Abstract Introduction: Short stems have been designed with the purpose of preserving bone tissue, decreasing the incidence of thigh pain and facilitating surgical techniques. The aim of our study was to assess whether a shortened tapered conventional stem was able to reduce the incidence of thigh pain.Methods:Between March 2010 and December 2012, 200 patients were enrolled in the study. Visual analogue scale (VAS) that included mapping of the pain, Harris Hip Score (HHS), Short Form-12 (SF-12) and radiographic outcomes were evaluated prior to surgery as well as at 6, 12 and 24 months post-operatively.Results: After 6 months, 6 patients (3%) had thigh pain. After 12 months, 3 patients (1.5%) complained about thigh pain. After 2 years, 2 patients (1%) had thigh pain. There was no correlation between pain and clinical, radiological, or demographic variables.Conclusion:The shortened tapered conventional stem resulted in a lower incidence of thigh pain for up to 2-years following surgery, compared with conventional or other short stems.

The following office tip describes four patients that underwent primary total knee arthroplasty and developed posterolateral knee pain at a mean follow-up duration of 1.6 months postoperatively. The first patient in this series noted substantial pain lying in bed (in a lateral decubitus position with the operative leg up) while attempting to abduct her leg to adjust her sheet in bed. A thorough clinical and radiographic work-up was performed. This patient’s posturing in bed (and subsequent physical exam maneuver) led to a presumptive diagnosis of popliteal tendinopathy. The diagnosis was confirmed arthroscopically by identifying a frayed and inflamed popliteal tendon. After undergoing arthroscopic popliteal tendon release, the patient noted complete pain relief while retaining coronal stability in both flexion and extension. The following office tip defines a previously undescribed clinical diagnostic examination for popliteal tendinopathy that was identified based on a patient’s symptomatology and subsequently utilized to identify three additional cases of arthroscopically confirmed popliteal tendinopathy.

Background: Extensor mechanism failure secondary to knee replacement could be due to tibial tubercle avulsion, Patellar tendon rupture, patellar fracture or quadriceps tendon rupture. An incidence of Patella tendon rupture of 0.17% and Quadriceps tendon rupture of around 0.1% has been reported after Total knee arthroplasty. These are considered a devastating complication that substantially affects the clinical results and are challenging situations to treat with surgery being the mainstay of the treatment.Case Description: We report here an interesting case of a patellar tendon rupture of one knee and Quadriceps tendon rupture of the contralateral knee following simultaneous bilateral knee replacement in a case of inflammatory arthritis patient. End to end repair for Quadriceps tear and augmentation with Autologous Hamstring tendon graft was done for Patella tendon rupture.OUTCOME: Patient was followed up for a period of 1 year and there was no Extension lag with a flexion of 100 degrees in both the knees.DISCUSSION: The key learning points and important aspects of diagnosing these injuries early and the management techniques are described in this unique case of bilateral extensor mechanism disruption following knee replacements.

In recent years, specialized, non-sterile, traction table systems have facilitated Direct Anterior Approach (DAA) hip arthroplasty. To combat the potential downsides of these traction systems, a sterile, intra-operative retractor option has emerged as a means to access the surgical site more easily, minimize soft-tissue trauma, and reduce the degree of required human assistance. This chapter describes the setup, surgical approach, and early results of a retractor system (the Phantom MIS Anterior Hip Retractor system [TeDan Surgical Innovations, Inc. {TSI}, Houston, Texas, US Patent # 8,808,176 B2]), which uses a standard operating table, allows preparation of both lower extremities free in the surgical field, is compatible with fluoroscopy, and aids in both acetabular and femoral exposure, preparation, and implantation. Early outcome data indicates that this system significantly minimizes the need for surgical assistance, while allowing for safe and effective DAA performance, facilitating the procedure for high-volume surgeons and shortening the learning curve for surgeons new to the procedure.

