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PURPOSE: To analyze the outcome of surgical treatment of tarsal coalition, assess the role of the surgical technique, as well as of coalition size and type on outcomes. METHODS: The search followed the Preferred Reporting Items of Systematic Review and Meta-Analysis and was performed in four databases: MEDLINE, Central, Scopus and Web of Science. The protocol has been registered in the international prospective register of systematic reviews. Patient-reported outcomes (PROMs), complications, revisions and radiographic recurrence were collected. Risk of bias was assessed using MINORS criteria. A random-effects model for meta-analysis was applied for analysis of data heterogeneity. RESULTS: Twenty-five studies including 760 tarsal coalitions were included and had a weighted average follow-up of 44 months. Studies scored fair to poor on the risk of bias assessment with a mean MINORS score of 67% (44-81%). In 77.8% (37.5-100%) of surgically treated tarsal coalitions, good/excellent/non-limiting or improved PROMs were reported. Calculated data heterogeneity was moderate (I2 = 57%). Open bar resection with material interposition had a clinical success rate of 78.8% (50-100%). Complications occurred in 4.96% of cases. Coalition size did not prove to be a determining factor in postoperative outcome. The influence of the coalition type was not investigated by any of the studies. CONCLUSION: Data on outcomes of surgical management for tarsal coalitions is limited to retrospective case series with high risk of bias and moderate data heterogeneity. In about ¾ of cases, open resection and interposition of material results in improved PROMs. The arbitrary margin of ≥ 50% of TC coalition size in relation to the posterior facet has little importance in surgical decision-making. None of the studies reported on the influence of the coalition type on postoperative clinical success.

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BACKGROUND: It is unclear whether there is a difference in the incidence of postoperative fever (POF) between hip, knee and shoulder arthroplasty. The influence of a trauma setting has not been investigated. METHODS: A retrospective review was performed on 675 joint replacement surgeries (hip, knee, shoulder arthroplasty) in an elective or trauma setting over a 2 year period (2016-2018). Patient demographics and perioperative/postoperative parameters were investigated. The fever curve was characterized. The results and costs of any fever-related diagnostic workup were reviewed. RESULTS: A total of 89 patients (13.2%) experienced a POF ≥ 38.0 °C, only 21 patients (3.1%) a POF ≥ 38.5 °C (of the latter: 4.6% of hip arthroplasties, 0.6% of knee arthroplasties, 0% of shoulder arthroplasties). There was a significantly greater risk (OR 3.88) for POF ≥ 38.5 °C in trauma total hip arthroplasty (THA) compared to elective THA (10.6 vs. 3.0%; p < 0.01). Differences in POF rate between the various joint areas were statistically insignificant when comparing only elective and trauma cases with each other, even though there was a trend for higher rates in hip surgery. Patients experiencing POF ≥ 38.5 °C were more often males (p < 0.01) and had an increased intraoperative blood loss (p = 0.03) and longer hospital stay (p < 0.01). There was only 1/89 POF patients developing an early periprosthetic joint infection. The cost of a positive fever workup (3/27 patients, 11.1%) leading to a new diagnosis and treatment was 2045 US$. CONCLUSION: POF ≥ 38.5 °C was more frequent in traumatic THA compared to elective THA. A trend of difference between POF rates between the different joint areas was statistically insignificant after separating elective and traumatic cases. The risk of developing an early periprosthetic joint infection was not increased in POF. A fever-related diagnostic workup was rarely helpful in the absence of clinical symptoms.

