Introduction

As the aging society progresses rapidly, the number of patients underwent total knee arthroplasty (TKA) is increasing especially for the elderly population. In Japan, the average age for TKA is around 75 years old. Japanese Orthopaedic Association indicated a new clinical entity of musculoskeletal ambulation disability symptom complex (MADS) to define the higher risk of fall and ambulatory disability in the elderly population in 2006. The diagnosing criteria for MADS consists of 2 simple performance tests. 3m timed up and go test (TUG) evaluates ambulatory function, and one leg standing time (ST) assesses balancing ability.

Operative management of clavicle fractures is increasingly common. In the context of explaining the risks and benefits of surgery, understanding the impact of incisional numbness as it relates to the patient experience is key to shared decision making. This study aims to determine the prevalence, extent, and recovery of sensory changes associated with supraclavicular nerve injury after open reduction and plate internal fixation of middle or lateral clavicle shaft fractures. Eighty-six patients were identified retrospectively and completed a patient experience survey assessing sensory symptoms, perceived post-operative function, and satisfaction. Correlations between demographic factors and outcomes, as well as subgroup analyses were completed to identify factors impacting patient satisfaction. Ninety percent of patients experienced sensory changes post-operatively. Numbness was the most common symptom (64%) and complete resolution occurred in 32% of patients over an average of 19 months. Patients who experienced burning were less satisfied overall with the outcome of their surgery whereas those who were informed of the risk of sensory changes pre-operatively were more satisfied overall. Post-operative sensory disturbance is common. While most patients improve, some symptoms persist in the majority of patients without significant negative effects on satisfaction. Patients should always be advised of the risk of persistent sensory alterations around the surgical site to increase the likelihood of their satisfaction post-operatively

Rotator cuff injuries represent a significant burden to the health care system, affecting more than 30% of the population over the age of sixty. Despite the advanced surgical techniques that are available, poor results are sometimes seen in a subset of patients receiving surgical treatment for their rotator cuff disease. The reasons for this failure of treatment remain unclear, particularly if the surgery was ‘technically’ successful. An increasing body of evidence has demonstrated a strong correlation between pre-operative psychological factors and functional outcome following several orthopaedic procedures. This association, however, has not been fully demonstrated or effectively investigated in the context of rotator cuff treatment. The main objective for this study was to conduct a systematic review to determine the impact of psychosocial factors on the outcome of treatment in patients with rotator cuff disease. A systematic search was conducted of Medline, CINAHL, and PsychInfo databases for articles published from database inception until September 2018. The titles and abstracts were screened for all of the studies obtained from the initial search. Inclusion and exclusion criteria were applied, and a full text review was conducted on those studies meeting the eligibility criteria. A total of 1252 studies were identified. Following removal of duplicates and application of the inclusion and exclusion criteria, 46 studies underwent a full-text review. Ten studies were included in the final analysis. A total of 1,206 patients, with a mean follow-up of 13 months, were included. Three studies examined patient expectations prior to treatment. All three found that higher expectations prior to treatment led to a significantly improved outcome following both operative and non-operative treatment. Three studies assessed the association between pre-operative general psychological measures and post-operative pain and function. All three studies found patients with worse pre-operative general psychological scores demonstrated increased post-operative pain. Two of the studies also found a negative association with post-operative function, while one of the studies found no association with post-operative function. Three studies assessed the impact of pre-operative anxiety and depression on outcomes following surgical treatment of rotator cuff disease. Only one of the studies found a negative association with post-operative pain and function. The remaining two studies found no association between anxiety or depression and any outcomes following surgery. Finally, one study examined the impact of general distress on outcomes following the surgical treatment of rotator cuff disease and found no association with post-operative levels of pain or function. The results of this systematic review indicate that there is somewhat conflicting and contradictory evidence within the literature. Overall, however, there does appear to be an association between pre-operative psychological factors and post-operative function and pain, in that higher levels of pre-operative psychological dysfunction are predictive of poorer function and increased pain following the treatment of rotator cuff disease

