Thumb carpometacarpal (CMC) arthritis is a common and disabling condition that can be treated with an operative procedure. Before operative measures, patients typically undergo conservative treatment utilizing methods such as physical therapy and injections. This study aims to determine what clinical modalities are being used for preoperative evaluation and nonoperative therapy and the associated cost prior to operative intervention. We queried Truven Market Scan, a large insurance provider database to identify patients undergoing CMC arthroplasty from 2010 to 2017. Patients were identified by common Current Procedural Terminology (CPT) codes for CMC arthroplasty. All associated CPT codes listed for each patient during the 1 year period prior to operative intervention were collected and filtered to only include those codes associated with the ICD-9/10 diagnosis codes relating to CMC arthritis. The codes were then categorized as office visits, x-ray, injections, physical therapy, medical devices, and preoperative labs. The frequency and associated cost for each category was determined. There were 44,676 patients who underwent CMC arthroplasty during the study period. A total of $26,319,848.36 was charged during the preoperative period, for an average of $589.13 per patient. The highest contributing category to overall cost was office visits (42.1%), followed by injections (13.5%), and then physical therapy (11.1%). The most common diagnostic modality was x-ray, which was performed in 74.7% of patients and made up 11.0% of total charges. Only 49% of patients received at least one injection during the preoperative period and the average number of injections per patient was 1.72. Patients who were employed full time were more likely to receive two or more injections prior to surgery compared to patients who had retired (47% of full-time workers; 34% of retirees). The modalities used for the preoperative evaluation and conservative treatment of CMC arthritis and the associated cost are important to understand in order to determine the most successful and cost-effective treatment plan for patients. Surprisingly, despite the established evidence supporting clinical benefits, many patients do not undergo corticosteroid injections. With office visits being the largest contributor to overall costs, further inquiry into the necessity of multiple visits and efforts to combine visits, can help to reduce cost. Also, with the advent of telemedicine it may be possible to reduce visit cost by utilizing virtual medicine. Determining the best use of telemedicine and its effectiveness are areas for future investigation

Background. Bacteriophages are natural viruses of interest in the field of PJI. A paper previously reported the PhagoDAIR procedure (use of phages during DAIR) in three patients with PJI for whom explantation was not desirable. As the need to isolate the pathogen before surgery to perform phage susceptibility testing is a strong hindrance for the development of this procedure, we developed post-operative phage injections using ultrasound, in patients infected with S. aureus and/or P. aeruginosa who were eligible for the PhagoDAIR procedure, but for whom phages were not available at the time of surgery. Materials/Methods. We performed a single center, exploratory, prospective cohort study including patients with knee PJI who received phage therapy with ultrasound after performance of a DAIR or a partial prosthesis exchange. All patients had PJI requiring conservative surgery and suppressive antimicrobial therapy (SAT) as salvage procedure. Each case was discussed in multidisciplinary meetings in agreement with French health authority, based on the clinical presentation, and the phage susceptibility testing. The cocktail of highly concentrate active phages (5 mL; about 10. e. 9 PFU/mL) was extemporaneous prepared and administered three times directly into the joint using sonography (1 injection per week during 3 weeks) during the postoperative period, before switching antibiotics to SAT. Results. Seven patients received phages under sonography after the DAIR, and one after a partial exchange (mean age 71 years). All had resection prosthesis or constrained knee prosthesis. Among these seven patients, three were infected with S. aureus (including one MRSA), two were infected with P. aeruginosa (one was a multidrug-resistant isolate), one was infected with both S. aureus and P. aeruginosa and the last one was infected with MRSA, S. epidermidis and Corynebacterium spp.. All patients received a cocktail of active phages provided by Pherecydes Pharma targeting S. aureus or P. aeruginosa. No adverse event was recorded during or after the local injections. All patients were switched to SAT after a primary postoperative antimicrobial therapy of three months. Under SAT, the patient with S. epidermidis co-infection developed a relapse due to the S. epidermidis. With a mean follow-up of 13 months after surgery (from 9 to 24 months), the outcome was favorable for all patients without any sign of infection; none of them had abnormal pain, joint effusion or loosening. Conclusions. Postoperative administration of phages using sonography is a potentially useful procedure in patients with complex PJI for whom a conservative approach is desirable

