Traditional procedures for orthopedic total joint replacements have relied upon bone cement to achieve long-term implant fixation. This remains the gold standard in number of procedures including TKR and PKR. In many cases however, implants fixed with cement have proven susceptible to aseptic loosening and 3. rd. body wear concerns. These issues have led to a shift away from cement fixation and towards devices that rely on the natural osteoconductive properties of bone and the ability of porous-coated implants to initiate on-growth and in-growth at the bone interface, leading to more reliable fixation. To facilitate long-term fixation through osseointegration, several mechanical means have been utilized as supplemental mechanism to aid in stabilizing the prostheses. These methods have included integrated keels and bone screws. The intent of these components is to limit implant movement and provide a stable environment for bone ingrowth to occur. Both methods have demonstrated limitations on safety and performance including bone fracture due keel induced stresses, loosening due to inconsistent pressfit of the keel, screw-thread stripping in cancellous bone, head-stripping, screw fracture, screw loosening, and screw pullout. An alternative method of fixation utilizing blade-based anchoring has been developed to overcome these limitations. The bladed-based fixation concept consists of a titanium alloy anchor with a “T-shaped” cross-section and sharped-leading end that can be impacted directly into bone. The profile is configured to have a bladed region on the horizontal crossbar of the “T” for engagement into bone and a solid rail at the other end to mates with a conforming slot on the primary body of the prosthesis. A biased chisel tip is added to the surface of the leading blade edge to draw the bone between the anchor's horizontal surface and surface of the implant, thus generating a compressive force at the bone-to-prothesis interface. The anchoring mechanism has been successfully been integrated into the tibial tray component of a partial knee replacement; an implant component that has a clinical history of revision due to loosening. A detailed investigation into the pulloff strength, wear debris generation, compressive-force properties, and susceptibility to tibial bone fracture was carried out on the anchor technology when integrated in a standard tibial tray of a partial knee replacement. When tested in rigid polyurethane bone foam (Sawbones, Grade 15) the pulloff strength of the construct increased by 360% when utilizing the anchor. The tibial tray and anchor construct were cycled under compressive loading and demonstrated no evidence of interface corrosion or wear debris generation after 1 million cycles. In addition, the anchor mechanism was shown to generate 340N of compressive force at the tibial tray-to-bone interface when evaluated with pressure sensitive film (Fuji Prescale, Medium Grade). Finally, the ultimate compressive load to induce tibial fracture was shown to increase by 17% for the anchored tray as compared to a traditional keeled tray when tested in an anatomic tibial sawbones model; and by 19% when evaluated in human cadaveric tibias. For any figures or tables, please contact authors directly

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

Aim. Review causes of anchor fixation failures in patients who underwent arthroscopic rotator cuff repair. Methods. Between 2003 and 2006, 650 arthroscopic rotator cuff repairs were performed by the senior author. Of these, anchor fixation failure occurred in fifteen patients. A retrospective review was undertaken to find out the reasons for their failure. Results. There were ten women and five men, age range 46-84 (mean age 64). Thirteen underwent repair with metallic knotless anchors (Arthrocare), and two with 5.5mm biodegradable screw anchors (Arthrotek). Knotless anchors were used to repair six massive, one large, three medium and three small tears. The two patients with biodegradable anchor repair had only small tears, each held with a single anchor. All but one failure was apparent at six weeks. One metallic anchor failed at four months. Twelve knotless anchors failed through pull-out and one broke. Both biodegradable anchors broke at the eyelet. Discussion. The increasing strength of suture material has shifted the weak point away from the suture-tendon interface towards the anchor-bone interface. Arthroscopic techniques permit a wider age range of patients suitable for surgery, each with varying degrees of osteoporosis in the proximal humerus, increasing risk of anchor pull-out. Multiple anchor insertions to reduce stiff, retracted tears may also lead to weakening of the bone table in the footprint area of the greater tuberosity. Incomplete anchor deployment, commonly at the curved cortical bone edge of greater tuberosity can also lead to failure. Conclusion. Anchors failed if tension in the repair exceeds the bones capacity to retain the anchor, if the anchor is incompletely deployed or if one anchor is stressed beyond its tension capability. We recommend that consideration is given to spreading the tension of the tissue repair amongst the anchors placed in the greater tuberosity

