Orthopaedic joint replacement surgery requires surgical assistants holding retractors in order to adequately visualise the operative field. Typically, total hip and knee replacement operations require at least one surgical assistant and preferably two. As such, tremendous resources are consumed in order to perform elective TJA.

A mechanised pulley system, called the Gripper (Medenvision, Belgium), has been devised to assist with this need for extra “hands” to hold retractors. The Gripper is a table mounted, disposable device used to hold retractors, and is infinitely adjustable with regard to position in space. As such, it can be used in a variety of situations to provide an additional retractor holder, without the need for extra manpower. It is sterile, in the operative field, and can fit retractors with a flat handle. With positioning of the table mounts before prepping and draping, the Gripper can be used during the operation to hold retractors that would otherwise require a surgical assistant. The Gripper can be moved around during different portions of the operation in order to make the most of it use.

In our experience, the Gripper has been most useful in direct anterior approach THA, holding a curved anterior retractor to facilitate acetabular exposure. It is also useful in holding a retractor placed over the tip of the greater trochanter during femoral preparation. In our estimation, it is able to replace a human surgical assistant at a fraction of the cost. Furthermore, the Gripper does not fatigue during the operation and does not compromise the surgical field by needing to adjust its handhold. Because of this, even in an academic center with residents, fellows, and visiting medical students, the Gripper is preferable to human hands holding retractors.

We estimate that a surgical assistant with a starting level salary would have to scrub in on over 300 cases per year in order to make him/herself more cost effective than the Gripper.

This technique is a novel superior based muscle sparing approach. Acetabular reaming in all hip approaches requires femoral retraction. This technique is performed through a hole in the lateral femoral cortex without the need to retract the femur. A 5 mm hole is drilled in the lateral femur using a jig attached to the broach handle, similar to a femoral nail. Specialised instruments have been developed, including a broach with a hole going through it at the angle of the neck of the prosthesis, to allow the rotation of the reaming rod whilst protecting the femur. A special C-arm is used to push on the reaming basket. The angle of the acetabulum is directly related to the position of the broach inside the femoral canal and the position of the leg. A specialised instrument allows changing of offset and length without dislocating the hip during trialling. Some instrumentation has been used in surgery but ongoing cadaver work is being performed for proof of concept. The ability to ream through the femur has been proven during surgery. The potential risk to the bone has been assessed using finite analysis as minimal. The stress levels for any diameter maintained within a safety factor >4 compared to the ultimate tensile strength of cortical bone. The described technique allows for transfemoral acetabular reaming without retraction of the femur. It is minimally invasive and simple, requiring minimal assistance. We are incorporating use with a universal robot system as well as developing an electromagnetic navigation system. Assessment of the accuracy of these significantly cheaper systems is ongoing but promising. This approach is as minimally invasive as is possible, safe, requires minimal assistance and has a number of other potential advantages with addition of other new navigation and simple robotic attachments

As the intervertebral disc is largely avascular, needle injection is the most practical method for delivery of therapeutic agents used in treatments for degenerative disc disease. Intradiscal pressure increases during injection, and insufficient recovery time prior to needle retraction may result in injectate leakage. In order to determine the maximum pressure and post-injection recovery time for a given injection volume and rate, an analytical model of intradiscal injection was developed and calibrated experimentally. A governing equation was derived defining intradiscal pressure as a function of effective permeability, initial elastic stiffness, nonlinear stiffness term, and injection rate. The equation was solved using a fourth order Runge-Kutta routine with a 0.05s time step and a ramp-dwell injection. The model was calibrated by performing controlled intradiscal injections on five bovine caudal intervertebral discs. Three had adjacent vertebrae intact, while two were separated from vertebrae and constrained between porous stainless steel platens. A syringe driven by a linear actuator was used to inject phosphate buffered saline through a 21g hypodermic needle inserted radially into the disc to a depth of one half of the disc diameter. Injection was performed at a rate of 75μL/s to a volume of 250μL followed by a 240s dwell. Fluid pressure was recorded during both the injection phase and subsequent recovery phase. For each experimental pressure vs time trace, model parameters were varied in order to obtain an optimal fit. The model was run with the average parameter values across a grid of possible injection protocols, with injection volume ranging from 30 to 300μL and injection time ranging from 0.1 to 5s. For each case, peak pressure and time required to reach a 1kPa threshold were recorded. Experimentally measured peak pressure ranged from 68 to 88kPa. Pressure at the end of the 240s dwell ranged from 49 to 69kPa. There was no apparent difference between discs with and without endplates. Leakage of fluid following needle retraction was observed in all specimens. Experimental data were well fit by the analytical model, which predicted higher peak pressure and longer recovery time with increasing volume, from approximately 1500s at 30μL to nearly 3000s at 300μL. The model was nearly insensitive to injection rate. The experimental data confirm pressurization of the disc during injection and injectate leakage resulting from insufficient recovery time. The model predicts that the time required to recover to below threshold leakage pressure is impractically long for both laboratory and clinical injection protocols. Similar behavior with and without endplates confirms that fluid flow is limited by permeability of the tissue itself, not the boundary conditions. Slow recovery is likely attributable to the fact that peak injection pressures were lower than the hydraulic swelling pressure of the nucleus pulposus, which has been reported to be approximately 140kPa. Due to the high swelling pressure of the nucleus pulposus, it is unlikely that intradiscal injection procedures can be performed without substantial injectate leakage following needle retraction

Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and tendon transfers are used. This study presents clinical and radiological outcomes of muscle advancement technique for repair of mRCT. Sixty-one patients (mean age 57±6, 77% males and 23% females) (66 shoulders) underwent all-arthroscopic rotator cuff repair that included supraspinatus and infraspinatus subperiosteal dissection off scapular bony fossae, lateral advancement of tendon laminae, and tension-free double-layer Lasso Loop repair to footprint. Pre-and post-operative range of motion (ROM), cuff strength, VAS, Constant, ASES, and UCLA scores were assessed. Radiologic assessment included modified Patte and Goutallier classifications. All patients had MRI at 6 months to evaluate healing and integrity of repair was assessed using Sugaya classification with Sugaya 4 and 5 considered retears. Advanced fatty degeneration (Goutallier 3-4) was present in 44% and 20% of supraspinatus and infraspinatus. Tendon retraction was to the level of or medial to glenoid in 22%, and just lateral in 66%. 50.8% mRCT extended to teres minor. Subscapularis was partially torn (Lafosse 1-3) in 46% and completely torn (Lafosse 4-5) in 20%. At mean follow-up (52.4 weeks), a significant increase in ROM, Relative Cuff Strength (from 57% to 90% compared to contralateral side), VAS (from 4 ±2.5 to 1±1.7), Constant (50±17.8 to 74 ±13.0), ASES (52 ±17.5 to 87 ±14.9), and UCLA (16± 4.9 to 30 ±4.9) scores were noted. There were six retears (10%), one failure due to P. acnes infection. 93% returned to pre-injury work and 89% of cases returned to pre-injury sport. Satisfaction rate was 96%. Muscle advancement technique for mRCT is a viable option with low retear rates, restoration of ROM, strength, and excellent functional outcomes

Analyzing shoulder kinematics is challenging as the shoulder is comprised of a complex group of multiple highly mobile joints. Unlike at the elbow or knee which has a primary flexion/extension axis, both primary shoulder joints (glenohumeral and scapulothoracic) have a large range of motion (ROM) in all three directions. As such, there are six degrees of freedom (DoF) in the shoulder joints (three translations and three rotations), and all these parameters need to be defined to fully describe shoulder motion. Despite the importance of glenohumeral and scapulothoracic coordination, it's the glenohumeral joint that is most studied in the shoulder. Additionally, the limited research on the scapulothoracic primarily focuses on planar motion such as abduction or flexion. However, more complex motions, such as internally rotating to the back, are rarely studied despite the importance for activities of daily living. A technique for analyzing shoulder kinematics which uses 4DCT has been developed and validated and will be used to conduct analysis. The objective of this study is to characterize glenohumeral and scapulothoracic motion during active internal rotation to the back, in a healthy young population, using a novel 4DCT approach. Eight male participants over 18 with a healthy shoulder ROM were recruited. For the dynamic scan, participants performed internal rotation to the back. For this motion, the hand starts on the abdomen and is moved around the torso up the back as far as possible, unconstrained to examine variability in motion pathway. Bone models were made from the dynamic scans and registered to neutral models, from a static scan, to calculate six DoF kinematics. The resultant kinematic pathways measured over the entire motion were used to calculate the ROM for each DoF. Results indicate that anterior tilting is the most important DoF of the scapula, the participants all followed similar paths with low variation. Conversely, it appears that protraction/retraction of the scapula is not as important for internally rotating to the back; not only was the ROM the lowest, but the pathways had the highest variation between participants. Regarding glenohumeral motion, internal rotation was by far the DoF with the highest ROM, but there was also high variation in the pathways. Summation of ROM values revealed an average glenohumeral to scapulothoracic ratio of 1.8:1, closely matching the common 2:1 ratio other studies have measured during abduction. Due to the unconstrained nature of the motion, the complex relationship between the glenohumeral and scapulothoracic joints leads to high variation in kinematic pathways. The shoulder has redundant degrees of freedom, the same end position can result from different joint angles and positions. Therefore, some individuals might rely more on scapular motion while others might utilize primarily humeral motion to achieve a specific movement. More analysis needs to be done to identify if any direct correlations can be drawn between scapulothoracic and glenohumeral DoF. Analyzing the kinematics of the glenohumeral and scapulothoracic joint throughout motion will further improve understanding of shoulder mechanics and future work plans to examine differences with age

