We present a prospective two-year follow-up study of 1038 hip arthroscopies performed at a high volume tertiary referral centre for hip preservation. We feel that this manuscript is both pertinent and timely due to the advances in the field of hip preservation. We used four validated patient-reported outcome (PRO) scores along with the visual analog scale (VAS) and patient satisfaction scores to assess preoperative and postoperative outcomes in all patients undergoing hip arthroscopy. We divided the entire cohort into patients undergoing primary and revision hip arthroscopies. We found a statistically significant improvement from preoperative to two-year postoperative PRO scores in the two subgroups. We also found a significant difference in the PRO scores at three months, one year, and two years postoperatively between the primary and revision subgroups. The revision subgroup had inferior VAS and patient satisfaction compared to the primary subgroup, however these results were not significant. The conversion to total hip arthroplasty/hip resurfacing (THA/HR) was 5.6% and 11.2% in the primary and revision subgroups, respectively. This resulted in a relative risk of 2.0 for conversion to THA/HR in the revision subgroup. We had a complication rate of 5.3 (only 0.5% of which were considered major) which was similar to that reported in the literature for hip arthroscopy. The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopy at a high volume tertiary referral centre for hip preservation with minimum two-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopy. From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopy. Patients were assessed pre- and post-operatively with modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport Specific Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. There were a total of 1155 arthroscopies performed, including 1040 primary arthroscopies (926 patients) and 115 revision arthroscopies (106 patients). Of these, 931 primary arthroscopies (89.5%) in 824 patients (89.0%) and 107 revision arthroscopies (93.0%) in 97 patients (91.5%), were available for follow-up and included in our study. The mean change in patient reported outcome (PRO) scores at two-year follow-up in the primary subgroup was 17.4 for mHHS, 19.7 for HOS-ADL, 23.8 for HOS-SSS, 21.3 for NAHS, and −3.0 for VAS. The mean change in PRO scores at two-year follow-up in the revision subgroup was 13.4, 10.9, 16.1, 15.4, and −2.7, respectively. All scores improved significantly compared to pre-operatively (p<0.001). PRO scores were higher at all time points for the primary subgroup compared to the revision subgroup (p<0.05). Satisfaction was 7.7 and 7.2 for primary and revision subgroups, respectively. Of 931 primary arthroscopies, 52 (5.6%) underwent THA/HR. Of 107 revision arthroscopies, 12 (11.2%) underwent THA/HR. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures. The overall complication rate was 5.3%. Hip arthroscopy showed significant improvement in all PRO, VAS, and satisfaction scores at two years postoperatively. Primary arthroscopy patients showed greater PRO scores and a trend towards greater VAS compared to the revision subgroup. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures

Aim. A growing number of recent investigations on the human genome, gut microbiome, and proteomics suggests that the loss of mucosal barrier function, particularly in the gastrointestinal tract, may substantially affect antigen trafficking, ultimately influencing the close bidirectional interaction between the gut microbiome and the immune system. This cross-talk is highly influential in shaping the host immune system function and ultimately shifting genetic predisposition to clinical outcome. Therefore, we hypothesized that a similar interaction could affect the occurrence of acute and chronic periprosthetic joint infections (PJI). Method. Multiple biomarkers of gut barrier disruption were tested in parallel in plasma samples collected as part of a prospective cohort study of patients undergoing revision arthroplasty for aseptic or PJI (As defined by the 2018 ICM criteria). All blood samples were collected before any antibiotic was administered. Samples were tested for Zonulin, soluble CD14 (sCD14), and lipopolysaccharide (LPS) using commercially available enzyme-linked immunosorbent assays. Statistical analysis consisted of descriptive statistics and ANOVA. Results. A total of 96 patients were consented and included in the study. 32 were classified as PJI (23 chronic and 9 acute), and 64 as aseptic. Both Zonulin and LPS were found to be increased in the acute PJI group 8.448 ± 7.726 ng/mL and 4.106 ± 4.260 u/mL, compared to chronic PJI (p<0.001) and aseptic revisions (p=0.025). sCD14 was found to be increased in both chronic (0.463 ± 0.168 ug/mL) and acute PJI (0.463 ± 0.389 ug/mL) compared to aseptic revisions (p<0.001). Conclusions. This prospective ongoing study reveals a possible link between gut permeability and the ‘gut-immune-joint axis’ in PJI. If this association continues to be born out with larger cohort recruitment, it would have a massive implication in managing patients with PJI. In addition to the administration of antimicrobials, patients with PJI and other orthopedic infections may require gastrointestinal modulators such as pro and prebiotics

