Anterior cruciate ligament (ACL) injuries have been increasing, especially amongst adolescents. These injuries can increase the risk for early-onset knee osteoarthritis (OA). The consequences of late-stage knee OA include structural joint change, functional limitations and persistent pain. Interleukin-6 (IL-6) is a pro-inflammatory biomarker reflecting knee joint healing, and increasing evidence suggests that IL-6 may play a critical role in the development of pathological pain. The purpose of this study was to determine the relationship between subjective knee joint pain and function, and synovial fluid concentrations of the pro-inflammatory cytokine IL-6, in adolescents undergoing anterior cruciate ligament reconstruction surgery. Seven youth (12-17 yrs.) undergoing anterior cruciate ligament (ACL) reconstruction surgery participated in this study. They completed the Pedi International Knee Documentation Committee (Pedi-IKDC) questionnaire on knee joint pain and function. At the time of their ACL reconstruction surgery, synovial fluid samples were collected through aspiration to dryness with a syringe without saline flushing. IL-6 levels in synovial fluid (sf) were measured using enzyme linked immunosorbent assay. Spearman's rho correlation coefficient was used to determine the correlation between IL-6 levels and scores from the Pedi-IKDC questionnaire. There was a statistically significant correlation between sfIL-6 levels and the Pedi-IKDC Symptoms score (-.929, p=0.003). The correlations between sfIL-6 and Pedi-IKDC activity score (.546, p = .234) and between sfIL-6 and total Pedi-IKDC score (-.536, p = .215) were not statistically significant. This is the first study to evaluate IL-6 as a biomarker of knee joint healing in an adolescent population, reported a very strong correlation (-.929, p=0.003) between IL-6 in knee joint synovial fluid and a subjective questionnaire on knee joint pain. These findings provide preliminary scientific evidence regarding the relationship between knee joint pain, as determined by a validated questionnaire and the inflammatory and healing status of the patient's knee. This study provides a basis and justification for future longitudinal research on biomarkers of knee joint healing in patients throughout their recovery and rehabilitation process. Incorporating physiological and psychosocial variables to current return-to-activity (RTA) criteria has the potential to improve decision making for adolescents following ACL reconstruction to reduce premature RTA thereby reducing the risk of re-injury and risk of early-onset knee OA in adolescents

For all the research into arthroplasty, provision of total knee arthroplasty (TKR) services based on gender in the Australian context is yet to be explored. International literature points toward a heavily gender biased provision of TKA services, skewed away from female patients. This research has aimed to assess the current experience of Australian female patients and to explore better assessment techniques that could provide more equitable services. A retrospective cohort analysis has been conducted using pre-op PROMs data, where available, from the Australian National Joint Replacement Registry (AOANJRR), between 7 August 2018 and 31 December 2021, including: EQ VAS Health; Oxford Knee Score; joint pain; and KOOS-12. Data was adjusted for age, ASA score, BMI, primary diagnosis, public vs private hospital, surgeon gender and years of practice (as estimated from years of registry data available). Of 1,001,231 procedures performed, 27,431 were able to be analysed (12,300 male and 15,131 female). Gender-based bias against female patients reached statistical significance across all PROM scores, according to the Kruskal-Wallis test of difference (p-value <0.0001). Males were more likely to undergo TKR than females, with odds ratios remaining statistically significant when adjusted for age, ASA score, BMI, primary diagnosis, and hospital type. Numbers were further analysed for surgeon years of recorded practice and surgeon gender with mixed results. This study found that women were less likely to undergo TKR despite worse scores on every pre-op PROM available, thus we demonstrate a statistically significant gender-based bias against female patients. More effort needs to be made to identify the base of this bias and find new ways to assess patients that can provide more equitable provision of healthcare

