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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]

Background: Approximately, 8% of community-based adults aged ≥ 50 years in England are frail. Frailty has been found to be associated with poorer outcomes after joint replacement. Targeting frailty preoperatively via exercise and protein supplementation has the potential to improve outcomes for people undergoing joint replacement. Prior to proceeding with a randomised controlled trial (RCT), a feasibility study is necessary to address key uncertainties and explore how to optimise trial design and delivery. Methods: The Joint PRehabilitation with Exercise and Protein (Joint PREP) study is a feasibility study for a multicentre, two-arm, parallel group, pragmatic, RCT to evaluate the clinical and cost-effectiveness of prehabilitation for frail patients undergoing total hip or knee replacement. Sixty people who are ≥ 65 years of age, frail according to the self-reported Groningen Frailty Indicator, and scheduled to undergo total hip or knee replacement at 2–3 hospitals in England and Wales will be recruited and randomly allocated on a 1:1 ratio to the intervention or usual care group. The usual care group will receive the standard care at their hospital. The intervention group will be given a daily protein supplement and will be asked to follow a home-based, tailored daily exercise programme for 12 weeks before their operation, in addition to usual care. Participants will be supported through six follow-up calls from a physiotherapist during the 12-week intervention period. Study questionnaires will be administered at baseline and 12 weeks after randomisation. Embedded qualitative research with patients will explore their experiences of participating, reasons for nonparticipation, and/or reasons for withdrawal or treatment discontinuation. Primary feasibility outcomes will be eligibility and recruitment rates, adherence to the intervention, and acceptability of the trial and the intervention. Discussion: This study will generate important data regarding the feasibility of a RCT to evaluate a prehabilitation intervention for frail patients undergoing total hip and knee replacement. A future phase-3 RCT will determine if preoperative exercise and protein supplementation improve the recovery of frail patients after primary joint replacement. Trial registration: ISRCTN11121506, registered 29 September 2022. [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]

Background: Artificial intelligence (AI) has become involved in many aspects of everyday life, from voice-activated virtual assistants built into smartphones to global online search engines. Similarly, many areas of modern medicine have found ways to incorporate such technologies into mainstream practice. Despite the enthusiasm, robust evidence to support the utility of AI in contemporary total knee arthroplasty (TKA) remains limited. The purpose of this review was to provide an up-to-date summary of the use of AI in TKA and to explore its current and future value. Methods: Initially, a structured systematic review of the literature was carried out, following PRISMA search principles, with the aim of summarising the understanding of the field and identifying clinical and knowledge gaps. Results: A limited body of published work exists in this area. Much of the available literature is of poor methodological quality and many published studies could be best described as "demonstration of concepts" rather than "proof of concepts". There exists almost no independent validation of reported findings away from designer/host sites, and the extrapolation of key results to general orthopaedic sites is limited. Conclusion: While AI has certainly shown value in a small number of specific TKA-associated applications, the majority to date have focused on risk, cost and outcome prediction, rather than surgical care, per se. Extensive future work is needed to demonstrate external validity and reliability in non-designer settings. Well-performed studies are warranted to ensure that the scientific evidence base supporting the use of AI in knee arthroplasty matches the global hype. [ABSTRACT FROM AUTHOR]

Background: Patellofemoral anatomy has not been well characterized. Applying deep learning to automatically measure knee anatomy can provide a better understanding of anatomy, which can be a key factor in improving outcomes. Methods: 483 total patients with knee CT imaging (April 2017–May 2022) from 6 centers were selected from a cohort scheduled for knee arthroplasty and a cohort with healthy knee anatomy. A total of 7 patellofemoral landmarks were annotated on 14,652 images and approved by a senior musculoskeletal radiologist. A two-stage deep learning model was trained to predict landmark coordinates using a modified ResNet50 architecture initialized with self-supervised learning pretrained weights on RadImageNet. Landmark predictions were evaluated with mean absolute error, and derived patellofemoral measurements were analyzed with Bland–Altman plots. Statistical significance of measurements was assessed by paired t-tests. Results: Mean absolute error between predicted and ground truth landmark coordinates was 0.20/0.26 cm in the healthy/arthroplasty cohort. Four knee parameters were calculated, including transepicondylar axis length, transepicondylar-posterior femur axis angle, trochlear medial asymmetry, and sulcus angle. There were no statistically significant parameter differences (p > 0.05) between predicted and ground truth measurements in both cohorts, except for the healthy cohort sulcus angle. Conclusion: Our model accurately identifies key trochlear landmarks with ~0.20–0.26 cm accuracy and produces human-comparable measurements on both healthy and pathological knees. This work represents the first deep learning regression model for automated patellofemoral annotation trained on both physiologic and pathologic CT imaging at this scale. This novel model can enhance our ability to analyze the anatomy of the patellofemoral compartment at scale. [ABSTRACT FROM AUTHOR]

Abstract Introduction Informed consent documentation is often the first area of interest for lawyers and insurers when a medico-legal malpractice suit is concerned. However, there is a lack of uniformity and standard procedure about obtaining informed consent for total knee arthroplasty (TKA). We developed a solution for this need for a pre-designed, evidence-based informed consent form for patients undergoing TKA. Materials and methods We extensively reviewed the literature on the medico-legal aspects of TKA, medico-legal aspects of informed consent, and medico-legal aspects of informed consent in TKA. We then conducted semi-structured interviews with orthopaedic surgeons and patients who had undergone TKA in the previous year. Based on all of the above, we developed an evidence-based informed consent form. The form was then reviewed by a legal expert, and the final version was used for 1 year in actual TKA patients operated at our institution. Results Legally sound, evidence-based Informed Consent Form for Total Knee Arthroplasty. Conclusion The use of legally sound, evidence-based informed consent for total knee arthroplasty would be beneficial to orthopaedic surgeons and patients alike. It would uphold the rights of the patient, promote open discussion and transparency. In the event of a lawsuit, it would be a vital document in the defence of the surgeon and withstand the scrutiny of lawyers and the judiciary.

Background and Aims: Postoperative analgesia for Total Knee Arthroplasty (TKA) is paramount for early mobilisation and rehabilitation. The newer motor sparing peripheral nerve blocks for analgesia for TKA are 4 in 1 block, modified 4 in 1 block, infiltration between popliteal artery and capsule of the knee (IPACK) block along with adductor canal block (ACB). We hypothesised that Modified 4 in 1 block is as efficient as the already proven technique of combined IPACK and ACB in providing post-operative analgesia to the patients of TKA. Methods: Seventy patients fulfilling the inclusion criteria posted for TKA surgery were randomised into two groups: Modified 4 in 1 block group (Group - M) and combined IPACK + ACB group (Group - I). After thorough preoperative evaluation and with mimimum standard monitoring the patients received sub-arachnoid block followed by the desired peripheral nerve block as per the group. After the surgery the visual analog scale (VAS) pain score was compared at 3, 6, 12, 24 hours postoperatively and tabulated. Results: The mean pain scores between both the groups was comparable at 3 hours, 6 hours and 24 hours. But at 12 hours after the surgery, VAS was less in Group-M in comparison to Group-I, Haemodynamic parameters were comparable between both the groups. None of the patients in both the groups showed any complications like muscle weakness in the post-operative period. Conclusion: Modified 4 in 1 block is a new and novel technique for the TKA surgeries and is comparable with already established combined IPACK+ACB technique for providing adequate postoperative analgesia after TKA.

