Collaborative Team Training in Virtual Reality is Superior to Individual Learning For Performing Complex Open Surgery: A Randomized Controlled Trial.

OBJECTIVE: To assess whether multiplayer immersive Virtual Reality (iVR) training was superior to single-player training for the acquisition of both technical and nontechnical skills in learning complex surgery. BACKGROUND: Superior teamwork in the operating room (OR) is associated with improved technical performance and clinical outcomes. iVR can successfully train OR staff individually; however, iVR team training has yet to be investigated. METHODS: Forty participants were randomized to individual or team iVR training. Individually trained participants practiced alongside virtual avatar counterparts, whereas teams trained live in pairs. Both groups underwent 5 iVR training sessions over 6 weeks. Subsequently, they completed a real-life assessment in which they performed anterior approach total hip arthroplasty surgery on a high-fidelity model with real equipment in a simulated OR. Teams performed together, and individually trained participants were randomly paired up. Videos were marked by 2 blinded assessors recording the 'Non-Operative Technical Skills for Surgeons, Oxford NOn-TECHnical Skills II and Scrub Practitioners' List of Intraoperative Non-Technical Skills' scores. Secondary outcomes were procedure duration and the number of technical errors. RESULTS: Teams outperformed individually trained participants for nontechnical skills in the real-world assessment (Non-Operative Technical Skills for Surgeons: 13.1±1.5 vs 10.6±1.6, P = 0.002, Non-TECHnical Skills II score: 51.7 ± 5.5 vs 42.3 ± 5.6, P = 0.001 and Scrub Practitioners' List of Intraoperative Non-Technical Skills: 10 ± 1.2 vs 7.9 ± 1.6, P = 0.004). They completed the assessment 33% faster (28.2 minutes ± 5.5 vs 41.8 ± 8.9, P < 0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, P < 0.001). CONCLUSIONS: Multiplayer training leads to faster surgery with fewer technical errors and the development of superior nontechnical skills.

Medial bicompartmental arthroplasty patients display more normal gait and improved satisfaction, compared to matched total knee arthroplasty patients.

PURPOSE: Medial bicompartmental arthroplasty, the combination of ipsilateral medial unicompartmental and patellofemoral arthroplasty, is an alternative to total knee arthroplasty for patients with medial tibiofemoral and severe patellofemoral arthritis, when the lateral tibiofemoral compartment and anterior cruciate ligament are intact. This study reports the gait and subjective outcomes following medial bicompartmental arthroplasty. METHODS: Fifty-five subjects were measured on the instrumented treadmill at top walking speeds, using standard metrics of gait. Modular, single-stage, medial bicompartmental arthroplasty subjects (n = 16) were compared to age, body mass index, height- and sex-matched healthy (n = 19) and total knee arthroplasty (n = 20) subjects. Total knee arthroplasty subjects with pre-operative evidence of tricompartmental osteoarthritis or anterior cruciate ligament dysfunction were excluded. The vertical component of ground reaction force and temporospatial measurements were compared using Kruskal-Wallis, then Mann-Whitney test with Bonferroni correction (α = 0.05). Oxford Knee and EuroQoL EQ-5D scores were compared. RESULTS: Objectively, the medial bicompartmental arthroplasty top walking speed of 6.7 ± 0.8 km/h was 0.5 km/h (7%) slower than that of healthy controls (p = 0.2), but 1.3 km/h (24%) faster than that of total knee arthroplasty subjects (5.4 ± 0.6 km/h, p < 0.001). Medial bicompartmental arthroplasty recorded more normal maximum weight acceptance (p < 0.001) and mid-stance forces (p = 0.03) than total knee arthroplasty subjects, with 11 cm (15%) longer steps (p < 0.001) and 21 cm (14%) longer strides (p = 0.006). Subjectively, medial bicompartmental arthroplasty subjects reported Oxford Knee Scores of median 41 (interquartile range 38.8-45.5) compared to total knee arthroplasty Oxford Knee Scores of 38 (interquartile range 30.5-41, p < 0.02). Medial bicompartmental arthroplasty subjects reported EQ-5D median 0.88 (interquartile range 0.84-0.94) compared to total knee arthroplasty median 0.81 (interquartile range 0.73-0.89, p < 0.02.) CONCLUSION: This study finds that, in the treatment of medial tibiofemoral osteoarthritis with severe patellofemoral arthritis, medial bicompartmental arthroplasty results in nearer-normal gait and improved patient-reported outcomes compared to total knee arthroplasty. LEVEL OF EVIDENCE: III.

