Plate 01Own reference
SignatureThe envelopeOpening under load across the arc — the measurement the implant is cut to, not a target it is aimed at.
Compartment opening under load, measured across the flexion arc, driving component geometry rather than only component position. The origin instance: functional-alignment-first, with the soft-tissue envelope read per structure and a pre-op clinic rating that predicts the tier before anyone opens anything.
Read the finding and its limit
Valgus and varus fail differently and the geometry should answer differently — laxity after the bone cuts is not the same problem as posterior osteophytes producing a fixed flexion contracture.
Honest limit. Conformity slopes, step gain, patellar-track gains and the rating-to-envelope lookup are hypotheses with no clinical validation. Stiffness is read from the tighter compartment, never an average.
Plate 02Coupled
Signature15° → 3°Width of the feasible cup window, 1A pelvis versus 2B. The number is the room you have, not the angle you want.
Spinopelvic mobility: functional pelvic tilt read supine, standing and seated. The instrument returns not a target angle but the width of the window in which a cup is safe for this particular pelvis.
Read the finding and its limit
The finding that matters clinically: immobility narrows the window, deformity does not. A stiff spine — not a deformed one — removes your margin. A 1A pelvis leaves 15° to work in; a 2B leaves 3°.
The instrument's own arithmetic. Cup window widths are computed here rather than taken from a published table — a way of thinking about margin, not a number to plan from.
Plate 03Attrition
SignatureCorrection budgetDegrees needed against degrees safely reamable. The gap is what the implant must carry.
How far the glenoid has travelled from its premorbid position, set against how far a reamer may safely go. What will not fit inside that budget is the residual, and the residual is what the construct has to supply — augment, graft, or a different operation.
Read the finding and its limit
The soft-tissue gate sits above the geometry, not beside it: if the envelope will not tolerate the correction, the arithmetic never runs.
No mandate reaches here. Neither TEAM nor ASM includes the shoulder. The page says so rather than implying a payment clock it does not have.
Plate 04Coupled
SignatureWhat the hindfoot gives backCompensation available below the ankle, tested past a 5° physiologic allowance.
The hip one segment down. The subtalar joint is the adjacent segment and the Coleman block is the seated film — the same two-position question, asked in a vocabulary that has no idea the hip is asking it too.
Read the finding and its limit
The result worth the build: the same deformity burden and the same residual can demand a different operation, depending entirely on what the hindfoot is willing to give back.
A modelling error, corrected mid-build. Flexibility was first credited as free self-correction. Wrong: a flexible hindfoot is correctable, and correcting it is the osteotomy. Flexibility decides osteotomy-versus-fusion; it does not shrink the burden.
Plate 05Own reference
SignatureArc available vs 55° demanded45–60° walking, ~65° running. Supply against demand, with pain as an overriding gate.
First MTP dorsiflexion available under load against roughly the 55° a gait cycle demands. Two nested two-position tests: Jack's test below for the windlass, Silfverskiöld above — because the calf loads the forefoot and the toe is downstream of it. Mid-range pain overrides the arithmetic entirely.
Read the finding and its limit
The weakest instrument in the programme, and its page says so first. Weight-bearing passive hallux dorsiflexion in standing has been reported not related to hallux dorsiflexion during walking.
Plate 06Coupled
SignatureMCP compensationHyperextension the adjacent joint has taken on. 30° published; 20° is ours.
The thumb CMC joint, and what the MCP is doing about it. As the base collapses into adduction the MCP hyperextends to keep the web open. Rebuild the base alone and the reconstruction inherits that compensation. The gate is clinical — failed non-operative management — not radiographic.
Read the finding and its limit
Structural, not kinematic. There is no second position, the hyperextension is measured once. The 30° decision point is published; the 20° watch level is this tool's own convention, marked as invented.
Plate 07Own reference
Signature26.3° vs 53.5°Correction demanded of identical films at 78 and at 34. A 27° swing on age alone.