Total hip and knee replacement are effective operations for the management of end-stage arthritis. There are increasing numbers of these operations being performed, and the rate of increase is anticipated to continue into the future (1, 2, 3, 4). There is also a substantial rise in the lifetime risk of a person receiving a total hip or knee replacement and this has been shown in several countries (5, 6, 7, 8). There are a large number of joint replacement prostheses on the market available for use and not all perform the same. Many have no published outcomes. Joint replacement registries provide an appropriate way to monitor the real-world outcomes of these procedures and can provide comparative data on the rates of revision for specific prostheses. Revisions are generally defined in joint registries as a removal or exchange of a prosthesis or part thereof and provide an unambiguous record of a problem with the joint replacement. There are many factors that affect revision rates. Non-device-related issues may include patient factors, surgical technique, surgeon experience and volume of cases. Device-related factors may contribute to the variation in the rates of revision with individual prostheses.

Knee osteoarthritis (OA) is a highly prevalent disease among the elderly population that results in joint degeneration, leading to reduced mobility and challenging daily living. Patients can choose from various treatment options depending on the stage of joint degeneration. In developing countries such as Pakistan, it is crucial to comprehend the financial burden borne by patients and their families due to this condition's high prevalence. Therefore, this exploratory study aimed to assess the financial burden of knee OA patients seeking healthcare services by analyzing the healthcare costs and expenses incurred by them. A purposive sampling technique was employed to recruit 112 knee OA patients undergoing any treatment modality from public and private hospitals in Lahore. A semistructured questionnaire collected patients' sociodemographic information and overall out-of-pocket health expenditures. Descriptive statistics and the Mann‒Whitney U test were utilized for data analysis. The patients' mean age was 53.69 ± 11.73 years, with 10.26 ± 4.83 years of education. Stage III knee OA was the most common diagnosis (30.36%), followed by stage IV (28.57%), stage II (22.32%), and stage I (18.75%). The direct medical cost was significantly higher [United States dollars (USD) 2,590.97] among patients who underwent surgery than among those who opted for alternative treatment procedures (USD 192.10) (p = 0.001). Similarly, the indirect medical cost was significantly higher (USD 371.75) among patients who underwent surgery than among those who chose other treatment options (USD 23.66) (p = 0.001). The overall cost of illness was 6.02 times higher among patients who had surgery (USD 3,050.93) than among those who opted for other treatment modalities (USD 507.19) (p = 0.001). The study’s findings provide insights into the financial burden borne by knee OA patients' families, emphasizing the need for policymakers to intervene. By understanding the costs of illness borne by patients and their families, policymakers can develop targeted interventions to alleviate the financial burden and improve access to healthcare services for knee OA patients.

Unicompartmental and Total Knee Arthroplasty (UKA and TKA) are both established surgical options for the treatment of medial compartment osteoarthritis of the knee. However, the superiority of one over the other remains controversial. Our retrospective study aims to compare short-term functional outcomes in similar patients who underwent either TKA or UKA. Pre- and post-operative range of motion (ROM), the Oxford Knee Score (OKS), Knee Society Knee Score (KSKS), and Knee Society Function Score (KSFS) were used as outcome measures. Our sample included 57 patients, among which 27 underwent TKA and 30 underwent UKA, including one patient who underwent bilateral UKA. At 1 year, there were no differences in the OKS, KSKS, or KSFS scores between the two groups. There was a significantly better range of motion in patients who underwent UKA compared to TKA (122.9 ± 11.7 degrees vs 109.9 ± 13.9 degrees, p < 0.001). Functional outcomes following UKA and TKA were found to be similar. Hence, in view of its lower morbidity and shorter length of hospital stay, UKA may be considered over a TKA for the treatment of medial compartment osteoarthritis whenever deemed appropriate.

There are significant medical, social and economic effects, such as decrease in the frequency of postoperative complications, mortality and reduction of hospital stay. The key aspects of the enhanced recovery program are preoperative preparation, anesthesia, postoperative analgesia, in particular multimodal analgesia and regional analgesia, and early rehabilitation. The implementation of the enhanced recovery program for knee and hip replacement in medical institutions of the Russian Federation based on clinical studies and meta-analyses of a high level of evidence, will improve the quality of medical care and patient satisfaction. It is important to note the need to develop the Russian recommendations taking into account experience of using various methods of enhanced recovery in domestic medical institutions, as well as the specific organization features of the Russian healthcare system. This will serve as a basis for further widespread implementation of protocols for enhanced recovery after surgery in this country.

Abstract Background Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level. Methods Retrospective review of consecutive hip and knee primary arthroplasty cases performed at a District Hospital (DH), and a Tertiary Academic Hospital (TH) in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts. Results Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2 ± 2.0 days at DH level and 7.6 ± 7.1 days for TH (p 0.05). Periprosthetic joint infection (PJI) rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level. During the study period, 228 patients received their arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list. Conclusions Hip and Knee Arthroplasty at District health care level is safe and; for the reason that the DH feeds into the TH; providing arthroplasty at district level may help ease the pressure on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures. Level of evidence Level III Retrospective cohort study

Abstract Background Pharmacological and mechanical thromboprophylaxis are frequently used together after total knee arthroplasty (TKA). Most studies in this context compare anticoagulants versus a combination of these drugs with an intermittent pneumatic compression device (IPCD). However, there is uncertainty about the need for the combination of both and whether a unilateral IPCD would alone affect other important clinical outcomes: edema and blood loss. We compared the effects of enoxaparin versus unilateral portable IPCD after TKA on edema and blood loss. We hypothesised that unilateral IPCD would cause the same level of edema and the same blood loss as enoxaparin. Methods In this open, randomized trial (1:1), adults with no history of coagulation disorders, anticoagulant use, venous thromboembolism, liver or malignant diseases underwent TKA. For 10 days, participants received the IPCD, used 24 h/day on the operated leg from the end of surgery, or 40 mg of enoxaparin, starting 12 h after surgery. All underwent the same rehabilitation and were encouraged to walk on the same day of surgery. We measured edema (thigh, leg and ankle circumference) before and on the third postoperative day. Blood loss (volume accumulated in the suction drain and drop of hemoglobin and hematocrit in 48 h) was a secondary outcome. Results We randomized 150 patients and lost 3 to follow-up with enoxaparin and 2 with IPCD. There was no case of symptomatic venous thromboembolism. Four patients needed transfusions (three receiving enoxaparin), one had infection and one hemarthrosis (both in the enoxaparin group). Leg circumference increased by approximately 2 cm for enoxaparin group and 1.5 cm in IPCD (p

Resumen: Antecedentes y objetivo: Durante la artroplastia de rodilla se produce una pérdida sanguínea importante. El objetivo de nuestro estudio es valorar la eficacia y la seguridad de la administración tópica de 3 g de ácido tranexámico (TXA) en cuanto a la reducción de pérdidas sanguíneas en artroplastia de rodilla. Material y método: Se ha realizado un ensayo clínico aleatorizado, fase iii, doble ciego, controlado con placebo. Se incluyó a 150 pacientes en 2 grupos paralelos de tratamiento (75 por brazo). La solución se administró de forma tópica intraarticular tras la cementación y previo al cierre capsular. Se realizaron determinaciones analíticas antes y después de la cirugía. Resultados: La pérdida total de sangre media para el grupo placebo fue de 831,5 ml y 662,3 ml para el grupo TXA con una diferencia entre ambos de 169,2 ml, lo que supone un ahorro del 20,4%, siendo estadísticamente significativa (p

Abstract Background Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty. Methods A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, “disparities”, “arthroplasty”, “income”, “insurance”, “outcomes”, and “hospital volume” in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data. Results A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients. Conclusion This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients’ access to, utilization of, and outcomes after TJA. Level of evidence IV.

