We report the medium term outcome of a 15 degrees face-changing acetabular cup in THA due to secondary OA in DDH.

We analysed 28 Hips in 26 patients who underwent THA between May 2007and September 2009. There were 20 females and 6 males with a mean age of 52 yrs (range 33–68yrs).

All patients received a cementless Exceed Advanced Bearing Technology 15° Face-changing cup (Biomet) with a ceramic liner through a posterior approach. A cementless or a cemented femoral stem, with 28 or 32mm Biolox Delta ceramic head, was used in all cases. All patients started full weight-bearing the next day. The average clinical and radiological follow-up was for 50 months (range 36–76 months). The mean Harris Hip Score improved to 94 and the Oxford Hip Score improved to 44. There was 100% survivorship of the hip joint for both components.

Post-operative radiographs revealed integration of the cup with no signs of loosening or osteolysis. The mean covered acetabular lip inclination angle was 51 degrees (range 43–61)and the true inclination angle of the bearing was 36 degrees (range 28–46).

The clinical results support the use of the cementless 15 degrees face-changing acetabular cup in the dysplastic acetabulum.

Psoas tendinopathy is a potential cause of groin pain after primary total hip arthroplasty (THA). The direct anterior approach (DAA) is becoming increasingly popular as the standard approach for primary THA due to being a muscle preserving technique. It is unclear what the prevalence is for the development of psoas-related pain after DAA THA, how this can influence patient reported outcome, and which risk factors can be identified. This retrospective case control study of prospectively recorded data evaluated 1784 patients who underwent 2087 primary DAA THA procedures between January 2017 and September 2019. Psoas tendinopathy was defined as (1) persistence of groin pain after DAA THA and was triggered by active hip flexion, (2) exclusion of other causes such as dislocation, infection, implant loosening or (occult) fractures, and (3) a positive response to an image-guided injection with xylocaine and steroid into the psoas tendon sheath. Complication-, re-operation rates, and patient-reported outcome measures (PROMs) were measured. Forty-three patients (45 hips; 2.2%) were diagnosed with psoas tendinopathy according to the above-described criteria. The mean age of patients who developed psoas tendinopathy was 50.8±11.7 years, which was significantly lower than the mean age of patients without psoas pain (62.4±12.7y; p<0.001). Patients with primary hip osteoarthritis were significantly less likely to develop psoas tendinopathy (14/1207; 1.2%) in comparison to patients with secondary hip osteoarthritis to dysplasia (18/501; 3.6%) (p<0.001) or FAI (12/305; 3.9%) (p<0.001). Patients with psoas tendinopathy had significantly lower PROM scores at 6 weeks and 1 year follow-up. Psoas tendinopathy was present in 2.2% after DAA THA. Younger age and secondary osteoarthritis due to dysplasia or FAI were risk factors for the development of psoas tendinopathy. Post-operatively, patients with psoas tendinopathy often also presented with low back pain and lateral trochanteric pain. Psoas tendinopathy had an important influence on the evolution of PROM scores

Protrusio acetabuli (arthrokatadysis or Otto pelvis) is a relatively rare condition associated with secondary osteoarthritis of the hip. Radiographically, protrusio acetabuli is present when the medial aspect of the femoral head projects medial to Kohler's (ilioischial) line. This results in medialization of the center of rotation (COR) of the hip. Protrusio acetabuli is typically associated with metabolic bone disease (osteoporosis, osteomalacia, Paget's disease) or inflammatory arthritis (RA or ankylosing spondylitis). Idiopathic acetabular protrusio can occur without the above associated factors however. Patients with protrusio acetabuli typically present with significant restriction of range of motion (ROM) of the hip due to femoral neck and trochanteric impingement in the deep acetabular socket and pain associated with secondary osteoarthritis (OA). Total hip arthroplasty (THA) in patients with protrusion acetabuli is more challenging than THA in patients with a normal hip COR. ROM is typically quite restricted which can compromise surgical exposure. Dislocation of the hip in the patient with a deep socket and medialised COR can be extremely difficult and associated with fracture of the femur if not carefully performed. Restoration of the hip COR to the normal more lateralised position is a principle goal of surgery. This restores more normal mechanics of the hip and has been associated with improved durability. A variety of techniques to accomplish this have been described including medial acetabular bone grafting with cemented cups, protrusio rings or porous coated cementless cups fixed with multiple screws. The latter technique has been shown to be more durable and associated with better outcomes. THA in protrusio acetabuli starts with templating of the preoperative x-rays to determine the optimal acetabular implant size and final position of the acetabular component that restores the hip COR to the normal position. Patients with protrusio acetabuli often have varus oriented femoral necks and the femur needs to be carefully templated as well to insure that an appropriate femoral component is available that will allow for restoration of the patient's anatomy. Cartilage covering the thinned medial wall needs to be carefully removed without disruption of the medial acetabular wall. The acetabulum is then carefully reamed with the goal of obtaining stable peripheral rim support of a cementless socket and at least 50% contact of the implant on good quality host bone. Unlike acetabular preparation in the normal hip, preventing the reamer from “bottoming out” is essential in order to obtain desired rim support and return of the hip COR to the normal lateralised position. When good rim support of the reamer is obtained, a trial component is placed and intraoperative x-ray obtained to confirm fit, position and restoration of hip COR. Limited addition reaming can be performed to obtain desired degree of press fit (1‐2mm) and contact with host bone. Morselised autograft from the femoral head and neck is then packed into the medial defect and reverse reamed. The cementless acetabular component is then impacted into position and fixed with screws. Weight bearing is determined by bone quality, size and containment of the medial defect, amount of contact of the cementless cup with host bone and stability of the acetabular construct. Incorporation of autograft bone in the acetabulum and stable long term fixation occurs reliably if stable initial press-fit fixation of the cementless cup is obtained. Restoration of hip COR to within 7mm of its normal location is associated with better implant survival

