Osteoarthritis (OA) is the most common form of arthritis and one of the ten most disabling diseases in developed countries. Total joint replacement (TJR) is considered by far as the most effective treatment for end-stage OA patients. The majority of patients achieve symptomatic improvement following TJR. However, about 22% of the TJR patients either do not improve or deteriorate after surgery. Several potential non-genetic predictors for the TJR outcome have been investigated. However, the results were either inconclusive or had very limited predictive power. The aim of this study was to identify genetic variants for the poor outcome of TJR in primary OA patients by a genome-wide association study (GWAS). Study participants were total knee or hip replacement patients due to primary OA who were recruited to the Newfoundland Osteoarthritis Study (NFOAS) before 2017. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess pain and functional impairment pre- and 3.99±1.38 years post-surgery. Two non-responder classification criteria were used in our study. One was defined by an absolute WOMAC change score. Participants with a change score less than 7/20 points for pain were considered as pain non-responders; and those with less than 22/68 points for function were classified as function non-responders. The second one was the Outcome Measures in Arthritis Clinical Trials and the Osteoarthritis Research Society International (OMERACT-OARSI) criteria. Blood DNA samples were genotyped using the Illumina GWAS microarrays genotyping platform. The quality control (QC) filtering was performed on GWAS data before the association of the genetic variants with non-responders to TJR was tested using the GenABEL package in R with adjustment for the relatedness of the study population and using the commonly accepted GWAS significance threshold p < 5*10. −8. to control multiple testing. In total, 316 knee and 122 hip OA patients (mean age 65.45±7.62 years, and 58% females) passed the QC check. These study participants included 368 responders and 56 non-responders to pain, and 364 responders and 68 non-responders to function based on the absolute WOMAC point score change classification. While 377 responders and 56 non-responders to pain, and 366 responders and 71 non-responders to function were identified by the OMERACT-OARSI classification criteria. Interestingly, the same results were obtained by both classification methods, and we found that the G allele of rs4797006 was significantly associated with pain non-responders with odds ratio (OR) of 5.12 (p<7.27×10. -10. ). This SNP is in intron one of the melanocortin receptor 5 (MC5R) gene on chr18. This gene plays central roles in immune response, pain sensitivity, and negative regulation of inflammatory response to antigenic stimulus. The A allele of rs200752023 was associated with function non-responders with OR of 4.41 (p<3.29×10. -8. ). The SNP is located in intron three of the RNA Binding Fox-1 Homolog 3 (RBFOX3) gene on chr17 which has been associated with numerous neurological disorders. Our data suggested that two chromosomal regions are associated with TJR poor outcomes and could be the novel targets for developing strategies to improve the outcome of the TJR

Total joint replacement (TJR) is by far the most effective therapy for end-stage OA patients. Most of patients achieve joint pain reduction and function improvement following to TJR, however up to 22% of them either do not improve or deteriorate after surgery. The aim of this study was to identify genetic variants to be associated with poor outcome of TJR in primary OA patients by a genome-wide association approach (GWAS). Study participants were primary OA patients from the Newfoundland Osteoarthritis Study (NFOAS) that comprised total knee or hip replacement and recruited before 2016 in St. John's, NL. DNA samples were extracted from patients' blood. Study participants completed their pre-operation and 3.99±1.38 years post-surgery outcome assessment using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). DNA samples were genotyped using the genome-wide Illumina HumanOmni2.58 genotyping microarray containing 2.4 million SNPs. Pre-association quality control filtering was conducted for the raw genotyping data using PLINK 1.7 program, and genotype imputation was performed using the IMPUTE2 algorithm with multiple population reference data from 1000 Genome Project. The imputed data with ∼3.1 million variants was used to test the association with non-responders to TJR using the additive genetic model. Eighty three primary OA patients (44 responders and 39 non-responders) were included in the analysis. Association analysis detected three chromosomal regions on chr5, 7, and 8 to be significantly associated with non-responding to pain. The top SNPs at these loci are intergenic variants that include SNP (rs17118094, p=4.4×10-5) on chr5. This SNP is adjacent to SGCD gene that plays an important role in muscular strength and maintenance. Another associated SNP (rs71572810, p=4.7×10-5) is nearby IMMP2L gene on chr7. This gene is reported to be associated with behavioral abnormalities. Finally, SNP (rs6992938, p=5.8×10-5) on chr8 is located downstream of TRPA1 gene that is known to have a central role in the pain response to endogenous inflammatory mediators. Three loci were also found to be significantly associated with non-responding to function. The lead variant in the locus on chr1 is an intergenic SNP (rs9729377, p=1.7×10-5) falling between CTBS and MCOLN2 genes. CTBS gene is associated with TNF-α, a cytokine that stimulate the inflammation acute phase reaction, and MCOLN2 gene plays a role in the chemokine secretion and macrophage migration in the innate immune response. Other top SNPs in loci on chr2 and 10 harbor CCDC93, INSIG2, and KLF6 genes that are associated with heel bone mineral density, hypercholesterolemia, obesity and BMI. To our knowledge, this project is the first study that investigated the association between genetic factors and TJR non-responders. Our results demonstrated that genes related to muscle strength, behavioral trait, pain response, and inflammation play a significant role in poor outcome of TJR, warranting further investigation

