Aims

The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system.

Aims

Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error.

Aims

Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck.

Aims

The direct anterior approach (DAA) for total hip arthroplasty (THA) has potential advantages over other approaches and is most commonly performed with the patient in the supine position. We describe a technique for DAA THA with the patient in the lateral decubitus position and report the early clinical and radiological outcomes, the characteristics of the learning curve, and perioperative complications.

Aims

The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups.

Aims

Inadvertent soft tissue damage caused by the oscillating saw during total knee arthroplasty (TKA) occurs when the sawblade passes beyond the bony boundaries into the soft tissue. The primary objective of this study is to assess the risk of inadvertent soft tissue damage during jig-based TKA by evaluating the excursion of the oscillating saw past the bony boundaries. The second objective is the investigation of the relation between this excursion and the surgeon’s experience level.

Objectives

The use of the haptically bounded saw blades in robotic-assisted total knee arthroplasty (RTKA) can potentially help to limit surrounding soft-tissue injuries. However, there are limited data characterizing these injuries for cruciate-retaining (CR) TKA with the use of this technique. The objective of this cadaver study was to compare the extent of soft-tissue damage sustained through a robotic-assisted, haptically guided TKA (RATKA) versus a manual TKA (MTKA) approach.

Aims

The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty.

Aims

We wished to quantify the extent of soft-tissue damage sustained during minimally invasive total hip arthroplasty through the direct anterior (DA) and direct superior (DS) approaches.

Aims

The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy.

We describe our technique and rationale using hybrid fixation for primary total hip arthroplasty (THA) at the Hospital for Special Surgery. Modern uncemented acetabular components have few screw holes, or no holes, polished inner surfaces, improved locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented sockets can be combined with highly cross-linked polyethylene liners, which have demonstrated very low wear and osteolysis rates after ten to 15 years of implantation. The results of cement fixation with a smooth or polished surface finished stem have been excellent, virtually eliminating complications seen with cementless fixation like peri-operative femoral fractures and thigh pain. Although mid-term results of modern cementless stems are encouraging, the long-term data do not show reduced revision rates for cementless stems compared with cemented smooth stems. In this paper we review the conduct of a hybrid THA, with emphasis on pre-operative planning, surgical technique, hypotensive epidural anaesthesia, and intra-operative physiology.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):54–9.

The modified Smith–Petersen and Kocher–Langenbeck approaches were used to expose the lateral cutaneous nerve of the thigh and the femoral, obturator and sciatic nerves in order to study the risk of injury to these structures during the dissection, osteotomy, and acetabular reorientation stages of a Bernese peri-acetabular osteotomy.

Injury of the lateral cutaneous nerve of thigh was less likely to occur if an osteotomy of the anterior superior iliac spine had been carried out before exposing the hip.

The obturator nerve was likely to be injured during unprotected osteotomy of the pubis if the far cortex was penetrated by > 5 mm. This could be avoided by inclining the osteotome 45° medially and performing the osteotomy at least 2 cm medial to the iliopectineal eminence.

The sciatic nerve could be injured during the first and last stages of the osteotomy if the osteotome perforated the lateral cortex of ischium and the ilio-ischial junction by > 10 mm.

The femoral nerve could be stretched or entrapped during osteotomy of the pubis if there was significant rotational or linear displacement of the acetabulum. Anterior or medial displacement of < 2 cm and lateral tilt (retroversion) of < 30° were safe margins. The combination of retroversion and anterior displacement could increase tension on the nerve.

Strict observation of anatomical details, proper handling of the osteotomes and careful manipulation of the acetabular fragment reduce the neurological complications of Bernese peri-acetabular osteotomy.

Cite this article: Bone Joint J 2015;97-B:636–41.

Objectives. Acetabular retractors have been implicated in damage to the femoral and obturator nerves during total hip replacement. The aim of this study was to determine the anatomical relationship between retractor placement and these nerves. Methods. A posterior approach to the hip was carried out in six fresh cadaveric half pelves. Large Hohmann acetabular retractors were placed anteriorly, over the acetabular lip, and inferiorly, and their relationship to the femoral and obturator nerves was examined. Results. If contact with bone was not maintained during retractor placement, the tip of the anterior retractor had the potential to compress the femoral nerve by passing superficial to the iliopsoas. If pressure was removed from the anterior retractor, the tip pivoted on the anterior acetabular lip, and passed superficial to the iliopsoas, overlying and compressing the femoral nerve, when pressure was reapplied. The inferior retractor pierced the obturator membrane in all specimens medial to the obturator nerve, with subsequent retraction causing the tip to move laterally, making contact with the nerve. . Conclusion. Iliopsoas can only offer protection to the femoral nerve if the retractor passes deep to the muscle bulk. The anterior retractor should be reinserted if pressure is removed intra-operatively. Vigorous movement of the inferior retractor should be avoided. Cite this article: Bone Joint Res 2014;3:212–6

The December 2013 Foot & Ankle Roundup³⁶⁰ looks at: Maisonneuve fractures in the long term; Not all gastrocnemius lengthening equal; Those pesky os fibulare; First tarsometatarsal arthrosis; Juvenile osteochondral lesions; Calcanei and infections; Clinical outcomes of Weber B ankle fractures; and rheumatologists have no impact on ankle rheumatoid arthritis.

As it remains unproven that hypermobility of the first tarsometatarsal joint (TMTJ-1) is a significant factor in hallux valgus deformity, the necessity for including arthrodesis of TMTJ-1 as part of a surgical correction of a hallux valgus is questionable. In order to evaluate the role of this arthrodesis on the long-term outcome of hallux valgus surgery, a prospective, blinded, randomised study with long-term follow-up was performed, comparing the Lapidus procedure (which includes such an arthrodesis) with a simple Hohmann distal closing wedge metatarsal osteotomy. The study cohort comprised 101 feet in 87 patients: 50 feet were treated with a Hohmann procedure and 51 with a Lapidus procedure. Hypermobility of TMTJ-1 was assessed pre-operatively by clinical examination. After a mean of 9.25 years (7.25 to 11.42), 91 feet in 77 patients were available for follow-up. There was no difference in clinical or radiological outcome between the two procedures. Also, there was no difference in outcome between the two procedures in the subgroup clinically assessed as hypermobile. This study does not support the theory that a hallux valgus deformity in a patient with a clinically assessed hypermobile TMTJ-1 joint requires fusion of the first tarso-metatarsal joint. Cite this article: Bone Joint J 2013;95-B:1222–6

In Neer type II (Robinson type 3B) fractures of the distal clavicle the medial fragment is detached from the coracoclavicular ligaments and displaced upwards, whereas the lateral fragment, which is usually small, maintains its position. Several fixation techniques have been suggested to treat this fracture. The aim of this study was to assess the outcome of patients with type II distal clavicle fractures treated with coracoclavicular suture fixation using three loops of Ethibond. This prospective study included 14 patients with Neer type II fractures treated with open reduction and coracoclavicular fixation. Ethibond sutures were passed under the coracoid and around the clavicle (UCAC loop) without making any drill holes in the proximal or distal fragments. There were 11 men and three women with a mean age of 34.57 years (29 to 41). Patients were followed for a mean of 24.64 months (14 to 31) and evaluated radiologically and clinically using the Constant score. Fracture union was obtained in 13 patients at a mean of 18.23 weeks (13 to 23) and the mean Constant score was 96.07 (91 to 100). One patient developed an asymptomatic fibrous nonunion at one year. This study suggests that open reduction and internal fixation of unstable distal clavicle fractures using UCAC loops can provide rigid fixation and lead to bony union. This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results.

Cite this article: Bone Joint J 2013;95-B:983–7.

We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98).

In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15).

Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement.

We assessed the reliability, accuracy and variability of closed-wedge high tibial osteotomy (HTO) using computer-assisted surgery compared to the conventional technique. A total of 50 closed-wedge HTO procedures were performed using the navigation system, and compared with 50 HTOs that had been performed with the conventional technique. In the navigation group, the mean mechanical axis prior to osteotomy was varus 8.2°, and the mean mechanical axis following fixation was valgus 3.6°. On the radiographs the mean pre-operative mechanical axis was varus 7.3°, and the mean post-operative mechanical axis was valgus 2.1°. There was a positive correlation between the measured data taken under navigation and by radiographs (r > 0.3, p < 0.05). The mean correction angle was significantly more accurate in the navigation group (p < 0.002). The variability of the correction was significantly lower in the navigation group (2.3° vs 3.7°, p = 0,012). We conclude that navigation provides reliable real-time intra-operative information, may increase accuracy, and improves the precision of a closed-wedge HTO.

We describe a retrospective review of the clinical and radiological parameters of 32 feet in 30 patients (10 men and 20 women) who underwent correction for malalignment of the hindfoot with a modified double arthrodesis through a medial approach. The mean follow-up was 21 months (13 to 37). Fusion was achieved in all feet at a mean of 13 weeks (6 to 30). Apart from the calcaneal pitch angle, all angular measurements improved significantly after surgery. Primary wound healing occurred without complications.

The isolated medial approach to the subtalar and talonavicular joints allows good visualisation which facilitated the reduction and positioning of the joints. It was also associated with fewer problems with wound healing than the standard lateral approach.

Radiographs of 110 patients who had undergone 120 high tibial osteotomies (60 closed-wedge, 60 open-wedge) were assessed for posterior tibial slope before and after operation, and before removal of the hardware. In the closed-wedge group the mean slope was 5.7° (sd 3.8) before and 2.4° (sd 3.9) immediately after operation, and 2.4° (sd 3.4) before removal of the hardware. In the open-wedge group, these values were 5.0° (sd 3.7), 7.7° (sd 4.3) and 8.1° (sd 3.9) respectively, when stabilised with a non-locking plate, and 7.7° (sd 3.5), 9.4° (sd 4.1) and 9.1° (sd 3.8), when stabilised with a locking plate. The reduction in slope (−2.7° (sd 4.1)) in the closed-wedge group and the increase (+2.5° (sd 3.4), in the open-wedge group was significantly different before and after operation (p = 0.002, p = 0.003). In no group were the changes in slope directly after operation and before removal of the hardware significant (p > 0.05). There was no correlation between the amount of correction in the frontal plane and the post-operative change in slope.

Posterior tibial slope decreases after closed-wedge high tibial osteotomy and increases after an open-wedge procedure because of the geometry of the proximal tibia. The changes in the slope are stable over time, emphasising the influence of the operative procedure rather than of the implant.