Introduction. The trapezio-metacarpal joint (TMCJ) is subject to constant multiplanar forces and is stabilised by the bony anatomy and ligamentous structures. Ligament reconstruction can correct the hypermobility and potentially prevent osteoarthritis. Eaton and Littler proposed a surgical technique to reconstruct the volar ligamentous support of this joint. In our cadaveric biomechanical study, we aimed to evaluate the resultant effect of this technique on the mobility of the thumb metacarpal. Materials and method. Seventeen cadaveric hands were prepared and placed on a custom-made jig. Movements at the trapeziometacarpal joint were created using weights. Static digital photographs were taken with intact anterior oblique (AOL) and ulnar collateral ligaments(UCL) and compared with those taken after sectioning these ligaments and following Eaton-Littler reconstructive technique. The photographic records were analyzed using Scion. Image™. Paired T-test was used to establish statistical significance with a p<0.05. Results. AOL and UCL stabilised the TMCJ in extension. Division of these ligaments produced a significant degree of subluxation of the metacarpal at this joint with the thumb in a neutral position. Reconstruction of the ligamentous supports, using the Eaton-Littler technique, reduced the degree of extension. Conclusion. The primary stabilising ligament of the TMCJ is a subject of debate. Our study objectively evaluates the effect of reconstruction of AOL and UCL on various movements at the TMCJ comparing with sectioned and unsectioned specimens. It confirms the role AOL and UCL in resisting extension and utility of the Eaton-Littler procedure in decreasing hyperextension at this joint. This may have clinical utility in traumatic injury and degenerative laxity, by reducing pain and potentially slowing or even preventing the progression of osteoarthritis

Background. Non-invasive hemoglobin measurement was introduced to potentially eliminate blood draws postoperatively. We compared the accuracy and effectiveness of a non-invasive hemoglobin measurement system with a traditional blood draw in patients undergoing total joint arthroplasty. Methods. After IRB approval, 100 consecutive patients undergoing primary total hip or knee arthroplasty had their hemoglobin level tested by both traditional blood draw and a non-invasive hemoglobin monitoring system. Results were analyzed for the entire group, further stratifying patients based on gender, race, surgery (THA versus TKA), and post-operative hemoglobin level. Finally, we compared financial implications and patient satisfaction with the device. Paired t-test with 0.05 conferring significance was used. Stratified analyses of the absolute difference between the two measures were assessed using Mann- Whitney test. To assess the level of agreement between the two measures, the concordance correlation coefficient (CCC) was calculated. Results. Mean blood-draw hemoglobin value on POD1 was 11.063 ± 1.39 g/dL and 11.192 ± 1.333 g/dL with the non-invasive device. For all patients, the mean absolute difference between the two methods was 0.13 g/dL (p = 0.30). The CCC between the two methods was 0.58, conferring a moderate to strongly positive linear relationship (Figure 1). Non-invasive measurement was preferred by 100% of patients with a mean VAS score of 0/10. Additionally, the cost savings with the non-invasive system was $16.50 per patient. Discussion. Overall, there was no significant difference between the hemoglobin level obtained by traditional laboratory methods versus the Masimo Radical-7 system on post-operative day #1 in patients who underwent total joint arthroplasty. In the minority of patients (19%) who had a hemoglobin level of less than 10 g/dL, the difference between the two methods was statistically significant. Additionally, 100% of patients preferred the Masimo device to a traditional blood draw and the Masimo device was substantially cheaper. While further investigation of non-invasive hemoglobin monitoring systems is necessary, particularly in patients with a post-operative hemoglobin of less than 10 g/dL, our study shows that the Masimo Radical-7 device provides an accurate, preferable, and less expensive alternative to a traditional blood draw after total joint replacement. Conclusion. Overall, the non-invasive hemoglobin monitoring system offered a similar hemoglobin reading to the standard lab-draw reading, while improving satisfaction and lowering cost. The system relies on adequate perfusion for measurement, and our study demonstrated that lower hemoglobin values may reduce finger-tip perfusion and affect the hemoglobin reading

