Introduction. Bernese periacetabular osteotomy (PAO) repositions the acetabulum to increase femoral head coverage (FHC) in hip dysplasia. Currently, there is a paucity of objective peri-operative metrics to plan for optimal acetabular fragment repositioning. The MSk Lab Hip 3D Planner (MSkL-HP) measures acetabular morphology and simulates PAO cuts to achieve optimal FHC. We evaluated how adjusting location and orientation of cutting planes can alter FHC. Method. MSkL-HP simulated 274 feasible PAOs on four dysplastic hips. Femoroacetabular anatomy was landmarked to simulate cutting planes. Posterior column and ischial cuts were standardised, whilst iliac and pubic cut combinations varied. The slope of the iliac cut was either neutral (aligned to pelvis), exit point 5mm above the entry point (+5), or 5mm below (-5). The slope of the pubic cut was either 90°, 50°, or 70° (medial-to-lateral). Iliac and pubic cuts were simulated 0, 5 and 15mm - distal and medial – to a classic cut. Outcome measures were achieved LCEA, Tönnis, FHC and % bone overlap at the pubic cut. Targets were LCEA >30°, Tönnis angle <10°, and FHC >70% and minimum bone overlap ≥10%. Results. All feasible PAOs resulted in improvement from pre-operative metrics. Personalised cutting planes provided greater benefit than standard planes. Kruskal Wallis tests showed that the iliac cut at 5mm or 15mm resulted in a greater LCEA and lower Tönnis compared to the classic cut (p<0.05). Changing location of the pubic cut, and slope of the iliac and pubic cuts did not significantly affect LCEA and Tönnis in all hips (p<0.05). Cut combinations optimising metrics were associated with a lower % pubic cut overlap. Conclusion. MSkL-HP feasibly and reliably planned personalised PAO, measuring pre-operative and simulated post-operative objective metrics. Patient-specific pubic and iliac cuts enable greater correction whilst maintaining bone overlap. Further simulations on patients with varying morphology may improve standard techniques

To describe clinical situations for use of modified VAC in POC based on: diagnosis, comorbidities, BMI, wound size in cm, days following trauma when VAC was first applied, total duration of uninterrupted use, frequency of change, settings, bacterial growth, outcomes. To report the outcomes of mVAC use in POC within 6 months to help improve and standardize its application in the institution. This study involves data gathering from inpatients handled by orthopedic surgeons in training and subspecialty rotations in POC. The data collected are highly dependent on the doctors-in-charge's complete charting, thorough reporting and accurate documentation. Modified Vacuum Assisted Closure (mVAC) is used frequently in this study and is defined as a form of revised, adapted and reformed use of VAC based on available materials in the involved institution. The materials that are included are, but not limited to the following: sterile Uratex™ blue foam, nasogastric or suction tubing, phlegm suction machine, Bactigras™ and Opsite™ or Ioban™. A total of 58 patients were included in the study. The average age of the population was 35 and are predominantly male. The most common mechanism of injury was motorcycle accident and 37 of the patients were diagnosed with an open fracture of the lower extremity with open tibia fractures (22) being the most common. Average wound area measured was 24.12 cm. 3. All patients yield a bacteria growth with e. coli being the most frequent. Average during of uninterrupted use was 39 days. Of the 58 included in the study, 8 patients underwent STSG, 2 had a flap coverage surgery, 4 patients eventually underwent amputation and 33 with complete resolution of soft tissue defect after conversion to biologic dressing post-mVAC. The rest of the population were still ongoing mVAC at the end of the study. mVAC is an alternative temporary medium for soft tissue coverage for cases with or without concomitant fractures. mVAC promotes removal of exudate from the wound, supports wound apposition and granulation bed proliferation. Usage mVAC helps prepare for skin coverage procedure and on some cases leads to full resolution of defect

Lesions within the articular cartilage layer of synovial joints do not heal spontaneously. Some repair cells may appear, but their failure to become established may be related to problems of adhesion to proteoglycan-rich surfaces. We therefore investigated whether controlled enzymatic degradation of surface proteoglycan molecules to a depth of about 1 μm, using chondroitinase ABC, would improve coverage by repair cells. We created superficial lesions (1.0 × 0.2 × 5 mm) in the articular cartilage of mature rabbit knees and treated the surfaces with 1 U/ml of chondroitinase ABC for four minutes. The defects were studied by histomorphometry and electron microscopy at one, three and six months. At one month, untreated lesions were covered to a mean extent of 28% by repair cells; this was enhanced to a mean of 53% after enzyme treatment. By three months, the mean coverage of both control and chondroitinase-ABC-treated defects had diminished dramatically to 0.2% and 13%, respectively, but at six months both untreated and treated lesions had a similar coverage of about 30%, not significantly different from that achieved in untreated knees at one month. These findings suggest that, with time, chondrocytes near the surface of the defect may compensate for the loss of proteoglycans produced by enzyme treatment, thereby restoring the inhibitory properties of the matrix as regards cell adhesion. This supposition was confirmed by electron microscopy. Our results have an important bearing on attempts made to induce healing responses by transplanting chondrogenic cells or by applying growth factors