Optimal management of acute patellar dislocation is still a topic of debate. Although, conventionally it has been managed by non-operative measures, recent literature recommends operative treatment to prevent re-dislocations. Our study recommends that results of non-operative measures comparable to that of operative management. Our study is the retrospective with 46 consecutive patients (47 knees) of first time patellar dislocation managed between 2012 and 2014. The study methodology highlighted upon the etiology, mechanism of injury and other characteristics of first time dislocations and also analysed outcomes of conservative management including re-dislocation rates. The duration of follow up ranged from 1 to 4 years. Average age at first-time dislocation was 23 years (Range 10–62 years). Male:Female ratio was 30:17. Twisting injury was the commonest cause. 1 patient required open reduction but all others relocated spontaneously or had successful closed reduction. Medial Patello-Femoral Ligament injury was frequent associated feature. 11 knees (24%) re-dislocated during follow up. Age was the significant risk factor for re-dislocations. All patients with re-dislocation were less than 30 years old. Maximum redislocations happened between 6 months to 1 year after index dislocation. Skeletal abnormality was the commonest pathology in re-dislocators. Only 4 patients (8.6%) finally required surgical intervention. One patient had persistent knee pain as a complication. Conservative management of primary patellar dislocation is successful in majority of patients. Surgery should be reserved for the carefully selected patients with specific indications

Patients presenting with arthrosis following high tibial osteotomy (HTO) pose a technical challenge to the surgeon. Slight overcorrection during osteotomy sometimes results in persisting medial unicompartmental arthrosis, but with a valgus knee. A medial UKA is desirable, but will result in further valgus deformity, while a TKA in someone with deformity but intact cruciates may be a disappointment as it is technically challenging. The problem is similar to that of patients with a femoral malunion and arthrosis. The surgeon has to choose where to make the correction. An ‘all inside’ approach is perhaps the simplest. However, this often means extensive release of ligaments to enable ‘balancing’ of the joint, with significant compromise of the soft tissues and reduced range of motion as a consequence. As patients having HTO in the first place are relatively high demand, we have explored a more conservative option, based upon our experience with patient matched guides. We have been performing combined deformity correction and conservative arthroplasty for 5 years, using PSI developed in the MSk Lab. We have now adapted this approach to the failed HTO. By reversing the osteotomy, closing the opening wedge, or opening the closing wedge, we can restore the obliquity of the joint, and preserve the cruciate ligaments. Technique: CT based plans are used, combined with static imaging and on occasion gait data. Planning software is then used to undertake the arthroplasty, and corrective osteotomy. In the planning software, both tibial and femoral sides of the UKA are performed with minimal bone resection. The tibial osteotomy is then reversed to restore joint line obliquity. The placing of osteotomy, and the angling and positioning in relation to the tibial component are crucial. This is more important in the opening of a closing wedge, where the bone but is close to the keel cut. The tibial component is then readjusted to the final ‘Cartier’ angle. Patient guides are then made. These include a tibial cutting guide which locates both the osteotomy and the arthroplasty. At operation, the bone cuts for the arthroplasty are made first, so that these cuts are not performed on stressed bone. The cuts are not in the classical alignment as they are based upon deformed bone so the use of patient specific guides is a real help. The corrective osteotomy is then performed. If a closing wedge is being opened, then a further fibular osteotomy is needed, while the closing of an opening wedge is an easier undertaking. Six cases of corrective osteotomy and partial knee replacement are presented. In all cases, the cruciates have been preserved, together with normal patello-femoral joints. Patient satisfaction is high, because the deformity has been addressed, restoring body image. Gait characteristics are those of UKA, as the ACL has been preserved and joint line obliquity restored

