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

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

Rationale: Effective preoperative assessments of determinants of health status and function may improve postoperative outcomes. Aims and Objectives: We developed risk scores of preoperative patient factors and patient‐reported outcome measures (PROMs) as predictors of patient‐rated satisfaction and improvement following hip and knee replacements. Patients and Methods: Prospectively collected National Health Service and independent sector patient data (n = 30,457), including patients' self‐reported demographics, comorbidities, PROMs (Oxford Hip/Knee score (OHS/OKS) and European Quality of Life (EQ5D index and health‐scale), were analysed. Outcomes were defined as patient‐reported satisfaction and improvement following surgery at 7‐month follow‐up. Univariable and multivariable‐adjusted logistic regressions were undertaken to build prediction models; model discrimination was evaluated with the concordance index (c‐index) and nomograms were developed to allow the estimation of probabilities. Results: Of the 14,651 subjects with responses for satisfaction following hip replacements 564 (3.8%) reported dissatisfaction, and 1433 (9.2%) of the 15,560 following knee replacement reported dissatisfaction. A total of 14,662 had responses for perceived improvement following hip replacement (lack of improvement in 391; 2.7%) and 15,588 following knee replacement (lack of improvements in 1092; 7.0%). Patients reporting poor outcomes had worse preoperative PROMs. Several factors, including age, gender, patient comorbidities and EQ5D, were included in the final prediction models: C‐indices of these models were 0.613 and 0.618 for dissatisfaction and lack of improvement, respectively, for hip replacement and 0.614 and 0.598, respectively, for knee replacement. Conclusions: Using easily accessible preoperative patient factors, including PROMs, we developed models which may help predict dissatisfaction and lack of improvement following hip and knee replacements and facilitate risk stratification and decision‐making processes. [ABSTRACT FROM AUTHOR]

Total knee arthroplasty (TKA) is a reliable procedure for end-stage osteoarthritis with excellent long-term survivorship, but approximately 15% of patients are not satisfied. Pain catastrophizing (PC) has been proposed as a potential cause but current evidence is limited to smaller studies with short-term follow-up. Our goal was to assess outcomes following TKA in a large cohort with and without PC. A prospective comparative study was performed with patients undergoing unilateral primary TKA between 2019 and 2021 with 2-year follow-up. All patients completed a PC Scale questionnaire preoperatively and a score of minimum 30 was considered PC. Outcomes consisted of Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS), numeric rating scale Pain, and aseptic revisions. Ultimately, 301 patients were included (mean age 69 years [range, 30-92 years], with 60.8% women). Forty four patients (14.6%) had PC. Preoperatively, PC patients had inferior KOOS-PS, inferior OKS, and more pain than non-PC patients (all P <.001). PC patients had more improvement from preoperatively to 6 months postoperatively for KOOS-PS, OKS, and pain (all P <.05) and to 12 months for KOOS-PS and OKS (both P <.005). Similarly, PC patients had more improvement from preoperative to 24 months for OKS (P =.003). At 24 months, however, PC patients reported more pain than non-PC patients. There was no difference in revision rates (P =.192). Patients who had PC reported worse function and pain preoperatively but had more improvement to 6 months and 12 months postoperatively. At 24 months, similar subjective function was noted, although PC patients reported more pain. [ABSTRACT FROM AUTHOR]

Background: Myocardial injury after noncardiac surgery (MINS) carries a high postoperative mortality. In this preplanned, subgroup analysis of the randomized DEX-2-TKA Trial, we investigated the effect of dexamethasone versus placebo on the concentration of cardiac troponin I and T (TnI and TnT) on the first postoperative morning after total knee arthroplasty. In addition, frequency of MINS, myocardial infarction, and major adverse cardiovascular events where evaluated.Methods: We included 290 patients who received either 24 mg of dexamethasone intravenously (given perioperatively) or placebo. Blood samples were analyzed as either TnI or T depending on trial site.Results: A total of 236 samples were eligible for analysis of TnI and 38 samples for TnT on the first postoperative morning. The median (IQR) TnI concentration was 4.6 ng/L (0-7.2 ng/L) in the dexamethasone group and 4.5ng/l (0-7.0 ng/L) in the placebo group (P = .96) on the first postoperative morning. The median TnT was 9 ng/L (6-11 ng/L) in the dexamethasone group and 8 ng/L (5-10 ng/L) in the placebo group (P = .68). The frequencies of MINS, myocardial infarction, and major adverse cardiovascular events were similar in the compared groups, but these analyses were underpowered.Conclusion: We found no effect of dexamethasone on postoperative concentration of troponin I or T on the first postoperative morning after total knee arthroplasty. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to compare two methods of wound skin closure—staples versus vertical mattress nylon sutures—in patients undergoing primary total hip (THR) and total knee replacements (TKR). The comparison was for wound complications as a primary outcome, and satisfaction of patient and nurse as secondary outcomes. Method: A prospective cohort study was conducted at an academic teaching hospital. All the patients who were admitted for either primary THR or TKR from September 2018 to September 2019 were included. Revision surgeries, patients >85 years of age, and those who were on steroid therapy were excluded. Patients were divided into two groups (staples and sutures) to compare the two methods of wound closure. Patients in each group were assessed for characteristics such as age, sex, weight, height, comorbidities, smoking status, postoperative wound complications, reoperation and patient/nurse satisfaction. Results: A total of 100 patients met the inclusion criteria. In the staples group (n=50), 26 patients underwent THR while 24 patients underwent TKR. In the sutures group (n=50), 23 patients underwent THR and 27 patients underwent TKR. Overall, there was no significant difference between the two groups (staples versus sutures) in terms of wound complications (p=0.401), patient satisfaction (p=0.357) and nurse satisfaction (p=0.513). Further analysis compared THR and TKR subgroups (THR staples versus THR sutures and TKR staples versus TKR sutures). The results showed no significant difference between the staples and sutures subgroups of THR and TKR in terms of wound complications, patient satisfaction and nurse satisfaction. Conclusion: In THR and TKR, there was no significant difference between either vertical mattress nylon sutures or staples primary skin closure in terms of wound complications and patient satisfaction in this study. The decision on wound closure method should be based on the availability of resources in the institution/country. [ABSTRACT FROM AUTHOR]

Alignment strategies for primary total knee arthroplasty (TKA) have changed significantly over time with a shift towards a more individualized alignment goal. At the same time, computer-assisted surgery (CAS) has gained interest for intraoperative control and accuracy in implant positioning and limb alignment. Despite the often discussed benefits and drawbacks of robotics and navigation for TKA, the routine use of these new devices on a day-to-day basis remains obscure. Therefore, nationwide hospital billing data based on the Operation Procedure Classification System (OPS) were retrieved from the Federal Statistical Office of Germany for the period from 2010 to 2021. OPS codes for primary total knee arthroplasty (OPS code: 5-822*) were further analyzed regarding the usage of computer navigation (additional OPS code: 5-988) or robotic devices (additional OPS code: 5-987). Gender and age at the time of surgery were also assessed. The results show a total of 2,226,559 primary TKAs were implanted between 2010 and 2021, of which 2,044,914 were performed conventionally (91.84% of all TKAs). A total of 170,276 TKAs were performed using navigation technique (7.65% of all TKAs) and another 11,369 TKAs were performed using robotics (0.51% of all TKAs). For the period from 2018 to 2021, a substantial increase in robot-assisted TKA (R-TKA) was observed, with an average increase rate of 84.74% per year, while the number of navigated TKAs declined (−3.67% per year). Computer-assisted surgery, and particularly robotics for TKA, are seeing growing popularity and stepwise translation into routine clinical use in Germany, with a steep increase rate of more than 80% per year since 2018. Nevertheless, the majority of TKAs are still performed using manual instrumentation, rendering conventional TKA the currently unchanged gold standard. [ABSTRACT FROM AUTHOR]