The aim of this study was to perform a systematic review of the literature on Gustilo-Anderson (GA) type IIIB open tibial shaft (AO-42) injuries to determine the consistency of reporting in the literature.

A search of PubMed, EMBASE and Cochrane Central Register of Controlled Trials was performed to identify relevant studies published from January 2000 to January 2021 using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The study was registered using the PROSPERO International prospective register of systematic reviews. Patient/injury demographics, management and outcome reporting were recorded.

There were 32 studies that met the inclusion criteria with a total of 1,947 patients (70.3% male, 29.7% female). There were 6 studies (18.8%) studies that reported on comorbidities and smoking, with mechanism of injury reported in 22 (68.8%). No studies reported on all operative criteria included, with only three studies (9.4%) reporting for time to antibiotics, 14 studies (43.8%) for time from injury to debridement and nine studies (28.1%) for time to definitive fixation. All studies reported on the rate of deep infection, with a high proportion documenting union rate (26/32, 81.3%). However, only two studies reported on mortality or on other post-operative complications (2/32, 6.3%). Only 12 studies (37.5%) provided any patient reported outcomes.

This study has demonstrated a deficiency and a lack of standardized variable and outcome reporting in the orthopaedic literature for Gustilo-Anderson type IIIB open tibial shaft fractures. We propose a future international collaborative Delphi process is needed to standardize.

Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery

Abstract. OBJECTIVES. Although surgical periacetabular osteotomy (PAO) for hip dysplasia aims to optimise acetabular coverage and restore hip function, it is unclear how surgery affects capsular mechanics and joint stability. The purpose was to examine how the reoriented acetabular coverage affects capsular mechanics and joint stability in dysplastic hips. METHODS. Twelve cadaveric dysplastic hips (n = 12) were denuded to the capsule and mounted onto a robotic tester. The robot positioned each hip in multiple flexion angles (Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°) and performed internal-external rotations and abduction-adduction to 5 Nm in each rotational or planar direction. Each hip underwent a PAO, preserving the capsule, and was retested postoperatively in the robot. Paired sample t-tests compared the range of motion before and after PAO surgery (CI = 95%). RESULTS. Pre-operatively, the dysplastic hips demonstrated large ranges of internal-external rotations and abduction-adduction motions throughout all flexion positions. Post-operatively, the PAO slackenend the anterosuperior capsule and tightened the inferior capsule. This increased external rotation in Flexion 60° and Flexion 90° (∆. ER. = +16 and +23%) but provided lateral coverage to decrease internal rotation at Flexion 90° (∆. IR. = –15%). The PAO also reduced abduction throughout, but increased adduction in Neutral 0°, Flexion 30°, and Flexion 60° (∆. ADD. = +34, +30%, +29% respectively). CONCLUSIONS. The PAO provided crucial osseous structural coverage to the femoral head, decreasing hypermobility and adverse loading at extreme hip flexion-extension. However, it also slackened the anterosuperior capsule and increased adduction and external rotation, which may lead to ischiofemoral impingement and adductor irritations. Capsular instability may be secondary to acetabular undercoverage, thus capsular alteration may be warranted for larger corrections or rotational osteotomies. To preserve native hip and delay joint degeneration, it is crucial to preserve capsule and elucidate amount of reorientation needed without causing iatrogenic instability. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

