We dissected 12 fresh-frozen leg specimens to identify the insertional footprint of each fascicle of the Achilles tendon on the calcaneum in relation to their corresponding muscles. A further ten embalmed specimens were examined to confirm an observation on the retrocalcaneal bursa. The superficial part of the insertion of the Achilles tendon is represented by fascicles from the medial head of the gastrocnemius muscle, which is inserted over the entire width of the inferior facet of the calcaneal tuberosity. In three specimens this insertion was in continuity with the plantar fascia in the form of periosteum. The deep part of the insertion of the Achilles tendon is made of fascicles from the soleus tendon, which insert on the medial aspect of the middle facet of the calcaneal tuberosity, while the fascicles of the lateral head of the gastrocnemius tendon insert on the lateral aspect of the middle facet of the calcaneal tuberosity. A bicameral retrocalcaneal bursa was present in 15 of the 22 examined specimens. . This new observation and description of the insertional footprint of the Achilles tendon and the retrocalcaneal bursa may allow a better understanding of the function of each muscular part of the gastrosoleus complex. This may have clinical relevance in the treatment of Achilles tendinopathies. Cite this article: Bone Joint J 2014; 96-B:1344–8

Abstract. The lateral ligaments of the ankle composed of the anterior talofibular (ATFL), calcaneofibular (CFL) and posterior talofibular ligaments (PTFL), are amongst the most commonly injured ligaments of the human body. Although treatment methods have been explored exhaustively, healing outcomes remain poor with high rates of re-injury, chronic ankle instability and pain persisting. The introduction and application of tissue engineering methods may target poor healing outcomes and eliminate long-term complications, improving the overall quality of life of affected individuals. For any surgical procedure or tissue-engineered replacement to be successful, a comprehensive understanding of the complete anatomy of the native structure is essential. Knowledge of the dimensions of ligament footprints is vitally important for surgeons as it guides the placement of bone tunnels during repair. It is also imperative in tissue-engineered design as the creation of a successful replacement relies on a thorough understanding of the native anatomy and microanatomical structure. Several studies explore techniques to describe ligament footprints around the body, with limited studies describing in-depth footprint dimensions of the ATFL, CFL and PTFL. Techniques currently used to measure ligament footprints are complex and require resources which may not be readily available, therefore a new methodology may prove beneficial. Objectives. This study explores the application of a novel technique to assess the footprint of ankle ligaments through a straightforward inking method. This method aims to enhance surgical technique and contribute to the development of a tissue-engineered analogue based on real anatomical morphometric data. Methods. Cadaveric dissection of the ATFL, CFL and PTFL was performed on 12 unpaired fresh frozen ankles adhering to regulations of the Human Tissue (Scotland) Act. The ankle complex with attaching ligaments was immersed in methylene blue. Dissection of the proximal and distal entheses of each ligament was carried out to reveal the unstained ligament footprint. Images of each ligament footprint were taken, and the area, length and width of each footprint were assessed digitally. Results. The collective area of the proximal entheses of the ATFL, CFL and PTFL measures 142.11 ± 12.41mm2. The mean areas of the superior (SB) and inferior band (IB) of the distal enthesis of the ATFL measured 41.72 ± 5.01mm2 and 26.66 ± 3.12mm2 respectively. The footprint of the distal enthesis of the CFL measured 146.07 ± 14.05mm2, while the footprint of the distal PTFL measured 126.26 ± 8.88mm2. The proximal footprint of the ATFL, CFL and PTFL measured 11.06 ± 0.69mm, 7.87 ± 0.43mm and 10.52 ± 0.63mm in length and 8.66 ± 0.50mm, 9.10 ± 0.92mm and 14.41 ± 1.30mm in width on average. The distal footprint of the ATFL (SB), ATFL (IB), CFL and PTFL measured 10.92 ± 0.81 mm, 8.46 ± 0.46mm, 13.98 ± 0.93mm and 11.25 ± 0.95mm in length and 7.76 ± 0.59mm, 7.51 ± 0.64mm, 18.98 ± 1.15mm and 24.80 ± 1.25mm in width on average. Conclusions. This methodology provides an effective approach in the identification of the footprint of the lateral ligaments of the ankle to enhance surgical precision and accuracy in tissue-engineered design. 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

