 patients required revision surgery and were not included in the analysis. One patient was lost to follow up, resulting in 17 patients included for ROM analysis. All patients received Latitude TEA through a posterior approach and underwent a standard rehab protocol. 11 Patients were recalled at least two years post-op and were administered DASH and MAYO questionnaires. Complications such as triceps insufficiency, ulnar nerve dysfunction, infection, and aseptic loosening were recorded. Outcomes were compared using the Wilcoxon Signed-Rank test in STATA. Immediate post-op radiographs and patients most recent radiographs were analysed by a blinded upper-extremity surgeon not involved in the initial operation and analysed for loosening and implant malpostioning. Mean follow up was 4.8 years (range 2.6–7.5 years). Analysis of 17 TEAs in 16 patients revealed no difference in pre-operative ROM and post-operative ROM for flexion (121°±20 vs 129°±16, p=0.13) extension (40°±27 vs 27°±15, p=0.19), pronation (73°±13 vs 75°±24, p=0.55) or supination (64°±22 vs 68°±14, p=0.52). Patients who underwent TEA for RA had a significant improvement in flexion (121°±15 vs 135°±10, p<0.02). There was a statistically significant improvement in flexion-extension arc post-operatively (101°±28) compared to pre-operative scores (83±23 degrees, p<0.02). DASH and MAYO scores were calculated from 11elbows in 11 non-revision patients able to return for examination. The average MAYO score was 87.9 with nine patients in the “excellent” category, two patients in the “good” category, one patient in the “fair” category, and one in the “poor” category. The average DASH score was 32.9. Two patients underwent revision for periprosthetic fractures, two patients underwent revision for infection, one underwent revision for aseptic loosening and two for radial head dissociation (rate of 30%). This is one of the first studies examining the outcomes of the Latitude TEA. This retrospective case series demonstrates that the Latitude TEA has promising outcomes with respect to improving patient pain and functioning as assessed by the MAYO. Treatment using the Latitude TEA results in favorable functional outcomes for a majority of patients and offers an improvement in flexion-extension arc. Furthermore, our results are comparable to the MAYO scores reported by other studies analysing different prosthesis designs. The complication rate in our series was comparable to published rates of 20–40%

Introduction. We perform PAO via a modified Smith-Petersen approach. The purpose of this study was to investigate the result of PAO via a modified Smith-Petersen approach at a minimum 10-years' follow-up. Methods. We retrospectively reviewed 209 hips in 179 patients with acetabular dysplasia who underwent PAO with a modified Smith-Petersen approach from August 1995 to April 2010. Exclusion criteria were as follows: under 10 year follow-up, incomplete clinical or radiographic data. Harris hip score (HHS) was investigated preoperatively, at the time of most improvement and at the final follow-up for clinical evaluation. Tönnis classification was investigated preoperatively and at the final follow-up for evaluation of osteoarthritis. Center edge (CE) angle and acetabular roof obliquity (ARO) were investigated preoperatively, postoperatively and at the final-follow up for radiographic evaluation. Tönnis classification and radiographic parameters were investigated on anterior-posterior radiographs. Patients of conversion of PAO to total hip arthroplasty (THA) were investigated for preparing Kaplan Myer survival analysis. The Wilcoxon signed-rank test was used to compare changes in HHS and radiographic parameters between the preoperative and the postoperative values. Statistical significance was defined a priori as p < 0.05. Results. Eighty-seven hips in 79 patients (44.1%) were included in this study. 100 patients were excluded from this study. The average age of the patients at the time of surgery was 39 years (rang, 15 to 65 years) and the mean follow-up period was 12 years and 2 months (range, 10 years to 18 years and 3 months). The mean HHS improved from 74 points (range, 38 to 98 points) preoperatively to 95 points (range, 62 to 100 points) at the time of most improvement (p < 0.01) and decrease slightly to 89 points (range, 32 to 100 points) at final follow-up. Tönnis classification was as follows: grade 0 was 4 hips preoperatively and 2 hips at the final follow-up, grade 1 was 55 hips preoperatively and 50 hips at the final follow-up, grade 2 was 25 hips preoperatively and 24 hips at the final follow-up, grade 3 was 3 hips preoperatively and 11 hips at the final follow-up. The mean CE angle improved from 5° (range, −19 to 24°) preoperatively to 30° (range, 2 to 56°) postoperatively (p < 0.01) and increased 38° (range, 12 to 68°) at final follow-up. The mean ARO improved from 24° (range, 6° to 45°) preoperatively to 6° (range, −14° to 48°) postoperatively (p < 0.01) and increased to 12° (range, −24 to 45°) at final follow-up. THA was performed on 5 hips in 5 patients (5.7%) after PAO. The mean duration between PAO and THA was 9 years and 6 months (range, 1 year and 4 months to 15 years 4 months). Ten-year survival rate was 97 % with conversion THA as the end point. Discussion & Conclusion. Clinical data and radiographic parameter were improved in patients who underwent PAO satisfactory. PAO was instrumental as time-saving surgical treatment of symptomatic acetabular dysplasia or slightly osteoarthritis because of 97% survival rate at 10 years

