Introduction. A total knee arthroplasty (TKA) is the standard of care treatment for end-stage osteoarthritis (OA) of the knee. Over the last decade, we have observed a change in TKA patient population to include younger patients. This cohort tends to be more active and thus places more stress on the implanted prothesis. Bone cement has historically been used to establish fixation between the implant and host bone, resulting in two interfaces where loosening may occur. Uncemented fixation methods provide a promising alternative to cemented fixation. While vulnerable during the early post-operative period, cementless implants may be better suited to long-term stability in younger patient cohorts. It is currently unknown whether the surgical technique used to implant the cementless prostheses impacts the longevity of the implant. Two different surgical techniques are commonly used by surgeons and may result in different load distribution across the joint, which will affect bone ingrowth. The overall objective of the study is to assess implant migration and in vivo kinematics following cementless TKA. Methods. Thirty-nine patients undergoing a primary unilateral TKA as a result of OA were recruited prior to surgery and randomized to a surgical technique based on surgeon referral. In the gap balancing surgical technique (GB) soft tissues releases are made to restore neutral limb alignment followed by bone cuts (resection) to balance the joint space in flexion and extension. In the measured resection surgical technique (MR) bone cuts are first made based on anatomical landmarks and soft tissue releases are subsequently conducted with implant components in-situ. Patients returned 2 weeks, 6 weeks, 12 weeks, 24 weeks, and 52 weeks following surgery for radiographic evaluation. Kinematics were assessed 52 weeks post-operatively. Results. No significant difference was observed between groups in maximum total point motion (MTPM) at any time point during the first post-operative year. MTPM of both the tibial and femoral component did not significantly change between the six month and one year follow up visits for both the GB (6 mths=0.67 ±0.34mm, 1 yr=0.65 ±0.52, p=0.71) and MR (6 mths= 0.79 ±0.53mm, 1 yr= 0.82 ±0.43mm, p=0.56) cohorts. MTPM for both components over the follow up period is displayed in Figure 1. No significant difference was observed in contact location or pattern on the medial condyle during deep flexion (Figure 2A). A significant difference (p=0.01) was observed, however, between surgical techniques in the lateral contact location at full extension (Figure 2B). No significant difference was observed in the magnitude of AP excursion for both the medial and lateral condyles within and between groups. Conclusion. Surgical technique did not impact the MTPM of an uncemented TKA design during the first post-operative year. By the six month post-operative period tibial and femoral MTPM plateaus indicating that osseointegration between the host bone and implanted components has occurred. Kinematic evaluation indicates contact locations anterior to the midline of the sagittal plane, paradoxical anterior translation, and a lateral pivot point, regardless of surgical technique

Introduction. Osteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods. Methodology. After the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct. Results. Three children ages 5,8 and 13 underwent the procedure. Five coxa vara femurs have undergone this technique with follow-up out to 62 months (41–85 months) from surgery. Improvements in the femoral neck shaft angle (FNSA) were av. 18. o. (10–38. o. ) with pre-op coxa vara FNSA av. 99. o. (range 87–114. o. ) and final FNSA 117. o. (105–125. o. ). Hilgenreiner's epiphyseal angle was improved by av. 29. o. (2–58. o. ). However only one hip was restored to <25. o. In the initial technique employed for 3 hips, the plates were left short in the neck to avoid damaging the physis. This resulted in 2 of 3 hips fracturing through the femoral neck above the plate at approximately 1 year. There were revisions of the 3 hips to longer plates to prevent intra-capsular stress riser. All osteotomies united and both intracapsular fractures healed. No further fractures have occurred within the protected femurs and no other repeat operations have been required. Conclusions. Surgical correction of the OI coxa vara hip is complex. Bone mineral density, multiplanar deformity, a desire to maintain physeal growth and protection of the whole bone all play a role in the surgeon's decision making process. Following modifications, this technique demonstrates a novel method in planning and control of multiplanar proximal femoral deformity, resulting in restoration of the FNSA to a more appropriate anatomical alignment, preventing long bone fracture and improved femoral verticalization in the medium term follow-up

