Background. Load transfer to the bone is believed to be more physiological around the short stem in total hip arthroplasty (THA). However, we found unusual bony remodeling around the shortened tapered femoral stem. Methods. Among 121 consecutive THA using the same shortened tapered stem, 25 hips were excluded because the lateral cortex was already disturbed by previous surgery on the proximal femur. Sixteen hips were also excluded either because direct measurement was unavailable due to improperly taken final radiographs (n=9) or the patient was lost to follow-up (n=7).80 THAs were finally enrolled. Radiographic measurements were made using anteroposterior (AP) radiographs taken immediately and at 2 years after surgery. The thickness of the lateral cortex at the level of the distal end of the coated surface and at 10, 20, 30, and 40 mm proximal to it were measured. Variables for detecting the causative factors were age, gender, BMI, proximal femoral geometry, whether the surgery was done to dominant side, diagnosis leading to surgery, size and offset of the stem, articulation, alignments and operative time. Results. The mean thickness of the lateral cortical bone measured at 10, 20, 30, and 40 mm above the tip of the proximal coating significantly decreased over the course of the 2 years (P<0.001 each). In 46 cases (57.5%), this presented as an intra-cortical osteolytic line (IOL). The mean thickness of the lateral cortex was reduced by more than 10% in 51 cases (63.8%). Sixty-one cases (76.3%) had either an IOL or showed a reduction in lateral cortical thickness greater than 10%. In 37 cases (46.3%), the lateral cortical thickness decreased by more than 20%. The risk of a mean reduction >20% was related to an increased operating time (odds ratio [OR] = 0.981; 0.966 < 95% confidence interval [CI] < 0.996) and lower body mass index (BMI) (OR = 1.216; 1.043 < 95% CI < 1.417). There was one periprosthetic fracture through the atrophied lateral cortex in one patient, The mean reduction of lateral cortex in this patient was 33.2%. Conclusion. Even with THA using a shortened stem, high incidence of proximal stress shielding was noted in the form of lateral cortical atrophy, especially for the patient with low BMI

Introduction. The presence of pluripotent mesenchymal cells in the periosteum along with the growth factors produced or released following injury provides this tissue with an important role in bone healing. Utilising this property, vascularised periosteal flaps may increase the union rates in recalcitrant atrophic long bone non-union. The novel chimeric fibula-periosteal flap utilises the periosteum raised on an independent periosteal vessel, thus allowing the periosteum to be inset freely around the osteotomy site, improving bone biology. Materials & Methods. Ten patients, with established non-union, underwent fibula-periosteal chimeric flaps (2016–2022) at the Canniesburn Plastic Surgery Unit, UK. Preoperative CT angiography was performed to identify the periosteal branches. A case-control approach was used. Patients acted as their own controls, which obviated patient specific risks for non-union. One osteotomy site was covered by the chimeric periosteal flap and one without. In two patients both the osteotomies were covered using a long periosteal flap. Results. Union rate of 100% (11/11) was noted with periosteal flap osteotomies, versus those without flaps at 28.6% (2/7) (p = 0.0025). Time to union was also reduced in the periosteal flaps at 8.5 months versus 16.75 months in the control group (p = 0.023). Survival curves with a hazard ratio of 4.1, equating to a 4 times higher chance of union with periosteal flaps (log-rank p = 0.0016) was observed. Conclusions. The chimeric fibula-periosteal flap provides an option for atrophic recalcitrant non-unions where use of vascularised fibula graft alone may not provide an adequate biological environment for consolidation

Background. We occasionally come across cortical atrophy of the femur with cemented collarless polished triple-taper stem, a short time after the operation. This study aimed to estimate the radiographs of cemented collarless polished triple-taper stem taken at three, six, twelve, and twenty-four months after the initial operation. Methods. Between May 2009 and April 2011, 97 consecutive patients underwent primary total hip arthroplasty and hemiarthroplasty using a SC-stem or C-stem implant. During the 24 month follow-up, radiographic examination was performed on a total of 95 patients (98 hips). Out of those 95 patients, 52 hips had total hip arthroplasty, 45 had osteoarthritis, 5 had idiopathic osteonecrosis, there were two 2 other cases and 46 hips had hemiarthroplasty for femoral neck fractures. The cementing grade was estimated on the postoperative radiographs. The 24 month postoperative radiographs were analyzed for changes in stem subsidence, cortical atrophy and cortical hypertrophy. According to the Gruen zone, cortical atrophy and cortical hypertrophy were classified on the femoral side. We defined no cortical atrophy as grade 0, cortical atrophy less than 1 mm as grade 1, more than 1 mm and less than 2 mm as grade 2, and more than 2 mm as grade 3. We defined Grade 1 as 1 point, Grade 2 as 2 points, and Grade 3 as 3 points. The points in every zone were calculated, and the average per zone was determined. Result. The mean points of the cortical atrophy adjacent to the stem was 1.19 in THA, and 1.58 in BHA in zone II, 0.98 in THA, and 1.15 in BHA in zone III, 0.34 in THA, and 0.6 in BHA in zone V, and 0.63 in THA, and 0.93 in BHA in zone VI. Statistical significance was found between the two groups (THA and BHA). Stem subsidence slightly increased with time. During the following 2 years there was not a single case with over 1.5mm of stem subsidence. The average stem subsidence after 24 months was 0.72 in THA, and 0.78 in BHA. Cortical hypertrophy was only demonstrated in 5 cases. Discussion. Cortical atrophy was recognized more in the femoral neck fracture group than in the THA group, and cortical atrophy was recognized in zone 2 and zone 3 more frequently than in zone 5 and zone 6. According to the finite element analysis of the SC-stem, more stress is received on the medial aspect of the stem during weight bearing, so it is suspected that more cortical atrophy on the lateral aspect is associated with stem design. These findings are compatible with the cortical hypertrophy reported with Exeter stem in zone 5. Conclusion. Cortical atrophy (cancellizaton) was recognized in 70% of THA group, and in 80% of BHA group, 2 years after the operation. Cortical atrophy in most cases was recognized in Gruen Zones 2 & 3 (P<0.01). Cortical atrophy was found more severely and more frequently in the femoral neck fracture group than the THA group (P<0.01)