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

Abstract Background The knee replacement (KR) surgery aims to restore the activity level and reduce the risk of experiencing disabilities. The outcomes of this surgery are evaluated mainly with subjective tools or low validity objective tools. However, the effect of the surgery on activity level using high validity objective accelerometer is still in question. Methods A systematic review and meta-analysis were conducted to evaluate the benefit of KR surgery alone to enhance physical activity recommendations based on high validity accelerometer. Two independent reviewers evaluated five electronic databases (Cochrane-Central-Register-of-Controlled Trials, EMBASE, PubMed, Web of Science, and Scopus) to find relative studies between January 2000 and October 2021. The quality assessments and risk of bias assessments were examined. Results Three articles were included with 202 participants (86 males, 116 females), with an average age of 64 years and an average 32 kg/m2 body mass index. The results found that the number of steps was significantly improved up to 36.35 and 45.5% after 6-months and 1-year of the surgery, respectively. However, these changes did not meet the recommended activity level guideline and could be related to the patients’ health status and their activity level before the surgery. No significant changes were seen in sedentary time, standing time, and upright time after 6-months and 1-year follow-ups. Heterogeneity among studies was low to moderate (0–63%). Conclusion Knee replacement surgery is an effective treatment for improving patients’ quality of life with severe knee injuries. However, various factors impact the success of surgical and achieving maximum benefit of the surgery. One factor, sedentary time, can be reduced by implementing pre-and post-surgery exercise or physical activity recommendations. Further studies are needed to understand the benefit of surgery with or without rehabilitation assessed using high validity monitors.

Objective: This study aims to translate and cross-culturally adapt the University of California at Los Angles Activity Scale (UCLA) to Iranian samples and evaluate the reliability and validity of the Persian UCLA in candidates for knee replacement surgery. Materials & Methods: In this cross-sectional study, cross-cultural adaptation was performed according to the international quality of life assessment protocol in three stages: standard forward translation, translation synthesis, and backward translation. The Persian UCLA, tegner activity scale (TAS), short-form health survey (SF-36) and international physical activity questionnaire (IPAQ) were completed by 103 participants (candidates for knee replacement surgery). The Persian UCLA questionnaire was re-completed by 66 participants in the retest session with an interval of 3-7 days. An intra-class correlation coefficient (ICC) was used to evaluate test-retest reliability. The standard error of measurement (SEM) was used to determine smallest detectable change (SDC) in scores. To evaluate convergent validity of the Persian UCLA, its correlation with TAS, SF-36, and IPAQ was assessed using Spearman’s correlation test. The ceiling and floor effects were also calculated. Results: In the Persian version, no special changes were made and no problem or ambiguity was reported by the respondents based on a pilot study. The type of activities mentioned in the original version was not changed either and none of the participants had difficulty understanding the items. The Mean±SD of UCLA scores were 2.98±1.37 in the test phase and 2.89±1.32 in the retest phase. Psychometric tests results showed acceptable test-retest reliability of the Persian UCLA (ICC=0.96, 95% CI=0.93-0.97). Given an SDC score of 0.50 at 95% confidence interval, it can be said that if the UCLA score be above or less than 0.50, there is an improvement or decline in the activity level of patients. Based on the results of Spearman correlation test, the Persian UCLA showed a strong correlation with TAS (rs=0.71, P

Aims: Treatment of end-stage anteromedial osteoarthritis (AMOA) of the knee is commonly approached using one of two surgical strategies: medial unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). In this study we aim to investigate if there is any difference in outcome for patients undergoing UKA or TKA, when treated by high-volume surgeons, in high-volume centres, using two different clinical guidelines. The two strategies are ‘UKA whenever possible’ vs TKA for all patients with AMOA. Methods: A total of 501 consecutive AMOA patients (301 UKA) operated on between 2013 to 2016 in two high-volume centres were included. Centre One employed clinical guidelines for the treatment of AMOA allowing either UKA or TKA, but encouraged UKA wherever possible. Centre Two used clinical guidelines that treated all patients with a TKA, regardless of wear pattern. TKA patients were included if they had isolated AMOA on preoperative radiographs. Data were collected from both centres’ local databases. The primary outcome measure was change in Oxford Knee Score (OKS), and the proportion of patients achieving the patient-acceptable symptom state (PASS) at one-year follow-up. The data were 1:1 propensity score matched before regression models were used to investigate potential differences. Results: The matched cohort included 400 patients (mean age 67 years (SD 9.55), 213 (53%) female, mean BMI 30.2 kg/m2, 337 (84%) American Society of Anesthesiologists grade ≤ 2). We found a mean adjusted difference in change score of 3.02 points (95% confidence interval (CI) 1.41 to 4.63; p < 0.001) and a significantly larger likeliness of achieving PASS (odds ratio 3.67 (95% CI 1.73 to 8.45); p = 0.001) both in favour of the UKA strategy. Conclusion: UKA and TKA are both good strategies for treating end-stage AMOA. However, when compared as a strategy, UKA achieved larger improvements in OKS, and were more likely to reach the PASS value at one-year follow-up. Cite this article: Bone Jt Open 2022;3(5):441–447.

Background and Objectives: National joint registries report higher total knee arthroplasty (TKA) revision rates in posterior-stabilized (PS) systems compared to non-posterior-stabilized designs. The purpose of this study was to investigate the implant survivorship and clinical outcomes of an anatomic implant with a PS bearing. Materials and Methods: An early- to mid-term follow-up of a prospective, multi-center, non-controlled outcomes study of patients who received primary TKA between November 2014 and June 2017 was performed. A total of 800 cases using PS bearings that were implanted in 664 patients were monitored post-operatively for their implant survivorship and adverse events for up to five years. The Knee Society Knee and Function scores, patient satisfaction, the five-dimensional European Quality of Life questionnaire, and range of motion (ROM) were evaluated pre-operatively and post-operatively at six weeks, six months, one year, two years, three years, and five years. Results: The mean follow-up period was 3.7 ± 1.3 years, and the three-year implant survival rate was 99.3% (95% CI: 98.4%, 99.7%) with five revisions during the five-year follow-up. Patient satisfaction was 96.1% at six weeks and increased to 99.3% at one year. All patient-reported outcome measures significantly (p < 0.0001) increased up to the one-year follow-up and then remained stable up to the five-year follow-up. Conclusions: This study supports the excellent survivorship and patient-reported outcomes of the Persona® Knee system using cemented, fixed bearing, posterior-stabilized components with minimal complications at early- to mid-term follow-up in an international Asian population. Ongoing observations are being performed to investigate the mid- to long-term survivorship and clinical outcomes associated with this knee system.