The compartmental approach to revision of partial knee arthroplasty results in nearer-normal gait and improved patient reported outcomes compared to total knee arthroplasty.

PURPOSE: This study investigated the gait and patient reported outcome measures of subjects converted from a partial knee arthroplasty to combined partial knee arthroplasty, using a compartmental approach. Healthy subjects and primary total knee arthroplasty patients were used as control groups. METHODS: Twenty-three patients converted from partial to combined partial knee arthroplasty were measured on the instrumented treadmill at top walking speeds, using standard gait metrics. Data were compared to healthy controls (n = 22) and primary posterior cruciate-retaining total knee arthroplasty subjects (n = 23) where surgery were performed for one or two-compartment osteoarthritis. Groups were matched for age, sex and body mass index. At the time of gait analysis, combined partial knee arthroplasty subjects were median 17 months post-revision surgery (range 4-81 months) while the total knee arthroplasty group was median 16 months post-surgery (range 6-150 months). Oxford Knee Scores and EuroQol-5D 5L scores were recorded at the time of treadmill assessment, and results analysed by question and domain. RESULTS: Subjects revised from partial to combined partial knee arthroplasty walked 16% faster than total knee arthroplasty (mean top walking speed 6.4 ± 0.8 km/h, vs. 5.5 ± 0.7 km/h p = 0.003), demonstrating nearer-normal weight-acceptance rate (p < 0.001), maximum weight-acceptance force (p < 0.006), mid-stance force (p < 0.03), contact time (p < 0.02), double support time (p < 0.009), step length (p = 0.003) and stride length (p = 0.051) compared to primary total knee arthroplasty. Combined partial knee arthroplasty subjects had a median Oxford Knee Score of 43 (interquartile range 39-47) vs. 38 (interquartile range 32-41, p < 0.02) and reported a median EQ-5D 0.94 (interquartile range 0.87-1.0) vs. 0.84 (interquartile range 0.80-0.89, p = 0.006). CONCLUSION: This study finds that a compartmental approach to native compartment degeneration following partial knee arthroplasty results in nearer-normal gait and improved patient satisfaction compared to total knee arthroplasty. LEVEL OF EVIDENCE: III.

Partial and Combined Partial Knee Arthroplasty: Greater Anterior-Posterior Stability Than Posterior Cruciate-Retaining Total Knee Arthroplasty.

BACKGROUND: Little is known regarding anterior-posterior stability after anterior cruciate ligament-preserving partial (PKA) and combined partial knee arthroplasty (CPKA) compared to standard posterior cruciate-retaining total knee arthroplasty (TKA). METHODS: The anterior-posterior tibial translation of twenty-four cadaveric knees was measured, with optical tracking, while under 90N drawer with the knee flexed 0-90°. Knees were tested before and after PKA, CPKA (medial and lateral bicompartmental and bi-unicondylar), and then posterior cruciate-retaining TKA. The anterior-posterior tibial translations of the arthroplasty states, at each flexion angle, were compared to the native knee and each other with repeated measures analyses of variance and post-hoc t-tests. RESULTS: Unicompartmental and bicompartmental arthroplasty states had similar laxities to the native knee and to each other, with ≤1-mm differences throughout the flexion range (P ≥ .199). Bi-unicondylar arthroplasty resulted in 6- to 8-mm increase of anterior tibial translation at high flexion angles compared to the native knee (P ≤ .023 at 80-90°). Meanwhile, TKA exhibited increased laxity across all flexion angles, with increased anterior tibial translation of up to 18 ± 6 mm (P < .001) and increased posterior translation of up to 4 ± 2 mm (P < .001). CONCLUSIONS: In a cadaveric study, anterior-posterior tibial translation did not differ from native laxity after PKA and CPKA. Posterior cruciate ligament-preserving TKA demonstrated increased laxity, particularly in anterior tibial translation.

Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty.

INTRODUCTION: Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty. MATERIALS AND METHODS: Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety. RESULTS: Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001). CONCLUSIONS: For scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world.

Can an Augmented Reality Headset Improve Accuracy of Acetabular Cup Orientation in Simulated THA? A Randomized Trial.

BACKGROUND: Accurate implant orientation reduces wear and increases stability in arthroplasty but is a technically demanding skill. Augmented reality (AR) headsets overlay digital information on top of the real world. We have developed an enhanced AR headset capable of tracking bony anatomy in relation to an implant, but it has not yet been assessed for its suitability as a training tool for implant orientation. QUESTIONS/PURPOSES: (1) In the setting of simulated THA performed by novices, does an AR headset improve the accuracy of acetabular component positioning compared with hands-on training by an expert surgeon? (2) What are trainees' perceptions of the AR headset in terms of realism of the task, acceptability of the technology, and its potential role for surgical training? METHODS: Twenty-four study participants (medical students in their final year of school, who were applying to surgery residency programs, and who had no prior arthroplasty experience) participated in a randomized simulation trial using an AR headset and a simulated THA. Participants were randomized to two groups completing four once-weekly sessions of baseline assessment, training, and reassessment. One group trained using AR (with live holographic orientation feedback) and the other received one-on-one training from a hip arthroplasty surgeon. Demographics and baseline performance in orienting an acetabular implant to six patient-specific values on the phantom pelvis were collected before training and were comparable. The orientation error in degrees between the planned and achieved orientations was measured and was not different between groups with the numbers available (surgeon group mean error ± SD 16° ± 7° versus AR 14° ± 7°; p = 0.22). Participants trained by AR also completed a validated posttraining questionnaire evaluating their experiences. RESULTS: During the four training sessions, participants using AR-guidance had smaller mean (± SD) errors in orientation than those receiving guidance from the surgeon: 1° ± 1° versus AR 6° ± 4°, p < 0.001. In the fourth session's assessment, participants in both groups had improved (surgeon group mean improvement 6°, 95% CI, 4-8°; p < 0.001 versus AR group 9°, 95% CI 7-10°; p < 0.001). There was no difference between participants in the surgeon-trained and AR-trained group: mean difference 1.2°, 95% CI, -1.8 to 4.2°; p = 0.281. In posttraining evaluation, 11 of 12 participants would use the AR platform as a training tool for developing visuospatial skills and 10 of 12 for procedure-specific rehearsals. Most participants (11 of 12) stated that a combination of an expert trainer for learning and AR for unsupervised training would be preferred. CONCLUSIONS: A novel head-mounted AR platform tracked an implant in relation to bony anatomy to a clinically relevant level of accuracy during simulated THA. Learners were equally accurate, whether trained by AR or a surgeon. The platform enabled the use of real instruments and gave live feedback; AR was thus considered a feasible and valuable training tool as an adjunct to expert guidance in the operating room. Although there were no differences in accuracy between the groups trained using AR and those trained by an expert surgeon, we believe the tool may be useful in education because it demonstrates that some motor skills for arthroplasty may be learned in an unsupervised setting. Future studies will evaluate AR-training for arthroplasty skills other than cup orientation and its transfer validity to real surgery. LEVEL OF EVIDENCE: Level I, therapeutic study.