Many pre-clinical models of atrophic non-union do not reflect the clinical scenario, some create a critical size defect, or involve cauterization of the tissue which is uncommonly seen in patients. Atrophic non-union is usually developed following high energy trauma leading to periosteal stripping. The most recent reliable model with these aspects involves creating a non-critical gap of 1mm with periosteal and endosteal stripping. However, this method uses an external fixator for fracture fixation, whereas intramedullary nailing is the standard fixation device for long bone fractures. OBJECTIVES. To establish a clinically relevant model of atrophic non-union using intramedullary nail and (1) ex vivo and in vivo validation and characterization of this model, (2) establishing a standardized method for leg positioning for a reliable x-ray imaging. Ex vivo evaluation: 40 rat's cadavers (adult male 5–6 months old), were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with an external fixator. Tibiae were harvested by leg disarticulation from the knee and ankle joints. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4) using Zwick/Roell® machine. Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. To maintain the non-critical gap, a spacer was inserted in the gap, the design was refined to minimize the effect on the healing surface area. In vivo evaluation was done to validate and characterize the model. Here, a 1 mm gap was created with periosteal and endosteal stripping to induce non-union. The fracture was then fixed by a hypodermic needle. A proper x-ray technique must show fibula in both views. Therefore, a leg holder was used to hold the knee and ankle joints in 90º flexion and the foot was placed in a perpendicular direction with the x-ray film. Lateral view was taken with the foot parallel to the x-ray film. Ex vivo: axial load stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices. Bending load to failure showed that 18G nails are significantly stronger than 20G, thus it is used for the in vivo experiments. In vivo: final iteration revealed 3/3 non-union, and in controls with the periosteum and endosteum intact but with the 1mm non-critical gap, it progressed to 3/3 union. X-ray positioning: A-P view in supine position, there was an unavoidable degree of external rotation in the lower limb, thus the lower part of the fibula appeared behind the tibia. To overcome this, a P-A view of the leg was performed with the body in prone rather, this arrangement allowed both upper and lower parts of the fibula to appear clearly in both views. We report a novel model of atrophic non-union, the surgical procedure is relatively simple and the model is reproducible

Introduction. Total hip arthroplasty (THA) is a common operation. Different operative approaches have specific benefits and compromises. Soft tissue injury occurs in total hip arthroplasty. This prospective study objectively measured muscle volume changes after direct anterior and posterior approach surgeries. Methods. Patients undergoing Direct Anterior Approach (DAA) and Posterior Approach (PA) THA were prospectively evaluated. 3 orthopaedic surgeons performed all surgeries. Muscle volumes of all major muscles around the hip were objectively measured using preoperative and 2 different postoperative follow-up MRIs. 2 independent measurers performed all radiographic volume measurements. Repeated-measures ANOVA was used to compare mean muscle volume changes over time. Student's t-test was used to compare muscle volumes between groups at specific time intervals. Results. MRIs for 10 DAA and 9 PA patients were analyzed. No significant differences between groups were found in BMI or Age. Pre-operative muscle volume comparisons showed no significant differences. Average postoperative follow-up times were 9.6 and 24.3 weeks. First follow-up showed significant atrophy for the DAA in Gluteus Medius (−7.3%), Gluteus Minimus (−17.5%), and Obturator Internus (−37.3%) muscles. Final follow-up showed significant recovery in Gluteus Medius (+12%) and Minimus (+11.1%) muscles. In the PA, atrophy was significant at first follow-up for Gluteus Minimus (−11.8%), Obturator Internus (−46.8%) and Externus (−16%), Piriformis (−26.5%), and Quadratus Femoris (−30.4%) muscles. Recovery was not seen in any of the significantly atrophied muscles. Muscles with significant quantified fatty atrophy at final follow-up were Obturator Internus [+5.51% (DAA); +7.65% (PA)] and Obturator Externus [+5.55% (PA)]. 3/9 PA patients demonstrated abductor tendinosis, while no DAA patients demonstrated tendinosis. Discussion. Significant atrophy for each group was seen more commonly in the anatomic regions disturbed by each approach respectively. In both approaches, muscles surgically released from their insertion showed greater atrophy, and incomplete recovery

