Introduction. Version abnormalities of the femur, either retroversion or excessive anteversion, cause pain and hip joint damage due to impingement or instability respectively. A retrospective clinical review was conducted on patients undergoing a subtrochanteric derotation osteotomy for either excessive anteversion or retroversion of the femur. Methods. A total of 49 derotation osteotomies were performed in 39 patients. There were 32 females and 7 males. Average age was 29 years (range 14 to 59 years). Osteotomies were performed closed with an intramedullary saw (Figure 1). Fixation was performed with a variety of intramedullary nails. Patients requiring a varus or valgus intertrochanteric osteotomy were excluded. Pure rotational corrections only were performed. Twenty-four percent of patients had a retroversion deformity (average −8° retroversion, range +1 to −23°), 76% had excessive anteversion of the femur (average +36° anteversion, range +22° to +53°). Etiology was post-traumatic in 5 (10%), diplegic cerebral palsy in 4 (8%), fibrous dysplasia in 2 (4%), Prader-Willi Syndrome in 1 (2%) and idiopathic in 37 (76%). Previous surgery had been performed in 51% of hips. Fifty-seven percent underwent concomitant surgery with the index femoral derotation osteotomy, including hip arthroscopy in 39% (labral debridement alone or with femoral neck osteochondroplasty), a tibial derotation osteotomy in 12% and periacetabular osteotomy in 6%. Concomitant tibial osteotomies were performed to correct a compensatory excessive external tibial torsion that would be exacerbated in the correction of excessive femoral anteversion. The modified Harris Hip Score was used to assess the results in patients with a minimum of 24 months follow-up. Results. There were no non-unions. Average time to union was 3.3 months. One late infection occurred 10 months after surgery, treated successfully with hardware removal and antibiotics. Two patients, one with Prader-Willi syndrome and one with Ehlers-Danlos syndrome, were converted to total hip replacement. At an average follow-up of 6.1 years (range 2 to 19.1 years), the modified Harris Hip Score improved by 26 points (p< 0.001, Wilcoxon signed-ranks test). The results were rated as excellent in 71%, good in 22%, fair in 5% and poor in 3%. Subsequent surgery was required in 73%, 93% of which were hardware removals. Discussion and Conclusion. A closed, subtrochanteric derotation osteotomy of the femur is a safe and effective procedure to treat either femoral retroversion or excessive anteversion. Excellent or good results were obtained in 93%, despite the need for subsequent hardware removal in more than two-thirds of the patients. For figures/tables, please contact authors directly.

Introduction. Osteotomies around the knee are traditionally templated on 2D plain X-rays. Results are often inaccurate and inconsistent and multiplanar ostetomies are hard to perform. The aim of this study is to evaluate the feasibility and accuracy of virtual three-dimensional CT-based planning and correct execution of osteotomies around the knee with the aid of patient specific surgical guides and locking plates. Methods. Eight consecutive patients with significant malalignment of the lower limb were included in the study. Pre-operative CT scans of the affected limb and the normal contra-lateral side were obtained and 3D models of the patient's anatomy were created, using dedicated software. The healthy contralateral limb was mirrored and geometrically matched to the distal femur or proximal tibia of the healthy side. A virtual opening wedge correction of the affected bone was used to match the geometry of the healthy contralateral bone. Standard lower limb axes measurements confirmed correction of the alignment. Based on the virtual plan, surgical guides were designed to perform the planar osteotomy and achieve the planned wedge opening and hinge axis orientation. The osteotomy was fixed with locking plates and screws. Post-operative assessment included planar X-rays, CT-scan and full leg standing X-rays. Results. One three-planar, three bi-planar and four single-plane osteotomies were performed. Maximum weightbearing mechanical femoro-tibial coronal malalignment varied between 7° varus and 14° valgus (mean 7.6°, SD 3.1). Corrective angles varied from 7°-15°(coronal), 0°–13°(sagittal) and 0°–23°(horizontal). The maximum deviation between the planned pre-operative wedge angle and the executed post-operative wedge angle was 1° in the coronal, sagittal and horizontal plane. The desired mechanical femorotibial axis on full-leg standing X-rays was achieved in 6 patients. Two patients were undercorrected by 1° and 2° respectively. Conclusion. 3D planning and guided correction of multi-planar deformity of femur or tibia is a feasible and accurate novel technique

