The aim of this retrospective study was to evaluate the failure rate among different fixation devices for undisplaced fracture neck of femur. All 52 patients with Garden I and II hip fractures who underwent surgery in a teaching hospital in London from January 2007 to June 2012 were included. Electronic patient records were accessed to collect the patient data. There were 52% females and the mean age of patients was 70 years. Thirty patients had cannulated screws, 18 – dynamic hip screw (DHS) with de-rotation screw and 4 had DHS alone. Initial results showed that 36% patients had re-operation. 7(77%) had total hip replacement and 1(11%) had metal work removal. The reason for revision was failure of fixation in 8 (88%) and avascular necrosis in 1 (11%). There was significantly higher failure rate in the DHS with derotation screw group (50%) compared to the cannulated screw group (35%) and the DHS alone group (0%). Average time to planned revision was 11.1 months. Traditionally undisplaced intra capsular hip fractures are treated by in-situ fixation using different devices. Biomechanically DHS with de-rotation screw achieves better rotational and axial stability compared to other fixation devices. However, our study showed a higher failure rate in this group. Inability to achieve a perfectly parallel screw position seems to be a significant factor responsible for high failure. Higher failure rates with fixation may boost the role of replacement arthroplasty as one off surgical treatment in elderly patients

Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population. The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded. The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively. We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture

Gunshot-induced fractures of the proximal femur typically present with severe comminution and bone loss. These fractures may also be associated with local damage to soft tissue, neurovascular structures and injuries to abdominal organs. The aim was to evaluate the outcomes of civilian gunshot injuries to the proximal femur at a major trauma center in South Africa. A retrospective review of all patients who sustained gunshot-induced proximal femur fractures between January 2014 and December 2017 was performed. Patients with gunshot injuries involving the hip joint, neck of femur or pertrochanteric fractures were included. Patient demographics, clinical- treatment and outcome data were collected. Results are reported as appropriate given the distribution of continuous data or as frequencies and counts. Our study included 78 patients who sustained 79 gunshot-induced proximal femur fractures. The mean age of patients was 31 ± 112, and the majority of patients were male (93.6%). Pertrochantenteric fractures were the most common injuries encountered (73.4%). Treatment included cephalomedullary nail (60.8%), arthrotomy and internal fixation (16.4%) and interfragmentary fixation with cannulated screws (6%). One case of complete neck of femur fracture had fixation failure, which required conversion to total hip arthroplasty. The overall union rate was 69.6%, and 6.3% of patients developed a fracture-related infection in cases who completed follow-up. The study shows an acceptable union rate when managing these fractures and a low risk of infection. As challenging as they are, individual approaches for each fracture and managing each fracture according to their merits yield acceptable outcomes

The aim of this study is to analyse the radiological outcomes and predictors of avascular necrosis following 2-hole DHS in Garden I and II neck of femur fractures in patients more than 60 years with a minimum follow up of one year. We retrospectively reviewed 51 consecutive patients aged more than 60 years who underwent DHS fixation for Garden I and II fractures. Demographics, fracture classification, time to surgery, pre-operative AMTS, preoperative posterior tilt angle, quality of reduction, pre and post-operative haemoglobin(hb), creatinine and comorbidities were analysed for correlation with AVN using Chi-Square test, Independent Sample and paired t test. There were 40 (78.4%) females and the mean age of the cohort was 77 years. 28 and 23 were Garden I and II NOF fractures respectively. Union was observed in all our patients except one(kappa =1). 12/51(23.5%) developed AVN of the femoral head. Statistically significant higher incidence of AVN was noted in patients with a pre-op tilt angle > 200 (p = 0.006). The mean drop in Hb was higher in patients who developed AVN (21.5 g/L) versus the non-AVN group (15.9 g/L) (p = 0.001). There was no difference in AVN rates with respect to laterality, mean time to surgery, pre-op AMTS and Charlson comorbidity index. 4/52 (7.6%) had re-operations (one hardware prominence, two conversions to arthroplasty, one fixation failure during the immediate post-op period). The 30-day and one year mortality rates were 1.9 % and 11.7 % respectively. 2-hole DHS fixation in undisplaced NOF fractures has excellent union rates. A pre-operative posterior tilt angle of >200 and a greater difference in pre and post operative haemoglobin were found to correlate positively with the progression to AVN . No correlation was observed between AVN and time to surgery, laterality, quality of reduction and comorbidities

