The effectiveness of extended reality on relieving pain after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Patients with total knee arthroplasty (TKA) often suffer from severe postoperative pain, which seriously hinders postoperative rehabilitation. Extended reality (XR), including virtual reality, augmented reality, and mixed reality, has been increasingly used to relieve pain after TKA. The purpose of this study was to evaluate the effectiveness of XR on relieving pain after TKA. METHODS: The electronic databases including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov were searched for studies from inception to July 20, 2023. The outcomes were pain score, anxiety score, and physiological parameters related to pain. Meta-analysis was performed using the Review Manager 5.4 software. RESULTS: Overall, 11 randomized control trials (RCTs) with 887 patients were included. The pooled results showed XR had lower pain scores (SMD = - 0.31, 95% CI [- 0.46 to - 0.16], P < 0.0001) and anxiety scores (MD = - 3.95, 95% CI [- 7.76 to - 0.13], P = 0.04) than conventional methods. The subgroup analysis revealed XR had lower pain scores within 2 weeks postoperatively (SMD = - 0.49, 95% CI [- 0.76 to - 0.22], P = 0.0004) and XR had lower pain scores when applying XR combined with conventional methods (SMD = - 0.43, 95% CI [- 0.65 to - 0.20], P = 0.0002). CONCLUSION: This systematic review and meta-analysis found applying XR could significantly reduce postoperative pain and anxiety after TKA. When XR was combined with conventional methods, postoperative pain can be effectively relieved, especially within 2 weeks after the operation. XR is an effective non-pharmacological analgesia scheme.

Description of pain associated with persistent postoperative pain after total knee arthroplasty.

After total knee arthroplasty (TKA), approximately 20% of patients experience persistent postoperative pain (PPP). Although preoperative and postoperative pain intensity is a relevant factor, more detailed description of pain is needed to determine specific intervention strategies for clinical conditions. This study aimed to clarify the associations between preoperative and postoperative descriptions of pain and PPP. Fifty-two TKA patients were evaluated for pain intensity and description of pain preoperatively and 2 weeks postoperatively, and the intensities were compared. In addition, the relationship between pain intensity and PPP at 3 and 6 months after surgery was analyzed using a Bayesian approach. Descriptions of arthritis ("Throbbing" and "aching") improved from preoperative to 2 weeks postoperative. Several preoperative ("Shooting", "Aching", "Caused by touch", "Numbness") and postoperative ("Cramping pain") descriptors were associated with pain intensity at 3 months postoperatively, but only "cramping pain" at 2 weeks postoperatively was associated with the presence of PPP at 3 and 6 months postoperatively. In conclusion, it is important to carefully listen to the patient's complaints and determine the appropriate intervention strategy for the clinical condition during perioperative pain management.

Clinical outcomes of primary total knee arthroplasty in non-syphilitic neuroarthropathy of the knee.

PURPOSE: Total knee arthroplasty (TKA) in syphilitic neuroarthropathy using earlier implant designs was associated with poorer outcomes. Literature on TKA for non-syphilitic neuroarthropathy using modern contemporary prosthesis is scarce. We aim to analyse the clinical and radiological outcomes of TKA in neuropathic joints. METHODS: A final cohort of 17 patients (21 knees) with the diagnosis of neuropathic joint undergoing primary TKA between January 2013 to January 2019 were included in the study. The preoperative ambulatory status, range of motion, type of prosthesis, level of constraint and any augmentation used were retrieved from medical records. Radiological evaluation includes Koshino's staging, the magnitude of deformity defined by the Hip-Knee-Ankle (HKA) angle, and any progressive loosening. Pre and postoperative functional scores were obtained by the Knee Society (KSS) and Knee Society Functional Score (KSS-F). Any complications or reoperation were noted till the final follow-up. Preoperative and follow-up functional scores, HKA and range of motion were compared using the paired Samples test. RESULTS: The mean follow-up was 40.2 months (range, 15 to 75 months). Preoperatively, according to the Koshino staging, five knees were in stage 3 (23.8%). The mean HKA angle in valgus knees was 23.60 (range, 11.10 to 42.50) and for the varus knees was 19.30 (range, 4.90 to 39.60). The prosthesis used were posterior stabilized in 7 knees (33.3%), varus-valgus constrained in five knees (23.8%) and a rotating hinge was required in nine knees (42.8%). Metaphyseal sleeves were used along with hinge prosthesis in six knees (28.6%). The mean arc of motion improved from 102.4 ± 22.7 degrees to 105.7 ± 15.5 degrees postoperatively (p = 0.27). The knee society and knee society functional scores improved from 23.3 ± 9.3 and 28.3 ± 12.2 preoperatively to 81.1 ± 5.4 and 80.4 ± 8.5 during the follow up respectively (p < 0.001). There were no progressive radiolucent lines in any knees at the final follow-up. One patient had intraoperative bony medial collateral ligament injury, one patient had deep vein thrombosis after five days from the index surgery and another had postoperative periprosthetic tibial shaft fracture. CONCLUSION: According to our study, the clinical outcomes of TKA for neuroarthropathy show significant improvement with the diagnosis of non-syphilitic neuroarthropathy, utilization of modern constrained prostheses, and early rehabilitation, at medium-term follow-up. Tibial and femoral stems are preferred for equal stress distribution and to prevent early loosening.