Background. In recent years, ‘Get It Right First Time (GIRFT)’ have advocated cemented replacements in femoral part of Total hip arthroplasty (THA) especially in older patients. However, many studies were unable to show any difference in outcomes and although cemented prostheses may be associated with better short-term pain outcomes there is no clear advantage in the longer term. It is not clear when and why to do cemented instead of cementless. Aim. To assess differences in patient reported outcomes in uncemented THAs based on patient demographics in order to decide when cementless THA can be done safely. Method. Prospective data collection of consecutive 1079 uncemented THAs performed for 954 patients in single trust between 2010 and 2020. Oxford Hip Score (OHS) and complications were analysed against demographic variables (age, sex, BMI, ASA) and prosthesis features (femoral and acetabular size, offset and acetabular screws). Results. The mean pre-operative OHS was 14.6 which improved to 39.0 at 1 year follow up (P Value=0.000). There was no statistically significant difference between OHS outcome in patients aged over 70 versus younger groups. With a small number of revisable complications increase with age from 50s upwards. Male patients’ OHS score was on average 2.4 points higher than women. Men, however were 2.9 times more likely to experience fractures and high offset hips were 2.5 times more likely to experience dislocations. DAIR, intraoperative calcar fractures, post-operative fractures and dislocations were not associated with worse OHS. Patients with increased BMI had worse pre and post-operative hip functions yet, there was a significant multivariate association between increased BMI and increased improvement in OHS from pre-op to 1 year in women aged 55–80 and men under the age of 60. Femoral stem size increases with age but decreases in male patients over 80. There was no difference found in OHS between bilateral hip replacements and unilateral, nor was there any change found with laterality side of the replacement. Conclusions. This study suggests that ageing >70 is not associated with poorer outcomes despite small number of revisable complication rates that increase with age from 50 upwards. Men had marginally higher average OHS than women At 1 year. Higher BMI or ASA scores are associated with worse pre-operative hips and worse final outcome score. Despite this, the Delta OHS increases with increased BMI shown in the 55–80 year old female patients and male patients under 60. Key Words: THR, Uncemented, Oxford hip score, outcome

Currently, hip implant designs are evaluated experimentally using mechanical simulators or cadavers, and total hip arthroplasty (THA) postoperative outcomes are evaluated clinically using long-term follow-up. However, these evaluation techniques can be both costly and time-consuming. Neither can provide an assessment of post-operative results at the onset of implant development. More recently, a forward-solution mathematical model was developed that functions as theoretical joint simulator, providing instant feedback to designers and surgeons alike. This model has been validated by comparing the model predictions with kinematic results from fluoroscopy for both implanted and non-implanted hips and kinetics from a telemetric hip. The model allows surgical technique modifications and implant component placement under in vivo conditions. The objective of this study was to further expand the capabilities of the model to function as an intraoperative virtual surgical tool (Figure 1). This new module allows the surgeon to simulate surgery, then predict, compare, and optimize postoperative THA outcomes based on component placement, sizing choices, reaming and cutting locations, and surgical methods. This virtual surgery tool simulates the quadriceps, hamstring, gluteus, iliopsoas, tensor fasciae latae, and an adductor muscle groups, as well as the hip capsular ligament groups. The model can simulate resecting, weakening, loosening, or tightening of soft tissues based on surgical techniques. Additionally, the model can analyze a variety of activities, including gait and deep flexion activities. Initially, the virtual surgery module offers theoretical surgery tools that allow surgeons to alter surgical alignments, component designs, offsets, as well as reaming and cutting simulations. The virtual model incorporates a built-in CT scan bone database which will assist in determining muscle and ligament attachment sites as well as bony landmarks. The virtual model can be used to assist in the placement of both the femoral component and the acetabular cup (Figure 2). Moreover, once the surgeon has decided on the placements of the components, they can use the simulation capabilities to run virtual human body maneuvers based on the chosen parameters. The simulations will reveal force, contact stress, and motion predictions of the hip joint (Figure 3). The surgeon can then choose to modify the positions accordingly or proceed with the surgery. This new virtual surgical tool will allow surgeons to gain a better understanding of possible post-operative outcomes under pre-operative conditions or intra-operatively. Simulations using the virtual surgery model has revealed that improper component placement may lead to non-ideal post-operative function, which has been simulated using the model. Further evaluation is ongoing so that this new module can reveal more information pre-operatively, allowing a surgeon to gain ample information before surgery, especially with difficult and revision cases

Knee replacement is a proven and reproducible procedure to alleviate pain, re-establish alignment and restore function. However, the quality and completeness to which these goals are achieved is variable. The idea of restoring function by reproducing condylar anatomy and asymmetry has been gaining favor. As knee replacements have evolved, surgeons have created a set of principles for reconstruction, such as using the femoral transepicondylar axis (TEA) in order to place the joint line of the symmetric femoral component parallel to the TEA, and this has been shown to improve kinematics. However, this bony landmark is really a single plane surrogate for independent 3-dimensional medial and lateral femoral condylar geometry, and a difference has been shown to exist between the natural flexion-extension arc and the transepicondylar axis. The TEA works well as a surrogate, but the idea of potentially replicating normal motion by reproducing the actual condylar geometry and its involved, individual asymmetry has great appeal. Great variability in knee anatomy can be found among various populations, sizes, and genders. Each implant company creates their specific condylar geometry, or “so called” J curves, based on a set of averages measured in a given population. These condylar geometries have traditionally been symmetric, with the individualised spatial placement of the (symmetric) curves achieved through femoral component sizing, angulation, and rotation performed at the time of surgery. There is an inherent compromise in trying to achieve accurate, individual medial and lateral condylar geometry reproduction, while also replicating size and avoiding component overhang with a set implant geometry and limited implant sizes. Even with patient-specific instrumentation using standard over-the-counter implants, the surgeon must input his/her desired endpoints for bone resection, femoral rotation, and sizing as guidelines for compromise. When all is done, and soft tissue imbalance exists, soft tissue release is the final, common compromise. The custom, individually made knee design goals include reproducible mechanical alignment, patient-specific fit and positioning, restoration of articular condylar geometry, and thereby, more normal kinematics. A CT scan allows capture of three-dimensional anatomical bony details of the knee. The individual J curves are first noted and corrected for deformity, after which they are anatomically reproduced using a Computer-Aided Design (CAD) file of the bones in order to maximally cover the bony surfaces and concomitantly avoid implant overhang. No options for modifications are offered to the surgeon, as the goal is anatomic restoration. In summary, the use of custom knee technology to more closely reproduce an individual patient's anatomy holds great promise in improving the quality and reproducibility of post-operative function. Compromises of fit and rotation are minimised, and implant overhang is potentially eliminated as a source of pain. Early results have shown objective improvements in clinical outcomes. Admittedly, this technology is limited to those patients with mild to moderate deformity at this time, since options like constraint and stems are not available. Yet these are the patients who can most clearly benefit from a higher functional state after reconstruction. Time will reveal if this potential can become a reproducible reality