Purpose: Given recent evolving guidelines regarding maximum allowable work hours and emphasis on resident quality of life, novel strategies are required for implementing call schedules. The night float system has been used by some institutions as a strategy to decrease the burden of call on resident quality of life in level one trauma centres. The purpose of this study was to determine whether there are differences in quality of life, work-related stressors, and educational experience between orthopaedic surgery residents in the night float and standard call systems at two level one trauma centres. Method: This was a prospective cohort study at two level one trauma hospitals comprised of a standard call (1 in 4) group and a night float (5pm-7am, Sunday to Friday) group for each hospital, respectively. Residents completed the Short Form 36 (SF-36) general quality-of-life questionnaire, as well as, questionnaires on stress level and educational experience before the rotation (baseline), at two, four and subsequently at six months. An analysis of covariance (ANCOVA) approach was used to compare between-group differences using the baseline scores as covariates. Wilcoxon Signed-Rank tests (non-parametric) were used to determine if the residents’ SF-36 scores were different from the age and sex matched Canadian norms. Predictors of resident quality of life were analyzed using multivariable mixed models. Results: Seven residents were in the standard call group and nine in the night float group for a total of 16 residents (all males, mean age=35.1 yrs). Controlling for between-group differences at baseline, residents on the night float rotation had significantly lower role physical (RP), bodily pain (BP), social function (SF) subscale scores (p< 0.05). Conclusion: Our study suggests that the residents in the standard call group had better health related quality of life in comparison with the night float group. No differences existed in subjective educational benefits and stress level between the groups. The study findings may be limited due to the small sample size. However, this sample size is substantial given the size of most orthopaedic residency programs in North America

CECS is an exercised induced condition that causes pain, typically in the lower limbs, and is relieved by rest. It is often seen in military personnel significantly restricting their duties. Conservative treatment is rarely successful and patients often require surgical decompression by fasciotomy or fasciectomy. All IMP (intramuscular pressure) tests (n=286) carried out between December 2007 and October 2010 on patients with suspected CECS in the anterior compartment of the lower leg were reviewed. The treatment and outcomes of those referred for surgery were analysed. Pre- and post-surgery military medical grading for leg function was extracted from the medical records system. Independent t-tests compared differences between patients that had surgery or did not. The Wilcoxon signed-rank test compared grades before and after surgery. According to the diagnostic criterion, 80% of patients undergoing IMP testing had CECS. Of these, 179 (68%) patients underwent surgery, 17 (9%) of these were for recurrent symptoms. Almost all decompressions were bilateral (95%). The majority of operations (121) were fasciectomies of the anterior compartment only and were performed by 2 surgeons. The remaining operations (58) were performed by 6 surgeons and were fasciotomies of both anterior and lateral compartments. The mean time from testing to surgery was 24 (median 11) weeks. There were 23 (13%) complications other than recurrence including 16 wound infections, 6 seromas and 1 haematoma. Pre- and post-surgery grading was available for 67% of patients. These patients had significantly better leg function after surgery (Z=−3.67, p<0.001). Of these, 47% improved, 38% showed no improvement and 15% had a poorer outcome had. Those who had a fasciectomy were significantly more likely to improve than those who had a fasciotomy (p=0.023, rho=−1.96). Our results demonstrate that patients generally improve lower limb function following surgical decompression. However, 53% showed no improvement or deteriorated in their medical grading. In addition, there is a high diagnosis rate for CECS following IMP measurement. This may reflect the poor validity of the diagnostic criterion or this could be due to good clinical selection for testing. Furthermore, fasciectomy shows a greater correlation with improved outcome than fasciotomy. There is a need to develop more accurate diagnostic criteria and to evaluate the benefits of standardising surgical technique