Distal radius fractures (DRF) are common and the indication for surgical treatment remain controversial in patients higher than 60 years old. The purpose of the study was to review and analyze the current evidence-based literature. We performed a systematic review and meta-analysis according to PRISMA guidelines in order to evaluate the efficacy of volar locking plating (VLP) and conservative treatment in DRF in patients over 60 years old. Electronic databases including MEDLINE, CENTRAL, Embase, Web of science and Clinical Trial.gov were searched from inception to October 2020 for randomized controlled trials. Relevant article reference lists were also passed over. Two reviewers independently screened and extracted the data. Main outcomes included functional status: wrist range of motion, validated scores and grip strength. Secondary outcomes include post-operative complications and radiologic assessment. From 3009 screened citations, 5 trials (539 patients) met the inclusion criteria. All trials of this random effect meta-analysis were at moderate risk of bias due to lack of blinding. Differences in the DASH score (MD −5,91; 95% CI, −8,83; −3,00), PRWE score (MD −9.07; 95% CI, −14.57, −3.57) and grip strength (MD 5,12; 95% CI, 0,59-9,65) were statistically significant and favored VLPs. No effect was observed in terms of range of motion. Adverse events are frequent in both treatment groups, reoperation rate is higher in the VLP group. VLP may provide better functional outcomes in patients higher than 60 years old. More RCT are still needed to evaluate if the risks and complications of VLP outweigh the benefits

Distal radius fractures (DRF) are common and the indication for surgical treatment remain controversial in patients higher than 60 years old. The purpose of the study was to review and analyze the current evidence-based literature. We performed a systematic review and meta-analysis according to PRISMA guidelines in order to evaluate the efficacy of volar locking plating (VLP) and conservative treatment in DRF in patients over 60 years old. Electronic databases including MEDLINE, CENTRAL, Embase, Web of science and Clinical Trial.gov were searched from inception to October 2020 for randomized controlled trials. Relevant article reference lists were also passed over. Two reviewers independently screened and extracted the data. Main outcomes included functional status: wrist range of motion, validated scores and grip strength. Secondary outcomes include post-operative complications and radiologic assessment. From 3009 screened citations, 5 trials (539 patients) met the inclusion criteria. All trials of this random effect meta-analysis were at moderate risk of bias due to lack of blinding. Differences in the DASH score (MD −5,91; 95% CI, −8,83; −3,00), PRWE score (MD −9.07; 95% CI, −14.57, −3.57) and grip strength (MD 5,12; 95% CI, 0,59-9,65) were statistically significant and favored VLPs. No effect was observed in terms of range of motion. Adverse events are frequent in both treatment groups, reoperation rate is higher in the VLP group. VLP may provide better functional outcomes in patients higher than 60 years old. More RCT are still needed to evaluate if the risks and complications of VLP outweigh the benefits

Treatment of acute Achilles tendon rupture is based on obtaining and maintaining apposition of the ruptured tendon ends. Surgical treatment utilises direct suture repair to produce this objective, while conservative or non-surgical management achieves the same effect of closing the tendon gap by immobilisation of the ankle joint in a plantar flexed position within a plaster cast or POP. There is still variability in the conservative treatment practices and protocols of acute Achilles tendon ruptures. The purpose of this study is to examine the current practice trends in the treatment of Achilles tendon ruptures amongst orthopaedic surgeons in the UK. A postal questionnaire was sent to 221 orthopaedic consultants in 25 NHS hospitals in the Greater London area in June 2010. Type and duration of immobilisation were considered along with the specifics of the regime used. Ninety questionnaires were returned giving a 41% response rate. Conservative treatment methods were used by 72% of respondents. A below knee plaster was the top choice of immobilisation (83%) within this group. The mean period of immobilisation was 9.2 weeks (Range 4-36). Weight bearing was allowed at a mean of 5.3 weeks (range 0-12). The specific regime used by consultants was quite heterogeneous across the group, however the most used immobilisation regimen was a below knee plaster in equinus with 3 weekly serial plaster changes to a neutral position, for a total of nine weeks. A heel raise after plaster removal was favoured by 73% of respondents used for a mean period of 6.4 weeks (Range 2-36). In response to ultrasound use as a diagnostic tool, 42.4% of respondents would never use it, 7.6% would use it routinely, while 50% would use it only according to the clinical situation. Comparison of foot and ankle specialists with non-specialists did not reveal a significant difference in practice in duration of immobilisation or time to bearing weight. Conservative management remains a widely practice option in the treatment of Achilles tendon ruptures. Although there are available a number of modern walking aids, the concept of functional brace immobilisation is not as widely used as below knee plaster cast immobilisation, which remains a popular choice amongst orthopaedic surgeons today. There is still no consensus on the ideal immobilisation regimen although a below knee plaster in equinus with serial changes for a total of nine weeks is the most frequently used choice. Further randomised controlled trials are required to establish the optimal treatment strategy for conservative management of Achilles tendon rupture