Ligament reconstruction following multi-ligamentous knee injuries involves graft fixation in bone tunnels using interference screws (IS) or cortical suspensory systems. Risks of IS fixation include graft laceration, cortical fractures, prominent hardware, and inability to adjust tensioning once secured. Closed loop suspensory (CLS) fixation offers an alternative with fewer graft failures and improved graft-to-tunnel incorporation. However, graft tensioning cannot be modified to accommodate errors in tunnel length evaluation. Adjustable loop suspensory (ALS) devices (i.e., Smith & Nephew Ultrabutton) address these concerns and also offer the ability to sequentially tighten each graft, as needed. However, ALS devices may lead to increased graft displacement compared to CLS devices. Therefore, this study aims to report outcomes in a large clinical cohort of patients using both IS and CLS fixation. A retrospective review of radiographic, clinical, and patient-reported outcomes following ligament reconstruction from a Level 1 trauma centre was completed. Eligible patients were identified via electronic medical records using ICD-10 codes. Inclusion criteria were patients 18 years or older undergoing ACL, PCL, MCL, and/or LCL reconstruction between January 2018 and 2020 using IS and/or CLS fixation, with a minimum of six-month post-operative follow-up. Exclusion criteria were follow-up less than six months, incomplete radiographic imaging, and age less than 18 years. Knee dislocations (KD) were classified using the Schenck Classification. The primary outcome measure was implant removal rate. Secondary outcomes were revision surgery rate, deep infection rate, radiographic fixation failure rate, radiographic malposition, Lysholm and Tegner scores, clinical graft failure, and radiographic graft failure. Radiographic malposition was defined as implants over 5 mm off bone or intraosseous deployment of the suspensory fixation device. Clinical graft failure was defined as a grade II or greater Lachman, posterior drawer, varus opening at 20° of knee flexion, and/or valgus opening at 20° of knee flexion. Radiographic failure was defined when over 5 mm, 3.2 mm, and/or 2.7 mm of side-to-side difference occurred using PCL gravity stress views, valgus stress views, and/or varus stress views, respectively. Descriptive statistics were used. Sixty-three consecutive patients (mean age = 41 years, range = 19-58) were included. A total of 266 CLS fixation with Ultrabuttons and 135 IS were used. Mean follow-up duration was 383 days. Most injuries were KD type II and III. Graft revision surgery rate was 1.5%. Intraosseous deployment occurred in 6.2% and 17% had implants secured in soft tissue, rather than on bone. However, the implant removal rate was only 6.2%. Radiographic PCL gravity stress views demonstrated an average of 1.2 mm of side-to-side difference with 6.2% meeting criteria for radiographic failure. A single patient met radiographic failure criteria for collateral grafts. Mean Lysholm and Tegner scores were 87.3 and 4.4, respectively, with follow-up beyond one year. Both IS and CLS fixation demonstrate an extremely low revision surgery rate, a high rate of implant retention, excellent radiographic stability, and satisfactory patient-reported outcome scores. Incorrect implant deployment was seen in a total of 17% of patients, yet none required implant removal. A single patient required graft revision due to implant failure