Jinghui Chang,1,&ast; Manru Fu,1,2,&ast; Peihua Cao,3 Changhai Ding,3,4,&ast; Dong Wang1,&ast; 1School of Health Management, Southern Medical University, Guangzhou, 510515, People’s Republic of China; 2The Third Affiliated Hospital, Southern Medical University, Guangzhou, 510282, People’s Republic of China; 3Clinical Research Center, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People’s Republic of China; 4Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia&ast;These authors contributed equally to this workCorrespondence: Dong Wang, School of Health Management, Southern Medical University of China, Guangzhou, 510515, People’s Republic of China, Tel +86 18620089545, Email dongw96@smu.edu.cnPurpose: To compare patients’ self-reported health-related quality of life (HRQoL) before and after total knee arthroplasty (TKA) and determine factors contributing to any heterogeneity in HRQoL.Patients and Methods: This prospective multicenter observational study included 404 patients with knee osteoarthritis who underwent TKA between April 1, 2019 and December 30, 2019 and whose HRQoL was assessed preoperatively and 7 days and 1, 3, and 6 months postoperatively. Sociodemographic characteristics were assessed using a General Information Questionnaire, disability using the Knee Injury and Osteoarthritis Outcome Score (KOOS-PS), resting pain using the visual analogue scale (Pain-VAS), and HRQoL using the European Quality of Life Five Dimension Five Level (EQ-5D-5L) scale. The growth mixture model was used to identify group heterogeneity in the developmental trajectories of KOOS-PS, Pain-VAS, and EQ5D5L. Logistic regression was used to explore the factors influencing the developmental trajectories of factors affecting the developmental trajectory of HRQoL.Results: The mean EQ-5D-5L score improved from 0.69 preoperatively to 0.90 at 6 months postoperatively. Longitudinal heterogeneity in HRQoL was observed in patients during recovery: 1) patients with a small and slow improvement in HRQoL and 2) patients who showed marked and rapid improvement in HRQoL. The main characteristics of the latter group were decreasing VAS pain scores, a monthly family income > 2000 CNY (100 CNY equals approximately 14.9 USD), exercising for < 30 min daily, and better knee function at baseline. Baseline knee function and change in knee function were significantly associated with the percentage change in HRQoL.Conclusion: HRQoL improved considerably after TKA. However, there was heterogeneity in the changes in HRQoL depending on patients’ socioeconomic status, exercise, and baseline knee function. Dynamic tracking of the HRQoL of TKA patients and timely provision of rehabilitation guidance will promote continuous improvement of the HRQoL of TKA patients.Keywords: knee osteoarthritis, knee replacement, knee function

Objective To investigate the incidence of preoperative skeletal muscle mass (SM) loss and related influencing factors in patients with hip or knee replacement. Methods A cross-sectional survey was performed on 267 patients who planned to undergo hip or knee replacement for first time from August 2020 to June 2021 in Army Medical Center. The demographic data, disease history and laboratory indicators were collected. Nutritional risk screening 2002 (NRS2002) scale was used to assess nutritional status, and chair test, 3-m reentry test and 6-min walking test were employed to evaluate lower extremity muscle strength and joint functional mobility. According to the screening criteria for bioelectrical impedance analysis (BIA) recommended by 2019 Consensus of Asian Working Group for Sarcopenia, the patients were divided into muscle mass reduction group (n=94) and normal muscle mass group (n=173). The related factors of muscle mass loss were analyzed. Results The detection rate of muscle mass loss was 35.21%. Statistical significances were seen in lower extremity joint function performance between the 2 groups by 3-m reentry test (Z=-4.744, P < 0.001) and 6-min walking test (Z=-4.889, P < 0.001). There were significant differences in age, BMI, results of nutritional risk screening, usage of walking aid, lymphocyte count, and levels of hemoglobin, serum albumin, serum prealbumin, and C-reactive protein between the 2 groups (P < 0.05). Multivariate logistic regression analysis showed that BMI (OR=0.640, 95%CI: 0.557~0.734) was an independent protective factor for muscle mass loss, and age (OR=1.093, 95%CI: 1.057~1.132) and usage of walking aid (OR=2.956, 95%CI: 1.179~7.410) were risk factors. Multiple linear regression analysis indicated that the influencing factors of muscle mass were sex (muscle mass of men larger than that of women, β=0.846, P < 0.001), age (β=-0.245, P < 0.001), history of smoking (β=-0.170, P=0.024), and hemoglobin (β=0.149, P=0.017), and age and smoking were negatively and hemoglobin was positively correlated with muscle mass. Conclusion Loss of muscle mass is more common in patients who choose hip or knee arthroplasty. Age, BMI, and use of walking aids may be related to the occurrence of muscle mass loss in them, and gender, age, and hemoglobin content may be used as predictors of preoperative skeletal muscle mass.

Matteo Briguglio,1 Thomas W Wainwright2,3 1IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy; 2Orthopaedic Research Institute, Bournemouth University, Bournemouth, UK; 3Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UKCorrespondence: Matteo BriguglioIRCCS Orthopedic Institute Galeazzi, Scientific Direction, Via Riccardo Galeazzi 4, Milan, 20161, ItalyTel +39 02 66214978Email matteo.briguglio@grupposandonato.itAbstract: In the past, good food and exercise were not considered effective interventions to promote recovery in orthopedic surgery, and prolonged bed rest with not many calories has been deemed sufficient for the proper health restoration until the end of the nineteenth century. The advancement of scientific knowledge proved just the opposite, thus pushing health professionals to sustain the nutritional status and physical fitness of surgical patients. Nevertheless, the impoverishment of lifestyles and the lengthening of life expectancy have invariably contrasted the strength of constitution, giving rise to two of the most hazardous conditions for orthopedic patients: malnutrition and sarcopenia, often hiding nutrient deficits and poor body composition. These conditions are known to be negative prognostic factors in several areas of major surgery, including hip replacement, knee replacement, and spine surgery. Scoring systems to screen for malnutrition and physical inabilities exist, but disciplined management of the derived risks remains untested, potentially hindering the implementation of research findings into practice. A methodical approach of preoperative analysis, critical monitoring, and risk correction before surgery could lead to a substantial improvement of the prognosis while warranting the safety of patients and the efficiency of enhanced recovery after surgery pathways. The aim of this article is to discuss from a dietetic and exercise perspective the ideal nutritional and physical prehabilitation to lay the foundations for designing the appropriate integration of dietitians and physiotherapists in a preoperative enhanced recovery pathway. This methodical analysis could effectively calculate the patient’s risks, detect the best choices for resolving the risk, underline the ignored aspects of perioperative care, and represent a concrete means to integrate novel discoveries.Keywords: hip replacement, knee replacement, malnutrition, sarcopenia, enhanced recovery after surgery, quality of health care

