Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired. We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility. This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile

Multiple studies have established an inverse relationship between ambient theatre temperatures and polymethyl methacrylate (PMMA) cement setting times. It is also known that allowing cement to equilibrate to ambient theatre temperatures restores expected setting characteristics. One overlooked entity is the transport and storage conditions of cement. This is important in tropical regions, where extreme temperature and humidity may cause rapid cement setting times, resulting in potentially significant intra-operative complications. This study investigated the relationship between extreme transport and storage conditions of Antibiotic Simplex cement (Stryker), and the effect on setting times at Cairns Hospital, Far North Queensland, Australia. Fifty units of cement were divided evenly into a control arm and four experimental arms. The experimental arms were designed to mimic potential transport and storage conditions. They included seven days of storage in a medication fridge, on the hospital loading dock, in a cane shed, and in a Toyota Landcruiser parked outdoors during January 2022. Humidity and temperature readings were recorded. The samples in each group were evenly distributed to equilibrate to theatre conditions for 1 hour and 24 hours. Setting time was recorded when a no. 15 scalpel blade was unable to mark the surface. All three ‘hot’ exposures setting times were significantly faster for both 1 hour (ρ=0.001) and 24 hours (ρ=0.024) equilibration times. The difference in setting times for the ‘cold’ exposure was not significant for either equilibration times (ρ=1). To our knowledge, this is the first study investigating cement setting times in tropical climates. Further studies are required to address the effect of these conditions on biomechanical strength of PMMA cement. We conclude that extreme heat and humidity during transport and storage have a statistically significant effect on cement setting times

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Introduction/Aim. The NAVIO robotic-assisted TKA (RA-TKA) application received FDA clearance in May 2017. This semi-active robotic technique aims to improve the accuracy and precision of total knee arthroplasty. The addition of robotic-assisted technology, however, also introduces another potential source of surgery-related complications. This study evaluates the safety profile of NAVIO RA-TKA. Materials and Methods. Beginning in May 2017, the first 250 patients undergoing NAVIO RA-TKA were included in this study. All intra-operative complications were recorded, including: bleeding; neuro-vascular injury; peri-articular soft tissue injury; extensor mechanism complications; and intra-operative fracture. During the first 90 days following surgery, patients were monitored for any post-operative complications, including: superficial and deep surgical site infection; pin-tract infection; pin site fractures; peri-prosthetic fractures; axial or sagittal joint instability; axial mal-alignment; patello-femoral instability; DVT/PE; re-operation or re-admission due to surgical-related complications. Surgical technique and multi-modality pain management protocol was consistent for all patients in the study. A combined anesthetic technique was employed for all cases, including: low-dose spinal, adductor canal block and general anesthetic. Patients were mobilized per our institution's rapid recovery protocol. Results. No patients were lost to follow-up. During the study period, no intra-operative complications were recorded. Specifically, no complications related to the introduction of the high-speed burr associated with the NAVIO RA-TKA were noted. Within the 90-day follow-up period, there was one case of deep infection. One patient sustained a fall resulting in a peri-prosthetic femoral fracture, that occurred remote from the femoral pin tracts. No cases of axial or sagittal joint instability, axial mal-alignment, patello-femoral instability, pin site infections or fractures; or DVT/PE were identified. Four patients underwent manipulation under anesthesia. No other patients required a re-operation or re-admission due to surgical-related complications. Discussion/Conclusions. The initial experience with the NAVIO robotic assisted total knee arthroplasty has demonstrated excellent safety profile. Relative to known risks associated with total knee arthroplasty, no increased risk of peri-operative complications, re-operation or re-admission for surgical related complications was identified with the introduction of the NAVIO RA-TKA

Intra-operative complications vary from extremely benign such as glenoid vault penetration to life and limb threatening for example brachial artery injury. Most intra-operative complications can be avoided with careful pre-operative planning, anticipation, and execution. However, even the best planning and execution including fluoroscopic guided reaming cannot prevent all complications. The following intra-operative complications will be discussed in detail in regards to both prevention and management: Glenoid vault penetration, Glenoid component malposition - reverse and primary, Glenoid fracture - reverse and primary, Humeral component malposition - reverse and primary, and Humeral fracture - reverse and primary

