One in five patients remain unsatisfied due to ongoing pain and impaired mobility following total knee arthroplasty (TKA). It is important if surgeons can pre-operatively identify which patients may be at risk for poor outcomes after TKA. The purpose of this study was to determine if there is an association between pre-operative measures and post-operative outcomes in patients who underwent TKA. This study included 28 patients (female = 12 / male = 16, age = 63.6 ± 6.9, BMI = 29.9 ± 7.4 kg/m2) with knee osteoarthritis who were scheduled to undergo TKA. All surgeries were performed by the same surgeon (GD), and a subvastus approach was performed for all patients. Patients visited the gait lab within one-month of surgery and 12 months following surgery. At the gait lab, patients completed the knee injury and osteoarthritis outcome score (KOOS), a timed up and go (TUG), and walking task. Variables of interest included the five KOOS sub-scores (symptoms, pain, activities of daily living, sport & recreation, and quality of life), completion time for the TUG, walking speed, and peak knee biomechanics variables (flexion angle, abduction moment, power absorption). A Pearson's product-moment correlation was run to assess the relationship between pre-operative measures and post-operative outcomes in the TKA patients. Preliminary analyses showed the relationship to be linear with all variables normally distributed, as assessed by Shapiro-Wilk's test (p > .05), and there were no outliers. There were no statistically significant correlations between any of the pre-operative KOOS sub-scores and any of the post-operative biomechanical outcomes. Pre-operative TUG time had a statistically significant, moderate positive correlation with post-operative peak knee abduction moments [r(14) = .597, p < .001] and peak knee power absorption [r(14) = .498, p = .007], with pre-operative TUG time explaining 36% of the variability in peak knee abduction moment and 25% of the variability in peak knee power absorption. Pre-operative walking speed had a statistically significant, moderate negative correlation with post-operative peak knee abduction moments [r(14) = -.558, p = .002] and peak knee power absorption [r(14) = -.548, p = .003], with pre-operative walking speed explaining 31% of the variability in peak knee abduction moment and 30% of the variability in peak knee power absorption. Patient reported outcome measures (PROMs), such as the KOOS, do indicate the TKA is generally successful at relieving pain and show an overall improvement. However, their pre-operative values do not correlate with any biomechanical indicators of post-operative success, such as peak knee abduction moment and knee power. Shorter pre-operative TUG times and faster pre-operative walking speeds were correlated with improved post-operative biomechanical outcomes. These are simple tasks surgeons can implement into their clinics to evaluate their patients. Future research should expand these findings to a larger sample size and to determine if other factors, such as surgical approach or implant design, improves patient outcomes

Background. Digital planning of implants in regard to position and size is done preoperatively in most cases. Intraoperative it can only be made by navigation systems. With the development of the VIPS-method (Virtual Implant Planning System) as an application for mobile C-arms, it is possible to do an intraoperative virtual planning of the screws near the joint in treatment of distal radius fractures by plating. Screw misplacement is a well known complication in the operative treatment of these fractures. The aim of this prospective randomised trial was to gain first clinical experiences and to compare VIPS with the conventional technique. The study hypothesis was that there will be less screw misplacement in the VIPS group. Methods. We included 40 patients with distal radius fractures type A3, C1 and C2 according to the AO-classification. In a pilot study the first 10 Patients were treated by the VIPS method to gain experience with VIPS in a clinical set-up. The results of the pilot-study are not part of this analysis. Then 15 Patients were web-based randomised into two groups. After diaphysial fixation of a 2.4 mm Variable Angle Two-Column Volar Distal Radius Plate and fracture reduction matching of a three-dimensional virtual plate to the two-dimensional image of the plate in the fluoroscopy shots in two plains was performed automatically in the VIPS group. The variable angle locking screws were planed in means of direction and length. Drilling was done by the use of the Universal Variable Angle Locking Drill Guide that was modified by laser marks at the rim of the cone to transfer the virtual planning. The drill guide enables drilling in a cone of 30°. In the control group the same implant was used in a conventional technique that means screw placement by the surgeon without digital planning. After implant placement an intraoperative three-dimensional scan was performed to check the position and length of the screws near the joint. OR- and fluoroscopy-time was documented. In addition the changes of misplaced screws were engaged. Results. In the VIPS group six A3-fractures, one C1-fracture and eight C2-fractures were included. In the control group six A3-fractures and nine C2-fractures were included. The intraoperative fluoroscopy time was 2.53 min (SD 1.44, range 1.27–7.14) in the VIPS group and 2.26 min (SD 0.51, range 1.55–3.39) in the control group (p=0.40). The OR-time was 53.33 min (SD 34.49, range 34–171) in the VIPS group and 42.27 min (SD 8.76, range 20–58) in the control group (p=0.23). In the VIPS group we changed three screws (two were too long, one was borderline near the joint) and two screws in the control group (one was too long, one was borderline near the joint) (p=0.24). Conclusions. The Virtual Implant Planning System is a reliable method that can be integrated easily in the workflow in treatment of distal radius fractures. There is a tendency that the virtual implant planning needs additional time, but there are no significant differences between the two groups. Further development is necessary to make the VIPS method beneficial