Objective. The purpose of this study was to compare outcome of arthroscopic stabilization of the shoulder using knotted and knotless anchors and two rehabilitation regimes. Method. This is a retrospective study of 58 patients who underwent arthroscopic shoulder stabilization over a five year period (2005–2009). There were two groups of patients. In group A stabilization was performed using absorbable anchors with a knotted technique using No.1 PDS suture. This group had an early mobilization regime. In group B a knotless anchor technique was used with PEEK anchors and nonabsorbable sutures. The patients in this group were immobilised in a sling for 6 weeks. There were a total of 58 patients, 37 in group A and 21 in group B. The mean age of patients undergoing the procedure was 35.7. There were a total of 23 males and 14 females in group A and 15 males and 6 females in group B. The number of dislocations prior to surgery ranged from 0 to multiple times a day. Patients had a mean follow up of 5 years (three to seven years - 2005 to 2009) and subjective shoulder function was evaluated using Oxford instability score and self-assessment questionnaire. Results. The Shoulder scores showed improvement in both groups and there were no significant differences in redislocation rates and patient satisfaction scores with 20 patients in group A and 11 patients in group B going back to sporting activities. Conclusion. Since there were no significant differences in shoulder scores in both groups our conclusion was that secure fixation was what mattered irrespective of the type of anchor used or the physiotherapy regimen

Background. Patellar ligament rupture is an uncommon but devastating complication of total knee arthroplasty. Many predisposing factors may lead to rupture of the ligament during or shortly after surgery. The most common predisposing factor is extensive release of the ligament to improve exposure in difficult cases or revisions. Purpose. The purpose of this study is to show the outcome of new technique for repair of overstretched patellar ligament during total knee arthroplasty. Patients and method. This is retrospective case series study for fourteen patients who had over stretched patellar ligament during difficult total knee arthroplasty. Ten patients had less than 50% partial injury of patellar ligament while four patients had more than 50% injury for the patellar ligament. four anteroposterior drill holes arranged in two rows were done from the tibial tuberosity to the medullary canal at the site of tibial component stem. No. 5 Ethibond sutures were passed in form of two loops that encircle the patellar ligament like a sleeve and left untied. The cemented tibial component was inserted then the suture loops were tied from distal to proximal while the knee in 90 degree flexion so as the ligament was anchored to the bone. Results. The mean follow up of these cases was 38± 2.6 STD months. Active extension to -5 degrees was achieved by all patients while the mean flexion range was 100± 4.8 STD. None of the patients had delayed rupture of the patellar ligament during follow up. Conclusion. The technique described was effective to regain normal extensor mechanism function after partial injury of the patellar ligament during TKA. It can be used as a prophylactic method against delayed rupture of the ligament when the ligament is overstretched during difficult cases of TKA

Utility score is a preference-based measure of general health state – where 0 is equal to death, and 1 is equal to perfect health. To understand a patient's smallest perceptible change in utility score, the minimal clinically important difference (MCID) can be calculated. However, there are multiple methods to calculate MCID with no consensus about which method is most appropriate. The aim of this study is to calculate MCID values for the Veterans-RAND 12 (VR12) utility score using varying methods. Our hypothesis is that different methods will yield different MCID values. A tertiary institutional registry (SMART) was used as the study cohort. Patients who underwent unilateral TKA for osteoarthritis from January 2012 to January 2020 were included. Utility score was calculated from VR12 responses using the standardised Brazier's method. Distribution and anchor methods were used for the MCID calculation. For distribution methods, 0.5 standard deviations of the baseline and change scores were used. For anchor methods, the physical and emotional anchor questions in the VR12 survey were used to benchmark utility score outcomes. Anchor methods included mean difference in change score, mean difference in 12 month score, and receiver operating characteristics (ROC) analysis with the Youden index. Complete case analysis of 1735 out of 1809 eligible patients was performed. Significant variation in the MCID estimates for VR12 utility score were reported dependent on the calculation method used. The MCID estimate from 0.5 standard deviations of the change score was 0.083. The MCID estimate from the ROC analysis method using physical or emotional anchor question improvement was 0.115 (CI95 0.08-0.14; AUC 0.656). Different MCID calculation methods yielded different MCID values. Our results suggest that MCID is not an umbrella concept but rather many distinct concepts. A general consensus is required to standardise how MCID is defined, calculated, and applied in clinical practice

