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Background: As one of the main goals of hip and knee replacements is to improve patients' health-related quality of life, a meaningful evaluation can be achieved by calculating minimal important changes (MICs) for improvements in patient-reported outcome measures (PROMs). This study aims at providing MICs adjusted for patient characteristics for EQ-5D-3L index score improvements after hip and knee replacements. It adds to existing literature by relying on a large national sample and precise clustering algorithms, and by employing a state-of-the-art methodology for the calculation of improved adjusted MICs. Methodology: A retrospective observational study was conducted using the publicly available National Health Service (NHS) PROMs dataset for primary hip and knee replacements. We used information on 252,331 hip replacements and 279,668 knee replacements from all NHS-funded providers in England between 2013 and 2020. Clusters of patients were created based on pre-operative EQ-VAS, depression status, and sex. Unstratified and stratified estimates for meaningful EQ-5D-3L improvements were obtained through anchor-based predictive MICs corrected for the proportion of improved patients and the reliability of transition ratings. Results: Stratifying patients showed that MICs varied across subgroups based on pre-operative EQ-VAS, depression status, and sex. MICs were larger for patients with worse pre-operative EQ-VAS scores, while patients with better pre-operative scores required smaller MICs to achieve a meaningful change. We show how after stratification the percentage of patients achieving their stratified MIC was better in line with the actual share of improved patients. Larger MICs were found for patients with depression and for female patients. MICs calculated for knee replacements were consistently lower than those for hip replacements. Conclusions: Our findings show the importance of adjusting MICs for patients' characteristics and should be considered for quality-related choices and policy initiatives. [ABSTRACT FROM AUTHOR]

Purpose: The potential influence of surgical sequence of elective hip-and-knee reconstructive surgery in relation to an infection-related procedure on postoperative infection rates is not clearly understood. Therefore, we aimed to examine the impact of surgical sequence on the incidence of postoperative infections within one-year and the longest available follow-up period in patients undergoing hip-and-knee reconstructive surgery. Methods: A case-control study with propensity matching was utilized to examine elective surgeries conducted at Sunnybrook Holland Orthopaedic & Arthritic centre, Toronto, Canada between 2015 and 2018. We determined and categorized them based on their operating room (OR) sequence in relation to an infected case; the cases were those performed right after (post-infection cohort), and the controls were those performed before an infection-related procedure in the same OR (pre-infection cohort). We employed survival analysis to compare the infection incidence within one year and at the longest available follow-up among the propensity-matched cohort. Results: A total of 13,651 cases were identified during the four year period. We successfully matched 153 cases (21 post-infection and 132 pre-infection) using propensity scores. Demographic and clinical characteristics were balanced through matching. Kaplan-Meier survival analysis showed no significant difference in infection-free survival within one year and at a median follow-up of 2.2 years [interquartile range 0.9-5.0] between surgeries conducted before and after infected cases (both log-rank p-values = 0.4). The hazard ratios for infection within one year and the longest follow-up period were both 0.37 [95%Confidence Interval 0.03–4.09, p = 0.418], as no more events occurred after one year. Conclusion: The sequence of surgical procedures, whether or not an elective arthroplasty or lower limb reconstructive procedure occurs before or after an infection-related case in the same OR, does not significantly affect postoperative infection rates. This finding supports the efficacy of the current infection control measures and suggests a reconsideration of surgical scheduling standards. Take home message: The sequence of surgical procedures, whether performed after an infected case or not, might not affect the rate of postoperative infections within the first year and until the median follow-up time of 2.2 years after surgery. [ABSTRACT FROM AUTHOR]

Purpose: The association between preoperative mental health and immediate postoperative ambulation in primary Total Joint Arthroplasty (TJA) has sparsely been studied. Thus, this study's objective was to investigate the association between mental health (measured by the Mental Component Score (MCS) from the Veterans RAND 12 (VR-12)) and peri-operative metrics. Methods: We conducted a retrospective study of patients who underwent primary TJA and completed a VR-12 questionnaire between January 2018 and June 2023 at a single academic hospital. Patients were stratified into terciles based on preoperative MCS. Patient demographics, ambulation within 4 h postop, LOS, and discharge location were compared. The effect of MCS on LOS while controlling discharge location was assessed using negative binomial regression. Results: 1120 patients were included in this analysis (432 THA and 688 TKA). After stratification into terciles (Low: 34.7 ± 6.6, Middle: 49.3 ± 3.7, High:62.1 ± 4.4), comparison of demographics revealed significant differences in age (p = 0.005) and sex distribution (p = 0.04) but no difference in surgery type (p = 0.857). There was no significant difference in ambulation rate between MCS groups (p = 0.789) or in distance covered during first ambulation (p = 0.251). Low MCS patients had a longer LOS (p = 0.000, p = 0.002) and a lower rate of discharged home (p = 0.016). After controlling discharge location, no significant association was found between MCS and LOS (p = 0.288). Conclusion: Patient with low MCS tended to be younger, women, and had poorer preoperative HOOS/KOOS scores. Low MCS was associated with longer LOS and lower rates of discharge home. However, MCS was not associated with early ambulation rate and LOS after controlling discharge location. [ABSTRACT FROM AUTHOR]

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Purpose: Cementless Oxford unicompartmental knee replacement (OUKR) is associated with less pain than cemented OUKR 5 years postoperatively. This may be due to improved fixation at the tibial wall, which transmits tension and reduces stress in the bone below the tibial component. This study compares tibial wall fixation with three different types of fixation: cemented, cementless with hydroxyapatite (HA) and cementless with a microporous titanium coat and HA (HA + MPC). Methods: Three consecutive cohorts were identified (n = 221 cemented in 2005–2007, n = 118 HA in 2014–2015, n = 125 HA + MPC in 2016–2017). Analysis was performed on anterior–posterior radiographs aligned on the tibial component taken 1–2 years postoperatively. Aligned radiographs are needed to see narrow radiolucencies adjacent to the wall. Alignment was assessed with rotation ratio (RR = wall width/internal wall height). Perfect RR is 0.3, and a maximum threshold of 0.5 was used. Quality of fixation to the wall was assessed with fixation ratio (FR = bone wall contact height/total wall height). Notable radiographic features at the tibial wall were also recorded. Results: A total of 33 knees with cement, 37 knees with cementless with HA and 57 knees cementless with HA + MPC had adequately aligned radiographs. Fixation was significantly better with HA compared with cement (55% vs. 25%, p = 0.0016). The microporous coat further improved fixation (81% vs. 55%, p < 0.0001). FR > 80% was achieved in 3% of the cemented implants, 32% of HA and 68% of HA + MPC. In cementless cohorts, features suggestive of a layer of bone that had delaminated from the wall were seen in 8 (22%) HA and 3 (5%) HA + MPC knees. Conclusion: Radiographic tibial wall fixation in OUKR is poor with cement. It improves with an HA coating and improves further with an intermediary MPC. Improved tibial wall fixation may explain the lower levels of pain observed with cementless rather than cemented fixation described in the literature, but further clinical correlation is needed. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Purpose: There is concern that using cementless components may increase polyethylene wear of the Oxford unicompartmental knee replacement (OUKR). Therefore, this study aimed to measure bearing wear at 10 years in patients from a randomized trial comparing Phase 3 cemented and cementless OUKRs and to investigate factors that may affect wear. It was hypothesized that there would be no difference in wear rate between cemented and cementless OUKRs. Methods: Bearing thickness was determined using radiostereometric analysis at postoperative, 3‐month, 6‐month, 1‐year, 2‐year, 5‐year and 10‐year timepoints. As creep occurs early, wear rate was calculated using linear regression between 6 months and 10 years for 39 knees (20 cemented, 19 cementless). Associations between wear and implant, surgical and patient factors were analysed. Results: The linear wear rate of the Phase 3 OUKR was 0.06 mm/year with no significant difference (p = 0.18) between cemented (0.054 mm/year) and cementless (0.063 mm/year) implants. Age, Oxford Knee Score, component size and bearing thickness had no correlation with wear. A body mass index ≥ 30 was associated with a significantly lower wear rate (p = 0.007) as was having ≥80% femoral component contact area on the bearing (p = 0.003). Bearings positioned ≥1.5 mm from the tibial wall had a significantly higher wear rate (p = 0.002). Conclusions: At 10 years, the Phase 3 OUKR linear wear rate is low and not associated with the fixation method. To minimize the risk of wear‐related bearing fracture in the very long‐term surgeons should consider using 4 mm bearings in very young active patients and ensure that components are appropriately positioned, which is facilitated by the current instrumentation. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Purpose: Restricted kinematically aligned total knee arthroplasty (rKA‐TKA) may not restore the constitutional varus alignment in most patients with knee osteoarthritis. This study aimed to investigate (1) the extent to which constitutional lower limb alignment can be restored by rKA‐TKA using an anatomically designed implant and (2) which lower limb alignment parameters are associated with patient‐reported outcome measures (PROMs). Methods: This study included 60 patients who underwent rKA‐TKA using an anatomically designed implant. Radiographic alignment parameters, including mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), coronal hip–knee–ankle angle (HKA), coronal joint line obliquity (JLO), posterior tibial slope (PTS), single‐leg standing knee flexion angle (KFA), sagittal JLO, and arithmetic HKA (aHKA), were evaluated preoperatively and postoperatively. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used for clinical evaluation. Results: The mLDFA, MPTA, and aHKA showed no significant differences before and after surgery. Coronal HKA and PTS have significantly changed from 8.1 ± 8.7° and 9.9 ± 8.6° preoperatively to 3.5 ± 3.1° and 2.5 ± 2.0° postoperatively, respectively (p < 0.001 for each comparison). The postoperative WOMAC total score was significantly correlated with the KFA (r = 0.4063, p = 0.0034) and sagittal JLO (r = −0.3435, p = 0.0157). Postoperative KFA is a causal factor for the increased postoperative WOMAC total score (r = 1.416, 95% confidence interval: 0.491–2.342, p = 0.003). Conclusion: rKA‐TKA using an anatomically designed implant can restore constitutional coronal lower limb alignment, while postoperative KFA and sagittal JLO were associated with poor PROMs. Care should be taken for the postoperative KFA because it is a risk factor for poor PROMs. Level of Evidence: Level III, case–control study. [ABSTRACT FROM AUTHOR]