Specific tibial landmarks to improve to accuracy of the tibial cut during total knee arthroplasty. A case control study.

INTRODUCTION: More personalized alignment techniques in total knee arthroplasty (TKA) have recently been described particularly for the young and active patients. Performing the ideal tibial cut might be challenging with a conventional ancillary. Therefore the aims of this study were: (1) to describe specific tibial landmarks to optimize the tibial cut in TKA; (2) to compare the accuracy of the tibial cut with these landmarks compared to a conventional technique. METHODS: This retrospective case-control study compared primary TKAs performed using a conventional technique with extramedullary guide associated with specific tibial landmarks. For each case, one control patient was matched based on body mass index (BMI), age, preoperative Hip Knee Ankle (HKA) angle, and Medial Proximal Tibial Angle (MPTA). All control patients were operated by the same surgeon and similar conventional technique but without landmarks. The MPTA target was to reproduce preoperative deformity with a 3° of varus limit. 34 TKA were included in each group. There was no preoperative difference between both groups. Mean age was 63 years old ± 8. Mean BMI was 32 kg/m2 ± 5. Mean HKA was 170.6° ± 2.5. Mean MPTA was 85.1° ± 2.3. The radiographic assessment was performed preoperatively and at 2 months: HKA, mechanical Medial Distal Femoral Angle (mMDFA), MPTA, tibial slope, restoration of the joint line-height. RESULTS: The tibial landmarks corresponded to the line of insertion of the deep medial collateral ligament fibers extended to the capsular insertion above the Gerdy tubercle. The postoperative MPTA was significantly more varus (87.2° ± 1.6 in landmark group versus 88.3° ± 2.2; p = 0.027) and closer to preoperative bone deformity in landmark group (p = 0.002) with significantly less outliers than in the conventional group. There was no significant difference between both groups postoperatively for HKA (175.4° ± 2.3 versus 175.9° ± 2.5; p = 0.42); mMDFA (88.9° ± 2.3 versus 88.2° ± 2.1; p = 0.18); tibial slope (82.6° ± 1.9 versus 82.4° ± 2.6; p = 0.67), the restoration of the joint line-height (1.5 mm ± 2 versus 1.8 mm ± 2; p = 0.56). CONCLUSION: Specific tibial landmarks during TKA can be used to increase the accuracy of the tibial cut when using personalized alignment techniques in TKA. LEVEL OF EVIDENCE: IV.

Total knee arthroplasty in schizophrenia patients: early complications and cost in a propensity-matched national database study.