The loading patterns of a short femoral stem in total hip arthroplasty: gait analysis at increasing walking speeds and inclines.

BACKGROUND: The purpose of this study was to examine the gait pattern of total hip arthroplasty (THA) patients with a new short femoral stem at different speeds and inclinations. MATERIALS AND METHODS: A total of 40 unilateral THA patients were tested on an instrumented treadmill. They comprised two groups (shorter stemmed THA n = 20, longer stemmed THA n = 20), both which had the same surgical posterior approach. The shorter femoral stemmed patients were taken from an ongoing hip trial with minimum 12 months postop. The comparative longer THR group with similar disease and severity were taken from a gait database along with a demographically similar group of healthy controls (n = 35). All subjects were tested through their entire range of gait speeds and inclines with ground reaction forces collected. Body weight scaling was applied and a symmetry index to compare the implanted hip to the contralateral normal hip. An analysis of variance with significance set at α = 0.05 was used. RESULTS: The experimental groups were matched demographically and implant groups for patient reported outcome measures and radiological disease. Both THA groups walked slower than controls, but symmetry at all intervals for all groups were not significantly different. Push-off loading was less favourable for both the shorter and longer stemmed THR groups (p < 0.05) depending on speed. CONCLUSIONS: Irrespective of femoral stem length, symmetry for ground reaction forces for both THA groups were returned to a normal range when compared to controls. However individual implant performance showed inferior (p < 0.05) push-off forces and normalised step length in both THR groups when compared to controls. LEVEL OF EVIDENCE: III.

The Effect of Hip Arthroplasty on Osteoarthritic Gait: A Blinded, Prospective and Controlled Gait Study at Fast Walking Speeds.

BACKGROUND: Painful unilateral cox arthrosis results in excessive forces passing through the "good leg." The impact of hip arthroplasty on contralateral leg gait has not been fully explored. We measured patients gait before and after arthroplasty, to answer 3 questions: (1) Are peak forces for the good legs outside the normal range? (2) Does arthroplasty protect contralateral limbs by reducing peak forces? and (3) Does arthroplasty result in a more symmetric and normal gait at fast walking speeds? METHODS: This prospective, controlled study, assessed ground reaction forces before and 13 months (range, 6-21 months) after hip arthroplasty. RESULTS: Peak ground reaction force in contralateral hips fell (1.45-1.38 times body weight, P = .04), whereas symmetry index maximum weight acceptance improved postoperatively (12.2 ± 11 vs 1.3 ± 6, P < .001). CONCLUSION: Although gait becomes more symmetrical, patients still experience higher peak loads than matched controls. These high forces may offer an explanation to the progression of arthrosis in lower limbs.

Downhill walking gait pattern discriminates between types of knee arthroplasty: improved physiological knee functionality in UKA versus TKA.

PURPOSE: To determine whether downhill walking gait pattern discriminates between different types of knee arthroplasty. METHODS: Nineteen unicompartmental knee arthroplasty (UKA) and fourteen total knee arthroplasty (TKA) patients who were well matched demographically and with high Oxford knee scores (OKS) for their operation type were evaluated at a minimum 1 year after their operation with downhill gait analysis. Nineteen healthy young subjects were used as controls. Downhill gait analysis was carried out on an instrumented treadmill that was ramped at the rear to produce a declination of 7°. All subjects after a period of habituation were tested for preferred and top downhill walking speed with associated ground reaction and temporospatial measurements. RESULTS: The UKA group had higher mean OKS (44.8 ± 2.9 vs 41.9 ± 4.7, p = 0.03) as predicted. The UKA group walked downhill 15% faster than the TKA group (1.75 ± 0.14 vs 1.52 ± 0.13 m/s, p < 0.0001) despite having the same cadence (134.9 ± 8.0 vs 133.9 ± 9.6 steps/min). This 15% difference in speed appeared largely due to a 15% increase in stride length (173 ± 14 vs 150 ± 17 cm, p = 0.0007) and normal weight acceptance, both of which were similar to the controls. CONCLUSION: Using an instrumented treadmill to test a commonly performed task, stride length when walking downhill highlights the functional differences between arthroplasty groups. Near normal restoration of physiological gait pattern was found in unicompartmentals as compared to total knee replacements. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Variable bone mineral density reductions post-unicompartmental knee arthroplasty.

