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

Purpose. It is well known that meniscus extrusion is associated with structural progression of knee OA. However, it is unknown whether medial meniscus extrusion promotes cartilage loss in specific femorotibial subregions, or whether it is associated with a increase in cartilage thickness loss throughout the entire femorotibial compartment. We applied quantitative MRI-based measurements of subregional cartilage thickness (change) and meniscus position, to address the above question in knees with and without radiographic joint space narrowing (JSN). Methods. 60 participants with unilateral medial OARSI JSN grade 1–3, and contralateral knee OARSI JSN grade 0 were drawn from the Osteoarthritis Initiative. Manual segmentation of the medial tibial and weight-bearing medial femoral cartilage was performed, using baseline and 1-year follow-up sagittal double echo steady-state (DESS) MRI, and proprietary software (Chondrometrics GmbH, Ainring, Germany). Segmentation of the entire medial meniscus was performed with the same software, using baseline coronal DESS images. Longitudinal cartilage loss was computed for 5 tibial (central, external, internal, anterior, posterior) and 3 femoral (central, external, internal) subregions. Meniscus position was determined as the % area of the entire meniscus extruding the tibial plateau medially and the distance between the external meniscus border and the tibial cartilage in an image located 4mm posterior to the central image (a location commonly used for semi-quantitative meniscus scoring). The relationship between meniscus position and cartilage loss was assessed using Pearson (r) correlation coefficients, for knees with JSN and without JSN. Results. The percentage of knees showing a quantitative value of >3mm medial meniscus extrusion was 50% in JSN knees, and only 12% in noJSN knees. The 1-year cartilage loss in the medial femorotibial compartment was 74±182µm (2.0%) in JSN knees, and 26±120µm (0.8%) in noJSN knees. There was a significant correlation between cartilage loss throughout the entire femorotibial compartment (MFTC) and extrusion area in JSN knees but not for noJSN knees. Also, the extrusion distance measured 4mm posterior to the central slice was not significantly correlated with MFTC cartilage loss. The strongest (negative) correlation between meniscus position and subregional femorotibial cartilage loss (r=−0.36) was observed for the external medial tibia. In contrast, no significant relationship was seen in the central tibia. No significant relationship was found in other tibial subregions, except for the anterior medial tibia, but only in JSN knees (r=−0.27). Correlation coefficients for the femoral subregions were generally smaller than those for tibial subregions, with only the internal medial weight-bearing femur attaining statistical significance (r =−0.26). Conclusions. The current results show that the relationship between meniscus extrusion and cartilage loss differs substantially between femorotibial subregions. The correlation was strongest for the external medial tibia, a region that is physiologically covered by the medial meniscus. It was less for other tibial and femoral subregions, including the central medial tibia, a region that exhibited similar rates of cartilage loss as the external subregion. The findings suggest that external tibia may be particularly vulnerable to cartilage tissue loss once the meniscus extrudes and the surface is “exposed” to direct, non-physiological, cartilage-cartilage contact

Background. The meniscal deficient knee often exists in the setting of associated pathology including instability, malalignment and chondral injury. Meniscal allograft transplantation (MAT) is established to be a reliable option in restoring function and treating symptoms. The aim of this study was to establish the role of MAT as part of a staged approach to treatment of the previously menisectomised knee. Methods. This prospective study included all patients that underwent arthroscopic MAT at our institution between 2010 to 2017. Fresh frozen allograft was utilised using a soft tissue fixation technique. Further data was collected for index surgical procedures before and after MAT. Data for pre and post-operative Knee Injury and osteoarthritis outcome scores (KOOS), Tegner scores, graft survival, reoperation rates, patient satisfaction and MRI extrusion measurements were collected and details of any further surgical intervention and / or complications also documented. Results. Twenty seven MAT procedures were performed in 26 patients. Sixteen patients underwent lateral MAT and 11 patients medial. Ten patients underwent ACL reconstruction, three ACI and two, osteotomy in the pre-MAT phase. A further seven patients underwent ACI within the post-operative phase. The post-operative mean KOOS scores improved significantly in all subscales as did Tegner scores. Graft survival was 100%, satisfaction rate 92%, and mean meniscal extrusion 3.04mm. Post operatively, three patients required meniscal repair and a single patient partial menisectomy of graft. Two patients underwent arthroscopic arthrolysis following MAT. Conclusions. This series highlights the multifactorial profile of the meniscal deficient knee and the role of MAT as a safe and reliable technique in the staged and comprehensive biologic treatment available to minimise symptoms and maximise outcomes

