Scope and Mission Mentors in Orthopedics is a peer-reviewed, Open Access journal dedicated to the clinical and technical advancement of surgical practice. The journal serves as a bridge between academic research and practical application in the operating room, with a primary focus on the operative management of joint pathologies (hip, knee, shoulder, and ankle) as well as hand and foot surgery. Editorial Focus The publication emphasizes mentorship and the transmission of surgical expertise. Its content includes: Original peer-reviewed research studies. Technical surgical insights and "pearls." Expert commentaries on clinical innovations. Resources for both seasoned surgeons and emerging specialists. Publication & Governance Editor/Publisher: Maîtrise Orthopédique Headquarters: 21 rue de la Ravinelle, 54000 Nancy, France Publishing Director: Olivier Melison Access Model: Open Access (OA) Target Audience: Orthopedic surgeons, surgical residents, and musculoskeletal healthcare professionals worldwide.
Implant allergy and total knee arthroplasty. What is the first-line management? Therapeutic options and outcomes
Background: Total knee arthroplasty (TKA) is a frequent procedure, yet persistent postoperative pain remains a significant cause for revision. Metal hypersensitivity, a type IV delayed immune reaction mediated by T-lymphocytes, is a controversial etiologic factor implicated in approximately 0.6% to 1% of TKA revisions. Objective: This article reviews the pathophysiological mechanisms of implant-related allergy, evaluates current diagnostic modalities, and analyzes clinical outcomes of hypoallergenic prosthetic alternatives in primary and revision settings. Key Points: Metal sensitization prevalence is estimated at 10% to 15% in the general population, increasing to 60% in cases of implant failure. Common haptens include nickel, cobalt, and chromium. Diagnosis relies on cutaneous patch testing and the lymphocyte transformation test (LTT), though both exhibit limitations in specificity and clinical correlation. Management of confirmed allergy involves hypoallergenic implants utilizing titanium nitride (TiN), zirconium nitride (ZrN), or ceramicized components like Oxinium. Prospective studies indicate that functional outcomes and ten-year survival rates for hypoallergenic implants in primary TKA are comparable to standard cobalt-chromium prostheses. However, registry data from the United Kingdom and Australia demonstrate higher cumulative revision rates for hypoallergenic designs, particularly in younger patient cohorts. In revision surgery for suspected allergy, outcomes are heterogeneous, with some series showing improved range of motion and pain relief following the use of coated implants. Conclusion: While hypoallergenic prostheses are viable for patients with confirmed symptomatic metal allergy, their routine use is not supported by registry data showing inferior long-term survivorship compared to standard implants. Diagnosis requires systematic exclusion of infection and mechanical loosening.
Copyright (c) 2025 Mentors in Orthopedics
Weil osteotomy of the first metatarsal in the management of grade 1 to 3 hallux rigidus: a retrospective cohort of 113 cases with a mean follow-up of four years
Background: Hallux rigidus is a prevalent degenerative condition of the first metatarsophalangeal joint. While arthrodesis is the established surgical standard for advanced stages, it significantly alters gait kinematics. Joint-preserving procedures, such as the Weil distal oblique shortening osteotomy, offer potential alternatives for maintaining motion, yet their efficacy across different radiographic grades and their impact on load distribution remain subjects of clinical investigation. Objective: This study evaluates the long-term clinical, functional, and radiological outcomes of the Weil first metatarsal osteotomy for the treatment of Coughlin and Shurnas Grade 1, 2, and 3 hallux rigidus. Key Points: A retrospective analysis of 87 feet (72 patients) with a mean follow-up of 51 months demonstrated a significant increase in mean AOFAS scores from 54.2 to 92.2 (p < 0.001). Mean dorsiflexion improved by 9°, while plantar flexion remained stable. Radiological analysis showed a mean metatarsal shortening ratio of 9.6%. Postoperative transfer metatarsalgia occurred in 17.2% of cases at six months, resolving in most patients through conservative management; only 4.6% reported persistent symptoms at final follow-up. No significant correlations were found between clinical outcomes and preoperative metatarsal index, Coughlin grade, or the degree of metatarsal shortening. The subjective satisfaction rate was 95.4%, and no patients required secondary arthrodesis. Conclusion: The Weil distal oblique osteotomy is an effective joint-preserving intervention for Grade 1 to 3 hallux rigidus. It provides significant pain relief and functional improvement with a low rate of persistent complications, regardless of the preoperative radiographic severity or metatarsal length.
The limits of implant retention in prosthetic joint infection
Background: Prosthetic joint infection (PJI) represents a significant complication in lower limb arthroplasty, compromising joint function and patient outcomes. The development of bacterial biofilms on prosthetic surfaces creates a protective environment against host immunity and antimicrobial therapy, typically becoming established within two weeks. Consequently, identifying the specific clinical conditions and temporal windows that permit implant retention is critical to avoid treatment failure and subsequent functional morbidity. Objective: This article aims to define the indications for implant retention in acute PJI and to describe a standardized surgical protocol, termed SYLAC (Synovectomy, Lavage, and Change of modular components), to optimize clinical outcomes. Key Points: Successful debridement, antibiotics, and implant retention (DAIR) requires adherence to a strict temporal window: three weeks from symptom onset or four weeks postoperatively. Contraindications include documented bacteremia, extensive soft tissue compromise, and high risk as determined by KLICC (>4) or CRIME-80 (>3) scores. The SYLAC protocol emphasizes radical synovectomy and the mandatory exchange of all modular components. Irrigation involves synergistic use of hydrogen peroxide and povidone-iodine, followed by six liters of pulsatile lavage. Postoperative management includes a three-month antibiotic regimen and structured laboratory monitoring. Failure to adhere to these selection criteria or surgical steps increases the risk of chronic infection and the need for radical explantation. Conclusion: Utilizing a structured decision-making algorithm and a standardized surgical technique allows for a cure rate of approximately 75% in appropriately selected PJI cases. Rigorous patient selection and meticulous surgical execution are essential to preserve prosthetic function and minimize long-term sequelae.