Introduction. Pseudotumors have been reported following metal-on-metal total hip arthroplasty (THA); however, the natural history and longitudinal imaging findings of pseudotumors have yet to be fully analyzed. Our hypothesis was that pseudotumor size might change over time following metal-on-metal THA. This hypothesis was studied longitudinally using magnetic resonance imaging (MRI). Materials and Methods. Screening for pseudotumors was performed using MRI after large-diameter metal-on-metal THA. Initial MRI was conducted at a mean of 36 months postoperatively. Follow-up MRI was performed at a mean of 20 months after the detection of 24 pseudotumors in 20 asymptomatic patients. Pseudotumors were classified as cystic, solid, and mixed types. Fourteen hips were characterized as cystic type and 10 hips were defined as mixed type. There were three men and 17 women with a mean age of 63 years. Pseudotumor size was determined on MRI by manually outlining the greatest size of the mass. Serum cobalt and chromium ion levels were measured in nine patients with unilateral THA at the time of MRI. Statistical analysis was performed using the Kruskal-Wallis test and chi square test to compare age, gender, BMI, head diameter, cup inclination, cup anteversion, and pseudotumor type among changes of pseudotumor size. We compared the pseudotumor size for the three groups (increase in size, no change, decrease in size) using Kruskal-Wallis test and Mann-Whitney U test. Wilcoxon signed-rank test was used to compare median serum metal ion levels over time. A p value < 0.05 was considered significant. This study was approved by the ethics committee of our institution, and all patients provided informed consent. Results. The mean pseudotumor size changed from 729 mm. 2. to 877 mm. 2. Among the 24 hips, pseudotumors increased in size (Fig. 1) in eight (three cystic and five mixed) and decreased in size in six (four cystic and two mixed). Ten hips showed no changes in size (seven cystic and three mixed). We found no significant differences between changes of pseudotumor size and patient characteristics. The mean initial size of pseudotumor was bigger in pseudotumors with increased in size (1002 ± 309 mm. 2. ) than in those with decreased in size (542 ± 295 mm. 2. , p = 0.020) or no change (622 ± 448 mm. 2. , p = 0.041). The median cobalt ion levels at initial MRI and follow-up MRI were 2.0 µg/L and 1.8 µg/L, respectively. The median chromium ion levels at initial MRI and follow-up MRI were 2.0 µg/L and 3.1 µg/L, respectively. No significant differences were observed between the levels of either metal at initial and subsequent MRI. Conclusions. The present results suggest that pseudotumors frequently change in size in asymptomatic patients, and our hypothesis was verified. The initial size of pseudotumor was bigger in pseudotumors with increased in size than in those with decreased in size or no change. And we might predict that bigger pseudotumors would tend to increase in size

Aims. The aims of this study were to determine the change in pelvic sagittal alignment before, during, and after total hip arthroplasty (THA) undertaken with the patient in the lateral decubitus position, and to determine the impact of these changes on acetabular component position. Patients and Methods. We retrospectively compared the radiological pelvic ratio among 91 patients undergoing THA. In total, 41 patients (46%) were female. The mean age was 61.6 years (. sd. 10.7) and the mean body mass index (BMI) was 20.0 kg/m. 2. (. sd. 5.5). Anteroposterior radiographs were obtained: in the standing position preoperatively and at six weeks postoperatively; in the lateral decubitus position after trial reduction intraoperatively; and in the supine position in the post-anaesthesia care unit. Pelvic ratio was defined as the ratio between the vertical distance from the inferior aspect of the sacroiliac (SI) joints to the superior pubic symphysis and the horizontal distance between the inferior aspect of the SI joints. Changes in the apparent component position based on changes in pelvic ratio were determined, with a change of > 5° considered clinically significant. Analyses were performed using Wilcoxon’s signed-rank test, with p < 0.05 considered significant. Results. Intraoperatively, in the lateral decubitus position, the pelvic ratio increased (anterior tilt) in 69.4% of cases, did not change significantly in 20.4%, and decreased (posterior tilt) in 10.2% of cases. When six-week postoperative radiographs were compared with preoperative radiographs, the pelvic ratio decreased in 44.9% of cases, did not change significantly in 42.3%, and increased in 12.8% of cases. This change in alignment correlated with a change in acetabular component version of > 5° in 79.6% of cases intraoperatively and 57.7% of cases at six weeks postoperatively. Conclusion. Changes in pelvic sagittal pelvic position occur throughout THA that, if unaccounted for, introduce errors in acetabular component placement. The use of intraoperative imaging may help the appropriate placement of the acetabular component. Cite this article: Bone Joint J 2019;101-B(6 Supple B):45–50

