Abstract. Introduction. We aimed to compare the outcomes of elderly patients with periarticular distal femur or supracondylar periprosthetic fractures treated with either open reduction internal fixation or distal femoral replacement. Methods. A retrospective review of patients over 65 years with AO Type B and C fractures of the distal femur or Su type I and II periprosthetic fractures treated with either a DFR or ORIF was undertaken. Outcomes including Length of Stay, PROMs (Oxford Knee Score and EQ 5D), infection, union, mortality, complication and reoperation rates were assessed. Data on confounding variables were also collected for multivariate analysis. Patients below 65 years and extra articular fractures were excluded. Results. 23 patients (11 in DFR group and 12 in ORIF group) fulfilled inclusion criteria and were included in the analysis. There was no difference between the DFR and ORIF groups with respect to SDI, demographic variables, ASA grade, FCI, preoperative Hb and renal function. There was no difference in 30 day mortality, reoperation rates, 30 day readmission rates and LOS between the two groups. Mean follow up was 12.7 and 15.9 months respectively in the DFR and ORIF groups. At final follow up after accounting for all confounding variables on multivariate analysis, functional outcomes using OKS (adjusted mean: 29.5 vs 15.8) and Health related Quality of Life outcomes using EQ 5D (adjusted mean: 0.453 vs −0.07) were significantly better in the DFR group. Conclusion. DFR for periarticular and periprosthetic distal femoral fractures in the elderly are associated with better patient reported outcomes

Controversy exists regarding the optimal technique for arthroscopic rotator cuff repair. No previous comparative trials have reported on the long-term follow-up of single and double row fixation in arthroscopic cuff repair. The purpose of this study was to compare the long-term functional outcomes of single-row and double-row suture techniques for repair of the rotator cuff 10-years post-operatively. Ninety patients undergoing arthroscopic rotator cuff repair were randomized to receive either single-row or double-row repair. The primary objective was to compare the Western Ontario Rotator Cuff Index (WORC) score 10-years post-operatively. Secondary objectives included comparison of the Constant, and American Shoulder and Elbow Surgeons (ASES) scores and supraspinatus strength between groups. Out of 90 patients originally randomized, 57 returned for the long-term 10-year follow-up. Baseline demographic data did not differ between groups. The WORC score was not significantly different between groups at long-term follow-up (p=0.13). No statistical differences were observed between groups for the Constant (p=0.51), ASES (p=0.48) scores, or strength scores (p=0.93). A significant improvement was observed between pre-operative and the final 10-year follow-up. There were no differences observed in all outcomes between two and 10-years post-operatively. No statistically significant differences in functional or quality of life outcomes were identified between single-row and double-row fixation techniques at long-term follow-up

In revision total hip arthroplasty (THA), acetabular reconstruction while dealing with severe bone loss is a challenge. The porous tantalum revision acetabular shells have been in use for the past decade. Several reports have documented successful use at early to mid-term follow up. There is, however, very little literature around the long-term survival and quality of life outcome with the use of these shells. We reviewed the results of 46 acetabular revisions with Paprosky 2 and 3 acetabular bone defects reconstructed with a hemispheric, tantalum acetabular shell and multiple supplementary screws. There were 31 females. Average age at revision was 64 years (range 23–85 years). The mean and median follow up was 11 years (range 10–12 years, SD 1). Morselised femoral allograft was used in 34 hips to fill contained cavitary defectes. Bulk femoral allografting was performed in 2 hips. At a minimum follow-up of 10 (range 10–12) years, the survivorship of the porous tantalum acetabular shell, with revision of the shell as end point was 96%. The minimum 10-year survivorship with hip revision for any reason as end point was 92%. We noted excellent pain relief (mean WOMAC pain 92.6) and good functional outcome (mean WOMAC function 90.3, mean UCLA 5); and generic quality of life measures (mean SF-12 physical component 48.3; mean SF-12 mental component 56.7). Patient satisfaction with pain relief, function and return to recreational activities were noted to be excellent. Cementless acetabular revision with the tantalum acetabular shell demonstrated excellent clinical and quality of life outcomes at minimum 10-year follow-up. As far as we are aware this is the first report of minimum 10-year follow up of use of this technique for revision hip arthroplasty