Osteotomies for valgus deformity are much less frequent than those for varus deformity as evidenced by published series which are, on one hand, less numerous and on the other hand, based on far fewer cases. For genu varum deformity, it has been proved that navigation allows to reach easier the preoperative correction goal. Our hypothesis was that navigation for genu valgum could be as accurate as for genu varum deformity. The aim of this paper was to present the mid-term results of 29 computer-assisted osteotomies for genu valgum deformity performed between September 2001 and March 2013. The series was composed of 27 patients (29 knees), 20 females and 7 males, aged from 15 to 63 years (mean age: 42.4+/−14.3 years). The preoperative functional status was evaluated according to the Lyshölm-Tegner score. The mean score was of 64+/−20.5 points (18–100). The stages of osteoarthritis were evaluated according to modified Ahlbäck's criteria. We operated on 12 stage 1, 9 stage 2, 5 stage 3 and 1 stage 4. 2 female patients had no osteoarthritis but a particularly unesthetic deformity (of which one was related to an overcorrected tibial osteotomy). The pre and postoperative HKA angle was measured according to Ramadier's protocol. We measured also the medial tibial mechanical angle (MTMA) and the medial femoral mechanical angle (MFMA). The mean preoperative HKA angle was 189.3°+/−3.9° (181° to 198°); the mean MFMA was 97.2° +/− 2.6° (93° to 105°) and the mean MTMA was 90.1° +/− 2.8° (86° to 95°). The goal of the osteotomies was to obtain an HKA angle of 179° +/− 2° and a MTMA of 90°+/2° in order to avoid an oblique joint line. We performed 24 femoral osteotomies (14 medial opening wedge and 10 lateral closing wedge) and 5 double osteotomies (medial tibial closing wedge + lateral opening wedge osteotomy). The functional results were evaluated according to Lyshölm-Tegner, IKS and KOO Scores, which were obtained after revision or telephone call. We did not find any complication except a transient paralysis of the common fibular nerve. 23 patients (4 lost to follow-up) were reviewed at a mean follow-up of 50.9+/−38.8 months (6–144). The mean Lyshölm-Tegner score was 92.9+/−4 points (86–100), the mean KOO score 89.7+/−9.3 (68–100), the mean IKS ≪knee≫ score 88.7 +/−11.4 points (60 à 100) and the mean ≪function≫ score 90.6 +/−13.3 points (55–100). 22 of the 23 reviewed patients (25 knees) were very satisfied or satisfied of the result. Regarding the radiological results, the mean HKA angle was of 180.1°+/−1.9° (176° to 185°), the mean MFMA of 90.7°+/−2.5° (86°-95°) and the mean MTMA of 89.1°+/−1.9° (86°-92°). The preoperative goal was reached in 86.2% (25/29) of the cases for HKA angle and in 100% of the cases for MTMA when performing double level osteotomy (5 cases). At this follow-up, no patient was revised to TKA. Computer-assisted osteotomies for genu valgum deformity lead to excellent results a mid-term follow-up. Navigation is very useful to reach the preoperative goal

