We present the clinical and radiological outcome of a prospective series of 22 Buechel-Pappas Total Ankle Replacements (TAR) implanted in 19 patients with a mean follow-up of 9 years (range 6 to 13). The only published long term results of this prosthesis in the literature are from the originators' unit. Patients have been prospectively reviewed yearly since 1991. None was lost to follow-up. The primary diagnosis was rheumatoid arthritis in 11 and osteoarthritis in 8 patients. 12 patients were female. Mean patient age was 64 (range 39 to 81). At the time of review 4 patients (6 ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration 11 years after a TAR which until that point had continued to function well. One patient with severe rheumatoid arthritis had the implant removed at 8 weeks for deep infection. Another patient with rheumatoid arthritis had the TAR revised to a tibio-talar-calcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with rheumatoid arthritis has intermittent pain at 8 years following her TAR. Every other implant continues to function well. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose. Our results suggest that the Buechel-Pappas TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis

Primary total hip arthroplasty in patients with osteoarthrosis secondary to developmental hip dysplasia is often more complex due to anterolateral acetabular bone deficiency. Femoral head (shelf) autograft provides a non-immunogenic, osteoconductive lateral support with the potential for enhanced bone stock should revision surgery be required. The technique has been shown in other series to give reliable early results but may be complicated by graft revascularisation and collapse. As yet, no study has assessed shelf grafts long term or quantified the need for further bone graft at revision surgery. This study aims to assess initial graft union rate; quantify long term graft resorption and; quantify the need for further bone graft in the patients requiring revision surgery. A retrospective analysis of a single surgeon's series of 31 THR in 25 patients was conducted. Post-operative, biplanar radiographic analysis was performed at 3 and 6 months and annually thereafter for a mean of 14 years (range 8-18). Grafts were assessed for union, resorption and displacement. Intra-operative necessity for bone graft at revision surgery was recorded. Union, osseous 93%, fibrous 7%. No grafts displaced. In 71% less than one-third of the graft resorbed, in 29% one-third to one-half resorbed and in no grafts did greater than a half resorb. Of 10 patients revised, 2 required bone graft for inadequate bone stock. Femoral head autograft allows effective acetabular coverage with excellent rates of union, minimal graft resorption in the long term and improves bone stock in revision surgery

A reduced range of movement post total knee replacement (TKR) surgery is a well recognised problem. Manipulation under anaesthesia (MUA) is a commonly performed procedure in the stiff post operative TKR. Long term results have been variable in the literature. We prospectively followed up 48 patients since 1996 from one centre, over an average of 7.5 years, (range 1 to 10 years) and report on the long term results. The mean time to MUA post TKR was 12.3 weeks (range 3 to 48). Pre MUA, the mean flexion was 53°. The mean immediate passive flexion post MUA was 97°, an improvement of 44° (Range 10° to 90°, CI < 0.05). By one year, the mean flexion was 87°, improvement of 34°, (range −15° to 70°, CI< 0.05). At ten years the mean flexion was 86°. We found no difference between those knees manipulated before or after 12 weeks. In addition there was no difference found in those knees which had a pre TKR flexion of greater or less than 90°. There were no complications as a result of MUA. However, one patient was eventually revised at two years secondary to low grade infection. Our findings show that MUA is safe and effective method at improving the range of motion in a stiff post operative TKR. The improvement is maintained in the long term irrespective of time to MUA and range of motion pre TKR