Objectives. Sacroiliac joint dysfunction is a degenerative condition that can result in low back pain and is likely underdiagnosed. Diagnosis is made clinically with the patient experiencing pain in the sacroiliac joint region. Initial management is non-operative with pain management, physiotherapy, injections, and rhizolysis. If these fail then surgical management, by sacroiliac joint fusion, can be considered. The aim of this study was to review the outcomes of all patients who underwent sacroiliac joint fusion by a single surgeon in a large district general hospital between April 2018 and April 2023. Design and Methods. A retrospective review of all patients who underwent sacroiliac joint fusion between April 2018 and April 2023 was conducted. Data was collected from clinical letters, operative notes, and the British Spinal Registry. Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for back and leg pain were recorded as well as any post-operative complications. Results. In total 19 patients underwent sacroiliac joint fusion. Mean age was 47 years (range 27 – 69 years). Nine were right sided procedures and ten were left. The mean BMI was 32.3. ODI improved from a mean of 55 pre-operative to 26 at one year and 15 at two years post-operative. VAS for back pain improved from a mean of six pre-operative to three at one year and one at two years post-operative. VAS for leg pain improved from a mean of five pre-operative to four at one year and zero at two years post-operative. There were no surgical site complications. One patient developed trochanteric bursitis post-operatively. Two patients have since undergone sacroiliac joint fusion on the contralateral side with a further patient awaiting contralateral surgery. Conclusion. In patients with sacroiliac joint pain where non-operative measures have failed to control symptoms sacroiliac joint fusion is a reliable and effective surgical option

Introduction. Transtibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have knee arthritis that would be relieved by a total knee replacement (TKR). No other group has reported performing a TKR in association with TTOI (TKR+TTOI). We report the outcomes of nine patients who had TKR+TTOI, followed for an average 6.5 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TTOI and who also had TKR, performed at least two years prior. Four patients had TKR first the TTOI, four patients had simultaneous TKR+TTOI, and one patient had 1 OI first then TKR. All constructs were in continuity from hinged TKR to the prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but two patients did not have complete survey and mobility tests at both time periods. Results. Six (67%) were male, average age 51.2±14.7 years. All primary amputations were performed to manage traumatic injury or its sequelae. No patients died. Five patients (56%) developed infection leading to eventual transfemoral amputation 36.0±15.3 months later, and 1 patient had a single debridement six years after TTOI with no additional surgery in the subsequent two years. All patients who had transfemoral amputation elected for and received transfemoral osseointegration, and no infections occurred, although one patient sustained a periprosthetic fracture which was managed with internal fixation and implant retention and walks independently. The proportion of patients who wore their prosthesis at least 8 hours daily was 5/9=56%, versus 7/9=78% (p=.620). Even after proximal level amputation, the QTFA scores improved versus prior to TKR+TTOI, although not significantly: Global (45.2±20.3 vs 66.7±27.6, p=.179), Problem (39.8±19.8 vs 21.5±16.8, p=.205), Mobility (54.8±28.1 vs 67.7±25.0, p=.356). SF36 changes were also non-significant: Mental (58.6±7.0 vs 46.1±11.0, p=.068), Physical (34.3±6.1 vs 35.2±13.7, p=.904). Conclusions. TKR+TTOI presents a high risk for eventual infection prompting subsequent transfemoral amputation. Although none of these patients died, in general, TKR infection can lead to patient mortality. Given the exceptional benefit to preserving the knee joint to preserve amputee mobility and quality of life, it would be devastating to flatly force transtibial amputees with severe degenerative knee joint pain and unable to use a socket prosthesis to choose between TTOI but a painful knee, or preemptive transfemoral amputation for transfemoral osseointegration. Therefore, TTOI for patients who also request TKR must be considered cautiously. Given that this frequency of infection does not occur in patients who have total hip replacement in association with transfemoral osseointegration, the underlying issue may not be that linked joint replacement with osseointegrated limb replacement is incompatible, but may require further consideration of biological barriers to ascending infection and/or significant changes to implant design, surgical technique, or other yet-uncertain factors