In the field of hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the WALANT method. We seek to investigate the degree of patient satisfaction, out of pocket cost, convenience and comfort experienced with in-office hand procedures. A ten question survey consisting of a ten-point Likert scale of agreement and questions asking for a numerical answer was administered via phone call to 33 patients treated with minor hand operations in the office setting in the United States. There were 18 male and 15 female respondents with an average age of 65.59±12.64 years. Respondents underwent procedures including trigger finger release (18), needle aponeurotomy (7), and other minor hand operations. Survey responses indicated strong agreement with questions 1-3 and 6–8, with responses averaging 9.60±0.23 in these positive metrics. Questions 4 and 5, which asked whether the surgery and recovery period were painful, respectively, averaged 2.65±0.49, indicating a mild level of disagreement that either was “painful”. Additionally, most patients responded that they did not take time off work (12) or are not currently employed (11). Other respondents (3) reported taking between one to five days off work post-operatively. 27 respondents also reported an out of pocket cost averaging $382±$976, depending on insurance coverage. Patients reported a small degree of pain in the operative and post-operative period, a high degree of comfort and convenience and a high degree of satisfaction. Likewise, the patient-reported out of pocket cost was far lower than comparable surgical costs in alternate settings. These results support the use of in-office procedures for minor hand surgeries from a patient perspective and indicate a nearly universal intent to repeat any future hand operations in the office setting

Calcium phosphates-based (CaPs) nanocoatings on metallic prosthesis are widely studied in orthopedics and dentistry because they mimic the mineral component of native human bone and favor the osseointegration process. Despite the fact that different calcium phosphates have different properties (composition, crystallinity, and ion release), only stoichiometric hydroxyapatite (HA) films have been analyzed in deep. Here, we have realized films of different CaPs (HA, beta-tricalcium phosphate (β-TCP) and brushite (DCPD)) onto Ti6Al4V microrough substrates by Ionized Jet Deposition (IJD). We have implemented the heating of substrates at 400°C during deposition to see the effect on coating properties. Different film features are evaluated: morphology and topography (FEG-SEM, AFM), physical-chemical composition (FT-IR and EDS), dissolution profile and adhesion to substrate (scratch test), with a focus on how the different CaPs and temperature changed the coating features. After coating optimization, we have studied the in vitro BM-MSC behavior, in term of viability and early adhesion. We have obtained good transfer of fidelity in composition from target to coating for all CaPs, with nanostructured films formed by globular aggregates (~300 nm diameter), with homogeneous and uniform coverage of the substrate surface, without cracks. The heating during deposition has increased the adhesion of the films to the substrate, with higher stability in medium immersion and wettability, features that can improve the biological behavior of cells. All CaP coatings have showed excellent biocompatibility, with DCPD coating that promote higher cells viability at 14 days respect to HA and β- TCP films. About the early cell adhesion, the BM-MSC have showed switch from a globular to an elongated morphology at 6 hours in all coatings respect to the uncoated titanium, sign of better adhesion. From these results, the fabrication of different CaP nanocoatings with IJD can be a promising for applications in orthopedics and dentistry

Reorientating pelvic osteotomies are performed to improve femoral head coverage and secondary degenerative arthritis. A rectangular triple pelvic innominate osteotomy (3PIO) is performed in symptomatic cases. However, deciding optimal screw fixation type to avoid complications is questionable. Therefore, this study aimed to investigate the biomechanical behavior of two different acetabular screw configurations used for rectangular 3PIO osteosynthesis. It was hypothesized that bi-directional screw fixation would be biomechanically superior to mono-axial screw fixation technique. A rectangular 3PIO was performed in twelve right-side artificial Hemi-pelvises. Group 1 (G1) had two axial and one transversal screw in a bi-directional orientation. Group 2 (G2) had three screws in the axial direction through the iliac crest. Acetabular fragment was reoriented to 10.5° inclination in coronal plane, and 10.0° increased anteversion along axial plane. Specimens were biomechanically tested until failure under progressively increasing cyclic loading at 2Hz, starting at 50N peak compression, increasing 0.05N/cycle. Stiffness was calculated from machine data. Acetabular anteversion, inclination and medialization were evaluated from motion tracking data from 250-2500 at 250 cycle increments. Failure cycles and load were evaluated for 5° change in anteversion. Stiffness was higher in G1 (56.46±19.45N/mm) versus G2 (39.02±10.93N/mm) but not significantly, p=0.31. Acetabular fragment anteversion, inclination and medialization increased significantly each group (p≤0.02) and remained non-significantly different between the groups (p≥0.69). Cycles to failure and failure load were not significantly different between G1 (4406±882, 270.30±44.10N) and G2 (5059±682, 302.95±34.10N), p=0.78. From a biomechanical perspective, the present study demonstrates that a bi-directional screw orientation does not necessarily advantageous versus mono-axial alignment when the latter has all three screws evenly distributed over the osteotomy geometry. Moreover, the 3PIO fixation is susceptible to changes in anteversion, inclination and medialization of the acetabular fragment until the bone is healed. Therefore, cautious rehabilitation with partial weight-bearing is recommended

