Enhanced recovery after surgery day surgery for MAKO® robotic-arm assisted TKA; better outcome for patients, improved efficiency for hospitals.

Introduction: Robotic-assisted Total Knee Arthroplasty (TKA) was designed to improve implant position accuracy by providing surgeons with real-time intra-operative data to tailor the operation to the patient. Proponents of robotic-assisted TKA believe that this translates into meaningful improvements in outcomes. However, there are concerns that the longer surgical duration associated with robotic-assisted TKA leads to longer length of stay (LOS). In this study, the authors investigated the outcome of MAKO® Robotic-arm Assisted TKA combined with ERAS protocol to assess its effect on LOS and short-term outcomes. Methods: All patients who had undergone unilateral MAKO® ERAS Day Surgery TKA from August 2020 to July 2021 were prospectively followed up and matched to patients who underwent conventional ERAS Day Surgery TKA in the same time period. Factors such as surgical duration, LOS, immediate reduction in pain, 30-days complications, and 6-month PROMs and knee ROM were compared between the two groups. Results: 42 patients underwent MAKO® ERAS Day surgery TKA and were matched to 42 patients who underwent conventional ERAS Day surgery TKA. The study found that despite the longer surgical duration, LOS was comparable between both groups (1.1 ± 0.9days in the MAKO® group vs 1.0 ± 0.3days in the conventional group, p = 0.755) with successful 24-hour discharge in 88.1 % of patients in the MAKO® group. The MAKO® group achieved significantly better ROM compared to the conventional group 6-months post operatively. Post-operative PROMs were comparable between both groups. Conclusion: ERAS Day Surgery protocol can significantly reduce the LOS of patient undergoing MAKO® Robotic-arm Assisted TKA, conferring cost savings and making it a valid option for patients.

Postponement of total knee arthroplasties due to pandemic causes significant deterioration on patients' preoperative knee and quality of life scores.

Introduction: Elective surgeries were postponed during the COVID-19 pandemic to alleviate healthcare strains, affecting majority of elective orthopaedic surgeries such as total knee arthroplasties (TKAs). The aim of this study is to evaluate the impact on knee function and quality of life of patients who had their planned TKA postponed due to the pandemic. Methods: This is a retrospective analysis of data collected in a tertiary hospital. Patients included were diagnosed with primary knee osteoarthritis and they were initially scheduled for primary TKA between January to April 2020 but surgery was postponed by at least 6 months from the initial operative date. 160 patients were included in this study (53 males and 107 females, mean age 68.0 ± 8.1). Patients were assessed prior to initial surgery date and assessed again, prior to the postponed surgery date. Clinical scores included Knee Society Function Score (KSFS), Knee Society Knee Score (KSKS), Oxford Knee scores (OKS) and Short-Form 36 Physical and Mental Component Scores. (SF36 PCS and MCS). Paired T-test was performed for parametric data whereas Wilcoxon signed-rank analysis was performed for non-parametric data. Results: Comparing initial preoperative versus postponement preoperative scores, the cohort had significantly poorer KSKS (38.4 ± 15.4 and 36.5 ± 15.4, p = 0.034), SF36 PCS (34.3 ± 9.2 and 32.7 ± 8.6, p = 0.02) and OKS (34.9 ± 0.77 and 35.8 ± 8.6, p = 0.02) scores respectively. Conclusion: The postponement of elective TKAs has resulted in a significant deterioration of knee scores and physical quality of live scores of patients in a short span of 6 months. Further studies can evaluate if there are repercussions on long term TKAs outcomes. Level of evidence: Retrospective study, Level III.

Adductor Canal Block Does not Confer Better Immediate Postoperative Pain Relief after Total Knee Arthroplasty.

