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BACKGROUND AND PURPOSE: Intramedullary bone-lengthening nails have become increasingly popular. The 2 most used and successful nails are the FITBONE and the PRECICE nails. Uniform reporting is lacking on complications of intramedullary bone-lengthening nails. The purpose was therefore to assess and categorize the complications of lower limb bone-lengthening nails and investigate risk factors.PATIENTS AND METHODS: We performed a retrospective review of patients operated on with intramedullary lengthening nails at 2 hospitals. We included only lower limb lengthening with FITBONE and PRECICE nails. Recorded patient data was patient demographics, nail information, and any complication. Complications were graded according to severity and origin classification. Complication risk factors were assessed with modified Poisson regression.RESULTS: 314 segments in 257 patients were included. The FITBONE nail was predominantly used (75%), and most of the lengthenings were performed in the femur (80%). 53% of the patients had complications. 269 complications were identified in 175 segments (144 patients). Device-related complications were most frequent (0.3 complications/segment), followed by joint complications (0.2 complications/segment). An increased relative risk was found for complications in the tibia compared with the femur and for age groups above 30 years compared with the 10-19 years group.CONCLUSION: Complications with intramedullary bone lengthening nails were more frequent than has previously been reported, with 53% of patients sustaining a complication. Future studies need to document the complications meticulously so that the true risk can be established.

Background and purpose — We noted several adverse events in patients in whom the first version of the STRYDE limb-lengthening nail (NuVasive Specialized Orthopaedics, San Diego, CA) had been implanted. Pain, osteolysis, periosteal reactions, and cortical hypertrophy at the nail junction were noted. Here, we present the analysis of 23 retrieved STRYDE implants. Materials and methods — We undertook visual inspection of the retrieved nails and screws, mechanical evaluation of the junction, micro-CT analyses, microscopic inspection of the bushing, screws, screw holes, and separated parts of the implants. Positive material identification (PMI) and energy-dispersive X-ray spectroscopy (EDS) were used to analyze the chemical composition. The hardness of the material was also investigated. Results — 20/23 retrieved nails had visible signs of corrosion, i.e., discoloration at the telescopic junction. Micro-CT verified corrosion attacks in 12/12 scanned bushings. Corrosion, predominantly mechanically assisted crevice corrosion, was observed at the locking screws and screw holes in 20/23 nails. Biological material inside the nail was observed in addition to oozing from the junction of 2 nails during hardware removal, which was experimentally reproducible. Notably, the mechanical construction of the bushing changed from PRECICE P2 to STRYDE nails. Interpretation — STRYDE nails are not hermetically sealed, and liquid can pass the bushing. Biodur 108 itself is corrosion resistant; however, mechanically assisted crevice corrosion of the bushing, locking screws, and screw holes may be aggravated due to manufacturing aiming for increased strength and hardness of the alloy. Observing several adverse events, we recently published a nationwide cross-sectional analysis of all 30 STRYDE limb- lengthening nails (NuVasive, Specialized Orthopedics, San Diego, CA) that were implanted in Denmark (Rölfing et al. 2021a). 27/30 STRYDE nails have now been removed and we present data from metallurgical analysis of 23 of the retrieved implants.

Background and purpose — In recent years motorized intramedullary lengthening nails have become increasingly popular. Complications are heterogeneously reported in small case series and therefore we made a systematic review of complications occurring in lower limb lengthening with externally controlled motorized intramedullary bone lengthening nails.Methods — We performed a systematic search in PubMed, EMBASE, and the Cochrane Library with medical subject headings: Bone Nails, Bone Lengthening, and PRECICE and FITBONE nails. Complications were graded on severity and origin.Results — The search identified 952 articles; 116 were full text screened, and 41 were included in the final analysis. 983 segments were lengthened in 782 patients (age 8–74 years). The distribution of nails was: 214 FITBONE, 747 PRECICE, 22 either FITBONE or PRECICE. Indications for lengthening were: 208 congenital shortening, 305 acquired limb shortening, 111 short stature, 158 with unidentified etiology. We identified 332 complications (34% of segments): Type I (minimal intervention) in 11% of segments; Type II (substantial change in treatment plan) in 15% of segments; Type IIIA (failure to achieve goal) in 5% of segments; and Type IIIB (new pathology or permanent sequelae) in 3% of segments. Device and bone complications were the most frequent.Interpretation — The overall risk of complications was 1 complication for every 3 segments lengthened. In 1 of every 4 segments, complications had a major impact leading to substantial change in treatment, failure to achieve lengthening goal, introduction of a new pathology, or permanent sequelae. However, as no standardized reporting method for complications exists, the true complication rates might be different. Background and purpose — In recent years motorized intramedullary lengthening nails have become increasingly popular. Complications are heterogeneously reported in small case series and therefore we made a systematic review of complications occurring in lower limb lengthening with externally controlled motorized intramedullary bone lengthening nails.Methods — We performed a systematic search in PubMed, EMBASE, and the Cochrane Library with medical subject headings: Bone Nails, Bone Lengthening, and PRECICE and FITBONE nails. Complications were graded on severity and origin.Results — The search identified 952 articles; 116 were full text screened, and 41 were included in the final analysis. 983 segments were lengthened in 782 patients (age 8–74 years). The distribution of nails was: 214 FITBONE, 747 PRECICE, 22 either FITBONE or PRECICE. Indications for lengthening were: 208 congenital shortening, 305 acquired limb shortening, 111 short stature, 158 with unidentified etiology. We identified 332 complications (34% of segments): Type I (minimal intervention) in 11% of segments; Type II (substantial change in treatment plan) in 15% of segments; Type IIIA (failure to achieve goal) in 5% of segments; and Type IIIB (new pathology or permanent sequelae) in 3% of segments. Device and bone complications were the most frequent.Interpretation — The overall risk of complications was 1 complication for every 3 segments lengthened. In 1 of every 4 segments, complications had a major impact leading to substantial change in treatment, failure to achieve lengthening goal, introduction of a new pathology, or permanent sequelae. However, as no standardized reporting method for complications exists, the true complication rates might be different.

Purpose: It is proposed that central femoral ACL graft placement better controls rotational stability. This study evaluates the consequence of changing the femoral tunnel position from the AM position drilled transtibially to the central position drilled transportally. The difference in ACL graft failure is reported. Methods: This prospective consecutive patient single surgeon study compares the revision rates of 1016 transtibial hamstring ACL reconstructions followed for 6–15 years with 464 transportal hamstring ACL reconstructions followed for 2–6 years. Sex, age, graft size, time to surgery, meniscal repair and meniscectomy data were evaluated as contributing factors for ACL graft failure to enable a multivariate analysis. To adjust for the variable follow-up a multivariate hazard ratio, failure per 100 graft years and Kaplan–Meier survivorship was determined. Results: With transtibial ACLR 52/1016 failed (5.1%). With transportal ACLR 32/464 failed (6.9%). Significant differences between transportal and transtibial ACLR were seen for graft diameter, time to surgery, medial meniscal repair rates and meniscal tissue remaining after meniscectomy. Adjusting for these the multivariate hazard ratio was 2.3 times higher in the transportal group (p = 0.001). Central tunnel placement resulted in a significantly 3.5 times higher revision rate compared to an anteromedial tunnel placement per 100 graft years (p = 0.001). Five year survival was 980/1016 (96.5%) for transtibial versus 119/131 (90.5%) for transportal. Transportal ACLR also showed a significantly higher earlier failure rate with 20/32 (61%) of the transportal failing in the first year compared with 14/52 (27%) for transtibial. (p = 0.001.) Conclusion: Transportal central femoral tunnel ACLR has a higher failure rate and earlier failure than transtibial AM femoral tunnel ACLR. Level of evidence: Level II—prospective comparative study.

Background: The aim of this study was to compare the accuracy of the oscillating tip saw system (Precision Saw = PS) with the more conventional fully oscillating blade system (Sagittal Saw = SS) during computer-assisted total knee arthroplasty (CAS-TKA).Methods: A prospective, randomised, controlled trial included 58 consecutive patients who underwent primary CAS-TKA and were randomly assigned in the PS group or the SS group to compare the accuracy of both blades. The primary outcome was the difference between the intended cutting planes and the actual cutting planes in degrees () in two planes of both the femur and the tibia. The secondary outcome was total surgery time.Results: Tibia: In the W-plane no significant differences were registered for the mean absolute deviation (p = 0.28). The PS was more accurate in the AP-plane (p = 0.03). Femur: The PS showed significantly fewer mean absolute deviations in the W-plane (p = 0.03); however, the SS revealed better accuracy in the FE-plane (p = 0.04). The difference in the surgery time between the groups was not statistically significant (p = 0.45). Two outliers were measured using the SS, while seven outliers were detected using the PS.Conclusion: The Precision Saw is not proven to be overall more accurate than the Sagittal Saw. Significantly better accuracy was shown with the PS in the two cutting planes, with the exception of one cutting plane that favoured the SS. Greater number of outliers were found using the PS. (C) 2017 Elsevier B.V. All rights reserved.

Background Due to its bone preserving philosophy, short-stem total hip arthroplasty (THA) has primarily been recommended for young and active patients. However, there may be benefits for elderly patients given a less invasive operative technique due to the short curved implant design. The purpose of this study was to compare the clinical and radiological outcomes as well as perioperative complications of a calcar-guided short stem between a young ( 75 years) population. Methods Data were collected in a total of 5 centers, and 400 short-stems were included as part of a prospective multicentre observational study between 2010 and 2014 with a mean follow-up of 49.2 months. Preoperative femur morphology was analysed using the Dorr classification. Clinical and radiological outcomes were assessed in both groups as well as perioperative complications, rates and reasons for stem revision. Results No differences were found for the mean visual analogue scale (VAS) values of rest pain, load pain, and satisfaction, whereas Harris Hip Score (HHS) was slightly better in the young group. Comparing both groups, none of the radiological parameters that were assessed (stress-shielding, cortical hypertrophy, radiolucency, osteolysis) reached differences of statistical significance. While in young patients aseptic loosening is the main cause of implant failure, in the elderly group particularly postoperative periprosthetic fractures due to accidental fall have to be considered to be of high risk. The incidence of periprosthetic fractures was found to be 0% in Dorr type A femurs, whereas in Dorr types B and C fractures occurred in 2.1 and 22.2% respectively. Conclusions Advanced age alone is not necessarily to be considered as contra-indications for calcar-guided short-stem THA, although further follow-up is needed. However, markedly reduced bone quality with femur morphology of Dorr type C seems to be associated with increased risk for postoperative periprosthetic fractures, thus indication should be limited to Dorr types A and B. Trial registration German Clinical Trials Register; DRKS00012634, 07.07.2017 (retrospectively registered).

PURPOSE: To compare anteromedial (AM) and transtibial (TT) femoral drilling hole techniques in primary anterior cruciate ligament reconstruction, using the Danish Knee Ligament Reconstruction Register, comparing revision rates and clinical outcomes from 2 time periods, 2007 to 2010 and 2012 to 2015.METHODS: A total of 8,386 primary anterior cruciate ligament reconstructions were registered between January 2007 to December 2010 and 8,818 in the period January 2012 to December 2015. Revision ACL was the primary endpoint. Secondary endpoints were the objective and subjective clinical outcomes. Crude and adjusted relative risks (RRs) with 95% confidence interval (CIs) were calculated.RESULTS: The adjusted RR for revision surgery in the AM (2007-10) group compared with the TT (2007-10) group was 1.45 (95% CI, 1.17-1.78; P < .05), but when comparing the AM (2012-15) group with TT (2012-15) group, the RR was 0.99 (95% CI, 0.68-1.45; P = .96). One-year postoperative objective stability testing showed an RR = 1.38 (95% CI, 1.19-1.60; P < .01) for rotational stability and an RR = 1.37 (95% CI, 0.99-1.89; P < .01) for sagittal stability when comparing AM (2007-10) to TT (2007-10). No significant difference in objective stability was found in the more recent period. Lastly, comparing the subjective scores, the AM (2012-15) had a significantly higher Tegner score 1 year postoperatively compared with the TT-group (2012-15).CONCLUSIONS: This study found an increased RR of revision anterior cruciate ligament and rotational and sagittal instability 1 year postoperatively for the AM technique in the period from 2007 to 2010. However, there was no significant difference in revision surgery and objective measures between the techniques from 2012 to 2015. Nevertheless, a higher activity level was found in the AM group. The results could indicate that the results found in the period 2007 to 2010 may have been caused by a learning curve when introducing a new and more complex procedure (AM).LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Place: United States

Purpose: The HemiCAP ® implant for femoral resurfacing treatment of cartilage lesions was introduced in 2003. We present outcome from a prospective cohort study of 61 patients with both trochleal and condylar lesions treated with the HemiCAP ® implant. Methods: From 2007 to 2012, 61 patients were treated with femoral resurfacing using the HemiCAP implant. There were 36 femoral condyle implants and 25 trochleal implants. Indication for treatment with HemiCAP implant was symptomatic cartilage lesion at the femoral condyle demonstrated by MRI or arthroscopy, which was ICRS grade 3–4 and size less than 4 cm 2. There were 24 males and 37 females with a median age of 49 (range 35–65) years. Patients were followed for 2 years with Knee Society subjective outcome scores (KSS), pain scores and radiographic evaluations and for 7 years with complications and reoperations. Results: At 2-year follow-up, mean KSS was improved from 52 (6.2) to 90 (7.9), mean KSS function score was improved from 45 (7.5) to 92 (8.3), and mean Pain score improved from 7.1 (0.7) to 1.8 (1.7). Twenty-three per cent of implants were revised within 7 years to arthroplasty due to progression of cartilage lesions, progression of osteoarthritis, or increased knee pain. No difference between females and males was found for reoperation rate. Conclusion: The present study demonstrated improved subjective outcome and reduced pain after femoral resurfacing using the HemiCAP implant in a relatively large cohort of patients with symptomatic cartilage lesions. A concerning 23 % reoperation rate with conversion to arthroplasty was found. Femoral resurfacing implantation treatment can be a temporary treatment for cartilage lesions expected to develop into osteoarthritis and for younger patients not eligible for arthroplasty treatment. Level of evidence: IV.

Introduction: Revision total knee arthroplasty with a cementless metaphyseal sleeve is suggested to be used without stem in revision total knee arthroplasty (rTKA). To the best of our knowledge, no papers investigating this have been published. The purpose of this study was to evaluate clinical outcome. Method: In this retrospective study, 71 patients operated with rTKA with sleeves without stem in the period 2009–2011 were identified; 63 were examined. All patients with the prosthesis still in place were invited to a medical examination including X-rays. American Knee Society Score (AKSS) and Oxford Knee Score (OKS) were used as primary clinical outcome scores. Results: Mean number of revisions including the revision with sleeve was 1.7. AKSS increased significantly from 62.7 to 109.6; (p value

We conducted a longitudinal study including patients with the same type of primary hybrid total hip replacement and evaluated patient activity and femoral osteolysis at either five or ten years post-operatively. Activity was measured using the University of California, Los Angeles scale. The primary outcome was the radiological assessment of femoral osteolysis. Secondary outcomes were revision of the femoral component for aseptic loosening and the patients’ quality of life. Of 503 hip replacements in 433 patients with a mean age of 67.7 years (30 to 91), 241 (48%) were seen at five and 262 (52%) at ten years post-operatively. Osteolytic lesions were identified in nine of 166 total hip replacements (5.4%) in patients with low activity, 21 of 279 (7.5%) with moderate activity, and 14 of 58 (24.1%) patients with high activity. The risk of osteolysis increased with participation in a greater number of sporting activities. In multivariate logistic regression adjusting for age, gender, body mass index and the inclination angle of the acetabular component, the adjusted odds ratio for osteolysis comparing high vs moderate activity was 3.6 (95% confidence interval 1.6 to 8.3). Stratification for the cementing technique revealed that lower quality cementing increased the effect of high activity on osteolysis. Revision for aseptic loosening was most frequent with high activity. Patients with the highest activity had the best outcome and highest satisfaction. In conclusion, of patients engaged in high activity, 24% had developed femoral osteolysis five to ten years post-operatively.

Purpose: The UniCAP ® implant for femoral resurfacing treatment of large cartilage lesions and early OA was introduced in 2006. The outcome of the present study is from a prospective cohort study of 64 patients, followed 2 years clinically and 7 years for revisions. Methods: From 2009 to 2013, 64 patients were treated with femoral resurfacing using the UniCAP implant. Indication for treatment with UniCAP implant was symptomatic huge cartilage lesion or early OA at the femoral condyle demonstrated by MRI or arthroscopy, which was ICRS grades 3–4 and more than 4 cm 2. There were 28 males and 36 females with a median age of 51 (range 35–65) years. Patients were followed for 2 years clinically with Knee Society subjective outcome scores (KSS), pain scores and radiographic evaluations and for 7 years with complications and reoperations. Results: At 2 years, the follow-up mean KSS improved from 49 (6.9) to 88 (17.1), the mean KSS function score improved from 46 (8.0) to 90 (17.1), and the mean Pain score improved from 7.4 (0.5) to 2.3 (1.4). 47 % of the implants were revised within 7 years to arthroplasty due to the progression of cartilage lesions, progressing of osteoarthritis or increased knee pain. The reoperation rate did not show any significant difference between females and males. The Kaplan–Meier survival rate was 50 % at 7 years, no difference among females and males. Conclusion: The present study demonstrated an improved subjective outcome and reduced pain after femoral resurfacing using the UniCAP ® implant in a relatively large cohort of patients with symptomatic large cartilage lesions or early OA. A 47 % reoperation rate with conversion to arthroplasty was found. The femoral resurfacing implantation can be a temporary treatment for large cartilage lesions or early OA that is expected to develop into osteoarthritis. For younger patients who are ineligible for arthroplasty treatment, this implant can offer a temporary solution. Level of evidence: IV.

Medial patellofemoral ligament (MPFL) reconstruction has recently been broadly accepted as primary surgical treatment in adults. Reconstruction techniques with osseous fixation in femur cannot be used for patients with open growth plates. Operative treatment of patella instability in children therefore is a challenge and requires alternative MPFL reconstruction techniques. Limited knowledge exists concerning outcome after MPFL reconstruction in children and adolescents. This study present clinical outcome in a consecutive single clinic series of children treated with paediatric MPFL reconstruction using a soft tissue femoral fixation technique. Twenty-four MPFL reconstructions in 20 operated children aged 8–16 were included in the study. Indication for surgery was two or more patella dislocations. MPFL reconstruction was performed by looping the released gracilis tendon around the adductor magnus tendon insertion and through drill holes in the proximal medial patella edge. Clinical outcome was evaluated by Kujala score and NRS pain score preoperatively, at 1-year follow-up and final follow-up at 39 months. Outcome was compared with a cohort of 179 adult patients with recurrent patella instability operated with an adult MPFL reconstruction technique. Kujala score improved from 61 (13) to 81 (16). NRS pain score improved from 3.0 (3.1) to 1.5 (1.3) in activity. Four patients (20 %) experienced redislocation within the first postoperative year compared with 5 % in an adult patient population. Five patients (25 %) experienced subluxations. One patient with a redislocation was re-operated with adult MPFL reconstruction technique. Cartilage injury was seen in six patients. There are clinical relevant improvements in knee function and pain after MPFL reconstruction in paediatric patients. Patella stability after MPFL reconstruction using femoral soft tissue graft fixation in paediatric patients was inferior to MPFL reconstruction using bony femoral fixation in adult patients. Case–Control study, Level III.

Aim: The present paper describes the rationale behind the surgical technique and the clinical results of the iso-anatomical, single bundle bone patellar-tendon bone anterior cruciate ligament (ACL) reconstruction. Method: Using a second incision on the distal lateral femur an outside-in femoral tunnel is drilled. Guided by a special aiming device it is possible to place the femoral tunnel in the centre of the ACL footprint in every single case. Conclusion: Since every crucial step of the procedure is under visual control, the technique is safe and reliable, which is mirrored by good clinical results