Introduction. While total hip arthroplasty is considered to be one of the most cost-effective medical interventions, the total cost of care for a population patients treated by THR can present a significant burden on the payer, whether it be an employer, private insurer or government. Data on the true cost of care has rarely been made available to the treating physician. Such lack of information makes comprehensive management difficult. Bundled payment models of care require knowledge of all costs associated with the care of our patients and opens new opportunity for analysis to improve management and outcomes. The current study assess the influence of surgical technique on total cost of care for total hip arthroplasty. Methods. Payment data for 341 patients who underwent total hip arthroplasty at a single institution from June 1. st. , 2011 to October 31. st. , 2014 were analyzed. Each procedure was performed using either the superior, anterior, or posterior exposure. The superior exposure was performed with femoral head excision and without dislocation of the hip. The data were analyzed for total cost, inpatient cost, inpatient physician cost, readmission cost, skilled nursing facility cost, and home healthcare agency cost among the different approaches. Results. The superior hip approach for total hip arthroplasty results in a significant total cost savings over a 90-day episode of care when compared to both the anterior and posterior exposure techniques. It reduced overall costs by approximately $2,000 and $7,000 per case versus the other groups respectively. The superior approach also demonstrated savings in inpatient and skilled nursing facility cost when compared to the other groups. Conclusions. Surgical technique can have a profound influence on the total cost of care for hip arthroplasty patients. The current study demonstrates that the posterior exposure resulted in the largest consumption of resources post-operatively as measured by total cost of care and that the superior exposure resulted in the least consumption of resources among the three surgical exposures assessed. The study suggests that while we focus on many aspects of improvement in the overall episode of care for our patients, that focus on surgical technique may be worthwhile

Introduction. To achieve well aligned and balanced knee is essential for the post-operative outcome in total knee arthroplasty (TKA). Gap balancing technique can adjust the bone cut depending on the soft tissue balance in addition to soft tissue releases. Therefore, gap balancing technique would be more advantageous in soft tissue balance comparing to measured resection technique (MRT) in which soft tissue balancing relayed on soft tissue releases alone. Nevertheless, the influence of surgical technique on the post-operative knee stability has not been fully investigated. Objective. We introduced a new surgical technique (medial gap technique: MGT) according to modified gap technique regarding medial knee stability as important. The intra-operative soft tissue balance and post-operative knee stability were compared between MGT and MRT in posterior-stabilized (PS) TKA for varus type osteoarthritic knees. Materials & Methods. Sixty varus type osteoarthritis knees were involved in this study. PS type TKAs (NexGen LPS flexR) were performed using MGT in 30 knees (MGT group) and MRT in 30 knees (MRT group). The extension gap was made in the same manners in both groups. Both femoral and tibial bone cuts were perpendicular to the mechanical axis. Medial soft tissue releases were limited until the spacer block with the thickness corresponding to the resected lateral tibial condyle could be inserted. After extension gap was prepared, OFR-tensorR was used to assess soft tissue balance (center gap, varus angle) at extension and flexion prior to posterior femoral condyle bone resection. Both differences of the center gap and varus angle between at extension and flexion were calculated and used for size selection and external rotation angle of femoral component in MGT. The final joint component gaps were evaluated using OFR-tensorR with both femoral trial in place and patello-femoral joint reduced at 0, 10, 30, 45, 60, 90, 120 and 135 degrees of flexion. Quantitative stress radiographies were performed at 1 month, 6 months and 1 year post-operatively to assess joint stability. Joint opening distance (mm) at both medial and lateral joint compartment were measured with knee extension and flexion. Each parameter was compared between MGT and MRT group using unpaired t-test (p<0.05). Results. Pre-operative factors showed no significant differences between 2 groups. The joint component gaps were significantly larger in MRT group from 45 to 135 degrees of flexion (Fig.1). The joint opening at the lateral compartment was significantly larger than medial at both knee extension and flexion in both groups. The joint openings were significantly larger bilaterally in MRT group comparing to MGT group at both extension and flexion (Fig.2, 3). Discussions. Medial instability has been reported as a possible reason for the persistent knee pain after TKA in the varus knees. We proposed a new surgical technique (MGT) not to deteriorate medial stability and allow lateral looseness in TKA. Post-operative knee stability was superior in MGT group comparing to MRT group from one month to one year after surgery. The difference of the intra-operative soft tissue balance might play an important role on the post-operative knee stability

Distal femur fractures (DFF) are common, especially in the elderly and high energy trauma patients. Lateral locked osteosynthesis constructs have been widely used, however non-union and implant failures are not uncommon. Recent literature advocates for the liberal use of supplemental medial plating to augment lateral locked constructs. However, there is a lack of proprietary medial plate options, with some authors supporting the use of repurposing expensive anatomic pre-contoured plates. The aim of this study was to investigate the feasibility of a readily available cost-effective medial implant option.

