Limitations of the knee society score in kinematically aligned total knee arthroplasty.

Purpose: The Knee Society Scoring System (KSS) is a frequently used outcome score which quantifies functional patients' outcomes before and after total knee arthroplasty (TKA). Several problems arise when trying to implement KSS for obtaining postoperative outcomes after more personalised aligned TKAs. Scoring for valgus femorotibial angle (FTA) intervals outside moderate ranges is often poorly explained, the specific version of KSS used for outcome collection is frequently unclear and the exact measuring methods are typically not described in the literature. The aims of this systematic review were to investigate the latest user practice, the application of KSS and its limitations after kinematically aligned (KA) TKA. Methods: A systematic literature search following PRISMA guidelines was conducted on PubMed, Embase, Medline and Scopus to identify potentially relevant articles for this review, published from the beginning of January 2013 until the end of January 2023. Broad Mesh terms such as 'kinematic alignment', 'total knee arthroplasty' and 'knee society score' were used for building search strategy in each database accordingly. Articles reporting postoperative values of the objective surgeon-assessed KSS after KA TKA or KA and mechanically aligned TKA were included. For assessing included randomised control trials (RCTs), an Agency for Healthcare Research and Quality's design-specific scale for assessing RCTs was used. The non-RCTs were assessed by using the Joanna Briggs Institute Critical Appraisal Tool. The Ottawa-Newcastle Score system was also used. Studies were additionally evaluated for their radiological methodology by using a five-question checklist (Radiological Assessment Qualit criteria). Results: The initial search identified 167 studies, of which 129 were considered for screening. Ten studies reporting outcomes after KA TKA did not use the objective surgeon-assessed part of KSS for clinical outcome measurement, and 30 studies reporting outcomes after KA TKA did not use KSS at all for clinical and/or functional outcomes. From the 10 included studies, only six have used the latest KSS score (2011), the rest using its 1989 variant; and out of these six studies, only two presented values of the FTA, which is needed for calculating the KSS's 'alignment' subcomponent, the rest presenting hip-knee-ankle angle (HKA) values. Additionally, when converting these HKA values to FTA intervals, the authors of this systematic review found that KA TKA FTA intervals display limits, which tend to be outside the 'well-scored' KSS anatomical alignment interval. Conclusion: The inconsistent and nonstandardised use of the surgeon-assessed KSS across studies reviewed compromises assessment reliability and patient outcome scores. To enhance precision and comparability, it is crucial to standardise the KSS application, incorporating personalised alignment strategies for more accurate patient evaluations. Level of Evidence: Level III.

Definition of normal, neutral, deviant and aberrant coronal knee alignment for total knee arthroplasty.