Background. We occasionally came across cortical atrophy of femurs with cemented collarless polished triple-taper stem in a short term period. This study aimed to estimate radiographs of cemented collarless polished triple-taper stem taken 6 months after the initial operation. Methods. Between May 2009 and April 2011, 97 consecutive patients underwent primary total hip arthroplasty and hemiarthroplasty using SC-stem or C-stem implants. At the 6 month follow-up, a radiographic examination was performed on 70 patients (71 hips). 44 hips had Total Hip Arthoplasty, 35 had osteoarthritis, 5 had idiopathic osteonecrosis, 2 had other diseases and 27 hips had hemiarthroplasty for femoral neck fractures. The postoperative radiographs were used to estimate the cementing grade. Then the 6 month postoperative radiographs were analyzed for changes in stem subsidence, cortical atrophy and cortical hypertrophy. According to the system of Gruen- cortical atrophy and cortical hypertrophy were classified on the femoral side. We defined no cortical atrophy as grade 0, cortical atrophy less than 1 mm as grade 1, more than 1 mm and less than 2 mm as grade 2, more than 2 mm as grade 3. Result. A cortical atrophy adjacent to the stem was found in zone II according to Gruen on grade 0 thirty-five radiographs (49%), grade 1 twenty (28%), grade 2 eleven (16%), grade 3 five (7%). in zone III grade 0 twenty-seven (38%), grade 1 thirty (42%), grade 2 ten (14%), grade 3 four (6%), in zone V grade 0 fifty (70%), grade 1 twenty (28%), grade 2 one (1%), grade 3 zero (0%), in zone VI grade 0 forty-nine (69%), grade 1 twenty (28%), grade 2 two (3%), grade 3 zero (0%). Cortical hypertrophy was only demonstrated in zone V in one case. In all cases the stem subsidence was less than 1 mm. Cortical atrophy including grade 1 was recognized in 38% of THA, and in 52% of femoral neck fractures. In one case the slight radiolucent line of the postoperative X-ray disappeared after 6 months. Discussion. Cortical atrophy was recognized more in the femoral neck fracture group than in the THA group. And Cortical atrophy was recognized in zone 2 and zone 3 more frequently than in zone 5 and zone 6. According to the finite element analysis of SC-stem more stress is received on the medial aspect of the stem during weight bearing, so it is suspected that more cortical atrophy on the lateral aspect is associated with stem design. This is compatible with the cortical hypertrophy reported with Exeter stem in zone 5. Conclusion. Cortical atrophy, including minor degree atrophy, occurred in 65% of cemented collarless polished triple-taper stem in short term periods after implantation. Cortical atrophy occurred in the lateral aspect of the stem more severely and more frequently than in the medial aspect. Cortical atrophy was also recognized in the femoral neck fracture group more more severely and more frequently than in the THA group

Introduction. Most of patients with unilateral hip disease shows muscle volume atrophy of pelvis and thigh in the affected side because of pain and disuse, resulting in reduced muscle weakness and limping. However, it is unclear how the muscle atrophy correlated with muscle strength in the patient with hip disorders. A previous study have demonstrated that the volume of the gluteus medius correlated with the muscle strength by volumetric measurement using 3 dimensional computed tomography (3D-CT) data, however, muscles influence each other during motions and there is no reports focusing on the relationship between some major muscles of pelvis and thigh including gluteus maximus, gluteus medius, iliopsoas and quadriceps and muscle strength in several hip and knee motions. Therefore, the purpose of the present study is to evaluate the relationship between muscle volumetric atrophy of major muscles of pelvis and thigh and muscle strength in flexion, extension and abduction of hip joints and extension of knee joint before surgery in patients with unilateral hip disease. Material and Methods. The subjects were 38 patients with unilateral hip osteoarthritis, who underwent hip joint surgery. They all underwent preoperative computed tomography (CT) for preoperative planning. There were 6 males and 32 females with average age 59.5 years old. Before surgery, isometric muscle strength in hip flexion, hip extension, hip abduction and knee extension were measured using a hand held dynamometer (µTas F-1, ANIMA Japan). Major muscles including gluteus maximus, gluteus medius, iliopsoas and quadriceps were automatically extracted from the preoperative CT using convolutional neural networks (CNN) and were corrected manually by the experienced surgeon. The muscle volumetric atrophy ratio was defined as the ratio of muscle volume of the affected side to that of the unaffected side. The muscle weakness ratio was defined as the ratio of muscle strength of the affected side to that of the unaffected side. The correlation coefficient between the muscle atrophy ratio and the muscle weakness ratio of each muscle were calculated. Results. The average muscle atrophy ratio was 84.5% (63.5%–108.2%) in gluteus maximus, 86.6% (65.5%–112.1%) in gluteus medius, 81.0% (22.1%–130.8%) in psoas major, and 91.0% (63.8%–127.0%) in quadriceps. The average muscle strength ratio was 71.5% (0%–137.5%) in hip flexion, 88.1% (18.8%–169.6%) in hip abduction, 78.6% (21.9%–130.1%) in hip extension and 84.3% (13.1%–122.8%) in knee extension. The correlation coefficient between the muscle atrophy and the ratio of each muscle strength between the affected and unaffected side were shown in Table 1. Conclusion. In conclusion, the muscle atrophy of gluteus medius muscle, psoas major muscle and quadriceps muscle significantly correlated with the muscle weakness in hip flexion. The muscle atrophy of psoas major muscle and quadriceps muscle also significantly correlated with the muscle weakness in knee extension. There were no significant correlation between the muscle atrophy and the muscle weakness in hip extension and abduction