Reverse Total shoulder arthroplasty (RTSA) was initially introduced to treat rotator cuff arthropathy. With proven successful long-term outcomes, it has gained a noteworthy surge in popularity with its indications consequently being extended to treating various traumatic glenohumeral diseases. Several countries holding national registries remain a guide to the use the prosthesis, however a notable lack of epidemiological data still exists. More so in South Africa where the spectrum of joint disease related to communicable diseases such as HIV and tuberculosis may influence indications and patient demographics. By analysing the epidemiology of patients who underwent RTSA at our institution, we aimed to outline the local disease spectrum, the patients afflicted and indications for surgery. A retrospective review of all patients operated within the sports unit between 1 January 2019 and 31 December 2022 was conducted. An analysis of the epidemiological data pertaining to patient demographics, diagnosis, indications for surgery and complications were recorded. Included in the review were 58 patients who underwent primary RTSA over the 4-year period. There were 41 females and 17 male patients, age <55 years (n= 14) >55 years (n=44). The indications included 23 rotator cuff arthropathy (40%), 12 primary glenohumeral osteoarthritis (OA) (20%), 10 avascular necrosis (AVN) humeral head (17%), 7 inflammatory OA (12%), 4 chronic shoulder dislocation (7%) and 2 sequalae of proximal humerus fractures (4%). The study revealed RTSA being performed in patients older than 55 years of age, the main pathologies included rotator cuff arthropathy and primary OA, however AVN and shoulder dislocations secondary to trauma contributed significantly to the total tally of surgeries undertaken. This highlights the disease burden of developing countries contributing to patients presenting for RTSA

Background. Cup anteversion and inclination are important to avoid implant impingement and dislocation in total hip arthroplasty (THA). However, it is well known that functional cup anteversion and cup inclination also change as the pelvic sagittal inclination (PSI) changes, and many reports have been made to investigate the PSI in supine and standing positions. However, the maximum numbers of subjects studied are around 150 due to the requirement of considerable manual input in measuring the PSIs. Therefore, PSI in supine and standing positions were measured fully automatically with a computational method in a large cohort, and the factors which relate to the PSI change from supine to standing were analyzed in this study. Methods. A total of 422 patients who underwent THA from 2011 to 2015 were the subjects of this study. There were 83 patients with primary OA, 274 patients with DDH derived secondary OA (DDH-OA), 48 patients with osteonecrosis, and 17 patients with rapidly destructive coxopathy (RDC). The median age of the patient was 61 (range; 15–87). Preoperative PSI in supine and standing positions were measured and the number of cases in which PSI changed more than 10° posteriorly were calculated. PSI in supine was measured as the angle between the anterior pelvic plane (APP) and the horizontal line of the body on the sagittal plane of APP, and PSI in standing was measured as the angle between the APP and the line perpendicular to the horizontal surface on the sagittal plane of APP (Fig. 1). The value was set positive if the pelvis was tilted anteriorly and was set negative if the pelvis tilted posteriorly. Type of hip disease, sex, and age were analyzed with multiple logistic regression analysis if they were related to PSI change of more than 10°. For accuracy verification, PSI in supine and standing were measured manually with the previous manual method in 100 cases and were compared with the automated system used in this study. Results. The median PSI in the supine position was 5.1° (interquartile range [IQR]: 0.4 to 9.4°), and the median PSI in the standing position was −1.3° (IQR: −6.5 to 4.2°). There were 79 cases (19%) in which the PSI changed more than 10° posteriorly from supine to standing with a maximum change of 36.9° (Fig. 2). In the analysis of the factors, type of hip disease (p = 0.015) and age (p = 0.006, Odds Ratio [OR] = 1.035) were the significant factors. The OR of primary OA (p = 0.005, OR: 2.365) and RDC (p = 0.03, OR: 3.146) were significantly higher than DDH-OA. In accuracy verification, the automated PSI measurement showed ICC of 0.992 (95% CI: 0.988 to 0.955) for supine measurement and 0.978 (95% CI: 0.952 to 0.988) for standing measurement. Conclusions. PSI changed more than 10° posteriorly from supine to standing in 19% of the cases. Age and diagnosis of primary OA and RDC were related to having their pelvis recline more than 10° posteriorly. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. Fracture around the knee can lead to posttraumatic osteoarthritis (PTOA) of the knee. Malunion, malalignment, intra-articular osseous defects, retained internal fixation devices, and compromised soft tissues may affect the outcome of total knee replacement (TKR). On average, the posttraumatic patient subsets were 10.4 years younger than those for primary knee OA. Recently, there were several studies reporting the outcome of THA for posttraumatic OA hip. However, no current literature defines the comparative functional outcome between PTOA and primary OA knee. The purpose of our study was to compare the midterm outcomes of patients undergoing TKR following periarticular knee fractures/ligamentous injuries versus primary osteoarthritis (PO) of the knee. Materials and methods. Retrospective chart reviews of patients underwent TKR between 2008 and 2013 were identified. 136 patients underwent open reduction and internal fixation with plate and screws or ligament reconstruction while 716 patients were primary OA. Mean follow up time was comparable in both groups. Demographic data, medical comorbidities, WOMAC, visual analogue scale, and complications were recorded. Results. There were significantly different in age (56.5 vs 63.8 years, p<0.0001), gender (48.5% vs 63.1% of female, p=0.0014), and obese (62.3% vs 76.0%, p=0.025) between PTOA and PO groups, respectively. The PO group had higher comorbidities than PTOA group including anticoagulant usage (51% vs 30.9%, p=0.0002), number of disease ≥ 4 (69.6% vs 45.3%, p<0.0001), ASA class ≥3 (38.8% vs 21.6%, p<0.0001), and Charlson Comorbidity Index (3.6 vs 2.8, p<0.0001). The PTOA group had longer operative time (110.9 vs 100.1 minutes, p<0.0001) than PO group. Preoperatively anatomical axis of the knee was approximately valgus in PTOA but varus alignment in PO group (p<0.0001). However, postoperatively anatomical and mechanical axis was comparable in both groups. Postoperative VAS (1.8 vs 1.2, p=0.002) at 1 year follow up and pain component of WOMAC (77.8 vs 85.7, p=0.013) in PTOA group was worse than PO group, respectively. On the contrary, there was no difference in postoperative complication and readmission rate between groups. Conclusion. Total knee replacement for Post-traumatic OA was associated with poorer functional outcome compared to those for primary osteoarthritis in midterm follow up