Abstract Background Knee replacement is a very effective and indispensable treatment option for end-stage knee arthritis, and the number of cases has been increasing worldwide. A replaced knee joint without patient joint awareness is thought to be the ultimate goal of artificial knees. Joint awareness reportedly correlates with patient satisfaction. Although numbness around a replaced knee is a minor but common problem, its effect on postoperative outcome is controversial. Joint awareness also is sensitive to subtle abnormalities of the joint, so it must be negatively affected by numbness. Although numbness is minor, it cannot be ignored to further improve knee replacement outcomes. This study investigated the relationship between patient-reported numbness and other patient-reported outcome measures (PROMs), including joint awareness, and kneeling. We developed a numbness score based on a 5-point Likert scale on frequency of numbness, with an intraclass correlation coefficient of 0.76 and higher scores indicating less numbness. Methods The numbness score, New Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS), Forgotten Joint Score-12 (FJS-12), and other clinical and radiological data from 311 patients (394 primary knee replacements) were analyzed. Kneeling ability was evaluated by using kneeling-specific items in the KSS (KSS-Kneeling). Results No numbness was found in 170 knees (43.1%), and some degree of numbness was found in the remaining 224 knees (56.9%). The numbness score showed weak-to-moderate correlations with KSS-Symptoms (r = 0.44), KSS-Satisfaction (r = 0.41), KSS-Activities (r = 0.29), and all KOOS subscales (r = 0.23–0.44), and FJS-12 (r = 0.42). Multiple regression analyses suggested that midline incision positively affected the numbness score over the anteromedial incision (p = 0.04) and that a better numbness score (p = 0.001), male sex (p

Abstract Background This study aimed to compare the short-term clinical results of slight femoral under-correction with neutral alignment in patients with preoperative varus knees who underwent total knee arthroplasty. Methods The medical records and imaging data were retrospectively collected from patients who had undergone total knee arthroplasty in our hospital from January 2016 to June 2019. All patients had varus knees preoperatively. Upon 1:1 propensity score matching, 256 patients (256 knees) were chosen and divided into a neutral alignment group (n=128) and an under-correction group (n=128). The patients in the neutral group were treated with the neutral alignment. In the under-correction group, the femoral mechanical axis had a 2° under-correction. The operative time, tourniquet time and the length of hospital stay in the two groups were recorded. The postoperative hip-knee-ankle angle, frontal femoral component angle and frontal tibial component angle were measured. Patient-reported outcome measures were also compared. Results The operative time, tourniquet time and the length of hospital stay in the under-correction group were significantly shorter than the neutral alignment group (P

Introduction Knee osteoarthritis affects the quality of life, with knee arthroplasty being a cost-effective treatment for the severe stage of this disease. Access to knee arthroplasty is a health indicator of the Organisation for Economic Co-operation and Development. The objectives of this study are to determine the incidence of knee arthroplasty between 2004 and 2021 in beneficiaries of the National Health Fund in Chile, the proportion of patients who underwent surgery in the private system, and to estimate the patient's out-of-pocket expenditure for surgery. Methods Cross-sectional study. We used the Department of Statistics and Health Information database. Patients discharged from a Chilean health center who underwent knee arthroplasty surgery between 2004 and 2021 were investigated. We analyzed the proportion of patients by their National Health Fund category and whether their surgery was performed in public or private network facilities. Results Of the 31 526 knee arthroplasty procedures, 21 248 (67.38%) were performed on National Health Fund patients and 16 238 in public institutions (51.49%). Patients from the National Health Fund showed a systematic increase in knee arthroplasty volume until 2019 but decreased in 2020 and 2021 by 68% and 51%. Of the total number of patients in the public system operated on for knee arthroplasty, 856 (9%) belonged to group A1, 12 806 (60%) to group B, 2044 (10%) to group C, and 4421 (21%) to group D. The expenditure incurred by these patients was estimated to vary between 24.4% and 27.2%. The historical proportions of access to this surgery in private institutions are 7% in group A, 13% in group B, 24% in group C, and 52% in group D. Conclusion Fifty percent of knee arthroplasty surgeries are performed in public institutions, and two-thirds are performed on patients of the National Health Fund. Forty-six percent of the C and D groups were operated in the private system. The pandemic has increased the access gap, leading to a substantial increase in the proportion of patients from the National Health Fund of the B, C, and D groups who have migrated to the private system to access this surgery.

Background: There is increasing interest in the development and use of clinical prediction models, but a lack of evidence-supported guidance on the merits of different modelling approaches. This is especially true for time-to-event outcomes, where limited studies have compared the vast number of modelling approaches available. This study compares prediction accuracy and variable importance measures for four modelling approaches in prediction of time-to-revision surgery following total knee arthroplasty (TKA) and total hip arthroplasty (THA).Methods: The study included 321,945 TKA and 151,113 THA procedures performed between 1 January 2003 and 31 December 2017. Accuracy of the Cox model, Weibull parametric model, flexible parametric model, and random survival forest were compared, with patient age, sex, comorbidities, and prosthesis characteristics considered as predictors. Prediction accuracy was assessed using the Index of Prediction Accuracy (IPA), c-index, and smoothed calibration curves. Variable importance rankings from the Cox model and random survival forest were also compared.Results: Overall, the Cox and flexible parametric survival models performed best for prediction of both TKA (integrated IPA 0.056 (95% CI [0.054, 0.057]) compared to 0.054 (95% CI [0.053, 0.056]) for the Weibull parametric model), and THA revision. (0.029 95% CI [0.027, 0.030] compared to 0.027 (95% CI [0.025, 0.028]) for the random survival forest). The c-index showed broadly similar discrimination between all modelling approaches. Models were generally well calibrated, but random survival forest underfitted the predicted risk of TKA revision compared to regression approaches. The most important predictors of revision were similar in the Cox model and random survival forest for TKA (age, opioid use, and patella resurfacing) and THA (femoral cement, depression, and opioid use).Conclusion: The Cox and flexible parametric models had superior overall performance, although all approaches performed similarly. Notably, this study showed no benefit of a tuned random survival forest over regression models in this setting. [ABSTRACT FROM AUTHOR]

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

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

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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). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p < 0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p < 0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (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 FROM AUTHOR]

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 <  0.001). The increase in ankle circumference was about 1.5 cm in the enoxaparin group (p <  0.001), and almost zero in IPCD (p = 0.447). Enoxaparin group lost 566.1 ml (standard deviation, SD, 174.5) of blood in the first 48 h, versus 420.8 ml (SD 142.5) in the IPCD.Conclusions: Exclusively mechanical prophylaxis after TKA with portable IPCD only on the operated leg reduces leg and ankle swelling and post-operative blood loss compared to exclusively pharmacological prophylaxis with enoxaparin. Portable devices that can prevent deep vein thrombosis and pulmonary embolism without increasing blood loss or other risks should be further investigated.Trial Registration: REBEC RBR-8k2vpx. Registration date: 06/04/2019. [ABSTRACT FROM AUTHOR]