Background. Rotator cuff atrophy evaluated with computed tomography scans has been associated with asymmetric glenoid wear and humeral head subluxation in glenohumeral arthritis. Magnetic resonance imaging has increased sensitivity for identifying rotator cuff pathology and has not been used to investigate this relationship. The purpose of this study was to use MRI to assess the association of rotator cuff muscle atrophy and glenoid morphology in primary glenohumeral arthritis. Methods. 132 shoulders from 129 patients with primary GHOA were retrospectively reviewed and basic demographic information was collected. All patients had MRIs that included appropriate orthogonal imaging to assess glenoid morphology and rotator cuff pathology and were reviewed by two senior surgeons. All patients had intact rotator cuff tendons. Glenoid morphology was assigned using the modified-Walch classification system (types A1, A2, B1, B2, B3, C, and D) and rotator cuff fatty infiltration was assigned using Goutallier scores. Results. 46 (35%) of the shoulders had posterior wear patterns (23 type B2s, 23 type B3s). Both the infraspinatus and teres minor independently had significantly more fatty infiltration in B2 and B3 type glenoids compared to type A glenoids (p<0.001). There was a greater imbalance in posterior rotator cuff muscle fatty atrophy in B2 and B3 type glenoids compared to type A glenoids (p<0.001). However, there was no difference in axial plane imbalance between B2 and B3 glenoids (p=1.00). There was increased amount fatty infiltration of the infraspinatus among B2 and B3-type glenoids compared to type A glenoids on multivariate analysis controlling for age and gender (p<0.001). Conclusions. These results identify significant axial plane rotator cuff muscle imbalances in B2 and B3-type glenoids compared to concentrically worn glenoids, favoring a relative increase in fatty infiltration of the infraspinatus and teres minor compared to the subscapularis in glenoids with patterns of posterior wear. For any figures or tables, please contact authors directly

Aim:. To assess the long term MRI pathoanatomical changes of unrepaired, isolated full thickness supraspinatus tears in a population of patients that had acromioplasty done for symptomatic impingement syndrome. Background:. To date there are no studies assessing the effect of acromioplasty on rotator cuff tear progression in impingement syndrome. The natural evolution of unrepaired tears suggests that small isolated tears may heal, and not all tears progress onto significant fatty change and atrophy. Which tears heal and which tears progress and the effect of acromioplasty on tear progression is still not known. Results:. There were 17 shoulders examined. Average age of our patients was 65 years at time of surgery and 73 years at follow up. The patients were divided into three groups depending on the size of the tear at the time of surgery: C1 tears (< 1cm) n = 5, C2 tears (1–2 cm) n = 8, C3 tears (2–3 cm) n = 4. The C1 tear group did the best clinically with a Constant score mean 86, 4(range 83–96) and mean Oxford score of 47 (range 46–48). The MRI findings in this group showed only one patient (20%) with significant fatty infiltration and atrophy. The C2 group had mean Constant scores of 72(range 65–98), mean Oxford score 45(range 42–48). On MRI evaluation there were 2 patients (11.8%) that had tears that had regressed in size (CI 1.4‐36.4). In the C3 group the mean Constant score was 75(range 65–85) and Oxford score 45(range 42–48). MRI evaluation revealed that all (100%) the rotator cuff tears went on to significant degeneration and atrophy in this group. No statistical difference was found between these groups when assessing Oxford score (p=0.75) and Constant scores(p=0.69). Significant associations were found between tear size and fatty infiltration (p=0.028), and tear size and atrophy (p=0.054. Conclusion:. Acromioplasty in the management of impingement syndrome may be protective when small isolated tears are noted during surgery as two tears regressed in size. Large tears all progress onto fatty infiltration and atrophy, but all three groups despite tear size had good clinical and functional outcomes. More research is needed to further understand the evolution of tears in impingement syndrome

