Clinicians are often asked by patients, “When can I drive again?” after lower limb injury or surgery. This question is difficult to answer in the absence of any guidelines. This review aims to collate the currently available evidence and discuss the factors that influence the decision to allow a patient to return to driving. Medline, Web of Science, Scopus, and EMBASE were searched using the following terms: ‘brake reaction time’, ‘brake response time’, ‘braking force’, ‘brake pedal force’, ‘resume driving’, ‘rate of application of force’, ‘driving after injury’, ‘joint replacement and driving’, and ‘fracture and driving’. Of the relevant literature identified, most studies used the brake reaction time and total brake time as the outcome measures. Varying recovery periods were proposed based on the type and severity of injury or surgery. Surveys of the Driver and Vehicle Licensing Agency, the Police, insurance companies in the United Kingdom and Orthopaedic Surgeons offered a variety of opinions. There is currently insufficient evidence for any authoritative body to determine fitness to drive. The lack of guidance could result in patients being withheld from driving for longer than is necessary, or returning to driving while still unsafe. Cite this article: Bone Joint J 2013;95-B:290–4

Aims. The aim of this study was to assess the current available evidence about when patients might resume driving after elective, primary total hip (THA) or total knee arthroplasty (TKA) undertaken for osteoarthritis (OA). Materials and Methods. In February 2016, EMBASE, MEDLINE, Web of Science, Scopus, Cochrane, PubMed Publisher, CINAHL, EBSCO and Google Scholar were searched for clinical studies reporting on ‘THA’, ‘TKA’, ‘car driving’, ‘reaction time’ and ‘brake response time’. Two researchers (CAV and JJT) independently screened the titles and abstracts for eligibility and assessed the risk of bias. Both fixed and random effects were used to pool data and calculate mean differences (MD) and 95% confidence intervals (CI) between pre- and post-operative total brake response time (TBRT). Results. A total of 19 studies were included. The assessment of the risk of bias showed that one study was at high risk, six studies at moderate risk and 12 studies at low risk. Meta-analysis of TBRT showed a MD decrease of 25.54 ms (95% CI -32.02 to 83.09) two weeks after right-sided THA, and of 18.19 ms (95% CI -6.13 to 42.50) four weeks after a right-sided TKA, when compared with the pre-operative value. Conclusion. The TBRT returned to baseline two weeks after a right-sided THA and four weeks after a right-sided TKA. These results may serve as guidelines for orthopaedic surgeons when advising patients when to resume driving. However, the advice should be individualised. Cite this article: Bone Joint J 2017;99-B:566–76

The ability to drive represents autonomy and independence of individuals. For many patients not being able to drive severely restricts their social, personal and professional activities leading to adverse effects on their well being. This study assessed the current evidence on driving advice after total hip replacement (THR) and compared it with the real time ability of patients to drive their own cars after primary THR. We present a prospective review of car driving ability of 130 patients (80 males and 50 females) who were treated with THR. The results show that 105 patients (81%) were able to drive within 6–8 weeks after surgery. It took more than 12 weeks for 22 patients (17%) to start driving again. There was no reported deterioration in the driving ability after primary total hip replacement surgery. Conversely, 49 patients (38%) felt a subjective improvement in their driving capability after THR. Three patients (2%) were still not confident to drive even at 12 weeks post THR. In spite of the clear advice, only 69% practiced on a stationary car before driving on the road. In our study sample 67 patients (63.8%) had a right THR and 65 patients (61.9%) were manual car drivers and all were able to drive between 6–8 weeks. This study demonstrates that patients should not resume driving motor vehicles for a minimum period of six weeks following total hip replacement surgery. This is inclusive of automatic and manually operated automobiles, and irrespective of laterality of surgical interventions. Return to driving after a six week period should be based on the individual’s capability and confidence to control the vehicle safely. Patients should be given clear advice to practice on the stationary vehicles before starting to drive on the road