INTRODUCTION: Studies investigating the link between mental health disorders and complications following total knee arthroplasty (TKA) have found worse outcomes in individuals with such disorders. Therefore, risk factors and outcomes following TKA in patients with schizophrenia should be better understood. This study aims to investigate cost and duration of hospital stay, inpatient complications, and mortality associated with TKA in patients with schizophrenia. MATERIALS AND METHODS: Utilizing the NIS database from 2016 to 2019, patients that underwent TKA were selected using ICD-10 codes. The selected patients were classified into a schizophrenia or control group and cost, hospitalization length, complications, and mortality rates were compared between the two groups in an unmatched and matched analysis. RESULTS: Our study dataset consisted of 558,371 patients that underwent a TKA during 2016 to 2019. 1,015 (0.2%) patients in the sample had a diagnosis of schizophrenia while the remaining 557,357 (99.8%) patients had no record of schizophrenia. An unmatched analysis found that schizophrenia patients had longer duration of hospital stay and greater charges incurred. Acute renal failure, myocardial infarction (MI), blood loss anemia, pneumonia, DVT, periprosthetic fracture, prosthetic dislocation, and periprosthetic infections were post-op complications with higher rates in the schizophrenia group. A matched cohort analysis found that schizophrenia patients still had longer duration of hospital stay and greater charges incurred. However, only acute renal failure, blood loss anemia, and pneumonia were found at higher rates in the schizophrenia group following TKA. CONCLUSIONS: Schizophrenia patients had a significantly longer hospital stay and increased charges acquired during their stay compared to the control group following TKA. Acute renal failure, blood loss anemia, and pneumonia were medical complications with an increased risk following TKA in patients with schizophrenia in a matched analysis. Increased care during the perioperative period following TKA in individuals with schizophrenia is thus warranted.

Malnutrition in total joint arthroplasty: what should the orthopaedic surgeon consider?

Total joint arthroplasty (TJA) is rising globally, with an associated increase in associated complications, necessitating increased efforts in prevention of these complications with pre-operative optimisation. Malnutrition has been highlighted as one of the most important pre-operative modifiable risk factors to be addressed in TJA, with the term malnutrition in orthopaedic surgery having a broad definition that encompasses a wide range of nutritional abnormalities from undernutrition to overnutrition contributing to the outcomes of TJA. Complications associated with malnutrition include periprosthetic joint infection (PJI), periprosthetic fracture, dislocations, aseptic loosening, anaemia, prolonged length of stay (LOS), increased mortality, and raised health care costs. Standardised nutritional scoring tools, anthropometric measurements, and serological markers are all options available in pre-operative nutritional assessment in TJA, but there is no consensus yet regarding the standardisation of what parameters to assess and how to assess them. Abnormal parameters identified using any of the assessment methods results in the diagnosis of malnutrition, and correction of these parameters of overnutrition or undernutrition have shown to improve outcomes in TJA. With the multiple nutritional parameters contributing to the success of total joint arthroplasty, it is imperative that orthopaedic surgeon has a thorough knowledge regarding nutritional peri-operative optimisation in TJA.

Personalized total knee arthroplasty in patients with extra-articular deformities.

Over the years, with a better understanding of knee anatomy and biomechanics, superior implant designs, advanced surgical techniques, and the availability of precision tools such as robotics and navigation, a more personalized approach to total knee arthroplasty (TKA) has emerged. In the presence of extra-articular deformities, performing personalized TKA can be more challenging and specific considerations are required, since one has to deal with an acquired pathological anatomy. Performing personalized TKA surgery in patients with extra-articular deformities, the surgeon can: (1) resurface the joint, omitting the extra-articular deformity; (2) partially compensate the extra-articular deformity with intra-articular correction (hybrid technique), or (3) correct the extra-articular deformity combined with a joint resurfacing TKA (single stage or two-stage procedure). Omitting the acquired lower limb malalignment by resurfacing the knee has the advantages of respecting the joint surface anatomy and preserving soft tissue laxities. On the other hand, it maintains pathological joint load and lower limb kinematics with potentially detrimental outcomes. The hybrid technique can be performed in most cases. It circumvents complications associated with osteotomies and brings lower limb axes closer to native alignment. On the other hand, it creates some intra-articular imbalances, which may require soft tissue releases and/or constrained implants. Correcting the extra-articular deformity (through an osteotomy) in conjunction with joint resurfacing TKA represents the only true kinematic alignment technique, as it aims to reproduce native knee laxity and overall lower limb axis.