Introduction. Aseptic loosening is one of the highest causes for revision in total knee arthroplasty (TKA). With growing interest in anatomically aligned (AA) TKA, it is important to understand if this surgical technique affects cemented tibial fixation any differently than mechanical alignment (MA). Previous studies have shown that lipid/marrow infiltration (LMI) during implantation may significantly reduce fixation of tibial implants to bone analogs [1]. This study aims to investigate the effect of surgical alignment on fixation failure load after physiological loading. Methods. Alignment specific physiological loading was determined using telemetric tibial implant data from Orthoload [2] and applying it to a validated finite element lower limb model developed by the University of Denver [3]. Two high demand activities were selected for the loading section of this study: step down (SD) and deep knee bend (DKB). Using the lower limb model, hip and ankle external boundary conditions were applied to the ATTUNE. ®. knee system for both MA and AA techniques. The 6 degree of freedom kinetics and kinematics for each activity were then extracted from the model for each alignment type. Mechanical alignment (MA) was considered to be neutral alignment (0° Hip Knee Ankle Angle (HKA), 0° Joint Line (JL)) and AA was chosen to be 3° varus HKA, 5° JL. It is important not to exceed the limits of safety when using AA as such it is noted that DePuy Synthes recommends staying within 3º varus HKA and 3º JL. The use of 5º JL was used in this study to account for surgical variation [Depuy-Synthes surgical technique DSUS/JRC/0617/2179]. Following a similar method described by Maag et al [1] ATTUNE tibial implants were cemented into a bone analog with 2 mL of bone marrow in the distal cavity and an additional reservoir of lipid adjacent to the posterior edge of the implant. Tibial implant constructs were then subjected to intra-operative ROM/stability evaluation, followed by a hyperextension activity until 15 minutes of cement curing time, and finally 3 additional ROM/stability evaluations were performed using an AMTI VIVO simulator. The alignment specific loading parameters were then applied to the tibial implants using an AMTI VIVO simulator. Each sample was subjected to 50,000 DKB cycles and 120,000 SD cycles at 0.8 Hz in series; approximating 2 years of physiological activity. After physiological loading the samples were tested for fixation failure load by axial pull off. Results. Following alignment specific physiological loading the average fixation pull-off load for MA was 3289 ± 400 N and for AA was 3378 ± 133 N (Figure 1). There was no statistically significant difference fixation failure load by axial pull-off between the two alignment types (p=0.740). Conclusion. This study indicated that anatomic alignment, as defined with the alignment limits of this study, does not adversely affect the fixation failure load of ATTUNE tibial implants. For any figures or tables, please contact the authors directly

Introduction. Distal femoral and proximal tibial osteotomies are effective procedures to treat degenerative disease of the knee joint. Previously described techniques advocate the use of bone graft to promote healing at the osteotomy site. In this present study a novel technique which utilises the osteogenic potential of the cambial periosteal layer to promote healing “from the outside in” is described. Materials and Methods. A retrospective analysis of a consecutive single-surgeon series of 23 open wedge osteotomies around the knee was performed. The median age of the patients was 37 years (range 17–51 years). The aetiology of the deformities included primary genu valgum (8/23), fracture malunion (4/23), multiple epiphyseal dysplasia (4/23), genu varum (2/23), hypophosphataemic rickets (1/23), primary osteoarthritis (1/23), inflammatory arthropathy (1/23), post-polio syndrome (1/23), and pseudoachondroplasia (1/23). Results. There were two cases lost to follow-up with a median follow-up period 17 months (range 1–32 months). Union was achieved in all cases, with 1/23 requiring revision for early fixation failure for technical reasons. The median time to radiographic union 3.2 months (95% Confidence Interval (CI) 2.5–3.8 95% CI). CT scans demonstrated early periosteal callus, beneath the osteoperiosteal flap, bridging the opening wedge cortex. Clinical union occurred at 4.1 months (95% CI 3.9–4.2 months). Complications included superficial surgical site infection (1/23), deep vein thrombosis (1/23), and symptomatic metalwork requiring removal (7/23). Conclusions. The osteoperiosteal flap technique was a safe and effective technique for opening wedge osteotomies around the knee with a reliable rate of union

Traditionally, open reduction and internal fixation (ORIF) and hemiarthroplasty (HA) have been the surgical treatments of choice for displaced proximal humerus fractures (PHF) despite high rates of fixation failure and tuberosity nonunion, especially in the elderly population with poor bone quality. Recently, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) as a treatment option in both acute fractures, as well as a salvage procedure for fracture sequelae (i.e., malunion, nonunion, fixation failure, tuberosity non-union). Despite the growing enthusiasm it remains unknown whether functional outcomes after RTSA as a salvage procedure are similar to those following acute RTSA. As a result, the purpose of this systematic review was to compare functional outcomes after RTSA as a primary versus salvage procedure for displaced PHF in the elderly. A literature search of the electronic databases EMBASE, MEDLINE, and PubMed was conducted to identify all studies comparing RTSA as a primary treatment for displaced PHF and as a salvage procedure for failed initial management. Only studies with a minimum follow-up of two years were included. Data pertaining to range of motion, patient reported outcome measures and complications were extracted from eligible studies and entered into a meta-analysis software package (RevMan version 5.1, The Cochrane Collaboration) for pooled analysis. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of eligible studies. The search identified four studies consisting of 200 patients with a mean age of 73.3 years and a mean follow-up of 3.2 years. There were a total of 76 patients (75% female) who underwent acute RTSA following displaced PHF, while 124 patients (77% female) required salvage RTSA for failure of initial treatment. Primary RTSA was found to have significantly higher American Shoulder and Elbow (ASES) (P = 0.04), Constant (P = 0.01) and University of California at Los Angeles (UCLA) (P = 0.0004) scores compared to salvage RTSA. Forward flexion (P = 0.001) and external rotation (P< 0.0001) were significantly greater amongst those undergoing RTSA acutely versus as a salvage procedure. The odds of having a complication (e.g., infection, dislocation, fracture) were 76% lower amongst those who had primary RTSA compared to salvage RTSA (P = 0.02). The overall quality of eligible studies was moderate to high. Based on the current available evidence, elderly patients with displaced PHF have significantly greater range of motion, higher patient reported outcomes and lower risk of complications with primary RTSA compared to those undergoing RTSA as a salvage procedure. Additional prospective studies are warranted to confirm these findings