Background. Osteotomies around the knee have been used to correct lower limb mal-alignment for over 50 years. The procedure is technically demanding and carries specific risks of neurovascular injury, incorrect planning and execution, and insufficient fixation. In recent years, with the advent of locking plates, fixation techniques have improved significantly but the correct planning and execution of the operation remains difficult. Despite the availability of CT and MRI 3D imaging, surgical planning is still traditionally performed on 2D plain X-rays [1]. Especially with multi-planar deformities, this technique is prone to error. The aim of this clinical pilot study is to evaluate the feasibility of virtual pre-operative three-dimensional planning and correct execution of osteotomies around the knee with the aid of patient specific surgical guides and locking plates. Patients and methods. Eight consecutive patients, presenting with significant malalignment of the lower limb were included in the study. Pre-operative CT scans of the affected limb and the normal contra-lateral side were obtained and 3D models of the patient's anatomy were created, using dedicated software (Mimics® 3-matic®, Materialise, Leuven Belgium) [2]. These models were used to evaluate the required surgical correction. The healthy contralateral limb was mirrored and geometrically matched to the distal femur or proximal tibia of the healthy side. A virtual opening wedge correction of the affected bone was used to match the geometry of the healthy contralateral bone. Standard lower limb axes measurements confirmed correction of the alignment [3]. Based on the virtual plan, surgical guides were designed to perform the planar osteotomy and achieve the planned wedge opening and hinge axis orientation (see figure 1). Apart from guiding the osteotomy, the patient specific surgical guide also guided drilling of the planned screw holes. Post-operative assessment of the correction was obtained through planar X-rays, CT-scan and full leg standing X-ray. Results. One three-planar, three bi-planar and four single-plane osteotomies were performed. All guides could be used during surgery and served accurate guidance of the osteotomy plane and screwholes. The guides matched the bone very well in all cases without remaining toggle. The maximum deviation between the planned pre-operative wedge angle and the executed post-operative wedge angle was 1° in the coronal, sagittal and horizontal plane. The desired mechanical femorotibial axis on full-leg standing X-rays was achieved in 6 patients. Two patients were undercorrected by 1° and 2° respectively. No significant peri-operative complications occurred. Conclusion. 3D planning and guided correction of multi-planar deformity of femur or tibia is a feasible and accurate novel technique

Introduction

Distal femoral and proximal tibial osteotomies are effective procedures to treat degenerative disease of the knee joint. Previously described techniques advocate the use of bone graft to promote healing at the osteotomy site. In this present study a novel technique which utilises the osteogenic potential of the cambial periosteal layer to promote healing “from the outside in” is described.

During a periacetabular osteotomy (PAO), intra-operative assessment of correction of acetabular parameters is typically performed using fluoroscopy of the hip, a technique that has not been shown to produce predictable measurements. Furthermore, paralysing agents are used in order to facilitate dissection and fragment mobilization. The effect of paralysing agents on spino-pelvic posture is yet to be investigated.

This study aims to: 1. Compare the reliability of intra-operative x-rays versus hip fluoroscopy in the assessment of acetabular fragment correction and 2. Evaluate the effect of changes in spino-pelvic alignment on the assessment of acetabular correction. An IRB approved, retrospective review of all patients who underwent a PAO at our institution between 2006–2018 was performed. Patient demographic data was collected and all available imaging studies were retrieved. Patients were excluded if there was no available to review intra-operative AP pelvis x-ray or intra-operative fluoroscopic PA image of the hip.

Using a validated hip analysis software (Hip2Norm), the lateral center edge angle (LCEA) and acetabular index (AI) of plain radiographs were measured. The sacro-femoral-pubic angle (SFP), along with the LCEA and AI of the fluoroscopic image were measured using ImageJ. A oneway ANOVA was used to detect differences between measured parameters in the intra-operative x-ray, the post-operative x-ray and the fluoroscopic image. A total of 93 patients were identified. 26 patients were excluded due to missing data. The mean LCEA in the post-operative, intra-operative, and fluoroscopic groups were as follows: 33.67° (range 5.3° to 52.4°), 30.71°(range 9° to 55.6°), and 29.23°(range 12.4° to 51.4°) respectively. The mean AI in the post-operative, intra-operative, and fluoroscopic groups were as follows: −0.65° (range −18.10° to 27.30°), 0.35°(range −16.10° to 17.20°), and 5.54°(range −11.66° to 27.83°) respectively.

When comparing intra-operative to post-operative plain radiographs, there was no statistically significant difference in AI (ΔAI −1±1.29° p=0.71) or LCEA (ΔLCEA 2.95±1.38° p=0.09). When comparing fluoroscopy to post-operative plain radiographs, there was a statistically significant difference in AI (ΔAI −6.21±1.29° p < 0 .0001) as well as LCEA (ΔLCEA 4.44±1.38° p < 0 .0001). Statistical analysis revealed no influence of demographics (age, BMI, gender), on acetabular correction parameters. The mean SPF angles measured from intra-operative and post-operative x-rays were 69.32±5.11° and 70.45±5.52°. There was a statistically significant difference between these 2 measurements with a ΔSFP of 1.03° (p < 0 .0001).