There are pros and cons of all bearing surface options for our young patients. I pick the bearing surface for my young patients trying to maximise durability and minimise risks. For the ultra-young, ≤30 years of age patient, I use ceramic-on-ceramic. The pros of this are the best wear couple available and a favorable track record (with well designed implants). The risks can be minimised: fracture risk now decreased, runaway wear minimised with good surgical technique, impingement problems minimised with good technique and well designed implants, as well as squeaking is minimised with good design (majority of reported squeakers are of one designed socket). I don't use metal-on-metal because I am not willing to subject young patients to potentially 50+ years of high metal ion exposure. I also don't use HCLPE. This would be okay from a biologic standpoint but I still have concerns about long-term wear durability. So the marked superior wear characteristics of ceramic-ceramic win in my view. For my middle age patients, 30–60, I use HCLPE I don't use ceramic-ceramic because at some point between 30 and 60 years of age the improved wear properties are outweighed by their potential risks (fracture, impingement, squeak). HCLPE at short F/U (<15 years) appears to be durable, reliable with good wear properties so it is a reasonable choice. Using a ceramic head versus CoCr provides minimal improvement in wear properties in the lab but no marked advantage in vivo. Concerns persist about cobalt-chrome corrosion so I use ceramic heads in the majority of patients. For patients under age 60 the wear characteristics of HCLPE appear very favorable and one doesn't assume other risks seen in with metal-on-metal and ceramic-ceramic. Little justification for a hard-on-hard bearing in this patient subgroup. I use ceramic heads in majority to avoid corrosion issues

Introduction. Pedicle Subtraction osteotomy (PRO) in correction of severe spinal deformities is well established. Prospective analysis of its efficacy in complex spinal deformities is sparse in literature. Aims and objectives. To assess the role of PRO in correction of uniplanar and multiplanar spinal deformity and to assess the role of revision PRO in failed corrections. Material and methods. 50 patients were operated between 1996-2007 and followed up for 2 years (2-6). 27 had uniplanar kyphosis (60-128 degrees) and kyphoscoliosis was seen in 10. Failed corrections were seen in 11 uniplanar and 2 multiplanar deformities. The average pre-operative kyphosis and sagittal balance was 78.7 degrees and 22 mm (7-30) respectively. Scoliotic deformity ranged from 97-138 (average 108 degrees) and the coronal imbalance from 10-55 (average 24mm). Deformity distribution was upper dorsal 5, mid dorsal 22, dorso-lumbar 18 and lumbar 5. A single posterior approach sufficed in 47 cases while 3 required an anterior approach for reconstruction. 13 patients had pre-operative neurological deficit (bedridden 10, ambulatory 3). The average surgical time required was 300 minutes and blood loss was 800cc. The anterior defect reconstructed averaged 16.5mm (5-28). Results. Pulmonary complications occurred in 8 (21%), (embolism 1, pneumonia 2, hypoxia 5). Wound infection required debridement in 3 (8%). Failed corrections were seen in 10 (3 out of 37 in our series, 8%) due to failure of construct 2, severe disease 2, infection (active 2, quiescent 4). Neurological deterioration occurred in 1(2%), medial pedicle wall perforation. 12 patients regained ambulation (independent 7, support 5). Post-operative kyphosis and sagittal balance was 36.5 (10-108) and 10mm (5-20) respectively. Average correction was: sagittal 46.4%, coronal 37.5% and revisions 58%. The correction of kyphosis and sagittal balance was statistically comparable between primary and revision cases (p >0.05). Conclusions. PRO offers an excellent single stage decompression and controlled correction of kyphosis