Knee replacement is a proven and reproducible procedure to alleviate pain, re-establish alignment and restore function. However, the quality and completeness to which these goals are achieved is variable. The idea of restoring function by reproducing condylar anatomy and asymmetry has been gaining favor As knee replacements have evolved, surgeons have created a set of principles for reconstruction, such as using the femoral transepicondylar axis (TEA) in order to place the joint line of the symmetric femoral component parallel to the TEA, and this has been shown to improve kinematics. However, this bony landmark is really a single plane surrogate for 3-dimensional medial and lateral femoral condylar geometry, and a difference has been shown to exist between the natural flexion-extension arc and the TEA. The TEA works well as a surrogate, but the idea of potentially replicating normal motion by reproducing the actual condylar geometry and its involved, individual asymmetry has great appeal. Great variability in knee anatomy can be found among various populations, sizes, and genders. Each implant company creates their specific condylar geometry, or “so called” J curves, based on a set of averages measured in a given population. These condylar geometries have traditionally been symmetric, with the individualised spatial placement of the (symmetric) curves achieved through femoral component sizing, angulation, and rotation performed at the time of surgery. There is an inherent compromise in trying to achieve accurate, individual medial and lateral condylar geometry reproduction, while also replicating size and avoiding component overhang with a set implant geometry and limited implant sizes. Even with patient-specific instrumentation using standard over-the-counter implants, the surgeon must input his/her desired endpoints for bone resection, femoral rotation, and sizing as guidelines for compromise. When all is done, and soft tissue imbalance exists, soft tissue release is the final, common compromise. The custom, individually made knee design goals include reproducible mechanical alignment, patient-specific fit and positioning, restoration of articular condylar geometry, and thereby, more normal kinematics. A CT scan allows capture of three-dimensional anatomical bony details of the knee. The individual J curves are first noted and corrected for deformity, after which they are anatomically reproduced using a Computer-Aided Design (CAD) file of the bones in order to maximally cover the bony surfaces and concomitantly avoid implant overhang. No options for modifications are offered to the surgeon, as the goal is anatomic restoration. Given these ideals, to what extent are patients improved? The concept of reproducing bony anatomy is based on the pretext that form will dictate function, such that normal-leaning anatomy will tend towards normal-leaning kinematics. Therefore, we seek to evaluate knee function based on objective assessments of movement or kinematics. The use of custom knee technology to more closely reproduce an individual patient's anatomy holds great promise in improving the quality and reproducibility of post-operative function. Compromises of fit and rotation are minimised, and implant overhang is potentially eliminated as a source of pain. Early results have shown objective improvements in clinical outcomes. Admittedly, this technology is limited to those patients with mild to moderate deformity at this time, since options like constraint and stems are not available. Yet these are the patients who can most clearly benefit from a higher functional state after reconstruction. Time will reveal if this potential can become a reproducible reality