Developmental dysplasia of the hip (DDH) represents a heterogeneous group of deformities that are commonly associated with secondary osteoarthritis. Affected hips may require total hip arthroplasty (THA) for endstage disease and these cases can present unique challenges for the reconstructive surgeon. While the severity of deformity varies greatly, optimizing THA can be challenging even in the “mildly” dysplastic hip. These disorders are commonly characterised by acetabular deficiency with inadequate coverage of the anterolateral femoral head and proximal femoral abnormalities including excessive femoral antetorsion, coxa valga and femoral stenosis. In more severe cases, major femoral head subluxation or dislocation can add additional complexity to the procedure. In addition to the primary deformities of DDH, secondary deformities from previous acetabular or proximal femoral osteotomies may also impact the primary THA. Primary THA in the DDH hip can be optimised by detailed understanding of the bony anatomy, careful pre-operative planning, and an appropriate spectrum of techniques and implants for the given case. This presentation will review the abnormal hip morphologies encountered in the dysplastic hip and will focus on the more challenging aspects of THA. These include acetabular reconstruction of the severely deficient socket and in the setting of total dislocation, femoral implant procedures combined with corrective osteotomy or shortening, and issues related to arthroplasty in the setting of previous pelvic osteotomy. Despite the complexity of reconstruction for various dysplastic variants the clinical outcomes and survivorship of these procedures are good to excellent for most patients. Nevertheless, more complex procedures are associated with an increased complication rate and this should be considered in the surgical decision-making process

INTRODUCTION. The direct anterior approach to THR has become an increasingly popular minimally-invasive technique in an effort to minimize dislocation risk, facility early recovery, and diminish soft tissue injury. However, it has been associated with unique complications including intraoperative femur fracture, cutaneous nerve palsy, stem subsidence, and wound healing complications. These risk of these complications have been documented to be more likely in the surgeon's early experience with the approach. The minimally-invasive Supercapsular Percutaneous-Assisted (SuperPATH) technique was developed to minimize capsular and short-external rotator injury, minimize dislocation risk, and provide an easier transition from the standard posterior approach. METHODS. Fifty (50) consecutive elective total hip replacements in 48 patients were performed using the SuperPATH technique. These also represented the first fifty elective THRs the surgeon performed in practice. Indications were primary or secondary osteoarthritis (92%), avascular necrosis (6%), and impending pathologic fracture (2%). Patients were evaluated retrospectively for dislocation, major, and minor complications. RESULTS. At average follow-up of 10.9 months (Range 1–27 months), there were no dislocation events. There was one periprosthetic fracture identified at 14-day follow-up that required femoral revision surgery in an elderly female patient with osteoporosis. Otherwise, there were no reoperations for any reason. There were no wound complications or deep infections. There was one stem subsidence (2%) of 4 mm. There were no neurovascular injuries. CONCLUSION. The SuperPATH technique can likely be performed at an early experience level with low early complication risk and lower early dislocation risk. This minimally-invasive technique deserves further interest and evaluation as it may present a gentle learning-curve to surgeons