Recent advances in arthroplasty for the hip and the knee have motivated modern foot and ankle research to perfect the implant and technique for the optimal total ankle replacement. Unlike in the hip where different approaches can be done with similar implants, the approach of a total ankle is intimately associated to the prosthetic design. The anterior and lateral approaches have pros and cons regarding their respective soft tissue complications, osteotomy necessity, orientation of the bone cut and gutter visualization. While both have been studied independently, very few reports have compared both in the same setting. This study retrospectively looked at the difference in reoperations rate after each ankle arthroplasty within two years estimating that both had similar rate of return to the operating room. A retrospective study was conducted from a single center between 2014 and 2017 including a total of 115 total ankles performed by one of four fellowship-trained foot and ankle surgeon. Re-operations were reported in the charts as an operative report. The index approach used was determined by the surgeon's practice preference. Patients were included when they had a primary TAR in the timeframe noted and had a complete dataset up to at least the two-year data. This cohort comprised 67 anterior and 48 lateral with balanced demographic for age (95%CI 63–67 yo) and gender (47% F). The lateral group had more complex cases with higher COFAS type arthritis. Comparing the two groups, a total of 40 reoperations (7 anterior, 33 lateral) occurred in 27 patients (5A, 22L). One patient had up to four related reoperations. The only revision was in the anterior group. The only soft tissue reconstruction was an STSG in the lateral group. Nine reoperations were irrigation debridement related to an infective process (3 A, 6L). The majority (19/33) of reoperations in the lateral group were gutter debridement (8) or lateral hardware removal (11). Operative time was not statistically different. The odds ratio of having a reoperation with a laterally based TAR was 6.19 compared to the anterior group. This retrospective study outlines the intermediate results at two years of lateral and anterior total ankle replacements. This is a first study of this kind in the literature. This study did show that there were more reoperations after a laterally-based TAR than an anterior TAR, recognizing the significant case complexity imbalance between groups. This speaks to the relative increase resource utilization of laterally based TAR patients. Both implant designs carry different reoperation rates favoring the anterior group however larger prospective datasets will be needed with patient-reported outcome

Two-stage treatment of chronically infected TKA is the most common form of management in North America and most parts of the world. One-stage management has pros and cons which will not be discussed in this lecture. There is great variation of techniques and timing and little data to definitively support one technique or timing approach vs. another. Most methods are based on empirical success and logic. At the time of surgery, the first step is removal of infected implants. All metallic implants and cement should be removed. The most common places to leave cement behind inadvertently include patellar lug holes, femoral lug holes, and the anterior proximal tibia behind the tibial tubercle. Formal synovectomy should be performed. The next step is typically antibiotic-impregnated spacer placement. There are pros and cons of dynamic and static spacers with no clear evidence of superiority of one vs. another. Dynamic spacers work satisfactorily with mild to moderate bone loss, but more severe bone loss is usually better treated with static spacers and a cast. Most antibiotic spacers are made of methyl methacrylate cement with addition of high-dose antibiotics. In most cases, doses of 4–8 gm of antibiotics per pack of cement are preferred. The type of dosing depends on the specific antibiotic and the type of cement used. The most common antibiotics used are vancomycin and gentamycin. When the femoral canals have been instrumented, antibiotic-impregnated cement wands are usually placed in the medullary canal, as the medullary canals have been shown to have high risk of residual bacteria being present. The resection interval may vary and there is no clear evidence of a “best” resection interval. Practically speaking, most surgeons use a resection period of 8–16 weeks depending on the type of spacer utilised. During the resection interval, serum markers (ESR and CRP) are followed periodically. One anticipates a decline or normalization of these parameters prior to second stage reimplantation procedure. There has not been a demonstrated advantage to reaspiration of the knee before reimplantation in most circumstances. At the time of reimplantation, the spacers are removed and the knee is redebrided. The key at the time of reimplantation is to obtain good implant fixation but to also balance this with the potential for manageable extraction of the implants at some later date. Good implant fixation is important because failure rates due to mechanical failure are approximately equal to those of failure due to reinfection by 10 years. It is important to remember that reinfection risk is at least 10% by ten years, and therefore extractability of implants is also important. Post-operative management typically includes IV antibiotics, followed by oral antibiotics until final intra-operative cultures are available. The results of two-stage reimplantation are reported in many series. Most show approximately 85–95% rate of successful eradication of infection in the first five years. Reinfections, often with different organisms, may occur even late after reimplantation. By ten years after surgery survival free of mechanical failure and infection in most series drops to 80% or less due to recurrent infections and mechanical failures