Background. Surgical site infection following spine surgery is associated with increased morbidity, mortality and increased cost for the health care system. The reported pooled incidence is 3%. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and often involve the lumbar spine. Accordingly, the objective was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column of the same lumbar vertebra using microdialysis in an experimental porcine model. Method. The lumbar vertebral column was exposed in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously over 10 min. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. Microdialysis is a catheter-based pharmacokinetic tool, that allows dynamic sampling of unbound and pharmacologic active fraction of drugs e.g., cefuroxime. The primary endpoint was the time with cefuroxime above the clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL as this has been suggested as the best predictor of efficacy for cefuroxime. The secondary endpoint was tissue penetration (AUC. tissue. /AUC. plasma. ). Results. Mean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105–141) in plasma, 97 min (79–115) in the anterior column and 93 min (75–111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40–0.56) and posterior column 0.40 (0.33–0.48). Conclusions. Open lumbar spine surgery often involves extensive soft tissue dissection, stripping and retraction of the paraspinal muscles which may impair the local blood flow exposing the lumbar vertebra to postoperative infections. A single intravenous administration of 1.5 g cefuroxime resulted in comparable T>MIC between the anterior and posterior column of the lumbar spine. Mean cefuroxime concentrations decreased below the clinical breakpoint MIC for S. aureus of 4 µg/mL after 123 min (plasma), 97 min (anterior column) and 93 min (posterior column). This is shorter than the duration of most lumbar spine surgeries, and therefore alternative dosing regimens should be considered in posterior open lumbar spine surgeries lasting more than 1.5 hours

Introduction. Patellar mobilisation methods used during total knee arthroplasty (TKA) have been debated in the literature, with some proponents of minimally invasive TKA suggesting that laterally retracting, rather than everting the patella may be beneficial. It was our hypothesis that by using randomised, prospective, blinded study methods, there would be no significant difference in clinical outcome measures based solely on eversion of the patella during total knee arthroplasty. Methods. After an a priori power analysis was done, 120 primary total knee replacements indicated for degenerative joint disease were included in the study and randomised to one of two patella exposure techniques: lateral retraction or eversion. Short-term outcomes were evaluated during hospitalisation and included time to return of straight leg raise (SLR), ambulation distance, and length of hospital stay. Long-term outcome values were evaluated pre-operatively, at 6 weeks, 3 months, and 1 year post-operatively, and included leg extension strength measured by dynamometer, knee range of motion (ROM), Visual Analog Scale (VAS) pain before and after knee motion, circumferential thigh measurements, and SF-36 Physical and Mental Component Scores (PCS, MCS). All collaborating investigators were blinded to each other's data. Surgical techniques and perioperative arthroplasty management protocols were those routinely and currently used during total knee replacement surgery at our institution. Results. 1 year follow-up data was available for 88.3% of patients. Mixed model analysis of variance showed no statistically significant differences between the two groups with respect to short or long term outcome measures. Ambulation distance improved dramatically from 24 (28±46 ft) to 48 hours (71±64; p<0.001) but was not different between groups (p=0.79). 24 of 51 retraction patients could straight leg raise within the first 24 hours versus 24 of 46 in the eversion group (p=0.69). At 48 hours, 23 of 48 and 31 of 53 respectively could SLR, (p=0.55). Improvements in VAS pain at rest were similar between groups (p=0.18–0.89), as were improvements in VAS pain after ROM (p=0.21–0.57). At 1 year postoperatively, quadriceps strength was not different between groups (p>0.5), and ROM improved by 6±18° from pre-operative values (p<0.001) with no statistically significant difference between groups. SF-36 PCS and MCS significantly improved for both study groups from preoperatively to 1 year postoperatively (time effect p<0.001) with similar effects between groups, and were not statistically significantly different at 1 yr after surgery (PCS: eversion 47.0±8.7, retraction 50.0±8.5, p=0.09), (MCS: eversion 53.7±9.0; retraction 53.0±10.3, p=0.69). Conclusion. With proper surgical technique and attention to detail, we believe that the standard medial parapatellar approach with anterior tibial translation can provide an excellent surgical exposure without compromising the surrounding soft tissue envelope. At times, exposure can be augmented by eversion of the patella, and in our subjective experience, this has not led to inferior post-operative results compared to lateral retraction of the patella. Results of this study give objective support for these observations

