In minimally invasive direct anterior total hip arthroplasty double offset broach handles are used, in order to facilitate the preparation of the femoral canal. The maximum value of the main force peak and the impulse of two types of double offset broach handles (A European version, B American version) were compared to a single offset broach handle (S). Results have demonstrated that the highest values of the main force peak and force impulse were found in the single offset broach handle. Broach handle A had higher impulse values and lower maximum force values compared to broach handle B. In double offset broach handles less energy is transmitted to the tip. Broach handle A has a lower force peak than B and therefore a reduced risk of bone fracture.

In Total Hip Arthroplasty (THA) bone loss is recovered by using compacted porous bone chips. The technique requires the morsellised allograft to be adequately compacted to provide initial stability for the prosthesis in order to prevent early massive subsidence and to induce bone remodeling. Therefore the bone grafts provide initial stability and an environment in which revascularization and incorporation of the graft into the host skeleton may occur. Acetabular reconstruction with impacted morsellised cancellous grafts and cement leads to satisfactory long-term results. In the acetabular impact-grafting procedure, a hammer and an impaction stick is used for manual compaction. Another technique uses a hammer driven by compressed air, which could lead to higher density and improved stability of bone chips in the acetabulum. The aim of this study was to compare two different compaction modes for bone impaction grafting for the acetabulum. The hypothesis was that a pneumatic impaction method would produce less variable results than the manual impaction mode and lead to better compaction results of the bone chips in less time.

Bone mass characteristics were measured by force and distance variation of a penetrating punch, which was lowered into a plastic cup filled with bone chips. For each compaction method and for each time interval (0, 3, 6, 9, 12, 15 and 30 [s] of compaction time) 30 measurements of force and distance variations were taken. From the measurements of force and distance variations bulk density, contact stiffness, impaction hardness and penetration resistance were calculated before and after the established time intervals of compaction. Since not all data was normally distributed the non-parametric U-Test was used for comparison of the two impaction methods. Particle size distribution was determined using sieve analysis according to Din 18123 standard after the compaction experiments.

Results have shown that the pneumatic method leads to higher values in impaction hardness, contact stiffness and bulk density and is more suitable to increase the primary stability of the implant. The differences in bulk density, impaction hardness and contact stiffness where statistically significant (p<0.01). No significant differences were found between the two different methods concerning the penetration resistance. The coefficient of uniformity C_u, calculated from the particle size distribution determined by the sieve analysis, has a value of 3.8.

The particle size distribution is comparable to the results published in literature. Pneumatic impaction achieves higher density values in less time with less force applied and results in more reproducible outcomes when used. It reduces therefore the risk of bone fracture, as smaller peak forces are used for less time. However for optimal osteointegration it is not recommended to achieve maximum density. Further clinical studies should determine a reference value for optimal growth-in of osteocytes. Manual impaction shows more variable results and depends much on the experience of the surgeon. The pneumatic hammer is therefore a suitable tool to standardize the impaction process for acetabular bone defects.

In revision total hip replacement, bone loss can be managed by impacting porous bone chips. In order to guarantee sufficient mechanical strength, the bone chips have to be compacted. The aim of this study was to determine in an in vitro simulation whether the use of a pneumatic hammer leads to higher primary stability than manual impaction. Bone mass characteristics were measured by force and distance variation of a penetrating punch, which was lowered into a plastic cup filled with bone chips. From these measurements bulk density, contact stiffness, impaction hardness and penetration resistance were calculated for different durations of impaction.

We found that the pneumatic method reached higher values of impaction hardness, contact stiffness and bulk density suggesting an increase in stability of the implant. No significant differences were found between the two different methods concerning the penetration resistance. The pneumatic method might reduce the risk of fracture in vivo, as force peaks are smaller and applied for a shorter period. Results from manual impaction showed higher variability and depend much on the experience of the surgeon. The pneumatic hammer is a suitable tool to standardise the impaction process.

Background: Recently, the effects of radiculopathy and nerve root blocks on driving reaction time (DRT) have been presented in the literature. To our knowledge, the relation between lumbar spinal fusion and DRT has not been studied before, although important for driving safety. So, we conducted the current study to test the hypotheses that DRT in the context of lumbar fusion is 1) altered in pre-postoperative comparison, 2) influenced by pain, 3) influenced by the patient’s driving skill and 4) different to the DRT of healthy controls.