Seniors make up 16.9 percent of the Canadian population. Furthermore, the number of Canadians who are 65 years or older is increasing at an average rate of 20 percent every 5 years. In 2017, Sing etal reported that there is an increasing number of patients undergoing degenerative scoliosis surgery with the largest increase attributed to patients aged 65–69 years followed by those aged 70–74 years. Therefore, the purpose of this study is to assess the effectiveness of undergoing spinal surgery to correct degenerative spinal scoliosis in the ever-growing number of elderly patients. We hypothesize that age is not an independent prognostic factor of patients' outcomes followings degenerative scoliosis surgery. A retrospective review of prospectively collected data within the Canadian Spine Outcome and Research Network (CSORN) was conducted. Data was analyzed using IBM-SPSS. ANOVA was used to analyze continuous variables while Chi Square test was used to analyze categorical variables. Significance level was p < 0.05. There were 165 patients identified from the registry who met the inclusion criteria, 94 patients (57 %) were female. There were 102 (61.8 %) patients who were 65 years or older. The overall average age was 66.6 years (range 35–84, SD 8.6). There were 27 intra-operative complications, 44 peri-operative complications and 18 post operative complications. There was no statistically significant difference between the two age groups with regards to risk of developing intra-operative, perioperative and post operative complications. Patients who underwent degenerative scoliosis surgery reported an average improvement of 2.95±3.32, 3.64±3.50, 16.84±20.44 points on the back-pain scale, leg pain scale and the Oswestry Disability Index (ODI) respectively, there was no statistically significant differences in these measures between the two age groups. As the number of patients undergoing degenerative scoliosis surgery increases, clinicians will need to determine which factors will significantly impact patients' outcomes following surgery. This study shows that age is not an independent prognostic factor when it comes to patients' outcomes following degenerative scoliosis surgery. In the future, research should examine the impact of age in conjunction with factors such as frailty, comorbidities and functional status on patient outcomes

The direct anterior (DA) approach for total hip arthroplasty (THA) has become increasingly popular in North America. With experience, exposure of both the acetabulum and femur can be achieved similar to those in other approaches. In cases of difficult femoral exposure, the conjoint tendon of the short external rotators can be released to improve visualisation. The effect of conjoint tendon release has not been previously explored in regards to overall outcomes, or postoperative pain. The goal of this study was to evaluate 1) the length of stay and inpatient pain medication requirements of patients undergoing DA THA on the basis of conjoint tendon release, and 2) whether conjoint tendon release influenced functional outcomes. We conducted a retrospective chart review of all cases of primary DA THAs conducted by single surgeon at LHSC University between August 2012 and July 2015. Patient demographics, bilateral THA cases, intraoperative conjoint tendon or other soft tissue releases, intra-operative complications, and length of stay (LOS) were evaluated for all cases. Inpatient pain medication data was available for all cases from Apr 2014 onwards. One year functional outcome scores, including WOMAC and Harris Hip Scores (HHS), were evaluated for all cases before August 2014. Six-week and three-month functional outcome scores were available and evaluated for a subset of cases. All data was analysed with multiple linear regression. Three hundred and twelve cases of primary DA THAs were identified, of which 29 were concurrent bilateral THAs. One hundred and eighty cases included a conjoint tendon release, while 29 cases had other soft tissue releases (tensor fascia lata). Mean age and BMI were 64.9±11.5 years and 29.0±5.3 respectively. Mean LOS was 1.3±1.1 days, with age, bilateral THA, non-conjoint tendon soft tissue release, and intra-operative complications being predictive of LOS (p<0.05). Pain medication data was available for 107 cases, of which 11 were concurrent bilateral THAs. Sixty four cases included a conjoint tendon release, while one case had other soft tissue releases. Mean daily morphine equivalent dose (MED) narcotic use was 43.2±48.2mg, with age being a negative predictor of narcotic use (p<0.05). BMI was a negative predictor of one year HHS pain, HHS total, and all WOMAC subcategory scores, while age was a negative predictor of one year HHS function and HHS total scores (p<0.05). None of the variables were predictive of six-week and three-month functional outcome scores. Conjoint tendon release was not predictive of LOS, inpatient pain medication requirements, or outcome scores. Conjoint tendon release did not affect postoperative pain, LOS, or functional outcomes. Given that conjoint release improves femoral exposure, intraoperative thresholds for conjoint release should be low. The effect of intraoperative release of other soft tissues is uncertain, as this increased LOS but not postoperative pain

Aim. Post traumatic distal tibia osteomyelitis (DTOM) with an upper ankle joint involvement is a serious complication after primary osteosynthesis and can be a nightmare for the patient and the surgeon as well. Our aim was to identify mayor complications during treatment and to find the way to prevent or treat them. Method. It is a retrospective analysis of eight patients with DTOM and an upper ankle joint involvement treated in our institution from 2012 to 2018. The average size of a bone defect after a debridement was 9 centimeters (4–15). Patients were treated in two stages. First stage was segmental bone resection, external fixation and soft tissue envelope reconstruction if necessary. At second stage a distraction frame was applied and proximal corticotomy performed. In all but one case a circular frame was used. Results. We have had one major intra-operative complication, an injury of arteria tibialis posterior during the corticotomy procedure. Except in one patient we did not observe major problems with pin-track infections. Despite bone-grafting in all patients, we observed three nonunions of docking site. We treated them by external fixator in two and retrograde intramedullar nail in one case. In two patient the distraction callus was weak. We had to bone graft and secure the callus with a plate in one and use a retrograde reamed intramedullar nail in second patient. We have observed two callus fracture after removal of the frame. A surgery was needed for both because of the deformation. The first patient was treated by new external frame, the second by retrograde reamed intramedullar nail. Conclusions. Callus distraction is a valuable option to treat a bone defect. The procedure has many possible problems and complications, especially during treatment of defects larger than six centimeters. It is very difficult for patients to tolerate a frame more than one year. We have found the use of an intramedullar tibial nail inserted in a retrograde way as a helpful option not just to shorten the time of external frame, but in combination with reaming also to accelerate the healing of the distraction callus and the upper ankle joint arthrodesis as well

Introduction. Revision TKA can be a difficult and complex procedure. Bone quality is commonly compromised and stem fixation is required in many cases to provide stability of the prosthetic construct. However, utilization of diaphyseal engaging stems adds complexity to the case and can present technical challenges to the surgeon. Press fit metaphyseal sleeves can provide stable fixation of the construct without the need for stems and allows for biologic ingrowth of the prosthesis. Metaphyseal sleeves simplify the revision procedure by avoiding the need to prepare the diaphysis for stems, alleviating the need for offset stems and decreasing the risk of intra-operative complications. The ability to obtain biologic fixation in the young patient is also appealing. This study reports on the author's mid-term experience with this novel technique. Methods. Between May 2007 and June 2009 the author performed 17 revisions TKA that utilized press-fit metaphyseal sleeves without stems on either the tibial side of the joint, the femoral side of the joint or both. Twenty six sleeves were implanted altogether (13 tibial, 13 femoral). Patients were limited to touch down weight bearing for 6 weeks post-operatively. The patients were followed prospectively with clinical and radiographic follow-up at routine intervals. Results. Average clinical and radiographic F/U for the cohort was 57 months (range 30 – 77). Fourteen of seventeen patients had a minimum of 4 years F/U. Average age at the time of surgery was 58 years (range 46–72) and average BMI was 32.4. Indications for the index revision included nine knees with aseptic loosening and / or osteolysis, two knees for septic loosening, two knees for instability and 4 knees for pain / stiffness or other causes. ROM at pre-op and latest F/U averaged 2–108 deg and 0–117 deg respectively. Knee Society Scores at pre-op and latest F/U averaged 35 and 86 respectively (range 57–100). Survivorship analysis revealed 25 of 26 sleeves (96%) to still be in situ at latest F/U. One tibial sleeve was revised at 30 months for septic loosening. Radiographic analysis revealed 22 of the remaining 25 sleeves (88%) to be ingrown. Two tibial sleeves and one femoral sleeve exhibit stable fibrous fixation and are asymptomatic. Conclusions. Press-fit metaphyseal sleeves utilized without stems appear to provide excellent stability of the revision TKA construct at mid-term F/U. Biologic fixation appears to be present in the majority of cases. This ability to obtain reliable osseointegration of the revision construct is appealing, especially in the younger revision patient. The sleeves have proven easy to use and there have been no intra-operative complications. This technique appears to provide a simple, but robust alternative when compared to revision TKA with stems in appropriate cases. Further F/U of this cohort is necessary to evaluate long term results

Background. Several recent reports have documented high frequency of malpositioned acetabular components, even amongst high volume arthroplasty surgeons. Robotic assisted total hip arthroplasty (THA) has the potential to improve component positioning; however, to our knowledge there are no reports examining the learning curve during the adoption of robotic assisted THA. Purpose. The purpose of this study was to examine the learning curve of robotic assisted THA as measured by component position, operative time, intra-operative technical problems, and complications. Methods. The first 105 robotic-assisted THAs performed by a single surgeon with a posterior approach from June 2011 to August 2013 patients were divided into three groups based on the order of surgery. Group A was cases 1–35, group B 36–70 and group C 71–105. Component position, operative time, intra-operative technical problems, and intra-operative complications were recorded. Results. There was no significant difference between groups A, B, and C for BMI or age (Figure 1). Gender was different between groups with 20 males in group A, 9 in group B, and 16 in group C (p < 0.05). There was no difference for mean acetabular inclination, acetabular anteversion, or leg length discrepancy between groups as experience increased (p > 0.05) (Figure 2). The average operative time for groups A, B, and C was 79.8 ± 27 min, 63.2 ± 14.2 min, and 69.4 ± 16.3 min respectively (p = 0.02). The cumulative number of outliers was two for the Lewenick safe zone and six for the Callanan safe zone. Figure 3 displays acetabular component positioning in relation to previously documented safe zones for the three groups. The risk of having an acetabular component outside of Lewenick's safe zone was not different between groups (p = 0.60). The risk of having an acetabular component outside of Callanan's safe zone decreased after group A and was statistically significant (p = 0.02). Overall there were nine (9%) intra-operative technical problems and complications. In group A there were three complications: one loosened femoral array, one loosened pelvic array, and one cup that appeared erroneous according to the navigation system. In group B there was one femoral calcar fracture treated with a cerclage wire, one loosened femoral array, and one intra-operative delay. In group C there were three technical problems, all a loosened femoral array. There was no difference in the overall number of intra-operative complications between groups (p = 1.0). Conclusion. A learning curve was observed, as a decreased incidence of acetabular component outliers and decreased operative time were noted with increased experience. Satisfactory acetabular component positioning and leg length matching were found throughout the learning curve of robotic assisted total hip arthroplasty, with very few outliers in either category. Based on these findings, we conclude that there is a learning curve of approximately 35 cases in robotic-assisted total hip arthroplasty

INTRODUCTION. Unicompartmental knee arthroplasty (UKA) allows replacement of a single compartment in patients who have isolated osteoarthritis as a minimally invasive procedure. However, limited visualization of the surgical site provides challenges in ensuring accurate alignment and placement of the prosthesis. With robot-assisted surgery, correct implant positioning and ligament balancing are obtainable with increased accuracy. To date, there has not been a large series reported in the literature of UKAs performed with robotic assistance. The aim of this study was to examine the clinical outcomes of robot-assisted UKA patients. METHODS. 510 patients who underwent robotic-assisted UKA between July 2008 and June 2010 were identified (average age 63.7 years, range: 22 to 28 years). Clinical outcomes were evaluated using the Oxford Knee Score (OKS) and patients without recent follow-up were phoned. Revision rate and time to revision were also examined. RESULTS. Average length of stay was 1.4 days (range: 1 to 7 days). There was minimal blood loss with most procedures. There were two intra-operative complications, both in early patients in the series. The first intra-operative complication was broken alignment pins in both the femur and tibia. In the second complication, preparation was finished manually with a burr due to registration problems with the software. Both patients were doing well at most recent follow up and neither experienced further complications. At latest clinical follow-up, patients reported a mean OKS of 36.1 + 9.92. The revision rate was 2.5% with 13 patients either converted from an inlay to onlay prosthesis or conversion to TKA. The most common indication for revision was tibial component loosening, followed by progression of arthritis. One patient was revised due to infection. Mean time to revision was 9.55 + 5.48 months (range: 1 to 19 months). CONCLUSION. UKA with a robotic system provides good pain relief and functional outcomes at short-term follow-up. Ensuring correct component alignment and ligament balancing increases the probability of a favorable outcome. Proper patient selection for appropriate UKA candidates remains an important factor for successful outcomes. In combination with robotic assistance there can be a reduction in many of the failures seen with early systems

Background. We identified several opportunities to significantly reduce cost for hip and knee arthroplasty procedures:. Customized instruments: by identifying the essential instruments for arthroplasty cases, we managed to have one universal tray for each case, and 3 specific trays from the implant manufacturing company. Customized wrap-free, color-coded, stackable trays: by using a wrap-free trays, preparation time in central sterile, opening tray time in OR and turn-over time were reduced. Also, stackable trays were organized based on side and size, therefore only 2 trays needed to be used in each case. Discounted implants: negotiated through optional case coverage with revision system and reps available as backup. Optional rep coverage protocols: designed through process management of the operating room surgical staff and central sterile. Aim of the study was to measure the cost savings, efficacy, and outcomes associated with primary total hip and knee arthroplasty by implementing these protocol. Methods. This is a prospective study from January to October 2016 for selected primary total hip and knee arthroplasties were performed with the above protocols by 2 experienced arthroplasty trained surgeons, were followed for minimum 3 months. Initiating the cost saving protocols were achieved by re-engineering customized trays, discounted implants through optional case coverage (Sourced Based Selection of a Cooperating Manufacturer, MTD), and focused on process management of the staff training. Staff responsibilities were divided into 2 categories:. Familiarity of the instruments, implant, and techniques; trays set up and assurance of availability of the implants. These responsibilities were covered by a trained OR technician and the surgeon. Final verification of the accurate implants prior to opening the packaging. This was achieved by a trained OR nurse and the surgeon. Results. We did not have any intra-operative complications. We also did not encounter any issued with the trays or errors in opening of the implants. There were no re-admissions, fracture, dislocation, or infection. The mean length of stay was 2.2 ± 0.5 days (range 1–3 days) with 68% home discharges. The cost of the implant was reduced from $4,800 to $1,895 with $2,905 cost saving per case and total savings of $58,100. The projected savings only for uncomplicated primary total hip arthroplasty (minimum 120 cases/year between 2 surgeons) is $384,600. Further cost saving from the process management changes were seen in central sterile processing time. Prior to the one tray system, the hospital had 3 in-house trays and there were 4 device company trays. We also noticed an approximate 27% improvement in turnover time. Conclusion. Repless model has significant cost saving potential. Preparation for the transition, proper patient selection, standardization of the trays and implants, and distribution of the responsibilities between OR nurses, technicians and the surgeon are essential

Introduction. 3 main challenges encountered in knee revision of Asians:. systemic: such as osteoporosis and laxity. anatomical variance: established in literature making revision system not appropriate. Neglected case revised late owes to extensive bone loss demanding bone substitute and increased constrain. Therefore we like to alert surgeon apprehending enhanced challenges while indulging in revision of Asian. Our emiratus author with USA background/qualification/experience has excuted 216 revision in 8yrs with at least 3yrs follow-up. Material & Method. Between 2003–2010 we performed 216 revision TKR, reviewed all parameters & compared our results with European revision statistics depicting a) intermedullary canal smaller b) metaphysis narrower & more triangular in comparision to Caucasian causing housing mechanism fit impossible, also increase impingment of stem at times. Bone loss is normally quiet extensive & available implant including the Tantalum cone sometimes is difficult to fit in a tight metaphyseal area, we had satisfactory outcome inspite of owing to intra-operative complication which lead to 3 intramedullary fracture resulting from inadequate avalibity of smaller size, incomplete seating of tibial component, overhang of femoral component.it also leads to more translucent line quoted in 15 cases. Centre of IM canal in both tibia & femur is positioned more posteriorly especially in smaller size proven by CT anatomical study analysis. These data we related to anatomic variance rather then surgical technique therefore representing deficit of proper size thereby contributing to inability to surgeon. Conclusion. Restoring joint line to tibia to prevent impingment of tibial housing is crucks, enabled by utilizing certain surgical tricks which all surgeon revising small stature Asian should bear in mind.in certain instances use totally cemented stubby stem. 2 important aspect of our abstract:. a). Present: we will review all tricks enabling appropriate/maximum utilization of inadequate current revision system. b). Future: we will also present specific recommendation to Industry based on anatomy variation alerting them need of. 1). asymmetrical tibial component. 2). natural femoral component. 3). repositioning of stem. Multiple factors contributes more challenges in Asian revision:. 1). mainly anatomy attributed to metaphyseal morphology. 2). unable to apply certain surgical tricks to fit implant in small patient. strong recommendation to Industry to alter revision system inorder to achieve more success in Asian revision surgery

Complication rate after total shoulder arthroplasty ranges around 10%. These can be divided into intra-operative and post-operative complications. Intra-operative complications are periprosthetic fracture, nerve injury and malpositioning of components. Post-operative complications are instability, infection, rotator cuff tear, periprosthetic fracture, aseptic loosening, stiffness, heterotopic ossification and implant dissociation. The most effective means of preventing a complication are meticulous pre-operative planning, experience of the surgeon, adherence to sound surgical technique and intelligent patient selection and education

Introduction. Hip and knee device sales representatives (reps) can provide intra-operative guidance through their knowledge of the products, especially in complicated cases such as revision hip and knee arthroplasty. However, for an experienced arthroplasty surgeon in the majority of straightforward primary cases, the rep's presence may not be required for clinical decision-makings. With recent challenges in cost savings and bundle payments, hospitals and surgeons have focused on reducing the implant costs, among others, with a “repless” model. The aim of this study was to describe the process of utilizing this model, assess its efficacy, and analyze the cost savings in primary hip arthroplasty. Methods. During the month of January 2016, 20 cases of primary, straightforward total hip arthroplasties were performed with the repless model by 2 experienced arthroplasty trained surgeons. All patients were followed prospectively for minimum 3 months. Prior to initiating the repless model, we focused on process management of the operating room with staff training and re-engineering of the trays to obtain a setup that included one hospital tray and one device company tray for each operation. The responsibilities of the rep were divided into 2 categories for better management:. Familiarity of the instruments, implant, and techniques; trays set up and assurance of availability of the implants. These responsibilities were covered by a trained OR technician and the surgeon. Final verification of the accurate implants prior to opening the packaging. This was done by a trained OR nurse and the surgeon. Results. We did not have any intra-operative complications. We also did not encounted any issued with the trays or errors in opening of the implants. There were no re-admissions, fracture, dislocation, or infection. The mean length of stay was 2.2 ± 0.5 days (range 1–3 days) with 68% home discharges. The cost of the implant was reduced from $4,800 to $1,895 with $2,905 cost saving per case and total savings of $58,100. The projected savings only for uncomplicated primary total hip arthroplasty (minimum 120 cases/year between 2 surgeons) is $384,600. Further cost saving from the process management changes were seen in central sterile processing time. Prior to the one tray system, the hospital had 3 in-house trays and there were 4 device company trays. We also noticed an approximate 27% improvement in turnover time. Conclusion. Repless model has significant cost saving potential. Preparation for the transition, proper patient selection, standardization of the trays and implants, and distribution of the responsibilities between OR nurses, technicians and the surgeon are essential

Introduction. Total knee arthroplasty (TKA) using conventional instrumentation has been shown to be a safe and effective way of treating end stage osteoarthritis by restoring function and alleviating pain. As robotic technology is developed to assist surgeons with intra-operative decision making such as joint balancing and component positioning, the safety of these advancements must be established. Furthermore, functional recovery and clinical outcomes should achieve comparable results to the gold standard of conventional instrumentation TKA. Methods. Eighty-seven subjects (89 knees) underwent robotic arm assisted TKA by one of three investigators as part of an FDA and IRB approved Investigational Device Exemption (IDE). To achieve the primary endpoint of intra-operative patient safety using a robotic arm assisted cutting tool, the investigators completed questionnaires to assess a series of complications related to soft tissue damage associated with conventional TKA. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Knee Scores (KSS) were collected pre-operatively and at three month follow-up. Results. The average subject age was 65.8 ± 8.5 and the average BMI was 31.4 ± 5.7. 55% of the subjects were female. No subject experienced any of the rare intra-operative complications that comprise the primary safety endpoint. The average WOMAC score improvement from pre-operative to three months was 33.1 ± 20.04 (p<0.0001). The average KSS Knee score improvement was 46.1 ± 19.7 (p<0.0001). Subjects recovered their pre-operative range of motion by three months post-operative. Conclusion. Results from this prospective robotic arm assisted trial indicated greater intra-operative safety in blood loss and ligamentous damage when compared to conventional TKA. Subjects had excellent return to function and pain relief by three months as indicated by the KSS and WOMAC scores. Robotic technologies should be considered a safe and effective method in total joint restoration