Introduction. Historically, the outcomes of knee replacement were evaluated based on implant longevity, major complications and range of motion. Over the last recent years however, there has been an intensively growth of interest in the patient's perception of functional outcome. However, the currently used patient related outcome (PRO) scores are limited by ceiling effects which limit the possibility to distinguish between good and excellent results post knee arthroplasty. The Forgotten Joint Score (FJS) is a new PRO score which is not influenced by ceiling effects, therefore making it the ideal instrument to compare functional outcome between various types of implants. It is based on the thought that the ultimate goal in joint arthroplasty is the ability of a patient to forget their artificial joint in everyday life. The aim of this study is to compare the FJS between patients who undergo TKA and patients who undergo medial UKA at least 12 months post-operatively. We hypothesized that the UKA which is less extensive surgical procedure will present better FJS than TKA, even 12 month postoperative. Methods. All patients who underwent medial UKA or TKA were contacted 12 months post-operatively. They were asked to complete the FJS, the Western Ontario and McMasters Universities Osteoarthritis index (WOMAC) and the EuroQol-5D (EQ-5D). A priori power analysis was conducted using two-sample t-test. 64 patients in each group were needed to reach 80% power for detecting a 12 point (SD 24) significant difference on the FJS scale with a two-sided significant level of 0.05. A p-value <0.05 was considered as statistically significant. Results. 128 patients were included. 64 underwent medial UKA and 64 TKA. At an average of 1.5 years follow-up in the UKA group and 1.4 years in the TKA group, the FJS was significantly higher in the UKA group (73.0±23.3) than the TKA group (59.1±26.8). No significant differences were noted for all 3 WOMAC domains (figure 1) and 5 EQ-5D domains (figure 2). Conclusion. Our data suggests that patients who undergo UKA are better capable of forgetting their artificial joint in daily life and therefore are more satisfied. Furthermore our data suggests that the FJS should be used in future studies since it has the ability to detect top-end differences where the conventional PRO scores are unable to distinguish between good and excellent results following knee replacement

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis

The range of allograft products for spinal fusion has been extended with the development of cellular bone matrices (CBMs). Most of these combine demineralized bone with viable cancellous bone prepared in a manner that retains cells with differentiation potential. The purpose of this study was to compare commercially-available human CBMs in the athymic rat model of posterolateral spinal fusion. The products compared were Trinity ELITE® (TEL, OrthoFix), ViviGen (VIV, DePuy Synthes), Cellentra (CEL, Zimmer Biomet), Osteocel® Pro (OCP, NuVasive), Bio4 (BIO, Stryker) and map3 (MAP, RTI Surgical). Bone from the ilia of syngeneic rats was used as a control to approximate the human gold standard. All implants were stored, thawed, and prepared per manufacturer's instructions and all implantations occurred within the manufacturer's time allowance for use after preparation. In total, fifteen 9–10 week old male rats were implanted per implant type, with three different lots of each implant used per five rats to account for lot-to-lot variability. Under anesthesia, a posterior midline longitudinal skin and subcutaneous incision was made, followed by bilateral longitudinal paraspinal myofascial incisions to expose the transverse processes at the L4–5 level. Implants (0.3 cc of allograft or freshly harvested syngeneic iliac bone graft) were placed bilaterally. Surgeons were blinded as to CBM implant type. Incisions were closed with sutures and in vivo microCT scans performed within 48 hours of surgery. A second microCT scan was taken at euthanasia, six weeks after surgery, and the lumbar spines harvested. Fusion was evaluated by manual palpation by three independent, blinded reviewers. MicroCT analysis was performed by an independent CRO (ImageIQ, Cleveland OH). Anonymity of implant type was rigorously kept to avoid bias. By manual palpation, 5/15 (33%) spines of the syngeneic bone group were fused at 6 weeks. The TEL (8/15, 53%) and CEL (11/15, 73%) groups were not significantly different from each other but were from all other CBM groups. Only 2/15 (13%) of VIV-implanted spines fused and none (0/15, 0%) of the OCP, BIO and MAP CBMs produced stable fusion. The mineralized cancellous bone component of the allografts confounded radiographic analysis but microCT analysis indicated bone volume increased over six weeks for all groups except the syngeneic bone (−4.3%). TEL (+65%) and CEL (+73%) were not different from each other but were significantly increased over all other groups (VIV 29%, OCP 37%, BIO 19%, and MAP 45%, respectively). CBMs have distinct formulations and are likely processed differently. The claimed live cell and stem cell contents differ between products. Additionally, map3 has cells added at the time of surgery, whereas the other CBMs are processed to retain matrix-adherent cells. Given the wide range of formulations, differences in performance were not surprising, and Trinity ELITE and Cellentra did significantly better than other implants at both forming new bone and achieving fusion. The other CBMs did not have greater bone formation than the control and were very poor at forming a solid fusion. These findings suggest more careful consideration of these allograft products is needed at the clinical level

