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Background: Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years. Methods: This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years. Results: We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and “others.” The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees. Conclusion: At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques. Level of Evidence: Level IV, meta-analysis.

To systematically review and meta-analyse the literature to determine which three-dimensional (3D) imaging modality provides the best diagnostic accuracy to detect pathologies of the long head of the biceps tendon (LHBT).A search was performed on PubMed, EmbaseFifteen studies were included; nine were eligible for meta-analysis. Six studies on instability indicated a sensitivity of 0.68 (CI 0.46-0.84) and specificity of 0.76 (CI 0.68-0.82). Four studies on full-thickness tears indicated a sensitivity of 0.56 (CI 0.28-0.81) and specificity of 0.97 (CI 0.93-0.99). Four studies on partial-thickness tears indicated a sensitivity of 0.52 (CI 0.20-0.82) and specificity of 0.64 (CI 0.25-0.91). Two studies on any tear indicated a sensitivity of 0.58 (CI 0.28-0.83) and specificity of 0.99 (CI 0.93-1.00). Only one study on other pathologies indicated a sensitivity of 0.61 and specificity of 0.84.To diagnose LHBT pathologies, 3D imaging modalities overall have low-to-moderate sensitivity, but high-to-excellent specificity. The consistency in reported sensitivity is generally poor, while the consistency and reported specificity is good for the detection of instability, full-thickness tears and any tear, but poor for the detection of partial-thickness tears. 3D imaging may be adequate to rule out LHBT pathologies, but are not sufficiently reliable to confirm the presence of such pathologies.III.

Background: The authors performed total hip arthroplasty (THA) using a novel hemispherical dual-mobility (DM) acetabular cup without a protrusive cylindro-spherical rim, intended to reduce risks of iliopsoas impingement without requiring changes to conventional intraoperative positioning as with unipolar cups. We aim to determine clinical scores and rates of dislocations, complications, and revisions of this hemispherical DM cup, with the hypothesis that this novel design would result in clinical scores and dislocation rates comparable to other contemporary DM cups with protrusive cylindro-spherical rims. Methods: We assessed 332 consecutive uncemented THAs performed using a hemispherical DM cup, at a minimum 2-year follow-up, using modified Harris Hip Score (mHHS) and Oxford Hip Score (OHS), and noting complications and revisions. Regression analyses were conducted to determine if mHHS and OHS depended on any independent factors. Results: At 2.8 ± 0.5 years (range, 2–5), 2 patients (0.6%) had stem and cup revisions, 3 patients (1%) had isolated stem revisions, 13 patients (4%) died, and none were lost to follow-up. No dislocations occurred. For the final cohort of 305 patients (314 hips) with their original implants in place, mHHS was 92 ± 12 (range, 46–100), and OHS was 57 ± 5 (range, 34–60). Multivariable analyses revealed that mHHS and OHS decreased significantly with age (β = -0.35, P < .001, and β = -0.15, P < .001, respectively). Conclusions: With no dislocations and satisfactory clinical scores, this sizable cohort confirms that the novel hemispherical DM cup studied is effective at preventing dislocations, although longer-term follow-up remains necessary to ascertain the longevity of clinical outcomes and radiographic stability. Level of Evidence: Level IV, multicentric retrospective case series.

Purpose Systematic reviews report return to play (RTP) within 5.8 months (range, 3–8) following the Latarjet procedure, but the factors that influence RTP remain unknown. The present study aimed to report the rate and time of return to play (RTP) during the first 8 months following the Latarjet procedure, and to determine the influence of sport type or patient characteristics. Methods The authors retrospectively collected the records of patients that underwent Latarjet procedures for anterior shoulder instability between 2015 and 2017. Patients were excluded if they had any concomitant rotator cuff tendon lesions, or previous ipsilateral shoulder surgery. The authors retrieved patient demographics, time from injury to surgery, type of sport practiced (overhead/non-overhead, contact/non-contact), as well as pre- and postoperative Western Ontario Shoulder Instability index (WOSI), Shoulder Instability-Return to Sport After Injury index (SIRSI), and Rowe score. Results A total of 217 patients (217 shoulders) were eligible for inclusion, comprising 184 males and 33 females, aged 26.8 ± 7.3 years at index surgery. The main sport practiced prior to surgery involved overhead (n = 173, 80%) and/or contact (n = 152, 70%) activities. By 8 month follow-up, 158 patients (73%) resumed their main sport, at a mean of 5.1 ± 1.5 months. Multivariable analysis revealed that RTP was more likely in patients with higher preoperative Rowe score (OR, 1.02; p = 0.024) and SIRSI score (OR, 1.02; p = 0.008). Conclusions By 8 months following the Latarjet procedure, 73% of patients had resumed their main sport. The likelihood of RTP was significantly associated with preoperative Rowe and SIRSI scores, but not with sport type. Level of evidence IV.