Aims. The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications. Patients and Methods. A total of 29 patients undergoing simultaneous bilateral total knee arthroplasty (TKA) were enrolled in a prospective, randomized blinded study. Patients were randomized to receive a CSD in one limb while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction (‘sham drain’). Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps activation, intra-articular effusion measured via ultrasound, lower limb swelling measured with bioelectrical impendence and limb girth, knee ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day two, two and six weeks, and three months. Differences between limbs were determined using paired Student’s t-tests or Wilcoxon’s signed-rank tests. Results. No significant differences were identified between limbs prior to surgery for the primary or secondary outcomes. No significant differences in quadriceps strength were seen between CSD and SCDRN limbs at postoperative day two (p = 0.09), two weeks (primary endpoint) (p = 0.7), six weeks (p = 0.3), or three months (p = 0.5). The secondary outcome of knee extension ROM was significantly greater in the CSD limb compared with the SCDRN (p = 0.01) at two weeks following surgery, but this difference was absent at all other intervals. Secondary outcomes of quadriceps activation, intra-articular effusion, lower limb swelling, and pain were not found to differ significantly at any timepoint following surgery. Conclusion. The use of CSD during TKA did not influence quadriceps strength, quadriceps activation, intra-articular effusion, lower limb swelling, ROM, or pain. These results have limited drain use by the authors in primary uncomplicated TKA. Cite this article: Bone Joint J 2019;101-B (7 Supple C):84–90

Introduction. Displaced fractures in the sacrum are associated with other intra-pelvic organ injuries. There are some reports on short term outcome, however there is little knowledge about the long-term morbidity after these severe injuries. Aims of study. -. Describe neurologic deficits in the lower extremities and impairments involving the uro-genital, bowel and sexual functions a minimum of 8 years after injury. -. Compare the long-term results with our previously published results after one-year follow-up (1). Materials and methods. 39 consecutive patients with displaced sacral fractures were prospectively registered at Oslo university hospital, Ullevaal between 1996 and 2001. Tötterman et al. published 1-year results on 32 of the 39 patients(1). In the present study we followed 29 of these 32 patients for 8 years or more. The following evaluation instruments were used: Neurology: Sensorimotor function was classified according to ASIA score. Bladder function: Structured questionnaire with regards to frequency, urge or incontinence. Also, flowmetry and ultrasound were done to determine maximum flow and post-micturition volume. Bowel function: Structured questionnaire with regards to frequency, urge, diarrhea, constipation and incontinence. Sexual function: Open questions to address any problems associated with sexual function. For male patients, selected questions from the International Index of Erectile Function were used. For comparison with previous data from the one year follow-up we used the Wilcoxon Signed-rank test for non-parametric data. Results. Neurology: 26 patients had neurologic deficits in the lower extremities. Two patients were not testable and only 1 was asymptomatic. Bladder function: 5 had slightly changed, 11 significantly changed and 4 completely changed voiding pattern. Bowel function: 6 had slightly changed and 3 completely changed bowel pattern. Comparing our results with previous data showed deterioration in voiding function over time in 38%(p=0.005), improved bowel function in 28%(p=0.047) and no significant changes in neurological deficits (p=0.47). Sexual function: 45% reported sexual dysfunction versus 38% at the 1-year follow-up. Conclusion. Neurologic deficits, uro-genital and bowel dysfunction are frequent after displaced sacral fractures. Voiding and sexual problems deteriorated over time, while bowel function improved, and neurological deficits showed no significant changes. Pathologic bladder function may cause irreversible structural damage to the bladder, and subsequent impaired renal function. These problems should therefore be addressed early in the rehabilitation period and the patients must be followed by adequate expertise for many years after the injury