Introduction. Meniscal tears in middle-aged patients are common. There is a lack of consensus regarding the optimum management of these injuries. Although arthroscopic partial meniscectomy (APM) is a frequently performed surgical option, literature has failed to prove its effectiveness over conservative approaches. Materials and Methods. We retrospectively reviewed 102 middle-aged (age > 40 years) patients who had been treated for meniscal tears between January 2010 and December 2012. We followed these patients up telephonically to assess knee outcome satisfaction rates, any early (6 weeks) improvements in pain and knee function and their pre-morbid and post-treatment activity levels (Tegner Activity Scale). Results. There were 65 male and 37 female patients with an average age of 58 years (range 40–79). After their first consultation 72 patients were treated conservatively and 30 patients were treated with an APM. There were no reported complications following surgery. We managed to contact 87 patients who were followed up at an average of 17.5 months (range 5–34 months). Overall, 72.4% of patients managed were satisfied with their knee outcomes. APM had a 78.9% satisfaction rate and 67.3% of patients treated conservatively were satisfied. There were no significant differences in early or long term pain or knee function improvements between APM or conservative modalities. 89.7% of patients returned to the same or better activity levels after treatment. There was a 1.5 times greater risk of worse activity level following APM. There was a 79.3% satisfaction rate in patients who remained at the same activity level (p=0.00). Analysis showed 21 of the 72 conservatively treated patients failed this approach. APM was performed on 18 of them resulting in a 75% satisfaction rate for this group. Conclusion. APM and conservative management produce equivalently good results for meniscal tears in middle-aged patients. Delayed surgery does not negatively influence the outcome of these patients. NO DISCLOSURES

There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The nonoperative treatment of OA is often highly effective for all stages of the disease; 2) A nonoperative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered. There are many potential causes of pain in an arthritic knee. These include intra-articular (e.g. degenerative meniscal tears, loose bodies, synovitis) and extra-articular (tendonitis, e.g. ilio-tibial band syndrome, bursitis, muscle overload syndromes and referred pain) sites. The potential sources of pain in an arthritic knee produce a wide range of symptoms that are not necessarily correlated with objective measurements (e.g. x-rays, MRI). Moreover, the natural history of an arthritic knee is unpredictable and variable. The treatment of the young, arthritic knee patient of all stages requires a systematic and consistent non-surgical approach. This approach includes the use of: 1) analgesics/anti-inflammatory agents; 2) activity modification; 3) alternative therapies; 4) exercise; 5) injections/lavage. The response to each form of non-surgical treatment is unpredictable at each stage (Kellgren 1–4) of OA. The placebo effect of each from of treatment, including the physician-patient interaction, is 50–60% in patients with mild-moderate OA. The components of a nonoperative treatment program include: 1) Education-emphasising the importance of the patient taking charge of his/her care; 2) Appropriate activity/life style modifications-emphasising the importance of remaining active while avoiding activities that aggravate symptoms (e.g. running to biking); 3) medications-oral, topical, intra-articular; 4) Physical therapy. There are extensive data to support each of these interventions. The AAOS has issued guidelines highlighted the literature based effectiveness of conservative interventions