The opposable thumb is one of the defining characteristics of human anatomy and is involved in most activities of daily life. Lack of optimal thumb motion results in pain, weakness, and decrease in quality of life. First carpometacarpal (CMC1) osteoarthritis (OA) is one of the most common sites of OA. Current clinical diagnosis and monitoring of CMC1 OA disease are primarily aided by X-ray radiography; however, many studies have reported discrepancies between radiographic evidence of CMC1 OA and patient-related outcomes of pain and disability. Radiographs lack soft-tissue contrast and are insufficient for the detection of early characteristics of OA such as synovitis, which play a key role in CMC OA disease progression. Magnetic resonance imaging (MRI) and two-dimensional ultrasound (2D-US) are alternative options that are excellent for imaging soft tissue pathology. However, MRI has high operating costs and long wait-times, while 2D-US is highly operator dependent and provides 2D images of 3D anatomical structures. Three-dimensional ultrasound imaging may be an option to address the clinical need for a rapid and safe point of care imaging device. The purpose of this research project is to validate the use of mechanically translated 3D-US in CMC OA patients to assess the measurement capabilities of the device in a clinically diverse population in comparison to MRI. Four CMC1-OA patients were scanned using the 3D-US device, which was attached to a Canon Aplio i700 US machine with a 14L5 linear transducer with a 10MHz operating frequency and 58mm. Complimentary MR images were acquired using a 3.0 T MRI system and LT 3D coronal photon dense cube fat suppression sequence was used. The volume of the synovium was segmented from both 3D-US and MR images by two raters and the measured volumes were compared to find volume percent differences. Paired sample t-test were used to determine any statistically significant differences between the volumetric measurements observed by the raters and in the measurements found using MRI vs. 3D-US. Interclass Correlation Coefficients were used to determine inter- and intra-rater reliability. The mean volume percent difference observed between the two raters for the 3D-US and MRI acquired synovial volumes was 1.77% and 4.76%, respectively. The smallest percent difference in volume found between raters was 0.91% and was from an MR image. A paired sample t-test demonstrated that there was no significant difference between the volumetric values observed between MRI and 3D-US. ICC values of 0.99 and 0.98 for 3D-US and MRI respectively, indicate that there was excellent inter-rater reliability between the two raters. A novel application of a 3D-US acquisition device was evaluated using a CMC OA patient population to determine its clinical feasibility and measurement capabilities in comparison to MRI. As this device is compatible with any commercially available ultrasound machine, it increases its accessibility and ease of use, while proving a method for overcoming some of the limitations associated with radiography, MRI, and 2DUS. 3DUS has the potential to provide clinicians with a tool to quantitatively measure and monitor OA progression at the patient's bedside

Introduction. Optimal implant position is critical to hip stability after total hip arthroplasty (THA). Recent literature points out the importance of the evaluation of pelvic position to optimize cup implantation. The concept of Functional Combined Anteversion (FCA), the sum of acetabular/cup anteversion and femoral/stem neck anteversion in the horizontal plane, can be used to plan and control the setting of a THA in standing position. The main purpose of this preliminary study is to evaluate the difference between the combined anteversion before and after THA in weight-bearing standing position using EOS 3D reconstructions. A simultaneous analysis of the preoperative lumbo pelvic parameters has been performed to investigate their potential influence on the post-operative reciprocal femoro-acetabular adaptation. Material and Methods. 66 patients were enrolled (unilateral primary THAs). The same mini-invasive anterolateral approach was performed in a lateral decubitus for all cases. None of the patients had any postoperative complications. For each case, EOS full-body radiographs were performed in a standing position before and after unilateral THA. A software prototype was used to assess pelvic parameters (sacral slope, pelvic version, pelvic incidence), acetabular / cup anteversion, femoral /stem neck anteversion and combined anteversion in the patient horizontal functional plane (the frontal reference was defined as the vertical plane passing through centers of the acetabula or cups). Sub-analysis was made, grouping the sample by pelvic incidence (<55°, 55°–65°, >65°) and by pre-operative sacral slope in standing position (<35°, 35°–45°, >45°). Paired t-test was used to compare differences between preoperative and postoperative parameters within each subgroup. Statistical significance was set at p < 0.05. Results. In the full sample, mean FCA increased postoperatively by 9,3° (39,5° vs 30,2°; p<0.05). In groups with sacral slope < 35° and sacral slope > 45°, postoperative combined anteversion increased significantly by 11,7° and 12,9°, respectively. In the group with pelvic incidence > 65°, postoperative combined anteversion increased significantly by 14,4°. There was no significant change of combined anteversion in the remaining subgroups. Discussion. In this series the FCA increased after THA, particularly in patients with a low or high sacral slope on the pre-operative evaluation in standing position. This may be related to a greater difficulty for the surgeon in anticipating the postoperative standing orientation of the pelvis in these patients, as they were standardly oriented during surgery (lateral decubitus). Interestingly the combined anteversion was also increased in patients with a high pelvic incidence that is commonly associated with a high sacral slope. Conclusion. Post-operative increase of anatomical cumulative anteversion has been previously reported using anterior approach. The FCA concept based on EOS 3D reconstructions brings new informations about the reciprocal femoro-acetabular adaptation in standing position. Differences found in combined anteversion before and after the surgery show that a special interest should be given to patients with high pelvic incidence and low or high sacral slope, to optimize THA orientation in standing position

