Background

Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit.

As arthroplasty demand grows worldwide, the need for a novel cost-effective treatment option for articular cartilage (AC) defects tailored to individual patients has never been greater. 3D bioprinting can deposit patient cells and other biomaterials in user-defined patterns to build tissue constructs from the “bottom-up,” potentially offering a new treatment for AC defects. Novel composite bioinks were created by mixing different ratios of methacrylated alginate (AlgMA) with methacrylated gelatin (GelMA) and collagen. Chondrocytes and mesenchymal stem cells (MSCs) were then encapsulated in the bioinks and 3D bioprinted using a custom-built extrusion bioprinter. UV and double-ionic (BaCl2 and CaCl2) crosslinking was deployed following bioprinting to strengthen bioink stability in culture. Chondrocyte and MSC spheroids were also bioprinted to accelerate cell growth and development of ECM in bioprinted constructs. Excellent viability of chondrocytes and MSCs was seen following bioprinting (>95%) and maintained in culture, with accelerated cell growth seen with inclusion of cell spheroids in bioinks (p<0.05). Bioprinted 10mm diameter constructs maintained shape in culture over 28 days, whilst construct degradation rates and mechanical properties were improved with addition of AlgMA (p<0.05). Composite bioinks were also injected into in vitro osteochondral defects and crosslinked in situ, with maintained cell viability and repair of osteochondral defects seen over a 14-day period. In conclusion, we developed novel composite bioinks that can be triple-crosslinked, facilitating successful chondrocyte and MSC growth in 3D bioprinted scaffolds and in vitro repair of an osteochondral defect model. This offers hope for a new approach to treating AC defects

An increased prevalence of osteoarthritis (OA) in post-menopausal women has led to the suggestion that hormonal factors may play a role in the pathogenesis. This study aims to examine if undergoing a hysterectomy, both with retention and removal of ovaries, predisposes women to OA and secondly if the development is influenced by hormone replacement therapy (HRT). Statistical shape modelling (SSM) is a method of image analysis allowing for detection of subtle shape variation described by landmark points. Through the generation of linearly independent modes of variation, each image can be described in terms of numerical scores. 149 radiographs from female participants of the Osteoarthritis Initiative (OAI) were examined to compare hip morphology in those who had undergone hysterectomies compared to controls. No differences were observed in BMI, age, height or weight between groups. ANOVA and Games-Howell post-hoc analysis showed that modes 3 and 5 were statistically significant. Lower mode 3 scores were associated with hysterectomy (p=0.019), with narrowing of the femoral neck and increased acetabular coverage. Lower mode 5 scores were associated with hysterectomy and oophorectomy (p=0.049), displaying reduced coverage of the femoral head, superolateral migration of the femoral head and larger greater trochanter. No associations were observed between HRT use and OA. The subtle morphologic features of hip OA present in only hysterectomised women suggests undergoing a hysterectomy may be a predisposing factor and a clinical consideration. The use of HRT was not observed to influence the development of OA and thus cannot be suggested as a protective measure

Bone shape variability within a specific population has been seldom investigated and used to optimize implant design. There is insufficient anatomical fitting of the existing prebend periarticular plates for the distal fibula. We developed a methodology for design of orthopaedic implants that fit a maximum percentage of the target population, both in terms of geometry and biomechanical stability. In co-operation with an implant manufacturer and different academic institutions, a virtual bone database has been developed that contains anatomical data of more than 1000 CT datasets with the implemented possibility to generate idealized implant fits for different anatomical sites. This program (Stryker Virtual Bone Database (VBD) is able to generate statistical anatomical shapes for different populations like age groups or ethnical groups. Based on this, an implant for the distal fibula has been developed (VariAx Distal Lateral Fibula Locking Plate) for distal fibula fracture treatment. Aim of this study was to develop and validate an implant that is optimized for the specific anatomical area. It should be precontoured and still fit to the majority of patients sustaining a distal fibular fracture. Another objective was to create a distally tapered design as there is less soft tissue cover in that anatomic area. Materials & Methods. ProE CAD system was used in combination with the Bone Database (VBDB) to evaluate the bone shape of the target population plate shape. Several bones (from CT scans) have been used in a first validation process in comparison with an implant already available on the market (SPS Fibula Plate). Additionally, the results have been verified with a bone fitting study which was conducted in collaboration with the Maurice E. Müller Institute (MEM) in Bern/Switzerland. In a second step, the finished implant design was validated against statistical bone shapes of populations of different ethical origin. Results. The comparison of the new Plate's shape with real bone data confirmed that the neutral form does cope with the anatomic situation laterally which means that no systematic pre-bending of the plate is required. Comparing with a conventional implant, the new implant could have been implanted unbend in 6 of 7 cases of virtual matching with real patient datasets compared to none with the conventional implant. The validation of statistical datasets of different ethnical origin (Caucasian, Asian) showed no statistical difference of implant mismatch. Conclusion. Based on these results, the new Plate can be considered an efficient solution to treat distal fibula fractures without or only limited time consuming intra-operative bending. Although technically now possible, different plate designs for Caucasians and Asians are not required

Aims

Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.