The direct lateral (or anterolateral) approaches to the hip for revision THA involve detachment of the anterior aspect of the gluteus medius from the trochanter along with a contiguous sleeve of the vastus lateralis. Anterior retraction of this flap of gluteus medius and vastus lateralis and simultaneous posterior retraction of the femur creates an interval for division of gluteus minimus and deeper capsular tissues and exposure of the joint. To enhance reattachment of this flap of the anterior portion of the gluteus medius and vastus lateralis back to the trochanter, an oblique wafer of bone can be elevated along with the muscle off of the anterolateral portion of the trochanter. This bony wafer prevents suture pull out when large nonabsorbable sutures are used around or through the fragment and passed into the bone of the trochanteric bed for reattachment during closure. To prevent excessive splitting proximally into the gluteus medius muscle (and resulting damage to the superior gluteal nerve), it is often helpful to extend the muscle split further distally down into the vastus lateralis. This combined with careful elevation of the gluteal muscles off of the ilium (instead of splitting them) helps provide excellent and safe exposure of the entire rim of the acetabulum and access to the supracetabular region for bone grafting, acetabular augment placement and even fixation of the flanges of a cage. A simple method for posterior column plating via the anterolateral approach involves contouring of the distal end of the plate around the base of the ischium at the inferior edge of the socket. When an extended osteotomy of the femur is needed to correct deformity, remove a well-fixed implant or cement, the “extensile” variation of this same surgical approach involves a Wagner style (lateral to medial) osteotomy of the greater trochanter and proximal femur. The anterior portion of the femur after it is osteotomised is elevated as a separate segment while maintaining the soft tissue attachments to the bone as much as possible to aid osteotomy healing. After implant or cement removal, this approach gives excellent direct access to the distal femur for placement of a long stem revision femoral component without bone-implant conflict proximally because of the bow of the femur. The anterolateral approach (and extensile variants detailed above) can be used routinely and safely in the full range of revision THA procedures, or it can be employed selectively, if desired, in cases at increased risk for dislocation

Purpose. Full-thickness tendon tears of the supraspinatus (SP) are common and can have a significant impact on shoulder function. To optimally treat supraspinatus tendon tears an accurate understanding of its musculotendinous architecture is needed. We have previously shown that the architecture of supraspinatus is complex. It has architecturally distinct regions: anterior and posterior, each of which is further subdivided into superficial, middle and deep parts (Kim et al., 2007). Data of FBL and PA of the torn supraspinatus could enhance clinical decision making and guide rehabilitative treatments (Ward et al., 2006). Currently, however, in vivo US quantification of the fiber bundle architecture of the distinct regions of supraspinatus in subjects with full-thickness tendon tears has not been investigated. PURPOSE: To quantify architectural parameters within the distinct regions of supraspinatus in subjects with a full-thickness tendon tear using the US protocol that we previously developed (Kim et al., 2010), and to compare findings with age and gender matched normal controls. Method. Twelve SP from eight subjects, mean age 576.0 years, were scanned using an US scanner (12 MHz). The SP was scanned in relaxed and contracted states. For the contracted state, SP was scanned with the shoulder in neutral rotation and 60 of active abduction. Fiber bundles of the anterior region (middle and deep) and posterior region (deep) could be visualized and measured. Muscle thickness, FBL, and PA were computed from US scans. Data was analyzed using Mann-Whitney and Wilcoxon Signed Rank Tests (P<0.05). Results. Intra-and inter-rater measurements of FBL were strongly correlated with no significant difference between measurements (P<0.001). In the anterior region, mean FBL did not significantly differ between the pathologic subjects and normal controls. In the pathologic subjects, mean PA was smaller compared to normal controls. The difference was significant between the subjects with a tear and retraction and normal controls (P<0.05). For the posterior region, mean FBL was shorter in the pathologic subjects compared to normal controls. The difference was significant between the subjects with a tear and retraction and normal controls (P<0.05). Conclusion. Findings suggest that significant FBL and PA changes are found with full-thickness tendon tears of SP and different regions of the muscle are impacted differently. Pennation angles are largely impacted in the anterior region and FBL in the posterior. The presence of tendon retraction was found to be related to the amount of change in architectural parameters. Data from this study may be useful to model muscle-joint behavior of the pathologic shoulder. This US protocol may be beneficial to carry out a larger study to determine which comes first, architectural changes in the muscle, or tendon tearing. If we identify changes in muscle architecture predate tendon pathology, we could develop techniques to prevent tendon tearing

The first rule in properly cementing a femoral component is obtaining adequate exposure of the proximal femur. This is achieved reproducibly in anterior approach surgery with anterior and superior capsulotomy, combined with release of the conjoined tendon from the inner trochanter and piriformis tendon retraction, or flip behind the trochanter. This will be demonstrated. The steps of cementation are well established, and not specific to one approach. They involve entry to the proximal femur in a lateral and posterior position, achieving central alignment within the proximal femur with the broach, application of a cement restrictor to a point 1.5 to 2cm distal to the proposed tip of the implant, appropriate preparation of the cancellous bone to receive the cement, applying cement in a sufficiently doughy state to be able to achieve penetration into the cancellous bone, and mechanical pressurization into that cancellous bone. We routinely apply cement directly to the proximal aspect of the femoral component as the cement sticks to the metal, preventing marrow contents generated during the insertion from contacting the metal. In discussing the factors contributing to a dry surgical field, the importance of relative hypotension achieved from regional anesthesia cannot be overstated

