The purpose of this study is to assess the long term results of combined ACL reconstruction and unicompartmental knee replacements (UKR). These patients have been selected for this combined operation due to their combination of instability symptoms from an absent ACL and unicompartmental arthritis. Retrospective review of 44 combined UKR and ACL reconstruction by a single surgeon. Surgeries included both medial and lateral UKR combined with either revision ACL reconstruction or primary ACL reconstruction. Patient reported outcomes were obtained preoperatively, at one year, 5 years and 10 years. Revision rate was followed up over 13 years for a mean of 7.4 years post-surgery. The average Oxford score at one year was 43 with an average increase from pre-operation to 1 year post operation of 15. For the 7 patients with 10 year follow up average oxford score was 42 at 1 year, 43 at 5 years and 45 at 10 years. There were 5 reoperations. 2 for revision to total knee arthroplasty and 1 for an exchange of bearing due to wear. The other 2 were the addition of another UKR. For those requiring reoperation the average time was 8 years. Younger more active patients presenting with ACL deficiency causing instability and unicompartmental arthritis are a difficult group to manage. Combining UKR and ACL reconstruction has scant evidence in regard to long term follow up but is a viable option for this select group. This paper has one of the largest cohorts with a reasonable follow up averaging 7.4 years and a revision rate of 11 percent. Combined unilateral knee replacements and ACL reconstruction can be a successful operation for patients with ACL rupture causing instability and unicompartmental arthritis

Hip instability is one of the most common causes for total hip arthroplasty (THA) revision surgery. Studies have indicated that lumbar fusion (LF) surgery is a risk factor for hip dislocation. Instrumented spine fusion surgery decreases pelvic tilt, which might lead to an increase in hip motion to accommodate this postural change. To the best of our knowledge, spine-pelvis-hip kinematics during a dynamic activity in patients that previously had both a THA and LF have not been investigated. Furthermore, patients with a combined THA and LF tend to have greater disability. The purpose was to examine spine-pelvis-hip kinematics during a sit to stand task in patients that have had both THA and LF surgeries and compare it to a group of patients that had a THA with no history of spine surgery. The secondary purpose was to compare pain, physical function, and disability between these patients. This cross-sectional study recruited participants that had a combined THA and LF (n=10; 6 females, mean age 73 y) or had a THA only (n=11; 6 females, mean age 72 y). Spine, pelvis, and hip angles were measured using a TrakSTAR motion capture system sampled at 200 Hz. Sensors were mounted over the lateral thighs, base of the sacrum, and the spinous process of the third lumbar,12th thoracic, and ninth thoracic vertebrae. Participants completed 10 trials of a standardized sit-to-stand-to-sit task. Hip, pelvis, lower lumbar, upper lumbar, and lower thoracic sagittal joint angle range of motion (ROM) were calculated over the entire task. In addition, pain, physical function, and disability were measured with clinical outcomes: Hip Disability Osteoarthritis Outcome Score (pain and physical function), Oswestry Low Back Disability Questionnaire (disability), and Harris Hip Score (pain, physical function, motion). Physical function performance was measured using 6-Minute Walk Test, Stair Climb Test, and 30s Chair Test. Angle ROMs during the sit-to-stand-to-sit task and clinical outcomes were compared between THA+LF and THA groups using independent t-tests and effect sizes (d). The difference in hip ROM was approaching statistical significance (p=0.07). Specifically, the THA+LF group had less hip ROM during the sit-to-stand-to-sit task than the THA only group (mean difference=11.17, 95% confidence interval=-1.13 to 23.47), which represented a large effect size (d=0.83). There were no differences in ROM for pelvis (p=0.54, d=0.28) or spinal (p=0.14 to 0.97; d=0.02 to 0.65) angles between groups. The THA+LF group had worse clinical outcomes for all measures of pain, physical function, and disability (p=0.01 to 0.06), representing large effect sizes (d=0.89 to 2.70). Hip ROM was not greater in the THA+LF group, and thus this is unlikely a risk factor for hip dislocation during this specific sit-to-stand-to-sit task. Other functional tasks that demand greater excursions in the joints should be investigated. Furthermore, the lack of differences in spinal and pelvis ROM were likely due to the task and the THA+LF group had spinal fusions at different levels. Combined THA+LF results in worse clinical outcomes and additional rehabilitation is required for these patients

