Reliability of the transverse acetabular ligament as a landmark for functional cup anteversion in total hip arthroplasty.

BACKGROUND: The transverse acetabular ligament (TAL) can be a useful and reproducible landmark in the orientation of the acetabular cup in total hip arthroplasty (THA). Its role in guiding cup orientation when aiming to implant in a functional anteversion orientation is unclear. The aim of this study was to assess the relationship between the TAL and the planned acetabular cup anteversion when implanted in a function orientation. MATERIAL AND METHODS: In a retrospective study the anteversion of the TAL in the contralateral un-replaced hip was measured in CT scans of patients undergoing THA and compared to the functional cup anteversion using the patient-specific spinopelvic parameters. Comparative measurements of the native acetabular version were made from the superior rim to the inferior rim and at 10 mm intervals between the 2, all in reference to the anterior pelvic plane. RESULTS: 96 hips were measured. The mean TAL anteversion angle was 17.2° ± 4.5°. The mean planned acetabular cup anteversion angle was 26.3° ± 4.7°. Pearson's correlation coefficient of this measurement with the TAL was -0.03 (p = 0.769). There was a significant difference between the planned acetabular cup anteversion and the measurement of the TAL (p < 0.0001). CONCLUSIONS: If cups are implanted parallel to the TAL, almost 80% will be >5° different to targeted functional cup version. It should be aimed to implant cups with more anteversion than the TAL indicates.

Unicortical fixation does not compromise bony union in the Latarjet procedure.

Background: Fixation of the coracoid during the Latarjet procedure can be performed with either unicortical or bicortical fixation. There is no clear evidence that the number of cortices fixed affects graft union, but in vitro studies suggest bicortical fixation is desirable. The primary aim of the study was to retrospectively review the coracoid union rates in our Latarjet cohort who have undergone either unicortical or bicortical graft fixation. Methods: A retrospective review of Latarjet patients receiving bicortical or unicortical fixation was performed. The rate of coracoid graft union was assessed via radiographs and computed tomography scans at minimum 8 weeks postoperatively. Primary analysis for graft union was performed with Chi-squared and Fisher's exact tests. Results: A total of 184 patients were enrolled (82 bicortical, 102 unicortical) with 20 patients lost to follow-up. There was no significant difference between union rates of bicortical and unicortical groups (union rate: 94% bicortical, 98% unicortical, P = .25). There were no significant differences in rate of instability recurrence (P = .5) or other postoperative complications (P = .83) between the groups. Discussion: At a minimum follow-up of 8 weeks, bicortical fixation was not shown to have a higher rate of union than unicortical fixation. Performing unicortical fixation is an acceptable practice without compromising bony graft union.

Does Humeral Component Version Affect Range of Motion and Clinical Outcomes in Reverse Total Shoulder Arthroplasty? A Systematic Review.

BACKGROUND: Prosthesis selection, design, and placement in reverse total shoulder arthroplasty (RTSA) affect post-operative results. The aim of this systematic review was to evaluate the influence of the humeral stem version and prosthesis design (inlay vs. onlay) on shoulder function following RTSA. METHODS: A systematic review of the literature on post-operative range of motion (ROM) and functional scores following RTSA with specifically known humeral stem implantations was performed using MEDLINE, Pubmed, and Embase databases, and the Cochrane Library. Functional scores included were Constant scores (CSs) and/or American Shoulder and Elbow Surgeons (ASES) scores. The patients were organised into three separate groups based on the implanted version of their humeral stem: (1) less than 20° of retroversion, (2) 20° of retroversion, and (3) greater than 20° of retroversion. RESULTS: Data from 14 studies and a total of 1221 shoulders were eligible for analysis. Patients with a humeral stem implanted at 20° of retroversion had similar post-operative mean ASES (75.8 points) and absolute CS (68.1 points) compared to the group with humeral stems implanted at less than 20° of retroversion (76 points and 62.5 points; p = 0.956 and p = 0.153) and those implanted at more than 20° of retroversion (73.3 points; p = 0.682). Subjects with humeral stem retroversion at greater than 20° tended towards greater active forward elevation and external rotation compared with the group at 20° of retroversion (p = 0.462) and those with less than 20° of retroversion (p = 0.192). Patients with an onlay-type RTSA showed statistically significantly higher mean post-operative internal rotation compared to patients with inlay-type RTSA designs (p = 0.048). Other functional scores and forward elevation results favoured the onlay-types, but greater external rotation was seen in inlay-type RTSA designs (p = 0.382). CONCLUSIONS: Humeral stem implantation in RTSA at 20° of retroversion and greater appears to be associated with higher post-operative outcome scores and a greater range of motion when compared with a retroversion of less than 20°. Within these studies, onlay-type RTSA designs were associated with greater forward elevation but less external rotation when compared to inlay-type designs. However, none of the differences in outcome scores and range of motion between the humeral version groups were statistically significant.