To determine whether patient-specific instrumentation (PSI), computer-assisted surgery (CAS) or robot-assisted surgery (RAS) enable more accurate rotational alignment of the tibial baseplate in primary total knee arthroplasty (TKA) compared to conventional instrumentation, in terms of deviation from the planned target and the proportion of outliers from the target zone. The authors independently conducted three structured electronic literature searches using the PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases from 2007 to 2020. Studies were included if they compared rotational alignment of the tibial baseplate during TKA using conventional instrumentation versus PSI, CAS, and/or RAS, and reported deviation from preoperatively planned rotational alignment of the tibial baseplate in terms of absolute angles and/or number of outliers. Methodological quality of eligible studies was assessed by two researchers according to the Downs and Black Quality Checklist for Health Care Intervention Studies. Fifteen studies, that reported on 2925 knees, were eligible for this systematic review, of which 6 studies used PSI, and 9 used CAS. No studies were found for RAS. Of the studies that reported on angular deviation from preoperatively planned rotational alignment, most found smaller deviations using PSI (0.5° to 1.4°) compared to conventional instrumentation (1.0° to 1.6°). All studies that reported on proportions of outliers from a target zone (± 3°), found lower rates of outliers using PSI (0 to 22%) compared to conventional instrumentation (5 to 96%). Most studies reported smaller angular deviation from preoperatively planned rotational alignment using CAS (0.1° to 6.9°) compared to conventional instrumentation (1.1° to 7.8°). Of the studies that reported on proportions of outliers from a target zone (± 3°), most found fewer outliers using CAS (10 to 61%) compared to conventional instrumentation (17 to 78%). This systematic review and meta-analysis revealed that both CAS and PSI can improve the accuracy of rotational alignment of the tibial baseplate by decreasing angular deviation from the preoperatively planned target and reducing the proportion of outliers from the target zone. The clinical relevance is that PSI and CAS can improve alignment, though the thresholds necessary to grant better outcomes and survival remain unclear. IV.

Background One goal of THA is to restore the anatomic hip center, which can be achieved in hips with developmental dysplasia by placing cups at the level of the native acetabulum. However, this might require adjuvant procedures such as femoral shortening osteotomy. Another option is to place the cup at the high hip center, potentially reducing surgical complexity. Currently, no clear consensus exists regarding which of these cup positions might offer better functional outcomes or long-term survival. Question/purpose We performed a systematic review to determine whether (1) functional outcomes as measured by the Harris hip score, (2) revision incidence, and (3) complications that do not result in revision differ based on the position of the acetabular cup (high hip center versus anatomic hip center) in patients undergoing THA for developmental dysplasia of the hip (DDH). Methods We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, including studies comparing the functional outcomes, revision incidence, and complications of primary THA in dysplastic hips with acetabular cups placed at the high hip center versus those placed at the anatomic hip center, over any time frame. The review protocol was registered with PROSPERO (registration number CRD42020168183) before commencement. Of 238 records, eight comparative, retrospective nonrandomized studies of interventions were eligible for our systematic review, reporting on 207 hips with cups placed at the high hip center and 268 hips with cups at the anatomic hip center. Risk of bias within eligible studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool. Due to low comparability between studies, data could not be pooled, so these studies were assessed without summary effects. Results Six studies compared Harris hip scores, two of which favored high hip center cup placement and three of which favored anatomic hip center cup placement, although none of the differences between cohorts met the minimum clinically important difference. Five studies reliably compared revision incidence, which ranged from 2% to 9% for high hip center at 7 to 15 years and 0% to 5.9% for anatomic hip center at 6 to 16 years. Five studies reported intra- and postoperative complications, with the high hip center being associated with higher incidence of dislocation and lower incidence of neurological complications. No clear difference was observed in intraoperative complications between the high hip center and anatomic hip center. Conclusion No obvious differences could be observed in Harris hip score or revision incidence after THA for osteoarthritis secondary to DDH between cups placed at the anatomic hip center and those placed at the high hip center. Placement of the acetabular cup in the high hip center may lead to higher risk of dislocation but lower risk of neurologic complications, although no difference in intraoperative complications was observed. Surgeons should be able to achieve satisfactory functional scores and revision incidence using either technique, although they should be aware of how their choice influences hip biomechanics and the need for adjunct procedures and associated risks and operative time. These recommendations should be considered with respect to the several limitations in the studies reviewed, including the presence of serious confounding factors and selection biases, inconsistent definitions of the high hip center, variations in dysplasia severity, small sample sizes, and follow-up periods. These weaknesses should be addressed in well-designed future studies. Level of evidence Level III, therapeutic study.