The advent of modern anatomic shoulder arthroplasty occurred in the 1990's with the revelation that the humeral head dimensions had a fixed ratio between the head diameter and height. As surgeons moved from the concept of balancing soft tissue tension by using variable neck lengths for a given humeral head diameter, a flawed concept based on lower extremity reconstruction, improvements in range of motion and function were immediately observed. Long term outcome has validated this guiding principle for anatomic shoulder replacement with improved longevity of implants, improved patient and surgeon expectations and satisfaction with results. Once the ideal humeral head prosthesis is identified, and its position prepared, the surgeon must use a method to fix the position of the head that is correct in three dimensions and has the security to withstand patient activities and provide maximal longevity. Based again on lower extremity concepts, long stems were the standard of care, initially with cement, and now, almost universally without cement for a primary shoulder replacement. The incredibly low revision rates for humeral stem aseptic loosening shifted much of the attempted innovation to the challenges on the glenoid side of the reconstruction. However, glenoid problems including revision surgery, infections, periprosthetic fractures, and other complications often required the removal of the humeral stem. And, in many cases, the overall results of the procedure and the patient's long-term outcome was affected by the difficulty in removing the stem, leading surgeons to compromise the revision procedure, avoid revision surgery, or add to the overall morbidity with humeral fractures and substantial bone loss. With improved technology, including bone ingrowth methods, better matching of the proximal stem geometry to the humerus, and an understanding that the center of rotation (torque) on the humeral component is at the level of the humeral osteotomy, shorter stems and stemless humeral components were developed, now more than 10 years ago, primarily in Europe. With more than a decade of experience, our European colleagues have shown us that stemless humeral component replacement with a device that has both cortical and cancellous fixation is as effective as a stemmed device, easier to implant as well as revise when needed. The short-term results of the cancellous fixation stemless devices are acceptable, but longer follow-up is needed. Currently, the most widely used humeral components in the USA are short stem components, although the recent FDA approval of numerous stemless devices has initiated a shift from short stems to stemless devices. The truth is, short stem devices have a firm position in the USA surgeons' armamentarium today due to regulatory restrictions. A decade ago, without a predicate on the market, it was not conceivable that a stemless device that was already gaining popularity in Europe would be able to get 510K approval, and therefore would require a lengthy and expensive FDA IDE process. However, shorter stems had already been approved in the USA, as long as the stem length was 7 centimeters, matching the market predicate. Now, in 2018, based on evidence and outcomes, stemless humeral components should be the first choice when treating primary osteoarthritis of the glenohumeral joint. Short stem or longer stem devices should be reserved for those cases where stemless fixation is not possible, which is less than 10% of patients with primary OA of the shoulder

When patients present at an early age with osteoarthritis of the hip, there is usually an underlying predisposing cause. In men, a common cause is femoroacetabular impingement (FAI). This is evident as anterior neck osteophytes, with retroversion and varus alignment of the femoral head, most likely the result of subclinical slipped capital femoral epiphysis. The resulting femoroacetabular cam impingement causes degenerative osteoarthritis (OA) of the hip, at an earlier age than primary OA. Patients present in their 40s and 50s with advanced arthritis, and are faced with the prospect of a total hip arthroplasty. Women may experience this as well, but may present with early hip arthritis as a result of subclinical dysplasia or pincer FAI more often than their male counterparts. Hip resurfacing has several advantages over traditional total hip replacement for younger patients, especially men. These include bone preservation, less dislocation, thigh pain or leg length inequality, easier return to athletics, and easy revision on the femoral side. It is indicated in young, active patients. The resurfacing procedure realigns the femoral head on the native and resurfaces the arthritic joint. Anterior neck osteoplasty is performed. Head retroversion is corrected. This restores deep flexion, and eliminates forced external rotation in flexion. Hip resurfacing can be done through either an anterior or posterior approach, although the anterior approach gives easier access to the anterior femoral neck, and preserves the blood supply to the head. This may help prevent femoral neck fractures and late head collapse