Introduction. One main perceived drawback for the adoption of computer assisted orthopedic surgery (CAOS) during total knee arthroplasty (TKA) relates to the increased surgical time compared to the use of standard mechanical instrumentation [1]. This study compared the time efficiency between a next generation CAOS system (ExactechGPS®, Blue-Ortho, Grenoble, FR) and conventional mechanical instrumentation, and assessed the impact of surgeon experience level on the efficiency. Materials and methods. Surgical time was retrospectively reviewed on 63 primary TKAs performed by a board-certified orthopedic surgeon (PP) using a cemented postero-stabilized knee system (Optetrak Logic PS, Exactech, Gainesville, FL), grouped as 1) Group I (control): 21 TKAs using conventional mechanical instruments; 2) Group II: 21 TKAs performed using the CAOS system with an early experience level (first 21 cases); and 3) Group III: 21 TKAs using the CAOS system with an advanced experience level (beyond 30 cases). Surgical time was compared across the three groups (with significance defined as p<0.05). Results. Patient condition (age, BMI, gender, etc.), surgical technique, and post-operative guidelines were similar across the three groups. No cases were lost and no patient had any intra-operative complications. Compared to the TKAs using conventional mechanical instrumentation, the average surgical time for the navigated TKAs performed with an early experience was 7 minutes longer. However, with an advanced experience level, the average surgical time was 2 minutes less than the time required using conventional mechanical instrument. Further, navigated TKAs with an advanced experience level exhibited the least variability among the three groups. None of the time differences were significant (p>0.20). Discussion. No significant difference in TKA surgical time was found between the evaluated CAOS system (both within or pass the learning curve) and the conventional instrumentation. Nevertheless, once the learning curve was reached, the system decreased the time variability compared to conventional mechanical instrumentation. The comparable efficiency reported in this study to the conventional mechanical instrumentation may be attributed to the unique features of the ExactechGPS system, such as indication for use inside the sterile field, blood occlusion-resistant tracker design, customizable operative technique tailored to the surgeon's preference, and compact and reduced number of instruments

One main perceived drawback for the adoption of computer assisted orthopaedic surgery (CAOS) during total knee arthroplasty (TKA) relates to the increased surgical time compared to the use of standard mechanical instrumentation. This study compared the time efficiency between a next generation CAOS system (ExactechGPS®, Blue-Ortho, Grenoble, FR) and conventional mechanical instrumentation, and assessed the impact of surgeon experience level on the efficiency. Surgical time was retrospectively reviewed on 63 primary TKAs performed by a board-certified orthopaedic surgeon (PP) using the Optetrak Logic® PS knee system (Exactech, Gainesville, FL), grouped as 1) Group I (control): 21 TKAs using conventional mechanical instruments; 2) Group II: 21 KAs performed using the CAOS system with an early experience level (first 21 cases); and 3) Group III: 21 TKAs using the CAOS system with an advanced experience level (beyond 30 cases). Patient condition (age, BMI, gender, etc.), surgical technique, and post-operative guidelines were similar across the three groups. No cases were lost and no patient had any intra-operative complications. Surgical time was compared across the three groups (with significance defined as p<0.05). Compared to the TKAs using conventional mechanical instrumentation, the average surgical time for the navigated TKAs performed with an early experience was 7 minutes longer. However, with an advanced experience level, the average surgical time was 2 minutes less than the time required using conventional mechanical instrument. Further, navigated TKAs with an advanced experience level exhibited the least variability among the three groups. None of the time differences were significant (p>0.20). No significant difference in TKA surgical time was found between the evaluated CAOS system (both within or pass the learning curve) and the conventional instrumentation. Nevertheless, once the learning curve was reached, the system decreased the time variability compared to conventional mechanical instrumentation. The comparable efficiency reported in this study to the conventional mechanical instrumentation may be attributed to the unique features of the ExactechGPS system, such as indication for use inside the sterile field, blood occlusion-resistant tracker design, customisable operative technique tailored to the surgeon's preference, and compact and reduced number of instruments