Femoral neck fractures are the second cause of hospitalization in elderly patients. Nowadays it is still not clear whether surgical treatment may provide better clinical outcome than conservative treatment in patients affected by mental disorders, such as senile dementia. The aim of this study was to retrospectively assess mortality and clinical and functional outcome after hemi arthroplasty operation following intracapsular neck fractures in patients with senile dementia. Between 2008 and 2014, 819 patients were treated at our Orthopaedic Institute for neck fracture of the femur (mean age: 83.8 years old). Eighty-four of these showed clear signs of cognitive impairment at time of admission in the Emergency Department. Mental state of patients was assessed in all cases, as routine, at the Emergency Room with the Short Portable Mental Status Questionnaire (Sh-MMT) and the Mini Mental State Examination (MMSE). Patients were divided in two groups depending whether they were surgically treated with hemiarthroplasty (Group B, 46 patients; 35 females, 11 males; mean age: 88.5 y.o.) or conservatively treated (Group C, 38 patients; 28 females, 10 males; mean age: 79.5 y.o.). These two groups were compared with a matched case-control group of patients surgically treated with no mental disorders (Group A, 40 patients; 34 females, 6 males; mean age: 81.5 y.o.). Incidence of mortality, systemic or local complications and functional clinical outcomes were evaluated with the ADL score and the Barthel index. Mortality rate was 35% (14 patients) for Group A, 50% (21 patients) for Group B and 95% (22 patients) for Group C. Paired t-test, with significance rate set at 0.05, showed significant higher mortality rate in Group A compared to both Group B (p:0.02) and Group C (p:0.001), and also between Group B and Group C (p:0.01). Three orthopaedic complications were found in Group B (two cases of infection and one dislocation of the prosthesis) while none in Group A (p<0.001). There have been 14 overall general complication in Group A (33%), 16 in group B (38%) and 15 in Group C (65%), with significant higher rate in Group B vs. Group A (p:0.02) and in group C vs. Group B (p: 0.001). Activity daily living scale and Barthel Index results showed higher results in Group B than Group C both in terms of recovery of walking ability and daily living (hairdressing, wearing clothes, eating). For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases. Methods. 44 distal humeral fractures were initially treated conservatively - 2004–2010. Mean age 73.9 yrs (40–91) and 34 F: 10 M. Clinical and radiological review at a mean follow-up of 2 years (1–6). Results. There were 18 AO Type A, 7 B and 19 C fractures. The range of elbow movement was extension/flexion 38/124, and pronation/supination 75/76 at their last follow-up. Using the Oxford elbow score (0 = worst/4 best result), the mean pain score was 2.44 (range 1–4), 2.26 (0–4) for function, and 2.04 (0–4) for psycho-social, although several patients had early dementia. Only 5 subsequently underwent replacement out of 44 patients whose residual symptoms have not been sufficient to require surgery. Discussion. We believe that there is a role for initial conservative treatment in selected higher-risk patients, as initial early mobilisation within the limits of discomfort can give good functional results. There is a significant complication rate after fixation or replacement in elderly, frail patients, which includes infection, stiffness and loosening. Unnecessary operations can be avoided in the majority of cases, with replacement of a virgin joint at a later date only if required

The purpose of this study was to evaluate total hip arthroplasty (THA) in the treatment of post-traumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation (ORIF) or conservative treatment of the acetabular fracture. Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from acetabular fractures. There were twenty-six males (27 hips) and eight females (9 hips). The mean age at the time of hip arthroplasty was 49 years (range, 25-78 years). The mean follow-up was eight years and nine months (range, 4-17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Two patients died of unrelated causes and two patients were lost to follow-up. Thirty patients (32 hips) were available for latest follow-up. Twenty-one hips had been previously treated by open reduction internal fixation and 11 hips had conservative treatment. Sixteen patients achieved and maintained a good to excellent result over the course of the follow-up. There was no difference in improvement of mean Harris Hip Score between both groups (p>0.05). Ten out of 32 hips required revision; 9 acetabular components were revised because of aseptic loosening (3), osteolysis/excessive wear (4), instability (1) and infection (1) with a total revision rate of 28%. Eight patients needed acetabular revision alone, one femoral revision alone and one revision of both components. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (p> 0.05). Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction internal fixation. At long term follow-up the main problem identified was osteolysis and acetabular wear