Distracted driving is now the number one cause of death among teenagers in the United States of America according to the National Highway Traffic Safety Administration. However, the risks and consequences of driving while distracted spans all ages, gender, and ethnicity. The Distractions on the Road: Injury eValuation in Surgery And FracturE Clinics (DRIVSAFE) Study aimed to examine the prevalence of distracted driving among patients attending hospital-based orthopaedic surgery fracture clinics. We further aimed to explore factors associated with distracted driving. In a large, multi-center prospective observational study, we recruited 1378 adult patients with injuries treated across four clinics (Hamilton, Ontario, Toronto, Ontario, Calgary, Alberta, Halifax, Nova Scotia) across Canada. Eligible patients included those who held a valid driver's license and were able to communicate and understand written english. Patients were administered questions about distracted driving. Data were analyzed with descriptive statistics. Patients average age was 45.8 years old (range 16 – 87), 54.3% male, and 44.6% female (1.1% not disclosed). Of 1361 patients, 1358 self-reported distracted driving (99.8%). Common sources of distractions included talking to passengers (98.7%), outer-vehicle distractions (95.5%), eating/drinking (90.4%), music listening/adjusting the radio (97.6%/93.8%), singing (83.2%), accepting phone calls (65.6%) and daydreaming (61.2%). Seventy-nine patients (6.3%), reported having been stopped by police for using a handheld device in the past. Among 113 drivers who disclosed the cause of their injury as a motor vehicle crash (MVC), 20 of them (17%) acknowledged being distracted at the time of the crash. Of the participants surveyed, 729 reported that during their lifetime they had been the driver in a MVC, with 226 (31.1%) acknowledging they were distracted at the time of the crash. Approximately, 1 in 6 participants in this study had a MVC where they reported to be distracted. Despite the overwhelming knowledge that distracted driving is dangerous and the recognition by participants that it can be dangerous, a staggering amount of drivers engage in distracted driving on a fairly routine basis. This study demonstrates an ongoing need for research and driver education to reduce distracted driving and its devastating consequences

INTRODUCTION. Hallux Valgus is a common foot condition, which may affect mobility and lifestyle. Corrective surgery is performed as a day case procedure, however, post-operatively; patients remain limited in their ability to drive for a variable period. In the laboratory settings, emergency brake response time after first metatarsal osteotomy has been studied but there is no published study of patients’ experience of driving after this surgery. This study was aimed at assessing patients’ driving ability and comfort after Hallux Valgus corrective surgery. METHODS. Fifty consecutive patients who underwent first metatarsal corrective osteotomy from January 2009 to July 2010 were reviewed. The operation type, foot side operated, postoperative complications and other conditions affecting driving were recorded from charts and operation notes. A telephonic survey was then conducted and information was recorded in a predesigned questionnaire. The questions included driving advice given by the medical staff, time interval to begin driving postoperatively, and how long the patient took to gain full confidence at driving. It was also noted whether patients required changing the type of car from manual to automatic. RESULTS. Of 50 patients, 10 never drove and were excluded. One patient had expired from unrelated health conditions. Two discontinued driving after surgery due to other (social) reasons, and one could not be contacted. The remaining thirty-six patients were analyzed. The mean age was 56.8+/-9.8 years with range of 36–74 years. Most were females (n=33, 91.7%), and the right side was operated upon in 17 (44.4%) patients. SCARF osteotomy was performed in 19 (52.8%) patients, basal osteotomy in 5 (13.9%), chevron osteotomy in 5 (13.9%) and other procedures (bunionectomy, Akin, soft tissue correction etc) were done in 7 (19.4%) patients. Out of the 28 patients driving manual cars, one required changing to automatic vehicle. The average post-operative period when patients resumed driving was 8.6 weeks with a range of 4 to 16 weeks. After SCARF, this average was 8.3 weeks (range 6–16), which was against 7.6(range 6–16) and 7.8 (range 4–12) weeks after basal and chevron procedures respectively (p=0.408). The mean period when patients reported comfortable foot control was 1.06 weeks after they had begun to drive for all groups. With SCARF this was 1.3 weeks, and 1.4 and 2.2 for basal and chevron groups respectively (p=0.162). Of the two patients that resumed driving after 16 weeks, one had infection and swelling of the foot postoperatively and the other had bilateral basal osteotomy performed simultaneously and was on crutches for 16 weeks. CONCLUSION. The mean time to resumption of automobile driving after corrective Hallux Valgus surgery is 8.6 weeks, and, on average patients takes another week to attain full confidence and comfort at driving postoperatively. There is no statistically significant difference between the types of surgery performed