The same spinopelvic films as the hip, read in the opposite direction. The hip asks will this pelvis move? The spine asks how much of that motion am I about to remove? A stiff spine is the hip's hazard and this operation's product.
Read the finding and its limit
Two identical radiographs: at 78 the age-adjusted target demands 26.3° of correction. At 34 it demands 53.5°. A universal 43° target undershoots the young man by 10.5° and overshoots the elderly woman by 16.7°.
The loudest safety framing in the programme, deliberately. The age brackets are approximate, showing the shape, not the primary regression. Reported correlation with junctional angle was small (r ≈ 0.32): direction supported, precision not.
Plate 08Coupled — confirms hardest
Signature>3 mm / >2 mmThe two published pull-test thresholds, reported as a gap. Expendability is conditional, never a property of the part.
The forearm is a ring: proximal joint, interosseous membrane, distal joint. The radial head is a secondary valgus stabiliser — expendable only while the coronoid and MCL are intact and the membrane holds.
Read the finding and its limit
Excise it with an incompetent membrane and the radius migrates proximally. The failure presents as ulnar-sided wrist pain, months later, at a joint nobody operated on — often to a different surgeon.
Reports the disagreement rather than resolving it. The radius pull test threshold is >3 mm conventionally and >2 mm by the RAIL criterion.
Plate 09Attrition — refutes
SignatureWhat survivesCapitate head and lunate fossa, intact or not. A gate, not a budget.
Built expecting an envelope. Found a gate. No neighbour compensates, there is no second position, and the midcarpal joint is resected rather than recruited.
Read the finding and its limit
A proximal row carpectomy makes the capitate articulate with the lunate fossa, so both must be intact — stage III degeneration of the proximal capitate excludes the operation rather than making it harder.
A classifier with a gate, not a calculator — and that is the finding. This joint refuted the programme's own rule, which is why it is here at full length rather than quietly dropped.
Plate 10Coupled
Signature2.5% → 52.7%Scapular share of the first 30° versus the 90–120° segment. The taught ratio fits no segment of the arc.
The scapulothoracic share of elevation — judged against the share expected for that segment of the arc, not against one taught ratio.
Read the finding and its limit
Scapulohumeral rhythm is taught as 2:1. In the cited series, no increment of the arc equalled it. The scapula supplies about 2.5% of the first 30° and about 52.7% of the arc from 90° to 120°.
Weak signals stay weak. Visible dyskinesis reaches tier B and never tier C on its own — reported in 68–100% of injured shoulders, so it discriminates almost nothing alone.
Plate 11Coupled — displaced failure
Signature66% vs 19%Projected adjacent-segment exposure from identical films at 45 and at 75 after a one-level fusion, if the published 2.9% yearly rate held until age 82 (beyond ten years, an extrapolation). The neighbour you are about to manufacture.
T1 slope behaves as the cervical pelvic incidence, correlating at about r = 0.89 with C0–C7 lordosis. The instrument reads the T1S−CL mismatch and the C2–C7 sagittal axis against a 40 mm threshold.
Read the finding and its limit
Symptomatic adjacent-segment disease runs at 2.9% per year and 25.6% at ten years — the model reproduces that figure to within a tenth of a point, the only external calibration in the programme.
Two warnings ride on the output. Past ten years it is extrapolation. Whether fusion causes adjacent-segment disease or merely reveals natural history is genuinely contested.
Plate 12Not built
The instrument that was never built
StatusNot builtThe measurement every other instrument silently assumes somebody made consistently.
Every one of the eleven above depends on a joint being loaded — under body weight, under an examiner's hand, under a block. Nothing in orthopaedics standardises that force. "Stress the joint" means whatever the examiner's grip means that afternoon.
Read the finding and its limit
A calibrated stress applicator with a load indicator would put a number under all eleven instruments at once. It is the highest-value missing piece in the programme.
Listed because it is absent. A programme that only shows what it built is advertising, not a record.