The results of our study show that the use of intra-operative x-ray for the assessment of LCEA and AI is more reliable than fluoroscopic images. Further, we found a difference in SFP angle, which offers an indirect assessment of pelvic tilt, between the intra-operative and the post-operative plain x-rays. This suggests that there are changes in pelvic tilt during the surgery, which can be attributed to either patient positioning or changes in spino-pelvic posture secondary to the paralysing agents used by the anesthetists. The use of intra-operative x-rays as well as the effect of paralysing agents on spino-pelvic alignment should be considered by surgeons performing PAO's.

Computer-aided surgical systems commonly use preoperative CT scans when performing pelvic osteotomies for intraoperative navigation. These systems have the potential to improve the safety and accuracy of pelvic osteotomies, however, exposing the patient to radiation is a significant drawback. In order to reduce radiation exposure, we propose a new smooth extrapolation method leveraging a partial pelvis CT and a statistical shape model (SSM) of the full pelvis in order to estimate a patient's complete pelvis. A SSM of normal, complete, female pelvis anatomy was created and evaluated from 42 subjects. A leave-one-out test was performed to characterise the inherent generalisation capability of the SSM. An additional leave-one-out test was conducted to measure performance of the smooth extrapolation method and an existing “cut-and-paste” extrapolation method. Unknown anatomy was simulated by keeping the axial slices of the patient's acetabulum intact and varying the amount of the superior iliac crest retained; from 0% to 15% of the total pelvis extent. The smooth technique showed an average improvement over the cut-and-paste method of 1.31 mm and 3.61 mm, in RMS and maximum surface error, respectively. With 5% of the iliac crest retained, the smoothly estimated surface had an RMS surface error of 2.21 mm, an improvement of 1.25 mm when retaining none of the iliac crest. This anatomical estimation method creates the possibility of a patient and surgeon benefiting from the use of a CAS system and simultaneously reducing the patient's radiation exposure.

Safely obtaining adequate exposure is an integral step in successfully performing a Total Knee Arthroplasty. In this study, we look at approaching the valgus knee through a lateral arthrotomy and tibial tubercle osteotomy.

20 knees in 19 consecutive patients with valgus deformities are included in this study (2006 to 2010). LCS mobile bearing prostheses were implanted by a single senior surgeon (GF). Navigation was used for all the knees. The knee is approached throught a skin incision 5–10mm more lateral than the standard midline incision. The lateral arthrotomy is made to Gerdy's tubercle 7–10cm distal to Tibial Tendon insertion. 7cm long and 2cm wide osteotomy is performed. Richards staples are used to fix the osteotomy once the prosthesis is fixed. All patients were followed up by the operating surgeon.

All osteotomies united. 2 postoperative complications were encountered during follow up. One patient had a postoperative haematoma that was washed out. A second patient had a fall 6/52 post-op and sustained a minimally displaced fracture at the navigation pin site (Tibia). This was treated in a cylinder cast and went onto full union.

Our technique of lateral arthrotomy and TTO in the valgus knee is safe and predictable. It delivers wider exposure, facilitates soft tissue management, preserves viability of the extensor mechanism and allows some movement of the tibial tubercle for improved patella tracking. We recommend planning this procedure preoperatively for best results.

Purpose

Successful outcome after opening wedge high tibial osteotomy (HTO) has been correlated with obtaining and maintaining angular correction while achieving union. Magnitude of correction, type of fixation and use of bone graft have been implicated as variables which can affect maintenance of correction.

The purpose of this study was to determine whether loss of coronal plane correction occurs over time following opening wedge HTO using our standard surgical techniques (unlocked plate with allograft). Our aim was also to correlate clinical outcome measures and radiographic findings. Our hypothesis was that no significant loss of correction would occur.

Introduction

Corrective femoral osteotomy in adults, as a closed procedure with the use of an intramedullary saw, is an elegant, minimally invasive technique for the correction of lower limb length inequalities or problems of torsion. Stabilisation following the osteotomy was achieved with a cephalo-medullary nail. We report the indications, results and complications following use of this technique.

Introduction

Torsional deformities of the femur have been recognized as a cause of femoroacetabular impingement (FAI) and hip pain. High femoral antetorsion can result in decreased external rotation and a posterior FAI, which is typically located extraarticular between the ischium and trochanter minor. Femoral osteotomies allow to correct torsional deformities to eliminate FAI. So far the mid-term clinical and radiographic results in patients undergoing femoral osteotomies for correction of torsional deformities have not been investigated.

Eight consecutive patients with significant malalignment of the lower limb were included in the study. Pre-operative CT scans of the affected limb and the normal contra-lateral side were obtained and 3D models of the patient's anatomy were created, using dedicated software. The healthy contralateral limb was mirrored and geometrically matched to the distal femur or proximal tibia of the healthy side. A virtual opening wedge correction of the affected bone was used to match the geometry of the healthy contralateral bone. Standard lower limb axes measurements confirmed correction of the alignment. Based on the virtual plan, surgical guides were designed to perform the planar osteotomy and achieve the planned wedge opening and hinge axis orientation. The osteotomy was fixed with locking plates and screws. Post-operative assessment included planar X-rays, CT-scan and full leg standing X-rays.

One three-planar, three bi-planar and four single-plane osteotomies were performed. Maximum weightbearing mechanical femoro-tibial coronal malalignment varied between 7° varus and 14° valgus (mean 7.6°, SD 3.1). Corrective angles varied from 7°–15°(coronal), 0°–13°(sagittal) and 0°–23°(horizontal). The maximum deviation between the planned pre-operative wedge angle and the executed post-operative wedge angle was 1° in the coronal, sagittal and horizontal plane. The desired mechanical femorotibial axis on full-leg standing X-rays was achieved in 6 patients. Two patients were undercorrected by 1° and 2° respectively.

Double level osteotomy (DLO) for severe genu varum is not a common technique. We performed our first computer-assisted double level osteotomy (CADLO) in March 2001 and we published our preliminary results in 2005 and 2007. The rationale to perform this procedure is to avoid oblique joint line in order to have less difficulty in case of revision to a total knee arthroplasty (TKA). The goal of this paper is to present the results of 37 cases operated on between August 2001 and January 2010.

The series was composed of 35 patients (two bilateral), nine females and 26 males, aged from 39 to 64 years old (mean age: 50.5 +/− 7.5). We operated on 20 right knees and 17 left ones. The mean BMI was 29.3 +/− 4.3 for a mean height of 1.71 m and a mean weight of 85.8 kg. The functional status was evaluated according to the LYSHÖLM and TEGNER score. The mean score was of 42.4 +/− 8.9 points (22–69). According to modified AHLBÄCK criteria we operated on seven stage 2, 22 stage 3, five stage 4 and two stage 5. We measured HKA (Hip-Knee-Ankle) angle using RAMADIER's protocol and we also measured the femoral mechanical axis (FMA) and the tibial mechanical axis (TMA) to pose the right indication. These measures were respectively: 168° +/− 3.4° (159°–172°), 87.5° +/− 2.1 (83°–91°) for the FMA and 83.7° +/− 2.6° (78°–88°) for the TMA.

The inclusion criteria were a patient younger than 65 years old with a severe varus deformity (more than 8° − HKA angle ≤ to 172°) and a FMA at 91° or less. All the osteotomies were navigated using the ORTHOPILOT® device (B-BRAUN-AESCULAP, TUTTLINGEN, GERMANY). The procedure was performed as follows: after inserting the rigid-bodies and calibrating the lower leg, we did first the femoral closing wedge osteotomy (from 4 to 7 mm) which was fixed by a an AO T-Plate, and secondly, after checking the residual varus, the high tibial opening wedge osteotomy using a BIOSORB® wedge (Tricalcium phosphate) and a plate (AO T-plate or C-plate). The goals of the osteotomy were to achieve an HKA angle of 182° +/− 2° and a TMA angle of 90° +/− 2°.

The functional results were evaluated using the LYSHÖLM-TEGNER score and the KOOS score. The patients answered the questionnaire at revision or by phone, and the radiological results were assessed by plain radiographs and standing long leg X-Rays between three and six months postoperatively.