A retrospective analysis from January 2014 to June 2022 was performed on DFF (primary or revision) managed with supplemental medial plating with a Large Fragment Locking Compression Plate (LCP) T-Plate (~$240 AUD) via a medial sub-vastus approach. The T-plate was contoured and placed superior to the medial condyle. A combination of 4.5mm cortical, 5mm locking and/or 6.5mm cancellous screws were used, with oblique screw trajectories towards the distal lateral cortex of the lateral condyle. All extra-articular fractures and revision fixation cases were allowed to weight bear immediately. The primary outcome was union rate.

This technique was utilised on sixteen patients; 3 acute, 13 revisions; mean age 52 years (range 16-85), 81% male, 5 open fractures. The union rate was 100%, with a median time to union of 29 weeks (IQR 18-46). The mean follow-up was 15 months. There were two complications: a deep infection requiring two debridements and a prominent screw requiring removal. The mean range of motion was 1–108^o.

Supplemental medial plating of DFF with a Large Fragment LCP T-Plate is a feasible, safe, and economical option for both acute fixation and revisions. Further validation on a larger scale is warranted, along with considerations to developing a specific implant in line with these principles.

INTRODUCTION. Evolving payment models create new opportunities for assessment of patient care based on total cost over a defined period of time. These models allow for analyses of economic data that was previously unavailable and well beyond our familiar studies which typically include length of stay, surgical complications, and post-operative clinical and radiographic assessments. In the United States, the new Federal program entitled TheBundled Payment for Care Initiative created new opportunities for the assessment of surgical interventions. The purpose of the reported study was to assess the total reimbursement for care as a function of surgical technique in primary total hip arthroplasty (THA). METHODS. The total reimbursement for services performed following primary THA for patients insured by Medicare was analyzed for a group of patients at a single institution during the fiscal years of 2013 and 2014. The population included data on 356 patients who had surgery performed by seven surgeons who used the same pre-operative education, OR, PACU, PT, nursing, and case management. A total of 38 “pre-selected” patients underwent THA by an anterior exposure, 219 had surgery performed by a posterior exposure, and 99 had surgery performed by the superior exposure utilizing mechanical surgical navigation (HipXpert System, Surgical Planning Associates, Boston, MA). Reimbursement for all in-patient and out-patient services performed over the initial 90-day period from sugeical admission was compared across surgical techniques. Reimbursement includes the sum of all payments including the hospital, physicians, skilled nursing facilities, home care, out-patient care, and readmission. RESULTS. The authors previously reported that primary THA cases performed using the superior approach have shorter average length of stay, a lower complication rate, higher percentage of acetabular components within the “safe zone” when compared to the other approaches and higer rate of patients discharged directly to home. An average reimbursement of $24,848 for THA performed using posterior exposure, $21,446 for the selected anterior exposure, and $20,268 for the superior exposure with navigation. The cost of care for treatment by the superior exposure with navigation was statistically significantly less than the posterior exposure (p<0.001) but not significantly less than the selected anterior exposure patients (p=0.287). Medicare in-patient reimbursements for patients treated by the superior exposure with mechanical surgical navigation was significantly less than the selected anterior exposure group (p<0.002) and the posterior exposure group (p<0.001). Overall, 84% of patients with the superior exposure were discharged directly to home versus 69% in the selected anterior group and 60% in the posterior group thus minimizing the out-patient Medicare cost burden in THA performed using the superior exposure over the other techniques. CONCLUSION. The current study demonstrates the influence of surgical technique on the direct reimbursement for the continuum of care, indicative of incurred costs, across the first 90-day post-operative period. The superior exposure combined with surgical navigation demonstrates the potential for significantly reduced total cost burden in Medicare patients when compared to two of the most common surgical approaches used for primary THA