Summary. In a rabbit model of early osteoarthritis, structural changes in femoral condyle cartilage were severer in the lateral compartment and preceded alterations in the underlying bone. In the medial compartment, altered bone properties occurred together with structural changes in cartilage. Introduction. Early osteoarthritic changes in cartilage have been previously studied through anterior cruciate ligament transection (ACLT) in rabbits. However, parallel changes in the structure of subchondral and trabecular bone at 4 weeks after ACLT are not known. Methods. Skeletally mature 14-month old New Zealand white rabbits (n=8) underwent ACLT in the left knee, while right knees were used as controls (CTRL). Femoral condyles (FCs) were harvested at 4 weeks after ACLT. INDENTATION TESTING. Stepwise stress-relaxation tests were performed on medial and lateral FC cartilage (100%/s ramp rate, 3×5% step, 15 min relaxation time). Sinusoidal loading was then applied (amplitude 4% of thickness, 1Hz, 4 cycles). Equilibrium (Eeq) and dynamic (Ed) moduli were derived from stress-relaxation and sinusoidal tests, respectively. STRUCTURAL ANALYSIS OF CARTILAGE. Polarised light microscopy (PLM) and digital densitometry (DD) were used to analyze the collagen orientation angle (COA) and proteoglycan content in the cartilage samples. STRUCTURAL ANALYSIS OF BONE. Distal compartments of FCs were scanned using a high-resolution µCT scanner (Skyscan 1172, Belgium) with an isotropic voxel size of 25 µm. µCT data were imported into Mimics (Materialise, Belgium) for segmentation. 2×2×4 mm. 3. volumes of interest (VOIs) were placed in weight-bearing regions of medial and lateral FCs. Subchondral bone plate thickness (Pt.Th), trabecular volume fraction (BV/TV), trabecular thickness (Tb.Th), structural model index (SMI) and trabecular separation (Tb.Sp) were calculated using the CTAnalyzer software (Skyscan) from the VOIs. STATISTICAL TESTS. Mixed linear model for cartilage parameters and Wilcoxon signed-rank test for bone parameters were used to compare ACLT and CTRL groups (p < 0.05). Results. In both lateral and medial FC compartments, Eeq was significantly smaller in ACLT than in CTRL cartilage. In the medial compartment, also Ed was significantly smaller in ACLT than in CTRL cartilage. As a result of ACLT, significant alterations in the COA extended deeper into cartilage in the lateral than medial compartment, while proteoglycan content was reduced significantly and similarly in both lateral and medial FC cartilages. After ACLT, Pt.Th was significantly reduced in the medial compartment, while no changes were observed in the lateral compartment. Furthermore, only in the medial compartment, both BV/TV and Tb.Th were significantly smaller in the ACLT compared to the CTRL group. Discussion. The study showed that disruption of the collagen architecture in the ACLT joint cartilage extended into the middle zone only in the lateral FC compartment. Instead, thinning of the subchondral bone plate combined with resorption of trabecular bone was observed only in the medial FC compartment. The former finding reflects early osteoarthritic changes, while the latter finding may be indicative of a diminished loading in the medial FC compartment, as caused by ACLT

Aims. The purpose of this study was to investigate the risk of additional surgery in the lumbar spine and to describe long-term changes in patient-reported outcomes after surgery for lumbar disc herniation in adolescents and young adults. Patients and Methods. We conducted a retrospective study design on prospectively collected data from a national quality register. The 4537 patients were divided into two groups: adolescents (≤ 18 years old, n = 151) and young adults (19 to 39 years old, n = 4386). The risk of additional lumbar spine surgery was surveyed for a mean of 11.4 years (6.0 to 19.3) in all 4537 patients. Long-term patient-reported outcomes were available at a mean of 7.2 years (5.0 to 10.0) in up to 2716 patients and included satisfaction, global assessment for leg and back pain, Oswestry Disability Index, visual analogue scale for leg and back pain, EuroQol five-dimension questionnaire (EQ-5D), and 36-Item Short-Form Health Survey (SF-36) Mental Component Summary and Physical Component Summary scores. Statistical analyses were performed with Cox proportional hazard regression, chi-squared test, McNemar’s test, Welch–Satterthwaite t-test, and Wilcoxon’s signed-rank test. Results. Any type of additional lumbar spine surgery was seen in 796 patients (18%). Surgery for lumbar disc herniation accounted for more than half of the additional surgeries. The risk of any additional surgery was 0.9 (95% confidence interval (CI) 0.6 to 1.4) and the risk of additional lumbar disc herniation surgery was 1.0 (0.6 to 1.7) in adolescents compared with the young adult group. Both age groups improved their patient-reported outcome data after surgery (all p < 0.001). Changes between short- (mean 1.9 years (1.0 to 2.0)) and long-term follow-up (mean 7.2 years (5.0 to 10.0)) were small. Conclusion. The risk of any additional lumbar spine surgery and additional lumbar disc herniation surgery was similar in adolescents and young adults. All patient-reported outcomes improved from preoperative to the short-term follow-up, while no likely clinically important differences between the short- and long-term follow-up were seen within both groups. Cite this article: Bone Joint J 2019;101-B:1534–1541