Postoperative early weight-bearing using double plating for periprosthetic, interprosthetic, and interimplant distal femur fractures following total knee arthroplasty: A report of three cases.

Background: Distal femur fractures (DFFs) following total knee arthroplasty (TKA) in older patients often require prolonged non-weight-bearing, thereby decreasing their activities of daily living (ADL) and increasing mortality. This report clarifies early weight-bearing safety and utility by using double-plate fixation on medial and lateral sides (LM180 double-plate fixation) for DFFs following TKA. Case presentation: Three cases of Su Type III periprosthetic, interprosthetic, and interimplant DFFs following TKA, where bone stock was limited, were treated with LM180 double-plate fixation using locking plates through medial and lateral incisions on the distal femur. In interprosthetic and interimplant DFF cases, the proximal section was secured by overlapping the lateral plate +/- medial plate with the proximal femur stem of the intramedullary nail by using monocortical screws and cerclage wires. Early postoperative partial weight-bearing was recommended, and full weight-bearing was allowed 4-5 weeks postoperation. All cases regained independent walking without hardware failure. Average ADL scores, namely, Barthel index (BI) and functional independence measure (FIM), were recovered to 85/100 and 114.7/126, respectively, approaching near-normal values. Conclusion: LM180 double-plate fixation for DFFs such as Su Type III periprosthetic, Vancouver type C interprosthetic, and interimplant DFFs following TKA with limited bone stock can be used to achieve early weight-bearing without fixation failure and help maintain ADL.

Component rotational mismatch in the standing position is a potential risk factor for unfavourable functional outcomes after total knee arthroplasty.

Purpose: This study assessed rotational mismatch between components after total knee arthroplasty (TKA) in the supine and standing positions and aimed to investigate the effect of rotational mismatch in the standing position on postoperative patient-reported outcome measures (PROMs). Methods: Seventy-one patients (71 knees) who underwent TKA for medial knee osteoarthritis were used to investigate rotational mismatches between components. Rotational mismatches between components were examined on postoperative standing whole-leg and supine knee radiographs using a three-dimensional-to-two-dimensional model image registration technique, and the angles between the reference axes of the components were measured. Component alignment was evaluated using postoperative computed tomography images, and a questionnaire (2011 version of the Knee Society Score: [KSS 2011]) was mailed to investigate postoperative PROMs. Results: In the entire cohort, rotational mismatches in the supine and standing positions were similar (p = 0.9315). In 15% of patients, the mismatch was large (>5°) in the supine position but small (<5°) in the standing position (overestimated group). However, in 23% of patients, the mismatch was small (<5°) in the supine position and large (>5°) in the standing position (underestimated group). The underestimated group had severe preoperative varus deformity, resulting in external rotation of both femoral and tibial components. Rotational mismatch in the standing position (p = 0.0032) was a significant risk factor for unfavourable PROMs. Patients with a mismatch in the standing position had significantly lower scores than those without a mismatch (p = 0.0215), exceeding the minimal clinically important difference values. Conclusions: The underestimated group is clinically important because the surgical procedure and intraoperative assessment of component placement are performed in the supine position. In cases of severe preoperative varus deformity, care should be taken not to place the component in malrotation to avoid rotational mismatch in the standing position. Level of Evidence: Ⅳ, Case series.

Role and Results of Constrained Insert in Computer-Assisted Primary Total Knee Arthroplasty: A Propensity-Matched Study.

Purpose: Mild ligament imbalance is often encountered in the mediolateral plane during complex primary total knee arthroplasty. A constrained (CP) polyethylene insert compatible with the primary femur is useful to manage these cases without the need to fall back on revision implants. The aim of the study was to define the correct indications of the use of a CP insert based on objective data from computer assisted surgery and to compare the early results of a CP insert with a standard posterior stabilized (PS) insert through one-to-one propensity score matching. Methods: This is a retrospective case study from a prospectively collected database. One-to-one matching without replacement was used with a caliper width of 0.2 to match the scores between CP (N = 64) and PS groups (N = 1624), resulting in equal covariate matching of PS (N = 64) and CP (N = 64) cohorts. Patients were assessed radiographically and functionally at a minimum follow-up of 3 years. Result: Average coronal and sagittal plane deformities were similar in both the group CP (varus 13.1 ± 5.2 valgus 13 ± 7.9) and the group PS (varus 13.4 ± 4.6 valgus 10.9 ± 8.6). The average residual medial lateral gap difference was significantly higher in group CP (3.8 ± 1.8) in comparison to group PS (1.3 ± 1) (P < .05). A CP insert was chosen where mild ligament imbalance of 3-5 mm persisted after medial soft tissue releases in a varus knee and in cases with residual medial collateral ligament laxity in valgus knees. Conclusions: Constrained insert used with the primary femoral component is a valuable option to handle mild ligamentous instability in complex primary total knee arthroplasty after mechanical alignment is achieved with computer navigation. Level of Evidence: III.