This article explores the benefits and limitations of using large data registries for artificial intelligence (AI) research in orthopaedics. It discusses two main types of data sources: institutional databases, which provide detailed patient information but require maintenance, and administrative databases, which have a larger pool of data but may lack specific details. While large data registries offer advantages such as robust sample sizes and readily available data, they also have limitations including coding inconsistencies and missing critical information. The article emphasizes the need for AI-specific data registries that capture diverse patient data to improve the accuracy and applicability of AI models in orthopaedic research and patient care. [Extracted from the article]

Purpose: The purposes of this study are to, firstly, develop techniques to accurately identify extensor mechanism malalignment by measuring the alignment of the quadriceps tendon (QTA) with computerized tomography (CT) scans. Secondly, to investigate correlations between QTA and lower limb bony anatomical variations within a representative normal population. Lastly, to evaluate the clinical significance of QTA by establishing its potential connection with lateral facet patellofemoral joint osteoarthritis (LFPFJOA). Method: CT scans were orientated to a mechanical axis reference frame and three techniques developed to measure the alignment of the quadriceps tendon. Multiple measurement of bony alignment from the hip to the ankle were performed on each scan. A series of 110 cadaveric CT scans were measured to determine normal values, reproducibility, and correlations with bony anatomy. Secondly, a comparison between 2 groups of 25 patients, 1 group with LFPFJOA and 1 group with isolated medial OA and no LFPFJOA. Results: From the cadaveric study, it was determined that the alignment of the quadriceps tendon is on average 4.3° (SD 3.9) varus and the apex of the tendon is 9.1 mm (SD 7.7 mm) lateral to the trochlear groove and externally rotated 1.9° (SD 12.4°) from the centre of the femoral shaft. There was no association between the quadriceps tendon alignment and any other bony measurements including tibial tubercle trochlear groove distance (TTTG), coronal alignment, trochlear groove alignment and femoral neck anteversion. A lateralized QTA was significantly associated with LFPFJOA. QTA in the LFPFJOA group was 9.6° varus (SD 2.8°), 21.3 mm (SD 6.6) lateralised and 17.3° ER (SD 11°) compared to 5.5° (SD 2.3°), 10.7 mm (SD 4.9) and 3.3° (SD 7.2°), respectively, in the control group (p < 0.001). A significant association with LFPFJOA was also found for TTTG (17.2 mm (SD 5.7) vs 12.1 mm (SD 4.3), p < 0.01). Logistic regression analysis confirmed the QTA as having the stronger association with LFPFJOA than TTTG (AUC 0.87 to 0.92 for QTA vs 0.79 for TTTG). Conclusion: These studies have confirmed the ability to accurately determine QTA on CT scans. The normal values indicate that the QTA is highly variable and unrelated to bony anatomy. The comparative study has determined that QTA is clinically relevant and a lateralised QTA is the dominant predictor of severe LFPFJOA. This deformity should be considered when assessing patella maltracking associated with patella osteoarthritis, patella instability and arthroplasty. Level of evidence: III (retrospective cohort study). [ABSTRACT FROM AUTHOR]

Purpose: The present study aims to translate, adapt and validate a Spanish version of the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR), including a reliability and validity analysis in patients with knee osteoarthritis (OA). Methods: This study conducted a prospective validation study following the six stages of the "Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures". Psychometric testing was conducted in patients with knee osteoarthritis. Subjects answered the Spanish KOOS, JR (S-KOOS, JR) and a validated Spanish Oxford Knee Score (S-OKS). Retest was conducted at 10 days. Acceptability, floor and ceiling effect, internal consistency (Cronbach's α), reproducibility (mixed-effect model coefficient [MEMC]) and construct validity (Spearman's correlation; p = 0.05) were assessed. Results: Forty-one patients (mean age: 65.6 ± 5.39; 48.8% female) participated in the study. All patients (100%) answered both scores during the first assessment and 38 (92.7%) during the second assessment. All patient-reported outcomes measures were answered completely (100%). The S-KOOS, JR resulted in 100% acceptability when answered. There were no ceiling or floor effects detected. The Cronbach's α for the S-KOOS, JR was 0.927 and its MEMC was 0.852 (CI 95% 0.636–1.078). The Spearman's correlation between the S-KOOS, JR and the S-OKS was 0.711 (CI 0.345–0.608; p < 0.001) and 0.870 (CI 0.444–0.651; p < 0.001) for the first and second assessments, respectively. Conclusion: The S-KOOS, JR has very high internal consistency and reproducibility, with a high correlation with the S-OKS; it is a reliable and valid instrument for characterising Spanish-speaking patients suffering from knee OA. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: To compare patient-reported pain scores and assess the influence of neuropathy and co-morbidity, on knee pain following cemented and cementless medial unicompartmental knee replacement (UKR) 5 years after surgery. Method: In this longitudinal study, 262 cemented and 262 cementless Oxford UKR performed for the same indications and with the same techniques were recruited. Patients were reviewed at five years, evaluating patient-reported pain and association with clinical outcomes. Intermittent and Constant Osteoarthritis Pain (ICOAP), PainDETECT (PD), Charnley score, Oxford Knee Score (OKS) and American Knee Society Score (AKSS) were compared. Results: In both cohorts, intermittent pain was more common than constant pain (47% vs 21%). Cementless knees reported significantly less pain than cemented (ICOAP-Total 5/100 vs 11/100, p < 0.0001). A greater proportion of cementless knees experienced no pain at all (ICOAP = 0/100, 61% vs 43%, p < 0.0001) and 75% fewer experienced severe or extreme pain. Pain sub-scores in PD, OKS and AKSS follow this trend. Pain was unlikely to be neuropathic (PD positive: 5.26%), but patients reporting high levels of 'strongest' pain were three times more likely to be neuropathic. Patients with co-morbidities (Charnley C) experienced greater pain than those without (Charnley A+B) across all knee-specific scores, despite scores being knee specific. Conclusion: Both cemented and cementless UKR in this study had substantially less pain than that reported in literature following TKR. Cementless UKR had significantly less pain than cemented UKR in all scores. Two-thirds of patients with a cementless UKR had no pain at all at 5 years, and pain experienced was most likely to be mild and intermittent with no patients in severe or extreme pain. Patients with cementless UKR that had higher levels of pain were more likely to have co-morbidity or evidence or neuropathic pain. It is unclear why cementless UKR have less pain than cemented; further study is necessary. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to analyze the clinical outcomes and radiologic position of the knee in two groups of patients after medial unicompartmental knee arthroplasty (UKA): one group with residual varus axis (RVA) alignment and other one with neutral mechanical axis (NMA) of the lower limb. Methods: All patients who underwent UKA between January 2015 and January 2018 were evaluated retrospectively. Inclusion criteria were: medial UKA for isolated medial femoro-tibial osteoarthritis, a varus deformity of < 15°, and a minimal follow-up of 2 years. All patients had a preoperative and postoperative clinical examination with functional scores (New International Knee Score (NewIKS) and Knee injury and Osteoarthritis Outcome Score (KOOS) and radiographs. Preoperative and postoperative values for continuous outcomes were compared using the Student's t test for paired data and differences between the groups were compared with the Mann–Whitney U test. p < 0.05 was considered statistically significant. Results: The RVA group consisted of 48 cases of medial UKA in 48 patients (22 females). Mean postoperative hip–knee–ankle (HKA) angle was 174.3° ± 2.8 and the corresponding mean AKI angle (tibial mechanical angle) was 82.9° ± 2.9. The NMA group consisted of 35 cases of medial UKA in 35 patients (14 females). Mean postoperative HKA angle was 178.9° ± 3 and the corresponding mean AKI angle was 85.5° ± 3.1. A significant difference was found between the two groups for the KOOS score and for global NewIKS, with a better score in the RVA group. Conclusions: RVA alignment after medial UKA results in a significant improvement in functional knee scores at 2-year post-surgery. Return to sport and recreational activities was better than in patients with postoperative NMA. Level of evidence: Level 3; retrospective cohort study. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to summarise the current use of outcome measures for the assessment of physical function after knee joint replacement. Methods: A systematic approach following the PRISMA guidelines was used. Literature search was performed on MEDLINE database via PubMed and on Epistemonikos. Clinical trials (level of evidence I-II) on knee joint replacement reporting data on the 'physical function' domain published between January 2017 and June 2022 were included. Descriptive statistics were used to summarise the evidence. Results: In the 181 articles that met the inclusion criteria, 49 different outcome measurements were used to evaluate clinical outcomes after knee joint replacement. The most frequently adopted patient-reported outcome measures (PROMs) were the Knee Society Score (KSS) (78 studies; 43.1%), the Western Ontario and McMaster Universities (WOMAC) Arthritis Index (62 studies; 34.3%), the Oxford Knee Score (OKS) (51 studies; 28.2%) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) (36 studies; 20%). The most frequently used performance-based outcome measures (PBOMs) were the Timed-Up-and-Go (TUG) test (30 studies; 16.6%) and the 6-min-walk test (6MWT) (21 studies; 11.6%). Among impairment-based outcome measures (IBOMs), range of motion (ROM) was the most used (74 studies; 40.9%). Conclusion: There is considerable variation among clinical studies regarding the assessment of the physical function of patients after knee joint replacement. PROMs were found to be the most commonly adopted outcome measures; however, no single PROM was used in more than half of the papers analysed. Level of evidence: Level II, systematic review of level I-II studies. [ABSTRACT FROM AUTHOR]