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis

At the present time, there is no bearing in total hip arthroplasty that a surgeon can present to a younger and/or more active patient as being the bearing that will necessarily last them a lifetime. This is the driver to offering alternative bearings (crosslinked polyethylene with either a CoCr or ceramic head, resurfacings, and ceramic-on-ceramic) to patients. Each of these bearings has pros and cons, and none has emerged as the clear victor in the ongoing debate. Ceramic-on-ceramic (CoC) bearings have been available for decades. Earlier generation CoC bearings did encounter problems with rare fractures, however, with a greater understanding and improvement in the material, the fracture incidence has been significantly reduced. However, what has emerged in the past few years is an increasing reporting of significant squeaking. The incidence of squeaking, reported in the literature in various series, has varied from less than 1% to over 20%, depending on the definition used. The primary reasons that ceramic-on-ceramic is not truly the articulation of choice for younger patients are: 1) There is absolutely no evidence that this bearing has a lower revision rate. Data from the Australian joint registry actually shows that at 15 years it has a significantly increased rate of revision (7.2%) compared with using a highly crosslinked liner with either a ceramic (5.1%) or a CoCr (6.3%) head; 2) This bearing is by far the most costly bearing on the market. In 2017 with significant constraints on health care systems across the globe, this is a significant concern; 3) This bearing has unique complications including squeaking and both liner and head fracturing. While ceramic-on-ceramic can be considered a viable alternative bearing in total hip arthroplasty, it can be in no way considered the articulation of longevity for the younger patient

Challenging shoulder cases will be presented and discussed by a panel of experts in the field. Emphasis will be on restoring glenohumeral anatomy, repairing or reconstructing the rotator cuff, and supervising rehabilitation. Different surgical options and new emerging technologies will be reviewed while highlighting the pros and cons of each

Total joint arthroplasty (TJA) is one of the most successful procedures in orthopaedics. Despite the excellent clinical and functional results, periprosthetic joint infection (PJI) following TJA is a feared complication. For instance, the reported PJI rate after primary total knee arthroplasty is about 0.5–1.9%. In general, prevention of periprosthetic joint and surgical site infections is of utmost importance. This can be reduced by strict antisepsis, adequate sterilization of the surgical instruments and meticulous surgical technique. An indisputable role in prevention of SSI in TJA has been the use of peri-operative systemic antibiotic prophylaxis. The most common recommended antibiotics for prophylaxis in TJA are cefazolin or cefuroxime. In contrast, routine use of commercial antibiotic-loaded bone cement (ALBC) in primary total joint arthroplasty is still a concern of open debate. The use of antibiotic-loaded bone cement delivers a high concentration of antibiotics locally and can decrease the infection rate, which is supported by several studies in the literature. In this context, we present the pros of routine use of commercial antibiotic-loaded bone cement

