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Producción Científica, Surgical treatment options for medial compartment osteoarthritis of the knee include high tibial osteotomy, total knee arthroplasty or unicompartmental knee arthroplasty (UKA), depending on the patient's age, level of physical activity and the degree of deformity. METHODS:In this study, we evaluated the long-term results of patients who underwent the Oxford cemented meniscal-bearing unicondylar knee prosthesis through a minimally invasive approach including a clinical, functional and radiographic assessment. RESULTS:Favourable clinical and radiological outcomes were registered overall at ten years after surgery. Overall results of UKA according to the American Knee Society (AKS) using Insall's criteria showed an excellent or good outcome for 492 knees (96.28 %), fair for 11 (2.15 %) and poor for eight (1.57 %) in the post-operative long term. CONCLUSIONS:We believe that with appropriate surgical technique, patient selection, prosthetic design and specific training, surgeons should achieve good outcomes with the added advantages of a minimally invasive approach. High volume for this technique is important in our opinion

Producción Científica, The current trend in hallux valgus surgery is directed toward percutaneous procedures. However, no evidence that any of these methods of treatment are superior to the others has been described, excepting studies in the long term. The aim of this study was to analyse a series of patients who had undergone a percutaneous distal retrocapital osteotomy of the first metatarsal, and had been followed up for ten years. METHODS: We carried out a clinical and radiological evaluation of 115 feet ten years after surgery. RESULTS: The AOFAS scale results in the tenth postoperative year remained significantly favourable compared to their corresponding values in the preoperative period, yielding an improvement of 42.2 points overall on average. In relation to radiological findings, the mean hallux angle was maintained below 20 °, with a mean intermetatarsal angle of 8.1 °. CONCLUSION: Percutaneous retrocapital metatarsal osteotomy for treatment of mild to moderate hallux valgus is effective in the long term, with the advantages of a minimally invasive procedure.

The aim of the present paper is to compare the results obtained using two osteosynthesis systems developed for the surgical treatment of fractures of the trochanteric region of the femur, based on the principles of closed intramedullary nailing: the Gamma nail and the proximal femoral nail (PFN). A prospective study is presented of 125 trochanteric fractures of the femur treated with PFN and 125 treated with the Gamma nail in our service between the years 1997 and 2000, with the prerequisite of a minimum follow-up of 1 year. Fractures were classified according to the AO system, the most commonly recorded subtype encountered being the A2. Clinical and radiographic controls were performed upon admission and in the post-operative follow-up at 1, 3, 6, and 12 months, the corresponding assessment protocol being completed on each occasion. Of the 250 patients, 179 were women and the rest men. The average age was 78.9 years. Both systems enabled early mobilisation and walking in most of our patients. There were no significant differences in the use of either nail in terms of the recovery of previous functional capacity, nor in terms of the time required for fracture healing (12 weeks on average). With regard to the more significant technical complications recorded, shaft fractures and the cutting-out phenomenon were more common with the use of the Gamma nail, while secondary varus occurred at a greater rate when using the PFN.

Dislocations of components, loosening of the stem, overstuffing and removal in up to 24 % of common radial head prostheses (RHP) after implantation in complex elbow injuries signal the need for improvement. The latest biomechanical evidence shows advantages for monopolar designs. Clinical results after primary and secondary implantation of the newly designed press-fit monobloc monopolar RHP in cases of complex elbow injury are evaluated. Twenty-nine patients [median age 60 years (29–86)] were followed up retrospectively for a median of 25 months (7–54) post-operatively. Subjective parameters, the Mayo Elbow Performance Score (MEPS), the Broberg and Morrey score (BMS), latest radiographs and complications were evaluated. MEPS and BMS averaged 87.2 ± 12.9 and 81.1 ± 11.9 points, respectively. No case of implant loosening was observed; the RHP had to be removed in one case (3 %). The overall complication and revision rate was higher after secondary (53 %) than after primary (19 %) implantation. Satisfactory clinical results and low short-term removal rates emphasise the practicality of monobloc monopolar RHP. Differentiated treatment of complex elbow fracture-dislocations is compulsory to avoid the need for secondary RHP implantation which carries a higher complication rate.

The purpose of this study was to assess the safety and preliminary clinical results of platelet-rich plasma (PRP) injections for treating chronic plantar fasciitis.Fourteen consecutive patients with chronic plantar fasciitis receiving three injections of PRP into the plantar fascia were assessed 12 months after the procedure. The modified Roles and Maudsley score and a visual analogue scale (VAS) for pain were used to evaluate the clinical results.According to criteria of the Roles and Maudsley score, at 12 months of follow-up, results were rated as excellent in nine (64.3 %), good in two (14.3 %), acceptable in two (14.3 %) and poor in one (7.1 %) patient. VAS for pain was significantly decreased from 7.1 ± 1.1 before treatment to 1.9 ± 1.5 at the last follow-up (p 0.01).In this single-centre, uncontrolled, prospective, preliminary study, results indicate that treating chronic plantar fasciitis with PRP injections is safe and has the potential to reduce pain.

Insulin is a commonly used additive in chondrogenic media for differentiating mesenchymal stem cells (MSCs). The indispensability of other bioactive factors like TGF-β or dexamethasone in these medium formulations has been shown, but the role of insulin is unclear. The purpose of this study was to investigate whether insulin is essential for MSC chondrogenesis and if there is a dose-dependent effect of insulin on MSC chondrogenesis.We cultivated human MSCs in pellet culture in serum-free chondrogenic medium with insulin concentrations between 0 and 50 μg/ml and assessed the grade of chondrogenic differentiation by histological evaluation and determination of glycosaminoglycan (GAG), total collagen and DNA content. We further tested whether insulin can be delivered in an amount sufficient for MSC chondrogenesis via a drug delivery system in insulin-free medium.Chondrogenesis was not induced by standard chondrogenic medium without insulin and the expression of cartilage differentiation markers was dose-dependent at insulin concentrations between 0 and 10 μg/ml. An insulin concentration of 50 μg/ml had no additional effect compared with 10 μg/ml. Insulin was delivered by a release system into the cell culture under insulin-free conditions in an amount sufficient to induce chondrogenesis.Insulin is essential for MSC chondrogenesis in this system and chondrogenic differentiation is influenced by insulin in a dose-dependent manner. Insulin can be provided in a sufficient amount by a drug delivery system. Therefore, insulin is a suitable and inexpensive indicator substance for testing drug release systems in vitro.

The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate.Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate.For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient.Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.

Several studies have reported a risk of dislocation in obese patients after total hip arthroplasty. In this study, we evaluated the interaction between obesity and dislocation by kinematic analysis using a navigation system.The intraoperative range of motion (ROM) and postoperative impingement-free ROM were measured in 38 patients, and we compared the impingement-free ROM in obese and non obese patients.The postoperatively simulated ROM was similar in the obese and non obese groups. The intraoperative ROM was smaller in the obese group. The difference values between the intraoperative ROM and postoperatively simulated ROM were larger in the obese group. These results indicate that obese patients have less ROM following primary total hip arthroplasty even when the implant positioning is performed correctly.Dislocations are multifactorial problems including soft tissue impingement. Therefore, the risk of dislocation caused by soft tissue impingement in obese patients may be increased.

A number of reconstructive procedures are available for the management of hip osteoarthritis. Hip resurfacing arthroplasty is now an accepted procedure, with implant survivorship comparable to THA at up to 10 years’ followup in certain series. Most reports focus on implant survivorship, surgeon-derived results, or complications. Fewer data pertain to patient-reported results, including validated measures of quality of life (QoL) and satisfaction and baseline measures from which to determine magnitude of improvement. Validated patient-reported results are essential to guide patients and surgeons in the current era of informed and shared decision making. We determined whether patients reported improvement in disease-specific, joint-specific, and generic QoL after hip resurfacing arthroplasty; whether patients were satisfied with the results of the procedure; and latest activity level and return to sport. We retrospectively reviewed 127 patients (100 men, 27 women) who underwent 143 hip resurfacing procedures between 2002 and 2006. Mean patient age was 52 years. Patients completed the WOMAC, Oxford Hip Score, and SF-12 at baseline and again at minimum 2-year followup (mean, 2.5 years; range, 2–6 years). At latest followup, patients completed a validated satisfaction questionnaire and UCLA activity score. All QoL scores improved (normalized to a 0–100 scale, where 100 = best health state). WOMAC improved from 46 to 95, Oxford Hip Score from 42 to 95, SF-12 (physical) from 34 to 54, and SF-12 (mental) from 46 to 56. Patient satisfaction score was 96. UCLA activity score was 8. The majority of patients reported improvement in QoL, were very satisfied with their outcome, and returned to a high level of activity after hip resurfacing arthroplasty. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

We designed a sensor that measures the bending moments at the articulations and the torque of the rod of a Hoffmann II® external fixation. We considered the effect of the callus formation in the stabilisation of a "fracture-fixation system."Four Hoffmann II® frame configurations were mechanically tested. Two carbon fibre tubes represent the bone fragments (length 180 mm, outer diameter 25 mm, inner diameter 19 mm). The callus is represented by the interposition of springs of different rigidity (10-405 N/mm) in the fracture gap between the tubes.The deformation of the frame is in inverse proportion to the stiffness of the callus; the slope of the curve drops rapidly during early development of the callus, to reach a plateau after some 50 % of recovery of the normal mechanical characteristics of the bone. This simulation supports the theoretical approach, i.e. the external frame resists larger stresses at the start of the fracture healing. Over a callus stiffness of some 200 N/mm the pattern of the curves remains similar, regardless of the frame configuration.An optimisation of the frame is possible, adapted to the actual mechanical situation of the callus. A monitoring system is deemed reliable after making sure that the elementary components behave the same way in the clinical condition as in the laboratory. In an experimental set up we confirmed its reliability in a clinical-like situation.

Highly crosslinked polyethylene (HXLPE) in THA was developed to reduce particle-induced periprosthetic osteolysis. A series of clinical studies were initiated to determine the clinical efficacy as judged by patient-reported scores, radiographic osteolysis, and wear analysis of one form of HXLPE.The purposes of this series of studies were to (1) determine the wear rates of one form of HXLPE; (2) report long-term (7-10 years) patient-reported outcome measures; (3) assess the effect of femoral head size on wear; and (4) determine the incidence of periprosthetic osteolysis.A single-center and two multicenter studies were conducted on 768 primary patients (head size 26-36 mm) undergoing THA at eight medical centers. Patient-reported outcome scores, radiographic grading for osteolysis, and radiographic wear evaluation were performed.Serial plain radiographs showed no periprosthetic osteolysis in the three studies. The average femoral head penetration rates did not correlate with time in vivo for patients with standard femoral head sizes. Although there was an indication of higher wear in patients with 36-mm diameter femoral heads, it was below the threshold for producing osteolysis.The introduction of this HXLPE substantially improved the prognosis of patients after THA up to 13 years as judged by clinical scores, incidence of osteolysis, and polyethylene wear measurements.Level III, therapeutic study. See the Guideline for Authors for a complete description of levels of evidence.

Navigated total knee arthroplasty (TKA) may improve coronal alignment outliers; however, it is unclear whether navigated TKA improves the long-term clinical results of TKA.Does the literature contain evidence of better long-term function and lower revision rates with navigated TKA compared with conventional TKA?A systematic literature review was conducted of navigated TKA reviewing articles related to coronal alignment, clinical knee and function scores, cost, patient satisfaction, component rotation, anteroposterior and mediolateral stability, complications, and longer-term reports.Coronal plane alignment is improved with navigated TKA with fewer radiographic outliers. We found limited evidence of improvements in any other variable, and function was not improved. The duration of surgery is increased and there are unique complications related to navigated TKA. The long-term benefits of additional increase in accuracy of alignment are not supported by any current evidence.The findings in reports of navigated TKA should be interpreted with caution. There are few short- and medium- and no long-term studies demonstrating improved clinical outcomes using navigated TKA. Despite substantial research, contradictory findings coupled with reservations about the cost and efficacy of the technology have contributed to the failure of computer navigation to become the accepted standard in TKA. Longer-term studies demonstrating improved function, lower revision rates, and acceptable costs are required before navigated TKA may be widely adopted. In the future, with improvements in study design, methodology, imaging, navigation technology, newer functional outcome tools, and longer-term followup studies, we suspect that navigated TKA may demonstrate yet unrecognized benefits.

Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture.We therefore determined: (1) local recurrence rates after curettage with adjuvants or en bloc resection; (2) complication rates after both surgical techniques and whether fracture healing occurred after curettage with adjuvants; and (3) function after both treatment modalities for giant cell tumor of bone with a pathologic fracture.We retrospectively reviewed 48 patients with fracture from among 422 patients treated between 1981 and 2009. The primary treatment was resection in 25 and curettage with adjuvants in 23 patients. Minimum followup was 27 months (mean, 101 months; range, 27-293 months).Recurrence rate was higher after curettage with adjuvants when compared with resection (30% versus 0%). Recurrence risk appears higher with soft tissue extension. The complication rate was lower after curettage with adjuvants when compared with resection (4% versus 16%) and included aseptic loosening of prosthesis, allograft failure, and pseudoarthrosis. Tumor and fracture characteristics did not increase complication risk. Fracture healing occurred in 24 of 25 patients. Mean Musculoskeletal Tumor Society score was higher after curettage with adjuvants (mean, 28; range, 23-30; n = 18) when compared with resection (mean, 25; range, 13-30; n = 25).Our observations suggest curettage with adjuvants is a reasonable option for giant cell tumor of bone with pathologic fractures. Resection should be considered with soft tissue extension, fracture through a local recurrence, or when structural integrity cannot be regained after reconstruction.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Purpose Traumatic shoulder dislocation may be complicated by concomitant bony injury of the glenoid rim or the humeral head. In Hill–Sachs lesions, reconstruction techniques vary widely and range from open reduction to tendon transposition or humeral head derotation. These operations are extensive and have questionable outcomes. With the expertise from vertebral compression fracture reduction by kyphoplasty, we examined in a cadaver feasibility study whether reduction of the Hill–Sachs lesion via hydraulic lift might be an anatomical and minimally invasive treatment option. We postulated that the use a of a balloon- assisted kyphoplasty reduction could achieve almost anatomical correction of the defect.

Excessive alcohol consumption has been associated with adverse health measures after elective surgery. The effects of low or moderate consumption remain unclear.We determined differences among patients with different consumption levels in (1) preoperative and postoperative patient-perceived outcomes and hip scores, (2) changes in those scores from preoperatively to postoperatively, (3) demographics and comorbidities, and (4) length of stay (LOS) and hospitalization charges.We retrospectively reviewed 191 patients (218 primary hips). Based on a self-administered consumption questionnaire, patients were stratified into three groups: (1) nondrinkers (n = 52), (2) occasional drinkers (n = 56), and (3) moderate drinkers (n = 17). Demographics, BMI, Charlson Comorbidity Index, and American Society of Anesthesiologists grade; preoperative and postoperative Quality of Well-being Scale, SF-36, WOMAC, Harris hip, and Merle d'Aubigné-Postel hip scores; and LOS and hospital charges were obtained and compared among groups adjusting for patient characteristics. Minimum followup was 1 year (mean, 3.5 years; range, 1-6 years).Most abstainers were older, female, and Hispanic. Preoperatively, moderate drinkers had better WOMAC function and total scores and Harris hip scores. There were no differences postoperatively among groups. However, nondrinkers had greater improvement (preoperative to postoperative) in the WOMAC function, pain, and total scores. Compared to nondrinkers, moderate drinkers had a higher contribution margin and net income.Alcohol consumption is more common among men and non-Hispanics. Moderate consumption was associated with better WOMAC and Harris hip scores. After surgery, abstainers achieved greater improvements in the WOMAC function, pain, and total scores.Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Computer navigation has improved accuracy and reduced the percentage of alignment outliers in TKA. However, the characteristics of outliers and the risk factors for limb malalignment after TKA are still unclear. We therefore addressed the following questions: (1) What is the incidence and characteristics of outliers for postoperative limb mechanical axis (hip-knee-ankle [HKA] angle outside the conventional 180° ± 3° range) and component alignment in TKA? And (2) what are the preoperative clinical or radiographic risk factors for limb mechanical axis malalignment in TKA? We retrospectively reviewed the clinical and radiographic records of 1500 computer-assisted TKAs to identify outliers for postoperative HKA axis and component alignment and determined risk factors for malalignment. Full-length hip-to-ankle and knee radiographs were used to measure preoperative HKA angle, femoral coronal bowing, joint divergence angle, tibial subluxation, and tibial bone loss and postoperative HKA angle and femoral and tibial component angle. The incidence of outliers for postoperative limb mechanical axis, femoral component alignment, and tibial component alignment was 7% (112 of 1500 TKAs), 7%, and 8%, respectively, with 70% of limbs placed in excessive varus and 30% in excessive valgus. Preoperative varus deformity of more than 20° and femoral bowing of more than 5° were associated with increased risk of placing the limb mechanical axis outside the acceptable ± 3° range after computer-assisted TKA. The presence of preoperative radiographic risk factors should alert the surgeon to increased chance of malalignment and every measure should be undertaken in such at-risk knees to ensure proper limb and component alignment and soft tissue balance. Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence

Tibial nail interlocking screw failure often occurs during delayed fracture consolidation or at early weight bearing of nailed unstable fractures, in general when high implant stress could not be reduced by other means. Is there a biomechanical improvement in long-term performance of angle stable locking screws compared to conventional locking screws for distal locking of intramedullary tibial nails?Surrogate bones of human tibiae were cut in the distal third and distal locking of the 10 mm intramedullary tibial nail was performed with either two angle stable locking screws or two conventional locking screws in the mediolateral plane. Six specimens per group were mechanically tested under quasi-static and cyclic axial loading with constantly increasing force.Angle stable locking screw constructs exhibited significantly higher stiffness values (7,809 N/mm ± 647, mean ± SD) than conventional locking screw constructs (6,614 N/mm ± 859, p = 0.025). Angle stable locking screw constructs provided a longer fatigue life, expressed in a significantly higher number of cycles to failure (187,200 ± 18,100) compared to conventional locking screw constructs (128,700 ± 7,000, p = 0.004).Fatigue performance of locking screws can be ameliorated by the use of angle stable locking screws, being especially important if the nail acts as load carrier and an improved stability during fracture healing is needed.

Metal-on-metal (MoM) THAs have reduced wear rates compared with metal-on-polyethylene. However, elevated serum metal ion levels and pseudotumors have been reported in large MoM articulations.We therefore determined (1) if corrosion occurred at the cone/taper interface leading to instability in patients with large-diameter THAs; (2) how patients presented clinically and radiographically; (3) if adverse periprosthetic tissue reactions occurred; (4) whether metal was released from the implants into the periprosthetic tissues; and (5) if head size correlated with metal release.We reviewed 114 patients who had revisions of large-diameter head MoM articulations. Mean time of implantation was 46 months. To identify adverse reactions and particle load, tissues were stained by hematoxylin and eosin and CD3/CD20/CD68 antibodies. Periprosthetic tissues were analyzed for metal content and distribution in different regions. Electrochemical reactions between the stem and adapter were investigated by a minicell electrode.Electrochemical studies on the stem and the head adapter showed a risk for galvanic corrosion. Ninety-four percent of patients had instability at the cone/taper interface. All patients presented with early clinical symptoms; 59 patients had radiographic signs of loosening. One hundred four patients had foreign body reactions and necrosis. The largest amounts of metal released were titanium or iron. We found no correlation between head size and metal ion release.These findings suggest that in modular cone/taper connections, friction of the MoM articulations may cause failure of the cone/taper interface leading to galvanic corrosion and loosening. It is unclear whether the design of this MoM system provides sufficient stability at the taper.

The popliteus tendon is known to play a key role in the stability of the posterolateral corner of the knee. While prior work suggests that isolated sectioning of the popliteus tendon has little consequence for the static stability of the knee following TKA, no studies have evaluated the effect of iatrogenic popliteal tendon injury on patient oriented outcome and knee function following TKA. The aims of this study are (1) to compare patient-oriented outcome scores of patients who suffered an iatrogenic injury to the popliteus tendon with a control group without such an injury and (2) to identify risk factors associated with iatrogenic injury to the popliteus tendon.Fifteen patients with an iatrogenic complete transection of the popliteus tendon during TKA were compared to the 666 patients who underwent TKA during the same time period without popliteus tendon injury.Postoperatively, IKS knee scores were similar between the two groups; however, significantly lower IKS function scores were noted in the study group (71 ± 31) compared to the control group (86 ± 19) (p = 0.0036). Iatrogenic popliteal tendon injury was only noted to occur in patients in whom components of size four or smaller were used.Intraoperative complete section of the popliteus tendon during the performance of TKA results in decreased IKS functional scores two to three years postoperatively. Patients with smaller knees may be at higher risk for this complication.

Aligning patient and surgeon expectations preoperatively may lead to better postoperative medical and rehabilitation compliance and therefore improve outcomes and increase satisfaction.We (1) determined the rate of discordantly high patient expectations compared with those of their surgeon in patients undergoing TKA; and (2) evaluated the impact of the preoperative educational class, patient characteristics, and functional status on the likelihood of having discordantly high patient expectations.We enrolled 205 patients awaiting TKA. Each patient completed a validated questionnaire that addresses expectations of postoperative pain relief, function, and well-being as part of a preoperative assessment. The surgeon completed the same expectations questionnaire preoperatively blinded to their patient's response. Patients had discordantly high expectations if their scores were ≥ 7 points higher than the surgeon on a 0 to 100 score range. Regression analysis was performed to determine the effect of class, patient characteristics, and functional status on the likelihood of having discordantly high patient expectations.Thirty-seven percent of the patients had expectation scores ≥ 7 points higher than those of their surgeon. Patients were less likely to have discordantly higher expectations if they were female (OR, 0.56; CI, 0.32-0.97) and if their pain level was high (OR, 0.99; CI, 0.98-0.99). Patients were more likely to have discordantly higher expectations if they filled out the expectations survey before rather than after the preoperative educational class (OR, 1.80; CI, 1.08-3.01).With increasing TKA use, surgeons will likely encounter more patients with discordantly high expectations. The preoperative educational class can be used to target patients more likely to have discordantly high expectations.

Many surgeons consider two-stage exchange the gold standard for treating chronic infection after TKA. One-stage exchange is an alternative for infection control and might provide better knee function, but the rates of infection control and levels of function are unclear.We asked whether a one-stage exchange protocol would lead to infection control rates and knee function similar to those after two-stage exchange.We followed all 47 patients with chronically infected TKAs treated with one-stage exchange between July 2004 and February 2007. We monitored for recurrence of infection and obtained Knee Society Scores. We followed patients a minimum of 3 years or until death or infection recurrence.Three of the 47 patients (6%) experienced a persistence or recurrence of the index infection with the same pathogen isolated. Three patients (6%) had control of the index infection but between 6 and 17 months experienced an infection with another pathogen. The 3-year survival rates were 87% for being free of any infection and 91% for being healed of the index infection. Twenty-five of the 45 patients (56%) had a Knee Society Score of more than 150 points.While routine one-stage exchange was not associated with a higher rate of infection recurrence failure, knee function was not improved compared to that of historical patients having two-stage exchange. One stage-exchange may be a reasonable alternative in chronically infected TKA as a more convenient approach for patients without the risks of two operations and hospitalizations and for reducing costs. The ideal one stage-exchange candidate should be identified in future studies.

NELL-1 is a novel osteoinductive growth factor that has shown promising results for the regeneration of bone. Moreover, NELL-1 has been used successfully in bone regeneration in the axial, appendicular and calvarial skeleton of both small and large animal models. Despite increasing evidence of NELL-1 efficacy and future usefulness as an alternative to traditional bone graft substitutes, much has yet to be understood regarding the mechanisms of action of this novel protein. The activation of the mitogen-activated protein kinase (MAPK) pathway has been well studied in the setting of growth factor-mediated changes in osteogenic differentiation.In this study, we provide evidence of the involvement of MAPK signalling pathways in NELL-1-induced terminal osteogenic differentiation of Saos-2 human osteosarcoma cells. Activation of extracellular signal-regulated kinase (ERK1/2), P38 and c-Jun N-terminal kinase (JNK) pathways were screened with MAPK signalling protein array after recombinant human (rh)NELL-1 treatment. Next, the mineralisation and intracellular phosphate levels after rhNELL-1 stimulation were assessed in the presence or absence of specific MAPK inhibitors.Results showed that rhNELL-1 predominantly increased JNK pathway activation. Moreover, the specific JNK inhibitor SP600125 blocked rhNELL-1-induced mineralisation and intracellular phosphate accumulation, whereas ERK1/2 and P38 inhibitors showed no effect.Thus, activation of the JNK pathway is necessary to mediate terminal osteogenic differentiation of Saos-2 osteosarcoma cells by rhNELL-1. Future studies will extend these in vitro mechanisms to the in vivo effects of NELL-1 in dealing with orthopaedic defects caused by skeletal malignancies or other aetiologies.

The aim of this study was to investigate a new drillable calcium phosphate cement (Norian drillable Synthes GmbH) as a bone substitute either alone or in combination with screws in the jail technique (Petersen et al. Unfallchirurg Mar 109(3):219-234, 2006; Petersen et al. Unfallchirurg Mar 109(3):235-244, 2006) with regard to the primary stability in lateral tibial depression fractures.Lateral depression fractures of the tibial plateau were created in a biomechanical fracture model. After reduction they were stabilised with bone substitute (group one), bone substitute with additional four screws in the jail technique (group two) or four screws only (group three). Displacement under cyclic loading, stiffness and maximum load in load-to-failure tests were determined.The groups with the bone substitute showed a lower displacement of the depressed articular fragment under cyclical loading and a higher stiffness. The maximum load was higher for the groups with screws.Only the combination of bone substitute and screws prevented secondary loss of reduction and, at the same time, provided enough stability under maximum load.

We observed isolated tibial component debonding from the cement in one modern primary TKA design (NexGen LPS 3° tibial tray; Zimmer, Warsaw, IN, USA). This failure mechanism is sparsely reported in the literature.We (1) assessed survivorship of this tibial tray with special emphasis on debonding; (2) described clinical and radiographic features associated with tibial failure; and (3) compared patient and radiographic features of the failures with a matched cohort.A total of 1337 primary TKAs were performed with a cemented NexGen LPS 3° tibial tray over an 11-year period. Twenty-five knees (1.9%) were revised for tibial debonding. BMI and radiographic alignment in the tibial debonding group were compared with a matched control group. Implant survivorship was assessed using tibial debonding as the end point.Survival free of revision from tibial debonding was 100% at 1 year and 97.8% at 5 years. The tibial failures shared a typical radiographic pattern with debonding at the cement-implant interface and subsidence into varus and flexion. We found no link between limb alignment or individual component alignment and failure because 22 of the 25 failures occurred in well-aligned knees.Our standardized followup of patients undergoing TKA at routine intervals allowed us to discover a higher rate of revision resulting from tibial debonding. We have discontinued the use of this particular tibial tray for primary TKA and surveillance for patients undergoing TKA continues to be warranted.

To compare and analyse the relationship between horizontal tear and root ligament tear of the posterior horn of the medial meniscus (PHMM) and the degree of varus in the axis of lower limb and body weight. One hundred and nineteen patients underwent surgical treatment as they were diagnosed with medial meniscus tear in our hospital from May 2006 to December 2009. Of these, 19 cases (group 1), underwent partial meniscectomy as they were confirmed to solely have horizontal tear of the PHMM on arthroscopic examination and 27 cases (group 2), underwent subtotal meniscectomy as they were confirmed to solely have root ligament tear of the PHMM on arthroscopic examination, were chosen for retrospective study. Standing radiographs were taken of every case prior to arthroscopic surgery to measure varus angle. Also, we checked body mass index (BMI) of two groups. The difference of varus angle and BMI between two groups were statistically verified using the Levene’s test, paired t-test. Group 1 showed mean value of varus angle of 2.30 ± 0.54, and BMI of 25.32 ± 3.23. Group 2 showed mean value of varus angle of 5.64 ± 0.54, and BMI of 25.67 ± 3.12. The degree of varus of group 2 was statistically significantly higher than group 1 (p = 0.002). Comparison between the BMI of two groups showed no statistical significance (p = 0.053). Through a comparative study of sole horizontal tear and root ligament tear of the PHMM, the authors have found that sole root ligament tear of the PHMM is more relative to the genu varum than sole horizontal tear of the PHMM. However, body weight was statistically irrelevant to the incidence of the two lesions.

Posterior cruciate ligament (PCL) injury has a reported incidence of 3-20 %. PCL reconstruction is aimed at reducing onset of premature articular degeneration and improving function. Numerous operative techniques have been described with varying degrees of result consistency.We evaluated 15 patients treated for isolated primary posterior cruciate ligament injury with a mean follow-up of 4.1 years (range one to nine). Post-reconstruction clinical assessment included the Lysholm and Tegner knee scoring scale, international knee documentation committee (IKDC) ligament evaluation, and KT2000 arthrometer assessment.On the Lysholm knee score 11 patients (73 %) had excellent results, three patients (20 %) had good results and one patient (7 %) had a poor result. On the Tegner activity score the majority of patients scored 7-8 with a return to high level sports. At the final follow-up, the post-reconstruction IKDC score was normal or nearly normal (A and B) in 14 (93 %) patients, and abnormal (C) in one (7 %) patient. According to KT-2000 arthrometer measurements at final follow-up review, 11 patients (73 %) were rated as normal (A, 0-2 mm), and four patients (27 %) as nearly normal (B, 3-5 mm). These results were independent of age, mechanism of injury, time elapsed to surgical reconstruction, and length of follow-up.Despite being a technically demanding procedure, the outcomes reported in this study show that single bundle transtibial arthroscopic PCL repair using four strands hamstring autograft provides satisfactory and consistent functional outcomes.

Purpose: The stress distribution of an ankle under various physiological conditions is important for long-term survival of total ankle arthroplasty. The aim of this study was to measure subchondral bone density across the distal tibial joint surface in patients with malalignment/instability of the lower limb. Methods: We evaluated subchondral bone density across the distal tibial joint in patients with malalignment/instability of the knee. Subchondral bone density of the ankle was measured by computed tomography (CT) osteoabsorptiometry from ten ankles as control and from 27 ankles with varus deformity/instability of the knee. The quantitative analysis focused on the location of the high-density area at the articular surface, to determine the resultant long-term stress on the ankle joint. Results: The area of maximum density of subchondral bone was located in the medial part in all subjects. The pattern of maximum density in the anterolateral area showed stepwise increases with the development of varus deformity/instability of the knee. Conclusions: Our results should prove helpful for designing new prostheses and determining clinical indications for total ankle arthroplasty.

In this retrospective study, we evaluated the treatment effect of ankle joint fracture surgery involving the posterior malleolus, and discuss relevant factors influencing the occurrence of traumatic arthritis of the ankle joint. A total of 102 cases of ankle joint fractures involving the posterior malleolus in five large-scale skeletal trauma centres in China, from January 2000 to July 2009, were retrospectively analysed in terms of surgical treatment and complete follow-up. Ankle joint mobility, posterior malleolus fragment size, articular surface evenness, Ankle-Hindfoot Scale of the American Orthopedic Foot and Ankle Society (AOFAS) score, and imaging scale score for arthritis were recorded. The degree of fracture pain during rest, active movement, and weight-bearing walking, and satisfaction with treatment were evaluated using a visual analogue scale (VAS). The average AOFAS score was 95.9, excellence rate was 92.2 %, and average VAS scores for degree of fracture pain during rest, active movement, and weight-bearing walking were 0.15, 0.31, and 0.68, respectively. Thirty-six cases showed arthritic manifestations. Ankle joint mobility along all directions on the injured side was lower than that on the unaffected side. There was no obvious difference in treatment effect between the fixed and unfixed posterior malleolus fragment groups for all and for fragment size of

Codivilla in 1901, Hey Groves in 1926, and Colonna in 1932 described similar capsular arthroplasties--wrapping the capsule around the femoral head and reducing into the true acetabulum--to treat completely dislocated hips in children with dysplastic hips. However, these procedures were associated with relatively high rates of necrosis, joint stiffness, and subsequent revision procedures, and with the introduction of THA, the procedure vanished despite some hips with high functional scores over periods of up to 20 years. Dislocated or subluxated hips nonetheless continue to be seen in adolescents and young adults, and survival curves of THA decrease faster for young patients than for patients older than 60 years. Therefore, joint preservation with capsular arthroplasty may be preferable if function can be restored and complication rates reduced.We describe a one-stage procedure performed with a surgical hip dislocation and capsular arthroplasty. Various additional joint preservation procedures included relative neck lengthening for improved motion clearance and head size reduction, roof augmentation, and femoral shortening/derotation for containment and congruency.We retrospectively reviewed nine patients (one male, eight female; age range, 13-25 years) who had such procedures between 1977 and 2010. Function was assessed by the Harris hip score (HHS). Minimum followup was 1 year (median, 2 years; mean, 7.5 years; range, 1-27 years).At latest followup, the mean HHS was 84 (n = 7) (range, 78-94). One patient underwent THA after 27 years. Complications included one deep vein thrombosis and one successfully treated neck fracture.Our data in these nine patients suggest capsular arthroplasty performed with a surgical hip dislocation and other appropriate adjunctive procedures is useful to treat dislocated hips in young patients with few complications. It may postpone THA.Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Fractures of the tibial plateau are among the most severe injuries of the knee joint and lead to advanced gonarthrosis if the reduction does not restore perfect joint congruency. Many different reduction techniques focusing on open surgical procedures have been described in the past. In this context we would like to introduce a novel technique which was first tested in a cadaver setup and has undergone its successful first clinical application.Since kyphoplasty demonstrated effective ways of anatomical correction in spine fractures, we adapted the inflatable instruments and used the balloon technique to reduce depressed fragments of the tibial plateau.The technique enabled us to restore a congruent cartilage surface and bone reduction.In this technique we see a useful new method to reduce depressed fractures of the tibial plateau with the advantages of low collateral damage as it is known from minimally invasive procedures.

The purpose of this study was to investigate whether acetabular morphology may influence both pathogenesis and prognosis of the acetabular rim lesions and to propose a new system to classify labral tears.We assessed radiographic and arthroscopic findings in 81 patients (40 male and 41 female patients, 86 hips) aged from 16 to 74 years (median, 31 years) who underwent hip arthroscopy.Acetabular rim lesions were associated with four different hip morphologies. Eleven (32 %) of 34 patients with severe rim lesions underwent hip arthroplasty for progressive symptoms, whereas no patient with early rim lesion reported significant progression of symptoms. The strategy of treatment was changed in 33 % of the patients undergoing arthroscopy before undertaking peri-acetabular osteotomy.Hip arthroscopy avoids more invasive procedures in patients with early acetabular rim lesions.

The purpose of our study is to evaluate the clinical results of anatomical reconstruction of the lateral ligaments with semitendinosus allograft.Thirty-six patients with chronic lateral instability underwent anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and the Karlsson score were used to evaluate the clinical results before and after surgery.A total of 35 patients (97.2 %) (36 ankles) were followed up for a mean of 37.9 months. The mean AOFAS score improved from 42.3 ± 4.9 points preoperatively to 90.4 ± 6.7 postoperatively. The mean Karlsson score improved from 38.5 ± 3.2 preoperatively to 90.1 ± 7.8 postoperatively.Anatomical reconstruction of the lateral ligaments with semitendinosus allograft achieves a satisfactory surgical outcome for chronic ankle instability.

Purpose: Muscle atrophy is a commonly encountered problem in osteoarthritis (OA). The aim of this study was to estimate the amount of muscle atrophy and fatty degeneration of the lower leg muscles related to ankle OA by magnetic resonance imaging (MRI). Methods: Twenty-one patients with unilateral ankle OA were included in this cohort study. Calf circumference of the affected and healthy lower leg was documented. The degree of OA was classified in conventional radiographs. The cross-sectional areas and fatty degeneration of the muscles of the lower leg were measured in bilateral MRI. Results: We found a significantly reduced calf circumference of the affected vs. healthy leg (p = 0.016). MRI showed a significantly lower cross-sectional area of the entire lower leg musculature in OA (p = 0.013). Sub-analysis of muscle groups revealed that only the M. soleus had a significant cross-sectional area decrease (p

Reconstruction rings and bone allografts have been proposed to manage severe acetabular bone loss. However, a high early failure rate of the Graft Augmentation Prosthesis (GAP) II reinforcement ring (Stryker Orthopaedics, Mahwah, NJ, USA) has been reported in one small series.We therefore determined (1) the survival of this device in combination with impacted morselized allograft bone in patients with severe defects and (2) the complication rate.We retrospectively reviewed 24 patients (21 aseptic and three septic) with severe acetabular bone loss (10 hips with Type III defects and 14 with Type IV defects according to the American Academy of Orthopaedic Surgeons classification). We determined function and numbers of failures. The minimum followup was 24 months (mean, 34 months; range, 24-72 months).At latest followup, the reconstruction had failed in nine of the 24 patients: six with aseptic loosening, three with infection. The average postoperative Merle d'Aubigné-Postel score of the patients whose reconstructions had not failed was 16.6 points; at latest followup, these patients had radiographic evidence of incorporation and consolidation of bone allografts. Seven of the nine patients whose reconstructions had failed underwent reoperation. Fatigue fracture of the ring at the plate-cup union occurred in five patients at an average of 45 months postoperatively. All patients with failed reconstructions who underwent reoperation were treated with Trabecular Metal(™) (Zimmer Inc, Warsaw, IN, USA) cups and were functioning well at latest followup.We observed a high rate (37%) of early catastrophic failures of the GAP II reconstruction ring, particularly in patients with Type IV defects. Due to this high failure rate, we have abandoned its use.Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Edge wear is an adverse factor that can negatively impact certain THAs. In some metal-on-metal THAs, it can lead to adverse tissue reactions including aseptic lymphocytic vasculitis-associated lesions and even to pseudotumor formation. In some ceramic-on-ceramic THAs, it can lead to squeaking and/or stripe wear. Edge wear in metal-on-metal and ceramic-on-ceramic THAs can also be associated with accelerated wear across the articulation of these joints.I asked: Does edge wear occur in metal-on-polyethylene (MOP) articulations? And if so, does it increase joint wear?I examined the evidence in the literature for edge wear occurring in MOP THA and then assessed the evidence in the literature for data supporting the concept that edge wear in MOP hips could accelerate wear across the articulation over time.Extensive data in the literature confirm edge wear is common in MOP THA. Surprisingly, the evidence does not support that it accelerates wear across the articulation. In fact, substantial data support the concept that it does not.These observations suggest, in terms of edge wear accelerating overall wear, MOP articulation may have a privileged position compared to hard-on-hard THA articulations.

Dislocation after THA continues to be relatively common. Dual mobility sockets have been associated with low dislocation rates, but it remains unclear whether their use in primary THA would not introduce additional complications.We therefore asked whether a current cementless dual mobility socket (1) reduced the dislocation rate after primary THA, (2) provided a pain-free and mobile hip, and (3) provided durable radiographic fixation of the acetabular component without any unique modes of failure.We retrospectively reviewed 168 patients who underwent primary THA using a dual mobility socket between January 2000 and June 2002. The average age at surgery was 67 years. We assessed the rate of dislocation, hip function, and acetabular fixation on serial radiographs. Of the 168 patients, 119 (71%) had clinical and radiographic evaluation at a minimum of 5 years (mean, 6 years; range, 5-8 years).A long-neck option left the base of the Morse taper uncovered in 53 hips. Four patients underwent revision for dislocation between the femoral head and the mobile insert (intraprosthetic dislocation) at a mean 6 years; all four revisions occurred among the 53 hips with an incompletely covered Morse taper.A current cementless dual mobility socket was associated with a pain-free and mobile hip and durable acetabular fixation without dislocations if the long-neck option was not used. However, intraprosthetic dislocation related to contact at the femoral neck to mobile insert articulation required revision in four hips. Surgeons should be aware of this specific complication.Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

A positive glide is a common finding after ACL reconstructions, especially in women. The aim of this study was to prospectively evaluate the role of Cocker-Arnold's extra-articular procedure in reducing the incidence of a residual postoperative rotational knee laxity.Sixty patients affected by an ACL injury with a +2 (clunk) or +3 (gross shift) pivot-shift test entered this prospective study; they were randomly assigned to group A (control group, hamstrings) or group B (study group, hamstrings plus Cocker-Arnold). Thirty-two patients entered group A and 28 group B. At follow-up, patients underwent clinical evaluation, KT-1000 arthrometer and Lysholm, Tegner, VAS and subjective and objective IKDC form.At a mean follow-up of 44.6 months, the same expert surgeon reviewed 55 patients (28 group A and 27 group B). The comparison of the results of the evaluation scales used and of the KT-1000 arthrometer did not show statistically significant differences (p0.05). Lachman test was negative (S/S) in all the patients of both groups (100 %). A residual positive pivot-shift (glide) was found in 16 patients (57.1 %) of group A and in five patients (18.6 %) of group B (p0.05).The extra-articular MacIntosh procedure modified by Cocker-Arnold in combination with ACL reconstruction significantly reduces the rotational instability of the knee.

The aim of this study was to evaluate the safety and efficiency, as well as the incorporation characteristics of a specific type of xenograft used for iliac crest defects post-harvesting tri-cortical iliac crest bone graft.Sixteen patients diagnosed with chronic anterior pelvic pain were operated for pubic symphysis fusion. The tri-cortical graft harvested from the iliac crest was inserted into the pubic symphysis and compressed with a reconstruction plate. The defect in the iliac crest was filled with a block of cancellous bovine substitute (Tutobone®). The length of iliac crest defect, time to fusion of pubic symphysis, time to incorporation of the graft and complications were recorded. The postoperative pain and patients' satisfaction were evaluated.The median age of patients was 36.5 years (range 27-75). Fusion was obtained in 15 patients (94 %). The median time to fusion was four months (range three to seven). The length of the iliac crest bone defect ranged from 40 to 70 mm. Integration of the bovine substitute was achieved in 15 patients (94 %) over a median period of three months (range two to six). The postoperative median pain score was 2 (range 1-5). Twelve patients (75 %) reported good satisfaction. No major complications or allergic reactions were observed.The xenograft used in this study provided a safe and effective method of reconstruction of iliac crest donor site defects. It has satisfactory incorporation, high biocompatibility and no signs of inflammatory reactions. This new technique is simple and easily reproducible in routine clinical practice.

The outcomes of bipolar hemiarthoplasty for osteonecrosis of femoral head have been disappointing due to cartilage degeneration and osteolysis. We investigated the cartilage degeneration, joint motion, and factors associated with osteolysis.We retrospectively reviewed 134 bipolar hemiarthroplasties. The wear rate of acetabular cartilage was calculated. The ranges of motion of outer bearing and inner bearing were determined, and the ratio (O/I ratio) was calculated.The mean degeneration rate of acetabular cartilage was 0.34 ± 0.35 mm/year. We could observe that the outer bearing motion was dominant, but decreased over time. In addition, the degeneration rate of cartilage and the decline rate of outer bearing motion of the osteolysis group were significantly higher than those of the control group.Close observation is needed in cases of high degeneration rate of cartilage and rapid decline of outer bearing motion due to possibility of osteolysis.

Pelvic radiation has been commonly used to treat gastrointestinal, genitourinary, or hematopoietic malignancies. Conventional THA in these patients reportedly have high rates of fixation failure. Although secure short-term fixation reportedly occurs with trabecular metal implants following pelvic radiation, it is unclear whether the fixation is durable.We determined the survival of trabecular metal acetabular components in patients having THA following pelvic radiation and assessed function and radiographic loosening.We retrospectively reviewed 29 patients with prior pelvic radiation who had 34 arthroplasties using trabecular metal acetabular components from 1998 and 2005. The mean pelvic radiation dose was 6300 cGy. We collected the following data: patient demographics, surgery and implant information, clinical and radiographic followup, and tumor and radiotherapy related details. We obtained Harris hip scores (HHS) on all patients. Ten patients died of disease prior to 5 years and two patients were excluded, leaving 17 patients (22 hips) with a minimum of 5 years of clinical (mean, 78 months; median, 71; range, 57-116) and radiographic (mean, 73; median, 65; range, 51-116) followup.All implants were in place in the surviving patients. The mean HHS improved from 36 preoperatively to 80 at latest followup. There were no reoperations for any reason, and we observed no implant loosening or migration at final followup in surviving or deceased patients.Tantalum trabecular metal acetabular components restored function and provided durable reconstruction in patients undergoing THA following prior pelvic radiation. We observed no clinical or radiographic failures at a minimum 5-year followup.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Metal-on-metal hip resurfacing is offered as an alternative to traditional hip arthroplasty for young, active adults with advanced osteoarthritis. The concept of hip resurfacing is considered very attractive for this specific population (hard-on-hard bearing component with a large femoral head limiting the risk of dislocation, and allowing femoral bone stock preservation). A prospective clinical trial was designed to investigate the outcome of hip resurfacing in young patients (under 30 years old). We studied 24 hips in 22 patients. Mean age at operation was 24.9 years (range 17.1–29.9). No patient was lost to follow-up. There was no revision at average follow-up of 50.6 months (44–59). Mean UCLA activity score improved from 5.5 (1–9) pre-operatively to 7.6 (1–10) postoperatively (p

Septic arthritis is a life-threatening emergency with high mortality of up to 11 %. We investigated if delay of arthroscopic lavage of infected major joints would have a bearing on the mortality and morbidity such as admission to an intensive care unit (ICU).We retrospectively reviewed patients presenting with septic arthritis to two regional hospitals over a period of seven years from 1 January 2005 to 31 December 2011. We divided our sample of 82 patients into four groups based on the time delay between clinical diagnosis and arthroscopic lavage ranging from less than six hours to more than 24 hours.We determined that 35.4 % of patients had prosthetic joints. Knee joints were predominantly involved (74.4 %). Staphylococcus aureus was the most commonly isolated pathogen (41.5 %). There were ten (12.2 %) deaths and the same number of admissions to an ICU. Our study revealed there was no statistical significance between the time delay and mortality (P = 0.25) or ICU admission (P = 0.74) or the number of washouts (P = 0.08) in all four groups.Up to 48 hours delayed arthroscopic lavage for septic arthritis does not increase the risk of mortality. Further prospective large sample studies are recommended to investigate this and the risk of long-term morbidity.

Scapular notching is a common worrying finding after reverse total shoulder arthroplasty (RSA). Eccentric glenospheres have recently been developed in an attempt to prevent notching. The purpose of this study was to evaluate the clinical and radiological results of RSA with an eccentric glenosphere and compare the incidence and the severity of scapular notching using a concentric glenosphere.A prospective evaluation was performed of 57 consecutive RSA performed over a two-year period. At a minimum of two years postoperatively, 47 RSAs with a mean 30.4 months follow-up were evaluated clinically and radiographically and compared to a historical control group of concentric glenospheres performed by the same surgeon.The mean Constant score significantly increased (from 32.4 to 71.8) postoperatively (p 0.0001). Active forward flexion and external rotation also significantly increased (p 0.0001). Overall, scapular notching was present in 19 shoulders (40.4 %). Grade 1 notching was observed in 13 shoulders (27.7 %), grade 2 in five shoulders (10.6 %), grade 3 in one shoulder (2.1 %), and grade 4 in no shoulders. There was no significant difference in the incidence (p = 0.289) of notching between the eccentric and concentric glenospheres. However, the severity of notching was significantly decreased (p = 0.011) with an eccentric glenosphere. The postoperative Constant score was not significantly different between patients with or without notching (p = 0.651).A Grammont type RSA with eccentric glenosphere can result in good clinical outcomes. An eccentric glenosphere does not prevent notching, but decreases the severity of scapular notching at early follow-up.

Administrative claims data are increasingly being used in public reporting of provider performance and health services research. However, the concordance between administrative claims data and the clinical record in lower extremity total joint arthroplasty (TJA) is unknown.We evaluated the concordance between administrative claims and the clinical record for 13 commonly reported comorbidities and complications in patients undergoing TJA.We compared 13 administratively coded comorbidities and complications derived from hospital billing records with clinical documentation from a consecutive series of 1350 primary and revision TJAs performed at three high-volume institutions during 2009.Concordance between administrative claims and the clinical record varied across comorbidities and complications. Concordance between diabetes and postoperative myocardial infarction was reflected by a kappa value0.80; chronic lung disease, coronary artery disease, and postoperative venous thromboembolic events by kappa values between 0.60 and 0.79; and for congestive heart failure, obesity, prior myocardial infarction, peripheral arterial disease, bleeding complications, history of venous thromboembolism, prosthetic-related complications, and postoperative renal failure by kappa values between 0.40 and 0.59. All comorbidities and complications had a high degree of specificity (92%) but lower sensitivity (29%-100%).The data suggest administratively coded comorbidities and complications correlate reasonably well with the clinical record. However, the specificity of administrative claims is much higher than the sensitivity, indicating that comorbidities and complications coded in the administrative record were accurate but often incomplete.

Despite advances in primary THA, dislocation remains a common complication. In New Zealand (NZ), dislocations are reported to the National Joint Registry (NJR) only when prosthetic components are revised in the treatment of a dislocation. Closed reductions of dislocated hips are not recorded by the NJR.We compared the true dislocation rate for patients receiving primary THA in the Wellington region with the rate reported by the NZ NJR for the same group of patients.The NZ NJR identified 570 patients undergoing primary THA from January 1, 2008, to December 31, 2009, with addresses in the Wellington region. The mean age was 67.5 years (range, 27-96 years). The minimum followup was 2 years (mean, 3 years; range, 2-4 years).Six patients required revision of at least one component for dislocation. There was 100% agreement between the hospital database and the NJR. Using the NJR criteria of revision of any component as an end point, the dislocation rate in the Wellington region after primary THA was 1.05%. The hospital database identified a further eight patients who presented with a dislocation of their primary THA and underwent a closed reduction. These patients were not recorded by the NJR. The true rate of all dislocations, which includes closed reductions, was 2.46%.This article documents the discrepancy between the NZ NJR reported rate of revision for dislocation and the true rate of dislocation in primary THA. We recommend documentation of all dislocations by NJR in their database to allow more accurate comparisons between centers and research outcomes.Level IV, clinical research study. See Guidelines for Authors for a complete description of levels of evidence.

The purpose of our study is to describe the rationale, the surgical technique and the early clinical and radiographic results of the treatment of patients with early stage osteonecrosis of the femoral head (ONFH) by performing: core decompression, injection of autologous bone marrow concentrate and the use of a new composite injectable bone substitute (PRO-DENSE(®)), as a mechanical supplementation associated with decompression.The study included 37 hips (31 patients, 14 females, 17 males; mean age 43.9 years, range 24-56 years) with stages IC-IIIA ONFH. The outcome was determined by the changes in the Harris hip score (HHS), by progression in radiographic stages and by the need for hip replacement. The mean follow-up was 20.6 months (range 12-32 months).At final follow-up the mean HHS increased from 68 points pre-operatively to 86 points post-operatively. The radiological results showed that 29 hips (78.4 %) improved or had no further collapse. The overall clinical success rate of the procedure was 86.5 %, with three conversions to THA, and a failure rate of only 3.3 % in the pre-collapse group.We are encouraged by these early results using core decompression, injection of the autologous bone marrow concentrate and backfilling the defect with an injectable bioceramic for the treatment of early stages of ONFH; as far as a conclusion can be drawn from the current data, this treatment seems to relieve hip pain and prevent the progression of ONFH in the majority of the cases.

We read with great interest the work of Chi-chuan Wu on the use of retrograde dynamic locked nailing for valgus deformity of knee [1].We would like to congratulate the author for devising a new technique for this deformity. The author has concluded that the use of intramedullary nail provides better biomechanics when compared to the use of plate and that patients have better symptomatic relief. However, we would like to bring forth a few points to the authors notice: 1. Most of the patients were young (average age of 28 years) in the study group when compared to the studies in which plating was used in whom the predominant reason for the osteotomy was osteoarthritis. So, for the outcome of time to union, postoperative satisfaction would be biased. It would have been better if the author would have created a control group in whom plating is used to overcome the bias. 2. The author did not comment on the stability of the implant in this study. Ito et al. [2] concluded that retrograde nail was noted to provide equal or greater stability than the plate, except when large torsional loads are anticipated. As the patient population in the study group was comprised of young individuals with high impact activities, concern regarding the stability of the implant exists. 3. The use of retrograde nails further entails potential risk of knee sepsis, damage to articular cartilage, and ligaments while inserting the nail. We conclude that the use of retrograde nail to correct the valgus deformity in young adults is a promising technique. However, a comparative trial with a longer follow-up would further shed more light on the advantages of this technique over plating.

The purpose of this study was to identify the relationship between an acromion index (AI) and the size of a rotator cuff tear. The hypothesis of our study was that an AI will be higher in patients with a full-thickness tear than in patients with a partial-thickness articular-side tear, and that it can be used as a predictor for the size of a rotator cuff tear.We included 284 patients who had been diagnosed with rotator cuff tears and had undergone arthroscopic rotator cuff repair at our institute. All patients were divided into five distinct groups (partial-thickness articular side tear, and four subgroups of full-thickness tears) depending on the size of the rotator cuff tear on arthroscopy. In each patient, an AI was measured on the pre-operative oblique coronal MR images and then analysed to determine the difference between groups.There were statistically significant differences between the partial-thickness articular side rotator cuff tear and large-to-massive rotator cuff tear groups (p 0.01), and the mean value of an AI was highest in the large-sized full-thickness tear group. The AI of the partial-thickness articular-side rotator cuff tear group was statistically different from the large-to-massive rotator cuff tear groups.The AI can be a predictor which can differentiate a partial-thickness articular-side tear and a large-to-massive rotator cuff tear pre-operatively. However the AI could not provide useful guidance on predicting the differences in tear size in full-thickness tear patients. We suggest that a high AI can be one of the associated factors for progression to large-to-massive rotator cuff tears in a rotator cuff disease.

The optimal reconstructive method after resection of malignant bone tumours of the proximal ulna is unknown.We report the outcome of endoprosthetic replacement in a young patient population.This was a retrospective review of four patients[three males and one female; mean age 17.5 (range 11–31)years] who underwent limb salvage with a proximal ulnar endoprosthetic replacement following excision of malignant bone tumour. Mean follow-up was 85 (range 14–194) months.All patients were alive at final follow-up and reported an improvement in pain. One patient required transhumeral amputation for intralesional excision complicating a local recurrence at one month. Two patients developed fixed flexion deformities of the elbow, one of whom required radial-head excision. Mean Musculoskeletal Tumour Society (MSTS)score and Toronto Extremity Salvage Score (TESS) were 27(range 25–28) and 81 (73–88), respectively.Custom-made proximal ulna endoprosthetic replacement following resection of malignant bone tumours in young patients provides a stable reconstruction option with satisfactory function and without apparent compromise in patient survival.

Our aim was to assess the basic musculoskeletal competency of pre-internship graduates from Nigerian medical schools.We administered the Freedman and Bernstein basic musculoskeletal competency examination to 113 pre-internship graduates from seven Nigerian medical schools over a three year period from 2008 to 2010 at the University of Uyo Teaching Hospital. Five specialist residents took the examination to test criteria relevance.All graduates failed this test, obtaining scores ranging from 7% to 67%. The duration of the orthopaedic posting, and observation of operative fracture fixation, were not significant determinants of the score. The two final-year specialist residents each had a marginal pass in the examination.Basic musculoskeletal competency among pre-internship Nigerian medical-school graduates is inadequate.