INTRODUCTION. The primary goal of THA or TKA is to relieve pain and restore mobility. The success is determined by the longevity of prostheses and early return to routine activities, such as driving. With enhanced recovery regimens, patients are being discharged within 24–48hrs post-op.. The aim of this study was to determine when our patients returned to driving after anterior hip replacements and patient specific knee replacements. METHODOLOGY. This study included 207 soft tissue sparing anterior bikini THA and 146 patient specific instrumented (PSI) TKAs between Feb 2017 and March 2018. All patients included drove before surgery. Non-drivers were excluded. A detailed questionnaire was sent to all patients 3 to 6 weeks after surgery to record their driving status. 50 patients were randomly selected to assess flexion at the hip, knee, and ankle joints whilst seated in the driver's seat of their vehicle. RESULTS. There were 213 females and 124 males (mean age of 69 years) and average BMI of 18.24. There were 207 THAs (99 left, 106 right and 1 bilateral one stage) and 146 TKAs (L=70 & R=76). 76% of patients returned to driving within the first 3 weeks after surgery of which 32 patients (21 THAs (14%) and 11 TKAs (10%)) resumed driving within the first post-op week, 110 patients (69 THAs (39%)and 49 TKAs (35%)) drove in the second week and 73 (38 THAs (23%)and 38 TKAs(28%)) returned to driving in the third week. The rest of the 82 patients reports that they could have driven earlier but chose not to, since they had alternatives that they preferred. The earliest a patient resumed driving post-surgery was on the 2. nd. day(Post THA and TKA). 96.4% stated that they were confident when they first resumed driving. There were 40 patients out of the total 337 that did not return to driving post-surgery. 3 (2 hips and 1 knee) due to medical comorbidities and the rest 37 (14 THAs and 6TKAs) reported they had their children/spouses to drive them but were confident that they could have driven themselves if required. There was statistically no direct correlation between resumption of driving and the side of surgery. There were 282 patients driving automatic cars, 23 driving manual cars and the remaining did not comment. Out of the manual car drivers, 8 were operated on the left side (5 hips and 3 knees), but still all confidently returned to driving within 6 weeks earliest returning within the 1st week. Post measurement of angles of flexion at hip, knee and ankle while accelerating and braking among 50 patients we found that ankle movements significantly affect driving more so than hip and knee. CONCLUSION. We found that after soft tissue sparing anterior bikini THA and PSI TKA, patients were driving as early as within a week with the majority feeling confident and less apprehensive about recommencing driving, potentially due to enhanced recovery measures which were taken, including the minimally invasive surgical technique, local analgesia infiltration and early mobilization post procedure

Purpose: The objective of the study was to determine the changes in the driving pattern – especially the capacity to use the steering wheel after carpal tunnel surgery so that recommendation for suitability to return back to driving can be made. Methods Used: A computerised driving simulator normally used for driving assessment of drivers with disability at the regional mobility centre at the Wrightington Hospital was used to assess the patient’s driving. Static and dynamic steering torque was measured before and at 2 & 6 weeks after carpal tunnel release in 25 patients using the static assessment rig. Driving reaction time was also studied in these patients. Results: There was decrease from preoperative static steering torque to that at 2 weeks postoperatively but the dynamic steering torque did not differ in most cases. By 6 to 8 weeks postoperatively, the mean torque values for static and dynamic steering capacity had significantly improved. The driving reaction times at preoperative assessment did not differ significantly from the post operative ones at all times. Conclusion: Although at 2 weeks postoperatively the ability to use the operated hand for static steering had not returned in most patients, their overall steering capacity was not affected as suggested by their unaffected dynamic steering time and the reaction time