Background Patients undergoing total hip arthroplasty (THA) frequently question surgeons on return to sports. We compared midterm sports participation and functional scores after THA by posterolateral approach (PLA) vs anterolateral approach (ALA). Methods Of 1381 patients who underwent uncemented ceramic-on-ceramic THA for primary osteoarthritis, 503 were excluded because of preoperative or postoperative lower limb surgery, leaving 594 operated by PLA and 284 by ALA. Forgotten Joint Score (FJS), Oxford Hip Score (OHS), satisfaction, as well as motivation, participation, and discomfort regarding 22 sports were collected. A 1:1 matching was performed to obtain 2 groups of PLA and ALA patients with similar age, gender, body mass index, and sports motivation. Results Matching yielded 2 equal groups of 259 patients. There were no significant differences in FJS (P = .057), OHS (P = .685), satisfaction (P = .369), or rates of participation in light (P = .999), moderate (P = .632), or strenuous sports (P = .284). Participation in strenuous sports was reported by 50 PLA (19%) and 61 ALA (24%) patients, with differences for downhill skiing (22 vs 39), running (10 vs 19), and cross-country skiing (18 vs 10). More than 50% of motivated patients practiced most of their sports. Severe discomfort was reported similarly in PLA and ALA patients, mainly during running (13 vs 11), team ball games (9 vs 7), and downhill skiing (7 vs 8). Conclusion There were no significant differences between PLA and ALA patients in terms of OHS, FJS, satisfaction, or sports participation rates. There is little or no evidence to promote an approach based on sports participation or functional improvement. Level of Evidence Level III, comparative study.

Purpose Dual-mobility (DM) cups are increasingly used in total hip arthroplasty (THA) but there lacks literature on their long-term results. We aimed to investigate outcomes of a fourth-generation cementless DM acetabular cup at 7–11 years. Methods We retrospectively evaluated 240 consecutive hips that received cementless THA using the same dual mobility cup (Novae Sunfit TH) and femoral stem (Corail). Patients were recalled at ≥7 years to collect Oxford hip scores (OHS), Harris hip scores (HHS), and inspect for radiolucent lines and granulomas. Multi-variable analyses were performed to determine whether HHS or OHS were associated with pre- or intra-operative variables. Results At 8.4 ± 0.8 years (range, 7–11), 6 hips were revised (2.5%), 54 deceased (22.5%), and 14 could not be reached (5.8%). Four revisions (2 cup+stem, 2 liners only) were due to sepsis (1.7%), one (cup and stem) for trauma (0.4%), and one (stem) due to aseptic loosening (0.4%). For the remaining 166 hips, HHS was 83.6 ± 13.2 and OHS was 20.3 ± 6.7. Multi-variable analysis confirmed that HHS (β = − 0.38; p = 0.039) and OHS (β = 0.36; p p = 0.009). Neither granulomas nor radiolucenies were observed around any cups, but radiolucenies were seen around 25 stems (20.3%). Conclusions This fourth-generation DM cup demonstrated satisfactory outcomes at 7–11 years, with no instabilities or cup revisions due to aseptic loosening. Better OHS was observed for younger patients and those presenting higher Charnley grade. Level of evidence Level IV, retrospective case study.