Aim. We aimed to assess the efficacy of conservative management of proximal phalanx fractures in a plaster slab. Methods. 23 consecutive patients with proximal phalanx fractures were included in this prospective study. The fractures were reduced and the position was held with a dorsal slab for three weeks. They were followed up an average of 7 weeks (range 2 to 45) after the injury. Radiographic confirmation of adequate reduction was carried out each week until union. After removal of the plaster, range of motion of the finger and radiological evidence of union, non-union or malunion was documented. Results. In united fractures, an average angulation of 4° (apex volar) was measured (range 0 to 45°). In one case (45°) this was not acceptable. All other cases measured less than 15° of angulation. On the AP radiograph the angulation was on average 2° (range 0 to 8°). On average 1.3 mm of shortening (range 0 to 5mm) were measured. In one case delayed union with rotational deformity of 20° was evident. After removal of the slab mild stiffness was noted in one case at the metacarpophalangeal joint and in two cases at the proximal interphalangeal joint. Conclusion. Most proximal phalanx fractures can be managed conservatively with acceptable results. NO DISCLOSURES

There is no clear consensus regarding the indications for surgical treatment of middle third clavicle fractures. An initial shortening of 2 cm or more of the clavicle was associated with poor clinical outcomes and higher rate of non-union. The number needed to treat (NNT) clavicle fractures in order to prevent non-union ranges in the recent literature from 4.5 to 9.2. A direct relationship between shortening of the clavicle and a poor clinical outcome has not yet been demonstrated. Prospective cohort study performed in a Level one trauma centre including 148 clavicle fractures treated conservatively. Eighty-five patients met the inclusion criteria (healed fracture in the middle third, no other upper limb lesions) and 63 were enrolled. A single assessment was realised at a minimum one year follow-up by an independent examiner and consisted in Constant and DASH scores, range of motion, strength in abduction (Isobex) and a specific radiographic evaluation using a calibrated AP radiographs of both clavicles. Two groups were constituted and analysed according to a radiologic shortening > 2 cm (patients and assessor blinded). Sub-analyses were performed to find any relevant clinical threshold. The rate of shortening > 2cm in this cohort is 16.1% (10 patients). No clinical differences between the two groups for Constant scores (shortened > 2 cm = 96.0 ± 6.0 vs 95.2 ± 6.6, p=0,73) and DASH scores (8.4 ± 11.9 vs 5.4 ± 8.1, p=0,32). A slight loss in flexion was observed with a shortening > 2cm (175 deg ± 8.5 vs 179.3 ± 3.4, p=0,007). No clinical threshold (in absolute or relative length) was associated with lower functional scores. No relationship between clinical results and patient characteristics. Interestingly, cosmesis was not an issue for patients. This study could not demonstrate any clinical impact of the shortening of the clavicle in patients treated conservatively for a fracture in the middle third. Functional scores are excellent and the slight difference in flexion is not clinically significant. We were not able to found patients unsatisfied with their treatment. The poor functional outcomes described in previous studies are mainly related to non-unions. Just after the trauma, protraction of the scapula and single AP views centered on the clavicle can overestimate the real shortening. An initial shortening of the clavicle > 2 cm is not a surgical indication for fractures in the middle third; patient selection for surgery should focus on risk factors for non-unions

Purpose of study. The outcomes of conservatively managed minimally displaced isolated greater tuberosity fractures are sparsely reported and the aim of this study was to look at the outcome of these fractures. patients and methods. Twenty-seven patients who had sustained a greater tuberosity fracture were identified. They were all managed by a single surgeon. All patients had a regime of initial immobilisation for 3 weeks followed by physiotherapy and range of motion exercises. They were all x-rayed at 1 week and 3 weeks after injury to monitor for any displacement. Four fractures occurred with an anterior dislocation. In seven patients the fracture was not visible on x-ray but was diagnosed on Ultrasound or MRI. Twenty-three of 27 patients were available for follow-up. For this follow up, the patients were telephonically contacted and the Oxford Shoulder Score (OSS) was completed to assess their outcome. Results. There were 12 males and 11 females in the review. The average age was 44 yrs (6–71 yrs) and the average follow up was 26.2 months (6–43 months). The OSS for the 23 patients ranged from 22–48 (average 44, median 47, mode of 48). Fourteen patients had LASI as part of their management after they started to develop pain and impingement symptoms. The ones with LASI had a slightly lower median OSS (46) compared to those without (48) but the modal scores were the same (48). One patient needed surgery after the initial fracture displaced at 3 weeks while another patient needed an acromioplasty at 10 months for impingement. Three patients developed a frozen shoulder but subsequently settled and had excellent outcome scores. Summary. In this study, 30% (7) of the fractures were not visible on the x-rays but diagnosed on ultrasound or MRI. Nearly half the patients required subacromial steroid injections to improve recovery. In only one patient did the fracture displace and require fixation. Conclusion. Conservative management of minimally displaced greater tuberosity fractures yields good functional results though a high percentage of patients require subacromial steroid injections. Secondary displacement is rare, however close vigilance of fracture is advised with x-rays done at 1 and 3 weeks postoperatively. NO DISCLOSURES