BACKGROUND. We conducted this study to determine if the pre-surgical patient specific instrumented planning based on Computed tomography scans can accurately predict each of the femoral and tibial resections. The technique helps in optimization of component positioning and hence overall alignment thereby reducing errors. This makes it less invasive, more efficient and cost effective. The surgical plan in combination with the cutting guides determine the resection thickness, component size, femoral rotation and femoral and tibial component alignment. Several clinical studies have shown that PSI is safe, accurate and reproducible in primary TKA. Accurate preparation of the femoral and tibial surfaces will determine alignment and component positioning and this in turn reflects on function and longevity. METHODS. The study was conducted prospectively between May 2016 and December 2017 in our institution. Patients admitted over a period of these twenty months were included in the study. Patients with primary or secondary osteoarthritis (OA) and inflammatory arthritis who were suitable to undergo patient-specific TKA were included in the study. Patients with conventional instrumented TKR and those with significant deformities requiring constrain including valgus or varus of greater than 20 degrees with incompetent lateral or medial collateral ligaments were excluded from the study along with revisions of partial knee to TKA using PSI blocks. Prophecy® Preoperative Navigation 3D printed Guides were used for the Evolution Medial Pivot knee replacement system (. Microport Orthopaedics (Arlington, TN 38002, USA)). in all cases. The operating surgeon measured all the resections made (4 femoral and 2 tibial) using vernier calipers intraoperatively. These measurements were then compared with the preoperative CT predicted bone resection surgical planning. The senior author (IN) also designed markings on the tibial cutting blocks to improve accurate placement on the tibia and further markings on the femoral cutting blocks to ensure accurate positioning and rotational alignment improving accuracy of the cuts and femoral rotation. Further markings by senior surgeon (IN) on the pre-operative plans included tibial rotational plans in relation to the tibial tubercle. RESULTS. A total of 3618 readings were calculated from 201 knees (105 right and 96 left). There were 112 females and 76 males, and the average age was 67.72 years (44 to 90 years) and average BMI 32.3 (25.1 to 42.3). The surgical time ranged from 46 to 102 minutes with a mean operating time of 62 minutes. All Femoral and Tibial blocks sat accurately on the bony surfaces before being pinned. 94% of all collected resection readings were below the error margin of ≤1.5 mm of which 90% showed resection error of ≤1mm. Mean error of different resections were ≤0.60 mm (P ≤ 0.0001). In 24% of measurements there were no errors or deviations from the templated resection (0.0 mm). CONCLUSION. The 3D printed cutting blocks with slots for jigs accurately predict bone resections in PSI total knee arthroplasty which would directly affect component positioning and hence longevity and function

A 51 years old female who experienced difficulty in gait ambulation due to secondary osteoarthritis of knee showed knee instability caused by paralysis associated with poliomyelitis and scoliosis. At the first medical examination, right knee range of motion was 0° to 90°, and spino malleolar distance (SMD) showed 72cm for the right leg, 78cm for the left leg, and the bilateral comparison of SMD indicated the leg length discrepancy of 6cm. The patient has a history of surgeries with an anterior – posterior instrument for the treatment of scoliosis, and with Langenskiöld method for the paralyzed right knee at the age of seventeen. The patient also experienced varus degeneration at the age of twenty seven, which was surgically treated with high tibial osteotomy. In this case, a reoperation of her right knee was performed due to the reoccurrence of the knee pain. Preoperative planning was performed using Patient-matched instrument (Signature; Biomet) which was created based on computed tomography data. Each part of osteotomy followed the resection guide by Signature, and a total knee arthroplasty was carried out using the Rotating Hinge Knee System (Zimmer, warsaw. Inc). Two week after the operation, the patient showed the ability to walk without any assistance, and has been in a good condition

Introduction. The aim of this study was to analyze the results of our series of female patients treated with <48 mm MOMHR devices at a minimum follow-up of 5 years, to understand which is the most important aspects affecting the results and to define if the metal ions dosage has to be indicated as a routinely follow-up. Methods. This is a retrospective clinical study; the cohort included 198 consecutive MOMHR implanted in 181 female patients (17 bilateral procedures). All operations were performed between 2002 and 2011. All operations were performed by the senior surgeon. Indications to MOMHR included primary or secondary osteoarthritis (OA), rheumatoid arthritis and avascular necrosis. Contraindications included poor proximal femoral bone stock (T-score<−2.5sd in BMD of the femoral neck) or severely distorted hip anatomy. All patients were advised to underwent clinical and radiological review with the operating surgeon at 5 weeks, 3, 6 and 12 months postoperatively and then every subsequent 2 years.182 patients answered to our phone calls; 4 patients died (one of them was operated bilaterally) for causes not related to the study, and in 11 cases the phone number was expired. The minimum follow-up was 5.0 years (mean 7.5, maximum 13.2, sd 0.11). Results. Fourteen devices were revised (7%) in 14 patients: 2 of them were operated bilaterally and the controlateral implant is still fine; thus, the Kaplan-Meier survival rate with revision for any reason as the end point was 92.7% at 13 years (95% confidence interval (CI) 0.9 to 1.0). Revisions data are resumed in table 2. Main OHS was 44 points (4–48, sd 7); no statistical relations were found about any aspect about relation between OHS and metal ions dosage (eg Chi Square Analysis p-value = 0.147>0,05 for Score and CR). Metal ions dosage was performed in only 2 cases before and after the revision (14%); in one case, the Cr dosage was 20 µg/L before and 8 µg/L after surgery; in the other case, the Cr dosage was 100 µg/L before and 10 µg/L after surgery, and the Co dosage was 70 µg/L before and 0.2 µg/L after surgery. Metal ions dosage was performed in 64 cases of the survived implants (35%). Main Cr dosage was 1.50 µg/L (0.09–7.00, sd 1.70) and main Co dosage was 1.30 µg/L (0.09–9.00, sd 1.60), at a main follow-up from surgery of 5.7 years (0.2–11.0, sd 3.1), in 14 different laboratories. No statistical relation were found between clinical outcomes and metal ions increase. Conclusions. MOMHR is a good choice for treating severe hip arthritis also in female patients with <48 mm devices. The results are affected especially by surgical technique and indications. The metal ions dosage has to be performed every year for the first two years and then at a larger follow-up. We believe that additional imaging, such as CT scanning to measure anteversion may better identify the ideal candidate, and specific training with largely experienced surgeons would be mandatory; the metal ions dosage would be used as a monitor of failures