The driving reactions of 25 patients were assessed before and after operation for hip replacement. Driving reactions were tested by monitoring the delay and force of brake application after an emergency signal, using a simulated driving control system. Fifteen normal subjects were also tested. Statistical analysis demonstrated significant differences between patients with either left or right hip replacement and between pre- and postoperative testing. Most patients improved by the eighth week, but some had deteriorated and did not recover until re-tested eight months after operation. It is concluded that for most patients eight weeks' delay for return to driving is appropriate, but for a minority of patients with right hip replacement recovery of reaction speed requires longer rehabilitation

Introduction. Self tapping bone screw has been widely used in the fixation of Arthroplasty implants and bone graft. But the unwanted screw or driver breakage can be a direct result of excessive driving torque due to the thread cutting resistance. Previous studies showed that bone drill bit cutting rake angle was a critical factor and was inversely related to the bone cutting efficiency. 1, 2, 3, 4. (Figure 1) However to date there was no data for how the rake angle could influence the performance of self tapping bone screw. The purpose of this study was to investigate the torque generated by the self tapping cortical screw in simulated bone insertion as a function of the screw tip cutting flute rake angle. Methods. Two 5 mm thick BM5166 polyurethane block were stacked together and drilled through with 2.5mm diameter holes. Five 30mm long 3.5 mm diameter Ti6AL4V alloy self tapping cortical screws with 0°rake angle cutting flutes (Figure 2) were inserted in the holes and driven by the spanner attached to the test machine (Z5.0TN/TC-A-10) with a displacement control of 3 revolutions/min and 30N constant axial loading. The screws were driven into the stacked polyurethane block for 8mm depth. The maximum driving torque was recorded. Procedure was repeated for five same screws but with 7° rake angle cutting flutes. (Figure 2) The driving torqueses were compared. Student t test was performed with confidence level of 95% was assumed. Results. The average insertion driving torque for the screw with 7° rake angle was 30% less torque required than that of the screw with 0° rake angle. (P=5.3E–06<0.05) (Table 1). Conclusion and discussion. Screw failure during the insertion would be a nightmare. A slight positive rake angle significantly decreases the torque resistance. This design feature can significantly increase the safety margin of the self tapping screw implants and screw driving instruments. The likely mechanism would be the positive rake angle generated a more efficient bone cutting instead of pushing. More study on driving torque as a function of wider rake angle change is warranted. For figures and tables, please contact authors directly

Background: Recently, the effects of radiculopathy and nerve root blocks on driving reaction time (DRT) have been presented in the literature. To our knowledge, the relation between lumbar spinal fusion and DRT has not been studied before, although important for driving safety. So, we conducted the current study to test the hypotheses that DRT in the context of lumbar fusion is 1) altered in pre-postoperative comparison, 2) influenced by pain, 3) influenced by the patient’s driving skill and 4) different to the DRT of healthy controls. Methods: 21 consecutive patients (age 53.5 years, SD 10.8) receiving primary lumbar fusion were tested for their DRT 1 day preoperatively (pre-op), 1 week postoperatively at the day before discharge (post-op) and at 3 months (follow-up; FU). DRT was assessed with a custom made driving simulator. Additionally, also the level of back pain was determined by VAS for usual pain (VAS-U) and for pain during testing (VAS-T). We also collected the participants’ subjective driving frequency. We used normative DRT data from 31 healthy controls of similar age for comparison with the patients. Results: Pre-op DRT was 685 msec (Md; IQR 246), post-op DRT increased to 728 msec (Md; IQR 264) and decreased again to 671 msec (Md; IQR 202) at FU (p=0.007). Post-hoc analyses (alpha=0.017) found significant differences between post-op and FU DRT (p=0.007). Moderate to high correlations (between 0.537 and 0.680) were found between VAS of back pain and DRT (p between 0.001 and 0.012). No correlations were found between driving frequency and DRT. Controls showed a DRT of 487 msec (Md; IQR 116) which was significantly different from DRT of the patients at all three test occasions (p< 0.001). Conclusion: We found minor increase in DRT 1 week post-op followed by a definite and significant decrease at 3 months FU. We think it is safe – with respect to DRT - to resume driving 3 months after lumbar fusion. It is difficult to draw any conclusions about the period between discharge and 3 months. We also found moderate and high correlations between DRT and the level of back pain and assume that back pain is a relevant factor influencing DRT

