Subsidence remains a concern when utilizing modern tapered fluted titanium (TFT) femoral stems and may lead to leg length discrepancy, impingement, instability and failure to obtain stem osseointegration. This study aims to compare stem subsidence across three modern TFT stems. Our secondary aim was to investigate the influence of bicortical contact or ‘scratch fit’ on subsidence, as well as the role of intraoperative imaging in maximizing this bicortical contact and preventing stem subsidence.

A retrospective review of 271 hip arthroplasties utilizing modern TFT stems in a single institution was performed. Three stem designs were included in the analysis: one monoblock TFT stem (n=91) and two modular TFT stems (Modular A [n=90]; Modular B [n=90]). Patient demographics, Paprosky femoral bone loss classification, bi-cortical contact, utilization of intra-operative imaging and stem subsidence (comparison of initial post-operative radiograph to the latest follow up radiograph - minimum three months) were recorded.

There was no statistically significant difference in the amount of subsidence between the three stems (Monoblock: 2.33mm, Modular A: 3.43mm, Modular B: 3.02mm; p=0.191). There was no statistical difference in subsidence >5mm between stems (Monoblock: 9.9%, Modular A: 22.2%, Modular B: 16.7%). Subgroup analysis based on femoral bone loss grading showed no difference in subsidence between stems. Increased bicortical contact was strongly associated with reduced subsidence (p=0.004). Intra-operative imaging was used in 46.5% (126/271) of cases; this was not correlated with bicortical contact (p=0.673) or subsidence (p=0.521). Across all groups, only two stems were revised for subsidence (0.7%).

All three modern TFT stems were highly successful and associated with low rates of subsidence, regardless of modular or monoblock design. Surgeons should select the stem that they feel is most clinically appropriate.

We recently performed a clinical trial comparing motor sparing blocks (MSB) to periarticular infiltration (PAI) following total knee arthroplasty (TKA). We found that MSBs provided longer analgesia (8.8 hours) than PAI with retention of quadriceps strength, and with similar function, satisfaction, and length of hospital stay. However, its potential increased cost could serve as a barrier to its adoption. Therefore, our aim was to compare the costs of MSBs to PAI following TKA.

We conducted a retrospective review of data from our previous RCT. There were 82 patients included in the RCT (n=41 MSB group, n=41 PAI group). We compared the mean total costs associated with each group until hospital discharge including intervention costs, healthcare professional service fees, intraoperative medications, length of stay, and postoperative opioid use.

Seventy patients were included (n=35 MSB group, n=35 PAI group). The mean total costs for the MSB group was significantly higher ($1959.46 ± 755.4) compared to the PAI group ($1616.25 ± 488.33), with a mean difference of $343.21 (95% CI = $73.28 to $664.11, p = 0.03). The total perioperative intervention costs for performing the MSB was also significantly higher however postoperative inpatient costs including length of stay and total opioid use did not differ significatnly.

Motor sparing blocks had significantly higher mean total and perioperative costs compared to PAI with no significant difference in postoperative inpatient costs. However, its quadricep sparing nature and previously demonstrated prolonged postoperative analgesia can be used to facilitate an outpatient TKA pathway thereby offsetting its increased costs.

Total knee arthroplasty is a successful procedure that reduces knee pain and improves function in most patients with knee osteoarthritis. Patient dissatisfaction however remains high, and along with implant longevity, may be affected by component positioning. Surgery in obese patients is more technically challenging with difficulty identifying appropriate landmarks for alignment and more difficult exposure of the joint. Patient specific instrumentation (PSI) has been introduced with the goal to increase accuracy of component positioning by custom fitting cutting guides to the patient using advanced imaging. A strong criticism of this new technology however, is the cost associated. The purpose of this study was to determine, using a prospective, randomized-controlled trial, the cost-effectiveness of PSI compared to standard instrumentation for total knee arthroplasty in an obese patient population.

Patients with a body mass index greater than 30 with osteoarthritis and undergoing a primary total knee arthroplasty were included in this study. We randomized patients to have their procedure with either standard instrumentation (SOC) or PSI. At 12-weeks post-surgery patients completed a self-reported cost questionnaire and the Western Ontario and McMaster Osteoarthritis Index (WOMAC). We performed a cost-effectiveness analyses from a public health payer and societal perspective. As we do not know the true cost of the PSI instrumentation, we estimated a value of $100 for our base case analysis and used one-way sensitivity analyses to determine the effect of different values (ranging from $0 to $500) would have on our conclusions.