Proximal humeral fractures occur frequently, with fixed angle locking plates often being used for their treatment. However, the failure rate of this fixation is high, ranging between 10 and 35%. Numerous variables are thought to affect the performance of the fixation used, including the length and configuration of screws used and the plate position. However, there is currently limited quantitative evidence to support concepts for optimal fixation. The variations in surgical techniques and human anatomy make biomechanical testing prohibitive for such investigations. Therefore, a finite element osteosynthesis test kit has been developed and validated - SystemFix. The aim of this study was to quantify the effect of variations in screw length, configuration and plate position on predicted failure risk of PHILOS plate fixation for unstable proximal humerus fractures using the test kit. Twenty-six low-density humerus models were selected and osteotomized to create a malreduced unstable three-part fracture AO/OTA 11-B3.2 with medial comminution which was virtually fixed with the PHILOS plate. In turn, four different screw lengths, twelve different screw configurations and five plate positions were simulated. Each time, three physiological loading cases were modelled, with an established finite element analysis methodology utilized to evaluate average peri-screw bone strain, this measure has been previously demonstrated to predict experimental fatigue fixation failure. All three core variables lead to significant differences in peri-screw strain magnitudes, i.e. predicted failure risk. With screw length, shortening of 4 mm in all screw lengths (the distance of the screw tips to the joint surface increasing from 4 mm to 8 mm) significantly (p < 0 .001) increased the risk of failure. In the lowest density bone, every additional screw reduced failure risk compared to the four-screw construct, whereas in more dense bone, once the sixth screw was inserted, no further significant benefit was seen (p=0.40). Screw configurations not including calcar screws, also demonstrated significant (p < 0 .001) increased risk of failure. Finally, more proximal plate positioning, compared to the suggested operative technique, was associated with reduced the predicted failure risk, especially in constructs using calcar screws, and distal positioning increased failure risk. Optimal fixation constructs were found when placing screws 4 mm from the joint surface, in configurations including calcar screws, in plates located more proximally, as these factors were associated with the greatest reduction in predicted fixation failure in 3-part unstable proximal humeral fractures. These results may help to provide practical recommendations on the implant usage for improved primary implant stability and may lead to better healing outcomes for osteoporotic proximal fracture patients. Whilst prospective clinical confirmation is required, using this validated computational tool kit enables the discovery of findings otherwise hidden by the variation and prohibitive costs of appropriately powered biomechanical studies using human samples

Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimise complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered. Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN. Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component, if necessary. Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95-degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone. Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common

Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimise complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered. Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN. Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component, if necessary. Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95 degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone. Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common

Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimize complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered. Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN. Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component if necessary. Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95 degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone. Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common