Background: Structural hip deformities including developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) are thought to predispose patients to degenerative joint changes. However, the natural history of these malformations is not clearly delineated. Methods: Seven-hundred twenty-two patients ≤55 years that received unilateral primary total hip arthroplasty (THA) from 1980–1989 were identified. Pre-operative radiographs were reviewed on the contralateral hip and only hips with Tönnis Grade 0 degenerative change that had minimum 10-year radiographic follow-up were included. Radiographic metrics in conjunction with the review of two experienced arthroplasty surgeons determined structural hip diagnosis as DDH, FAI, or normal morphology. Every available follow-up AP radiograph was reviewed to determine progression from Tönnis Grade 0–3 until the time of last follow-up or operative intervention with THA. Survivorship was analyzed by Kaplan-Meier methodology, hazard ratios, and multi-state modeling. Results: One-hundred sixty-two patients met all eligibility criteria with the following structural diagnoses: 48 DDH, 74 FAI, and 40 normal. Mean age at the time of study inclusion was 47 years (range 18–55), with 56% females. Mean follow-up was 20 years (range 10 – 35 years). Thirty-five patients eventually required THA: 16 (33.3%) DDH, 13 (17.6%) FAI, 6 (15.0%) normal. Kaplan-Meier analysis demonstrated that patients with DDH progressed most rapidly, followed by FAI, with normal hips progressing the slowest. The mean number of years spent in each Tönnis stage by structural morphology was as follows: Tönnis 0: DDH = 17.0 years, FAI = 14.8 years, normal = 22.9 years; Tönnis 1: DDH = 12.2 years, FAI = 13.3 years, normal = 17.5 years; Tönnis 2: DDH = 6.0 years, FAI = 9.7 years, normal = 8.6 years; Tönnis 3: DDH = 1.6 years, FAI = 2.6 years, normal = 0.2 years. Analysis of degenerative risk for categorical variables showed that patients with femoral head lateralization >10 mm, femoral head extrusion indices >0.25, acetabular depth-to-width index <0.38, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all had a greater risk of progression from Tönnis 0 to Tönnis 3 or THA. Among patients with FAI morphology, femoral head extrusion indices >0.25, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all increased the risk of early radiographic progression. Analysis of degenerative risk for continuous variables using smoothing splines showed that risk was increased for the following: femoral head lateralization >8 mm, femoral head extrusion index >0.20, acetabular depth-to-width index <0.30, lateral center-edge angle <25 degrees, and Tönnis angle >8 degrees. Conclusions: This study defines the long-term natural history of DDH and FAI in comparison to structurally normal young hips with a presumably similar initial prognostic risk (Tönnis Grade 0 degenerative change and contralateral primary THA). In general, the fastest rates of degenerative change were observed in patients with DDH. Furthermore, risk of progression based on morphology and current Tönnis stage were defined, creating a new prognostic guide for surgeons. Lastly, radiographic parameters were identified that predicted more rapid degenerative change, both in continuous and categorical fashions, subclassified by hip morphology

The modification of bearing surfaces with poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) is known to increase the hydration of the surfaces and decrease the wear of the substrates. PMPC grafting to acetabular liner of total hip arthroplasty showed a drastic reduction of cross-linked polyethylene (CLPE) wear in a long-term hip simulator test and achieved a good short-term clinical result. To apply this technique to other joint prostheses, the wear resistance under various conditions needs to be evaluated because every joint has a different wear mode. ASTM F732 gives a method that disk shaped polymer specimen is loaded with hemispherical pin using pin-on-disk tester, which is suitable for hydrated polymer because the lubricant is supplied every loading cycle on the surface. The purpose of this study is to evaluate the performance of PMPC-grafted hydrated CLPE under multidirectional wear condition in anticipation of applying PMPC to various prostheses. The CLPE disks of 3 or 6-mm in thickness were machined from a bar stock. The PMPC was grafted onto the CLPE surfaces using a photoinduced polymerization of MPC in aqueous medium. All disks were irradiated with a total amount of 75-kGy gamma-ray. The wear resistance of the CLPE and PMPC-grafted CLPE disks against Co-Cr-Mo alloy pin was evaluated using Ortho-POD pin-on-disk tester. The disks were fixed to the tester with a Ti-6Al-4V alloy plate that has screw hole in the center. The test conditions were a static load of 213 N, sliding shape of 5 mm × 10 mm rectangular, frequency of 1 Hz and maximum cycles of 1.0 × 10. 6. [Fig. 1]. Gravimetric wear was determined by weighing the disks and soak controls were used to compensate for the fluid absorption. After the wear test, volumetric changes of sliding and backside surfaces of disks were evaluated using a noncontact optical three-dimensional profiler. The PMPC-grafted surface showed decrease in the gravimetric wear drastically [Fig. 2]. The thickness of CLPE had no substantial effect on the wear resistance. Three-dimensional profile measurements of sliding surfaces detected a substantial volumetric penetration; the corner of sliding track were deeper than the straight-line portion. Backside extrusion was observed in all disks. The thickness of CLPE affected both volumetric penetration and backside extrusion for both untreated and PMPC-grafted CLPE. The PMPC grafting had no discernible effect on volumetric changes [Fig. 3]. Results of this study revealed: (1) the PMPC-grafted surface decreases wear of CLPE, however, the thickness of disk has no effect, in contrast, (2) thinner thickness of CLPE increases the volumetric changes including penetration in sliding surface and extrusion in back surface but the PMPC-grafted surface has no effect. Gravimetric wear did not correlate with the volumetric penetration in sliding surface because the volumetric penetration might be caused by not only the wear but also the creep deformation. In conclusion, hydrated bearing surface and thickness of bearing substrate are essential for the wear and fatigue resistance properties for an increasing longevity of artificial joint. In addition, PMPC grafting is a promising technique for increasing the longevity of various joint prostheses

The main objective of joint arthroplasty is to improve activities of daily living of the patient. However, normal daily activities may lead to separation of articular surfaces of an artificial joint, possibly as a result of a combined impact and sliding motion. Therefore, the properties of articular surfaces define the durability of implant materials. Modification of bearing surfaces with poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) increases the hydration of the surfaces and decreases the wear of the substrates. Hence, a PMPC layer can potentially cushion the impact and improve the resistance of cross-linked polyethylene (CLPE). This study aimed to explore the fatigue and wear resistance of PMPC-grafted hydrated CLPE under impact-to-wear conditions using a pin-on-disk tester. The surfaces of a CLPE disk (3- or 6-mm thick) were modified with PMPC by photoinduced polymerization and were sterilized using gamma rays. The wear resistance of PMPC-grafted CLPE disks against a Co-Cr-Mo alloy pin was evaluated and compared to that of untreated disks. The disks were fixed to the tester with a metal plate (Ti-6Al-4V alloy) that had a central hole. The test was performed for 2 × 10. 6. cycles of repetitive impact and unidirectional sliding with the maximum load of 150 N, sliding distance of 10 mm, and frequency of 1 Hz [Fig. 1]. Gravimetric wear was determined by weighing the disks, and soak controls were used to compensate for fluid absorption. Volumetric changes in the surfaces of the disks were evaluated using a three-dimensional non-contact optical profiler. The average gravimetric wear (mg) after 2 × 10. 6. cycles was 0.000/0.120 for CLPE (3/6 mm) and −0.073/–0.137 for PMPC-CLPE (3/6 mm). The weight gain of the PMPC-CLPE disks was due to their greater fluid absorption compared to that of the soak controls under the impact-to-wear conditions, as judged from the fact that during the load-soak in the lubricant this gain was observed for all the disks irrespectively of PMPC grafting. PMPC-grafting decreased the gravimetric wear of CLPE (p < 0.01) in the 6-mm group, whereas the thickness of the CLPE disks had no substantial effect on the wear resistance [Fig. 2]. In all cases, three-dimensional measurements detected a remarkable volumetric penetration in the impact-sliding surfaces and an extrusion of CLPE from the backside surfaces into the hole in the metal plate. Both the volumetric penetration and backside extrusion were smaller in the 6-mm group. The PMPC grafting had no discernible effect on these volumetric changes [Fig. 3]. Even after 2 × 10. 6. cycles of impact loads, mechanical fracture or delamination of the impact-sliding or backside surfaces were hardly observed in all the groups. The results of this study revealed that: (1) PMPC-grafting of CLPE surfaces decreased the gravimetric wear irrespectively of the disk thickness; and (2) thinner CLPE increased the risk of volumetric changes, including penetration in the impact-sliding surface and extrusion of the backside surface. In conclusion, PMPC grafting can potentially improve the wear resistance of the bearing surface of biomaterials even under impact-to-wear conditions, increasing the longevity of artificial joints