Purpose: It is well-known that revision rates after primary knee arthroplasty vary widely. However, it is uncertain whether hospital revision rates are reliable indicators of general surgical quality as defined by patients. The SPARK study compared primary knee arthroplasty surgery at three high-volume hospitals whose revision rates differed for unknown reasons. Methods: This prospective observational study included primary knee arthroplasty patients (total, medial/lateral unicompartmental and patellofemoral) in two low-revision hospitals (Aarhus University Hospital and Aalborg University Hospital Farsø) and one high-revision hospital (Copenhagen University Hospital Herlev-Gentofte). Patients were followed from preoperatively (2016–17) to 1-year postoperatively with patient-reported outcome measures including Oxford Knee Score (OKS), EQ-5D-5L and Copenhagen Knee ROM (range of motion) Scale. The surgical outcomes were compared across hospitals for patients with comparable grades of radiographic knee osteoarthritis and preoperative OKS. Statistical comparisons (parametric and non-parametric) included all three hospitals. Results: 97% of the 1452 patients who provided baseline data (89% of those included and 56% of those operated) responded postoperatively (90% at 1 year). Hospitals' utilization of unicompartmental knee arthroplasties differed (Aarhus 49%, Aalborg 14%, and Copenhagen 22%, p < 0.001). 28 patients had revision surgery during the first year (hospital independent, p = 0.1) and were subsequently excluded. 1-year OKS (39 ± 7) was independent of hospital (p = 0.1), even when adjusted for age, sex, Body Mass Index, baseline OKS and osteoarthritis grading. 15% of patients improved less than Minimal Important Change (8 OKS) (Aarhus 19%, Aalborg 13% and Copenhagen 14%, p = 0.051 unadjusted). Patients with comparable preoperative OKS or osteoarthritis grading had similar 1-year results across hospitals (OKS and willingness to repeat surgery, p ≥ 0.087) except for the 64 patients with Kellgren–Lawrence grade-4 (Aarhus 4–6 OKS points lower). 86% of patients were satisfied, and 92% were "willing to repeat surgery", independent of hospital (p ≥ 0.1). Hospital revision rates differences diminished during the study period. Conclusions: Patients in hospitals with a history of differing revision rates had comparable patient-reported outcomes 1 year after primary knee arthroplasty, supporting that surgical quality should not be evaluated by revision rates alone. Future studies should explore if revision rate variations may depend as much on revision thresholds and indications as on outcomes of primary surgery. Level of evidence: Level II (Prospective cohort study). [ABSTRACT FROM AUTHOR]

Purpose: Revision rates following primary knee arthroplasty vary by country, region and hospital. The SPARK study was initiated to compare primary surgery across three Danish regions with consistently different revision rates. The present study investigated whether the variations were associated with differences in the primary patient selection. Methods: A prospective observational cohort study included patients scheduled Sep 2016 Dec 2017 for primary knee arthroplasty (total, medial/lateral unicompartmental or patellofemoral) at three high-volume hospitals, representing regions with 2-year cumulative revision rates of 1, 2 and 5%, respectively. Hospitals were compared with respects to patient demographics, preoperative patient-reported outcome measures, motivations for surgery, implant selection, radiological osteoarthritis and the regional incidence of primary surgery. Statistical tests (parametric and non-parametric) comprised all three hospitals. Results: Baseline data was provided by 1452 patients (89% of included patients, 56% of available patients). Patients in Copenhagen (Herlev-Gentofte Hospital, high-revision) were older (68.6 ± 9 years) than those in low-revision hospitals (Aarhus 66.6 ± 10 y. and Aalborg (Farsø) 67.3 ± 9 y., p = 0.002). In Aalborg, patients who had higher Body Mass Index (mean 30.2 kg/m2 versus 28.2 (Aarhus) and 28.7 kg/m2 (Copenhagen), p < 0.001), were more likely to be male (56% versus 45 and 43%, respectively, p = 0.002), and exhibited fewer anxiety and depression symptoms (EQ-5D-5L) (24% versus 34 and 38%, p = 0.01). The preoperative Oxford Knee Score (23.3 ± 7), UCLA Activity Scale (4.7 ± 2), range of motion (Copenhagen Knee ROM Scale) and patient motivations were comparable across hospitals but varied with implant type. Radiological classification ≥ 2 was observed in 94% (Kellgren-Lawrence) and 67% (Ahlbäck) and was more frequent in Aarhus (low-revision) (p ≤ 0.02), where unicompartmental implants were utilized most (49% versus 14 (Aalborg) and 23% (Copenhagen), p < 0.001). In the Capital Region (Copenhagen), the incidence of surgery was 15–28% higher (p < 0.001). Conclusion: Patient-reported outcome measures prior to primary knee arthroplasty were comparable across hospitals with differing revision rates. While radiographic classifications and surgical incidence indicated higher thresholds for primary surgery in one low-revision hospital, most variations in patient and implant selection were contrary to well-known revision risk factors, suggesting that patient selection differences alone were unlikely to be responsible for the observed variation in revision rates across Danish hospitals. Level of evidence: II, Prospective cohort study. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR). Methods: We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1 months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed. Results: Mean age was 77.1 years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality. Conclusion: DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate. [ABSTRACT FROM AUTHOR]

Background: Total knee arthroplasty requires effective rehabilitation to achieve optimal results, but institutions often rely on unsupervised home exercises due to cost constraints. Wearable sensors have become increasingly popular as a potential method of monitoring patients remotely to ensure efficacy and compliance. This review assesses the current evidence for their use in remotely monitored rehabilitation following knee arthroplasty. Methods: A systematic review of the literature from 1st January 2000 to 17th February 2022 was undertaken. Devices were categorised as joint-specific or physical activity sensors. Studies were classified as those providing remotely supervised rehabilitation as an additional or as an alternative intervention. Results: Remotely supervised rehabilitation using wearable sensors demonstrated similar outcomes when provided as an alternative to standard care in most studies. One group found improved outcomes for knee-specific sensors compared with standard care. There were improved physical activity and healthcare resource use outcomes described in the literature where sensors were used in addition to standard care. Discussion: This review found evidence for the use of wearable sensors in remotely supervised rehabilitation following knee arthroplasty surgery. This included methodological heterogeneity, differing definitions of standard care, and variable follow-up periods. Robust randomised control trial data with a longer follow-up period are needed. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the incidence of intraoperative mid-flexion laxity using continuous flexion-arc gap assessment, risk factors for mid-flexion laxity, and clinical results in navigation-assisted total knee arthroplasty (TKA). Methods: Ninety posterior-stabilized TKAs were performed under navigation guidance for patients with degenerative arthritis and varus deformity. Intraoperatively, the gap between the trial femoral component and insert was evaluated in the navigation system with continuous flexion-arc gap assessment. Each medial and lateral gap at flexion (90°) and extension (0°) were made to be less than 3 mm. Mid-flexion laxity was determined when the gap in the flexion range between 15° and 60° was 3 mm or more. The proportion of knees with mid-flexion laxity was investigated. The factors affecting mid-flexion laxity were identified in terms of demographics, preoperative convergence angle, and change in joint line height and posterior femoral offset. The Knee Society Score and Western Ontario and McMaster Universities Osteoarthritis Index were evaluated. Results: There were 31 cases (34.4%) of lateral mid-flexion laxity (average peak mid-flexion gap = 3.7 mm). The other 59 cases did not show mid-flexion laxity. The preoperative convergence angle was the only significant factor affecting lateral mid-flexion laxity (odds ratio = 1.466, p = 0.002). There were no significant differences in the clinical results between the groups with and without mid-flexion laxity. Conclusions: The continuous flexion-arc gap assessment was useful in evaluating mid-flexion laxity using navigation-assisted TKA. The preoperative convergence angle, reflecting soft-tissue laxity, can be a practical and simple radiographic finding for predicting lateral mid-flexion laxity. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Introduction: Cartilage defects in the knee can be caused by injury, various types of arthritis, or degeneration. As a long-term consequence of cartilage defects, osteoarthritis can develop over time, often leading to the need for a total knee replacement (TKR). The treatment alternatives of chondral defects include, among others, microfracture, and matrix-associated autologous chondrocyte implantation (M-ACI). The purpose of this study was to determine cost-effectiveness of M-ACI in Germany with available mid- and long-term outcome data, with special focus on the avoidance of TKR. Materials and methods: We developed a discrete-event simulation (DES) that follows up individuals with cartilage defects of the knee over their lifetimes. The DES was conducted with a status-quo scenario in which M-ACI is available and a comparison scenario with no M-ACI available. The model included 10,000 patients with articular cartilage defects. We assumed Weibull distributions for short- and long-term effects for implant failures. Model outcomes were costs, number of TKRs, and quality-adjusted life years (QALYs). All analyses were performed from the perspective of the German statutory health insurance. Results: The majority of patients was under 45 years old, with defect sizes between 2 and 7 cm2 (mean: 4.5 cm2); average modeled lifetime was 48 years. In the scenario without M-ACI, 26.4% of patients required a TKR over their lifetime. In the M-ACI scenario, this was the case in only 5.5% of cases. Thus, in the modeled cohort of 10,000 patients, 2700 TKRs, including revisions, could be avoided. Patients treated with M-ACI experienced improved quality of life (22.53 vs. 21.21 QALYs) at higher treatment-related costs (18,589 vs. 14,134 € /patient) compared to those treated without M-ACI, yielding an incremental cost‐effectiveness ratio (ICER) of 3376 € /QALY. Conclusion: M-ACI is projected to be a highly cost‐effective treatment for chondral defects of the knee in the German healthcare setting. [ABSTRACT FROM AUTHOR]