Introduction. Acetabular fractures management is controversial since, despite a good anatomical reduction, clinical outcome is not satisfactory very often and the probability of a total hip arthroplasty (THA) is high. Surgical treatment include long operating times, large approach, blood loss, neural and muscle damage, and a high risk of failure and secondary osteoarthritis related to bone necrosis, cartilage damage, and bone loss. We hypothesized that the acetabular fracture management affected the clinical and radiological outcome of THA after posttraumatic arthritis. Materials and Methods. We compared 49 patients (49 hips) initially treated conservatively followed some months later by THA in conjunction with acetabular reconstruction (group 1); and 29 patients (29 hips) who had undergone THA after a failed osteosynthesis (group 2). There were more associated fractures according to Letournel in group 2. The mean age was 59.3±15.8 years for group 1 and 52.9±15.2 years for group 2. The mean delay between fracture and THA was 75.4±5 months for group 1 and 59.4±5 for group 2. The mean follow-up was 11.7 in group 1 and 10.2 in group 2. Preoperative bone defect was similar. We used bone autograft in 13 hips (26.5%) in group 1 and four (13.6%) in group 2. We used acetabular reconstruction plates in 2 hips with a pelvic discontinuity in group 1. Complications, clinical outcome according to Harris Hip Score, and radiological reconstruction were compared. Two-way ANOVA with repeated measures were used for comparison. Results. There were 5 cups revised for aseptic loosening in group 1 and 2 in group 2. The cumulative probability of not having a cup revision at 16 years was 90.6% (95% confidence interval (CI) 78,1 to 100) for group 1 and 94.1% (95% CI 86.5 to 100) for group 2 (p=0.76). There were 4 sciatic palsies in group 2, 4 of which developed after trauma and 2 after osteosynthesis. There were no infections. Although pre-operative clinical score was better in group 1, post-operatively at latest follow-up there were no differences. The radiological reconstruction was better in group 1 for version angle (p=0.03) and abductor lever arm (p=0.02). The change from the pre- to post-operative situation was greater in group 2 for the latter (Delta value, p=0.002). The rate of post-operative heterotopic ossifications was greater in group 2 (p=0.04). Conclusions. Long-term clinical and radiograph results are good in patients who underwent THA after a complex acetabular fracture, however, primary THA in conjunction with acetabular reconstruction had a lower number of complications and a better radiographic acetabular reconstruction than a THA after failed osteosynthesis

The aim of this study is to document the outcome of a large cohort of patients treated with the Bereiter trochleoplasty with between 1 and 12 years of follow up. 215 consecutive cases in 186 patients were recorded prospectively. All patients were offered yearly clinical and radiological review. PROMs were recorded including the IKDC, OKS, Kujala and SF-12. Patients unable to attend clinic were assessed with PROMS and radiographs from their local institutions where possible. There were 133 females and 53 males, with a mean age of 21 (14–38). There were no infections and only 6 patients reported further dislocations. There was one flap breakdown and no identified cases of secondary osteoarthritis. PROMs were available for 194 cases in 167 patients (90% follow up). 84% of patients were satisfied, 87% felt their symptoms had improved and 69% had gone back to sport. All scores improved (all p<0.001) except for the SF-12 mental score (p=0.42), with averages comparable to the results of MPFL reconstruction. Good outcomes were observed despite the difficult patient population in which these cases were performed. The Bereiter trochleoplasty is an effective method of treating recurrent patella instability in patients with severe trochlea dysplasia