One-stage revision arthroplasty for infected total hip replacement: principles and outcomes
Background: Periprosthetic joint infection (PJI) of the hip is a significant complication traditionally managed via two-stage revision. While one-stage revision has gained traction due to reduced healthcare costs and the avoidance of multiple surgeries, its implementation requires strict surgical rigor and multidisciplinary coordination to ensure outcomes comparable to two-stage protocols. Objective: This article aims to define the prerequisites, pathophysiological rationale, and technical principles of one-stage revision arthroplasty for chronic hip PJI, while evaluating its clinical indications and success rates. Key Points: Successful management relies on a multidisciplinary team involving infectious disease specialists, microbiologists, and orthopedic surgeons. Pre-operative joint aspiration is essential, demonstrating 88% concordance with intra-operative cultures. The surgical procedure necessitates radical debridement of all infected soft tissue and complete removal of implants and cement, often requiring extended femoral osteotomies. Reconstruction utilizes modular revision implants, dual-mobility components, or structural allografts to address bone loss. Post-operative antibiotic therapy is typically administered for six to twelve weeks. Clinical data from a prospective cohort of 157 chronic PJI cases treated with one-stage revision showed a 95% infection-free survival rate at five years, even in cases involving resistant organisms or sinus tracts. Conclusion: One-stage revision arthroplasty is an effective strategy for the majority of hip PJI cases. By achieving high infection eradication rates and superior functional outcomes compared to two-stage procedures, it serves as a primary treatment option when managed within specialized referral centers.
Pierre Barouk’s trajectory reflects a deliberate balance between heritage and professional autonomy. Having witnessed the introduction of the SCARF osteotomy firsthand, he refined his expertise through rigorous training in Lille before establishing an independent practice in Bordeaux. Now presiding over the AFCP, Barouk emphasizes clinical pragmatism and the necessity of peer-to-peer knowledge transfer. His focus on long-term surgical outcomes and the sustainability of ankle arthroplasty underscores a commitment to advancing the specialty through collective evidence and technical precision.
Arun Mullaji is a famous knee surgeons in India and very active in Europe. He is one of the founding members of the Indian Hip and Knee Surgery Society and the past president of the Asia Pacific Arthroplasty Society.
Copyright (c) 2020 Mentors in Orthopedics
A pictorial and systematic approach to varus deformity
Background: Varus deformity is the most prevalent malalignment in total knee arthroplasty (TKA), ranging from mild, passively correctable cases to recalcitrant deformities. Traditional correction often involves extensive soft tissue release, yet controversy remains regarding the optimal sequence and necessity of releasing the superficial medial collateral ligament (MCL). Objective: This article describes a systematic approach to achieving coronal alignment and gap balancing in varus TKA without superficial MCL release, utilizing computer navigation and specific osteotomy techniques. Key Points: The methodology is based on the premise that the superficial MCL is often tented by osteophytes rather than contracted. Preoperative and intraoperative assessments must identify extra-articular deformities (EAD) and hindfoot valgus, which influence the weight-bearing axis. Following bone resections perpendicular to the mechanical axes, three clinical scenarios guide soft tissue management. Symmetrical gaps require no further release. If the extension gap is tight medially but the flexion gap is symmetrical, a posteromedial capsular release or a sliding medial condylar osteotomy is indicated. If both gaps are tight medially, a reduction osteotomy of the posteromedial tibial flare is performed, followed by semimembranosus release or corrective metaphyseal osteotomy if EAD is present. Conclusion: Precise alignment and ligamentous balance in severe varus deformity can be achieved by addressing bone morphology and posteromedial structures. This systematic protocol prioritizes preservation of the superficial MCL and utilizes intra-articular or extra-articular osteotomies to manage complex deformities without requiring constrained implants.
Hip arthroscopy on the orthopaedic table: Technique, tips and tricks to avoid potential complications
Background: Hip arthroscopy has evolved significantly since 1931, with expanding indications for intra-articular and extra-articular pathologies. The procedure involves a demanding learning curve and specialized instrumentation, while training is often limited by the scarcity of anatomical specimens and specialized centers. Objective: This article provides a comprehensive review of hip arthroscopy, detailing surgical anatomy, clinical indications, potential complications, and standardized technical approaches for accessing the various arthroscopic compartments. Key Points: The hip is categorized into central, peripheral, peritrochanteric, and posterior compartments. Accessing the central compartment requires approximately 1 cm of joint distraction under fluoroscopic guidance, typically performed in the supine position. Standard portals—anterolateral, anterior, and posterolateral—must be established within safe zones to avoid neurovascular structures like the femoral and sciatic nerves. Complication rates currently range from 0.5% to 7.9%, primarily involving traction-related neuropraxia, iatrogenic chondral injury, and fluid extravasation. For the peripheral compartment, traction is released and the hip flexed to 20°–45° to visualize the femoral head-neck junction. Peritrochanteric access enables management of extra-articular conditions, including gluteus medius tears and bursitis. Technical success relies on precise portal placement and sequential exploration of the joint spaces. Conclusion: Hip arthroscopy is a technically complex procedure requiring precise anatomical knowledge and adherence to safety protocols. Standardized portal placement and careful patient selection are essential to minimize complications and optimize outcomes in the management of coxofemoral pathology.
