Influence of vitamin D levels on outcomes and nosocomial COVID-19 infection in patients undergoing total knee arthroplasty- a cohort study.

Purpose: This study aimed to audit the effects of vitamin D3 on the early functional outcomes, the incidence of nosocomial COVID-19 infection and complications in patients undergoing elective Total Knee Arthroplasty (TKA). Methods: This was a retrospective study involving patients undergoing primary unilateral TKA between January 2020 to May 2021 operated by a single surgeon using a single implant. Participants were divided into two cohorts, Deficient-vitamin D3 level <20 ng/ml and Sufficient-vitamin D3 level ≥20 ng/ml. Assessment for Knee Society Score and Oxford Knee Score (OKS) was done preoperatively and one year after TKA. Nosocomial COVID-19 infection rate, 30-day re-admissions and complications were noted during the study. Results: 235 patients were divided into 2 cohorts matched by age, gender and ASA grades. 74 patients belonged to the deficient group and 161 belonged to the sufficient group. The mean preoperative scores in the sufficient group were higher than the deficient group (OKS = 15.74 vs 12.95; KSS = 88.91vs 85.62). Similarly, the one-year postoperative scores in the sufficient group were significantly higher (OKS = 36.54 vs 35.16; KSS = 164.01 vs 161.22). A linear correlation was present between preoperative score (r = 0.273) & post-operative scores (r = 0.141) with serum vitamin D3 levels. Vitamin D3 deficient individuals had higher nosocomial COVID-19 infection rate (10.81% vs 4.96%,p = 0.16). The incidence of complications like DVT, embolism, stroke, infection and fracture were not statistically different in the two groups. Conclusion: Vitamin D positively influences the outcomes of TKA and protects against nosocomial COVID-19 infection in patients undergoing elective TKA.

Does Early Debridement, Antibiotic Therapy and Implant Retention (DAIR) have a Role in Managing Periprosthetic Joint Infection of the Knee in Indian Scenario: A Retrospective Analysis of Outcomes.

PURPOSE: To report outcomes of Debridement, Antibiotic therapy and Implant Retention (DAIR) for periprosthetic knee joint infections (PJI) in the Indian population and to study factors influencing outcomes. METHODS: This was a Retrospective study of 80 cases of acute PJI after total knee arthroplasty who were treated by DAIR, within 2 weeks of onset of infection. A standardised institutional management protocol was applied to all cases. Patients were followed up for a minimum 1 year. Outcomes of DAIR were classified as successful or unsuccessful based on resolution or persistence of infection, and subsequent requirement of revision surgery. Influence of factors, like comorbidities, culture status and microbiological characteristics of causative organism, on outcomes was assessed. RESULTS: Overall 55 patients (68.75%) had successful eradication of infection after DAIR. 27 (33.7%) patients were culture negative and 53 (66.2%) patients grew organisms on culture. There was no statistically significant difference in outcomes (p = 0.082) between culture-positive cases (69.8% success rate) and (66.7% success rate) in culture negative cases. Furthermore, no difference in outcomes was observed in culture-positive patients between those who grew Gram-positive organisms versus Gram-negative organisms (p = 0.398) Similarly, patient comorbidities did not significantly alter the outcomes after DAIR (p = 0.732). CONCLUSION: Our study demonstrates that early DAIR within 2 weeks of onset of infection using a standard protocol during surgery and postoperatively can result in good outcomes. Patient comorbidities, culture status (positive versus negative), Gram staining characteristics of organisms and the identity of pathogenic bacteria did not influence outcomes of DAIR for acute PJI.

Comparative study of existing knee prosthesis with anthropometry of Indian patients and other races, a computer tomography 3D reconstruction-based study.

Background: Appropriate component sizing plays an important role in determining the functional outcome following total knee arthroplasty. Comparative studies of different populations have shown significant differences in the anthropometric parameters of knees in different race groups which negates the possibility of using a single sized implant system across different ethnic groups. This study evaluates the dimensions of femoral and tibial articular surfaces of Indian patients and compares the parameters with other ethnic groups and correlates the dimensions with five different commercially available knee systems.Material & Methods: Computerized tomography (CT) scans of contralateral normal knees of patients who underwent the scan for various ailments of the knee were retrieved retrospectively from the hospital database and 3D reconstruction of the images was done. Mediolateral dimensions (fML,tML), Anteroposterior dimensions (fAP, tAP) and aspect ratio (fML/fAP, tML/tAP) of the femur and tibia respectively were calculated and compared with the dimensions of different ethnic groups as well as the femoral and tibial components of five different knee prosthesis systems. RESULTS: The average fML in the study group was less than that of Caucasian knees but was marginally larger than other ethnic groups. The fAP, tML and tAP was found to be smaller than all other ethnic groups but a larger femoral aspect ratio was reported than other ethnic groups. Among the implant systems, only NexGen LPS and Scorpio NRG implant femoral components closely matched the femoral dimensions in the study group whereas all implant systems showed significant mismatch with tibial component dimensions when compared to the study populations. CONCLUSION: This study concludes that the dimensions of Indian knees are different from other ethnic groups and the use of commercially available knee Implants designed based on measurements in Caucasian populations can lead to significant mismatch between implant and resected bone surfaces.