Starting in 1977 a new cemented stem made of titanium alloy (with vanadium) was designed regarding some principle: rectangular shape, smooth surface covered with thin layer of titanium oxide, filling the medullar cavity. As a consequence: a thin layer of cement. It was designed with a collar. Initial Cementing technique used dough cement, vent tube and finger packing; then we applied cement retractor low viscosity cement and sometimes Harris Syringe. At the moment we went back to initial technique plus a cement retractor made of polyethylene. Many papers looked at long term follow up results depicting about 98 to 100 percent survivors at 10 years and 95 to 98% at 20 years (Hernigou, Hamadouche, Nizard, El Kaim). Clinical as well as radiological results are available. Radiological results depicted some radiolucent lines that appeared at the very long term. They could be related to friction between the stem and the cement. As advocated by Robin Ling, he called “French paradox” the fact that if a cemented prosthesis is smooth and fills the medullary cavity, long term excellent results could be expected. This was the case with stainless steel Kerboull shape, the Ling design (Exeter)and the Ceraver design. The majority of these stems were implanted with an all alumina bearing system. And in some occasion, when revision had to be performed, the stem was left in place (108 cases over 132 revisions). Our experience over more than 5000 stems implanted is outstanding (see figure 1: aspect after 30 years). Discussion other experience with cemented titanium stem were bad (Sarmiento, Fare). We suspect that this was related either to the small size of this flexible material, or to the roughness of its surface. If one uses titanium cemented stem it must be large enough and extra smooth

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006. Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications. 30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p< 0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph. We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery

Purpose. Disc degeneration is known to occur early in adult life, but at present there is no medical treatment to reverse or even retard the problem. Development of medical treatments is complicated by the lack of a validated long term organ culture model in which therapeutic candidates can be studied. The objective of this study was to optimize and validate an organ culture system for intact human intervertebral disc (IVD), which could be used subsequently to determine whether synthetic peptide growth factors can stimulate disc cell metabolism and initiate a repair response. Method. Seventy lumbar IVDs, from 14 individuals, were isolated within 24 h after death. Discs were prepared for organ culture by removing bony endplates but retaining cartilaginous endplates (CEP). Discs were cultured with no external load applied. The effects of glucose and FBS concentrations were evaluated. Dulbeccos Modified Eagle Media (DMEM) was supplemented with glucose, 4.5g/L or 1g/L, referred to as high and low (physiological) glucose, and FBS, 5% or 1%, referred to as high and low FBS, respectively. After a four week culture period, samples were taken across the disc using a 4 mm biopsy punch. Cell viability was analyzed using a live/dead fluorescence assay (Live/Dead, Invitrogen) and visualized by confocal microscopy. CEP discs were also placed in long term culture for four months, and cell viability was assessed. Western bolt analysis for the G1 domain of aggrecan was also performed to assess the effect of nutritional state on disc catabolism. Results. Cell viability in CEP isolated discs was evaluated after four weeks and four months of organ culture under high and physiological nutritional state. Previous studies have shown that high glucose levels are needed to maintain cell viability in organ culture, but in our model 96–98% live cells were present throughout the disc independent of FBS and glucose levels and the duration of culture tested. Western blot probing for the G1 domain of aggrecan showed no difference with the change of nutritional state across all regions indicating that low nutritional state had no detrimental effect on disc metabolism. Conclusion. We have developed a novel technique for isolation and culturing of intact IVDs. The described CEP system maintained sufficient nutrient supply and high cell survival in all regions of the disc for up to four months of culture also under physiological culturing condition. As the CEP system maintains high cell viability in long term cultures, it is a suitable model in which the regenerative effect of various bioactive peptides can be studied. The availability of an intact disc organ culture system has considerable advantage over the culture of isolated disc cells, as it maintains the cells in their unique microenvironment, so making any response to catabolic or anabolic agents more physiologically relevant