Aims. This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices. Methods. Using a life-cycle assessment approach, we conducted a prospective study on ten cemented and ten hybrid THA cases, evaluating carbon emissions from anaesthetic room to recovery. Scope 1 and scope 2 emissions were considered, focusing on direct emissions and energy consumption. Data included detailed assessments of consumables, waste generation, and energy use during surgeries. Results. The carbon footprint of an uncemented THA was estimated at 100.02 kg CO2e, with a marginal increase to 104.89 kg CO2e for hybrid THA. Key contributors were consumables in the operating theatre (21%), waste generation (22%), and scope 2 emissions (38%). The study identified opportunities for reducing emissions, including instrument rationalization, transitioning to LED lighting, and improving waste-recycling practices. Conclusion. This study sheds light on the substantial carbon footprint associated with THA. Actionable strategies for reducing emissions were identified, emphasizing the need for sustainable practices in orthopaedic surgery. The findings prompt a critical discussion on the environmental impact of single-use versus reusable items in the operating theatre, challenging traditional norms to make more environmentally responsible choices. Cite this article: Bone Jt Open 2024;5(9):742–748

Recent studies on animal models focused on the effect of preserving tendon remnant of rotator cuff on tendon healing. A positive effect by combining tendon remnant preservation and small bone vents on the greater tuberosity in comparison with standard tendon-to-bone repair has been shown. The purpose of the present clinical study was to evaluate the efficacy of biologic augmentation of arthroscopic rotator cuff repair by maintaining tendon remnant on rotator cuff footprint combined with small bone vents of the greater tuberosity. A retrospective study was conducted. All patients who underwent arthroscopic rotator cuff repair associated with small bone vents (nanofractures) and tendon footprint preservation were considered eligible for the study. Inclusion criteria were: diagnosis of full-thickness rotator cuff tear as diagnosed at preoperative magnetic resonance imaging (MRI) and confirmed at the time of surgery; minimum 24-month of follow-up and availability of post-operative MRI performed not earlier than 6 months after surgery. Exclusion criteria were: partial thickness tears, irreparable tears, capsulo-labral pathologies, calcific tendonitis, gleno-humeral osteoarthritis and/or previous surgery. Primary outcome was the ASES score. Secondary outcomes were: Quick-DASH and WORC scores, and structural integrity of repaired tendons by magnetic resonance imaging (MRI) performed six months after surgery. A paired t-test was used to compare pre- and postoperative clinical outcomes. Subgroup analysis was performed according to tear size. Significance was set at p < 0.05. The study included 29 patients (M:F = 15:14). Mean age (+ SD) of patients was 61.7 + 8.9 years. Mean follow-up was 27.4 ± 2.3 months. Comparison between pre- and postoperative functional scores showed significant clinical improvement (p < 0.001). Subgroup analysis for tear size showed significant differences in the QuickDASH score (0.04). Particularly, a significant difference in the QuickDASH score could be detected between medium and large tears (p=0.008) as well as medium and massive lesions (p=0.04). No differences could be detected between large and massive tears (p= 0.35). Postoperative imaging showed healed tendons in 21 out of 29 (72%) cases. Preservation of tendon remnant combined with small bone vents in the repair of medium-to-massive full-thickness rotator cuff tears provided significant improvement in clinical outcome compared to baseline conditions with complete structural integrity in 72% of the cases