Purpose. To evaluate early and mid-term risk factors and dislocation rates in the posterior surgical approach in three separate community private practices using a short curved neck-sparing total hip stem design.Material and Methods.The three senior authors performed 338 short curved neck-sparing stem designs since April 2010 to June 2014. Various cementless acetabular components were used for all three surgical centers based on preoperative and intraoperative risk factors. All cases were reviewed retrospectively for incidence of dislocation after surgery.Version and inclination of the acetabular component and version of the femoral component were assed intra-operatively prior to final implantation. Various risk factors were reviewed including surgical approach, cup position, combined cup and stem positioning, and femoral head size.There have been significant papers in the past ten years that have recommended large head diameters to reduce the chances of head/neck mechanical impingement. Since the neck-sparing designs have a potentially increased risk of mechanical impingement head diameters were restricted to 32 mm or larger. In the smaller patient profile if a 32 mm head size could not be reached a dual-mobility style implant was chosen or stem choice was changed to a conventional style design.Results.Historically the posterior approach has had higher reports of dislocations as compared to direct anterior, anterolateral or straight lateral approach in conventional cemented and cementless implant designs. Older neck-sparing designs of conventional stem length by Freeman, Townley and Whiteside have not reported any increased dislocation problems but these stems have been associated with modified acetabular component designs, including the short curved neck sparing design of Pipino back in the 1980s.Incidence of dislocation in our series utilizing a short curved neck-sparing stem with more traditional hemispherical cementless acetabular components was 3 or 0.88%.Conclusion.Neck sparing stem designs do save significantly more bone and require less soft tissue dissection as compared to conventional cementless stem designs. Mechanical risk factors are increased with the use of short curved neck-sparing stem designs. Careful pre-operative and intra-operative evaluation does reduce the risk factors resulting in low and in some cases lower than previous published rates with conventional style stems.Short curved neck sparing stems do provide safe and reliable reproduction of the joint mechanics in routine primary total hip arthroplasty in both short and mid term results.Key Words: hip, arthroplasty, posterior approach, dislocation, neck sparing, and risk factors

Poly(ether-ether-ketone) (PEEK)s are a group of polymeric biomaterials with excellent mechanical properties, chemical stability, and nonmagnetism. In the present study, we propose a novel self-initiated surface graft polymerization technique, using which we demonstrate the fabrication of a highly hydrophilic and biocompatible nanometer-scale layer on the surfaces of PEEK and carbon fiber-reinforced PEEK (CFR-PEEK) by the photoinduced graft polymerization of 2-methacryloyloxyethyl phosphorylcholine (MPC) without using any photoinitiators. The thus formed hydrophilic and smooth 100-nm-thick PMPC-grafted layer caused a significant reduction in the sliding friction of the bearing interface because the thin water film and hydrated PMPC layer acted as extremely efficient lubricants (so-called fluid-film lubrication or hydration lubrication). Fluid-film lubrication suppressed the direct contact of the counter-bearing surface with the PEEK substrate and thus reduced the frictional force. A PMPC-grafted layer is therefore expected to significantly increase bearing durability. Furthermore, the PMPC-grafted layer shows unique phenomena, e.g., it prevents damage of the metal counter surface regardless of the carbon fiber content of CFR-PEEK. Smart PEEK using the self-initiated surface graft polymerization of MPC should lead to development of novel orthopedic bearings.Keywords: poly(ether-ether-ketone), 2-methacryloyloxyethyl phosphorylcholine, surface modification, photopolymerization, joint replacement, wear mechanism

