To document and assess the available evidence regarding single bundle, hamstrings autograft preparation techniques for Anterior Cruciate Ligament reconstruction (ACLR) and provide graft preparation options for different clinical scenarios.

Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until April 10, 2021. The inclusion criteria were English language studies, human studies, and operative technique studies for single bundle hamstrings autograft preparation for ACLR. Descriptive characteristics, the number of tendons, number of strands, tendon length, graft length and graft diameter were recorded. The methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for non-randomized and randomized studies, respectively.

The initial search yielded 5485 studies, 32 met the inclusion criteria. The mean MINORS score across all nonrandomized studies was 8.2 (standard deviation, SD 6.6) indicating an overall low quality of evidence. The mean MINORS score for comparative studies was 17.4 (SD 3.2) indicating a fair quality of evidence. The GRADE assessment for risk of bias in the randomized study included was low.

There were 2138 knees in 1881 participants, including 1296 (78.1%) males and 363 (21.9%) females recorded. The mean age was 30.3 years. The mean follow-up time was 43.9 months when reported (range 16-55 months). Eleven studies utilized the semitendinosus tendon alone, while 21 studies used both semitendinosus and gracilis tendons. There were 82 (3.8%) two-strand grafts, 158 (7.4%) three-strand grafts, 1044 (48.8%) four-strand grafts, 546 (25.5%) five-strand grafts, and 308 (14.4%) six-strand grafts included. Overall, 372 (19.7%) participants had a single-tendon ACLR compared to 1509 (80.2%) participants who had a two-tendon ACLR.

The mean graft diameter was 9.4mm when reported. The minimum semitendinosus and gracilis tendon lengths necessary ranged from 210-280mm and 160-280mm respectively. The minimum graft length necessary ranged from 63-120mm except for an all-epiphyseal graft in the paediatric population that required a minimum length of 50mm. The minimum femoral, tibial, and intra-articular graft length ranged from 15-25mm, 15-35mm and 20-30mm respectively. Thirteen studies detailed intra-operative strategies to increase graft size such as adding an extra strand or altering the tibial and/or femoral fixation strategies to shorten and widen the graft.

Two studies reported ACL reinjury or graft failure rate. One study found no difference in the re-injury rate between four-, five- and six-strand grafts (p = 0.06) and the other found no difference in the failure rate between four- and five- strand grafts (p = 0.55). There was no difference in the post-operative Lysholm score in 3 studies that compared four- and five-strand ACLR. One of the five studies that compared post-operative IKDC scores between graft types found a difference between two- and three- strand grafts, favoring three-strand grafts.

There are many single bundle hamstrings autograft preparation techniques for ACLR that have been used successfully with minimal differences in clinical outcomes. There are different configurations that may be utilized interchangeably depending on the number, size and length of tendons harvested to obtain an adequate graft diameter and successful ACLR.

Introduction

External fixators are common surgical orthopaedic treatments for the management of complex fractures and in particular, the use of circular frame fixation within patients requiring limb reconstruction. It is well known that common complications relating to muscle length and patient function without rehabilitation can occur. Despite this there remains a lack of high-quality clinical trials in this area investigating the role of physiotherapy or rehabilitation in the management of these patients. We aim to complete a systematic review of rehabilitation techniques for patients undergoing external fixator treatment for Limb Reconstruction of the lower limb.

This study aimed to analyze the effect of two different techniques of cement application: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term effect of radiolucent lines (RLL) in primary fully cemented total knee arthroplasties (TKA) with patella resurfacing.

379 fully cemented TKAs (318 patients) were included in this monocentric study. Preoperative and postoperative at week 4 and 12 month after surgery all patients had a clinical and radiological examination and were administered the Oxford Knee Score (OKS). Cement was applied in two different ways among the two study groups: cement on bone surface (CoB group) or cement on bone surface and implant surface (CoBaI group). The evaluation of the presence of RLL or osteolysis was done as previously described using the updated Knee Society Radiographic Evaluation System.

The mean OKS and range of motion improved significantly in both groups at the 4-week and 12-month follow-up, with no significant difference between the groups (CoB vs. CoBaI). RLL were present in 4.7% in the whole study population and were significantly higher in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up RLL were seen in 29.8% of the TKAs in the CoBaI group, whereas the incidence was lower in the CoB group (24.0% (n.s.)). There were two revisions in each group. None of these due to aseptic loosening.

Our study indicated that the application of bone cement on bone surface only might be more beneficial than onto the bone surface and onto the implant surface as well in respect to the short-term presence of RLL in fully cemented primary TKA.

The long-term results will be of interest, especially in respect to aseptic loosening and might guide future directions of bone cement applications in TKA.