Introduction. Most of the algorithm available today to balance varus knee is based on a surgeon's hands-on experience without full understanding of pathological anatomy of varus knee. The high-resolution MRI allows us to recognize the anatomical details of the posteromedial corner and the changes of the soft tissue associated with the osteoarthritis and varus deformity. We have in this study, reviewed 60 cases of severe varus knee scheduled for TKR and compared it to normal MRI and those MRI were evaluated and read by a musculoskeletal radiologist. We have documented clearly the changes that happens in soft tissue, leading to tight medial compartment. We will also show multiple short intra-operative video confirming that MRI findings. Material & method. We have retrospectively reviewed the MRI on 60 patients with advanced osteoarthritis varus knee. We also reviewed 20 MRI for a normal knee matched for age. We evaluated the posteromedial complex and MCL in sagittal PD-weighted VISTA to check the alignment of the MCL and posteromedial complex and the associate MCL bowing and deformity that could happen in osteoarthritis knee. We have measured the thickness of the posteromedial complex and the posterior medial bowing of the superficial MCL and the involvement of the posterior oblique ligament in those patients. To measure the posterior bowing of the MCL, a line was drawn through the posterior aspect of both menisci and we measured the distance between the posterior edge of MCL to that line in actual image. To measure the thickness of the posteromedial complex, we measured it at two areas in the posterior medial corner posteriorly at the level of the medial meniscus. Measuring the medial bowing of the MCL was done by a line drawn through the medial edge of the femoral condyle and the tibial condyle at the level of the medial meniscus to the inner aspect of the MCL. The normal distance between the posterior aspects of the MCL to the posterior meniscus line was approximately measured 2 cm. in average. Results. We were able to recognize and measure the medial deviation of MCL in all arthritic knees due to the deformity and the effect of the medial margin osteophyte and medial extrusion of the meniscus. Thickening of posteromedial complex was recognized in the majority of the cases with prominent thickening seen in 50/60 knees with average thickness measuring approximately 1.2 cm due to the synovial thickening, adhesions, granulation tissue, degenerated medial meniscus, and involvement of the posterior oblique ligament and the capsular branch of the semimembranosus tendon, as well as the oblique popliteal ligament. The involvement of posterior oblique ligament were seen in majority of the cases. In 55 cases we have showed a heterogeneous appearance of the ligament and loss of normal signal within the postero medial complex and we have documented that the oblique ligament will cause the posterior bowing of the MCL. The medial bowing of the MCL is also correlated to the severity of the varus deformity with an average distance to the normal medial line of the medial meniscus measuring approximately 1.1 cm. Discussion. Our study shows that the changes affecting the superficial MCL is likely to be secondary to the obvious changes involving the posteromedial complex and to the marginal osteophyte as well as the extrusion of the medial meniscus. Also, we have confirmed that there are deforming structures such as the oblique ligament with adhesion and thickening with all the posterior medial complex. Those changes clearly caused the posterior bowing to the superficial MCL without an actual shortening of the ligament. The scarring tissue in the posteromedial corner and the adhesion is acting as a soft phyte tensioning and deforming the ligament and the posterior capsule. The oblique ligament act as a deforming forces forcing the superficial MCL to bow posteriorly. The lengths of the superficial MCL stayed the same. Conclusion. The conventional wisdom of releasing the distal attachment of the superficial medial MCL to balance knee has to be a challenge based on our MRI finding. Releasing the superficial MCL can sometimes lead to a major instability of the knee requiring a more constrained implant. Our MRI assessment clearly showed that the Superficial MCL is deformed because of posterior bowing and medial bowing and considerable thickening of the posteromedial corner, as well as the accompanying osteophyte. We believe that clearing the superficial MCL and excising those thickened scar tissue in the posterior medial corner will enable us to balance the knee without creating instability Conclusion: The conventional wisdom of releasing the distal attachment of the superficial medial MCL to balance knee has to be a challenge based on our MRI finding. Releasing the superficial MCL can sometimes lead to a major instability of the knee requiring a more constrained implant. Our MRI assessment clearly showed that the Superficial MCL is deformed because of posterior bowing and medial bowing and considerable thickening of the posteromedial corner, as well as the accompanying osteophyte. We believe that clearing the superficial MCL and excising those thickened scar tissue in the posterior medial corner will enable us to balance the knee without creating instability