We perform the direct approach using a standard radiolucent operative table with extender at the foot, and the assistance of fluoroscopy. The patient is positioned supine with the pubic symphysis aligned at the table break. The anterior superior iliac spine (ASIS) and center of the knee are marked, and a line drawn between. The incision commences proximally from two finger breadths distal and two finger breadths lateral to the ASIS, and extends distally 8–10 cm. Using fluoroscopy, the anterior aspect femoral neck is located. The incision is placed over the lateral aspect of the greater trochanter, which avoids the lateral femoral cutaneous nerve. The tensor fascia lata is identified, which has a distinctive purple hue, and dissected free from the intermuscular septum lateral to the sartorius and the rectus muscles. The deep, investing aponeurosis of the tensor fascia lata is split using a tonsil. Just below lie the lateral circumflex vessels, two veins and one artery, which must be either ligated or cauterised. A retractor is placed superior to the femoral neck over top of the superior hip capsule. A blunt, cobra-type retractor is then placed along the inferior femoral neck, deep to the rectus muscle and the rectus tendon. A sharp retractor is then used to peel the rectus off from the anterior capsule and placed over the anterior rim of the acetabulum. An anterior capsulectomy is performed. A saw blade is positioned for femoral neck resection and confirmed with fluoroscopy. After resection, acetabular retractors are placed, the socket is reamed, the cup is placed, and position confirmed with fluoroscopy. Turning to the femoral side, the surgeon palpates underneath and around the tensor, around the lateral aspect of the femur, proximal to the gluteus maximus tendon, and places a bone hook around the proximal femur. Femoral preparation and stem insertion require maneuvering the table and adjusting the patient position. The table is “jack-knifed” by lowering the foot of the table to approximately 45 degrees and placing the bed into approximately 15 degrees of Trendelenburg. The contralateral well leg is placed on the padded Mayo stand. A table-mounted femur elevator is attached to the bed, requiring a change in surgical gloves, and attached to the traction hook around the proximal femur. Gentle retraction is placed on the femur to tension the capsule. As the capsule is released the femur will begin to come up/out of the wound and into view. With increasing gentle retraction via the table-mounted hook, the femur is elevated. Simultaneously, the operative limb is externally rotated and adducted underneath the non-operative leg in a lazy “figure of 4” position by the assistant. The use of a “broach-only” stem design is preferred as direct straight reaming of the femur is difficult in most cases. Fluoroscopic images are obtained to confirm femoral implant positioning, offset, neck and leg length. A standardised rapid recovery hospitalization and rehabilitation protocol is used in all cases

Neurovascular injury during shoulder arthroplasty is uncommon and has been reported to occur in 1–4% of cases. The incidence of nerve abnormalities during intraoperative nerve monitoring during shoulder arthroplasty is substantially higher. However, the rate of false positives with nerve monitoring is high and the clinical significance of these intraoperative findings is unknown. Therefore, the clinical utility of intraoperative nerve monitoring is unproven. Regardless, experience with intraoperative nerve monitoring has allowed us to identify the times during the procedure when measurable nerve dysfunction is most common. Moreover, experience as well as familiarity with reported patient and anatomic risk factors may help reduce the incidence of neurovascular injury. Five rules that will likely help to reduce intraoperative nerve injuries include recognition of reported patient risk factors, knowledge of relevant anatomy and normal anatomic variations, intraoperative identification and protection of at-risk neurovascular structures, limitation of overall operative time and the amount of time with the arm in at-risk positions, and minimization of retraction force. It is likely not possible to completely avoid neurovascular injuries during TSA. However, by following these five rules, the risk of neurovascular injury can be minimised

General Principles. All repairs should be repaired in full extension. Repairs should be immobilised in full extension for 6–12 weeks. Gradual resumption of motion in a hinged brace over an additional 6–8 weeks almost always yields flexion to at least 90 degrees. Marlex mesh has been shown to be an excellent replacement as well as an augment for deficient soft tissue. Acute tibial tuberosity avulsion. Open repair is best accomplished with a non-absorbable heavy Krackow suture, secured distally around a screw and washer followed by 6 to 8 weeks of immobilization. Augmentation with a semitendinosus graft or Marlex mesh can provide additional support. Acute Patella Tendon Rupture. End-to-end repair is standard, but re-rupture is not uncommon, so supplemental semitendinosus reconstruction is recommended. The tendon is harvested proximally, left attached distally and passed through a transverse hole in the inferior patella. The gracilis tendon can be harvested and sutured to semitendinosus for additional length, if needed. Acute Quadriceps Tendon Rupture. These can be repaired end-to-end with a non-absorbable heavy Krackow suture. A superficial quadriceps fascial turndown or mesh may be a useful adjunct. Patella Fracture. Treatment depends on the status of the patellar component and the loss of active extension. If the component remains well fixed and the patient has less than a 20-degree lag, non-operative treatment in extension. A loose component and/or > 20-degree extensor lag requires ORIF +/− component revision. Chronic Disruptions. While standard repair techniques are possible, tissue retraction usually prevents a “tension-free” repair. If the patella remains viable and has not retracted proximally an Achilles tendon graft is appropriate. In chronic disruptions with loss of the patella, allograft extensor mechanism reconstruction may be considered. Marlex mesh repair has also been shown to be effective in reconstruction of chronic patellar and quadriceps tendon defects