Medial unicompartimental knee arthroplasty : Indications and limits
Background: Medial unicompartmental knee arthroplasty (UKA) serves as an intermediary surgical intervention between osteotomy and total knee arthroplasty (TKA). Despite historical concerns regarding failure rates and restrictive selection criteria established in 1989, advancements in tribology and surgical technique have improved clinical outcomes to levels comparable with TKA. Objective: This article evaluates the evolution of indications and contraindications for medial UKA, examining the impact of patient factors and surgeon experience on long-term implant survivorship. Key Points: Modern evidence suggests that traditional contraindications, including age under 60, obesity, and asymptomatic patellofemoral chondrosis, do not significantly compromise outcomes. While inflammatory arthritis remains a definitive contraindication, ACL deficiency may be managed successfully in specific older populations. Optimal results are strongly correlated with surgical volume, specifically when UKA constitutes 20–50% of a surgeon's total knee replacement caseload. Technical precision is critical, as axial alignment must avoid overcorrection to prevent lateral compartment degeneration or undercorrection leading to polyethylene wear. The Unicompartmental Indication Score (UIS) provides a contemporary framework for patient selection, with scores exceeding 25 predicting superior clinical satisfaction. Conclusion: Medial UKA is a highly effective treatment for localized osteoarthritis when performed with meticulous technique. Success depends less on strict adherence to historical age or weight limits and more on the surgeon’s proficiency and the relative proportion of UKA procedures within their clinical practice.
Lateral unicompartmental knee arthroplasty: sticking to the indications and applying a meticulous technique in order to guarantee excellent long-term outcomes
Background: Lateral unicompartmental knee arthroplasty (UKA) is performed significantly less frequently than medial UKA, often due to the lower prevalence of valgus deformities and historical concerns regarding implant survival and specific complications such as bearing dislocation. Despite these concerns, recent data suggest functional outcomes and long-term survival rates comparable to total knee arthroplasty (TKA) when treating isolated lateral compartment disease. Objective: This article provides a technical update on lateral UKA, detailing patient selection criteria, surgical methodology, and long-term clinical outcomes based on a multicenter retrospective study. Key Points: Indications include isolated lateral osteoarthritis or necrosis with reducible deformity and an intact anterior cruciate ligament. Surgical technique emphasizes a lateral parapatellar approach without ligamentous release to avoid overcorrection. A 1–2 mm laxity safety margin is recommended. Analysis of 268 lateral UKA procedures with a mean 9.1-year follow-up demonstrated a 10-year survival rate of 85.4% and a 20-year rate of 79.4%. The primary cause of failure was disease progression in other compartments (n=26). No statistically significant differences in survival were observed between resurfacing and cutting implants or between cemented and cementless fixation, although cemented implants showed superior postoperative IKS scores. Conclusion: Lateral UKA is a reliable surgical option for isolated lateral compartment disease. Success depends on strict adherence to indications, preservation of the ligamentous envelope, and precise component positioning to accommodate the specific anatomy and biomechanics of the lateral tibiofemoral joint.
Femoro-acetabular impingement (FAI): Is there still a place for open surgery?
Background: Femoroacetabular impingement (FAI) is a dynamic hip dysfunction caused by morphological alterations of the acetabulum, femoral head-neck junction, or femoral torsion. If left untreated, the resulting labral and chondral damage may progress to premature coxarthrosis in young, active populations. Objective: This review evaluates the diagnostic imaging requirements for FAI and defines the specific clinical indications for arthroscopic versus open surgical interventions, including pelvic and femoral osteotomies. Key Points: Diagnosis requires standardized pelvic radiographs and arthro-MRI to quantify acetabular coverage (Lateral Center Edge angle >33°), alpha angles, and torsional deformities. While conservative management is the initial approach, surgical intervention is indicated upon failure. Hip arthroscopy is effective for labral repair and focal osteochondroplasty but has limitations in addressing global acetabular retroversion or significant torsional abnormalities. Open surgical dislocation provides circumferential joint access for complex cam morphologies and focal retroversion (<30%). For global acetabular retroversion (>30%), periacetabular osteotomy (PAO) demonstrates superior long-term joint survivorship compared to rim trimming. Femoral derotation osteotomy is specifically indicated for impingement secondary to femoral retroversion (<0°) or excessive anteversion (>35°). Conclusion: Surgical management of FAI must be tailored to the specific morphological deformity. While arthroscopy is a primary minimally invasive option, open surgical dislocation, PAO, and femoral osteotomy remain essential for correcting global version abnormalities and complex femoral deformities to optimize clinical outcomes and joint preservation.