Introduction. Subtle deformities of the acetabulum and proximal femur are recognised as biomechanical risk factors for the development of hip osteoarthritis (OA) as well as a cause of hip and groin pain. We undertook this study to examine relationships between a number of morphological measurements of the acetabulum and proximal femur and the hip pain in a 20-year longitudinal study. Methods. In 1989 women of 45–64 years of age were recruited. Each had an AP-Pelvis radiograph at Year-2. These radiographs were analysed using a validated programme for measuring morphology. All morphological measurements were read blinded to outcome. At year 3 all participants were asked whether they experienced hip pain (side specific). This was repeated at visits up to and including 20-years. Logistic regression analysis (with robust standard errors and clustering by subject identifier) was performed using hip pain as a binary outcome. The model adjusted for baseline age, BMI and joint space and included only participants who were pain free on initial questioning. Results. 743 participants were included in the analysis. Median age 74.0. Pain was reported in 14.2% of hips. Logistic regression analyses revealed that extrusion index and LCE were significantly associated with hip pain before and after adjusting for covariates (OR 4.88[95%CI 1.32–17.97, p=0.017] and 0.84[95%CI 0.74–0.96, p=0.012] respectively). Modified triangular index height (MTIH) was also significantly associated after adjusting for covariates (OR 1.10[95%CI 1.01–1.20, p=0.022]). Extrusion index and MTIH were independently associated with hip pain at 20-years when used in the same model. No significant interaction was identified. Conclusions. This study provides evidence that measurements of hip morphology characteristic of previously undiagnosed dysplasia and FAI are predictive of hip pain in a 20-year longitudinal study. MTIH, LCE and Extrusion index were significant predictors of pain. This is the first study to describe these associations between hip morphology and pain in a longitudinal cohort

Tissue engineering by self-assembly is a technique that consists of growing cells on surfaces made of thermoresponsive polymers, that allow the production of contiguous cell sheets by simply lowering the temperature below the polymer's low critical solution temperature. In this approach cell-cell junctions and deposited extracellular matrix (ECM) remain intact, which provides a better cell localisation at the site of injury. However, these systems lack the possibility to fabricate multi-layered and three-dimensional cell sheets that would better recapitulate native tissues. Moreover, the fabrication of ECM-rich cell sheets would be highly desirable. This limitation could be overcome by inducing macromolecular crowding (MMC) conditions. Herein we venture to fabricate electrospun thermoresponsive nanofibres to sustain the growth and detachment of ECM-rich tissue substitutes in the presence of a MMC microenvironment. A copolymer of 85% poly-N-isopropylacrylamide and 15% N-tert-butylacrylamide (pNIPAAm/NTBA) were used for all experiments. To create aligned nanofibers, the polymer was electrospun and collected on a mandrel rotating at 2000 rpm. Human adipose derived stem cells (hADSC) were treated with media containing macromolecular crowders to enhance matrix deposition. Cell viability and morphology were assessed, and immunocytochemistry was conducted in order to estimate matrix deposition and composition. Adipogenic, osteogenic and chondrogenic assays were performed both with and without the presence of MMC. Non-invasive cell detachment was enabled by decreasing the temperature of culture to 10 °C for 20 minutes. The electrospinning process resulted in the production of pNIPAm/NTBA fibres in the diameter range from 1 to 2 µm and an overall alignment of 80%. Cell viability, proliferation and metabolic activity revealed that hADSCs were able to grow on the thermoresponsive scaffold. The cells were able to detach as an intact cell sheet in presence of MMC. Moreover, it was demonstated that MMC, by a volume extrusion effect, enhances Collagen type I deposition, which is one of the main components of the ECM. Histological analysis revealed that in the presence of MMC the cells were able to self-assembled into three dimensional multi-layers. The cells were able to differentiate towards the osteogenic and adipogenic lineage in the presence of MMC. Interestingly we were able to fabricate three-dimensional chondrogenic cell sheet both with and without MMC. Collectively the pNIPAm/NTBA thermoresponsive fibres were able to sustain the growth and the detachment of ECM-rich multi-layered cell sheets. The pNIPAm/NTBA fibres were able to successfully sustain growth and detachment of ECM-rich tissue equivalents. We believe that replacement, repair and restoration of tissue function can be accomplished best using cells that create their own tissue-specific extracellular matrix with a precision and stoichiometric efficiency still unmatched by man-made devices

There is no question that at some point many TKAs will be cementless-the question is when. The advantages of cementless TKA include a shorter operative time, no need for a tourniquet, more suitability for MIS, no concern for cement extrusion, and the history of THA. The concerns for cementless TKA include the history to date with cementless TKA (tibia and metal-backed patella), variable bony substrate, surgical cut precision, cost, revision concerns, and the patella (for patella component resurfacers). Cemented total knee arthroplasty remains the gold standard and has proven to provide durable results in most patients. The early experience with cementless tibial fixation was problematic due to tibial micromotion leading to pain and loosening. Screw fixed tibial components had additional problems as portals for polyethylene debris leading to tibial osteolysis. Moreover, metal-backed patellar components were associated with a high failure rate and most surgeons began to cement all three components. Renewed interest in cementless tibial fixation is driven in part by newer materials felt to be more suitable for ingrowth and by the perceived benefit of minimally invasive surgery. One of the concerns in limited exposure total knee arthroplasty is the difficulty in preventing the extravasation of cement posteriorly. If there is evidence-based data that quad sparing non-patella everting and limited incision length facilitates rehabilitation and does not jeopardise outcome, cementless tibial fixation will be a more attractive option in some patients. An additional concern is that the tibial surface is frequently quite variable in terms of the strength of the cancellous bone. Bone cement stabilises those differences and provides a homogeneous platform for load bearing through the tibial component