General Principles: All repairs should be repaired in full extension. Repairs should be immobilised in full extension for 6–12 weeks. Gradual resumption of motion in a hinged brace over an additional 6–8 weeks almost always yields flexion to at least 90 degrees. Marlex Mesh has been shown to be an excellent replacement as well as an augment for deficient soft tissue. Acute tibial tuberosity avulsion: Open repair is best accomplished with a non-absorbable heavy Krackow suture, secured distally around a screw and washer followed by 6 to 8 weeks of immobilization. Augmentation with a semitendinosus graft or Marlex can provide additional support. Acute Patella Tendon Rupture: End-to-end repair is standard, but re-rupture is not uncommon, so supplemental semitendinosus reconstruction is recommended. The tendon is harvested proximally, left attached distally and passed through a transverse hole in the inferior patella. The gracilis tendon can be harvested and sutured to semitendinosus for additional length, if needed. Acute Quadriceps Tendon Rupture: These can be repaired end-to-end with a non-absorbable heavy Krackow suture. A superficial quadriceps fascial turndown or mesh may be a useful adjunct. Patella Fracture: Treatment depends on the status of the patellar component and the loss of active extension. If the component remains well fixed and the patient has less than a 20-degree lag, non-operative treatment in extension. A loose component and/or > 20-degree extensor lag requires ORIF +/− component revision. Chronic Disruptions: While standard repair techniques are possible, tissue retraction usually prevents a “tension-free” repair. If the patella remains viable and has not retracted proximally an Achilles tendon graft is appropriate. In chronic disruptions with loss of the patella, allograft extensor mechanism reconstruction may be considered. Marlex mesh repair has also been shown to be effective in reconstruction of chronic patellar and quadriceps tendon defects

General Principles - All repairs should be repaired in full extension. Repairs should be immobilised in full extension for 6–12 weeks. Gradual resumption of motion in a hinged brace over an additional 6–8 weeks almost always yields flexion to at least 90 degrees. Marlex Mesh has been shown to be an excellent replacement as well as an augment for deficient soft tissue. Acute Tibial Tuberosity Avulsion - Open repair is best accomplished with a non-absorbable heavy Krackow suture, secured distally around a screw and washer followed by 6 to 8 weeks of immobilisation. Augmentation with a semitendinosus graft or Marlex can provide additional support. Acute Patella Tendon Rupture - End-to-end repair is standard, but re-rupture is not uncommon, so supplemental semitendinosus reconstruction is recommended. The tendon is harvested proximally, left attached distally and passed through a transverse hole in the inferior patella. The gracilis tendon can be harvested and sutured to semitendinosus for additional length, if needed. Acute Quadriceps Tendon Rupture - These can be repaired end to end with a non-absorbable heavy Krackow suture. A superficial quadriceps fascial turndown or mesh may be a useful adjunct. Patella Fracture - Treatment depends on the status of the patellar component and the loss of active extension. If the component remains well fixed and the patient has less than a 20-degree lag. A loose component and/or >20-degree extensor lag requires ORIF +/− component revision. Chronic Disruptions - While standard repair techniques are possible, tissue retraction usually prevent a “tension-free” repair. If the patella remains viable and has not retracted proximally an Achilles tendon graft is appropriate while in any patellar tendon defect, mesh repair has been shown to be effective. In most chronic disruptions with loss of the patella allograft extensor mechanism reconstruction may be considered