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Background: Reverse total shoulder arthroplasty (RTSA) has become an established treatment for cuff arthropathy, severe osteoarthritis and in certain fracture cases. Due to the increasingly aging population, patients who have already exceeded their life-expectancy pose a significant challenge to the shoulder surgeon. Methods: Patients older than 83 years who received a RTSA were included. Elective cases were compared to fracture cases. Patient demographics, hospital stay length, complication rate, functional outcome, patient reported outcome scores and mortality were assessed retrospectively. Results: We included 110 cases, 48 in the elective group and 62 in the fracture group. The average age at time of surgery was 86.6 ± 3.5 years. Mean follow-up was 30 months. Elective cases had a significant shorter hospital stay length (P = .014). Functional outcome scores showed better results for the elective group with ASES 79 ± 12 vs 69 ± 19 (P = .07), QuickDASH 29 ± 16 vs 37 ± 21 (P = .22), subjective shoulder value 86 ± 14 vs 75 ± 19 (P = .04*) and VAS .7 ± 1.5 vs 2.1 ± 2.5 (P = .02*). There was no significant difference in ROM and mean quality-adjusted-life-years (QALY) with 3.2 ± 1.8 vs 3.5 ± 2.5 years (P = .69). The complication rate requiring surgical intervention was 2.4% in the elective and 6.5% in the fracture group. The 1-year mortality was 3 (6%) respectively 9 (15%). Conclusion: RTSA in elderly patients can be successful with good functional outcomes. Age should not be a contraindication. Instead, the patient's activity level and quality of life should be taken into account. Elective RTSA show better functional outcome scores and lower complication rates compared to RTSA in proximal humeral fractures.

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Background: In anatomic anterior cruciate ligament (ACL) reconstruction, graft placement through the anteromedial (AM) portal technique requires more horizontal drilling of the femoral tunnel as compared with the transtibial (TT) technique, which may lead to a shorter femoral tunnel and affect graft-to-bone healing. The effect of coronal and sagittal femoral tunnel obliquity angle on femoral tunnel length has not been investigated. Purpose: To compare the length of the femoral tunnels created with the TT technique versus the AM portal technique at different coronal and sagittal obliquity angles using the native femoral ACL center as the starting point of the femoral tunnel. The authors also assessed sex-based differences in tunnel lengths. Study Design: Descriptive laboratory study. Methods: Magnetic resonance imaging scans of 95 knees with an ACL rupture (55 men, 40 women; mean age, 26 years [range, 16-45 years]) were used to create 3-dimensional models of the femur. The femoral tunnel was simulated on each model using the TT and AM portal techniques; for the latter, several coronal and sagittal obliquity angles were simulated (coronal, 30°, 45°, and 60°; sagittal, 45° and 60°), representing the 10:00, 10:30, and 11:00 clockface positions for the right knee. The length of the femoral tunnel was compared between the techniques and between male and female patients. Results: The mean ± SD femoral tunnel length with the TT technique was 40.0 ± 6.8 mm. A significantly shorter tunnel was created with the AM portal technique at 30° coronal/45° sagittal (35.5 ± 3.8 mm), whereas a longer tunnel was created at 60° coronal/60° sagittal (53.3 ± 5.3 mm; P < .05 for both). The femoral tunnel created with the AM portal technique at 45° coronal/45° sagittal (40.7 ± 4.8 mm) created a similar tunnel length as the TT technique. For all techniques, the femoral tunnel was significantly shorter in female patients than male patients. Conclusion: The coronal and sagittal obliquity angles of the femoral tunnel in ACL reconstruction can significantly affect its length. The femoral tunnel created with the AM portal technique at 45° coronal/45° sagittal was similar to that created with the TT technique. Clinical Relevance: Surgeons should be aware of the femoral tunnel shortening with lower coronal obliquity angles, especially in female patients.

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BACKGROUND: The study aimed to (1) investigate the variability of the femoral ACL center in ACL-ruptured patients, (2) identify whether the currently available over-the-top femoral ACL guides could allow for anatomical reconstruction of the native ACL footprint. MATERIAL AND METHODS: Magnetic resonance images of 95 knees with an ACL rupture were used to create three-dimensional models of the femur. The femoral ACL footprint area was outlined on each model, and the location of the femoral ACL center was reported using an anatomical coordinate system. The distance of the femoral ACL center from the over-the-top position was measured. RESULTS: The femoral ACL center demonstrated a high intersubject variability ranging from 1.8 mm (9%) to 12.3 mm (60%) posterior and from 7.7 mm (37%) distal to 4.8 mm (23%) proximal using the posterior condyle circle reference. The average distance of the femoral ACL center from the over-the-top position was 1.9 ± 1.5 mm posterior and 13.8 ± 2.7 mm distal, respectively. The contemporary over-the-top femoral ACL aimers could restore the femoral ACL center in only 6.5% of the patients. CONCLUSIONS: The femoral ACL center demonstrated a high variation on its location, which resulted in a high intersubject variability from the over-the-top position. The contemporary over-the-top femoral tunnel guides do not provide sufficient offset to allow for an anatomical ACL reconstruction. Anteromedial-portal specific femoral ACL guides with a femoral offset ranging from 10 to 18 mm in the proximal/distal direction are required to restore the native ACL footprint.