Purpose: This retrospective study aims to analyse the survivorship and functional outcomes of two samples with similar preoperative clinical and demographic data of lateral unicompartmental knee arthroplasty (UKA) performed with robotic and conventional surgery at a minimum 5-year follow-up. Methods: In this retrospective study, the clinical records of two cohorts for 95 lateral UKA implants were analysed. The first cohort consisted of 43 patients with cemented lateral UKA performed with the conventional procedure (Conventional group). The second cohort consisted of 52 patients who received robot-assisted cemented lateral UKA (Robotic group). Clinical evaluation of the two samples entailed evaluating the Knee Injury and Osteoarthritis Outcome Score divided into subscales (symptoms and stiffness, pain, function in daily living, function in sport and recreation and quality of life) for each patient. Revision was defined as the failure of the implant (periprosthetic joint infection, periprosthetic fracture or aseptic loosening), and survival was based on implant revision. Results: The mean follow-up time was 90.3 ± 9.1 months for the Conventional Group and 95.4 ± 11.0 months for the Robotic Group (n.s.). Each patient was clinically evaluated on the day before surgery (T0), at a minimum 1-year follow-up (T1) and at a minimum 5-year follow-up (T2). In both groups, all clinical scores improved between T0 and T1 and between T0 and T2 (p < 0.05); for both groups, no differences were noted in any clinical scores between T1 and T2 (n.s.). No significant differences in any clinical score were found between the two groups at each follow-up (n.s.). Survival analysis reported no differences between the two groups at the final 1-year follow-up, with three failures (2 aseptic loosening and 1 periprosthetic fracture) in the Conventional group and two failures (1 patellofemoral osteoarthritis and 1 inexplicable pain) in the Robotic group (n.s.). Conclusions: This study shows excellent clinical outcomes and revision rates in robotic arm-assisted and manual techniques for lateral UKA, with no clinical differences at medium- to long-term follow-up. Level of evidence: Level III—comparative study. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this systematic review and metanalysis was to assess clinical and radiological outcomes of metaphyseal sleeves and cones and to identify their possible advantages and disadvantages. Methods: A comprehensive search from the inception of the databases to March 2021 was performed on Medline, Scopus, CINAHL, Cochrane, Embase, Ovid, and Google scholar databases. Coleman Methodology Score was used for quality assessment. Author, year of publication, type of study, level of evidence, sample size, number of patients, number of knees treated, mean age, gender, mean follow-up, clinical outcomes, complications, the reason for revision and, type of prosthesis were extracted for analysis. Clinical studies providing data about patient's outcomes after the primary and Total Knee Arthroplasty revision with the usage of sleeves or cones and a minimum of 2 years of follow-up were included. Results: The literature search and cross-referencing resulted in a total of 93 articles, but only 30 articles were appropriate for the systematic review. Comparable clinical results were reported between cones and sleeves. The meta-analysis showed a greater incidence of intraoperative fractures in patients treated with sleeves (1.6%, [95% CI 0.7; 3.4] in cones and 4.6%, [95% CI 3.3; 6.4] in sleeves, p = 0.01), while the risk of postoperative fractures (4.3%, [95% CI 2.7; 7] in cones and 2.1%, [95% CI 1.2; 3.5] in sleeves, p = 0.04) and infections (8.5%, [95% CI 6; 12] in cones and 3.7%, [95% CI 2.1; 7.3] in sleeves, p = 0.03) was higher with cones. Conclusion: A higher incidence of intraoperative fracture was reported in patients treated with sleeves, while a higher rate of postoperative fractures and infections was described in patients treated with cones. Nonetheless, complications were reported in both groups. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: UKA has higher revision risk, particularly for lower volume surgeons. While robotic-arm assisted systems allow for increased accuracy, introduction of new systems has been associated with learning curves. The aim of this study was to determine the learning curve of a UKA robotic-arm assisted system. The hypothesis was that this may affect operative times, patient outcomes, limb alignment, and component placement. Methods: Between 2017 and 2021, five surgeons performed 152 consecutive robotic-arm assisted primary medial UKA, and measurements of interest were recorded. Patient outcomes were measured with Oxford Knee Score, EuroQol-5D, and Forgotten Joint Score at 6 weeks, 1 year, and 2 years. Surgeons were grouped into 'low' and 'high' usage groups based on total UKA (manual and robotic) performed per year. Results: A learning curve of 11 cases was found with operative time (p < 0.01), femoral rotation (p = 0.02), and insert sizing (p = 0.03), which highlighted areas that require care during the learning phase. Despite decreased 6-week EQ-5D-5L VAS in the proficiency group (77 cf. 85, p < 0.01), no difference was found with implant survival (98.2%) between phases (p = 0.15), or between 'high' and 'low' usage surgeons (p = 0.23) at 36 months. This suggested that the learning curve did not lead to early adverse effects in this patient cohort. Conclusion: Introduction of a UKA robotic-arm assisted system showed learning curves for operative times and insert sizing but not for implant survival at early follow-up. The short learning curve regardless of UKA usage indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons. Level of evidence: Level III, Retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: There are various classification systems described in the literature for managing bone defects in revision knee arthroplasty (RTKA). We analysed the reliability and usefulness of these classification systems. Questions/purposes: (1) To review and critique the various classification systems proposed for bone loss in RTKA. (2) Among all the proposed classifications which one is the most commonly used by surgeons to report their results. (3) What is the reliability of various bone defect classification systems for RTKA. In this review, we have assessed the studies validating those classifications with a detailed description of the limitations and the proposed modifications. Methods: This systematic review was conducted following PRISMA guidelines. Pubmed/Medline, CINAHL, EMBASE, Scopus, Cochrane databases and Web of Science databases were searched using multiple search terms and MeSH terms where possible. Studies meeting inclusion criteria were assessed for statistical parameters of reliability of a classification system. Results: We found 16 classification systems for bone defects in RTKA. Six studies were found evaluating a classification system with reporting their reliability parameters. Fifty-four studies were found which classified bone loss using AORI classification in their series. AORI classification is most commonly reported for classifying bone defects. Type T2B and F2B are the most common bone defects in RTKA. The average kappa value for AORI classification for femoral bone loss was 0.38 (0.27–0.50) and 0.76 (0.63–1) for tibial bone loss assessment. Conclusion: None of the available classification systems is reliably established in determining the bone loss and treatment plans in RTKA. Among all, AORI classification is the most widely used system in clinical practice. The reliability of AORI Classification is fair for femoral bone loss and substantial for tibial bone loss. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the effect of obesity on patient outcome, procedure failure rate and osteoarthritis (OA) progression in the tibiofemoral compartments in a series of isolated patellofemoral arthroplasty (PFA) performed with a third-generation implant. Methods: The study population was patients who had undergone third-generation PFA at a specialized orthopedic center between 2007 and 2017. Patients were categorized by body-mass index (BMI) as obese (O, BMI > 30 kg/m2) or nonobese (NO, BMI < 30 kg/m2). Preoperative and postoperative clinical and functional assessment included knee range of motion, Knee Society Score (KSS), University of California Los Angeles (UCLA) Activity Score, Tegner Activity Level Scale, and visual analogue scale (VAS) for pain. Preoperative and postoperative radiographs were evaluated for progression of tibiofemoral compartment OA, changes in patellar height and in knee coronal alignment. Multiple logistic regression models were used to assess the effect of BMI on outcomes together with other covariates. Results: A total of 120 PFAs with a mean follow-up of 6.9 ± 2.5 years were included: 25 in the O group and 95 in the NO group. Significant improvement was noted in in knee range of motion (P < 0.001), clinical and functional KSS (P < 0.001), UCLA Activity Score (P < 0.001), Tegner score (P < 0.001) and VAS pain (P < 0.001) without inter-groups differences. Worsening of the medial Kellgren–Lawrence (KL) grade (but not the lateral KL grade) was more frequent in the O than the NO group during the follow-up period (P = 0.014). Failure occurred in 4.2% of NO and in 20% of O group patients; the difference was solely due to failure because of OA progression in the tibiofemoral compartment (16% in the O group). There were no between group differences in the failure rate for any cause other than OA progression (4.2% in the NO group, 4.0% in the O group). Conclusions: An equal improvement in function after PFA was noted in both obese and nonobese patients; however, the high failure rate due to OA progression in the medial tibiofemoral compartment warrants caution when considering PFA in obese patients. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this meta-analysis was to to determine the influence of obesity on patient outcome and implant survivorship after primary unicompartmental knee arthroplasty (UKA). Methods: A PRISMA systematic review was conducted by searching the Medline (PubMed), EMBASE, and Cochrane electronic databases to identify clinical studies investigating the effect of obesity on outcomes after UKA. Data were collected on aspecifically designed extraction form. Methodological quality was assessed using the Methodological Index for Nonrandomized Studies score. Quantitative meta-analysis was carried out using RevMan 5.4 software. Results: A total of 17 studies were included; 43,845 primary UKA patients were classified by their BMI: on-obese (BMI 25 to < 30 kg/m2); obese (BMI 30 to < 35 kg/m2); severely obese (BMI > 35 kg/m2). Pooled analysis showed no statistically significant difference in Knee Society Score (KSS) pain in the obese (n.s.) and the severely obese (n.s.) group compared to the non-obese group, while the KSS function score was lower in the severely obese (P = 0.0002) compared to the obese (P = 0.06) and the non-obese group. Postoperative Oxford Knee Score (OKS) was lower in the obese group (P = 0.01) but not in the severely obese group (P = 0.16). Postoperative Range of Motion (ROM) was comparable in the obese and non-obese group (P = 0.16). Implant survival at 10 years follow-up was significantly lower in the obese (82.5–95.3%; P < 0.0001) and the severely obese group (87.5–93.8%; P < 0.0001) thanthe non-obese group (83.6–98.6%). Conclusion: Obesity and severe obesity were associated with significantly higher revision and lower implant survival rates. Obesity did not influence clinical and most functional outcomes after UKA, whereas KSS function score was significantly lower only for the severely obese patient group. Level of Evidence: III, meta-analysis. [ABSTRACT FROM AUTHOR]