Simultaneous Concurrent Bilateral Total Knee Replacement in a Patient With Bilateral Lipoma Arborescens With End-Stage Osteoarthritis.

A 78-year-old Thai male presented with chronic bilateral knee pain and swelling. X-ray imaging revealed osteoarthritis in both knees, with a suspicious soft tissue shadow. Magnetic resonance imaging suggested lipoma arborescens (LA). The patient underwent LA excision with a complete synovectomy, followed by simultaneous bilateral total knee arthroplasty (SBTKA). Pathological examination confirmed LA. At the 2-year follow-up, the patient reported no complications, adverse outcomes, or recurrence. The intervention improved joint function and pain relief, allowing for early ambulation and full weight-bearing post-surgery. This case highlights the success of complete synovectomy with SBTKA, addressing bilateral knee pathology concurrently. The combined approach reduced operative time and significantly improved joint function and pain relief, emphasizing the benefits of timely surgical intervention and suggest potential advantages of SBTKA for optimal patient outcomes.

Optimizing Tourniquet Pressure in Primary Total Knee Arthroplasty: Limb Occlusion Pressure vs Systolic Blood Pressure Method: A Randomised Controlled Study.

Background: This study aims to systematically compare the efficacy of two distinct approaches that is limb occlusion pressure (LOP) and systolic blood pressure (SBP) in determining the optimal tourniquet pressure for primary total knee arthroplasty. The overarching goal is to identify the method that yields superior outcomes in minimizing post-operative thigh pain while simultaneously reducing complications in our patient population. Methods: 311 patients scheduled for primary total knee replacement (TKR) were randomized in two groups. Group A (LOP) had 154 patients and group B had 157 patients. In group A, LOP was determined for all patients. After adding the safety margin, the tourniquet pressure was determined which was kept during the procedure. By adding 150 mm Hg to SBP in group B, the tourniquet inflation pressure was ascertained. Postoperatively, thigh pain was evaluated from day 1 to day 3 and at 6 weeks. Results: The average tourniquet pressure in group A patients having thigh circumference between 40 and 50 cm was 223.8 mm + - 19.8 mm Hg and in group B it was 262.1 + - 15.9 mm Hg (P < .01). Patients having thigh circumference between 51 and 60 cm had average tourniquet pressure of 240.07 + - 20.1 mm Hg in group A and 264.5 + - 17.4 mm Hg in group B (P < .01). The average tourniquet pressure for patients with thigh circumference more than 60 cm was 296 + /15.3 mm Hg in group A and 267.3 + /19.2 mm Hg in group B (P < 0.01). Conclusion: Tourniquet pressure determination based on the limb occlusion pressure (LOP) method provide less postoperative thigh pain and better range of motion. Graphical Abstract: Optimizing Tourniquet Pressure in Primary Total Knee Replacement: Limb Occlusion Pressure vs Systolic blood pressure method to minimize thigh pain.

Does Patellar Denervation with Electrocautery Benefits for Total Knee Arthroplasty without Patellar Resurfacing: A Meta-analysis of Randomized Controlled Trails.