Background: The objective is to determine whether body mass index is associated with patient‐reported expectations and well‐being before primary total hip or total knee arthroplasty, and patient‐reported outcomes 6 months after surgery. Methods: Data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Outcome measures included pre‐operative expectations for post‐operative mobility, joint pain and health, pre‐ and post‐operative EQ‐5D‐5L, EQ‐VAS, Oxford Hip/Knee Scores and joint pain scales, and post‐operative perceived change and perceived satisfaction. Associations with BMI were assessed using chi‐square tests, analysis of variance and Linear Mixed Models equations. Results: Data were available for 12 816 primary THA patients and 20 253 primary TKA patients. Pre‐operatively, patients in higher BMI categories were significantly more likely to expect ongoing problems with mobility, more joint pain and poorer health following surgery (P<0.01 for all analyses). For arthroplasty patients, higher BMI was associated with poorer pre‐operative and post‐operative scores for all measures. BMI was positively associated with improvements in EQ‐5D, OHS/KS and joint pain. While between‐group differences were statistically significant, many were small in magnitude. There was no association between BMI and patient‐perceived change or satisfaction after arthroplasty. Conclusion: Patients undergoing THA/TKA, higher BMI was associated with lower pre‐operative expectations, poorer well‐being before surgery, and worse scores after surgery. Patients who were obese demonstrated comparable satisfaction with their operated joint, compared with non‐obese patients. BMI was associated with greater pre‐ to post‐operative improvements in outcome scores for EQ‐5D, VAS knee, OHS/OKS and joint pain but these differences may not be clinically important. [ABSTRACT FROM AUTHOR]

Aims and Objectives: This study was designed to examine the contents and methods of patient educational interventions about total knee arthroplasty (TKA) and their effectiveness in reducing postoperative pain and enhancing range of motion (ROM) in the literature. Background: Patient education has been provided to facilitate recovery after TKA; however, little is known about the contents and methods of the interventions and their effectiveness in reducing postoperative pain and enhancing ROM. Design: This is a systematic review and meta‐analysis of randomised controlled trials (RCTs). Methods: Published studies from June 1998–June 2021 were identified from electronic databases. Two independent investigators assessed the quality of the studies by using the revised Cochrane risk‐of‐bias tool. Meta‐analyses with random‐effects models were conducted to assess the effectiveness of the interventions using the Comprehensive Meta‐Analysis Software. The study was performed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guideline. Results: Among 12 articles that met the inclusion criteria, three interventions provided education on pain management and mobility/exercises. The most common educational methods were the combinations of oral explanation, written materials, and audiovisual materials, group discussion, while four studies used information technology (IT) devices. The meta‐analysis demonstrated that the educational interventions using IT devices were effective in improving pain and ROM, but not the interventions that did not use IT devices. Conclusion: Structured education for pain management, communication and/or exercise support programs utilising diverse methods have been provided to patients undergoing TKA. Using IT devices could successfully enhance the effectiveness of educational interventions for patients undergoing TKA. Relevance to clinical practice: Integration of postoperative pain management and mobility/exercises with the use of IT devices should be actively considered in providing patient education in clinical nursing practice. [ABSTRACT FROM AUTHOR]

Ideal goals for alignment and balance in total knee arthroplasty (TKA) remain controversial. We aimed to compare initial alignment and balance using mechanical alignment (MA) and kinematic alignment (KA) techniques and to analyze the percentage of knees that could achieve balance using limited adjustments to component position. Prospective data on 331 primary robotic TKAs (115 MAs and 216 KAs) were analyzed. Medial and lateral virtual gaps were recorded in both flexion and extension. A computer algorithm was used to calculate potential (theoretical) implant alignment solutions to achieve balance within 1 millimeter (mm) without soft tissue release given an alignment philosophy (MA or KA), angular boundaries (±1, ±2, or ±3°), and gap targets (equal gaps or lateral laxity allowed). The percentage of knees that could theoretically achieve balance was compared. Less than 5% of TKAs were initially balanced. Limited adjustments to component position increased the percentage of TKAs that could be balanced in a graduated manner, with no difference between MA and KA start points: adjustments of ±1 (10% versus 6%, P =.17), ±2 (42% versus 39%, P =.61), or of ±3 (54% versus 51%, P =.66). A higher percentage of TKAs could be balanced when a greater range for lateral gap laxity was allowed. Balancing from KA resulted in increased joint line obliquity in the final implant alignment. A high percentage of TKAs can be balanced without soft tissue release using minor adjustments to component position. Surgeons should consider the relationship between alignment and balance goals when optimizing component positioning in TKA. [ABSTRACT FROM AUTHOR]

Staged, bilateral total knee arthroplasty (TKA) has an increased risk of complications if the second procedure is performed before physiologic recovery from the first. The aims of this study were to 1) determine whether there is a time-dependent relationship between TKA staging and rates of revisions and complications and 2) identify data-driven time intervals that reduce risk of revisions and complications. Data were collected from a national insurance database from 2015 to 2018. Staged intervals were initially assessed using fixed 6-week intervals. Stratum-specific likelihood ratio analyses were subsequently conducted to observe data-driven staging thresholds. Bivariate and multivariable regression analyses were conducted to determine the associations between the time intervals and 2-year rates of revision surgery and 90-day major complications. We included 25,527 patients undergoing staged bilateral TKA. In comparison to the shortest fixed time interval (1-6 weeks), as the staging interval increased the odds of 2-year all-cause revision and 90-day major complications significantly decreased (P <.05 for all). Stratum-specific likelihood ratio analysis identified 3 data-driven staging categories 1-5, 6-17, and 18-24 weeks that maximized the difference in both 2-year rates of revision and 90-day major complications. Our data showed a time-dependent relationship between the timing of TKA stages and complications. If staging is considered, a delayed interval of at least 6 weeks between procedures may significantly reduce revision and major complications. Level III Therapeutic Study. [ABSTRACT FROM AUTHOR]

Background: The number of primary knee arthroplasties (KAs) performed annually is rising, especially among active, working age patients. Consequently, revision KA is also increasingly performed. Our aim was to systematically review the extent to which patients were physically active following revision KA, and the rate and timing of return to sport and work. Methods: A search was conducted in the databases Medline and Embase until February 24th, 2023. Studies describing patients with revision total knee arthroplasty (rTKA) or revision unicondylar knee arthroplasty (rUKA), with outcomes regarding physical activity or return to sport (RTS) or work (RTW) were included. Quality of studies was assessed using the Newcastle–Ottawa scale, meta-analyses were performed using RevMan 5.4 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Results: Of the 4,314 articles screened, 22 studies were included describing 2,462 rTKA patients (no rUKA), 42% were male with a mean age of 67 years (range 24 – 95). No studies reported objective physical activity measurements. Twenty-two studies reported patient reported outcome measures (PROMs). The PROMs that were pooled on a scale from zero to ten were the UCLA Activity Score, the Tegner Activity Level Scale, the Lower-Extremity Activity Scale, Devane Activity Score, and physical activity related subscales of the Knee injury and Osteoarthritis Outcome Score. The retrospective studies of moderate quality showed a statistically significant postoperative improvement of 1.7 points (MD = 1.71, 95% CI 1.48 – 1.94 (p < 0.0001); 14 studies, n = 1,211). For the prospective moderate-quality studies, a statistically significant postoperative increase of 0.9 points was found (MD = 0.89, 95% CI 0.48 – 1.30 (p < 0.0001); 6 studies, n = 1,027). Regarding RTS, 12% of patients participated in so-called 'non-recommended' activities (i.e., hockey, soccer, football, gymnastics, jogging, singles tennis, and basketball) after rTKA (1 study, n = 206). The pooled RTW was 86% (2 studies, range 18–95%, n = 234). Conclusions: The majority of patients self-reported an improved postoperative activity level after rTKA. Patients could maintain an active lifestyle in daily life, including sports and work. For reliable physical activity, RTS and RTW estimations, more studies are required. In terms of GRADE, the quality of evidence for the five prospective studies was rated as low. Level of evidence: Level 3. [ABSTRACT FROM AUTHOR]