Introduction. The popliteus tendon is a component of the posterolateral corner of the knee, which controls the external rotation of the tibia. In our clinical practice, the femoral footprint of the popliteus tendon is occasionally excised as the bone is resected during total knee arthroplasty (TKA). Although the excision of the popliteus tendon femoral footprint could result in excessive external rotation of the tibia and may have adverse effects on the long-term outcomes of TKA, little attention has been paid to the popliteus tendon femoral footprint during TKA. The purpose of the present study is to assess the frequency of the excision and its associated risk factors. Methods. One hundred eleven knees of 90 patients with varus knee osteoarthritis who underwent primary TKA were included in the present study. There were 13 males and 77 females, and their average age was 74 years. The NexGen knee replacement system (Zimmer, Warsaw, IN, USA) was used in all cases. The excision of the popliteus tendon femoral footprint was intraoperatively evaluated, and the patients were divided into three groups depending on the status of the femoral footprint, i.e., the preserved, partially excised, and completely excised groups. The thickness of the distal femoral osteotomy, femoral component size, and background data including height, body weight, gender, and age were compared among these groups. Analysis of variance followed by Student–Newman–Keuls test were used to compare the continuous values and ordinal scales. Gender was compared using Fisher's exact test and residual analysis. Statistical significance was set at p < 0.05. Results. The popliteus tendon femoral footprint was preserved in 48 knees (43.2%), partially excised in 45 knees (40.5%), and completely excised in 18 knees (16.2%). The mean patient height was 154.6, 150.1, and 148.7 cm in the preserved, partially excised, and completely excised groups, respectively, and these differences were statistically significant (p < 0.01). Femoral component size was significantly smaller in the partially and completely excised groups compared with that in the preserved group (p < 0.05). The preserved group included more male patients (p < 0.01). There were no significant differences in body weight, age, and thickness of the distal femoral osteotomy among the groups. Conclusion. The partial or complete excision of the popliteus tendon femoral footprint was observed in more than half of the evaluated knees. Shorter height, smaller femoral component size, and female sex were considered to be the possible risk factors for the excision of the popliteus tendon femoral footprint

Introduction:. The insertion footprint of the different muscles tendon fascicles of the Achilles Tendon on the calcanium tuberosity has not been described before. Method:. Twelve fresh frozen leg specimens were dissected to identify the different Achilles Tendon fascicles insertion footprint on the calcaneum in relation to their corresponding muscles. Further ten embalmed cadaveric leg specimens were examined to confirm an observation on the retrocalcaneal bursa. Results:. The superficial part of the AT insertion is made by tendon fascicles from the medial head of the gastrocnemius muscle which insert over the entire width of the inferior facet of the calcaneal tuberosity. In three specimens, this insertion had continuity with the plantar fascia in the form of periostium. The deep part of the TA insertion is made of fascicles from the soleus tendon which insert on the medial aspect of the middle facet of the calcaneal tuberosity while the lateral head of the gastrocnemius tendon fascicles insert on the lateral aspect of the middle facet of the calcaneal tuberosity. A bicameral retrocalcaneal bursa was present in 68% of examined legs. Conclusion:. This new observation and description of the Achilles insertion footprint and the retrocalcaneal bursa may allow a detailed understanding of the function of each muscular part of the gastrosoleous complex. This has potential significant clinical relevance in the treatment of Achilles pathologies around its insertion

Previous studies describing drill trajectory for single incision distal biceps tendon repair suggest aiming ulnar and distal (Lo et al). This suggests that the starting point of the drill would be anterior and radial to the anatomic insertion of the distal biceps tendon. Restoration of the anatomic footprint may be important for restoration of normal strength, especially as full supination is approached. To determine the safest drill trajectory for preventing injury to the posterior interosseous nerve (PIN) when repairing the distal biceps tendon to the ANATOMIC footprint through a single-incision anterior approach utilising cortical button fixation. Through an anterior approach in ten cadaveric specimens, three drill holes were made in the radial tuberosity from the centre of the anatomic footprint with the forearm fully supinated. Holes were made in a 30º distal, transverse and 30º proximal direction. Each hole was made by angling the trajectory from an anterior to posterior and ulnar to radial direction leaving adequate bone on the ulnar side to accommodate an eight-millimetre tunnel. Proximity of each drill trajectory to the PIN was determined by making a second incision on the dorsum of the proximal forearm. A K-wire was passed through each hole and the distance between the PIN and K-wire measured for each trajectory. The PIN was closest to the trajectory K-wires drilled 30° distally (mean distance 5.4 mm), contacting the K-wire in three cases. The transverse drill trajectory resulted in contact with the PIN in one case (mean distance 7.6 mm). The proximal drill trajectory appeared safest with no PIN contact (mean distance 13.3 mm). This was statistically significant with a Friedman statistic of 15.05 (p value of 0.00054). When drilling from the anatomic footprint of the distal biceps tendon the PIN is furthest from a drill trajectory aimed proximally. The drill is aimed radially to minimise blowing out the ulnar cortex of the radius. For any reader inquiries, please contact . vansurgdoc@gmail.com

