Tibial derotation osteotomies are effective in improving pain and function and avoiding hip arthroscopy in patients with hip pain-a short-term follow-up.

The primary objective was to determine short-term clinical outcomes following distal tibial derotation osteotomy (DTDO) performed to manage hip pain in the presence of tibial maltorsion and to review how co-existing pathomorphology affected the management. All patients undergoing DTDO for hip pain with tibial rotational deformities recognized as the predominant aetiology were included. Normal tibial torsion range was assumed as 0-40°, measured by trans-malleolar line relative to femoral posterior condyles. All patients had a positive hip impingement test Flexion Adduction Internal Rotation test (FADIR). The patients older than 50 years or presenting with degenerative joint changes and neuromuscular conditions were excluded. Associated ipsilateral MRI-defined intra-articular pathomorphology (cam/pincer), non-cam/pincer-related labral tears and abnormal combined femoral/acetabular version (McKibbin index) were noted. Pre-operative and post-operative functional outcomes were analysed. Thirty-two patients underwent DTDO. Mean tibial torsion was 48.8° (41-63°), average age was 27 years (18-44), and average follow-up was 30 months (16-45). Nine patients (28%) had a co-existing cam/pincer, and eight patients (25%) had an excessive McKibbin index (51-76°). Overall, 63% of all patients (including 54% of patients with co-existing pathology) experienced significant hip functional improvement following DTDO alone. Pre-operative vs 12 months post-operative scores were calculated as follows: International Hip Outcome Tool-12-41 vs 67 (P < 0.01); Hip Outcome Score Activities of Daily Living Scale-47 vs 70 (P < 0.05); and Hip Outcome Score Sport Scale-36 vs 64 (P < 0.05). Patients with hip pain frequently present with a combination of tibial and/or femoral rotational deformity and cam/pincer lesions. It is important to consider tibial maltorsion as an aetiology of hip pain. Tibial derotation with DTDO results in significant clinical and functional recovery within 12 months in symptomatic hip impingement patients even in the presence of co-existing pathomorphology.

Custom 3D-Printed Triflange Implants for Treatment of Severe Acetabular Defects, with and without Pelvic Discontinuity: Early Results of Our First 19 Consecutive Cases.

Treatment of massive acetabular defects, both with and without pelvic discontinuity, is challenging. The implants utilized in the surgical procedure need to be stable and integrate with poor host bone stock. In the present study, we describe our experience addressing this challenge. METHODS: We identified all patients who underwent surgical implantation of a custom 3D-printed triflange prosthesis with dual-mobility bearings for the treatment of Paprosky 3B acetabular defects between 2014 and 2020. Operative, functional, and radiographic outcomes were assessed. RESULTS: A total of 19 patients were identified, including 11 women. The mean age was 77 years (range, 53 to 91 years), and 8 patients (42%) had proven or likely pelvic discontinuity. The mean follow-up was 53 months (range, 17 to 88 months; mode, 57 months). The cumulative implant survivorship was 100%. Two patients suffered notable sciatic nerve palsy, with 1 case being recurrent. There were no dislocations or fractures. The mean Oxford Hip Score improved significantly, from a mean of 8.6 (range, 0 to 22) preoperatively to 35 (range, 10 to 48) postoperatively (p < 0.0001). Radiographically, there was excellent correlation between implant position and the preoperative plan (p > 0.05). There were no cases of implant loosening or migration, which suggests that stabilization was achieved even among cases with pelvic discontinuity. CONCLUSIONS: These early results suggest that the use of a custom 3D-printed triflange implant has potential advantages over traditional constructs in the treatment of massive acetabular defects, with and without pelvic discontinuity. Excellent implant survivorship and functional improvement were demonstrated in this challenging patient cohort. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Dynamic Hip Examination Under Fluoroscopic Guidance Enhances the Understanding of Femoroacetabular Impingement Pathology and Treatment Planning.

