Introduction. Shoulder arthoplasty has increased in the last years and its main goal is to relieve pain and restore function. Shoulder prosthesis enters in the market without any type of pre-clinical tests. Within this paper we present study experimental and computational tests as pre-clinical testing to evaluate total shoulder arthoplasty performance. Materials and methods. An in vitro experimental simulator was designed to characterize experimentally the intact and implanted shoulder glenoid articulation. Fourth generation Sawbones® composite left humerus and scapula were used and the cartilage was replicated with silicone for the intact articulation (figure 1). In the intact experimental articulation we considered the inferior glenohumeral ligament as an elastic band with equivalent mechanical properties. For the implanted shoulder, the Comprehensive® Total Shoulder System (Biomet®) with a modular Hybrid® glenoid base and Regenerex® central post was considered (figure 2). The prostheses were implanted by an experienced surgeon and clinical results from orthopedic registers were collected. The system structures were placed to simulate 90º in abduction, including the following muscle forces: Deltoideus 300N, Infraspinatus 120N, Supraspinatus 90N and Subscapularis 225N. The finite element model was created with tetrahedral linear elements with linear elastic and isotropic material for the humerus in figure 3, (Young's modulus for cortical bone − 16.5 GPa; trabecular bone − 124 MPa). Anisotropic behavior was considered for the scapula model (E11 = 342.1 MPa, E22 = 212.8 MPa, E33 = 194.4 MPa). The shoulder prosthesis was of polyethylene with 1GPa and titanium with 110 GPa. The Poisson's ratio was 0.3 in all material, except for polyethylene where we assumed a value of 0.4. A long-term post-operative condition was simulated. Results. The experimental results were compared with numerical ones for model validation. The strains measured evidence the effect of the implant presence, manly in the scapula. In the anterior region presents an increase of strains (+26%) was observed for the anterior region and decrease (−52%) in the posterior region, suggesting strain shielding in figure 4. At the glenoid cavity, the numerical principal strains present safety values of strains (200 to 2500) µε in both axial and coronal planes. This indicates that on the long-term the glenoid prosthesis is well fixed to the surrounding bone tissue and bone integrity is maintained despite the presence of the implant. However there are some peak values (2500, 25 000 µε) that were observed in some small areas in the posterior and distal regions. Results were compared with clinical ones. Discussion and Conclusions. The proposed pre-clinical test with the articulation at 90º in abduction can predict bone behavior when total shoulder prosthesis is implanted and in the long term post-operative condition. The results obtained evidence some critical regions around the glenoid component. This pre-clinical test can be implemented to improve the concepts before market

Purpose

To compare Radiostereometric Analysis (RSA) and subjective outcomes of Total Knee Arthroplasty (TKA) and Total Ankle Arthroplasty (TAA).

Commercial C-arm fluoroscopes are routinely used to analyze human skeletal joints during motions such as deep knee bends, or chair rises. Such diagnostics are used to characterize pre and post operative arthoplasty results, particularly in association with total joint replacement procedures. Stationary fluoroscopes restrict the patient motion and load conditions, thus diminishing the diagnostic utility of the results. A new class of fluoroscopy has been developed in which a robotic mechanization is used to allow selected joints to be x-rayed while the human subjects perform natural motions such as walking. The tracking fluoroscope system (TFS) is a mobile robot that acquires real-time x-ray records of hip, knee, or ankle joint motion while the patient walks normally. Because the fluoroscope line of sight dynamically tracks the joint of interest, the TFS provides clearer and contained joint images. The technical features of the TFS will be reviewed, recent development testing summarized, and the results of preliminary patient trials presented