Approximately 20% of patients feel unsatisfied 12 months after primary total knee arthroplasty (TKA). Current predictive tools for TKA focus on the clinician as the intended user rather than the patient. The aim of this study is to develop a tool that can be used by patients without clinician assistance, to predict health-related quality of life (HRQoL) outcomes 12 months after total knee arthroplasty (TKA). All patients with primary TKAs for osteoarthritis between 2012 and 2019 at a tertiary institutional registry were analysed. The predictive outcome was improvement in Veterans-RAND 12 utility score at 12 months after surgery. Potential predictors included patient demographics, co-morbidities, and patient reported outcome scores at baseline. Logistic regression and three machine learning algorithms were used. Models were evaluated using both discrimination and calibration metrics. Predictive outcomes were categorised into deciles from 1 being the least likely to improve to 10 being the most likely to improve. 3703 eligible patients were included in the analysis. The logistic regression model performed the best in out-of-sample evaluation for both discrimination (AUC = 0.712) and calibration (gradient = 1.176, intercept = -0.116, Brier score = 0.201) metrics. Machine learning algorithms were not superior to logistic regression in any performance metric. Patients in the lowest decile (1) had a 29% probability for improvement and patients in the highest decile (10) had an 86% probability for improvement. Logistic regression outperformed machine learning algorithms in this study. The final model performed well enough with calibration metrics to accurately predict improvement after TKA using deciles. An ongoing randomised controlled trial (ACTRN12622000072718) is evaluating the effect of this tool on patient willingness for surgery. Full results of this trial are expected to be available by April 2023. A free-to-use online version of the tool is available at . smartchoice.org.au.

The Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0) is a patient-reported disease-specific quality of life (QOL) outcome measure used to assess patients with recurrent lateral patellofemoral instability (LPI) both pre- and post-operatively. The purpose of this study was to compare the BPII 2.0 to four other relevant patient reported outcome measures (PROMs): the Tampa Scale-11 for kinesiophobia (TSK-11), the pain catastrophizing scale (PCS), a general QOL (EQ-5D-5L), and a return to sport index (ACL-RSI). This concurrent validation sought to compare and correlate the BPII 2.0 with these other measures of physical, psychological, and emotional health. The psychological and emotional status of patients can impact recovery and rehabilitation, and therefore a disease-specific PROM may be unable to consistently identify patients who would benefit from interventions encompassing a holistic and person-focused approach in addition to disease-specific treatment. One hundred and ten patients with recurrent lateral patellofemoral instability (LPI) were assessed at a tertiary orthopaedic practice between January and October 2021. Patients were consented into the study and asked to complete five questionnaires: the BPII 2.0, TSK-11, PCS, EQ-5D-5L, and the ACL-RSI at their initial orthopaedic consultation. Descriptive demographic statistics were collected for all patients. A Pearson's r correlation coefficient was employed to examine the relationships between the five PROMs. These analyses were computed using SPSS 28.0 © (IBM Corporation, 2021). One hundred and ten patients with a mean age of 25.7 (SD = 9.8) completed the five PROMs. There were 29 males (26.3%) and 81 females (73.6%) involving 50% symptomatic left knees and 50% symptomatic right knees. The mean age of the first dislocation was 15.4 years (SD = 7.3; 1-6) and the mean BMI was 26.5 (SD = 7.3; range = 12.5-52.6) The results of the Pearson's r correlation coefficient demonstrated that the BPII 2.0 was statistically significantly related to all of the assessed PROM's (p. There was significant correlation evident between the BPII 2.0 and the four other PROMs assessed in this study. The BPII 2.0 does not explicitly measure kinesiophobia or pain catastrophizing, however, the significant statistical relationship of the TSK-11 and PCS to the BPII 2.0 suggests that this information is being captured and reflected. The preliminary results of this concurrent validation suggest that the pre-operative data may offer predictive validity. Future research will explore the ability of the BPII 2.0 to predict patient quality of life following surgery