Aim. Treatment regimens for fracture-related infection (FRI) often refer to the classification of Willenegger and Roth, which stratifies FRIs based on time of onset of symptoms. The classification includes early (<2 weeks), delayed (2–10 weeks) and late (>10 weeks) infections. Early infections are generally treated with debridement and systemic antibiotics but may not require implant removal. Delayed and late infections, in contrast, are believed to have a mature biofilm on the implant, and therefore, treatment often involves implant removal. This distinction between early and delayed infections has never been established in a controlled clinical or preclinical study. This study tested the hypothesis that early and delayed FRIs respond differently to treatment comprising implant retention. Method. A complete humeral osteotomy in 16 rabbits was fixed with a 7-hole-LCP and inoculated with Staphylococcus aureus. The inoculum size (2×106 colony forming units per inoculum) was previously tested without antibiotic intervention to result in infection of all animals persisting for at least 12 weeks.4 The infection was allowed to develop for either 1 (early group) or 4 (delayed group) weeks (n= 8 per group) after bacterial inoculation. At these time points, treatment involved debridement and irrigation of the wound (no implant removal) and quantitative bacteriological evaluation of the removed materials. Systemic antibiotics were administered according to a common clinical regimen (2 weeks: rifampin + nafcillin, followed by 4 weeks: rifampin + levofloxacin). After an additional one-week antibiotic washout period, animals were euthanized and a quantitative bacteriology of soft tissue, implant (after sonication) and bone was performed. Results. Greater numbers of bacteria were recovered by debridement and irrigation in the early group compared with the delayed group, which may indicate retraction of the infection in the delayed stage. Treatment was successful in both the early and delayed group: all animals in both groups were infection free at euthanasia. Furthermore, all osteotomies had healed, although animals in the delayed group displayed irregular callus formation. Conclusions. In both groups, treatment successfully eradicated the infection, suggesting that, at least in this model, the maturity of the infection does not impact upon treatment success within the first four weeks. Acknowledgements. This work was funded by AOTrauma

General Principles. All repairs should be repaired in full extension. Repairs should be immobilised in full extension for 6–12 weeks. Gradual resumption of motion in a hinged brace over an additional 6–8 weeks almost always yields flexion to at least 90 degrees. Marlex Mesh has been shown to be an excellent replacement as well as an augment for deficient soft tissue. Acute tibial tuberosity avulsion. Open repair is best accomplished with a non-absorbable heavy Krackow suture, secured distally around a screw and washer followed by 6–8 weeks of immobilization. Augmentation with a semitendinosus graft or Marlex can provide additional support. Acute Patella Tendon Rupture. End to end repair is standard, but re-rupture is not uncommon, so supplemental semitendinosus reconstruction is recommended. The tendon is harvested proximally, left attached distally and passed through a transverse hole in the inferior patella. The gracilis tendon can be harvested and sutured to semitendinosus for additional length, if needed. Acute Quadriceps Tendon Rupture. These can be repaired end to end with a non-absorbable heavy Krackow suture. A superficial quadriceps fascial turndown or mesh may be a useful adjunct. Patella Fracture. Treatment depends on the status of the patellar component and the loss of active extension. If the component remains well fixed and the patient has less than a 20-degree lag. A loose component and/or >20-degree extensor lag requires ORIF +/− component revision. Chronic Disruptions. While standard repair techniques are possible, tissue retraction usually prevents a “tension-free” repair. In most chronic disruptions allograft extensor mechanism reconstruction is preferable. If the patella remains viable and has not retracted proximally, an Achilles tendon graft is appropriate while in any patellar tendon defect, mesh repair has been shown to be effective

Introduction. Few studies are published about total hip arthroplasties (THA) in Parkinson's disease as it is often considered as a contraindication for hip replacement. THA for fracture is reported as a high complication rate surgery. Regarding bone quality these cases are assimilated to elderly patients and cemented implants are generally preferred. However, due to the improved length and quality of life, we face more potential indications for joint replacement. The aim of this study is to report our experience of cementless dual mobility implants for primary THAs for osteoarthrosis and THA revisions focusing on the risks and benefits of surgery. Material and methods. 65 THA were performed in 59 patients (34 men, 25 women, mean age 73 years, 55–79). Mean latest follow-up was 8,3 years (4–14). Indications were 42 primary THA (osteoarthrosis) and 21 revisions (11 recurrent dislocation, 6 acetabular PE wear, 4 femoral loosening). Surgical approach was always antero-lateral. All patients were implanted with the same dual mobility cementless cup. The same cementless corail-type stem was used for primary THA cases. All the cemenless implants were hydroxyapatite coated. The disability caused by the disease was classified according to Hoehn and Yahr. (19 stage 1, 21 stage 2,16 stage 3). Results. 2 patients were lost for follow-up before 2 years. general complications were 3 pulmonary infection, 7 urinary tract infection, 12 cognitive impairment and 2 sacral pressure ulcer. A post-op. wound infection (E Coli) required an early revision in 2 cases without secondary consequencies (7 and 9 years follow-up). We did not observe early or late THA dislocation except in one case at 9 years follow-up (intraprosthetic dislocation due to an increase of ilio psoas muscle retraction requiring a revision of the dual mobility mechanism). We did not observe loosening cases of the cementless cup. 4 patients fell and fractured the femur. The cementless cup was not affected. 10 patients died. Good to excellent pain relief was achieved in 53/57cases at 2 years and in 40/47 cases at latest follow-up. The progression of neurological disability was observed in most of cases. At the latest follow-up for the 47 remaining patients, we had 5 stage 1, 12 stage 2, 21 stage 3,9 stage 4. Discussion. According to literature infection and dislocation are the main concerns for THA in Parkinson patients. This study does not report any trauma cases; this may explain the rather good results on a mean follow-up to more than 8 years. Nevertheless progression of Parkinson's disease is the rule, with significant disability or even death (10 /57 cases). Cementless fixation is possible even on the acetabular side. The poor bone quality of these patients was not an argument against hydroxyapatite coated implants. Conclusion. THA in Parkinson's disease is a challenging surgery due to associated comorbidity. For all patients the functional status improved in the early follow-up and declined with the disease progression. Cementless dual mobility cups and femoral stems can be used with a very low rate of mechanical complication