Copyright (c) 2022 Mentors in Orthopedics
Biplanar opening-wedge tibial valgus osteotomy for medial knee OA: Review of 20 year’s experience with tips and tricks
Background: Medial compartment gonarthritis associated with varus malalignment remains a significant cause of cartilage degeneration. While lateral closing-wedge techniques were historically preferred, medial open-wedge biplanar tibial valgus osteotomy using locking plate fixation has emerged as a standard joint-preserving intervention. Objective: This article provides a clinical algorithm and technical framework for performing medial open-wedge biplanar tibial valgus osteotomy, focusing on patient selection, preoperative planning, and intraoperative maneuvers to optimize alignment and minimize complications. Key Points: Success depends on precise deformity analysis using the Mikulicz line, medial proximal tibial angle (MPTA), and joint line obliquity. Indications include symptomatic Outerbridge grade 1–3 medial cartilage lesions with varus deformity exceeding 3°. Critical surgical steps involve a subperiosteal release of the superficial medial collateral ligament to prevent increased medial compartment pressure and a multi-chisel technique to create a stable lateral hinge. The biplanar cut protects the tibial tuberosity and allows for sagittal plane adjustments, such as slope reduction to address extension deficits. Locking plate fixation, specifically the Tomofix system, provides primary stability without the necessity for bone grafting in most cases. Long-term data from 92 patients demonstrate high union rates and significant pain reduction, with a mean correction angle of 9.2°. Potential complications include lateral hinge fractures, thromboembolism, and rare neurovascular injuries. Conclusion: Medial open-wedge biplanar osteotomy is an effective, reproducible procedure for medial gonarthritis. Adherence to a structured surgical protocol and precise intraoperative alignment control are essential for achieving durable clinical outcomes and delaying the requirement for arthroplasty.
Practical approach to modern cartilage repair combined with realignment osteotomy of the knee joint
Background: Realignment osteotomies are established procedures for treating unicompartmental knee osteoarthritis and focal cartilage injuries. However, persistent mechanical malalignment frequently compromises the success of cartilage restoration. Addressing the load-bearing axis is essential when treating deep-seated defects to prevent graft overload and subsequent failure. Objective: This article reviews the clinical indications, surgical planning, and technical execution of combining various cartilage repair techniques with realignment osteotomies in patients presenting with concomitant bony deformities. Key Points: Preoperative assessment requires comprehensive radiographic deformity analysis, including weight-bearing long-leg films to evaluate the mechanical axis. For defects smaller than 1.5 cm², microfracture or osteochondral transfer are viable options. Matrix-augmented bone marrow stimulation (M-BMS) serves as a single-stage alternative for medium-sized defects. Matrix-associated autologous chondrocyte transplantation (M-ACT) remains the gold standard for defects exceeding 2.5 cm², although it necessitates a two-stage approach and higher costs. Emerging techniques like autologous minced cartilage offer single-stage biological restoration but require further comparative evidence. Surgical sequencing typically involves performing the osteotomy first to ensure a stable mechanical environment before graft implantation. Postoperative protocols generally mandate six weeks of restricted weight-bearing to protect the regenerative tissue. Conclusion: Integrating realignment osteotomy with cartilage repair provides a comprehensive approach to unicompartmental pathology. Success depends on precise axis correction—typically indicated for malalignment exceeding 3°—and selecting a restoration procedure tailored to the specific ICRS grade and defect dimensions.
Current techniques in arthroscopic Bankart repair
Background: Since its initial description, Bankart repair techniques have transitioned from open procedures to arthroscopic stabilization, which is now the preferred intervention for over 90% of surgeons. While open techniques were historically the gold standard, concerns regarding postoperative external rotation restrictions and secondary osteoarthritis have led to the increased adoption of arthroscopic methods. Modern advancements in suture anchor technology and instrumentation have improved success rates, making arthroscopic outcomes comparable to open repair. Objective: This article details a standardized arthroscopic Bankart repair technique using suture anchors, emphasizing patient selection, portal placement, and specific intra-operative maneuvers to optimize clinical outcomes. Key Points: Successful stabilization requires a comprehensive preoperative work-up, including 3D-CT to quantify glenoid bone loss and Hill-Sachs lesions. The procedure is performed in the lateral decubitus position using three portals. Critical technical steps include the complete mobilization of the capsulolabral complex from the glenoid neck until subscapularis fibers are visible and the preparation of the glenoid rim to facilitate biological healing. The authors utilize 1.8mm all-suture anchors, typically placing three anchors starting from the 5:30 position. Labral tension is maintained during the application of sliding Duncan loop knots to ensure anatomical restoration of the native joint stability. Conclusion: Arthroscopic Bankart repair is an effective treatment for anterior shoulder instability in patients without significant bone loss. Success depends on meticulous labral mobilization and anatomical fixation, which restores the native stabilizers of the glenohumeral joint.
Dr. Sanjay Desai’s career reflects a transition from general orthopedics to pioneering specialized shoulder surgery across India. Following formative fellowships under Christopher Constant and David Dandy, he rejected a career in the United Kingdom to repatriate advanced arthroscopic techniques. His early practice involved transporting portable surgical equipment to remote regions, effectively establishing a national sub-specialty. Now focused on elevating clinical research to international standards, Desai discusses the evolution of upper limb reconstruction and the necessity of rigorous academic documentation.