The adductor canal block (ACB) is a useful adjunct to control postoperative pain in total knee arthroplasty (TKA). The aim of our study was to compare postoperative day 1 (POD1) pain scores, ambulation distance, range of motion, active straight leg raise (SLR), and length of stay (LOS) in TKA patients receiving no ACB (NACB), ACB by surgeon (ACBS), or ACB by anesthetist (ACBA). After obtaining institutional ethics approval, a retrospective review of 135 patients who underwent TKA between September 2020 and March 2021 was performed. All patients underwent TKA by the same surgeon and received the same standardized postoperative rehabilitation. Operating theater time was shortest in the NACB group with 129.3 ± 23.1 minutes compared with 152.4 ± 31.6 minutes in ACBA and 139.2 ± 29.4 minutes in ABCS (p = 0.001). For the POD1 pain score after therapy, the NACB group scored 4.9 ± 3.1 compared with 3.5 ± 2.2 and 3.9 ± 1.8 scored by the ACBA and ACBS groups, respectively (p = 0.302). The mean POD1 ambulation distance was 21.1 ± 15.2 m in the NACB group compared with 15.4 ± 1.3 and 17.8 ± 13.2 m in the ACBA and ACBS groups (all p > 0.05), respectively. There were no significant differences in the median LOS between three groups or ability to perform active SLR (all p > 0.05). Our study found no significant differences when comparing ACBS and ACBA by POD1 pain score, ambulation distance, range of motion, and LOS. We recommend against the use of ACB and instead recommend surgeons to perform an adequate periarticular cocktail injection.

Improving Acetabular Component Positioning in Supine Direct Anterior Total Hip Arthroplasty with a Transparency Template: A Novel, Simple, and Cost-effective Technique.

PURPOSE: A novel and simple method to ensure accurate acetabular component anteversion and inclination intraoperatively with the use of a transparency template is described. MATERIALS AND METHODS: Patients who underwent total hip arthroplasty (THA) via direct anterior approach (DAA) from June 2019 to January 2020 were included. A transparency template that can be placed over the image intensifier monitor to allow surgeons an accurate reading of the acetabular component position intraoperatively was designed, developed and utilized to determine effectiveness. The first template consists of two perpendicular lines indicating the "trans-ischial line" and the "pubic symphysis/coccyx". The second template consist of a line indicating 45° inclination and parallel lines of corresponding distances apart required to achieve 20° anteversion based on Lewinnek's formula: version=sin-1 (D1/D2), where D1: minor axis and D2: major axis of the component. This template was used throughout the acetabular part of the surgery, from reaming to impaction of component. Postoperative acetabular inclination, anteversion, surgical duration, length of stay, as well as complications were recorded. RESULTS: Twenty-six patients were included in this study. Mean postoperative acetabular cup inclination was 43.46±3.09° and mean version was 19.98±2.89°. A total of 21 patients (80.8%) fell within the Callanan safe zone and all 26 patients (100%) were within the Lewinnek safe zone. CONCLUSION: The transparency template is a simple, reproducible, and effective tool with a minimal learning curve and no requirement for expensive equipment. This template has the potential to assist surgeons, especially those who are less experienced with DAA THA, in obtaining better postoperative radiographic outcomes.

Increased constraint of rotating hinge knee prosthesis is associated with poorer clinical outcomes as compared to constrained condylar knee prosthesis in total knee arthroplasty.

The aim of this study was to evaluate whether there are any differences in patient-reported outcome measures between semi-constrained condylar constrained knee (CCK) and fully constrained rotating hinge knee (RHK) prostheses in midterm follow-up. We reviewed prospectively collected data of our hospital arthroplasty registry between 2007 and 2014. Thirty-nine patients were identified to have RHK prosthesis TKA and matched for a number of primary/revision TKA, gender, age, body mass index and pre-operative clinical scores to a control group of 78 patients with CCK TKA. Patient demographics, range of movement, varus/valgus deformity, Short Form 36 (SF-36) scores, Oxford Knee Score (OKS), Knee Society Score (KSS) and patient satisfaction were evaluated. Pre-operatively, the RHK and the control group of CCK had similar demographics, proportion of primary/revision TKA and baseline clinical scores (p > 0.05). At 2-year follow-up, patients with CCK prostheses had significantly better clinical outcomes as compared to patients with RHK prosthesis in terms of KSS functional scores, OKS, SF-36 sub-domains of physical functioning, physical role functioning and physical component score. We conclude that at midterm follow-up of 2 years, the CCK patients as compared to RHK patients reported better clinical and functional outcomes in terms of OKS, KSS functional score and SF-36 with a greater proportion of patients who were satisfied and had their expectations met by surgery. Further biomechanical studies are needed to investigate the association between component constraint and clinical outcomes for these prostheses.