Purpose. Introduce an Integrated Approach for Orthopedic-Sports Medicine Practice and Patient Care Management that. Is built around effective and efficient surgical techniques, and patient care management processes. Integrates Operations and Service Excellence best practices with patient care management processes. Integrates orthopedic care delivery between outpatient clinic, pre-surgery, surgery, inpatient, (acute care) and post acute care settings. Delivers exceptional clinical, patient satisfaction and financial outcomes as validated by independent national healthcare benchmarking organization. Helps position Ortho-Sports medicine services for strategic growth. Is replicable to develop Ortho-Sports Medicine Centers of Excellence. Presentation illustrates the ‘Ten Elements’ approach to implement the Ortho-Sports Medicine Centers of Excellence and demonstrate the effectiveness of the approach with an outcomes study from over 1000 total knee arthroplasty (TKA) procedures. During the presentation, the speakers would share the key clinical, patient satisfaction, and financial outcomes achieved by the implementation of the best practices defined in our ‘Ten Elements’ approach. All performance data elements are collected, validated and analyzed by an independent third party, national healthcare benchmarking company. During the presentation Dr. Bramlett would elaborate on the surgical protocol, and the key differentiating steps in procedure technique from traditional approach that significantly enhances procedure effectiveness, efficiency and lowers the patient complication rate as demonstrated by benchmarking data. Speakers would further present the key elements of Total Knee Arthoplasty procedure that focus on patient education, patient participation in pre-surgical weight loss and pre-habilitation program, anesthesia approach, avoiding tourniquet use and deep veen thrombosis (DVT) risk reduction, early post operative patient ambulation and weight bearing, and post operative patient management approach. On average the ortho-sports medicine clinical of Alabama TKA patients are disharged from the hospital in 2.6 days, and experience 65 percent less complications than expected for a similar patient population and assume early control of their independent functionality

High complication rates and poor outcomes have been widely reported in patients undergoing revision of large head metal-on-metal arthroplasty. A previous study from our centre showed high rates of dislocation, nerve injury, early cup loosening and pseudotumor recurrence. After noting these issues, we implemented the following changes in surgical protocol in all large head MOM revisions: One: Use of highly porous shells in all cases. Two: Use of largest femoral head possible. Three: Low threshold for use of dual mobility and constrained liners when abductors affected or absent posterior capsule. Four: Use of ceramic head with titanium sleeve in all cases. Five: Partial resection of pseudotumor adjacent to sciatic and femoral nerves.

The purpose of the present study is to compare the new surgical protocol above to our previously reported early complications in this group of patients

We specifically looked at (1) complications including reoperations, (2) radiologic outcomes, and (3) functional outcomes. Complication rates after (Group 1), and before (Group 2) modified surgical protocol were compared using Chi-square test, assuming statistical significance p < 0 .05.

Major complications occurred in 4 (8.3%) of 48 patients who had modified surgical technique, compared to 12 (38%) of 32 revisions prior to modification (p < 0 .05). Two hips of 48 (4.17%) endured dislocations in Group 1, compared to 9 of 32 (28%) in Group 2 (p < 0 .05). Four patients of 48 had repeat revision in Group 1: 2 for recurrence of pseudotumor, 1 for dislocation, and 1 for infection, compared to 6 patients who had 7 repeat revisions of 32 patients in Group 2: 3 for acetabular loosening, 3 for dislocation, and 1 for recurrence of pseudotumor (p=0.1). None of 48 revisions in Group 1 had acetabular loosening, compared to 4 of 32 in Group 2 (p=0.02). Two patients had nerve injury in Group 2, compared to none in Group 1 (p=0.16). The mean WOMAC pain score was 87.1 of 100 and the function score was 88.4 of 100 in Group 1, compared to a mean WOMAC pain score of 78 of 100 (p=0.6) and a function score of 83 of 100 in Group 2 (p=0.8).

Modification of the surgical techniques described in the introduction has resulted in a significant decrease in complications in revision of large head MOM total hips. We continue to use this protocol and recommend it for these difficult cases.

Introduction

Decreasing tissue damage and recovery time, while improving quality of life have been the focus of many approaches to total hip arthroplasty (THA). In this study, we compared two approaches, a tissue-sparing superior capsulotomy percutaneously assisted approach (SP) and the traditional posterior approach (TR), to address the question of whether the novel technique reduces tissue damage. The secondary aim of this study focused on the measurement technologies utilized to quantify the damage resulting from either SP or TR. Image J, BioQuant, and cellSens were the image analysis programs employed. Statistical validation and comparisons of results between all platforms were performed.

Aim

To assess the effectiveness of role of frozen section in revision arthroplasty.

Introduction

In total knee arthroplasty, the aim is to relieve pain and provide a stable, functional knee. Sagittal stability is crucial in enabling a patient to return to functional activities. Knee implants with a medial pivot (MP) design are thought to more accurately reproduce the mechanics of the native joint, and potentially confer greater antero-posterior stability through the range of flexion than some other implant designs.

Purpose

With growing attention being paid to quality and cost effectiveness in healthcare, outcome evaluations are becoming increasingly important. This determination can be especially difficult in reverse shoulder arthroplasty (RSA) given the complex pathology and extensive disabilities in this patient population. Several different scoring systems have been developed and validated for use in various shoulder pathologies. The purpose of this study was to assess the use three outcome scores in a population of patients undergoing RSA. We aim to demonstrate the validity of three outcome scores in patients undergoing RSA, and to determine if one score or a combination of scores is superior to others.

Introduction

The optimal goal for cup positioning in hip arthroplasty in individual patients is affected by many factors including surgical exposure, femoral anteversion, and pelvic tilt. Some navigation systems ignore pelvic tilt and are based strictly on the anterior pelvic plane while others incorporate pelvic tilt, as measured in the supine position on the operating table. Neither approach incorporates knowledge of preoperative spino-pelvic flexibility or predictions of the change in spino-pelvic attitude or flexibility following surgery. While prior studies have shown little change in pelvic tilt postoperatively, one recent study based on gait analysis, suggested that changes in pelvic tilt are not predictable. The current study aims to assess changes in pelvic tilt following surgery.

Purpose

Clinical outocome of revision total elbow arthroplasty(TEA) in rheumatoid arthritis(RA) patients were evaluated.

A Tracking Fluoroscope System (TFS), the first of its kind, has been developed and the design of this new technology has been previously presented. The TFS is a unique mobile robot that can acquire real-time x-ray records of hip, knee, or ankle joint motion while a subject walks/maneuvers naturally within a laboratory floor area. By virtue of its mechanizations, test protocols can involve many types maneuvers such as chair rises, stair climbing/descending, ramp crossing, walking, etc. Because the subjects are performing such actions naturally, the resulting fluoroscope images reflect the full functionality of their musculoskeletal anatomy. The goal of this follow-up study is to conduct a comparative analysis with traditional stationary fluoroscopy units to determine if this new technology does offer clinical and research advantages.

Technical trials with human subjects and active fluoroscope operation were designed to evaluate and refine the TFS engineering and operational features. These trials have been completed and the key results were compared with the traditional stationary fluoroscopic units. The technical trials verified that the TFS is ready for actual clinical diagnostic use and provides the researcher an opportunity to evaluate in vivo kinematics of subjects while performing normal daily activities at various speeds. Using the mobile fluoroscopic unit, patients performed activities that were not possible to capture with a stationary unit. Also, with the upgrade to an image recording rate of 60 frames per second, the quality of the fluoroscopic images using the TFS were superior to stationary units.

Further analyses are now being conducted to compare the kinematic results for a deep knee bend and gait, traditionally analyzed in the past using stationary fluoroscopic units to determine if there are unique advantages. It is hypothesized that the more normal-like gait patterns may produce kinematic patterns that differ from stationary fluoroscopic units. At present, the TFS has proven to be superior over other fluoroscopic units and will allow clinicians to evaluate patients under and unrestricted kinematic environment. Also, future research studies will be able to compare patients with or without a TKA under more challenging kinematic conditions, producing kinematic patterns that may lead to incites pertaining to TKA failure and/or concerns.

Infection is a complication in hip arthroplasty. It increases mortality and morbidity and is a cause for patient's dissatisfaction.

Previous Works report an infection rate between 0,4% e 1,5% in primary hip replacement and between 3,2% in revision hip replacement.

The aim of this work was to access the infection rates in one hospital, compare them with the reported rates and investigate possible risk factors for infection.

Electronic clinical records were consulted. Patients who underwent total hip arthroplasty (primary or revision) or hemiarthroplasty in one hospital, between the 1st February 2011 and 31st February 2013, were included.

Two hundred and sixty one patients (267 surgeries) were included.

Demographically, 57,5% were female patients and 42,5% were male patients with an average age of 77,1 years (± 12,3 years).

Infection rate for hemiarthroplasty 3,1%, for primary total hip arthroplasty was 1,4% and for revision procedures 4,8%.

A statistically significant relation was found between arthroplasty infection and superficial wound infection (p<0,001), wound dehiscence (p<0,001), and surgery performed during summer months (p<0,05)

No relation was found with duration of the surgery or the hospital stay or the patient's comorbidities.

The infection rate is similar to the rate reported in other clinical centres.

Superficial wound complications are a good predictor for arthroplasty infection, so it is important to diagnose and start prompt appropriate management and vigilance.

The increase in infection rates in summer months may be related to higher operating room temperature or less routined personal.

We concluded, therefore, that infection is a complication in hip arthroplasty being prevention is a key feature when arthroplasty is performed, as well as clinical vigilance for infection signs.

Multimodal analgesia protocols for pain control following total joint arthroplasty can reduce post-operative pain, allow early mobilisation and early discharge from hospital.

This study analyses the achievement of functional milestones, patient satisfaction, length of stay and adverse outcomes using a multimodal analgesia protocol in total joint arthroplasty.

All patients planned for elective hip and knee arthroplasty in a NSW teaching hospital under one surgeon between July 2007 and January 2009 were included in this prospective study. Patients undergoing revision surgery, bilateral arthroplasty or total hip arthroplasty for fractures were excluded. Unless contraindicated, all patients followed the multimodal analgesia protocol based on the local infiltration analgesia technique described by Kerr and Kohan.

To date, there are no clear guidelines from the National Institute of Clinical Excellence or the British Orthopaedic Association regarding the use of Autologous Blood Transfusion (ABT) drains after elective primary Total Knee Replacement (TKR). There is little evidence to comparing specifically the use of ABT drains versus no drain. The majority of local practice is based on current evidence and personal surgical experience.

We aim to assess whether the use of ABT drains effects the haemoglobin level at day 1 post-operation and thus alter the requirement for allogenic blood transfusion. In addition we aim to establish whether ABT drains reduce post-operative infection risk and length of hospital stay.

Forty-two patients undergoing elective primary TKR in West London between September 2011 and December 2011 were evaluated pre- and post-operatively. Patient records were scrutinised. The patient population was divided into those who received no drain post-operatively and those with an ABT drain where fluid was suctioned out of the knee in a closed system, filtered in a separate compartment and re-transfused into the patient.

Twenty-six patients had ABT drains and 4 (15.4%) required an allogenic blood transfusion post-operatively. Sixteen patients received no drain and 5 (31.3%) required allogenic blood. There was no statistical difference between these two groups (p=0.22). There was no statistical difference (p=0.75) in the average day 1 haemoglobin drop between the ABT drain and no drain groups with haemoglobin drops of 2.80 and 2.91 respectively. There was no statistical difference in the length of hospital stay between the 2 groups (p=0.35). There was no statistical difference (p=0.26) in infection rates between the 2 groups (2 in ABT drains Vs. 0 in no drains). Of the 2 patients who experienced complications one had cellulitis and the other had an infected haematoma, which was subsequently washed out.

The results identify little benefit in using ABT drains to reduce the requirement for allogenic blood transfusion in the post-operative period following TKR. However, due to small patient numbers transfusion rates of 31.3% in the ABT drain group Vs. 15.4% in the no drain group cannot be ignored. Therefore further studies including larger patient numbers with power calculations are required before a true observation can be identified.