Purpose. Osteochondral lesions of the knee are relatively common both in young and senior population. The very disabling clinical symptoms, in association to the scarce regenerative capacity of the articular cartilage and the increased risk of developing a secondary osteoarthritis make an effective treatment mandatory. Methods and Materials. From December 2008 to January 2013, 34 patients (35 knees), 24 males and 10 females (mean age 36.2 years range 14–66) underwent implant of Maioregen® (Finceramica Faenza S.P.A, Italy) biomimetic tri-layer osteochondral scaffold. In 17 cases the osteochondral lesion was cause by an osteochondritis dissecans (acute or sequela), in 13 cases by a spontaneous osteonecrosis and in 4 cases the etiology was traumatic. Patients were evaluated with subjective IKDC and Tegner Lysholm scores, VAS and Tegner Activity Scale before surgery and at regular follow up (mean follow up 38.4 months, range 13 months max 63 months). Results. Both Lysholm and IKDC Subjective scores significantly increased from 57.5 and 48.2 before surgery to 89.7 and 76.3 at 1 year follow up. Mean VAS scale score decreased from 6.3 to 2 at 1 year follow up. At 3 years follow up 20 evaluated patients showed an increment on both scales (Lysholm 92.38, IKDC 84.7). Only 4 patients were evaluated at 5 years follow up with mean subjective IKDC 92.5, Lysholm 98.75 and VAS 1. Conclusion. Maioregen® biomimetic osteochondral scaffold showed very good results as surgical treatment option in treating ICRS grade 3–4 osteochondral lesions whatever the etiology. In particular, the implant showed good results also in treatment of osteonecrosis and could provide an alternative to unicompartimental arthroplasty in young and active patients

The endoprosthetic treatment of secondary osteoarthritis resulting from congenital hip dysplasia is difficult due to the small diameter of the acetabulum and the hypoplastic anterolateral bone stock. On the femoral side the increased femoral anteversion, insufficient femoral offset and proximal femoral deformities (mostly valgus deformities) as well as the small diameter and straight form of the intramedullary canal pose challenges. Careful preoperative planning is mandatory. The Crowe classification is usually used to describe these pathologies. In severe cases (Crowe 3 and especially Crowe 4) a shortening and derotating femoral osteotomy should be taken into account. Small acetabular components, acetabular augments, and modular femoral components must be available at all times. For acetabular fixation press-fit cups are preferred today, but excellent results were also described for threaded cups. The advantage of press-fit cups is the extensively documented and superior track record, but threaded cups allow for an easier reconstruction of the original hip center as well as slight medialization. As a result of medialization a reduction in polyethylene wear together with a low rate of loosening lead to very good long-term results in a younger patient population. Cementless straight stems are documented to be preferable for the small femoral diameter and the straight anatomic shape of the proximal femur. Nevertheless, the higher complication rate, especially the increased rate of nerve palsies, should be preoperatively discussed with the patient. The ideal bearing surface is currently unclear, ceramic-on-ceramic seems to be promising, although the longest data available support the use of metal-on-polyethylene

INTRODUCTION. Osteochondral lesions of the knee are relatively common both in young and senior population. The very disabling clinical symptoms, in association to the scarce regenerative capacity of the articular cartilage and the increased risk of developing a secondary osteoarthritis make an effective treatment mandatory. MATERIALS AND METHODS. From December 2008 to January 2013, 34 patients (35 knees), 24 males and 10 females (mean age 36.2 years range 14–66) underwent implant of Maioregen® (Finceramica Faenza S.P.A, Italy) biomimetic osteochondral scaffold. In 17 cases the osteochondral lesion was cause by an osteochondritis dissecans (acute or sequela), in 13 cases by a spontaneous osteonecrosis and in 4 cases the etiology was traumatic. Patients were evaluated with subjective IKDC and Tegner Lysholm scores, VAS and Tegner Activity Scale before surgery and at regular follow up (mean follow up 38.4 months, range 13 months max 63 months). RESULTS. Both Lysholm and IKDC Subjective scores significantly increased from 57.5 and 48.2 before surgery to 89.7 and 76.3 at 1 year follow up. Mean VAS scale score decreased from 6.3 to 2 at 1 year follow up. At 3 years follow up 20 evaluated patients showed an increment on both scales (Lysholm 92.38, IKDC 84.7). Only 4 patients were evaluated at 5 years follow up with mean subjective IKDC 92.5, Lysholm 98.75 and VAS 1. DISCUSSION. Maioregen ® biomimetic osteochondral scaffold showed very good results as surgical treatment option in treating ICRS grade 3–4 osteochondral lesions whatever the etiology. In particular, the implant showed good results also in treatment of osteonecrosis and could provide an alternative to unicompartimental arthroplasty in young and active patients

Osteonecrosis of femoral head is well known and recognised complication in Sickle cell disease patients. Due to the severity of the Osteonecrosis, hip pain is major limiting factor for these patients requiring total hip arthroplasty in relatively young age. We studied and report our results in total hip arthroplasty of sickle cell patients. We studied 80 patients from our combined Orthopaedic & Haematology Sickle cell clinic. Twenty four patients had painful Osteonecrosis with secondary osteoarthritis of hip and underwent total hip arthroplasty. Three patients had bilateral hip replacements. A total of twenty seven replacements were studied retrospectively. 19 patients had uncemented (Corail/Pinnacle), 5 patients had hybrid(Pinnacle/Exeter) and 3 patients had cemented(Exeter) total hip arthroplasties respectively. The patients were serially followed up for clinical and radiological assessments for loosening. Oxford hip score (OHS) was used to assess the functional outcome. The average age of the patients at the time of surgery was 38.4 (Range – 20 to 59 years. The average follow up was 5.1 years (Range – 6 months to 10 years). There were 13 female and 11 male patients. The average oxford hip score was 38.07 with 10% infection rate and 11% aseptic loosening. Arthroplasties carry high risk in patients with sickle cell disease. We report lower rates of infection and loosening rates compared to the earlier studies. Combined Haematological and Orthopaedic team input is optimal during assessment, surgery, peri-operative period and follow up. Our results of total hip replacements in sickle cell disease patients are good