Knee replacement is a proven and reproducible procedure to alleviate pain, re-establish alignment and restore function. However, the quality and completeness to which these goals are achieved is variable. The idea of restoring function by reproducing condylar anatomy and asymmetry has been gaining favor. As knee replacements have evolved, surgeons have created a set of principles for reconstruction, such as using the femoral transepicondylar axis (TEA) in order to place the joint line of the symmetric femoral component parallel to the TEA, and this has been shown to improve kinematics. However, this bony landmark is really a single plane surrogate for 3-dimensional medial and lateral femoral condylar geometry, and a difference has been shown to exist between the natural flexion-extension arc and the TEA. The TEA works well as a surrogate, but the idea of potentially replicating normal motion by reproducing the actual condylar geometry and its involved, individual asymmetry has great appeal. Great variability in knee anatomy can be found among various populations, sizes, and genders. Each implant company creates their specific condylar geometry, or “so called” J curves, based on a set of averages measured in a given population. These condylar geometries have traditionally been symmetric, with the individualised spatial placement of the (symmetric) curves achieved through femoral component sizing, angulation, and rotation performed at the time of surgery. There is an inherent compromise in trying to achieve accurate, individual medial and lateral condylar geometry reproduction, while also replicating size and avoiding component overhang with a set implant geometry and limited implant sizes. Even with patient-specific instrumentation using standard over-the-counter implants, the surgeon must input his/her desired endpoints for bone resection, femoral rotation, and sizing as guidelines for compromise. When all is done, and soft tissue imbalance exists, soft tissue release is the final, common compromise. The custom, individually made knee design goals include reproducible mechanical alignment, patient-specific fit and positioning, restoration of articular condylar geometry, and thereby, more normal kinematics. A CT scan allows capture of three-dimensional anatomical bony details of the knee. The individual J curves are first noted and corrected for deformity, after which they are anatomically reproduced using a Computer-Aided Design (CAD) file of the bones in order to maximally cover the bony surfaces and concomitantly avoid implant overhang. No options for modifications are offered to the surgeon, as the goal is anatomic restoration. Given these ideals, to what extent are patients improved? The concept of reproducing bony anatomy is based on the pretext that form will dictate function, such that normal-leaning anatomy will tend towards normal-leaning kinematics. Therefore, we seek to evaluate knee function based on objective assessments of movement or kinematics. In summary, the use of custom knee technology to more closely reproduce an individual patient's anatomy holds great promise in improving the quality and reproducibility of post-operative function. Compromises of fit and rotation are minimised, and implant overhang is potentially eliminated as a source of pain. Early results have shown objective improvements in clinical outcomes. Admittedly, this technology is limited to those patients with mild to moderate deformity at this time, since options like constraint and stems are not available. Yet these are the patients who can most clearly benefit from a higher functional state after reconstruction. Time will reveal if this potential can become a reproducible reality

Introduction. Patients undergoing a total knee arthroplasty (TKA) are now living longer and partaking in more active lifestyles. They expect a high level of post-operative function and long term durability of their implant. Using electromyography (EMG) analysis helps further explain biomechanical findings by giving insight as to what is occurring at the level of the muscles. Normal biomechanics are not restored post-TKA as patients have reduced knee flexion and weakened quadriceps muscles compared to their healthy peers. Purpose. The purpose of this study was to compare muscle activation in TKA patients who received a medial pivot (MP) or posterior stabilized (PS) implant to those of healthy controls (CTRL) during a stair ascent task. Methods. A total of 12 patients were assigned to either a MP or PS TKA operated by the same surgeon. Approximately 9 months following surgery, the 12 patients along with 6 CTRL patients completed an EMG analysis during a stair ascent task (Table 1). Wireless EMG electrodes were placed on 4 muscles: vastus medialis (VM), vastus lateralis (VL), biceps femoris long head (BF), and semimembranosus (SM) muscles. All participants completed maximal voluntary contractions (MVICs) during knee flexion and extension while seated with the knee flexed at 60°. Following the MVICs, participants completed 5 trials of a 3-step stair ascent task. TKA patients were instructed to make the first step onto the staircase with their operated limb. EMG data were processed in Matlab. Peak muscle activity (PeakLE EMG) and total muscle activity (iEMG) from each muscle was obtained during stance phase. Data were averaged between left and right limbs for the CTRL group and compared to the operated limb of TKA groups. Non-parametric Kruskal Wallace ANOVA tests were used to test for statistical significance between groups and Wilcoxon rank sum tests were used to identify differences with α=0.05. Results. Both TKA groups had significantly greater PeakLE EMG of the quadriceps muscles compared to the CTRL group (Figure 1). PeakLE EMG of the BF and VM muscles were significantly greater in the PS group compared to both CTRL and MP groups. The PS group had significantly greater iEMG of the BF, VL and VM muscles compared to the CTRL group (Figure 2) whereas the PS group had significantly greater iEMG of the SM and VM muscles compared to the MP group. Conclusion. The MP group had lower PeakLE EMG for both VM and BF muscles compared to the PS group, indicating that the MP group activates these muscles less to achieve the stair ascent task. BF muscle stabilizes the knee roll-back motion while the VM muscle extends the leg to clear the steps. iEMG for the VM and BF muscles were greater for the PS group indicating that they have to activate their muscles longer and to a greater extent in order to stabilize the joint. This increased stability in MP implants is achieved through the concave aspect on the medial tibial plateau for the femoral condyle to pivot in. This will reduce implant wear, prolonging implant longevity