A total of 173 patients were enrolled in the study with 86 patients randomized to the PSI group and 87 to the SOC group. We found the PSI group to be both less effective and more costly than SOC when using a public payer perspective, regardless of the cost of the PSI. From a societal perspective, PSI was both less costly, but also less effective, regardless of the cost of the PSI. The mean difference in effect between the two groups was −1.61 (95% CI −3.48, 026, p=0.091). The incremental cost-effectiveness ratio was $485.71 per point increase in the WOMAC, or $7285.58 per clinically meaningful difference (15 points) in the WOMAC.

Overall, our results suggest that PSI is not cost-effective compared to standard of care from a public payer perspective. From a societal perspective, there is some question as to whether the decreased effect found with the PSI group is worth the reduced cost. The main driver of the cost difference appears to be time off of volunteer work, which will need to be investigated further. In future, we will continue to follow these patients out to one year to collect cost and effectiveness data to investigate whether these results remain past 12 weeks post-surgery.

Increasing pressure to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA) is evident in current health care systems for numerous reasons. Patient autonomy and health care economics has challenged the ability of THA implants to maintain functional integrity before achieving bony union. Although collared stems have been shown to provide improved axial stability, it is unclear if this stability correlates with activity levels or results in improved early function to patients compared to collarless stems. This study aims to examine the role of implant design on patient activity and implant fixation. The early follow-up period was examined as the majority of variation between implants is expected during this time-frame.

Patients (n=100) with unilateral hip OA who were undergoing primary THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=50) or collarless (n=50) cementless femoral stem. Patients will be seen at nine appointments (pre-operative, < 2 4 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Patients also underwent supine radiostereometric analysis (RSA) imaging < 2 4 hours post-operation prior to leaving the hospital, and at all follow-up appointments.

Nineteen collared stem patients and 20 collarless stem patients have been assessed. There were no demographic differences between groups. From < 2 4 hours to two weeks the collared implant subsided 0.90 ± 1.20 mm and the collarless implant subsided 3.32 ± 3.10 mm (p=0.014). From two weeks to three months the collared implant subsided 0.65 ± 1.54 mm and the collarless implant subsided 0.45 ± 0.52 mm (p=0.673). Subsidence following two weeks was lower than prior to two weeks in the collarless group (p=0.02) but not different in the collared group. Step count was reduced at two weeks compared to pre-operatively by 4078 ± 2959 steps for collared patients and 4282 ± 3187 steps for collarless patients (p=0.872). Step count increased from two weeks to three months by 6652 ± 4822 steps for collared patients and 4557 ± 2636 steps for collarless patients (p=0.289). TUG test time was increased at two weeks compared to pre-operatively by 4.71 ± 5.13 s for collared patients and 6.54 ± 10.18 s for collarless patients (p=0.551). TUG test time decreased from two weeks to three months by 7.21 ± 5.56 s for collared patients and 8.38 ± 7.20 s for collarless patients (p=0.685). There was no correlation between subsidence and step count or TUG test time.

Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. The presence of a collar on the stem did not affect patient activity and function and these factors were not correlated to subsidence, suggesting that initial fixation is instead primarily related to implant design.

HXLPE acetabular liners were introduced to reduce wear-related complications in THA. However, post-irradiation thermal free radical stabilization can compromise mechanical properties, leave oxidation-prone residual free radicals, or both. Reports of mechanical failure of HXLPE acetabular liner rims raise concerns about thermal free radical stabilization and in vivo oxidization on implant properties. The purpose of this study is to explore the differences in the mechanical, physical and chemical properties of HXLPE acetabular liner rims after extended time in vivo between liners manufactured with different thermal free radical stabilization techniques.