Purpose. Tenodesis of the long head of biceps is an established technique for management of biceps pathology including tears, instability, and chronic tendinosis intractable to non-operative management. Very few studies have reported on clinical outcomes of all-arthroscopic, non-interference, biceps tenodesis techniques. The purpose of this study is to evaluate the functional and quality of life outcomes of patients treated with an all-arthroscopic biceps tenodesis with a suture anchor. Method. Case Series Level 4 Evidence. Fifty-eight (58) patients with a mean age of 58.5 years were treated with an arthroscopic biceps tenodesis in a single surgeons practice. A single suture anchor was used with a non-interference technique, either in isolation or in association with an arthroscopic rotator cuff repair. A retrospective analysis was performed on prospectively collected outcome measures on patients with a minimum one-year follow-up. Patients were evaluated with an ASES, Constant, and WORC scores pre-operatively and at 6 and 12 months post-operatively. In addition, patients were questioned post-operatively as to whether they experienced any biceps cramping, fatigue, or cosmetic deformity (popeye sign). Results. Following an all-arthroscopic biceps tenodesis, the ASES, Constant, and WORC scores improved significantly from 45, 54, 32 to 58, 75, 73 respectively (P<0.001). When analyzed separately, patients who underwent an arthroscopic biceps tenodesis in isolation (no cuff repair) and in association with an arthroscopic cuff repair demonstrated similar gains in functional and quality of life outcomes. (P<0.001). Few patients reported post-operative bicipital cramping, fatigue, or cosmetic deformity. Conclusion. The all-arthroscopic biceps tenodesis is a reliable procedure that results in significant improvement in functional outcome and quality of life measures

Purpose. An open superior capsular shift is a well-established technique for the management of patients with multidirectional shoulder laxity and the absence of a Bankart lesion. Few studies have reported on functional and quality of life outcomes using arthroscopic technique for shoulder stabilization using superior capsular shift in patients with no Bankart lesion. The purpose of this study was to assess the functional and quality of life outcome scores following shoulder stabilization with a selective arthroscopic superior capsular shift with suture anchors, for treatment of multidirectional laxity and the absence of a Bankart lesion. Method. Case Series Level 4 Evidence. Thirty-six (36) patients with a mean age of 30.8 years, with a diagnosis of recurrent anterior atraumatic shoulder instability, and no Bankart lesion, were identified in a single surgeons practice. These patients underwent an arthroscopic shoulder stabilization with an anterior inferior to superior capsular shift. The labrum was arthroscopically released from the anterior/inferior glenoid and was shifted superiorly in conjunction with a capsular plication. A retrospective analysis was performed on prospectively collected outcome scores of patients who had with a minimum of 1 year of follow-up. The ASES and WOSI scores were administered pre-operatively and at 6 and 12 month follow-up. The presence of a positive post-operative apprehension sign was also recorded on follow-up. Results. After an arthroscopic capsular shift, the ASES and WOSI scores improved significantly from 57, 28 to 78, 68 respectively (P<0.001). Few patients had a positive apprehension sign at 1 year follow-up. Conclusion. An arthroscopic capsular shift is a reliable procedure that resulted in satisfactory outcomes in patients with shoulder instability and the absence of a Bankart lesion