For clinical movement analysis, optical marker-based motion capture is the gold standard. With the advancement of AI-driven computer vision, markerless motion capture (MMC) has emerged. Validity against the marker-based standard has only been examined for lightly-dressed subjects as required for marker placement. This pilot study investigates how different clothing affects the measurement of typical gait metrics. Gait tests at self-selected speed (4 km/h) were performed on a treadmill (Motek Grail), captured by 9 cameras (Qualisys Miqus, 720p, f=100Hz) and analyzed by a leading MMC application (Theia, Canada). A healthy subject (female, h=164cm, m=54kg) donned clothes between trials starting from lightly dressed (LD: bicycle tight, short-sleeved shirt), adding a short skirt (SS: hip occlusion) or a midi-skirt (MS: partial knee occlusion) or street wear (SW: jeans covering ankle, long-sleeved blouse), the lattern combined with a short jacket (SWJ) or a long coat (SWC). Gait parameters (mean±SD, t=10s) calculated (left leg, mid-stance) were ankle pronation (AP-M), knee flexion (KF-M), pelvic obliquity (PO-M) and trunk lateral lean (TL-M) representing clinically common metrics, different joints and anatomic planes. Four repetitions of the base style (LD) were compared to states of increased garment coverage using the t-test (Bonferroni correction). For most gait metrics, differences between the light dress (LD) and various clothing styles were absent (p>0.0175), small (< 2SD) or below the minimal clinically important differences (MCID). For instance, KF-M was for LD=10.5°±1.7 versus MD=12.0°±0.5 (p=0.07) despite partial knee cover. AP-M measured for LD=5.2°±0.6 versus SW=4.1°±0.7 (p<0.01) despite ankle cover-up. The difference for KF-M between LD=10.5°±1.7 versus SWL=6.0°±0.9, SW and SWJ (7.6°±1.5, p<0.01) indicates more intra-subject gait variability than clothing effect. This study suggests that typical clothings styles only have a small clinically possibly negligible effect on common gait parameters measured with MMC. Thus, patients may not need to change clothes or be instructed to wear specific garments. In addition to avoiding marker placement, this further increases speed, ease and economy of clinical gait analysis with MMC facilitating high volume or routine application

Objectives. Excessive acetabular coverage is the most common cause of pincer-type femoroacetabular impingement. To date, an association between acetabular over-coverage and genetic variations has not been studied. In this study we investigated the association between single nucleotide polymorphisms (SNPs) of paralogous Homeobox (HOX)9 genes and acetabular coverage in Japanese individuals to identify a possible genetic variation associated with acetabular over-coverage. . Methods. We investigated 19 total SNPs in the four HOX9 paralogs, then focused in detail on seven of those located in the 3’ untranslated region of HOXB9 (rs8844, rs3826541, rs3826540, rs7405887, rs2303485, rs2303486, rs79931349) using a case-control association study. The seven HOXB9 SNPs were genotyped in 316 subjects who had all undergone radiological examination. The association study was performed by both single-locus and haplotype-based analyses. . Results. The genotype and allele frequencies of the five HOXB9 SNPs showed significant association with acetabular over-coverage compared with controls (rs7405887 OR = 3.16, p = 5.29E-6, 95% CI 1.91 to 5.25). A significant difference was also detected when haplotypes were evaluated (OR = 2.59, p = 2.61E-5, 95% CI 1.65 to 4.08). The two HOXB9 SNPs (rs2303485, rs2303486) were associated with decreased acetabular coverage (rs2303485 OR = 0.524, p = 0.0091, 95% CI 0.322 to 0.855; rs2303486 OR = 0.519, p = 0.011, 95% CI 0.312 to 0.865). . Conclusions. The five HOXB9 SNPs (rs8844, rs3826541, rs3826540, rs7405887, rs79931349) were associated with acetabular over-coverage. On the other hand, the two SNPs (rs2303485 and rs2303486) were associated with the lower acetabular coverage. The association of rs2303486 would be consistent with the previous study. Therefore, the HOXB9 SNPs might be involved in the morphogenesis of acetabular coverage, and could be an independent risk factor for developing pincer-type femoroacetabular impingement. Cite this article: Bone Joint Res 2015;4:50–5