Neer Type-IIB lateral clavicle fractures are inherently unstable fractures with associated disruption of the coracoclavicular (CC) ligaments. A novel plating technique using a superior lateral locking plate with antero-posterior (AP) locking screws, resulting in orthogonal fixation in the lateral fragment has been designed to enhance stability. The purpose of this study was to biomechanically compare three different clavicle plating constructs.

24 fresh-frozen cadaveric shoulders were randomised into three groups (n=8 specimens). Group 1: lateral locking plate only (Medartis Aptus Superior Lateral Plate); Group 2: lateral locking plate with CC stabilisation (Nr. 2 FiberWire); and Group 3: lateral locking plate with two AP locking screws stabilising the lateral fragment. Data was analysed for gap formation after cyclic loading, construct stiffness and ultimate load to failure, defined by a marked decrease in the load displacement curve.

After 500 cycles, there was no statistically significant difference between the three groups in gap-formation (p = 0.179). Ultimate load to failure was significantly higher in Group 3 compared to Group 1 (286N vs. 167N; p = 0.022), but not to Group 2 (286N vs. 246N; p = 0.604). There were no statistically significant differences in stiffness (Group 1: 504N/mm; Group 2: 564N/mm; Group 3: 512N/mm; p = 0.712). Peri-implant fracture was the primary mode of failure for all three groups, with Group 3 demonstrating the lowest rate of peri-implant fractures (Group 1: 6/8; Group 2: 7/8, Group 3: 4/8; p = 0.243).

The lateral locking plate with orthogonal AP locking screw fixation in the lateral fragment demonstrated the greatest ultimate failure load, followed by the lateral locking plate with CC stabilization. The use of orthogonal screw fixation in the distal fragment may negate against the need for CC stabilization in these types of fractures, thus minimizing surgical dissection around the coracoid and potential complications.

Meniscal root tears can result from traumatic injury to the knee or gradual degeneration. When the root is injured, the meniscus becomes de-functioned, resulting in abnormal distribution of hoop stresses, extrusion of the meniscus, and altered knee kinematics. If left untreated, this can cause articular cartilage damage and rapid progression of osteoarthritis. Multiple repair strategies have been described; however, no best fixation practice has been established. To our knowledge, no study has compared suture button, interference screw, and HEALICOIL KNOTLESS fixation techniques for meniscal root repairs. The goal of this study is to understand the biomechanical properties of these fixation techniques and distinguish any advantages of certain techniques over others. Knowledge of fixation robustness will aid in surgical decision making, potentially reducing failure rates, and improving clinical outcomes.

19 fresh porcine tibias with intact medial menisci were randomly assigned to four groups: 1) native posterior medial meniscus root (PMMR) (n = 7), 2) suture button (n = 4), 3) interference screw (n = 4), or 4) HEALICOIL KNOTLESS (n = 4). In 12 specimens, the PMMR was severed and then refixed by the specified group technique. The remaining seven specimens were left intact. All specimens underwent cyclic loading followed by load-to-failure testing. Elongation rate; displacement after 100, 500, and 1000 cycles; stiffness; and maximum load were recorded.

Repaired specimens had greater elongation rates and displacements after 100, 500, and 1000 cycles than native PMMR specimens (p 0.05). The native PMMR showed greater maximum load than all repair techniques (p 0.05). In interference screw and HEALICOIL KNOTLESS specimens, failure occurred as the suture was displaced from the fixation and tension was gradually lost. In suture button specimens, the suture was either displaced or completely separated from the button. In some cases, tear formation and partial failure also occurred at the meniscus luggage tag knot. Native PMMR specimens failed through meniscus or meniscus root tearing.

All fixation techniques showed similar biomechanical properties and performed inferiorly to the native PMMR. Evidence against significant differences between fixation techniques suggests that the HEALICOIL KNOTLESS technique may present an additional option for fixation in meniscal root repairs. While preliminary in vitro evidence suggests similarities between fixation techniques, further research is required to determine if clinical outcomes differ.

The extracortical single-button (SB) inlay repair is one of the most preferred distal biceps tendon repair techniques. However, specific complications such as neurovascular injury and non-anatomic repairs have led to the development of techniques that utilize intracortical double-button (DB) fixation.

To compare the biomechanical stability of the extracortical SB repair with the anatomical DB repair technique.

Controlled laboratory study.

The distal biceps tendon was transected in 18 cadaveric elbows from 9 donors. One elbow of each donor was randomly assigned to the extracortical SBor anatomical DB group. Both groups were cyclically loaded with 60N over 1000 cycles between 90° of flexion and full extension. The elbow was then fixed in 90° of flexion and the repair construct loaded to failure. Gap-formation and construct stiffness during cyclic loading, and ultimate load to failure was analysed.

