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

Abstract. Background. Extracorporeal radiation therapy (ECRT) has been reported as an oncologically safe and effective reconstruction technique for limb salvage in diaphyseal sarcomas with promising functional results. Factors affecting the ECRT graft-host bone incorporation have not been fully investigated. Methods. In our series of 51 patients of primary bone tumors treated with ECRT, we improvised this technique by using a modified V-shaped osteotomy, additional plates and intra-medullary fibula across the diaphyseal osteotomy in an attempt to increase the stability of fixation, augment graft strength and enhance union at the osteotomy sites. We analyzed our patients for various factors that affected union time and union rate at the osteotomy sites. Results. On univariate analysis, age <20 years, metaphyseal osteotomy site, V-shaped diaphyseal osteotomy, extramedullary plate fixation and use of additional plate at diaphyseal ostetomy had a significantly faster time to union while gender, tumor type, resection length, chemotherapy and use of intra-medullary fibula did not influence union time. In multivariate analysis, metaphyseal ostoeotomy, V-shaped diaphyseal osteotomy and use of additional plate at diaphyseal ostetomy were the independent factors with favourable time to union. Although the rate of union was higher with V-shaped diaphyseal osteotomy and use of additional plate and intra-medullary fibula at diaphyseal ostetomy, this difference could not be established statistically. None of the analyzed factors apparently affected the union rate in univariate analysis. Conclusion. Judicious choice of osteosynthesis and augmentation of ECRT graft can enhance incorporation with reduced complications and good functional outcome

Anterior cruciate ligament (ACL) injuries are one of the most common ligament injury occurring in young and active individuals. Reconstruction of the torn ligament is the current standard of care. Of the many factors which determine the surgical outcome, fixation of the graft in the bony tunnels has significant role. This study compared the clinical and functional outcome in patients who underwent ACL reconstruction by standard anteromedial portal technique with single bundle hamstring graft anchored in the femoral tunnel using rigidfix and cortical button with adjustable loops. The tibial fixation and rehabilitation protocol were same in both groups. 107 patients underwent ACL reconstruction over a two-year period (87 males, 20 females, 44 after motor vehicle accident, 34 after sports injuries, 79 isolated ACL tear, 21 associated medial meniscus tear, 16 lateral meniscus tear and 11 both menisci). Rigid fix group had 47 patients and adjustable loop 60 patients. Clinical evaluation at end of one year showed better stability in rigid fix group regarding Lachman, anterior drawer, pivot shift tests, KT 1000 arthrometer side to side difference and hop limb symmetry index. However, the differences were not statistically significant. Functional evaluation using IKDC 2000 subjective score and Lysholm score showed better results in rigidfix group than variable loop, but was not statistically significant. However, lower scores were noted in patients with concomitant meniscal injury than in isolated acl tear patients and this was statistically significant in both groups. Rigidfix seems to give better graft fixation on femoral side than variable loop, but by the end of one year the functional outcome is comparable in isolated acl reconstructions

To evaluate the efficacy of using a novel button-suture construct in place of traditional screws to provide bone block fixation for the Latarjet procedure. Four paired cadaveric shoulders (n=8) were denuded, with the exception of the conjoint tendon on the coracoid, and were potted. A 15% anterior glenoid bone defect was simulated. Right and left specimens were randomised into two groups: double-screw versus quadruple-button Latarjet reconstruction techniques. A uniaxial mechanical actuator loaded the Latarjet reconstructed glenoid articular surface via a 47mm diameter metallic hemisphere. Cyclic loading between 50–200N was applied to the glenoid at a rate of 1Hz for 1000 cycles. Testing was repeated three times for conjoint tendon loads of 0N, 10N and 20N. The relative positions of three points on the inferior, central and superior edges of the coracoid bone fragment were optically tracked with respect to a glenoid coordinate system throughout testing. Screw and button constructs were compared on the basis of maximum relative displacement at these points (RINF, RCENT, RSUP). Statistical significance was assessed using a paired-samples t-test in SPSS. When conjoint tendon loading was not present the double screw and quadruple button constructs were not significantly (P>0.779) different (0N: RINF: 0.11 (0.05)mm vs. 0.12 (0.03)mm, RCENT: 0.12 (0.04)mm vs. 0.12 (0.03)mm, RSUP: 0.13 (0.04)mm vs. 0.12 (0.03)mm). Additionally, the double screw construct was not found to differ (P>0.062) from the quadruple button in terms of resultant coracoid displacement for all central and superior points, regardless of conjoint loading (10N: RCENT: 0.11 (0.03)mm vs. 0.19 (0.05)mm, RSUP: 0.11 (0.01)mm vs. 0.18 (0.04)mm; 20N: RCENT: 0.13 (0.01)mm vs. 0.30 (0.13)mm, RSUP: 0.13 (0.03)mm vs. 0.26 (0.14)mm). It was only for the inferior point with conjoint loading of 10N and 20N that the double screw construct began to produce significantly lower displacements than the quadruple button (10N: RINF: 0.11 (0.03)mm vs. 0.23 (0.05)mm, P=0.047; 20N: RINF: 0.12 (0.02)mm vs. 0.39 (0.15)mm, P=0.026). The results of the screw and button constructs when conjoint tendon loading was absent suggest that the button may be a suitable substitute to the screw when the coracoid is used as a bone block. Due to the small resultant displacements (max: screw = 0.19mm, button = 0.52mm), it is suggested that buttons may also act as a substitute to screws for Latarjet procedures, provided conjoint tendon overloading is minimised during the post-operative graft healing period. These in-vitro results support the in-vivo results of Boileau et al (2015) that demonstrated the suture-button technique to be an excellent alternative to screw fixation Latarjet, with graft healing in 91% of their subjects

