Introduction: Recent studies suggested that trans-epicondylar axis (TEA) as the origin of collateral ligament was valuable axis for the parallel cut of the posterior condyle. An alternative landmark of the angle between the TEA and anterior trochlear line of the lateral and medial femoral condyles (trochleo-epicondylar angle) for determining the rotational positioning of the femoral component could be considered. We here report a simple radiographic view with a landmark of the anterior and posterior femoral condyle for determining the rotational alignment of the femoral component in TKA.

Subjects and methods: Our new radiograph presented an axial view of distal femur of a patient. The patient lay in the supine position and flexed the knee about 120 to 130 degrees. An x-ray beam was applied to the knee at the angle of 20 degrees to the ground surface. We measured the external rotational angle between posterior condylar (PC) line and clinical TEA that was condylar twist angle, and the internal rotational angle between the anterior trochlear line (AT line) and clinical TEA. This study involved 122 knees in 82 patients with osteoarthritis of the knee, an average age of 67.3 years. And we compared our measured angle with the angle from 3D reconstructed images with 3-dimensional helical CT system (n=35).

Results: The former angle was 5.7° ± 3.2° and the latter was −5.6° ± 2.9°. There was a variation by individual patients, the condylar twist angle was negative correlation with tibio-femoral angle. The internal rotation angle of the trochlear line and clinical TEA (trochleo-epicondylar angle) was 4.9°±2.1°. The tibio-femoral angle was positively correlated with the trochlear line angle. The trochlear line angle from 3D-CT was 5.4°±1.9°. The average of the difference between our view and the 3D-CT was 0.5°± 1.0°, R=0.87 with a Spearman’s rank test.

Discussion and conclusion: We improved the simple radiographic view in order to evaluate the TEA and PC line, and also the anterior trochlear line, for assessing the rotational alignment of the distal femur in total knee arthroplasty (TKA). We are able to measure and evaluate both angles and do double-checking the condylar twist angle and trochlear line angle. Our new radiographic technique is easy to measure the condylar twist angle, and the angle between AT line and clinical TEA (trochleo-epicondylar angle), simple and reliable, and may be an alternative method for the assessment of TEA of the femur in TKA as preoperative planning.

Introduction: Recent studies suggested that trans-epicondylar axis (TEA) as the origin of collateral ligament was valuable axis for the parallel cut of the posterior condyle. An alternative landmark of the angle between the TEA and anterior trochlear line of the lateral and medial femoral condyles (trochleo-epicondylar angle) for determining the rotational positioning of the femoral component could be considered. We here report a simple radiographic view with a landmark of the anterior and posterior femoral condyle for determining the rotational alignment of the femoral component in TKA.

Subjects and methods: Our new radiograph presented an axial view of distal femur of a patient. The patient lay in the supine position and flexed the knee about 120 to 130 degrees. An x-ray beam was applied to the knee at the angle of 20 degrees to the ground surface. We measured the external rotational angle between posterior condylar (PC) line and clinical TEA that was condylar twist angle, and the internal rotational angle between the anterior trochlear line (AT line) and clinical TEA. This study involved 122 knees in 82 patients with osteoarthritis of the knee, an average age of 67.3 years. And we compared our measured angle with the angle from 3D reconstructed images with 3-dimensional helical CT system (n=35).

Results: The former angle was 5.6° ± 2.8° and the latter was −5.7° ± 3.2°. There was a variation by individual patients, the condylar twist angle was negative correlation with tibio-femoral angle. The internal rotation angle of the trochlear line and clinical TEA (trochleo-epicondylar angle) was 4.9°±2.1°. The tibio-femoral angle was positively correlated with the trochlear line angle. The trochlear line angle from 3D-CT was 5.6°±2.0°. The average of the difference between our view and the 3D-CT was 0.5°± 1.0°, R=0.87 with a Spearman’s rank test.

Discussion and conclusion: We improved the simple radiographic view in order to evaluate the TEA and PC line, and also the anterior trochlear line, for assessing the rotational alignment of the distal femur in total knee arthroplasty (TKA). We are able to measure and evaluate both angles and do double-checking the condylar twist angle and trochlear line angle. Our new radiographic technique is easy to measure the condylar twist angle, and the angle between AT line and clinical TEA (trochleo-epicondylar angle), simple and reliable, and may be an alternative method for the assessment of TEA of the femur in TKA as preoperative planning.