Aims

Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data.

Aims

Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

Introduction. Plate fixations have been recommended for dislocated clavicle fractures. However, existing plates are inadequate for morphological compatibility with the clavicle. The aim of this study is to measure the anatomical shape of the clavicle and to compare the radiographical and clinical outcomes of our tree-dimensional (3D) reconstruction plate with conventional straight plate. Methods. Chest CT image of 15 patients with normal clavicle were analyzed. Their clavicles were reconstructed and measured their anatomical variables. A hospital-based case-control study was conducted, including a consecutive series of 52 patients with displaced midshaft clavicle fractures. 3D reconstruction plate was used for 26 patients and another 26 patients were treated with conventional straight plate. Outcome measures included the period of bone union, revision surgery, operating times and clinical symptoms using DASH score. Results. The result indicated that plates applying to any shape of the clavicle require a strong curve on the distal part and a twist on the proximal part. A case-control study demonstrated that the conventional straight plate group had higher rate of delayed union and had more symptomatic than the 3D group. Conclusion. The plates with a strong curve on the distal end and a twist on the proximal end exhibit better compatibility with the clavicle. Our 3D reconstruction plate showed superiority in both radiographical and clinical outcome than conventional straight ones

We hypothesised that the anterior and posterior walls of the body of the first sacral vertebra could be visualised with two different angles of inlet view, owing to the conical shape of the sacrum. Six dry male cadavers with complete pelvic rings and eight dry sacrums with K-wires were used to study the effect of canting (angling the C-arm) the fluoroscope towards the head in 5° increments from 10° to 55°. Fluoroscopic images were taken in each position. Anterior and posterior angles of inclination were measured between the upper sacrum and the vertical line on the lateral view. Three authors separately selected the clearest image for overlapping anterior cortices and the upper sacral canal in the cadaveric models. The dry bone and K-wire models were scored by the authors, being sure to check whether the K-wire was in or out. In the dry bone models the mean score of the relevant inlet position of the anterior or posterior inclination was 8.875 (standard deviation (. sd. ) 0.35), compared with the inlet position of the opposite inclination of –5.75 (. sd. 4.59). We found that two different inlet views should be used separately to evaluate the borders of the body of the sacrum using anterior and posterior inclination angles of the sacrum, during placement of iliosacral screws. Cite this article: Bone Joint J 2015;97-B:705–10

This randomised study compared outcomes in patients with displaced fractures of the clavicle treated by open reduction and fixation by a reconstruction plate which was placed either superiorly or three-dimensionally. Between 2003 and 2006, 133 consecutive patients with a mean age of 44.2 years (18 to 60) with displaced midshaft fractures of the clavicle were allocated randomly to a three-dimensional (3D) (67 patients) or superior group (66). Outcome measures included the peri-operative outcome index, delayed union, revision surgery and symptoms beyond 16 weeks. CT was used to reconstruct an image of each affected clavicle and Photoshop 7.0 software employed to calculate the percentage of the clavicular cortical area in the sagittal plane. The patients were reviewed clinically and radiographically at four and 12 months after the operation. The superior plate group had a higher rate of delayed union and had more symptomatic patients than the 3D group (p < 0.05). The percentage comparisons of cortical bone area showed that cortical bone in the superior distal segment is thicker than in the inferior segment, it is also thicker in the anterior mid-section than in the posterior (p < 0.05). If fixation of midshaft fractures of the clavicle with a plate is indicated, a 3D reconstruction plate is better than one placed superiorly, because it is consistent with the stress distribution and shape of the clavicle

Aims

Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles.