PURPOSE: One of the most pertinent questions in total knee arthroplasty (TKA) is: what could be considered normal coronal alignment? This study aims to define normal, neutral, deviant and aberrant coronal alignment using large data from a computed tomography (CT)-scan database and previously published phenotypes. METHODS: Coronal alignment parameters from 11,191 knee osteoarthritis (OA) patients were measured based on three dimensional reconstructed CT data using a validated planning software. Based on these measurements, patients' coronal alignment was phenotyped according to the functional knee phenotype concept. These phenotypes represent an alignment variation of the overall hip knee ankle angle (HKA), femoral mechanical angle (FMA) and tibial mechanical angle (TMA). Each phenotype is defined by a specific mean and covers a range of ±1.5° from this mean. Coronal alignment is classified as normal, neutral, deviant and aberrant based on distribution frequency. Mean values and distribution among the phenotypes are presented and compared between two populations (OA patients in this study and non-OA patients from a previously published study). RESULTS: The arithmetic HKA (aHKA), combined normalised data of FMA and TMA, showed that 36.0% of knees were neutral within ±1 SD from the mean in both angles, 44.3% had either a TMA or a FMA within ±1-2 SD (normally aligned), 15.3% of the patients were deviant within ±2-3 SD and only 4.4% of them had an aberrant alignment (±3-4 SD in 3.4% and >4 SD in 1.0% of the patients respectively). However, combining the normalised data of HKA, FMA and TMA, 15.4% of patients were neutral in all three angles, 39.7% were at least normal, 27.7% had at least one deviant angle and 17.2% had at least one aberrant angle. For HKA, the males exhibited 1° varus and females were neutral. For FMA, the females exhibited 0.7° more valgus in mean than males and grew 1.8° per category (males grew 2.1° per category). For TMA, the males exhibited 1.3° more varus than females and both grew 2.3° and 2.4° (females) per category. Normal coronal alignment was 179.2° ± 2.8-5.6° (males) and 180.5 > ± 2.8-5.6° (females) for HKA, 93.1 > ± 2.1-4.2° (males) and 93.8 > ± 1.8-3.6° (females) for FMA and 86.7 > ± 2.3-4.6° (males) and 88 > ± 2.4-4.8° (females) for TMA. This means HKA 6.4 varus or 4.8° valgus (males) or 5.1° varus to 6.1° valgus was considered normal. For FMA HKA 1.1 varus or 7.3° valgus (males) or 0.2° valgus to 7.4° valgus was considered normal. For TMA HKA 7.9 varus or 1.3° valgus (males) or 6.8° varus to 2.8° valgus was considered normal. Aberrant coronal alignment started from 179.2° ± 8.4° (males) and 180.5 > ± 8.4° (females) for HKA, 93.1 > ± 6.3° (males) 93.8 > ± 5.4° (females) for FMA and 86.7 > ± 6.9° (males) and 88 > ± 7.2° (females) for TMA. This means HKA > 9.2° varus or 7.6° valgus (males) or 7.9° varus to 8.9° valgus was considered aberrant. CONCLUSION: Definitions of neutrality, normality, deviance as well as aberrance for coronal alignment in TKA were proposed in this study according to their distribution frequencies. This can be seen as an important first step towards a safe transition from the conventional one-size-fits-all to a more personalised coronal alignment target. There should be further definitions combining bony alignment, joint surfaces' morphology, soft tissue laxities and joint kinematics. LEVEL OF EVIDENCE: III.

A comparison of continuous cold flow and compression device and traditional icing regimen and no icing following anterior cruciate ligament reconstruction: A pilot study.

The aim of this study was to investigate the effectiveness of continuous cold flow and compression device as against traditional icing regimen and without icing after anterior cruciate ligament (ACL) reconstruction. All patients undergoing ACL reconstruction from June 2021 to August 2021 were enrolled in this study. Patients were randomly allocated to three groups: A control group (n=10) with no ice regimen post-operatively, a second control group (n=10) with ice bag, and a third group (n=10) with continuous cold flow and compression device (physiolab). All patients who had isolated ACL tear evident on magnetic resonance imaging were included. Pain intensity, limb girth, Oxford Knee Score, and 12-item survey form were measured pre- and post-operatively. Significant difference was noted between pain scores in all groups at two- and six-week follow-ups with p-value of 0.004 and 0.01. The test for "between subject effects" showed significant difference (p=0.007) in limb girth between the two groups. Cold and compression device can be used to reduce swelling immediately after ACL reconstruction.

Clinical and functional outcomes of displaced proximal humerus fractures treated with PHILOS plate system and autologous bone graft.

This retrospective case series analyses the clinical and radiological outcomes of displaced proximal humerus fractures treated with PHILOS plate system and iliac crest bone autograft. Twenty-six patients with displaced fractures of proximal humerus, who were treated with PHILOS plate and autologous iliac crest bone grafts from January 2015 to September 2020, were included in this study. The inclusion criteria were proximal humerus fractures with displacement of more than 1cm and angulation of more than 45 degrees. The functional outcomes were evaluated using DASH and constant score. Radiological outcomes were measured by calculating the fracture union. The average age of the cohort was 47.28±13.69 years. Over all, the mean DASH score was 10.25 and constant score was 77.65 at three-year follow-up. The PHILOS plate with iliac crest bone autologous graft provides good radiological and functional outcomes, especially for the cases with bone defects and poor-bone stock.

Dynamic Hip Screw Fixation Vs. Proximal Femur Nail For Unstable Per-Trochanteric Fractures: A Comparative Analysis Of Outcomes And Complications.