Purpose. Disc degeneration is known to occur early in adult life, but at present there is no medical treatment to reverse or even retard the problem. Development of medical treatments is complicated by the lack of a validated long term organ culture model in which therapeutic candidates can be studied. The objective of this study was to optimize and validate an organ culture system for intact human intervertebral disc (IVD), which could be used subsequently to determine whether synthetic peptide growth factors can stimulate disc cell metabolism and initiate a repair response. Method. Seventy lumbar IVDs, from 14 individuals, were isolated within 24 h after death. Discs were prepared for organ culture by removing bony endplates but retaining cartilaginous endplates (CEP). Discs were cultured with no external load applied. The effects of glucose and FBS concentrations were evaluated. Dulbeccos Modified Eagle Media (DMEM) was supplemented with glucose, 4.5g/L or 1g/L, referred to as high and low (physiological) glucose, and FBS, 5% or 1%, referred to as high and low FBS, respectively. After a four week culture period, samples were taken across the disc using a 4 mm biopsy punch. Cell viability was analyzed using a live/dead fluorescence assay (Live/Dead, Invitrogen) and visualized by confocal microscopy. CEP discs were also placed in long term culture for four months, and cell viability was assessed. Western bolt analysis for the G1 domain of aggrecan was also performed to assess the effect of nutritional state on disc catabolism. Results. Cell viability in CEP isolated discs was evaluated after four weeks and four months of organ culture under high and physiological nutritional state. Previous studies have shown that high glucose levels are needed to maintain cell viability in organ culture, but in our model 96–98% live cells were present throughout the disc independent of FBS and glucose levels and the duration of culture tested. Western blot probing for the G1 domain of aggrecan showed no difference with the change of nutritional state across all regions indicating that low nutritional state had no detrimental effect on disc metabolism. Conclusion. We have developed a novel technique for isolation and culturing of intact IVDs. The described CEP system maintained sufficient nutrient supply and high cell survival in all regions of the disc for up to four months of culture also under physiological culturing condition. As the CEP system maintains high cell viability in long term cultures, it is a suitable model in which the regenerative effect of various bioactive peptides can be studied. The availability of an intact disc organ culture system has considerable advantage over the culture of isolated disc cells, as it maintains the cells in their unique microenvironment, so making any response to catabolic or anabolic agents more physiologically relevant

The purpose of this study was to review the long term functional results of patients undergoing treatment for high energy tibial plateau fractures. Between January 1994 and June 2013 our unit managed 105 high energy tibial plateau fractures (Schatzker IV-VI) with an Ilizarov frame. All cases were treated via ligamentotaxis and percutaneous fine wire fixation or with a limited open reduction of the joint surface. A retrospective analysis of all patients that have undergone Ilizarov fixation of a tibial plateau fracture was performed with radiological and clinical functional outcome measurements. We analysed 105 patients with a mean follow up of 93.5 months (range 5–200). The patient group had an average age of 49 years (range 15–87) with 62 patients being male. Fracture pattern was analysed with Schatzker's classification showing 18 type IV, 10 type V and 77 type VI tibial plateau fractures. All fractures had an average time to union of 145 days. Patients had and average range of movement of 117 degrees. Patients undergoing Ilizarov treatment for high energy tibial plateau fractures achieve successful results long term. Definitive treatment should be decided with respect to fracture pattern and the soft tissue envelope. The management aim should be to achieve anatomical reduction and stable fixation to enable early mobilization. Our study confirms the good functional outcomes and low morbidity that can be achieved in high energy fractures treated with Ilizarov fixation

The femur begins to bow anteriorly at the 200 mm level, but may bow earlier in smaller people. If the stem to be used is less than 200 mm, a straight stem can be used. If the stem is longer than 200 mm, it will perforate the anterior femoral cortex. I know this because I did this on a few occasions more than 20 years ago. To use a long straight stem, there are two techniques. One can either do a diaphyseal osteotomy or one can do a Wagner split (extended trochanteric osteotomy). Both of these will put the knee in some degree of hyperextension, probably insignificant in the elderly, but it may be of significance in the young. In very young people, therefore, it may be preferable to use a bowed stem to avoid this degree of recurvatum. There are two different concepts of loading. Diaphyseal osteotomy implies a proximal loading has been sought. The Wagner split ignores the proximal femur and seeks conical fixation in the diaphysis. There will be very little bone-bone contact between what remains of the attached femur and the detached anterior cortex so that it is important to ensure that the blood supply to the anterior cortex remains intact, preferably by using Wagner's technique, using a quarter-inch osteotome inserted through the vastus to crack the medial cortex. Current modularity is of two types. Distal modularity was attempted many years ago and was never successful. Proximal modularity, as for example, the S-ROM stem, implies various sizes of sleeves fit onto the stem to get a proximal canal fill. In mid-stem modularity, the distal stem wedges into the cone. It has to be driven into where it jams and this can be somewhat unpredictable. For this reason, the solid Wagner stem has been replaced by the mid-stem modular. Once the distal femur is solidly embedded, the proximal body is then selected for height and version. The proximal body is unsupported in the mid-stem modular and initially, few fractures were noted at the taper junction. Cold rolling, shot peening and taper strengthening seem to have solved these problems. There are a variety of types of osteotomy, which can be used for different deformities. With a mid-stem modular system, generally, all that needs to be done is a Wagner-type split and fixation is sought in the mid-diaphysis by conical reaming. No matter what stem is used, distal stability is necessary. This is achieved by flutes, which engage the endosteal cortex. The flutes alone must have sufficient rotational stability to overcome the service loads on the hip of 22 Nm. I divide revision into three categories. In type one, the isthmus is intact, i.e. the bone below the lesser trochanter so that a primary stem can be used. In type two, the isthmus is damaged, i.e. the bone below the lesser trochanter, so a long revision stem is required. In a type three, there is more than 70 mm of missing proximal femur. The Wagner stem may be able to handle this on its own, but most other stems are better supported with a structural allograft cemented to the stem. The reported long term results of mid-stem modular revision implants are good as in most, over 90% survivorship. The introduction of modularity appears to have overcome initial disadvantage of the Wagner stem, i.e. its unpredictability in terms of leg length