Background: Moving Well is a behavioral intervention for patients with knee osteoarthritis (KOA) scheduled for a total knee replacement (TKR). The objective of this intervention is to help patients with KOA mentally and physically prepare for and recover from TKR. Methods: This is an open-label pilot randomized clinical trial that will test the feasibility and effectiveness of the Moving Well intervention compared to an attention control group, Staying Well, to reduce symptoms of anxiety and depression in patients with KOA undergoing TKR. The Moving Well intervention is guided by Social Cognitive Theory. During this 12-week intervention, participants will receive 7 weekly calls before surgery and 5 weekly calls after surgery from a peer coach. During these calls, participants will be coached to use principles of cognitive behavioral therapy (CBT), stress reduction techniques, and will be assigned an online exercise program, and self-monitoring activities to complete on their own time throughout the program. Staying Well participants will receive weekly calls of similar duration from research staff to discuss a variety of health topics unrelated to TKR, CBT, or exercise. The primary outcome is the difference in levels of anxiety and/or depression between participants in the Moving Well and Staying Well groups 6 months after TKR. Discussion: This study will pilot test the feasibility and effectiveness of Moving Well, a peer coach intervention, alongside principles of CBT and home exercise, to help patients with KOA mentally and physically prepare for and recover from TKR. Trial registration: Clinicaltrials.gov. NCT05217420; Registered: January 31, 2022. [ABSTRACT FROM AUTHOR]

Background: Knee replacements are increasingly performed in older adults but uncertainty remains regarding their benefits in the context of age-related decline in physical function and other comorbidities. This study aimed to examine (1) the effect of knee replacement on functional outcomes in the context of age-related decline in physical function and (2) the factors associated with minimal important improvement in physical function after knee replacement in community-dwelling older adults aged ≥ 70 years. Methods: This cohort study was performed within the ASPREE trial, with 889 participants undergoing knee replacement during the trial and 858 age- and sex-matched controls without knee or hip replacement identified from 16,703 Australian participants aged ≥ 70 years. Health-related quality of life was assessed annually using the SF-12, including its physical and mental component summary (PCS and MCS). Gait speed was measured biennially. Multiple linear regression and analysis of covariance were used to adjust for potential confounders. Results: Participants with knee replacement had significantly lower pre- and post-replacement PCS scores and gait speed compared with age- and sex-matched controls. Participants with knee replacement had significant improvement in PCS score following knee replacement (mean change 3.6, 95% CI 2.9–4.3) while PCS score remaining unchanged in age- and sex-matched controls (-0.02, 95% CI -0.6 to 0.6) during follow-up period. The greatest improvements were observed for bodily pain and physical function. Following knee replacement, 53% of participants experienced minimal important improvement in PCS score (increased by ≥ 2.7), while 24% experienced worsened PCS score (reduced by > 2.7). Participants experiencing improved PCS score postoperatively had significantly lower PCS and higher MCS scores pre-surgery. Conclusions: Although community-based older adults experienced a significant improvement in PCS scores after knee replacement, their postoperative physical functional status remained significantly lower than age- and sex-matched controls. The degree of preoperative physical function impairment was a strong predictor of functional improvement, suggesting that this could be an important consideration when identifying older people most likely to benefit from knee replacement surgery. [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: Neuroarthropathy of the knee or Charcot knee, leading to chronic joint destruction, is a rare disease that is difficult to diagnose. The treatment of this condition is difficult and controversial. Case Presentation: A 74‐year‐old Asian woman has had bilateral knee pain for 22 years and deformity for 10 years, which has been aggravating for 2 months. Physical examination showed bilateral knee varus deformity greater than 15°, and −20 to 90° range of motion. X‐ray revealed bilateral varus deformity with massive free body hyperplasia. Combined with medical history as syringomyelia, the patient was diagnosed with bilateral Charcot knees and bilateral joint replacements were performed using Legacy Constrained Condylar Knee prostheses (LCCK; Zimmer, USA). The patient reported satisfactory treatment outcomes, pain relief, and improved range of motion in both knees, without postoperative complications or prosthesis loosening at 2 year after operation. Conclusions: Total knee arthroplasty (TKA) may be considered a viable option for treating the Charcot knee. The use of constrained condylar prostheses can produce satisfactory results. Attention should be given to survival risks, complications, and other potential determining factors associated with TKA when devising a treatment strategy for the Charcot knee. [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]

Background: The physical and mental health benefits of golf are well recognized, and as a moderate-intensity activity, it is an ideal sport for patients after joint arthroplasty. Purpose: To assess the rate and timing of returning to golf and the factors associated with these after hip, knee, or shoulder arthroplasty. Study Design: Meta-analysis; Level of evidence, 4. Methods: A search of PubMed and Medline was performed in March 2021 in line with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Search terms included sport, golf, and arthroplasty. The criterion for inclusion was any published research article studying return to golf after arthroplasty. Random-effects modeling was used to measure rates of returning to golf for each type of arthroplasty. Results: A total of 23 studies were included for review. All studies were retrospective in their methodology. The mean age of patients was 66.8 years (SD, 3.37). Four studies reported on hip arthroplasty, 6 on knee arthroplasty, and 13 on shoulder arthroplasty. Among 13 studies, the mean rate of returning to golf was 80% (95% CI, 70%-89.9%). Hip, knee, and shoulder arthroplasty had mean return rates of 90% (95% CI, 82%-98%), 70% (95% CI, 39%-100%), and 80% (95% CI, 68%-92%), respectively. Among 9 studies, the mean time to return to golf was 4.4 months (95% CI, 3.2-6). Change in handicap was reported in 8 studies (35%) with a mean change of −0.1 (95% CI, –2.4 to +2.2). There were no studies presenting factors associated with return to golf. Conclusion: This is the first meta-analysis of returning to golf after joint arthroplasty. The study reports a high rate of returning to golf, which was greatest after hip arthroplasty. However, the study highlights the paucity of prospective data on demographic, surgical, and golf-specific outcomes after arthroplasty. Future prospective studies are required to eliminate response bias and accurately capture golf and patient-specific outcomes. [ABSTRACT FROM AUTHOR]

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Background: Although disease-modifying properties of nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis (OA) have been reported, the effects of NSAIDs on OA progression remain controversial. The purpose of this study was to investigate the effect of early initiation of oral NSAID therapy on the progression of knee OA. Methods: In this retrospective cohort study, we extracted data of patients newly diagnosed with knee OA between November 2007 and October 2018 from a Japanese claims database. The primary outcome was the time to knee replacement (KR), and the secondary outcome was the time to composite event including joint lavage and debridement, osteotomy, or arthrodesis in addition to KR. Weighted Cox regression analysis with standardized mortality/morbidity ratio (SMR) weight was performed to compare the outcomes between patients prescribed oral NSAID (NSAID group) and those prescribed oral acetaminophen (APAP) (APAP group) early after a diagnosis of knee OA. Propensity scores were calculated using logistic regression conditioned on potential confounding factors, and SMR weights were calculated using the propensity scores. Results: The study population comprised 14,261 patients, who were divided into two groups as follows: 13,994 in the NSAID group and 267 in the APAP group. The mean ages of patients in the NSAID and APAP groups were 56.9 and 56.1 years, respectively. Furthermore, 62.01% and 68.16% patients in the NSAID and APAP groups, respectively, were female. The NSAID group had a reduced risk of KR compared with the APAP group in the analysis using SMR weighting (SMR-weighted hazard ratio, 0.19; 95% confidence interval, 0.05–0.78). While no statistically significant difference was found for the risk of composite event between the two groups (SMR-weighted hazard ratio, 0.56; 95% confidence interval, 0.16–1.91). Conclusions: The risk of KR in the NSAID group was significantly lower than that in the APAP group after accounting for residual confounding using SMR weighting. This finding suggests that oral NSAID therapy early after the initial diagnosis is associated with a reduced risk of KR in patients with symptomatic knee OA. [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: Internal rotation of the femoral component is detrimental to the functional results of total knee replacement. However, recent concepts test the limits of internal rotation that may be acceptable. We present an unusual case of an early revision of a total knee replacement for severe internal rotation of the femoral component leading to severe restriction of movement, further complicated by infection and gross instability. The case: A 63-year-old diabetic lady with a 4-month old knee replacement had persistent pain, instability, flexion of only 10°, and a seropurulent discharge. She needed a staged revision. Because of a femoral internal rotation of between 30 and 40°, the second stage required a reconstruction of the anteromedial aspect of the femoral condyle using structural bone graft to reproduce external rotation and a hinge for stability. The patient has since recovered well and has regained good function with no recurrence of sepsis 22 weeks post op. Conclusion: We present in this case a rare revision for an unusual amount of severe internal rotation of the femoral component needing a bone graft reconstruction at a location where metal augments are not usually available, further made complex by multiple other complications.