Paediatric femoral fractures are a common result of significant trauma, and always require intervention. Hip spica casting, traction, and surgical fixation can all be used to treat these fractures. This variety in treatment options leads to a vast potential for variability in management decisions among surgeons and has prevented effective comparative studies to show which treatment methods provide optimal outcomes for patients. The purpose of this study was to identify practice variability in management and follow-up and assess patient outcomes to aid in the development of a comprehensive, prospective, evidence-based pathway for the management of paediatric femoral fractures. A retrospective chart review was performed of all patients treated surgically for isolated femoral fractures during a six year period at a single tertiary care paediatric centre. Patients were identified from a surgical database and were included if there was no pre-existing pathology and no history of previous femoral fracture. Demographic data, operative details, post-operative management, and clinical outcomes were collected. Radiographic images and reports were analyzed to determine fracture classification and imaging parameters. Variability in treatment among eight surgeons was assessed, including number of follow-up appointments and length of follow-up. Patient demographics and follow up measures were summarised for each surgeon and between surgeon variability was assessed with linear models. In total, 138 femoral fractures in 134 patients (101 male, 33 female) were included in analysis. Of these patients, 55 had right femoral fractures, 76 left, and three bilateral (one bilateral patient had three distinct femoral fractures). Of 138 total fractures, 131 were of the diaphysis of the femur. 14 patients sought initial surgical treatment at our institution but received follow-up management elsewhere. Across all patients, median follow-up time was 32.8 weeks (0–201.4) with a median of three follow-up visits (0–26) in that period. Mean number of follow-up clinic visits ranged from 3 to 4.8 among surgeons, and mean length of follow-up ranged from 31.8 to 62.3 weeks. No significant differences in follow-up between surgeons were found, but small sample sizes are a likely contributing factor. Summary statistics show large ranges in most variables and differences in patient demographics between surgeon groups. The large ranges in follow-up time and visit number suggest a lack of consensus on optimal management for paediatric femoral fractures. Further prospective study examining long-term functional and quality of life outcomes will be required to identify and develop optimized management guidelines

Purpose. This prospective, expertise-based randomized clinical trial compares arthroscopic to open shoulder stabilization by measuring the disease-specific quality of life outcome in patients with traumatic unidirectional anterior shoulder instability, and determining the incidence of recurrent instability at 2-years post-operatively. Method. One hundred and ninety-six patients were randomly allocated to arthroscopic (n=98) or open (n=98) repair using an expertise-based approach with a surgeon specializing in one type of surgery. Randomization was performed using computer-generation, variable block sizes and concealed envelopes. Outcomes were measured at baseline, 3 and 6 months, 1 and 2 years post-operatively. These outcomes included the Western Ontario Shoulder Instability (WOSI) Index quality of life outcome and the American Shoulder and Elbow Society (ASES) functional outcome. Both outcomes were measured on a visual analog scale from 0 to 100, where a higher score represents better quality of life or function. Recurrent instability was categorized as traumatic/atraumatic, and as a subluxation/dislocation. Analyses included ANOVA of repeated measures and independent t-tests. Bonferroni adjustments for pairwise contrasts were made for multiple comparisons. Chi-squared analyses were performed on recurrence. Statistical significance was reported at p < 0.05. Results. There were no statistically significant differences at baseline with respect to gender, involved dominant shoulders, age, WOSI or ASES scores. At 2-years post-operatively, 19 patients in the Open group and 14 patients in the Arthroscopic group were lost to follow-up. A comparison of the baseline characteristics of these lost to follow-up patients showed no statistically significant differences in WOSI and ASES scores, age, involved dominant shoulder, gender and presence of Hill Sachs lesions between the groups. Of the patients that completed 2-year follow-up, there was no difference in mean WOSI score between the two groups: Open = 85 (SD = 20; 95% CI = 81 89), Arthroscopic = 82 (SD = 20; 95% CI = 77 86), p = 0.31. The ASES score for the Open group at 2-years was 91 (SD = 13; 95% CI = 88 94) and 88 (SD = 16; 95% CI = 85 92) for the Arthroscopic group, p = 0.17. Recurrence rates at 2-years were statistically different with 11% in the Open (9/80) and 23% in the Arthroscopic (20/87) groups, p = 0.05. Conclusion. At 2-years post-operative follow-up, there was no difference in disease-specific quality of life between Open and Arthroscopic repair. Open repair had a significantly lower risk of recurrence