Background. Long term success of any shoulder joint reconstruction procedure involving subscapularis attachment take down is dictated by the way one chooses to release and repair/reconstruct the subscapularis insertion. There are several methods that were reported in the literature without any preset guidelines which are easily reproducible. Methods. 5 specimens of fresh cadaver shoulder joints dissected and the subscapularis footprint insertion involving the tendon and muscle exposed. We intend to preserve subscapularis tendon footprint along with the lesser tuberosity by performing the footprint osteotomy fashioned step wise in the following manner. Results. It has two vertical components (sagittal and coronal plane osteotomies) and one horizontal component (distal osteotomy at musculo tendinous junction level). Figure 1: demonstrating the three step cuts in the dry bone of proximal humerus with three different ostetomes to mark the plain of osteotomies in the lesser tuberosity. Step-1: Medial wall ridge of the inter-tubercular sulcus serves as landmark for sagittal component. The depth of sagittal component is just 5 – 10mm and its length extending from articular margin proximally and distally up to musculo tendinous junction, measuring approximately 15–20mm. Step-2: Coronal plane osteotomy is in line with and parallel to undersurface of subscapularis tendon adjacent to the articular margin and connecting sagittal component and measured 10–15mm approximately. Figure 2: demonstrating the two cuts / osteotomies to mark the sagittal and coronal components of the subscapularis foot print osteotomy in the lesser tuberosity of a fresh cadaver. Step-3: The horizontal component (distal osteotomy at musculo tendinous junction level is 5–10 mm in width, connects the two vertical components, thus completing the footprint osteotomy. Discussion. Subscapularis reattachment plays a pivotal role in the shoulder joint reconstruction procedures especially total joint arthroplasty. Subscapularis take down either by tenotomy or by periosteal elevation from lesser tuberosity followed by repair carries a risk of retraction and poor healing and early failure. Footprint osteotomy as a thin sliver of cortical bone instead of these above described three steps with the attached tendon carries a risk of fragmentation of the bone sliver along with lack of rotation control on the repair. The necessity for doing such a three step osteotomy procedure which results in a wedge shaped bone tendon foot print construct, we believe is of paramount importance for a successful reconstruction. Figure 3: demonstrating the marking sutures passed into the bone tendon construct comprising of lesser tuberosity and subscapularis for effective foot print reconstruction in a fresh cadaver. Conclusions. This three step footprint osteotomy of the Subscapularis tendon offers a stable construct which is easy to reproduce with better healing potential. For figures, please contact authors directly

Higher re-tear rates after arthroscopic single row rotator cuff repairs have been linked with the inability to restore the native footprint. The objective in our study was to evaluate the biomechanical properties and anatomic footprint restoration after both single and double row repairs. Human cadaveric shoulders (n=22) were tested using a materials testing machine. Cyclic loading was performed on intact, injured (3cm tear), and arthroscopically repaired rotator cuff. Repairs tested: 1) single row A (Lateral Simple, n=6); 2) single row B (Lateral Mattress, n=5); 3) double row A (Medial Mattress/Lateral Simple, n=6); and 4) double row B (Transosseus Simple, n=5). Percentage of footprint restoration was calculated for each repair followed by a load-to-failure protocol. Biomechanical properties were determined from the load-displacement curves. Single and double row repairs restored an average of 40% and 90% of the native footprint (p< 0.05) with small amounts of cyclic creep and permanent elongation. No differences were detected between any of the repairs for the ultimate load (724±344N, 879±247N, 741±339N and 896±229N) and stiffness (100±43N/mm, 106±31N/mm, 89±34N/mm and 100±14N/mm), respectively. Double row repairs have comparable initial strength and increased footprint restoration compared to single row repairs. These similarities can be attributed to the inclusion of surrounding soft tissue structures during testing; however, the increased restoration of the anatomic footprint may lead to increased tendon-to-bone healing with the possibility of improved biomechanical properties and should be examined in the future. The characteristic U-shaped tear confirms clinically observed scenarios which may be caused by overuse after a RC injury has been sustained. The small amount of cyclic creep and permanent deformation in all arthroscopic repairs suggest that initial rehabilitation could be prescribed after surgery without compromising the initial stability of the repair; however, surgeons should carefully select a RC repair based on the state of the surrounding tissue