Complete or nearly complete disruption of the attachment of the gluteus is seen in 10–20% of cases at the time of THA. Special attention is needed to identify the lesion at the time of surgery because the avulsion often is visible only after a thickened hypertrophic trochanteric bursa is removed. From 1/1/09 to 12/31/13, 525 primary hip replacements were performed by a single surgeon. After all total hip components were implanted, the greater trochanteric bursa was removed, and the gluteus medius and minimus attachments to the greater trochanter were visualised and palpated. Ninety-five hips (95 patients) were found to have damage to the muscle attachments to bone. Fifty-four hips had mild damage consisting of splits in the tendon, but no frank avulsion of abductor tendon from their bone attachments. None of these cases had severe atrophy of the abductor muscles, but all had partial fatty infiltration. All hips with this mild lesion had repair of the tendons with #5 Ticron sutures to repair the tendon bundles together, and drill holes through bone to anchor the repair to the greater trochanter. Forty-one hips had severe damage with complete or nearly complete avulsion of the gluteus medius and minimus muscles from their attachments to the greater trochanter. Thirty-five of these hips had partial fatty infiltration of the abductor muscles, but all responded to electrical stimulation. The surface of the greater trochanter was denuded of soft tissue with a rongeur, the muscles were repaired with five-seven #5 Ticron mattress sutures passed through drill holes in the greater trochanter, and a gluteus maximus flap was transferred to the posterior third of the greater trochanter and sutured under the vastus lateralis. Six hips had complete detachment of the gluteus medius and minimus muscles, severe atrophy of the muscles, and poor response of the muscles to electrical stimulation. The gluteus medius and minimus muscles were sutured to the greater trochanter, and gluteus maximus flap was transferred as in the group with functioning gluteus medius and minimus muscles. Postoperatively, patients were instructed to protect the hip for 8 weeks, then abductor exercises were started. The normal hips all had negative Trendelenburg tests at 2 and 5 years postoperative with mild lateral hip pain reported by 11 patients at 2 years, and 12 patients at 5 years. In the group of 54 with mild abductor tendon damage that were treated with simple repair, positive Trendelenburg test was found in 5 hips at 2 years and in 8 hips at 5 years. Lateral hip pain was reported in 7 hips at 2 years, and in 22 at 5 years. In the group of 35 hips with severe avulsion but good muscle tissue, who underwent repair with gluteus maximus flap transfer, all had good abduction against gravity and negative Trendelenburg tests at 2 and 5 years postoperative, and none had lateral hip pain. Of the 6 hips with complete avulsion and poor muscle who underwent abductor muscle repair and gluteus maximus flap transfer, all had weak abduction against gravity, mildly positive Trendelenburg sign, and mild lateral hip pain at 2 and 5 years postoperative. Abductor avulsion is uncommon but not rare, and is detected during THA only by direct examination of the tendon and removal of the trochanteric bursa. Simple repair of mild abductor tendon damage did not prevent progressive abductor weakness in some hips; and the increase in number of patients with lateral hip pain from 2 to 5 years suggests progressive deterioration. Augmentation of the repair with a gluteus maximus flap appears to provide a stable reconstruction of the abductor muscles, and seemed to restore abductor function in the hips with functioning muscles

Objectives. Our objectives were to describe the therapeutic aspects and assess the prognosis of chronic osteomyelitis in children. Materials and methods. We made a retrospective study from January 2007 to December 2016. The study concerned children from 0 to15 years, treated for chronic osteomyelitis and monitored in the pediatric surgery department of the teaching hospital Gabriel Toure, Bamako (Mali). The other types of bone infections, osteitis and bone tumors were not included in the study. In 10 years we received and treated 215 children with chronic osteomyelitis. This represented 3.56% of all the hospitalizations. The mean age was 8.8 (± 6.67) years with extremes of 28 days and 15 years. The patients were first seen by the traditional healer in 165 (76.7%) cases. The sex ratio was 1.26. The major clinical feature was local swelling associated with pain in 110 cases (51.2%). In 135 cases (62.8%) the staphylococcus aureus was found in direct examination or culture. After a year we performed a functional and morphological assessment according to the method of DIMEGLIO. Results. Surgical treatment was performed in all patients. The average delay of stay in hospital was 4.95 ± 4.57 weeks, with extremes of 2 and 12 weeks. The means follow-up was 13 months with extremes of 3 and 20 months. Good results were found in 115 patients, fair in 60 (40 in keloid knee valgus to 11 ° in 10, muscular atrophy 10), bad in 40 (shortening member in 25 non-union in 10 valgus to 18 ° in 5) According Dimeglio score. There was no significant association between the time of consultation, prior treatment received, the surgical technique and the occurrence of complications (p> 0.05). Conclusion. The management of the chronic osteomyelitis is well codified. The functional prognosis is dependent on an early care and sequels can be dramatic in children of school age. Keywords. Chronic osteomyelitis, Treatment, Prognosis, Children

Aims

This study explored the shared genetic traits and molecular interactions between postmenopausal osteoporosis (POMP) and sarcopenia, both of which substantially degrade elderly health and quality of life. We hypothesized that these motor system diseases overlap in pathophysiology and regulatory mechanisms.