Hip fusion is an uncommon procedure. Hip fusion takedown, therefore, is equally an uncommon procedure. What is of considerable interest is that the results, which I achieved in 20 cases in a paper published in 1987 are considerably superior to the results, which I am achieving today. This suggests that no simple case is now fused. It also equally suggests that there is little sense in looking at literature more than 10 or 15 years old on fusion takedowns as the two conditions are likely completely different. Most patients do not like a hip fusion. There are long-term problems with low back pain, ipsilateral global instability and contralateral patellofemoral osteoarthritis. A stiff hip produces a poor quality of life, especially in a tall person. The main problem in doing a hip fusion takedown is the condition of the abductors muscles. If fused before growth was complete, there may be pelvic hypoplasia. If the pelvis is small, the glutei will also be small. Sometimes, the glutei may have undergone fatty degeneration. This can be assessed by means of an MRI. If the abductors were damaged during fusion, a limp may persist. Other problems are that leg lengthening is difficult to achieve any longstanding hip fusion. Lengthening of 1–2 cm is usually about all that can safely be achieved. If the hip was fused in childhood, there is likely to be femoral hypoplasia. There is also likely absence of proximal cancellous bone and the proximal femur is a thin brittle cortical tube. The greater trochanter should not be detached as it is difficult to obtain union under such circumstances. The approach, which I prefer for a fusion takedown is an anterior Smith Peterson. The glutei are slid off the pelvis sidewall and then the upper part of the fusion can be exposed, blunt Hohmans can then be passed around the femoral neck prior to transection. Obviously, if any AO cobra plate has been used for a fusion, a trochanteric osteotomy may be required to preserve any glutei left. Old hardware can be removed either concurrently or as an interval procedure. In 1986, I published the results of 20 cases with a five to 40-year fusion time (mean 19). I used a variety of implants. Flexion was achieved to 90 degrees at 12 months in about 88% of people. Seventy-five percent ceased to limp by year one, although the elderly limp when tired. One patient was dissatisfied with the procedure. One was revised for pain. I have reviewed the cases done in the last 20 years. These were 28 cases, two bilateral. Seven were spontaneous fusions. Twenty-one were formal hip fusions. One was an AO fusion with a cobra plate. There were various intra-operative complications including two calcar cracks, which were wired, three femoral shaft fractures, which necessitated the use of long stems. There was one drop foot, which recovered. At review, a limp was absent in 20%, mild in 12% and severe, i.e. Trendelenburg positive in 68%. Harris hip scores were excellent in 28%, good in 32%, fair in 16% and poor in 24%. Four patients only, however, continued to use canes. The eventual range of movement was good. In 80%, more than 90 degrees of flexion was obtained, but it took up to two years to obtain maximum flexion. In 12%, the range of motion was poor at being 50 degrees to 85 degrees. The range of motion was poor, i.e. less than 45 degrees in one bilateral case of athrogryposis. This was a stiff arthrogrypotic. Further surgery is required in several cases. An ipsilateral total knee replacement and one a supracondylar femoral osteotomy. One cup loosened and was revised at seven years and one liner was exchanged at ten years

An increasing use of short stem femoral components (SSA), in favour of conventional or “shaft” stems in THA has been reported. SSA components have been reported as bone conserving. Shaft stems are a proven and accepted form of treatment. FEA studies predict more physiological loading of bone with SSA. Cadaver femur studies demonstrate adequate stability for bone ingrowth, more physiological loading of the femur and reduced stress shielding with SSA. Clinical studies report improved outcomes with SSA compared to shaft stems (reduced bone loss, reduced pain, reduced intra-operative complication rate, improved early rehabilitation times and reduced overall cost). A mechanical analysis, to examine the reported improved outcomes with short stems and a rationale for the use of short stems rather than shaft stems is considered