Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

Introduction. A bicruciate retaining (BCR) TKA is thought to maintain a closer resemblance to the native knee kinematics compared to a posterior cruciate retaining (CR) TKA. With BCR TKAs retainment of the anterior cruciate ligament (ACL) facilitates proprioception and balance which is thought to lead to more natural knee kinematics and increased functional outcome. The aim of this study was to quantify and compare the kinematics of a BCR and CR TKA during functional tests. Materials and Methods. In this patient-blinded randomized controlled trial, a total of 40 patients with knee osteoarthritis were included, 18 of them received a BCR TKA (Vanguard XP, Zimmer-Biomet) and 22 received a CR TKA (Vanguard CR, Zimmer-Biomet). Fluoroscopic analysis was done 1 year post-operatively. The main outcome was posterior femoral rollback (i.e. translation of the femorotibial contact point (CP)) of the BCR and CR TKA during a step-up test. Secondary, the kinematics during a lunge test were quantified as anterior-posterior (AP) translation of the femorotibial CP. Independent student t-tests (or non-parametric equivalent) were used to analyze the effect of BCR versus CR TKA on these measures, to correct for the multiple testing problem post-hoc Bonferroni-Holm corrections were applied. Results. The mean AP CP for the BCR implant was not significantly different from the CR implant in the medial compartment (Figure 1, left). However, laterally the BCR implant shows a more posterior CP during late extension i.e. from 30° flexion to 0° extension (Figure 1, right). Figure 2 shows the AP CP during the final extension phase (30° flexion to 0° extension) of the step-up task for both implants on the tibia plateau. While the CR TKA remains mostly stable throughout this phase, the BCR TKA shows tibial internal rotation from 30° to 10° and tibial external rotation in the final extension phase: a kinematic pattern comparable to the natural knee's screw home mechanism. The lateral AP CP of the BCR TKA is more posterior compared to the CR TKA during the whole lunge task (Figure 3, right) the medial CP is more anterior in the 0–30° flexion (Figure 3, left). The main differences between the implants during the lunge task are observable in the early flexion phase, which is in line with ACL function. Conclusion. These preliminary results suggest that the kinematics of the BCR implant reproduces the natural screw-home mechanism in early flexion/late extension. The difference between the BCR and CR implants is mostly visible in the flexion phase in which the ACL is effective, which is in congruency with the absence of the ACL in CR TKAs. For any figures or tables, please contact the authors directly

Purpose. Total knee replacement is the one of the most performed surgeries. However, patient's satisfaction rate is around 70–90 % only. The sacrifice of cruciate ligament might be the main reason, especially in young and active patients. ACL stabilizes the knee by countering the anterior displacing and pivoting force, absorbs the shock and provides proprioception of the knee. However, CR knees has been plagued by injury of PCL during the surgery and preservation of the ACL is a demanding technique. Stiffness is more common comparing to PS designed knee. To insert a tibial baseplate with PE is usually thicker than 8 mm comparing to 2–4 mm of removed tibial bone. The stuffing of joint space may put undue tension on preserved ACL and PCL. Modern designed BCR has been pushed onto market with more sophisticated design and instrumentation. However, early results showed high early loosening rate. Failure to bring the tibia forward during cementing may be the main cause. The bone island where ACL footprint locates is frequently weak, intraoperative fracture happens frequently. A new design was developed by controlled elevation and reattachment of the ACL footprint to meet all the challenges. Method. A new tibial baseplate with a keel was designed. The central part of the baseplate accommodates elevated bony island with ACL footprint. The fenestrations at the central part is designed for reattachment of bony island under proper tension with heavy sutures and fixed at anterior edge of the baseplate in suture bridge fashion and also for autograft to promote bony healing after reattachment. The suture bridge method has been used by arthroscopists for ACL avulsion fracture without the need of immobilization. The elevation of bony island release the tension in the ACL which come from stuffing of baseplate and PE insert and greatly facilitate cementing of the baseplate. The keel improve the weakness of traditional U shape design of BCR knees. Instead of keeping the bony island intact by separately cutting the medial and lateral tibial plateau in BCR knees in the past, we choose to saw the tibial plateau in one stroke as in PS knees, then removes the two condyles. The bony island includes the footprint both ACL and PCL. The central part of tibial baseplate will push the bony island upward which release the undue tension in the cruciate ligaments. Summary. We proposed a new solution for the kinematic conflict in the present bi-cruciate knee designs by elevation and re- attachment of bony island with ACL footprint at the same time simplify the ACL preservation. The simple tibial cutting procedure also facilitate the process. The technique protects PCL from injury during tibial bone cutting in CR knees. We believe the new BCR design has the potential to replace CR knee in term of function and longevity in the future