Knee osteoarthritis (KOA) is the most common chronic articular disease, and its prevalence has doubled since the mid-20th century. It affects 16% of the adult population over 50 years of age in the post-industrial era [1]. Obesity is one of the only modifiable risk factors for both incidence and progression of Osteoarthritis (OA).[2] Although OA was previously regarded as a disease of the elderly, its development starts much earlier than originally thought, and OA is ranked among the top 20 diseases in the 40–45 years age group [3]. This review aims to provide a comprehensive analysis of the outcomes of knee replacement surgery following up physical therapy, versus intra-articular steroid injections for obese patients (BMI >30) The study design employed in this review is narrative, and articles published after 2010 from PubMed were considered for inclusion. The review examines the impact of each intervention on the complete regain of knee function in this specific population. Through the analysis of relevant studies, this review seeks to inform clinical decision-making and guide the management of obese patients with knee osteoarthritis. Conclusion. Based on the reviewed literature, knee replacement surgery appears to offer a better chance of achieving complete regain of knee function in obese patients (BMI >30) undergoing physical therapy compared to intra-articular steroid injections. However, the findings are limited by the availability of studies and the heterogeneity in the research methodologies.

Sustainable materials are required for providing good design to products and proper application. It is economical, environmentally friendly and is widely accepted in society. The demand for knee replacement can be fulfilled with fulfilling aesthetic design and bio-compatibility of knee replacement. As the knee is the most important part of the body and the mobility of a person depends on its proper surgery and sustainable knee implants, in this paper an effort is made to design the knee implants using solid work design and the best implant material is selected Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) method. The selection criteria of sustainable implant materials are dependent on properties like mechanical property, bio-compatibility ness and cost of the material , which helps in selection of best material, where as solid work helps in designing, optimizing and simulating sustainable knee implant design before manufacturing. For analyzing the material selection process, durability, performance and patients ' requirements are taken care of. Case studies and examples demonstrate the effectiveness of this approach in advancing orthopedic implant design and material selection, ultimately contributing to the improvement of patient care in the field of orthopedic surgery.

Anterior tibiofemoral dislocation after total knee arthroplasty is an extremely rare and serious event. Amongst English-published papers, we found only 15 relevant cases, 3 of which presented vascular complications. This manuscript aims to present a 77-year-old woman with a TC-Plus (Smith & Nephew) cruciate-retaining type in first time of knee prosthesis, who suffered an anterior tibiofemoral dislocation and were admitted to our hospital. The clinical management and outcome were evaluated. Furthermore, a review of literature was performed. We concluded that early detection and surgical intervention of vascular injury is the key in the survival of the limbs. If there is still knee instability after acute recovery, it seems that revision surgery with constrained total knee arthroplasty can bring about good clinical and functional results.