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BACKGROUND: Anterior cruciate ligament (ACL) rupture is often accompanied by an injury to the anterolateral ligament (ALL) of the knee. Detailed knowledge of the ALL attachments in ACL-ruptured patients is essential for an anatomical ALL reconstruction to avoid knee over-constraint and successfully treat the residual rotational instability. The aim of the present study was to investigate the three-dimensional (3D), topographic anatomy of the ALL attachment in both ACL-ruptured and ACL-intact patients using 3 Tesla magnetic resonance imaging (3T MRI). METHODS: In the present, retrospective case-control study, the magnetic resonance images of 90 knees with an ACL-rupture and 90 matched-controlled subjects, who suffered a non-contact knee injury without an ACL-rupture, were used to create 3D models of the knee. The femoral and tibial ALL footprints were outlined on each model, and their position was measured using an anatomical coordinate system. RESULTS: The femoral origin of the ALL was located 4.9 ± 2.8 mm posterior and 3.8 ± 2.4 mm proximal to the lateral epicondyle in a non-isometric location in control subjects. In ACL-ruptured patients, it was located in a more posterior and distal, at 6.0 ± 1.9 mm posterior and 2.4 ± 1.7 mm proximal to the lateral epicondyle (p < 0.01), also in a non-isometric location. No difference was found in the tibial ALL insertion between groups. CONCLUSION: The femoral ALL origin was significantly different in ACL-ruptured patients compared to ACL-intact patients. The recommended femoral tunnel position for the anatomical ALL reconstruction, does not represent the femoral ALL origin in the ACL-ruptured knee.

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BACKGROUND: Aseptic loosening and periprosthetic osteolysis are frequent complications in total hip arthroplasty requiring revision surgery. Highly cross-linked polyethylene (HXLPE) implants have improved wear resistance, permitting larger femoral heads. However, such implants may experience surface cracking, mechanical failure, and oxidative damage. Vitamin E-infused HXLPE (VEPE) implants were therefore developed to reduce oxidation without compromising mechanical strength. We addressed the following questions: (1) Does femoral head size affect the midterm annual polyethylene wear rates of VEPE acetabular cups? (2) Does femoral head size affect the midterm migration rates of VEPE acetabular cups? (3) Are clinical outcomes affected by femoral head size? HYPOTHESIS: Annual wear rate, migration rate, and clinical outcomes of VEPE acetabular cups are independent of femoral head size. PATIENTS AND METHODS: This was a prospective, multicentre, observational study of patients that underwent total hip arthroplasty. Hips were grouped according to the size of femoral head implanted (28 mm, 32 mm, and 36 mm). We determined annual wear rate and migration rate of VEPE acetabular cups using the Einzel-Bild-Röntgen-Analyse software. Clinically, we assessed the Harris Hip Score and visual analog score for pain and satisfaction. RESULTS: We followed 253 patients (267 hips) for a mean of 55.0±20.6 months in the 28 mm, 46.2±21.4 months in the 32 mm, and 43.8±22.6 months in the 36 mm group. The annual wear rate was 0.025 mm per year from 1 year to the last follow-up and remained similar between the groups (p>0.05). Also, mean two-dimensional migration rates did not exceed 0.05 mm from 2 years to the last follow-up and remained similar between the groups (p=0.355). Finally, clinical outcomes also did not differ between the groups (p>0.05). Two patients required revision surgery. DISCUSSION: Femoral head size did not influence midterm annual wear rate, migration rate, and clinical outcomes of VEPE acetabular cups. Furthermore, wear and cup migration rates were below the reported values leading to osteolysis and aseptic loosening. Nevertheless, studies with extended follow-up periods will be necessary to confirm these results in the long term. LEVEL OF EVIDENCE: IV.