Background The direct anterior approach (DAA) is increasingly used for total hip arthroplasty (THA). Although the DAA can reduce pain, recovery time, and dislocations in nondysplastic hips, few studies report its results in patients with severe dysplasia. We aimed to evaluate outcomes of primary THA through the DAA with cup placement at the true acetabulum in hips with severe dysplasia. Methods We retrospectively evaluated 23 consecutive patients (29 hips) who underwent THA by DAA for osteoarthritis secondary to Crowe III-IV dysplasia. Surgical procedures were performed on a traction table, and the acetabular cup was placed in the true acetabulum. Patients were assessed clinically (complications, modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Hip Score) and radiographically (radiolucencies, subsidence, leg length discrepancies, cup inclination, and cup coverage) at a minimum of 2 years. Results One patient (2 hips) died with original implants (at 13 and 14 years), 3 patients (3 hips) were revised due to wear-induced loosening (at 14, 16, and 18 years), and there were no dislocations or infections. The remaining 19 patients (24 hips) were assessed at 8.4 ± 4.7 years (range 2-20); 2 patients (2 hips) had complications that required reoperation without implant removal. The modified Harris Hip Score improved from 32 ± 9 to 94 ± 7, Western Ontario and McMaster Universities Osteoarthritis Index from 46 ± 18 to 90 ± 7, and Oxford Hip Score was 56 ± 4. Patients were very satisfied (90%) or satisfied (10%). Limb length discrepancy was 2.5 ± 9.0 mm. Conclusion THA through the DAA with cup placement at the true acetabulum provides satisfactory mid to long-term clinical and radiographic outcomes compared to other approaches for hips with severe dysplasia. Level of Evidence Level IV, retrospective cohort study.

In posttraumatic wrist arthritis of intermediate severity, two main palliative procedures are used to preserve some mobility in the wrist: proximal row carpectomy (PRC) and scaphoid excision followed by four corner arthrodesis (4CA). Despite satisfactory overall results, the debate continues about which one provides the best results and long-term outcomes, particularly prevention of arthritis progression. Recent comparative studies now provide us with information about mid- and long-term results. The aim of this study was to compare the clinical results, complications, conversion rate to total wrist arthrodesis and progression to osteoarthritis of PRC versus 4CA in the medium and long term.The null hypothesis was that there is no significant difference between PRC and 4CA in the clinical results, complications, conversion to total wrist arthrodesis and arthritis progression.A systematic literature review was carried out by following the PRISMA guidelines. Included were studies comparing 4CA and PRC for the treatment of post-traumatic wrist arthritis secondary to scapholunate dissociation (SLAC) and scaphoid nonunion (SNAC) with a mean follow-up of 5 years. A search was performed of the MEDLINE, EMBASE and Cochrane databases that identified 831 articles. After removing 230 duplicates and excluding 595 articles based on their title and/or abstract, and then adding 1 article manually, 7 articles were included in our analysis. Parameters analyzed were range of motion (ROM), pain, grip strength, functional scores, complications, conversion to total wrist arthrodesis, and arthritis progression.In the 7 articles, 1059 wrists - 582 PRC and 477 4CA - were analyzed with follow-up ranging from 5.2 to 18 years. PRC produced significantly better ROM in flexion (weighted mean difference [WMD]=10.0°; p0.01) and in ulnar deviation (WMD=8.7°; p0.01) along with significantly lower complication rates (OR=0.3; p0.01) and reoperation rates (OR=0.1; p0.01). There was no significant difference in the conversion rate, grip strength, extension, radial deviation, pain, DASH and PRWE scores. The progression of osteoarthritis could not be analyzed due to lack of data.This meta-analysis was the first to include recently published mid- and long-term studies comparing PRC and 4CA. The main finding is that PRC is superior overall with better ROM and a lower complication rate. Another important finding was the absence of differences in grip strength and the conversion rate to total wrist arthrodesis. Unfortunately, the lack of systematic studies on arthritis progression leaves this question unanswered. Our findings must be interpreted cautiously because it was impossible to stratify the cases by etiology and osteoarthritis stage.III; systematic review and meta-analysis.