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

Subscapularis tenotomy (SST) has been the preferred approach for shoulder arthroplasty for decades but recent controversy has propelled lesser tuberosity osteotomy (LTO) as a potential alternative. Early work by Gerber suggested improved healing and better outcomes with LTO although subscapularis muscular atrophy occurred in this group as well with unknown long-term implications. However, we previously performed a biomechanical study showing that some of the poor results following tenotomy may have been due to historic non-anatomic repair techniques. Surgical technique is critical to allow anatomic healing – this is true of both SST or LTO techniques. A recent meta-analysis of biomechanical cadaveric studies showed that LTO was stronger to SST at “time-zero” with respect to load to failure but there were no significant differences in cyclic displacement. A recent study evaluated neurodiagnostic, functional, and radiographic outcomes in 30 patients with shoulder arthroplasty who had SST. The authors found that the EMG findings were normal in 15 patients but abnormal in the other 15 and that these abnormalities occurred in 5 muscle groups (not just the subscapularis). In another study, patient outcomes were inferior in those patients who had documented subscapularis dysfunction following SST compared to patients who had LTO (none of whom had subscap dysfunction). The literature is not clear, however, on ultimate outcomes based on subscapularis dysfunction post-arthroplasty with some studies showing no difference and others showing significant differences

Aims

The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors.

Introduction. Patients with hip osteoarthritis have a substantial loss of muscular strength in the affected limb compared to the healthy limb preoperatively, but there is very little quantitative information available on preoperative muscle atrophy and degeneration and their influence on postoperative quality of life (QOL) and the risk of falls. The purpose of the present study were two folds; to assess muscle atrophy and degeneration of pelvis and thigh of patients with unilateral hip osteoarthritis using computed tomography (CT) and to evaluate their impacts on postoperative QOL and the risk of falls. Methods. We used preoperative CT data of 20 patients who underwent primary total hip arthroplasty. The following 17 muscles were segmented with our developed semi-automated segmentation method: iliacus, gluteus maximus, gluteus medius, gluteus minimus, rectus femoris, tensor facia lata, adductors, pectinus, piriformis, obturator externus, obturator internus, semimenbranosus, semitendinosus, vastus medialis and vastus lateralis/intermedius (Fig. 1). Volume and radiological density of each muscle were measured. The ratio of those of affected limb to healthy limb was calculated. At the latest follow-up, the WOMAC score was collected and a history of falls after surgery was asked. The average follow- up period was 6 years. Comparison of the volume and radiological density of each muscle between affected and healthy limbs was performed using the Wilcoxon signed rank test. Correlations between the volume and radiological density of each muscle and each score of the WOMAC were evaluated with Spearman's correlation coefficient. The volume and radiological density of each muscle between patients with and without a history of falls were compared using Mann-Whitney U test. Results. 13 of 17 muscles showed significant decrease in muscle volume in affected limb compared to healthy limb. The mean muscle atrophy ratio was 18.6±7.1 (SD) % (0–28.3%). Iliacus, psoas, adductors and piriformis showed a significant volume reduction more than 25 %. All 17 muscles showed reduced radiological density along the affected limb compared to the healthy side. The difference was 8.7±4.2 (SD) Hounsfield units (3.2 to 16.4). Gluteus medius and gluteus minimus showed a significant decrease of radiological density more than 15 HU. The radiological density of gluteus minimus showed higher correlation (R>0.7) with physical function scores of WOMAC for descending stairs, rising from sitting, walking on flat surface, going shopping and rising from bed. Seven of 20 patients had a history of falls, who showed significant reduced radiological density of gluteus minimus and obturator internus compared to the 13 patients without a history of falls. Conclusion. Almost all muscles of pelvis and thigh along the affected limb showed marked atrophy and fatty degeneration compared to the healthy side. Especially, the degree of fatty degeneration of gluteus minimus showed significant impacts on postoperative physical function and the risk of falls of patients