Antibacterial Hydrogel Coating of Implants in Orthopedics and Trauma: Surgical Technique and Clinical Applications
Background: Implant-associated infections and subsequent biofilm formation remain primary causes of orthopedic surgery failure, affecting up to 80% of bacterial infections and resulting in significant socioeconomic burdens. Bacterial colonization typically occurs within hours of implantation, creating a protective intercellular matrix that resists systemic antimicrobial therapy and host immune responses. Objective: This article describes the surgical application, technical specifications, and clinical outcomes of a fast-resorbable, hyaluronic acid-based hydrogel coating designed to prevent bacterial adhesion on orthopedic and trauma implants. Key Points: The Defensive Antibacterial Coating (DAC®) consists of hyaluronic acid grafted to polylactic acid. This biocompatible hydrogel acts as a physical barrier against microbial colonization and can be intraoperatively loaded with antibiotics, such as vancomycin or meropenem, at concentrations of 2% to 5%. The coating is compatible with various biomaterials, including titanium, cobalt-chrome, and polyethylene, and retains 60% to 80% adherence following press-fit insertion. Clinical data from 724 patients indicate an eightfold reduction in early post-surgical infections compared to uncoated controls. No adverse effects on bone healing, osseointegration, or systemic laboratory markers have been reported. The hydrogel undergoes complete resorption within 72 hours, coinciding with the window of maximum infection risk. Conclusion: The application of a resorbable, antibiotic-loaded hydrogel provides a versatile and safe method for reducing peri-prosthetic and fracture-related infections. This technology effectively bridges the gap between initial implantation and host tissue integration by inhibiting early biofilm formation without compromising long-term implant stability.
Copyright (c) 2019 Mentors in Orthopedics
Is there still any place for femoral osteotomy in conservative hip surgery?
Background: Traditional proximal femoral osteotomy for the correction of architectural deformities has declined in frequency due to the technical complexity of lateral approaches, extensive soft tissue disruption, and prolonged postoperative recovery. While hip arthroplasty is often preferred, joint-preserving salvage surgery remains indicated for young adults with severe femoral malalignment to delay or prevent secondary osteoarthritis. Objective: This article describes a minimally invasive surgical technique for proximal femoral osteotomy utilizing the Hueter anterior approach and evaluates its clinical outcomes and technical advantages. Key Points: The procedure utilizes an intermuscular and interneural plane between the tensor fasciae latae and rectus femoris, preserving the gluteal musculature and the medial femoral circumflex artery. Technical variations include varus, valgus, and derotation osteotomies performed at the base of the femoral neck. Fixation is achieved using cannulated screws and, in valgus or derotation cases, hydroxyapatite or bone wedges to maintain correction. In a series of 15 hips with a mean follow-up of four years, the average Harris Hip Score improved from 60 to 90. Most patients achieved full weight-bearing within two months without instances of femoral head necrosis. The technique allows for simultaneous intra-articular procedures, such as labral repair or mosaicplasty, through a single incision. Conclusion: The minimally invasive anterior approach for proximal femoral osteotomy facilitates accelerated rehabilitation and high union rates while preserving the femoral diaphysis for potential future arthroplasty. It represents a viable joint-preserving option for young patients with complex hip deformities.
Registries and the new EU Medical Device Regulation: Impact on Patient Care, Product Development, Financial Support and Research
Background: The transition from the Medical Device Directive (MDD) to the Medical Device Regulation (MDR) in the European Union addresses historical failures in identifying suboptimal orthopedic implants. Previous reliance on sample-based clinical studies often failed to detect high revision rates in devices such as the ASR hip system until significant patient harm occurred. Structural biases and insufficient statistical power in published literature have historically delayed the identification of device-related incidents. Objective: This article evaluates the regulatory shift toward the MDR, focusing on the integration of real-world evidence and registry data to enhance the monitoring of safety and performance in orthopedic arthroplasty. Key Points: The MDR mandates systematic reviews and the utilization of registries, broadly defined to include national quality databases, institutional records, and manufacturer-led observational systems. Unlike traditional clinical trials that prioritize internal validity, registries offer superior external validity by reflecting average clinical practice. Manufacturers are now legally required to perform annual clinical evaluations for high-risk devices, utilizing representative market samples. This regulatory evolution necessitates more rigorous pre-market testing and continuous post-market surveillance, shifting the research landscape from isolated expert-center studies toward professionalized data extraction and large-scale correlation analysis. Conclusion: The implementation of the MDR transforms orthopedic device development and research by prioritizing longitudinal registry data over short-term follow-up studies. This framework aims to improve patient safety through transparent clinical evaluation reports and proactive identification of implant deficiencies, requiring increased cooperation between manufacturers, surgeons, and healthcare institutions.
REGISTRIES....What have we all learned and what of the future? Our experiences with NJR
Background: Arthroplasty registries have transitioned from experimental initiatives to essential components of orthopedic practice. Historically, significant implant failures, such as the 3M Capital Hip and metal-on-metal bearing surfaces, underscored the necessity for systematic longitudinal surveillance to identify poor-performing designs and ensure patient safety through evidence-based decision-making. Objective: This article reviews the evolution of national joint registries, examines the technical requirements for robust data collection, and discusses the role of surveillance systems in monitoring implant performance, surgeon outcomes, and hospital standards. Key Points: Effective registries integrate patient demographics, hospital data, and implant-specific attributes via Universal Device Identification barcodes. High granularity in database architecture is critical to prevent "camouflaging," where the aggregate performance of a large cohort masks the failure of specific implant variants. The National Joint Registry utilizes Patient Time Incident Rates and funnel plots to identify outliers among implants and clinicians. Collaborative initiatives like the Orthopaedic Data Evaluation Panel and "Beyond Compliance" provide independent benchmarking and early-stage monitoring of new technologies. Furthermore, the integration of Patient-Reported Outcome Measures addresses the limitations of revision rates as a solitary metric for success. International cooperation through organizations such as the International Society of Arthroplasty Registries facilitates the standardization of data quality and global surveillance of orthopedic devices. Conclusion: Arthroplasty registries are vital for maintaining clinical standards and enhancing patient safety. Future developments will involve the integration of mobile applications for data collection and the application of machine learning to analyze increasingly complex datasets, ensuring that orthopedic practice remains rooted in objective clinical evidence.