Validating the Role of Steroid in Analgesic Cocktail Preparation for Local Infiltration in Total Knee Arthroplasty: A Comparative Study.

BACKGROUND: Pain control after total knee arthroplasty (TKA) through local analgesic cocktail preparation has gained widespread popularity in recent times. Local steroids have potent anti-inflammatory effect leading to reduced postoperative swelling and pain which might increase the efficacy and duration of local infiltration analgesia. AIM: The aim is to evaluate whether the addition of local steroid to an injectable analgesic cocktail for periarticular infiltration leads to better pain control and knee range of motion (ROM) in the immediate postoperative period compared to patients who do not receive steroid in their cocktail. SETTINGS AND DESIGNS: A prospective study was conducted in a group of 140 patients undergoing unilateral TKA between June 2017 and December 2017. MATERIALS AND METHODS: All the patients in the study group received either periarticular infiltration with an analgesic cocktail (Group I, n = 70) or analgesic cocktail with 100 mg methylprednisolone (Group II, n = 70) for postoperative pain with ultrasound-guided adductor canal block (ACB). Patients were evaluated with visual analog scale (VAS) for pain at 8, 24, and 48 h postoperatively and ROM at 48 h after surgery. STATISTICAL ANALYSIS: The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Student t-test has been used to find the pairwise significance. RESULTS: Group II had a statistically significant decrease in VAS scores at 8 h (P = 0.096), first postoperative day (P = 0.0001) and second postoperative day (P = 0.0001) as compared to Group I. However, there was no statistically significant difference seen with early ROM in both the groups at 48 h (P < 0.361). CONCLUSION: Patients who received steroid cocktail infiltration plus ACB had an improved and better postoperative analgesia in an early postoperative period of 24-48 h; however, there was no significant difference in clinical ROM and functional outcome when compared to the study group.

Salvage of infected total knee arthroplasty with Ilizarov external fixator.

BACKGROUND: Knee arthrodesis may be the only option of treatment in cases of chronic infected total knee arthroplasty (TKA) with concomitant irreparable extensor mechanism disruption, extensive bone loss or severe systemic morbidities. Circular external fixation offers possible progressive adjustment to stimulate the bony fusion and to make corrections in alignment. We evaluated the results of knee arthrodesis with one or two stage circular external fixator for infected TKA. MATERIALS AND METHODS: 16 cases of femoro-tibial fusion were retrospectively evaluated. Male-to-female ratio was 10:6. Mean age of the patients was 62.2 years. Cierney-Mader classification was used for anatomical and physiological evaluation while the bone stock deficiency was classified into mild, moderate and severe. Surgical technique involved either single or two stage arthrodesis using circular external fixator. RESULTS: Union was achieved in 15 patients (93.75%). The mean duration for union (frame application time) in these patients was 28.33 weeks (range 22 to 36 weeks). Analysis showed that in the group with frame application time of less than 28 weeks, the incidence of mild to moderate bone deficiency was 83.33%, while in the frame application time more than 28 weeks group the incidence was 20% (P-value 0.034). Similarly the incidence of Cierney-Mader 4B (Bl, Bs, Bls) was found to be 33.33% in the group of frame application time of less than 28 weeks, while it was 90% in the group with frame application time more than 28 weeks (P-value 0.035). CONCLUSION: Circular external fixator is a safe and reliable method to achieve knee arthrodesis in cases of deep infection following TKA. Severe bone stock deficiency and Cierney- Mader type B host are likely risk factors for prolonged frame application time. We recommend a two-stage procedure especially when there is compromised host or severe bone loss.

Are both the knees of the same size? Analysis of component asymmetry in 289 bilateral knee arthroplasties.

BACKGROUND: Variations in the anatomy of knee are well described, however the true incidence of component asymmetry in bilateral total knee arthroplsties is rarely reported. Incidence of component asymmetry in bilateral total knee arthroplasties (TKA) was retrospectively analysed in 289 cruciate retaining total knee arthroplasties. MATERIALS AND METHODS: Medical records of these 289 patients were evaluated for the incidence of asymmetry of either femoral or tibial components. Clinical outcomes were compared between the cases of asymetrical components to that of symmetrical components. RESULTS: Incidence of femoral component asymmetry was found to be 9.2% and tibial component asymmetry to be 8.7%. Of 289 cases, TKA 178 were done in a single day (group A), while 111 were done at 2- to 3-day intervals (group B). Asymmetric and symmetric knees were equally distributed among both groups, male and female patients in both groups, and the incidence of component asymmetry was similar between all four different implants - Optetrak-CR (Exactech, Gainesville, FL, USA), Nexgen-CR (Zimmer, Warsaw, IN, USA), PFC-Sigma CR (DePuy, Warsaw, IN, USA), Genesis II CR (Smith and Nephew, Memphis, TN, USA) we used. The pre- and postoperative range of motion and pre- and postoperative knee society scores were compared between the symmetric and asymmetric cases in both the groups and the difference was found to be insignificant. CONCLUSION: We conclude that incidence of component asymmetry in bilateral total knee arthroplasty is around 9 % and independent sizing of both knees during bilateral arthoplasty is recommended rather than simply relying on the contralateral knee measurements.