Remelted, single annealed and sequentially annealed retrieved HXLPE acetabular liners with in vivo times greater than 4.5 years were obtained from our implant retrieval laboratory. All retrieved liners underwent an identical sanitation and storage protocol. For mechanical testing, a total of 55 explants and 13 control liners were tested. Explant in vivo time ranged from 4.6 – 14 years and ex vivo time ranged from 0 – 11.6 years. Rim mechanical properties were tested by microindentation hardness testing using a Micromet II Vickers microhardness tester following ASTM standards. A subset of 16 explants with ex vivo time under one year along with five control liners were assessed for oxidation by FTIR, crystallinity by Raman spectroscopy, and evidence of microcracking by SEM.

No significant difference in in vivo or ex vivo was found between thermal stabilization groups in either set of explants studied. In the mechanically tested explants, there was no significant correlation between in vivo time and Vickers hardness in any thermal stabilization group. A significant correlation was found between ex vivo time and hardness in remelted liners (r=.520, p = .011), but not in either annealed cohort. ANCOVA with ex vivo time as a covariate found a significant difference in hardness between the thermal free radical stabilization groups (p 0.1) was found in retrieved remelted (25%), single annealed (100%) and sequentially annealed (75%) liner rims. Crystallinity was increased in the subsurface region relative to control liners for both annealed, but not remelted, liner rims. Hardness was increased in oxidized rims for both annealed cohorts but not in the remelted cohort. Microcracking was only found along the surface of one unoxidized remelted liner rim.

Mechanical properties were reduced at baseline and worsened after in vivo time for remelted HXLPE liner rims. Rim oxidation was detected in all groups. Oxidation was associated with increased crystallinity and hardness in annealed cohorts, but not remelted liners. Increased crystallinity and oxidation do not appear to be directly causing the worsened mechanical behavior of remelted HXLPE liner rims after extended in vivo time.

With the success of the medial parapatellar approach (MPA) to total knee arthroplasty (TKA), current research is aimed at reducing iatrogenic microneurovascular and soft tissues damage to the knee. In an effort to avoid disruption to the medial structures of the knee, we propose a novel quadriceps-sparing, subvastus lateralis approach (SLA) to TKA. The aim of the present study is to compare if a SLA can provide adequate exposure of the internal compartment of the knee while reducing soft tissue damage, compared to the MPA. Less disruption of these tissues could translate to better patient outcomes, such as reduced post-operative pain, increased range of motion, reduced instances of patellar maltracking or necrosis, and a shorter recovery time.

To determine if adequate exposure could be achieved, the length of the skin incision and perimeter of surgical exposure was compared amongst 22 paired fresh-frozen cadaveric lower limbs (five females/six males) which underwent TKA using the SLA or MPA approach. Additionally, subjective observations which included the percent of visibility of the femoral condyles and tibial plateau, as well as the patellar tracking, were noted in order to qualify adequate exposure. All procedures were conducted by the same surgeon. Subsequently, to determine the extent of soft tissue damage associated with the approaches, an observational assessment of the dynamic and static structures of the knee was performed, in addition to an examination of the microneurovascular structures involved. Dynamic and static structures were assessed by measuring the extent of muscular and ligamentus damage during gross dissection of the internal compartment of the knee. Microneurovascular involvement was evaluated through a microscopic histological examination of the tissue harvested adjacent to the capsular incision.

Comparison of the mean exposure perimeter and length of incision was not significantly different between the SLA and the MPA (p>0.05). In fact, on average, the SLA facilitated a 5 mm larger exposure perimeter to the internal compartment, with an 8 mm smaller incision, compared to the MPA, additional investigation is required to assert the clinical implications of these findings. Preliminary analysis of the total visibility of the femoral condyles were comparable between the SLA and MPA, though the tibial plateau visibility appears slightly reduced in the SLA. Analyses of differences in soft tissue damage are in progress.

Adequate exposure to the internal compartment of the knee can be achieved using an incision of similar length when the SLA to TKA is performed, compared to the standard MPA. Future studies should evaluate the versatility of the SLA through an examination of specimens with a known degree of knee deformity (valgus or varus).

Closed ankle fractures have been reported to account for 10% off all fractures presenting to the Emergency Department. Many of these injuries require acute surgical management either via direct admission or through defined outpatient surgical pathways. While both methods have been shown to be safe, few studies have examined the cost effectiveness of each clinical scenario. The purpose of this study is to compare cost and resource utilization associated with inpatient and outpatient ankle fracture surgery at a Canadian academic institution.