Introduction: To retrospectively investigate the early postoperative range of motion (ROM) (days 4, 7, 10) after total knee arthroplasty (TKA) and to test for associations (a) with long-term outcome in terms of ROM and (b) with a disease-specific knee score. Materials and methods: A retrospective analysis was performed in patients with previous primary TKA. Data taken from the medical records were ROM from preoperative and postoperative days 4, 7 and 10 and 1 year. As patient-reported outcome the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC Score) was taken from preoperative and one year after TKA. Results: 316 patients (330 knees) were available. Only negligible correlations were determined between ROM at twelve months postoperative and ROM in the early postoperative days (days 4, 7, 10). Similarly, only negligible correlations were determined between ROM in the early postoperative days (days 4, 7, 10) and the 1-year WOMAC. Conclusion: From the main findings it would seem that steepness of ROM ascent in the early postoperative days is of minor importance for (a) long-term ROM and (b) long-term knee score outcome after TKA. [ABSTRACT FROM AUTHOR]

Purpose: Indications for unicompartmental knee arthroplasty (UKA) are controversial. Studies based solely on radiographic criteria suggest up to 49% of patients with knee osteoarthritis (OA) are suitable for UKA. In contrast, the 'Appropriate use criteria' (AUC), developed by the AAOS, apply clinical and radiographic criteria to guide surgical treatment of knee OA. The aim of this study was to analyze patient suitability for TKA, UKA and osteotomy using both radiographic criteria and AUC in a cohort of 300 consecutive knee OA patients. Methods: Included were consecutive patients with clinical and radiographic signs of knee OA referred to a specialist clinic. Collected were demographic data, radiographic wear patterns and clinical findings that were analyzed using the AUC. A comparison of the radiographic wear patterns with the treatment suggested by the AUC as well as the Surgeon Treatment Decision was performed. Results: There were 397 knees in 300 patients available for analysis. Median age was 68 [IQR 15], BMI 30 [6] with 55% females. Excellent consistency for both the radiographic criteria and the AUC criteria was found. Based on radiological criteria, 41% of knees were suitable for UKA. However, when using the AUC criteria, UKA was the appropriate treatment in only 13.3% of knees. In 19.1% of knees, no surgical treatment was appropriate at the visit, based on the collected data. Conclusion: Application of isolated radiologic criteria in patients with knee OA results in a UKA candidacy is misleadingly high. AUC that are based on both radiological and clinical criteria suggest UKA is appropriate in less than 15% of patients. Level of evidence: III retrospective study. [ABSTRACT FROM AUTHOR]

Introduction: The influence of a previous high tibial osteotomy (HTO) on the outcome and survival of a knee arthroplasty is a debated issue. The purpose of this study is to compare subjective, radiographic, and functional outcomes of unicompartmental knee replacement (UKR) and total knee replacement (TKR) after failed open wedge HTO. Methods: 26 post-HTO UKRs (group A) with an average follow-up of 7.8 years (range 2–13), and 33 post-HTO TKRs (group B) with an average follow-up of 11.2 years (range 4–16) operated between 2001 and 2017, were retrospectively reviewed. Assessment included Knee Society Score (KSS), University of California at Los Angeles Activity Score (UCLA), and Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Standard knee X-rays, and long-standing X-rays were performed pre-operatively and at follow-up to evaluate prosthesis survival, coronal alignment, and patellar height. Results: Improvements regarding KSS, UCLA and WOMAC scores were noted at follow-up in both groups compared to pre-operatory status (p < 0.001). No statistically significant differences in clinical and functional postoperative scores were reported between groups (p = n.s.) at follow-up. Group B presented a more neutral mean mechanical axis of 0.5° compared to 2.7° in Group A (p < 0.001). Conclusions: Performing UKR after previous failed HTO is a safe and effective procedure which leads to clinical, radiological and functional outcomes comparable to TKR after HTO. [ABSTRACT FROM AUTHOR]

Purpose: To identify factors influencing patient's availability to re-schedule primary total knee replacement (TKR) or revision (RKR) surgery after the lockdown (March–May 2020) during the COVID-19 pandemic. Methods: A prospective cohort study through a telephone survey was performed in 156 patients (143 for primary and 13 for revision) included in the TKR and RKR surgical waiting list before March 2020. Contact of each patient with COVID-19, stress and anxiety, perceived pain, and function were obtained in the interviews, and also the preference of each patient to have re-scheduled surgery (early or late). Finally, we registered their response (acceptance or refusal) when surgery was effectively re-scheduled. Results: 88 out of 156 patients waiting for knee replacement (76/143 of those waiting for TKR, 12/13 of those waiting for RKR) declared themselves ready for surgery in less than 1 month. When re-scheduled, 115 patients underwent surgery and 41 refused. Significantly different preferences were found for age (more prone to surgery if under 65), revision surgery (more readily available), pain (7.9 ± 1.7/10 in NRS in those undergoing surgery, 5.6 ± 2.3/10 in those refusing, p = 0.000), or COVID-19 diagnosis, but not other close contact with COVID-19, comorbidities, stress, or anxiety. A logistic regression model confirmed that revision surgery (OR 9.33), perceived severe pain (OR 5.21), and age under 65 years (OR 5.82) were significantly associated with patient preference. The probability of patients over 65 to prefer early surgery reached 60% only with pain at or above 9/10. Conclusions: Surgical timing preferences for knee replacement vary between patients older than 65 years (immediate surgery only when pain is intense) and younger patients (immediate surgery no matter the amount of pain). Even if COVID-19 severely stroke our population, the need for knee replacement stood in the young population and even in the aged population at risk for COVID when pain was important. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the study was to compare clinical and radiological results between kinematic alignment (KA) and mechanical alignment (MA) with a posterior-stabilized (PS) total knee arthroplasty (TKA) with a post-cam mechanism at a minimum follow-up of 3 years. The authors hypothesized a higher risk of aseptic loosening when performing KA using PS TKA. Methods: A retrospective monocentric single surgeon case control study was performed comparing 100 matched patients who had TKA performed using a MA philosophy to 50 patients receiving TKA with a KA technique between January 2016 and October 2017. All patients had the same knee prosthesis (GMK primary posterior-stabilized, Medacta®, Switzerland). Patient specific cutting blocks were used in both groups and a restricted KA (rKA) was aimed in the KA group. A hybrid cementation technique was performed. The new Knee Society Score (KSS) and radiological assessment were collected preoperatively and at the final follow-up. Comparisons between groups were done with the T test or Fisher exact test. Global survival curves were estimated with Kaplan–Meier model. Significance was set at p < 0.05. Results: Mean follow-up was 42.9 months ± 3.6 (range 37.6–46.7) and 53.3 months ± 4.1 (range 45.5–59.8) for rKA and MA groups. Postoperatively, no significant differences were found for clinical scores between both groups. Radiological assessment found similar postoperative Hip–Knee–Ankle angle for rKA and MA groups (178° versus 179° respectively, NS). At last follow-up, a significant higher survivorship was found for the MA group compared to the rKA group (97 versus 84%; p < 0.001) for aseptic loosening revision as the endpoint. Conclusion: An increased risk of tibial implant loosening was found with rKA compared to MA using a posterior-stabilized TKA with a post-cam system at short-term follow-up. Caution should be taken when choosing the TKA design while performing rKA. Level of evidence: Retrospective case–control study, Level IV. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the study was to compare clinical and radiological outcomes between primary and aseptic revision TKAs using the same posterior-stabilised (PS) prosthesis. The authors hypothesised similar outcomes between both groups for selected patients. Methods: This retrospective, case–control study assessed 36 patients who underwent aseptic revision TKA compared to a match group of 72 primary TKA. Both groups had the same PS design implant (ANATOMIC®, Amplitude, Valence, France). The International Knee Society (IKS) score, radiological outcomes (postoperative alignment, patellar tilt and radiolucent lines), re-intervention and revision rate were compared between the two groups with a minimum follow-up of 3 years. Results: The final study cohort included 29 patients and 63 patients respectively in the revision and primary group, with a mean follow-up of 49.1 months (range 36.1–69). Postoperatively, there was no significant difference in IKS scores between the two groups [169.8 for the revision group and 179.6 for the primary group (p = 0.09)]. No statistical difference was observed for post-operative satisfaction 86.2% versus 92.1% (p = 0.46). Between the two groups, there was no difference in mean radiological assessment, including radiolucent lines (p = 0.7). There was no significant difference for overall implant survivorship 96.5% versus 100% (p = 0.13) at 36 months. Conclusion: Similar clinical, radiological and survivorship outcomes were found between rTKA and primary TKA groups using the same PS level of constraint in patients undergoing revision surgery for aseptic indications at 3-year follow-up. Use of PS implants in rTKA for the correct indication suggests this to be a safe approach at least in the medium term. Level of evidence: IV, retrospective case–control study. [ABSTRACT FROM AUTHOR]