The extracortical single-button (SB) inlay repair is one of the most preferred distal biceps tendon repair techniques. However, specific complications such as neurovascular injury and non-anatomic repairs have led to the development of techniques that utilize intracortical double-button (DB) fixation. To compare the biomechanical stability of the extracortical SB repair with the anatomical DB repair technique. Controlled laboratory study. The distal biceps tendon was transected in 18 cadaveric elbows from 9 donors. One elbow of each donor was randomly assigned to the extracortical SBor anatomical DB group. Both groups were cyclically loaded with 60N over 1000 cycles between 90° of flexion and full extension. The elbow was then fixed in 90° of flexion and the repair construct loaded to failure. Gap-formation and construct stiffness during cyclic loading, and ultimate load to failure was analysed. After 1000 cycles, the anatomical DB technique compared with the extracortical SB technique showed significantly less gap-formation (mean difference 1.2 mm; p=0.017) and significantly more construct stiffness (mean difference 31 N/mm; p=0.023). Ultimate load to failure was not significantly different comparing both groups (SB, 277 N ±92 vs. DB, 285 N ±135; p=0.859). The failure mode in the anatomical DB group was significantly different compared with the extracortical SB technique (p=0.002) and was due to fracture avulsion of the BicepsButton in 7 out of 9 specimens (vs. none in SB group). Our study shows that the intracortical DB technique produces equivalent or superior biomechanical performance to the SB technique. The DB repair technique reduces the risk of nerve injury and better restores the anatomical footprint of biceps tendon. The DB technique may offer a clinically viable alternative to the SB repair technique

Anterior cruciate ligament (ACL) reconstruction allows overall good results, but there is still a significant rate of failure. It is well accepted that the main reason for ACL reconstruction failure is a misplacement of tibial or femoral tunnels. Conventional techniques rely mainly on surgical skill for intra-operative tunnel placement. It has been demonstrated that, even by experienced surgeons, there was a significant variation in the accuracy of tunnel placement with conventional techniques. Navigation systems might enhance the accuracy of ACL replacement. 10 cadaver knees with intact soft-tissue and without any intra-articular abnormalities were studied. We used a non image based navigation system (OrthoPilot ®, Aesculap, Tuttlingen, FRG). Localizers were fixed on bicortical screws on the distal femur and on the proximal tibia. Both kinematic and anatomic registration of the knee joint were performed by moving the knee joint in flexion-extension and palpating relevant intra- and extra-articular landmarks with a navigated stylus. The most anterior, posterior, medial and lateral point of both tibial and femoral attachment of the ACL were marked with metallic pins. The navigated stylus was positioned on these points, and the system recorded its position in comparison to the bone contours. Subsequently, we performed conventional plain AP and lateral X-rays and a CT-scan, and measured the position of the pins in comparison to the bone contours. Finally, all measurements were made again with a caliper after disarticulating the knee joint. We calculated the center of the footprint as the mid-point between the four pins of both tibial and femoral attachment for each measurement technique. All measurements were expressed as percentages of the bone size to compensate for the different sizes. There were no significant difference in the paired measurements of the location of the ACL footprints on both femur and tibia between anatomic, radiographic, CT-scan and navigated measurements. There was a significant correlation between the paired measurements of the location of the ACL footprints on both femur and tibia with either measurement techniques. Anatomic measurement is the gold standard experimental technique for the positioning of the ACL foot-print, and CT-scan measurement is currently the gold standard technique in clinical situation. According to this reference, the position of ACL attachments on the tibia and on the femur can be accurately defined by the navigation system. Intra-operative measurement of the location of the bone tunnels during ACL replacement with this navigation system should be accurate as well