This is a retrospective chart review of patients who underwent acute ankle fracture surgery at London Health Sciences Centre between 2016 and 2018. Thirty patients who underwent inpatient ankle surgery for closed, isolated ankle fractures at University Hospital were compared to 30 consecutive patients who underwent outpatient ankle surgery for similar fractures at Victoria hospital. Data pertaining to age at time of surgery, sex, BMI, fracture type, operating/recovery room time, and length of hospital stay were collected. All emergency room visits, readmissions and complications within 30 days of surgery were also recorded.

Inpatient and outpatient cohorts were similar with respect to average age (48 vs. 44, P=0.326) and body mass index (29.8 vs. 29.1, P=0.741). There was a greater proportion of patients with an American Society of Anesthesia (ASA) Classification of 3 or greater in the inpatient surgery group (48% vs. 23%). The inpatient group spent an average of 1.2 days in hospital while waiting for surgery and a average of 72 hours in hospital for their entire surgical encounter. The outpatient group spent an average of eight days (at home) waiting for surgery while spending an average of 7.4 hours in hospital during their entire surgical encounter. Outpatient ankle fracture surgery was associated with a cost savings of 35.9% in comparison to inpatient ankle fracture surgery (P < 0 .001). There were no significant differences in the rates of emergency room visits, readmissions, or complications between cohorts.

Preliminary findings suggest that outpatient ankle fracture surgery is appropriate for most patients, requires less hospital resources and is associated with similar rates of readmission and complications as inpatient surgery. An established outpatient surgical pathway may offer significant cost savings in the treatment of the common closed ankle fracture that requires surgical intervention.

During revision total knee arthroplasty (rTKA), proximal tibial bone loss is frequently encountered and can result in a less-stable bone-implant fixation. A 3D printed titanium alloy (Ti6Al4V) revision augment that conforms to the irregular shape of the proximal tibia was recently developed. The purpose of this study was to evaluate the fixation stability of rTKA with this augment in comparison to conventional cemented rTKA.

Eleven pairs of thawed fresh-frozen cadaveric tibias (22 tibias) were potted in custom fixtures. Primary total knee arthroplasty (pTKA) surgery was performed on all tibias. Fixation stability testing was conducted using a three-stage eccentric loading protocol. Static eccentric (70% medial/ 30% lateral) loading of 2100 N was applied to the implants before and after subjecting them to 5×103 loading cycles of 700 N at 2 Hz using a joint motion simulator. Bone-implant micromotion was measured using a high-resolution optical system. The pTKA were removed. The proximal tibial bone defect was measured. One tibia from each pair was randomly allocated to the experimental group, and rTKA was performed with a titanium augment printed using selective laser melting. The contralateral side was assigned to the control group (revision with fully cemented stems). The three-stage eccentric loading protocol was used to test the revision TKAs. Independent t-tests were used to compare the micromotion between the two groups.

After revision TKA, the mean micromotion was 23.1μm ± 26.2μm in the control group and 12.9μm ± 22.2μm in the experimental group. There was significantly less micromotion in the experimental group (p= 0.04). Prior to revision surgery, the control and experimental group had no significant difference in primary TKA micromotion (p= 0.19) and tibial bone loss (p= 0.37).

This study suggests that early fixation stability of revision TKA with the novel 3D printed titanium augment is significantly better then the conventional fully cemented rTKA. The early press-fit fixation of the augment is likely sufficient for promoting bony ingrowth of the augment in vivo. Further studies are needed to investigate the long-term in-vivo fixation of the novel 3D printed augment.

Dexmedetomidine, an alpha 2 agonist, has been approved for providing sedation in the intensive care unit. Along with sedative properties, it has analgesic activity through its highly selective action on alpha 2 receptors. Recent studies have examined the use of dexmedetomidine as an adjuvant to prolong the duration of peripheral nerve blocks. Studies showing effectiveness of dexmedetomidine for adductor canal block in knee surgery are small. Also, its effectiveness has not been compared to Epinephrine which is a strong alpha and beta receptor agonist. In a previous study, we showed that motor sparing knee blocks significantly increased the duration of analgesia compared with periarticular knee infiltration using local anesthetic mixture containing Epinephrine following total knee arthroplasty (TKA). In this study, we compared two local anesthetic mixtures: one containing Dexmedetomidine and the other Epinephrine for prolongation of motor sparing knee block in primary TKA patients.