Total knee arthroplasty (TKA) has been performed by orthopedic surgeons for decades, but the cementless TKA has only recently gained much interest in the world of arthroplasty. Initially, early designs had multiple complications, particularly with aseptic loosening due to osteolysis and micromotion. However, modifications have shown good outcomes and excellent survivorship. Over the last several decades, changes in implant designs as well as implant materials/coatings have helped with bone in growth and stability. Furthermore, surgeons have been performing TKA in younger and more obese patients as these populations have been increasing. Good results from the cementless TKA compared to cemented TKA may be a better option in these more challenging populations, as several studies have shown greater survivorship in patients that are younger and have a greater BMI. Additionally, a cementless TKA may be more cost effective, which remains a concern in today's healthcare environment. Overall, cemented and cementless TKA have great results in modern times and there is still a debate as to which implant is superior. [ABSTRACT FROM AUTHOR]

Background: Robotic‐arm assisted systems are increasingly used for knee arthroplasty, however introduction of new systems can involve a learning curve. We aimed to define the learning curve in terms of operative time and component placement/sizing of a robotic system for total knee arthroplasty (TKA) in a team of experienced surgeons, and to investigate mid‐term patient outcomes. Methods: A total of 101 consecutive patients underwent primary robotic‐arm assisted TKA by three surgeons (mean 2 year follow‐up). Operative times, component placement, implant sizing and reoperations were recorded. Cumulative Summation (CUSUM) was used to analyse learning curves. Patient outcomes were compared between learning and proficiency phases. Results: The learning curve was 16 cases, with a 12‐min increase in operative time (P < 0.01). Once proficiency was achieved, the greatest time reductions were seen for navigation registration (P = 0.003) and bone preparation (P < 0.0001). A learning curve was found with polyethylene (PE) insert sizing (P = 0.01). No differences were found between learning and proficiency groups in terms of implant survival (100% and 97%, respectively, NS) or patient‐reported outcome measures at 2 years (NS). Conclusion: Introduction of a robotic‐arm assisted system for TKA led to increased operative times for navigation registration and bone preparation, and a learning curve with PE insert sizing. No difference in patient outcomes between learning and proficiency groups at 2 years was found. These findings can inform surgeons' expectations when starting to use robotic‐assisted systems. [ABSTRACT FROM AUTHOR]

Deep periprosthetic infection after total knee arthroplasty is a serious and challenging complication for the orthopedic surgeon. Muscular flaps may represent a valid treatment option for the treatment of this condition. We present a systematic literature review about the use of muscular flaps for the treatment of knee prosthetic joint infection. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 70 articles, out of 589 titles, were considered eligible for the full-text analysis. Finally, 27 studies that met inclusion criteria were included in this review. Overall, 345 patients (139 males, 206 females) suffering from TKA infection treated with muscular flaps were collected. The mean age was 57.3 years. Mean follow-up, reported in all studies, was 30.1 months. The results presented by the different authors, highlight the effectiveness of muscular flaps for the treatment of periprosthetic infection, in terms of function, limb salvage, prevention of recurrences, cost-effectiveness, and quality of life postoperatively. Muscle flaps provide an excellent management option for patients with persistent infection after total knee arthroplasty. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To obtain an in‐depth understanding of the specific needs of patients for rehabilitation services delivered via mobile applications after total hip or knee arthroplasty. Background: Due to increased demand for arthroplasty, the provision of face‐to‐face rehabilitation services for patients is becoming challenging. New approaches using digital technologies are being developed, such as mobile applications to deliver rehabilitation services. However, the perspectives of patients on the delivery of these services via mobile applications after total hip or knee arthroplasty have not been explored extensively. Design: A qualitative descriptive study. Methods: Twenty patients who had been discharged from the hospital after a total hip or knee arthroplasty were interviewed via telephone about their needs regarding the future use of mobile applications to conduct arthroplasty rehabilitation. Interview records were transcribed verbatim and analysed using inductive content analysis. Reporting of the findings complies with the COREQ checklist for qualitative studies. Results: Four categories emerged from the data collected from the participants: (1) assisting rehabilitation self‐management, (2) facilitating peer support, (3) facilitating contact with healthcare professionals and (4) supporting emotional well‐being. Conclusions: The study provided an in‐depth understanding of the specific needs of patients for rehabilitation services delivered via mobile applications after total hip or knee arthroplasty. The findings of the study could be used in the development or revision of mobile application rehabilitation programmes to better support the rehabilitation of patients. Future studies are needed to evaluate the effectiveness of such programmes, especially including the self‐efficacy of patients as an outcome measure. Relevance to clinical practice: From the perspective of patients who have undergone arthroplasty, a mobile application rehabilitation programme should encourage patients in rehabilitation self‐management, assist them to contact healthcare professionals and other patients and support their postoperative emotional well‐being. The study findings will assist nurses with the preparation and delivery of telerehabilitation programmes after arthroplasty. [ABSTRACT FROM AUTHOR]

Several innovations have been introduced in recent years to improve total knee arthroplasty (TKA). Robotic-assisted surgery is gaining popularity for more precise implant placement while minimizing soft tissue injury. The main concerns are increased cost, operative time, and a significant learning curve. This systematic review aims to analyze the surgical time learning curve, implant placement accuracy, and complications related to robotic-assisted TKA (raTKA). A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The research was conducted up to September 2022 in four databases (PubMed/MEDLINE, Embase, Scopus, and the Cochrane Database of Systematic Reviews), with the following key terms: "robotic-assisted", "total knee arthroplasty", "robotic", "TKA", "learning", and "TKR". The methodology quality of the studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO), ID: CRD42022354797, in August 2022. Fifteen clinical studies that analyzed the raTKA learning curve of 29 surgeons and 2300 raTKAs were included in the systematic review. Fourteen surgeons reported the presence of an inflection point during the learning curve. Few studies have reported the learning curve of raTKA regarding lower limb alignment, component position, and intraoperative and postoperative complications. The main finding of this systematic review is that the procedure number required to reach the learning plateau is about 14.9 cases. Furthermore, an average decrease in surgical time of 23.9 min was described between the initial and proficiency phases; the average surgical time in the two phases was 98.8 min and 74.4 min, respectively. No learning curve was observed for implant placement and lower limb alignment because the implants were correctly placed from the first raTKAs. No significant complication rates were reported during the raTKA learning curve. [ABSTRACT FROM AUTHOR]

Objective To measure the values of normal knee joints and provide data reference for the design of total knee arthroplasty prosthesis in the Chinese population. Methods A total of 1143 (569 men, 574 women) participants were divided into four age groups of A (212, 25-29 years), B (310, 30-39 years), C (330, 40-49 years), and D (291, 50-59 years). The joint angles, lengths and spaces were measured on the digital radiography images. Results In 1143 knee joints, the mean lateral angle of distal femur was 83.13°, the lateral angle of proximal tibia was 92.12°, the femoral tibial angle was 175.74°, the femoral condylar shaft angle was 98.82°, the transverse diameter of medial and lateral femoral condyles was 7.95 cm, the transverse diameter of tibial plateau was 7.61 cm, the medial knee joint space was 0.53 cm, and the lateral space was 0.51 cm. Statistical analysis showed that the femoral tibial angle, the transverse diameter of medial and lateral femoral condyles, the transverse diameter of the tibial plateau, and the medial and lateral joint spaces were significantly smaller in women than men (P<0.05). The lateral angle of proximal tibia and femoral tibial angle were significantly smaller on the left than the right (P<0.05). There were significant differences between the medial and lateral knee joint spaces (P<0.05), and the right was smaller than the left side. There were also significant differences in the transverse diameters of medial and lateral femoral condyles, transverse diameters of tibial plateaus, femoral condyle shaft angles, distal femoral lateral angles, and the medial and lateral joint spaces between different age groups (P<0.05). Conclusion Knee arthroplasty prosthesis design should be based on national data, and should fully account for differences between race, sex, side, and age groups. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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