After 1000 cycles, the anatomical DB technique compared with the extracortical SB technique showed significantly less gap-formation (mean difference 1.2 mm; p=0.017) and significantly more construct stiffness (mean difference 31 N/mm; p=0.023). Ultimate load to failure was not significantly different comparing both groups (SB, 277 N ±92 vs. DB, 285 N ±135; p=0.859). The failure mode in the anatomical DB group was significantly different compared with the extracortical SB technique (p=0.002) and was due to fracture avulsion of the BicepsButton in 7 out of 9 specimens (vs. none in SB group).

Our study shows that the intracortical DB technique produces equivalent or superior biomechanical performance to the SB technique. The DB repair technique reduces the risk of nerve injury and better restores the anatomical footprint of biceps tendon. The DB technique may offer a clinically viable alternative to the SB repair technique.

The infected TKA is one of the most challenging complications of knee surgery, but spacers can make them easier to treat. An articulating spacer allows weight bearing and range of motion of the knee during rehabilitation. This spacer is made using antibiotic-impregnated bone cement applied to the tibial and femoral implants. For our purpose, 4.8g powdered tobramycin is mixed with 2gm vancomycin and one batch of antibiotic. Cement is applied early to the components, but applied late to the femur, tibia, and patella to allow molding to the defects and bone without solid adherence to bone. Patients have tailored intravenous antibiotic therapy for 6 weeks for treatment of various gram-positive and gram-negative organisms. At 10–12 weeks patients are revised to a cemented revision total knee arthroplasty using standard cementing techniques. From our experience, range of motion before reimplantation was 5 – 90 degrees. Follow-up averaged 73 months for fifty patients with 90% good to excellent results; 10% had a recurrence of infections. Use of an articulating spacer achieves soft tissue compliance, allows for ease of re-operation, reduced postoperative pain, improved function, and eradicates infection equal to standards reported in the literature.

Surgeon-performed periarticular injection and anesthesiologist-performed femoral nerve or adductor canal block with local anesthetic have been used in multimodal pain management for total knee arthroplasty (TKA) patients. Anesthesiologist-performed adductor canal blocks are costly, time consuming, and may be unreliable. We investigated the feasibility of a surgeon-performed saphenous nerve (“adductor-canal”) block from within the knee joint.

A retrospective analysis of 94 thigh-knee MRI studies was performed to determine the relationship between the width of the distal femur at the epicondylar axis and the proximal location of the saphenous nerve after its exit from the adductor canal and separation from the superficial femoral artery. After obtaining these data, TKA resections and trial component implantation were performed, using a medial parapatellar approach, in 11 fresh cadaveric lower extremity specimens. Using a blunt tip 1.5cm needle, we injected 10 ml each of two different colored solutions at two different intra-articular medial injection locations, and after 30 minutes, dissected the femoral and saphenous nerve and femoral artery from the hip to the knee to determine the location of the injections.

Based upon the MRI analysis, the saphenous nerve was located (and had exited the adductor canal) at a mean of 1.5 times the epicondylar width in females, and mean 1.3 times the epicondylar width in males, proximal to the medial epicondyle. After placement of TKA trial components and injection, the proximal injection site solution bathed the saphenous nerve in 8 of 11 specimens. The proximal blunt needle and solution was adjacent, but did not puncture, the femoral artery and vein in only one specimen. This study suggests that a surgeon-performed injection of the saphenous nerve from within the knee is a feasible procedure. This technique may be a useful alternative to ultrasound guided block. A trial comparing surgeon and anesthesiologist-performed nerve block should be considered to determine the clinical efficacy of this procedure. Our anecdotal use of this intra-articular injection over the past year has been favorable. Newer, extended release anesthetic agents should be investigated with this technique.

The number of shoulder arthroplasty procedures performed in the United States continues to rise. Currently, the number of procedures performed per year ranges from 55,000–80,000 and is expected to increase more than 300% in the coming years. Periprosthetic joint infection (PJI) is one of the most serious complications associated with arthroplasty surgery, leading to poor outcomes, increased cost, and technically difficult revision surgery. The incidence of infection following primary shoulder arthroplasty has been reported between 0.7% and 4%, representing 2.9–4.6% of all complications.