Introduction

In total knee arthroplalsties, there are risks of revision surgeries because of aseptic loosening, polyethylene wear, and metal component breakage. The data such as model, type, size, and manufacturing companies are required at the time of revision surgeries. However, it is sometimes difficult to acquire such data due to patient's change of address and the elimination and consolidation of hospitals in the long-term. Therefore, we try to use the Radio Frequency IDentification (RFID) in the total knee joint system.

Introduction

Reverse Total Shoulder Arthroplasty (rTSA) is an efficient treatment, to relieve from pain and to increase function. However, scapular notching remains a serious issue and post-operative range of motion (ROM) presents many variations. No study compared implant positioning, different implant combinations, different implant sizes on different types of patient representative to undergo for rTSA, on glenohumeral ROM in every degree of freedom.

BACKGROUND:

Bony increased-offset reverse shoulder arthroplasty (BIO-RSA) creates a long-necked scapula, providing the benefits of lateralization. Experience with allogenic bone grafting of the glenoid in shoulder arthroplasty is mainly based on its use with total shoulder arthroplasty (TSA). Therefore, our study objectives were: 1) verify if the use of BIO-RSA together with glenoid surface grafting with allogenic bone would provide similar benefits (clinical and functional) as found with autologous bone, 2) determine if allograft could be a good alternative in the absence of (good quality) autograft bone, and 3) to see if the allograft would incorporate with the native glenoid bone.

An attempt to analyse whether impaction allografting without cement is more or less satisfactory than the technique with the addition of cement is compromised by conflicting reports of where the migration actually occurs. In some cemented series distal migration of the prosthesis within the cement mantle has been recorded as well as migration of the whole cement/prosthesis construct into the graft.

Two prospective consecutive series of revision hip arthroplasties by a single surgeon:- Group 1; Uncemented impaction grafting revision hip replacement in a series of 30 patients (33 hips). Group 2; Cemented impaction grafting revision hip replacement in a series of 30 patients (31 hips). Group demographics were similar. Each case used the same design of hip implant with the only difference in design being a proximal hydroxyapatite coating used on the uncemented implants.

Follow-up ranged from 2 to 17 years for the uncemented group and from 1 to 11 years for the cemented group. A validated hip scoring system was employed at regular follow up incorporating pain and functional assessment.

Migration rates for the uncemented group were 0 to 15 mm for 30 hips; however 3 hips were revised early due to excessive migration. 3 hips sustained early complications (1 fracture, 1 dislocation, 1 varus malposition of stem). Migration rates for the cemented group were 0 to 9 mm for 29 hips, however the remaining 3 hips were revised due to excessive migration (up to 33mm). Although similar results were obtained in terms of success and also pain and function scores, marginal improvement in results did occur with the cemented series overall. Statistical significance was not reached however. More sinkage occurred in the uncemented group overall, the majority occurring in the first 6 post-operative months. Part of the improvement with the cemented series results may be explained by the improved techniques achieved whilst performing the uncemented series.

These results from a single surgeon demonstrate that the method is highly technique dependent and relies on adequate graft impaction. With sufficient graft and an appropriate prosthetic design, cement is not essential to the early success of this method. However, the extent of the initial migration did not accurately predict a successful outcome for the procedure. The absence of cement removes any confusion as to the location of any migration.

Introduction

Surgical treatment options for osteoarthritis of the first MTPJ include fusion, excision arthroplasty, interposition arthroplasty and replacement arthroplasty. ¹ Arthroplasty of the first MTPJ is not a treatment modality that is, as yet, widely accepted. ^2,3 although early results are promising.

The Toefit-plus (tm) first MTP joint arthroplasty is an uncemented modular hemi or total joint replacement. The aim of this study was to look at the short to medium term outcome of the Toefit-plus(tm) system, performed by a single surgeon in a district general hospital.