Background The treatment of osteoarthritis with knee replacement aims to reduce pain and disability. However, some people experience chronic pain. Objectives To improve outcomes for people with chronic pain after knee replacement by identifying post-surgical predictors and effective interventions, characterising patient pathways and resource use, developing and evaluating a new care pathway, and exploring non-use of services. Design The programme comprised systematic reviews, national database analyses, a cohort study, intervention development, a randomised controlled trial, health economic analyses, qualitative studies and stakeholder engagement. Extensive and meaningful patient and public involvement underpinned all studies. Setting NHS, secondary care, primary care. Participants People with, or at risk of, chronic pain after knee replacement and health-care professionals involved in the care of people with pain. Interventions A care pathway for the management of people with pain at 3 months after knee replacement. Main outcome measures Patient-reported outcomes and cost-effectiveness over 12 months. Data sources Literature databases, the National Joint Registry, Hospital Episode Statistics, patient-reported outcomes, the Clinical Practice Research Datalink, the Clinical Outcomes in Arthroplasty Study, the Support and Treatment After joint Replacement randomised trial, interviews with 90 patients and 14 health-care professionals, and stakeholder events. Review methods Systematic reviews of cohort studies or randomised trials, using meta-analysis or narrative synthesis. Results In the Clinical Outcomes in Arthroplasty Study cohort, 14% of people experienced chronic pain 1 year after knee replacement. By 5 years, 65% reported no pain, 31% fluctuated and 4% remained in chronic pain. People with chronic pain had a worse quality of life, higher primary care costs, and more frequent analgesia prescriptions, particularly for opioids, than those not in chronic pain. People with chronic pain after knee replacement who made little or no use of services often felt nothing more could be done, or that further treatments may have no benefit or cause harm. People described a feeling of disconnection from their replaced knee. Analysis of UK databases identified risk factors for chronic pain after knee replacement. Pre-operative predictors were mild knee pain, smoking, deprivation, body mass index between 35 and 40 kg/m2 and knee arthroscopy. Peri- and post-operative predictors were mechanical complications, infection, readmission, revision, extended hospital stay, manipulation under anaesthetic and use of opioids or antidepressants. In systematic reviews, pre-operative exercise and education showed no benefit in relation to chronic pain. Peri-operative interventions that merit further research were identified. Common peri-operative treatments were not associated with chronic pain. There was no strong evidence favouring specific post-operative physiotherapy content. We evaluated the Support and Treatment After joint Replacement care pathway in a multicentre randomised controlled trial. We randomised 363 people with pain at 3 months after knee replacement from eight NHS Trusts in England and Wales. At 12 months’ follow-up, the intervention group had lower mean pain severity (adjusted difference –0.65, 95% confidence interval –1.17 to -0.13; p = 0.014) and pain interference (adjusted difference –0.68, 95% confidence interval –1.29 to -0.08; p = 0.026), as measured on the Brief Pain Inventory subscales (scale 0–10). People receiving the Support and Treatment After joint Replacement pathway had lower NHS and Personal Social Services costs (–£724, 95% confidence interval –£150 to £51) and higher quality-adjusted life-years (0.03, 95% confidence interval –0.008 to 0.06) than those with usual care. The Support and Treatment After joint Replacement pathway was cost-effective with an incremental net monetary benefit at the £20,000 per quality-adjusted life-year threshold of £1256 (95% confidence interval £164 to £2348), indicating a 98.79% probability that the intervention is the cost-effective option. Participants found the Support and Treatment After joint Replacement pathway acceptable, with opportunities to receive information and discuss concerns while ensuring further treatment and support. In systematic reviews considering treatments for chronic pain after surgery we identified some unifactorial interventions that merit further research after knee replacement. Health-care professionals delivering and implementing the Support and Treatment After joint Replacement pathway valued its focus on neuropathic pain and psychosocial issues, enhanced patient care, formalised referrals, and improved pain management. Stakeholders supported pathway implementation. Limitations Database analyses were limited to factors recorded in data sets. Pain was only measured 6 months after surgery. However, analyses including large numbers of centres and patients should be generalisable across the NHS. In many studies found in systematic reviews, long-term pain was not a key outcome. Conclusions The Support and Treatment After joint Replacement pathway is a clinically effective and cost-effective, acceptable intervention for the management of chronic pain after knee replacement. Unifactorial interventions merit further study before inclusion in patient care. People with pain should be empowered to seek health care, with the support of health-care professionals. Future work Future work should include research relating to the implementation of the Support and Treatment After joint Replacement pathway into the NHS, an assessment of its long-term clinical effectiveness and cost-effectiveness and wider application, and an evaluation of new interventions for incorporation in the pathway. It will also be important to design and conduct research to improve communication between patients and health-care professionals before surgery; explore whether or not education and support can enable earlier recognition of chronic pain; consider research that may identify how to support people’s feelings of disconnectedness from their new knee; and design and evaluate a pre-surgical intervention based on risk factors. Study registration All systematic reviews were registered on PROSPERO (CRD42015015957, CRD42016041374 and CRD42017041382). The Support and Treatment After joint Replacement randomised trial was registered as ISRCTN92545361. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 11, No. 3. See the NIHR Journals Library website for further project information. Plain language summary People with severe knee osteoarthritis may have knee replacement surgery to reduce pain and disability. Although highly successful for many people, some people report long-term pain. Our research looked at why some people are more likely to have long-term pain, its personal and economic consequences, and how to prevent and treat it. We reviewed previous research; analysed UK health-care databases; interviewed and met with patients, surgeons and health-care professionals; and developed and evaluated a new care pathway for patients with pain after knee replacement. We found that about one in seven people experience significant pain 6 months after knee replacement. For many, pain fluctuates over time. Some people with long-term pain feel that nothing more can be done to help and that further treatments may even cause harm. Changes to aspects of patient health and care merit further research as they may prevent the development of long-term pain. The Support and Treatment After joint Replacement pathway comprises a detailed assessment by a trained health-care professional; referral to appropriate services, such as an orthopaedic surgeon, physiotherapist, general practitioner for treatment of depression or anxiety, or pain specialist; and telephone follow-up. A total of 363 people with pain at 3 months after their knee replacement were randomly allocated to receive either the Support and Treatment After joint Replacement pathway or their hospital’s usual care. Participants were followed for 1 year to assess their long-term pain. We also looked at health-care costs and the acceptability of the Support and Treatment After joint Replacement pathway to patients and health-care professionals. This research was supported by a dedicated patient advisory group. For people with pain after knee replacement, the Support and Treatment After joint Replacement pathway leads to reduced long-term pain severity and reduced interference with everyday life, and is acceptable to patients and health-care professionals. NHS, personal social services and patient costs were lower in the group receiving the Support and Treatment After joint Replacement pathway. Scientific summary Background Chronic pain after total knee replacement places considerable burden on individuals, society and the NHS. With nearly 100,000 patients receiving knee replacements in the NHS annually, around 20,000 patients will have chronic post-surgical pain. Pre-operative prediction of who will have chronic pain after knee replacement is of limited value, referral for assessment and care is inconsistent and varies widely, and people do not necessarily receive or seek care. This programme aimed to address these issues and provide evidence on improvements to patient care and service delivery. Objectives The programme aimed to improve outcomes for patients with chronic pain ≥ 3 months after total knee replacement. Specific programme objectives were as follows: 1.synthesise evidence on the effectiveness of interventions for preventing chronic pain after knee replacement and the treatment of chronic pain after diverse surgeries, and identify post-surgical predictors of chronic pain after knee replacement 2.characterise the long-term trajectory of chronic pain, including pain characteristics and resource use up to 5 years after total knee replacement 3.finalise an assessment process and a care pathway for patients with chronic pain after total knee replacement 4.evaluate the clinical effectiveness and cost-effectiveness of a new care pathway for patients with chronic pain after total knee replacement 5.identify reasons for non-use of services 6.make evidence-based suggestions about the best-practice care for patients with chronic pain after total knee replacement and evaluate the implementation of these. Methods To meet the objectives, we conducted six work packages. Work package 1: systematic reviews and analysis of national databases Systematic reviews of the following were carried out: post-surgical predictors of chronic pain after total knee replacement; the effectiveness of pre-, peri- and post-operative interventions for chronic pain after total knee replacement; and the effectiveness of interventions for chronic pain after diverse surgeries. In addition, we undertook an analysis of data from the National Joint Registry (NJR) linked to Hospital Episode Statistics (HES) and Patient Reported Outcome Measures (PROMs) databases to identify post-operative predictors of chronic pain. Work package 2: long-term follow-up and analysis of databases Using the annual follow-up of the Clinical Outcomes in Arthroplasty Study (COASt) cohort of patients with total knee replacement, we were able to collect pain and resource use data for 5 years after surgery. We also analysed the Clinical Practice Research Datalink (CPRD), linked to the Hospital Episode Statistics (HES) and Patient Reported Outcome Measures (PROMs) database, to characterise the natural history of chronic pain after total knee replacement, including resource use. Work package 3: finalisation of an assessment protocol and care pathway Consensus questionnaires completed by and meetings with health-care professionals were used to refine our previously developed intervention. We also tested intervention delivery and acceptability with 10 patients and evaluated the views of 10 health-care professional stakeholders on future implementation using a questionnaire based on the Normalisation Measure Development (NoMAD) instrument. Work package 4: randomised controlled trial The multicentre Support and Treatment After joint Replacement (STAR) randomised controlled trial was carried out with 363 participants to evaluate the clinical effectiveness and cost-effectiveness of a new care pathway for patients with chronic pain after total knee replacement. The primary follow-up time point was 12 months post randomisation and the coprimary outcomes were the Brief Pain Inventory (BPI) severity and interference scales (scored 0–10), with the minimal clinically important difference pre-specified as 1 point on either scale. Two embedded qualitative studies with 56 patients explored trial processes and acceptability of the intervention. Work package 5: qualitative study We undertook a qualitative interview study with 34 people with chronic pain after total knee replacement who made little or no use of formal health-care