Functional outcomes are commonly reported in studies of musculoskeletal oncology patients undergoing limb salvage surgery; however, interpretation requires knowledge of the smallest amount of improvement that is important to patients – the minimally important difference (MID). We established the MIDs for the Musculoskeletal Tumor Society Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) in patients with bone tumors undergoing lower limb salvage surgery. This study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. This data was used to calculate: (1) the anchor-based MIDs using an overall function scale and a receiver operating curve analysis, and (2) the distribution-based MIDs based on one-half of the standard deviation of the change scores from baseline to 12-month follow-up, for both the MSTS and TESS. There were 591 patients available for analysis. The Pearson correlation coefficients for the association between changes in MSTS and TESS scores and changes in the external anchor scores were 0.71 and 0.57, indicating “high” and “moderate” correlation. Anchor-based MIDs were 12 points and 11 points for the MSTS and TESS, respectively. Distribution-based calculations yielded MIDs of 16-17 points for the MSTS and 14 points for the TESS. The current study proposes MID scores for both the MSTS and TESS outcome measures based on 591 patients with bone tumors undergoing lower extremity endoprosthetic reconstruction. These thresholds will optimize interpretation of the magnitude of treatment effects, which will enable shared decision-making with patients in trading off desirable and undesirable outcomes of alternative management strategies. We recommend anchor-based MIDs as they are grounded in changes in functional status that are meaningful to patients

The Latarjet procedure is a well described method to stabilize anterior shoulder instability. There are concerns of high complication rates, one of these being a painful shoulder without instability due to screw irritation. The arthroscopic changes in the shoulder at time of screw removal compared to those pre-Latarjet have not been described in the literature. We conducted a retrospective review of arthroscopic videos between 2015 and 2022 of 17 patients at the time of their Latarjet screw removal and where available (n=13) compared them to arthroscopic findings at time of index Latarjet. Instability was an exclusion criterion. X-rays prior to screw removal were assessed independently by two observers blinded to patient details for lysis of the graft. Arthroscopic assessment of the anatomy and pathological changes were made by two shoulder surgeons via mutual consensus. An intraclass correlation coefficient (ICC) was analyzed as a measure for the inter-observer reliability for the radiographs. Our cohort had an average age of 21.5±7.7 years and an average period of 16.2±13.1 months between pre- and post-arthroscopy. At screw removal all patients had an inflamed subscapularis muscle with 88% associated musculotendinous tears and 59% had a pathological posterior labrum. Worsening in the condition of subscapularis muscle (93%), humeral (31%) and glenoid (31%) cartilage was found when compared to pre-Latarjet arthroscopes. Three failures of capsular repair were seen, two of these when only one anchor was used. X-ray review demonstrated 79% of patients had graft lysis. Excellent inter-rater reliability was observed with an ICC value of 0.82. Our results show a high rate of pathological change in the subscapularis muscle, glenoid labrum and articular cartilage in the stable but painful Latarjet. 79% of patients had graft lysis with prominent screws on X-ray

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand. The Oxford Knee Score (OKS) is a 12-item questionnaire used to track knee arthroplasty outcomes. Validation of such patient reported outcome measures is typically anchored to a single question based on patient ‘satisfaction’, however risk of subsequent revision surgery is also an important outcome measure. The OKS can predict subsequent revision risk within two years, however it is not known which item(s) are the strongest predictors. Our aim was to identify which questions were most relevant in the prediction of subsequent knee arthroplasty revision risk. . All primary TKAs (n=27,708) and UKAs (n=8,415) captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months, five years or ten years post-surgery were included. Logistic regression and receiver operating characteristics (ROC) curves were used to assess prediction models at six months, five years and ten years. Q1 ‘overall pain’ was the strongest predictor of revision within two years (TKA: 6 months, odds ratio (OR) 1.37; 5 years, OR 1.80; 10 years, OR 1.43; UKA: 6 months, OR 1.32; 5 years, OR 2.88; 10 years, OR 1.85; all p<0.05). A reduced model with just three questions (Q1, Q6 ‘limping when walking’, Q10 ‘knee giving way’) showed comparable or better diagnostic ability with the full OKS (area under the curve (AUC): TKA: 6 months, 0.77 vs. 0.76; 5 years, 0.78 vs. 0.75; 10 years, 0.76 vs. 0.73; UKA: 6 months, 0.80 vs. 0.78; 5 years: 0.81 vs. 0.77; 10 years, 0.80 vs. 0.77). The three questions on overall knee pain, limping when walking, and knee ‘giving way’ were the strongest predictors of subsequent revision within two years. Attention to the responses for these three key questions during follow-up may allow for prompt identification of patients most at risk of revision