Background. Stemless prostheses are recognized to be an effective solution for anatomic total shoulder arthroplasty (TSA) while providing bone preservation and shortest operating time. Reverse shoulder arthroplasty (RSA) with stemless has not showed the same effectiveness, as clinical and biomechanical performances strongly depend on the design. The main concern is related to stability and bone response due to the changed biomechanical conditions; few studies have analyzed these effects in anatomic designs through Finite Element Analysis (FEA), however there is currently no study analyzing the reverse configuration. Additionally, most of the studies do not consider the effect of changing the neck-shaft angle (NSA) resection of the humerus nor the proper assignment of spatial bone properties to the bone models used in the simulations. The aim of this FEA study is to analyze bone response and primary stability of the SMR Stemless prosthesis in reverse with two different NSA cuts and two different reverse angled liners, in bone models with properties assigned using a quantitative computed tomography (QCT) methodology. Methods. Sixteen fresh-frozen cadaveric humeri were modelled using the QCT-based finite element methodology. The humeri were CT-scanned with a hydroxyapatite phantom to allow spatial bone properties assignment [Fig. 1]. Two implanted SMR stemless reverse configurations were considered for each humerus: a 150°-NSA cut with a 0° liner and a 135°-NSA cut with a 7° sloped liner [Fig. 2]. A 105° abduction loading condition was simulated on both the implanted reverse models and the intact (anatomic) humerus; load components were derived from previous dynamic biomechanical simulations on RSA implants for the implanted stemless models and from the OrthoLoad database for the intact humeri. The postoperative bone volume expected to resorb or remodel [Fig. 3a] in the implanted humeri were compared with their intact models in sixteen metaphyseal regions of interest (four 5-mm thick layers parallel to the resection and four anatomical quadrants) by means of a three-way repeated measures ANOVA followed by post hoc tests with Bonferroni correction. In order to evaluate primary stability, micromotions at the bone-Trabecular Titanium interface [Fig. 3b] were compared between the two configurations using a Wilcoxon matched-pairs signed-rank test. The significance level α was set to 0.05. Results. With the exception of the most proximal layer (0.0 – 5.0 mm), the 150°-NSA configuration showed overall a statistically significant lower bone volume expected to resorb (p = 0.011). In terms of bone remodelling, the 150°-NSA configuration had again a better response, but fewer statistically significant differences were found. Regarding micromotions, there was a median decrease (Mdn = 3.2 μm) for the 135°-NSA configuration (Mdn = 40.3 μm) with respect to the 150°-NSA configuration (Mdn = 43.5 μm) but this difference was non-significant (p = 0.464). Conclusions. For the analyzed SMR Stemless configurations, these results suggest a reduction in the risk of bone resorption when a 0° liner is implanted with the humerus cut at 150°. The used QCT-based methodology will allow further investigation, as this study was limited to one single design and load case. For any figures or tables, please contact the authors directly

Aims

Total knee arthroplasty (TKA) may provoke ankle symptoms. The aim of this study was to validate the impact of the preoperative mechanical tibiofemoral angle (mTFA), the talar tilt (TT) on ankle symptoms after TKA, and assess changes in the range of motion (ROM) of the subtalar joint, foot posture, and ankle laxity.

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The objective of this study was to present the outcomes of rotational acetabular osteotomy (RAO) over a 30-year period for osteoarthritis (OA) secondary to dysplasia of the hip in pre- or early-stage OA.

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Ganz’s studies made it possible to address joint deformities on both the femoral and acetabular side brought about by Perthes’ disease. Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency, along with periacetabular osteotomy (PAO), which may enhance coverage and containment. The purpose of this study is to show the clinical and morphological outcomes of the technique and the use of an implemented planning approach.

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Lateral femoral cutaneous nerve (LFCN) injury is a complication after periacetabular osteo-tomy (PAO) using an anterior approach, which might adversely affect the outcome. However, no prospective study has assessed the incidence and severity of this injury and its effect on the clinical outcomes over a period of time for longer than one year after PAO. The aim of this study was to assess the incidence and severity of the symptoms of LFCN injury for ≥ three years after PAO and report its effect on clinical outcomes.