At the present time, there is no bearing in total hip arthroplasty that a surgeon can present to a younger and/or more active patient as being the bearing that will necessarily last them a lifetime. This is the driver to offering alternative bearings (crosslinked polyethylene with either a CoCr or ceramic head, resurfacings, and ceramic-on-ceramic) to patients. Each of these bearings has pros and cons, and none has emerged as the clear victor in the ongoing debate. Ceramic-on-Ceramic (CoC) bearings have been available for decades. Earlier generation CoC bearings did encounter problems with rare fractures, however, with a greater understanding and improvement in the material, the fracture incidence has been significantly reduced. However, what has emerged in the past few years is an increasing reporting of significant squeaking. The incidence of squeaking, reported in the literature in various series, has varied from less than 1% to over 20%, depending on the definition used. The primary reasons that Ceramic-on-Ceramic is not truly the articulation of choice for younger patients are:. 1). There is absolutely no evidence that this bearing has a lower revision rate. Data from the Australian joint registry actually shows that at 15 years it has a significantly increased rate of revision (7.2%) compared with using a highly crosslinked liner with either a ceramic (5.1%) or a CoCr (6.3%) head. 2). This bearing is by far the most costly bearing on the market. In 2017 with significant constraints on health care systems across the globe, this is a significant concern. 3). This bearing has unique complications including squeaking and both liner and head fracturing. While Ceramic-on-Ceramic can be considered a viable alternative bearing in total hip arthroplasty, it can be in no way considered the articulation of longevity for the younger patient

Introduction. Robotic systems have been used in TKA to add precision, although few studies have evaluated clinical outcomes. We report on early clinical results evaluating patient reported outcomes (PROs) on a series of robotic-assisted TKA (RAS-TKA) patients, and compare scores to those reported in the literature. Methods. We prospectively consented and enrolled 106 patients undergoing RAS-TKA by a single surgeon performing a measured-resection femur-first technique using a miniature bone-mounted robotic system. Patients completed a KOOS, New Knee Society Score (2011 KSS) and a Veterans RAND-12 (VR-12) pre-operatively and at 3, 6 and 12 months (M) post- operatively. At the time of publication 104, 101, and 78 patients had completed 3M, 6M, and 12M PROs, respectively. Changes in the five KOOS subscales (Pain, Symptoms, Activities of Daily Living (ADL), Sport and recreation function (Sport/Rec) and Knee-related Quality of Life (QOL)) were compared to available literature data from FORCE – TJR, a large, prospective, national cohort of TJR patients enrolled from diverse high-volume centers and community orthopaedic practices in the U.S, as well as to individual studies reporting on conventional (CON-TKA) and computer-assisted (CAS- TKA) at 3M, and on conventional TKA at 6M. The 2011 KSS is a validated method for quantifying patient's expectations and satisfaction with their TKA procedure. Improvements in the 2011 KSS were compared with literature data at 6M post-operatively. Results. RAS-TKA PRO's significantly improved at 3, 6, and 12M from pre-operative baseline values. When compared to the FORCE registry cohort data, the improvement in KOOS subscales were generally higher for RAS for pain at 6M, and for pain, ADL, and QOL at 1Y when compared with FORCE 2Y data. Higher improvements were also seen at 3M, except for Sports/Rec, and at 6M for symptoms and QOL when compared with smaller cohort studies. Improvements in 2011 KSS patient satisfaction and functional scores at 6M were 11 and 10 points greater than those reported for conventional TKA. A mean of 31 pts for the Patient Satisfaction score indicates that on average patients were ‘Satisfied’ with their knee function and pain level. Mean rates of dissatisfaction with knee pain level and function were 9.2%, 3.8% and 3.1% at 3, 6, and 12M postoperatively, respectively. A mean of 10pts for the Expectation score post-operatively indicates that on average patients felt their expectations for pain relief, ADL, and leisure/sports/rec activities were between “Just Right” or “Too Low”. Discussion. Early results of RAS-TKA demonstrated significant improvements in pain, function, and QOL from baseline pre-operative values. PROs for robotic TKA also compared favorably with results reported in the literature; however, additional randomized control studies are required to provide more meaningful comparisons with conventional techniques and with other advanced technologies

Aims

Delayed postoperative inoculation of orthopaedic implants with persistent wound drainage or bacterial seeding of a haematoma can result in periprosthetic joint infection (PJI). The aim of this in vivo study was to compare the efficacy of vancomycin powder with vancomycin-eluting calcium sulphate beads in preventing PJI due to delayed inoculation.