Introduction. Patients who undergo hip resurfacing, total hip arthroplasty (THA), and total knee arthroplasty (TKA) are frequently assessed post-operatively using objective scoring indices. A small yet significant percentage of these patients report specific unfulfilled functions following surgery, indicating unmet expectations. The purpose of this study was to examine the types of functional deficits reported for each class of surgery, how frequently these limitations occur, and the demographic of patients who experience/report these limitations. Methods. Four groups of subjects were enrolled in this study: (i) 111 hip resurfacing patients at an average of 14 months after resurfacing, (ii) 170 patients at an average of 16 months post-primary THA, (iii) 61 patients at an average of 12 months post-primary TKA, and (iv) 64 control subjects with no history of hip or knee surgery or pathology. Each participant completed a self-administered Hip Function Questionnaire, Knee Function Questionnaire, or Hip Resurfacing Questionnaire which assessed each subject's overall satisfaction and expectations following surgery. The questionnaires included numerical scores of post-operative function as well as an open-ended question which inquired “Is there anything your knee/hip keeps you from doing?”. Results. A population of patients self-reported specific functional deficits after surgery, including 29 (26.1%) resurfacing, 5 (2.9%) THA, and 32 (52.5%) TKA. The unfulfilled functions varied based on the procedure, with most resurfacing and THA patients reporting trouble with running/jogging, while TKA patients experienced difficulty kneeling. Patients who reported functional deficits also tended to endorse lower overall satisfaction levels after surgery; the mean satisfaction score for hip resurfacing in those who reported deficits was 4.03 (scale of 1–5) versus 4.50 (p=0.09) in those who denied a functional deficit, 2.20 versus 4.47 (p=0.003) in THA patients, and 4.10 versus 4.36 (p=0.35) in TKA patients. The demographic of patients who reported limitations varied based on the type of surgery. After hip resurfacing 19.0% (4/21) of female patients reported specific deficits compared to 27.3% (23/84) of male patients; 6.1% (5/81) of female THA patients reported compared to 0% (0/84) of males, and 48.6% (18/37) of female TKA patients reported compared to 58.3% (14/24) of males. The mean age of those who reported deficits versus those who did not report deficits was not significant. Conclusions. Despite advances in arthroplasty and resurfacing techniques, a significant portion of patients are experiencing functional limitations following hip resurfacing, TKA, and THA procedures. The frequency and types of limitations reported vary based on the surgery, with TKA patients reporting deficits with the highest frequency and THA patients reporting with the lowest frequency. The gender of the patient appears to play a role in whether specific functional deficits are reported or not, with female patients more likely to report after THA and male patients slightly more likely to report after either hip resurfacing or TKA. Summary. A small portion of hip resurfacing, THA, and TKA patients report specific unfulfilled functions following surgery. The frequency and types of deficits, and the demographic of patients reporting them, varies based on the procedure

Surface replacement of the hip has become established as an alternative treatment to total hip replacement in the younger, active, male patient. By the very nature of preserving the femoral head and neck, there may be failures due to femoral neck fracture and femoral component loosening. Additionally, revisions of hip resurfacing for acetabular loosening may be necessary. Other scientific papers have described problems that may arise as a result of the metal-on-metal bearing either due to excess metal production or an immunologic-mediated reaction to the metal debris. Grammatopolous et al. describe poor results of revisions of surface replacements due to massive tissue destruction at the time of revision surgery, persistent pain, and swelling. In my experience with hip resurfacing, this complication is extremely rare. In my series of 925 resurfacings with a minimum of 2 year follow up, 12 revisions (1.3%) have been performed. Of these revisions, only 3 (0.3%) were for complications related to the metal-on-metal bearing; 2 for edge-loading and excess metal production, and 1 for metal hypersensitivity. None of the revision cases have had abductor destruction, or nerve/vascular involvement. Reconstruction of the joint was carried out with standard and revision components; post-operative function of these patients has been comparable to that of a primary total hip replacement. With careful monitoring of the post-operative resurfacing patient, problems can be identified early and surface replacement conversion can be performed with excellent results

Introduction. Total knee arthroplasty (TKA) has proven clinical success with reported longterm survivorship of 92% in the elderly population. Concerns regarding increased loosening rates and potential need for multiple revision surgeries in patients younger than 60 years have traditionally discouraged TKA in younger patients. The purpose of this study was to review the longterm clinical and radiographic results of patients under the age of 45 yrs who underwent a total knee replacement. Materials and Methods. A retrospective review of our institutional database was performed between January 1996 and December 2004 The criteria for inclusion in the study were as follows: age 45 years or younger at index arthroplasty, cemented condylar prosthesis, and a minimum follow-up of 9 years. A total of 39 consecutive primary cemented condylar knee arthroplasties in patients with end stage arthritis were performed in 36 patients who were 45 years or younger. The median length of followup was 13.6 years. There were 18 men and 21 women. The mean age was 40.6 years (range, 28–44). There were 23 right, 16 left, and 3 bilateral procedures. The mean body mass index was 31.2 kg/m2. Clinical and radiological evaluations were performed before surgery and at 6 weeks, 3 months, 1 year and every 2 years subsequently. Knee scores were calculated using the Knee Society Clinical Rating Scores (KSCRS), SF-12 and WOMAC scores to assess pre, and post-operative function. Postoperative anteroposterior and lateral views were assessed for femoral and tibial component position, alignment, and presence or progression of radiolucent lines at the bone-cement and prosthesis-cement interfaces. Statistical analysis was performed using the 2-sample test or Wilcoxon rank sum test for comparison of continuous variables. Kaplan-Meier analysis of implant survival was performed with failure defined as femoral component revision due to any cause. Results. There was a statistically significant improvement in clinical outcome measures between pre and post-operative SF-12, WOMAC, and KSCRS validated scoring systems. 41% of patients had previous surgery prior to the TKA with 87% of patients receiving a cruciate sacrificing TKA and 64% of patients receiving a patellar resurfacing. There were 4 revisions in total, 2 patients were revised for pain, 1 for instability and 1 for infection treated with a single stage revision, the average time to revision was 3 years. There were no cases of aseptic loosening with an overall survival of 89.8% at an average follow-up of 13.6 yrs. The Kaplan-Meier estimated survival rate to revision was estimated to be % at 10 years and % at 15 years Radiographic assessment did not reveal any evidence of component migration, malalignment or radiolucencies at final follow up. There was no evidence of progressive radiolucencies noted on zonal analysis around both tibial and femoral components on serial radiographs in any patient. Conclusion. Excellent clinical outcomes are reported for patients 45 years of age or less who have undergone TKA. For the young patient who is not a candidate for other joint conserving or preserving procedures, Total Knee Replacements provide a successful longterm outcome