Introduction. Cementless acetabular fixation in total hip replacement (THA) is reliable and has been the fixation method of choice in the United States for decades. While revision for failure of osseointegration or early loosening is relatively rare, recurrent dislocation remains a leading cause of early revision. Novel acetabular implants and those offered by smaller companies often lack constrained or dual mobility liners, which may result in revision of well-fixed, well-positioned cups in cases of recurrent dislocation. The purpose of this study was to compare outcomes of THA with three different acetabular cups with differing fixation surfaces. One hydroxyapatite (HA)-coated cup (Trident, Stryker, Kalamazoo, MI, USA) offered dual mobility or constrained liner options. The other cups were a novel highly porous cup (Restoris PST, Stryker, Kalamazoo, MI, USA), and a Calcium Phosphate (CaP)-coated cup (Trinity, Corin, Cirincester, UK), neither of which offered dual mobility or constrained options at the time of investigation. Endpoints of interest were: clinical and radiographic outcomes including evidence of osseointegration, overall reoperations, reoperations for acetabular fixation failure, and reoperations to address dislocation in which a well-positioned shell was revised due to the lack of dual mobility or constrained options. Methods. A retrospective review of 370 acetabular cups implanted in 328 patients for THA by a single surgeon between February 2013 and June 2016 was performed. There were 100 Trident cups (Stryker, Kalamazoo, MI, USA), 105 Restoris PST Acetabular Cups (Stryker, Kalamazoo, MI, USA), and 165 Trinity Acetabular Cups (Corin, Cirincester, UK). Patient records were reviewed for post-operative complications, clinical outcomes scores and radiographic signs of acetabular osseointegration at minimum 1-year follow-up. Results. Despite differences in fixation surface, there was no difference in Harris Hip Scores at minimum 1-year follow-up and all three cohorts had 100% 1-year survivorship free of revision for failure of acetabular fixation. No cup showed signs of acetabular migration or loosening. Overall reoperation rates were low, ranging from 2.4%-3.8% (p=0.81). Femoral fractures and fixation problems were the most common cause of reoperation, occurring in nearly 2% of cases (n=7), but did not differ between groups. Reoperation for infection occurred in less than 1% of cases (n=3) and did not differ between groups. Revision for recurrent dislocation occurred in 1% of cases (n=4). All occurred with cups lacking dual mobility or constrained options. In all 4 cases the acetabular component was within the Lewinnek “safe zone” and deemed well positioned. In one revision, a lipped liner and longer head were used given concerns about the risk of acetabular component revision due to poor bone stock. In the remaining revisions, the well-positioned cup was revised to allow for the use of constrained or dual mobility implants. Conclusion. All acetabular revisions in our cohort were related to instability or infection, while none were related to acetabular fixation. Subsequent to this experience and analysis, we are wary to select any “new and improved” acetabular cup that does not have an option for a constrained or dual mobility liner, even when enabling technology makes us confident of safe-zone placement. For any figures or tables, please contact authors directly

Total knee replacements are being more commonly performed in active younger and obese patients. Fifteen-year survivorship studies demonstrate that cemented total knee replacements have excellent survivorship, with reports of 85 to 97%. Cemented knee arthroplasties are doomed to failure due to loss of cement-bone interlock over time. Inferior survivorship occurs in younger patients and obese patients who would be expected to place increased stress on the bone-cement interfaces. Roentgen stereophotogrammetric analysis (RSA) studies have indicated that cementless fixation should perform better than cemented fixation. However, cementless fixation for total knee replacement has not gained widespread utilization due to the plethora of poor results reported in early series. The poor initial results with cementless total knee replacement have occurred due to poor implant designs such as cobalt chrome porous interfaces, poor initial tibial component stability, lack of continuous porous coating, poor polyethylene, and use of metal-backed patellae. I have used cementless fixation for total knee replacements for young, active, and heavy patients since 1986 when durability over 20 years is desirable. My series of over 1,300 cementless TKAs represents about 20% of the 6,500 total knees I have performed from 1986 to 2017. I have seen initial failures in my series due to the use of metal-backed patellae with thin polyethylene, older generation polyethylene, and use of screws with the tibial components which provide access to the metaphyseal bone for polyethylene wear debris. Overall implant fixation failures were still significantly low due to the use of a highly porous titanium surface on both the tibial and femoral components. With the advent of utilizing implants with continuous porous surfaces and highly crosslinked polyethylene, and elimination of use of metal-backed patellae and tibial screws, I have only had one revision due to aseptic loosening or osteolysis in the last 1,071 cases performed since 2002. Almost 50% of total knees are now performed on patients under the age of 65. A 55-year-old patient has a 30 year life expectancy. Modern total knee replacement design has made biological fixation predictable for young and heavy patients. Because it is a biological interface, it should respond better than cement to the increased stresses that will be applied over many years by our younger, more active and heavier total knee population