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BACKGROUND: There has been an evolution in cementless total hip arthroplasty (THA) with newer short stem designs aimed to preserve metaphyseal bone stock and facilitate implantation through minimally invasive approaches. While early subsidence has been correlated to aseptic loosening in conventional stems, there is a paucity of data regarding short stems. The current study aims to report on stem subsidence and mid-term clinical outcomes of a cementless, metaphyseal-anchored short femoral stem, specifically designed for the direct anterior approach (DAA). METHODS: Ninety-four consecutive patients (100 hips) with a minimum follow-up of 5 years following cementless THA were included in this single-center retrospective study. Subsidence was evaluated using the "Ein-Bild-Roentgen-Analyse" (EBRA). Periprosthetic radiolucency allocated to the zones of Charnley and Gruen was assessed. Additionally, demographic and implant-related factors potentially associated with increased subsidence and clinical outcomes were evaluated. RESULTS: At the last follow-up, the average stem subsidence was 1.98 ± 1.20 mm, with 48% of the implants demonstrating subsidence of > 2 mm. Periprosthetic radiolucency of > 2 mm was found in 26% of the implants in zone 1 and in 9% in zone 7, respectively. Neither the amount of subsidence nor proximal periprosthetic radiolucency was associated with aseptic loosening or worse clinical outcomes. CONCLUSIONS: Comparable to other proximally fixed short stem designs, the highest subsidence was observed within the first 3 months following implantation. No demographic or implant-related factors were found to have a statistically significant influence on stem subsidence. Periprosthetic radiolucency and subsidence of the AMISstem is not correlated with worse clinical outcomes at 5-year follow-up.

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BACKGROUND: Addition of vitamin E to polyethylene is theorized to reduce the potential for oxidative wear in acetabular components. This paper presents a multicenter prospective cohort study that reports on outcomes from use of a Vitamin E-infused highly cross-linked polyethylene acetabular cup. METHODS: Patients were recruited across nine medical institutions. Clinical outcome measures recorded were the Harris Hip Score, visual analogue score for pain and satisfaction. Evidence of implant loosening or osteolysis was collected radiologically. Cup survival and reasons for revision in relevant cases were also recorded. Data collection was undertaken preoperatively, at 6-12 weeks, 6 months, 1 year, 2 years, and 5 years. A total of 675 patients were recruited, with 450 cases available at final review. Data regarding cup survival was available to 8 years and 9 months postoperatively. RESULTS: Improvements in both the Harris Hip Score and visual analogue score for pain and satisfaction were recorded at all time points, with these being maintained through the length of follow-up. In total, 89% of cups were implanted within the Lewinnek safe zone. A lucent line was identified in one case, with no evidence of acetabular osteolysis observed throughout the follow-up period. Cup survival was 98.9% at 8 years and 9 months. No revisions for aseptic loosening were observed. CONCLUSIONS: The use of a vitamin E-infused polyethylene acetabular cup demonstrates reassuring patient-reported outcomes, radiological measures, and cup survival at medium to long-term follow-up.