Subscapularis function following Total shoulder joint replacement has been a concern in recent literature. It has been postulated that lesser tuberosity osteotomy approach may have better Subscapularis function than transtendonous approach. To assess whether lesser tuberosity osteotomy vs. subscapularis tenotomy is better for post-operative function of subscapularis in total shoulder replacements done by a single surgeon in a District general hospital. 117 shoulder replacements performed by the senior author (TH) at Waikato district general hospital between years January 2002 to January 2010 were reviewed retrospectively. Revision replacement, inverse shoulder replacement & acute traumatic hemiarthroplasty were excluded. Patients with previous rotator cuff problems, previous surgery to subscapularis, rheumatoid arthritis and post-trauma sequelae were also excluded from the study. Inclusion criteria were normal subscapularis function and intact subscapularis on MRI pre-operatively. 41 shoulders were eligible to participate in study of which 1 pt died (bilateral TSR), 1 pt unfit to participate due to cervical disc problems. Of remaining 38 shoulders 11 shoulders had transtendonous and 27 shoulders had lesser tuberosity osteotomy approach. 37 shoulders were reviewed clinically for range of motion of the shoulder and subscapularis strength. Range of motion and subscapularis strength was significantly higher in the osteotomy group. All osteotomies were united on axillary radiograph. Lesser tuberosity osteotomy approach result in better subscapularis function than transtendonous approach

Several factors have been identified that may affect outcome after total knee replacement (TKR). We performed a systematic review of studies that looked at the association of pre-operative factors and outcome after primary total knee replacement for osteoarthritis. All study types that investigated TKR for osteoarthritis were considered except retrospective case-series. Studies that included patients undergoing revision TKR were excluded if they did not provide separate results for primary and revision knee replacement. Any patient factor that was measured in the pre-operative period was included. The factors measured included age, sex, race, income, body mass index (BMI), medical or joint co-morbidity, level of education, disease specific scores and their subcategories and general health scores. Studies that recorded outcome measures were only included if evidence of validation for use after total knee replacement was available. We identified 590 studies purporting to evaluate TKR for OA. Of these, 25 studies were retrieved for in-depth consideration and 10 were found to meet the inclusion criteria. Most of these were cohort studies that used some form of regression analysis. The results showed that the strongest and most consistent correlations were between pre-operative pain scores, pre-operative function scores, co-morbidity and post-operative function scores. Age, gender and level of education were not significant predictors of outcome. However, even the best models could only predict 36% of the variance in outcome. Understanding which factors influence outcome the most will be of great benefit to patients and those who plan and deliver healthcare

The question of whether to reconstruct an ACL-deficient knee as early as possible following injury or to delay surgery remains unanswered. Early reconstruction potentially reduces the risk of secondary damage. However, there is also concern regarding the risk of arthrofibrosis if surgery is undertaken too soon. The aim of this study was to investigate whether injury-to-surgery delay determines ACL-reconstruction outcomes at up to 2years post-operatively. A retrospective analysis of prospectively collected data from 211 knees with isolated primary ACL ruptures was performed. Patients were examined preoperatively, at 6months, 1 year, and 2 years post-operatively using International Knee Documentation Committee (IKDC) and Lysholm scores. Side to side differences in knee laxity were also measured with a KT1000 arthrometer. Spearman's rho correlations were used to associate injury-to-surgery delay with outcome scores. Outcomes scores significantly increased for both IKDC (p<0.05) and Lysholm (p<0.05) questionnaires. Significant positive correlations (p<0.05) were also found between injury-to-surgery delay and IKDC and Lysholm subjective scores. Strongest correlation coefficients were noted at the 2yr follow-up for both IKDC and Lysholm scores (r = 0.79 and 0.8 respectively). Side-to-side laxity measures also showed significant positive correlations with injury-to-surgery delay at 1 year (r = 0.17) and 2 year (r = 0.41) follow ups. The positive correlation suggests that delayed surgery is positively related to subjective outcomes, as well as objective measures of knee laxity. However, this relationship also suggests that other factors such as the patient's functional status at time of surgery may play a role in their post-operative function. For example, those who can compensate for the ruptured ligament may function well following delayed surgery. These findings highlight the need for more detailed investigation of the interaction between functional status, injury-to-surgery delay and post-operative recovery