Objective: The high incidence of retear following primary rotator cuff tendon (RCT) repair necessitates new strategies for tendon footprint augmentation. This study’s objective was to evaluate the SeriCuff™, a non-mammalian derived silk-based long-term bioresorbable implant, for RCT footprint reinforcement. The study aimed to characterize the device when overlaid on the infraspinatus tendon footprint of sheep in a RCT repair model. The technique was not targeted for the repair of massive RCT defects but advocated as a preventive measure to cuff reruptures in mid-to-large cuff tears, avoiding the need for surgical revision. Methods: Bilateral surgeries were performed on each of 10 sheep during a single surgical session. The right shoulder of each animal was implanted with SeriCuff and the left shoulder was used as an operated control. The superficial layer of the infraspinatus tendon was removed and feathered for a distance of 1 cm. The remaining footprint was bluntly dissected from the humeral head with the exception of a thin band of the superior portion of the infraspinatus tendon. The footprint was approximated, 3 suture anchors placed equi-distantly along the edge of the full thickness region of the tendon and the tendon sutured to the anchors with a modified Mason-Allen stitch. Two additional anchors were placed along the lateral edge of the tendon in the right shoulder. The SeriCuff device was positioned over the 5 anchors and sutured in place using a single suture at each location (Fig 1B). In the left shoulder, no device was implanted and a second row of anchors was not used. Animals were allowed to ambulate immediately post-op with unrestrained motion for the duration of the study. All animals were necropsied at 3 mos and evaluated histologically (N=4) and mechanically (N=6). Samples designated for mechanical analysis were dissected leaving only the infraspinatus tendon and muscle attached to the humorous. The tendon was pulled to failure at a rate of 500 mm/min with the sample positioned such that the longitudinal axis of the tendon was collinear with the applied load. Results: The animals were able to ambulate following surgery with return to normal gait at an average of 6 days post-operatively. Pain scores diminished with time throughout the first two weeks. Mechanical analysis indicated an average 42% increase in repair strength of the SeriCuff reinforced repair as compared to the contralateral control at 3 months. The SeriCuff device supported the formation of Sharpy’s fibers in the remodeling tendon tissue. Conclusions: The addition of SeriCuff helped to reestablish the tendon footprint resulting in significantly increased repair strength 3 most post-op and therefore may have applications in reducing the high incidence of primary repair failure

Introduction:. The anterior column of the spine is often destroyed by trauma or disease. It is reconstructed by using autograft, allograft, or synthetic cages. The fibula strut graft provides good strength, incorporates quickly and has less risk of disease transmission, which is a big advantage in communities with high incidence of HIV. Various authors cite that its major drawback is the size of its foot print. We could not find any literature that measures its size. We undertook a study to measure the size of the footprint of the fibular in relation to the surface area of the endplate. The clinical relevance is that it may guide the surgeon in deciding how many struts of fibular are required in reconstructing the anterior column, and also quantifies the statement that the fibular strut has a small footprint. Material and Method:. CT angiograms are done frequently for peripheral vascular diseases. These angiograms also show CT scans of the lumbar and thoracic vertebrae, and fibulae of the same patient. We retrospectively examined the first 35 scans done during the year 2012 at Steve Biko Academic Hospital. From the CT we measured the surface area of the endplate of the vertebral bodies T6, 8, 12, L2, and the surface area of the cut surface of the proximal, middle and distal thirds of the fibular, all in square millimetres. We then compared the areas of the vertebral measurements to the area of the fibular measurements. Results:. The middle third of the fibular had the biggest cross sectional surface area. This fact, together with anatomical features of the fibula, explains why the middle part of the fibular is the preferred graft donor site. The ratio of the fibular surface area to that of the vertebral endplate is 1:3–6. It is difficult to advise in a biological system how many struts are required, as compared to a mechanical system. However these ratios suggest that more than one fibular strut graft is required to reconstruct the anterior column. Conclusion:. This is the first time to our knowledge that the surface area of the fibular graft is quantified against the vertebral end plate surface area. The study shows that at least 2 fibula struts are required to reconstruct the thoracic and lumbar anterior columns

Patient education programmes prior to hip and knee arthroplasty reduce anxiety and create realistic expectations. While traditionally delivered in-person, the Covid-19 pandemic has necessitated change to remote delivery. We describe a ‘Virtual Joint School’ (VJS) model introduced at Ysbyty Gwynedd, and present patient feedback to it.