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PURPOSE: The aim of the present study was to investigate the validity and reliability of the deep lateral femoral notch sign (DLFNS) in identifying a concomitant anterior cruciate ligament (ACL)/anterolateral ligament (ALL) rupture and predicting the clinical outcomes following an anatomical single-bundle ACL reconstruction. It was hypothesized that patients with a concomitant ACL/ALL rupture would have an increased DLFNS compared to patients without a concomitant ACL/ALL rupture. METHODS: The lateral preoperative radiographs and MRI images of 100 patients with an ACL rupture and 100 control subjects were evaluated for the presence of a DLFNS and ACL/ALL rupture, respectively. The patients were evaluated clinically preoperatively and at a minimum 1 year following the ACL reconstruction. A receiver operator curve (ROC) analysis was performed to define the optimal cut-off value of the DLFNS for identifying a concomitant ACL/ALL injury. The relative risk (RR) was also calculated to determine whether the presence of the DLFNS was a risk factor for residual instability or ACL graft rupture following an ACL reconstruction. RESULTS: The prevalence of DLFNS was 52% in the ACL-ruptured patients and 15% in the control group. At a minimum 1-year follow-up, 35% (6/17) of the patients with DLFNS > 1.8 mm complained of persistent instability, and an MRI evaluation demonstrated a graft re-rupture rate of 12% (2/17). In patients with a DLFNS < 1.8 mm, 8% (7/83) reported a residual instability, and the graft rupture rate was 2.4% (2/83). A DLFNS > 1.8 mm demonstrated a sensitivity of 89%, a specificity of 95%, a negative predictive value of 98%, and a positive predictive value of 89% in identifying a concomitant ACL/ALL rupture. Patients with a DLFNS > 1.8 mm had 4.2 times increased risk for residual instability and graft rupture compared to patients with a DLFNS ≤ 1.8 mm. CONCLUSIONS: A DLFNS > 1.8 mm could be a clinically relevant diagnostic tool for identifying a concomitant ACL/ALL rupture with high sensitivity and PPV. Patients with a DLFNS > 1.8 mm should be carefully evaluated for clinical and radiological signs of a concomitant ACL/ALL rupture and treated when needed with a combined intra-articular ACL reconstruction and extra-articular tenodesis to avoid a residual rotational instability and ACL graft rupture. LEVEL OF EVIDENCE: III.

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BACKGROUND: The purpose of this study was to compare the clinical and radiological outcomes following open reduction and internal fixation (ORIF) of Vancouver B2 periprosthetic femoral fractures versus stem revision (SR) surgery. METHODS: Between 2004 and 2018, 39 patients were treated with SR and 31 with ORIF for a Vancouver type B2. Mean follow-up was 40.4 months for the ORIF group and 43.5 months for the SR group. 22 of 31 stems in the ORIF group were uncemented, of which 7 (23%) were short stems. Perioperative complications, intraoperative blood loss, revision rate, and mortality were recorded. Functional outcomes included Harris Hip Score, Parker Mobility Score and hip abductor strength. RESULTS: Both groups did not differ in the American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, body mass index, age, and sex. Compared to SR, patients treated with ORIF had a decreased blood loss, transfusion rate, operation duration, and mortality. Total complication and re-operation rates were similar. The relative risk for complication and re-operation was 0.5 and 0.7, respectively, in favour of ORIF. CONCLUSIONS: ORIF might be a valuable alternative to SR in the treatment of Vancouver type B2 periprosthetic fractures with shorter operation duration, lower blood loss and similar complication rate compared to SR. Moreover, re-stabilization seems possible irrespective of stem's design or fixation technique. LEVEL OF EVIDENCE: Level III.

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PURPOSE: The present study aimed to investigate the three-dimensional topographic anatomy of the anterior cruciate ligament (ACL) bundle attachment in both ACL-rupture and ACL-intact patients who suffered a noncontact knee injury and identify potential differences. METHODS: Magnetic resonance images of 90 ACL-rupture knees and 90 matched ACL-intact knees, who suffered a noncontact knee injury, were used to create 3D ACL insertion models. RESULTS: In the ACL-rupture knees, the femoral origin of the anteromedial (AM) bundle was 24.5 ± 9.0% posterior and 45.5 ± 10.5% proximal to the flexion-extension axis (FEA), whereas the posterolateral (PL) bundle origin was 35.5 ± 12.5% posterior and 22.4 ± 10.3% distal to the FEA. In ACL-rupture knees, the tibial insertion of the AM-bundle was 34.3 ± 4.6% of the tibial plateau depth and 50.7 ± 3.5% of the tibial plateau width, whereas the PL-bundle insertion was 47.5 ± 4.1% of the tibial plateau depth and 56.9 ± 3.4% of the tibial plateau width. In ACL-intact knees, the origin of the AM-bundle was 17.5 ± 9.1% posterior (p < 0.01) and 42.3 ± 10.5% proximal (n.s.) to the FEA, whereas the PL-bundle origin was 32.1 ± 11.1% posterior (n.s.) and 16.3 ± 9.4% distal (p < 0.01) to the FEA. In ACL-intact knees, the insertion of the AM-bundle was 34.4 ± 6.6% of the tibial plateau depth (n.s.) and 48.1 ± 4.6% of the tibial plateau width (n.s.), whereas the PL-bundle insertion was 42.7 ± 5.4% of the tibial plateau depth (p < 0.01) and 57.1 ± 4.8% of the tibial plateau width (n.s.). CONCLUSION: The current study revealed variations in the three-dimensional topographic anatomy of the native ACL between ACL-rupture and ACL-intact knees, which might help surgeons who perform anatomical double-bundle reconstruction surgery. LEVEL OF EVIDENCE: III.