Studies have shown that the trees minor plays an important role after total (TSA) and reverse (RSA) shoulder arthroplasty, as well as in maintenance of function in the setting of infraspinatus wasting. In this regard, teres minor hypertrophy has been described as a compensatory change in response to this infraspinatus wasting, and has been suggested that this compensatory hypertrophy may mitigate the loss of infraspinatus function in the patient with a large rotator cuff tear. The purpose of this study was to determine the prevalence of teres minor hypertrophy in a cohort of patients undergoing rotator cuff repair, and to determine its prognostic effect, if any, on outcomes after surgical repair. Over a 3 year period, all rotator cuff repairs performed in a single practice by 3 ASES member surgeons were collected. Inclusion criteria included both preoperative and postoperative validated outcomes measures (minimum 2 year), and preoperative Magnetic Resonance Imaging (MRI) scanning. 144 patients met all criteria. MRIs were evaluated for rotator cuff tear tendon involvement, tear size, and Goutallier changes of each muscle. In addition, occupational ratios were determined for the supraspinatus, infraspinatus, and teres minor muscles. Patients were divided into 2 groups, based upon whether they had teres minor hypertrophy or not, based on a previously established definition. A 2 way ANOVA was used to determine the effect of teres minor hypertrophy(tear size by hypertrophy) and Goutallier. Teres minor hypertrophy was a relatively common finding in this cohort of rotator cuff patients, with 51% of all shoulders demonstrating hypertrophy. Interestingly, in patients without an infraspinatus tear, teres minor hypertrophy was still present in 19/40 (48%) of patients. Teres minor hypertrophy had a significant, negative effect ASES scores after rotator cuff repair in patients with and without infraspinatus tearing, infraspinatus atrophy, and fatty infiltrative changes (P<0.05). In general, the presence of teres minor hypertrophy showed 10–15% less improvement (Figure 1) than when no hypertrophy was present, and this was consistent across all tear sizes, independent of Goutallier changes. Teres minor hypertrophy is a common finding in the setting of rotator cuff tearing, including in the absence of infraspinatus tearing. Contrary to previous publications, the presence of teres minor hypertrophy in patients with rotator cuff repair does not appear to be protective as a compensatory mechanism. While further study is necessary to determine the mechanism or implication of teres minor hypertrophy in setting of rotator cuff repair, our results show it is not a positive of outcomes following rotator cuff repair

Tourniquet use in total knee arthroplasty is convenient for the surgeon and provides a bloodless field for expeditious surgery and a dry field for cementation, but can best be described as an orthopaedic tradition. It is logical for complex anatomy of ligament, nerve, and vessel surgery but it may not be necessary for total knee replacement. In one recent randomised trial, the absence of the tourniquet was not found to affect the quality of cement fixation. There are numerous potential downsides to the use of a tourniquet including decrease range of motion, delayed recovery, increased pain, wound complications, micro-emboli, neuropathy, and increased VTE. There are also a number of complications associated with the use of a tourniquet including arterial thrombosis, skin irritation below the tourniquet, post-operative hyperemia, blood loss, less accurate intra-operative assessment, and it complicates intravenous drug administration. Studies of range of motion have shown that when there is a difference noted, the range of motion is consistently better without tourniquet use. When a tourniquet is utilised it has been found to be advantageous to only use of tourniquet for a minimal amount of the case, typically when cementing is performed. Functional strength has also been found to be improved without the use of a tourniquet. This was attributed to muscle damage, tourniquet-induced ischemia, and compressive injury. Increased peri-operative pain has also been reported in randomised trials associated with the use of a tourniquet. Edema, swelling, and limb girth issues have also been noted to be associated with tourniquet use. Exsanguinating a limb will result in swelling approximately 10% of the original volume half due to a return of blood, and half due to reactive hyperemia. Longer tourniquet times are also associated with increased wound drainage and more wound hypoxia. Tourniquet use has also been associated with embolic phenomenon with several times greater risk of large emboli associated with tourniquet use. A number of complications have been associated with tourniquet use including thromboembolic complications. In one study where quantitative MRI was utilised on both thighs after unilateral total knee replacement with and without a tourniquet, the tourniquet group showed more atrophy with a loss of 20% of the volume compared to the normal side in total knees performed with a tourniquet which also performed clinically worse. There is a small but substantial risk of arterial thrombosis particularly in patients that have atherosclerotic plaque. Ironically there is a risk of increased post-operative blood loss due to the post-tourniquet “blush” as the blood pressure and pain increase hours after a surgical procedure is completed. There is also difficulty in identifying and coagulating posterior and lateral geniculate vessels with the components in place. Utilizing a tourniquet also interferes with intra-operative assessment of patella tracking, range of motion, ligament stability, and gap balancing. Randomised clinical trials have concluded that there is less pain and quicker recovery without the use of a tourniquet. There have also been reports of less swelling, increased range of motion, less analgesic use and better clinical outcome when a tourniquet is not utilised. A meta-analysis of systematic reviews favored not utilizing a tourniquet due to the decrease in complication rate and the improvement in clinical results. While it is standard practice in the US to utilise a tourniquet, the strong consensus of the literature on the subject favors either not using a tourniquet or minimizing the use of a tourniquet for the period of time necessary for a very dry field for cement fixation