Combined Partial Knee Arthroplasty (CPKA) is a promising alternative to Total Knee Arthroplasty (TKA) for the treatment of multi-compartment arthrosis. Through the simultaneous or staged implantation of multiple Partial Knee Arthroplasties (PKAs), CPKA aims to restore near-normal function of the knee, through retention of the anterior cruciate ligament and native disease-free compartment. Whilst PKA is well established, CPKA is comparatively novel and associated biomechanics are less well understood. Clinically, PKA and CPKA have been shown to better restore knee function compared to TKA, particularly during fast walking. The biomechanical explanation for this superiority remains unclear but may be due to better preservation of the extensor mechanism. This study sought to assess and compare extensor function after PKA, CPKA, and TKA. An instrumented knee extension rig facilitated the measurement extension moment of twenty-four cadaveric knees, which were measured in the native state and then following a sequence of arthroplasty procedures. Eight knees underwent medial Unicompartmental Knee Arthroplasty (UKA-M), followed by patellofemoral arthroplasty (PFA) thereby converting to medial Bicompartmental Knee Arthroplasty (BCA-M). In the final round of testing the PKA implants were removed a posterior-cruciate retaining TKA was implanted. The second eight received lateral equivalents (UKA-L then BCA-L) then TKA. The final eight underwent simultaneous Bi-Unicondylar Arthroplasty (Bi-UKA) before TKA. Extensor efficiencies over extension ranges typical of daily tasks were also calculated and differences between arthroplasties were assessed using repeated measures analysis of variance. For both the medial and lateral groups, UKA demonstrated the same extensor function as the native knee. BCA resulted in a small reduction in extensor moment between 70–90° flexion but, in the context of daily activity, extensor efficiency was largely unaffected and no significant reductions were found. TKA, however, resulted in significantly reduced extensor moments, leading to efficiency deficits ranging from 8% to 43% in flexion ranges associated with downhill walking and the stance phase of gait, respectively. Comparing the arthroplasties: TKA was significantly less efficient than both UKA-M and BCA-M over ranges representing stair ascent and gait; TKA showed a significant 23% reduction compared to BCA-L in the same range. There were no differences in efficiency between the UKAs and BCAs over any flexion range and TKA efficiency was consistently lower than all other arthroplasties. Bi-UKA generated the same extensor moment as native knee at flexion angles typical of fast gait (0–30°). Again, TKA displayed significantly reduced extensor moments towards full extension but returned to the normal range in deep flexion. Overall, TKA was significantly less efficient following TKA than Bi-UKA. Recipients of PKA and CPKA have superior functional outcomes compared to TKA, particularly in relation to fast walking. This in vitro study found that both UKA and CPKA better preserve extensor function compared to TKA, especially when evaluated in the context of daily functional tasks. TKA reduced knee extensor efficiency by over 40% at flexion angles associated with gait, arguably the most important activity to maintain patient satisfaction. These findings go some way to explaining functional deficiencies of TKA compared to CPKA observed clinically

The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. One hundred and fifteen patients were identified. 63% were male; mean age was thirty-seven years; mean ISS was thirty. Three patients died from their injuries. At a mean follow-up of 3.5 years, patients exhibited profound functional deficits compared to the normal population. Those with an acetabular fracture involving the posterior wall or an associated lower extremity injury have a particularly poor prognosis. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. To evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. These results will allow us to further investigate which injury is dictating prognosis in the combined injury – the pelvic or the acetabular fracture. One-hundred and fifteen patients with combined pelvic and acetabular injuries were identified at a level One trauma centre. 63% were male; mean age was thirty-seven years (13–88); mean ISS was thirty (16–75). Three patients died from their injuries. 16% involved bilateral pelvic fractures; 7% bilateral acetabular fractures; and for 2%, both were bilateral. 64% were Tile B and 34% were Tile C. Most acetabular fractures involved the anterior column or both column. Only 18% were treated with ORIF for both injuries. 25% had ORIF of their acetabulum and 14% had ORIF on their pelvis. Sixty-five patients completed validated functional outcome questionnaires at a mean follow-up of 3.5 (one to eleven) years. Patient function was significantly compromised with a mean MFA score of 33.8 (SD 21.8). Function was worse for all 8 SF-36 domains and the two component scores compared to the health status of the Canadian normal population (p< 0.001). Those individuals with an acetabular fracture involving the posterior wall or an associated lower extremity injury have a particularly poor prognosis. There was no relationship found between treatment or the pre-defined stability groups and functional outcome. Funding: Grant funded from AO/ASIF