Aim. Arthroscopic interventions have revolutionized the treatment of joint pathologies. The appropriate diagnostics and treatment are required for infections after ligament reconstructions using non-resorbable material such as tendon grafts, anchors, and sutures, prone to biofilm formation. The infection rate is around 1% for knee and shoulder, while up to 4% for Achilles tendon reconstructions. Despite high number of these procedures worldwide, there is limited evidence about the best treatment protocol. Our study aimed to provide a general protocol for the treatment of small implants for soft tissue reconstruction. Method. Between 2019 and 2023, we treated 48 infections of ligament, meniscus, and tendon reconstructions out of 7291 related procedures performed in the same time period. Early infection (<30 days) were treated with an arthroscopic debridement and implant retention (DAIR), except Achilles tendons had open DAIR, while those with delayed or chronic infection (>30 days) were treated with extensive debridement and lavage combined with one-stage exchange (OSE) or implant removal. During surgery, at least 5 microbiological s and samples for histopathology were obtained. The removed material was sonicated. After surgery, all patients were one week on iv. antibiotics, followed by oral antibiofilm antibiotics for 6 weeks including rifampicin and/or a quinolone. All patients were followed for at least 1 year. Failure was defined as the need for additional revision surgery after finished iv. antibiotic treatment. Results. Among 48 patients, 38 were early and 10 were late acute or chronic infections. The incidence of infection for our cohort was 0.7%. We observed 27 infections after ligament reconstruction of the knee, 15 of the shoulder, 5 of the ankle, and 1 infection of the elbow joint. 40 patients were treated with DAIR, 5 with OSE, and 3 with implant removal. We had 11 C. acnes, 10 S. aureus, 6 S. epidermidis, 2 P. aeruginosa, 2 S. lugdunensis, 10 mixed flora, and 3 culture-negative infections. 12 patients received antibiotics before surgery, and all culture-negative infections were related to this subgroup. We observed 2 failures, both in a combination of proximal tibial osteotomy and ligament reconstruction of the knee joint. The success rate of our protocol was 96%. Conclusions. Prompt surgical treatment followed by 6 weeks of antibiotic treatment cured 96% of infections of small implants after reconstruction procedures of knee, shoulder, and ankle joints. Our study is the first to provide a treatment protocol for infections of small implants after ligament reconstruction procedures

In the current healthcare environment, cost containment has become more important than ever. Perioperative services are often scrutinized as they consume more than 30% of North American hospitals’ budgets. The procurement, processing, and use of sterile surgical inventory is a major component of the perioperative care budget and has been recognized as an area of operational inefficiency. Although a recent systematic review supported the optimization of surgical inventory reprocessing as a means to increase efficiency and eliminate waste, there is a paucity of data on how to actually implement this change. A well-studied and established approach to implementing organizational change is Kotter's Change Model (KCM). The KCM process posits that organizational change can be facilitated by a dynamic 8-step approach and has been increasingly applied to the healthcare setting to facilitate the implementation of quality improvement (QI) interventions. We performed an inventory optimization (IO) to improve inventory and instrument reprocessing efficiency for the purpose of cost containment using the KCM framework. The purpose of this quality improvement (QI) project was to implement the IO using KCM, overcome organizational barriers to change, and measure key outcome metrics related to surgical inventory and corresponding clinician satisfaction. We hypothesized that the KCM would be an effective method of implementing the IO. This study was conducted at a tertiary academic hospital across the four highest-volume surgical services - Orthopedics, Otolaryngology, General Surgery, and Gynecology. The IO was implemented using the steps outlined by KCM (Figure 1): 1) create coalition, 2) create vision for change, 3) establish urgency, 4) communicate the vision, 5) empower broad based action, 6) generate general short term wins, 7) consolidate gains, and 8) anchor change. This process was evaluated using inventory metrics - total inventory reduction and depreciation cost savings; operational efficiency metrics - reprocessing labor efficiency and case cancellation rate; and clinician satisfaction. The implementation of KCM is described in Table 1. Total inventory was reduced by 37.7% with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1333 hours per annum and labour cost savings of $39 995 per annum. Depreciation cost savings was $64 320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80% post-IO. This was the first study to show the success of applying KCM to facilitate change in the perioperative setting with respect to surgical inventory. We have outlined the important organizational obstacles faced when making changes to surgical inventory. The same KCM protocol can be followed for optimization processes for disposable versus reusable surgical device purchasing or perioperative scheduling. Although increasing efforts are being dedicated to quality improvement and efficiency, institutions will need an organized and systematic approach such as the KCM to successfully enact changes. For any figures or tables, please contact the authors directly