The surgical approach that is adequate for a primary total hip replacement may need to be modified to achieve a more extensile exposure as required for the revision procedure. A straightforward revision total hip replacement procedure can become quite complex when implant removal is attempted without adequate skill, instrumentation, or exposure. The most commonly used approaches in total hip replacement revision surgery are the transtrochanteric, posterolateral, and anterolateral. Although the effects of these approaches on the long-term clinical survival of the prosthetic composite are not completely clear, surgical approach does affect dislocation rates, trochanteric nonunion rates, and other indicators of clinical success. Transtrochanteric Approach - Three variations of the transtrochanteric approach exist: A) The classic Charnley trochanteric approach was popularised by virtue of its use in primary total hip arthroplasty (THA) and, therefore, was easily applied to revision THA. This approach allows excellent visualization of the lateral shaft of the femur, thus enhancing implant and cement removal. However, the classic Charnley approach is associated with a high incidence of trochanteric nonunion. Reattachment of the atrophied trochanteric fragment often requires adjunct fixation such as cables, hooks, or bolts. These devices can subsequently break, migrate, or generate particulate debris which, in turn, is capable of producing extensive granuloma. B) The trochanteric slide is accomplished by an anteromedial inclination of the osteotomy, thus providing a more stable interface for reattachment. The trochanteric slide offers the advantage of maintaining muscle continuity. The disadvantage of this technique is decreased visualization of the acetabulum. Adjunct fixation of the trochanter is also required with this approach. C) By creating a 6 cm to 12 cm distal extension to the trochanteric fragment, a large lateral window is developed which enhances both prosthesis and cement removal. Subsequently, trochanteric fixation is enhanced because the extended fragment increases the surface area available for fixation. Because the extended trochanteric osteotomy requires a larger bone resection, proximal femoral bone stock can be compromised. As a result, proximal prosthetic support with a tapered device can force the trochanteric fragment laterally, increasing the likelihood of nonunion. When an extended trochanteric osteotomy is used, the patient's postoperative physical therapy and rehabilitation course should be modified to protect the healing trochanteric fragment. Posterolateral Surgical Approach is used commonly in revision THA. The technique is popular because it is used widely for endoprosthetic replacement in the treatment of subcapital fractures. Also, the posterolateral approach is quite popular for primary THA. This approach has the advantage of maintaining the integrity of the abductor mechanism. Although femoral exposure is adequate, acetabular exposure can be limited. Also, this approach is associated with an increased incidence of dislocation. Another concern is its close proximity to the sciatic nerve, thus predisposing the patient to the risk of nerve injury. Anterolateral Surgical Approach has the advantage of improved visualization of the acetabulum and femur without the attending trochanteric complications and proximity to the sciatic nerve. This approach is associated with a low incidence of dislocation. However, the abductor muscle is divided or split and, therefore, abductor dysfunction can occur post-operatively. There also can be an increased incidence of heterotopic ossification, but it avoids the problem of trochanteric nonunion

Supercharged end-to-side nerve transfer for severe cubital tunnel syndrome is a recently developed technique which involves augmenting the ulnar motor branch with anterior interosseous nerve (AIN). Previous studies suggested that this technique augments or “babysits” the motor end plates until reinnervation occurs, however, some authors suggested possible reinnervation by the donor nerve. We present two cases where this transfer was done for rapid progressive (6–9 months) cubital tunnel syndrome. The first case was a 57 year-old right hand dominant female who presented to us with severe right cubital tunnel syndrome clinically, including intrinsic wasting and claw deformity. The patient had significant loss of function and visible atrophy to her hand intrinsics over the last few months. Electrodiagnostic studies confirmed the diagnosis of severe cubital tunnel syndrome demonstrating axonal loss, positive sharp waves and fibrillations in the ulnar nerve distribution distally. The patient underwent cubital tunnel ulnar nerve release, subcutaneous anterior transposition, Guyon's canal release along with an AIN to ulnar motor nerve end-to-side transfer. Patient-based functional outcome instruments were prospectively collected with improved overall pain and function as demonstrated from a quickDASH score of 9.1 1 year post-op in comparison to a score of 34.1 pre-op. Recovery was monitored clinically and electrodiagnostic studies at 6 months and 1 year post-operatively. She demonstrated improved intrinsic muscle bulk and strength. The nerve studies at one year showed reinnervation with large amplitude motor unit potentials in the 1st dorsal interosseous and abductor digiti minimi but the 5th finger sensory response remained absent. The second case was a 58 year-old right hand dominant male diagnosed with severe and progressive right cubital tunnel syndrome. Clinically, he had significant muscle wasting and weakness and confirmed denervation on electrodiagnostic studies. He underwent the same surgical procedure as described for the first case and follow-up regimen. The patient demonstrated improved pain score and significant overall function recovery with a quickDASH score of 11.4 one year post-op in comparison to 72.7 pre-op. Nerve studies at one year confirmed our clinical impression, showing ulnar nerve reinnervation with large amplitude motor unit potentials in the 1st dorsal interosseous, while sensory response remained absent. It is yet unclear if end-to-side nerve transfers allow reinnervation of the target muscles. Previous studies have demonstrated clinical improvement with this transfer, however we are unaware of any electrodiagnostic studies demonstrating this effect. These two cases support the notion of reinnervation after an end-to-side procedure. Further studies are needed to assess outcomes of such nerve transfers