services and explored reasons for non-use of services. Work package 6: implementation and dissemination Interviews, based on the NoMAD instrument, were carried out with 14 health-care professionals who implemented the intervention within the trial. An online meeting, short animated film and survey were all used to communicate findings to key stakeholders and engage health-care professionals in maximising the embedding of the intervention in practice. A range of dissemination activities to engage health-care professionals, researchers, policy-makers, patients and the public were undertaken. Patient and public involvement Patient and public involvement was integral to the programme’s design and remained at its core during the programme. We worked with an existing patient forum and developed a complementary group focusing exclusively on chronic pain after total knee replacement. Contributions of this group included the design of study materials and processes, research management and dissemination strategies. Results Work package 1: systematic reviews Our systematic review of post-operative risk factors for chronic pain after total knee replacement included 14 studies published up to October 2016, with data from 1168 people. Studies focused on acute pain, function and psychological factors. Risk factor measures and outcomes were heterogeneous. In a narrative synthesis we were unable to draw firm conclusions on potential interventions. The need for further prospective studies in representative populations was clear. Research published up to December 2018 into pre-operative interventions mainly focused on exercise and education. In the eight trials, with a total of 960 people randomised, there was no association with these interventions and long-term pain outcomes. In the peri-operative setting, we identified 44 trials published up to February 2018, with a range of 10 to 280 people randomised. Unifactorial interventions including some forms of analgesia, early rehabilitation, electrical muscle stimulation and anabolic steroids were associated with improved long-term pain outcomes. However, studies were small and merit further evaluation. There was reassurance that some common peri-operative treatments are not associated with chronic pain. Post-operative interventions evaluated in 17 trials published up to November 2016, with a total of 2485 people randomised, mainly focused on physiotherapy. There was no strong evidence favouring one format of therapy over another. There has been little research into treatments for chronic pain after total knee replacement. Considering interventions for general chronic post-surgical pain, we identified 66 randomised trials with a total of 3149 participants in our systematic review with searches up to March 2016. A more focused updated search including treatments for chronic pain after arthroplasty of the large joints was conducted in October 2020. Many unifactorial interventions have been evaluated, and specific nerve-focused treatments deserve further research. Work packages 1 and 2: analysis of national databases We undertook two analyses of linked databases to identify pre-, peri- and post-operative risk factors for chronic pain outcome. In the first analysis with NJR and HES data, the pre- and 6-month-post-operative Oxford Knee Scores (OKS) was available for 258,386 patients, 43,702 (16.9%) of whom were identified as having chronic pain at 6 months post surgery. Post-surgical predictors of chronic pain were mechanical complication of prosthesis, surgical site infection, readmission, reoperation, revision and an extended hospital stay. However, these post-surgical predictors explained only a limited amount of variability in chronic pain outcome. In the second analysis, we analysed primary care data from CPRD and secondary care data from the HES–PROMs database and included 4570 patients. At 6 months after surgery, 10.4% of patients were classified as non-responders to surgery regarding their knee pain. Expressing the effects as absolute risk differences allowed us to quantify the relative importance of individual risk factors in terms of the absolute proportions of patients achieving poor pain outcomes. Pre-operative risk factors were having only mild knee pain symptoms, currently smoking, living in the most deprived areas, having a body mass index between 35 and 40 kg/m2 and having had previous knee arthroscopy surgery. Post-operative risk factors were revision surgery and manipulation under anaesthetic within 3 months after the operation, and use of opioids and antidepressants within 3 months after surgery. Work package 2: long-term follow-up of COASt cohort and analysis of national databases We characterised the long-term trajectory of chronic pain, including pain characteristics and resource use, through the 5-year follow-up of the COASt cohort of 1581 patients with total knee replacement, and analysis of the linked CPRD and HES databases. We applied cluster analysis to data on 128,145 patients with primary total knee replacement included in the English PROMs programme to derive a cut-off point on the pain subscale of the OKS. A high-pain group was identified, defined as those with a score of ≤ 14 points on the OKS pain subscale 6 months after total knee replacement. About one in eight people experienced chronic pain 1 year after total knee replacement. Of these patients with chronic pain after surgery, after imputing significant missing data assumed to be missing at random, 65% experienced no-chronic-pain by year 5, 31% fluctuated and 4% remained in chronic pain. People with chronic pain in year 1 had worse quality of life to start with; this improved, but less rapidly than for those not in chronic pain. People with chronic pain reported slightly higher primary care consultation costs than those not in chronic pain but their prescriptions for analgesia were much more frequent, more costly to the health-care system and continued to grow even after surgery, especially prescriptions for opioids. Work package 3: finalisation of an assessment protocol and care pathway We refined and finalised the novel STAR care pathway and associated training materials. The STAR care pathway involves a clinic appointment for patients who have troublesome pain at 3 months after surgery. A specially trained extended scope practitioner (ESP) conducts a clinic assessment with the patient, comprising history, examination, radiography and questionnaire completion. Based on this assessment, which focuses on understanding the reasons for and impact of the pain, the patient is referred to the appropriate existing services for treatment, such as a surgeon, general practitioner (GP) or specialist, or receives ongoing monitoring. The ESP follows up with patients by telephone for up to 12 months. Work package 4: randomised controlled trial In a multicentre pragmatic, open randomised controlled trial, we evaluated the STAR care pathway. We screened 5036 people, randomised 363 patients with pain at 3 months after knee replacement from eight NHS Trusts in England and Wales and collected 12-month outcomes from 313 (85%) randomised participants. The sample had a mean age of 67 years, was 60% female and 94% white. Our analysis of clinical effectiveness indicated that at 12 months the intervention arm had lower mean pain severity and lower mean pain interference than the usual care arm. For pain interference at 12 months, the adjusted difference in means was –0.68 points on the Brief Pain Inventory pain interference scale [95% CI –1.29, –0.08; p = 0.026]. For pain severity at 12 months, the adjusted difference in means was –0.65 points on the Brief Pain Inventory pain severity scale [95% CI –1.17, –0.13; p = 0.014]. Our analysis of cost-effectiveness indicated that people receiving the STAR pathway from an NHS and personal social services perspective had lower costs (–£724, 95% CI -£1500 to £51) and more quality-adjusted life-years (QALYs) (0.03, 95% CI –0.008 to 0.06) than those receiving usual care. The STAR pathway was the cost-effective option: the incremental net monetary benefit at the £20,000-per-QALY threshold was £1256 (95% CI £164 to £2348). This was also the case from a patient perspective. Embedded qualitative research found that patients thought that the STAR pathway was acceptable, and patients described how it provided an opportunity for them to discuss their concerns and to receive more information about their condition while ensuring they received further treatment and ongoing support. Work package 5: qualitative study In semistructured interviews with 34 people, we found that people with chronic pain after total knee replacement who made little or no use of services did so because they became stuck in a cycle of appraisal of the validity of their need for help and concern that treatment may not be of benefit. Some were concerned that further treatment may even worsen their pain or cause further harm. When describing chronic post-surgical pain, some participants described sensations of discomfort including heaviness, numbness, pressure and tightness associated with the prosthesis, and some also reported a lack of felt connection with their knee as their movement was no longer natural and required deliberate attention, and that they had a lack of confidence in it. Work package 6: implementation and dissemination We found that health-care professionals involved in the delivery and implementation of the STAR care pathway valued its focus on the identification of neuropathic pain and psychosocial issues, enhanced patient care, formalisation and validation of referral practices and an increased knowledge of pain management. Stakeholders supported formal implementation of the STAR pathway. Whether or not this would be supported by hospital management was felt to be dependent on whether or not it was shown to be cost-effective. Conclusions: implications for health care After knee replacement, screening for pain with the OKS pain subscale beginning at 2 months after surgery can facilitate the delivery of targeted care from 3 months. Our findings indicate that the STAR care pathway can provide improved care and outcomes for people who have pain after knee replacement. To our knowledge, the STAR care pathway is the first multifactorial intervention for the treatment of post-surgical pain to have been evaluated in a randomised controlled trial. In database analyses and systematic reviews, we identified risk factors for and univariable interventions to prevent or treat chronic pain. After further research these may provide additional components to the care pathway. Our work also indicates that people with pain could be empowered to seek health care and that health-care professionals can be encouraged provide support. This could include information for people living with chronic pain to inform them that health care may provide benefit and that seeking care is not futile. Informing patients of the likely outcomes after surgery may be a key part of pre- and post-surgical care. Recommendations for research We recommend that further research addresses the following points, numbered in descending order of priority: 1.How to implement the STAR care pathway into the NHS. 2.How to improve communication between patients and professionals before surgery. 3.Whether or not patient education and supportive care can enable earlier recognition of chronic pain. 4.The STAR care pathway showed benefit to patients for both pain and interference at 6 and 12 months. Further follow-up would describe the longer-term outcomes of this intervention and the health-care resources utilised by participants. 5.How to reshape the STAR pathway for other surgeries. 6.The STAR programme focused on care after surgery. Future research could make use of the recently developing evidence base about the time before surgery as an opportunity for intervention. Specifically, we now have a greater understanding of risk factors for poor outcome and using this understanding to design and evaluate pre-surgical intervention may prove of long-term benefit to patients and health-care systems. 7.How to better manage patient’s feelings of disconnectedness from the new knee and sensations of otherness to improve incorporation of the prosthesis. 8.Promising interventions, identified in systematic reviews and suggested by our risk factor studies, should be evaluated in appropriately powered high-quality randomised controlled trials. 9.New interventions with evidence of effectiveness in the treatment of chronic pain after knee replacement should be considered as new components of multifaceted personalised care as delivered in the STAR intervention. Study registration All systematic reviews were registered on PROSPERO (CRD42015015957, CRD42016041374 and CRD42017041382). The STAR randomised trial was registered as ISRCTN92545361. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 11, No. 3. See the NIHR Journals Library website for further project information.