Background:. There is little knowledge about wear performance of total ankle arthroplasties (TAR). However, revisions rates are high for TAR [1] and wear associated revisions are frequent [2]. Therefore, the aim of this study is . (1). To test the wear behavior of a TAR using a biomechanically valid testing scenario. (2). To test the influence of an alternative ceramic tibial component. (3). To test the long term wear performance of TAR. Material and Methods:. In the first part of this study the HINTEGRA (Smith & Nephew) TAR has been used for wear testing. Wear testing was performed on a modified AMTI knee simulator. Level walking according to a previous described testing standard [see abstract: Development of a force controlled testing scenario for total ankle replacements] has been used. Level walking was simulated in three clinical relevant situations, first simulating the reduced loading after implantation, secondly simulating an increasing range of motion and at last a loading pattern orientating at the loadings in the native/healthy joint. Every simulation was run for 3 million cycles, resulting in 9 million total cycles. In the second part of this study the metal tibial plateau was replaced by a ceramic tibial component (Biolox® Delta, CeramTec). Simulation was run, as described above, for additional 9 million cycles. Termed as a long term test, in total 18 million cycles of testing are performed. Results:. When simulating level walking with loadings assumed after implantation a wear rate of 19.5 ± 1,49 mg/Mc has been determined. Increasing the range of motion lead to a wear rate of 18.0 ± 2,56 mg/Mc and simulating loading as assumed in a healthy joint, a wear rate of 23.8 ± 1,47 mg/Mc was determined. When replacing the metal tibial component by a ceramic tray the wear rate decreased between 20–30% dependent on the tested scenario. No delamination occurred during 18 millon cycles of testing. Conclusion:. In this study, high wear rates for TAR were determined. Compared to standardized wear testing of total knee replacements in our laboratory the wear rate of TAR was approximately 2.5 times increased. Ceramics seem to be an option to decrease the wear rate. The high wear rate of the polyethylene may be a factor contributing to the high revision rates seen in TARs