Methods: 21 consecutive patients (age 53.5 years, SD 10.8) receiving primary lumbar fusion were tested for their DRT 1 day preoperatively (pre-op), 1 week postoperatively at the day before discharge (post-op) and at 3 months (follow-up; FU). DRT was assessed with a custom made driving simulator. Additionally, also the level of back pain was determined by VAS for usual pain (VAS-U) and for pain during testing (VAS-T). We also collected the participants’ subjective driving frequency. We used normative DRT data from 31 healthy controls of similar age for comparison with the patients.

Results: Pre-op DRT was 685 msec (Md; IQR 246), post-op DRT increased to 728 msec (Md; IQR 264) and decreased again to 671 msec (Md; IQR 202) at FU (p=0.007). Post-hoc analyses (alpha=0.017) found significant differences between post-op and FU DRT (p=0.007). Moderate to high correlations (between 0.537 and 0.680) were found between VAS of back pain and DRT (p between 0.001 and 0.012). No correlations were found between driving frequency and DRT. Controls showed a DRT of 487 msec (Md; IQR 116) which was significantly different from DRT of the patients at all three test occasions (p< 0.001).

Conclusion: We found minor increase in DRT 1 week post-op followed by a definite and significant decrease at 3 months FU. We think it is safe – with respect to DRT - to resume driving 3 months after lumbar fusion. It is difficult to draw any conclusions about the period between discharge and 3 months. We also found moderate and high correlations between DRT and the level of back pain and assume that back pain is a relevant factor influencing DRT.

Introduction: With non-fusion stabilization surgery technique, the demands on the pedicle screw system have increased. The screw implants require a high press fit for optimum bone integration and a high pullout strength to guarantee primary stability. We compared the cylindrical screw design from a pedicle screw system with the conical design in regard to the insertional torque and pullout strength.

Methods: Three human cadaver specimens L1 – L5 (15 vertebrae, 30 pedicles) were fitted with pedicle screws on both sides. The pedicles were randomized to one of two screw types: 1) cylindrical pedicle screw, 2) conical. A computer tomographic bone density measurement was performed beforehand. The insertional torque was measured while inserting the pedicle screws. The correct position of the screw was verified using computer tomography. In order to test the pullout strength, the preparations were divided up into individual vertebrae and fixed.

Results: The mean peak insertional torque for the conical screws was significantly higher than that for the cylindrical screws. The pullout strength showed no significant difference between the two types of pedicle screws. With both the conical and the cylindrical pedicle screws, the pullout strength and insertional torque significantly decreased with decreasing bone density in the preparations.

Conclusions: Statements in the literature about the effect on insertional torque and pullout strength of using a conical or cylindrical pedicle screw design vary. The two screw designs in our study only differed in regard to their internal diameter. The significantly higher insertional torque values found for the conical screws could describe the improved screw press-fit behavior. The pullout strength was not significantly affected by the conical design. No correlation was found between the insertional torque and pullout strength. In order to optimize the adjustment of insertional torque and pullout strength, we recommend the conical pedicle screw design for non-fusion surgical techniques for the surgical treatment of degenerative diseases of the lumbar spine.

We report the ten-year results for three designs of stem in 240 total hip replacements, for which subsidence had been measured on plain radiographs at regular intervals. Accurate migration patterns could be determined by the method of Einzel-Bild-Roentgen-Analyse-femoral component analysis (EBRA-FCA) for 158 hips (66%).

Of these, 108 stems (68%) remained stable throughout, and five (3%) started to migrate after a median of 54 months. Initial migration of at least 1 mm was seen in 45 stems (29%) during the first two years, but these then became stable. We revised 17 stems for aseptic loosening, and 12 for other reasons. Revision for aseptic loosening could be predicted by EBRA-FCA with a sensitivity of 69%, a specificity of 80%, and an accuracy of 79% by the use of a threshold of subsidence of 1.5 mm during the first two years. Similar observations over a five-year period allowed the long-term outcome to be predicted with an accuracy of 91%.

We discuss the importance of four different patterns of subsidence and confirm that the early measurement of migration by a reasonably accurate method can help to predict long-term outcome. Such methods should be used to evaluate new and modified designs of prosthesis.