Introduction. Early complication post total knee replacement reported to be higher in obese patient in general. Also the outcome of cruciate retaining and PS knee has been fully discussed before and there was no major difference in the outcomes for all the patients overall regardless of their weight. However, the purpose of this paper is to find out if the CR knee has superiority over PS knee in terms of clinical and functional outcomes and if early complication postTKR such as fracture and instability is more common in PS implant than in CR knee. This is a retrospective study comparing two groups of obese patients. The first using PS implant and the other using CR implant. These two groups were matched for age, body mass and severity of deformity. Materials & Methods. At our institution we have been using Persona implant which has the option of using PS insert or a CR. The decision to proceed with CR or PS mainly depends on the availability of the implant and also the ability to well balance the knee in patients. In most patients we try to proceed with CR implant. However, the flow of implant sometime sometimes limit us from using CR or the imbalance in the ligament force us to process with PS implant. We have reviewed a chart of over 200 patients in each group of obese patient they were done within the last three years. All cases had a minimum follow up of 6 months. Those groups were matched for body mass, age and severity of deformity. After matching the groups we documented Knee Society Score (KSS), Knee Society Function Score (KSFS), blood loss, post – operative pain and complications. All surgeries were performed by the same surgeon. Results. Our study showed that the clinical scores (KSS) in both groups were very close while significant differences were observed in functional scores (KSFS) for the CR knee. We had 8 cases of per-prosthetic fracture in the PS group and one in the CR implant. We had 4 revisions in the PS group for instability and MCL insufficiency and non in the CR implant. Infection, wound complication, blood loss, and patient satisfaction were same in both groups. Discussion. This study suggests a significant difference in functional outcomes, especially walking, stair climbing and the use of walking aids, between CR and PS that favors CR implant which may be related to the CR knee retaining proprioception and ligaments tension with balance. In addition, PS knee have more varus-valgus and mid-flexion laxity than CR knee throughout the range of motion which appear clearly in obese patient. On the other hand, the study clearly shows that the decrease incidence of peri-prosthetic fracture in the CR implant which could be easily explained by the fact that a good cortical bone is resected in order to make room for the PS spine. Also, the fact that resecting the posterior cruciate ligament might cause more stress on the implant versus the CR. Instability also were more common in the PS group. We believe this has to do with the fact that the PCL serve as a secondary constraint to the MCL. The presence of the PCL help maintain the stability in case of incidental injury to the MCL during surgery which was reported to be higher in obese patients. Conclusion. There is clear advantage of improving the outcomes or knee scores and decreasing the early postoperative complications in obese patient using CR knee and we strongly recommend using CR implant in obese patients in order to restore functionality faster and reduce the incidence of peri-prosthetic fracture and the revision for instability

Dislocation is a particular problem after total hip replacement in femoral neck fractures and elderly, especially female, patients. The increased rate of dislocation in this population is probably due to significant ligamentous laxity in these patients and poor coordination and proprioception. Another population of patients with increased propensity for dislocation is the revision hip replacement patient. Current dislocation rates in these patients can approach 10% with conventional implant systems. The Dual Mobility total hip system is composed of a cobalt chrome acetabular shell that has a grit blasted, beaded and/or hydroxyapatite coating to improve bone ingrowth. The polyethylene liner is highly crosslinked polyethylene and fits congruently into the cobalt chrome shell and acts like a large femoral head (usually > 40 mm). The femoral head attached to the trunnion is usually 28 mm. The femoral head snaps into the polyethylene liner to acts as a second protection against dislocation. Indications for the Dual Mobility socket are in the high risk for dislocation patient and particularly in elderly, female patients. It is also indicated in patients with neuromuscular disease who are at more risk to dislocate. To date 237 dual mobility cups have been performed with an average age of 79 and 207 of the procedures in women. The follow up extends to 5.6 years with an average of 3.5. There has been 1 dislocation which occurred after a traumatic event. There have been no mechanical failures, no infections and no other revisions in this series. Interprosthetic dislocation has been reported in long term follow up and there was, in this series, when reduction was performed on the only liner dislocation. Pain relief has been no different than conventional hip replacement and range of motion is unchanged as well

In 1983 we underscored the importance of understanding the cause or mechanism of failure following total knee arthroplasty. In this article we reported that revision total knee replacement was generally unsuccessful unless the surgeon new the mechanism of failure. In the ensuing years we have collectively made improvements in instrumentation, component design and material properties such that the mechanisms of failure are now different and less common than in the earlier years. Early failure following total knee arthroplasty is generally related to technical issues. There are a myriad of such issues but many of them relate to component positioning and soft tissue balance. Post-operative wound complications are concerning as they cause an increased incidence of deep infection. Hematoma from over anticoagulation is a particular problem that leads to stiffness and increased risk for infection. Most knee systems now have multiple sizing options and instrument systems that can improve reproducibility of component implantation. Midterm failure is often due to flexion instability which has been reported in cruciate substitution and cruciate retention knees. The instability can be global, mid flexion, flexion or a combination of all 3. Issues with extension and mid flexion instability but no flexion instability are generally those with tight extensor mechanisms. Pain and stiffness are frequently due to component malalignment. One common problem is abnormal internal rotation of the tibial component. Late failure in our institution is generally seen due to wear and loosening from earlier designs with inferior polyethylene. Late hematogenous infection occurs in people with immunocompromise, severe diabetes and diagnoses that alter the patient's ability to mount an immune response. The newest epidemic in total knee failure has been that of periprosthetic fracture. As these patients are becoming older and with worse proprioception, they are at greater risk. Generalised osteopenia and increased activity also increase the risk of fracture. Total knee arthroplasty represents a remarkable improvement in the care of the patient with knee arthritis. It is only by focusing upon and decreasing the causes of failure that we will advance use of this procedure in patient care