Coccidioidomycosis is a fungal infection endemic to certain regions of the Americas. In some cases, the organism may infect the musculoskeletal system, resulting in a prosthetic joint infection (PJI). Due to its difficulty in diagnosis, treatment of coccidioidomycosis in PJI is often delayed. Furthermore, with limited number of case reports, a standard of care in treatment has yet to be established. We present 2 cases of coccidioidomycosis PJI, the extensive evaluation that led to the diagnosis, and the treatment provided. This report highlights the natural progression of coccidioidomycosis in a prosthetic joint, the diagnostic features including histology, advanced imaging, and final treatment administered.

Objective: Unilateral strength training has been shown to be more effective than bilateral training to increase strength in healthy people. The aims of this study were to test the feasibility of unilateral strength training during total knee arthroplasty (TKA) rehabilitation and compare it with standard bilateral training. Methods: Twenty-four TKA patients from an inpatient rehabilitation programme were randomly assigned to unilateral and bilateral strength training groups. Both groups completed 6 strength training sessions during 3 weeks of rehabilitation. Isometric strength, knee joint flexibility, knee circumference, chair rise and walking abilities, and perceived exertion and pain were assessed before and after the training period. Results: Both training groups increased isometric strength of both legs (+17–25%) and flexibility of the affected leg (+7.6%). Improvements in isometric strength of the healthy leg (+23% vs +11%) and flexibility of the affected leg (+10.7% vs +4.5%) were greater in the unilateral training group. Chair rise and 2-min walk test results improved in both groups, to the same extent. Perceived exertion decreased only in the unilateral training group (–20%), while perceived pain did not change in either group. Conclusion: This study showed the feasibility of unilateral strength training in TKA rehabilitation. Strength and flexibility improved similarly or better with unilateral strength training compared with standard bilateral strength training. Future studies should analyse the efficacy of prolonged unilateral strength training following TKA. LAY ABSTRACT The rehabilitation process following a total knee replacement surgery is aimed at regaining strength and flexibility of the knee joint and improving the movements of daily living, such as walking and standing up from a chair. However, to date, it is not known which kind of strength training is most effective in achieving this aim within a rehabilitation programme. During standard rehabilitation, both legs are trained. The current study tested whether training of the affected leg only is feasible, and compared it with standard strength training of both legs. Training the affected leg only resulted in greater improvements in flexibility and similar or greater improvements in strength. Both types of training resulted in improvements in walking and standing up from a chair. In conclusion, strength training of the affected leg only is a feasible alternative to standard strength training with both legs in total knee replacement rehabilitation.

Background and Aims: Postoperative analgesia for Total Knee Arthroplasty (TKA) is paramount for early mobilisation and rehabilitation. The newer motor sparing peripheral nerve blocks for analgesia for TKA are 4 in 1 block, modified 4 in 1 block, infiltration between popliteal artery and capsule of the knee (IPACK) block along with adductor canal block (ACB). We hypothesised that Modified 4 in 1 block is as efficient as the already proven technique of combined IPACK and ACB in providing post-operative analgesia to the patients of TKA. Methods: Seventy patients fulfilling the inclusion criteria posted for TKA surgery were randomised into two groups: Modified 4 in 1 block group (Group - M) and combined IPACK + ACB group (Group - I). After thorough preoperative evaluation and with mimimum standard monitoring the patients received sub-arachnoid block followed by the desired peripheral nerve block as per the group. After the surgery the visual analog scale (VAS) pain score was compared at 3, 6, 12, 24 hours postoperatively and tabulated. Results: The mean pain scores between both the groups was comparable at 3 hours, 6 hours and 24 hours. But at 12 hours after the surgery, VAS was less in Group-M in comparison to Group-I, Haemodynamic parameters were comparable between both the groups. None of the patients in both the groups showed any complications like muscle weakness in the post-operative period. Conclusion: Modified 4 in 1 block is a new and novel technique for the TKA surgeries and is comparable with already established combined IPACK+ACB technique for providing adequate postoperative analgesia after TKA. [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]

Background: Cemented and uncemented fixation are the primary methods of tibial prosthesis fixation in total knee arthroplasty. However, the optimal fixation method remains controversial. This article explored whether uncemented tibial fixation has better clinical and radiological outcomes, fewer complications, and revision rates compared to cemented tibial fixation. Methods: We searched the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2022 to identify randomized controlled trials (RCTs) that compared uncemented total knee arthroplasty (TKA) and cemented TKA. The outcome assessment consisted of clinical and radiological outcomes, complications (aseptic loosening, infection, and thrombosis), and revision rate. Subgroup analysis was used to explore the effects of different fixation methods on knee scores in younger patients. Results: Nine RCTs were finally analyzed with 686 uncemented knees and 678 cemented knees. The mean follow-up time was 12.6 years. The pooled data revealed significant advantages of uncemented fixations over cemented fixations in terms of the Knee Society Knee Score (KSKS) (p = 0.01) and the Knee Society Score–Pain (KSS–Pain) (p = 0.02). Cemented fixations showed significant advantages in maximum total point motion (MTPM) (p < 0.0001). There was no significant difference between uncemented fixation and cemented fixation regarding functional outcomes, range of motion, complications, and revision rates. When comparing among young people (<65 years), the differences in KSKS became statistically insignificant. No significant difference was shown in aseptic loosening and the revision rate among young patients. Conclusions: The current evidence shows better knee score, less pain, comparable complications and revision rates for uncemented tibial prosthesis fixation, compared to cemented, in cruciate-retaining total knee arthroplasty. [ABSTRACT FROM AUTHOR]

Introduction: Informed consent documentation is often the first area of interest for lawyers and insurers when a medico-legal malpractice suit is concerned. However, there is a lack of uniformity and standard procedure about obtaining informed consent for total knee arthroplasty (TKA). We developed a solution for this need for a pre-designed, evidence-based informed consent form for patients undergoing TKA. Materials and methods: We extensively reviewed the literature on the medico-legal aspects of TKA, medico-legal aspects of informed consent, and medico-legal aspects of informed consent in TKA. We then conducted semi-structured interviews with orthopaedic surgeons and patients who had undergone TKA in the previous year. Based on all of the above, we developed an evidence-based informed consent form. The form was then reviewed by a legal expert, and the final version was used for 1 year in actual TKA patients operated at our institution. Results: Legally sound, evidence-based Informed Consent Form for Total Knee Arthroplasty. Conclusion: The use of legally sound, evidence-based informed consent for total knee arthroplasty would be beneficial to orthopaedic surgeons and patients alike. It would uphold the rights of the patient, promote open discussion and transparency. In the event of a lawsuit, it would be a vital document in the defence of the surgeon and withstand the scrutiny of lawyers and the judiciary. [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]