Method. 286 patients underwent total hip arthroplasty with a cemented titanium femoral implant (Ultima, Johnson & Johnson) between July 1995 and July 2001. The acetabular component was either a porous coated cup or a cemented all-polyethylene cup. A 28mm cobalt chromium head was used in all patients. Patients were prospectively evaluated with clinical examination, Harris hip scores and radiographic assessment. Analysis of the data was performed. Results. Of the 286 patients, 11 patients were excluded from analysis for reasons including incomplete data (8) and death (3). The remaining 275 patients were comprised of 118 males and 157 females with an average age of 70.8 years (55–89 years). The average follow up was 10.5 years (1.03–14.23). The median follow up was 10 years. 177 cemented all-polyethylene and 98 porous coated acetabular cups were used. The average Harris hip scores were 34.4 and 81.25 for preoperative and last follow up visit respectively. 11 stems were revised (aseptic loosening 9, infection 2). Radiographic assessment showed vertical subsidence in 30 patients (10.9%) (>5mm in 6 and < 5mm in 24 patients). Complete cement-bone radiolucency was noted in 11 stems (4%). Radiolucent lines covering < 50% of cement-bone interface were noted in 18 stems (6.5%). There were no cases of cement fracture. Kaplan-Meier survivorship was 91% at 10 years & 89.8% at 12 years. Conclusions. This prospective study represents the largest reported cohort of patients with a cemented titanium alloy femoral stem. The long term clinical outcome of this stem is similar to that reported in other studies, but not equivalent to collarless polished tapered or modern uncemented stems. Radiographic loosening of these stems is similar to other studies in the current literature. Long-term follow-up is required to identify patients at risk of needing revision, and our institution no longer uses this implant

Background. In 2011 Aird et al published their results of the effects of HIV on early wound healing in open fractures treated with internal and external fixation. The study was conducted between May 2008 and March 2009 and performed in semi-rural area of KwaZulu-Natal, South Africa. These results suggested that HIV is not a contraindication to internal or external fixation of open fractures, as HIV is not a significant risk factor for acute wound implant infection. We present a longer term follow up of this same cohort of patients from the original study. Methods. From March 2011 to January 2012 we attempted to contact all patients from Airds original study. A simple telephonic questionnaire was obtained from all the patients contacted, regarding possible late sepsis, non-union and implant removal. Patients were requested to visit the outpatient department for a clinical assessment, a repeat HIV test and new X-rays. Results. Of the initial 133 patients, 27 patients had external fixators, which were removed, leaving 106 patients with implants in situ at the time of follow up. Six patients had died, 4 of AIDS, 1 of a traffic accident and one of community assault. We were able to obtain telephonic questionnaires of 46 patients in total. Of these 46 patients, 31 were seen at a dedicated research clinic for re-assessment. In the initial study, 33 patients were HIV positive. We re-assessed 14 of these HIV positive patients and of these, 1 patient had metal removed for sepsis and 1 patient had a non-union. The remaining 12 patients had implants in situ without sepsis or non-union. Conclusion. This is the longest follow up to date of the effect of HIV on surgical implants following open fractures. Our results suggest HIV is not a contraindication for internal surgical fixation of open fractures in HIV positive patients with regards to long term sepsis and the risk of non-unions. THIS RESEARCH IS SUPPORTED BY A RESEARCH GRANT OF THE ROYAL COLLEGE OF SURGEONS

PURPOSE. Lateral osteoarthritis of the valgus knee is a challenging problem, especially for young and active patients, where prosthetic replacement is not indicated. The purpose of the present study is to evaluate clinically and radiographically 91 patients with valgus knee treated with distal femoral varus osteotomy in mid and long term follow-up. METHODS. A clinical retrospective evaluation based on IKDC, OXFORD and WOMAC scores of 91 patients at 4 to 10 years of follow-up was performed. Subjective evaluation was based on a VAS for pain self-assessment. Radiographic evaluation was performed by an independent observer of all 91 patients at 2 to 6 years of follow-up. A survival analysis was performed assuming revision for any reason as primary endpoint. RESULTS. The present study reported a marked improvement in clinical score at a mean 8,3 years of follow-up with statistical significance (p<0.005). The radiographic evaluation revealed a reduction of 7,0° and 4,2° of FTA and HKA angles respectively (p<0.05) at a mean follow up of 4,3 years, while small differences were observed with TPA and PTS angles. The 8-years treatment survivorship was 95,6%. CONCLUSIONS. The present study demonstrates that distal femoral varus osteotomy is an effective and reliable option to manage lateral tibio-femoral compartment early degenerative joint disease in young- to middle-age patients, providing a satisfactory clinical improvement at a mean follow-up of 8 years. Furthermore, its survivorship at 8-years follow-up is over 95%