In a society dependent upon the motor car, impaired driving ability is a significant disability which may affect patients with total knee replacement during the postoperative rehabilitation. Recently, there has been much interest in minimally invasive surgery for total knee arthroplasty (TKA). This study evaluated the hypothesis that a minimally invasive technique using a small incision (7 to 10 cm), and a minimal quadriceps muscle splitting without eversion of the patella (MIS approach) would have a beneficial effect on driving reaction time. 15 patients undergoing a primary TKA with the MIS approach were compared with 15 TKAs using a standard approach. An experimental car was used to measure the force and timing of pressure by the foot on accelerator and break pedals. The mean reaction time for normal adults was 0.442 s to go from the accelerator to the brake pedal. This time falls well within the code guideline of 0.7 s. The driving reaction times of the patients with knee arthroplasty were measured at one, two and three months after the operation. The ability to perform an emergency stop was assessed as the time taken to achieve a brake pressure of 100 N after a visual stimulus.The patients have an actual follow-up of 2 years. A clinical and radiological evaluation was performed. Radiographic analysis included evaluation of postoperative alignment variables and progressive radioluciencies. Over all 27 among the 30 knees have good and excellent objective knee Society Scores and patient satisfaction indices. The patients in the MIS group had a statistically shorter time until they could straight leg raise, used less epidural analgesia, used less overall analgesics and had a more rapid regaining of flexion. Patients with standard approach and technique for total knee replacement recovered sufficient knee function to return to driving at only three months after the operation according to the time and the force necessary to the brake pedal. Patients with mini invasive surgery approach have recovered sufficient knee function to return driving at one month after the operation. There was no significant difference in alignment of implants and in alignment of the knee between the two groups. Three knees had radioluciencies (two with a standard incision and one with a MIS approach). Using a small incision without patellar eversion does not jeopardize the alignment of the implants and improves postoperative rehabilitation

The time at which patients should drive following total hip replacement (THR) is dependant upon recovery and the advice they are given. The Driver Vehicle and Licensing Agency (DVLA) in the United Kingdom does not publish recommendations following THR and insurance companies usually rely on medical instruction. Few studies have been performed previously and have reached different conclusions. Brake reaction times for patients undergoing primary THR were measured pre-operatively and at four, six and eight weeks after surgery using a vehicle driving simulator at a dedicated testing centre. Patients were prospectively recruited. Ethical approval was granted. Participants included eleven males and nine females, mean age 69 years. Side of surgery, frequency of driving and type of car (automatic or manual) were documented. Patients with postoperative complications were excluded. No adverse events occurred during the study. Statistical analysis using Friedman's test demonstrated a statistically significant difference (P=0.015) in reaction times across the four time periods. Wilcoxon test demonstrated a highly significant difference between initial and six week mean results (P=0.003), and between four and six week results (P=0.001). No significant difference was found between six and eight weeks. Our data suggests reaction times improve until week six and significantly between week four to six. Patients making an uncomplicated recovery following primary THR may be considered safe to return to driving from week six onwards. We recommend this is clearly documented in the medical notes, and patients should check with their insurance company prior to recommencement