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PURPOSE: The aims of the present study were (1) to investigate the tibial footprint location of the anterior cruciate ligament (ACL) in both ACL-ruptured and ACL-intact patients, (2) to identify the relationship of the tibial footprint to the anterior root of the lateral meniscus (ARLM) and medial tibial spine (MTS), and (3) to evaluate the reliability of the ARLM and MTS for identifying the center of the tibial ACL footprint. METHODS: Magnetic resonance images of 90 knees with ACL rupture and 90 matched-controlled knees were used to create three-dimensional models of the tibia. The tibial ACL footprint was outlined on each model, and its location was measured using an anatomical coordinate system. RESULTS: No significant difference in the location of the tibial footprint was found between ACL-ruptured and ACL-intact knees. The tibial ACL footprint was located in very close proximity to the ARLM, especially in the M/L direction. The safe zone of tibial tunnel reaming for avoiding damage to the ARLM was 2.6 mm lateral to the center of the native tibial footprint. Both the ARLM and MTS were reliable intraoperative landmarks for identifying the tibial footprint. CONCLUSIONS: Orthopedic surgeons should be aware of the safe zone of tibial tunnel reaming for avoiding injury to the ARLM. Both the ARLM and MTS might be reliable landmarks for identifying the center of the tibial ACL footprint and may facilitate tibial tunnel placement during anatomical single-bundle ACL reconstruction, especially in cases of revision where the tibial ACL stump is not available. LEVEL OF EVIDENCE: Level III.

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BACKGROUND: Female sex is an independent risk factor for an anterior cruciate ligament (ACL) injury, as the incidence of an ACL rupture is 4- to 6-fold higher in female athletes compared with their male counterparts. The ACL attachment location as a potential risk factor for the increased ACL rupture rate in women has never been reported in the literature. PURPOSE/HYPOTHESIS: The purpose of the present study was to investigate the 3-dimensional topographic anatomy of the ACL bundle attachment in female and male patients, with and without an ACL rupture, and identify potential sex-related differences. We hypothesized that the ACL attachment location would be significantly different between men and women, in both the intact- and ruptured-ACL states. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Magnetic resonance images of the knee from 90 patients (55 men, 35 women) with a ruptured ACL and 90 matched controls (55 men, 35 women), who suffered a noncontact knee injury without ACL rupture, were used to create 3-dimensional models of the femur and tibia. The ACL bundles' origin and insertion were outlined on each model, and their location was measured using an anatomical coordinate system. A 2-way analysis of variance was used to compare the ACL attachment location between male and female patients, with and without an ACL rupture. RESULTS: No significant differences were found between female and male participants regarding ACL attachment location (femoral origin and tibial insertion). Patients with a ruptured ACL demonstrated a significantly different ACL origin compared with the participants with an intact ACL by an average difference of 8.9% more posterior (P < .05) and 4.0% more proximal (P < .05) in men and 13.0% more posterior (P < .05) and 5.5% more proximal (P < .05) to the flexion-extension axis of the knee in women. CONCLUSION: The ACL attachment location should not be considered a risk factor for the increased ACL rupture rates in female compared with male athletes. However, a more posterior and proximal location of the femoral ACL origin might be a predisposing factor to an ACL rupture regardless of sex.