Clinical outcomes and patient satisfaction following revision of failed unicompartmental knee arthroplasty to total knee arthroplasty are as good as a primary total knee arthroplasty.

BACKGROUND: With unicompartmental knee arthroplasty (UKA) being increasingly performed for medial compartment osteoarthritis (OA) of the knee, revision total knee arthroplasty (TKA) for failed UKA is expected to increase. Our primary aim is to evaluate patients in our tertiary institution who underwent revision of failed UKA to TKA to compare their pre-operative clinical scores (patient-reported outcome measures, PROMs) to those of primary TKA. METHODS: Retrospective review of our institutional arthroplasty registry between 2001 and 2014 was performed. We identified 70 patients who underwent revision of UKA to TKA. The revision UKA to TKA patients was matched with 140 patients who underwent primary TKA for OA in terms of preoperative demographics, gender, age at time of surgery, body mass index (BMI), primary surgeon, and PROMs. Intra-operative data and postoperative complications or re-revision surgeries performed were reviewed. RESULTS: In the revision UKA to TKA group, more stems, augments or constrained implants were used compared to primary TKA. A greater proportion of patients with metal-backed UKA revision to TKA required stems, augments or constrained implants as compared to all-polyethylene UKA revision to TKA, but not a significant proportion (P = 0.250). At two years postoperatively, there were no significant differences observed between the groups in terms of patient satisfaction and PROMs. CONCLUSIONS: This study showed similar outcomes following revision of failed UKA to TKA and primary TKA. There were significant improvements in PROMs for revision UKA to TKA, which is comparable to that of primary TKA.

Sacral chordoma: clinical experience of a series of 11 patients over 18 years.

Sacral chordoma are rare low-to-intermediate grade malignant tumours that occur most commonly within the sacrum. Sacrectomy with wide resection margins seems to offer the best long-term prognosis.  This study aims to review the management of sacral chordomas including the duration of symptoms, features, treatment, complications and local recurrence rate following surgery at a tertiary centre. We retrospectively reviewed 11 patients treated at our institution between years 1999 and 2015. Patient data included age, sex, history, radiographs, surgical details, onset of recurrence, subsequent treatment, disease-free survival and overall survival were analyzed. Nine patients underwent surgical management with 1 through a sacral approach and eight patients through a combined abdominosacral approach. Despite wide resection in our series, sacral chordoma poses a major problem with approximately 60% of patients having local recurrence in their follow-up.

Preoperative Leg Pain Score Predicts Patient Satisfaction After Transforaminal Lumbar Interbody Fusion Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study aims to determine the preoperative predictors of postoperative satisfaction in transforaminal lumbar interbody fusion (TLIF) surgery in order to improve management of patient groups at high risk of dissatisfaction. We retrospectively reviewed prospectively collected data on patients who underwent open TLIF in a tertiary hospital between 2008 and 2012 with 2-year follow-up and performed multivariate analysis for their preoperative variables. METHODS: A multivariate regression analysis was performed for the 217 patients to identify preoperative predictors of postoperative satisfaction. Clinical outcomes were evaluated using Oswestry Disability Index (ODI), North American Spine Society (NASS) Neurogenic Symptom Score (NSS), 36-item Short-Form Survey (SF-36; mean Physical and Mental Health scores), numerical pain rating scale (NPRS) for pain, and NASS Questionnaire. RESULTS: Significant improvements were seen in the postoperative ODI, NSS, SF-36, and NPRS scores at 2 years (P < .05). Eighty-six percent of the patients had their expectations of surgery met, and 94.7% of the patients were satisfied with the results of treatment at 2 years. From the multivariate regression model, patients with higher preoperative NPRS pain score (odds ratio = 1.323; 95% confidence interval = 1.071-1.633; P = .009) was more likely to be satisfied at 2 years. CONCLUSIONS: TLIF surgery provided significant health-related quality-of-life scores and symptom improvement in terms of SF-36, ODI, NSS, and NPRS, with a high proportion of patients being satisfied with the results of surgery. Patients with higher preoperative NPRS leg pain were more likely to be satisfied at 2 years. Patient-reported satisfaction may be largely influenced by the improvement of radicular leg pain.