Purpose. The purpose of this study is to analyse regional differences in the microstructural and mechanical properties of the distal femur depending on osteoarthritic changes using micro-images based on finite element analysis. Materials and Methods. Distal femur specimens were obtained from ten donors composed of 10 women with OA (mean age of 65 years, ranging from 53 to 79). As controls, the normal distal femur was sampled from age and gender matched donors consisting of 10 women(mean age of 67 years, ranging from 58 to 81). The areas of interest were six regions of the condyles of the femur(Lateral-Anterior, Middle, Posterior; Medial=Anterior, Middle, Posterior). A total of 20 specimens were scanned using the micro-CT system. Micro-CT images were converted to micro-finite element model using the mesh technique, and micro-finite element analysis was then performed for assessment of the mechanical properties. Results. Trabecular bones from the distal femur in control and OA groups exhibited different microstructural and mechanical properties in the same region. BV/TV, Tb.N, Tb.S and Yield strength were different between LA and MMsignificantly (p=0.005). In control group, the lateral anterior region of the distal femur reflected subchondral trabecular remodeling, while in advanced OA group, the medial middle region showed prominent changes in the microstructural and mechanical properties. Conclusion. The authors concluded that with aging and the progress of primary OA, changes of patello-femoral reaction force induced subchondral trabecular changes of the anterolateral region initially, and then progressed to the medial middle and posterior region in advanced OA

Total hip arthroplasty (THA) is one of the most successful and effective treatments for advanced hip osteoarthritis (OA). Over the last 5 years, Canada has seen a 17.8% increase in the number of hip replacements performed annually, and that number is expected to grow along with the aging Canadian population. However, the rise in THA surgery is associated with an increased number of patients at risk for the development of an infection involving the joint prosthesis and adjacent deep tissue – periprosthetic joint infections (PJI). Despite improved hygiene protocols and novel surgical strategies, PJI remains a serious complication. No previous population-based studies has investigated PJI risk factors using a time-to-event approach and none have focused exclusively on patients undergoing THA for primary hip OA. The purpose of this study is to determine risk factors for PJI after primary THA for OA using a large population-based database collected over 15 years. Our secondary objective is to determine the incidence of PJI, the time to PJI following primary THA, and if PJI rates have changed in the past 15 years. We performed a population-based cohort study using linked administrative databases in Ontario, Canada in accordance with RECORD and STROBE guidelines. All primary total hip replacements performed for osteoarthritis in patients aged 55 or older between January 1st 2002 – December 31st 2016 in Ontario, Canada were identified. Periprosthetic joint infection as the cause for revision surgery was identified with the International Classification of Diseases, 10th Edition (ICD-10), Clinical Modification diagnosis code T84.53 in any component of the healthcare data set. Data were obtained from the Institute for Clinical Evaluative Sciences (ICES). Demographic data and outcomes are summarized using descriptive statistics. We used a Cox proportional hazards model to analyze the effect of surgical factors and patient factors on the risk of developing PJI. Surgical factors include the approach, use of bone graft, use of cement, and the year of surgery. Patient factors include sex, age at surgery, income quintile and rurality (community vs. urban). We compared the 1,2,5 and 10 year PJI rates for patients undergoing THA each year of our cohort with the Cochran-Armitage test. Less than 0.1% of data were missing from all fields except for rurality which was lacking 0.3% of data. A total of 100,674 patients aged 55 or older received a primary total hip arthroplasty for osteoarthritis from 2002–2016. We identified 1034 cases of revision surgery for prosthetic joint infection for an overall PJI rate of 1.03%. When accounting for patients censored at final follow-up, the cumulative incidence for PJI is 1.44%. Our Cox proportional hazards model revealed that male sex, Type II diabetes mellitus, discharge to convalescent care, and having both hips replaced during one's lifetime were associated with increased risk of developing PJI following primary THA. Importantly, the time adjusted risk for PJI was equal for patients operated within the past 5 years, 6–10 years ago, or 11–15 years ago. The surgical approach, use of bone grafting or cement were not associated with increased risk of infection. PJI rates have not changed significantly over the past 15 years. One, two, five and ten-year PJI rates were similar for patients undergoing THA in all qualifying years. Analysis of a population-based cohort of 100,674 patients has shown that the risk of developing PJI following primary THA has not changed over 15 years. The surgical approach, use of bone grafting or cement were not associated with increased risk of infection. Male sex, Type II diabetes Mellitus and discharge to a rehab facility are associated with increased risk of PJI. As the risk of PJI has not changed in 15 years, an appropriately powered trial is warranted to determine interventions that can improve infection rate after THA

18 Patients with SCD and 2ndry Osteoarthritis of their hips due to Avascular Necrosis underwent uncemented THA. There were 12 male and 6 female patients. Patient had their pre op WOMAC/SF-36/HOOS/and Oxford hip scores recorded preoperatively a well as 3 month, 6months and one year post op. The outcome scores at one year were significantly better than the pre operative scores. However, when compared to a matched cohort of patients who underwent THA for reasons other than SCD/AVN, e.g. primary OA, rheumatoid arthritis, post traumatic OA, the WOMAC pain score improvement was less