The purpose of this systematic review was to synthesise the available literature and critically appraise current evidence on the functional and radiographic outcomes as well as reoperation and revision rates of custom partial knee arthroplasty, i.e., unicompartmental knee arthroplasty (UKA), bicompartmental knee arthroplasty (BKA), and patellofemoral arthroplasty (PFA). This systematic review was performed in accordance with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and a protocol was registered with Prospero. On 25 May 2021, two authors independently searched and screened Level I–IV studies that reported on outcomes of custom partial knee arthroplasty using the databases of MEDLINE®, EMBASE®, and the Cochrane Library without restriction on date of publication. Findings from eligible articles were synthesised and tabulated, and quality assessments were done according to the guidelines of the Joanna Briggs Institute (JBI) Checklists. Fifteen articles were eligible for data extraction, of which two comparative and four case series were on custom UKA (follow-up, 0–9 months), one comparative and five case series on custom BKA (follow-up, 0.25–72 months), and three case series on custom PFA (follow-up, 2–119 months). Three studies on custom UKA reported mean Knee Society Score (KSS) Knee of 86–94 and mean KSS Function of 94–95, and two studies on custom BKA reported mean KSS Knee of 90–94 and KSS function of 81, whereas one study on custom PFA reported KSS Knee of 91 and KSS Function of 89. Custom implants tended to have less bone–implant mismatch compared to off the shelf (OTS) implants. Revision rates were 3–25% for custom UKA (at 0–109 months), 3–5% for custom BKA (at 12–72 months), and 0–14% for custom PFA (at 2–119 months). Due to the small number of comparative studies and lack of consistency in reported outcomes, it remains difficult to ascertain the benefits of custom partial knee arthroplasty. Anecdotal evidence suggests that, compared to OTS implants, custom implants result in less bone–implant mismatch and that 78–91% of patients are either satisfied or very satisfied after custom partial knee arthroplasty. IV.

To determine demographic, anatomic, and surgical factors associated with static and dynamic Anterior Tibial Translation (ATT) following ACL reconstruction. The hypothesis was that both static and dynamic ATT would be greater in knees with high tibial slope or that required meniscectomy. The authors prospectively enrolled 280 consecutive patients that had primary ACL reconstruction using hamstring autografts at one center for which preoperative tear type, meniscal tears, and medial tibial slope were documented. A total of 137 were excluded due to concomitant extra-articular tenodesis or surgical antecedents on either knee, and 18 were lost to follow-up, leaving 125 that were evaluated at a minimum of 6 months including: static ATT on monopodal weight-bearing radiographs, and dynamic ATT on differential stress radiographs using the Telos™ device. Both postoperative static and dynamic ATT were strongly associated with preoperative static and dynamic ATT (respectively, β = 0.068 and β = 0.50, p

To date, there is no clear consensus on the superiority of shoulder hemiarthroplasty (HSA) or reverse shoulder arthroplasty (RSA) for the treatment of acute proximal humeral fractures (PHF). The aim of this study was to review the relevant literature for level I and II studies reporting clinical outcomes and revision rates for HSA or RSA in the treatment of acute PHF. Two electronic databases (PubMed, and Embase) were systematically searched for level I and II studies published after 1998 reporting clinical and/or radiographic outcomes of primary HSA or primary RSA as treatments for acute PHF. Of the 628 studies that were identified, nine were selected (four level I and five level II), with some heterogeneity in describing outcomes, complications, and revisions. The three studies that compared HSA versus RSA in patients with a mean age of >70 years found that RSA grants better clinical scores, less pain, higher forward elevation, and greater patient satisfaction. The remaining six studies compared outcomes of acute PHF treated by conventional HSA versus HSA + biceps tenodesis, trabecular metal HSA, intramedullary fibular allograft with locking compression plates, open reduction with internal fixation, or nonoperative treatment. Reverse shoulder arthroplasty is a reliable treatment for acute PHF in elderly patients, which grants better outcomes and is associated with fewer complications than HSA at short-term follow-up. Future research is needed to establish the best surgical treatment for acute PHF in young patients. Level II, systematic review of level I and II studies.

Though numerous studies highlighted benefits of ambulatory total joint arthroplasty (TJA), most had selected patients with age and comorbidities thresholds. We aimed to report proportions of unselected TJAs that could be scheduled for and operated in ambulatory settings, and to determine factors that hinder same-day discharge (SDD).We studied 1100 consecutive primary TJAs (644 THAs and 456 TKAs) that were prepared following a multidisciplinary protocol for patient education and logistical preparation. Data were stratified for THA vs TKA and for success vs failure of SDD to home and multivariable analysis was performed to determine factors associated with failure of scheduled SDD to home.In total, 860 (78.2%) were scheduled for ambulatory surgery, but only 819 (74.5%) achieved SDD to home; 240 (21.8%) were scheduled for non-ambulatory surgery, but 103 (9.3%) achieved SDD to rehabilitation centre. Re-operations were required in 9 (1.0%) ambulatory TJAs vs 2 (0.8%) non-ambulatory TJAs (p = 0.769), while revisions were required in 13 (1.5%) ambulatory TJAs vs 1 (0.4%) non-ambulatory TJAs (p = 0.181). Multivariable analysis confirmed that failure of SDD to home was greater for women (OR 2.59; p = 0.011) and THA (vs TKA, OR 2.41; p = 0.023).With appropriate education and preparation, 75% of unselected primary hip and knee arthroplasties achieved SDD to home without compromising risks of complications, re-operations, or revisions. A further 9% achieved SDD to rehabilitation centre, implying that 84% of patients did not require overnight stay. These findings suggest that ambulatory surgery is feasible and safe to implement in most unselected lower limb arthroplasties.