Introduction: The wear particles produced from the metal-on-metal hip prosthesis causes measurable rise of metal ion levels in the patient’s body fluids. Wear of the bearing is directly related to its use. The goal of this study is to test two hypotheses. Firstly, that exercise causes increased wear particles in vivo which can cause immediate measurable rise in the serum metal ion levels. Secondly, that this rise in metal ion level is different for different types of bearings.

Material and Methods: Eighteen participants were allocated to four different groups i.e. Birmingham Hip Resurfacing prosthesis group, Cormet 2000 resurfacing prosthesis group, Thrust plate prosthesis group (28mm metasul articulation) and group four with out any metal work. Blood samples were taken immediately before, immediately after and one hour after exercise. Plasma cobalt and chromium was determined using Inductively-Coupled-Plasma-Mass-Spectrometry and Dynamic-reaction-cell respectively with detection limit of 2nmol/l each.

Results: The four patient groups were comparable. A significant increase (p< 0.005) in serum cobalt and chromium of 13% and 11% respectively, was noticed after the exercise. Rise of cobalt levels in patients with a resurfacing MOM was 8.5 times (BHR group) and 6.5 times (Cormet group) larger than in those with a Metasul (p=0.021 and p=0.047). Neither rise of metal levels nor baseline levels correlated with any other factor (p> 0.27).

Discussion: Physiologic exercise causes immediate detectable rise in the serum metal ion levels. The increase is predominantly related to the size of the bearing surface. Exercise-related-cobalt-rise could be used to assess the tribology of the different metal on metal designs in vivo for future research

Introduction: Diaphyseal fracture at a cortical perforation is the commonest postoperative complication of hips revised with impacted morsellised bone. To reduce fracture risk, surgeons can apply mesh, augment the bone with plate or strut graft, or bypass the perforation with a longer stem. No biomechanical data exists to choose between these alternatives. The objective of this study was to compare the above methods of cortical repair in terms of (i) bone fracture risk and (ii) stem migration.

Methods: Fourteen large composite femora (Sawbones, Malmö, Sweden) were prepared to simulate cavitary defects. An 18×40 mm lateral cortical perforation was made in 12 diaphyses. These diaphyses were repaired with mesh only, mesh and plate, or mesh and strut graft (n=4 each). Strut graft and plate were fixed with cables. Porcine cancellous bone was morsellised and impacted into each cavitary defect. Simplex P bone cement was injected. In the 12 femora with repaired perforation, a standard or a long Exeter prosthesis, bypassing the perforation 2 cortical diameters, was implanted. Thus, 6 methods of defect repair were created (mesh, plate and strut, combined with either long or short stem, each n=2). Standard stems impaction-grafted in the two femora without perforation served as control (n=2). Femora were placed in a testing machine and loaded at 1 Hz with 100 cycles of joint and abductor force. Peak joint force was 2,500 N. Strain amplitudes at the perforation and stem migration were determined. Statistical analysis was by 2-way and 1-way ANOVA, and the Student-Newman-Keuls (SNK) post-hoc test.

Results: Stem length did not affect average defect strain if used with plate or strut graft (2x2 ANOVA, p=0.62). Four combinations remained for further analysis: standard stem with mesh, long stem with mesh, plate, and strut graft, with defect strains of 5250, 3620, 2940, and 2480 μstrain. In controls, strains were 1750 μstrain. Defect strains differed significantly (ANOVA, p=0.0004), with strains for standard stems with mesh significantly higher than all other groups, those for long stems with mesh significantly higher than controls, and those for plate or strut graft no different from controls (SNK). Maximum permanent subsidence was 0.71 mm and retroversion 1.6°. For repaired perforations, stem length did not affect subsidence (p=0.96), but repair method did (p=0.03, both 2-way ANOVA). For further analysis, subsidence of the three repair methods (mesh, plate and strut graft with subsidence of 0.24, 0.47 and 0.19 mm, resp.) was compared with that of controls (0.52 mm). Subsidence differed significantly (ANOVA, p=0.02), and stems with strut graft subsided significantly less than those with plate or controls (SNK). Permanent retroversion was similar for each group.