Professor Rob Nelissen’s trajectory reflects a rigorous commitment to data-driven surgical precision. From early research on artificial hearts in Utah to chairing the Department of Orthopaedics at Leiden University, his focus remains on objective outcomes. As a founder of the Dutch Arthroplasty Register, he transitioned from clinical practice to establishing European quality standards. His current research explores novel solutions like induction heating for infections, advocating for a holistic, evidence-based approach that prioritizes patient safety and international collaboration.
From Vision to Reality: the Clinical Experience and Future of Knee Robotic Surgery
Background: Robotic-assisted surgery represents an evolution in computer-assisted orthopedic procedures, aiming to enhance the precision and reproducibility of bone preparation in lower limb arthroplasty. While traditional robotic systems often require preoperative computed tomography and bulky equipment, image-free systems utilizing bone-morphing technology have emerged to streamline the surgical workflow and eliminate preoperative radiation exposure. Objective: This article describes the clinical application, technical implementation, and surgical outcomes of the Navio® image-free robotic-assisted system across various knee arthroplasty indications. Key Points: The system utilizes an infrared camera, tracking arrays, and a handheld robotic bur with automatic feedback to ensure bone resection remains within planned boundaries. The workflow integrates dynamic ligament balancing and 3D anatomical mapping to optimize implant positioning in unicompartmental (UKA), patellofemoral (PFA), and total knee arthroplasty (TKA). Clinical data indicate that robotic assistance achieves superior joint line restoration and more accurate radiological positioning compared to conventional techniques. Furthermore, studies report a lower revision rate for lateral UKA and a significantly faster return to sporting activities, such as cycling and skiing, following robotic-assisted procedures. The technology also facilitates complex indications, including bicruciate-retaining TKA and combined UKA with anterior cruciate ligament reconstruction, by providing precise control over tibial slope and gap symmetry. Conclusion: Image-free robotic assistance provides a highly accurate, reproducible method for knee arthroplasty that improves component alignment and soft tissue balancing. These technical advantages translate into enhanced functional recovery and reduced complication rates without the need for preoperative imaging.
PCL reconstruction using INLAY technique tips and tricks
Background: Posterior cruciate ligament (PCL) injuries frequently result from high-energy trauma and often present as multiligamentous complexes. Chronic PCL insufficiency alters knee kinematics, increasing anteromedial and patellofemoral joint pressures, which predisposes the patient to secondary osteoarthritis. Despite these risks, posterior instability remains frequently underdiagnosed, necessitating standardized clinical and radiological evaluation algorithms. Objective: This article describes a systematic approach to the diagnosis of PCL instability and details an arthroscopic inlay reconstruction technique using a quadriceps tendon autograft with an integrated bone block. Key Points: Clinical evaluation utilizes the posterior sag sign and measurement of anteromedial step-off, supplemented by the dial test to assess posterolateral corner involvement. Radiological screening includes standing long-film radiographs for alignment and Bartlett kneeling stress views to quantify posterior translation. Surgical intervention is indicated for instability exceeding 8 mm or cases with associated rotatory laxity. The described arthroscopic inlay technique employs a quadriceps tendon graft with a 10 mm bone block, fixed in a tibial socket created via retro-drilling. This approach aims to mitigate the "killer turn" effect associated with traditional transtibial tunnels, which biomechanical studies suggest leads to graft elongation. Postoperative management requires a specialized PCL brace and a protected rehabilitation protocol focusing on quadriceps strengthening and gravity-controlled flexion. Conclusion: Arthroscopic PCL inlay reconstruction using a quadriceps tendon autograft provides a viable alternative to transtibial techniques. Precise tunnel placement and a cautious, gravity-protected rehabilitation program are essential to maintain graft integrity and restore joint stability in chronic cases.
Technical Advice for Patellofemoral Arthroplasty
Background: Isolated patellofemoral arthroplasty (PFA) is a bone-preserving intervention for localized compartment disease, offering rapid mobilization and high functional recovery. Despite these advantages, historical data indicate revision rates significantly higher than those of total knee arthroplasty, often attributed to suboptimal implant design and exacting surgical requirements. Objective: This article aims to delineate specific surgical techniques, preoperative planning strategies, and intraoperative considerations essential for optimizing clinical outcomes and reducing failure rates in PFA. Key Points: Successful PFA requires stringent patient selection, excluding those with tibiofemoral degeneration or regional pain syndromes. Precise patella preparation must maintain a minimum bone thickness of 12 mm and replicate the native apex position to prevent soft tissue over-tensioning. Trochlea component positioning is critical; current evidence supports an anatomical "inlay" approach to match the patient’s natural tracking rather than adhering to traditional total knee arthroplasty alignment landmarks. Rotational alignment should prioritize lateral marginal congruence to prevent patellar clunking or instability. Intraoperative assessment must evaluate the need for tibial tuberosity osteotomy—specifically distalization for patella alta—and titrated lateral release or medial soft tissue reconstruction to ensure stable tracking from full extension through deep flexion. Conclusion: While technically demanding, PFA can achieve revision rates comparable to total knee arthroplasty when surgeons prioritize anatomical trochlear orientation and precise soft tissue balancing. Mastery of extensor mechanism realignment and component congruence is fundamental to avoiding common complications such as instability, persistent effusion, and chronic anterior knee pain.