PURPOSE: To review the relative accuracy of preoperative magnetic resonance imaging (MRI) and fluoroscopically guided examination-under-sedation (EUS) findings and to explore the validity of the anterior acetabular sector angle (AASA) as a radiologic MRI-based marker of anterior acetabular coverage in pincer-type impingement. METHODS: A cohort of 150 consecutive patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) in 2018 to 2019 was reviewed. The inclusion criteria were pure FAI unilateral symptomatic pathology and the availability of complete data sets (MRI, EUS, and intraoperative records). Preoperative MRI and EUS findings were compared with gold-standard intraoperative arthroscopic findings, specifically evaluating the alpha angle in the presence of cam lesions, AASA in the presence of pincer lesions, as well as soft-tissue lesions. An alpha angle greater than 50° and an AASA greater than 65° were deemed pathologic. RESULTS: The patient cohort included 78 women and 72 men with an average age of 38 years (range, 18-53 years). Intraoperatively, pincer lesions were present in 20% of patients; cam lesions, 26%; and mixed impingement, 54%. MRI versus EUS correctly identified pincer lesions in 36% versus 89% of cases and identified cam lesions in 44% versus 77% of cases. MRI findings characterizing labral tears and articular cartilage pathology were accurate in 80% and 10% of cases, respectively. Although there was no difference in the AASA between pure pincer- and mixed-type impingements (62° and 63°, respectively; P = .62), there was a statistically significant difference in reported AASA values between pure cam-type impingement and impingement involving the presence of pincer lesions (57° and 63°, respectively; P = .03). Furthermore, 31% of patients with intraoperatively identified pincer lesions had an AASA of 60° to 65°. CONCLUSIONS: Fluoroscopic EUS is accurate in characterizing FAI pathology. In addition, MRI is useful to diagnose or rule out non-FAI pathology, ascertain labral pathology, and outline hip alignment. These methods of preoperative planning are complementary. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Nanopatterned Titanium Implants Accelerate Bone Formation In Vivo.

Accelerated de novo formation of bone is a highly desirable aim of implants targeting musculoskeletal injuries. To date, this has primarily been addressed by biologic factors. However, there is an unmet need for robust, highly reproducible yet economic alternative strategies that strongly induce an osteogenic cell response. Here, we present a surface engineering method of translating bioactive nanopatterns from polymeric in vitro studies to clinically relevant material for orthopedics: three-dimensional, large area metal. We use a titanium-based sol-gel whereby metal implants can be engineered to induce osteoinduction both in vitro and in vivo. We show that controlled disordered nanotopographies presented as pillars with 15-25 nm height and 100 nm diameter on titanium dioxide effectively induce osteogenesis when seeded with STRO-1-enriched human skeletal stem cells in vivo subcutaneous implantation in mice. After 28 days, samples were retrieved, which showed a 20-fold increase in osteogenic gene induction of nanopatterned substrates, indicating that the sol-gel nanopatterning method offers a promising route for translation to future clinical orthopedic implants.

Human Skeletal Stem Cell Response to Multiscale Topography Induced by Large Area Electron Beam Irradiation Surface Treatment.

The healthcare socio-economic environment is irreversibly changing as a consequence of an increasing aging population, consequent functional impairment, and patient quality of life expectations. The increasing complexity of ensuing clinical scenarios compels a critical search for novel musculoskeletal regenerative and replacement strategies. While joint arthroplasty is a highly effective treatment for arthritis and osteoporosis, further innovation and refinement of uncemented implants are essential in order to improve implant integration and reduce implant revision rate. This is critical given financial restraints and the drive to improve cost-effectiveness and quality of life outcomes. Multi-scale modulation of implant surfaces, offers an innovative approach to enhancement in implant performance. In the current study, we have examined the potential of large area electron beam melting to alter the surface nanotopography in titanium alloy (Ti6Al4V). We evaluated the in vitro osteogenic response of human skeletal stem cells to the resultant nanotopography, providing evidence of the relationship between the biological response, particularly Collagen type I and Osteocalcin gene activation, and surface nanoroughness. The current studies demonstrate osteogenic gene induction and morphological cell changes to be significantly enhanced on a topography Ra of ~40 nm with clinical implications therein for implant surface treatment and generation.

Application of 3D-printed patient-specific skeletal implants augmented with autologous skeletal stem cells.

Joint replacements have proved a medical success providing symptomatic relief and return to mobility in many patients with arthritis. However, multiple revision surgeries due to joint failure can result in complex revision scenarios with significant bone tissue loss, in an elderly population, which poses a significant clinical challenge. Computer-aided design-computer-assisted manufacturing (CAD-CAM) prototyped bespoke implants are currently being used as an alternative and innovative approach for joint restoration in salvage cases, while the incorporation of autologous skeletal stem cells to optimize regenerative capacity can enhance implant osseointegration. We present a case series of 11 patients with severe disability and significant bone loss due to failed joint replacements. The choice of CAD-CAM prototyped joint implants enhanced with autologous skeletal stem cells resulted in significant patient-reported clinical and radiological improvements.