Prosthetic shoulder joint infections are unlike prosthetic joint infections of the hip and knee. Shoulder PJIs are primarily indolent in nature and difficult to diagnose using traditional methods that have been shown to be accurate for periprosthetic infections of the hip and knee. The majority of infected revision shoulder arthroplasties are associated with growth of Propionibacterium acnes (P. Acnes). This slow-growing, anaerobic organism requires longer than normal incubation times for culture (7–21 days), and typically demonstrates a subtle, non-specific clinical presentation that can make the presence of infection difficult to identify. In the reported literature, P. Acnes accounts for about 70% of cases with positive cultures associated with revision for treatment of a painful shoulder arthroplasty and due to the bacteria's slow growing nature and virulence profile, the rate of infection following shoulder arthroplasty may often be underestimated.

A more recent and promising tool for evaluation of periprosthetic infection has been analysis of synovial fluid. Synovial fluid biomarkers have been identified as part of the innate response to pathogens, and include pro-inflammatory cytokines and anti-microbial peptides, and marker levels have shown promise for improved diagnostic efficacy in hip and knee PJI. Currently, no highly predictive clinical test for diagnosis of PJI in the shoulder exists, however, several of these synovial biomarkers have recently been analyzed for their diagnostic capacity in the setting of periprosthetic shoulder infection.

Synovial fluid cytokine analysis shows the potential to improve diagnosis of infection in revision shoulder arthroplasty. This information can help to guide decision-making in the management of PJI of the shoulder, including the decision to perform a single- vs. two-stage revision surgery, and the need for post-operative antibiotics following an unexpected positive culture result after revision surgery. However, there are still challenges to broader use of these synovial biomarkers. Synovial α-defensin (Synovsure, CD Diagnostic) is the only marker currently available as a commercial test, and no point-of-care test is currently available for any of the biomarkers to allow for intraoperative decision-making. While a preoperative synovial aspirate is possible to send for α-defensin analysis currently, with results back in approximately 24 hours, dry fluid aspirations are frequent in the shoulder because of the predominance of indolent pathogens and may limit utility of the test.

In summary, indolent infection associated with P. acnes is a common cause for the painful total shoulder arthroplasty. Pre-operative diagnosis of infection is difficult as a result of the poor diagnostic accuracy of traditional methods of testing. Synovial biomarker testing may ultimately improve our ability to more accurately diagnosis and treat prosthetic shoulder joint infections.

Hip arthroscopy rates continue to increase. As a result, there is growing interest in capsular management techniques. Without careful preservation and surgical techniques, failure of the repair result in capsular deficiency, contributing to iatrogenic instability and persistent post-operative pain. In this setting, capsular reconstruction may be indicated, however there is a paucity of objective evidence comparing surgical techniques to identify the optimal method. Therefore, the objective of this study was to evaluate the biomechanical effect of capsulectomy and two different capsular reconstruction techniques (iliotibial band [ITB] autograft and Achilles tendon allograft) on hip joint kinematics in both rotation and abduction/adduction.

Eight paired fresh-frozen hemi-pelvises were dissected of all overlying soft tissue, with the exception of the hip joint capsule. The femur was potted and attached to a load cell connected to a joint-motion simulator, while the pelvis was secured to a custom-designed fixture allowing adjustment of the flexion-extension arc. Optotrak markers were rigidly attached to the femur and pelvis to track motion of the femoral head with respect to the acetabulum. Pairs were divided into ITB or Achilles capsular reconstruction. After specimen preparation, three conditions were tested: (1) intact, (2) after capsulectomy, and (3) capsular reconstruction (ITB or Achilles). All conditions were tested in 0°, 45°, and 90° of flexion. Internal rotation (IR) and external rotation (ER) as well abduction (ABD) and adduction (ADD) moments of 3 N·m were applied to the femur via the load cell at each position. Rotational range of motion and joint kinematics were recorded.

When a rotational force was applied the total magnitude of internal/external rotation was significantly affected by the condition of the capsule, independent of the type of reconstruction that was performed (p=0.001). The internal/external rotation increased significantly by approximately 8° following the capsulectomy (p<0.001) and this was not resolved by either of the reconstructions; there remained a significant difference between the intact and reconstruction conditions (p=0.035). The total anterior/posterior translation was significantly affected by the condition of the capsule (p=0.034). There was a significant increase from 6.7 (6.0) mm when the capsule was intact to 9.0 (6.7) mm following the capsulectomy (p=0.002). Both of the reconstructions (8.6 [5.6] mm) reduced the anterior/posterior translation closer to the intact state. There was no difference between the two reconstructions. When an abduction/adduction force was applied there was a significant increase in the medial-lateral translation between the intact and capsulectomy states (p=0.047).