The philosophy of total hip replacement revision at Mayo Clinic
Background: Revision total hip arthroplasty (THA) rates are increasing, with instability, aseptic loosening, and infection identified as primary indications for surgery. Managing significant acetabular and femoral bone loss remains a complex challenge, requiring standardized classification systems to guide reconstruction strategies. Objective: This article reviews current surgical protocols and clinical outcomes for complex THA revisions, specifically focusing on the management of bone defects and periprosthetic fractures using techniques employed at the Mayo Clinic. Key Points: Preoperative evaluation must prioritize the exclusion of infection via inflammatory markers and joint aspiration. Acetabular reconstructions are categorized by the Paprosky classification; Type 3 defects often necessitate jumbo cups, porous tantalum augments, or custom triflange implants to achieve stability. In cases of pelvic discontinuity, tantalum cup-cage constructs or distraction techniques are utilized, showing high short-term survival despite risks of stress fractures or reduced bone stock. Femoral revisions utilize modular fluted tapered stems (TMFT) for Paprosky Type 3 and 4 defects, providing superior axial and longitudinal stability compared to cemented options. Extended lateral femoral osteotomy is frequently employed to facilitate component removal. Periprosthetic fractures are managed according to the Vancouver classification, with stable stems treated via internal fixation and loose stems requiring TMFT or proximal femoral replacement. Conclusion: Successful THA revision relies on meticulous preoperative planning and the selection of implants that ensure osseointegration and mechanical stability. The shift toward porous metal technology and modular femoral components has improved outcomes in cases of severe bone deficiency.
How to avoid tunnel convergence during multiple-ligament knee surgery: a practical guide
Background: Multiple ligament knee injuries, often resulting from high-energy trauma or sports-related dislocations, necessitate complex reconstructive procedures to restore joint stability and functional capacity. A significant intraoperative challenge in these cases is tunnel convergence, where the proximity of multiple osseous tunnels increases the risk of hardware collision, compromised graft fixation, impaired biological integration, and potential iatrogenic fractures. Objective: This article provides a technical guide and 3D mapping strategy to assist surgeons in optimizing tunnel orientation during multiligament reconstructions, including procedures involving the cruciate ligaments, collateral ligaments, and anterolateral structures. Key Points: In the tibia, the primary risk of confluence occurs between the posterior cruciate ligament (PCL) and posterior oblique ligament (POL) tunnels; directing the POL tunnel 15–20° toward the Gerdy tubercle mitigates this risk. For combined PCL and medial collateral ligament (MCL) reconstructions, angling the tibial MCL tunnel 30° distally prevents convergence. In the femur, lateral condyle tunnels for the fibular collateral ligament and popliteus should be oriented 20–30° anteriorly to avoid the anterior cruciate ligament (ACL) tunnel. On the medial condyle, the MCL and POL tunnels should be angled 30° anteriorly and 30° proximally to maintain adequate bone bridges and avoid the PCL tunnel. Conclusion: Precise tunnel orientation is the primary modifiable factor for preventing convergence in multiligament knee surgery. Adhering to specific angular guidelines for tibial and femoral drilling reduces the risk of mechanical failure and optimizes the structural integrity of the reconstruction.
Anterior Cruciate Ligament Reconstruction
Professor Andrew Price represents the academic surgeon who balances rigorous research with active clinical practice at the Nuffield Orthopaedic Centre. His trajectory, defined by the Oxford school of biomechanical thought, focuses on the refinement of unicompartmental knee arthroplasty. From early kinematic analysis to directing multicenter randomized trials, Price prioritizes empirical evidence in surgical decision-making. As President of the British Association for Surgery of the Knee, he currently oversees the transition toward robotic assistance and longitudinal registry data analysis.
Adjusted mechanical alignment to achieve a well-balanced knee with less soft tissue releases: Surgical tips and tricks for a modified “extension gap first technique” in TKA
Background: Traditional mechanical alignment in total knee arthroplasty aims for a neutral limb axis to ensure implant longevity, yet approximately 20% of patients report functional dissatisfaction. This has prompted interest in alternative alignment philosophies, such as adjusted mechanical alignment, which prioritize patient-specific anatomy and soft tissue tension over systematic neutral targets. Objective: This article describes a surgical technique for adjusted mechanical alignment using a modified extension gap-first approach and a guided-motion total knee system to improve functional outcomes in varus osteoarthritis. Key Points: The technique utilizes preoperative long-leg radiographs to differentiate between osteoarthritic and constitutional varus. Intraoperatively, an adjustable distal femoral cutting block allows for a maximum of 2.5° additional medial varus to balance the extension gap, reducing the need for extensive medial soft tissue releases. Femoral rotation is determined by soft tissue tension using a quantitative laminar tensioner, with bony landmarks serving as secondary controls. Clinical data from 600 patients demonstrated a mean postoperative hip-knee-ankle angle of -2.9° ± 2.1°, indicating a deliberate residual varus. A randomized trial of 75 patients showed that this adjusted approach yielded significantly higher Knee Society Scores (178.5 vs. 162.4) and Forgotten Joint Scores (78.2 vs. 64.1) at 24-month follow-up compared to traditional mechanical alignment. Conclusion: Adjusted mechanical alignment combined with gap balancing effectively restores knee function and improves patient satisfaction scores. By allowing conservative deviations from a neutral axis, surgeons can achieve symmetrical ligament tension while maintaining safe implant alignment parameters.