The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. One hundred and fifteen patients were identified. 63% were male; mean age was thirty-seven years; mean ISS was thirty. Four died from their injuries. Five patients had open injuries. Only 18% were treated with ORIF for both injuries. At a mean follow-up of 3.5 years, patients with combined pelvic and acetabular fractures exhibit profound functional deficits compared to the normal population. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. Those individuals with an acetabular fracture involving the posterior wall and an associated lower extremity injury have a particularly poor prognosis. Individuals who have sustained high energy combined injuries exhibit profound functional impairments compared to the general normal population even in the long term. One hundred and fifteen patients with combined pelvic and acetabular injuries were identified using a trauma database at a level one trauma centre. 63% were male; mean age was thirty-seven years (13–8); mean ISS was thirty (9–5). 16% involved bilateral pelvic fractures; 7% bilateral acetabular fractures; and for 2%, both were bilateral. 64% were Tile B and 34% were Tile C. Most acetabular fractures were anterior column (31%) or both column fractures (26%). Only 18% were treated with ORIF for both injuries. 25% had ORIF of their acetabulum and 14% had ORIF on their pelvis. Sixty-five patients completed functional outcome questionnaires at a mean follow-up of 3.5 years (1–21). Function was significantly compromised with a mean MFA score of 33.8±21.8. Function was worse for all eight SF-36 domains and the two component scores compared to the Canadian normal population (p< 0.001). There was no relationship found between severity of pelvic or acetabular injury and patient function nor between treatment and functional outcome. Funding: Grant funded from AO/ASIF

Introduction

In recent literatures dealing with optimisation of prosthetic alignment in total hip arthroplasty (THA), the concept of combined anteversion (CA), sum of acetabular anteversion (AV) and femoral antetorsion (AT), has been addressed. We have been using an image-free THA navigation system?OrthoPilot THAPro?to achieve improved overall alignment with both stem and cup. In the use of this system, we have used the stem-first procedure so-called CA technique. In this technique, the femur was prepared first with the target angle corresponding to the native femoral AT and the cup AV was decided considering CA calculated with the formula of Widmer (37.3°= cup AV + 0.7 stem AT). The purpose of this study was to evaluate the accuracy of CA by using CA technique with image-free navigated THA.

Over the last two decades, anatomic anterior cruciate ligament (ACL) reconstructions have gained popularity, while the use of extraarticular reconstructions has decreased. However, the biomechanical rationale behind the lateral extraarticular sling has not been adequately studied. By understanding its effect on knee stability, it may be possible to identify specific situations in which lateral extraarticular tenodesis may be advantageous. The primary objective of this study was to quantify the ability of a lateral extraarticular sling to restore native kinematics to the ACL deficient knee, with and without combined intraarticular anatomic ACL reconstruction. Additionally, we aimed to characterise the isometry of four possible femoral tunnel positions for the lateral extraarticular sling. Eight fresh frozen hip-to-toe cadavers were used in this study. Navigated Lachman and mechanised pivot shift examinations were performed on ACL itact and deficient knees. Three reconstruction strategies were evaluated: Single bundle anatomic intraarticular ACL reconstruction, Lateral extraarticular sling, Combined intraarticular ACL reconstruction and lateral extraarticular sling. After all stability tests were completed, we quantified the isometry of four possible femoral tunnel positions for the lateral extraarticular sling using the Surgetics navigation system. A single tibial tunnel position was identified and digitised over Gerdy's tubercle. Four possible graft positions were identified on the lateral femoral condyle: the top of the lateral collateral ligament (LCL); the top of the septum; the ideal tunnel position, as defined by the navigation system's own algorithm; and the actual tunnel position used during testing, described in the literature as the intersection of the linear projections of the LCL and the septum over the lateral femoral condyle. For each of the four tunnel positions, the knee was cycled from 0 to 90® of flexion and fiber length was recorded at 30® intervals, therefore quantiying the magnitude of anisometry for each tunnel position. Stability testing: Sectioning of the ACL resulted in an increase in Lachman (15mm, p = 0.01) and mechanised pivot shift examination (6.75mm, p = 0.04) in all specimens compared with the intact knee. Anatomic intraarticular ACL reconstruction restored the Lachman (6.7mm, p = 3.76) and pivot shift (−3.5mm, p = 0.85) to the intact state. With lateral extraarticular sling alone, there was a trend towards increased anterior translation with the Lachman test (9.2mm, p = 0.50). This reconstruction restored the pivot shift to the intact state. (1.25mm, p = 0.73). Combined intraarticular and extraarticular reconstruction restored the Lachman (6.2mm, p = 2.11) and pivot shift (−3.75mm, p = 0.41) to the intact state. There was no significant difference between intraarticular alone and combined intraarticular and extraarticular reconstruction. (p = 1.88). Isometry: The ideal tunnel position calculated by the navigation system was identified over the lateral femoral condyle, beneath the mid-portion of the LCL. The anisometry for the ideal tunnel position was significantly lower (5.9mm; SD = 1.8mm; P<0.05) than the anisometry of the actual graft position (14.9mm; SD = 4mm), the top of the LCL (13.9mm; SD = 4.3mm) and the top of the septum (12mm; SD = 2.4mm). In the isolated acute ACL deficient knee, the addition of a lateral extraarticular sling to anatomic intraarticular ACL reconstruction provides little biomechanical advantage and is not routinely recommended. Isolated lateral extraarticular sling does control the pivot shift, and may be an option in the revision setting or in the lower demand patient with functional instability. Additionally, the location of the femoral tunnel traditionally used results in a significantly more anisometric graft than the navigation's system mathematical ideal location. However, the location of this ideal tunnel placement lies beneath mid-portion of the fibers of the LCL, which would not be clinically feasible

Presentation and subsequent publication has become ‘the holy grail’ of surgical trainees. This perceived importance of presenting work is further reinforced by the fact that over sixty percent of information contained in standard orthopaedic texts is quoted from published abstracts and not full papers. There is concern that increasing reliance is placed on such work and there are calls to restrict the routine use of abstracts in this manner. This concern is born out of evidence that conversion of presented work into peer-reviewed publication is globally poor throughout the medical specialities. The purpose of this study is to determine the conversion rate of work presented at the Combined Services Orthopaedic Society into peer review publication. A Medline search of 81 consecutive published abstracts over six years was carried out. Further cross-referencing was established using Dialog Datastar with a search strategy. The rate of publication of papers presented at these meetings was then compared against other medical specialities across national and international forums. 26 full paper publications were identified. This yields a conversion rate of 32%. This figure is on a par with meetings such as the BOA (35%), the AAOS (34%) and EFORT (40%). It is also a similar level to that seen with work presented at other speciality meetings. The conversion rate of papers presented at the Combined Services Orthopaedic Society is competitive with other orthopaedic and medical meetings. Overall conversion of presented works to robust literature is poor. Reasons for low publication rates include pressures of time, insufficient planning and disputes amongst colleagues. In light of increasing pressure on selection of trainees and the perceived need to present work at meetings, this paper reinforces the need for thorough planning when undertaking research & audit and strict acceptance criteria from organising bodies. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

Objective: To demonstrate possible advantages of combined (motor and sensory) versus single modality (either motor or sensory) intraoperative spinal cord monitoring. Design: Retrospective and prospective clinical study. Materials and Methods: One hundred and twenty-six consecutive operations in 97 patients had peroperative monitoring the lower limb motor evoked potentials (MEPs) to multi- pulse transcranial electrical stimulation (TES), and tibial nerve somatosensory evoked potentials (SEPs). Seventy-nine patients had spinal deformity surgery, and eighteen had surgery for trauma, tumor or disc herniation. Results: Combined motor and sensory monitoring was successfully achieved in 104 of 126 (82%) operations. Monitoring was limited to MEPs alone in two, and SEPs alone in eighteen cases. Neither MEPs nor SEPs were obtainable in two cases with Friedreich’s ataxia. Significant evoked potentials (EP) changes occurred in one or both modalities in 16 patients, in association with instrumentation (10) or systemic changes (6). After appropriate remedial measures, SEPs recovered either fully or partially in all cases (8/8) and MEPs in 10/15. New neurodeficits developed post-operatively in six of the sixteen patients with abnormal EPs, including two in whom SEPs had either not changed or recovered fully after remedial measures. One patient developed S3–5 sensory loss despite full recovery of both SEPs and MEPs. Two patients without neurological consequences had persistent MEP changes. Normal MEPs (but not SEPs) at the end of the operation correctly predicted the absence of new motor deficits. There were no false negative MEP changes. Conclusion: MEPs are more sensitive than SEPs, but may rarely raise false positive alarm. SEPs are unaffected by anaesthetics and can be monitored more frequently. Combined monitoring is safe, complimentary to each other, and increases sensitivity and predictivity of adverse neorological consequences. True incidence of false positive MEP or SEP changes are difficult to define. Remedial measures after monitoring changes may help cord ischaemia to recover and absence of neurological deficit, therefore, may not indicate a false positive monitoring change

The management of medial osteoarthritis of the knee with underlying anterior cruciate ligament deficiency is challenging. Stabilization of the ligament instability at the time of re-alignment osteotomy addresses both components of the disability. We are reporting a retrospective study of thirty-two cases of combined osteotomy and ligament repair between 1995 and 2000. Patients were assessed by questionnaire and clinical examination. Objective measures, using the modified Lystolm score, WOMAC index and SF36 were performed. Radiological examination as well as a survivor-ship analysis were performed. The average age at operation was thirty-six with an average follow-up of five years. Surgery was performed in patients who had complaints of both pain and instability and also had objective findings of Uni-compartmental osteoarthritis and anterior cruciate deficiency. Seventy five percent of patients were classed as good to excellent with only five percent of patients classed as poor. Combined tibial osteotomy and anterior cruciate reconstruction is an effective means to deal with this complex problem

Our clinical experience in treating lower limb deformities by external fixation started in 1982 by applying an Ilizarov external fixation frame. Correcting lower limb deformity by gaining the proper length and the optimal mechanical performance is of the outmost importance and essential for valid restoration of the articular function. We treated 145 patients: 25 patients affected by post-traumatic deformities; 12 patients affected by axial deviation of the knee; 82 patients affected by limb shortening and associated limb deformities; eight patients with lower limb deformities and shortening following pathological hip alterations; and 18 patients affected by severe foot deformities. It is important to stress that in congenital lower limb deformities both axial deviation and limb shortening contribute to the final picture of the deformity. Combined (hybrid) external fixation provides an adequate correction of the mechanical axis and a proper lengthening of the shorter limb by a corticotomy followed by a gradual distraction

Rotator cuff repair has excellent clinical outcomes but continues to be a challenge when it comes to large and massive tears as well as revision procedures. Reported symptomatic retear rates are still too high to be acceptable. The purpose of the present study was to evaluate the effectiveness of a combination of augmentation techniques consisting of microfractures of the greater tuberosity, extracellular matrix (ECM) patch graft and subsequent platelet concentrate (PC) subacromial injections in revision rotator cuff repair.

The study was designed as a retrospective comparative study on prospectively collected data from a consecutive cohort of patients. All patients who underwent arthroscopic revision rotator cuff repair for symptomatic failure of previous posterosuperior rotator cuff repair were considered eligible for the study. Symptomatic failure had been diagnosed according to clinical examination and confirmed by magnetic resonance imaging (MRI). Structural integrity had been assessed on MRI and classified according to Sugaya classification. Only patients affected by stage IV-V were considered eligible. Tear reparability was confirmed during arthroscopy. Only patients with a minimum 2 years follow-up were included. Patients were divided in two groups. In group 1 (control group) a standard arthroscopic revision and microfractures of the greater tuberosity were performed; in group 2 (experimental group), microfractures of the greater tuberosity and a ECM patch graft were used to enhance tendon repair, followed by postoperative PC injections. Minimum follow-up was 12 months. Primary outcome was the Constant-Murley score (CMS) normalized for age and gender. Subjective outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score in its short version (Quick-DASH). Tendon integrity was assessed with MRI at 6 months after surgery. Comparison between groups for all discrete variables at baseline and at follow-up was carried out with the Student's t-test for normally distributed data, otherwise Mann-Whitney U-test was used. Within-group differences (baseline vs follow-up) for discrete variables were analyzed by paired t-test, or by Wilcoxon signed-rank test in case of data with non-normal distribution. Differences for categorical variables were assessed by chi-squared test. Significance was considered for p values < 0.05.

Forty patients were included in the study (20 patients for each group). The mean follow-up was 13 ± 1.6 months. No patients were lost at the follow up. Comparison between groups did not show significant differences for baseline characteristics. At follow-up, mean CMS was 80.7 ± 16.6 points in group 1 and 91.5 ± 11.5 points in group 2 (p= 0.022). Mean DASH score was 28.6 ± 21.6 points in group 1 and 20.1 ± 17.4 points in group 2 (p= 0.178). Post-operative MRI showed 6 healed shoulders in Group 1 and 16 healed shoulders in Group 2 (p<0.004). No postoperative complications were reported in both groups.

The combination of microfractures of the greater tuberosity, ECM patch graft, and subsequent PC subacromial injections is an effective strategy in improving tendon healing rate.

Background:. Long-Term Follow-Up Of Lung Function And Quality Of Life (Qol) In Those Undergoing Combined Anterior And Posterior Spinal Fusion (A/Psf) For Ais Is Not Well Documented With Only One Study Extending Beyond 2 Years. Aim:. To Evaluate Long-Term Change In Pulmonary Function And Qol Following A/Psf For Ais. Methods:. Patients Who Underwent A/Psf For Ais From 2005–2007 Were Prospectively Studied (2011/2012). Lung Function [Forced Expiratory Volume In 1 Second (Fev1) And Forced Vital Capacity (Fvc)] Was Performed Along With Qol (Srs-22 Questionnaire). Paired T-Test Was Used To Compare Pre- And Post-A/Psf Data. Results:. Paired Pre- And Post-A/Psf Data Were Available For 12 Patients Who Underwent A/Psf At Mean(Range) 13.8(11.8–15) Years. 9/12 Were Female. Mean(Range) Follow-Up Was 5.8(4.1–6.7) Years Post-Operatively. Height Increased From Mean (Sd) 169(9) Cm. Pre-Operatively To 175(5) Cm. At Follow-Up (P<0.01). Scoliosis Corrected From 100(15) To 29(11) Degrees (P<0.001). %Predicted Fev1 Was 60(19) Pre-Operatively Versus 62(19) Post-Operatively (P=0.32); And Fvc Was 62(19) Pre-And 64(13) Post-A/Psf (P=0.67). Overall Srs-22 Scores Improved From Baseline Mean(Sd) 3.6(0.3) To 4.6(0.4) Post-Operatively (P<0.001). Improvements In Srs-22 Domains For Function [3.9(0.2) Vs. 4.9(0.2), P<0.001], Pain [3.5(0.4) Vs. 4.5(0.5), P<0.001], Self-Image [3.3(0.3) Vs. 4.4(0.5), P<0.001] And Mental Health [3.7(0.5) Vs. 4.4(0.6), P<0.001] Were Also Noted. High Patient Satisfaction Rates [4.8(0.3)] Were Recorded. No Correlation Was Noted Between Changes In Fev1 (R=0.08, P=0.8) Or Fvc (R=0.01, P=0.97) And Change In Srs-22 Score. Conclusion:. Long-Term Follow-Up Of Ais Patients Suggests No Deficit In Pulmonary Function, Whilst Quality Of Life And Patient Satisfaction Are High 6 Years After Combined A/Psf. Conflict Of Interest Statement: No conflict of interest

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME.

Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up.

Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference.

Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery.

Summary. From a large 3D Caucasian bone data base, female population had significantly larger acetabular anatomical anteversion angle and combined acetabular-femoral anteversion angle than that of male population. There was no significant difference in femoral neck anteversion angles between the groups. Introduction. Combined Anteversion (CA) angle of acetabular component and femoral neck is an important parameter for a successful Total Hip Arthroplasty (THA). The purpose of this study was to electronically measure the version angles of native acetabulum and femur in matured normal Caucasian population from large 3D CT data base. Our question was if there was any significant difference in CA between male and female population. Methods. 221 anonymous (134 males and 87 females) CT paired pelvic and femoral scans from normal Caucasian population with age range of 30–93 years old were analyzed. CT data was converted to virtual bones using custom CT analytical software. 1. (SOMA. TM. V.3.2). Acetabular Anatomical Anteversion (AA) angle as defined by Murray. 2. was selected. The acetabular rim plane was constructed by selecting 3 bony land marks from pubis, ilium and ischium. The AA was measured against pelvic frontal plane. Femoral neck Anteversion (FA) was measured between neck axis plane and the Coronal plane which was defined by posterior condyles. The neck axis plane was defined as being the plane passing through femoral neck axis and being perpendicular to the transverse plane which is defined by distal femoral condyles. The CA angle in standing position was computed as the summation of AA and FNA angles. All the measurements were performed for total, male and female populations. Student's t tests were performed to compare gender difference with an assumed 95% confidence level. The relationship between AA and FA for each gender was studied by the plot of AA and a function of FA. Results. The mean AA angle for total population was 25.8°, SD=6.52°. (male 24.8°, SD=5.91°, female was 27.3°, SD=7.12°. P=0.006). The mean FA angle for total population was 14.3°, SD=7.95°. (male 13.4°, SD=7.99°, female 15.6°, SD=7.76°. P=0.051). The mean CA angle for total population was 40.1°, SD=10.76°. (male 38.2° SD= 10.38 °, female 42.9° SD= 10.79 °. P=.0002). The plot of AA as a function FA is shown. The frequency distribution of CA angle is plotted for males and females. Discussion/Conclusion. The results showed both AA and CA angles were significantly smaller in the male than that in female. However there was no significant difference in FA between male and female. The plot of AA as a function of FA showed no correlation (R. 2. <.09) between the two angles for both male (R. 2. =.0097) and female (R. 2. =.0029). The FA angle of a femoral stem implant in THA may be smaller than that of natural femur, therefore a higher AA or higher posterior build up may be required for the acetabular component to achieve optimal function of a THA. This may be a more significant issue in female population. The limitations of this study was that this population did not have pathological conditions which could lead to THA. However, it should provide reference guidance comparing normal anatomy between male and female

Introduction: Spinal stenosis may present as intermittent claudication and may be indistinguishable from vascular claudication as both could co exist. These patients often required expertise from both the speciality. Combined Vascular and spinal clinic after primary screening with the help of MRI scan may reduce the waiting time to the appropriate speciality. Aim: We prospectively reviewed all the patients referred to senior author from vascular unit to assess the final outcome and evaluate whether primary to referral to vascular surgeon was unnecessary. Study Design: Prospective study from November 2004 to May 2005. Methodology: Review of Hospital case notes – 23 patients were referred to us from one of the vascular surgeons’ unit after excluding vascular etiology as the cause of the leg pain and MRI confirmation of spinal stenosis. Result: Mean waiting time to see the spine consultant 103 days [20–195] from the date of referral by the vascular team. The waiting time to primary referral to vascular team was 164 days [43–194]. 43.5% of the referred patients required to have spinal decompression. Conclusion: To improve the waiting time primary physician should have access of MRI scan to delineate the pathology and combined vascular and spinal clinic may achieve waiting time target

Introduction

Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated.

Critical size bone defects are frequently caused by accidental trauma, oncologic surgery, and infection. Distraction osteogenesis (DO) is a useful technique to promote the repair of critical size bone defects. However, DO is usually a lengthy treatment, therefore accompanied with increased risks of complications such as infections and delayed union.

Herein, we developed an innovative intramedullary biodegradable magnesium (Mg) nail to accelerate bone regeneration in critical size bone defect repair during DO.