Harnessing Nanotopography to Enhance Osseointegration of Clinical Orthopedic Titanium Implants-An in Vitro and in Vivo Analysis.

Despite technological advancements, further innovations in the field of orthopedics and bone regeneration are essential to meet the rising demands of an increasing aging population and associated issues of disease, injury and trauma. Nanotopography provides new opportunities for novel implant surface modifications and promises to deliver further improvements in implant performance. However, the technical complexities of nanotopography fabrication and surface analysis have precluded identification of the optimal surface features to trigger osteogenesis. We herein detail the osteoinductive potential of discrete nanodot and nanowire nanotopographies. We have examined the ability of modified titanium and titanium alloy (Ti64) surfaces to induce bone-specific gene activation and extracellular matrix protein expression in human skeletal stem cells (SSCs) in vitro, and de novo osteogenic response within a murine calvarial model in vivo. This study provides evidence of enhanced osteogenic response to nanowires 300 surface modifications, with important implications for clinical orthopedic application.

Bone Tissue Engineering.

Medical advances have led to a welcome increase in life expectancy. However, accompanying longevity introduces new challenges: increases in age-related diseases and associated reductions in quality of life. The loss of skeletal tissue that can accompany trauma, injury, disease or advancing years can result in significant morbidity and significant socio-economic cost and emphasise the need for new, more reliable skeletal regeneration strategies. To address the unmet need for bone augmentation, tissue engineering and regenerative medicine have come to the fore in recent years with new approaches for de novo skeletal tissue formation. Typically, these approaches seek to harness stem cells, innovative scaffolds and biological factors that promise enhanced and more reliable bone formation strategies to improve the quality of life for many. This review provides an overview of recent developments in bone tissue engineering focusing on skeletal stem cells, vascular development, bone formation and the translation from preclinical in vivo models to clinical delivery.

Bone and metal: an orthopaedic perspective on osseointegration of metals.

The area of implant osseointegration is of major importance, given the predicted significant rise in the number of orthopaedic procedures and an increasingly ageing population. Osseointegration is a complex process involving a number of distinct mechanisms affected by the implant bulk properties and surface characteristics. Our understanding and ability to modify these mechanisms through alterations in implant design is continuously expanding. The following review considers the main aspects of material and surface alterations in metal implants, and the extent of their subsequent influence on osseointegration. Clinically, osseointegration results in asymptomatic stable durable fixation of orthopaedic implants. The complexity of achieving this outcome through incorporation and balance of contributory factors is highlighted through a clinical case report.

Do the cup surface properties influence the initial stability?

This project tests the relationship between the acetabular cup surface characteristics and their initial stability by comparing uncemented (Trabecular Metal (TM) and Trilogy) and cemented polyethylene shells. We hypothesised that different surface properties of uncemented cups will influence the cup stability. Mounted directly onto host bone, TM and cemented cups were significantly more stable than Trilogy cups (P < 0.01), with minimal difference between TM and cemented cups (P > 0.1). On 100% graft bed, there was marginal difference between all three cup types (P > 0.1). Incremental cavitary and segmental defects resulted in reducing stability, with cemented cups being minimally more stable (P > 0.1). TM cups possess satisfactory initial stability in bone graft constructs. This study demonstrates that TM shells are marginally less stable than cemented cups in the absence of significant host bone contact.

Traumatic dislocation of the pisiform: a case report.

Isolated pisiform dislocation is rare. We present one such case in a 20-year-old man occurring after a direct injury to the wrist. After an initial delay in diagnosis and unsuccessful closed reduction, he underwent resection of the pisiform. At 12-month follow-up, he had full range of movement of the wrist and no residual pain.

Anastomotic leak rate and outcome for laparoscopic intra-corporeal stapled anastomosis.