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Although the Fitmore Hip Stem has been on the market for almost 15 years, it is still not well documented in randomized controlled trials. This study compares the Fitmore stem with the CementLeSs (CLS) in several different clinical and radiological aspects. The hypothesis is that there will be no difference in outcome between stems.

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A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability.

Aims

The primary aim of this study was to assess whether patients waiting six months or more for a total hip (THA) or knee (KA) arthroplasty had a deterioration in their health-related quality of life (HRQoL). Secondary aims were to assess changes in frailty and the number of patients living in a state considered to be worse than death (WTD), and factors associated with changes in HRQoL and frailty.

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Patients with midcarpal instability are difficult to manage. It is a rare condition, and few studies have reported the outcomes of surgical treatment. No prospective or retrospective study has reported the results of arthroscopic palmar capsuloligamentous suturing. Our aim was to report the results of a prospective study of arthroscopic suture of this ligament complex in patients with midcarpal instability.

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This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate.

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The goal was to evaluate tibiofemoral knee joint kinematics during stair descent, by simulating the full stair descent motion in vitro. The knee joint kinematics were evaluated for two types of knee implants: bi-cruciate retaining and bi-cruciate stabilized. It was hypothesized that the bi-cruciate retaining implant better approximates native kinematics.

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Mid-level constraint designs for total knee arthroplasty (TKA) are intended to reduce coronal plane laxity. Our aims were to compare kinematics and ligament forces of the Zimmer Biomet Persona posterior-stabilized (PS) and mid-level designs in the coronal, sagittal, and axial planes under loads simulating clinical exams of the knee in a cadaver model.

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The primary aim was to assess change in health-related quality of life (HRQoL) of patients as they waited from six to 12 months for a total hip (THA) or total or partial knee arthroplasty (KA). Secondary aims were to assess change in joint-specific function, mental health, quality of sleep, number living in a state worse than death (WTD), wellbeing, and patient satisfaction with their healthcare.

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To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

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To investigate the correlations among cytokines and regulatory T cells (T-regs) in ankylosing spondylitis (AS) patients, and their changes after anti-tumour necrosis factor-α (TNF-α) treatment.

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Implantation of ultra-purified alginate (UPAL) gel is safe and effective in animal osteochondral defect models. This study aimed to examine the applicability of UPAL gel implantation to acellular therapy in humans with cartilage injury.

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Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections.

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The tibial component of total knee arthroplasty can either be an all-polyethylene (AP) implant or a metal-backed (MB) implant. This study aims to compare the five-year functional outcomes of AP tibial components to MB components in patients aged over 70 years. Secondary aims are to compare quality of life, implant survivorship, and cost-effectiveness.

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The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

Introduction: Implantation of a THA changes the strain distribution pattern in the proximal femur, with a massive loss of stress in the proximal part of the femur and an increase in stress at the distal part of the femoral component. Aim: The purpose of this study was to quantify the changes in BMD during long-term follow-up, i.e. five years, after insertion of the collarless, two-side conical, cemented Exeter stem. Material & Methods: Eighteen patients (all women), aged 55 to 80 years, undergoing THA were included in the study after informed consent. BMD was measured in 7 regions of interest according to Gruen et al., using Dual Energy X-ray Absorptiometry postoperatively, after 18 and 60 months of follow-up. At the same time, the contra lateral hip and spine were scanned. Results were tested using Wilcoxon matched-pairs signed-rank test. P values below 0.05 were considered significant. Results: During the first 18 months, a significant decrease in BMD was present in Gruen zones 2, 3, 6, and 7. No significant changes were seen in BMD of the zones 4, and 5 in the contra lateral hip, nor at the spine. In zone 1 there was a small but significant rise in BMD. From 18 to 60 months of follow up we observed a significant rise in BMD in all Gruen zones but zone 4 and 7. Despite this the total periprostetic BMD decreased during the study periode. There was no significant decrease in BMD in the contra lateral hip. In the spine, we observed a significant rise in BMD. Conclusion: During short-term follow-up (i.e. 18 months) after THA, BMD decreased in Gruen zones 2, 3, 6 and 7. The bone loss is similar to findings in other implants and seems to be related to the changes in stress pattern within the proximal femur. During long-term follow-up (i.e. 5 years) BMD increased again in these zones, however, BMD remained lower than baseline