BACKGROUND: There are various implant choices to fix unstable per- trochanteric fractures. The aim of this study was to compare the outcomes of dynamic hip screw and proximal femur nail for unstable per-trochanteric fractures including complications associated with both fixations. METHODS: A retrospective analysis done on pertrochanteric fractures of femur who were treated with Dynamic hip Screw (DHS) and Proximal Femur Nail (PFN). The data was taken from our hospital hip data base for the past two years from January 2017 to January 2019. Data of 174 patients was analysed, divided in to Group A with DHS (n=122) and Group B with PFN (n=52). Follow up included X-ray (anteroposterior and lateral) views for fracture union and collapse, femur neck shortening, implant position and identification of mode of failure or collapse (cut out risk) by using tip-apex distance. The Harris hip score used to evaluate mobility status and other functional outcomes. RESULTS: The mean age in years of patients treated with PFN and DHS were 55.9 and 59.8, ranging from 39-83 years. The mean of Harris hip score at 2 year was 69.28±9.99 in DHS group and 72.12±9.71 in PFN group with the p-value 0.31. The mean of limb shortening was 12mm in DHS and 9 mm in PFN group. In DHS group, four cases had tip-apex distance of 39 mm and reported implant cut out that needs revision of surgery. CONCLUSIONS: Proximal Femur Nail group demonstrated no implant cut out and less mean limb length shortening where as other parameter like functional outcomes, fracture union, rate of infection, hospital stay and postoperative pain are not significantly different in two groups.

Evaluation of Patient Perception and Satisfaction Toward the Use of Telemedicine During Pandemic of Novel Coronavirus in Pakistan.

Background:The trend of telemedicine is exponentially increasing worldwide due to the coronavirus disease (COVID-19) pandemic. However, patient satisfaction is always a concern regarding the use of telemedicine.Introduction:The aim of this study is to evaluate the perception and satisfaction level of patients toward the use of telemedicine during the pandemic of COVID-19 among Pakistani population.Materials and Methods:The survey questionnaires were distributed to 251 patients who received telemedicine consultation in any of three specializations: orthopedic, ophthalmology, and general medicine. The questionnaire contains 15 questions that covered four categories of patient satisfaction: interpersonal communication, caring, care delivery, and proficiency. Descriptive and analytical statistics were obtained by analyzing data using SPSS software version 20.Results:A total of 251 patients responded to the telemedicine questionnaire. Overall, 61.35% patients reported that they did not need any support for using technology during consultation and 96.41% of the patient population reported that telemedicine saved their travel time. It was found that gender, education, and age were significantly associated with the ease in technology with the p-value 0.012, 0.004 and <0.001, respectively, whereas the use of telemedicine again in future is found to be significantly associated with only education and age p-value <0.001. The statistically significant difference was found in three specialized consultation regarding the overall satisfaction, χ2 = 5.83, p-value = 0.05, with a mean rank in orthopedic is 133.6, 134.4 in ophthalmology, and 113.6 in internal medicine.Conclusion:Telemedicine is convenient and satisfactory way to provide health care services during pandemic. Although a considerable number of participants reported good response for telemedicine, there is a need of establishing local telemedicine guidelines, training of consultants and advancement in technology.

Histological and cellular evaluation of anterior cruciate ligament.

BACKGROUND: We hypothesized that the torn anterior cruciate ligament (ACL) demonstrates a great healing response after initial trauma and has competent cells leading to the healing but differs in its response based on the type of tear and duration of injury. This study aimed to evaluate the histological and cellular responses to the injured ACL. METHODS: Fifty-two tissue samples from the ACL were harvested from patients undergoing arthroscopy. Detailed histological and cellular examinations were performed for ligament angiogenesis, fibrocytes, and synovial tissue infiltration. We compared the cellular response to injury in partially and completely ruptured ACLs. The duration of ACL injury and its response to cellular characteristics were also examined. Immunohistochemical studies using cluster of differentiation 34 (CD34) staining was used to evaluate endothelial cells and fibrocytes. RESULTS: We found a significantly higher density of synovial and ligament angiogenesis and fibrocytes at the torn end of ACL (Mann-Whitney, P < 0.050). Numerous fibrocytes were identified in complete ACL tears versus partial tears (Mann-Whitney = 0.020). Increased cellular proliferation was identified at the ruptured end of ACL remnant (Kruskal-Wallis, P < 0.050). The cellular proliferation of ruptured ACL decreased after 12 months. CONCLUSIONS: Based on our findings of the time-dependent decrease in the cellular response at the torn ends of the ACL, we recommend early intervention, preservation of the ACL remnant, and primary ACL repair or augmented reconstruction.