Background:. Leg length discrepancy related to absence of the femoral head with proximal migration of the femur presents a treatment dilemma. Late sequelae of neonatal hip sepsis and chronic hip dislocation due to developmental dysplasia are the most common causes. Traditional teaching dictates that the hip is stabilised prior to limb lengthening. Reconstructive options alter the shape of the proximal femur which complicates future surgery. Methods:. We retrospectively reviewed 3 cases of femoral lengthening with an ‘unstable’ hip without prior stabilization. The aetiology was neonatal hip sepsis in 2 cases and chronic hip dislocation due to developmental dysplasia in 1 case. Lengthening was performed with the use of a retrograde Precice lengthening nail. Results and Discussion:. The desired length (range 5.5 to 6cm) was achieved in all patients without migration of the proximal femur. In all cases patient satisfaction was high with the lengthening and the ability to abort shoe raises. There was an improvement in gait pattern in all patients. Conclusion:. Femoral lengthening is possible without prior stabilisation of the hip in so called ‘unstable’ hip situations. The proximal femoral anatomy is not further altered and future salvage procedures such as a total hip replacement are not compromised

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle

Aims

Minimally invasive fixation of pelvic fragility fractures is recommended to reduce pain and allow early mobilization. The purpose of this study was to evaluate the outcome of two different stabilization techniques in bilateral fragility fractures of the sacrum (BFFS).

Aims

No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

Component malalignment has long been implicated in poor implant survival in Total Knee Arthroplasty (TKA). Malalignment can occur in orientation of bony cuts, and in component cementation/implantation. Several systems exist to aid bony cut alignment (navigation, shape matching), but final implantation technique is common to all TKA. Correction of errors in bony cut alignment at cementation/implantation by surgeons has been described. Changes in alignment at this stage are likely to result in asymmetrical cement penetration, which is implicated in early failure. This study reviewed a consecutive series of 150 primary cemented TKAs using an imageless navigation system (aiming for neutral overall limb alignment). Deviation at implantation was calculated by comparing limb alignment recorded using the trial components with limb alignment recorded with the final implanted components, prior to closure. 136 patients (91%) had a final overall limb alignment within 2° of neutral. Three patients (2%) had a final overall limb alignment greater than 3° from neutral. Deviation occurring at implantation is shown in Figure 1 with deviations distributed around zero (mode 0, median 0.3, range −2 to +4,)

Triple arthrodesis is the most effective treatment resource for restoring shape and stability to the hind-foot. It is used in order to achieve a plantigrade foot, aligned, stable and painless, in the treatment of various pathologies. However, it has the effect of changing the dynamic mobility of the foot and diminishes the adapting ability to uneven ground, influencing the outcome. Opinions differ on the necessity of internal fixation to maintain the proper alignment of the hind-foot and improve consolidation, influencing the results. The authors reviewed the patients who underwent triple arthrodesis between 01/01/1998 and 31/12/2008. Of a total of 46 patients 28 were reviewed, corresponding to 29 feet that underwent 36 interventions (7 recurrences). Patients were divided into two groups according to whether or not the placement of internal fixation. They were evaluated according to the AOFAS ankle and hindfoot score and correlated with the radiologic result. The most frequent indications for surgery were osteoarthrosis of the tarsus and sequelae of fractures of the calcaneus. In the group without fixation 68% had radiological signs of consolidation. 24% required revision for non consolidation. In the group with internal fixation there was 72.7% consolidation and 9.1% required revision surgery. Bone graft was more often used in internal fixation group (72.7% vs 40%). Group without fixation vs group with internal fixation:. AOFAS mean score: 74.5% vs 61.6%, patients without pain: 50% vs 20%; plantigrade foot with good alignment: 66.7% vs 40% without pain: 50% vs 20%; tibiotarsal arthritis: 48% vs 63.6%; Lisfranc arthrosis: 44% vs 63.6%. There is a higher rate of consolidation in the group setting. However, the functional outcome seems to be better in the group without fixation. Fixation seems to be associated with better consolidation. The functional outcome is related to a plantigrade and well aligned foot

Skin cover after below-knee amputation has been extensively discussed. We describe the flaps which are commonly used and discuss their vascular basis in the context of the current knowledge of the fasciocutaneous system. An understanding of this vascular system will enable surgeons to plan and shape flaps for surgical exposure and coverage