Introduction. Despite advances in surgical technique and prosthetics there continues to be a number of patients who are dissatisfied with the results of their knee replacement procedure. The outcome after total knee arthroplasty (TKA) has been reported frequently with use of condition-specific measures, but patient satisfaction has not been well studied. Material and methods. 160 patients who received primary total knee arthroplasty (TKA) were evaluated prospectively to evaluate factors that may be associated with patient satisfaction. At minimum one year follow-up all patients were evaluated and completed validated self-report satisfaction questionnaires. Patient, surgeon, implant and process of care variables were assessed along with WOMAC, Oxford Knee and SF-12 scores. Univariate and multivariate analyses were performed to assess for independent factors associated with post-operative satisfaction. Results. Significant factors associated with post-operative satisfaction include (p<0.05): pre-operative pain and function, presence of comorbidity, post-op complication or stiffness. Age, gender, pre-operative diagnosis, flexion contracture, pre-op range of motion, implant type (fixed vs rotating platform), and surgeon did not significantly affect patient-reported satisfaction (p>0.05). Post-operative function and pain (WOMAC, Oxford Knee Score), comorbidity, and mental status (SF-12 mental) were also highly associated with post-operative satisfaction (p<0.05) at one year post-op. Discussion and conclusion. The primary drivers of patient satisfaction appear to be related to patient-related factors including magnitude of baseline disability and comorbidity as well as the development of any post-op complication. Surgeon and implant related factors do not appear to have a significant effect on satisfaction. Understanding determinants of satisfaction may assist the surgeon and patient when planning for surgery and setting realistic expectations for post-operative outcome

Introduction:. Total knee replacement (TKR) and total hip replacement (THR) reliably relieve pain, restore function, and ensure mobility in patients with advanced joint arthritis; however these results are not uniform across all patient populations. Moreover, it is well established that knee replacement patients have outcomes inferior to those undergoing hip replacement procedures with lower rates of dissatisfaction with post-operative function and pain relief. We compared baseline demographic and symptom profiles in patients from a US national cohort undergoing primary TKR and THR to determine whether differences in demographic make-up, pre-operative symptoms, or pre-existing co-morbidities might contribute to these differences observed post-operatively. Methods:. A cohort of 2375 patients undergoing primary TKR and THR was identified from the FORCE national research consortium from all surgeries performed between July 1. st. 2011 and March 30. th. 2012. This set of patients was derived from 120 contributing surgeons in 23 US states. Gathered data included patient demographics, comorbidity (Charlson Comorbidity Index), operative joint pain severity (Western Ontario and McMaster Universities Arthritis Index (WOMAC)), physical function (SF-36; Physical Component Score (PCS)), emotional health (SF-36; Mental Component Score (MCS)), and musculoskeletal burden of illness (Hip and Knee Disability and Osteoarthritis Outcome Scores; Oswestry Disability Index). Using descriptive statistics, we compared the baseline demographic characteristics and symptom profiles of patients undergoing TKR (n = 1362) and those undergoing THR (n = 1013). Results:. In this large national sample, patients receiving knee replacements were found to be significantly older (66.5 vs. 64.3 years), more obese (BMI 31.7 vs. 29.3), and less educated (p < 0.005) than those undergoing THR. TKR patients had higher rates of medical comorbidities, specifically diabetes, gastrointestinal ulcers, and cerebrovascular disease (p ≤ 0.006). Conversely, THR patients had significantly worse physical function (PCS 31.6 vs. 33.3), lower back pain (35.6% vs. 30.5% moderate-severe), and operative joint pain, stiffness, and function (p < 0.005) when compared to those undergoing TKR. Conclusions:. US patients undergoing primary TKR are older with more comorbidities, however THR patient baseline functional and musculoskeletal limitations are significantly greater than primary TKR patients. These data may help explain the variability in physical function after primary TKR as compared to primary THR