What Are the Preoperative Outcome Measures That Predispose to Periprosthetic Fractures After Primary Total Knee Arthroplasty?

BACKGROUND: There is little known in the literature about whether preoperative patient-reported outcome measures (PROMs) would affect the risk of periprosthetic fractures (PPFs) after primary total knee arthroplasty (TKA). Our study aims to evaluate the predictive values of PROMs on PPF after primary TKA. We hypothesize that poorer PROMs are associated with a higher risk of PPF after primary TKA. METHODS: We reviewed prospectively collected data in our hospital arthroplasty registry. Patients who sustained PPF after primary TKA between 2000 and 2015 were identified. Forty-two patients were identified and matched for gender, age, and body mass index to a control group of 84 patients who had primary TKA without PPF in a 2:1 ratio. Preoperative demographics, Short Form-36 (SF-36) scores, Oxford Knee score and Knee Society Score were evaluated. Variables of PROMs were entered into a multivariate logistic regression model. A variable was considered to be a significant predictor if its odds ratio was significant at P < .05. RESULTS: After multivariate regression analysis, SF-36 subdomains of physical functioning (PF) and vitality (VT) were identified as significant predictors for PPFs after primary TKA. A lower SF-36 PF and VT scores were associated with higher risks of sustaining a PPF after primary TKA. CONCLUSION: From our study, low preoperative SF-36 PF and VT scores are associated with a higher risk of PPFs after primary TKA. These results can allow the preoperative identification of patients at higher risk of PPF, and appropriate preoperative counseling, optimization, and close follow-up can be instituted for this at-risk group.

Is clinical evaluation alone sufficient for the diagnosis of a Bankart lesion without the use of magnetic resonance imaging?

BACKGROUND: Imaging modalities such as magnetic resonance arthrogram (MRA) offer great utility in diagnosing Bankart lesions but they are associated with a high degree of intra and interobserver variability. This study aims to evaluate the diagnostic accuracy of clinical evaluation and imaging modalities in Bankart lesions such as magnetic resonance imaging (MRI) and MRA of the shoulder. METHODS: Between February 2004 to January 2015, a retrospectively review of the surgical records at a tertiary hospital identified a total of 250 patients treated with a shoulder arthroscopy for Bankart repair. All patients were thoroughly investigated preoperatively in which a detailed history were obtained, relevant physical examinations were performed (Load and Shift/Anterior Apprehension test) and pre-operative radiographs taken. Some patients subsequently underwent either an MRI or an MRA scan if the initial clinical evaluation was equivocal. RESULTS: Anterior Shoulder Apprehension test and the Load and Shift test identified 214 of 227 Bankart tears, with a sensitivity of 94% [95% confidence interval (CI), 90-97%]. MRI correctly identified 23 of 26 Bankart tears, with a sensitivity of 89% (95% CI, 70-98%). Out of the five superior labrum anterior-posterior (SLAP) tears identified on MRI, only three were confirmed during arthroscopic surgery. MRA correctly identified 84 of 89 Bankart tears, for a sensitivity of 94% (95% CI, 87-98%). CONCLUSIONS: In our study, we report that clinical evaluation with focused history-taking and anterior apprehension, load and shift clinical examination can diagnose anterior shoulder instability as reliably as MR imaging. For patients with equivocal clinical findings, MR imaging can aid in the diagnosis.

History of previous knee surgery does not affect the clinical outcomes of primary total knee arthroplasty in an Asian population.