Across all three flexion angles the integrity of the native hip capsule played a significant role in rotational stability, where capsulectomy significantly increased rotational ROM. Hip capsule reconstruction did not restore rotational stability and also increased rotational ROM compared to the intact state a statistically significant amount. However, hip capsule reconstruction restored coronal and sagittal plane stability to approach that of the native hip. There was no difference in stability between ITB and Achilles reconstructions across all testing conditions.

Rotator cuff tears are the most common cause of shoulder disability, affecting 10% of the population under 60 and 40% of those aged 70 and above. Massive irreparable rotator cuff tears account for 30% of all tears and their management continues to be an orthopaedic challenge. Traditional surgical techniques, that is, tendon transfers are performed to restore shoulder motion, however, they result in varying outcomes of stability and complications. Superior capsular reconstruction (SCR) is a novel technique that has shown promise in restoring shoulder function, albeit in limited studies. To date, there has been no biomechanical comparison between these techniques. This study aims to compare three surgical techniques (SCR, latissimus dorsi tendon transfer and lower trapezius tendon transfer) for irreparable rotator cuff tears with respect to intact cuff control using a clinically relevant biomechanical outcome of rotational motion.

Eight fresh-frozen shoulder specimens with intact rotator cuffs were tested. After dissection of subcutaneous tissue and muscles, each specimen was mounted on a custom shoulder testing apparatus and physiologic loads were applied using a pulley setup. Under 2.2 Nm torque loading maximum internal and external rotation was measured at 0 and 60 degrees of glenohumeral abduction. Repeat testing was conducted after the creation of the cuff tear and subsequent to the three repair techniques. Repeated measures analysis with paired t-test comparisons using Sidak correction was performed to compare the rotational range of motion following each repair technique with respect to each specimen's intact control. P-values of 0.05 were considered significant.

At 0° abduction, internal rotation increased after the tear (intact: 39.6 ± 13.6° vs. tear: 80.5 ± 47.7°, p=0.019). Internal rotation was higher following SCR (52.7 ± 12.9°, intact - SCR 95% CI: −25.28°,-0.95°, p=0.034), trapezius transfer (74.2 ± 25.3°, intact – trapezius transfer: 95% CI: −71.1°, 1.81°, p=0.064), and latissimus transfer (83.5 ± 52.1°, intact – latissimus transfer: 95% CI: −118.3°, 30.5°, p=0.400) than in intact controls. However, internal rotation post SCR yielded the narrowest estimate range close to intact controls. At 60° abduction, internal rotation increased after the tear (intact: 38.7 ± 14.4° vs. tear: 49.5 ± 13°, p=0.005). Internal rotation post SCR did not differ significantly from intact controls (SCR: 49.3 ± 10.1°, intact – SCR: 95% CI: −28°, 6.91°, p=0.38). Trapezius transfer showed a trend toward significantly higher internal rotation (65.7 ± 21.1°, intact – trapezius transfer: 95% CI: −55.7°, 1.7°, p=0.067), while latissimus transfer yielded widely variable rotation angle (65.7 ± 38°, intact – latissimus transfer: 95% CI: −85.9°, 31.9°, p=0.68). There were no significant differences in external rotation for any technique at 0° or 60° abduction.

Preliminary evaluation in this cadaveric biomechanical study provides positive evidence in support of use of SCR as a less morbid surgical option than tendon transfers. The cadaveric nature of this study limits the understanding of the motion to post-operative timepoint and the results herein are relevant for otherwise normal shoulders only. Further clinical evaluation is warranted to understand the long-term outcomes related to shoulder function and stability post SCR.

When dealing with a flexion contracture, a surgeon first should consider all potential causes, specifically ligament contracture and osteophytes. Then consider the size of the femoral component and its position proximal to distal and also the posterior slope of the tibial component.

Most knee flexion contractures are caused by osteophytes and tight ligaments, and once these problems are corrected, no further work needs to be done on the knee. So when the bone surface cuts are made, in general, little compensation is done in terms of positioning the femoral component proximal or distal, or in terms of sloping the tibial component (beyond the normal 3–4 degrees posterior slope), before the ligaments or osteophytes are managed. If the deep medial collateral ligament (MCL) and posterior portion of the superficial MCL are tight, a flexion contracture will almost always be present after the bone surfaces are finished. Once this is corrected with proper ligament releases and removal of osteophytes, then ligament balance and flexion contracture should be reassessed. In the very few cases that still have a flexion contracture, posterior capsule release should be done. Once this is finished, releasing the capsule from both the femur and the medial aspect of the tibia, then ligament balance is reassessed again. If flexion contracture still remains (<10% of cases), then the distal surface of the femur is resected another 4–6 mm, trial components are inserted, and flexion contracture is evaluated. If more bony resection is needed, then changing tibial slope from 4 degrees posterior slope to 0 degrees slope is another step that can be done to remove bone from extension space of the knee finally to achieve full extension. Virtually all flexion contractures, except those with severe contracture resulting from hamstring tightness, can be corrected with this method.