Introduction. The use of screws is frequent for additional fixation, however, since some disadvantages have been reported a cup press-fit is desirable, although this can not always be obtained. Cup primary intraoperative fixation in uncemented total hip replacement (THR) depends on sex, acetabular shape, and surgical technique. We analyzed different factors related to primary bone fixation of five different designs in patients only diagnosed with osteoarthritis, excluding severe congenital hip disease and inflammatory arthritis, and their clinical and radiological outcome. Materials y Methods. 791 hips operated in our Institution between 2002 and 2012 were included for the analysis. All cases were operated with the same press-fit technique, and screws were used according to the pull-out test. Two screws were used if there was any movement after the mentioned manoeuvres. Acetabular and femoral radiological shapes were classified according to Dorr et al. We analyzed radiological postoperative cup position for acetabular abduction angle, the horizontal distance and the vertical distance. Cup anteversion was evaluated according to Widmer and the hip rotation centre according to Ranawat. Results. Screws were required in 155 hips (19.6%) and were more frequently used in women and patients with a type A acetabulum (p<0.001, p=0.021, respectively). There were no differences among the different cups evaluated. The need for screws was more frequent in hips with a smaller version of the cup and with a distance greater than 2 mm to the approximate femoral head centre from the centre of the prosthetic femoral head (p=0.022, 0.012, respectively). Adjusted multivariate analysis revealed that female patients (p<0.001, Odds Ratio (OR): 2.063; 95% Confidence Interval (CI) 1.409–3.020), cups with a smaller version (p=0.012, OR: 0.966, 95% CI 0.94–0.992), and a greater distance to the rotation hip center (p<0.005, OR: 1.695; 95% CI 1.173–2.450) had a higher risk for screw use. No hips needed revision for aseptic loosening. Conclusions. Cup press-fit depends on gender and surgical technique in hips without significant acetabular abnormalities or inflammatory arthritis. Contemporary uncemented cups provide similar primary fixation and mid-term outcome

Introduction. Two principal targets are dominating the spectrum of goals in total knee arthroplasty: first of all the orthopedic surgeon aims at achieving an optimal pain-free postoperative kinematic motion close to the individual physiologic range of the individual patient and secondly he aims for a concurrent high ligament stability within the entire range of movement in order to establish stability for all activities of daily living. This study presents a modified surgical procedure for total knee replacement which is ligament-controlled in order to put both component into the “ligamentous frame” of the patients individual kinematics. Methods. The posterior femero-condylar index (PFC-I) is defined as being the posterior condylar offset divided by the distal antero-posterior diameter on a lateral radiograph. After careful preoperative planning the positions and orientations of the osteotomies is controlled intraoperatively via ligamentous guidance. Anterior and distal femoral osteotomy are planned on antero-posterior and lateral radiographs considering intramedular and mechanical axes as well as the orientation of the posterior condyles. Osteotomies are carried out in a stepwise fashion, starting with the anterior femoral osteotomy followed by the distal femoral osteotomy as planned. Then the extension gap is finalized by tensioning the ligaments and “top-down” referencing the level of the tibial osteotomy. After rotating the femur into the 90°-flexion position the flexion gap is finalized by referencing the level of the posterior condyle osteotomy in a “bottom-up” fashion to the tibial osteotomy. Hence, this technique determines the size of the femoral component with the last osteotomy. It likewise respects the new, ACL-lacking ligamentous framework and it drives the prosthetic components to fit into the new ligamentous envelope to follow the modified kinematics. Results. More than 130 patients have been operated on using this surgical technique, 104 of them have been followed-up after a minimum of one year: age 73+/−9, m/f 37/67, 71% had a varus, 29% a valgus-deformity. In all patients a subvastus approach was applied, 12 from medial, 92 from lateral. Mean flexion reached 122°+/−7.4 and a 120°-flexion or more was achieved by 86% of the patients. All patients reveived a LCS total knee prosthesis with either a rotating or an antero-posterior gliding inlay. No fixed tibial inlays were used. Antero-posterior translation of the APG-insert was 13 to 16mm immediately postoperatively whereas after one year it decreased to 4 to 10mm. We succeeded in reconstructing the posterior femero-condylar index (PFC-I) and found a linear correlation of 0.98 +/−0.06 of pre- to postoperative PFC-I. Conclusion. This PCL-retaining surgical technique respects the new, ACL-lacking kinematics in total knee replacement. The anterior and distal femoral osteotomies are femur-axis-controlled while the extension and flexion gaps are ligament-controlled. The size of the femoral component is regarded as a variable within the procedure and is only determined while performing the last osteotomy, i.e. the posterior condylar osteotomy. This technique is suitable for both PCL-retaining and also for PCL–sacrificing techniques