Coracoid fractures during screw insertion and graft osteolysis are serious concerns with standard screw fixation techniques in Latarjet procedure. This study tends to evaluate the outcome of mini open Latarjet using Arthrex mini-plate for coracoids graft fixation. We did retrospective analysis of 30 patients with recurrent anterior shoulder instability after arthroscopic Bankart's repair. A low profile wedge plate (Arthrex) with two low profile screws was used for fixation of the coracoid graft. CT analysis was performed at final follow up to see graft union and results were evaluated using American shoulder and elbow score (ASES) and Western Ontario shoulder instability score (WOSIS). Mean follow up time was 24 months. Postoperatively, mean forward elevation was 162.8 degrees and external rotation was 44.6 degrees. All patients returned to their previous occupation. None reported to be having any recurrent subluxation post-surgery. The mean ASES score was 92.5 while the mean WOSIS score was 76.84%. Only one patient had screw backing out from the plate. There was no case of coracoid graft osteolysis. The mini-open Latarjet procedure with graft fixation with Arthrex mini-plate provides satisfactory outcome and stabilization in patients who present with dramatic bone loss and failed soft tissue reconstruction. It not only ensures early rehabilitation but also minimum loss of external rotation. The only drawback is the relatively high cost of the implant

As the incidence of total hip arthroplasty (THA) rises, an increasing prevalence of peri-prosthetic femur fractures has been reported. This is likely due to the growing population with arthroplasties, increasing patient survival and a more active life-style following arthroplasty. It is the 3rd most common reason for THA reoperation (9.5%) and 5th most common reason for revision (5% with fracture risk after primary THA reported at 0.4%-1.1% and after revision at 2.1%-4%). High quality radiographs are usually sufficient to classify the fracture and plan treatment. Important issues in treatment include stem fixation status and fracture location relative to the stem. Additional comorbidities will also influence treatment choices, of which the most critical is the presence of infection and the quality of bone stock. The most commonly studied, and reported classification system is the Vancouver. Type A are peri-trochanteric fractures with AL at the lesser and AG at the greater trochanter. B fractures are those around the stem with B1 fractures having a well-fixed stem, B2 a loose stem with adequate bone stock, and B3 representing loose stem and inadequate bone stock. C fractures are distal to the stem. Type A) Trochanteric Fractures: These are usually associated with lysis. Displaced fractures can be managed adequately with cerclage fixation and cancellous allograft to fill osteolytic defects. Undisplaced fractures usually heal well with symptomatic treatment. Type B) Fractures Around the Stem: The B1 type has a well-fixed component and is usually treated with extramedullary fixation plus graft. Contemporary plates have been designed specifically for these fractures. Strut allograft may be used to provide a more rigid construct. Spiral and long oblique fractures can be cerclaged while short oblique or transverse fractures require fixation anterior and lateral with cable plates and cortical strut grafts. Screws can be used distal to the implant, and cables used proximally. The B2 type has a loose prosthesis but otherwise good bone stock. In this setting, the fracture line may be extended on the lateral cortex of the femur as an extended osteotomy to provide easy access for cement removal. These fractures can be managed with an extensively coated stem if rotational stability can be obtained in the distal segment. If rotational stability over a 4 cm scratch interference fit of the stem isn't possible, then a fluted tapered modular stem should be used. Strut allografts improve initial stability. The B3 type has both a loose prosthesis and poor bone stock and in the younger patient restoration of bone stock should be a priority. Bulk femoral grafts may be needed. The elderly or low functional demand patient may be treated with a proximal femoral replacement. Because of soft-tissue deficiencies, a constrained acetabular liner may be needed to prevent instability. Type C) Fractures Distal to the Stem: These usually accompany a stable stem and many fixation devices are available. Locking plates have become most popular and should be secured with cerclage wires proximally around the component with screws distally. Retrograde nails may be employed if there is adequate bone distal to the stem tip and above the fracture