We had no complication in this series but one case of recurrence of the deformity related to an impaction of the femoral osteotomy on the medial side. Two patients were lost to follow-up after removing of the plates (24 months) but were included in the results because the file was complete at that date. All the patients were assessed at a mean follow-up of 43 +/− 27 months (12–108). The mean LYSHÖLM-TEGNER score was 78.7 +/− 7.5 points (59–91) and the mean KOOS score was 94.9 +/− 3.3 points (89–100). Thirty-five patients were satisfied (18) or very satisfied (17) of the result. Only two were poorly satisfied. Regarding the radiological results, if we exclude the patient who had a loss of correction, the goals were reached in 32 cases (89%) for the HKA angle and in 31 cases (86%) for the TMA with only one case at 93°. The mean angles were: 181.97° +/− 1,89° (177°–185°) for HKA, 89.86° +/− 1,85° (85°–93°) for TMA and 93.05° +/− 2.3° (89°–99°) for FMA. At that mid-term follow-up no patient had revision to a total knee arthroplasty.

DLO is a very demanding technique. Navigation can improve the accuracy of the correction compared to non computer-assisted osteotomies. The functional results are satisfying and the satisfaction of the patients is very high. Despite the difficulty of the procedure, complications are, in our hands, very rare. We recommend DLO for severe genu varum deformity in young patients to avoid oblique joint line, which will be difficult to revise to TKA.

Through the paediatric LCP Hip plating system (Synthes GmBH Eimattstrasse 3 CH- 4436 Oberdorff), the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to pediatrics. We are presenting the outcome of the paediatric LCP hip plating system used for a variety of indications in our institution.

We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications.

Forty-three Paediatric LCP hip plates were used in forty patients (24 males and 13 females) for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, developmental dysplasia of hip, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of Slipped Upper Femoral Epiphysis.

Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy.

All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p= 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing.

Among the children treated without hip spica, 1 child suffered a periprosthetic fracture. Of the children treated in hip spica, 2 had pressure sores, 3 had osteoporotic distal femur fractures and 2 had posterior subluxations requiring further intervention.

There were no implant related complications.

The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions.

In order to manage painful subluxation/dislocation secondary to cerebral palsy, 12 hips in 11 patients received combined femoral and Chiari pelvic osteotomies with additional soft tissues releases at an average age of 14.1 (9.1-17.8) years. Pain relief, improvement in the arc of movement, sitting posture and ease of perineal care was recorded in all, and these features have been maintained at an average follow-up of 13.1 (8-17.5) years.

The improvement of general mobility was marginal, but those who were community walkers benefited the most. Pre-operative radiological measurements have been modified post-operatively to use lateral margin of the neo-acetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% to 13.7% [p<0.0001]. The mean changes in CE angle and Sharp's angle were 72° (range 56°- 87°) [p<0.0001] and 12.3° (range 9°- 15.6°) [p< 0.0001] respectively. Radiological evidence of progressive arthritic change was seen in only one hip, in which only a partial reduction had been achieved, and there was early joint space narrowing in another. Heterotopic ossification was observed in one patient with athetoid quadriplegia who remained pain free. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.

This combined procedure provides a stable hip with sustained pain relief for the adolescent and young adult presenting with pain.