Total knee replacement (TKA) surgery is an excellent and well-proven procedure for the treatment of end stage arthritis of the knee. Many refinements have taken place over time in an attempt to improve the components, wear qualities of the polyethylene, and the surgical technique to improve accuracy of component positioning, reduce patient pain, improve postoperative range of motion, ultimately improve results and to prolong the time until revision surgery may occur. This study examines the results of a gap balancing surgical technique in which components were implanted that had a posterior cruciate substituting design. This technique is performed with exacting alignment and balancing of the flexion and extension gaps prior to implantation of the knee components. The follow up is at a minimum of ten years. 515 consecutive knee replacements were followed prospectively for a minimum of ten years. The average age at surgery was 70 years, 73% of patients were female, with an average BMI of 31. All patients carried a diagnosis of osteoarthritis and a cemented, posterior stabilized design TKA (Balanced Knee System, Ortho Development) was implanted. All cases were performed by one of two experienced joint replacement surgeons. The surgical technique demanded flexion and extension gap balancing as well as soft tissue balancing prior to finishing cuts being performed on the femoral side (See figures 1 and 2). Polyethylene spacers come in 1 millimeter increments. 28% of patients died postoperatively at an average of 7.4 years. These patients were older on average at the time of index surgery (76.6 years). None had undergone revision surgery. Of the remaining patients Knee Society scores (39 preop to 91 post op at ten years), function scores and range of motion all improved significantly. What's more, these results were not diminished at ten years. There were no component failures and less than 1% radiographic progressive lucent lines. Eleven revision surgeries (2.1 %) were performed with 2 acute superficial wound revisions, 3 late infections, one patellar tendon disruption from a fall at 7 years (BMI 45.7), 2 complete revisions performed elsewhere for unsatisfactory results, and 3 spacer exchanges for perception of postoperative laxity. For the current study we also examined subgroups of the morbidly obese, octogenarians, and those with a preoperative valgus deformity of greater than 15%. At follow-up these subgroups fared very well with the exception of the heaviest BMI's being limited in range of motion because of soft tissue impingement. Results suggest that this balancing technique gives excellent results with few complications at ten year evaluation. We believe that careful attention to bony and soft tissue balancing and equalization of gaps in flexion and in extension will prove beneficial for TKA longevity in even longer-term evaluation. Figures 1 and 2 demonstrate gap balancing blocks and alignment rods in extension and in flexion

Introduction. Total hip replacement (THR) is one of the most successful orthopedic surgeries performed today. Long term success of THR has been well established, but there remains significant room to improve early outcomes (e.g. pain, length of hospital stay, readmissions). The surgical technique is a key variable affecting these early outcomes. The objective of the current study was to evaluate outcomes for over 1,000 consecutive THRs using the supercapsular percutaneously-assisted total hip (SuperPath) approach. Patients and Methods. Between September 2008 and April 2015, one surgeon performed 1,074 consecutive primary THRs using the SuperPath surgical technique. All THRs were performed without local anesthesia, patient controlled analgesia (PCA), or postoperative hip precautions. Surgical outcomes including operative time, blood loss, incision length, length of stay (LOS), and complications were collected as part of this IRB approved study. Harris Hip Scores (HHS) and UCLA scores were obtained preoperatively and at 6 and 12 months postoperatively. Results. The mean operative time, blood loss, incision length, and LOS were 75 minutes (range, 40–141), 150 mL (range, 50–900), 7.4 cm (range, 5–12), and 1.4 days, respectively. In total there were 29 complications including: 6 (0.5%) periprosthetic fractures; 4 (0.3%) thromboembolisms; 3 (0.2%) subsidence; 2 (0.1%) heterotropic ossifications; and 1 (0.09%) dislocation. There were no instances of infection or neurovascular injury. Mean HHS improved from 45.4 preoperatively to 89.9 and 87.2 at 6 and 12 months, respectively. Mean UCLA scores improved from 3.9 preoperatively to 5.5 and 5.6 at 6 and 12 months, respectively. Conclusions. These results from over 1,000 consecutive THRs using the SuperPath technique demonstrate this technique is safe and reliable, with results similar or better than those reported for other THR surgical techniques. There was a low rate of complications with an even distribution and no bias to early cases

Aim

Clavicular osteotomy was described as an adjunct to deltopectoral approach for improved exposure of the glenohumeral joint. This study aims to present contemporary outcomes and complications associated with the routine use of clavicular osteotomy by a single surgeon in a regional setting within New Zealand.