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

Introduction. Computer navigation systems are quite sophisticated intra-operative support systems for the precise placement of acetabular or femoral components in THA. However, few studies have addressed the clinical benefits derived from using a navigation system to achieve precise placement of the implants. The purpose of this study is to investigate the early dislocation rate of navigation-assisted primary THA through a posterior approach in order to clarify the short-term benefit of using a computer navigation system. Methods. We retrospectively reviewed the early dislocation rate (within 12 months after surgery) of 475 consecutive primary cementless or hybrid THAs with femoral head sizes ≦32mm performed via posterior approach. There were 85 men and 390 women, with a mean age of 60 years (17 to 88) at operation. Preoperative diagnoses included osteoarthritis in 384 hips, osteonecrosis in 45 hips, and others in 46 hips (ex. RA, trauma, infection, congenital disease). All THAs were planned using a 3D templating system based on the combined anteversion theory, performed by single surgeon through a posterior approach with repair of the posterior capsule, assisted by a CT-based surface matching type computer navigation system for cup implantation. All patients were directly followed up at least 1 year after surgery. We classified all 475 joints into four groups: normal or mildly deformed hips (Group A; 308 joints, ex. primary OA, Crowe group 1, osteonecrosis), moderately deformed hips (Group B; 97 joints, ex. Crowe group 2, protrusio acetabuli, Perthes like deformity), severely deformed hips (Group C; 53 joints, ex. Crowe group 3 or 4, ankylosis, fused hip), and neuromuscular and cognitive disorders (Group D; 17 joints), and examined the dislocation rate for each group. Results. We had eleven early dislocations, for an overall dislocation rate of 2.3% (11/475). All dislocations occurred posteriorly within 6 weeks after surgery. Three joints were Crowe group 4 dislocated hips, three were Charcot joints, two were Girdlestone hips after pyogenic arthritis, two was a Crowe group 1 hip, and one was osteonecrosis. All 11 cups were implanted within 5 degree of error from the preoperative planning, and all were placed within the Lewinnek safe zone. The dislocation rates according to group were 0.6% for group A (2/308), 0% for B (0/97), 9.4% for C (5/53), and 23.5% for D (4/17). Discussion. The use of computer navigation system in patients undergoing THA improves the precision of acetabular cup placement by decreasing the number of outliers, which may result in reducing the risk of dislocation. In this series, most dislocations occurred in the highly risky or rare condition cases in groups C or D. In such cases, precise and appropriate cup implantation assisted by the navigation system could not completely prevent dislocation because of the patients' specific special backgrounds. On the other hand, early dislocation was prevented for the normal/mild to moderately deformed joints such as those in groups A or B. Computer navigation system was effective for prevent early dislocation in the normal or mild to moderately deformed joints

Introduction. In the year 1977 we started to use ceramic on ceramic total hip (Ceraver*). The prosthesis was cemented on both sides. Ceramic was medical grade with relative large grains and high porosity. The stem was made of titanium alloy smooth and oxidized. In 1990 we published the results of 86 hips in 75 patients who were less than 50 years of age at time of operation (1). Recently we tried to reach the same patients, looking specifically to those who could have more than 20 or 30 years follow-up. Material and methods. This study design included all patients operated between 1977 and 1986 and having less than 50 years of age at time of surgery. Eighty six hips in 75 patients, 34 females and 41 men. Mean age was 43 (from 18 to 50) nine had a BMI in excess. 66 hips were performed primaries while 20 consisted in revision procedure including 6 total hip revisions, 5 resurfacing, 4 single cup, 3 hemiarthroplasty, and 2 acetabula fractures. Four of these had a past history of infection. Preoperative diagnosis were secondary osteoarthritis in 41, AVN in 26, primary OA in 3, Rheumatoid arthritis in 12, tuberculosis in 2 and hemophilic in two. Results. Complications: one early sepsis was cured by reoperation without material exchange, another septic case was revised at 2 years, 6 years later the results was poor and we could not trace him. One had a nonunion of the greater trochanter and one had one isolated dislocation. One presented with a fracture of an extra small ceramic head of 22 mm in diameter for high Crowe 4 DDH. The broken head was replaced by a metallic head and the socket by a polyethylene one. We tried to reach every patient and did separate them in four groups:. -. 13 hips in 12 patients that were not followed more than 2 years: they usually leaved in Africa (Algeria, Ivory Coast or Senegal and could not be traced),. -. 6 deceased from one to 28 years after index procedure, with no relation with their hip still in place. -. A group of 25 hips in 22 patients that were reached recently (some are still followed some were found by Google and reached by phone), and had not been revised. One of these had a fractured head at 21 years. -. The last group consisted in 49 hips in 48 patients who were followed for periods from 2 to 20 years. Four of these were revised always for socket loosening at period from 12 to 18 years. No reoperation for stem loosening. The revision consisted in socket exchange for a press fit material with a ceramic liner. As in our first study we identified some cases that presented with radiolucent lines at the socket side, we found no correlation between this aspects and the risk of revision. We worked more precisely on the group of 22 patients effectively followed more than 20 years, 10 more than 30 years. They had no limitation on the operated hip; some are still performing heavy activities including sports; they have no complain about noise. Slight pain was noticed in two of them. Conclusion. We found an extremely good results; no degradation of the hip clinically nor radiographic. Some radiolucent lines are still visible but not harmful. The most intriguing aspect is the total absence of osteolytic lesions. With a contemporary material implanted since 15 years we suppose to avoid some of the complications observed in this first trial group

Introduction. The advance of surgical technique and implant design have led to improvement in total hip arthroplasty (THA), and short stem THA is now gaining number as a treatment option for younger patients to preserve bone in the proximal femur for a future revision. The SMF stem is shorter stem, and requires a slightly higher neck resection and implanted in slight varus to contact at lateral cortex. Developmental dysplasia of the hip (DDH) is the most common cause to hip osteoarthritis (OA) in Japan, and the morphology of the dysplastic femur is narrow canal and increased anteversion. Thus, the purpose of this study is to evaluate the SMF stem design can fit for Japanese patients, using CT based 3-D template planning. Methods. We evaluated 30 patients who required THA in our institution. Inclusion criteria are hip OA, but cases with post-trauma, post-osteotomy, and any other hip disease in childhood are excluded. Patients were selected with their femoral anteversion, based on the dispersion of anteversion in dysplastic hip population, which was reported by Noble and collegues in 2003. Preoperative planning with ZedHip software (Lexi, Japan) was performed by established protocol. The center of socket was placed at 15mm proximal from teardrop and medialized to primary acetabulum, with 40° of radiographic inclination and 20° of anteversion. Neck resection of femur was 20mm proximal from the top of smaller trochanter, and stem was placed with lateral fit at distal and medial fit at calcar with appropriate size. Stem offset was selected by leg extension and balanced shenton line. Finally, ROM simulation was performed and the socket anteversion was arranged to achieve the optimal ROM. And then, SMF stem alignment and appropriate fitting was evaluated in Japanese OA cases. Results. Within 30 cases, 28 were female and 2 were male. Mean age was 66.0±9.6, and 8 (26.7%) were primary OA and 22 (73.3%) were secondary OA, from dysplastic hip. SMF stem was placed at average 2.7° varus and 7.2° flexion against femoral axis [Fig. 1]. The average degree of femoral anteversion was 34.0°±10.9 at pre-implantation and 22.7°±9.9 after implantation, which means average 11.4° retroverted [Fig. 2]. Stem offset and neck length variation was acceptable in 28/30 cases (93.3%). Finally, the mean flexion was 130°±7.1 and abduction was 56.0°±5.5, and optimal ROM was achieved 19/30 cases (63.3%). We cannot find any correlation between femoral anteversion pre-implantion and ROM post-implantation, however positive correlation was found between flexion angle and offset length after implantation (r2=0.48). Conclusion. The stem design of SMF is unique to preserve bone stock, but impossible to control anteversion after implantation, so it should be evaluated if it could fit to dysplastic hip. In this 3-D simulation study, SMF stem can be appropriately fitted in most of Japanese cases. Neck length and offset is important to achieve optimal ROM. Large diameter head (≥32mm) and high-offset stem would be suggested, and it may spread the indication for most of the cases regardless of the anteversion of femur. To view tables/figures, please contact authors directly

A femoral head/neck ratio (HNR) of less than 1.27 is associated with an increased risk of arthritis. The aim of this study was to establish whether there is evolutionary evidence that the homonin, bipedal stance has led to alterations in HNR that predispose humans to osteoarthritis (OA). Specimens provided by The Natural History Museums of London, Oxford and the Department of Zoology, University of Oxford were grouped according to gait pattern, HAKF (Hip and knee flexed), Arboreal (ability to stand with hip and knee joints extended) and homonin/bi-pedal. Specimens included those from Devonion, Triassic, Jurrasic, Cretaceous, Miocene, Paleolithic, Pleistocene periods to modern day. Three-dimensional skeletal geometries were segmented using CT images and HNR measurements were taken from coronal views. These were compared with the HNR of 119 asymptomatic human volunteers and 210 patients that had a hip joint replacement for primary OA. Species of the HAKF group had the smallest HNR (1.10, SD:0.09). Species of the Arboreal group had significantly higher HNR (1.63, SD:0.15) in comparison to the Bipedal group (1.41, SD:0.04) (p=0.006), Human (1.33, SD:0.08) and the OA group (1.3, SD:0.09). The range of movement associated with arboreal habitat caused an associated change in HNR. This study would suggest that the HNR peaked in the Miocene period with species that ambulated on both ground and trees. More recent homonin gait appears to have developed a smaller HNR and humans have the smallest amongst their close ancestors. Evolutionary theory would suggest that modern environmental pressures might pre-dispose future hominin evolution to OA, secondary to a further reduction in HNR

Metal on metal hip resurfacing is increasing in popularity for the young, active patient. We present the results of a consecutive series from a single surgeon over a ten year period; 295 hip resurfacings (McMinn and Cormet; Corin, Cirencester, UK) with a minimum follow up of 2 years and a mean follow up of 4 years. There were 173 males with a mean age of 53.4 years and 121 females with a mean age of 50.3 years. Forty-six patients underwent bilateral resurfacings. All resurfacings were performed through a posterior approach. The aetiology in this group was primary OA in 75.9%, inflammatory arthritis in 6.1%, DDH in 6.1%, AVN in 4.7%, trauma in 4.7%, Perthes in 1.7% and SUFE in 0.7%. Patients were reviewed clinically and radiographically on an annual basis. Follow-up was available on 93% of patients. 94.2% of hips have survived and the mean Harris Hip Score is 87.5. Females had a higher failure rate (10.7%) than males (2.3%). There was no clear trend between patient age and failure rate. The highest failure rate (33.3%) was seen in patients with DDH whilst only 4.5% of patients with OA failed. One patient with AVN failed but no failures occurred in patients with inflammatory arthritis, trauma, Perthes or SUFE. Failures occurred due to cup loosening (2.0%), neck fractures (1.7%), head loosening (1.0%), head collapse (0.3%), infection (0.3%) and pain (0.3%). The five patients who suffered neck fractures were symptomatic within 3 months of surgery. We remain cautiously optimistic about the medium term results of hip resurfacing. Careful patient selection is important and caution should be taken in females and patients with DDH