Background. Hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) are treatments of end-stage hip disease. Gait analysis studies comparing HRA and THA have demonstrated that HRA results in a more normal gait than THA. The reasons may include the larger, more anatomic head diameter or the preservation of the neck of the femur with restoration of the anatomical position of the hip centre and normal proprioception. This study investigated (1) whether femoral head size diameter affects gait; (2) whether gait still differs between THA and HRA patients even with comparable head diameters. Methods. We retrospectively analysed the gait of 33 controls and 50 patients with a unilateral hip replacement, operated by the same surgeon. Follow-up ranged from 9–68 months. In 27 hips a small femoral head size was used (≤ 36mm); in 23 hips a large head size (>36mm). The small size group consisted of 11 long femoral stem THA and 16 short-stem THA and the large group of 5 long-stem THA, 8 short-stem THA and 10 HRA patients. There were 14 females/19 males in the control group; 22 females/5 males in the small size group; 13 females/10 males in the large size group. Results. (1) We found a significant difference in the step-length between the small head size group and the controls (p<0.01) at speeds ranging from 4.0 to 5.5 km/h but no difference between the larger head size and the controls. There was no significant difference in maximum speed, weight acceptance, push-off, mid-stance, impulse and cadence between the groups. (2) Analysis between THA and HRA in the large head size group revealed that there was a significant difference in the maximum speed (p=0.021) between the long-stem THA (6.338 km/h± 1.542) and HRA (7.756km/h± 0.7604) patients. At 5.5 km/h there was a significantly better weight acceptance (p=0.009) and mid-stance (p=0.041) of the HRA compared to short-stems. Impulse was significantly higher for HRA compared to long-stem THA (p<0.05) at all speeds ranging 4 to 5.5 km/h. (3) Males (7.1972 km/h ± .9700) had significantly higher maximum speeds compared to females (6.6524km/h± 1.019) (p=0.017) and lower gait impulse (p<0.01) at speeds ranging from 4 to 5.5km/h. (4) There was no significant difference in the Oxford Hip Score (OHS) and EQ-5D of patients in the small compared to the large head size group. Conclusions. Gait analysis demonstrated a significant difference in step length between THA patients with head size ≤ 36mm and normal controls. There was no difference in step length between normal controls and THA patients with larger head sizes. Compared to larger head size THA, the HRA still revealed higher maximum speeds and better weight acceptance. Males had significantly higher maximum speeds compared to females (controls and hip replacement patients). We could not demonstrate a correlation between better gait and Oxford scores or EQ-5D scores but these scores are known to have a ceiling effect. In a former study, better gait parameters such as longer step length and higher maximum speed have been associated with higher patient satisfaction

Introduction. The advantages of UKA include bone stock preservation, physiologic kinematics, retention of main knee ligaments, improved proprioception, & better functional outcome. A semi-active robotic system using CT-based data combined with intraoperative registration & tactile feedback has the potential for more precise implant placement & alignment. This purpose of this study was to compare robotic-assisted implantation (RAI) with conventional manual implantation (CMI) & to investigate whether this technology could lead to more reliable & reproducible outcomes. Methods. We prospectively collected data on 32 RAI UKR and 30 CMI UKR. Baseline data collection included: age, gender, BMI, comorbidities, diagnosis, & pre-operative SF-12 Physical Component, SF-12 Mental Component, WOMAC pain, WOMAC Stiffness, & WOMAC Physical Functional scores. Postoperatively, SF-12 & WOMAC scores were recorded, in addition to routine arthroplasty follow-up. Results. Preoperative characteristics were similar. At mean follow-up of 3.20 years (range 2 – 6.2 years), no significant differences were found on SF-12 Physical Component, SF-12 Mental Component, WOMAC pain, & WOMAC Physical Functional scores. Multivariate analysis demonstrated higher WOMAC stiffness scores (p=0.049) in the RA-UKR group. There was no component loosening, progression of the arthritis in the remaining compartments, infection, or PE wear in either group. Revision of UKA to TKA was performed in 1 RAI patient due to persistent medial pain. One technology failure occurred. Additionally, there was a significant increase in operative time in the RAI group (average 20.4 min; p < 0.01) and in OR turnover time (average 32%; p =0.022). Conclusion. No significant differences were found in function, pain, or mental well being at mid-term follow-up of patients that underwent either robotic assisted or conventional UKR. As has been found in other studies, there was improved mechanical alignment & component positioning radiographically but there were no significant differences in functional outcomes. Patient satisfaction is high & there is there is reduced patient cost when the procedure is performed conventionally. Robotic assisted procedures have been discontinued due to lack of clear advantages. We will continue to follow these patients to determine whether better clinical outcomes &/or increased implant longevity occurs over time