Introduction. Management of the sequelae of arthritis of the hip joint has changed over time. Total joint replacement has gained popularity due to retained mobility and stability. In the high demand paediatric and adolescent population problems are encountered with longevity of the procedure. Hip arthrodesis is a useful alternative procedure that sacrifices mobility of the joint to achieve pain relief and restores function. Several surgical techniques have been described to achieve hip fusion. We describe a technique that achieves concentric bone surfaces with hip resurfacing reamers. Maximum bone is preserved to maintain leg length. Trans-articular compression is achieved with cannulated screw fixation. Subtrochanteric de-functioning osteotomy completes the procedure to protect the fusion site and control the position of the limb. Our optimal position of fusion was 30 degrees of flexion, neutral to 5 degrees of abduction and neutral to 10 degrees of external rotation. Methods. Fourteen patients (8 female) treated by hip arthrodesis over a two-year period are reviewed in terms of clinical and radiological outcome in the short term. Their mean age at hip fusion was 11 years (6–18). The etiology included TB (6 cases), staphylococcal infection (2), non-specific arthritis (3), Perthe's (1), chondrolysis (1) and avascular necrosis following trauma (1). Results. Fusion was achieved in 12/14 patients. All patients in whom fusion was achieved had relief of pain and returned to their normal activities. Conclusion. We believe hip arthrodesis performed in the correct patient is a good procedure to preserve function and relieve pain. The procedure is technically demanding and careful follow-up to ensure optimal positioning and solid fusion is essential to ensure good results. NO DISCLOSURES

Introduction. Femoral neck fracture is a common injury in elderly patients. To restore the activity with an acceptable morbidity and to decrease of mortality, surgical procedures are thought to be superior to conservative treatments. Osteosynthesis with internal fixation for nondisplaced type, and hemiarthroplasty or total hip replacement (hip arthroplasties) for displaced type are commonly performed. Cemented arthroplasty has been preferred over non-cemented arthroplasty because of less postoperative pain, better mobility and excellent initial fixation of the implant, especially for osteoporotic and stove-pipe bones. However, pressurizing bone cement may cause cardiorespiratory and vascular complications, and occasionally death, which has been termed as “bone cement implantation syndrome”. To avoid the occurrence of this syndrome, non-cemented implants have been developed. However, most implants with the press fit concepts and flat wedge taper designs have a risk of intraoperative and early postoperative periprosthetic fracture. Recently, we have employed a non-cemented femoral component, which has a lateral expansion to the proximal body as compared to a conventional hip stem. Because of this shape, which is called a “lateral flare”, this stem provides a physiological loading on both the medial and lateral endosteal surfaces of the femur. This is in contrast to conventional hip stem which prioritizes loading on the medial and metaphyseal /dyaphyseal surfaces of the femur. Moreover, the cross section of this stem is trapezoid with the flat posterior surface. This shape provides the stem with rotational stability along the long axis of the femur, and maximizes loading transfer to the posterior aspect of the proximal femur. These mechanical features avoid the need for aggressive impaction of the stem at the time of insertion. It is necessary to only tap gently to achieve the secure initial implant fixation by a “rest fit”. Thus, this technique reduces the risk of fracture. Patients and methods. We employed this technique using a non-cemented lateral flare design device for displaced femoral neck fractures since 1996. Surgical procedures were performed with posterior approach under the spinal or epidural anesthesia. Full weight bearing ambulation with a walker was allowed on post-op day one. Results and discussion. Since that time, we have had no femoral fracture, no dislocation of the hip, nor severe complications intraoperatively and post operatively. There has been no evidence of radiographic aseptic loosening or axial migration of the stems during this time period. Conclusions. “Rest fit” surgical technique avoids complications associated with cemented and traditional non-cemented arthroplasties for displaced femoral neck fractures. It however requires specific geometric features to be included the designs of the femoral component to assure secure initiate fixation at the time of arthroplasty. Therefore, this lateral flare implants are effective for the treatment of the displaced type of femoral neck fracture

Introduction. Review the results of modified Lautenbach procedure (new method) to treat chronic osteomyelitis of the long bones. Patients and methods. Retrospective analysis of sixty-seven patients with osteomyelitis of the long bones treated over 5-year period with modified Lautenbach procedure. Four patients were excluded from this study, as we were unable to retrieve the case notes. 48 men and 16 women were included and the average age was 33 years. All these patients had prior operative intervention including plating, intramedullary nailing or external fixator. Forty-seven patients had discharging sinuses and deformed leg. We noted the pre-operative inflammatory markers, bacteriology and pain score. We also recorded the duration of the hospital stay, post-operative recovery, deformity and the ability of the patient to resume his prior occupation. Surgical technique. Surgical technique included radical debridement, reaming of the medullary canal and on table irrigation and lavage until all the debri was cleared. We did not use the continuous irrigation system originally used by Lautenbach. Arrangements were done for regular dressings of the wounds. Results. Most of the patients got better with no signs of osteomyelitis. Four patients still has had sinuses. One patient needed amputation and another one arthrodesis. Eleven patients needed walking stick while others were able to mobilise without a walking aid. Twelve patients returned to their previous occupation, 39 changed their occupation and others were retired. The follow up radiographs revealed a solid union with no signs of osteomyelitis in 57 patients at the end of treatment. Conclusion. The above-described method is easy and very effective. This is a modification of Lautenbach procedure and the results are impressive. This is more patient compliant as there is no need for the patient to stay in the ward for continuous irrigation