We present the results of a bi-centre, retrospective study examining the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus locking plates and Tri-Lock® variable angle locking screws. We assessed 61 patients with distal radius fractures with a minimum of six months follow-up. Functional assessment was made using the DASH score. We measured wrist range of movement and grip strength, and reviewed radiographs to assess restoration of anatomy, fracture union and complications. All fractures united within six weeks. Mean ranges of movement and grip strength were only mildly restricted compared to the normal wrist. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although 3 of these remained asymptomatic. Five other patients developed minor complications. Variable angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures. However, variable-angle systems may lead to increased rates of screw misplacement

The ITS volar radial plate (Implant Technology Systems, Graz/Austria) is a fixation device that allows for the distal locking screws to be fixed at variable angles (70°-110°). This occurs by the different material properties, with the screws (titanium alloy) cutting a thread through the plate holes (titanium). We present our experience with the ITS plate. We retrospectively studied 26 patients who underwent ITS plate fixation for unstable multifragmentary distal radial fractures (AO types A3, B2, B3, C2, C3). The surgery was performed either by a consultant orthopaedic hand surgeon or senior registrar. A volar approach was used every time and 10 cases required synthetic bone grafting. Post-operatively they were immobilised for an average of 2.5 weeks. The 26 patients had a mean age of 58 and the dominant side was affected in 46% of cases. 5 cases were open fractures and 10 cases followed failed manipulation under general anaesthesia. The average interval between injury and surgery was 7 days. Union was achieved in all cases. No implant infections, failure or tendon rupture/irritation occurred. There were two fractures which loss reduction, of which one required revision surgery. There was one case of CRPS. The six month average DASH score was 27.5. We consider the ITS plate a technically easy plate to use and a reliable implant at early follow-up. We value the versatility of its variable angle screw fixation ability for complex intra-articular distal radial fractures

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

Backgrounds. The rigid fixation of glenoid base plate is essential for the prevention of dissociation of the construct in the reverse total shoulder arthroplasty. For the rigid fixation, ideal placement of fixation screw is crucial but it is difficult to determine the best direction and length of screws. The purpose of this study was to determine configuration of optimal screw in cadaveric scapulae and compare with that in patient who underwent reverse total shoulder arthroplasty. Materials and methods. Seven scapulae were used and implanted using a variable angle base plate with four directions screws. Optimal screw placement was defined as that which maximized screw length, accomplished far cortical purchase. Insertion angle and length of every screw was measured from AP and axial radiograph taken after the screws fixation. In a similar manner, the insertion angles of screws were measured from radiographs of 7 postoperative patients who underwent reverse total shoulder arthroplasty. The averages of length and insertion angle of 4 screws from two groups were compared. Result. The average lengths of screws were anterior 29.4 mm, posterior 15.0 mm, superior 36.0 mm, inferior 46.7 mm in the cadavers group and 22.2 mm, 22.3 mm, 28.0 mm, 29.1 mm each in the patient group. There was statistical significance of the difference of the insertion angle of superior and inferior screws between two groups. Conclusion. Trajectory angles of superior and inferior screw were smaller than those of optimal screws. Awareness of this tendency is helpful to insert the optimal screws intraoperatively

Prevalence. Periprosthetic fractures around a total knee are uncommon but not rare; various large database studies suggest 0.3–2.5%. Patients at highest risk are typically older patients and those with poor quality bone from various etiologies. Supracondylar femur fractures are often associated with a high stress zone at the metaphysis/diaphysis junction near the superior edge of femoral component. Etiology. Low energy trauma is the most common preceding event as most of these occur in patients with poor bone quality. Elderly patients are at particular risk because standing-height falls generate enough energy to create fractures. Given the durable nature of most modern TKA designs the prosthesis is usually fixed well. Goals. The goals of treatment are typically fracture union, avoidance of infection, avoidance of stiffness, and maintenance of overall limb alignment. Recent gains in knowledge indicate the need to attain maximal distal fragment fixation in order to achieve the surgical goals. Correct alignment, length and rotation are often best assessed with a combination of radiographic images and intra-operative clinical inspection. Modern internal fixation principles emphasise the need to minimise stripping/devascularization of comminuted zones. Options. Three major treatment options exist for supracondylar fractures. Retrograde nails have advantages in that they are tissue-friendly and are mechanically advantageous in the face of medial comminution. Difficult to use with most posterior stabilised TKA (box). There are limited distal fixation options and malalignment is often hard to avoid. With plating the distal fixation can be maximised and there is less risk for malalignment. Typically requires more soft tissue dissection. Locked plates provide good coronal plane stability and 2nd generation locked plates allow variable screw angles such that far distal fixation is possible. Revision TKA is required when implants are loose. Revision may be more reliable than fixation options in very elderly with badly comminuted bone. Be aware that a hinged tumor type implant may be needed in many cases