Lateral meniscal failure and secondary valgus with lateral compartment arthrosis is quite common in the developed world. The varus knee is the common phenotype of the ‘jock’ of both genders, while the valgus knee is a common consequence of lateral meniscal tear, skiing or ‘catwalk’ life. Occurring more commonly in ‘flamingo’ phenotypes, lateral meniscal failure can be disabling, entirely preventing high heels being worn for instance. Indications. Lateral UKA is indicated for most valgus knees, and is substantially safer than TKA. ACL integrity is not essential in older people, as the patello-femoral mechanism is in line with the lateral compartment. Severe valgus with substantial bone loss is not a contraindication, if the deformity is simply angular. As long as there is not marked subluxation, fixed flexion deformity invariably corrects after notch osteophyte removal from femur and tibia. Combinations. Lateral UKA can be combined safely with PFJA: performed through a lateral approach, this is a safe and conservative procedure. ACL integrity is not essential – reconstruction can be undertaken simultaneously, if necessary. Combining lateral UKA with medial UKA is only rarely needed, and sometimes needs ACL reconstruction too. Adding a medial UKA in under 5 years usually results from overcorrection of the valgus. Mid Term Results, at a median of 7 years postop: Between 2005 to 2009, 64 knees in 58 patients had a lateral UKA using a device designed for the lateral compartment. This included 41 females and 17 males with a mean age of 71 years at the time of surgery (range 44–92). Thirty-nine patients underwent surgery on the right knee and 6 underwent bilateral procedures, of which four were performed under a single anesthetic. Primary lateral compartment osteoarthritis was the primary diagnosis in 63 cases with secondary osteoarthritis to a lateral tibial plateau fracture the indication in one patient. At 119 months follow up, the predicted cumulative survival was 0.97. With re-operation as an endpoint, 11% of patients within the study had undergone re-operation with a predicted cumulative survival of 0.81 at 119 months. This compares well with historic fixed bearing series. Preoperative OKS scores were available for 50 knees, scores were available for 63 knees at 9–48 months and 52 knees at 61–119 months post index operation. There was a significant improvement in the OKS between the preoperative scores (median 26 range 9–36) and early postoperative time points of 9–48 months, (median 42 range 23–48) (p<0.001). At the later postoperative time point of 61–119 months the score had been maintained (42 range 10–48). Conclusion. Lateral UKA is a small and safe procedure, with clinical outcomes that are equivalent to a medial UKA and are maintained at a median of 7 years postoperatively

Background. Composite screws of uncalcined and unsintered hydroxyapatite (HA) particles and poly-l-lactide (PLLA) were developed as completely absorbable bone fixation devices. So far the durability of HA-PLLA composite screws is unclear when used for the fixation of acetabular bone graft in total hip arthroplasty under full-weight conditions. We have used this type of screw for the fixation of acetabular bone graft in cemented or reverse-hybrid total hip arthroplasty since 2003. Hence, we conducted a follow-up study to assess the safety and efficacy of these screws when used for cemented socket fixation. Methods. During 2003–2009, HA-PLLA composite screws were used for fixation of acetabular bone graft in cemented or reverse-hybrid primary THA in 106 patients (114 cases). All the THAs were performed through direct lateral approaches, and postoperative gait exercise with full weight bearing usually started two days after surgery. One patient died of an unrelated disease and seven patients were lost to follow-up within 5 years. Finally, 98 patients (106 cases) were followed up for over 5 years and were reviewed retrospectively (follow-up rate, 93%). Radiographic loosening of the acetabular component was assessed according to the criteria of Hodgkinson et al., and the radiolucent line around the socket was evaluated in all zones, as described by DeLee and Charnley. Results. The patient population comprised 10 men and 88 women with a mean age of 60.3 years (range, 41–81 years) at the time of surgery. The mean follow-up period was 7.6 years (range, 5–11 years). The original diagnosis for primary THA was secondary osteoarthritis in 97 cases and high hip dislocation in nine cases. No patient in this series required revision surgery, and no radiographical loosening occurred during the follow-up period. Grafted bone union was confirmed in all cases, and no apparent osteolysis around the cemented socket or composite screws was detected. Configurations of the HA-PLLA composite screws appeared obscure on radiographs at 5 years after surgery, and only osteosclerotic traces remained in the screw positions at the final follow-up. This finding was consistent in this series. The screw heads sometimes appeared to be broken with absorption within 3 years of surgery, and the remnants were identified in situ at the final follow up. Kaplan–Meier survival analyses with socket revision surgery for any reason, socket loosening, and appearance of a radiolucent line >1 mm in any zone as the endpoints yielded survival rates of 100%, 100%, and 86.8% at 5 years, and 100%, 100%, and 85.8% at 10 years, respectively. Conclusion. This absorbable screw seems to have no negative effects on the mid-term clinical results of cemented socket fixation