To investigate the effects of patellar denervation (PD) and non-patellar denervation (NPD) after primary total knee arthroplasty (TKA) without patellar resurfacing, this study conducted systematic electronic searches in November 2023 using PubMed, Embase, Web of Science, Cochrane, and Scopus, adhering to Cochrane Collaboration recommendations. Only randomized controlled trials (RCTs) were included. Additionally, a manual search was performed to identify potentially eligible studies from the reference lists of review articles. Two researchers independently conducted literature reviews, data extraction, and risk of bias assessments. The outcome analysis encompassed the incidence of anterior knee pain (AKP), visual analogue scale (VAS), range of motion (ROM), American Knee Society Score (KSS), Oxford Knee Score (OKS), patellar score (PS), complications, and reoperations. Meta-analysis was executed using RevMan 5.3 software. To enhance the credibility of the study, TSA v0.9 software was utilized to perform power analysis on the overall efficacy of primary and secondary outcomes. Twelve studies involving 1745 patients (1587 knees) were included, with 852 undergoing PD and 893 undergoing NPD. Results indicated a superior reduction in AKP incidence in the PD group compared to the NPD group. Statistically significant differences were observed between PD and NPD in KSS, OKS, and PS. However, the upper limit of the 95% confidence interval for each outcome fell below the minimal clinically important difference (MCID). No significant differences were found in VAS and ROM between PD and NPD. Additionally, PD was not associated with an increased incidence of complications or reoperations. Within 12 months and beyond, PD was proven to be a beneficial intervention in reducing AKP following TKA without patellar resurfacing, achieved without an increase in complications or reoperations. Regarding KSS, OKS, and PS, the minimal advantage achievable through PD may not be clinically significant.

Robotic-assisted total knee arthroplasty reduces postoperative complications and length of stay without increased cost compared to navigation-guided techniques: A national analysis.

INTRODUCTION: This study compares postoperative outcomes of robotic-assisted total knee arthroplasty (RA-TKA) versus navigation-guided total knee arthroplasty (NG-TKA). Using Nationwide Inpatient Sample (NIS) data, it provides an analysis of postoperative complications, mortality, hospital costs and duration of stay. METHODS: The study analysed 217,715 patients (81,830 RA-TKA; 135,885 NG-TKA) using NIS data from 2016 to 2019. Elective TKA patients were identified through the International Classification of Diseases, 10th Revision codes. Statistical analyses, including logistic regression modelling, were performed using Statistical Package for the Social Sciences and MATLAB. RESULTS: RA-TKA patients were younger (66.1 vs. 67.1 years, p < 0.0001) and had similar mortality rates (0.024% vs. 0.018%, p = 0.342) but shorter length of stay (LOS) (1.89 vs. 2.1 days, p < 0.0001). Mean total charges were comparable between RA-TKA ($66,180) and NG-TKA ($66,251, p = 0.669). RA-TKA demonstrated lower incidences of blood-related complications (11.67% vs. 14.19%, p < 0.0001), pulmonary oedema (0.0306% vs. 0.066%, p < 0.0001), deep vein thrombosis (0.196% vs. 0.254%, p = 0.006) and acute kidney injury (AKI) (1.356% vs. 1.483%, p = 0.016). CONCLUSION: RA-TKA reduces postoperative complications and LOS without increasing costs, highlighting the relevance of this technology in patient care. LEVEL OF EVIDENCE: Level III.

Comparison of short-term clinical results between modified kinematically-aligned and guided motion bicruciate stabilized total knee arthroplasty.

BACKGROUND: Both kinematically-aligned (KA) total knee arthroplasty (TKA) and bicruciate stabilized (BCS) TKA aim to reproduce the physiological knee kinematics. In this study, we compared the femoro-tibial component rotational mismatch between patients who underwent modified KA-TKA and those who received guided-motion BCS-TKA, and its influence on the clinical outcomes. METHODS: In this retrospective study, 77 consecutive patients were included and divided into two groups: subjects who underwent modified KA-TKA with Persona (KA Group; n = 42) and those who received BCS-TKA with JOURNEY II (BCS group; n = 35). Range of motion, the 2011 Knee Society Score (KSS), the rotational alignment of the femoral and tibial components, and the correlations between the rotational mismatch and the 2011 KSS subscales were examined. RESULTS: The postoperative objective knee indicators (P = 0.0157), patient satisfaction (P = 0.0039) and functional activity scores (P = 0.0013) in the KA group were significantly superior to those in the BCS group 1 year postoperatively. There was no significant difference between the two groups observed in the rotational mismatch. In the BCS group, significant negative correlations were identified between the rotational mismatch and objective indicators, patient satisfaction, and functional activity scores but not in the KA group. CONCLUSIONS: The short-term clinical results following KA-TKA showed superior objective knee indicators, patient satisfaction and functional activity scores. A negative correlation was observed between component rotational mismatch and the 2011 KSS subscales in the BCS group, compared to no relationship found between the two in the KA group. These findings suggested that KA-TKA has a relatively higher tolerance for rotational mismatch than BCS-TKA.