Eligible patients first viewed online educational videos created by our Multi-Disciplinary Team (MDT); and then attended an interactive virtual session where knowledge was reinforced. Each session was attended by 8–10 patients along with a relative/friend; and was hosted by the MDT consisting of nurses, physiotherapists, occupational therapists, and a former patient who provided personal insight. Feedback on the VJS was obtained prospectively using an electronic questionnaire.

From July 2022 to February 2023, 267 patients attended the VJS; of which 117 (44%) responded to the questionnaire. Among them, 87% found the pre-learning videos helpful and comprehensible, 92% felt their concerns were adequately addressed, 96% felt they had sufficient opportunity to ask questions and 96% were happy with the level of confidentiality involved. While 83% felt they received sufficient support from the health board to access the virtual session, 63% also took support from family/friends to attend it. Only 15% felt that they would have preferred a face-to-face format. Finally, by having ‘virtual’ sessions, each patient saved, on average, 38 miles and 62 minutes travel (10,070 miles and 274 hours saved for 267 patients).

Based on the overwhelmingly positive feedback, we recommend implementation of such ‘Virtual Joint Schools’ at other arthroplasty centres as well.

Rotator cuff repair failure may to some extent be attributed to tendon-bone gap formation at the repair sight caused by insufficient suture tightening. We measured the footprint contact properties over time of single row and trans-osseous equivalent repairs. We also investigated the effect of suture retightening on the repair. Rotator cuff tears (RCT) were created in the supra-spinatus tendon of 6 cadaveric shoulders. An electronic pressure sensor (Tekscan) was placed between the tendon and bone to measure the footprint pressure. The OPUS AutoCuff System was used to consecutively repair the RCT using a single row repair (SR-R) and two trans-osseous equivalent repair (TOE-R) techniques;. two parallel sutures (TOE-P) and. cross over suture pattern (TOE-C). Sutures were tightened, then retightened in each group. Peak initial contact force, were recorded on suture tightening (peak force) and equilibrium contact properties after 300 seconds relaxation (equilibrium force). Data were analysed using pairwise ANOVA. All techniques demonstrated a similar trend in the contact properties over the test period with an initial peak in contact force on tightening of the sutures, followed by a rapid drop in contact pressure immediately after suture tightening, and finally tending towards equilibrium contact force at 300 seconds. The TOE-C group demonstrated the highest mean ‘peak force’ and the highest ‘equilibrium force’ after 300 seconds relaxation. The TOE-P ‘peak force’ and ‘equilibrium force’ were −15% and −3% that of TOE-C, while the SRR was −45% and −25% that of TOE-C. Retightening the sutures a second time had little effect on the SSR contact properties, while retightening the TOE repairs increased the equilibrium contact force by 30% although this was not significant. Significant relaxation occurs especially within the first 30s, compromising the contact properties. TOE-R’s exhibit better contact properties than SRR. Retightening the TOE-R’s tended towards a higher final equilibrium contact force. SRR repair contact properties were unaffected by a second tightening. TOE-R’s should be re-tightened before the suture is locked

The rotator cuff is sited on the anatomical neck of the humerus and is formed by the insertion of the supraspinatus (SP), infraspinatus (IS), teres minor (TM) and subscapularis. All play a vital role in the movement of the glenohumeral joint, and the anatomy is of critical importance in arthroscopic rotator cuff repair. We undertook an osteological and gross anatomical dissection study of the insertion mechanism of these tendons, in particular the SP .