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BACKGROUND: To date, only limited literature exists regarding revision of total hip arthroplasty (THA) through the direct anterior approach (DAA). However, as the popularity of the DAA for primary surgery is increasing, surgeons will be confronted with the challenge of performing revision surgery through the DAA. The aim of this study was to review the potential of the DAA in the revision setting and to report the clinical results, radiologic outcomes and complication rates of 63 patients undergoing revision THA through the DAA. METHODS: From 01/2009 to 08/2017, 63 patients underwent revision THA through the DAA. Depending on the performed procedure, patients were separated into 4 groups: liner and head exchange (21 patients), revision of the acetabular cup (26 patients), revision of the femoral stem (13 patients) or revision of both components (3 patients). Postoperative complications as well as the clinical and radiological outcome were assessed retrospectively. RESULTS: At a mean follow-up of 18 months, the overall complication and re-operation rates were 14.3% and 12.7%, respectively. Specifically, the complication and re-operation rates were 14.2% and 9.5% after liner and head exchange, 15.4% after revision of the acetabular cup, 15.3% after revision of the femoral stem and 0% after revision of both components. The mean postoperative HHS at 1 year postoperatively was 91 (range 74-100). CONCLUSION: The DAA offers appropriate exposure for exchange of mobile liners and acetabular cup revision. In selected cases with appropriate stem design, femoral stem revision through the DAA is feasible. However, surgeons should be aware of the technical difficulties related to femoral revision and be prepared to extend the approach distally or perform a trochanteric osteotomy.

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BACKGROUND: Implant malpositioning, low surgical caseload, and improper patient selection have been identified as essential factors, which could negatively affect the longevity of unicompartmental knee arthroplasty (UKA). The aim of the current study was to evaluate the impact of the surgeon's caseload on patient selection, component positioning, as well as component survivorship and functional outcomes following a PSI-UKA. METHODS: A total of 125 patient-specific instrumented (PSI) UKA were included. One hundred and two cases were treated by a high-volume surgeon (usage 40%) and 23 cases by a low-volume surgeon (< 10 cases/year, usage 34%). Preoperative UIS, as well as the postoperative clinical and radiologic outcome, were assessed retrospectively. RESULTS: Irrespective of the surgeon's UKA caseload, PSI allowed good accuracy in component positioning (p > 0.05). The high-volume surgeon had a more strict indication for UKA with 89% showing a UIS > 25 (considered a good indication) compared to 70% for the low-volume surgeon (p = 0.016). The low-volume surgeon achieved worse results regarding functional outcome (p < 0.05) and a tendency toward an increased risk for UKA failure (p = 0.11) compared to the high-volume surgeon. CONCLUSION: Due to potential selection errors, mostly connected to a low UKA-caseload, low-volume UKA surgeons might achieve worse outcomes. Very strict indications for UKA might be recommended in low-volume surgeons to achieve excellent clinical outcomes following a UKA.