Introduction. Dissemination of Total hip Arthroplasty through the direct anterior approach has, depending upon one's experience and perspective, benefitted from or been plagued by aggressive marketing. Although first developed over 60 years ago it was all but unknown until the past decade. This study exams one community surgeon's experience and thus sheds light on whether the ATHA is a viable operation for all orthopaedic surgeons. Methods. 332 hips having a THA through the direct anterior approach were prospectively studied. Side and sex distribution were approximately equal; primary OA was by far the most common diagnosis. 4 hips were converted from a previous operation for fracture. No hips were excluded; all hips were replaced through the direct anterior approach. All hips had the same HA coated, cementless triple-taper stem; a variety of cups were used. 92% of the bearings were ceramic on poly including 22% “dual mobility” design; 88% of the heads were 28 or 32 mm. A special orthopaedic table and intraoperative c-arm were used universally. Charnley Merle D'Aubigne, Harris, and WOMAC scores were obtained before surgery and annually thereafter. Anti-embolic prophylaxis was with intraop bilateral thigh high sequential pumps, early mobilization and aspirin for most. Those patients deemed at risk received lovenox, and those already on Coumadin continued – with bridging lovenox. Results. The mean time for surgery was 70 minutes (60 to 175); for c-arm use: 7 seconds (maximum 21). 78% went directly home after an average hospital stay of 2 days. Less than 10% required a blood transfusion. 80% had none or a leg length difference less than 5 mm. Acetabular abduction angle was within the safe zone for all hips; 1 hip was outside the anteversion safe zone. Hip scores improved significantly for all hips (p < 0.001). There were 5 (1.5%) intra-operative complications; all were recognized and none required further treatment or modification of the usual postop regimen. 3 dislocations occurred (0.9%). 3 reoperations (0.9%) were required: 1 early (a fall and fractured femur) and 2 late (1 fall with acetabular fracture and 1 recurrent dislocation). Another fracture occurred from a fall but additional surgery was not needed. There were 4 (1.2%) systemic complications: 1 PE, 1 UGI bleed, 1 ileus, 1 CVA. 2 patients died for reasons unrelated to the arthroplasty. Discussion/Conclusion:. These data suggest that satisfactory or better results with few complications can be achieved through the direct anterior approach utilizing a special orthopaedic table and intraop fluoroscopy. Using an HA coated triple-taper stem there was no atraumatic loosening in this short term follow-up. C-arm time was comparatively minimal and seems to contribute to good implant positioning. The dislocation rate was low even though large head sizes were rarely employed. There were no periprosthetic infections suggesting that claims for relative soft tissue sparing may be factual

Background. The Copeland shoulder resurfacing arthroplasty (CSRA) (Figure1) is a cementless, pegged humeral head surface replacement which has been in clinical use since 1986. The indications for CSRA are more or less the same as conventional stemmed arthroplasty. This procedure can be considered for all patients who require shoulder replacement due to GHJ arthritis resulted from primary or secondary OA, RA, and other variations of inflammatory arthritis. It is also suggested as the first choice option for relatively young patients with post-traumatic arthritis, avascular necrosis (AVN), and instability arthropathy. This observational study reports functional and radiological outcome in CSRA during 4 years follow-up. Methods. 109 consecutive patients with primary osteoarthritis (45.9%), rheumatoid arthritis (39.4%), rotator cuff arthropathy (9.2%), and avascular necrosis (5.5%) underwent CSRA. Patients including 68 females (63%) and 41 males (37%) underwent this procedure (63 right-sided and 46 left-sided including 9 bilateral shoulders). The outcome assessment included pain and satisfaction, Oxford Shoulder Score (OSS), Constant Score (CS), and SF-12. Imaging was reviewed for glenoid morphology (Walch classification) (Figure2) and humeral head migration. The average follow-up period was 4 years, (range: 1 to 10 years). Results. Primary OA and RA were the most common underlying pathologies in 45.9% and 39.4% of patients, respectively, followed by RCA (9.2%) and AVN (5.5%). Approximately 89% of arthroplasties were primary and 11% were revisions. Other body joints were affected in 85% of patients and nearly 70% of them had accompanying health conditions and co-morbidities (e.g. heart diseases, hypertension, and diabetes mellitus). A strong correlation found for OSS regarding CS and physical SF-12 subscale. Pain and physical limitation had negative correlation with satisfaction and shoulder-specific tools. Walch type A (68%) and superior HH migration (16.8%) were the commonest radiographic presentations. There was high correlation between migration and physical limitation, pain, satisfaction, OSS, and CS. A significant difference noted for OSS, CS, physical limitation, pain and satisfaction between migration and non-migration groups. Discussion. The CSRA provides pain relief and a good functional outcome in many patients. The main disadvantage is the technical difficult of implanting a glenoid which many surgeons now perceive as being essential in order to gain early pain relief and a better functional outcome. Our results show a predictable relationship between outcome and pathology, with osteoarthritic patients having the most favourable outcome. Glenoid wear and cuff related problems are the major reasons for failure. Improvements in the design and surgical technique to reduce the likelihood of HH migration remain the major challenge. CSRA should be considered the implant of choice in younger patients with osteoarthritis and RA where there is concern over conserving bone stock for future revision. Considering the nature of underlying pathologies it is appropriate to use a combination of generic and shoulder-specific outcome tools