Major bone loss involving the acetabulum can be seen during revision THA due to component loosening, migration or osteolysis and can also occur as a sequela of infected THA. Uncemented porous ingrowth components can be used for reconstruction of the vast majority of revision cases, where smaller segmental or cavitary defects are typically present. But when stable structural support on host bone is lacking, highly porous metal acetabular augments have been described as an alternative to large structural allograft, avoiding the potential for later graft resorption and the resulting loss of mechanical support that can follow. The fundamental concept behind these acetabular augments is the provision of critical additional fixation, structural support and increased contact area against host bone over the weeks following surgery while the desired ingrowth into porous implant surfaces is occurring. Three separate patterns of augment placement have been utilised in our practice since the development of these implants a decade ago: Type 1 – augment screwed onto the superolateral acetabular rim in a “flying buttress” configuration for treatment of a segmental rim defect, Type 2 – augment placed superiorly against host and then fixed (with cement) to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect, and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial or medial wall, and allow peripheral cup placement against the still intact acetabular rim. In all cases the acetabular component and augment interface is fixed together with cement, with care to prevent any cement extrusion between any implant and the bone. When possible, we now prefer to place the acetabular component first and fix it provisionally with 2 or more screws, and then place the augments second as this is technically quicker and easier. This order of insertion is only possible though in type 1 and a few select type 2 cases. Type 3 cases always require placement of one or more augments first, before cup insertion. Supplemental cancellous bone graft is used routinely, but the need for structural bone is avoided. Highly porous metal acetabular augments are an infrequently needed, but extremely valuable, versatile and reliable adjunctive fixation method for use with uncemented acetabular components during complex revision THA associated with major bone deficiency. Smaller (often female) patients are more likely to require this approach as reaming away defects to allow insertion of a jumbo cup is more difficult in small patients with a smaller AP dimension to the acetabular columns and less local bone for implant support. Intermediate term durability and apparent radiographic incorporation has been very good despite the complex reconstructions originally required. This technique can allow the avoidance of structural bone grafting for even the most massive of bone defect problems, but additional followup is needed to see how durable these encouraging results are over the longer term

Background. Constitutional knee varus increases the risk of medial OA disease due to increase in the knee adduction moment and shifting of the mechanical axis medially. Hueter-Volkmann's law states that the amount of load experienced by the growth plate during development influences the bone morphology. For this reason, heightened sports activity during growth is associated with constitutional varus due to added knee adduction moment. In early OA, X-rays often show a flattened medial femoral condyle extension facet (EF). However, it is unknown whether this is a result of osteoarthritic wear, creep deformation over decades of use, or an outcome of Hueter-Volkmann's law during development. A larger and flattened medial EF can bear more weight, due to increased load distribution. However, a flattened EF may also extrude the meniscus, leading meniscus degeneration and joint failure. Therefore, this study aimed to investigate whether varus knees have flattened medial EFs of both femur and tibia in a cohort of patients with no signs yet of bony attrition. Methods. Segmentation and morphology analysis was conducted using Materialise software (version 8.0, Materialise Inc., Belgium). This study excluded knees with bony attrition of the EFs based on Ahlbäck criteria, intraoperative findings, and operation notes history. Standard reference frames were used for both the femur and tibia to ensure reliable and repeatable measurements. The hip-knee-angle (HKA) angle defined varus or valgus knee alignment. Femur: The femoral EFs and flexion facets (FFs) had best-fit spheres fitted with 6 repetitions. (Fig1). Tibia: The slopes of the antero-medial medial tibial plateau were approximated using lines. (fig2). Results. 72 knees met the inclusion and exclusion criteria. The average age was 59 ± 11 years. The youngest was 31 and the oldest 84 years. Thirty-three were male and 39 were female. There was good intra- and inter-observer reliability for EF sphere fitting. Femur: The results demonstrated that the medial femoral condyle EF is flattened in knees with constitutional varus, as measured by the Sphere Ratios between the medial and lateral EF (varus versus straight: p = 0.006), and in the scaled values for the medial EF sphere radius (varus versus straight: p = 0.005). There was a statistically significant, moderate and positive correlation between the medial femoral EF radius, and the medial femoral EF-FF AP offset. (fig3). Tibia: There was a statistically significant difference between the steepness of the slopes of the medial tibial plateau EF in varus and valgus knees, suggesting varus knees have a less concave (flatter) medial EF. (fig3). Conclusions. In comparison to straight knees, varus knees have flattened medial EFs in both femur and tibia. As this was the case in knees with no evidence of bony attrition, this could mean flattened medial EFs may be a result of medial physis inhibition during development, due to Hueter-Volkmann's law. Flattened medial EFs may increase load distribution in the medial compartment, but could also be a potential aetiology in primary knee OA due to over extrusion of the medial meniscus and edge loading

Introduction. Chronic uneven distribution of forces over the articular cartilage, which are present in OA, has been shown to be a risk factor for the development of OA. Certain regions of the articular cartilage will be exposed to increased chronic peak loads, whereas other regions encounter a corresponding relative reduction of transmitted forces. This has a well known influence on cartilage viability and is a precursor of degenerative progression. Congruence of joints has an important impact on force distribution across articular surfaces. Therefore, tibiofemoral incongruence could lead to alterations of load distribution and ultimately to progressive degenerative changes. In clinical practice the routine method for evaluation of progressive OA is analysis of joint space width (JSW) using weight bearing radiographs. Recent studies have suggested that JSW has a strong positive correlation with cartilage compression, volume and meniscal extrusion. Lateral unicondylar knee arthroplasty (UKA) has gained increasing popularity over the last decade in the treatment of isolated unicompartmental osteoarthritis (OA). However, progressive degenerative alterations of the medial compartment following lateral unicompartmental knee arthroplasty remains a leading cause of revision surgery. Therefore, the purpose of this study is to evaluate the medial compartment congruence (MCC) and joint space width (JSW) alterations following lateral UKA. Methods. The MCC of 53 knees following lateral UKA was evaluated on pre- and postoperative radiographs and compared to 41 healthy knees, using an Interative Closest Point (ICP) algorithm. The ICP algorithm calculated the Congruence Index (CI) by performing a rigid transformation that best aligns the digitized tibial and femoral surfaces (figure 1A). Inner, middle and outer JSW was measured by subdividing the medial compartment into four quarters on weight bearing tunnel view radiographs pre- and postoperatively (figure 1B). Results. The measured CI of the healthy control group was 0.99. The pre-operative CI of knees undergoing lateral UKA was 0.92, which significantly improved to 0.96 (p<0.0001) post-operatively (figure 2). Post-operatively the inner JSW increased (p=0.006) and the outer decreased (p=0.002). JSW was restored post-operatively since no significant differences were noted in all three measured post-operative JSW locations compared to the control group (figure 3). Conclusion. Our data suggests that lateral UKA improves MCC and normalizes JSW of the medial compartment, potentially preventing osteoarthritic progression in the uninvolved medial compartment