Introduction. Young, high-demand patients with large post-traumatic tibial osteochondral defects are difficult to treat. Fresh osteochondral allografting is a joint-preserving treatment option that is well-established for such defects. Our objectives were to investigate the long-term graft survivorships, functional outcomes and associated complications for this technique. Methods. We prospectively recruited patients who had received fresh osteochondral allografts for post-traumatic tibial plateau defects over 3cm in diameter and 1cm in depth with a minimum of 5 years follow-up. The grafts were retrieved within 24 hours, stored in cefalozolin/bacitracin solution at 4°C, non-irradiated and used within 72 hours. Tissue matching was not performed but joints were matched for size and morphology. Realignment osteotomies were performed for malaligned limbs. The Modified Hospital for Knee Surgery Scoring System (MHKSS) was used for functional outcome measure. Kaplan-Meier survivorship analysis was performed with conversion to TKR as end point for graft failure. Results. Of 132 patients identified, 14 were lost to follow-up and 37 had less than 5 years follow-up, leaving 81 patients. There were 29 conversions to TKR at a mean of 12 (3-23) years post-operatively. The remaining 52 patients had a mean MHKSS score of 83 (49-100) with a mean follow-up of 11.7 (5-34) years. The Kaplan-Meier graft survivorships were 94% at 5 years (SE 2.7), 83% at 10 years (SE 4.6), 62% at 15 years (SE 7.4) and 45% at 20 years (SE 8.5). Associated complications included infection (1.2%) treated by 2-stage TKR, graft collapse (8.6%) treated by TKR, osteotomy and conservatively and knee pain relieved by hardware removal (7.4%). Conclusion. Fresh osteochondral allograft is a successful treatment option for large post-traumatic tibial osteochondral defects in young patients, with satisfactory long term survivorships and functional outcomes with acceptable complication rates

Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation. Aim. The aim of our study was to review our long term results of arthroscopic treatment of osteochondral lesions of the talus. Materials and methods. 65 patients underwent arthroscopic treatment of the OCL between 1993 and 2000. There were 46(71%) men and 19(29%) women. The mean age at surgery was 34.2 years. The right side was affected in 43 patients and the left side in 22 patients. Results. 40/65(61.5%) patients who underwent arthroscopic treatment of the OCL were followed up. The mean follow-up was 13.1 years (9 to 18 years). The average age at final follow was 49.6 years (25–80 years). 15 (39.5%) patients reported poor, 14 (36.8%) fair, 9 (23.6%) good outcomes based on the Berndt and Harty criteria. 20/40 patients (50 %) needed further surgery. This appears a significant deterioration since this cohort were studied at 3.5 years, when the clinical results were 21.3% poor, 26.2% fair and 52.3% good, although losses to followup make exact comparison impossible. Conclusion. Arthroscopic treatment of osteochondral lesions of the talus gives medium term improvement in the majority of patients, but it appears that results deteriorate with time. Recurrence of symptoms sufficient to require further surgical intervention occurred in half the patients studied