After local ethics board approval and gaining Notice of Compliance (NOC) from Health Canada for use of Dexmedetomidine perineurally, 70 patients between the ages 18 – 95 of ASA class I to III undergoing unilateral primary total knee arthroplasty were enrolled. Motor sparing knee block − 1) Adductor canal continuous catheter 2) Single shot Lateral Femoral Cutaneous Nerve block 3) Single shot posterior knee infiltration was performed in all patients using 60 ml mixture of 0.5% Ropivacaine, 10 mg Morphine, 30 mg Ketorolac. Patients randomized into the Dexmedetomidine group (D) received, in addition to the mixture, 1mcg/kg Dexmedetomidine and the Epinephrine (E) group received 200mcg in the mixture. The primary outcome was time to first rescue analgesia as a surrogate for duration of analgesia and secondary outcomes were NRS pain scores up to 24 hours and opioid consumption.

The time to first rescue analgesia was not significantly different between Epinephrine and dexmedetomidine groups, Mean and SD 18.45 ± 12.98 hours vs 16.63 ± 11.80 hours with a mean difference of 1.82 hours (95% CI −4.54 to 8.18 hours) and p value of 0.57. Pain scores at 4, 6, 12, 18 and 24 hours were comparable between groups. Mean NRS pain scores Epinephrine vs Dexmedetomidine groups were 1.03 vs 0.80 at 4 hours, 1.48 vs 3.03 at 6 hours, 3.97 vs 4.93 at 12 hours, 5.31 vs 6.18 and 6.59 v 6.12 at 24 hours. Opioid consumption was also not statistically significant between both groups at 6, 12 18, 24 hours (p values 0.18, 0.88, 0.09, 0.64 respectively).

Dexmedetomidine does not prolong the duration of knee motor sparing blocks when compared to Epinephrine for total knee arthroplasty. Pain scores and opioid consumption was also comparable in both groups. Further studies using higher dose of dexmedetomidine are warranted.

While Oxidized Zirconium (OxZr) femoral heads matched with highly cross-linked polyethylene (XLPE) have demonstrated the lowest rate of revision compared to other bearing couples in the Australian National Joint Registry, it has been postulated that these results may, in part, be due to the fact that a single company offers this bearing option with a limited combination of femoral and acetabular prostheses. The purpose of this study was to assess clinical and radiographic outcomes in a matched cohort of total hip replacements (THR) utilizing an identical cementless femoral stem and acetabular component with either an Oxidized Zirconium (OxZr) or Cobalt-Chrome (CoCr) femoral heads at a minimum of 10 years follow-up.

We reviewed our institutional database to identify all patients whom underwent a THR with a single cementless femoral stem, acetabular component, XLPE liner and OxZr femoral head with a minimum of 10 years of follow-up. These were then matched to patients who underwent a THR with identical prosthesis combinations with CoCr femoral head by gender, age and BMI. All patients were prospectively evaluated with WOMAC, SF-12 and Harris Hip Score (HHS) preoperatively and postoperatively at 6 weeks, 3 months, 1 and 2 years and every 2 years thereafter. Charts and radiographs were reviewed to determine the revision rates and survivorship (both all cause and aseptic) at 10 years for both cohorts. Paired analysis was performed to determine if differences exist in patient reported outcomes.

There were 208 OxZr THRs identified which were matched with 208 CoCr THRs. There was no difference in average age (OxZr, 54.58 years, CoCr, 54.75 years), gender (OxZr 47.6% female, CoCr 47.6% female), and average body max index (OxZr, 31.36 kg/m2, CoCr, 31.12 kg/m2) between the two cohorts. There were no significant differences preoperatively in any of the outcome scores between the two groups (WOMAC (p=0.449), SF-12 (p=0.379), HHS(p=0.3718)). Both the SF12 (p=0.446) and the WOMAC (p=0.278) were similar between the two groups, however the OxZr THR cohort had slightly better HHS compared to the CoCr THR cohort (92.6 vs. 89.7, p=0.039). With revision for any reason as the end point, there was no significant difference in 10 years survivorship between groups (OxZr 98.5%, CoCr 96.6%, p=0.08). Similarly, aseptic revisions demonstrated comparable survivorship rates at 10 year between the OxZr (99.5%) and CoCr groups (97.6%)(p=0.15).