Two stage exchange has been the gold standard in North America for the treatment of infected knee replacements. The choice of static vs. articulated spacers has been debated for a number of years. At our institution our choice of spacer for 2 stage exchanges is an articulated spacer. This allows motion between stages which facilitates recovery, and makes the second stage technically easier. In a study from our institution we followed 115 infected TKAs treated with the PROSTALAC articulated spacer for 5–9 years. Success for eradication of infection was 88%. With a repeat 2 stage, overall infection control was 98%. In addition, we compared functional outcomes to a group of aseptic knee revisions and found no difference in functional outcomes with standard quality of life outcome scores. While the articulated spacer was our treatment of choice in 2 stage exchange around 2012, the company that manufactured the PROSTALAC knee components ceased to manufacture them. At that time, based on the work of 2 previous studies (Hofmann, Lee), we continued to use articulated spacers. However, this was now the so-called Hofmann technique with a new standard femoral component with an all polyethylene tibia. The only difference from a standard knee revision was no stems and the utilization of high dose antibiotics. We also followed the principles from Europe of one stage exchange, such as wide debridement and soaking in dilute betadine for 15 minutes. More recently as of Sept 2015 we have used an all polyethylene tibia with a keel. The hope being that this will give a more stable tibia than previous and perhaps make a second stage unnecessary. Our first case was September 2015. The intention was not to do a second stage if the infection was eradicated and the patient had good pain relief and function. To date we have implanted 28 of these and in 80% of cases we have not had to do a second stage revision. Further study will reveal where this inadvertent one stage fits in our practi

Introduction. While THA is associated with positive results and long-term improvement in patient quality of life, outcomes are nonetheless associated with adverse events and post-procedural deficits related to discrepancies in leg length (LLD), offset and cup placement. Post-THA errors in these parameters are associated with gait alteration, low back pain and patient dissatisfaction. Such discrepancies often necessitate revision and increasingly lead to medical malpractice litigation. Maintaining accuracy in post-surgical leg length, offset and cup placement during THA is difficult and subject to error. The sensitivity of these factors is highlighted in studies that have shown that a change of as little as 5 degrees of flexion or abduction can induce alterations in leg length of up to several millimeters. Similarly, positioning of implants can alter global and femoral offset, affecting abductor strength, range of motion and overall physical function. Compounding the biochemical issues associated with inaccurate leg length are the costs associated with these deficits. Traditional freehand techniques of managing intra-operative parameters rely on surgeon experience and tissue tensioning to manually place components accurately. These methods, however, are only able to assess leg length and are subject to inaccuracies associated with patient movement or orientation changes during surgery. Mechanical methods of minimizing post-surgical discrepancies have been developed, such as outrigger or caliper devices, although these methods also address leg length only and provide poor feedback regarding offset and center of rotation, therefore providing insufficient data to accurately achieve appropriate post-surgical leg length. Computer-assisted navigation methods provide more data regarding leg length, offset and center of rotation, but are limited by their cumbersome nature and the large capital costs associated with the systems. The Intellijoint HIP. ®. surgical smart tool (Intellijoint Surgical, Inc., Waterloo, ON) is an intra-operative guidance tool that provides surgeons with real time data on leg length, offset and center of rotation, thereby allowing for confident selection of the correct implant in order to ensure appropriate post-surgical biomechanics. The early clinical results from an initial cohort of patients indicate that Intellijoint HIP. ®. is safe and effective. No adverse events were reported in the initial cohort, and the smart tool was able to measure surgical parameters to within 1mm when compared to radiographic measurements. With training cases removed, 100% of cases had a post-procedure leg length discrepancy of less than 5mm. This paper describes the indications, procedural technique and early clinical results of the Intellijoint HIP. ®. smart tool, which offers a safe, accurate and easy-to-use option for hip surgeons to manage leg length, offset and cup position intra-operatively