Total joint replacement (TJR) is by far the most effective therapy for end-stage OA patients. Most of patients achieve joint pain reduction and function improvement following to TJR, however up to 22% of them either do not improve or deteriorate after surgery. The aim of this study was to identify genetic variants to be associated with poor outcome of TJR in primary OA patients by a genome-wide association approach (GWAS). Study participants were primary OA patients from the Newfoundland Osteoarthritis Study (NFOAS) that comprised total knee or hip replacement and recruited before 2016 in St. John's, NL. DNA samples were extracted from patients' blood. Study participants completed their pre-operation and 3.99±1.38 years post-surgery outcome assessment using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). DNA samples were genotyped using the genome-wide Illumina HumanOmni2.58 genotyping microarray containing 2.4 million SNPs. Pre-association quality control filtering was conducted for the raw genotyping data using PLINK 1.7 program, and genotype imputation was performed using the IMPUTE2 algorithm with multiple population reference data from 1000 Genome Project. The imputed data with ∼3.1 million variants was used to test the association with non-responders to TJR using the additive genetic model. Eighty three primary OA patients (44 responders and 39 non-responders) were included in the analysis. Association analysis detected three chromosomal regions on chr5, 7, and 8 to be significantly associated with non-responding to pain. The top SNPs at these loci are intergenic variants that include SNP (rs17118094, p=4.4×10-5) on chr5. This SNP is adjacent to SGCD gene that plays an important role in muscular strength and maintenance. Another associated SNP (rs71572810, p=4.7×10-5) is nearby IMMP2L gene on chr7. This gene is reported to be associated with behavioral abnormalities. Finally, SNP (rs6992938, p=5.8×10-5) on chr8 is located downstream of TRPA1 gene that is known to have a central role in the pain response to endogenous inflammatory mediators. Three loci were also found to be significantly associated with non-responding to function. The lead variant in the locus on chr1 is an intergenic SNP (rs9729377, p=1.7×10-5) falling between CTBS and MCOLN2 genes. CTBS gene is associated with TNF-α, a cytokine that stimulate the inflammation acute phase reaction, and MCOLN2 gene plays a role in the chemokine secretion and macrophage migration in the innate immune response. Other top SNPs in loci on chr2 and 10 harbor CCDC93, INSIG2, and KLF6 genes that are associated with heel bone mineral density, hypercholesterolemia, obesity and BMI. To our knowledge, this project is the first study that investigated the association between genetic factors and TJR non-responders. Our results demonstrated that genes related to muscle strength, behavioral trait, pain response, and inflammation play a significant role in poor outcome of TJR, warranting further investigation

Background. Acromegaly, which stems from high level of serum growth hormone secreted by a benign tumour in the anterior pituitary gland, is likely to cause severe peripheral joint pains due to hypertrophic changes in such joints. Recently, the life expectancy of such patients has been improved and more patients with acromegaly have undergone joint surgeries to mitigate joint pain and malfunctions. However, little is known about to what extent surgical procedures can improve the joint functions of acromegalic patients compared to non-acromegalic cases. Methods. First, we qualitatively analysed prognosis of total hip arthroplasty (THA) of acromegalic patients by investigating 11 cases in which direct anterior approach (DAA) THAs were performed to 8 acromegalic patients in our hospital between 2012 and 2015. Second, we quantitatively compared the functional prognosis of the 11 cases with that of 107 non-acromegalic cases. Technically, to control the difference in age, sex, height, and weight between the two patient groups, we first identified a model that could predict 3month-/6month-/12month-functional prognosis in the control cases. We estimated differences in functional outcomes between the two groups by calculating how accurately the control-case-based model could predict the prognosis of the acromegalic cases. Results. In the qualitative analysis, we found that compared to the control, the most acromegalic cases had atypically advanced degenerative arthritides with osteophytes and enthesophytes proliferations. In addition, some cases showed other signs, such as flattering of femoral head and arthritis with slight osteophytes. Regarding surgical procedures, acromegalic cases were likely to require longer operation time and larger amounts of blood loss compared to the control. In the quantitative analysis, we first identified a model in which age and body height could predict the functional prognosis of DAA THA in the non-acromegalic cases (F[2,104] = 6.7, P = 0.0017). We then found that the actual functional outcomes of the acromegalic cases were not significantly different from those predicted by this control-case-based model (P = 0.18). Conclusions. The qualitative analysis shows the atypical joint structures and resultant prolonged operation time and blood loss in the acromegalic cases. However, the quantitative analysis could not find significant differences in prognosis between the acromegalic and non-acromegalic cases. Although these observations and analyses need to be examined in studies with large sample sizes, this work suggests that functional outcomes of DAA THA to acromegalic patients can be comparable to that to non-acromegalic patients