Introduction. Minimally invasive, computer navigated techniques are gaining popularity for total knee replacement (TKA). While these techniques may have the potential to provide improved functional outcomes with more rapid recovery, little quantitative data exists comparing long-term gait function following surgery with different exposure approaches. This study compares functional gait differences between surgical approach groups two year following TKA. Kinetics, kinematics, and temporospatial parameters were assessed to determine if differences exist between groups in long term follow-up. Methods. This study was approved by the Banner IRB (Sun Health Panel). 95 subjects volunteered to participate in the study and signed informed consent prior to testing. The subjects were prospectively randomized to one of four surgical approach groups, mini-midvastus (MV), mini-subvastus (SV), mini-parapatellar (MP), and standard parapatellar (SP). These subjects were also compared to 45 age-matched, asymptomatic controls. Surgery was performed by one of two fellowship trained orthopedic surgeons specializing in adult reconstruction. Subjects were assessed in the gait laboratory two years after receiving surgery. Three dimensional kinetic and kinematic data were captured using a ten-camera passive marker system, a modified Helen Hayes marker set (Eagle-4, Motion Analysis, Santa Rosa, CA), and four floor embedded force platforms (AMTI Inc., Watertown, MA). Subjects were instructed to walk at a self selected speed down an 8 meter walkway. Kinetic and kinematic data were post processed using EVaRT and OrthoTrak 6.23 biomechanical software (Motion Analysis, Santa Rosa, CA). Statistical analyses were performed using SPSS (v14.0, SPSS Inc, Chicago, IL) and included a one-way ANOVA and post hoc testing. Results. 50 subjects returned for a two year gait analysis. Selected results are provided in Table 1. All approach groups regained near normal knee function compared to age matched controls. Motion analysis provided specific statistical differences between parameters about the knee and hip. The MV approach group maintained greater flexion than other groups at the knee and hip throughout the gait cycle. The MP group maintained the most extended knee postures throughout the task with significant differences from controls being noted during peak flexion in swing (p = 0.039) and at foot strike (p = 0.034). They also had reduced external knee rotation angles (p = 0.010) and a larger pelvic rotation range of motion (p = 0.020). Although not significant, the MP group had a concurrent increase in pelvic obliquity on the operative limb during weight acceptance. The MP group also had the highest velocity, cadence, stride length, and the earliest toe off when compared to other groups. Discussion. The results indicate that there are subtle differences in gait strategy between approach groups at the two year time point. The MV group maintains increased flexion angles at the hip and knee throughout the gait cycle which could be characterized as a “bent-hip bent-knee” gait. This could be due to differences in capsular and muscle scarring between the different surgical approach groups. The MP approach group maintained more extended knee postures with improved velocity, cadence, and stride length. No differences in pain were detected in clinical scores

Introduction. Advances in the management of open tibial fractures have reduced the incidence of long-term complications of these injuries. However, a number of patients continue to suffer from sequelae such as infection, non-union and malunion. Many orthopaedic surgeons believe a below-knee amputation with a well-fitted prosthesis is a better alternative to limb reconstruction surgery. There are few studies that evaluate the long-term functional outcomes of amputees against patients who have undergone limb salvage procedures, and their results are conflicting. The hypothesis of this study is that patients who have undergone limb salvage have as good or better outcomes than those who have had below-knee amputations. Methods. This is a retrospective case study. One group (n=12) had been treated with below-knee amputation following a variety of lower limb fractures. The other group (n=11) had developed complications following tibial fractures and undergone limb salvage surgery using the Ilizarov method. The groups were compared by means of a postal questionnaire, comprising the Oswestry Disability Index and the SF-36 Health Survey. Results. There were no statistically significant differences between the groups for any of the health scales measured. However, for the two scales in the SF-36 measuring functional health (Physical Functioning and Role-Physical) the differences were much lower than for any of the other scales (both p=0.13). The 95% confidence intervals for the difference between the means for each group were -6.4 to 45.4 for PF and -7.4 to 61.2 for RP. Discussion. This study provides evidence that limb conserving surgery offers a genuine improvement in long term functional health. The failure to reach statistical significance is a reflection of the relatively small numbers of patients affected and the difficulties in collecting data retrospectively

Objective. To assess the long term functional and objective outcomes for 2 stage Dupuytrens contracture correction. Methods. Patients with severe contracture were offered a 2 stage correction. This involved application of external fixator to distract the contracture over the course of 2 weeks and subsequent partial fasciectomy (in primary contractures) and dermofasciectomy with full thickness skin graft (in recurrent contractures). A series of 54 corrections in 47 patients were identified. Of these, 6 were lost to follow-up, 1 deceased. Pre-operative total range of active movement (TRAM), total flexion contracture and PIP flexion contracture, Tubiana grade and DASH/Michigan Hand Scores were recorded and compared to post-operative data. Results. Mean age was 61 (range 43–90), 44 male, 10 females. The average duration of follow-up was 32 months (range 6–96). The mean fixed flexion deformity (FFD) in the PIPJ improved from 84 degrees (range 50–110, SD-12) to 30 degrees (range −5–90, SD-27) (p< 0.0001). Mean total flexion contracture improved from 123 degrees(range 50–210, SD-34) to 46 degrees (range 0–195, SD-50) (p< 0.0001). The mean TRAM improved from 70 degrees (range 10–140, SD-33) to 148 degrees (range 25–135, SD-52) (p< 0.0001). DASH scores improved from 32.0 to 27.6. Michigan hand scores improved from 68 to 76. There was no statistical difference in pre- and post-op hand scores. Complications include CRPS (8%), infection (6%), stiffness (4%), graft failure (4%), neurovascular injury (2%), fracture (4%). Conclusions. Long term follow-up of this two stage technique shows that the correction, range of movement and function is maintained. We consider that the complications rate is acceptable for these very severe deformities where amputation, joint fusions and total collateral ligament and volar plate release are the only other comparable surgical alternatives