Introduction. Understanding hip-spine relationships and accurate evaluation of the pelvis position are key- points for the optimization of total hip arthroplasty (THA). Hip surgeons know the importance of pelvic parameters and the adaptation mechanisms of pelvic and sub-pelvic areas. Literature about posture after THA remains controversial and adaptations are difficult to predict. One explanation can be the segmental analysis focused on pelvic parameters and local planning. In a significant number of patients a global analysis may be important as a cascade of compensatory mechanisms is implemented, the hip being only one of the links of this chain reaction. 3 parameters can be measured on full body images:. SVA (sagittal vertical axis) : horizontal distance between the vertical line through the center of C7 and the postero-superior edge of S1. T1 pelvic angle (TPA) : line from femoral heads to T1center and line from the femoral heads to S1center. TPA combines informations from both the sagittal vertical axis and pelvic tilt. Global Sagittal Angle (GSA) : line from the midpoint of distal femoral condyles to C7 center and line from the midpoint between distal femoral condyles to the postero-superior S1corner. The objective of this preliminary study is to report the post-operative evolution of posture after THA. Material and Method. 49 patients (28 women, 21 men, mean age 61 years) were enrolled for full-body standing EOS images before and after THA. The sterEOS software was used to measure pelvic parameters (sacral slope SS, pelvic incidence PI) and global postural parameters (TPA, GSA, SVA). Sub-analysis was made, grouping the sample by TPA (<14°, 14°–22°, >22°), by PI (<55°, 55°–65°, >65°) and by SS (<35°, 35°–45°, >45°). Paired t-test was used to compare differences between preoperative and postoperative parameters within each subgroup. Statistical significance was set at p < 0.05. Results. TPA, SVA and GSA may change independently following THA surgery. In the 2 groups with TPA< 19° and 14° <TPA< 22°, GSA and SVA decreased significantly after THA (p < 0.05). The difference was not significant in the group with TPA>22°. In the group with SS between 35° and 45°, the GSA and SVA decreased after THA (p < 0.05). In the group with SS > 45° only GSA decreased. In the group with PI < 55°, GSA and SVA decreased after THA. There was no significant change in the remaining subgroups. Discussion. This preliminary study confirms a decrease of GSA and SVA after THA. Some preoperative characteristics are observed in patients with significant global sagittal postural modifications: low to standard TPA, low PI or standard to high SS. Conclusion. Planning and prediction of sagittal postural changes after THA implantation is challenging. It is an important topic in patients with stiff and degenerative spine or in case of spinal fusion. In case of complex hipspine cases, the timing of the procedures can be a real concern. The combined analysis of SVA, TPA and GSA may open new perspectives for a more rationale planning of THA