Introduction. Although total knee arthroplasty (TKA) in end-stage hemophilic arthropathy can reduce the severe joint pain and improve the functional disability, it is technically demanding. In addition, it has generally reported a high rate of complication including periprosthetic joint infection (PJI) and component loosening up to 20%. Although the Knee Society classification system of TKA complication was introduced, the complications of TKA in hemophilic arthropathy has not stratified using this classification system in previous articles to the best of our knowledge. The purpose of this study was to evaluate the mid-term outcomes and complications of TKA in hemophilic arthropathy. Methods. The study retrospectively reviewed 131 consecutive primary TKAs (102 patients) in single institute. The mean patient age was 41.0 years and mean follow-up time was 6.4 years. The clinical and radiographic results were evaluated. The complications were categorized according to the classification system of the Knee Society for TKA complications. Results. The average WOMAC score improved from 66.0 to 24.2. The average flexion contracture significantly decreased from 17.3° to 4.7°, but the average pre and postoperative maximum flexion did not differ (80.9 ° vs. 85.6°). The average mechanical axis was varus 5.2° preoperatively and valgus 0.3° postoperatively. The coronal position of femoral and tibial components and sagittal position of those components were within ±3° in 83.2%, 89.3%, 63.4%, and 73.3%. The complications occurred in 17 knees (13.0%). There were 7 bleeding and hemarthrosis. Five knees were treated with increased amounts of coagulation factor concentrate and two knees were treated with incision and drainage of hematoma. One medial collateral ligament injury of grade 2 required change of postoperative rehabilitation protocol and bracing. Two stiffness of grade 3 required unplanned admission and manipulation under anesthesia. Three deep PJI were treated with 2 stage revision TKA. There were 4 periprosthetic fractures. Three distal femur fractures were treated with open reduction and internal fixation for 3 knees. One patellar fracture was healed with conservative treatment. Conclusions. The mid-term results of TKA in end-stage hemophilic arthropathy were satisfactory with obtaining pain relief, improving function, and decreasing flexion contracture. Bleeding and PJI continues to be a major concern for TKA in patients with hemophilic arthropathy, and risk of periprosthetic fracture has to be taken into account for patient education and appropriate prevention. Level of evidence. Level IV

Introduction:. Total knee replacement (TKR) and total hip replacement (THR) reliably relieve pain, restore function, and ensure mobility in patients with advanced joint arthritis; however these results are not uniform across all patient populations. Moreover, it is well established that knee replacement patients have outcomes inferior to those undergoing hip replacement procedures with lower rates of dissatisfaction with post-operative function and pain relief. We compared baseline demographic and symptom profiles in patients from a US national cohort undergoing primary TKR and THR to determine whether differences in demographic make-up, pre-operative symptoms, or pre-existing co-morbidities might contribute to these differences observed post-operatively. Methods:. A cohort of 2375 patients undergoing primary TKR and THR was identified from the FORCE national research consortium from all surgeries performed between July 1. st. 2011 and March 30. th. 2012. This set of patients was derived from 120 contributing surgeons in 23 US states. Gathered data included patient demographics, comorbidity (Charlson Comorbidity Index), operative joint pain severity (Western Ontario and McMaster Universities Arthritis Index (WOMAC)), physical function (SF-36; Physical Component Score (PCS)), emotional health (SF-36; Mental Component Score (MCS)), and musculoskeletal burden of illness (Hip and Knee Disability and Osteoarthritis Outcome Scores; Oswestry Disability Index). Using descriptive statistics, we compared the baseline demographic characteristics and symptom profiles of patients undergoing TKR (n = 1362) and those undergoing THR (n = 1013). Results:. In this large national sample, patients receiving knee replacements were found to be significantly older (66.5 vs. 64.3 years), more obese (BMI 31.7 vs. 29.3), and less educated (p < 0.005) than those undergoing THR. TKR patients had higher rates of medical comorbidities, specifically diabetes, gastrointestinal ulcers, and cerebrovascular disease (p ≤ 0.006). Conversely, THR patients had significantly worse physical function (PCS 31.6 vs. 33.3), lower back pain (35.6% vs. 30.5% moderate-severe), and operative joint pain, stiffness, and function (p < 0.005) when compared to those undergoing TKR. Conclusions:. US patients undergoing primary TKR are older with more comorbidities, however THR patient baseline functional and musculoskeletal limitations are significantly greater than primary TKR patients. These data may help explain the variability in physical function after primary TKR as compared to primary THR

Aims

COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.