Instability after total hip arthroplasty is the primary cause for revision surgery and is a frequent complication following revision surgery for any reason (Bozic et al, JBJS 2009). Surgical management of the unstable hip has not been uniformly successful with the best results occurring in those hips in which an identifiable cause of instability can be determined (Daly & Morrey, JBJS 1992). It was these sobering findings that led to the development of and increased use of constrained acetabular components. While the results of revision surgery for instability using constrained components have been encouraging (Shapiro, Padgett, Sculco J Arthroplasty 2003) with a re-dislocation rate of less than 3%, reoperation for other reasons have noted to increase with time. The commonly used tripolar configuration has been susceptible to bearing damage at both the inner and outer bearing surface by the nature of the constrained mechanism (Shah, Padgett, Wright, J Arthroplasty 2009). In addition, we have noted instances of fixation failure directly related to the constrained acetabular device either from loss of implant fixation to the pelvis with or without cement (Yun, Padgett, Dorr, J Arthroplasty 2005). The observation of these failure modes ranging from either fixation failures to overt biomaterial failure have led us to be extremely cautious in the “routine” use of constrained liners in revision THR. Stratification of the recurrent dislocator has been nicely described by Wera et al (J Arthroplasty, 2012). The etiology of dislocation includes: acetabular malposition, femoral malposition, abductor deficiency, impingement, late bearing wear and unknown causes. Implant instability due to malposition, impingement, and poly wear should be revised as appropriate to correct the underlying problem in addition to the use of either larger diameter heads. The emerging use of dual mobility articulations remains to be determined. However, the indiscriminate use of constrained liners should be avoided as the risk of problems outweighs their benefits

Severe glenoid bone loss in patients with osteoarthritis with intact rotator cuff is associated with posterior glenoid bone loss and posterior humeral subluxation. Management of severe glenoid bone loss during shoulder arthroplasty is controversial and technically challenging and options range from humeral hemiarthroplasty, anatomic shoulder replacement with glenoid bone grafting or augmented glenoid component implantation, to reverse replacement with reaming to correct version or structural bone grafting or metallic augmentation of the bone deficiency. Shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complications and revisions. Hemiarthroplasty has limited benefit for pain relief and function especially if eccentric glenoid wear exists. Bone loss with >15 degrees of retroversion likely requires version correction include bone-grafting, augmented glenoid components, or reverse total shoulder replacement. Asymmetric reaming may improve version but is limited to 15 degrees of version correction in order to preserve subchondral bone and glenoid bone vault depth. Bone-grafting of glenoid wear and defects has had mixed results with graft-related complications, periprosthetic radiolucent lines, and glenoid component failure of fixation. Implantation of an augmented wedge or step polyethylene glenoid component improves joint version while preserving subchondral bone, but is technically demanding and with minimal short term clinical follow-up. A Mayo study demonstrated roughly 50% of patients with posteriorly augmented polyethylene had radiolucent lines and 1/3 had posterior subluxation. Another wedge polyethylene design had 66% with bone ingrowth around polyethylene fins at 3 years. Long term outcomes are unknown for these new wedge augmented glenoid components. Reverse shoulder arthroplasty avoids many risks of anatomic replacement glenoid component fixation and stability but is associated with a high complication rate (15%) including neurologic and baseplate loosening and often requires structural bone grafting behind the baseplate with suboptimal outcomes or metallic augmented baseplates with limited evidence and short term outcomes. Reverse replacement with baseplate bone grafting or metal augmentation is technically challenging due to limited native glenoid bone stock available for baseplate component ingrowth and long term fixation. Failure to correct glenoid superior inclination and restore neutral version within 10 degrees increases the risks of reverse baseplate failure of fixation, pull out, and failure of reverse replacement. Reverse baseplate failure rates in patients with severe glenoid bone loss and concomitant glenoid bone grafting range from 5–11%. The minimum native glenoid bony contact with the baseplate is unknown but likely is approximately 1cm of native bone contacting a central ingrowth post and a minority (∼15–25%) of native glenoid contacting the backside of the baseplate. Failure to correct posterior bone loss can lead to retroversion of the baseplate, reduced external rotation, posterior scapular notching, and posteromedial polyethylene wear. In summary, shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complication and revision