Introduction: This study aims to determine which Periprosthetic Distal Femur Fracture (PDFF) classification system is the most reliable. The secondary aim was to determine which classification system correlated most accurately with the surgical management recommended and delivered.Methods: Between 2011 and 2019, 83 patients with 83 PDFFs that extended to the femoral component of a total knee arthroplasty (TKA) were retrospectively identified from a trauma database. Minimum follow-up was 1 year. Age, BMI, time from TKA, operative management, and Nottingham Hip Fracture Scores were collected, and AP and lateral radiographs used to classify all fractures using seven established classification systems by two observers blinded to management. In patients treated operatively (n = 69), preoperative radiographs were reviewed by two surgeons with expertise in trauma and knee revision who recommended fixation or distal femoral replacement (DFR) requirement.Results: Mean age was 80.7 years (SD9.4) and 50 (84.7%) were female. PDFFs occurred at a mean 9.5 years (SD5.2) after primary TKA. Mean follow-up was 3.8 years (SD2.9). Management was fixation in 47, DFR in 22 and non-operative for 14. The Fakler classification demonstrated highest interobserver reliability (ICC=0.948), followed by the Rorabeck (ICC=0.903), UCS (ICC=0.850) and Chen (ICC=0.906). The Neer classification demonstrated weakest agreement (ICC=0.633). Overall accuracy of predicting DFR requirement (as determined by two experts) was highest for the Fakler system (83.9%). Compared with actual management delivered the Rorabeck system was most accurate (94.1%). Multivariate regression demonstrated that the ultimate need for DFR (n = 22) was independently associated with medial comminution (HR 2.66 (1.12-6.35 95%CI), p = 0.027) and fractures distal to the anterior flange and posterior condyle of the femoral component (HR 2.45 (1.13-5.31), p = 0.024).Conclusion: The Fakler classification showed highest interobserver agreement and was most accurately predictive of the management recommended by two experts. No classification system accurately predicted the fractures that required DFR, and none included medial comminution which was independently associated with DFR requirement. There remains a need for a PDFF classification system that reliably guides operative management of PDFFs. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To observe the effectiveness of participation of pharmacists in pain management of knee replacement under accelerated rehabilitation. METHODS: From Jun. 2018 to Jun. 2021, 120 patients underwent knee replacement in the orthopedics department of the hospital were randomly divided into the observation group and the control group, with 60 cases in each group. The control group received conventional pain management after surgery, while the observation group was given postoperative pain management with the participation of clinical pharmacists. Differences in postoperative pain scores, sleep quality, irrational drug use, adverse drug reactions, length of stay, and hospitalization cost were compared between two groups. RESULTS: The pain score and sleep quality indicators in the observation group were significantly lower than those in the control group from 1 to 7 d after surgery, and the differences were statistically significant (P<0. 05). After surgery, the irrational use rate of analgesics and incidence of adverse drug reactions in the observation group were significantly lower than those in the control group, the differences were statistically significant (P<0. 05). Compared with the control group, the length of stay in the observation group was shortened from (14. 4 ± 4. 2) d to (12. 9 ± 3. 3) d, and the cost of analgesics per capita was reduced from (1 796. 0±779. 7) yuan to (1 030. 3 ± 409. 7) yuan, the differences were statistically significant (P < 0. 05). CONCLUSIONS: Participation of clinical pharmacists in pain management can accelerate the patient recovery, effectively improve the postoperative analgesia and sleep quality, reduce the adverse drug reactions, shorten the length of stay and reduce the hospitalization cost. OBJECTIVE: To observe the effectiveness of participation of pharmacists in pain management of knee replacement under accelerated rehabilitation. METHODS: From Jun. 2018 to Jun. 2021, 120 patients underwent knee replacement in the orthopedics department of the hospital were randomly divided into the observation group and the control group, with 60 cases in each group. The control group received conventional pain management after surgery, while the observation group was given postoperative pain management with the participation of clinical pharmacists. Differences in postoperative pain scores, sleep quality, irrational drug use, adverse drug reactions, length of stay, and hospitalization cost were compared between two groups. RESULTS: The pain score and sleep quality indicators in the observation group were significantly lower than those in the control group from 1 to 7 d after surgery, and the differences were statistically significant (P<0. 05). After surgery, the irrational use rate of analgesics and incidence of adverse drug reactions in the observation group were significantly lower than those in the control group, the differences were statistically significant (P<0. 05). Compared with the control group, the length of stay in the observation group was shortened from (14. 4 ± 4. 2) d to (12. 9 ± 3. 3) d, and the cost of analgesics per capita was reduced from (1 796. 0±779. 7) yuan to (1 030. 3 ± 409. 7) yuan, the differences were statistically significant (P < 0. 05). CONCLUSIONS: Participation of clinical pharmacists in pain management can accelerate the patient recovery, effectively improve the postoperative analgesia and sleep quality, reduce the adverse drug reactions, shorten the length of stay and reduce the hospitalization cost. [ABSTRACT FROM AUTHOR]

This study used knee MR imaging features to quantify the severity of knee injury in patients and analyzed the predictive value of knee MR imaging features in their risk of knee replacement. A total of 120 patients with knee arthritis were included from a public knee arthritis database FNIH OAI. First, univariate logistic regression was used to screen clinical features to obtain the clinical risk factors. Then the minimum redundancy maximum correlation (mRMR) method was used to reduce the image features, and the LASSO method was used to further screen the retained image features to construct a Rad model. Next, the multivariate logistic regression method was used to combine the Rad model and the screened clinical risk factors to construct a combined model and its corresponding nomogram. Finally, ROC curve and its related metrics, Hosmer–Lemeshow test and Delong test were used to evaluate and compare the accuracy and consistency of the model performance. Age and body mass index (BMI) were found as significant clinical risk factors for knee replacement. After using mRMR and LASSO methods, 147 image features were reduced to 30 and 7 features, respectively, then these 7 features were linearly combined to construct the Rad model. Age, BMI, and the Rad model were combined to establish the combined model and its corresponding nomogram. The resulted two models showed high accuracy (AUC ∼ 0. 8) and consistency (H-L test: p > 0. 0 5) on both the training set and test set. Finally, the comparison results showed that the prediction performance of the combined model was better than that of the Rad model, but their difference was not significant (Delong test: p > 0. 0 5). This paper studied the predictive performance of MR imaging features on the risk of knee replacement and built a model that can be used to predict the potential risk of knee replacement in patients with knee arthritis. The resulting models showed good predictive accuracy and consistency. The drawn nomogram could be used as a useful tool to personalize the prognosis of patients with knee arthritis and guide clinical decisions on knee replacement. [ABSTRACT FROM AUTHOR]