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In 2 studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a match cohort of monoblock cobalt chromium stems. As mentioned, one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction, more recently, at our institution, we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with a monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done with a endofemoral approach. In this approach the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this stem more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

Introduction. We aimed to determine whether there are differences in patient-reported quality of life (QoL) outcome between local flap versus free flap. Materials and Methods. All patients admitted with lower limb open fractures were retrospectively reviewed. Patient notes were assessed for demographics, time to fracture union, wound healing and patient-reported QoL with EQ-5D-5L, alongside a novel flap assessment tool. Results. A total of 40 patients had flap reconstruction of their lower limb injury; 23 local flap (Group I) and 17 free flaps (Group II). The average length of follow-up was 33.8 months. Group I - 10 revisions of flaps (43.5%) and 14 surgical complications (60.9%). Fracture union was 171 days and wound healing 130 days. EQ-5D index and EQVAS scores were 0.709 and 79.3, respectively. Group II – 8 revision of flaps (47.1%) and 12 surgical complications (70.6%). Fracture union was 273 days and wound healing 213 days. EQ-5D index and EQ-VAS scores were 0.525 and 57.2, respectively. Aesthetic appeal - 48% Group I vs. 66% Group II. Significant differences were found between the two flap groups with higher scores for daily living in Group I (p–0.007) compared to higher overall flap ratings in Group II (p–0.049). Both groups were comparable in terms of complications, while flap congestion and dehiscence were more common with free flaps. statistical interrogation did not elicit significance (p > 0.05). Conclusions. Local flap and free flap techniques offer distinct advantages. Local flaps have a better surgical outcome and patient-reported QoL in the first few years post soft tissue reconstruction. Differences between local and free reconstructive techniques in terms of patient health and function are ameliorated in the longer term

Two stage exchange has been the gold standard in North America for the treatment of infected knee replacements. The choice of static versus articulated spacers has been debated for a number of years. At our institution our choice of spacer for two-stage exchanges is an articulated spacer. This allows motion between stages which facilitates recovery, and makes the second stage technically easier. In a study from our institution we followed 115 infected TKAs treated with the PROSTALAC articulated spacer for 5–9 years. Success for eradication of infection was 88%. With a repeat two stage overall infection control was 98%. In addition we compared functional outcomes to a group of aseptic knee revisions and found no difference in functional outcomes with standard quality of life outcome scores. While the articulated spacer was our treatment of choice in two-stage exchange around 2012 the company that manufactured the PROSTALAC knee components ceased to manufacture them. At that time based on the work of 2 previous studies (Hofmann, Lee), our institution continued to use articulated spacers. However, this was now the so-called Hofmann technique with a new standard femoral component with an all-polyethylene tibia. The only difference from a standard knee revision was no stems and the utilisation of high dose antibiotics. We also followed the principles from Europe of one-stage exchange, such as wide debridement and soaking in dilute betadine for 15 minutes. More recently, as of Sept 2015, we have used an all-polyethylene tibia with a keel. The hope being that this will give a more stable tibia than previous and perhaps make a second stage unnecessary. Our first case was September 2015. The intention was not to do a second stage if the infection was eradicated and the patient had good pain relief and function. To date we have implanted 12 of these and in all cases we have not had to do a second stage revision. Further study will reveal where this inadvertent one stage fits in our practice