This cross-sectional study aims to evaluate the predictors, outcomes, and resource utilization of total knee arthroplasty (TKA) in calcium pyrophosphate deposition disease (CPPD) patients. We used the US National Inpatient Sample database to identify CPPD and non-CPPD who underwent TKA from 2006 to 2014. Data collection included patient demographics and comorbidities. Outcomes following TKA included in-hospital mortality, complications, length of hospitalization, hospital charges, and disposition. Among the 5,564,005 patients who have undergone TKA, 11,529 (0.20%) had CPPD, with a median age of 72 years, and 53.7% were females. Compared with non-CPPD, patients with CPPD were more likely to be older (mean 72 vs 66 years; p < 0.001), male, white, and have Medicare insurance. CPPD patients were more likely to have ≥ 2 comorbidities calculated by the Charlson Comorbidity Index and discharge to an inpatient/rehabilitation facility. Regarding inpatient complications, myocardial infarction and knee reoperation were significantly more common in CPPD patients. TKA in CPPD patients was associated with significantly higher odds of increased length of stay (> 3 days) than those without CPPD (OR 1.43, 95% CI 1.37–1.49). There was no significant difference in the in-hospital mortality even after adjusting for possible confounders. CPPD patients who underwent TKA were more likely to have a longer hospital stay and discharge to a non-home setting than non-CPPD. Also, CPPD patients had a higher comorbidity burden and risk for myocardial infarction and reoperation. Key Points • This is the largest study to analyze data of CPPD patients who underwent TKA and compare them with non-CPPD patients, using a large nationwide database. • Compared to non-CPPD patients, TKA in CPPD patients is associated with a greater length of stay and disposition to a nursing/rehabilitation facility. • In-hospital complications such as myocardial infarction and reoperation were more frequently observed in CPPD patients than non-CPPD. • The results of this study should alert healthcare providers to develop strategies in order to improve outcomes of CPPD patients undergoing TKA. [ABSTRACT FROM AUTHOR]

Purpose: One of the key factors to the successful revision of total knee arthroplasty (rTKA) is the reconstruction of the joint line, which can be determined using the epicondylar ratio (ER). The measurement is established in X-ray and MRI. However, it is not known whether computed tomography (CT) allows a more reliable determination. The objective was to assess the reliability of the ER in CT and to determine the correlation between the ER in CT and a.p. X-ray of the knee. Methods: The ER was determined on X-ray and CT images of a consecutive series of 107 patients, who underwent rTKA. Measurements were made by two blinded observes, one measured twice. The inter- and intraobserver agreement, as well as the correlation between the two methods, were quantified with the Intraclass Correlation Coefficient. Results: The average lateral ER was 0.32 (± 0.04) in X-ray and 0.32 (± 0.04) in CT. On the medial side, the average ER was 0.34 (± 0.04) in X-ray and 0.35 (± 0.04) in CT. The interobserver agreement for the same imaging modality was lateral 0.81 and medial 0.81 in X-ray as well as lateral 0.74 and medial 0.85 in CT. The correlation between the two methods was lateral 0.81 and medial 0.79. Conclusions: The ER can be reliably determined in X-ray and CT. Measurements of the two image modalities correlate. Prior to rTKA, the sole use of the X-ray is possible. [ABSTRACT FROM AUTHOR]

Objectives: Self-transcendent experiences have been infrequently examined by modern psychological science, despite their purported healing potential. The two studies reported here were designed to test whether surgical patients could achieve self-transcendent states and whether those states predicted better clinical outcomes. Methods: Two, single-site, parallel-group randomized clinical trials (RCTs) involving knee and hip replacement patients were conducted. In Study 1 (N = 196), patients were randomized to a preoperative, 15-min mindfulness of breath or cognitive-behavioral pain psychoeducation intervention. In Study 2 (N = 118), patients were randomized to a preoperative, 20-min mindfulness of breath, mindfulness of pain, or cognitive-behavioral pain psychoeducation intervention. Self-transcendent state and acute clinical symptomology were assessed immediately before and after the preoperative interventions. Postoperative outcomes were also assessed. Results: A brief MBI induced self-transcendent states in a general sample of knee and hip replacement patients (Study 1: F = 36.79, p <.001; Study 2: F = 7.25, p =.001). MBI-induced self-transcendent states were associated with decreases in pain intensity (Study 1: β = −.26, p =.001; Study 2: β = −.30, p =.004), pain unpleasantness (β = −.21, p =.008), and anxiety (β = −.36, p <.001) immediately after the preoperative intervention. The depth of self-transcendent states achieved during meditation before surgery predicted better postoperative physical function (β =.21, p =.033) in Study 1 and less postoperative pain intensity (β = −.35, p =.016) and pain interference (β = −.32, p =.019) in Study 2. Conclusions: These two studies suggest self-transcendence is a therapeutic mechanism of mindfulness that is accessible to a general sample of surgical patients and can improve clinical outcomes. Clinical Trial Registration for Study 1: ClinicalTrials.gov = NCT03665727. Clinical Trial Registration for Study 2: ClinicalTrials.gov = NCT04520958. [ABSTRACT FROM AUTHOR]

Obesity is associated with an increased risk of cardiovascular disease (CVD) and other adverse health outcomes. In patients with pre-existing heart failure or coronary heart disease, obese individuals have a more favourable prognosis compared to individuals who are of normal weight. This paradoxical relationship between obesity and CVD has been termed the 'obesity paradox'. This phenomenon has also been observed in patients with other cardiovascular conditions and diseases of the respiratory and renal systems. Taking into consideration the well-established relationship between osteoarthritis (OA) and CVD, emerging evidence shows that overweight and obese individuals undergoing total hip or knee replacement for OA have lower mortality risk compared with normal weight individuals, suggesting an obesity paradox. Factors proposed to explain the obesity paradox include the role of cardiorespiratory fitness ("fat but fit"), the increased amount of lean mass in obese people, additional adipose tissue serving as a metabolic reserve, biases such as reverse causation and confounding by smoking, and the co-existence of older age and specific comorbidities such as CVD. A wealth of evidence suggests that higher levels of fitness are accompanied by prolonged life expectancy across all levels of adiposity and that the increased mortality risk attributed to obesity can be attenuated with increased fitness. For patients about to have joint replacement, improving fitness levels through physical activities or exercises that are attractive and feasible, should be a priority if intentional weight loss is unlikely to be achieved. [ABSTRACT FROM AUTHOR]

Purpose: Various alignment philosophies for total knee arthroplasty (TKA) have been described, all striving to achieve excellent long-term implant survival and good functional outcomes. In recent years, in search of higher functionality and patient satisfaction, a shift towards more tailored and patient-specific alignment is seen. The purpose of this study was to describe a restricted 'inverse kinematic alignment' (iKA) technique, and to compare clinical outcomes of patients that underwent robotic-assisted TKA performed by restricted iKA vs. adjusted mechanical alignment (aMA). Methods: The authors reviewed the records of a consecutive series of patients that received robotic-assisted TKA with restricted iKA (n = 40) and with aMA (n = 40). Oxford Knee Score (OKS) and satisfaction on a visual analogue scale (VAS) were collected at a follow-up of 12 months. Clinical outcomes were assessed according to patient acceptable symptom state (PASS) thresholds, and uni- and multivariable linear regression analyses were performed to determine associations of OKS and satisfaction with six variables (age, sex, body mass index (BMI), preoperative hip–knee–ankle (HKA) angle, preoperative OKS, alignment technique). Results: The restricted iKA and aMA techniques yielded comparable outcome scores (p = 0.069), with OKS, respectively, 44.6 ± 3.5 and 42.2 ± 6.3. VAS Satisfaction was better (p = 0.012) with restricted iKA (9.2 ± 0.8) compared to aMA (8.5 ± 1.3). The number of patients that achieved OKS and satisfaction PASS thresholds was significantly higher (p = 0.049 and p = 0.003, respectively) using restricted iKA (98% and 80%) compared to aMA (85% and 48%). Knees with preoperative varus deformity, achieved significantly (p = 0.025) better OKS using restricted iKA (45.4 ± 2.0) compared to aMA (41.4 ± 6.8). Multivariable analyses confirmed better OKS (β = 3.1; p = 0.007) and satisfaction (β = 0.73; p = 0.005) with restricted iKA. Conclusions: The results of this study suggest that restricted iKA and aMA grant comparable clinical outcomes at 12-month follow-up, though a greater proportion of knees operated by restricted iKA achieved the PASS thresholds for OKS and satisfaction. Notably. in knees with preoperative varus deformity, restricted iKA yielded significantly better OKS and satisfaction than aMA. Level of evidence: Level III, comparative study. [ABSTRACT FROM AUTHOR]