The challenges of total knee arthroplasty in posttraumatic osteoarthritis: A cook book approach
Background: Posttraumatic osteoarthritis of the knee presents unique surgical challenges compared to primary osteoarthritis due to complex intraarticular and extraarticular deformities, ligamentous instability, and preexisting hardware. While total knee arthroplasty (TKA) can provide satisfactory outcomes, the heterogeneity of these deformities requires specialized preoperative planning and surgical techniques to address malalignment and stiffness. Objective: This article aims to provide a systematic framework for performing primary TKA in patients with complex posttraumatic lower extremity deformities, focusing on indications for deformity correction, implant selection, and exposure strategies. Key Points: Extraarticular coronal deformities exceeding 20 to 25 degrees generally require staged or concurrent corrective osteotomy, as intraarticular balancing alone may be insufficient. Preoperative assessment must include hip-to-ankle standing radiographs and potentially axial imaging to evaluate rotational malalignment. For intraarticular pathology, surgeons must address joint subluxation and significant bone loss. Posterior or anterior knee dislocations often necessitate constrained or hinged implants, particularly when preoperative range of motion is less than 80 degrees or when extensive distal femoral resection is required for extension. Medial hardware can typically be removed during the primary TKA approach, whereas lateral hardware may require staged removal. In the stiff knee, a systematic medial release—including the medial collateral ligament if necessary—is essential for adequate exposure. Conclusion: Successful TKA in posttraumatic cases depends on precise deformity analysis and a low threshold for using constrained components. While technically demanding and associated with higher complication rates than primary TKA, adherence to established alignment principles and careful soft tissue management can achieve stable, functional results.
Cup-cage reconstruction for severe acetabular bone loss and pelvic discontinuity
Background: Management of severe acetabular bone loss and pelvic discontinuity in revision total hip arthroplasty remains a significant surgical challenge. Traditional ilioischial antiprotrusio cages often fail due to a lack of biological ingrowth, leading to mechanical fatigue and hardware failure. Objective: This article describes the surgical technique and clinical outcomes of cup-cage reconstruction, a hybrid construct designed to provide immediate mechanical stability and facilitate long-term biological fixation. Key Points: The technique utilizes a porous trabecular metal acetabular component supplemented by an antiprotrusio cage. Key surgical steps include thorough debridement to bleeding host bone, morselized allograft impaction, and precise screw fixation into the ilium and ischium. In a series of 35 cases with Paprosky type 2C to 3B defects, the five-year implant survivorship was 89%. The mean Harris Hip Score improved from 30 preoperatively to 71 postoperatively. While effective, the procedure carries risks of sciatic nerve injury and iatrogenic pelvic dissociation during inferior flange placement. Dual-mobility liners are frequently employed to mitigate the risk of postoperative dislocation in patients with abductor deficiency. Conclusion: Cup-cage reconstruction is a reliable salvage option for major uncontained acetabular defects and pelvic discontinuity. The construct provides sufficient initial stability to allow for secondary osseointegration of the porous shell, demonstrating favorable mid-term durability and functional improvement in complex revision scenarios.
A new approach for Paprosky 3 acetabular defects with patient matched 3D printed implants based on bone quality assessment
Background: Reconstruction of Paprosky type 3 acetabular defects and pelvic dissociation remains a significant challenge in revision hip arthroplasty. Conventional techniques, including structural allografts and reconstruction cages, often yield inconsistent results due to inadequate primary stability and limited biological ingrowth. Objective: This study describes the preoperative planning, surgical technique, and preliminary clinical outcomes of a patient-matched, 3D-printed monobloc trabecular titanium acetabular revision system. Key Points: The system utilizes CT-based software to subtract existing hardware, assess bone quality via Hounsfield units, and determine the native center of rotation. A custom implant with integrated flanges and pre-planned screw trajectories is manufactured via 3D printing. In a cohort of 32 patients (median age 68 years) with a minimum 2-year follow-up, the Oxford Hip Score improved from a preoperative mean of 51 to 29 postoperatively. Visual analog scale scores for activity decreased from 89 to 11. Radiographic analysis confirmed no implant migration or construct breakage, although screw loosening occurred in three cases. Complications included three re-operations for delayed wound healing (9%), one deep infection, and one dislocation. The surgical technique emphasizes a posterolateral approach with extensive exposure of the ilium, ischium, and pubic bone to ensure precise implant seating. Conclusion: Patient-specific 3D-printed titanium implants provide a viable solution for complex acetabular reconstructions. The technology allows for accurate restoration of hip mechanics and stable primary fixation through bone-quality-guided screw placement, resulting in favorable short-term clinical and radiological outcomes.