Two-stage exchange has been the gold standard in North America for the treatment of infected knee replacements. The choice of static versus articulated spacers has been debated for a number of years. At our institution our choice of spacer for 2-stage exchanges is an articulated spacer. This allows motion between stages which facilitates recovery, and makes the second stage technically easier. In a study from our institution we followed 115 infected TKAs treated with the PROSTALAC articulated spacer for 5–9 years. Success for eradication of infection was 88%. With a repeat two-stage, overall infection control was 98%. In addition, we compared functional outcomes to a group of aseptic knee revisions and found no difference in functional outcomes with standard quality of life outcome scores. While the articulated spacers were our treatment of choice in 2-stage exchange, around 2012 the company that manufactured the PROSTALAC knee components ceased to manufacture them, based on the work of 2 previous studies (Hofmann, Lee). At our institution, we continued to use articulated spacers. However, this was now the so-called Hofmann technique with a new standard femoral component with an all-polyethylene tibia. The only difference from a standard knee revision was no stems and the utilization of high dose antibiotics. Around the same time as we instituted the change in articulated spacers, results out of Europe were showing promising results with one-stage exchange. In September 2015, our technique was modified to now include an all-polyethylene tibia with a keel. To date we have no results but it is our hope that a high percent of these will achieve stable fixation and will then have a one-stage exchange

Two stage exchange has been the gold standard in north America for the treatment of infected knee replacements. The choice of static versus articulated spacers has been debated for a number of years. At our institution our choice of spacer for 2 stage exchanges is an articulated spacer. This allows motion between stages which facilitates recovery, and makes the second stage technically easier. In a study from our institution we followed 115 infected TKAs treated with the PROSTALAC articulated spacer for 5–9 years. Success for eradication of infection was 88%. With a repeat two stage overall infection control was 98%. In addition we compared functional outcomes to a group of aseptic knee revisions and found no difference in functional outcomes with standard quality of life outcome scores. While the articulated spacers was our treatment of choice in 2 stage exchange around 2012 the company that manufactured the PROSTALAC knee components ceased to manufacture them. At that time based on the work of 2 previous studies (Hofmann, Lee), at our institution we continued to use articulated spacers. However, this was now the so called Hofmann technique with a new standard femoral component with an all polyethylene tibia. The only difference from a standard knee revision was no stems and the utilization of high dose antibiotics. We also followed the principles from Europe of one stage exchange, such as wide debridement and soaking in dilute betadine for 15 minutes. More recently as of Sept 2015 we have used an all-polyethylene tibia with a keel. The hope being that this will give a more stable tibia than previous and perhaps make a second stage unnecessary. Our first case was September 2015. The intention was not to do a second stage if the infection was eradicated and the patient had good pain relief and function. To date we have implanted 12 of these and in all cases we have not had to do a second stage revision. Further study will reveal where this inadvertent one stage fits in our practice

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared the modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In 2 studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a match cohort of monoblock cobalt chromium stems. As mentioned one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post-revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction more recently at our institution we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done with an endofemoral approach. In this the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this stem more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

1) INTRODUCTION. Acetabular fixation in cementless total hip arthroplasty (THA) relies on new technology for stability and survivorship of the implant. A highly porous 3D titanium coating was developed with a biologically inspired pore structure to improve initial friction fixation with mechanical stability and long term biological fixation. Ongoing research is investigating potential radiographic phenomenons these coatings produce, resulting in the presence of lucent lines. The purpose of this study was to evaluate clinical and radiographic outcomes of a 3D highly porous-coated titanium acetabular shell. 2) METHODS. One hundred and sixty-two cases as part of a non-randomized, post-market, multicenter study received a primary cementless THA. Clinical outcomes including the Harris Hip Score (HHS), Lower Extremity Activity Scale (LEAS), Short Form 12 (SF12), and EuroQol 5D Score (EQ-5D) were collected preoperatively and at six weeks, one year postoperative. Additionally, radiographs, radiographic parameters and techniques were analyzed for institutional differences. 3) RESULTS. Significant postoperative improvements were seen in pain, function and quality of life outcomes through one year. The HHS improved significantly (p< 0.0001) by 28.9 points at six weeks and 41.7 points at one year postoperative (Figure 1), with 53.4% of patients scoring Excellent or Good at six weeks and 87.5% at one year (Figure 2). Pain and physical functioning reported by the SF-12, EQ-5D and LEAS showed further clinical improvements at one year (Figure 1). Radiographically, 9.5% of cases reviewed displayed ‘radiolucent lines’ of less than 2mm in all three acetabular zones at six weeks. These cases only displayed radiolucent lines in one zone at the one year timepoint (Figure 3). Patients with radiolucent lines reported an average HHS score of 77 and 96 at six weeks and one year, respectively, with no radiographic failures or any revisions to date. The radiographic parameters and techniques were collected to analyze differences between the imaging techniques between institutions. Institutions utilizing digital radiography with an automatic exposure control technique, had cases where ‘radiolucent lines’ were present. One institution utilizing computed radiography with a manual technique did not have any cases display ‘radiolucent lines’. 4) DISCUSSION and CONCLUSION. Despite the appearance of transient radiographic lucent lines, patients in this study have shown positive clinical outcomes and initial stability through one year postoperative. These results do not correlate with the presence of radiolucent lines. Additionally, there may be a correlation between the imaging techniques and the presence of ‘radiolucent lines.’ As this device is still widely implanted using the same surgical technique, longer follow-up is needed to confirm a true biologic fixation and survivorship of the shell