Introduction and Objective. The aim of this study was to evaluate whether CT-based pre-operative planning, integrated with intra-operative navigation could improve glenoid baseplate fixation and positioning by increasing screw length, reducing number of screws required to obtain fixation and increasing the use of augmented baseplate to gain the desired positioning. Reverse total shoulder arthroplasty (RSA) successfully restores shoulder function in different conditions. Glenoid baseplate fixation and positioning seem to be the most important factors influencing RSA survival. When scapular anatomy is distorted (primitive or secondary), optimal baseplate positioning and secure screw purchase can be challenging. Materials and Methods. Twenty patients who underwent navigated RSA (oct 2018 and feb 2019) were compared retrospectively with twenty patients operated on with a conventional technique. All the procedures were performed by the same surgeon, using the same implant in cases of eccentric osteoarthritis or complete cuff tear. Exclusion criteria were: other diagnosis as proximal humeral fractures, post-traumatic OA previously treated operatively with hardware retention, revision shoulder arthroplasty. Results. The NAV procedure required mean 11 (range 7–16) minutes more to performed than the conventional procedure. Mean screw length was significantly longer in the navigation group (35.5+4.4 mm vs 29.9+3.6 mm; p . .001). Significant higher rate of optimal fixation using 2 screws only (17 vs 3 cases, p . .019) and higher rate of augmented baseplate usage (13 vs 4 cases, p . .009) was also present in the navigation group. Signficant difference there is all in function outcomes, DASH score is 15.7 vs 29.4 and constant scale 78.1 vs 69.8. Conclusions. The glenoid component positioning in RSA is crucial to prevent failure, loosening and biomechanical mismatch, coverage by the baseplate of the glenoid surface, version, inclination and offset are all essential for implant survival. This study showed how useful 3D CT-based planning helps in identifying the best position of the metaglena and the usefulness of receiving directly in the operation theater real-time feedback on the change in position. This study shows promising results, suggesting that improved baseplate and screw positioning and fixation is possible when computer-assisted implantation is used in RSA comparing to a conventional procedure

Introduction and Objective. Management of bone loss associated with bone contamination or infection represents a double biological and clinical challenge frequent in traumatology. The advent of new biomaterials can allow a different approach in the treatment of bone gap. The purpose of this study was to evaluate the prophylactic and therapeutic effectiveness of addition of a new absorbable bone substitute (BS) eluting different antibiotics in reconstruction of bone defects after infections and fractures with soft tissue damage. Materials and Methods. We conducted a review of patients with contaminated or infected bone defects treated using a new biomaterial, a porous composite of collagen matrices and Beta tricalcium phosphate (β TCP), able to provide a long-term release of different antibiotics. We have included treatment of osteomyelitis and osteosynthesis of exposed fracture (Gustilo Anderson 1–3b) or fractures with soft tissue damage and high risk of contamination. Surgical technique included debridement filling bone defect with BS eluting antibiotics, osteosynthesis (plate, nail, external fixator, kirschner wire), soft tissue coverage, and systemic antibiotic therapy. Radiographic and clinical data including complications (wound dehiscence, superficial or deep infection, osteomyelitis) were collected. Results. We treated 25 patients (21 male, 4 female) with mean age 47 yrs. (range 21–83). The locations treated (for incidence) was: 9 femurs (7 plates, 2 nail), 7 calcanei (one bilateral), 3 tibias, 2 forearms, 2 metatarsi, 2 hands, 1 elbow. 6 patients had large bone loss. 7 patients had bone infections (4 were Cierny Madern 4); 8 patients had osteosynthesis of exposed fractures Gustilo Anderson 1–3b (9 plate, one bilateral calcaneus). 8 patients had treatment for pseudoarthrosis of exposed fractures (6 femurs, 1 forearm, 1 metatarsus) and 3 patients a prophylactic treatment for calcaneal fractures with soft tissue damage. 4 deep infection were treated with multiple surgical debridement and new filling bone defect with BS eluting antibiotic with infection eradication. We have used a combination of vancomycin and gentamicin on 15 cases, vancomycin alone on 4 cases, combination of vancomycin and amikacin on 1 case and amikacin and Linezolid in a targeted multi drug resistance. At final follow-up functional outcome was good in all cases with bone healing. Conclusions. Extensive debridement is a fundamental requisite for eradication of bone infections and contamination. Filling of the bone void with loaded bio-composite eluting diversifiable local antibiotics with synergistic anti-biofilm activity is desirable. Treatment of this bone defects are advantaged when combining his reconstruction with BS and the possibility of release high antibiotic concentration at least for 10 days. This is an important complementing prophylactic and therapeutic antimicrobial option with adjuvant role to systemic therapy that enlarges the success rate