Background: The use of fixation screws with uncemented cups is controversial particularly for dual mobility (DM) cups where perforation of the articular surface could compromise implant longevity. We aimed to compare outcomes of total hip arthroplasty (THA) using uncemented DM cups with supplementary screw fixation versus simple press-fit fixation. Methods: From 235 consecutive THAs performed using uncemented DM cups, 203 were fixed by simple press-fit and 32 fixed with additional screws. The Oxford hip score (OHS) and EuroQol 5 Dimensions (EQ-5D) score were available at 3.3±1.1 years. To enable direct comparison, each screw fixation cup was matched to three simple press-fit cups using propensity scores, based on age, sex and bone quality. Results: The two groups had equivalent age, body mass index, gender distribution, femoral morphology and bone quality. Compared to the press-fit group (n=96), the screw fixation group had more surgical antecedents (p=0.032), higher femoral neck angles (p=0.028), and received slightly larger cups (p=0.036). Revision was required for two (6%) screw fixation cups (only one implant-related) and one (1%) press-fit cup (none implant-related). There were no differences between OHS (19±8 vs 18±7, p=0.682) nor EQ-5D (0.63±0.37, p=0.257). Conclusions: Revision rates were greater for DM cups fixed with additional screws than for those fixed by simple press-fit, but clinical scores were equivalent. There was only one implant-related revision (acetabular fracture) in the screw fixation group and it is unclear whether this is related to the additional screws or to patient/surgical factors. Level of evidence: Level IV, retrospective case series.

The aim of this study was to determine patient and anatomic factors that influence anteroposterior and rotational laxity in knees with ACL tears. Based on the findings of biomechanical studies, we hypothesized that static and dynamic anterior tibial translation (ATT) as well as positive pivot shift would increase with female gender, tibial slope, and meniscal tears. The authors prospectively collected preoperative data and intraoperative findings of 417 patients that underwent ACL reconstruction. The exclusion criteria were: revision ACL procedures (n = 53), other surgical antecedents (n = 27), prior osteotomies (n = 7) or concomitant ligament tears on the ipsilateral knee (n = 34), and history of ACL tears in the contralateral knee (n = 45), leaving a study cohort of 251 patients. Their preoperative anteroposterior knee laxity was assessed objectively using ‘static’ monopodal weight-bearing radiographs and ‘dynamic’ instrumented differential measurements of ATT. Rotational laxity was assessed subjectively using the pivot shift test. Multivariable regression showed that static ATT increases only with tibial slope (β = 0.30; p

Item does not contain fulltext BACKGROUND: The goal of patellofemoral arthroplasty (PFA) is to replace damaged cartilage and correct underlying deformities to reduce pain and prevent maltracking. We aimed to determine how PFA modifies patellar height, tilt, and tibial tuberosity-trochlear groove (TT-TG) distance. The hypothesis was that PFA would correct trochlear dysplasia or extensor mechanism malalignment. METHODS: The authors prospectively studied a series of 16 patients (13 women and 3 men) aged 64.9 +/- 16.3 years (range 41-86 years) who received PFA. All knees were assessed preoperatively and 6 months postoperatively using frontal, lateral, and "skyline" x-rays, and computed tomography scans to calculate patellar tilt, patellar height, and TT-TG distance. RESULTS: The interobserver agreement was excellent for all parameters (intraclass correlation coefficient >0.95). Preoperatively, the median patellar tilt without quadriceps contraction (QC) was 17.5 degrees (range 5.3 degrees -33.4 degrees ) and with QC was 19.8 degrees (range 0 degrees -52.0 degrees ). The median Caton-Deschamps index was 0.91 (range 0.80-1.22) and TT-TG distance was 14.5 mm (range 4.0-22.0 mm). Postoperatively, the median patellar tilt without QC was 0.3 degrees (range -15.3 degrees to 9.5 degrees ) and with QC was 6.1 degrees (range -11.5 degrees to 13.3 degrees ). The median Caton-Deschamps index was 1.11 (range 0.81-1.20) and TT-TG distance was 10.1 mm (range 1.8-13.8 mm). CONCLUSION: The present study demonstrates that beyond replacing arthritic cartilage, trochlear-cutting PFA improves patellofemoral congruence by correcting trochlear dysplasia and standardizing radiological measurements as patellar tilt and TT-TG. The association of lateral patellar facetectomy improves patellar tracking by reducing the patellar tilt.

