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This technical note describes an arthroscopic technique to enhance visualization during minimally invasive total knee arthroplasty. The arthroscope is used, with the aid of balloon catheter retractors, to allow intraoperative identification of potentially adverse findings, including retained bone and cement fragments. This technique has been used successfully to identify and treat knees with these findings. Although further study and refinement are needed, this technique shows promise in reducing postoperative complications and improving outcomes in total knee arthroplasty., (Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Two important issues affecting the outcome of total hip arthroplasty have been dislocation and wear, despite excellent clinical results. Larger femoral heads have had success in decreasing dislocation rates; however, there are concerns regarding the subsequent use of thinner polyethylene liners, and their effects on wear rates. Historically, high stresses on thin polyethylene bearings have caused concerns, including rim cracking and catastrophic implant failure with polyethylene thicknesses less than 5 millimeters. Recently, sequentially cross-linked and annealed polyethylene has been shown to reduce the wear rate significantly, compared to conventional ultra-high-molecular-weight polyethylene (UHMWPE) in vitro. The purpose of this study was to analyze the clinical and radiographic outcomes in a cohort of patients treated with sequentially cross-linked and annealed polyethylene bearings with a nominal thickness of 3.8 millimeters. Outcomes were compared to a similar cohort of patients who were treated with total hip arthroplasty during the same time period and utilizing the same polyethylene thickness of 5.8 millimeters or greater., Materials and Methods: We identified 50 patients (53 hips) who had a minimum 2-year clinical and radiographic follow-up after a standard total hip arthroplasty, performed with a thin, sequentially cross-linked and annealed polyethylene bearing surface. There were 15 males and 35 females, with a a mean age of 60 years (range, 16 to 93 years) and a mean body mass index of 28.6 kg/m² (range, 17.2 to 47.5 kg/m²). Overall survivorship was compared to a cohort of 50 patients (53 hips) treated with total hip arthroplasty during the same time period, utilizing the same polyethylene of 5.8 millimeters or greater thickness. Radiographic analysis of polyethylene wear was performed on a subset of 26 hips, using a previously validated two-dimensional computer-aided technique. Volumetric wear was calculated and subsequent annual volumetric and linear wear rates were derived for each patient in the study cohort. Additionally, radiographic analysis was performed to assess for any progressive radio-lucencies or malalignment., Results: The overall survivorship of the study cohort was 100%, compared to a 96% survivorship in the comparison group (two failures due to infection). The mean Harris hip scores in the thin polyethylene cohort improved from 43 points (range, 10 to 67 points) pre-operatively to 91 points (range, 69 to 100 points) postoperatively. Upon radiographic review, no malalignment, radiolucencies, or polyethylene fracture was noted in the study cohort. The mean volumetric wear rate was 0.4122 mm³/year (range, 0.2311 to 0.7310 mm³/year), and the mean linear wear rate was 0.0004 mm/year (range, 0.0002 to 0.0007 mm/year) for the thin polyethylene group. The mean volumetric wear was 0.8839 mm³ (range, 0.4621 to 1.5839 mm³) for this cohort. Excellent clinical and radiographic outcomes were found for patients treated with thin, sequentially cross-linked and annealed polyethylene bearings utilized in total hip arthroplasty, with a nominal thickness of 3.8 millimeters. We have not seen any failures with thin polyethylene liners that have undergone this manufacturing process, which is in contradistinction to results of previously reported thin polyethylene liners. Wear rates were lower than other bearing surfaces at similar periods.

Minimally invasive total hip arthroplasty (MIS THA) has recently increased in popularity. Concurrently, newly developed short femoral components are being used. These short components may make insertion during MIS approaches easier and preserve more bone than traditional femoral stems, while providing a more anatomic stress distribution in the proximal femur. Our purpose was to review the literature concerning MIS THA, to determine if using short stems over standard femoral components is beneficial and if surgical approach affects the ability to use any type of stem. Successful clinical survivorship and functional outcomes have been reported with both short and standard length femoral implant types for all MIS approaches. Therefore, the type of implant should be chosen based on other factors, such as diagnosis, bone type and condition, patient age, and surgeon preference.

The goal of this study was to evaluate the treatment of femoral notch stenosis caused by soft tissue hypertrophy. Nineteen patients (19 knees) were evaluated arthroscopically for late-onset clinical findings of progressive loss of extension, pain, and/or crepitus after posterior-stabilized total knee arthroplasty. The patients had similar pathology that included marked hypertrophic soft tissue in the posterior-stabilized box impinging against the polyethylene post. Patients underwent arthroscopic débridement, with a mean increase in Knee Society pain scores of 39 points (range, 6-76 points), a mean increase of Knee Society function scores of 37 points (range, 10-72 points), and a mean increase in range of motion of 12° (range, -15° to 61°). One patient had a recurrence of symptoms at final follow-up, which was treated with reoperation. In patients with normal radiographs and clinically stable knees, the findings of progressive loss of extension with pain and crepitus may merit further evaluation. If notch stenosis is identified, arthroscopic débridement usually leads to a satisfactory result, at least at short-term follow-up., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Despite reports of complications, there has been tremendous interest in using minimally invasive surgery (MIS) for total knee arthroplasty (TKA). Over the past 10 years, we have used an MIS approach for all TKAs. In the study described here, we examined the complications of the first 1000 of these TKAs. These cases involved a minimal incision (mean, 10 cm), a quadriceps muscle-sparing approach, and a non-patellar-everting technique. The complications assessed included manipulations, reoperations, and component revisions. We also analyzed for deviations in radiographic alignment or radiographic failures. There were 45 clinical complications-25 manipulations under anesthesia, 12 arthroscopic procedures for painful patellofemoral crepitus (mostly for an initially nonvisualized retained lateral band), and 8 operative explorations for various component problems. Radiographically, there were 3 impending component failures-2 tibial and 1 femoral. Excluding manipulations, there was a significant decrease in operative complication rate from the first 200 cases (6.0%) to the next 800 cases (1.0%), with overall complication rates similar to those of a control cohort treated with traditional surgical techniques. From this analysis, the major concern was potential tibial component loosening, which may be related to decreased exposure and possibly poor cement pressurization. Despite the low complication rate, this study yielded insights into further potential improvements in using this MIS technique for TKAs.