BACKGROUND: Patients with a history of previous knee surgeries, such as anterior cruciate ligament reconstruction (ACLR) and high tibial osteotomy (HTO), often have a higher likelihood of requiring a subsequent total knee arthroplasty (TKA). However, there is relatively limited data, especially in the Asian population, on how previous knee surgery could affect the clinical outcomes of TKA. Therefore, this study aims to evaluate the impact of previous knee surgeries on the clinical outcomes of future TKA. METHODS: We reviewed the prospectively-collected data of 303 patients who underwent TKA by a single surgeon from a total joint registry of a tertiary hospital over a period of 5 years. Those with a history of previous knee surgery were identified. The SF-36 Health Survey, Oxford Knee Score (OKS) and Knee Society Score (KSS) were used to evaluate clinical outcomes pre-operatively, at 6 months and 2 years. RESULTS: Previous knee surgery did not have a significant impact on the patients' pre-operative baseline clinical scores and body mass index (BMI). Patients with a history of knee surgery undergo TKA at a significantly younger age (mean of 6.6 years younger). On follow-up, patients with a history of knee surgery have similar post-operative outcome scores as those without previous knee surgery. Also, a high proportion of these patients are satisfied with their post-operative results and feel that their expectations have been met. CONCLUSIONS: Patients with previous knee surgery had TKA at a significantly younger age than those without. But these patients have similar clinical and quality of life outcomes after TKA. In addition, a high proportion of these patients are satisfied with the results of surgery and feel that their expectations of TKA are met. This is important for clinicians when counselling patients pre-operatively.

Gender-specific total knee arthroplasty in Singaporean women.

PURPOSE: To compare the outcome of 145 women who underwent conventional total knee arthroplasty (TKA) with 77 women who underwent gender-specific TKA. METHODS: Records of 222 women who underwent primary TKA using a conventional (n=145) or gender-specific (n=77) size E or F prosthesis for end-stage osteoarthritis were reviewed. The gender-specific prosthesis has a narrower mediolateral dimension. Patients were assessed for flexion, Oxford Knee Score, Knee Society function and knee scores, and Short Form-36 Health Survey preoperatively and postoperatively (at 6 months and 2 years). RESULTS: The 2 groups were comparable in terms of age (67.8 vs. 68.1 years, p=0.789), body mass index (28.6 vs. 27.8 kg/m(2), p=0.189), and preoperative scores. 12 women with conventional TKA and 4 women with gender-specific TKA were lost to followup. Compared with women with conventional TKA, women with gender-specific TKA had better flexion at 6 months (116° vs. 121.9°, p=0.007) and 2 years (118.7° vs. 124.6°, p=0.006), better bodily pain score at 2 years (65.1 vs. 72.4, p=0.049), and greater improvement in bodily pain score from baseline to 2 years (30 vs. 38.5, p=0.034). CONCLUSION: Gender-specific TKA enables better knee flexion and less bodily pain in women who have a high propensity to develop mediolateral overhang of the femoral component.

Gender difference in outcome after total knee replacement.

PURPOSE: To compare the outcome after primary total knee replacement (TKR) for end-stage knee osteoarthritis (OA) in men versus women. METHODS: Records of 214 men and 1040 women who underwent primary TKR for end-stage knee OA and were followed up for a minimum of 2 years were reviewed. Knee flexion, Oxford Knee Score, Knee Society Score (KSS), and 8 subscores of Short Form 36 (SF-36) were recorded preoperatively and at postoperative 6 months and 2 years. RESULTS: Men and women were comparable only in age (67.9 vs. 67.3 years, p=0.244); men had a lower mean body mass index (27.0 vs. 28.3 kg/m(2), p<0.001). Preoperatively, men had better knee flexion (117º vs. 114.8º, p=0.05), Oxford Knee Score (33.5 vs. 36.8, p<0.001), KSS knee score (44.3 vs. 40.3, p=0.001), KSS function score (52.5 vs. 47.1, p<0.001), and all 8 subscores of SF-36 (p=0.005 to p<0.001). Compared with men, women achieved greater improvement at 6 months in Oxford Knee score (13.2 vs. 15.1, p=0.009) and KSS knee score (36.9 vs. 41.6, p=0.016), and at 2 years in Oxford Knee Score (15.0 vs. 17.9, p<0.001), KSS knee score (39.8 vs. 43.9, p=0.009), and SF-36 subscores of social functioning (23.6 vs. 35.1, p<0.001) and mental health (3.9 vs. 8.2, p=0.003). CONCLUSION: Compared with men, women had poorer preoperative knee flexion, Oxford Knee Score, KSS, and 8 subscores of SF-36, but achieved greater improvement in the Oxford Knee Score and KSS knee score at 6 months and 2 years, as well as in SF-36 subscores of social functioning and mental health at 2 years.