Background. Long term success of any shoulder joint reconstruction procedure involving subscapularis attachment take down is dictated by the way one chooses to release and repair/reconstruct the subscapularis insertion. There are several methods that were reported in the literature without any preset guidelines which are easily reproducible. Methods. 5 specimens of fresh cadaver shoulder joints dissected and the subscapularis footprint insertion involving the tendon and muscle exposed. We intend to preserve subscapularis tendon footprint along with the lesser tuberosity by performing the footprint osteotomy fashioned step wise in the following manner. Results. It has two vertical components (sagittal and coronal plane osteotomies) and one horizontal component (distal osteotomy at musculo tendinous junction level). Figure 1: demonstrating the three step cuts in the dry bone of proximal humerus with three different ostetomes to mark the plain of osteotomies in the lesser tuberosity. Step-1: Medial wall ridge of the inter-tubercular sulcus serves as landmark for sagittal component. The depth of sagittal component is just 5 – 10mm and its length extending from articular margin proximally and distally up to musculo tendinous junction, measuring approximately 15–20mm. Step-2: Coronal plane osteotomy is in line with and parallel to undersurface of subscapularis tendon adjacent to the articular margin and connecting sagittal component and measured 10–15mm approximately. Figure 2: demonstrating the two cuts / osteotomies to mark the sagittal and coronal components of the subscapularis foot print osteotomy in the lesser tuberosity of a fresh cadaver. Step-3: The horizontal component (distal osteotomy at musculo tendinous junction level is 5–10 mm in width, connects the two vertical components, thus completing the footprint osteotomy. Discussion. Subscapularis reattachment plays a pivotal role in the shoulder joint reconstruction procedures especially total joint arthroplasty. Subscapularis take down either by tenotomy or by periosteal elevation from lesser tuberosity followed by repair carries a risk of retraction and poor healing and early failure. Footprint osteotomy as a thin sliver of cortical bone instead of these above described three steps with the attached tendon carries a risk of fragmentation of the bone sliver along with lack of rotation control on the repair. The necessity for doing such a three step osteotomy procedure which results in a wedge shaped bone tendon foot print construct, we believe is of paramount importance for a successful reconstruction. Figure 3: demonstrating the marking sutures passed into the bone tendon construct comprising of lesser tuberosity and subscapularis for effective foot print reconstruction in a fresh cadaver. Conclusions. This three step footprint osteotomy of the Subscapularis tendon offers a stable construct which is easy to reproduce with better healing potential. For figures, please contact authors directly

To report our experience with the use of local antibiotic co-delivery with a synthetic bone graft substitute during a second stage re-implantation of an infected proximal humeral replacement. A 72 year old man was admitted to our department with a pathological fracture through an osteolytic lesion in the left proximal humerus, due to IgG Myelomatosis. He was initially treated with a cemented proximal humerus replacement hemiarthroplasty. Peri-prosthetic joint infection (PJI) with significant joint distention was evident three weeks post operatively. Revision surgery confirmed presence of a large collection of pus and revealed disruption of the soft tissue reattachment tube, as well as complete retraction of rotator cuff and residual capsule. All modular components were removed and an antibiotic-laden cement spacer (1.8g of Clindamycin and Gentamycin, respectively) was implanted onto the well-fixed cemented humeral stem. Initial treatment with i.v. Amoxicillin/Clavulanic acid was changed to Rifampicin and Fusidic Acid during a further 8 weeks after cultures revealed growth of S. epidermidis. During second stage revision, a hybrid inverse prosthesis with silver coating was implanted, with a total of 20 ml Cerament ™G (injected into the glenoid cavity prior to insertion of the base plate and around the humeral implant-bone interface) and again stabilized with a Trevira tube. Unfortunately, this prosthesis remained unstable, ultimately requiring re-revision to a completely new constrained reverse prosthesis with a custom glenoid shell and silver-coated proximal humeral component. 18 months postoperatively, the patient's shoulder remains pain free and stable, without signs of persistent or reinfection since the initial second stage revision. The function however, unfortunately remains poor. This case report illustrates the application of an antibiotic-eluting bone graft substitute in a specific clinical situation, where co-delivery of an antibiotic together with a bone remodeling agent may be beneficial to simultaneously address PJI as well as poor residual bone quality