In the valgus knee with flexion contracture, similar management is used. Knees that will not extend and remain tight on the lateral side usually are corrected with release of the posterior capsule and posterior portion of the iliotibial band. Just as on the lateral side, bone resection from the distal femur can be performed as a final effort to achieve full extension of the knee.

It is worth reiterating that almost all flexion contractures are caused by ligament imbalance, and that over-resection of the distal femur at the start of these cases can easily result in hyperextension that is difficult to manage once ligaments have been balanced.

Deep peri-prosthetic infection after partial or total knee arthroplasty is a disconcerting problem for patient and surgeon alike. The diagnosis of infection is sometimes obvious but frequently requires that the surgeon maintain a substantial index of suspicion for infection as the cause of pain or poor outcome after any joint arthroplasty. While surgical debridement with component retention is appropriate in a subgroup of patients with an acute peri-prosthetic infection, most delayed and chronic infections are best treated with component resection. With carefully selected patients and very aggressive debridement protocols some success has been demonstrated in Europe with single-stage exchange for infection. Most surgeons in North America, however, are unfamiliar with the very aggressive debridement techniques employed at European centers that promote single stage replant; and few surgeons in North America are currently comfortable in cementing a hinged total knee replacement in place for the typical infected TKA nor do they have the patience to re-prep and drape with an entirely new OR setup after debridement and prior to the insertion of the new implant − 2 steps that are often mentioned as important to the success of single stage exchange.

The pre-eminent role of two-stage exchange as the definitive treatment was established over 30 years ago. Two-stage exchange remains the gold-standard in treatment with an established track record from multiple centers and with multiple different types of infecting organisms. Some of the historical problems with two-stage exchange, such as limited mobility during the interval stage, have been mitigated with the development of effective articulating spacer techniques. Further, the emergence of drug resistant bacteria and the possibility of fungal infection make two-stage exchange the best choice for the majority of patients with deep periprosthetic joint infection in 2017.

Aims

Accurate and precise acetabular reaming is a requirement for the press-fit stability of cementless acetabular hip replacement components. The accuracy of reaming depends on the reamer, the reaming technique and the bone quality. Conventional reamers wear with use resulting in inaccurate reaming diameters, whilst the theoretical beneficial effect of ‘whirlwind’ reaming over straight reaming has not previously been documented. Our aim was to compare the accuracy and precision of single use additively-manufactured reamers with new conventional reamers and to compare the effect of different acetabular reaming techniques.

Periprosthetic joint infection (PPJI) following shoulder arthroplasty is uncommon, with an overall rate of 0.98%. However, the rates following revision arthroplasty and reverse arthroplasty are much higher. Given the rapid increase in the prevalence of shoulder arthroplasty and the increasing revision burden, the cost of PPJI to society will likely increase substantially. The most common organisms found in PPJI following shoulder arthroplasty are Staphylococcus aureus, coagulase-negative Staphylococcus, and Propionibacterium acnes (P. acnes). P. acnes is especially common in males. Traditional testing for PPJI includes aspiration, white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP). Aspiration often yields a dry tap and when fluid is obtained for culture, a positive result is helpful but a negative result does not rule out PPJI. Although WBC, ESR, and CRP are often positive with PPJI in the lower extremity, they are most often negative in shoulder PPJI. Although bone scans and WBC labeled scans are used, they are expensive and have low sensitivity and specificity.

New testing and techniques have been reported in an attempt to improve sensitivity and specificity for PPJI. These techniques can be divided into tests on serum, synovial fluid, and tissue. Serum Interleukin-6 (IL-6) is highly specific (94%) for shoulder PPJI but has low sensitivity (14%). Synovial fluid can be tested for leukocyte esterase using a simple and cheap technique. In lower extremity PPJI it has shown to be helpful. It is not as helpful in shoulder PPJI with 30% sensitivity and 67% specificity. Alpha defensin has been reported to be more sensitive (63%) and as specific (95%) as traditional techniques but still lacks predictive value. Testing for specific cytokines (IL-2, IL-6, TNF- α) within synovial fluid is not widely used as yet but has shown promise with 80% sensitivity and 90% specificity. Obtaining tissue for culture and other testing is probably the most reliable way of confirming PPJI for the shoulder. Frozen sections taken at the time of revision can be helpful but is very pathologist dependent and institution specific. With a dedicated musculoskeletal pathologist, the finding of 10 or more WBCs per high powered field has been reported to be 72% sensitive and 100% specific for P. acnes and 63% sensitive and 100% specific for other organisms. Cultures from arthroscopic tissue biopsy have also been found to have high sensitivity (100%) and specificity (100%). Genetic testing of tissue biopsy specimens (PCR/NGS) has recently been reported and shows great promise. The significance of positive cultures and other tests, especially for P. acnes is unclear. There is a high rate of positive intra-operative cultures in primary cases of shoulder arthroplasty. In addition, intra-operative cultures taken at the time of revision, even in cases in which infection is not suspected, are frequently positive for P. acnes with weak correlation with rates of post-operative clinical infection.