Dislocation is a particular problem after total hip replacement in femoral neck fractures and elderly especially female patients. The increased rate of dislocation in this population is probably due to significant ligamentous laxity in these patients and poor coordination and proprioception. Another population of patients with increased propensity for dislocation is the revision hip replacement patient. Current dislocation rates in these patients can approach 10% with conventional implant systems. The Dual Mobility total hip system is composed of a cobalt chrome acetabular shell with a grit blasted, beaded and/or hydroxyapatite coating to improve bone ingrowth. The polyethylene liner is highly cross-linked polyethylene and fits congruently into the cobalt chrome shell and acts like a large femoral head (usually >40mm). The femoral head attached to the trunnion is usually 28mm or 32mm. The femoral head snaps into the polyethylene liner to acts as a second protection against dislocation. Indications for the Dual Mobility socket are in the high risk for dislocation patient and particularly in elderly female patients. One hundred fifty-six patients with an average age of 79 have been performed to date with a maximum follow up to 4.2 years. To date there have been no mechanical or septic failures and no dislocations. Pain relief has been no different than conventional hip replacement and range of motion is unchanged as well. There have been reported cases of intraprosthetic dislocation but these have not occurred to date

Introduction. Compared with the cruciate-retaining (CR) insert for total knee arthroplasty (TKA), the cruciate-substituting (CS) insert has a raised anterior lip, providing greater anterior constraint, and thus, can be used in cases of posterior cruciate ligament (PCL) sacrifice. However, studies have shown that the PCL maintains femoral rollback during flexion, acts as a stabilizer against distal traction force and aids knee joint proprioception; therefore, the argument for PCL excision in CS TKA remains controversial. The purpose of this study was to analyze CS TKA kinematics and identify the role of the PCL. Methods. Seven fresh-frozen lower-extremity cadaver specimens were analyzed using Orthomap. ®. Precision Knee Navigation software (Stryker Orthopaedics, Mahwah, NJ, USA). They were surgically implanted with Triathlon. ®. components (Stryker Orthopaedics). The CS insert has a raised anterior lip, and the posterior geometry shares the same profile as the CR, so we can choose retaining or sacrificing the PCL. Six patterns were analyzed: (1) natural knee; (2) only anterior cruciate ligament excision; (3) CS TKA, PCL retention, and bony island preservation; (4) CS TKA, PCL retention, and bony island resection; (5) CS TKA and PCL excision; and (6) CR TKA and PCL excision. Center of the knee and center of the proximal tibia were registered using navigation system, and the magnitudes of the condylar translation were evaluated. And then, using trigonometric function, the magnitude of anterior-posterior translation of the femur was calculated. Results. PCL excision patterns showed that the magnitude of anterior-posterior (AP) translation was higher in mid-flexion and lower in deep flexion than in other patterns (Fig. 1). Comparing two PCL excision patterns, in CS insert, the anterior translation magnitude was a little lower in extension and 30° flexion. Comparing two PCL retention patterns, the both posterior translation magnitudes in deep flexion were comparable to that of the natural knee. Discussion. Very few studies have reported about comparison of PCL retention with PCL excision in CS TKA. Omori et al. evaluated the medial pivot type TKA, and found that the design showed no femoral rollback under the PCL-sacrificing condition. In our study, increased anterior translation magnitudes in mid-flexion indicated paradoxical roll-forward, and decreased posterior translation magnitudes in deep flexion indicated decreased rollback. In other words, PCL excision in CS TKA caused mid-flexion instability and decreased the femoral rollback, so raised anterior lip was not likely to contribute to TKA kinematics. Another research is necessary to evaluate the effects of the raised anterior lip. On the other hand, PCL retention in CS TKA maintained physiological femoral rollback. The AP translation magnitude was not dependents on the bony island. Conclusions. We had better retain the PCL in raised anterior lip type CS TKA to ensure physiological knee kinematics. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Whether to preserve the posterior cruciate ligament in total knee arthroplasty remains a topic of debate. Long term studies out to 20 or more years have shown both posterior-stabilised (PS) as well as cruciate-retaining (CR) total knees to perform well. Studies supporting both sides are abundant, and there are even studies supporting one being superior to the other, and vice versa. In closer examination of this issue through a recent meta-analysis, the following conclusions can be drawn: . Flexion: mean difference of 2.24, favoring PS designs (p = 0.009). Range of Motion: mean difference of 3.33, favoring PS designs (p = 0.0009). Complications: no statistical difference between PS vs CR. Proprioception. Swanik et al. – PS knee patients were more accurate at reproducing joint position. My bias: PS knees can be utilised in all patients with all deformities. Patellar crepitance with PS designs can be minimised with design alternations and techniques for patella preparation. Any issues with post impingement can be minimised using PS rotating platform designs. The debate of PS vs CR total knees remains unresolved. There is not a 100% clear advantage. Surgeons should make their choice based on their own clinical outcomes, objectively monitored over the long term. For me personally, the choice is PS