Introduction. CMS is now publicly reporting 30-day readmission rates following total joint replacement (TJR) by hospital and is planning the collection of patient-reported function and pain after TJR. Nationally, 5% of patients are readmitted to the hospital after TJR for both medical and orthopedic-related issues. However, the relationship between readmission and functional gain and pain relief after TJR has not been evaluated. Methods. Clinical data on 2990 CMS patients from over 150 surgeons practicing in 22 US states who elected primary unilateral TJR in 2011–2012 were identified. Measures include pre-operative demographics, BMI, medical and musculoskeletal comorbidities, pain and function (KOOS/HOOS; SF36) and 6 month post-TJR pain and function. Data were merged with CMS claims to verify 30-day readmissions. Descriptive statistics and multivariate models adjusted for covariates and clustering within site were performed. Results. Overall 4.7% of patients were readmitted; 2.0% due to limb related diagnoses. Readmitted patients had significantly greater number of medical comorbidities; more severe OA in non-operated knees and hips; were more likely to smoke; and have poorer pre-TJR function (all p<0.05). After TJR, a greater proportion of readmitted patients had poor global function (PCS<30= 14% vs. 8%; p<0.008) but knee/hip function was similar in both groups. Joint pain improvement did not differ by readmit status. Conclusion. In this national representative cohort of CMS patients, patients readmitted within 30 days after TJR had poorer global function but similar joint specific function as non-readmitted patients. Readmitted patients also had significantly more medical comorbidities, more severe osteoarthritis in non-operated knees and hips; were more likely to smoke; and have poorer pre-TJR function. The overall rate of FORCE-TJR CMS patients readmitted within 30 days (4.7%) is consistent with national CMS analyses (5%). Of interest, in our cohort, readmitted patients had poorer global function after surgery, but similar joint specific (hip/knee) function compared to patients who were not readmitted. They also had poorer pre-THR function, and more severe OA in other joints, which may contribute to their overall lower global function scores. As CMS moves to use PROs in its bundled payment, these data support the importance of hip/knee-specific PRO measures to assess THR outcomes in quality of care programs and CMS reporting programs

Post operative prosthetic joint infection (PJI) is the most common cause of failure of total joint arthroplasty, requiring revision surgery, but a gold standard for the diagnosis and the treatment of PIJ is still lacking [1]. SuPAR, the soluble urokinase plasminogen activation receptor, has been recently described as a powerful diagnostic and prognostic tool, able not only to detect sepsis but also to discriminate different grade of sepsis severity [2,3]. This study aimed to examine the diagnostic value of SuPAR in post operative PJI, in order to explore the possible application of this new biomarker in the early diagnosis of PJI. The level of SuPAR have been measured in PJI patients and controls (patients undergoing prosthesis revision without infection), and correlated with pro and anti inflammatory markers (CRP C-reactive protein, IL-6, IL-1 TNFα, IL-10, IL-12, IL-8, IL1ra and the chemokine CCL2). Statistical analysis of Receiver Operating Characteristic (ROC) curves and Area Under the Curve (AUC) was performed. As described in Figure 1, serum SuPAR displayed a strongly significative increase in PJI patients compared to not infected controls, and a significative positive correlation with C-reactive protein, IL-6, IL-1 and TNFα and the chemokine CCL2. SuPAR displayed a very good AUC, significantly higher than CRP and IL-6 AUC. This study clearly show that the measure of Serum level of SuPAR provide a extremely important benefit because it is a precise indicator of bacterial infection, and the addition of SuPAR serum level measurement to classical inflammatory markers can strongly improve the diagnosis of prosthesis joint infection. The authors acknowledge ViroGates, Denmark for providing suPARNOSTIC Standard Kit. The authors would also acknowledge the Italian Ministero dell’ Istruzione, Università e Ricerca (MIUR) and Italian Ministero della Salute for providing funds for this research project