Aim: The aim of this prospective study was to evaluate the outcome of open reduction and Tönnis acetabuloplasty as the first method of treating developmental dysplasia of the hip (DDH) in children in early childhood at walking age. Materials and methods: Between 2005 and 2009, 34 hips of 34 children were operated on with the aforementioned method. Mean age was 25.6 (range 12-44) months, and mean follow-up was 3.6 years. During the follow-up period,the hips were evaluated using the acetabular index and for development of avascular necrosis and redislocation. Functional evaluation was also conducted. Results: Clinically, 97.3 % of patients had excellent and good results. The acetabular angle decreased from 45 preoperatively to 21 early postoperatively and at the last follow-up had improved to 18. In two hips, type 2 avascular necrosis developed. Hip instability was not observed, and no additional surgery was performed. Conclusion: Tönnis acetabuloplasty is a powerful tool to increase primary stability of the hip when acetabular coverage is inadequate in DDH. Besides its acute correction ability, when performed properly, it has no unwanted effects on acetabular growth. As an isolated procedure or as a part of combined open reduction and/or femoral osteotomy, Tönnis type acetabuloplasty is a safe and effective method. © 2012 The Japanese Orthopaedic Association.

The study hypothesis was that the outcome of semitendinosus gracilis double bundle (STG-DB) anterior cruciate ligament (ACL) reconstruction is advantageous in terms of clinical results and restoration of anterior-posterior and rotational laxity in comparison to bone-patellar tendon-bone single-bundle (PTB-SB) ACL reconstruction. We analysed 41 PTB-SB and 51 STG-DB patients using the Tegner, IKDC and WOMAC scores preoperatively and at a minimum follow-up of two years. At follow-up, there was no significant difference in the clinical scores. The KT 1000 side-to-side measurement showed no significant difference between groups. The STG-DB group was significantly superior in terms of the pivot-shift sign and anterior knee pain. We conclude that the outcome of STG-DB reconstruction in the mid-term was not advantageous in terms of clinical scores and anterior-posterior laxity evaluated by the KT 1000. Nevertheless, the restored rotational laxity measured by the pivot shift test was significantly superior in the STG-DB technique.

Rotational deformities are common lower extremity abnormalities in children with cerebral palsy, which include intoeing and outtoeing. Intoeing is caused by one of the three types of deformity: increased femoral anteversion, internal tibial torsion, and metatarsus varus, while out-toeing, the less common form, is caused by femoral retroversion and external tibial torsion. An accurate diagnosis should be made with careful physical and radiographic examination., Rotasyonel deformiteler beyin felçli çocuklarda yaygın olarak görülen, içe dönük ve dışa dönük yürümeyi içeren alt ekstremite anormallikleridir. İçe dönük yürüme üç tür deformitenin birinden kaynaklanır: artmış femoral anteversiyon, internal tibial torsiyon ve metatarsus varus; daha nadir görülen dışa dönük yürüme ise femoral retroversiyon ve eksternal tibial torsiyondan kaynaklanır. Dikkatli fizik ve radyografik inceleme ile doğru tanı konmalıdır.

Posterior tibial subluxations because of combined or isolated posterior cruciate ligament (PCL) injuries require detailed evaluation. PCL reconstructions are difficult procedures because of the low rate of such injuries and the complex anatomy of the ligament. We report on 2 cases of failed PCL reconstruction because of malpositioned femoral tunnels. These 2 cases support the existing biomechanical evidence that the correct placement of the tunnels, especially in the femur, is a major factor in defining the outcome. It seems that the drilling of the tunnels, especially in the femur, during PCL reconstruction must be performed with accuracy and always be evaluated in cases of graft failure. In addition, failed PCL reconstructions are usually accompanied by a short-term excessive arthritis that results in poor functional outcome. Arthroscopy

This is a description of the anaesthetic management of a patient with a flow patent foramen ovale undergoing intramedullary nailing of the femur. In order to detect the flow patent foramen ovale, we used transoesophageal echocardiography. During the ventilation maneuver with positive airway pressure of 20 cmH2O, a right-to-left interatrial shunt was observed. After the administration of 500 ml hydroxy-starch solution (6%) intravenously, detection of the right-to-left shunt flow was no longer possible. This case report shows that the volume status in a patient with a patent foramen ovale could influence the right to left interatrial shunt during general anaesthesia. Anaesthesist