Traditionally, arthritis is a disease which generally affects the elderly population. However, the incidence in young patients is well described and is increasing with the ever-growing obese population. Currently, the non-surgical treatment of osteoarthritis consists of corticosteroid injections, hyaluronic acid injections, weight loss, physical therapy, bracing, orthotics, narcotics, and non-steroidal anti-inflammatory drugs (NSAIDS). Oral medications (NSAIDS, tramadol, and opioids) can provide effective pain relief. Improvement with NSAIDs has been reported to be 20% relative to baseline, with better improvements seen with selective cox-2 inhibitors, which also have reduced gastrointestinal and renal toxicity. Additionally, the recent AAOS guidelines strongly recommend using NSAIDs or tramadol for pain relief. Although narcotics are effective analgesics, their use in young arthritic patients can potentially predispose individuals to future opioid dependency, and thus should be used sparingly. The primary purpose of physical therapy is to improve range of motion, strengthen muscles, and improve proprioception. Currently, the AAOS strongly recommends that patients undergo self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education. Similarly, they moderately recommended that patients with a BMI ≥ 25 undergo weight loss for symptomatic arthritis. Bracing options consist of the following: off-loader braces and transcutaneous nerve stimulation braces. These work to either off-load pressure in the knee or to scramble small nerve pain sensation, respectively. Corticosteroid injections are used to minimise pain and reduce inflammation in the joint associated with arthritis. However, their long-term repetitive use in young patients is not recommended, and current AAOS guidelines are inconclusive on their effectiveness. Additionally, the AAOS guidelines strongly recommend against the use of acupuncture, glucosamine/chondroitin, and hyaluronic acid injections

Introduction. Anterior cruciate ligament (ACL) reconstructive surgery is one of the most commonly performed surgical procedures. Synthetic ACL repair surgery with the Lars ligament is designed to repair, rather than replace, the torn ACL. Once the ACL is repaired, the level of function, biomechanical attributes and proprioception should be similar to the pre-injury state. All patients in this cohort have undergone surgical repair of the torn ACL with synthetic Lars ligament augmentation. The indications and surgical technique will be outlined. Patients have been assessed at follow-up with KOOS and Marx scores, which reflect the surgical outcome. The preliminary results with a six-month minimum follow-up will be presented. The results reflect previous published studies that show that surgical repair of the torn ACL with Lars ligament augmentation, can reliably and reproducibly stabilise the knee and allow an early return to sport. Complications include one septic arthritis, superficial wound infections and improperly placed bone tunnels. Synthetic ACL repair using the Lars ligament is a reprodicible technique that allows a rapid post-operative rehabilitation and avoids all complications relating to graft harvesting. The indications and the surgical technique are quite specific and must be adhered to in order to achieve the best results

Total knee replacement (TKR) is considered the “gold standard” treatment for advanced osteoarthritis (OA) of the knee with good survivorship and functional outcomes. However up to 20% of patients undergoing TKR may have unicompartmental disease only. Treatment options for medial compartment arthritis can include both unicompartmental knee replacements (UKR) and TKR. While some surgeons favor TKR with a proven track record, others prefer UKR due to more normal joint kinematics, better proprioception and better motion. There is also a higher rate of return to sports amongst patients with UKR compared to TKR. When considering all knee procedures, partial knee replacements account for 7–9%, primary TKRs for 83–88%, and revision knee replacements for 5–8%. Unicompartmental Knee Replacements comprise more than 90% of all partial knee replacement procedures. Proponents of UKR cite as advantages the preservation of normal knee kinematics, lower peri-operative morbidity, blood loss and infection risk compared with TKRs, as well as accelerated patient rehabilitation and recovery. However, partial knee replacements have a higher rate of revision than TKRs. This may be partly because they are inserted in patients with higher expectations, and partly because they are easier to revise. As a result, the volume of UKRs implanted has diminished over time and continues to decline. We compared patient reported outcomes, satisfaction and perception of normality of the knee post-operatively between UKR and TKR. A single unit and single surgeon series of patients were recruited. Data was collated for 68 well-matched patients with more than 24 months follow-up. UKR was undertaken in patients with isolated medial compartment osteoarthritis; stable ACL and less than grade 3 lateral patellar changes of the Outerbridge classification. TKR was undertaken for the rest. The patients were assessed with validated knee scores including the Total Knee Function Questionnaire (TKFQ) which focuses on recreational and sporting outcomes as well as activities of daily living (ADL). Patient satisfaction and perception of knee normality was measured on a visual analogue scale. Thirty-four patients with a TKR and 34 patients with a UKR were analyzed. The average ages in the TKR and UKR groups were 69.25 and 67.26 years, respectively. The patients were well-matched for demographics and had equivalent pre-operative morbidities and scores. The UKR group had better WOMAC (p=0.003), SF36 (physical: p<0.001 mental: p=0.25), Oxford knee (p<0.001) and Knee Society scores (p=0.002, function: p<0.001). The UKR group showed better outcomes in the TKFQ including exercise and sport (p= 0.02), movement and lifestyle (p=0.02) and the ADL (p=0.002). There was, however, no difference in patient satisfaction scores (p=0.41) and perception of how normal the knee felt between the two groups (p=0.99). A UKR procedure confers better functional outcome in terms of recreation and sport compared to TKR procedures. While UKR is an appropriate choice in the elderly yet active patient with unicompartmental knee arthritis, satisfaction is similar to that of patients with a TKR reflecting higher pre-operative expectations. We believe that in appropriate centers, the UKR procedure is associated with excellent outcomes. UKR should have a secure place in the knee arthroplasty armamentarium provided current knowledge regarding patient selection and surgical technique is followed