Background and Objectives: Numbness, one of the complications after knee replacement (KR), has been studied far less than other complications, and there are few studies on this topic. Without comprehensive research on numbness, there is a need to design a study that includes all relevant parameters. This study investigated the relationship between numbness and pain and neuropathic pain and its impact on functional and emotional life and the functioning of the knee. Materials and Methods: The 105 knees with KRs were divided anteriorly into six regions. Numbness was determined with a pinprick test. Douleur Neuropathique 4 (DN4) and a painDETECT questionnaire (PD-Q) were tested for neuropathic pain. Patients' physical, emotional, and social status and functional knee abilities were assessed with the Short Form (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) test. The relationships between numbness and gender, age, bilaterality, postoperative follow-up time, and incision measures were examined. The binomial logistic regression model was applied to investigate the effects of age, gender, bilaterality, incision length, and postoperative follow-up time on numbness. Results: A total of 88.6% of the patients were female, half had bilateral KRs, and the mean age was 68.3 years. Numbness occurred more frequently in the L3 and L2 areas than in other regions. There was no association with gender, bilaterality, and age, but there was a weak association with postoperative follow-up time. There was a positive correlation between numbness and neuropathic pain. It has been found that there is a significant relationship between numbness and physical function, and it has a negative effect. Emotional health was not significantly associated with numbness. The effect of numbness on social functioning was statistically significant. Knee functioning was measured with the WOMAC, and significant differences were found in the numbness group. Conclusions: According to the results, numbness is considered to be a complication that affects social and physical life and has a negative impact on functional outcomes of the knee. The results show that it should be considered a statistically significant complication. Numbness and its indirect effects should be considered in patients whose follow-up parameters are normal over one year but whose symptoms do not resolve. [ABSTRACT FROM AUTHOR]

Introduction: In recent years, the internet and social media have become the primary source for patients to research their medical conditions. Given the billions of links that result from research, it has become increasingly important how medically high quality the priorities of the search algorithms are. This study aims to examine the medical quality of videos on social media. Material and Method: A new Gmail account was never used, and Facebook, Instagram, Twitter, and YouTube accounts were opened. The word "knee replacement" was searched via social media. The video duration, daily views, total views, number of likes, source, and shared content were recorded. The parameters were statistically evaluated using the scales JAMA, GQS, DISCERN, and VPI to measure the quality of the medical posts. Results: Correlations were found between JAMA, GQS, and DISCERN. No correlation between the VPI scales with other scales was found. It was found that the promotional content in videos other than Instagram was very high (56–70%). Academics and healthcare workers produced greater quality content than other groups. There is a clear dominance of healthcare practitioners on Instagram. The most shared content was informative, depending on the content. The most frequent users were alternative health practitioners. While YouTube had the highest JAMA, GQC, and DISCERN (2.98, 3.18, 37.5) scores, the lowest VPI (0.761) score was found. Discussion and Conclusions: It has been shown that Instagram and Twitter are not the right places to share videos with medical content. However, everyone should remember that Instagram is the best place to share short but popular videos. YouTube and Facebook are available resources to share videos of better medical quality with a higher score than others. We can say that the most reliable medical sources are Facebook and YouTube videos of physicians and medical staff. [ABSTRACT FROM AUTHOR]

Background: Electronic health records (EHRs) have the potential to facilitate consistent clinical data capture to support excellence in patient care, quality improvement, and knowledge generation. Despite widespread EHR use, the vision to transform health care system and its data to a "learning health care system" generating knowledge from real-world data is limited by the lack of consistent, structured clinical data. Objective: The purpose of this paper was to demonstrate the design of a web-based structured clinical intervention data capture system and its evaluation in practice. The use case was ambulatory physical therapy (PT) treatment after total knee replacement (TKR), one of the most common and costly procedures today. Methods: To identify the PT intervention type and intensity (or dose) used to treat patients with knee arthritis following TKR, an iterative user-centered design process refined an initial list of PT interventions generated during preliminary chart reviews. Input from practicing physical therapists and national and international experts refined and categorized the interventions. Next, a web-based, hierarchical structured system for intervention and intensity documentation was designed and deployed. Results: The PT documentation system was implemented by 114 physical therapists agreeing to record all interventions at patient visits. Data for 161 patients with 2615 PT visits were entered by 83 physical therapists. No technical problems with data entry were reported, and data entry required less than 2 minutes per visit. A total of 42 (2%) interventions could not be categorized and were recorded using free text. Conclusions: The use of user-centered design principles provides a road map for developing clinically feasible data capture systems that employ structured collection of uniform data for use by multiple practitioners across institutions to complement and augment existing EHRs. Secondarily, these data can be analyzed to define best practices and disseminate knowledge to practice. [ABSTRACT FROM AUTHOR]

Introduction: Unicompartmental knee arthroplasty (UKA) treats osteoarthritis in one knee compartment, while total knee arthroplasty (TKA) addresses all compartments. The debate focuses on UKA's advantages of quicker recovery and fewer complications versus TKA's lower long-term revision rates, emphasizing the need for thorough outcome evaluations. The aim of the present study is to describe and compare the pain, functional and psychological trajectories during a 6-month postoperative rehabilitation period between total and unicompartmental knee arthroplasties., Materials and Methods: 115 participants who had undergone either TKA or UKA were recruited. Outcome measurements were performed at 1, 4, 12 and 24 weeks post-surgery. Measurements included pain intensity (Visual Analog Scale), range of motion, walking speed (4 m walking test), physical performance (30-s chair stand test), health functioning (Western Ontario and McMaster Universities Osteoarthritis Index), pain catastrophizing (pain catastrophizing scale), fear of movement (Tampa Scale of Kinesiophobia), anxiety and depression (Hospital Anxiety and Depression Scale). A mixed-effects model was used to estimate the influence of type of surgery (either unicompartmental or total knee arthroplasty) to pain, function, and psychological trajectories., Results: Both TKA and UKA groups showed significant improvements across the six-month rehabilitation period except for anxiety symptoms in the TKA group, and fear of movement and depression in the UKA group. Between group analysis revealed that in the acute phase UKA patients showed improved range of motion and TKA patients displayed faster walking speed but higher fear of movement. Overall, the type of surgery does not significantly influence the overall rehabilitation pain, functional and psychological trajectories., Conclusions: Despite differences in the acute phase, there are no differences in pain, functional and psychological trajectories throughout the six-month rehabilitation period. These results should be acknowledged to better inform patients and to improve patient education during the perioperative period., Trial Registration Number: NCT03378440 (2017-12-18), retrospectively registered., Level of Evidence: Level II., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2024. The Author(s).)