Normal human locomotion entails a rather narrow base of support (BoS), of around 12cm at normal walking speeds. This relatively narrow gait requires good balance, and is beneficial, as it minimises the adduction moment at the knee. Normal knees have a slightly oblique joint line, and slight varus, which allow the normal human to walk rapidly with a narrow BoS. Patients with increased varus and secondary osteoarthritis have a broader BoS, which exacerbates the excessive load, making walking painful and ungainly. We wondered if there would be a difference between the base of support of patients whose knee kinematics had been preserved, by retaining the native jointline obliquity and the acl, in comparison with those whose alignment had been altered to a mechanically correct ‘neutral’ alignment. Materials and Methods. Of 201 patients measured following knee arthroplasty, 31 unicondylar patients and 35 total knee patients, with a single primary arthroplasty, and no co-morbidities, over 1 year post-operatively were identified. Two control groups of controls, a younger cohort of 112 people and 17 in an age matched older cohort. All operations were performed by the same surgeon. The total knees were cruciate retaining devices, inserted in mechanical alignment, and the unicondylar knees were inserted retaining the native alignment and joint-line obliquity. The gait of all subjects was analysed on an instrumented, calibrated treadmill with underlying force plates. Patients start by walking at a comfortable speed for them for 5 minutes, before the speed of the treadmill is increased at 1/2 km/h increments until maximum walking speed obtained, spending 30 seconds at each. After the flat test, it was then repeated on a downhill slope of 6°. Base of Support is interpreted as the distance between the centre point of heel strike and toe off from one foot to that of the other. The top walking speed in the unicondylar group was significantly greater than that of the total knee group, as we reported in 2013. TKA patients have an average BoS of 14cm, while UKA patients and controls have a 12cm BoS. The BoS did not reduce with speed. This 2cm, or 17% increase in BoS is significant. Shapiro-Wilk tests demonstrate a normal distribution to the results, and ANOVA testing reveals a significant difference (p<0.05) within the groups between the speeds of 4.5 to 9. Post-Hoc Bonferroni testing reveal a significant difference between the TKA group and each of the other three groups. On the downhill test (figure 1), the mean BoS in the TKA group increased to 16cm. This increase is highly significant, with a p value of <0.001, while the increase in the UKA group at higher speeds failed to reach significance, and the controls both stayed at 12cm. 6 Bi-uni knees tested acted just like the UKAs. Discussion. A narrow base of support minimises excessive loads across the joint line. Maintenance of jointline obliquity and an ACL enables this feature to be returned to normal following uni, or bi-uni, while a well aligned TKA seems to prevent it

Introduction. Secondary osteoarthritis in a dysplastic hip is a surgical challenge. Severe leg length discrepancies and torsional deformities add to the problem of inadequate bony support available for the socket. Furthermore, many of these patients are young and wish to remain active, thereby jeopardising the long-term survival of any arthroplasty device. For such severely dysplastic hips, the Birmingham Hip Resurfacing (BHR) device provides the option of a dysplasia component, a hydroxyapatite-coated porous uncemented socket with two lugs to engage neutralisation screws for supplementary fixation into the solid bone of the ilium more medially. The gap between the superolateral surface of the socket component and the false acetabulum is filled with impacted bone graft. Methods and results. One hundred and thirteen consecutive dysplasia BHRs performed by the senior author (DJWM) for the treatment of severely arthritic hips with Crowe grade II and III dysplasia between 1997 and 2000 have been reviewed at a minimum five year follow-up. There were 106 patients (59M and 47F). Eighty of the 113 hips were old CDH or DDH, 29 were destructive primary or secondary arthritis with wandering acetabulae and four were old fracture dislocations of the hip. Mean age at operation was 47.5 years (range 21 to 68 years – thirty-six men and forty-four women were below the age of 55 years). There were two failures (1.8%) out of the 113 hips at a mean follow-up of 6.5 years (range 5 to 8.3 years). One hip failed with a femoral neck fracture nine days after the operation and another failed due to deep infection at 3.3 years. Conclusion. The dysplasia resurfacing device offers a good conservative arthroplasty option for these severely deficient hips