BACKGROUND. Our modified procedure for rotational acetabular osteotomy (RAO) aimed to reduce operative invasion of soft tissue and to minimize incision length. SURGICAL TECHNIQUE. A shortened skin incision (10–15 cm versus 20–30 cm in traditional RAO) is curved over greater trochanter and exposed by transtrochanteric approach. Medial gluteus muscle is retracted to expose the ilium without detachment from iliac crest. Similarly the rectus femoris muscle tendon was retracted, not excised, from the anterior inferior iliac spine. The lateral part of the osteotomized ilium is cut in lunate and trapezoid shape to form the bone graft instead of the outer cortical bone of the ilium. PATIENTS. We performed RAO on 66 patients (75 hips) using this modified procedure between 2000 and 2009. Follow-up rate was 95% (71/75 hips). Of 71 hips, 28 had early-stage, and 43 had advanced-stage osteoarthritis. Mean patient age was 39.7 years at time of surgery. Mean length of follow-up was 5.3 years. Clinical assessment was performed using the Merle d'Aubigne & Postel scores. Radiographically, the lateral center-edge (CE) angle, the Sharp angle and acetabular head index (AHI) were evaluated pre- and post-operatively. RESULTS. Mean CE angle, Sharp angle and AHI improved pre- to post-operatively from −1.3 degrees to 36.5 degrees (p<0.00001), 50.3 degrees to 39.4 degrees (p<0.00001), 54.0 % to 95.7 % (p<0.00001), respectively. Clinical hip scores at latest follow-up were significantly improved. No progression of osteoarthritis was seen in hips with early-stage osteoarthritis. Ten hips with advanced-stage osteoarthritis preoperatively had radiographic evidence of progression of osteoarthritis, and six of those were converted to total hip arthroplasty. Complications included two transient lateral femoral cutaneous nerve palsies and ectopic bone formation in 15 hips, one of which required excision 1.5 years post-RAO. Kaplan-Meier survivorship analysis, with decreased clinical scores from pre-operatively and radiographic signs of progression of osteoarthritis as the end point, predicted a 10-year survival rate of 100% for early-stage osteoarthritis hips and 72.1 % for advanced-stage osteoarthritis. CONCLUSIONS. Less invasive surgical procedure for RAO preserved function of hip abductor muscle and did not adversely influence on clinical or radiographic outcome

When removing femoral cement in revision hip surgery, creating an anterior femoral cortical window is an attractive alternative to extended trochanteric osteotomy. We describe our experience and evolution of this technique, the clinical and radiological results, and functional outcomes.

Between 2006 and 2021 we used this technique in 22 consecutive cases at Whanganui Hospital, New Zealand. The average age at surgery was 74 years (Range 44 to 89 years). 16 cases were for aseptic loosening: six cases for infection.

The technique has evolved to be more precise and since 2019 the combination of CT imaging and 3-D printing technology has allowed patient-specific (PSI) jigs to be created (6 cases). This technique now facilitates cement removal by potentiating exposure through an optimally sized anterior femoral window.

Bone incorporation of the cortical window and functional outcomes were assessed in 22 cases, using computer tomography and Oxford scores respectively at six months post revision surgery. Of the septic cases, five went onto successful stage two procedures, the other to a Girdlestone procedure.

On average, 80% bony incorporation of the cortical window occurred (range 40 −100%). The average Oxford hip score was 37 (range 22 – 48). Functional outcome (Oxford Hip) scores were available in 11 cases (9 pre-PSI jig and 2 using PSI jig). There were two cases with femoral component subsidence (1 using the PSI jig).

This case series has shown the effectiveness of removing a distal femoral cement mantle using an anterior femoral cortical window, now optimized by using a patient specific jig with subsequent reliable bony integration, and functional outcomes comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry.