Although there are several reports of excellent long-term survival after cemented total hip arthroplasty (THA), cemented acetabular components are prone to become loose when compared with femoral components. On the other hand, the survival of cementless acetabular components has been reported to be equal or better than cemented ones and the use of cementless acetabular components is increasing. However, most of the reports on survival after THA are for patients with primary hip osteoarthritis (OA) and there is no report of 20-year survival of cementless THA for patients with hip dysplasia. It is supposed to be more difficult to fix cementless acetabular components for OA secondary to hip dysplasia than primary OA. The purposes of this study were to review retrospectively the 20-year survival of cemented and cementless THA for hip dysplasia and to compare the effect of fixation methods on the long-term survival for patients with hip dysplasia. We retrospectively reviewed all patients with OA secondary to hip dysplasia treated with a cemented Bioceram hip system between 1981 and 1987, and a cementless cancellous metal Lübeck hip system between 1987 and 1991. We excluded patients aged more than 60 years, males, and Crowe 4 hips. The studied subjects were 70 hips of cemented THA (Group-C) and 57 hips of cementless THA (Group-UC). Both hip implants had a 28-mm alumina head on polyethylene articulation. The mean age at operation was 50.5 years (range, 36–60 years) in Group-C and 50.0 years (range, 29–60 years) in Group-UC. The mean BMI was 23.2 kg/m. 2. in Group-C (range, 17.3–29.3 kg/m. 2. ) and 22.9 kg/m. 2. in Group-UC (range, 18.8–28.0 kg/m. 2. ). There were no significant differences in age and BMI between the two groups. The average follow-up period was 18.0 years in Group-C and 18.4 years in Group-UC. In Group-C, revision was performed in 33 hips due to aseptic cup loosening (30 hips), stem loosening (one hip), and loosening of both components (two hips). In Group-UC, revision was performed in 10 hips due to stem fracture secondary to distal fixation (4 hips), cup loosening (three hips), polyethylene breakage (two hips), and extensive osteolysis around the stem (one hip). The survival at 20 years regarding any revision as the endpoint was 51% in Group-C and 84% in Group-UC. This difference was significant using Log-rank test (P=0.006). The cup survival at 20 years was 54% in Group-C and 92% in Group-UC. This difference was also significant (P = 0.0003). The stem survival at 20 years was 95% in Group-C and 92% in Group-UC. This difference was not significant (P = 0.4826). Cementless THA showed a higher survival rate at 20 years for hip dysplasia than cemented THA because of the excellent survival of the acetabular component without cement. We conclude that cementless THA with the cancellous metal Lübeck hip system led to better longevity at 20 years than cemented THA with the Bioceram for patients with OA secondary to hip dysplasia

Purpose. Total Ankle Replacement (TAR) is increasingly being offered to patients as an alternative to arthrodesis for the operative management of debilitating end-stage ankle arthritis. The Mobility Total Ankle System is a third-generation design consisting of a three component, cementless, unconstrained, mobile-bearing prosthesis. This study reports the early results of a multi-centre prospective study of the Mobility prosthesis. This is the first such report by independent researchers. Method. The senior authors implanted 86 consecutive Mobility prostheses. The underlying diagnosis was primary OA in 24 ankles, secondary OA in 47 ankles and inflammatory arthritis in 15 ankles. There were 41 males (Mean age 67 / Range 51–87) and 44 females (Mean age 60 / Range 29–72). The mean BMI was 28 (Range 22–36) for males, and 28 (Range 20–39) for females. Previous ankle operations were performed in 24 patients, 22 of which were for fracture fixation. Ankles were classified according to the COFAS end-stage ankle arthritis classification system. Coronal plane deformity was quantified pre-operatively. Clinical outcome was assessed using the AOFAS hindfoot score. Radiological assessment was performed from weight-bearing radiographs, documenting post-operative alignment, osseous integration, edge-loading and heterotopic bone formation. The mean follow-up time was 40 months (Range 30–60). Survival analysis was calculated according to the Kaplan-Meier method. Failure was defined as exchange of any component of the TAR, arthrodesis or amputation. Results. Type 1 ankle arthritis was demonstrated in 54 ankles (63%). No patient had pre-operative coronal plane angulation > 20. In 30 ankles (35%), the pre-operative coronal alignment was neutral, and in 32 ankles (37%), the deformity was < 10. The mean AOFAS hindfoot score improved from 37.4 (Range 12–59) pre-operatively to 77.9 (Range 51–100) post-operatively. 78 (90%) of prosthetic components were implanted within 5 of the optimal position. Bone-implant interface abnormalities were identified in 16 ankles (18%). In total, 5 TARs required revision, 4 for aseptic loosening and one for component malpositioning. There was one conversion to arthrodesis, and one BKA for CRPS. 30 simultaneous procedures were performed in 28 patients. The most common was gastrocnemius recession. There were 8 re-operations, most commonly for impingement due to peri-articular ossifications. Delayed wound healing occurred in 3 patients, and there was one case of deep infection. There were 5 patients that sustained fractures of the medial malleolus: 2 were intra-operative, and underwent internal fixation. There are 6 patients being investigated for ongoing pain. The 2-year survival was 96.4% (95% CI 89.4–99.1) and 3-year survival was 91.7% (95% CI 83.3–96.3). Conclusion. Although early results of the Mobility TAR are encouraging for independent researchers, they do not match those reported by designer surgeons. Most patients achieve good pain relief and improved function post-operatively