Introduction. CMS is now publicly reporting 30-day readmission rates following total joint replacement (TJR) by hospital and is planning the collection of patient-reported function and pain after TJR. Nationally, 5% of patients are readmitted to the hospital after TJR for both medical and orthopedic-related issues. However, the relationship between readmission and functional gain and pain relief after TJR has not been evaluated. Methods. Clinical data on 2990 CMS patients from over 150 surgeons practicing in 22 US states who elected primary unilateral TJR in 2011–2012 were identified. Measures include pre-operative demographics, BMI, medical and musculoskeletal comorbidities, pain and function (KOOS/HOOS; SF36) and 6 month post-TJR pain and function. Data were merged with CMS claims to verify 30-day readmissions. Descriptive statistics and multivariate models adjusted for covariates and clustering within site were performed. Results. Overall 4.7% of patients were readmitted; 2.0% due to limb related diagnoses. Readmitted patients had significantly greater number of medical comorbidities; more severe OA in non-operated knees and hips; were more likely to smoke; and have poorer pre-TJR function (all p<0.05). After TJR, a greater proportion of readmitted patients had poor global function (PCS<30= 14% vs. 8%; p<0.008) but knee/hip function was similar in both groups. Joint pain improvement did not differ by readmit status. Conclusion. In this national representative cohort of CMS patients, patients readmitted within 30 days after TJR had poorer global function but similar joint specific function as non-readmitted patients. Readmitted patients also had significantly more medical comorbidities, more severe osteoarthritis in non-operated knees and hips; were more likely to smoke; and have poorer pre-TJR function. The overall rate of FORCE-TJR CMS patients readmitted within 30 days (4.7%) is consistent with national CMS analyses (5%). Of interest, in our cohort, readmitted patients had poorer global function after surgery, but similar joint specific (hip/knee) function compared to patients who were not readmitted. They also had poorer pre-THR function, and more severe OA in other joints, which may contribute to their overall lower global function scores. As CMS moves to use PROs in its bundled payment, these data support the importance of hip/knee-specific PRO measures to assess THR outcomes in quality of care programs and CMS reporting programs

Aims

The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital.

Septic arthritis is a rare form of infection in the healthy adult population, especially adults who have never been submitted to any articular procedure. Our objective is to describe a rare case of an infectious arthritis of a hip caused by bone abscess in a previously healthy patient with few risk factors. This is the case of a 40 year-old female, who had a history of heavy smoking and low socioeconomic status. She was examined complaining with pain in the left hip and the x-ray showed a lytic image in the intracapsular femoral neck, but it was overlooked and the diagnosis of bone abscess was missed. She was to the hospital 3 weeks later with intense pain and a suppurative and swollen right thigh. Blood analyses were compatible with infection (elevated white-blood cells and C-reactive protein). Pelvic CT scan showed a lytic image in the intracapsular femoral neck with pus inside the hip. It also showed a huge abscess and infiltration of the tissues surrounding. She was then submitted to multiple surgeries in order to drain the abscess and articular cleaning. A S. aureus MSSA was isolated and an adequate antibiotic was instituted. Although this measures, there was only partial clinical and analytical success. We eventually ended-up by resecting the femoral head, which had no viability, as shown in an MRI, and was behaving as a sequestrum, justifying the impossibility in controlling the infection. The femoral head was replaced by a temporary cement-spacer impregnated with vancomycin, and the patient maintained adequate antibiotic therapy until normalization of the infection parameters. She now has no signs of infection, and is waiting to be submitted to a total hip replacement. This is a rare case of a septic arthritis with an uncommon onset in a healthy woman who had never been submitted to a hip procedure and had no local risk factors for the development of such pathology. In the research we did, we found no other case similar to this, in which the arthritis started as an intracapsular bone abscess with hematogenous origin. Reporting this case, we would also like to emphasize that, although its rarity, it is extremely important to always exclude septic arthritis in cases of joint pain, in order to prevent catastrophic consequences