Background: There is considerable diversity in arthroplasty follow-up pathways. This qualitative study aimed to understand healthcare professionals' practice and attitude to follow-up, their motivation for change and what evidence they considered before implementing new pathways., Methods: The main UKSAFE study enroled 38 centres providing revision procedures across the United Kingdom. A purposive sample of professional leads and service managers was identified from site contacts. Individual interviews were conducted by telephone, transcribed verbatim and analysed using a theoretical framework derived from current evidence and the data collected in our previous studies., Results: We found that there had been a shift away from bringing patients back into the clinic for repeat follow-up assessments, but that this was not universal, and some centres had long-established care pathways that involved long-term follow-up. The way in which those services were provided might be different or have common features, but centres were likely to face common problems including large patient numbers and funding restraints., Conclusion: The reliability of newer prosthetics and surgical skill has influenced some changes by increasing confidence in a pathway which does not routinely provide long-term follow-up. Service commissioners also have a role to play in how follow-up care pathways are configured, but scrutiny of the ratio of new to follow-up appointments can put pressure on clinical staff to follow-up only patients with identified clinical need. Virtual clinics can provide a service to patients and use scarce resources efficiently, but NHS IT systems that would be needed to support more remote working, for example, telemedicine and plans to collect PROMS data online from patients to assist with monitoring were not advanced., (© 2024 The Author(s). Musculoskeletal Care published by John Wiley & Sons Ltd.)

Introduction: Tibial plateau fractures are complex, peri-articular fractures that can have poor outcomes resulting in conversion to total knee arthroplasty (TKA). This study evaluates the 10-year survival of tibial plateau fractures treated with open reduction and internal fixation and identifies risk factors associated with conversion to TKA., Methods: This retrospective cohort study evaluates the outcomes of 126 patients undergoing tibial plateau ORIF from January 2011 to December 2012 at Glasgow Royal Infirmary. As well as patient factors, radiographic assessments were analysed including the degree of articular depression, medial proximal tibial angle, and femoral width ratio pre-operatively, peri-operatively and at the time of union. Patients requiring further surgical intervention, including TKA, were evaluated further., Results: A bell-shaped distribution of patient age was observed. Schatzker II fractures were most prevalent (48%). Pre-operative articular depression averaged 6.9 mm ranging from 0.0 - 36.0 mm. Operative reduction was generally satisfactory (mean articular depression 1.3 mm, femoral width 0.96, mPTA 89.6⁰), with 82% achieving an anatomical reduction. 12 patients (9.3%) required TKA during follow-up with Kaplan-Meier calculated as 91.9% at 5 years and 87.4% at 10 years. Articular depression > 4 mm (HR = 16.2), femoral width ratio > 1.05 (HR = 14.7) and age > 50 years (HR = 4.2) at time for fracture union were independently associated with progression to TKA., Conclusion: 9.3% of patients required TKA within 10 years of tibial plateau ORIF, Kaplan Meier 10-year survivorship was 87.4%. Joint depression and increased tibial width at time of union and age were independent risk factors associated with need for TKA. Particular care must be taken during operative intervention to ensure adequate reduction to lower this risk., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier B.V. All rights reserved.)

Unicompartmental knee arthroplasty (UKA) offers a more conservative treatment than total knee arthroplasty when osteoarthritis affects only one tibiofemoral knee compartment. Cemented UKA has become the gold standard due to its good functional outcomes and low revision rates. The most common reasons for revision with cemented UKA include aseptic loss, unexplained pain, and radiolucent lines. Cementless UKA, which adds a porous coating of titanium and hydroxyapatite as well as an additional peg on the femoral component, has been shown to reduce the prevalence of radiolucencies compared to cemented UKAs. National registry data have demonstrated comparable functional outcomes and improved revision rates with cementless UKA. This review aims to summarize various advancements in unicompartmental prostheses, and to highlight how the conceptual advantages of the cementless model lead to superior implant survivorship and functional outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The utilization of unicompartmental knee arthroplasty (UKA) has increased worldwide and has become a favourable alternative to total knee arthroplasty (TKA) in patients with isolated single-compartment knee osteoarthritis. With the increase in UKA utilization, there has been an increase in the number of revisions. The two most common causes of revision are the progression of osteoarthritis in other compartments and aseptic loosening with polyethylene wear, with other common causes for revision including periprosthetic fracture, bearing dislocation, infection, instability and unexplained pain. This narrative review will outline how UKA implant design has evolved and specifically outlines important differences in wear biomechanics, survival and clinical outcomes between the most commonly employed implant designs: metal-backed (MB) versus all-polyethylene (AP) and fixed-bearing (FB) versus mobile-bearing (MoB) MB tibial components., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Chloe Scott reports consulting fees from Smith and Nephew. In addition, she reports payment for delivering educational courses for Stryker and DePuy, none of which were related to this study. She is a part of an advisory board for Pfizer. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Unicompartmental knee arthroplasty (UKA) faces significant challenges, including lower survival rates and higher revision rates than total knee arthroplasty (TKA). To address these issues, technological advancements like custom-made implants (CMI), patient-specific alignment (PSA), and computer-assisted systems (CAS) are being explored. These innovations aim to tailor procedures to individual joint morphology, soft tissue balance, and limb alignment, moving away from the traditional "one size fits all" approach. Early studies suggest that CMI may improve survival rates and patient-reported outcomes, though conclusive evidence is lacking. PSA shows potential for restoring pre-surgical alignment; however, its long-term benefits are uncertain. CAS improves implant placement precision and ligament balance; nevertheless, long-term survival data remain inconclusive. Moreover, economic and implementation challenges, such as cost and the need for specialized training, remain underexplored. While promising, further research is needed to fully understand the long-term efficacy and practical application of these technologies in UKA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The impact of acupuncture on knee function and pain intensity following knee replacement remains controversial. Therefore, we categorized the postsurgery recovery period into 3 phases: short-term (≤2 weeks), intermediate-term (2 weeks-3 months), and long-term (>3 months), and then assessed the effectiveness of acupuncture in improving function and alleviating pain at different stages following knee replacement. This meta-analysis included randomized controlled trials that compared acupuncture intervention with either no treatment or a sham group after knee replacement. Six databases were searched from inception to December 31, 2023, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and 2 Chinese databases (Chinese National Knowledge Infrastructure and WanFang Data). A total of 23 studies comprising 1,464 participants were included. Significant improvement of active range of motion was observed on day 7 and week 2 after operation. Lower pain intensity at rest was noted in patients receiving acupuncture in short-term periods after operation (12 hours, day 1, day 2, day 5, and week 2). A reduction in pain intensity during movement with acupuncture was observed on postoperative day 1 and day 7. Auricular acupuncture did not show not significant effectiveness in improving range of motion and pain intensity. For conventional acupuncture, the combination of distal and local point selection was found to be the most effective. Early application of acupuncture, in conjunction with physical therapy, starting before postoperative day 1 or day 2, was recommended. Further high-quality researches are warranted to validate the findings in this meta-analysis. PERSPECTIVE: This article demonstrates that acupuncture has short-term effects (≤2 weeks) on improving active range of motion and reducing pain during rest and during movement following knee replacement surgery. The findings support the early application of acupuncture in hospital settings after knee replacement. REGISTRATION ID: The study was registered on PROSPERO (CRD42024503479)., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)