Femoral neck fractures are the second cause of hospitalization in elderly patients. Nowadays it is still not clear whether surgical treatment may provide better clinical outcome than conservative treatment in patients affected by mental disorders, such as senile dementia. The aim of this study was to retrospectively assess mortality and clinical and functional outcome after hemi arthroplasty operation following intracapsular neck fractures in patients with senile dementia. Between 2008 and 2014, 819 patients were treated at our Orthopaedic Institute for neck fracture of the femur (mean age: 83.8 years old). Eighty-four of these showed clear signs of cognitive impairment at time of admission in the Emergency Department. Mental state of patients was assessed in all cases, as routine, at the Emergency Room with the Short Portable Mental Status Questionnaire (Sh-MMT) and the Mini Mental State Examination (MMSE). Patients were divided in two groups depending whether they were surgically treated with hemiarthroplasty (Group B, 46 patients; 35 females, 11 males; mean age: 88.5 y.o.) or conservatively treated (Group C, 38 patients; 28 females, 10 males; mean age: 79.5 y.o.). These two groups were compared with a matched case-control group of patients surgically treated with no mental disorders (Group A, 40 patients; 34 females, 6 males; mean age: 81.5 y.o.). Incidence of mortality, systemic or local complications and functional clinical outcomes were evaluated with the ADL score and the Barthel index. Mortality rate was 35% (14 patients) for Group A, 50% (21 patients) for Group B and 95% (22 patients) for Group C. Paired t-test, with significance rate set at 0.05, showed significant higher mortality rate in Group A compared to both Group B (p:0.02) and Group C (p:0.001), and also between Group B and Group C (p:0.01). Three orthopaedic complications were found in Group B (two cases of infection and one dislocation of the prosthesis) while none in Group A (p<0.001). There have been 14 overall general complication in Group A (33%), 16 in group B (38%) and 15 in Group C (65%), with significant higher rate in Group B vs. Group A (p:0.02) and in group C vs. Group B (p: 0.001). Activity daily living scale and Barthel Index results showed higher results in Group B than Group C both in terms of recovery of walking ability and daily living (hairdressing, wearing clothes, eating). For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. Allogeneic blood transfusion (ABT) remains a widely used therapeutic intervention in patients undergoing total knee arthroplasty (TKA). There is mounting evidence that tranexamic acid (TXA), a powerful antifibinolytic, can significantly reduce perioperative blood loss with a concomitant lower ABT rate. In May 2012, TXA intravenous infusion was introduced as standard therapy in all patients undergoing major hip and knee arthroplasty. The TXA protocol included infusing 1 gm prior to incision and 1 gm after lowering the tourniquet. Nadir hemoglobin (Hb) level has been shown to be the single most important predictor of ABT in patients undergoing TKA. It is often used as the main trigger for ABT and in research trials examining restrictive transfusion trials. There is a paucity of information regarding the impact of TXA on Hb levels in patients undergoing primary TKA. The purpose of this retrospective study was to examine the impact of TXA on hemoglobin levels in primary TKA patients. Methods. Patients undergoing primary single, or bilateral, TKA from a single orthopedic surgeon from the years 2009–2010 before TXA infusion (n=78) were compared to patients undergoing the same operation after TXA was introduced as a therapeutic intervention (n=97). TKA is a very standardized operation that has stayed consistent over the convening years in terms of surgical technique and intra-operative management. The following Hb values were selected for analysis between the two groups: pre-surgical Hb value, immediate post-operative Hb, nadir Hb, and discharge Hb. Paired t-test was used for analysis with p-value set at 0.05. Additional data analysis included: length of stay (LOS) and rate of ABT. Results. Demographically, the control group was younger compared to the experimental group (60 vs. 64 years). Table 1 shows the difference in the selected Hb values between the two groups. There was no difference in Hb values going into surgery between the two groups. For all other Hb values, there was a significant difference between the control group and the TXA group throughout the postoperative period. In addition, Hb drift was significantly lower in the TXA group compared to the control group by 0.7 g/dl. ABT rate was 4% for the TXA group and 50% for the control group. The control group had a higher LOS compared to the TXA, 4.9 vs. 4.3 days. Conclusion. TXA infusion in the intraoperative period is an effective therapeutic intervention for reducing the downward drift of Hb levels throughout the postoperative period in patients undergoing TKA, and in turn, significantly impacts ABT rate and resource utilization