Prediction of Distal Femoral and Posterior Articular Surfaces in Total Knee Arthroplasty With Severe Bone Defects Using Computed Tomography-Based Templating Software.

Introduction Optimal repair of the joint line (JL) in total knee arthroplasty (TKA) is critical for knee joint motion reconstruction and ligament balance. Identification of JL may be difficult, particularly in revision or primary cases of severe femoral condylar bone loss. We aimed to define the relationship between the epicondyles and the articular surface (AS) of the femur using computed tomography-based three-dimensional digital templating software. Methods The study included 127 knees with osteoarthritis of the knee below grade 2 on the Kellgren-Lawrence index. A perpendicular line was drawn from the medial and lateral femoral epicondylar processes to the most distal point of the AS, and the distance was measured in the axial and coronal planes. Femoral width was measured as the distance between the medial and lateral epicondyles. All distances described above were converted to a ratio by division with femoral width. Results On the axial plane, the distance from epicondyles to the posterior ASs was 29.4 ± 2.2 mm medially and 21.3 ± 2.1 mm laterally. The width of the distal femur was 75.2 ± 4.2 mm. On the coronal plane, the distances from epicondyles to the distal ASs were 25.2 ± 2.9 mm on the medial side and 21.3 ± 2.5 mm on the lateral side. The ratio of the distance from epicondyles to the distal and posterior ASs divided by the width of the femur was 0.39 ± 0.02, 0.28 ± 0.03, 0.34 ± 0.03, and 0.28 ± 0.03. Conclusions The distance from the epicondyles to the distal and posterior JLs correlates with the distal femur width. These findings may be useful in determining an appropriate JL.

Hip Strengthening After Total Knee Arthroplasty: A Meta-analysis and Systematic Review.

Objectives: As the population is growing older, incidence of knee osteoarthritis is largely increasing and the rate total knee arthroplasty surgery is following that same trend. However, patients post-operatively are retaining weakness in the quadriceps and hip abductors for a period reaching up to 3 years following surgery. The current literature results on the effectiveness of rehabilitation programs that also includes hip strengthening exercises are still highly contradicting. This meta-analysis studies and assesses the efficacy of hip strengthening exercises following total knee arthroplasty surgery. Methods: PubMed, Embase, Cochrane and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes consisted of the post-operative tests (6MWT, TUG, SLS), pain, and range of motion (flexion and extension). Results: Three randomized clinical studies were included in the meta-analysis. When compared to the standard rehabilitation, hip strengthening exercises proved a better improvement of single leg stance with no difference observed in the remaining outcomes. Conclusion: Hip strengthening exercise protocols ensured a better improvement of single leg stance scores. However, no difference was observed in the remaining analyzed outcomes. This contradictions between studies can be explained by the different physical therapy protocols used. Nevertheless, more randomized controlled studies are needed to confirm such results.

Primary Total Knee Arthroplasty in Hemophilia and Allied Disorders: Revision Rates and Their Causes.

When patients with hemophilia and allied disorders (von Willebrand disease and other congenital bleeding disorders) do not receive adequate primary hematologic prophylaxis from infancy, their joints will suffer knee joint degeneration; when such joint degeneration becomes very advanced (painful and disabling) despite previous conservative treatment, the only way to alleviate the problem will be to implant a primary total knee arthroplasty (TKA). The literature has shown that twenty years after implantation, 71% of primary TKAs are still functional; on the other hand, 18% have to be revised as a consequence of periprosthetic joint infection (PJI). The main causes of revision total knee arthroplasty are PJI and aseptic loosening (39% each).