In conclusion, shoulder PPJI is a difficult problem to deal with. The definition of shoulder PPJI is currently unclear and further study is needed. There is no ideal test to confirm it. A reasonable approach is to aspirate for culture, and perform serum tests for WBC, ESR, and C-reactive protein. If any of these is positive in the setting of a painful arthroplasty, PPJI should be assumed until proven otherwise. Operative tissue cultures are probably the most reliable test but the clinical significance is not always obvious. Synovial fluid cytokine profiles and tissue PCR/NGS show promise for the future.

Two-stage treatment of chronically infected TKA is the most common form of management in North America and most parts of the world. One-stage management has pros and cons which will not be discussed in this lecture.

There is great variation of techniques and timing and little data to definitively support one technique or timing approach vs. another. Most methods are based on empirical success and logic. At the time of surgery, the first step is removal of infected implants. All metallic implants and cement should be removed. The most common places to leave cement behind inadvertently include patellar lug holes, femoral lug holes, and the anterior proximal tibia behind the tibial tubercle. Formal synovectomy should be performed. The next step is typically antibiotic-impregnated spacer placement. There are pros and cons of dynamic and static spacers with no clear evidence of superiority of one vs. another. Dynamic spacers work satisfactorily with mild to moderate bone loss, but more severe bone loss is usually better treated with static spacers and a cast. Most antibiotic spacers are made of methyl methacrylate cement with addition of high-dose antibiotics. In most cases, doses of 4–8 gm of antibiotics per pack of cement are preferred. The type of dosing depends on the specific antibiotic and the type of cement used. The most common antibiotics used are vancomycin and gentamycin. When the femoral canals have been instrumented, antibiotic-impregnated cement wands are usually placed in the medullary canal, as the medullary canals have been shown to have high risk of residual bacteria being present.

The resection interval may vary and there is no clear evidence of a “best” resection interval. Practically speaking, most surgeons use a resection period of 8–16 weeks depending on the type of spacer utilised. During the resection interval, serum markers (ESR and CRP) are followed periodically. One anticipates a decline or normalization of these parameters prior to second stage reimplantation procedure. There has not been a demonstrated advantage to reaspiration of the knee before reimplantation in most circumstances.

At the time of reimplantation, the spacers are removed and the knee is redebrided. The key at the time of reimplantation is to obtain good implant fixation but to also balance this with the potential for manageable extraction of the implants at some later date. Good implant fixation is important because failure rates due to mechanical failure are approximately equal to those of failure due to reinfection by 10 years. It is important to remember that reinfection risk is at least 10% by ten years, and therefore extractability of implants is also important. Post-operative management typically includes IV antibiotics, followed by oral antibiotics until final intra-operative cultures are available.

The results of two-stage reimplantation are reported in many series. Most show approximately 85–95% rate of successful eradication of infection in the first five years. Reinfections, often with different organisms, may occur even late after reimplantation. By ten years after surgery survival free of mechanical failure and infection in most series drops to 80% or less due to recurrent infections and mechanical failures.

To assess the current literature on suture anchor placement for the purpose of identifying factors that lead to suture anchor perforation and techniques that reduce the likelihood of complications.

Three databases (PubMed, Ovid MEDLINE, EMBASE) were searched, and two reviewers independently screened the resulting literature. Methodological quality of all included papers was assessed using Methodological Index for Non-Randomized Studies criteria and the Cochrane Risk of Bias Assessment tool. Results are presented in a narrative summary fashion using descriptive statistics.

Fourteen studies were included in this review. Four case series (491 patients, 56.6% female, mean age 33.9 years), nine controlled cadaveric/laboratory studies (111 cadaveric hips and 12 sawbones, 42.2% female, mean age 60.0 years), and one randomized controlled trial (37 hips, 55.6% female, mean age 34.2 years) were included. Anterior cortical perforation by suture anchors led to pain and impingement of pelvic neurovascular structures. The anterior acetabular positions (three to four o'clock) had the thinnest bone, smallest rim angles, and highest incidence of articular perforation. Drilling angles from 10° to 20° measured off the coronal plane were acceptable. The mid-anterior (MA) and distal anterolateral (DALA) portals were used successfully, with some studies reporting difficulty placing anchors at anterior locations via the DALA portal. Small-diameter (< 1 .8-mm) suture anchors had a lower in vivo incidence of articular perforation with similar stability and pull-out strength in biomechanical studies.