(Introduction). Metal on Metal (MoM) THA bearing as the second generation Total Hip Arthroplasty, widely came into use in Japan since 2000s. And it was expected to be able to ensure long-term use, the range of motion in the joints after surgeries, and the resistance to the dislocation, because MoM THAhad been considered to be able to use the large diameter head for its lower wear. However, there are some reports that the metal wear debris from MoM bearing surface generates the elevated serum ion level in the blood and the incidence of pseudotumor may occur subsequent to the metal wear debris. We performed MoM THA for 291 joints in 234 patients in our hospital since May 2005. But now, we refrain to use this. In this time, we will describe two cases of pseudotumor after implantation of MoM THA. (Case1) Age 64 years, female. This case showed the hip osteoarthritis on the right side, and we performed MoM THA in 2005. After that, she had slipped just prior to the three-year postoperative check-up, andstarted swelling up, hip joint pain, and the rise in CRP. Then, we performed to remove pesudotumor in 2008 and her CRP turned into negative. However, she was repeating hip dislocation several times and an MRI showed recur of pseudotumor. Finally, we changed her metal liner into a polyethylene liner in 2012. (Case2) Age 57 years, female. This case showed the hip osteoarthritis on the bilateral side, and we performed MoM THA in 2005. We had regularly measured her serum ion levels since 2009, and her cobalt level was indicating high concentration. In addition, there was shown 46ng/ml blood concentration of cobalt in her postoperative check-up in 2013. In 2014, she came to our hospital with chief complaint of the pain in the right groin, and we confirmed pseudotumor with MRI. (Conclusion). Nowadays, there have been various reports regarding the formation of mass lesion around the joint implants with MoM bearing, and the incidence rates, the methods of the diagnosis, and the treatment policies are introduced. However, they are realistically still not standardized. For this reason, we should fully understand the properties of MoM THA to perform the surgeries. And there is a need to be performed CT scans, MRI and ultrasound examination for the patients who claim a pain or the sense of discomfort in the area after surgery

Aims

The worldwide COVID-19 pandemic is directly impacting the field of orthopaedic surgery and traumatology with postponed operations, changed status of planned elective surgeries and acute emergencies in patients with unknown infection status. To this point, Germany's COVID-19 infection numbers and death rate have been lower than those of many other nations.

Melorheostosis is a very rare mesenchymal dysplasia of bone, characterized by sclerosing hyper-pigmentation appearances on the bone, may involve the adjacent soft tissues and lead to joint pain, limitation of joint motion and stiffness as a result of abnormal ossifications and soft tissue contractures, due to periarticular fibrosis. It is well known to tend to affect only one limb, but multifocal involvement, such as multiple limbs, spine and rib, has been extremely rarely reported. A variety of treatment options have been tried so far, none being specific surgical treatments. Here we present a case of a 43-year-old man who sustained melorheostosis with multifocal involvement including the axial skeleton and a whole entire lower limb. He had painful swelling of his left lower limb and mainly complained of difficulty walking due to severe hip pain and knee stiffness, which persisted for 20 years and was aggravated during the last 5 years. Total hip arthropasty [Fig. 1] was done first, and then total knee arthroplasty [Fig. 2, 3] was performed. During operation, there were difficulties in bone cutting and implant insertion due to mixed pattern of hard sclerotic portion and osteoporotic portion despite complete synovectomy and sufficient soft tissue release. He was eventually free of pain during walking and able to walk without a crutch and joint motion of hip and knee was substantially improved after surgery. We found that hip pain and contracture due to osteoarthritis and knee contracture secondary to multifocal melorheostosis could be successfully treated by total hip and knee arthroplasty. To the best of our knowledge, this is the first reporting the total joint arthroplasty performed in the patients with multifocal melorheostosis

Purpose. Although total knee replacement (TKR) has a high reported success rate, the pain relief and functional improvement after surgery varies. We asked what is the prevalence of patients showing no clinically significant improvement 1-year after TKR, and what are the patient level factors that may predict this outcome. Method. We reviewed primary TKR registry data that were collected from two academic hospitals: the Toronto Western Hospital (TWH) and the Henderson Hospital(HH) in Ontario. Relevant covariates including demographic data, body mass index, and comorbidity were recorded. Knee joint pain and functional status were assessed at baseline and at 1-year follow-up with the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Oxford knee score (OKS) to measure the change using the minimal clinically important difference (MCID). Logistic regression modeling was used to identify the predictors of interest. Results. Overall, 11.7% (373/3177) of patients reported no clinically significant improvement 1-year after surgery. Logistic regression modeling showed that a greater patient age independently predicted no clinically significant improvement on the WOMAC scale 1-year after surgery (p=0.0003), while male gender independently predicted no clinically significant improvement on the OKS 1-year after surgery (p=0.008). Conclusion. Awareness of the prevalence of patients who may show no clinically significant improvement and factors that predict this outcome will help patients and surgeons to set realistic expectations of surgery