Tibiofemoral joint dislocations are uncommon. Four cases of paediatric knee dislocation are described, none in British journals. We report two paediatric patients who presented with a 3-ligament knee injury following in-field or spontaneous reduction. One case was initially diagnosed as patella dislocation. One patient, age 12 years, had associated nerve and vessel injury so underwent fixation, vascular grafting and fasciotomy emergently. The second, age 15 years, underwent acute reconstruction following MRI evidence of both cruciates and medial-collateral ligament ruptures, with tears to both menisci. History is essential to diagnosis as the knee is often relocated at the scene. Tibiofemoral dislocation can be confused with patellofemoral dislocation. There are important differences on examination, which should be performed carefully, and must include neurovascular status. Knee AP and lateral radiographs can exhibit subtle signs, posterior subluxation of the tibia is pathognomonic of PCL rupture and should raise suspicion of dislocation. These cases show that traumatic dislocation is an important differential diagnosis in a child that presents with a painful knee. Although an uncommon injury, particularly in the skeletally immature, it is essential to recognise the possibility of knee dislocation in children so that prompt diagnosis and treatment of this limb threatening injury can occur

Scaphoid injuries remain a challenge in both diagnosis and subsequent management. Untreated scaphoid non-union leads to inevitable osteoarthritis. Non-unions are picked up via an established management pathway in out trust and treated surgically with a standardised technique of non-vascularised bone grafting and retrograde screw fixation. Patients that underwent primary screw fixation and grafting for scaphoid non-union between 2004-2008 were reviewed. These patients were followed up clinically and radiologically. They were assessed for time to union, complications, DASH score, patient satisfaction and return to work. In addition comparison was made between the use of Herbert screw and Twinfix screw fixation and between tricortical iliac crest graft and corticocancellous distal radial bone graft. Forty-two consecutive patients underwent surgery of which 35 (83%) were available for follow up. Mean follow up was 39 months (range 13-72). 31 (89%) patients had gone on to radiological union. Of those united the mean DASH score was 11. Mean time to union was 4.4 months (range 2-15 95% CI 3.3 – 5.5). 95% of patients were satisfied with their operation and would recommend it to a friend in the same situation. No significant difference in outcomes were identified between Herbert screw and Twinfix screw fixation or between iliac crest or distal radial bone grafting techniques. This study has shown encouraging results for an established protocol for management of scaphoid non-union. Outcomes are as a good as any published comparable series in the literature and provide further support to the use of this technique

We aimed to assess whether using long stem femoral components, with cemented distal fixation and proximal impaction grafting allows early patient mobilisation, reconstitution of the proximal femur and long term stability of fixation in patients with aseptic loosening and proximal femoral analysis. Over the past ten years 239 patients have been treated with an Elite Plus cemented long stem femoral implant, 33% with concomitant proximal impaction bone grafting. Many of the patients had co-morbidities. The average age at revision was 72 years (range 48 to 91). There was a slight female predominance. Fourteen percent of hips had been previously revised. Forty-eight patients were deceased and 22 were not available for follow-up; this left a cohort of 169 patients who were available for radiological and questionnaire review at an average of 4.5 years. According to the Paprosky grading for pre-operative bone loss 40% had moderate to severe bone loss (grade IIIb or IV). The Barrack grading was used to assess the cement mantle post-operatively with 65% showing good cementation. The Harris and O'Neill grades were used at final review to assess probability of loosening with only 8% being probably or definitely loose. The average Oxford Hip Score was 29. Mesh ± cables were required in a third of cases to allow adequate containment and pressurisation. It was generally felt that the long stem needed to be at least one third longer than the initial component. The re-revision rate was 1.2 with a 10 year survivorship analysis of 94%. The complication rate of almost 6% included periprosthetic fractures, dislocations, infection and mesh breakage. A long stem cemented femoral implant can be useful in bypassing proximal femoral deficiency in the appropriate patient