AimsThe morphometry of the distal femur was largely studied to improve bone-implant fit in total knee arthroplasty (TKA), but little is known about the asymmetry of the posterior condyles. This study aimed to investigate the dimensions of the posterior condyles and the influence of externally rotating the femoral component on potential prosthetic overhang or under-coverage.Patients and MethodsWe analysed the shape of 110 arthritic knees at the time of primary TKA using pre-operative CT scans. The height and width of each condyle were measured at the posterior femoral cut in neutral position, and in 3º and 5º of external rotation, using both central and medial referencing systems. We compared the morphological characteristics with those of 14 TKA models.ResultsIn the neutral position, the dimensions of the condyles were nearly equal. Externally rotating the femoral cut by 3º and 5º with ‘central referencing’ induced width asymmetry > 3 mm in 23 (21%) and 33 (30%) knees respectively, while with ‘medial referencing’ it induced width asymmetry > 3 mm in 43 (39%) and 75 (68%) knees respectively. The asymmetries induced by rotations were not associated with gender, aetiology or varus-valgus alignment.ConclusionExternal rotation may amplify the asymmetry between the medial and lateral condyles, and exacerbate prosthetic overhang, particularly in the superolateral zone. ‘Central referencing’ guides result in less potential prosthetic overhang than ‘medial referencing’ guides. Cite this article: Bone Joint J 2017;99-B:894–903

Several methods were introduced to limit perioperative blood loss in total knee arthroplasty (TKA). By transcollation of soft tissues below 100°C, bipolar sealers intend to reduce bleeding and tissue damage, compared with conventional electrocautery. Existing studies report contradictory findings about the performance of bipolar sealers. The purpose of this study was to evaluate the effect of a bipolar sealer on blood loss, transfusions, hospital length of stay (LOS), and functional scores in primary TKA. In this single-center prospective study, 101 patients, undergoing primary TKA in a fast-track setting without tourniquet use, were randomly assigned to either (1) the study group which was operated with a bipolar sealer or (2) the control group operated with conventional electrocautery. The study cohort comprised 49 men and 52 women, aged 71.1 ± 8.8 years. There was no significant difference between the bipolar sealer group and the control group in terms of blood loss at day 3 (1,240 ± 547.4 vs. 1,376 ± 584.4 mL; p = ns [not significant]), transfusion rate (10 vs. 4%; p = ns), surgery time (48.2 ± 10.8 vs. 46.6 ± 9.1 minute; p = ns) or LOS (4.1 ± 2.7 vs 4.3 ± 2.0 days; p = ns). At a mean follow-up of 63.3 ± 4.9 days, there was no significant difference between the bipolar sealer group and the control group in terms of net improvement of Knee Society Score (KSS) knee (26.0 ± 16.7 vs. 23.7 ± 12.3; p = ns) and KSS function (20.4 ± 19.3 vs. 20.8 ± 19.9; p = ns). Compared with the use of conventional electrocautery in primary TKA without tourniquet, we found no effect of bipolar sealer use on blood loss, transfusion rates, LOS, or functional recovery. This is a Level II, prospective cohort study.