The efficacy and safety of intra-articular injection of corticosteroids in multimodal analgesic cocktails in total knee arthroplasty-a historically controlled study.

Background: Total knee arthroplasty (TKA) is a common and effective procedure. Optimizing pain control and reducing postoperative discomfort are essential for patient satisfaction. No studies have examined the safety and efficacy of intra-articular corticosteroid injections following TKA. This study aims to examine the safety and efficacy of corticosteroids in intra-articular multimodal analgesic injections. Materials and methods: This was a historically controlled study conducted at a single academic institution. Before May 2019, patients received an intra-articular cocktail injection without corticosteroids during surgery, referred to as the non-corticosteroid (NC) group. After June 2019, intraoperatively, patients received an intra-articular cocktail injection containing corticosteroids, referred to as the corticosteroid (C) group. Finally, 738 patients were evaluated, 370 in the C cohort and 368 in the NC cohort. The mean follow-up duration was 30.4 months for the C group and 48.4 months for the NC group. Results: The mean VAS scores at rest on postoperative day (POD) 1 (2.35) and POD3 (3.88) were significantly lower in the C group than those in the NC group, which were 2.86 (POD1) and 5.26 (POD3) (p < 0.05). Walking pain in the C group (4.42) was also significantly lower than that (5.96) in the NC group on POD3 (p < 0.05). Patients in the C group had a significantly higher mean range of motion (ROM) (92.55) on POD3 than that (86.38) in the NC group. The mean time to straight leg raise for group C (2.77) was significantly shorter than that (3.61) for the NC group (p < 0.05). The C group also had significantly fewer rescue morphine (1.9) and metoclopramide (0.21) uses per patient than the NC group, which were 3.1 and 0.24, respectively. No significant differences in fever or vomiting rates between groups were found. Patients in neither group developed periprosthetic joint infections or skin necrosis. One patient in the C group suffered from wound dehiscence, and the wound healed well after debridement. No patient died or had a re-operation in either group. Conclusions: This pilot trial found that intra-articular injection of multimodal analgesia (including corticosteroids) reduced initial postoperative pain, increased ROM in the early postoperative days (up to POD3), and did not increase wound complications or infection rates in approximately 30 months of follow-up.

Comparable results in total knee arthroplasty using the ROSA knee system versus the conventional technique: A retrospective propensity-matched cohort study.

PURPOSE: Robotic-assisted total knee arthroplasty (RA-TKA) is an increasingly popular alternative that may increase the accuracy of conventional TKA techniques. This study aims to evaluate RA-TKA accuracy and compare its radiographic and clinical outcomes to conventional TKA (cTKA). METHODS: A retrospective examination of patients with bi- or tricompartmental knee osteoarthritis who underwent RA-TKA (RObotic Surgical Assistant system) or cTKA and were prospectively documented in the TKA registry. Accuracy was assessed using standardized radiographic implant position evaluations, namely femoral and tibial coronal angles and femoral and tibial sagittal angles. Baseline demographics, surgery details and 6- and 12-month post-TKA patient-reported outcomes (PROMs; e.g., Oxford Knee Score [OKS] and Core Outcome Measures Index) were compared between RA-TKA and propensity score-matched cTKA patients. RESULTS: Overall correlation between preset and 6-week postoperative angle measurements for RA-TKA was low with significant differences noted only for mean tibial sagittal angles (84.6° [RA-TKA] vs. 82.3° [cTKA]) (p < 0.001). The study groups were demographically similar, although RA-TKA patients had slightly longer operative times and higher blood loss but shorter inpatient stays. There were sustainable improvements in all PROMs already at 6 months, yet RA-TKA patients had significantly higher OKS values over their conventional counterparts at this time point. CONCLUSION: Radiological and clinical outcomes were comparable between RA-TKA and cTKA. The robotic-assisted system demonstrated higher accuracy in the coronal than sagittal plane and RA-TKA patients achieved better short-term outcomes for pain and disability. While both methods are similar in the hands of a skilled surgeon, long-term studies are necessary to establish clear method superiority. LEVEL OF EVIDENCE: Therapeutic, Level III.