Aim. To develop a new system for antibacterial coating of joint prosthesis and osteosynthesis material. The new coating system was designed to release gentamicin immediately after insertion to eradicate surgical contamination. Method. Steel implants (2×15mm) were coated with a solid nanocomposite xerogel made from silica and the dendritic polymer, hyperbranched polyethyleneimine. The xerogel was anchored inside a porous surface made by pre-coating with titanium microspheres. Finally, gentamicin was encapsulated in the xerogel, i.e. no chemical binding. A total of 50 µg gentamicin was captured into each implant. The efficacy of the new coating was evaluated in a porcine model of implant associated osteomyelitis. In total, 30 female pigs were randomized into 3 study groups (n=10). Group A; plain implants + saline, Group B; plain implants + 10. 4. CFU of Staphylococcus aureus, and Group C; coated implants + 10. 4. CFU of S. aureus. Implant + inoculum was placed into a pre-drilled implant cavity of the right tibia and the pig was euthanized 5 days afterwards. Postmortem microbiology and pathology were performed. Two additional pigs were used in a pharmacokinetic study where microdialysis (MD) catheters were placed alongside coated implants. Extracellular fluid was sampled regularly for 24 hours from the MD catheters and analyzed for gentamicin content. Results. Within Groups A and C, all implants were found sterile by sonication and bacteria could not be identified within the surrounding bone tissue. In contrast, all Group B animals had S. aureus positive implant and tissue microbiology. Macroscopic and microscopic pathological examinations confirmed that Group A and C animals were complete identic, i.e. no pus around implants and only minor peri-implant inflammation related to insertion of implants per se. All Group B animals had pus around their implants and a massive peri-implant inflammatory response dominated by neutrophil granulocytes. Maximum gentamicin release (35 µg /mL) was measured in the first obtained MD sample, i.e. after 30 min, and the concentration stayed above the MIC level for the used S. aureus strain for 8 hours. Conclusions. The new xerogel coating prevented development of osteomyelitis. Prevention was due to a fast gentamicin release immediately following insertion and antimicrobial active concentrations were detectable several hours after implantation. This means that the critical time point of most relevant surgical procedures potentially could be protected by the novel coating. The new coating will be investigated on larger scale implants and full-size prosthesis in the future

Suture anchors have gained popularity in recent years, particularly owing to their ease of use for attaching soft tissues to bone and improved biomechanical properties. Three methods to reattach avulsed finger flexor tendons to the distal phalanx were biomechanically compared: a 1.8mm metal Mitek barbed suture anchor, twin 1.3mm PLA suture anchors (Microfix), or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, 90° to the anchor's axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure. The results were subject to statistical analysis using Student t test (p< 0.001) and 1-way ANOVA (p<0.0001). The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3mm anchors than the other methods; this method was significantly weaker. The 1.8mm anchor gave similar performance to the pull-out suture and button, while the twin 1.3mm anchors were weaker and vulnerable to gap formation even with passive motion alone. A suture anchor embedded at between 45 and 90o to the direction of pull gave greater strength than if the pull was in-line. The absorbable 1.3 mm Microfix PLA anchors appeared to be a weak construct, even when twin 1.3 mm anchors were compared to a single metallic 1.8 mm Mitek anchor or the pull-out suture over button technique. All three methods are likely to be satisfactory for reattachment of finger flexor tendons if a low load or non-loading rehabilitation of the hand is planned; however the gap formation on cyclic loading with the Microfix is a concern even if patients are restricted to passive motion