PURPOSE: Radiolucencies are commonly observed in unicompartmental knee arthroplasty (UKA) patients within 1 year of arthroplasty. The objective of the study was to identify how the bone mineral density (BMD) changes up to 1 year post-arthroplasty. METHODS: Dual X-ray absorptiometry scans were obtained from 11 UKA patients at 10 days and 3, 6, and 12 months post-surgery. Patients were scanned in both anteroposterior and lateral knee orientations. RESULTS: Most subjects saw a large decline in BMD in the first 6 months following surgery, followed by some recovery in bone mass. The biggest change occurred under the tibial intercondylar eminence, which decreased significantly by an average of 18 % at 6 months and was 15 % at 1 year. The average bone loss under the tibial tray was low; however, the bone loss at the anterior portion was higher with a significant average decrease of 14 %. There was no change in BMD under the tibial keel. There was significant bone loss of 13 % under the femoral component; the regions anterior and posterior to the central femoral implant peg both had significant bone loss of 14 %. The bone response between patients was very variable, with some patients losing bone steadily, and others gaining it rapidly after an early fall. CONCLUSIONS: While the overall reduction in BMD under both components was low, it was significant and there was substantial individual variation superimposed on this. Improving our understanding of this response to surgery may impact on prosthesis survival. LEVEL OF EVIDENCE: Therapeutic study: case series with no comparison group, Level IV.

2D measurements of cup orientation are less reliable than 3D measurements.

BACKGROUND AND PURPOSE: 2D analysis of metal-on-metal (MoM) hip arthroplasty (HA) has been conducted in several large series on conventional radiographs with the use of Ein Bild Roentegen Analyse (EBRA) software, but there have been no comparisons with 3D analysis in the literature. The main aim of this study was to quantify the agreement in measurements of cup version of large-diameter MoM hips obtained by EBRA and by 3D computed tomography (3D-CT). The secondary aim was to quantify the agreement for cup inclination. Lastly, we wanted to determine the inter- and intra-observer reliability of both methods. PATIENTS AND METHODS: 87 MoM hips in 81 patients were analyzed for cup inclination and version in 2D on conventional radiographs using EBRA software. The results were compared with 3D measurements using CT. RESULTS: Cup version was underestimated by EBRA when compared to 3D-CT, by 6° on average with the pelvis supine and by 8° on average with the pelvis orientated to the anterior pelvic plane (APP). For inclination, the mean difference was no more than 1°. 53% of hips were within a 10° safe zone of 45° inclination and 20° version when measured by 3D-CT with the pelvis supine (and 54% with the pelvis in the APP). The proportion was only 24% when measured by EBRA. Inter- and intra-observer reliability of cup version is poorer using 2D analysis than when using 3D-CT. INTERPRETATION: Errors in version in 2D were due to the difficulty in delineating the cup rim, which was obscured by a large-diameter metal head of the same radio-opacity. This can be overcome with 3D analysis. The present study demonstrates that measurements using EBRA have poor agreement and are less reliable than those with 3D-CT when measuring cup version and inclination in MoM hips.

Computed tomography scanogram compared to long leg radiograph for determining axial knee alignment.