Last decade, a shift towards operative treatment of midshaft clavicle fractures has been observed [T. Huttunen et al., Injury, 2013]. Current fracture fixation plates are however suboptimal, leading to reoperation rates up to 53% [J. G. Wijdicks et al., Arch. Orthop. Trauma Surg, 2012]. Plate irritation, potentially caused by a bad geometric fit and plate prominence, has been found to be the most important factor for reoperation [B. D. Ashman et a.l, Injury, 2014]. Therefore, thin plate implants that do not interfere with muscle attachment sites (MAS) would be beneficial in reducing plate irritation. However, little is known about the clavicle MAS variation. The goal of this study was therefore to assess their variability by morphing the MAS to an average clavicle. 14 Cadaveric clavicles were dissected by a medical doctor (MH), laser scanned (Nikon, LC60dx) and a photogrammetry was created with Agisoft photoscan (Agisoft, Russia). Subsequently a CT-scan of these bones was acquired and segmented in Mimics (Materialise, Belgium). The segmented bone was aligned with the laser scan and MAS were indicated in 3-matic (Materialise, Belgium). Next, a statistical shape model (SSM) of the 14 segmented clavicles was created. The average clavicle from the SSM was then registered to all original clavicle meshes. This registration assures correspondences between source and target mesh. Hence, MAS of individual muscles of all 14 bones were indicated on the average clavicle. Mean area is 602 mm. 2. ± 137 mm. 2. for the deltoid muscle, 1022 mm. 2. ±207 mm. 2. for the trapezius muscle, and 683 mm. 2. ± 132 mm. 2. for the pectoralis major muscle. The sternocleidomastoid muscle has a mean area of 513 mm. 2. ± 190 mm. 2. and the subclavius muscle had the smallest mean area of 451 mm. 2. ± 162 mm. 2. Visualization of all MAS on the average clavicle resulted in 72% coverage of the surface, visualizing only each muscle's largest MAS led to 52% coverage. The large differences in MAS surface areas, as shown by the standard deviation, already indicate their variability. Difference between coverage by all MAS and only the largest, shows that MAS location varies strongly as well. Therefore, design of generic plates that do not interfere with individual MAS is challenging. Hence, patient-specific clavicle fracture fixation plates should be considered to minimally interfere with MAS

Objective. To determine the use of oral anti-inflammatory drugs use in the year before and the two years after primary total hip (THR) or knee (TKR) replacement, and to assess whether this varied according to the Body mass Index (BMI). Design. Population based retrospective case control study. Setting. 433 General Practitioner practices contributing to the General Practitioner Research Database. Participants. 28,068 patients who had undergone a THR and 24,364 patients who had undergone a TKR between 1991-2006. 5 controls per case were matched for age, sex and GP practice. Main Outcome measures. Two categories of oral anti-inflammatory usage: (1)”zero coverage” – patients who were not prescribed any anti-inflammatory medication; (2)”greater than 80% coverage” – patients who were prescribed anti-inflammatory medication for greater than 80% of the days in the year. Secondary subset analysis according to BMI. Results. At 1 year post surgery the proportion of cases on >80% coverage reduced from 21% (95%CI: 20% to 22%) to 8% (95%CI: 7% to 10%) for THR and 21% (95%CI: 20% to 22%) to 13% (95%CI: 11% to 14%) for TKR, with no ongoing reduction at 2 years. The proportion of THR/TKR cases on zero coverage increased at both 1 and 2 years post op (THR: Pre op 39%, 95%CI: 38% to 40%); 1 year post op 52% (95%CI: 51% to 53%); 2 year post op 66% (95%CI: 65% to 67%) and TKR: Pre op 39% (95%CI: 38% to 40%); 1 year post op 46% (95%CI: 45% to 47%); 2 year post op 58% (95%CI: 57% to 59%). BMI analysis. >80% coverage increased with BMI in the control groups. The proportion of THR cases on >80% coverage increased with BMI pre op. The magnitude in reduction of >80% coverage post op was similar across all BMI groups. The proportion of TKR cases on >80% coverage pre op was greatest in the extreme BMI categories. Again the magnitude in reduction of >80% coverage post op was similar across all BMI groups. Conclusion. THR/TKR's reduce the patients' need for anti-inflammatory medication, with implications regarding the side effects of their long-term use. The majority of the benefit from reduction in anti-inflammatory use is observed by 1 year post operatively. Increasing BMI affects anti-inflammatory use in both the general population as well as those undergoing THR/TKR surgery but without strong evidence of a detrimental effect on the benefits of pain relief