Both THR cohorts demonstrated outstanding survivorship and improvement in patient reported outcomes. The only difference was a slightly better HHS score for the OxZr cohort which may represent selection bias, where OxZr implants were perhaps implanted in more active patients. Implant survivorship was excellent and not dissimilar for both the OxZr and CoCr groups at 10 years. Therefore, with respect to implant longevity at the end of the first decade, there appears to be no clear advantage of OxZr heads compared to CoCr heads when paired with XLPE for patients with similar demographics. Further follow-up into the second and third decade may be required to demonstrate if a difference does exist.

Introduction

Surgeons performing a total knee replacement (TKR) have two available techniques available to help them achieve the proper bone resections and ligament tension – gap balancing (GB) and measured resection (MR). GB relies on balancing ligaments prior to bony resections whereas bony resections are made based on anatomical landmarks in MR. Many studies have been done to compare the joint kinematics between the two techniques, however the results have been varied. These studies were not done with anatomically designed prostheses. The Journey II (Smith & Nephew, Memphis, TN) is one such design which attempts to mimic the normal knee joint structure to return more natural kinematics to the joint, with emphasis on eliminating both paradoxical anterior motion and reduced posterior femoral rollback. Given the design differences between anatomical and non-anatomical prostheses, it is important to investigate whether one technique provides superior kinematics when an anatomical design is used. We hypothesize that there will be no difference between the two techniques.

Introduction

Infections affect 1–3% of Total Knee Arthroplasty (TKA) patients with severe ramifications to mobility. Unfortunately, reinfection rates are high (∼15%) suggesting improved diagnostics are required. A common strategy to treat TKA infection in North America is the two-stage revision procedure involving the installation of a temporary spacer in the joint while the infection is treated for 6–12 weeks before permanent revision. Subdermal temperature increases during infection by 1–4°C providing a potential indicator for when the infection has been cleared. We propose an implantable temperature sensor integrated into a tibial spacer for telemetric use. We hypothesized that suitable sensing performance for infection monitoring regarding precision and relative accuracy can be attained using a low power, compact, analog sensor with <0.1ºC resolution.

Objective

Wearable sensors have enabled objective functional data collection from patients before total knee replacement (TKR) and at clinical follow-ups post-surgery whereas traditional evaluation has solely relied on self-reported subjective measures. The timed-up-and-go (TUG) test has been used to evaluate function but is commonly measured using only total completion time, which does not assess joint function or test completion strategy. The current work employs machine learning techniques to distinguish patient groups based on derived functional metrics from the TUG test and expose clinically important functional parameters that are predictive of patient recovery.

Introduction

HXLPE acetabular liners were introduced to reduce wear-related complications in THA. However, post-irradiation thermal free radical stabilization can compromise mechanical properties, leave oxidation-prone residual free radicals, or both. Reports of mechanical failure of HXLPE acetabular liner rims raise concerns about thermal free radical stabilization and in vivo oxidization on implant properties. The purpose of this study is to explore the differences in the mechanical, physical and chemical properties of HXLPE acetabular liner rims after extended time in vivo between liners manufactured with different thermal free radical stabilization techniques.

Introduction

A total knee arthroplasty (TKA) is the standard of care treatment for end-stage osteoarthritis (OA) of the knee. Over the last decade, we have observed a change in TKA patient population to include younger patients. This cohort tends to be more active and thus places more stress on the implanted prothesis. Bone cement has historically been used to establish fixation between the implant and host bone, resulting in two interfaces where loosening may occur. Uncemented fixation methods provide a promising alternative to cemented fixation. While vulnerable during the early post-operative period, cementless implants may be better suited to long-term stability in younger patient cohorts. It is currently unknown whether the surgical technique used to implant the cementless prostheses impacts the longevity of the implant. Two different surgical techniques are commonly used by surgeons and may result in different load distribution across the joint, which will affect bone ingrowth. The overall objective of the study is to assess implant migration and in vivo kinematics following cementless TKA.