Abstract

Background. Management of the patella with poor bone stock remains a challenge in revision total knee arthroplasty (TKA). The purpose of this study was to evaluate the results of a novel surgical technique in which widely available wires and acrylic bone cement are used in the reconstruction of a deficient patella. Methods. Twenty-eight patients (30 knees) underwent revision TKA in which a deficient patella was treated with an onlay-type prosthesis and bone-augmenting procedure, using transcortical wiring. The technique was indicated when the thickness of remnant patella was less than 8mm with variable amounts of the peripheral rim. The remaining patellar height ranged from 3.2mm to 7.3mm. Follow-up was available for all patients with a mean of 36.6 months (range, 24 to 55 months). Results. The respective mean Knee Society scores for knee and function improved from 34.2 points (range, 18 to 65 points) and 23 points (range, 18 to 46 points) preoperatively to 73.5 points (range, 30 to 88 points) and 61points (range, 34 to 80 points) at final follow-up. The mean thickness of the patellar construct was 14.6mm (range, 12.2 – 18.3mm). One patient experienced patellar fracture during knee flexion one week after surgery. There were no complications associated with implanted hardware. Conclusions. A patellar bone-augmenting procedure using transcortical wiring is a straightforward technique that potentially allows firm fixation. Considering the satisfactory short- to mid-term results, we believe that this technique provides a good alternative option in addressing this challenging problem in revision TKA

Outpatient total hip arthroplasty (THA) has remained controversial and challenging. Traditional hospital stays following total joint arthroplasty were substantial and resulted in increased rates of morbidity, significant pain, and severe restriction in mobility. Advancements in the surgical approach, anesthetic regimens, and the initiation of rapid rehabilitation protocols have had an impact on the length of recovery following elective THA. Still, very few studies have specifically outlined outpatient hip arthroplasty and, thus far, none have addressed the use of robotic-arm navigation in outpatient THA. This article describes in detail the technique used to perform outpatient THA with the use of robotic-arm assistance. We believe that outpatient THA using robotic-arm assistance in combination with tissue-preserving surgery, multi-modal pain and nausea management, early rehabilitation, and stringent patient selection yields a suitable alternative to inpatient joint replacement.

Introduction. Lewinnek et al described a safe zone of acetabular component placement in Total Hip Arthroplasty (THA) to reduce complications. Callanan et al proposed a modified safe zone with a reduced range of acetabular inclination of 30–45 degrees to eliminate the steeper or more inclinated cups 2. This study compares the accuracy of cup placement in the safe zones described by Lewinnek et al and Callanan et al, leg length discrepancy (LLD) and global offset (GO) measurement in THA using five different surgical techniques performed by six different surgeons. Methods. Between June 2008 and April 2014, 2330 THRs were performed by six different surgeons. Post-operative radiographic images were retrospectively reviewed and measured using TraumaCad® software to determine cup placement, LLD, and GOD. Results. One thousand, nine hundred-eighty patients met the inclusion and exclusion criteria. Ninety-three (4.69%) patients underwent robotic-assisted THA anterior approach, 135 (6.8%) had robotic-assisted THA posterior approach, 942 (47.5%) patients underwent fluoroscopic guided THA anterior approach, 708 (35.7%) had THA without guidance using posterior approach, 43 (2.1%) patients underwent navigation-guided anterior approach and 59 (2.9%) patients underwent radiographic-guided posterior approach THAs. Robotic guidance groups had a significantly greater percentage of hips in the Lewinnek's and Callanan's safe zone (p < 0.005). Between robotic guidance groups, the group with posterior approach has more cups placed in the Lewinnek's and Callanan's safe zone (p < 0.005). The frequency of hips within the Lewinnek's safe zone was significantly greater in the navigation guided group, compared to the other groups except robotic guided (p < 0.05). Sixty-four (3.2%) of our cases were with LLD greater than or equal to 10mm, five of those cases were (8.5%) in the group treated with x-ray guidance. (p < 0.05). The mean GOD for the overall cohort was 4.0mm ± 0.4mm (p < 0.0001). Mean ages of patients in the treatment groups were significantly different (p < 0.0001). Conclusion. Robotic assisted surgery was more consistent than the other techniques in placing the acetabular cup into the Lewinnek and Callanan safe zone. The use of robotic assistance in hip arthroplasty surgery is more accurate fulfilling the goals needed to actual hip arthroplasty. Long term follow-up is required to determine clinical impact of increased accuracy