Recently, studies have begun to assess the use of custom-fit arthroplasty sytsems that use magnetic resonance imaging to determine component placement. The purpose of this study was to assess how commonly this new technique is being used by surgeons and whether they perceive any benefits to their patients and/or to their practices. Fifty orthopaedic surgeons responded to a 19-question survey regarding custom-fit positioning total knee arthroplasty as part of a regional orthopaedic meeting. Overall, 10 of the 50 surgeons surveyed reported using custom-fit positioning technology. Of the remaining questionnaire participants, 29 of 40 indicated that they were interested in trying the new technique. The two reasons that were most frequently cited by the surgeons who were not interested in adopting the technique were costs and not enough clinical outcomes reports. The results of the present study suggest that if additional clinical studies at longer-term follow-up support these findings, then more surgeons may adopt this technique. Although cost was a perceived barrier to using this technique, the results of this survey suggest that some surgeons who use this technique may have reduced procedure time.

The primary purpose of this study was to compare clinical and functional results of bilateral total knee arthroplasties in which a conventional total knee replacement was initially performed on one knee and a minimally invasive total knee replacement was later performed on the contralateral side. Operative factors, clinical and radiographic outcomes, and quadriceps muscle strength were evaluated in twenty-five patients (50 total knee arthroplasties). Twenty-one of the 25 patients preferred the minimally invasive approach. Knee society objective scores and range-of-motion were significantly greater in the minimally invasive group. Isokinetic testing demonstrated statistically improved quadriceps muscle strength in the minimally invasive technique group compared to the standard approach at both 12 weeks and one year postoperatively. Radiographic analysis did not reveal differences in alignment variables between the two approaches. The results of this study suggest that minimally invasive total knee arthroplasty offers superior short-term as well as possible long-term results.

Hypothesis: Loss of range of motion after injury or surgery of the elbow is a common complication. We hypothesized that an orthosis that used progressive stretch and stress relaxation principles would improve elbow range of motion., Methods: This study evaluated the result of a patient-directed, bidirectional orthosis that uses static progressive stretch and stress relaxation principles to improve elbow range of motion in patients who had posttraumatic elbow contractures. Treatment in 37 elbows consisted of a 30-minute stretching protocol performed in 1 to 3 sessions daily for a mean of 10 weeks (range, 2-22 weeks)., Results: The mean gain in range of motion was 26 degrees (range, 2 degrees -60 degrees ). Gains of motion were noted in 35 of 37 elbows. Patients lowered their analgesic use and were highly satisfied with the device (mean satisfaction score of 8.5 of 10 points possible)., Discussion: This device compared favorably with reports of other devices. Consistent improvements in restoring range of motion can be achieved with short treatment times by using a device based on the principles of static progressive stretch and stress relaxation in patients with posttraumatic elbow contractures., (Copyright 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Spontaneous osteonecrosis of the knee was originally described as a distinct disorder in 1968. Characteristic imaging findings and distinctive demographic and clinical factors help distinguish this disease from other osteonecrotic conditions, with which it can be confused. This report presents a rare, atypical case of bicondylar spontaneous osteonecrosis of the knee in a young patient, and highlights the importance of a clear understanding of the clinical and radiographic characteristics of this condition to accurately diagnose and treat it when evaluating osteonecrotic lesions of the knee., (Copyright 2009 Elsevier B.V. All rights reserved.)

Unicompartmental knee arthroplasty as a surgical treatment for monocompartmental knee arthritis remains a controversial procedure with questions surrounding the benefits and survivorship of the procedure versus osteotomies or total knee arthroplasties. The authors, by examining the complete body of literature for scientific evidence concerning the procedure, will describe the history of usage of these prostheses, their rationale for usage, modern devices and their results, and why they may have advantages as a treatment modality for monocompartmental knee arthritis. Outcomes of current unicompartmental designs will be presented and evaluated to determine which aspects of the design and patient selection technique are associated with success or failure. Commonly asked questions regarding the use of these devices will be addressed. The authors will also describe some potential modifications that might affect the use of these components in the future, including minimally invasive procedures and robotics, and how these devices may change over the next 5 years.

Background: The mini-subvastus and the mini-midvastus approaches are among the most common alternatives to the medial parapatellar approach for total knee arthroplasty. The purpose of this study was to compare the early clinical outcomes of these two approaches., Methods: In this prospective, randomized study of fifty-one patients who underwent bilateral total knee arthroplasty, the mini-subvastus approach was used in one knee and the mini-midvastus approach, in the contralateral knee. There were forty-two women and nine men who had a mean age of seventy years at the time of the index arthroplasties, and they were followed for two years postoperatively. Clinical outcome was assessed and compared with use of the Knee Society pain and function scores, the straight-leg-raising test, range of motion, and isokinetic strength testing. Operating time and blood loss for each approach were also compared. In addition, patients were surveyed concerning which knee they preferred., Results: Comparisons of postoperative Knee Society scores between both approaches at the time of the two-year follow-up did not yield a significant difference in outcome. Isokinetic strength testing at twelve weeks postoperatively revealed no significant differences in muscle strength, with a mean extensor peak torque-to-body weight ratio of 0.14 Nm/kg for both groups. No significant difference was found with respect to total blood loss, straight-leg-raising test, range of motion, or patient preference. There was no clinically relevant difference in operative times between the two approaches., Conclusions: The minimally invasive subvastus and midvastus approaches for total knee arthroplasty were both associated with excellent short-term clinical results. Some surgeons believe that the subvastus approach completely avoids damage to the quadriceps mechanism and therefore would be associated with improved muscle function. This prospective series did not identify a substantive difference between the two approaches. We believe that the decision between these surgical approaches should be based on surgeon preference and experience.

This technical note describes the use of an arthroscope or endoscope to enhance visualization during minimally invasive total hip arthroplasty. The arthroscope/endoscope is used to verify seating of the components and to look for potential impingements, loose bodies, or fractures. This technique was successfully used to identify and address 2 bony or soft tissue impingements as well as a calcar fracture that might otherwise have been missed. Although further study is necessary, we believe that this technique might reduce postoperative complications and improve clinical outcomes of total hip arthroplasty., (2010 Elsevier Inc. All rights reserved.)

Arthrofibrosis is a relatively common complication after total knee arthroplasty that negatively affects function and quality of life. Static progressive stretching is a technique that has shown promising results in the treatment of contractures of the elbow, ankle, wrist and knee. This study evaluated a static progressive stretching device as a treatment method for patients who had refractory knee stiffness after total knee arthroplasty. Twenty-five patients who had knee stiffness and no improvement with conventional physical therapy modalities were treated with the device. After a median of 7 weeks (range, 3-16 weeks), the median increase in range of motion was 25 degrees (range, 8-82 degrees). The median gain in knee active flexion was 19 degrees (range, 5-80 degrees). Ninety-two percent of patients were satisfied with the results. The authors believe static progressive stretching devices may be an effective method for increasing the ranges of motion and satisfaction levels of patients who develop arthrofibrosis after total knee arthroplasty.

Total knee arthroplasty is often considered one of the most successful surgical operations, with implant survival rates as high as 95% reported over follow-up periods of 15 to 20 years. Despite these excellent reported results, some level of outcome dissatisfaction is reported in a considerable numbers of patients. Minimally invasive surgical techniques have been developed in an attempt to reduce or eliminate the surgical factors perceived to contribute to this dissatisfaction. An overview of minimally invasive total knee arthroplasty, with specific focus on level I (prospective, randomized) studies when available is presented along with an examination of how the published literature supports some of the more commonly stated benefits and drawbacks of minimally invasive techniques. Minimally invasive total knee arthroplasty generally encompasses the following goals: reduced skin incision size, minimal or no incision of the extensor muscles and quadriceps tendon, minimal or no eversion of the patella, the use of downsized instrumentation, making bone cuts in situ, and minimal dislocation of the knee joint. Five principal surgical approaches have been developed that incorporate these aims, and, to date, four level I studies have been reported that compare the results of one or more of these techniques to traditional total knee arthroplasty. Three of these four studies showed no knee score differences at 3 months; one study showed higher scores at up to 9 months follow-up. In the opinion of the authors, these surgeons may have still been on their learning curve. Further studies that examine patients treated by surgeons who have mastered minimally invasive techniques may provide further insight into the true benefits and drawbacks of these techniques.

The anterior medial parapatellar approach has long been the standard approach for total knee arthroplasty. Although this approach uses a simple, reproducible technique, some patients have reported lasting functional limitations after the surgery. Recently, marked interest has arisen in developing minimally invasive surgical approaches, implants, and instruments with the aim of improving patient outcomes. Five principal surgical approaches-the mini medial parapatellar, the quadriceps muscle-sparing, the mini-midvastus, the mini-subvastus, and the direct lateral-are most commonly used with minimally invasive techniques. Understanding the benefits and drawbacks of each approach as well as the reported results will aid orthopaedic surgeons in selecting the best treatment option for their patients.

Background: To date, reports of surgical treatment of spontaneous osteonecrosis of the knee (SPONK) refractory to non-operative treatment have primarily focused on knee arthroplasty. This report presents an overview of the characteristics of SPONK and reports our experience with joint-preserving surgical treatment of this condition., Methods: Fifteen patients who had joint-preserving surgery after failed non-operative modalities were studied. These patients were treated at a single center between January 1998 and September 2006 with a combination of arthroscopy and core decompression, or osteochondral autograft transfers., Results: Thirteen of the 15 knees (87%) had knee joint survival with a mean Knee Society Score of 81 points (range 45–100 points) at a mean follow-up of 40 months (range 9–120 months). Five of seven knees treated with core decompression had a successful clinical outcome. One of the patients who failed core decompression later underwent osteochondral autograft transfer, and eight of nine knees treated with this modality had a successful outcome., Conclusion: Overall, these results demonstrate that joint-preserving surgical treatment can successfully postpone the need for knee arthroplasty in selected patients with pre-collapse SPONK.

Refined prosthetic designs and surgical techniques for unicompartmental knee arthroplasty have recently been associated with improved outcomes. The purpose of the present study was to evaluate the clinical and radiographic outcomes of the EIUS unicompartmental design, which has an all-polyethylene tibial component, and to compare these outcomes with published reports of other unicompartmental prostheses. Between February 2002 and March 2005, 113 patients (144 knees) underwent a medial unicompartmental knee arthroplasty, all performed by a single surgeon who used the EIUS prosthesis. At a mean follow-up of 36 months (range, 24-54 months), the mean Knee Society objective and functional scores improved from 55 points (range, 31-77 points) and 49 points (range, 35-60 points) to 92 points (range, 45-100 points) and 89 points (range, 10-100 points), respectively. The implant survival rate was 89%, with 16 knees either revised or scheduled for revision. The reasons for revision included aseptic loosening of the tibial component (eight knees), progressive symptomatic patellofemoral disease (four knees), and tibial component subsidence (four knees). Multiple regression analysis revealed that age, gender, and body mass index were not significantly correlated with success or failure of this design, although nine of the 16 patients who required revision were obese. This prosthesis was associated with higher revision rates than components which utilize metal-backed implants. Further modifications in the design, indications, or technique may be necessary to improve outcomes of this unicompartmental knee arthroplasty system.

Recently, patellofemoral arthroplasty has attracted increased interest as a salvage treatment for isolated patellofemoral arthritis. However, there are very few reports of the experience with modern generation patellofemoral arthroplasties. This investigation describes a collective experience of four centres reporting on the outcome in patients of the use of one patellofemoral arthroplasty device. There were 70 patients (79 knees) who had failed an extensive non-operative treatment regimen and/or various conventional alternative surgical treatments. At a mean follow-up of three years (range: 2-6 years), there were 66 knees that had Knee Society Scores greater than 80 points (84%). Seventy-one knees (90%) functioned without pain in daily activity and stair climbing. Symptomatic isolated patellofemoral arthritis was successfully treated with a patellofemoral arthroplasty in the short term. We are encouraged by these excellent early results and await longer follow-up.

Background: Controversies exist regarding the indications for unicompartmental knee arthroplasty. The objective of this study is to report the mid-term results and examine predictors of failure in a metal-backed unicompartmental knee arthroplasty design., Methods: At a mean follow-up of 60 months, 80 medial unicompartmental knee arthroplasties (68 patients) were evaluated. Implant survivorship was analyzed using Kaplan-Meier method. The Knee Society objective and functional scores and radiographic characteristics were compared before surgery and at final follow-up. A Cox proportional hazard model was used to examine the association of patient's age, gender, obesity (body mass index > 30 kg/m2), diagnosis, Knee Society scores and patella arthrosis with failure., Results: There were 9 failures during the follow up. The mean Knee Society objective and functional scores were respectively 49 and 48 points preoperatively and 95 and 92 points postoperatively. The survival rate was 92% at 5 years and 84% at 10 years. The mean age was younger in the failure group than the non-failure group (p < 0.01). However, none of the factors assessed was independently associated with failure based on the results from the Cox proportional hazard model., Conclusion: Gender, pre-operative diagnosis, preoperative objective and functional scores and patellar osteophytes were not independent predictors of failure of unicompartmental knee implants, although high body mass index trended toward significance. The findings suggest that the standard criteria for UKA may be expanded without compromising the outcomes, although caution may be warranted in patients with very high body mass index pending additional data to confirm our results., Level of Evidence: IV.

Resurfacing is a type of shoulder arthroplasty that involves replacing the humeral joint surface with a metal covering, or cap, thus preserving the bone of the proximal part of the humerus. If the glenoid is also replaced, a current conventional polyethylene glenoid replacement prosthesis or an interposed soft-tissue graft is used. The potential advantages of humeral resurfacing, as compared with conventional shoulder arthroplasty, are: (1) no osteotomy is performed (and thus the head-shaft angle does not have to be addressed); (2) minimal bone resection; (3) a short operative time; (4) a low prevalence of humeral periprosthetic fractures; and (5) ease of revision to a conventional total shoulder replacement, if needed. Outcomes of surface replacement arthroplasty have been comparable with those of arthroplasties with a stemmed prosthesis in numerous short and mid-term follow-up studies. Future studies are required to assess the long-term outcomes of humeral resurfacing and to evaluate alternative surface bearing materials, especially on the glenoid side. Resurfacing appears to be a viable option for shoulder replacement, especially in young patients.

Osteonecrosis of the knee is a debilitating disease that is poorly understood. Originally described as a single disorder, it encompasses three distinct conditions: spontaneous osteonecrosis of the knee (SPONK), secondary osteonecrosis of the knee, and post-arthroscopic osteonecrosis of the knee. This article reviews the current knowledge of these distinct conditions by describing their etiology, pathology, and pathogenesis, as well as their clinical and radiographic presentations. The various treatment options available for each condition are reviewed, with a discussion of their rationale and indications, and a summary of results with various techniques. A thorough understanding of these conditions and their distinguishing features is critical to selecting the best treatment option for an individual patient.

A number of patients have anatomic or physiologic variations that may adversely affect the performance of a primary total hip arthroplasty. Various technologies have been utilized in an attempt to improve the outcomes for these patients; however, some of these potential solutions are controversial. The authors examined the complete body of literature for scientific evidence regarding the use of these new technologies. The anatomic and physiologic anomalies that were studied include extra-articular deformities, developmental dysplasia, Perthes disease, Type C femoral bone, acetabular bone deficiency, femoral rotational abnormalities, variations that increase the risk of hip dislocation, sickle cell anemia, and extremely small or large bone sizes. This article presents the current scientific evidence and imparts an unbiased view of the use of various technologies to provide individualized solutions for patients who have anatomic or physiologic variations.

Primary total knee arthroplasties have high success rates, but certain patient anatomic or other variations may adversely affect the performance or the clinical outcomes of these procedures. Various technologies and techniques have been developed in attempts to overcome these challenges. However, there is controversy concerning whether these innovations are beneficial. This article assessed the scientific evidence regarding the use of these technologies to address various anatomic variations by examining the complete body of literature. The anatomic variations that were examined included extra-articular deformities, bone deficiencies, ligamentous instability, post-patellectomy knees, patella baja, variations in bone size and high-flexion knees. Recommendations for each circumstance were presented based upon the available scientific evidence.

This study examined the use of a bidirectional, patient-directed orthosis that used the principles of static progressive stress to improve forearm rotation. Thirty-eight patients who had limited pronation and supination motions after injuries and who failed other physical therapy techniques underwent a 30- to 60-minute stretching protocol with the orthosis one to three times per day. The mean arc of rotation increased by 42 degrees (range, 0-122) after a mean treatment duration of 12 weeks (range, 3-57). The mean patient satisfaction score was 8.1 points on a scale of 0-10 points. All of the patients completed the treatment and no short-term complications were reported. The gains in motion were comparable to the published results of other orthoses as well as surgical procedures such as external fixators and closed manipulation, but fewer complications occurred with the static progressive stress technique. This orthosis is a useful treatment for patients who have limitations of forearm rotation.

Improved TKA designs and surgical techniques have allowed surgeons to not only treat the pain associated with osteoarthritis but also to restore function. The present study analyzed whether the increase in physical activity of patients following surgery is associated with their level of functional and objective improvement. An activity questionnaire was utilized to collect pre- and post-operative information from 355 patients (417 knees). Corresponding functional and objective assessments were collected using the Knee Society rating system. Overall, a mean 48 point (range, -44 to 97 points) improvement in Knee Society function score showed moderate correlation to a 2.5 point (range, -40 to 57 points) increase in weighted activity score (R = 0.362). There was less of a correlation between the mean objective score increase of 49 points (-32 to 84 points) and change in activity level (R = 0.194). There were 29% of the patients who showed no change in activity level. These results suggest that change in activity level is more closely associated with improved function than changes in objective measures. With more than 52% of TKA patients reporting increased activity scores, further studies are needed to assess longer-term effects of activity levels on the durability of these prostheses.

Purpose: Decreased wrist flexion and/or extension after trauma or surgery can be a challenging problem. Physical therapy, orthoses, and additional surgical interventions may not restore the desired range of motion or functionality. The purpose of this study was to assess the total arc of motion and the satisfaction scores of patients who had wrist stiffness and who were treated with a bidirectional, patient-directed orthosis that used the principles of static progressive stretch., Methods: Forty-seven patients who experienced posttraumatic or postsurgical wrist stiffness were treated with a patient-directed orthosis. Treatment consisted of a 30- to 60-minute stretching protocol performed 1 to 3 times per day. Compliance with the device, treatment duration, mean total arc of motion, patient satisfaction, and complications were evaluated., Results: The total arc of motion increased by a mean of 35 degrees (range, 5 degrees to 100 degrees ) after a mean of 10 weeks of treatment (range, 5 to 26 weeks). The mean flexion and extension increased by 18 degrees (range, 1 degrees to 50 degrees ) and 17 degrees (range, 3 degrees to 50 degrees ), respectively. Assessment of age, gender, and time before commencement of treatment showed that these factors did not significantly affect the magnitude of improvement or the final arc of motion. The mean patient satisfaction score was 8.2 points on a scale of 0 to 10 points. All patients completed the treatment, and there were no complications reported with use of the device., Conclusions: All of the patients who used this protocol improved their total arc of motion. A splinting device that uses the principles of static progressive stretch is a useful treatment for patients who have posttraumatic or postsurgical wrist stiffness and whose progress has plateaued after a course of conventional physical therapy., Type of Study/level of Evidence: Therapeutic IV.

Contemporary unicompartmental knee arthroplasty has shown resurgence in use partly because of studies reporting excellent long-term survivorship. Both fixed-bearing as well as mobile-bearing designs have shown comparable results. Fixed-bearing designs, in particular, implants with metal-backed tibial components have shown more consistent long-term survival, whereas fixed bearings with an all-polyethylene tibial component have had mixed results. Similar to the all-polyethylene tibial component designs, mobile-bearing designs have demonstrated mixed results. One concern with mobile bearings is the high rate of complete tibial radiolucent lines. The keys to long-term survival of both fixed and mobile-bearing designs in unicompartmental knee arthroplasty are patient selection, surgical technique, and surgical experience.

Persistent knee stiffness is common after knee arthroplasties, cruciate ligament repairs, and trauma. Static progressive stretch protocols have shown success in treating contractures of the elbow, ankle, and knee in case reports and small case series. This study evaluated static progressive stretch as a treatment method for patients who had refractory knee stiffness, and compared the outcomes to published results of other therapeutic modalities. Forty-one patients who had knee stiffness and who had not improved with conventional physical therapy modalities were treated with a patient-directed orthosis that utilized the principles of static progressive stretch. After a mean of 9 weeks of use (range, 3 to 27 weeks), the total arc of motion increased by a mean of 33 degrees (range, 0 to 85 degrees ). Forty of 41 patients had increased motion at a mean final follow-up time of 1 year (range, 6 months to 2 years), and 93% were satisfied with the results. The outcomes were comparable to other nonoperative treatments reported in the literature, but the results in the present study occurred in a shorter mean treatment time. An orthosis that utilizes the principles of static progressive stretch may be a successful treatment for improving the range of motion and satisfaction of patients who have knee contractures.

Many procedures have been used to treat advanced isolated patellofemoral arthritis, with varying results. Patellofemoral arthroplasty (PFA) is a bone-conserving procedure that has shown short-term success but has relatively high revision rates. Total knee arthroplasty (TKA) has been recommended for treatment of this disease in patients who are older than 60 years of age. Recent literature indicates that PFA is most successful in patients who have isolated patellofemoral arthritis secondary to trochlear dysplasia or patellar fracture and in patients who are younger than 60 years; TKA is recommended for older patients who have primary or idiopathic isolated patellofemoral arthritis.

This review provides an overview of the use of bone morphogenetic proteins to enhance bone healing and bone graft incorporation in difficult defects created from failed total hip arthroplasties, osteonecrosis of the femoral head and trauma. Multiple publications have demonstrated that bone morphogenetic proteins are osteoinductive in preclinical trials (i.e., animal models); however, there is controversy and limited understanding of the use of this technology in orthopedic surgical practice. The question remains as to whether they are useful in difficult fractures, nonunions and large defects created from failed total hip arthroplasty or femoral head osteonecrosis. There might be a small risk for infection by the process of introducing foreign materials in a clinical situation, but this has not yet been realized to date. In addition, these materials offer an advantage in large defects where there is not enough transplantable material available from the host. We believe that the use of these materials will become more widespread with newer carriers, minimally invasive applications and diminished commercial costs.

Minimally invasive surgeries, as well as computer-assisted surgery for total hip replacement have gained popularity over recent years. This article provides an overview of state-of-the-art minimally invasive surgery (MIS) and computer-assisted surgery for total hip arthroplasty. A comprehensive review of the literature for scientific evidence supporting the use of these technologies was undertaken. This review evaluates whether commonly asked questions concerning these topics have been addressed. Controversy remains as to whether there are significant benefits of MIS or computer-assisted surgery for total hip arthroplasty. Fortunately, most studies report similar outcomes for both technologies. Minimally invasive techniques have been developed that do not significantly increase operative time or immediate postoperative complications. Computer-assisted navigation has shown improved radiographic alignment for total hip arthroplasty and may allow MIS to be performed more optimally. The authors believe that both of these technologies are likely to have a place in the future for hip arthroplasty with expectations of increased successful outcomes with these techniques while lowering complications and costs. Long-term outcomes of both techniques will need to be investigated.

Minimally invasive knee surgery can be accomplished through several exposures used in standard total knee arthroplasty. These exposures include the medial parapatellar, subvastus, and midvastus approaches. The authors describe a new minimally invasive direct lateral approach in an attempt to minimize soft tissue damage and preserve quadriceps muscle function in 35 patients (35 knees). There were 23 women and 12 men with a mean age of 65 years. At a mean follow-up of 3.8 years, the mean Knee Society objective and functional scores improved to 94 and 92 points, respectively. The assessment of quadriceps muscle strength, anterior knee pain, and patient satisfaction was promising. However, the downside of this pilot cohort was that using instruments and implants that have not been customized for this approach led to a considerable rate of early complications that may limit the potential of this new approach. Thus, further refinements are needed to increase clinical success and allow this technique for general use.

This review provides an overview of the field of minimally invasive surgery and computer-assisted surgery for total knee arthroplasty. The authors have examined the complete body of literature for scientific evidence supporting the use of these new technologies and how the literature specifically supports commonly asked questions. There is controversy concerning the benefits of minimally invasive surgery and computer-assisted surgery for total knee arthroplasty. However, in most studies the results are similar for minimally invasive surgery compared to standard approaches. Computer-assisted navigation has been found in some studies to improve radiographic alignment of total knee arthroplasty. The authors believe that there is evidence for both technologies to be at least equivalent in terms of results, as well as expectations of increased success with the techniques. Both technologies have led manufacturers to invest more effort into newer prosthetic instrumentations and designs to facilitate these techniques.

There has been recent attention concerning minimally invasive techniques for knee arthroplasty. It is not clear whether these complicated techniques can be reproduced across multiple centers and for all surgeons. This prospective, randomized, multicenter study was carried out to assess safety and efficacy of a minimally invasive total knee arthroplasty. The study consisted of 80 knees. There were no differences in blood loss, operative time for completion of surgery, infection, and ultimate wound healing. There were 4 knees with delayed wound healing in the minimally invasive surgical technique group versus 1 in the standard group, which did not affect outcome. Early clinical and radiographic results were also indistinguishable. At 12 weeks follow-up, there was no difference in mean Knee Society objective and functional scores. In summary, in this study, minimal incision total knee arthroplasty demonstrated no improvement over a standard approach.

Unlabelled: Exposure in revision total knee arthroplasty can be difficult. For example, eversion of the patella may require a number of procedures including vastus snips, V-Y turndowns, and tibial tubercle osteotomies. A minimally invasive approach further adds to exposure difficulties. We report a new approach for exposure during difficult revision total knee arthroplasties. A soft tissue envelope technique allows retraction of the patella and avoids eversion. This technique reduces the size of the incision, reduces quadriceps muscle damage, and enhances exposure. It is essential that appropriate instrumentation is used along with down sized femoral and tibial cutting blocks. We report all 17 revision knee arthroplasties using this technique including unicompartmental revisions, tibial component revisions, and femoral component revisions. Followup averaged 29 months (range, 24-39 months). We had one case of posterior retained cement after a full revision with no subsequent complications. One patient required an arthroscopic lateral release for patellar maltracking. Preliminary results are encouraging using improved instrumentation we find essential for enhanced exposure. We believe this a reasonable approach for selected total knee arthroplasty revisions., Level of Evidence: Therapeutic study, level IV (retrospective case series). See the Guidelines for Authors for a complete description of levels of evidence.

Allograft anchors that can be inserted directly through the greater tuberosity were developed, tested, and used clinically for rotator cuff repair. Mechanical strength testing was performed, and allograft anchors were used in 63 consecutive procedures by a single surgeon. The insertion technique involved directly impacting the allograft anchor through the greater tuberosity without drilling a hole in the bone. Results of mechanical testing showed strengths comparable with those of other anchors (155.8 N), and the anchors locked consistently. This direct insertion technique saves time and procedural steps over traditional anchor insertion techniques while using an allograft anchor that reincorporates into host bone.

There should not be a revolution to MIS-TKA but rather an evolutionary approach. This includes progressively downsizing incisions and causing less damage to the quadriceps mechanism. Previously,there was an extensive open exposure prolonged patella eversion and dislocation of the tibio-femoral joint. This should be evolved into a VMO muscle split with patella subluxation, retraction but not dislocation, and no gross dislocation of the tibio-femoral joint. Although the present MIS-TKA technique can be difficult and time-consuming, the resulting patient benefits should outweigh the extra effort required. In the future, we may use bone cuts and implantation with computer navigation. Each advance, however, will require new techniques, instrumentation, implants, and careful clinical studies. Caution should be taken by surgeons to avoid revolutionary approaches with existing implants, because they harbor a risk of catastrophic failure.

The decision of what procedure to perform for the treatment of monocompartmental osteoarthritis of the knee when nonsurgical treatment methods fail remains controversial. Recent advances using osteotomy, unicompartmental knee replacement, and total knee replacement have been reported. For example, there are new concepts for performing high tibial osteotomies rather than the traditional Coventry method. Many techniques now involve osteotomies below the tibial tubercle. Unicompartmental knee replacement can be done using a standard approach, but less invasive approaches exist, along with minimally invasive approaches for total knee replacement, rather than the standard large incision, that promote decreased soft-tissue destruction.

This article describes an approach to minimize the soft-tissue trauma associated with total knee arthroplasty. A suspended leg technique provides full access to the knee by using flexion and the weight of the limb to stretch the incision. Violation of the extensor mechanism is minimized and soft-tissue balancing is enhanced with the suspended technique.

Bone button anchors constructed from allograft bone were investigated as an alternative for rotator cuff repair. Bone button anchors were used in 59 consecutive procedures after mechanical pullout strength and cyclical loading bench testing. Sequential radiographs demonstrated that the anchors locked in cancellous bone and provided consistent fixation with no loosening or lysis in 1 year of clinical follow-up. Mechanical testing demonstrated mean, pullout strength of 160.2 N (36 lbs), and the anchors did not migrate when cyclically loaded. Clinical results showed an allograft anchor is viable for rotator cuff tendon repair.

Full-thickness tears of the rotator cuff are uncommon in the first 4 decades of life. A retrospective analysis was conducted of 19 consecutive patients who were 40 years of age or younger and had been treated surgically for a full-thickness tear of the rotator cuff. Sixteen patients (84%) recalled an acute injury that heralded the onset of symptoms. Five of the patients had sustained an initial glenohumeral dislocation. At an average follow-up of 5.7 years, all patients were evaluated with regard to pain, function, range of motion, strength, return-to-work status, return-to-sport status, and overall postoperative satisfaction. After operation, 15 patients (79%) reported diminished pain relative to their preoperative level, and 12 (63%) of 19 were able to function with the extremity above shoulder level. Fourteen patients (74%) returned to full-time employment, and half returned to sporting activities. Thirteen patients (68%) reported subjective improvement with regard to daily functional activities after surgical intervention. The most favorable results were seen in those patients who had sustained an acute glenohumeral dislocation in conjunction with a full-thickness rotator cuff tear and underwent combined stabilization and repair. The outcome for patients who received worker's compensation was less favorable.

Nine patients with symptomatic glenoid loosening were identified and ultimately underwent surgical revision. Preoperative assessment demonstrated that pain, decreased range of motion, and functional disability were common features. A painful clunking sensation with forward elevation of the arm was noted in four of the nine patients. At surgical revision, a grossly loose glenoid component was found in all cases and removed. Seven of the nine patients underwent revision using another cemented glenoid component, and two patients were left with a hemiarthroplasty due to glenoid bone deficiency. Results following revision surgery demonstrated increased range of motion, decreased pain, and increased functional ability with good overall patient satisfaction in seven of nine patients. Two patients in whom revision glenoid components were implanted were considered failures due to recurrent loosening. Although revision of the glenoid component is often technically feasible, recurrent loosening may occur. Revision to a hemiarthroplasty may be an acceptable alternative to glenoid replacement.

Total knee arthroplasty surgical exposure compromises blood flow to the patella. This reduction in blood flow may result in numerous patellar related complications. This study examined the intraosseous blood supply in normal patellas and those simulating total knee arthroplasty exposure. Fifteen anatomic specimen patellas were used. Ten undisturbed patellas were injected intravascularly with a colored perfusate via at least one geniculate artery, and five were subjected to a median parapatellar approach and a lateral release before injecting. Every patella was removed, embedded in epoxy, and sequentially milled. An orthogonal grid was used to position evident interosseous vessels, and each grid was normalized, allowing comparison among patellas. Perfused intrapatellar arteries formed an anastomotic network of penetrating and radiating arteries. Eighty percent of the interosseous blood supply was found in the central 50% of the undisturbed patellas. The surgically exposed patellas incurred a 75% decrease in total perfusion. There was no significant inflow from the periphery of the patella because the entire blood supply appeared to come from the anterior cortical perforating vessels. Damage to the central 50% of interosseous bone or anterior soft tissue cuff because of a central fixation post or anterior cruciate ligament graft increases the risk for segmental devascularization.

Autogenous cancellous bone fragments can be compressed rapidly during surgery to create reproducible load-bearing grafts. Of the 32 grafts tested, 10 were constructed of composite cortical-cancellous bovine bone and 22 of cancellous human bone. Compressed composite bovine grafts and compressed human cancellous grafts supported average axial compressive loads of 2148 N and 960 N, respectively. Compared to iliac crest grafts, compression grafts may have better load-bearing capabilities and greater reproducibility. Potential applications include trauma, delayed unions, arthrodesis, and spinal fusions.

Cine magnetic resonance imaging (MRI) was used to define the normal space between the humeral head and coracoid process, known as the subcoracoid space, to quantify the subcoracoid space in symptomatic patients and identify the anatomic structures responsible for narrowing of this space. The study population was comprised of 50 normal volunteers and 75 patients with shoulder pain. All subjects underwent cine MRI of the shoulder using a shoulder-rotating device that allows progressive rotation of the glenohumeral joint in 10 degrees increments from internal to external rotation while scanning the shoulder in the axial plane. In asymptomatic patients, the normal interval between the lesser tuberosity and coracoid process (coracohumeral distance) averaged 11 mm in maximum internal rotation. In symptomatic patients, impingement or entrapment of the subscapularis tendon and other soft-tissue structures between the lesser tuberosity and the coracoid process in internal rotation was identified, and the mean distance between the lesser tuberosity and coracoid process measured 5.5 mm in maximum internal rotation. This new MRI technique for shoulder imaging is safe, easy to perform, noninvasive, and well-tolerated by patients. Cine MRI provides valuable information on the subcoracoid region not obtainable with other methods.

Static progressive stretch (SPS) is a technique using the biomechanical principle of stress relaxation to restore range of motion (ROM) in joint contractures. Existing techniques such as dynamic splinting and traction rely on a time-dependent material property, creep, which applies a continuous load. Other techniques, such as serial casting and static splinting, are time intensive and usually require assistance by a therapist. This study evaluates SPS via a new orthosis that directly applies SPS incrementally through patient-controlled therapy, allowing for stress relaxation of contracted tissue. Patients used the device in 30-minute treatment protocols. The length of treatment time varied between one and three months. Twenty patients with elbow contractures who had limited success with other treatment modalities including serial casting, dynamic splinting, physical therapy, and/or surgery, underwent SPS using the new orthosis. The increase in motion for the 20 patients in the study averaged 31 degrees (69%). All patients expressed satisfaction, with no complications and no deterioration in ROM at the one-year follow-up evaluation.

Objective: Clinical evaluation of shoulder pain can be difficult. Pain in the shoulder is often dynamic/positional, and it can often be elicited only during specific activity or function. Soft tissue deforms or changes in shape through motion. These complex interrelationships at the glenoid humeral joint require dynamic studies to accurately evaluate normal anatomy and abnormal pathology. The objective of our study was to evaluate the use of a dynamic cyclic cine imaging to evaluate the glenoid humeral joint., Materials and Methods: Kinematic MRI was performed using axial 5 mm sections of the gradient echo and dedicated shoulder surface coil. The patient's arm was placed in the Bonutti cine shoulder system and allowed fixed incremental rotational movement of the shoulder at 10 degrees intervals. Images were reformatted onto a dynamic cine motion by oscillating from internal to external rotation then back to internal rotation. A total of 24 asymptomatic shoulders and 35 symptomatic painful shoulders were studied., Results: Normal variations in the glenoid labrum were readily identified. The glenoid labrum in external rotation is taunt and triangular with well-identified capsular attachments. In neutral rotation the labrum often has increased signal and the middle glenoid humeral ligament occasionally blends with the labrum, making identification difficult. In maximum internal rotation the labrum is rounded and occasionally infolded. Variations in signal through the labrum are not indicative of tears. Capsular attachment must be followed from maximum internal to external rotation to identify stripping. The middle and inferior glenoid humeral ligaments often blend with labrum and internal rotation; however, in external rotation they can be identified as distinct and separate structures. Subcoracoid impingement can be identified in maximum internal rotation with a narrowing of the subcoracoid space to < 11 mm and buckling of the subscapularis and lesser tuberosity against the coracoid process., Conclusion: Accurate evaluation of the capsular/labral complex requires cine studies for accurate diagnosis. Signal changes alone or labral morphology alone varies through rotation, and static MRI does not accurately assess these morphologic changes, which vary with extremity position. Capsular attachments can be identified with cine studies accurately and reproducibly. Subcoracoid impingement can be identified with a narrowing of the coracohumeral distance to < 11 mm in internal rotation, which is suggestive of pathology.