Survey of trainee attitudes to skill development and simulation training in trauma and orthopaedics.

Background: Simulation training in surgery is widespread and allows surgeons to practise novel operative techniques and acquaint themselves with unfamiliar surgical procedures. The use of box or virtual reality simulators in many surgical specialities is established; however, its use within trauma and orthopaedics (T&O) in the UK and the attitudes of trainee towards it are not known. The aim of this study is to explore the experiences and opinions of T&O trainees towards simulation training. Methods: An electronic survey consisting of 11 questions on the experiences of simulation training and attitudes towards it was sent to all T&O speciality trainees in London. Results: Fewer than 10% of the responders had used or had ready access to simulators to prepare for unfamiliar operations, with almost 90% preferring to read about them in a journal or watch them on an online video site. Over half had only seen simulators on courses or been aware of them. Over 75% of the responders believed that simulators should be available for trainees, but most did not feel that they should be used as part of formal assessments. Conclusions: Methods for preparing for new operations have expanded over the past 20 years, yet the use of simulator machines is not widespread. Many trainees believe current machines are not widely available nor realistic enough to be useful, with most preferring online videos and operative technique books for preparing for an unfamiliar operation.

Return to sport after lower limb arthroplasty - why not for all?

BACKGROUND: Total hip and knee replacements are being performed in increasing numbers in progressively younger patients with higher activity demands. Many such patients have expectations of returning to athletic activity post-operatively yet are not always able to do so and the reasons behind this have not been extensively examined. We hypothesise that any reasons for a failure to return to athletic activity post-operatively are multi-factorial. AIM: To quantify the return to athletic activity following lower limb joint arthroplasty and understand qualitative reasons for altered activity participation. METHODS: A single centre, single surgeon retrospective questionnaire for hip and knee arthroplasty patients under age 60 years, minimum two years post-surgery with exclusion criteria of multiple degenerative joint involvement and multiple medical co-morbidities. Outcomes were validated joint-specific (Oxford hip and knee) and lifestyle questionnaires [short form 12 (SF-12) and University of California, Los Angeles (UCLA)] and an activity questionnaire assessing ability participation in athletic activity post-operatively. Statistical analysis was performed on the validated outcome data, including comparison between hip and knee replacements. Frequency tables were produced to quantify the different athletic activities participated in by patients. RESULTS: Responses were received from 64 patients (80% response rate). There was a statistically significant improvement in Oxford hip and knee scores following surgery. SF-12 scores also improved for all patients, but no statistically significant difference was seen between joints (P = 0.88). Mean UCLA scores pre-operatively were 7.67 and at two years post-operatively were 7.69, with no statistically significant change (P = 0.91). All patients reported high satisfaction and improved ability to perform athletic activity at a higher frequency compared to pre-operatively. The most common reasons for changing activity participation were not wanting to stress their joint replacement or instructions by other doctors or the lead surgeon. There was no difference in the responses to the questionnaire based on type of joint replacement (P = 0.995). CONCLUSION: Patients receiving a joint replacement are able to participate in athletic activity to high levels and are satisfied with their outcomes. Reasons for non-participation are multi-factorial.

Robotic and navigation systems in orthopaedic surgery: how much do our patients understand?

BACKGROUND: Technology in orthopaedic surgery has become more widespread in the past 20 years, with emerging evidence of its benefits in arthroplasty. Although patients are aware of benefits of conventional joint replacement, little is known on patients' knowledge of the prevalence, benefits or drawbacks of surgery involving navigation or robotic systems. METHODS: In an outpatient arthroplasty clinic, 100 consecutive patients were approached and given questionnaires to assess their knowledge of navigation and robotics in orthopaedic surgery. Participation in the survey was voluntary. RESULTS: Ninety-eight patients volunteered to participate in the survey, mean age 56.2 years (range, 19 to 88 years; 52 female, 46 male). Forty percent of patients thought more than 30% of National Health Service (NHS) orthopaedic operations involved navigation or robotics; 80% believed this was the same level or less than the private sector. One-third believed most of an operation could be performed independently by a robotic/navigation system. Amongst perceived benefits of navigation/robotic surgery was more accurate surgery (47%), quicker surgery (50%), and making the surgeon's job easier (52%). Sixty-nine percent believed navigation/robotics was more expensive and 20% believed it held no benefit against conventional surgery, with only 9% believing it led to longer surgery. Almost 50% would not mind at least some of their operation being performed with use of robotics/navigation. CONCLUSIONS: Although few patients were familiar with this new technology, there appeared to be a strong consensus it was quicker and more accurate than conventional surgery. Many patients appear to believe navigation and robotics in orthopaedic surgery is largely the preserve of the private sector. This study demonstrates public knowledge of such new technologies is limited and a need to inform patients of the relative merits and drawbacks of such surgery prior to their more widespread implementation.