Are there any patho-anatomical features that might predispose to primary knee OA? We investigated the 3D geometry of the load bearing zones of both distal femur and proximal tibias, in varus, straight and valgus knees. We then correlated these findings with the location of wear patches measured intra-operatively. Patients presenting with knee pain were recruited following ethics approval and consent. Hips, knees and ankles were CT-ed. Straight and Rosenburg weight bearing X-Rays were obtained. Excluded were: Ahlbäck grade “>1”, previous fractures, bone surgery, deformities, and any known secondary causes of OA. 72 knees were eligible. 3D models were constructed using Mimics (Materialise Inc, Belgium) and femurs oriented to a standard reference frame. Femoral condyle Extension Facets (EF) were outlined with the aid of gaussian curvature analysis, then best-fit spheres attached to the Extension, as well as Flexion Facets(FF). Resected tibial plateaus from surgery were collected and photographed, and Matlab combined the average tibia plateau wear pattern. Of the 72 knees (N=72), the mean age was 58, SD=11. 38 were male and 34 female. The average hip-knee-ankle (HKA) angle was 1° varus (SD=4°). Knees were assigned into three groups: valgus, straight or varus based on HKA angle. Root Mean Square (RMS) errors of the medial and lateral extension spheres were 0.4mm and 0.2mm respectively. EF sphere radii measurements were validated with Bland-Altman Plots showing good intra- and interobserver reliability (+/− 1.96 SD). The radii (mm) of the extension spheres were standardised to the medial FF sphere. Radii for the standardised medial EF sphere were as follows; Valgus (M=44.74mm, SD=7.89, n=11), Straight (M=44.63mm, SD=7.23, n=38), Varus (M=50.46mm, SD=8.14, n=23). Ratios of the Medial: Lateral EF Spheres were calculated for the three groups: Valgus (M=1.35, SD=.25, n=11), Straight (M=1.38, SD=.23, n=38), Varus (M=1.6, SD=.38, n=23). Data was analysed with a MANOVA, ANOVA and Fisher's pairwise LSD in SPSS ver 22, reducing the chance of type 1 error. The varus knees extension facets were significantly flatter with a larger radius than the straight or valgus group (p=0.004 and p=0.033) respectively. In the axial view, the medial extension facet centers appear to overlie the tibial wear patch exactly, commonly in the antero-medial aspect of the medial tibial plateau. For the first time, we have characterised the extension facets of the femoral condyles reliably. Varus knees have a flatter medial EF even before the onset of bony attrition. A flatter EF might lead to menisci extrusion in full extension, and early menisci failure. In addition, the spherical centre of the EF exactly overlies the wear patch on the antero-medial portion of the tibia plateau, suggesting that a flatter medial extension facet may be causally related to the generation of early primary OA in varus knees

Major bone loss involving the acetabulum can be seen during revision THA due to component loosening, migration or osteolysis and can also occur as a sequela of infected THA. Uncemented porous ingrowth components can be used for reconstruction of the vast majority of revision cases, where smaller segmental or cavitary defects are typically present. But when stable structural support on host bone is lacking, highly porous metal acetabular augments have been described as an alternative to large structural allograft, avoiding the potential for later graft resorption and the resulting loss of mechanical support that can follow. The fundamental concept behind these acetabular augments is the provision of critical additional fixation, structural support and increased contact area against host bone over the weeks following surgery while the desired ingrowth into porous implant surfaces is occurring. Technique: Three separate patterns of augment placement have been utilised in our practice since the development of these implants: Type 1 - augment screwed onto the superolateral acetabular rim in a “flying buttress” configuration for treatment of a segmental rim defect, Type 2 – augment placed superiorly against host and then fixed (with cement) to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect, and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial or medial wall, and allow peripheral cup placement against the still intact acetabular rim. In all cases the acetabular component and augment interface is fixed together with cement, with care to prevent any cement extrusion between any implant and the bone. When possible, we now prefer to place the acetabular component first and fix it provisionally with 2 or more screws, and then place the augments second as this is technically quicker and easier. This order of insertion is only possible though in type 1 and a few select type 2 cases. Type 3 cases always require placement of one or more augments first, before cup insertion. Supplemental cancellous bone graft is used routinely. Results: From 2000 through 2007, porous tantalum acetabular augments were used very selectively in 85 revision THA procedures out of total of 1,789 revision hip cases performed at our institution in that time frame. All cases had associated massive acetabular deficiency precluding stable mechanical support for a cup alone. Fifty-eight hips had complete radiographic as well as clinical follow at minimum 5 years. The majority of patients had either Paprosky type 3A defects (28/58, 48%) or 3B defects (22/58, 38%). Ten out of 58 had pre-operative pelvic discontinuities. At 5 years, 2/58 (3%) were revised for aseptic loosening and another 6/58 demonstrated incomplete radiolucencies between the acetabular shell and zone 3. One of the revised cups and 5 of 6 of the cups with radiolucencies had an associated pelvic discontinuity. Summary: Highly porous metal acetabular augments are an infrequently needed, but extremely valuable, versatile and reliable adjunctive fixation method for use with uncemented acetabular components during complex revision THA associated with major bone deficiency. Intermediate term durability and apparent radiographic incorporation has been very good despite the complex reconstructions originally required. This technique can allow the avoidance of structural bone grafting for even the most massive of bone defect problems, but additional followup is needed to see how durable these encouraging results are over the longer term