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BACKGROUND: Direct fixation of posterior malleolar fractures has been shown to lead to higher accuracy of fracture reduction compared to an indirect anterior to posterior fixation but lacks long-term clinical results. This study shows the mid- to long-term clinical and radiological outcome after direct fixation of the posterior malleolus through a posterolateral approach. MATERIALS AND METHODS: Thirty-six patients with an ankle fracture including a posterior malleolar fragment (23 × AO-44C, 12 × AO-44B, 1 × unclassifiable) treated with direct fixation of the fragment through a posterolateral approach were retrospectively evaluated. There were 24 females (67%) with a mean age of 63 (range 34-80) years and a BMI of 28 (range 19-41) kg/m2 at the time of surgery. An initial fracture-dislocation was seen in 67%. The clinical outcome was assessed with the Visual Analog Scale (VAS, 0-10 points) and the American Foot and Ankle Society (AOFAS, 0-100 points) score. Posttraumatic osteoarthritis was recorded with the Van Dijk Classification (grade 0-III). Subgroup analyses of patient- and fracture-associated risk factors (age, BMI, smoking, fracture-dislocation, postoperative articular step-off) were assessed to reveal possible negative prognostic predictors. RESULTS: After a mean follow-up of 7.9 (range 3-12) years, the median VAS was 1 (IQR 0-2) point, and the median AOFAS score was 96 (IQR 88-100) points. Ankle range of motion measurements showed a significant, but clinically irrelevant, difference in plantar- and dorsiflexion between the affected and unaffected ankle. 92% of the patients were very satisfied or satisfied with the postoperative course. 89% had no preoperative signs of ankle osteoarthritis. Osteoarthritis progression was seen in 72%, with 50% showing grade II or III osteoarthritis at the final follow-up. No significant negative prognostic factors for a worse clinical outcome could be detected. CONCLUSION: Direct fixation of posterior malleolar fractures through a posterolateral approach showed good clinical mid- to long-term results with a high satisfaction rate but substantial development of posttraumatic ankle osteoarthritis. Further studies should include CT analysis of the preoperative fracture morphology and even, perhaps, the postoperative reduction accuracy to evaluate the benefit of posterior malleolar fracture reduction in preventing ankle osteoarthritis in the long term. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

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INTRODUCTION: Due to demographic changes, the annual incidence of femoral neck fractures (FNF) in patients reaching the 9th and 10th decade of life is increasing. Although active and cognitively intact elderly patients could benefit from total hip arthroplasty (THA) in case of a FNF, there is no clear consensus on whether THA should be performed in this particular subgroup of patients with very advanced age. The purpose of this study was to report the complication rate, mortality, clinical outcomes and quality-adjusted life year (QALY) gained in patients treated with total THA for FNF, while having exceeded the mean life expectancy at the time of surgery, compared to a younger control group. MATERIALS AND METHODS: Patients treated with THA through a direct anterior approach (DAA) for FNF and exceeding the average life expectancy in Switzerland (age ≥ 83 y, n = 45) were matched for gender, body mass index (BMI) and ASA score with patients under the age of 83 (age = 65-83, n = 45). Perioperative complications, clinical and radiologic outcomes, as well as mortality were compared between groups. RESULTS: Total complication rate did not differ significantly with 22.2% in the older group compared to 17.8% in the control group. The 30-day and 1-year mortality was slightly but not significantly higher in the older group (2.2% and 8.9% vs. 2.2% and 2.2%). The average QALY gained was 3.4 years and 4.1 years for the older group and their younger counterparts, respectively. CONCLUSION: THA through the DAA for FNF in cognitively intact and active patients might be a credible and safe option even after reaching mean life expectancy with excellent functional outcomes and similar surgery-related complications compared to patients younger than 83 years. Our results imply that an advanced age should not be considered a contraindication for THA in case of a FNF.

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INTRODUCTION: Proximal humeral fracture is a common cause of morbidity in the elderly and poses a challenge for the orthopedic surgeon. Open reduction and internal fixation (ORIF) with a locking plate is associated with high rate of secondary implant-related complications (IRC). Early implant removal could potentially reduce the risk of IRC and further improve the outcome in relatively asymptomatic patients. The purpose of this study was to evaluate the clinical and radiologic outcomes following implant removal. METHODS: A total of 56 patients with an average age of 63 ±â€¯13 years and a mean follow-up of 29 months were evaluated retrospectively following removal of a locking plate in the proximal humerus. Postoperative functional outcomes were evaluated with the Constant-Score, Subjective shoulder value and Quick-DASH score. RESULTS: Early implant removal resulted in high functional outcomes with 96% of the patients reporting an improvement of their shoulder function following implant removal. No intraoperative complications were reported. Avascular necrosis (AVN) of the humeral head occurred in 12.5% of the patients, but no secondary screw cut-out was reported. CONCLUSION: Early implant removal might be a safe option to avoid secondary IRC with significant subjective functional improvement also in asymptomatic patients. Although early implant removal cannot reverse the process of AVN, it could potentially prevent secondary IRC and subsequent glenohumeral cartilage destruction.