Purpose: Implementation of morphometric reference data from the contralateral, unaffected lower limb is suggested when reconstructing the coronal plane alignment in TKA. Limited information, however, is available which confirms this left-to-right symmetry in coronal alignment based upon radiographs. The purpose of the study was, therefore, (1) to verify if a left-to-right symmetry is present and (2) to assess whether the contralateral lower limb would be a reliable reference for reconstructing the frontal plane alignment. Methods: Full-leg standing radiographs of 250 volunteers (male, 125; female,125) were reviewed for three alignment parameters (Hip–Knee–Ankle angle (HKA), Femoral Mechanical Angle (FMA) and Tibial Mechanical Angle (TMA)). Evaluation of assumed left-to-right symmetry was performed according to two coronal alignment classifications (HKA subdivisions (HKA) and limb, femoral and tibial phenotypes (HKA, FMA and TMA)). Inter- and within-subject variability was calculated, along with correlations coefficients (r) and coefficients of determination (r2). Reliability of the contralateral limb as a personalized reference to reconstruct the constitutional alignment was investigated by intervals, expanding by 1° increments (0.5° increment both to varus and valgus) around the right knee alignment parameters. Subsequently, it was verified whether or not the left knee parameters fell within this interval. Results: Symmetrical distribution in coronal alignment was found in 79% (HKA subdivision) and 59% (limb phenotype) of the cohort. Gender differences were present for the most common symmetric limb phenotypes (VARHKA3° (23.2%) in males and NEUHKA0° (38.4%) in females). Inter-subject variability was more prominent than the within-subject side differences for all parameters. Correlations analyses revealed mostly moderate correlations between the alignment measurements. Coefficients of determination showed overall weak left-to-right relationship, except for a moderate predictability for HKA (r2 = 0.538, p < 0.001) and FMA (r2 = 0.618, p < 0.001) in females. FMA and TMA marked weak predictive values for contralateral HKA. Only 60% of left knees were referenced within a 3° interval around the right knee. Conclusion: No strict left-to-right symmetry was observed in coronal alignment measurements. There is insufficient left-to-right agreement to consider the concept of the contralateral unaffected limb as an idealized reference for frontal plane alignment reconstruction based upon full-leg standing radiographs. Level of evidence: I. [ABSTRACT FROM AUTHOR]

Background: We established a method in which patients are instructed before total knee arthroplasty (TKA) in a differentiated way without the necessity of reading any self-orientation, which can be applied even for illiterate patients Methods: We developed a multidisciplinary approach to improve patient education in TKA comprising of a differentiated orientation conducted by an orthopedic surgeon, a nurse and a physiotherapist. It consists of standardized lectures regarding on pre-, intra- and postoperative issues in a randomized controlled trial of 79 consecutive patients undergoing primary TKA. Thirty-four patients received the standard education (control group), and 45 patients received the differentiated education (intervention group). The patients were evaluated during at least 6 months. Results: After a 6-month follow-up period, the Short Form Health Survey (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the visual analogue pain scale (VAS) and knee range of motion (ROM) improved significantly in both groups. Range of motion was better in the intervention group (mean and SD—106.9 ± 5.7 versus 92.5 ± 12.1 degrees, p = 0.02). Moreover, walk ability (more than 400 m) was better in the intervention group compared with the control group (97.4% versus 72.4%, p = 0.003). In the intervention and control groups, respectively, 10.5% and 31% of patients reported the need for some walking devices (p = 0.03). Conclusions: A differentiated educational program with a multidisciplinary team had a positive impact on functional outcomes, improving ROM and walk ability of patients undergoing TKA in a short-term evaluation. [ABSTRACT FROM AUTHOR]

Purpose: Very few studies focus on lateral unicompartmental arthroplasty (LUKA) in the setting of post-traumatic osteoarthritis (PTOA). The hypothesis of our study is that LUKA is an effective procedure for isolated lateral PTOA with similar outcomes to non-traumatic LUKA. Methods: Between 1990 and 2016, eighteen LUKA performed for isolated lateral tibiofemoral osteoarthritis secondary to tibial plateau fracture were retrospectively reviewed (post-traumatic group) and matched with a control group of thirty-six LUKA performed for non-traumatic OA. Clinical (International Knee Score), radiological outcomes and revision rate were compared between the two groups with a minimum follow-up of three years. Results: With a mean follow-up of 10.1 years, postoperative IKS scores were similar between the two groups (IKS Knee: 89.1 (control) versus 85 (p = 0.03) and IKS Function: 85.9 (control) versus 77.9 (n.s.). Clinical improvement was greater for the post-traumatic group. No difference was observed with regard to revision rate (3/18 (16.7%) cases in the post-traumatic group and 7/36 (19.4%) in the control group, n.s.) or polyethylene wear per year between the two groups. The revision free-survival rate was 64.8% for the post-traumatic group and 58.8% for the control group at 22-year follow-up (n.s.). Conclusion: LUKA is an effective procedure at long-term for patients suffering from isolated lateral PTOA with similar clinical and radiographic results compared to LUKA performed for non-traumatic OA and without increased risk of revision or prosthetic wear. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The Oxford unicompartmental knee replacement (UKR) has a fully congruent mobile bearing to minimise wear. However, with younger higher demand patients, wear remains a concern. The aim of this study was to quantify the wear rate of Phase 3 Oxford UKR bearings over the course of 5 years and to identify the factors that influence it. Methods: 40 medial Oxford UKRs recruited for a randomised study of cemented and cementless fixation were studied with Radiostereometric analysis (RSA) at 1 week, 3 months, 6 months, 1 year, 2 years, and 5 years post-operatively and bearing thickness was calculated. Penetration, defined as the change in thickness compared to the 1-week measurement, was determined. Creep (early penetration) and wear (late penetration at a constant rate) were calculated. The influence of demographic factors, Oxford Knee Score (OKS), Tegner score, fixation and bearing overhang (determined by RSA) on wear was analysed. Results: After 6 months the penetration rate was constant, indicating that wear alone was occurring. The wear rate was 0.07 mm/year (SD 0.03). The creep was 0.06 mm with about 95% occurring during the first 3 months. There was no significant relationship between fixation (cemented/cementless), age, component size, OKS and Tegner score with wear rate. Increasing BMI was associated with decreasing wear (p = 0.042). 37/40 bearings overhung the tibia to some extent and 23/40 overhung the tibia medially. An increase in the area of overhang (p = 0.036), amount of medial overhang (p = 0.028) and distance between the bearing and tibial wall (p = 0.019) were associated with increased wear. Bearings that did not overhang (0.06 mm/year) had less wear (p = 0.025) than those that did (0.08 mm/year). There was no relationship (p = 0.6) between the femoral contact area and wear. Conclusion: During the first three to six months after implantation, the bearing becomes 0.06 mm thinner due to creep. The combined wear rate of the upper and lower surfaces of the bearing is constant (0.07 mm/year). The wear is lower if the bearing does not overhang the tibia so surgeons should aim for the bearing to be close to the tibial wall. The orientation of the femoral component does not influence wear. Level of evidence: Retrospective Study, Level III. [ABSTRACT FROM AUTHOR]

Purpose: Metaphyseal fixation with porous titanium sleeves in revision knee surgery provides mechanical support to the implant, promotes biological fixation, and has shown satisfactory short- and mid-term results. Cement is commonly used to fix the tibial tray to the epiphyseal area. The objective of this study is to determine whether cement should be used to achieve fixation of the tibial tray with the hypothesis that metaphyseal sleeves would provide enough axial and rotational stability making cementation unnecessary. Material and methods: Prospective study of 60 patients undergoing knee replacement surgery with metaphyseal sleeves in type 2B defects in femur and tibia. Patients were divided into two groups according to the use of cement on the tibial component. Analysis included the American Knee Society Score (KSS) knee and functional scales, the Western Ontario and McMaster Universities (WOMAC) index, the Short Form 12 (SF-12) health survey, and radiographic assessment with a maximum follow-up of 5 years. Results: No statistically significant differences were found between the two groups in any of the parameters assessed. Conclusion: Metaphyseal sleeves showed a 100% survivorship at five years of followup. There were no differences in clinical and radiographic outcomes at five years of follow-up depending on whether or not cement was used for tibial platform fixation. Cementation of the tibial tray would therefore not be required to achieve satisfactory mid-term results. Level of evidence: Level II: prospective cohort study. Therapeutic. [ABSTRACT FROM AUTHOR]

Purpose: Anterior knee pain (AKP) is a frequent symptom after a total knee arthroplasty (TKA). Patellar denervation (PD) has been put forth as a technique to reduce this pain; however, its effects have not been assessed in combination with patellar resurfacing. The aim of this study is to evaluate the effect of PD on AKP and functional outcomes after TKA with patellar resurfacing. Methods: A prospective study was designed that included patients scheduled for TKA with patellar resurfacing. The 202 recruited patients were randomized into either the PD group or the non-denervation group [mean age 72.7 years (SD 8.2); 119 (70.4%) women and 50 (29.6%) men; average body mass index 31.4 kg/m2 (SD 4.9)]. Pressure pain threshold (PPT) assessed by pressure algometry (PA), visual analogue scale(VAS), patellofemoral Feller score and the Knee Society Scores (KSS) were recorded preoperatively and at the 1-year follow-up. Results: 169 patients were included in data analysis. At the 1-year follow-up, there were mild differences between denervation and non-denervation group in PPT value (494.4 kPa vs. 552.3 kPa, p = 0.047) and in VAS at stairs (2.9 vs. 1.5, p = 0.003) in favour of the non-denervation group. There was no difference in the improvement between groups in patellofemoral Feller score and KSS, but slightly higher improvement in non-denervation group in PPT (94.1 kPa vs. 160 kPa, p = 0.047), VAS walking (5.3 vs. 6.2, p = 0.041) and VAS at stairs (4.6 vs. 5.7, p = 0.022). Conclusion: Patellar denervation does not improve AKP and clinical outcomes in primary TKA with patellar resurfacing compared to patellar replacement without denervation. PD cannot be recommended when patellar replacement is performed in TKA. Level of evidence: II. [ABSTRACT FROM AUTHOR]

Purpose: The Attune® Knee System provides new instrumentation to achieve symmetric flexion/extension gaps in total knee arthroplasty (TKA). However, there is limited information on the optimal TKA technique using this system. The aim of this randomised controlled trial was to determine which surgical technique results in better postoperative clinical outcomes after TKA using the contemporary Attune® Knee System: the measured resection or gap balancing technique. Methods: A prospective randomized controlled trial was conducted with 100 patients undergoing TKA using measured resection (n = 50) or gap balancing (n = 50) technique. The measured femoral sizer was used in the measured resection group, while the balanced femoral sizer was used in the gap balancing group. Functional outcomes and quality of life were assessed preoperatively and at 6 months and 2 years post-surgery, using the Knee Society Function Score (KSFS), Knee Society Knee Score (KSKS), Oxford Knee Score (OKS), the Physical Component Score (PCS) and Mental Component Score (MCS) of Short-Form 36 (SF-36). Using weight-bearing coronal radiographs, the hip-knee-ankle angle (HKA), coronal femoral component angle (CFA), coronal tibial component angle (CTA) and joint line height were also evaluated for each patient. Results: There were no significant differences in the functional scores or the proportion of patients from each group who were satisfied or had their expectations fulfilled at 6 months or 2 years post-surgery. There was also no significant difference in the number of patients who attained minimum clinically important difference (MCID) postoperatively between the groups. Postoperatively, there was no significant difference in the number of HKA outliers between the groups (p = 0.202). The postoperative CFA (p = 0.265) and CTA (p = 0.479) were similar between the groups. There was also no significant difference in the absolute change (p = 0.447) or proportion of outliers (p = 0.611) for joint line height between the groups. Conclusion: Both measured resection and gap balancing techniques resulted in comparable functional and quality of life outcomes up to 2 years post-surgery. Both techniques appear to be equally effective in achieving excellent outcomes with the Attune® Knee System. Level of evidence: I. [ABSTRACT FROM AUTHOR]

Purpose This study compared the preoperative levels and postoperative recovery courses of physical and mental impairments, activity limitations and participation restrictions of working-age patients who return to work (RTW) by 3, 6 or 12 months after total knee arthroplasty (TKA). Methods A prospective survey study including TKA patients (aged < 65) (n = 146) who returned to work (RdTW) in the first postoperative year. Three groups were compared: those who returned by 3 (n = 35), 6 (n = 40) or 12 (n = 29) months. Surveys were completed preoperatively and at 6 weeks and 3, 6 and 12 months postoperatively. Outcomes represented domains of the International Classification of Functioning, i.e. physical impairments (pain, stiffness, vitality), mental impairments (mental health and depressive symptoms), activity limitations (physical functioning) and participation restrictions (social and work functioning). Results Preoperative knee-specific pain and physical functioning levels were better among patients who RdTW by 3 months, compared to those who returned by 12 months. Patients who RdTW by 3 months experienced significantly better recovery from physical impairments than those who returned by 6 months (on general pain) or 12 months (on general and knee-specific pain and on stiffness). Patients returning by 3 months experienced significantly better recovery from activity limitations (on knee-specific physical functioning). Conclusions To optimize return to work outcome after TKA surgery, the focus should lie on physical impairments (general and knee-specific pain, stiffness) and activity limitations (knee-specific physical functioning) during recovery. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to evaluate the safety and efficacy of fusiform capsulectomy of posterior capsule in correcting severe flexion contracture during total knee arthroplasty (TKA). Methods: A retrospective analysis was performed in the patients who had preoperative severe flexion contracture (> 30 degrees) prior to TKA and received fusiform capsulectomy of posterior capsule during TKA between December 2013 and November 2018. Range of motion (ROM), knee functional score, forgotten joint score (FJS), post-operative complications, and radiographic results were collected and evaluated. Result: Twenty patients (32 knees) were enrolled in this study. The mean duration of follow-up was 27.19 ± 15.92 months. The flexion contracture improved from pre-operative 37.69 ± 11.79° to post-operative 5.78 ± 4.44° (p < 0.001), and ROM increased from pre-operative 63.50 ± 21.74° to post-operative 97.88 ± 13.20° (p < 0.001). KSS clinical score increased from pre-operative 32.94 ± 11.03 to post-operative 82.34 ± 10.73 (p < 0.001), and KSS function score increased from pre-operative 28.97 ± 18.43 to post-operative 68.75 ± 15.96 (p < 0.001). The post-operative FJS was 76.08 ± 2.14. There was no implant loosening, infection, obvious haematoma formation, resultant instability, neurovascular complications, or revision for any reasons in the cohort until the last follow-up. Conclusions: The technique of fusiform capsulectomy of posterior capsule to correct the severe flexion contracture during primary TKA is safe and effective and could provide good short-term results. [ABSTRACT FROM AUTHOR]

Background Increasing evidence for the use of the aspirin in patients undergoing an orthopaedic surgery for venous thromboembolism prophylaxis has led to a change in the national guidelines substituting anticoagulants with aspirin. Little is known about the impact of such substitution on real-world outcomes from clinical practice. Objective The study was designed to examine clinical outcomes associated with the use of aspirin and apixaban. Setting Two large-scale general hospitals in West Yorkshire region of England. Method A 1-year observational study among adults who underwent elective knee replacements and received venous thromboembolism prophylaxis within the first 14 days post replacements. Main outcome measure The incidence of postoperative venous thromboembolism, leaking wounds during the hospital stay, and 30-day any readmission for the two drugs. Results A total of 420 patients were included. There was a significant drop in apixaban prescribing (from 80.37 to 10.51%) and increase in aspirin use (from 19.02 to 81.71%) after the implementation of the revised guidelines. There were 52 (12.38%) cases of leaking wound, 16 (3.81%) cases of postoperative venous thromboembolism, 45 (10.71%) cases of 30-day readmission and no case of 30-day major bleeding. The leaking wounds and 30-day readmissions were almost twice more frequent in obese compared to non-obese patients. Multivariate logistic regression found an increased risk of leaking wound with apixaban and postoperative venous thromboembolism and 30-day readmission with aspirin use but the differences were not statistically significant. Conclusion The results suggest aspirin to be as effective as apixaban in preventing venous thromboembolism and readmission. Apixaban usage decreased with a corresponding increase in Aspirin use. The impact of obesity and length of hospital stay need further investigations. [ABSTRACT FROM AUTHOR]

Purpose: To elaborate recommendations for sports participation following TKA among the members of the European Knee Associates (EKA). Methods: A prospective online survey was conducted among the members of the European Knee Associates (EKA). The European Knee Associates (EKA) are a section of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The survey investigated recommendations for 47 sports disciplines. Possible answers were: allowed, allowed if experienced, not allowed, no opinion. The survey was conducted separately for 4 specific time frames: within 6 weeks after TKA; 6–12 weeks after TKA; 3–6 months after TKA; and more than 6 months after TKA. Consensus among the respondents was then analyzed. Results: EKA members (N = 120) participated in the survey. A high level of consensus was reached for a recommendation to allow 5 different sports in the first 6 weeks after TKA, 7 sports 6–12 weeks after surgery, 14 sports 3–6 months after TKA, and 21 out of 47 activities 6 months after surgery. In the first 6 weeks after TKA walking, stair climbing, swimming, aqua fitness, and static cycling were recommended. Six to twelve weeks after TKA, cycling on level ground and yoga were recommended in addition to the aforementioned activities. Further sports activities recommended beyond 12 weeks after TKA were: tennis doubles, golf, fitness/weight lifting, aerobics, hiking, Nordic walking and sailing. The sport for which the recommendation was "not allowed" following TKA was squash. Conclusion: The number of sports recommended by EKA surgeons increases stepwise over the postoperative time frames. The findings are regarded as clinically relevant as they may serve as a basis for answering patient questions on timing and giving recommendations for the resumption of sports activities following standard primary TKA and should be individualized by surgeons for their patients' expectations and goals. Level of evidence: V. [ABSTRACT FROM AUTHOR]

Purpose: Malrotation of the femoral component after primary total knee arthroplasty (TKA) is one of the most important problems leading to painful TKA requiring revision surgery. Methods: A comprehensive systematic review of the literature was performed to present current evidence on how to optimally place the femoral component in TKA. Several landmarks and techniques for intraoperative determination of femoral component placement and examination of their reliability were analyzed. Results: 2806 articles were identified and 21 met the inclusion criteria. As there is no unquestioned gold standard, numerous approaches are possible which come along with specific advantages and disadvantages. In addition, imaging modalities and measurements regarding postoperative femoral component rotation were also investigated. Femoral component rotation measurements on three-dimensional (3D) reconstructed computerised tomography (CT) images displayed intraclass correlation coefficients (ICC) above 0.85, significantly better than those performed in radiographics or two-dimensional (2D) CT images. Thus, 3D CT images to accurately evaluate the femoral prosthetic component rotation are recommended, especially in unsatisfied patients after TKA. Conclusion: The EKA Femoral Rotation Focus Group has not identified a single best reference method to determine femoral component rotation, but surgeons mostly prefer the measured resection technique using at least two landmarks for cross-checking the rotation. Level of evidence: III. [ABSTRACT FROM AUTHOR]

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