Increasing incidence of osteoporosis, obesity and an aging population have led to an increase in low energy hip fractures in the elderly. Perceived lower blood loss and lower surgical time, media coverage of minimal invasive surgery and patient expectations unsurprisingly have led to a trend towards intramedullary devices for fixation of extracapsular hip fractures. This is contrary to the Cochrane review of random controlled trials of intramedullary vs extramedullary implants which continues recommends the use of a sliding hip screw (SHS) over other devices. Furthermore, despite published literature of minimally invasive surgery (MIS) of SHS citing benefits such as reduced soft tissue trauma, smaller scar, faster recovery, reduced blood loss, reduced analgesia needs; the uptake of these approaches has been poor. We describe a novel technique one which remains minimally invasive, that not only has a simple learning curve but easily reproducible results. All patients who underwent MIS SHS fixation of extracapsular fractures were included in this study. Technique is shown in Figure 1. We collated data on all intertrochanteric hip fractures that were treated by a single surgeon series during period Jan 2014 to July 2015. Data was collected from electronic patient records and radiographs from Picture Archiving and Communication System (PACS). Surgical time, fluoroscopy time, blood loss, surgical incision length, post-operative transfusion, Tip Apex Distance (TAD) were analyzed. There were 10 patients in this study. All fractures were Orthopaedic Trauma Association (OTA) type A1 or A2. Median surgical time was 36 minutes (25–54). Mean fluoroscopy time was similar to standard incision sliding hip screw fixation. Blood loss estimation with MIS SHS can be undertaken safely and expeditiously for extracapsular hip fractures

Calcium phosphates-based coatings have been widely studied to favour a firm bonding between orthopaedic implants and the host bone. To this aim, thin films (thickness below 1 μm) having high adhesion to the substrate and a nanostructured surface texture are desired, capable of boosting platelet, proteins and cells adhesion. In addition, a tunable composition is required to resemble as closely as possible the composition of mineralized tissues and/or to intentionally substitute ions having possible therapeutic functions. The authors demonstrated nanostructured films having high surface roughness and a composition perfectly resembling the deposition target one can be achieved by Ionized Jet Deposition (IJD). Highly adhesive nanostructured coatings were obtained by depositing bone-apatite like thin films by ablation of deproteinized bovine bone, capable of promoting host cells attachment, proliferation and differentiation. Here, biomimetic films are deposited by IJD, using biogenic and synthetic apatite targets. Since IJD deposition can be carried out without heating the substrate, application on heat sensitive polymeric substrate, i.e. 3D printed porous scaffolds, is investigated. Biogenic apatite coatings are obtained by deposition of deproteinized bone (bovine, ovine, equine, porcine) and compared to ones of stoichiometry hydroxyapatite (HAp). Coatings composition (FT-IR-ATR, FT-IR microscopy, XRD, EDS) and morphology (SEM, AFM) are tested for deposition onto metallic and 3D-printed polymeric substrates (polyurethane (PU)). Different post-treatment annealing procedures for metallic substrates are compared (350–425°C), to optimize crystallinity. Then, uniformity of substrate coverage and possible damage caused to the polymeric substrate are studied by SEM, DSC and FT-IR microscopy. Biogenic coatings are composed by carbonated HAp (XRD, FT-IR). Trace ions Na. +. and Mg. 2+. are transferred from deposition target to coating. All coatings are nanostructured, composed by nano-sized globular aggregates, of which morphology and dimensions depend on the target characteristics. As-deposited coatings are amorphous, but crystallinity can be tuned by post-treatment annealing. A bone-like crystallinity can be achieved for heating at ≥400°C, also depending on duration. When deposited on 3D-printed PU scaffolds, coatings, owing to sub-micrometric thickness, coat them entirely, without altering their fibre shape and porosity. Obtained biomimetic bone apatite coatings can be deposited onto a variety of metallic and polymeric biomedical devices, thus finding several perspective applications in biomedical field