We observed that Mg nail induced almost 4-fold increase of new bone formation and over 5-fold of new vessel formation at 2 weeks after distraction. Mg nail upregulated the expression of calcitonin gene-related peptide (CGRP) in the new bone as compared with the DO alone group. We further revealed that blockade of the sensory nerve by overdose capsaicin blunted Mg nail enhanced critical size bone defect repair during the DO process. Moreover, inhibitors/antagonist of CGRP receptor, FAK, and VEGF receptor blocked the Mg nail stimulated vessel and bone formation.

In summary, we revealed, for the first time, a CGRP-FAK-VEGF signaling axis linking sensory nerve and endothelial cells, which may be the main mechanism underlying Mg-enhanced critical size bone defect repair when combined with DO, suggesting a great potential of Mg implants in reducing DO treatment time for clinical applications.

Introduction: In cases of severe, rigid scoliotic curves, anterior or posterior fusion alone is inadequate and surgical treatment with a combined anterior and posterior) approach is required. The purpose of this study is to evaluate the effectiveness and the complications of these lengthy procedures. Material and Methods: Between 1993 and 2002, 125 patients with scoliosis were surgically treated in our department. A total of 18 patients with scoliosis were treated with a combined anterior and posterior approach. The mean age of these patients was 19.6 years (range 5.5 – 60 years). Fourteen patients were subjected to a single-stage procedure, while 4 patients underwent a staged procedure. Thirteen patients underwent anterior release and posterior nstrumentation, while 5 patients underwent both anterior and posterior instrumentation. Additional thoracoplasty was performed in 3 cases. The mean duration of the operation was 12.1 hours (range 4.5 – 14 hours). All patients were monitored postoperatively in the Intensive Care Unit. The mean duration of follow-up was 4.5 years (0.6 – 9 years). Results: Anterior release and posterior instrumentation achieved a mean 30% correction of curves that were corrected by only 15% with traction preoperatively. Combined anterior and posterior nstrumentation achieved a mean 44% correction of curves that were corrected by only 22% with traction preoperatively. One patient presented residual pneumothorax that was treated with chest tube. One patient with neuromuscular scoliosis presented wound dehiscence and early infection, which led to removal of the posterior instrumentation. Conclusions: A combined anterior and posterior procedure is indicated in patients with severe, rigid curves. It achieves greater correction, and prevents the crankshaft phenomenon in immature patients. We recommend the single-stage procedure (if patient general condition permits), because: 1) total anesthesia time is reduced, 2) total intraoperative blood loss is reduced, 3) hospital stay is reduced, and 4) greater curve correction is achieved. Severe complications include respiratory dysfunction and diffuse intravascular coagulation in multiply transfused patients, especially with use of an intraoperative autotransfusion device

Dislocation after Total Hip Arthroplasty (THA) is a frequent cause of revision and patients with intrinsic risk factors have been identified. The use of dual mobility (DM) cup has shown great efficiency in preventing dislocation, with questions regarding selective or absolute use. The aim of this study was to compare the outcome of single mobility THA (SM-THA) and DM-THA, when used for selected patients.

This retrospective continuous cohort study evaluated 490 patients of whom 275 received SM-THA and 215 received DM-THA. There were 304 primary osteoarthritis (62%), 121 femoral neck fractures (24%) and 65 other indications (14%). The surgical approach was anterior (AA) in 79% and posterior (PA) in 21% of cases. In the DM-THA group, 189 patients (87%) presented at least one dislocation risk factor compared to 128 patients (46%) in the SM-THA group. The primary outcome was revision for all causes, with or without implant removal. Secondary outcomes included length of hospital stay.

There was no difference in all cause revision at two years follow up with 9 procedures (3.2%) in SM-THA group and 11 in DM-THA group (5.1%) (p=0.3). There were 3 dislocations in SM-THA group (3 AA) and 3 in DM-THA group (2 PA and 1 AA) (p=0.4).

The length of stay was significantly longer in DM-THA group with 7 days (2–12) compared to 4 days (1–7) in SM-THA group (p=0.001).

SM-THA and DM-THA are two complementary devices in the management of patients requiring primary THA. SM-THA is a safe option for patients without dislocation risk factors, especially when using AA. The identification of such factors is important to select patients requiring DM-THA and provide reproducible outcomes in a University Hospital practice including various levels of surgeon experience.