Instability after total hip arthroplasty is the primary cause for revision surgery and is a frequent complication following revision surgery for any reason (Bozic et al, JBJS 2009). Surgical management of the unstable hip has not been uniformly successful with the best results occurring in those hips in which an identifiable cause of instability can be determined (Daly & Morrey, JBJS 1992). It was these sobering findings that lead to the development of and increased use of constrained acetabular components. While the results of revision surgery for instability using constrained components have been encouraging (Shapiro, Padgett, Sculco, J Arthroplasty 2003) with a re-dislocation rate of less than 3%, reoperation for other reasons have noted to increase with time. The commonly used tripolar configuration has been susceptible to bearing damage at both the inner and outer bearing surface by the nature of the constrained mechanism (Shah, Padgett, Wright, J Arthroplasty 2009). In addition, we have noted instances of fixation failure directly related to the constrained acetabular device either from loss of implant fixation to the pelvis with or without cement (Yun, Padgett, Dorr, J Arthroplasty 2005). The observation of these failure modes ranging from either fixation failures to overt biomaterial failure have lead us to be extremely cautious in the “routine” use of constrained liners in revision THR. Implant instability due to poor position should be revised as appropriate to correct alignment. The use of either larger diameter heads or the emerging use of dual mobility articulations seems more appropriate at this time

The Fixion expandable nailing system provides an intramedullary fracture fixation solution without the need for locking screws. Proponents of this system have demonstrated shorter surgery times with rapid fracture healing, but several centres have reported suboptimal results with loss of fixation. This is the largest comparative series to be reported to date. We compared outcomes between 50 consecutive diaphyseal tibial fractures treated with a Fixion device at our institution to an age, sex and fracture configuration matched series of 57 fractures at a neighbouring hospital treated with a conventional interlocked intramedullary nail. Minimum follow up time was 2 years. Operating time was significantly reduced in the Fixion group (mean 61 minutes, range 20–99) compared to the interlocked group (88 minutes, 52–93), p< 0.00001. The union rate was no different between the Fixion group (93.9%) and the interlocked group (96.5%), p=0.527. Time to clinical and radiological union was significantly faster in the Fixion group (median 85 days, range 42–243) compared to the interlocked group (119, 70–362), p< 0.0001. The overall reoperation rate was lower in the Fixion series (24.5% vs 38.6%, p=0.121), although the majority of reoperations in the interlocked group were more minor, for screw removal. 3 Fixion nails were revised for fixation failure and 2 manipulations were required for rotational deformities after falls; all of these patients were non-compliant with post-operative instructions. There were no fixation failures in the interlocked group. 3 fractures were noted to propagate during inflation of Fixion nails. The Fixion nail is faster to implant and allows more physiological loading of the fracture, with a faster union time. However, these advantages are offset by a reduction in construct stability. Our results have demonstrated a learning curve with a reduction in complications as our indications were narrowed, avoiding osteoporotic, multifragmentary, unstable fractures and non-compliant patients

To identify ideal screw placement for internal fixation of intra capsular fracture neck of femur to avoid fixation failures, 20 cadaveric bone measurements of the neck of femur in basal, midcervical and at sub capital regions were carried out using Vernial caliper and CT scan. Midcervical region of neck of femur measurements were further divided into upper half (Superior half) and Inferior half (Inferior Half). AP and Lateral view X-rays were obtained following three parallel screws placements in Femur neck:. Configuration 1: Triangular configuration where two screws are inferior and one superior. Configuration 2: Triangular configuration where two screws are placed superiorly and one screw inferiorly. Neck has wider diameter in the upper half of neck of femur than in the lower half in the mid cervical region. Placing two 7.0 mm cancellous screws (total 14 mm) in the lower half of the neck of femur, as widely practised, has more likely chances of not having purchase in the mid cervical region of the femur neck by at least one screw. Cannulated screws fixation carried out in reverse triangular configuration by placing two screws superiorly (superior-anterior and superior-posterior) and one screw inferiorly (inferior-central) has better fixation and avoids fixation failure. Reverse triangular configuration of fixation is also likely to support the weaker superior half of the neck which lacks stronger cortex and calcar part as in the inferior part of the neck. We also recommend placing a larger screw in the superior half of femur neck and a smaller screw in the inferior half in recon-–IM nail fixation, based upon our experiment result

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