There has been a renewed interest in surface replacement arthroplasty over the last decade, with the hope and expectation that this procedure would provide an advantage over conventional total hip arthroplasty, especially in the young, active patient. More specifically, the promises of surface replacement arthroplasty have been: 1) preservation of bone stock so that future revisions would be easier, 2) potential to be minimally invasive in their approach, 3) better functional outcomes because of the stability associated with a larger femoral head with potential associated proprioceptive advantages, and 4) improved survivorship. Unfortunately, these promises have not been realised. Surface replacement arthroplasty does maintain more initial bone stock on the femur, but also tends to remove more bone initially on the acetabular side. Long term, it is the loss of acetabular bone stock that is more problematic from a reconstructive perspective. Further, the “simple” revision afforded in surface replacement arthroplasty has led to reports of inferior clinical outcomes, especially with respect to subjective complaints of pain. Surface replacement arthroplasty is more invasive than conventional total hip arthroplasty as the femoral head is maintained and the window to the acetabulum is subsequently partially blocked. This is exacerbated by the fact that many of these patients are young active males. There is no compelling evidence that surface replacement arthroplasty offers improved functional outcomes over conventional total hip arthroplasty, particularly when considering gait and proprioception. Some studies have in fact shown inferior outcomes. The concept of the larger femoral head in surface replacement arthroplasty providing increased range of motion and subsequent better function is flawed as it is the head-to-neck ratio that appears to be a more important determinant of outcome in this sense. Total hip arthroplasty generally has a more favorable ratio. Surface replacement arthroplasty has inferior survivorship to conventional total hip arthroplasty, even when accounting for the younger age of this patient cohort. This finding is consistent across multiple national joint replacement registries. The outcomes and survivorship are particularly poor in females, with many authors now advocating that the procedure be reserved for males. Surface replacement arthroplasty has introduced several new problems and mechanisms of failures, most concerning of which is the formation of pseudotumors in some patients. It is unclear as to who is at risk for this significant complication, and the ability to diagnose and treat this disorder is difficult and still in evolution. Likely associated is the significant elevation of metal ions in the serum and urine of some surface replacement arthroplasty patients. Neck fractures and loss of bone stock around the femoral implant have also been noted as problematic for these devices. Some of these problems have led to specific surface replacement arthroplasty systems being recalled. Finally, surface replacement arthroplasties are premium products with associated increased costs, which, frankly, are not justified

Patients with above knee amputation face many challenges to mobility including difficulty with socket fit and fatigue due to high energy consumption. The aim of the Endo - Exo-Femur Prosthesis is to avoid problems at the interface between the sleeve of the socket-prosthesis and the soft tissue coat of the femur stump which often impedes an inconspicuous and harmonic gait. In 1999 we began using a transcutaneous, press-fit distal femoral intramedullary device whose most distal external aspect serves as a hard point for AKA prosthesis attachment. The bone guided prosthesis enables an advanced gait via osseoperception and leads to a decreased oxygen consumption of the patient. 43 patients were implanted between 1999 and 2009. Four of the 43 required removal:one for intramedullary infection, one due to stem fracture (replaced), and the two for soft tissue infection. The remaining 39 original prostheses remained. Two pertrochanteric fractures occurred, treated with ORIF. Two bilateral procedures were performed. Initially, twenty patients had chronic soft tissue irritation requiring debridement. This completely resolved by changing the connecting components to a highly polished cobalt chrome. All patients reported increased comfort when compared to socket use. The following additional advantages were observed: improved mobility and endurance, improved proprioception, decreased time required for prosthetic donning, lack of concern regarding changing body weight, and the absence of skin irritation. All patients reported an improvement in sense of position and tactile sensation, leading to an improved gait pattern. Subjectively, the EEFP represents a significant improvement in terms of comfort. Since the introduction of high-gloss polished surfaces, soft tissue irritation is largely eliminated. Intramedullary infection has been negligible, as osseointegration seals the medullary cavity. In summary, the EEFP appears to be an attractive option in transfemoral amputees