BACKGROUND AND PURPOSE: Supine computed tomography scanogram (CTS) is a commonly used alternative to weight bearing long leg plain radiograph (LLR) in measuring knee alignment. No published studies have validated its use in the native knee and the post-unicompartmental replacement knee (UKR). We quantified the difference in measurements obtained from CTS and LLR for knee alignment. PATIENTS AND METHODS: Supine CT scanograms and weight bearing long leg plain anteroposterior radiographs were obtained for 40 knees (in 25 patients), 17 of which were native, and 23 of which were post-UKR. The mechanical and anatomical axes of the tibio-femoral joint were measured. Bland-Altman plots were used to calculate the 1.96 standard deviation limits of agreement between CTS and LLR. Intraclass correlation was used to assess intra-rater and inter-rater reliability (where values > 0.81 indicate very good reliability). RESULTS: CTS and LLR were equally reliable in measurement of the mechanical and anatomical axes of the tibio-femoral joint (intraclass correlation coefficient (ICC) > 0.9 for all parameters). Statistically significant and clinically relevant differences were found between CTS and LLR in measurement of the mechanical axis (limits of agreement: UKR -3.2° to 6.3°; native -3.2° to 5.6°) and the anatomical axis (limits of agreement: UKR -3.7° to 8.7°; native -2.0° to 8.8°). INTERPRETATION: Although it is a reliable tool, CTS is not necessarily an accurate one for measurement of knee alignment when compared to LLR. We recommend that CTS should not be used as a substitute for LLR in measurement of the mechanical or anatomical axes of the knee.

Short uncemented stems allow greater femoral flexibility and may reduce peri-prosthetic fracture risk: a dry bone and cadaveric study.

BACKGROUND: Short femoral stems for uncemented total hip arthroplasty have been introduced as a safe alternative to traditional longer stem designs. However, there has been little biomechanical examination of the effects of stem length on complications of surgery. This study aims to examine the effect of femoral stem length on torsional resistance to peri-prosthetic fracture. MATERIALS AND METHODS: We tested 16 synthetic and two paired cadaveric femora. Specimens were implanted and then rapidly rotated until fracture to simulate internal rotation on a planted foot, as might occur during stumbling. 3D planning software and custom-printed 3D cutting guides were used to enhance the accuracy and consistency of our stem insertion technique. RESULTS: Synthetic femora implanted with short stems fractured at a significantly higher torque (27.1 vs. 24.2 Nm, p = 0.03) and angle (30.3° vs. 22.3°, p = 0.002) than those implanted with long stems. Fracture patterns of the two groups were different, but showed remarkable consistency within each group. These characteristic fracture patterns were closely replicated in the pair of cadaveric femora. CONCLUSIONS: This new short-stemmed press-fit femoral component allows more femoral flexibility and confers a higher resistance to peri-prosthetic fracture from torsional forces than long stems.

A local reference frame for describing the proximal human femur: application in clinical settings.

OBJECTIVE: The conventional reference frame for the femur has limited relevance for the planning of hip surgery as the femoral neck axis, a crucial reference for surgeons, has to be independently derived. The purpose of this study is to develop and validate a reliable frame of reference for the proximal femur that can be applied in clinical settings. MATERIALS AND METHODS: Ten three-dimensional models of femurs were obtained. An iterative method was developed to find the femoral neck axis (X-axis). A second axis was also created from the lesser trochanter to the piriformis fossa (LTPF). The origin was defined as the femoral head centre. The cross product of the neck and LTPF axes provided the Z-axis and the third axis (Y-axis) was perpendicular to the other two. Intra-/inter-investigator reliability was assessed on the ten femur models; ten times by one investigator and twice by three investigators respectively. The results were then compared with the conventional reference frame using landmarks on the distal femur. RESULTS: The femoral neck and LTPF axes had mean intra-/inter-investigator angle differences of 0.5° (SD 0.4°) and 0.7° (SD 0.5°), and 0.8° (SD 0.5°) and 0.9° (SD 0.6°) respectively while the variations of the X-, Y- and Z- axes were SD 0.6°, 0.7° and 0.5°. CONCLUSIONS: A reliable method of obtaining the three-dimensional proximal femoral frame was developed, using the femoral neck axis, with greater relevance to clinical settings, preoperative planning and accurate assessment of procedures post-operatively.