We reported a case of the acetabular depression fracture in conjunction with a central fracture dislocation of the hip that was treated with a unique surgical technique. CASE REPORT:. A 76-year-old man suffered a left acetabular fracture with severe left hip joint pain and walking disability. Acetabular fracture was not apparent on the initial radiographs including anteroposterior and oblique views of the pelvis. However, computed tomography (CT) scanning showed displaced acetabular depression fracture (a third fracture fragment) in the center of the weight-bearing area with fracture of the ilium and spontaneous reposition of central dislocation of the hip (Fig. 1, 2). It seemed that this fracture fragment created incongruity of the acetabular articular surface and the potential for hip joint instability. Therefore, the patient was treated with open reduction and internal fixation. SURGICAL TECHNIQUE:. To perform the procedure, the patient was placed in the lateral decubitus position. A direct lateral approach to the hip was used for exposure. The vastus lateralis was released 1 cm distal from its origin, trochanteric osteotomy was done by the Gigli saw. To observe the hip articular surface and to identify the fracture fragment, the femoral head was posterior dislocated with excision of teres ligamentum after T-shaped capsulotomy. The depressed fragment in the acetabulum was identified under direct vision but could not be reduced. Therefore, the outer cortex of the ilium was fenestrated in a size of 2 × 2 cm so that a 1-cm-wide levator was inserted to the depressed fragment at 2 cm proximal from the hip articular surface through the fenestrated window (Fig. 3). Subsequently, the displaced bone fragment was pushed down by using the levator to the adequate articular joint level. The fragment was stabilized with packed cancellous bone graft harvested from the osteotomized greater trochanter. The removed outer cortex of the ilium from fenestrated site was repositioned and fixed by a reconstruction plate and screws. The osteotomized greater trochanter was reattached and fixed with two cannulated cancellous hip screws. RESULTS:. At 9-month follow-up, he was pain-free and continued to function well without the use of external supports. The acetabular depression fracture was completely reduced and healed in the CT scanning evaluation. The patient had no signs of posttraumatic osteoarthritis in radiographs. DISCUSSION and CONCLUSION:. In acetabular fracture dislocations of the hip joint, the precise pathological anatomy is not easily demonstrated by routine radiographs with classification of acetabular fractures. In our case, however, details of acetabular fracture were not well visible on conventional radiographs. It has been shown that computed tomography is useful method in precise evaluation of the fracture type with bone damage and integrity of joint configuration. Concerning approach to the fracture fragment which existed in the center of the weight bearing area of acetabulum, we performed to fenestrate on the intact bony cortex of the ilium just proximal to the fracture site. It was convenient and useful to gain good reduction of the central acetabular depression fracture, although there was no report on such a ‘fenestration’ method

Introduction. The Bristol Knee Group has prospectively followed the results of over 500 isolated patellofemoral arthroplasties. Initial experience with the Lubinus prosthesis was disappointing. The main causes of failure were mal-tracking and instability leading to excessive polythene button wear and disease progression in the tibio femoral joint. This experience resulted in the design of a new prosthesis to correct the tracking problems and improve the wear. We have now performed over 425 Avon arthroplasties with a maximum follow-up of 9 years. Results. Survivorship at 5 years and the functional outcome have been reported with 95.8% survivorship, and improved function with Oxford score from 18 to 39 points out of 48. There have been 14 cases with mal-tracking (3%). Several of these cases have required proximal or distal realignment with the Elmslie or Insall procedures. Two knees with patella alta required distalisation of the tibial tubercle. Symptomatic progression of the arthritic disease in the medial or lateral tibio-femoral compartments has occurred in 28 cases (7%) causing recurrent joint pain. Radiographic follow-up has shown a higher rate of disease progression emphasising the importance of careful assessment of patients prior to operation. We have investigated 8 cases of persistent unexplained pain. Analysis of these cases suggests 3 possible causes. An extended anterior cut leading to overstuffing, insufficient external rotation and over sizing of the femoral component leading to medial or lateral retinacular impingement. Six of these cases have been successfully treated by revision of the femoral component leading to dramatic resolution of the symptoms. Conclusion. Minor misplacement of the femoral component can lead to retinacular impingement causing persistent pain. Attention to detail in the performance of the operation will prevent these problems. Disease progression remains a risk in any compartmental arthroplasty and may be inevitable, thus strict pre-operative criteria are essential