Introduction. Hip resurfacing arthroplasty has been surgical options in younger and more active patients with osteoarthritis (OA) and osteonecrosis (ON) of the femoral head. Although excellent midterm results of this procedure have been reported, there is a concern about postoperative impingement between the preserved femoral neck and the acetabular component. There were few reports about kinematics after hip resurfacing. Therefore, the purpose of this study was to investigate the postoperative motion analysis after hip resurfacing using a noble dynamic flat-panel detector (FPD) system by which clear sequential images were obtained with low dose radiation exposure. Materials and methods. 11 patients (mean age: 47.8 ± 7.4), 15 hips were included in this study. There were ten men and one woman. The preoperative diagnoses were ON of the femoral head in 10 hips, OA in 3 hips, and others in 2 hips. Mean postoperative follow-up period was 25.1 ± 21.6 months. Femoral anteversion, cup inclination and cup anteversion were measured on computed tomography and plain radiograph. Impingement signs such as the reactive osteophyte formation and divot around the femoral neck were also investigated on the anteroposterior (AP) and lateral radiographs. Sequential images of active and passive flexion motion in 45-degrees semilateral position, and active abduction motion in a supine position were obtained using a noble dynamic FPD system. Results. Mean femoral anteversion was 13.2° ± 9.1° and mean cup inclination and anteversion were 35.4° ± 2.3° and 6.8° ± 3.9°, respectively. The reactive osteophyte formation apeared in 1 hip (6.7%) on AP radiograph and 4 hips (26.7%) on lateral radiograph, and divot sign was observed in 1 hip (6.7%) on each radiographs. The location of the impingement signs were mostly observed at the anteroinferior portion of the femoral neck. In motion analysis, impingement between the femoral neck and the acetabular component was detected in 12 hips (80.0%) in flexion motion and 2 hips (13.3%) in abduction motion (Figure). There were no findings of the subluxation between the acetabular and femoral component after the impingement, but cooperative motion of lumber and pelvic flexion was occurred. None of the patients who had a impingement signs on plain radiographs and motion analysis had any symptoms and pain during hip motion. Discussion and conclusion. Postoperative motion analysis is a noble and useful technique and that can detect various findings which could not be detected by the routine static radiographs. Also, postoperative kinematics after hip resurfacing remains unknown and we investigated it in detail using a noble dynamic FPD system. The present study indicated that impingement between the preserved femoral neck and the acetabular component and consequent cooperative motion of lumber and pelvic flexion were similar to the physiological motion of the nomal hip joint. No sign of the subluxation between the component proved the good stability of the resurfacing articulation. Proprioception of the preserved femoral neck can be related to this unique kinematics

Background. Performing total knee replacement needs both bony & soft tissue consideration. Late John Insall advocating spacer blocks with concept of balanced & equal flexion – extension Gap. Although we usually excise both ACL & PCL, still it is possible to retain more soft tissue. Both PCL retaining & sacrificing Require intact collaterals for stability. Superficial MCL & LCL should be preserved, if possible. After PCL removal the following advantages could obtain: More correction of fixed varus or valgus deformity, More surgical exposure. but there are no proved disadvantages like; increasing in stress & loosening of bone-cement-prosthesis interface, specific clinical difference in ROM, forward lean during stepping up, proprioception inferiority. In other hand over tight PCL cause excessive rollback of tibia & knee hinges open, preventing flexion (booking), and Severe posteromedial poly wear in poor balance PCL might be happened. Mid range laxity when Post. Capsule is tight, even with correct tensioning in full extension & 90 degree flexion, may occur (and secondary collateral ligaments imbalance throughout ROM). There is a major effect of capsular contracture in coronal mal alignment with flexion contracture. Full MCL releases not only correct fixed varus but also open the medial space in flexion. MCL & post. Capsule has combined valgus resistant effect in extension. PCL release increase flexion gap more, May be necessary to release something that affect extension gap as compensated balancing (Post.medial capsule). Any flexion contracture need to posterior capsulotomy & post. Condyle osteophyte removal before femoral recut. So it is possible to perform posteromedial capsulotomy prior to superficial MCL release. Method. From May 2009 to June 2013, 219 TKA (165 patient) (bilateral in 54 patients, simultaneous bilateral in 5 patients) with primary DJD and varus deformity of knees were operated by myself with joint replacement. Most patients had some degree of varus correction in flexion, passively. The varus angle was less than 25*, means mild to severe but not decompensate. 46 patients had some degree of patella baja. For soft tissue balancing during Total knee arthroplasty I consider the following steps; Medial capsule & deep MCL release, PCL release, Posteromedial capsulotomy, semimembranous release, Superficial MCL release, Pes anserinous release. Post.medial capsulotomy was done in all cases. The Average Age was 65.47 years, 131 patients (177 knees) were female (79.3%) and five of them had bilateral TKA simultaneously. Lt Knee was operated in 94 cases (42.9% of 219). Spinal anesthesia was applied in 54.3% (119 patients) & epidural anesthesisa in 5 % (13 cases). 14 knees were operated with MIS technique and 205 knees with Standard medial parapatellar incision. Semi membranous release was necessary in 72 knees (33 pure=15%, without S.MCL release). S.MCL release was mandatory in 39 (17.8 %) knees for checking balanced medial and lateral subtle laxity (playing), I have used simple blade with 1 & 2 mm thickness in each ends for younger patients, and the other one with 3&4 mm thickness in elder cases. Results. Average follow up period is 2.07 years. Average Operating time was 1: 38 (h: m). Average Transfusion = 1.29 unit packed cell. Average varus malalignment=14.76*(2–25*) / Av. Valgus angle= 7.11* (5–10 *) / Av. DLFA= 91.15* (85–102*) / Av. PMTA = 82.04* (68.5–90*) / Av. Ext. rotation cut = 5.7* (0–9). Stage l + PCL + Post. Med. Capsular release was performed in all. pure stage l + P.M.capsular release in147 cases(67.2%), plus semimembrnous release in33 cases(15%), S.MCL release in 39cases(17.8%)/ Av. Post op alignment:1.01 * varus(0 −6 *) (worse in medial pivot knee). so S.MCL release was preventedin 82.1% of cases. Av. Polyethylen size: 12.26 (9 in oxynium −19 in plus) / Semi membranous release was necessary in 72(32.8%) cases (preop varus 17.57*). / S.MCL release was mandatory in 39(17.8 %) cases (preop varus 17.6 * & No Flexibility in 30* flexion). pre operation knee society score: stage I = 26.6, stage II = 38.7 increase to stage I = 86.45, stage II = 77.63. Conclusion. In society with more kneeling habitués, during performing total knee arthroplasty with less than 25* degree varus malalignment plus some degree flexibility of the deformity in flexion, it is wise to consider posteromedial capsular release prior to semi membranous & S.MCL release to obtain full correction of alignment. But the most important thing is reaching to more align limb without instability, regardless of various technique