Introduction: Obstruction of the surgical suction instrument is a common problem in orthopaedic surgery. Previous attempts have tried to address this problem. The ‘Super Sucker’ has a screen compartment that can be unclogged upon disassembly. The Yankauer sucker has small holes in its tip that strain larger bits of debris. The aim of this study is to clinically evaluate a new gas-actuated suction instrument in which a special screen at its tip is cleared, as needed, by a rapid burst of pressurized carbon dioxide gas.Methods: This IRB-approved, prospective, randomized study compared a gas-actuated suction instrument with the Super Sucker and Yankauer in 70 consecutive primary total joint arthroplasty cases. Outcome measures included: incidence of complete suction loss due to suction instrument obstruction; time lost while unplugging the suction instrument; number of additional suction instruments needed; and a subjective surgeon-assessed performance score (1 to 5, with 5 being most favorable) for type of suction instrument. Results: There were no cases in which the gas-actuated suction instrument could not be rapidly cleared of debris. The Super Sucker completely plugged in 71% of cases, requiring 67 minutes total to unplug (3.9 minutes per case, range 0 to 12 minutes). In four cases, replacement Super Suckers were required to finish the case. The Yankauer completely plugged in 47% of cases, requiring 52 minutes total to unplug (2.8 minutes per case, range 0 to 10 minutes). In three cases, replacement Yankauers were required to finish the case. The average performance score was 2.7 for the Super Sucker, 3.6 for the Yankauer, and 5 for the gas-actuated suction instrument on a scale of 1 to 5, with 5 being most favorable.Discussion: This study evaluated a suction instrument in which a screen tip prevents obstruction, and a burst of pressurized carbon dioxide gas clears debris from the tip. The new suction instrument was successful in 100% of cases, with considerably less time lost compared to the other suction instruments. The gas-actuated suction tool actively and rapidly cleared obstructive debris with minimal disruption to the surgical flow. Recent clinical experience has shown the gas-actuated suction tool to be particularly enabling in the settings of tourniquet-free total knee replacement, small incision total hip replacement, bipolar hemiarthroplasty, and revision total hip replacement.Keywords: suction, total joint arthroplasty, tourniquet-less, carbon dioxide gas

This study prospectively reviews 368 consecutive primary TKA’s, documenting the status of the PCL during 3 stages of the TKA procedure: 1) at initial arthrotomy, 2) after all bone cuts were made, and 3) after final balancing with all components in place. We found at initial presentation that 94% of PCL’s were intact. After the bone cuts were made only 51% of PCL’s remained intact. Finally, after knee balancing and all implants were in place, only 33% of PCL’s remained intact. Furthermore, 43% of PCL’s were attenuated at the final evaluation stage and were at risk for late PCL stretch-out. In this series, patients with a deficient or attenuated PCL were treated with an anterior stabilized bearing that could be utilized with a cruciate retaining femoral component. We advocate that a cruciate substituting bearing be routinely available when undertaking a cruciate retaining TKA.\nKey words: TKA, CR TKA, PCL, ACL, Anterior Stabilized, Primary \nLevel of Evidence: AAOS Therapeutic Study Level III

Most investigators credit Branemark (1965) in Sweden with the idea of a percutaneous, osteointegrated prosthesis which has been successful in dental implantation. [1] In 1997, R. Branemark reported on the first femoral intramedullary percutaneous device using a 12 cm screw-type device for a patient with an above-knee amputation. [2] In 1999, ESKA produced the Endo-Exo Femurprosthesis (EEFP) which was first implanted into the femoral canal of a young motorcyclist who lost his leg in an accident and subsequently used for a number of patients in Germany. There have been variations in the design, including some types to allow proximal fixation to other devices such as a hip replacement, but commonly the device is a modular, noncemented device that fits within the intramedullary canal of the femur and has a hardpoint attachment that exits through the skin. [3]Three of our co-authors (JK,RK, & TC) have been to Germany, studied this procedure and reviewed historical outcomes. The original device utilized a spongiosa surface of casted cobalt chrome that allows for a porous surface for bone ingrowth.

Modern hip resurfacing arthroplasty (HRA) with a metal-on-metal articulation has attracted many patients worldwide over the last 15 years for the potential benefits of high activity level and bone preservation. Good mid-term results are reported, especially in male patients. However, there is now a need for revision options for a subset of patients who will require early revision for unanticipated adverse local tissue reaction (ALTR) associated with the metal-on-metal articulation. We present a case of HRA conversion to total hip arthroplasty (THA) using a neck-sparing THA component.