A morphometric study of normal and varus knees.

PURPOSE: The aim of the study was to investigate varus and normal knee morphologies to identify differences that may affect knee replacement alignment or design for varus knees. METHODS: Computed tomography scans of varus and normal knees were analyzed, and geometric shapes, points and axes were fit to the femur and tibia independently. These points were then projected in the three anatomical planes to measure the variations between the two groups. RESULTS: In the femur, varus knees had less femoral anteversion (p < 0.0001) and a larger medial extension facet (p < 0.05) compared with normal knees. In the tibia, the tubercle was found to be externally rotated in varus knees (12°), with a significant increase in the coronal slope (p = 0.001) and the extension facet angle (p = 0.002). CONCLUSIONS: The study highlighted the differences and similarities found between the two groups, which raises awareness on changes required during surgical intervention and component placement or design for a varus knee. This is particularly relevant for the design of patient-specific instrumentation and implants. LEVELS OF EVIDENCE: Diagnostic study, Level III.

Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach.

Aims: Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA. Methods: Nine fresh-frozen hip joints from five pelvis to mid-tibia cadaveric specimens were approached using the DAA. A custom fixture consisting of a six-axis force/torque sensor and motion sensor was attached to tibial diaphysis to measure manually applied torques and joint angles by the surgeon. Following dislocation, the torques generated to visualize the acetabulum and proximal femur were assessed after sequential release of the joint capsule and short external rotators. Results: Following initial exposure, the ischiofemoral ligament (7 to 8 o'clock) was the largest restrictor of exposure of the acetabulum, contributing to a mean 25% of overall external rotational restraint. The ischiofemoral ligament (10 to 12 o'clock) was the largest restrictor of exposure of the proximal femur, contributing to 25% of overall extension restraint. Releasing the short external rotators had minimal contribution in torque generated during joint exposure (≤ 5%). Conclusion: Adequate exposure of both proximal femur and acetabulum may be achieved with minimal torque by performing a full proximal circumferential capsulotomy while preserving short external rotators. The joint torque generated and exposure achieved is dependent on patient factors; therefore, some cases may necessitate further releases.

TGFß1-Endo180-dependent collagen deposition is dysregulated at the tumour-stromal interface in bone metastasis.

Cellular niches in adult tissue can harbour dysregulated microenvironments that become the driving force behind disease progression. The major environmental change when metastatic cells arrive in the bone is the destruction of mineralized type I collagen matrix. Once metastatic niches establish in bone, the invading tumour cells initiate a vicious cycle of osteolytic lesion formation via the dysregulation of paracrine signals and uncoupling of normal bone resorption and production. Here we report that the collagen receptor Endo180 (CD280, MRC2, uPARAP) participates in collagen deposition by primary human osteoblasts during de novo osteoid formation. This newly recognized function of Endo180 was suppressed in osteoblasts following heterotypic direct cell-cell contact in co-culture with prostate tumour cells. Reciprocal Endo180 up-regulation in osteolytic prostate tumour cells (PC3 and DU145) followed their direct contact with osteoblasts and promoted de novo collagen internalization, which is a previously characterized function of the constitutively recycling Endo180 receptor. The osteoblastic suppression and tumour cell-associated enhancement of Endo180 expression were equally sustained in these direct co-cultures. These findings are the first to demonstrate that increased tumour cell participation in collagen degradation and decreased collagen formation by osteoblasts in the osteolytic microenvironment are linked to the divergent regulation of a collagen-binding receptor. Immunohistochemical analysis of core biopsies from bone metastasis revealed higher levels of Endo180 expression in tumour cell foci than cells in the surrounding stroma. Additional experiments in prostate cell-osteoblast co-cultures indicate that divergent regulation of Endo180 is the result of dysregulated TGFß1 signalling. The findings of this study provide a rationale for targeting collagen remodelling by Endo180 in bone metastases and other collagen matrix pathologies.

Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs.

BACKGROUND: Plantar fasciitis is the most common cause of heel pain. It may remain symptomatic despite conservative treatment with orthoses and analgesia. There is conflicting evidence concerning the role of extracorporeal shock wave therapy (ESWT) in the management of this condition. QUESTIONS/PURPOSES: We investigated whether there was a significant difference in the change of (1) VAS scores and (2) Roles and Maudsley scores from baseline when treated with ESWT and placebo. Specifically we compared overall improvement from baseline composite VAS, reduction in overall VAS pain, success rate of improving overall VAS pain by 60%, success rate of improving VAS pain by 60% when taking first steps, doing daily activities, and during application of a pain pressure meter. METHODS: MEDLINE, Embase, and CINAHL databases were searched from January 1980 to January 2013 and a double extraction technique was used to obtain relevant studies. Studies had to be prospective randomized controlled trials on adults and must not have used local anesthesia as part of their treatment protocol. Studies must have specifically recruited patients who continued to be symptomatic despite a minimum of 3 months of conservative treatments. All papers were assessed regarding their methodologic quality and a meta-analysis performed. Seven prospective randomized controlled trials were included in this study. There were 369 patients included in the placebo group and 294 in the ESWT group. RESULTS: After ESWT, patients had better composite VAS scores (random effects model, standardized mean difference [SMD] = 0.38; 95% CI, 0.05, 0.72; z = 2.27). They also had a greater reduction in their absolute VAS scores compared with placebo (random effects model, SMD = 0.60; 95% CI, 0.34, 0.85; z = 4.64). Greater success of improving heel pain by 60% was observed after ESWT when taking first steps (random effects model, risk ratio [RR] = 1.30; 95% CI, 1.04, 1.62; z = 2.29) and during daily activities (random effects model, RR = 1.44; 95% CI, 1.13, 1.84; z = 2.96). Subjective measurement of pain using a pressure meter similarly favored ESWT (random effects model, RR = 1.37, 95% CI, 1.06, 1.78; z = 2.41). There was a significant difference in the change to "excellent - good" Roles and Maudsley scores in favor of the ESWT group. CONCLUSIONS: ESWT is a safe and effective treatment of chronic plantar fasciitis refractory to nonoperative treatments. Improved pain scores with the use of ESWT were evident 12 weeks after treatment. The evidence suggests this improvement is maintained for up to 12 months. We recommend the use of ESWT for patients with substantial heel pain despite a minimum of 3 months of nonoperative treatment.

Cam type femoro-acetabular impingement: quantifying the diagnosis using three dimensional head-neck ratios.

OBJECTIVE: Cam hips are commonly quantified using the two-dimensional α angle. The accuracy of this measurement may be affected by patient position and the technician's experience. In this paper, we describe a method of measurement that provides a quantitative definition of cam hips based upon three-dimensional computed tomography (CT) images. MATERIALS AND METHODS: CT scans of 47 (24 cam, 23 normal) femurs were segmented. A sphere was fitted to the articulating surface of the femoral head, the radius (r) recorded, and the femoral neck axis obtained. The cross sectional area at four locations spanning the head neck junction (r/4, r/2, 3r/4 and r), perpendicular to the neck axis, was measured. The ratios (Neck/Head) between the areas at each cut relative to the surface area at the head centre were calculated and aggregated. RESULTS: Normal and cam hips were significantly different: the sum of the head-neck ratios (HNRs) of the cam hips were always smaller than normal hips (p < 0.01). A cut off point of 2.55 with no overlap was found between the two groups, with HNRs larger than this being cam hips, and smaller being normal ones. CONCLUSION: Owing to its sensitivity and repeatability, the method could be used to confirm or refute the clinical diagnosis of a cam hip. Furthermore it can be used as a tool to measure the outcome of cam surgery.