While no one would argue the necessary role for the medical management of patients with early knee arthritis, significant controversy remains regarding the ideal treatment for a patient with bone-on-bone osteoarthritis who could equally be treated with a high tibial osteotomy, a uni-compartmental total knee, potentially a patello-femoral replacement if dealing with isolated patello-femoral disease or lastly, a complete total knee replacement. While clearly to date there has not been consensus on this issue, a review of the arguments, both pro and con, should be used as a guide to the surgeon in making this clinical judgment. 1. Patient Satisfaction.- Many ardent supporters of uni-compartmental knee replacements espouse one of the principle benefits of the uni knee as much greater patient satisfaction. Unfortunately, what is never taken into account is the pre-selection bias that occurs in this patient population. Patients with the most minimal amount of arthritis and those with the greatest range of motion are pre-selected to undergo a uni-compartmental knee replacement compared to the more advanced arthritic knee with mal-alignment and more significant pre-operative disability that will undergo a total knee replacement. Additionally the sources of data to draw the conclusions must be carefully analyzed. We must avoid using data from small series with unblinded patients performed by surgeons expert in the technique. Instead registry data, with its broad based applicability, is a much more logical source of information. Of significance, when over 27,000 patients were assessed regarding satisfaction following knee surgery; there was no difference in proportions of satisfied patients whether they had a total knee or a uni-compartmental knee. 2. Implant Longevity - Once again large prospective cohort data in the form of arthroplasty registries strongly favors total knee arthroplasty over uni-compartmental knee arthroplasty. The Swedish Knee Arthroplasty Registry demonstrated higher revision rates with uni's as compared with total knee replacements. In the Australian Joint Replacement Registry the cumulative 13-year percent revision rate for primary total knee replacements is 6.8% and for uni-compartmental knee replacements is 15.5%. Higher failure rates in uni-compartmental knee replacements seen in Australia has correlated to a significant decrease in the number of uni's being performed, which peaked at 15.1% in 2003 and in 2014 has reduced to 4.7%. There is a direct correlation to age, with younger patients having a significantly higher percentage of revision following uni-compartmental knee replacements (25% failure rate at 11 years if less than 55 years old). There is also tremendous variability in the success rate of the uni in the Australian Registry depending on the implant design (5 year cumulative revision rate range 5.0% to 18.9%), which is simply not seen in the total knee replacement population (5 year cumulative revision rate range 1.6% to 7.7%). While one can perform the philosophical exercise of debating the merits of a total knee versus uni-compartmental knee, the evidence is overwhelming that in the hands of the masses a total knee replacement patient will have equal satisfaction to a uni-compartmental patient, and will enjoy a much lower probability of revision in the short term and in the long term

Purpose. Implant positioning is one of the critical factors influencing the postoperative outcome in total hip arthroplasty (THA). Conventional (manual) intraoperative stem adjustment may result in variability and inaccuracy of stem antetorsion (AT). Since March 2013, we have measured stem antetorsion with CT free Navigation system (OrthoPilot Navigation System THA Pro Ver4.2, B/Braun Aesculap Germany: Navi). We have developed a simple instrument, the Gravity-guide (G-guide), for intraoperative assessment and adjustment of stem AT. We evaluated the accuracy and effectiveness of G-guide and navigation software as referenced to postoperative CT evaluation with 3D template system (Zed hip, LEXI, Japan). Method. Between March 2013 and December 2014, 50 patients underwent primary THA were evaluated. Surgeries were performed with routine techniques with a modified Hardinge approach with the patient at a lateral decubitus position in all cases. The G-guide consists of two parts: one attached to the lower leg and the other attached to the handle of the rasp. During surgery, AT value was determined with navigation at the time of final rasping of the femur. Additionally, the G-guide was utilised at the time of final rasp insertion. In intraoperative AT assessment using this instrument, a correction was required considering the discrepancy between the perpendicular to the posterior condylar axis and the longitudinal axis of the lower leg. The angle of discrepancy between posterior condylar line and femoral trans-epicondyler axis needs to be taken into consideration. Therefore, correction by the angle between the trans-epicondylar and posterior condylar lines (correction angle) was required for each patient when the intraoperative AT as measured by the G-guide. Therefore, the correction angle should be added to the AT value obtained from the G-guide for comparison with postoperative value measured with Zed Hip. Result. The discrepancy between the intraoperative G-guide with correction angle and postoperative Zed Hip measurements was 4.7° ± 3.9°. The discrepancy between Navi AT and postoperative Zed HIP measurements was 5.9° ± 4.1°. A discrepancy was 10° or more were 7 cases in Navi and 4 cases in G-guide. Conclusion. Navi and G-guide measured intraoperative stem antetorsion was comparable utility