The Gibson and Moore postero-lateral approach is one of the most often used in hip replacement. The advantage of this approach is an easy execution but it's criticized because of its invasivity to muscle-tendinous tissues especially on extrarotators muscles and because of predisposition to posterior dislocation. Since June 2003 we executed total hip replacements using a modified postero-lateral approach which allows to preserve the piriformis and quadratus femoris muscles and to detach just the conjoint tendon (gemelli and obturator internus). Articular capsule is preserved and it will be anatomically sutured at the end of the procedure as well as the conjoint tendon with two transossesous sutures. Piriformis and quadratus femoris muscles result untouched by this approach. We have executed 500 surgeries with this modified approach. We have used different stems (straight, anatomical, modular and short) and press fit acetabular cup with polyethylene or ceramic insert and we have always used 36 mm femoral heads when allowed by the cup dimensions. We have used any size both of stems and cups without limitation due to the surgical approach. The mean age is 61.8 y.o., 324 females and 176 males. Obese patients, hip dysplasia Crowe 3 and 4 and post traumatic arthrosis are exclusion factors for the execution of this approach. If possible we have maintained the capsulo-tendinous less invasivity. The BMI is not an excluding factor because it's just the gluteus region that is an important factor to decide if to execute or not a less invasive approach. Analyzing our 500 cases we didn't have any case of malpositioning of the stem in varus or valgus (more than 5°) and considering acetabular cup we had the tendency to position it in valgus position (not more than 40°) in the first 20 cases. No leg discrepancy more than 1 cm were observed. Intra-operative blood loss have been reduced of about 30 % and 50% in the post-operative. All the patients were able to active hip mobilization within the first day after surgery with a mean range of motion of 0-70°. The patients were mobilized the first day after surgery and 80% of them were able to assisted walk within second day after surgery. The mean time of stay in hospital was 6.8 days. After 4 weeks 98% of the patients were able to walk without crutches. One case of deep infection were evaluated and then solved with surgical debridement; no wound dehiscence. We had 1 case of anterior hip dislocation in dysplastic arthrosis due to a technical mistake. In 1 case we had femoral nerve palsy, then solved, probably because of anterior retractor malpositioning. We had 5 cases of piriformis muscle contracture without sciatic nerve palsy, then solved. We think that for total hip replacement this conservative postero-lateral approach, thanks to capsule-tendinous modification we have adopted, could be considered an anatomical approach, which doesn't present more dislocation risks compared to other approaches to the hip also thanks to the introduction of 36 mm femoral head that gives more stability and proprioceptiveness. Besides this approach gives the possibility of a shorter rehabilitation as seen above and it could be consider optimal for total hip replacement