AIMS: A prospective clinical audit of all patients undergoing laparoscopic surgery with the intention of primary colonic left-sided intracorporeal stapled anastomosis to identify the rate of anastomotic leaks on an intention to treat basis with or without defunctioning stoma. MATERIALS AND METHODS: All patients undergoing laparoscopic colorectal surgery resulting in left-sided stapled anastomosis were included with no selection criteria applied. All operations were conducted by the same surgical team and the same preparation and intraoperative methods were used. The factors analyzed for this audit were patient demographics (age and sex), indication for operation, procedure performed, height of anastomosis, leak rate and the outcome, inpatient stay, mortality, rate of defunctioning stomas, and rate of conversion to open procedure. Results for anastomotic leakage were compared with known results from the Wessex Colorectal Audit for open colorectal surgery. RESULTS: A total of 69 patients (43 females, 26 males; median age 69 years, range 19 - 86 years) underwent colonic procedures with left-sided intracorporeal stapled anastomoses. Of these, 14 patients underwent reversal of Hartmann's, 42 - Anterior Resection, 11 - Sigmoid Colectomy, 2 - Left Hemicolectomy. Excluding reversals of Hartmann's, 29 operations were performed for malignant and 26 for benign disease. Five patients were defunctioned, and 3 were subsequently reversed. The median height of anastomosis was 12 cm, range 4 - 18 cm from anal verge as measured either intra-operatively, or by rigid sigmoidoscopy post-operatively. Four cases were converted to open surgery. There was 1 post-operative death within 30 days. There was 1 anastomotic leak (the patient that died), and 1 patient developed a colo-vesical fistula. Median post-operative stay was 7 days, range 2-19. CONCLUSION: This clinical audit confirms that the anastomotic leak rate for left-sided colorectal stapled anastomosis is no worse than that for open surgery. Therefore the decision making process for defunctioning stoma should be guided by the same principles as open surgery.

Does the Pirani score predict relapse in clubfoot?

PURPOSE: Presented here is a retrospective clinical audit of clubfoot patients to determine the value of the Pirani clubfoot scoring system at initial presentation in the estimation of subsequent relapse. METHODS: All clubfoot patients treated by the same surgeon from 2002 to 2006 were included. The treatment adhered to the standard protocol, involving weekly stretching and casting until the foot was corrected, followed by Achilles tenotomy and plasters for 3 weeks. Thereafter, the child was placed in a foot abduction splint. The severity of clubfoot was assessed using the Pirani scoring system, consisting of two sub-scores-the midfoot contracture score (MFCS) and the hindfoot contracture score (HFCS). The MFCS and HFCS can each be 0.0-3.0, giving rise to a total Pirani score (TPS) of 0.0-6.0. Any recurrent deformity was classed as a relapse. RESULTS: Sixty-one clubfoot patients were treated. Five patients were lost to follow-up and six patients were excluded due to the presence of identified syndromes or having had primary treatment elsewhere. A total of 80 clubfeet were included. There were 17 relapses. The average interval between the initiation of foot abduction splint and relapse was 23 months. The median TPS was 3.5 in the no relapse group and 5.0 in the relapse group. The median MFCS was 1.5 in the no relapse group and 2.0 in the relapse group. The median HFCS was 2.0 in the no relapse group and 3.0 in the relapse group. Higher TPS and HFCS were statistically significant when the relapse group was analysed against the no relapse group (P = 0.05 × 10(-4) and 0.02 × 10(-4), respectively). CONCLUSIONS: Higher Pirani scores were associated with the late relapse group. The TPS and HFCS were shown to be statistically significant predictors of potential relapse. Closer follow-up is advised for patients at risk of relapse.

[Not Available].

OBJECTIVES: A prospective audit of all patients undergoing laparoscopic surgery with the intention of primary colonic left-sided intracorporeal stapled anastomosis to identify the clinical anastomotic leak rate on an intention to treat basis. METHODS: All patients undergoing laparoscopic colorectal surgery resulting in left-sided stapled anastomosis were included. All operations were conducted by the same surgical team with the same pre-operative preparation and surgical technique. The factors analysed for this audit were patient demographics (age and sex), indication for operation, procedure performed, height of anastomosis, leak rate and the outcome, inpatient stay, mortality, rate of defunctioning stomas, and rate of conversion to open procedure. RESULTS: Eighty-four patients (49 females, 35 males; median age 70 years, range 19-89 years) underwent colonic procedures with left-sided intracorporeal stapled anastomosis. An intra-operative air leak was evident in one patient, whose anastomosis was oversewn intracorporeally and defunctioned by ileostomy. There were only two clinically evident anastomotic leaks post-operatively (2.9%). One patient died of overwhelming sepsis within 48h of re-operation: Seven patients (8.3%) had a primary defunctioning stoma, with two further stomas formed due to anastomotic leakage. Five cases (6%) were converted to open surgery. The median post-operative stay was six days, range 2-23. Thirty-day mortality was 50% in the leak group and 0% in the non-leak group. CONCLUSION: We believe that this study demonstrates that the anastomotic leak rate from intra-corporeal laparoscopic anastomosis is no greater than for open surgery or laparoscopic surgery with extra-corporeal anastomosis.