Poly-ether-ether-ketone (PEEK) is a biomaterial commonly used for spinal implants and screws. It is often desirable for orthopaedic implants to osseointegrate, but as PEEK is biologically inert this will not occur. The aim of this project was to determine if injection mould nanopatterning can be used to create a make PEEK bioactive and stimulate osteogenesis in vitro. PEEK substrates were fabricated by injection mould nanopatterning to produce near-square (NSQ) nanopatterned PEEK and planar (FLAT) PEEK samples. Atomic force microscopy (AFM) and scanning electron microscopy were used to characterize the surface topography. Human bone marrow stromal cells (hBMSCs) were isolated from patients undergoing primary hip replacement operations and seeded onto the PEEK substrates. After 6 weeks the cells were stained using alizarin red S (ARS) stain (to detect calcium) and the von Kossa technique (to detect phosphate) and analyzed using CellProfiler image analysis software to determine: surface coverage; cell number; and expression of either calcium (ARS stain) or phosphate (von Kossa technique). ARS stain showed calcium expression (quantified relative to the number of cells) was increased on NSQ PEEK compared to FLAT PEEK (not statistically significant) and the surface coverage was similar. Von Kossa staining revealed more surface coverage on FLAT PEEK (69.1% cf. 31.9%), cell number was increased on FLAT PEEK (9803 ± 4066 cf. 4068 ± 1884) and phosphate expression relative to cell number was also increased (seven-fold) on NSQ PEEK (P < 0.05) compared to FLAT PEEK. Although hBMSCs may adhere to NSQ PEEK in smaller numbers, the cells expressed a relatively larger amount of calcium and phosphate. This indicates that the cells adopted a more osteoblastic phenotype and that nanopatterning PEEK induces hBMSC differentiation and stimulates osteogenesis. Injection mould nanopatterning therefore has the potential to improve osseointegration of PEEK implants in vivo

When performing total hip replacements in patients with hip dysplasia, acetabular augmentation may be required to prevent early component failure. Preoperative radiographic templating may help estimate acetabularcomponent coverage but has not previously been shown to predict the need for augmentation. We developed a simple method to estimate the percentage of acetabular component coverage from pre-operative radiographs (True: False cup ratio). We aimed to evaluate whether this couldpredict the need foracetabular augmentation at primary total hip replacement for patients with dysplastic hips. We reviewed all patients with hip dysplasia who underwent a primary total hip replacement from 2005–2012. Classification of hip dysplasia (Crowe), centre edge angle (CEA), Sharp and Tonnis angles were determined on pre-operative radiographs for each patient. Templating was performed on anteroposteriorand lateral view hip radiographs to determine the likely percentage of acetabular component coverage using the True: False cup ratio. Patients requiring acetabular augmentation at time of primary total hip arthroplasty were noted. 128 cases were reviewed, 31 (24%) required acetabularaugmentation. Comparison between augmented and non-augmented cases revealed no difference in the mean CEA (p = 0.19), Sharp angles (p = 0.76) or Tonnis angles (p = 0.32). A lower True Cup: False Cup ratio was observed in the augmented groupcompared to the non-augmented group(median = 0.68 vs 0.88, p < 0.01). Preoperative templating can help predict which dysplastic hips are likely to require acetabular augmentation at primary total hip replacement

One of the most common bacteria in orthopaedic prosthetic infections is Staphylococcus Aureus. Infection causes implant failure due to biofilm production. Biofilms are produced by bacteria once they have adhered to a surface. Nanotopography has major effects on cell behaviour. Our research focuses on bacterial adhesion on nanofabricated materials. We hypothesise that surface nanotopography impacts the differential ability of staphylococci species to adhere via altered metabolomics and may reduce orthopaedic implant infection rate. Bacteria were grown and growth conditions optimised. Polystyrene and titanium (Ti) nanosurfaces were studied. The polystyrene surfaces had different nanopit arrays, while the Ti surfaces expressed different nanowire structures. Adhesion analysis was performed using fluorescence imaging, quantitative PCR and bacterial percentage coverage calculations. Further substitution with ‘heavy’ labelled glucose into growth medium allowed for bacterial metabolomic analysis and identification of any up-regulated metabolites and pathways. Our data demonstrates reduced bacterial adhesion on specific nanopit polystyrene arrays, while nanowired titanium showed increased bacterial adhesion following qPCR (P<0.05) and percentage coverage calculations (P<0.001). Further metabolomic analysis identified significantly increased intensity counts of specific metabolites (Pyruvate, Aspartate, Alanine and Carbamoyl aspartate). Our study shows that by altering nanotopography, bacterial adhesion and therefore biofilm formation can be affected. Specific nanopatterned surfaces may reduce implant infection associated morbidity and mortality. The identification of metabolic pathways involved in adhesion may allow for a targeted approach to biofilm eradication in S. aureus. This is of significant benefit to both the patient and the surgeon, and may well extend far beyond the realms of orthopaedics