Surgical reattachment of torn rotator cuff tendons can lead to satisfactory clinical outcome but failures remain common. Ortho-R product is a freeze-dried formulation of chitosan (CS) that is solubilized in platelet-rich plasma (PRP) to form injectable implants. The purpose of the current pilot study was to determine Ortho-R implant acute residency, test safety of different implant doses, and assess efficacy over standard of care in a sheep model. The infraspinatus tendon (ISP) was detached and immediately repaired in 22 skeletally mature ewes. Repair was done with four suture anchors in a suture bridge configuration (n = 6 controls). Freeze-dried formulations containing 1% w/v chitosan (number average molar mass 35 kDa and degree of deacetylation 83%) with 1% w/v trehalose (as lyoprotectant) and 42.2 mM calcium chloride (as clot activator) were solubilized with autologous leukocyte-rich PRP and injected at the tendon-bone interface and on top of the repaired site (n = 6 with a 1 mL dose and n = 6 with a 2 mL dose). Acute implant residency was assessed histologically at 1 day (n = 2 with a 1 mL dose and n = 2 with a 2 mL dose). Outcome measures included MRI assessment at baseline, 6 weeks and 12 weeks, histopathology at 12 weeks and clinical pathology. MRI images and histological slides were scored by 2 blinded readers (veterinarian and human radiologist, and veterinarian pathologist) and averaged. The Generalized Linear Model task (SAS Enterprise Guide 7.1 and SAS 9.4) was used to compare the different groups with post-hoc analysis to test for pairwise differences. Ortho-R implants were detected near the enthesis, near the top of the anchors holes and at the surface of ISP tendon and muscle at 1 day. Numerous polymorphonuclear cells were recruited to the implant in the case of ISP tendon and muscle. On MRI, all repair sites were hyperintense compared to normal tendon at 6 weeks and only 1 out 18 repair sites was isointense at 12 weeks. The tendon repair site gap seen on MRI, which is the length of the hyperintense region between the greater tuberosity and tendon with normal signal intensity, was decreased by treatment with the 2 mL dose when compared to control at 12 weeks (p = 0.01). Histologically, none of the repair sites were structurally normal. A trend of improved structural organization of the tendon (p = 0.06) and improved structural appearance of the enthesis (p = 0.1) with 2 mL dose treatment compared to control was seen at 12 weeks. There was no treatment-specific effect on all standard safety outcome measures, which suggests high safety. Ortho-R implants (2 mL dose) modulated the rotator cuff healing processes in this large animal model. The promising MRI and histological findings may translate into improved mechanical performance, which will be assessed in a future study with a larger number of animals. This study provides preliminary evidence on the safety and efficacy of Ortho-R implants in a large animal model that could potentially be translated to a clinical setting

This is a case series of a senior surgeon's experience; the purpose being to illustrate the problems encountered when using bio-absorbable anchors for various indications in shoulder surgery. Method. A retrospective analysis of 7 patients' notes, radiology and arthroscopic findings between 2006 and 2010. Results. There were 5 females and 2 males, with an average age of 50 years 3 months. The indications for using these anchors varied; 5 patients had rotator cuff repairs, 1 had a SLAP repair and the other had a Bankart repair. Patients complained of pain (3), a noisy shoulder (2), deformity (1) and symptoms similar to an infection (1). Average time from surgery to symptoms varied, with the shortest time being 3 months and the longest being 4 years 2 months. Some had dramatic MRI changes showing significant lysis around the anchors. Arthroscopic findings included anchor debris in the joint, loose anchors with significant defects and resultant irreversible cartilage damage. Conclusion. We conclude that even though these anchors are widely marketed and used in shoulder surgery, they are not without their problems, which can occur as early as three months post insertion. This has certainly changed our minds regards the use of bio-absorbable anchors in our practice

Background. Successful use of bioabsorbable anchors for capsulolabral and rotator cuff repair is well documented. The bioknotless anchor (DePuy mitek) has demonstrated reliable fixation of these pathologies. However, this poly (L-lactide) polymer has recently demonstrated some similar complications to those documented for the earlier polyglycolic acid implants; namely synovitis and chondral damage with osteolysis. We report three cases with osteolysis and chondral damage associated with bioknotless anchors. Methods. A prospective record of shoulder arthroscopy is maintained by the senior author. From this, three patients with post-operative complications of arthropathy and osteolysis, following bioabsorbable anchor repair of capsulolabral lesions were identified. A retrospective review of case notes, radiographs, operative records and intraoperative video and photographic material was undertaken. Results. All patients had acceptable initial progress of rehabilitation. At 12-15 months, recurrence of symptoms promoted further radiological investigation and where the patient consented, repeat arthroscopy. In all cases advanced arthropathy was noted. Conclusion. It is likely that the use of knotless bioabsorbable anchors may promote advanced arthropathy. Initial loss of fixation and early pullout of the anchors may allow synovial contact with anchor material promoting hydrolysis and early arthropathy