Massive rotator cuff tears are challenging to treat, with few or no studies on long-term outcomes of repair. The purpose of this study was to report 10-year outcomes following repair of massive posterosuperior rotator cuff tears, with and without extension into the subscapularis, and to determine prognostic factors that could influence clinical scores and retear rates.The records of 234 patients who underwent repair of a massive posterosuperior rotator cuff tear at a total of 15 centers were retrieved. Patients were asked to return for evaluation at 10 years; 78 patients could not be contacted, 7 had died, and 19 had undergone a reoperation. A total of 130 patients (68% men) with a mean age (and standard deviation) of 56.1 ± 7.7 years (range, 26 to 79 years) were evaluated clinically, and 102 of them were also evaluated using magnetic resonance imaging (MRI). The tear was confined to the supraspinatus and infraspinatus tendons in 94 shoulders and also involved the superior portion of the subscapularis in 36 shoulders. Univariable and multivariable regressions were performed to determine whether 10-year total Constant-Murley scores and repair integrity were associated with patient characteristics, tear patterns, or repair techniques.In the study cohort, complications were noted in 14 shoulders (11%) (stiffness in 10 and infection in 4). For the 130 shoulders evaluated clinically, the mean total Constant-Murley score improved from 53.1 ± 15.9 (range, 14 to 83) preoperatively to 78.5 ± 11.3 (range, 36 to 98) at 10 years. Of the 102 shoulders evaluated using MRI, 32 had a retear (Sugaya type IV or V). Of the 19 shoulders that underwent a reoperation (excluded from the study cohort), 9 had a retear. The overall prevalence of retears was 34%. Multivariable regression analysis revealed a significant association between the 10-year Constant-Murley score and preoperative retraction of the infraspinatus tendon, but no association between retears and any of the variables. Involvement of the subscapularis had no significant effect on preoperative or postoperative Constant-Murley scores or retear rates.Patients who had repair of a massive posterosuperior rotator cuff tear maintained considerable improvements in clinical and radiographic outcomes at 10 years. Partial concomitant tears of the subscapularis did not affect the total postoperative Constant-Murley scores or retear rates.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

There is no present consensus on the most reliable anatomical landmarks or axes for tibial rotational alignment in total knee arthroplasty (TKA). The goal was therefore to review the literature and compare accuracy and repeatability of different axes for tibial baseplate rotation in TKA. Medline and Embase were searched for articles that reported accuracy in terms of error or discrepancy from the trans-epicondylar axes (TEA), and/or repeatability in terms of intraclass correlation coefficient, of one or more axes used for tibial baseplate rotation in TKA. Twenty-one articles met criteria, and their data were extracted and tabulated. The selected articles evaluated 15 different axes, 13 for reliability, 12 for repeatability. The lowest errors or discrepancies from the projected TEA were reported for the original ‘Akagi line’ (posterior cruciate ligament posteriorly to medial border of tibial tuberosity), its variant using the sulcus of the tibial spines as anterior landmark, as well as the anterior tibial border and the curve-on-curve technique. The best inter-observer repeatabilities were reported for ‘Akagi line’ variants that use the geometric centre of the tibial plateau posteriorly and the medial border of the tibial tuberosity, or the medial sixth of the patellar tendon anteriorly. Considering accuracy and repeatability simultaneously, only two axes were found to satisfy both criteria consistently: the original ‘Akagi line’ and the anterior tibial border. Because of the small number of studies found, the collected evidence remains insufficient to recommend reference axes for intra-operative rotational alignment of the tibial baseplate in TKA. A combination of two or more anatomical landmarks or projected axes could be used to ensure adequate tibial baseplate rotation, while considering individual patient morphology and implant design to optimize knee kinematics and prevent prosthetic overhang. Level IV, systematic review of level III and IV studies.

The study aimed to compare trochlear profiles in recent total knee arthroplasty (TKA) models and to determine whether they feature improvements compared to their predecessors. The hypothesis was that recent TKA models have more anatomic trochlear compartments and would display no signs of trochlear dysplasia.The authors analyzed the geometry of the 6 following TKA models using engineering software: PFC and Attune (DePuy), NexGen and Persona (Zimmer), Noetos and KneeTec (Tornier). The mediolateral trochlear profiles were plotted at various flexion angles (0°, 15°, 30° and 45°) to deduce the sulcus angle.Analysis of sulcus angles reveals general convergence of recent designs towards anatomic values. At 0° of flexion, sulcus angles of recent implant models were between 156.0-157.4°, while those of previous generation models between 154.5-165.5°. At 30° of flexion, sulcus angles of recent models also lie within 145.7-148.6°, but those of previous models are between 149.5-152.0°. All three manufacturers deepened their trochlear profile at 30° of flexion in recent models compared to earlier designs. Sulcus angles converge towards anatomic values but still exceed radiologic signs of dysplasia by 2-5°.Recent TKA designs have more anatomic trochlear geometries than earlier TKA models by the same manufacturers, but trochlear compartments still exceed radiologic signs of trochlear dysplasia by 2° to 5°. The hypothesis that recent TKA models display no signs of trochlear dysplasia is therefore refuted. Surgeons should be aware of design limitations to optimize choice of implant and extensor mechanisms alignment.IV geometric implant analysis.