Introduction. Primary stability is essential for long-term performance of cementless femoral components. There is debate as to whether collars contribute to primary stability. The results from experimental studies and finite element (FE) analysis have been variable and contradictory. Subtle differences in performance are often swamped by variation between cadaveric specimens in vitro, whereas FE studies tend to be performed on a single femur. However, FE studies have the potential to make comparisons of implant designs within the same cohort of femurs, allowing for subtle performance differences to be identified if present. This study investigates the effect of a collar on primary stability of a femoral prosthesis across a representative cohort of femurs. Materials and Methods. FE models were generated from QCT scans of eight cadaveric femurs taken from the Melbourne Femur Collection (4 male and 4 female; BMI: 18.7 – 36.8 kg.m-2; age: 59 – 80 years) which were of joint replacement age. Heterogeneous bone material properties were assigned based on the CT greyscale information. Each femur was implanted with the collared and collarless version of Corail femoral stem (DePuy, Leeds, United Kingdom). The stems were sized and positioned so that the prosthesis filled the medullary canal with minimal gap between the prosthesis and the inner boundary of the cortical bone. The peak muscle and joint contact forces associated with level gait were applied and the distal femur was rigidly fixed. The forces were scaled based on the body weight for each subject. Micromotion, as well as microstrains at the bone-prosthesis interface were measured for each subject. Paired t-test was run to compare the micromotion and the microstrains measured for the collared and collarless prosthesis. Results. There were no significant differences in micromotion (p > 0.005) and microstrains (p » 0.005) between collared and collarless prostheses. The mean of the median micromotions for the collared and the collarless prostheses were 19.4 microns and 20.5 microns, respectively. The mean of the median equivalent strains at the bone-implant interface for the collared and the collarless prostheses were 828.5 microstrains and 824.3 microstrains, respectively. The mean percentage of the area at the contact interface that experienced equivalent strains lower than 2000 microstrains was 69.9% for the collared and 70.0% for the collarless designs. The mean percentage of the contact area at the bone-prosthesis interface that experience equivalent strains greater than 7000 microstrains, the yield strain, was only 9.9% for the collared and 5.7% for the collarless designs. Discussion and conclusions. There was considerable variation across the cohort of femurs, with a factor of two difference for both micromotion and interface strain While small differences were noted between the collared and collarless prostheses implanted in the same femur, these differences were minimal and were likely to have little affects on primary stability, at least for a level gait load case. More demanding load cases may result in greater differences between collared and collarless implants. The results suggest that the addition of a collar in routine cases may not enhance the primary stability of a cementless hip stem

Purpose. The measurement of radial head translation about the capitellum (in percent): the radio-capitellum ratio (RCR) has proven to have excellent inter- and intra-observer reliabilities when measuring the RCR on a lateral radiological view of elbows at 90° of flexion and in the neutral position of the forearm. However, in the clinical setting, radiographs may be taken with the elbow in different positions. However, the purpose was to validate the RCR measurement method on elbows in different positions in flexion-extension and in different positions of the forearm in pronation-supination. Method. Fifty-one healthy volunteers were recruited to evaluate the RCR in different elbow positions. Lateral elbow radiographs were taken with the elbow in different magnitude of ROM: maximal extension, maximal flexion, elbow at 90° and forearm in neutral, elbow at 90° and forearm in supination and elbow at 90° and forearm in pronation. The measurements of the RCR were done using the software SliceOmatic. ANOVA and paired T-test were used to assess the difference of the RCR depending on the position of the elbow and of the forearm. Pearson coefficients were calculated to obtain the correlation between the RCR in each different position. Results. The mean RCR for each position were the following: elbow in maximal extension: −2%±7%, elbow in maximal flexion: −5%±9%, elbow at 90° and forearm in neutral: −2%±5%, elbow at 90° and forearm in supination: 1%±6% and elbow at 90° and forearm in pronation: 1%±5%. According to the Anova results, a significant difference exists between the RCR in different elbow positions (p=0.01) and in the different forearm positions (p<0.001). Paired T-test confirmed a significant difference between maximal elbow flexion and elbow flexion at 90° (p=0.003), as well as for maximal elbow extension and maximal elbow flexion (p=0.034). According to the Pearson coefficient, significant correlations exist between: elbow flexion at 90° and in maximal flexion (r=0.19, p=0.050); the forearm in neutral and in supination (r=0.34, p<0.001); the forearm in neutral and in pronation (r=0.42, p<0.001). Conclusion. The RCR method is dependent on elbow (flexion-extension) and forearm (pronation-supination) positions. At both maximal elbow positions in flexion and extension, the measurements of the RCR have a higher standard deviation. In order to decrease its variability, we recommend as a convention measuring the RCR on lateral radiographs with the elbow at 90° and the forearm in neutral position. However, 95% of the values of RCR (except in maximal flexion which is unusual in trauma) are included in the normal range of RCR from −5% to 13%. Thus a value outside this range in any elbow positions (except maximal flexion) or any forearm positions must raise doubt on elbow alignment. Then, with a capitellum of 25 mm of diameter, the translation of the radial head must be less than 1 mm posterior and less than 3 mm anterior from the center of the capitellum

Aims

Disorders of bone integrity carry a high global disease burden, frequently requiring intervention, but there is a paucity of methods capable of noninvasive real-time assessment. Here we show that miniaturized handheld near-infrared spectroscopy (NIRS) scans, operated via a smartphone, can assess structural human bone properties in under three seconds.