Are patients more satisfied and have better functional outcome after bilateral total knee arthroplasty as compared to total hip arthroplasty and unilateral total knee arthroplasty surgery? A two-year follow-up study.

This study aims to review the quality of life and physical improvement achieved by total joint arthroplasty surgery, namely unilateral TKA, bilateral TKA and THA. We hypothesize that patients who undergo bilateral TKA should have greater improvement in patient-reported outcome measures, as compared to patients who had unilateral TKA, and their outcomes may be comparable to that of THA. We analyzed prospectively collected data of all patients who underwent unilateral TKA, bilateral TKA and THA (5291, 187 and 529 patients respectively) for end-stage osteoarthritis at a tertiary hospital during the 5-year period. Patients who underwent bilateral TKA had a greater degree of improvement in SF-36 and Knee Society Scores as compared to unilateral TKA at 6 months and 2 years follow-up. Bilateral TKA had the highest proportion of patients who were satisfied and had expectations met by surgery.

Aneurysmal bone cysts of the vertebrae.

PURPOSE: To review records of 14 patients with aneurysmal bone cysts (ABCs) of the spine. METHODS: Using the Scottish Bone Tumour Registry for the period of October 1952 to November 2005, records of 9 females and 5 males aged 8 to 63 (mean, 25.3) years who had ABCs of the spine and were followed up for a mean of 7.1 years were reviewed. RESULTS: The most commonly involved site was the lumbar vertebrae (n=6), followed by the thoracic (n=4), cervical (n=3), and sacral (n=1) vertebrae. The mean duration of symptoms at presentation was 8.8 (range, 0.3-24) months. The symptoms included gradually increasing pain in the back (n=14), a palpable spinal mass (n=4), spinal deformity (n=2), and neurological deficits (n=5). All the patients underwent surgery: intra-lesional excision (curettage) without bone grafting (n=3), excision (n=7, 2 of whom had adjuvant radiotherapy), and open excisional biopsy (n=4, 2 of whom had iliac crest bone grafting). One patient with a cervical ABC underwent preoperative angiographic embolisation. Another patient with a sacral ABC underwent percutaneous sclerotherapy. Two patients had recurrence. One had recurrence within 4 months and underwent adjuvant radiotherapy; another had recurrence 16.8 years later and underwent repeat curettage. No major complications were encountered. CONCLUSION: Most ABCs of the spine occurred in young females. Intra-lesional excision was an effective treatment.

Revisional surgery for hallux valgus with serial osteotomies at two levels.

The aetiology and form of hallux valgus (HV) is varied with many corrective procedures described. We report a 39-year-old woman, previously treated with a Chevron osteotomy, who presented with recurrent right HV, metatarsus primus varus, and associated bunion. Osteotomies were performed at two levels as a revisional procedure. This report highlights (1) limitations of the Chevron osteotomy and (2) the revisional procedure of the two level osteotomies: (i) proximal opening-wedge basal osteotomy and (ii) distal short Scarf with medial closing wedges. If a Chevron osteotomy is used inappropriately, for example, in an attempt to correct too large a deformity, it may angulate laterally causing a malunion with an increased distal metatarsal articular angle. Secondly, it is feasible to correct this combined deformity using a combination of proximal opening-wedge and distal short Scarf osteotomies.