Treatment of segmental bone defects remains a major clinical problem, and innovative strategies are often necessary to successfully reconstruct large volumes of bone. When fractures occur, the resulting hematoma serves as a reservoir for growth factors and a space for cell infiltration, both crucial to the initiation of bone healing. Our previous studies have demonstrated very clear ultrastructural differences between fracture hematomas formed in normally healing fractures and those formed in segmental bone defects. However, there is little information available regarding potential differences in the underlying gene expression between hematomas formed in normal fractures, which usually heal by themselves, and segmental bone defects, which do not. Therefore, the aim of this study was to identify differences in gene expression within hematomas collected from 0.5 mm (normal fracture) and 5 mm (segmental bone defect) fracture sites during the earliest stages of bone healing. Osteotomies of 0.5 and 5 mm in the femur of Fisher 344 rats were stabilized with external fixators (RISystem AG). After 3 days the rats were sacrificed, and the fracture hematomas were collected for RNA-sequencing. Ingenuity pathway analysis (IPA) was used to identify upstream regulators and biological functions that were significantly enriched with differentially expressed genes from the RNA-sequencing analysis. Animal procedures were conducted following the IACUC protocol of the UT Health Science Center San Antonio. Key upstream regulators of bone formation were less active (e.g. TGFB1, FGF2, SMAD3) or even inhibited (e.g. WNT3A, RUNX2, BMP2) in non-healing defects when compared to normally healing fractures. Many upstream regulators that were uniquely enriched in healing defects were molecules recently discovered to have osteogenic effects during fracture healing (e.g. GLI1, EZH2). Upstream regulators uniquely enriched in non-healing defects were mainly involved in an abnormal modulation of hematopoiesis, revealing evidence of impaired maturation of functional macrophages and cytokines (e.g. IL3, CEBPE), both essential for successful bone healing. In addition, the enrichment pattern suggested a dysregulation of megakaryopoiesis (e.g. MRTFA, MRTFB, GATA2), which directly affects platelet production, and therefore fracture hematoma formation. Remarkably, the organization of the ECM was the most significantly enriched biological function in the normally healing fractures, and implies that the defect size directly affected the structural properties within the fracture hematoma. Conversely, genes encoding important ECM components (e.g. BGN, various collagens, IBSP, TNC), cell adhesion molecules, MMPs (MMP2), and TIMPs were all significantly downregulated in non-healing defects. Our most recent findings reveal new important key molecules that regulate defect size-dependent fracture healing. Combined with our previous results, which identified structural differences in fracture hematomas from both types of defects, current findings indicate that differential expression of genes is dictated by the structural properties of the hematomas formed during early fracture healing. Consequently, creating a bioscaffold that mimics the structure of normal fracture hematomas could be the first step towards developing new orthoregenerative treatment strategies that potentiate healing of large bone defects and non-healing fractures

Revision hip approaches can be divided into posterior, anterior, transgluteal, and transtrochanteric. The approach chosen is dictated by what needs to be exposed and the approaches with which the surgeon is comfortable. The posterior approach remains posterior to the gluteus medius and protects the hip abductors. The disadvantage of a posterior approach is post-operative dislocation. The direct anterior approach is currently enjoying popularity as a primary technique. Surgeons experienced in the primary technique are applying it to revision surgery. The anterior approaches also protect the hip abductors. The disadvantage is poor access to the posterior acetabular column and mobilization of the femur to gain access to the femoral diaphysis. Transgluteal approaches split the gluteus medius typically keeping the anterior portion of the medius intact with the vastus lateralis. Proximal exposure is limited by the superior gluteal nerve, which is 4 cm above the tip of the trochanter. The disadvantage of the transgluteal approach is difficult access to the posterior acetabular column and occasional abductor weakness. The advantage of both the anterior and transgluteal approaches is a lower dislocation rate. All three approaches are acceptable for revisions that only require acetabular rim and proximal femoral exposure. More extensive exposure requires modifications to these approaches or the use of a transtrochanteric approach. Transtrochanteric approaches are defined by the length of the osteotomy (conventional or extended) and if the vastus lateralis remains attached to the trochanteric fragment (slide). Distally extended osteotomies improve access to the femur. Osteotomies without a distal attachment to the lateralis can be retracted proximally thus improving exposure of the ilium

Subscapularis repair and integrity after a primary total shoulder arthroplasty is critical for successful outcomes. One should be familiar with the 3 basic takedown and repair techniques commonly utilised. Subscapularis repair after reverse shoulder arthroplasty is not as critical and in some cases may be detrimental to return of external rotation strength and motion. Subscapularis tenotomy: The tendon is incised approximately 1 cm from the lesser tuberosity and an oblique incision is created from proximal lateral to distal medial stopping at the sentinel vessels. A combination of tendon-to-tendon figure of 8 sutures. Lesser tuberosity osteotomy: This approach is helpful not only in obtaining a bone-to-bone healing, but also in the exposure. Osteotomies range from a fleck of bone in patients with minimal deformity, to a C-shaped osteotomy including part of the head which facilitates exposure of the posterior glenoid. Despite an ability to document radiographic healing of the lesser tuberosity fragment, this technique does not prevent fatty infiltration of the subscapularis. Subscapularis Peel: This repair requires tendon healing to bone and probably incomplete, in most cases, reconstitution of a normal enthesis. External rotation can be gained by recessing the subscapularis insertion medially with the arm in external rotation. While bone-to-tendon sutures are the gold standard, augmentation of the sutures using a prosthesis as the anchor has led to the development of prostheses with multiple holes. Dual row repair of the tendon, however, may lead to medial rupture