The aim of an anterior cruciate ligament (ACL) reconstruction is to regain functional stability of the knee following ACL injury, ideally allowing patients to return to their pre-injury level of activity. The purpose of this study was to assess clinical, functional and patient-centered outcomes a minimum of 1-year following ACL reconstruction. This study assessed for relationships between post-operative ACL graft laxity, functional testing performance, and scores on the ACL Quality of Life (ACL-QOL) questionnaire. A prospective cohort study design (n = 1938) was used to gather data on clinical laxity, functional performance and quality of life outcomes. Post-operative ACL laxity assessment using the Lachman and Pivot-shift tests was completed independently on each patient by a physiotherapist and an orthopaedic surgeon at a minimum of 12-months post-operatively. A battery of functional tests was performed including single leg balance, single leg landing, 4 single-leg hop tests, and tuck jumps. The hop tests provided a comparative assessment of limb-to-limb function including a single hop for distance, a 6m timed hop, a triple hop for distance, and a triple crossover hop. Patients com¬pleted the ACL-QOL at the 12-month and 24-month post-operative appointments. Descriptive and demographic data were collected for all patients. The degree and frequency of post-operative laxity was calculated. A Pearson r correlation coefficient was employed to determine the relationship between the presence of post-operative laxity and the ACL-QOL scores, between the battery of functional tests and the ACL-QOL scores, as well as between the functional tests and the laxity assessments. Data was gathered for 1512/1938 patients (78%). At clinical assessment a minimum of 1-year post-operatively, 13.2% of patients demonstrated a positive Lachman and/or Pivot-shift test. The mean ACL-QOL score for patients with no ACL laxity was 80.8/100, for patients with a positive Lachman or Pivot-shift test the mean score was 72.3/100, and for patients with both positive Lachman and Pivot-shift tests the score was 66.9/100. Pearson r correlation coefficient demonstrated a significant relationship between the presence of ACL graft laxity and ACL-QOL score (p < 0.05). Statistically significant correlations were evident between all of the operative limb single-leg hop tests and the post-operative ACL-QOL scores (p < 0.05). Statistically significant correlations were evident between the operative limb triple-hop tests and presence of ACL graft laxity (p < 0.05). Patients with clinically measurable ACL graft laxity demonstrate lower ACL-QOL scores as well as lower performance on a battery of functional tests. The disease-specific outcome measure was strongly correlated to the patient's ability to perform single-limb functional tests, indicating that the ACL-QOL score accurately predicted level of function

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared the modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In two studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a matched cohort of monoblock cobalt chromium stems. As mentioned one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post-revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction more recently, at our institution we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done through an endofemoral approach. In this the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this system more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution, we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases