Search

IntroductionTibia valga, an extra-articular valgus deformity of the tibia, is common in valgus knees and can result in component misplacement and early total knee arthroplasty (TKA) failure. However, the prevalence and importance of tibia valga in TKA has been seldom reported. This study aims to describe the prevalence and characteristics of tibia valga morphology in valgus knees and describes implications for surgical planning in primary TKA.MethodsWe prospectively examined pre-operative weightbearing whole-body EOS digital radiographs of patients with knee osteoarthritis listed for TKA between December 2018 and December 2020. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), joint line convergence angle (JLCA) and tibial morphology with centre of rotation of angulation of tibia (CORA-tibia) were measured and analysed.ResultsIn 830 knees, 253 (30%) and 577 (70%) were classified as valgus and varus respectively. In valgus knees, 89 knees (35%) had tibia valga. Median CORA-tibia was 2.8o (range 0.2-10.9o). Tibia valga knees had no difference in mLDFA, higher HKA (5.0o versus 3.0o, p=0.002) and mMPTA (89.6o versus 88.1o, po versus 2.3o, po (range 0.5-5.5o). Tibia valga knees had higher mMPTA (87.0o versus 85.2o, pConclusionsTibia valga is common in valgus knees, occurring in 35% of this population. Extra-articular tibial rather than distal femoral anatomy contributes most to valgus HKA. To detect the deformity, full leg-length radiographs should be acquired pre-operatively. Intramedullary instrumentation should be used cautiously in knees with tibia valga when performing TKA.

Background: Direct anterior approach (DAA) to hip replacement is increasingly popular. Despite the well-published benefits of early recovery, the approach can be associated with a number of complications that may be underreported. We aim to report the incidence of some of these complications in a large retrospective case series. Methods: 270 consecutive DAA hip replacements are studied which are performed by a single high-volume hip surgeon from 2013 to 2015, not including the surgeon’s learning curve. Operation and consultation records were screened, and focused questioning via telephone was employed to capture specific complications including dislocations, wound infections, lateral femoral cutaneous nerve (LFCN) injury and revision surgery. Results: 240 of 270 patients or family were contactable. The mean age and body mass index of the cohort was 66 (range 30–89) years and 27 (range 18–40) kg/m2 respectively. The mean follow-up was 3.7 years. Wound issues were encountered in 24 patients (8.8%). There were 9 dislocations (3%). 27 (10%) patients needed revision surgery in the follow-up period. Reasons for revision included leg-length discrepancies, dislocations, ongoing pain and aseptic loosening. 9 (3.4%) patients had to return to operating theatre for reasons other than revision surgery. Symptoms of lateral femoral cutaneous nerve injury was reported by 54 patients (21%). Conclusions: While the short-term benefits of DAA have been widely reported, our review shows a relatively high rate of revision surgery. We feel that the enthusiasm for DAA should be tempered until further evidence is available.

Background Templating for total knee arthroplasty (TKA) is routinely performed on two-dimensional standard X-ray images and allows template-directed instrumentation. To date, there is no report on one-dimensional (1D) anteroposterior (AP) templating not requiring specific templating software. We aim to describe a novel technique and explore its reliability, accuracy and potential cost-savings. Methods We investigated a consecutive series of TKAs at one institution between January and July 2019. Patients with preoperative low-dose linear AP EOS radiography images were included. Implant component sizes were retrospectively templated on the AP view with the hospitals imaging viewing software by two observers who were blinded to the definitive implant size. Planning accuracy as well as inter- and intra-observer reliability was calculated. Cost-savings were estimated based on the reduction of trays indicated by the 1D templating size estimations. Results A total of 141 consecutive TKAs in 113 patients were included. Accuracy of 1D templating was as follows: exact match in 53% femoral and 63% tibial components, within one size in 96% femoral and 98% tibial components. Overall 58% of TKA components were planned correctly and 97% within one size. Inter- and intra-rater reliability was good (κ = 0.66) and very good (κ = 0.82), respectively. This templating process can reduce instrumentation from six to three trays per case and therefore halve sterilisation costs. Conclusions The new 1D templating method using EOS AP imaging predicts component sizes in TKA within one size 97% of the time and can halve the number of instrumentation trays and sterilisation costs.

While opioids have well-established benefits in managing postoperative pain, the adverse effects of persistent opioid use are a subject of increasing concern. The prevalence of persistent opioid use in opioid naive patients undergoing Orthopaedic surgery has been reported as 13.7%. In this study, we aimed to quantify the prevalence of opioid use in our arthroplasty patients. Methods: This single centre observational cohort study evaluated the duration of postoperative opioid use in consecutive patients undergoing unilateral primary knee or hip arthroplasty. A survey designed by a panel of experienced clinicians, consisted of 10 multiple-choice questions and 1 free text response, was sent via email or post 3 months post-surgery. The data was collated on Excel and analysed. Results: Eighty-eight (88) patients responded to our survey. The overall prevalence of persistent opioid use at 3 months following total joint arthroplasty was 7%. Almost 80% of patients had ceased opioids by 6-weeks after surgery. Preoperative opioid users, patients having total knee arthroplasty, females and patient with low back pain were more likely to be members of the persistent opioid group. 87% of patients rated their understanding regarding opioids usage as adequate or excellent. Conclusion: The incidence of persistent opioid use in our population was low, especially in the opioid naive group. We believe the key to the low rate of persistent opioid use lies in patient education, tapering opioids before surgery and use of evidence-based care pain management pathways.

As a potential osteotomy tool, laser ablation is expected to provide rapid machining of bone, while generating minimal thermal damage (carbonization) and physical attributes within the machined region conducive to healing. As these characteristics vary with laser parameters and modes of laser operation, the clinical trials and in vivo studies render it difficult to explore these aspects for optimization of the laser machining parameters. In light of this, the current work explores various thermal and microstructural aspects of laser-ablated cortical bone in ex vivo study to understand the fundamentals of laser-bone interaction using computational modeling. The study employs the Yb-fiber Nd:YAG laser (λ = 1064 nm) in the continuous wave mode to machine the femur section of bovine bone by a three-dimensional machining approach. The examination involved thermal analysis using differential scanning calorimetry and thermogravimetry, phase analysis using X-ray diffractometry, qualitative analysis using X-ray photoelectron spectroscopy, and microstructural and semiquantitative analysis using scanning electron microscopy equipped with energy-dispersive spectrometry. The mechanism of efficient bone ablation using the Nd:YAG laser was evaluated using the computational thermokinetics outcome. The use of high laser fluence (10.61 J/mm2) was observed to be efficient to reduce the residual amorphous carbon in the heat-affected zone while achieving removal of the desired volume of the bone material at a rapid rate. Minimal thermal effects were predicted through computational simulation and were validated with the experimental outcome. In addition, this work reveals the in situ formation of a scaffold-like structure in the laser-machined region which can be conducive during healing.

The erector spinae plane block is an emerging analgesic technique, which is gaining popularity for a large number of procedures. The majority of publications are at the thoracic level and almost all indicate some benefit to patients. However, there have been relatively few randomized controlled trials and even fewer studies at the lumbar level. The aim of this study was to assess whether the erector spinae plane block at the lumbar level would confer early analgesic benefits and improve the quality of recovery in patients undergoing elective unilateral primary hip arthroplasty. Sixty-four patients were randomized to receive an erector spinae plane block at the third lumbar vertebra with either 30milliliters (ml) of 0.2% ropivacaine or 30 ml of 0.9% saline. The patient, anesthetist and assessor were blinded to allocation. The primary outcome was pain on movement at 6 h (numeric rating scale 0–10) with a reduction of 2 points considered clinically significant. Secondary outcomes included quality of recovery (QoR-15 score), mobilization and length of stay. In this study there was no appreciable analgesic benefit to adding an erector spinae plane block to patients who already receive neuraxial blocks, local anesthetic infiltration and oral multimodal analgesia for elective primary total hip arthroplasty. Both groups were found to have relatively low pain scores and a high quality of recovery with no significant difference in mobilization or length of stay.

Objective: To investigate the DRS of ovine joint tissue to determine the optimal optical wavelengths for tissue differentiation and relate these wavelengths to the biomolecular composition of tissues. In this study, we combine machine learning with DRS for tissue classification and then look further at the weighting matrix of the classifier to further understand the key differentiating features. Methods: Supervised machine learning was used to analyse DRS data. After normalising the data, dimension reduction was achieved through multiclass Fisher’s linear discriminant analysis (Multiclass FLDA) and classified with linear discriminant analysis (LDA). The classifier was first run with all the tissue types and the wavelength range 190 nm – 1081 nm. We analysed the weighting matrix of the classifier and then ran the classifier again, the first time using the ten highest weighted wavelengths and the second using only the single highest. Our method was applied to a dataset containing ovine joint tissue including cartilage, cortical and subchondral bone, fat, ligament, meniscus, and muscle. Results: It achieved a classification accuracy of 100% using the wavelength 190 nm – 1081 nm (2048 attributes) with an accuracy of 90% being present for 10 attributes with the exception of those with comparable compositions such as ligament and meniscus. An accuracy greater than 70% was achieved using a single wavelength, with the same exceptions. Conclusion: Multiclass FLDA combined with LDA is a viable technique for tissue identification from DRS data. The majority of differentiating features existed within the wavelength ranges 370-470 and 800-1010 nm. Focusing on key spectral regions means that a spectrometer with a narrower range can potentially be used, with less computational power needed for subsequent analysis.

ObjectivesClinicians who use the biopsychosocial approach to manage musculoskeletal pain disorders aim to understand how patients make sense of their symptoms. Treatment includes targeting the negative beliefs and coping responses that can lead to progressive pain and disability. We aimed to explore how people seeking care for persistent hip pain and disability make sense of their symptoms.MethodsCross-sectional qualitative study. People were eligible if they were aged ≥18 years, were consulting an orthopaedic surgeon for persistent hip pain and offered a non-surgical intervention. Data were collected through interviews that explored patients’ beliefs about the identity (diagnosis), causes, consequences, timeline and controllability of their symptoms, their strategies to cope with pain and their experiences in seeking healthcare. Transcribed interview data were analysed thematically using a framework approach.ResultsSixteen people (median age=51, range=33–73 years; median duration hip pain=3 years, range=3 months–20 years) participated. Most participants (10/16) believed their pain was caused by an exercise-related injury. Because of the results of imaging and interactions with healthcare professionals, all participants believed they had damaged hip structures. All described ineffective strategies to manage their pain and multiple failed treatments. For many (7/16), a lack of control over symptoms threatened their physical and mental health.ConclusionsThe way participants with persistent hip pain and disability made sense of their symptoms contributed to them avoiding physical activity, and it impaired their sleep, emotional well-being and physical health.

Objectives: The risk of hip dislocation after revision total hip arthroplasty can be as high as 27% following surgery for periprosthetic fractures. A novel technique described by the senior authors in 2015, involving a transtrochanteric osteotomy and minimal superior capsulotomy, minimises this risk.Design: Prospective cohort study Setting: Sir Charles Gairdner Hospital, Hollywood Private HospitalPatients: Forty-two patients with Vancouver B type periprosthetic hip fractures, fixed using our superior capsulotomy technique. Intervention: The approach involves extending the fracture proximally to the tip of the greater trochanter, splitting the gluteal tendons and superior capsule in the same plane, in a titrated manner such that the head dislocates from the socket with a ‘pop’. The femoral component is revised and the cup and liner retained.Main Outcome Measurements: The primary outcome of interest was dislocation rate.Results: Patients averaged 80 years of age. Mean follow up was 31 months (range 12 months to 5 years). The primary finding was zero cases of hip joint dislocation. The average Oxford hip score was 31/48, the physical component and mental component Short Form 12 mean scores were 31.7 and 53.6 respectively at 1 year following revision. Functional scores did not significantly thereafter at 2 and 5 years. Mean subsidence at 1-year post operatively was 8.73mm. Two stems were revised.Conclusion: The outcomes of this operative technique in revision arthroplasty of Vancouver B periprosthetic hip fractures is promising, with no cases of hip dislocation, along with satisfactory patient clinical outcomes.Level of Evidence: Prospective Cohort Study, Level II.

Knee range of motion (ROM) following a knee arthroplasty is an important clinical outcome that directly relates to the patient's physical function. Smartphone technology has led to the creation of applications that can measure ROM. The aim was to determine the concurrent reliability and validity of the photo-based application 'Dr Goniometer' (DrG) compared with a universal goniometer performed by a clinician. A smartphone camera was used to take photographs of the knee in full flexion and full extension, and the images were sent by participants to a study phone. Participants then rated the ease of participation. To assess validity, the patient's knee was measured by a clinician using a goniometer. To examine reliability, four clinicians assessed each image using DrG on four separate occasions spaced 1 week apart. A total of 60 images of knee ROM for 30 unicondylar or total knee arthroplasty were assessed. The goniometer and DrG showed strong correlations for flexion (r=0.94) and extension (r=0.90). DrG showed good intrarater reliability and excellent inter-rater reliability for flexion (intraclass correlation coefficient=0.990 and 0.990) and good reliability for extension (intraclass correlation coefficient=0.897 and 0.899). All participants found the process easy. DrG was proven to be a valid and reliable tool in measuring knee ROM following arthroplasty. Smartphone technology, in conjunction with patient-reported outcomes, offers an accurate and practical way to remotely monitor patients. Benefit may be found in differentiating those who need face-to-face clinical consult to those who do not.

The extensive research on the laser machining of the bone has been, so far, restricted to drilling and cutting that is one- and two-dimensional machining, respectively. In addition, the surface morphology of the laser machined region has rarely been explored in detail. In view of this, the current work employed three-dimensional laser machining of human bone and reports the distinct surface morphology produced within a laser machined region of human bone. Three-dimensional laser machining was carried out using multiple partially overlapped pulses and laser tracks with a separation of 0.3 mm between the centers of consecutive laser tracks to remove a bulk volume of the bone. In this study, a diode-pumped pulse Er:YAG laser (λ = 2940 nm) was employed with continuously sprayed chilled water at the irradiation site. The resulting surface morphology evolved within the laser-machined region of the bone was evaluated using scanning electron microscopy, energy dispersive spectroscopy, and X-ray micro-computed tomography. The distinct surface morphology involved cellular/channeled scaffold structure characterized by interconnected pores surrounded by solid ridges, produced within a laser machined region of human structural bone. Underlying physical phenomena responsible for evolution of such morphology have been proposed and explained with the help of a thermokinetic model.

Background The prevalence of obesity is rising, and increasing numbers of joint arthroplasty surgeries are being performed on obese patients. Concern exists that obesity increases surgical risk; however, its impact on function following total hip arthroplasty (THA) is inconsistently affirmed and less understood. A paucity exists in the literature pertaining long-term objective functional measures. Therefore, we investigated the impact of obesity on hip pain, function, and satisfaction 10 years following THA. Methods This single-center, prospective, observational study categorized consecutive THA patients according to their body mass index to nonobese ( Results The series included 191 primary THA patients. No significant differences were found in hip pain or function between the obese and nonobese groups. Obese patients however had poorer walking capacity (P = .008), were more likely to use walking aids (P = .04), and were less satisfied (P = .04) at 10 years. Conclusion THA confers significant long-term symptom resolution irrespective of obesity; however, despite undergoing surgery, obese patients can be counseled they may not be as satisfied as or achieve the same walking capacity as nonobese individuals.

This is the protocol for a review and there is no abstract. The objectives are as follows: To identify and summarise the evidence from randomised controlled trials assessing the clinical efficacy and safety of resurfacing the patella versus not resurfacing the patella in total knee arthroplasty. The following null hypotheses will be tested: 1.There is no difference in outcome between resurfacing the patella and not resurfacing the patella in patients with osteoarthritis of the knee. 2.There is no difference in outcome between resurfacing the patella and not resurfacing the patella in patients with inflammatory arthritis of the knee. 3.There is no difference in outcome between not resurfacing the patella and resurfacing the patella with different prosthetic designs. 4.There is no difference in outcome between resurfacing the patella and not resurfacing the patella in patients with grade varying grades of patellofemoral arthritis, and varus or valgus deformity of the knee

Background Approximately 18% of the patients are dissatisfied with the result of total knee replacement. However, the relation between dissatisfaction and prosthetic alignment has not been investigated before. Methods We retrospectively analysed prospectively gathered data of all patients who had a primary TKR, preoperative and one-year postoperative Oxford Knee Scores (OKS) and postoperative computed tomography (CT). The CT protocol measures hip–knee–ankle (HKA) angle, and coronal, sagittal and axial component alignment. Satisfaction was defined using a five-item Likert scale. We dichotomised dissatisfaction by combining ‘(very) dissatisfied’ and ‘neutral/not sure’. Associations with dissatisfaction and change in OKS were calculated using multivariable logistic and linear regression models. Results 230 TKRs were implanted in 105 men and 106 women. At one year, 12% were (very) dissatisfied and 10% neutral. Coronal alignment of the femoral component was 0.5 degrees more accurate in patients who were satisfied at one year. The other alignment measurements were not different between satisfied and dissatisfied patients. All radiographic measurements had a P -value > 0.10 on univariate analyses. At one year, dissatisfaction was associated with the three-months OKS. Change in OKS was associated with three-months OKS, preoperative physical SF-12, preoperative pain and cruciate retaining design. Discussion Neither mechanical axis, nor component alignment, is associated with dissatisfaction at one year following TKR. Patients get the best outcome when pain reduction and function improvement are optimal during the first three months and when the indication to embark on surgery is based on physical limitations rather than on a high pain score. Level of evidence 2

Background A substantial proportion of patients undergoing lower limb arthroplasty are of working age. This study aims to identify when patients return to work (RTW) and if they return to normal hours and duties, and to identify which factors influence postoperative RTW. The hypothesis is that there is no difference in time of RTW between the different types of surgery, and no difference in time of RTW based on the physical demands of the job. Materials and methods Consecutive patients aged < 65 years who had undergone unilateral primary total hip arthroplasty (THA), total knee arthroplasty (TKA), or medial unicompartmental knee arthroplasty (UKA) from 2015 to 2017 were sent a questionnaire. Quantitative questions explored timing and nature of RTW, and qualitative questions explored factors influencing timing of RTW. Results There were 116 patients (64 male, 52 female) with an average age of 56 years. Thirty-one patients were self-employed and 85 were employees. Of these patients, 58 had undergone THA, 31 had undergone TKA, and 27 had undergone UKA. One hundred and six (91%) patients returned to work. Patients returned to work after (mean) 6.4 weeks (THA), 7.7 weeks (TKA), and 5.9 weeks (UKA). Time of RTW was not significantly influenced by type of surgery (p = 0.18) (ns). There was a non-significant correlation between physical demands of the work versus time of RTW (p = 0.28) (ns). There was a significantly earlier time of RTW if flexible working conditions were resumed (p = 0.003). Active recovery, motivation, necessity and job flexibility enabled RTW. The physical effects of surgery, medical restrictions and work factors impeded RTW. Conclusion The time of RTW was not significantly influenced by the type of operation or by the physical demands of the job. Patients returned to work 5.9–7.7 weeks after hip/knee arthroplasty. Rehabilitation, desire, and necessity promoted RTW. Pain, fatigue and medical restrictions impeded RTW. Level of evidence 3.

Achieving adequate surgical exposure is a key to successful implant removal and re-implantation during revision knee arthroplasty. This, however, has to be done with careful attention to the vital bony and soft tissue structures about the knee so that risks are minimized and long-term function is optimized. An in-depth understanding of the normal anatomy of the knee as well as the patho-anatomy in the revision setting will facilitate pre-operative planning, preservation of vital structures intra-operatively and anticipation of problems intra- and post-operatively so measures can be taken to forestall these. Standard approaches to the knee often fail to provide the access required for revision surgery, and extensile approaches may need to be deployed. A variety of extensile approaches are available to the surgeon, each with its merits and drawbacks. We present a concise review of the standard and extensile approaches deployed in revision knee surgery, with an overview of the relevant anatomy and an evidence base for the different extensile approaches.

We describe a new revision technique for Vancouver B periprosthetic hip fractures that leaves the original acetabular components in situ and causes minimal damage to the hip capsule. Twenty-eight patients, average age 79, with Vancouver B periprosthetic fracture had femoral component revision using

This study describes the fundamentals of laser–bone interaction during bone machining through an integrated experimental-computational approach. Two groups of laser machining parameters identified the effects of process thermodynamics and kinetics on machining attributes at micro to macro. A continuous wave Yb-fiber Nd:YAG laser (wavelength 1070 nm) with fluences in the range of 3.18 J/mm2–8.48 J/mm2 in combination of laser power (300 W–700 W) and machining speed (110 mm/s–250 mm/s) were considered for machining trials. The machining attributes were evaluated through scanning electron microscopy observations and compared with finite element based multiphysics-multicomponent computational model predicted values. For both groups of laser machining parameters, experimentally evaluated and computationally predicted depths and widths increased with increased laser energy input and computationally predicted widths remained higher than experimentally measured widths whereas computationally predicted depths were slightly higher than experimentally measured depths and reversed this trend for the laser fluence >6 J/mm2. While in both groups, the machining rate increased with increased laser fluence, experimentally derived machining rate remained lower than the computationally predicted values for the laser fluences lower than ∼4.75 J/mm2 for one group and ∼5.8 J/mm2 for other group and reversed in this trend thereafter. The integrated experimental-computational approach identified the physical processes affecting machining attributes.

Using optical spectroscopy, we are developing a tissue identification technology for a robotic orthopedic surgery system. Biological tissues are heterogeneous structures that interact with light to absorb, reflect, scatter and re-emit. Reflected light can be measured by diffuse reflectance spectroscopy (DRS) and autofluorescence light can be measured by fluorescence excitation spectroscopy [1]. The majority of biological tissues exhibit unique spectral characteristics in the ultraviolet, visible and near infrared due to their biochemical and morphological state [2, 3]. Therefore, these sensing techniques have been found to be useful for tissue identification. To our knowledge there has been no published research that has explored these modalities to identify the different human joint tissue.

Preoperative anxiety positively correlates with postoperative levels of pain, analgesic use and length of hospital stay. This preliminary study aimed to determine if the principle of distraction, using a relaxing Virtual Reality (VR) immersion, would reduce preoperative anxiety in patients undergoing arthroscopic knee surgery. Sixty patients were randomised into three groups (Standard care group, Virtual Reality group and iPad group). Anxiety scores (Hospital Anxiety and Depression Scale), Galvanic Skin Response (GSR), heart rate and blood pressure were measured pre and post intervention. The Standard care group received no intervention. The iPad group watched a video slideshow of beaches around the world and the VR group experienced a virtual beach immersion. Guided relaxation audio content (via headphones) was replicated across VR and iPad groups. Planned comparisons showed a significant difference between the average GSR measures at Time 1 and Time 2 between the Standard group and VR group. GSR measures for the Standard care group increased by 54 per cent from time 1 to time 2 and the VR and iPad groups reduced slightly, demonstrating an ameliorating effect on anxiety levels. A marginal difference between the Standard care group and VR group in anxiety change scores was reported. Whilst the VR condition reduced anxiety more than Standard care in both GSR and Anxiety change score measures, it provided no significant advantage over iPad condition. In conclusion, distraction using VR and iPad temporarily reduces self-reported anxiety levels and GSR measures compared to standard care in patients prior to knee arthroscopy. Further study is required to determine how long-lasting these benefits are in a clinical setting. The continuing advancements in VR technology, including immersion quality, present an opportunity to investigate the application of VR as a ‘digital pre-med’.

Virtual Reality (VR) demonstrates unique educational benefits over other teaching mediums including enhanced engagement and learner motivation. Such benefits could be exploited to improve teaching of surgical hand preparation (SHP), a practice crucial in preventing post-surgical infection. This study hypothesises that the utilisation of VR technology to demonstrate SHP technique will produce superior skill acquisition and longer skill retention than the standard practice of video demonstration. 40 healthcare students unfamiliar with SHP were recruited from a tertiary university and randomised into two groups. The control group (n=21) viewed a video demonstration of SHP while the VR group (n=19) viewed a VR demonstration of the same technique. Participants were assessed immediately after demonstration (acquisition score), and again one week later (retention score), using a 20-point assessment scale. Scores were compared between the groups. Groups were equal in age, prior education, handedness and gender distribution. Neither skill acquisition (Control mean: 12.29, VR mean: 12.84; p = 0.57) nor retention (Control mean: 12.29, VR mean: 12.74; p = 0.52) differed significantly between groups however a non-significant trend toward better performance in the VR group was observed. Parallel scoring of 35% of participants showed very high inter-rater reliability (intra-class correlation coefficient = 0.92). Utilisation of VR technology did not demonstrate a perceivable acquisition or retention benefit in the teaching of SHP. Future studies could investigate the value of more immersive features including 360-degree point of view or haptic feedback which were not features of the technology used in the present study.

Introduction Hip abductor insufficiency is often associated with lateral hip pain, movement disorder and Trendelenburg gait. The aims of this study are to predict if preoperative radiological findings correlate with postoperative outcomes and if pre and postoperative radiological findings correlate with postoperative function. Methods Patients with clinical and MRI evidence of hip abductor tears that had failed to nonoperative treatment underwent surgical repair. Pre and postoperative MRI analysis was carried out by an experienced musculo-skeletal radiologist. Clinical analysis consisted of Harris Hip Score, a measure of patient satisfaction, pre and postoperative walking aids and Trendelenburg test. Results This study shows no real improvement in the MRI appearances of the tendons after surgery. Preoperative MRI absence of gluteus minimus was 100% predictive of a poor outcome, whilst thickening of the posterior gluteus medius was 83% predictive of a poor outcome. Postoperative MRI absence of posterior gluteus medius was 75% predictive of a poor outcome. Thickening of anterior gluteus medius and posterior gluteus medius were 71% and 83% predictive of a poor outcome respectively. Absence of posterior gluteus medius correlated with poor outcome in 75% of cases. Discussion The MRI appearance of the tendon does not normalise after surgery and there is limited correlation between the MRI appearances pre and postoperatively with the postoperative outcome.

This work aims to understand the fundamental aspects of the laser-bone interaction in three-dimensional laser machining of the bone through an integrated experimental-computational approach. The study introduces 3-dimensional laser machining of bones through multilaser passes and attempts to establish the dimensional control over the laser-machined cavity through a finite element method based multiphysics computational model. A continuous wave Yb-fiber Nd:YAG laser ( λ = 1064 nm) was employed with laser fluences ranging from 5.31 J / mm 2 to 25.46 J / mm 2 generated in combination of laser power (400 W–700 W) and machining speed (50 mm/s–250 mm/s). In multilaser pass machining, the optimum fill spacing of 0.2 mm was identified for higher machining rates with low deviation from linearity of machined edge ( d = 9 μ m). This resulted in high machining rates ranging from 16.49 ± 0.2 mm 3 / s to 45.26 ± 0.66 mm 3 / s for a given range of laser fluence. The optimization for machining efficiency and physical attributes of the machined cavity were comprehended through thermodynamics and kinetics of the laser interaction with the bone based on the computational model for varying laser processing parameters.

One hundred four hips in 107 patients undergoing revision arthroplasty of the hip were identified at risk of dislocation and treated with the constrained cup. Radiostereometric analysis was performed to assess prosthesis migration. Mean follow-up was 3.0 years (range, 2.0-4.8). At last review, 19 patients had died and 6 were lost to follow-up. There were 5 revisions for cup loosening and a further 4 with radiographic evidence of loosening. There were 3 dislocations and 3 dissociations in 5 patients. Radiostereometric analysis demonstrated that cup migration at 24 months was up to 0.82 mm of translation and 1.58 degrees of rotation. Our results confirm that the constrained acetabular component is a highly effective option for the treatment for patients with instability of the hip. The aseptic loosening rate was higher than previously reported.

We present our experience with the collagen-covered autologous chondrocyte implantation (CACI) technique. Thirty two implantations were performed in 31 patients. Clinical outcome was measured using the KOOS score and the 6-minute walk test, as well as an MRI scoring protocol (75% of patients had a complete data set for MRI follow-up) to describe the repair tissue generated by CACI. We have also correlated our MRI results with our clinical outcome. To the authors knowledge there are no comparative studies of MRI and clinical outcome following CACI in the current literature. Patients demonstrated an increased walk distance that improved significantly from 3 months to 24 months postoperatively (p

Approximately 18% of the patients are dissatisfied with the result of total knee replacement. However, the relation between dissatisfaction and prosthetic alignment has not been investigated before.We retrospectively analysed prospectively gathered data of all patients who had a primary TKR, preoperative and one-year postoperative Oxford Knee Scores (OKS) and postoperative computed tomography (CT). The CT protocol measures hip-knee-ankle (HKA) angle, and coronal, sagittal and axial component alignment. Satisfaction was defined using a five-item Likert scale. We dichotomised dissatisfaction by combining '(very) dissatisfied' and 'neutral/not sure'. Associations with dissatisfaction and change in OKS were calculated using multivariable logistic and linear regression models.230 TKRs were implanted in 105 men and 106 women. At one year, 12% were (very) dissatisfied and 10% neutral. Coronal alignment of the femoral component was 0.5 degrees more accurate in patients who were satisfied at one year. The other alignment measurements were not different between satisfied and dissatisfied patients. All radiographic measurements had a P-value0.10 on univariate analyses. At one year, dissatisfaction was associated with the three-months OKS. Change in OKS was associated with three-months OKS, preoperative physical SF-12, preoperative pain and cruciate retaining design.Neither mechanical axis, nor component alignment, is associated with dissatisfaction at one year following TKR. Patients get the best outcome when pain reduction and function improvement are optimal during the first three months and when the indication to embark on surgery is based on physical limitations rather than on a high pain score.2.

Background Obtaining adequate exposure while maintaining the integrity of the extensor mechanism is crucial to the success of revision knee arthroplasty. This is particularly important in infected cases where staged procedures are necessary. While the use of a long, tibial tubercle osteotomy (TTO) is an established method to improve exposure, controversy still exists concerning complication rates and sequential use. Methods Forty-two TTOs were performed in revision knee arthroplasties between 2009 and 2015. Follow-up period ranged from 3 to 24 months. Twenty-four TTOs were performed for single-stage revisions, and 18 TTOs were performed for 2-stage infected revisions. In infected cases, the initial osteotomy was left unfixed between stages. Screws were used to fix the osteotomy flap in all cases. Results All osteotomies united with no fractures, and there were no extensor lags. Minor proximal migration was noted in 1 case, and refixation was required in another. Greater range of motion (ROM) and improved Oxford Knee Scores were achieved in the single-stage revision group. In the infected 2-stage group, sequential use did not decrease union rates, and infection was eradicated in 14 of the 16 knees (88%). Conclusion We conclude that TTO is a safe and reproducible procedure when exposure needs improving in revision knee arthroplasty. In 2-stage revisions, sequential osteotomies do not decrease union rates, and leaving the osteotomy unfixed after the first stage does not cause any adverse issues.

We describe a new technique and aim to justify its use in total hip arthroplasty. The incision is short and there is minimal soft tissue dissection: piriformis and most of quadratus femoris remain intact. A meticulous capsular repair is performed. Patients are mobilized without restrictions. One hundred total hip arthroplasties by the standard posterior approach (group 1) were compared with 100 by the less invasive approach (group 2). Minimum follow-up was 2 years. Mean blood loss in group 1 was higher (P < .0001) and inpatient stay longer (P < .0001). There was greater improvement in WOMAC scores for up to 1 year in the less invasive group (P = .027). In conclusion, the less invasive approach is safe and the functional benefits last up to 1 year.

Acute compartment syndrome is the condition of raised pressure within an enclosed compartment, such that the perfusion and the function of the tissues within are compromised, resulting in ischemia and eventually necrosis. Although, in theory, it can occur in any compartment, it is most commonly seen in the lower limb. We describe a rare case of acute compartment syndrome in the paraspinal muscles that responded well to surgical decompression. Our patient was informed that data concerning this case would be submitted for publication. Athirty-five-year-old man on the third day of a skiing holiday presented to the emergency department because of severe, unrelenting pain in the right lumbosacral paraspinal area, radiating across the abdomen to the groin. The pain had been present for four hours and had begun spontaneously with no history of trauma. In retrospect, the patient had experienced similar but milder pains during previous ski trips and during long-distance running. There was associated numbness in the right lumbosacral area. Positive findings on physical examination were bilateral paraspinal muscle rigidity associated with swelling, marked tenderness, and loss of the lumbar lordosis. There was dense loss of sensation in the paraspinal area to the midaxillary line and altered sensation extending anteriorly to the midline. Reduced abdominal muscle tone on the right side, resulting in asymmetry, was also noted. Active movement of the spine was minimal and exacerbated the pain. The patient had mild tenderness of the abdomen with absent bowel sounds. The initial differential diagnosis included a renal stone, a herniated disc, discitis, and a retroperitoneal abnormality. A urine specimen was dark in appearance, and analysis revealed 3+ myoglobinuria. Blood chemistry studies showed elevation of aspartate aminotransferase (804 IU/L; …

There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace.To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures.We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries.All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures.Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale.Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes.Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28).Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved.Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76).Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients).Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

Background There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace. Objectives To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures. Search strategy We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries. Selection criteria All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures. Data collection and analysis Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale. Main results Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes. Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28). Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved. Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76). Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients). Reviewers' conclusions Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

arthroscopy (LSCA) for the postoperative histological assessment of cartilage repair. Methods and Materials: Defects (AE6mm) were created in the trochlea and medial femoral condyle of twenty-one sheep randomised into untreated controls, matrix-induced autologous chondrocyte implantation (MACI[O]), or unseeded MACI treatment, then further divided into 8, 10, and 12 week time points. Repair outcomes were examined using LSCA, routine histology, macroscopic ICRS evaluation, magnetic resonance imaging (MRI), and tissue stiffness testing. Interobserver variability and score system correlation was conducted to validate system reliability in assessing cartilage repair. Results: Assessment of MACI treatment by LSCA, MRI, histology, and macroscopic IRCS grading, illustrated improvement in repair compared to controls across all modalities. Additionally, MACI repair resembled native articular cartilage in early-stage remodeling histologically, but the stiffness of the MACI repair was inferior to the native tissue. Interobserver analysis of the blinded LSCA scoring validated our scoring protocol, with almost perfect agreement illustrated (ICC=0.9201). Furthermore, Pearson correlation analysis demonstrated that LSCA scoring correlated (P

SummaryObjectiveOsteoarthritis (OA) inflicts an enormous burden upon sufferers and healthcare systems worldwide. Continuing efforts to elucidate the aetiology of OA have indicated the need for non-destructive methods of in vivo microstructural assessment of articular cartilage (AC). In this study, we describe the first use of a recently developed laser scanning confocal arthroscope (LSCA) to image the cartilage of a fresh frozen cadaveric knee from a patient with OA.DesignUsing an adaptation of the International Cartilage Repair Society (ICRS) joint mapping protocol, the joint was divided into three discrete regions (femoral condyle, patella and tibial plateau) for grading according to the ICRS (Outerbridge) system. The LSCA was used to generate images from each area within the three regions. Following imaging, the joint was sectioned and histology was performed on the corresponding sites with histological grading (modified-Mankin).ResultsQuantitative results of ICRS, LSCA and histological OA assessment were compared using intraclass correlation (ICC) and Pearson correlation analysis. The LSCA enabled visualisation of chondrocyte morphology and cell density, with classical OA changes such as chondrocyte clustering, surface fibrillation and fissure formation evident. Obvious qualitative similarities between LSCA images and histology were observed, with fair to moderate agreement (P

BACKGROUND: Dislocation following hip replacement is associated with significant morbidity and functional cost. The cause is usually multifactorial. A variety of treatment options are available which can broadly be classified into operative and non‐operative. OBJECTIVES: To determine the best methods of treatment of recurrent dislocation following total hip replacement. SEARCH METHODS: The following databases were searched until August 2006: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), Health Technology Assessment database (HTA), Database of Abstracts of Reviews of Effectiveness (DARE), International Standard Randomised Controlled Trial Number Register (ISRCTN), and MetaRegister of Controlled Trials (mRCT). SELECTION CRITERIA: Randomised and quasi‐randomised trials comparing operative and non‐operative treatments for recurrent dislocation following total hip replacement. DATA COLLECTION AND ANALYSIS: Two independent reviewers applied the inclusion criteria to identified studies. MAIN RESULTS: Searches identified 269 studies. None fulfilled the inclusion criteria. AUTHORS' CONCLUSIONS: The authors invite researchers to perform RCTs comparing different treatment options for recurrent dislocation of the hip. The heterogeneity of the population and variety of underlying causes would favour a multi‐centre study to achieve an adequate sample size.