Background. Unicompartmental knee arthroplasty provides a good alternative to total knee arthroplasty in patients with isolated medial compartment osteoarthritis. Reported ten-year survival for the Oxford medial unicompartmental knee arthroplasty is variable, ranging from 80.2% to 97.7% in the originator series. The aim of this study was to determine the survival and reasons for revision of the Oxford medial unicompartmental knee arthroplasty when performed at a specialist orthopaedic centre. Methods. Details of consecutive patients undergoing Oxford unicompartmental knee arthroplasty at our centre between January 2000 and December 2009 were collected prospectively. Failure of the implant was defined as conversion to total knee arthroplasty. Survival was determined using the Kaplan-Meier method. Results. There were 494 Oxford unicompartmental knee arthroplasties implanted in 425 patients for isolated medial compartment osteoarthritis. Mean age was 62.8 yrs (range 34.6-90.1 yrs) and 53.4% were female. During a mean follow-up time of 3.0 yrs (range 0.5-9.2 yrs), twenty-two knees (4.5%) were revised to a total knee arthroplasty. Reasons for revision were aseptic loosening of the femoral (n=8) or tibial component (n=2), undiagnosed pain (n=5), patellofemoral pain (n=2), infection (n=1), lateral meniscus tear (n=1), periprosthetic fracture (n=1), joint instability (n=1), and dislocation of meniscal bearing (n=1). Mean time to revision surgery from the primary procedure was 3.0 yrs. Eight-year survival for the cohort was 87.4%. The median pre-operative Oxford knee score was 62.5% which reduced to 27.7% at four years post-operatively. Conclusion. This study has demonstrated our revision rate for the Oxford unicompartmental knee replacement is comparable to independent series and national registry data. Post-operative function in patients not revised was good. The commonest reason for failure was aseptic component loosening which usually occurred within two to four years. Extended follow-up may therefore be beneficial in these patients so these cases are identified early and subsequently revised

Developments in adjuvant therapies and surgical techniques have allowed more confident excision of the neoplastic scapula without radical margins. Total scapular excision has been proven to be an effective limb salvage procedure for tumours involving the whole scapula, with or without gleno-humeral extension. The two most common types of excision are the Tikhoff-Linberg procedure or total scapulectomy. We identified 13 patients who had undergone total scapular excision between 1995 and 2008. Eight patients underwent total scapulectomy and five underwent a Tikhoff-Linberg procedure. All reconstructions were in the form of humeral suspension. There were four females and nine males with a mean age at operation of 47.7 years (range 16-81). Most tumours excised were either Ewing's sarcoma or chondrosarcoma and mean follow-up was 44 months (7-167). Functional outcomes were assessed using the Musculoskeletal Tumor Society Score (MSTS) and the Disabilities of the Arm, Shoulder and Hand Score (DASH). Active flexion and abduction ranges were also assessed. Of the original 13 patients, five died at a mean of 21 months post-operatively. One patient developed a recurrence after five months, which was successfully excised. The mean forward flexion and abduction following all procedures was 22.5 degrees (0-30) and 22.9 degrees (0-40) respectively. There was no statistical difference between ranges of motion of total scapulectomy and Tikhoff-Linberg procedures. The mean MSTS score for the entire group was 65.8% and there was no statistical difference between total scapulectomy and Tikhoff-Linberg (p = 0.69). The mean DASH score for all patients was 39.7 with no statistically significant difference between the two procedures (p = 0.46). Both procedures allow successful excision of scapular tumours with an acceptable level of post-operative function. Total scapulectomy and Tikhoff-Linberg procedures followed by humeral suspension compare favourably with forequarter amputation, endoprosthetic reconstruction and allografting

Purpose. Patient expectations influence post-treatment outcomes, both surgical and non-surgical. Existing studies evaluate the technical aspects of interventions and functional outcomes but fail to take into account patient expectations. This retrospective analysis of prospectively collected multi-center data aims to explore the relationship between pre-operative expectations and post-operative outcomes and satisfaction in lumbar and cervical spine surgery. The authors hypothesized that expectations dramatically affect spine patient satisfaction independent of functional outcomes. Method. Patient data from lumbar and cervical spine patients collected prospectively using a patient health survey system was analyzed. The study included patients who underwent operative intervention (decompression with or without fusion) with at least a 3-month period of follow-up. Pre-operative expectations were measured using the MODEMS expectation survey. Post-operative satisfaction and fulfillment of expectations were measured using the MODEMS satisfaction survey. Post-operative functional outcomes were measured using the ODI and SF-36. Multi-variate ordinal logistic regression modeling was used to examine predictors of post-operative satisfaction. Multi-variate linear regression modeling was used to examine predictors of functional outcomes. Results. 402 patients were included in the study. Significant predictors of increased satisfaction include: higher fulfillment of expectations regarding work (p=0.003) and pain relief (p=0.008), greater post-operative SF-36 (p=0.04), and lower pre-operative expectations regarding ability to exercise (p=0.03). Lumbar spine patients were more satisfied than cervical-spine patients. Significant predictors of better post-operative function include: higher expectations regarding sleep (p<0.0002), fulfillment of expectations regarding work (p<0.0001), sleep (p=0.03), and daily activities (p=0.02). Cervical spine patients had better functional outcomes (p=0.006). Conclusion. This study showed that pre-operative expectations and their fulfillment influence post-operative satisfaction in lumbar and cervical spine patients. This underlines the importance of taking pre-operative expectations into account in order to obtain an informed choice based on patient preferences