Latissimus dorsi anterior to major transfers have been advocated in the setting of loss of external rotation and elevation in conjunction with reverse shoulder replacement. Reverse shoulder replacement is a prosthesis specifically designed for shoulders with poor rotator cuff function. In the vast majority of cases, some teres minor function at the minimum is maintained in shoulders destined for a reverse shoulder replacement. However, in certain circumstances there is complete loss of any external rotation, and a muscle transfer can be performed in order to restore some external rotation function. A reverse shoulder replacement in the absence of any rotator cuff function goes into obligate internal rotation with elevation. A minimum of external rotation strength is necessary in order to maintain the arm in normal rotation. The first tip is patient selection. Physical examination of active external rotation, external rotation strength and forward elevation should be just performed. A latissimus transfer is indicated in patients who cannot maintain their arm in neutral to at least a few degrees of external rotation. A lag sign is another physical examination finding which can indicate complete loss of rotator cuff function. The latissimus dorsi transfer is performed by first identifying and releasing the latissimus from its insertion on the anterior humerus. The arthroplasty is performed. The passage for the latissimus muscle is developed carefully and being mindful of the axillary nerve in particular. The latissimus is directed inferior to the nerve and around the medial and posterior aspect of the proximal humerus. Different ways of securing the transfer to the humerus have been described including bone tunnels and anchors. Often it is easier to place the anchors and/or the bone tunnels prior to inserting the humeral prosthesis. The latissimus is secured in the new position, enabling it to participate in external rotation. The value of this is difficult to clearly establish. Most studies are evidence level IV and there are no good comparative studies in a controlled patient population. This is a good option for shoulders with no active external rotation, but they may increase overall complication rate. Complications include dislocation, infection, and transient nerve palsy

Quadriceps tendon ruptures are a rare but debilitating injury resulting in loss of knee extension necessitating surgical intervention. Currently, multiple different surgical techniques and rehabilitation programs are utilized by surgeons. Researchers have been unable to determine the best surgical technique with respect to function and complication rate; certain techniques are more cost-effective than others. Early vs. late motion rehabilitation programs are utilized; recent evidence suggests that less aggressive initial rehabilitation may lead to decreased extensor lag and fewer additional surgeries. The goal of our study is to determine the treatment practices of orthopaedic surgeons across Canada. Our study was completed anonymously via . SurveyMonkey.com. (Palo Alto, California). Based on current literature, a 26-question survey was distributed. E-mail invitations were be sent to all members of the Canadian Orthopaedic Association. Participation is voluntary. Currently, 104 surveys have been completed. 78% of respondents utilize transosseous drill holes, 13% utilize suture anchors and 9% utilize a combined surgical technique. The majority of surgeons begin range of motion (ROM) at 2 weeks (42%) or 6 weeks (24%); ROM is then commonly progressed in a step-wise fashion at 2-week intervals (58%). Approximately half of respondents have performed revision surgery for quadriceps re-rupture. Surgical management of quadriceps tendon ruptures is fairly consistent amongst Canadian orthopaedic surgeons. However, wide variation exists regarding rehabilitation, favoring early initiation and progression of ROM despite some evidence recommending a longer period of immobilization