Periprosthetic osteolysis depends on the biological activity of wear particles, but there is little known about the distribution of polyethylene wear particles (PE) in the surrounding joint tissue. The purpose of this study was to examine the localisation of wear particles of six different PEs, including four crosslinked polyethylenes (XPE), as well as their biological activity in the murine knee. Material and Methods. Wear particles of 4 XPE- and 2 UHMWPE-inserts were isolated (knee joint simulator). For all groups the particles were similar in size and shape (mean diameter 0.3–05μm; 20nm-nucleopore-filter; ISO; n = 100.000).56 female Balb/c mice were randomly assigned to six treatment groups and one control group: control (PBS), XPE1 (3×30 kGy Gamma, annealed/sequential irradiated), XPE2 (95 kGy E-beam, remelted), XPE3 (65 kGy E-beam, remelted), XPE 4 (50 kGy Gamma, remelted), UHMWPE 1, UHMWPE 2. 50 μl of each particle suspension [(0.1% vol/vol (particle volume/PBS volume) after removal of endotoxin] were injected into the left knee joint. After 1 week the mice were killed and a histological and immunhistochemical analysis of the knee joints was done (IL-1, TNF-, ICAM-1). For the immunhistochemistry the articular cartilage, the bone marrow and the synovial membrane were evaluated semiquantitatively (Kruskal-Wallis test; all pairwise multiple comparison procedure; Bonferoni correction; significance level: p<0.05). Results. All groups showed a thickened synovial layer with an increased cellular infiltration. The particles of XPE 1 and 2 were localised in the bone marrow as well as in the joint space. In contrast, the particles of XPE 3 and 4 were distributed in the synovial layer and in the bone marrow as well, but not in the joint space. The UHMWPE1 particles were mainly located in the bone marrow and joint space while the UHMWPE2 particles were mainly found in the bone marrow and the synovial layer. For all PE groups there was a higher cytokine expression compaired to control (p<0.0024) without any differences between the groups (bone marrow/synovial layer). The chondrocytes in the groups with XPE 1- and XPE 2-particles expressed more TNF- than in the control group and the other treatment groups (p = 0.000). Conclusion. XPEs lead to a similar inflammatory reaction in vivo compared to conventional polyethylenes. The high TNF- expression in the articular cartilage (groups XPE 1 and 2) might be explained by the localisation of the wear particles in the joint space in direct contact with the chondrocytes. Long-term studies are necessary to analyse the effects of different wear particle distributions in the joint surrounding tissue after knee and hip replacement. Furthermore it has to be investigated, whether their distribution in the joint space or their transport into the bone marrow is responsible for the level of the chronic inflammatory reaction

Introduction. The origins of the uncemented tapered wedge hip stem design currently offered by several orthopaedic device companies can be linked back to the cemented Straight Mueller type stem design first used in 1977. The design, a wedge shape with a taper angle of 6 degrees, maintains a single medial curvature for all sizes and increases laterally in the width to accommodate different size femurs. Although evolutionary improvements have been made over the years the basic body geometry of the stem has stayed mainly unchanged with excellent clinical survivorship. Over the past decade, the demographics of hip replacement have changed, with a large increase in younger male patients in the age range of 40 to 60 years. In this study the femoral fit of a novel tapered stem, designed to fit a wide array of patient types, is compared to a standard predicate tapered stem design. Methods. A bone morphology study was performed on a patient population of 556 patients using three dimensional digital data from CT-scans. To characterize the fit of the stem designs we analyzed the ratio of a distal (60mm below lesser trochanter) and a proximal (10mm above lesser trochanter) cross section. The same measurements were taken with the standard tapered stem design and the novel tapered stem design, with a given constant implantation height of 20mm above the lesser trochanter. The fit of the stems was classified as Type 1, where there was both proximal and distal engagement, Type 2, proximal engagement only, Type 3, distal engagement only. The distal and proximal engagement, Type 1, was specified with a maximum engagement difference of 2mm proximal to distal. Results. The standard tapered stem showed a well balanced distal to proximal ratio in the median sizes. However, with increasing stem size the distal engagement increases. The novel tapered stem design showed a well balanced proximal to distal ratio throughout the complete size range. With respect to Type 3 fit classification the novel tapered stem design showed a reduced percentage of distal engagements (2.8%) compared to the predicate standard stem (17.2%). In the 40 to 60 year old male group the distal engagements for the standard stem increases (28.2%), whereas the distal engagements for the novel stem remains unchanged (1.3%). Discussion. The cementless, tapered wedge stem design is used in large numbers globally due to its ease of use and reproducibility. However, changing patient demographics and associated bone morphology represents a challenge for existing designs to achieve a proximal fit. The novel tapered stem design presented here was adapted to these influencing factors by optimizing the proximal to distal ratio with respect to the whole patient group resulting in a particularly marked improvement in proximal fit in the male 40–60 age group compared to predicate stem designs