Introduction. Short stems have been developed for some years for preservation of femoral bone stock and achieve physiological proximal loading. Shortening stem length is a merit for bone stock preservation. However, it might lead to reduction of primary stability. We investigated relationship between stem length and primary stability by patient specific finite element analysis (FEA). Materials and Methods. Thirty-one hips in 31 patients were performed total hip arthroplasty with standard length tapered wedge-shaped (TW) cementless stem (CTi-II: Corin, Cirencester, UK). There were 6 males and 25 females. The average age at operation was 69 years old. The average body mass index was 23.9 kg/m2. Primary diagnoses were secondary osteoarthritis due to developmental dysplasia of the hip in 29 hips. Femoral canal shapes were normal in 21, stovepipe in 6 and champagne-flute in 4 hips. Bone qualities were type A in 6, B in 19 and C in 6 hips. The patients underwent computed tomography (CT) preoperatively and postoperatively. We constructed preoperative three dimensional (3D) femur surface models from preoperative CT data with individual bone mineral density (BMD) mapping. The postoperative 3D femur and rough stem surface models were obtained from postoperative CT data. The coordinates of the postoperative femur were transformed to fit the preoperative femur model. A precise stem model constructed using computer-assisted design data was matched to the transformed rough stem model using the iterative closest point algorithm. We obtained a patient-specific model with the proximal bone geometry, allocation of BMD and stem alignment. We estimated the average of axial and rotational micromotion (MM) at stem-bone interface and the ratio of area (MM â�¦ 40 micrometers) on the porous surface in order to analyze primary stability of TW stem with several lengths (standard (100 %), 75 %, 50 %, 40 % and 30 % length). Results. The average MM in standard length stem was 14.3 micrometers and the ratio of area with MM â�¦ 40 micrometers was 97.9 %. The average of axial and rotational MM in shorter length (75 %) stem were respectively 9.7, 8.3 micrometers. There were no differences in the average of axial and rotational MM between standard and shorter (75 %) length stems. MM at the porous surface was increased as the stem length grew shorter. The ratio of area with MM â�¦ 40 micrometers on the porous surface were reduced by 50 to 80 % in −40 % or less length stem, comparing with the standard length stem. Discussion and Conclusion. The present FEA on the stem length and MM demonstrated that primary stability in 40 % or less short length TW stem was extensively reduced, which might lead to failure of bone ingrowth on the porous surface and early loosening. Shortening of stem length less than 50 % is a risk for reduced primary stability in TW stem

Introduction. In the year 1977 we started to use ceramic on ceramic total hip (Ceraver*). The prosthesis was cemented on both sides. Ceramic was medical grade with relative large grains and high porosity. The stem was made of titanium alloy smooth and oxidized. In 1990 we published the results of 86 hips in 75 patients who were less than 50 years of age at time of operation (1). Recently we tried to reach the same patients, looking specifically to those who could have more than 20 or 30 years follow-up. Material and methods. This study design included all patients operated between 1977 and 1986 and having less than 50 years of age at time of surgery. Eighty six hips in 75 patients, 34 females and 41 men. Mean age was 43 (from 18 to 50) nine had a BMI in excess. 66 hips were performed primaries while 20 consisted in revision procedure including 6 total hip revisions, 5 resurfacing, 4 single cup, 3 hemiarthroplasty, and 2 acetabula fractures. Four of these had a past history of infection. Preoperative diagnosis were secondary osteoarthritis in 41, AVN in 26, primary OA in 3, Rheumatoid arthritis in 12, tuberculosis in 2 and hemophilic in two. Results. Complications: one early sepsis was cured by reoperation without material exchange, another septic case was revised at 2 years, 6 years later the results was poor and we could not trace him. One had a nonunion of the greater trochanter and one had one isolated dislocation. One presented with a fracture of an extra small ceramic head of 22 mm in diameter for high Crowe 4 DDH. The broken head was replaced by a metallic head and the socket by a polyethylene one. We tried to reach every patient and did separate them in four groups:. -. 13 hips in 12 patients that were not followed more than 2 years: they usually leaved in Africa (Algeria, Ivory Coast or Senegal and could not be traced),. -. 6 deceased from one to 28 years after index procedure, with no relation with their hip still in place. -. A group of 25 hips in 22 patients that were reached recently (some are still followed some were found by Google and reached by phone), and had not been revised. One of these had a fractured head at 21 years. -. The last group consisted in 49 hips in 48 patients who were followed for periods from 2 to 20 years. Four of these were revised always for socket loosening at period from 12 to 18 years. No reoperation for stem loosening. The revision consisted in socket exchange for a press fit material with a ceramic liner. As in our first study we identified some cases that presented with radiolucent lines at the socket side, we found no correlation between this aspects and the risk of revision. We worked more precisely on the group of 22 patients effectively followed more than 20 years, 10 more than 30 years. They had no limitation on the operated hip; some are still performing heavy activities including sports; they have no complain about noise. Slight pain was noticed in two of them. Conclusion. We found an extremely good results; no degradation of the hip clinically nor radiographic. Some radiolucent lines are still visible but not harmful. The most intriguing aspect is the total absence of osteolytic lesions. With a contemporary material implanted since 15 years we suppose to avoid some of the complications observed in this first trial group