Treatment of recurrent dislocation: approximately: 1/3 of failures (probably higher in the absence of a clear curable cause).

In the US: most popular treatment option: constrained liners with high redislocation and loosening rates in most reports. Several interfaces leading to various modes of failures.

In Europe: dual mobility cups (or tripolar unconstrained): first design Gilles Bousquet 1976 (Saint Etienne, France), consisting of a metal shell with a highly polished inner surface articulating with a mobile polyethylene insert (large articulation). The femoral head is captured into the polyethylene (small articulation) using a snap fit type mechanism leading to a large effective unconstrained head inside the metal cup. With dual mobility, most of the movements occur in the small articulation therefore limiting wear from the large polyethylene on metal articulation.

Contemporary designs include: CoCr metal cup for improved friction, outer shell coated with titanium and hydroxyapatite, possible use of screws to enhance primary stability (revision), cemented version in case of major bone defect requiring bone reconstruction.

Increased stability obtained through an ultra-large diameter effective femoral head increasing the jumping distance.

Dual mobility in revision for recurrent dislocation provided hip stability in more than 94% of the cases with less than 3% presenting redislocation up to 13-year follow-up. A series from the UK concerning 115 revisions including 29 revisions for recurrent dislocation reported 2% dislocation in the global series and 7% re-dislocation in patients revised for instability. A recent report of the Swedish hip arthroplasty register including 228 patients revised for recurrent dislocation showed 99% survival with revision for dislocation as the endpoint and 93% with revision for any reason as the endpoint.

One specific complication of dual mobility sockets: intra-prosthetic dislocation (ie: dislocation at the small articulation): often asymptomatic or slight discomfort, eccentration of the neck on AP radiograph, related to wear and fatigue of the polyethylene rim at the capturing are through aggressive stem neck to mobile polyethylene insert contact (3rd articulation). Risk factors include: large and aggressive femoral neck design implants, small head/neck ratio, skirted heads, major fibrosis and periprosthetic ossifications.

Current (over ?) use in France: 30% of primary THA, 60% in revision THA.

Proposed (reasonable) indications: primary THA at high risk for dislocation, revision THA for instability and/or in case of abductors deficiency, Undisputed indication: recurrent dislocation.

Currently the debate continues in definitive fixation method for complex tibial plateau fractures. The aim of surgical management remains prevention of further damage to the articular cartilage, whilst avoiding iatrogenic risks - Low Risk Surgery (LRS). The purpose of this study was to determine the functional impact, clinical radiological outcome following tibial plateau fractures treated with either external fixation or internal fixation. 124 Schatzker IV-VI tibial plateau fractures were reviewed following surgical fixation. Fractures analysed included 24 type IV, 20 type V and 80 type VI tibial plateau fractures. The majority of Schatzker IV fractures were treated with internal fixation, but 67 of 80 Schatzker VI fractures were treated with the Ilizarov method. The average IOWA knee score, was 86 (16 to 100) and the average range of motion was 133 degrees (60 to 150). There were no differences between the circular fixator group and the internal fixation group in terms of range of motion or IOWA scores. There were comparable functional outcomes and complication rates between both groups. In summary patients with high energy tibial plateau fracture treated with internal or external fixation, have a good chance of achieving satisfactory long term knee function