Major bone loss involving the acetabulum can be seen during revision THA due to component loosening, migration or osteolysis and can also occur as a sequela of infected THA. Uncemented porous ingrowth components can be used for reconstruction of the vast majority of revision cases, where smaller segmental or cavitary defects are typically present. But when stable structural support on host bone is lacking, highly porous metal acetabular augments have been described as an alternative to large structural allograft. The fundamental concept behind these acetabular augments is the provision of critical additional fixation, structural support and increased contact area against host bone over the weeks following surgery while the desired ingrowth into porous implant surfaces is occurring. Three separate patterns of augment placement have been utilised in our practice since the development of these implants a decade ago: Type 1 - augment screwed onto the superolateral acetabular rim in a “flying buttress” configuration for treatment of a segmental rim defect, Type 2 – augment placed superiorly against host and then fixed to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect, and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial or medial wall, and allow peripheral cup placement against the still intact acetabular rim. In all cases the acetabular component and augment interface is fixed together with cement, with care to prevent any cement extrusion between any implant and the bone. When possible, we now prefer to place the acetabular component first and fix it provisionally with 2 or more screws, and then place the augments second as this is technically quicker and easier. This order of insertion is only possible in type 1 and a few select type 2 cases. Type 3 cases always require placement of one or more augments first, before cup insertion. Supplemental cancellous bone graft is used routinely, but the need for structural bone is avoided. From 2000 through 2007, porous tantalum acetabular augments were used very selectively in 85 revision THA procedures out of total of the 1,789 revision hip cases performed at our institution. All cases had associated massive acetabular deficiency precluding stable mechanical support for a cup alone. Fifty-eight hips had complete radiographic and clinical follow at minimum 5 years. The majority of patients had either Paprosky type 3A defects (28/58, 48%) or 3B defects (22/58, 38%). Ten out of 58 had pre-operative pelvic discontinuities. Three separate patterns of augment placement were utilised: Type 1 - augment screwed onto the superolateral acetabular rim (21%), Type 2 – augment fixed to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect (34%), and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial medial wall (45%). At 5 years, 2/58 (3%) were revised for aseptic loosening and another 6/58 demonstrated incomplete radiolucencies between the acetabular shell and zone 3. One of the revised cups and 5 of 6 of the cups with radiolucencies had an associated pelvic discontinuity. Highly porous metal acetabular augments are an infrequently needed, but extremely valuable, versatile and reliable adjunctive fixation method for use with uncemented acetabular components during complex revision THA associated with major bone deficiency. Smaller patients are more likely to require this approach as reaming away defects to allow insertion of a jumbo cup is more difficult with a smaller AP dimension to the acetabular columns and less local bone for implant support. Intermediate term durability and apparent radiographic incorporation has been very good despite the complex reconstructions originally required. This technique can allow the avoidance of structural bone grafting for even the most massive of bone defect problems, but additional followup is needed to see how durable these encouraging results are over the longer term

INTRODUCTION. Meniscal tears are very common and treated surgically by suturing or partial or total meniscectomy. After meniscectomy, the tibiofemoral contact area is decreased whih leads to higher contact stresses associated with clinical symproms and a faster progression of tibiofemoral osteoarthritis. Besides meniscus allograft transplantation, artificial implants have been developed to replace the menisci after meniscectomy. AIM. We investigated the short- and medium-term clinical results and survivorship of two artificial meniscus implants used as a treatment for post-meniscectomy pain in young to middle-aged patients: the anchored polyurethane degradable Actifit® (2007–2013) and the non-anchored polycarbonate-urethane NUSurface® meniscal implants (2011–2013). PATIENTS AND METHODS. Sixty-seven Actifit were implanted in 67 patients with a mean age of 30.5 years (12 to 50) as a lateral meniscus replacement in 24 cases and medial in 43. Forty-one NUSurface were implanted as a medial meniscus replacement in 35 patients aged 31 to 61 at surgery. Clinical scores (KOOS, Lysholm, IKDC, VAS and EQ-5D) and MRI were obtained preoperatively and at 1, 2 and 5 years (if applicable) postoperatively. Complications and reinterventions were noted and cumulative implant survivorship computed. RESULTS. Seventeen Actifit had been removed at a mean of 22 months postop for persisting pain and/or extrusion of the implant on MRI. Three were converted to a Total Knee Arthroplasty (TKA), 7 replaced by a meniscal allograft and 7 were removed. The cumulative survivorship was 63.6% at 6 years. Forty-six patients with the Actifit in situ had a significant improvement of all clinical scores compared to preoperative scores (p<0.05) and were satisfied with the result. In the NUSurface group, 19 of the 41 implanted menisci had been removed at 2 to 26 months follow-up. Reasons for failure were radial tear or rupture of the meniscus in 7 cases, dislocation with or without tear in 4, synovitis and hydrops in 2 possibly related to synovial reaction to polymer particles, medial pressure caused by a too large size in 3 and persistent pain or OA evolution in 3. In 5 patients the implant was replaced by the same type artificial meniscus, unsuccessfully in 3. Besides, complications occurred in 32 patients including inflammation, effusion and squeaking. Nevertheless the KOOS, IKDC and VAS for pain were significantly improved at 12 months postoperatively (p<0.001). DISCUSSION. Short-term clinical evaluation of artificial meniscal replacement after meniscectomy showed an initial improvement of pain and knee function. However, both in the anchored degradable polyurethane meniscal implant group as in the non-anchored polycarbonate-urethane implant group the number of short-term failures was high and associated with important morbidity. The hard, non-degradable polycarbonate-urethane meniscal implant was torn or worn in 7 cases within 2 years postop. Three patients had synovial reactions possibly related to particulate debris. In conclusion, the currently available artificial meniscal transplants have a too high short-term failure rate to be advocated for widespread clinical use