Revision hip approaches can be divided into posterior, anterior, transgluteal, and transtrochanteric. The approach chosen is dictated by what needs to be exposed and the approaches with which the surgeon is comfortable. The posterior approach remains posterior to the gluteus medius and protects the hip abductors. The disadvantage of a posterior approach is post-operative dislocation. The direct anterior approach is currently enjoying popularity as a primary technique. Surgeons experienced in the primary technique are applying it to revision surgery. The anterior approaches also protect the hip abductors. The disadvantage is poor access to the posterior acetabular column and mobilisation of the femur to gain access to the femoral diaphysis. Transgluteal approaches split the gluteus medius typically keeping the anterior portion of the medius intact with the vastus lateralis. Proximal exposure is limited by the superior gluteal nerve, which is 4cm above the tip of the trochanter. The disadvantage of the transgluteal approach is difficult access to the posterior acetabular column and occasional abductor weakness. The advantage of both the anterior and transgluteal approaches is a lower dislocation rate. All three approaches are acceptable for revisions that only require acetabular rim and proximal femoral exposure. More extensive exposure requires modifications to these approaches or the use of a transtrochanteric approach. Transtrochanteric approaches are defined by the length of the osteotomy (conventional or extended) and if the vastus lateralis remains attached to the trochanteric fragment (slide). Distally extended osteotomies improve access to the femur. Osteotomies without a distal attachment to the lateralis can be retracted proximally thus improving exposure of the ileum

Introduction. Two principal targets are dominating the spectrum of goals in total knee arthroplasty: first of all the orthopedic surgeon aims at achieving an optimal pain-free postoperative kinematic motion close to the individual physiologic range of the individual patient and secondly he aims for a concurrent high ligament stability within the entire range of movement in order to establish stability for all activities of daily living. This study presents a modified surgical procedure for total knee replacement which is ligament-controlled in order to put both component into the “ligamentous frame” of the patients individual kinematics. Methods. The posterior femero-condylar index (PFC-I) is defined as being the posterior condylar offset divided by the distal antero-posterior diameter on a lateral radiograph. After careful preoperative planning the positions and orientations of the osteotomies is controlled intraoperatively via ligamentous guidance. Anterior and distal femoral osteotomy are planned on antero-posterior and lateral radiographs considering intramedular and mechanical axes as well as the orientation of the posterior condyles. Osteotomies are carried out in a stepwise fashion, starting with the anterior femoral osteotomy followed by the distal femoral osteotomy as planned. Then the extension gap is finalized by tensioning the ligaments and “top-down” referencing the level of the tibial osteotomy. After rotating the femur into the 90°-flexion position the flexion gap is finalized by referencing the level of the posterior condyle osteotomy in a “bottom-up” fashion to the tibial osteotomy. Hence, this technique determines the size of the femoral component with the last osteotomy. It likewise respects the new, ACL-lacking ligamentous framework and it drives the prosthetic components to fit into the new ligamentous envelope to follow the modified kinematics. Results. More than 130 patients have been operated on using this surgical technique, 104 of them have been followed-up after a minimum of one year: age 73+/−9, m/f 37/67, 71% had a varus, 29% a valgus-deformity. In all patients a subvastus approach was applied, 12 from medial, 92 from lateral. Mean flexion reached 122°+/−7.4 and a 120°-flexion or more was achieved by 86% of the patients. All patients reveived a LCS total knee prosthesis with either a rotating or an antero-posterior gliding inlay. No fixed tibial inlays were used. Antero-posterior translation of the APG-insert was 13 to 16mm immediately postoperatively whereas after one year it decreased to 4 to 10mm. We succeeded in reconstructing the posterior femero-condylar index (PFC-I) and found a linear correlation of 0.98 +/−0.06 of pre- to postoperative PFC-I. Conclusion. This PCL-retaining surgical technique respects the new, ACL-lacking kinematics in total knee replacement. The anterior and distal femoral osteotomies are femur-axis-controlled while the extension and flexion gaps are ligament-controlled. The size of the femoral component is regarded as a variable within the procedure and is only determined while performing the last osteotomy, i.e. the posterior condylar osteotomy. This technique is suitable for both PCL-retaining and also for PCL–sacrificing techniques