Introduction. A new conservative hip stem has been designed to address the complex problem of total hip arthroplasty in the younger population. Objectives. To assess the stability and strain distribution of a new conservative hip stem. Materials and Methods. The prosthesis is tapered and collared and made from titanium (Ti6Al4V) with a titanium porous plasma spray to encourage bony ingrowth (Figure.1). It is circular-trapezoidal in cross-section to provide optimal ‘fit and fill’ in the femoral neck. (i) Finite Element Analysis (FEA). Computed tomography scans of an intact femur were modelled using MARC software and consisted of 161390 elements and 174881 nodes. The implant was modelled (Unigraphics) as a titanium alloy stem with a cobalt-chrome alloy head and consisted of 93440 hexahedral elements and 101133 nodes. This study compared the strains in the femoral calcar of an intact femur with a stem ‘implanted’ in neck shaft angles of 125°, 135°, and 145°. The head of all models received a load of 2.3KN at 7 degrees medially. (ii) Photoelastic Coating. A photoelastic coating was moulded around the medial cortices of ten third generation femora Sawbones. Strain before and after prosthesis insertion was measured at one-centimetre intervals down the medial cortex of the bones using a polariscope. The bones were positioned in a simplified single leg stance (7° physiological alignment), and loaded at 2.3 KN with strain recorded. (iii) Linear Variable Differential Transducers (LVDT's). Micromotion and migration of the prosthesis was measured using LVDT's. The femoral heads were cyclically loaded with 2.3KN at 1Hz for 2,500 cycles and held in a single leg stance. The bones were then repositioned at 70° of flexion to produce torsional (stair climbing) forces and loaded with 0.5KN for 2,500 cycles. Statistical analysis of non-parametric data was performed using a two-tailed Wilcox signed rank test (p<0.05). Results. The FEA analysis revealed strains in the neutral position most closely resembled that of an intact femur (Figure.2). Photoelastic strain readings for intact bone and following insertion were paired and statistically analysed using the Wilcox signed rank test (two tailed). The composite bones with prostheses inserted at 125° and 145° demonstrated a significant difference to the intact bones, whereas those at 135° showed no significant difference in the surface strain pattern of the femur following prosthetic insertion (Figure.3). Under single leg stance loading all prostheses produced axial micromotion of less than 200 µm and 50 µm in the varus-valgus direction. Implants inserted at 135° and 125° produced the least micromotion, the implants inserted at 145° had the greatest magnitude of motion and may be more susceptible to loosening. Under torsional load the same was true with the 135° and 125° producing the least micromotion while with the angulation of 145° micromotion increased over the test period – again suggesting loosening. Conclusion. This design transfers load in a physiological manner and the prosthesis is most stable in the neutral position. The findings from this study have been translated into clinical practice with the prosthesis implanted into two patients with promising results

The objective of this study was to evaluate the short term clinical and radiological results of a new short stem hip implant. In 29 consecutive patients suffering from osteoarthritis with 33 affected hip joints, the clinical and radiological results of 33 cementless hip arthroplasties using a cementless implanted short stem prosthesis type Aida and a cementless cup type Ecofit were evaluated prospectively between October 2009 and June 2015 in two hospitals. The median age of patients at time of surgery was 55 years (range, 30–71 years), 23 male and 10 female patients were included in the study. The median clinical follow up was 24 months (range, 1.5–51 months), and the median radiological follow up was 12 months (range, 1–51 months). Two patients were lost to follow up and two patients had only one immediate postoperative x- ray. The Harris Hip Score improved from a median preoperative value of 53 to a median postoperative value of 93 at follow up. Radiological analysis showed that 19 stems (58%) showed stable bony ingrowth, five cases (15%) showed stable fibrous ingrowth. Four cases need further follow up for proper evaluation of stem fixation. The short term survival of this new short stem is very promising, and achieving the goals of standard hip arthroplasty.

Purpose

The Birmingham Mid-Head Resection (BMHR) is a bone-conserving, short-stem alternative to hip resurfacing for patients with compromised femoral head anatomy. It is unclear, however, if an uncemented, metaphyseal fixed stem confers a mechanical advantage to that of a traditional hip resurfacing in which the femoral prosthesis is cemented to the prepared femoral head. Thus, we aimed to determine if a metaphyseal fixed, bone preserving femoral component provided superior mechanical strength in resisting neck fracture compared to a conventional hip resurfacing arthroplasty.

INTRODUCTION:

Good survival rates of cementless hip stems serve as motivation for further development, just like modular implant systems or short stems. New aims are worth striving for, e.g. soft tissue or bone sparing options with similar survival rates in case of short stems. Even minimal design modifications might result in complications, e.g. missing osseointegration, loosening of the implant or painful stem, as shown in the past.

One of these developments is the Biomet – GTS™ stem [Fig. 1], a hybrid between conventional cementless straight stem and potentially sparing short stem.

Aim of this biomechanical study was to analyze, if the biomechanical behavior of the stem is comparable to a clinically proofed design with respect to the stem fixation in the bone and to the mechanical behavior of the stem itself. That's why the primary stability of the GTS™ stem has been determined and subsequently was compared to the Zimmer – CLS® stem.