Aims

Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.

Background. Performing total knee replacement needs both bony & soft tissue consideration. Late John Insall advocating spacer blocks with concept of balanced & equal flexion – extension Gap. Although we usually excise both ACL & PCL, still it is possible to retain more soft tissue. Both PCL retaining & sacrificing Require intact collaterals for stability. Superficial MCL & LCL should be preserved, if possible. after PCL removal the following advantages could obtain: More correction of fixed varus or valgus deformity, More surgical exposure. but there are no proved disadvantages like; increasing in stress & loosening of bone-cement-prosthesis interface, specific clinical difference in ROM, forward lean during stepping up, proprioception inferiority. in other hand Over tight PCL cause excessive rollback of tibia & knee hinges open, preventing flexion (booking), and Severe posteromedial poly wear in poor balance PCL might be happened. Mid range laxity when Post. Capsule is tight, even with correct tensioning in full extension & 90 degree flexion, may occur (and secondary collateral ligaments imbalance throughout ROM). There is a major effect of capsular contracture in coronal mal alignment with flexion contracture. Full MCL releases not only correct fixed varus but also open the medial space in flexion. MCL & post. Capsule has combined valgus resistant effect in extension. PCL release increase flexion gap more, May be necessary to release something that affect extension gap as compensated balancing (Post.medial capsule). Any flexion contracture need to posterior capsulotomy & post. Condyle osteophyte removal before femoral recut. So it is possible to perform posteromedial capsulotomy prior to superficial MCL release. Method. From May to Dec. 2009, 22 patients (23 knees) with primary DJD and varus deformity of knees were operated by myself with joint replacement. most patients had some degree of varus correction in flexion, passively. the varus angle was less than 25∗, means mild to severe but not decompensated. For soft tissue balancing during Total knee arthroplasty I consider the following steps;. Medial capsule & deep MCL release, PCL release, Posteromedial capsulotomy, semimembranous release, Superficial MCL release, Pes anserinous release. Post. medial capsulotomy was done in all cases. The Average Age was 64.74 years, 19 patients were female (83%) and one of them had bilateral TKA simultaneously. Lt Knee was operated in 14 cases (70% of 24). Spinal anesthesia was applied in 82%. 10 patients were operated with MIS technique and 13 patients with Standard medial parapatellar incision. Semi membranous release was necessary in 4 cases (preop varus 17,20,24,25∗). MCL release was mandatory in 2 cases (preop varus 17, 24 ∗ & No Flexibility in 30∗ flexion).for checking balanced medial and lateral subtle laxity (playing), I have used simple blade with 1 & 2 mm thickness in each ends for younger patients, and the other one with 3&4 mm thickness in elder cases. Results. Average follow up period is 234.45 days. Average Operating time was 1: 32 (h:m). Average Transfusion = 1.22 unit packed cell. No Flexibility in 30∗ flexion was seen in 3 patients. Average varus malalignment =15.29∗ (2-25∗)/Av. Valgus angle = 7.19∗ (5-10 ∗)/Av. DLFA = 90.47∗ (87-93∗)/Av. PMTA = 83.41∗ (77-88.5∗)/Av. Ext. rotation cut = 3.11∗. Stage l + PCL + Post. Med. Capsular release was performed in 82.61%./Av. Post op alignment: 1.8 ∗ varus (0 -6 ∗) (worse in medial pivot knee). Av. Polyethylen size: 12.4 (9 in oxynium -19 in plus)/Semi membranous release was necessary in 4 cases (preop varus 17,20,24,25∗) (Post. Op varus 1,6,4,2)./S.MCL release was mandatory in 2 cases (preop varus 17, 24 ∗ & No Flexibility in 30∗ flexion) (Post. Op varus: 1, 4 ∗). pre operation knee society score: stage I = 27.8, stage II = 37.9 increase to stage I = 85.47, stage II = 75.65. Conclusion. In society with more kneeling habitués, during performing total knee arthroplasty with less than 25∗ degree varus malalignment plus some degree flexibility of the deformity in flexion, it is wise to consider posteromedial capsular release prior to semi membranous & S.MCL release to obtain full correction of alignment. But the most important things is reaching to full align limb regardless of which chosen technique