Background

There is increasing impetus to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA). The direct anterior (DA) approach is a muscle sparing technique that is believed to support these new pathways. Implants designed for these approaches are available in both collared and collarless variations and understanding the impact each has is important for providing the best treatment to patients.

Introduction

Despite improvements in the survivorship of total knee replacements (TKR) over the years, patient satisfaction following TKR has not improved, with approximately 20% of patients recording dissatisfaction with their new knee joint. It is unclear why many patients feel this way, but it may relate in part to implant designs that do not provide a “natural” feeling knee. Implant manufacturers continue to introduce new concepts for implant design, which are essential for reaching the goal of a “normal” knee after TKR surgery. The Journey II TKR (Smith & Nephew) was developed with this goal in mind. Its anatomical design attempts to mimic the normal knee joint structure to return more natural kinematics to the joint, with emphasis on eliminating both paradoxical anterior motion and reduced posterior femoral rollback. Our objective is to examine patients receiving the Journey II TKR to measure the knee joint contact kinematics of the Journey II TKR compared to a non-anatomically designed implant by the same manufacturer. We hypothesize that the Journey II TKR will have more natural contact kinematics that differ from the non-anatomically designed implant.

Introduction

HXLPE acetabular liners were introduced to reduce wear-related complications in THA. However, post-irradiation thermal free radical stabilization can compromise mechanical properties, leave oxidation-prone residual free radicals, or both. Reports of mechanical failure of HXLPE acetabular liner rims raise concerns about thermal free radical stabilization and in vivo oxidization on implant properties. The purpose of this study is to explore the differences in the mechanical, physical and chemical properties of HXLPE acetabular liner rims after extended time in vivo between liners manufactured with different thermal free radical stabilization techniques.

Introduction

Surgeons performing a total knee replacement (TKR) have two techniques to assist them achieve proper bone resections and ligament tension – gap balancing (GB) and measured resection (MR). GB relies on balancing ligaments prior to bony resections, whereas bony resections are made based on anatomical landmarks in MR. Many studies have been done to compare the implant migration and kinematics between the two techniques, but the results have been varied. However, these studies have not been done on modern anatomically designed prostheses using radiostereometric analysis (RSA). Anatomical designs attempt to mimic the normal knee joint structure to return more natural kinematics to the joint, with emphasis on eliminating both paradoxical anterior motion and reduced posterior femoral rollback. Given the major design differences between anatomical and non-anatomical prostheses, it is important to investigate whether one surgical technique may have advantages another. We hypothesize that there would be no difference between GB and MR techniques in implant migration, but that GB might provide better knee kinematics.

Trainees experience significant stress in the operating room, with potentially adverse effects on performance and learning. Psychological resilience explains why some individuals excel despite significant stress, meeting challenges with optimism and flexibility. The purpose of this study was to explore the relationships between trainee resilience, intraoperative stress, and desire to leave residency training.

Qualitative focus groups and a literature review were used to develop a new instrument to assess Surgical TRainee Experiences of StresS in the Operating Room (STRESSOR). STRESSOR was used in a survey of Canadian surgical residents to assess trainee stress. Resiliency was measured using the 10-item Connor-Davidson Resiliency Scale (CD-RISC-10).

The survey was distributed nationally and 171 responses were collected for a 36% response rate. The greatest sources of intraoperative stress were time pressure, attending temperament, and being interrupted by a pager. The STRESSOR instrument had strong reliability (Cronbach's α=0.92) and demonstrated good construct validity using confirmatory factor analysis. The mean CD-RISC-10 score was 28.8, which is similar to that of Canadian medical students. Resilience was protective against intraoperative stress (R2=0.16, p<0.001). Residents with higher stress or lower resilience were more likely to have seriously considered leaving their training program (Spearman's rho = 0.42, p<0.001).

Screening for resilience may assist in selecting trainees who are better able to manage stress during surgery and reduce resident attrition. Resiliency training may help learners manage the high stress environment of the operating room, potentially improving surgical performance and learning in the next generation of surgeons.