Introduction. Backside wear of polyethylene (PE) inlays in fixed-bearing total knee replacement (TKR) generates high number of wear debris, but is poorly studied in modern plants with improved locking mechanisms. Aim of study. Retrieval analysis of PE inlays from contemporary fixed bearing TKRs - to evaluate the relationship between backside wear and liner locking mechanism and material type and roughness of the tibial tray. Methods. MATERIAL. We included five types of implants, revised after min. 12 months (14–71): three models with a peripheral locking rim and two models with a dove-tail locking mechanism. Altogether this study included 15 inlays were removed from TKRs with CoCr alloy tray with a roughened surface and a peripheral locking lip liner (Stryker Triathlon, Ra 5,61 µm), 9 from CoCr trays with peripheral locking lip and untreated surface (Aesculap Search, Ra 0,81 µm), 13 from Ti alloy trays with peripheral locking lip and untreated surface (DePuy PFC Sigma 0,61 µm), 11 from Ti alloy trays with untreated surface and dovetail locking mechanism (Zimmer NexGen, 0,34 µm), and 9 from iplants with a Ti alloy tibial tray with mirror polished surface and dovetail locking mechanism (Smitn&Nephew Genesis II, 0,11 µm). METHODS. Wear of bearing surface and back side of retrieved inlays was examined in 10 sectors under a light microscope. Seven modes of wear were analysed and quantified according to the Hood scale: surface deformation, pitting, embedded third bodies, pitting, scratching, burnishing (polishing), abrasion and delamination. Damage of inlays caused by backside wear was also evaluated using scanning electron microscopy (SEM). Roughness of tibial tray was evaluated using a contact profilometer. Results. We found no differences between wear scores on the articulating surface in all group, they did not correlate with backside wear scores in all groups as well. Compared to all other groups, backside wear scores were significantly higher in implants with untreated Ti alloy tibial tray (P<0,001 Wilcoxon test). Lowest wear rates were found in implants from both Ti and CoCr alloys and peripheral locking rim. Interestingly there was no difference between wear of implants with polished and untreated surface (Fig. 1). SEM analysis demonstrated different wear modes in implants with dovetail mechanism and peripheral rim. The first group demonstrated signs of gross rotational instability, with severe abrasion with an arch-shaped pattern and delaminated PE (Fig 2). In one design we observed severe extrusion of PE into screw holes of the tibial tray. Inlays from trays with peripheral rim presented two types of wear: flattening of machining marks or protrusion of the material caused by the rough surface (Fig 3). Conclusions. This study demonstrates that backside wear is still a problem in modern TKR. Our findings suggest that it is predominantly affected by type of locking mechanism (with peripheral rim performing better), to a lesser extent by surface roughness of the tibial component, while material type does not seem to play an important role. This study was funded by a grant from the National Science Centre nr 2012/05/D/NZ5/01840. To view tables/figures, please contact authors directly

Perthes disease often leaves young adults with hip joint incongruency due to femoral head asphericity, (extra-articular extrusion and superior flattening). This causes femoro-acetabular impingement, a reduced range of movement and early degenerative change. We report a novel method for restoration of femoral head sphericity and femoro-acetabular congruency. Two males (aged 21 and 22 years) presented with groin pain and severe hip stiffness after childhood Perthes disease. Imaging confirmed characteristic saddle shaped deformities of the femoral head, with cartilage loss overlying a central depression in the superior section of the head. A new method of treatment was proposed. Both cases were treated in the same manner. A surgical dislocation was performed with a trochanteric flip osteotomy. The extra-articular bump was removed with osteotomes and a burr to reduce femoro- acetabular impingement. The sphericity of the femoral head was restored using a HemiCap partial re-surfacing (Arthrosurface, MA, USA). The radius of the implant was selected to match that of the acetabulum. Restoration of the height of the flattened portion of the weight-bearing surface of the femoral head reduces abnormal loading of the acetabular articular cartilage by improving congruency of the joint. Both patients recovered without incident and were mobilised with crutches, restricted to touch weight-bearing for six weeks to protect union of the trochanteric osteotomy. At a minimum of three year follow-up both patients had sustained improved range of movement, pain and Oxford hip score. Repeated imaging shows no evidence of joint space narrowing or loosening at this stage. We conclude that this novel treatment functions well in the short term. Further surveillance is on-going to confirm that this treatment results in improved long term durability of the natural hip joint after Perthes disease

Purpose. Introduction: The Dega osteotomy is a versatile procedure that is widely used to treat neuromuscular hip dysplasia. There is a paucity of English-language literature on its use in acetabular dysplasia seen in developmental dysplasia of the hip (DDH). Method. A retrospective radiographic and chart review was performed for all patients diagnosed with DDH who underwent a modified Dega osteotomy between March 1995 and December 2008 at the Shriners Hospital for Children or the Montreal Children's Hospital (Montréal, Canada) by two orthopedic surgeons. Radiographic parameters were measured at the preoperative, immediate postoperative and final follow-up time points. These parameters included the acetabular index (AI), center edge angle (CEA), Reimer's extrusion index, Shenton's line and grading by the Severin classification. Results. A total of 21 patients (22 hips) of which 18 were female, underwent a modified Dega osteotomy at an average age of 55.4 months (range: 20 to 100 months). Out of the 22 hips (1 bilateral and 19 single cases), 9 involved the right side and 13 involved the left side. Prior to surgery, 10 patients had a subluxated hip, 7 had a dislocated hip and 5 had a dysplastic hip. Twelve hips underwent concomitant procedures including 10 open reductions with capsulorraphy. The AI improved from 36 degrees (St. Dev 8) preoperatively to 19 degrees (St. Dev 7) on the date of last visit. The CEA improved from 4 (St. Dev 17) to 22 degrees (St. Dev 12). Conclusion. Results from this study demonstrate that the modified Dega osteotomy produces nearnormal lateral coverage parameters in children with DDH