Purpose: Until now no experimental study has evaluated the effect of orthopedic immobilizations of the lower right limb on driving performances. Clinicians and legislators therefore cannot appropriately advise patients with this type of treatment on their driving capabilities and put forth recommendations for road safety. Method: An experimental study of the effect of orthopedic immobilizations of the lower right limb on driving performances has been conducted at the Research Center on Aging of the Sherbrooke Geriatric University Institute. The breaking capabilities of forty-eight healthy volunteers were tested in three conditions: wearing their usual running shoes and two types of immobilization, namely the walking cast (Delta-Cast Conformable, BSN Medical, Leuven, Belgium) and the foam pneumatic walker (Aircast, Vista, CA). The order in which each condition was tested was randomly determined for each volunteer. A custom driving simulator was used to measure the force applied on the break pedal and the breaking time using the software LabVIEW (National Instruments, Austin, TX). In addition, each volunteer completed a socio-demographic survey, a brief physical exam and two clinical tests (stepping and standing). Results: The average maximum breaking forces exerted by the volunteers with the walking cast, the foam walker and the shoes are 275,4 lb, 287,2 lb and 293,8 lb respectively. The two significant differences are between the walking cast and the shoes (18,4 lb, p< 0,001) and between the walking cast and the foam walker (11,8 lb, p< 0,001). The measured average breaking reaction times are (from the slowest to the fastest) 619 ms, 609 ms, and 580 ms with the foam walker, the walking cast and the shoes respectively. The two significant differences are between the shoes and the foam walker (39 ms, p< 0,001) and between the shoes and the walking cast (29 ms, p< 0,001). The results of this study also confirm the correlation between the measured breaking reaction times and the stepping and standing clinical test (p< 0,05). Conclusion: Although this study observed statistically significant changes in breaking force and reaction time in volunteers wearing two common

The time at which patients should drive following total hip replacement (THR) is dependant upon recovery and the advice they are given. The Driver Vehicle and Licensing Agency (DVLA) do not publish recommendations following THR and insurance companies usually rely on medical instruction. Brake reaction times for patients undergoing THR were measured before and four, six and eight weeks after surgery using a vehicle-driving simulator. Patients were prospectively recruited. Ethical approval was granted. Participants included eleven males and nine females, mean age 69 years. Side of surgery, frequency of driving and type of car (automatic or manual) were documented. Patients with postoperative complications were excluded. No adverse events occurred during the study. Statistical analysis using Friedman’s test demonstrated a statistically significant difference (P=0.015) in reaction times across the four time periods. Wilcoxon test demonstrated a highly significant difference between initial and six week mean results (P=0.003), and between four and six week results (P=0.001). No significant difference was found between six and eight weeks. Our data suggests reaction times improve until week six and significantly between week four to six. Patients making an uncomplicated recovery should be considered safe to drive by week six

Introduction: Insufficiency of poroelastic bone bending as the sole mechanism driving bone interstitial fluid flow (BIFF) to account for the shear stress required to activate mechanoreceptors on osteocytes and osteoblasts, has stimulated a search for alternative or complementary mechanisms in the quest for a comprehensive bone remodeling model. Some investigators, noting that a substantial amount of interstitial fluid is exchanged with blood and lymphatic capillaries, have suggested that this exchange may play a substantial role in both microtransport through the collagen matrix and lacunar-canalicular transport. In order to accept the vascular system as a significant source of transport driving BIFF, it must first be demonstrated that capillary filtration, the proc ess by which fluid is transported from blood vasculature, is sufficiently convective to drive interstitial percolation. We have proposed that while, as shown by Otter et al., resting transmural vascular pressures are sufficient to generate streaming potentials across cortical bone, it is likely that these forces must be complemented by muscle pump contractions during exercise to generate convective percolation flows which will develop the required mechanotransducer shear stress activation threshold. To determine a minimal baseline for a muscle pump driven BIFF (MPD-BIFF) model, we have investigated the role of repetitive skeletal muscle contractions, uncoupled from gravitational loading, on blood flow and capillary filtration in cortical bone of the rabbit tibia. We tested the hypothesis that these effects increased when the muscle pump was activated. Materials & Methods: The experimental model combined non-invasive, low magnitude transcutaneous neuromuscular stimulation (TENS), with real-time measurements from intravital microscopy (IVM) of optical bone chamber implants. Sling suspension of rabbits was utilized to eliminate gravitational reaction forces throughout TENS and data collection. TENS-induced muscle contraction forces were measured in situ, resultant bone strains were calculated, and systemic circulatory parameters were monitored, in order to eliminate these factors as contributors to blood flow changes. Blood flow rates and capillary filtration were measured by video-image analysis of 1 μm fluorescent microspheres and dextran-conjugated fluorescein isothiocyanate (FITC) and rhodamine (ITC) injected intravascularly during IVM. Bone formation, angiogenesis, and mineral apposition rates (tetracycline labelling) were analyzed from weekly microscopy pictures. Changes in bone mineral content and density were determined with CT scans obtained at implantation and termination. Results: Mechanical loading and baseline systemic circulation did not significantly contribute to the findings. Rhythmic muscle contractions were shown to increase cortical blood flow, rate of capillary filtration, rate of bone apposition, and angiogenesis. Discussion: The hypothesis was supported by the data. However, since no measurements were made on single capillaries, we could not confirm previous reports by this laboratory of convective extravasation