Suture anchors at anterior acetabular rim positions (3–4 o'clock) should be inserted with caution. Large-diameter (>2.3-mm) suture anchors increase the likelihood of articular perforation without increasing labral stability. Inserting small-diameter (< 1 .8-mm) all-suture suture anchors (ASAs) from 10° to 20° using curved suture anchor drill guides, may increase safe insertion angles from all cutaneous portals. Direct arthroscopic visualization, use of fluoroscopy, distal-proximal insertion, and the use of nitinol wire can help prevent articular violation.

Anterior cruciate ligament (ACL) injuries are one of the most common ligament injury occurring in young and active individuals. Reconstruction of the torn ligament is the current standard of care. Of the many factors which determine the surgical outcome, fixation of the graft in the bony tunnels has significant role. This study compared the clinical and functional outcome in patients who underwent ACL reconstruction by standard anteromedial portal technique with single bundle hamstring graft anchored in the femoral tunnel using rigidfix and cortical button with adjustable loops. The tibial fixation and rehabilitation protocol were same in both groups.

107 patients underwent ACL reconstruction over a two-year period (87 males, 20 females, 44 after motor vehicle accident, 34 after sports injuries, 79 isolated ACL tear, 21 associated medial meniscus tear, 16 lateral meniscus tear and 11 both menisci). Rigid fix group had 47 patients and adjustable loop 60 patients. Clinical evaluation at end of one year showed better stability in rigid fix group regarding Lachman, anterior drawer, pivot shift tests, KT 1000 arthrometer side to side difference and hop limb symmetry index. However, the differences were not statistically significant.

Functional evaluation using IKDC 2000 subjective score and Lysholm score showed better results in rigidfix group than variable loop, but was not statistically significant. However, lower scores were noted in patients with concomitant meniscal injury than in isolated acl tear patients and this was statistically significant in both groups.

Rigidfix seems to give better graft fixation on femoral side than variable loop, but by the end of one year the functional outcome is comparable in isolated acl reconstructions.

Introduction

Surgeons performing a total knee replacement (TKR) have two available techniques available to help them achieve the proper bone resections and ligament tension – gap balancing (GB) and measured resection (MR). GB relies on balancing ligaments prior to bony resections whereas bony resections are made based on anatomical landmarks in MR. Many studies have been done to compare the joint kinematics between the two techniques, however the results have been varied. These studies were not done with anatomically designed prostheses. The Journey II (Smith & Nephew, Memphis, TN) is one such design which attempts to mimic the normal knee joint structure to return more natural kinematics to the joint, with emphasis on eliminating both paradoxical anterior motion and reduced posterior femoral rollback. Given the design differences between anatomical and non-anatomical prostheses, it is important to investigate whether one technique provides superior kinematics when an anatomical design is used. We hypothesize that there will be no difference between the two techniques.

In North America, cementless femoral replacement has all but replaced cementing and cement technique is at risk for becoming a lost art. Published results of cemented femoral components with a well-designed femoral component and good surgical technique are excellent and equivalent to cementless technology. With an increasing focus on cost as part of value-based care, consideration for returning to cement for a select population is appropriate. Furthermore, there are patient populations that may benefit from a cemented femur with registries demonstrating superior short term outcomes. These include the elderly and patients with osteoporotic femurs.

The goal of femoral cementing is to maximise the interdigitation of bone cement with metaphyseal trabecular bone and the irregular surface of the endosteum while at the same time minimizing the risk of embolization.

The steps for femoral cementing include:cFemoral broaching – understand the relationship between the broach and stem as it relates to cement mantle thickness; Canal preparation; Gentle curetting to remove loose cancellous bone; Pressurised lavage to remove fat and marrow elements – this decreases the risk of embolization and enhances the strength of the bone-cement interface; Dry the canal – suction, adrenaline soaked sponge – this minimises bleeding and enhances the strength of the bone cement interface; Cement preparation – vacuum mix or centrifuge the bone cement – this minimise large voids that weaken the bone cement; Cement insertion – insert in a retrograde fashion and pressurise the cement – this optimises the cement column and the bone cement interface; Stem insertion – insert slowly with a system that centralises the stem – this prevents mantle defects that have been associated with stem loosening.