The SP inserts by a triple or quadruple mechanism. The ‘heel’ (medial) and capsule fuse, inserting into the anatomical neck proximal to the anterior facet of the greater humeral tubercle. The ‘foot arch’ inserts as a strong, flat, fibrous tendon into the facet. This area is cuboidal, rectangular, or ellipsoid, and measures 36 mm² to 64 mm². In about 5%, the insertion is fleshy (pitted), rendering it weaker than a tendinous attachment. The ‘toe’ lips over the edge of the facet laterally and fuses with the periosteum, fibres of the inter-transverse ligament and the IS. A proximal ‘hood’ of about 4 mm stretches down inferiorly and fuses with the periosteum of the humeral shaft. The subacromial or subdeltoid synovial bursa are sited laterally.

The IS and TM insert into the middle and posterior facets (225 mm and 36 mm²) at respective angles of 80° and 115°. The inferior portion of the TM facet is not fused with the shoulder capsule. The subscapularis inserts broadly into the lesser tubercle, and the superior fibres fuse with the shoulder capsule and intertransverse ligament. The insertion of the subscapularis does not contribute directly to the formation of the ‘hood’, which belongs exclusively to the SP, IP and TM.

This study confirms the complexity of the SP insertion and suggests that an unfavourable attachment or biomechanical anatomical malalignment may lead to eventual tendon/cuff degeneration.

The supraspinatus tendon (SP) often ruptures. Gray established that the tendinous insertion always attaches to the highest facet of the greater tubercle of the humerus. Our osteological study of 124 shoulders in men and women between the ages of 35 and 94 years refocuses on the humeral insertion of the SP in relation to infraspinatus (IS) and teres minor (TM).

We found type-I SFs (cubic) in 53 shoulders (43%) and type-II SFs (rectangular or oblong) in 21 (17%). Type-III (ellipsoid) SFs were present in 20 shoulders (16%) and type-IV (angulated or sloping) in 11 (9%). SFs were type V (with tuberosity) in 12 shoulders (10%) and type VI (pitted) in three (2%). The facet area of the SP, IP and TM varied from 49 mm, 225 mm and 36mm2. Of the three muscles, the IS facet was consistently the largest (p < 0.05) and shaped rectangularly.

The SP inserted in a cubic or rectangular facet format in 75% of people. SP facet-size may relate to tendon strength, degeneration and rupture. This information may contribute to the understanding of tears of the rotator cuff.

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as ‘critical types’, due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation.

We therefore emphasise the need for ‘fastidious’ pre-operative planning to minimise this risk.

Cite this article: Bone Joint J 2014;96-B:249–53.

This study looks at the dynamic tendon-to-bone contact properties of rotator cuff (RC) repairs—comparing single row repairs (SRR) with double row transosseous- equivalent (TOE) repairs. It was postulated that relaxation during, and movement following, the repair would significantly compromise contact properties and therefore, the ability of the tendon healing.

Simulated tears were created in the supraspinatus tendon of six cadaveric human shoulders. A SRR was then performed using the OPUS System, creating two horizontal mattress sutures. An I-Scan electronic pressure-sensor (Tekscan, Boston, MA) was placed between the supraspinatus tendon and bone. The arm was then rested for 300secs (relaxation) before being passively moved twice through a range-of-motion (0-90 degrees abduction, 0-45 external and 0-45 internal rotation) and finally returned to neutral. The contact properties were recorded throughout each movement. The procedure was then repeated using two TOE techniques: parallel sutures (TOE-P) and a cross over suture pattern (TOE-C).

While peak pressures during the repair were higher in the two TOE repairs, all three methods demonstrated relaxation over 300s such that there was no significant diference in contact pressures at the end of this time. TOE parallel and cross-over repairs demonstrated no significant change in mean TTB contact pressure, force and area during abduction, external rotation and return to neutral, when compared to the 300sec relaxation state. TOE-C demonstrated a higher contact force on internal rotation (+53%). The SRR demonstrated a significant drop in contact force on abduction (−63%), and return to neutral (−43%) and a trend on external rotation (−34%). SRR exhibited no change on internal rotation.

There have been very few biomechanical studies with which observe RC repair contact properties dynamically. Relaxation of the repair can be partially reversed. Significant decrease in contact area with SRR during movement occurred, compared to the TOE repairs, which remains unaltered. This is an important consideration when determining postoperative rehabilitation.