Purpose. To evaluate the clinical and radiologic midterm results of rotational acetabular osteotomy (RAO) in incongruent hip joints. Material and Methods. A consecutive series of 15 hips in 14 patients who underwent RAO in incongruent hip joint were evaluated at an average follow-up of 52.3 months (range from 36 to 101 months). The average age at operation was 27 years (range from 12 to 38 years) old. The preoperative diagnoses were developmental dysplasia in 4 hips, sequelae of Legg-Calvé-Perthes disease in 8 hips, and multiple epiphyseal dysplasia in 3 hips. The RAO procedures were combined with a femoral valgus oseotomy in 10 hips, advance osteotomy of greater trochanter in 4 hips, derotational osteotomy in 2 hips. Clinically, Harris hip score, range of motion, leg length discrepancy(LLD) and hip joint pain were evaluated. Radiological changes of anterior and lateral center-edge(CE) angle, acetabular roof angle, acetabular head index(AHI), ratio of body weight moment arm to abductor moment arm, and a progression of osteoarthritis were analyzed. Results. The Harris hip score ha been improved from average from 67.5 points preoperatively to 97.6 points postoperatively. There have been no significant changes in the range of motion. The anterior CE angle increased from an average of 9.0°(-19.7□18.6°) to 32.5°(22.6□39.1°), the lateral CE angle from 7.6°(-12.1□14.1)° to 31.7°(26.5□37.8°) and the AHI from 61%(33□73%) to 86%(65□100%). The average ratio of body weight moment arm to abductor moment arm was changed 1.88 to 1.49. There was no case showing progression of osteoarthritis. None of the patients experienced revision surgery. Conclusion. The conventional salvage operation, such as Chiari osteotomy, has been recommended in incongruent hip. However, if we can expect to have a congruency after RAO with/without any femoral osteotomies, it would be a hopeful procedure for the incongruent joints by enhancing acetabular coverage, taking joint surface with normal articular cartilage, increasing abductor moment arm with additional improvement in LLD

Valgus knee unloader braces are often prescribed as treatment for knee osteoarthritis (OA). These braces are designed to redistribute the loading in the knee, thereby reducing medial contact forces. Patient response to bracing is variable; some patients experience improvements in joint loading, pain, and function, others see little to no effect. We hypothesised that patients who experienced beneficial response to the brace, measured by reductions in medial contact force, could be predicted based on static and dynamic measures. Participants completed a WOMAC questionnaire and walked overground with and without an OA Assist knee brace in a motion capture lab. Eighteen patients with medial compartment OA (8 female, 53.8±7.0 years, BMI 30.3±4.1, median Kellgren-Lawrence grade 4 (range 1–4)) were evaluated. The abduction moment applied by the brace was estimated by multiplying brace deflection by the pre-determined brace stiffness. A generic musculoskeletal model was scaled for each participant based on standing full length radiographs and anatomical markers. Inverse kinematics, inverse dynamics, residual reduction, and muscle analysis were completed in OpenSim 3.2. A static optimisation was then performed to estimate muscle forces and then tibiofemoral contact forces were calculated. Brace effectiveness was defined by the difference in the first peak of the medial contact force between braced and unbraced conditions. Principal component analysis was performed on the hip, knee, and ankle angles and moments from the unbraced walking condition to extract the principal component (PC) scores for these variables. A linear regression procedure was used to determine which variables related to brace effectiveness. Potential regressors included: hip-knee-ankle angle and medial joint space measured radiographically; KL grade; mass; WOMAC scores; unbraced walking speed; and the first two principal component scores for each of the unbraced hip, knee, and ankle joint angles and moments. KL grade, walking speed, and hip adduction moment PC1, which represented the magnitude of the first peak were all found to be correlated with change in medial contact force. The brace was more successful in reducing medial contact force in subjects with higher KL grades, faster self-selected walking speeds, and larger peak external hip adduction moments. The R2 value for the overall regression model was 0.78. The best predictor of brace effectiveness was the hip adduction moment, indicating the need to consider dynamic measures. Participants who had hip adduction moments and walking speeds similar to those of their healthy counterparts saw a greater reduction in medial contact force. Thus, those who responded to bracing had more severe OA as measured by the KL grade but had not experienced changes in their hip adduction moment due to OA. The results of this study suggest that there is potential for an objective criterion for valgus knee brace use to be established