Introduction. Post-meniscectomy syndrome is broadly characterised by intractable pain following the partial or total removal of a meniscus. There is a large treatment gap between the first knee pain after meniscectomy and the eligibility for a TKA. Hence, there is a strong unmet need for a solution that will relieve this post-meniscectomy pain. Goal of this first-in-man study was to evaluate the safety and performance of an anatomically shaped artificial medial meniscus prosthesis and the accompanying surgical technique. Methods. A first-in-man, prospective, multi-centre, single arm clinical investigation was intended to be performed on 18 post-medial meniscectomy syndrome patients with limited underlying cartilage damage (Kellgren Lawrence scale 0–3) in the medial compartment and having a normal lateral compartment. Eventually 5 patients received a polycarbonate urethane mediale meniscus prosthesis (Trammpolin® medial meniscus prosthesis; ATRO Medical B.V., the Netherlands) which was clicked onto two titanium screws fixated at the native horn attachments on the tibia. PROMs were collected at baseline and at 6 weeks, 3, 6, 12 and 24 months following the intervention including X-rays at 6, 12 and 24 Months. MRI scans were repeated after 12 and 24 months. Results. The surgical technique to select the appropriately sized implant and correct positioning of the fixation screws and meniscus prosthesis onto the tibia was demonstrated feasible and reproducible. The surgeries showed that in particular the positioning of the posterior screw is crucial for correct positioning of the prosthesis. Inclusion stopped after 5 patients, who reached the 6 months evaluation. The PROMs did not improve in the first 6 months after surgery. All patients reported knee joint stiffness and slight effusion in their knee at 6 months follow-up. In case of symptomatic patients an evaluation of the device position and integrity was performed by MRI. In three patients the implants were removed because of implant failure and in one patient the implant was removed because of persistent pain and extension deficit. At present one patient has the implant still in situ. The explantations of the implants demonstrated no articular cartilage damage and the fixation screws were securely anchored. Discussion. This is the first clinical study with an artificial meniscus-like prosthesis. Except one, all implants were removed due to implant breakage or discomfort of the patient. Analysis of the torn implants showed fatigue failure resulting from the lack of loadsharing between implant and cartilage: the implant was too stiff and carried all the load in the medial compartment of the knee. Furthermore, the fixation with screws seemed too rigid which restricted the motion of the posterior horn. Based on previous in vitro and animal experiments, we expected more creep of the material and more motion on the screw fixation. Conclusion. This first-in-man clinical study demonstrates that the investigated device design is not safe and did not perform as expected. Therefore, modification of the meniscus prosthesis design and fixation technique is required to allow for more motion of the meniscus prosthesis during knee joint movement

Correct alignment of tibial and femoral components is one of the most important factors that determine favorable long-term results of total knee arthroplasty (TKA). Computer-assisted TKA allows for more accurate component positioning and continuous intraoperative monitoring of the alignment. However, the pinholes created by the temporally anchored pins used as reference points may cause problems. Here we report a case of tibial stress fracture that occurred after a TKA was performed with the use of a computer navigation system. Case report. The patient, a 76-year-old woman (height 157 cm, weight 73 kg and BMI 29.5 kg/m. 2. ) with bilateral knee osteoarthritis. The right knee was replaced first and recovered without complications. The left knee was replaced 2 weeks later. The patient underwent computer-assisted (Stryker Co., Allendale, NJ, USA), cemented, posterior cruciate ligament sacrificing replacement of the left knee (with a Zimmer Gender Solutions Knee). A midline skin incision was made and a 5.0 mm bicortical self-tapping anchoring pin was inserted 10 cm below the tibiofemoral joint line. The other anchoring pin was inserted into the femur at the same distance from the joint to the line. These pins were inserted bicortically, anterior to posterior. Femur and tibia resections were performed according to the light-emitting diode tracker on the navigation system and cutting jig. Femoral and tibial implants were fixed with cement. The anchoring screws were then removed after the fixation of all implants. For two weeks, the patient tolerated significant walking but experienced only vague pain and swelling at the site of the left proximal tibial area. Local heat or redness was not observed and inflammatory serological markers (erythrocyte sedimentation rate, c-reactive protein level and white blood cell count) were within normal limits. One week later the patient complained of more aggravated and persistent pain. The patient immediately had a radiography check-up which showed a long linear radiolucent line and cortical defect through the pinholes (Fig. 1A–D). Through close scrutiny of the radiographs taken immediately after and two weeks after the operation, it was realized that she had a tibial stress fracture resulting from a misplaced fixation pin (Fig. 2A, B). As a result, the patient wore a long leg splint and was instructed to avoid weight bearing for two weeks. She was then allowed to gradually put more weight after wearing along leg cast for four weeks. Clinically, a satisfactory outcome was reported by the patient with good recovery of her daily activities; crutches were no longer needed to walk after three months. Physical examination showed no tenderness and final ROM was 0–120 degrees. Radiography showed that the stress fracture was completely healed (Fig. 3A, B). Conclusively, we suggest that unicortical anchoring pins with a small diameter should be considered for use in the metaphyseal area and avoidance of transcortical drilling is recommended. Care should be taken to avoid stress fracture during rehabilitation in case of the development of pain after a pain-free period following computer assisted TKA