Dicussion: Non-reinforced defects with a standard stem generated high defect strain amplitudes. A long stem bypassing the defect reduced these strains by 30%, and might suffice in case of otherwise strong cortex. In other cases, augmentation of the perforated diaphysis with either strut graft or plate needed to minimise fracture risk. Stem migration in reconstructed perforated diaphyses was always less than control cases, suggesting stem migration is no specific problem in reconstruction.

The use of impaction bone grafting during revision arthroplasty of the hip in the presence of cortical defects has a high risk of post-operative fracture. Our laboratory study addressed the effect of extramedullary augmentation and length of femoral stem on the initial stability of the prosthesis and the risk of fracture.

Cortical defects in plastic femora were repaired using either surgical mesh without extramedullary augmentation, mesh with a strut graft or mesh with a plate. After bone impaction, standard or long-stem Exeter prostheses were inserted, which were tested by cyclical loading while measuring defect strain and migration of the stem.

Compared with standard stems without extramedullary augmentation, defect strains were 31% lower with longer stems, 43% lower with a plate and 50% lower with a strut graft. Combining extramedullary augmentation with a long stem showed little additional benefit (p = 0.67). The type of repair did not affect the initial stability. Our results support the use of impaction bone grafting and extramedullary augmentation of diaphyseal defects after mesh containment.

Aim: The purpose of this study is to investigate the outcomes of bone conserving hip replacements: the Thrust Plate Prosthesis (TPP) and Buechel Pappas (BP) Resurfacing. Method:We have performed total hip replacements in 2 consecutive groups of young patients with osteoarthritis of the hips. In group 1 (TPP group) consists of 103 hips with the thrust plate prosthesis, HA coating and metal on metal bearings (1995~2000). The group 2 (BP group) consists of 25 hips with Buechel Pappas resurfacing with a thin polyethylene liner, ethylene oxide sterilized, and a nitrided titanium bearing surface (1989~1994). The outcomes were evaluated by complication rates, survival, standardized X-rays, a self-assessment satisfaction score, a Harris Hip Score and a Merle dñAubigne score. Results: In group 1, one hip had revision due to infection, and one following traumatic intertrochanteric fracture. No osteolysis and gross migration is seen In group 2, 17 of 25 hips had revision due to osteolysis or femoral neck fracture (mean 4y10m). Conclusion: The Thrust Plate Prosthesis has good outcome at 1 to 6 years follow-up. Buechel pappas resurfacing replacement had poor outcome and almost all cases had osteolysis, which are thought to be due to polyethylene particles.

We measured the pressure distribution across the tibiofemoral and patellofemoral joints during total knee arthroplasty (TKA) using Fuji pressure-sensitive film (Prescale) in 51 patients (63 joints) comparing the results with those in 21 patients in whom Prescale was not used.

We classified the stress-distribution patterns in the tibiofemoral joints into four types: normal, varus-valgus instability, rotational malalignment, and a combination of instability and malrotation. The medial ligaments were then released according to the information obtained from these patterns. The conformity ratio of the contact area between repeated trials was 87.0%. Pressure distribution across the patellofemoral joints was also considered.

There was a significant decrease in the mean valgus stress angle in the Prescale group compared with the control group (p < 0.01). Release of the lateral retinaculum according to the results showed no significant differences in subluxation of the patella between the released group and the group which did not appear to need this procedure.

We treated 12 shoulders in ten patients with irreparable rotator-cuff tears by transfer of the latissimus dorsi. There were nine men and one woman. Their average age was 64.0 years and the average follow-up was 35.6 months (26 to 42).

The results were excellent in four shoulders, good in four, fair in one, and poor in three. Active forward flexion improved from a preoperative average of 99° to a postoperative average of 135°. Osteoarthritic changes appeared in five shoulders and proximal migration of the humeral head progressed in six. EMG revealed that nine of the 12 transferred muscles showed activity which was synergistic with the supraspinatus on external rotation with abduction.

We conclude that latissimus dorsi transfer can be effective in restoring shoulder function after massive irreparable tears of the rotator cuff.