Introduction

Wear of polyethylene tibial inserts has been cited as being responsible for up to 25% of revision surgeries, imposing a very significant cost burden on the health care system and increasing patient risk. Accurate measurement of material loss from retrieved knee bearings presents difficult challenges because gravimetric methods are not useful with retrievals and unworn reference dimensions are often unavailable. Geometry and the local anatomy restrict in vivo radiographic wear analysis, and no large-scale analyses have illuminated long-term comparative wear rates and their dependence on design and patient factors. Our study of a large retrieval archive of knee inserts indicates that abrasive/adhesive wear of polyethylene inserts, both on the articular surface and on the backside of modular knees is an important contributor to wear, generation of debris and integrity of locking geometry.

The objective of the current study is to quantify wear performance of tibial inserts in a large archive of retrieved knees of different designs. By assessing wear in a large and diverse series, the goal is to discern the effect on wear performance of a number of different factors: patient factors that might help guide treatment, knee design factors and bearing material factors that may inform a surgeon's choice from among the array of arthroplasty device options.

The ankle joint offers adverse conditions to any prosthetic replacement: high loads on small surfaces, only vague landmarks for the insertion, complex and individually very different functional anatomy.

Despite these obstacles many excellent short- and some long-term results have been published, giving little way to a learning curve. This contrasts with our own experiences over at all 29 years now: 24 % failures of cemented two-component EP’s after 14,6 (6,1–21,2) years (n=67) and 8,7 % failures of uncemented tri-component EP’s after 3,7 (0,6–7,6) years (n=92).

We analyze and explain special problems and typical failures by a brief historical review of ankle joint replacement: as a logical sequence of various concepts, each of them basing on the knowledge of preceding insufficiencies. The general concern of the functionally useful, but limited mobility after the implantation will be discussed, also on the basis of own early and medium-term results: ROM ranging on average from 26° for TPR-(n=35) and 29° for New Jersey LCS-(n=30) up to 35° for S. T. A. R.-prostheses (n=12). Possible solutions of problems will be considered, respecting assumed causalities.

Basing on the literature and own earlier investigations, especially the long-term results will be compared critically.

The incertitude of an exact implantation has been partly compensated by the actual „meniscal“ concept of tricomponent prostheses. It should be favourable for their fixation to the bone and moreover reduce polyethylene-wear. But – as before – the discrepancy of high loads on a small area threatens the durability of ankle joint prostheses.

Prosthetic replacement has become indispensable in the treatment of painfully destructed ankle joints, but it demands a careful and critical indication.

The August 2024 Wrist & Hand Roundup. 360. looks at: Methotrexate shows potential in reducing pain for hand osteoarthritis with synovitis; Circumferential casting versus plaster splinting in adult distal radius fractures: the CAST study findings; Surgery shows superior long-term success for Dupuytren contracture compared to needle fasciotomy and collagenase injection; Evolving trends in surgical management of wrist arthritis: a decade-long national analysis; Mid-term outcomes of three commonly used surgical reconstructions for scapholunate instability; SLAC and SNAC: what is the evidence for treatment?; Steroids for trapeziometacarpal osteoarthritis?; When is it safe to return to driving after distal radius fracture fixation? A prospective study

The October 2023 Wrist & Hand Roundup. 360. looks at: Distal radius fracture management: surgeon factors markedly influence decision-making; Fracture-dislocation of the radiocarpal joint: bony and capsuloligamentar management, outcomes, and long-term complications; Exploring the role of artificial intelligence chatbot in the management of scaphoid fractures; Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations; Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial; Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study; On the road again: return to driving following minor hand surgery; Open versus single- or dual-portal endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials

The December 2022 Shoulder & Elbow Roundup. 360. looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae