No evidence of mid-flexion instability after robotic-assisted total knee arthroplasty as assessed by intraoperative pressure sensors.

PURPOSE: Mid-flexion instability has been identified as a cause for dissatisfaction following total knee arthroplasty (TKA). Robotic-assisted surgery using the Mako robot only allows for assessment of stability at 10° and 90°. This study aimed to investigate any evidence of mid-flexion instability in Mako-assisted TKA. METHODS: Data from 72 TKA in 59 patients from 2018 to 2022 were collected. All patients underwent an RA (Mako, Stryker, Fort Lauderdale, FL, USA), single-radius design, cruciate-retaining TKA. Intraoperatively, medial, and lateral pressures were measured at 10°, 45° and 90° of flexion using a pressure sensor (Verasense, OrthoSensor, 59 Inc., Dania Beach, FL, USA). The knee was considered balanced if the difference in pressures between compartments was less than 15 pounds-force (lbf). RESULTS: There was no significant difference between the pressures measured in the medial compartment at 10°, 45° and 90° of flexion (P = 0.696). A statistically significant difference was found between the pressures measured in the lateral compartment at 10°, 45° and 90° of flexion, with the 10° value being significantly higher (P < 0.001), but this did not exceed the threshold of 15 lbf. None of the patients had a pressure difference of more than 15 lbf when pressures at 45° were compared to that at 10° and 90°, medially or laterally. CONCLUSION: This study showed no evidence of mid-flexion instability in Mako-assisted TKA, using a single radius, cruciate-retaining prosthesis whilst maintaining the joint height. LEVEL OF EVIDENCE: Level III retrospective cohort study.

Functionally aligned total knee arthroplasty: A lateral flexion laxity up to 6 mm is safe!

PURPOSE: Loose flexion gaps are associated with poor functional outcomes and instability in total knee arthroplasty (TKA). The effect of a trapezoidal flexion gap in a functionally aligned TKA remains unknown. The aim of this study was to investigate the effect of a larger lateral flexion gap in a robotic-assisted (RA), functionally aligned (FA) and cruciate-retaining (CR) TKA on clinical outcomes. METHODS: Data from 527 TKA in 478 patients from 2018 to 2020 were collected. All patients underwent an RA (MAKO, Stryker), FA and CR TKA. Gap measurements were collected intraoperatively. Patient-reported outcome measures (PROMs), pain Visual analogue score (VAS) and range of motion were collected postoperatively. Patients were also asked about the ease of stair ascent and descent and kneeling on a 5-point scale. The minimum follow-up was 2 years. Patients were stratified into three groups based on lateral flexion laxity. RESULTS: At 2 years postoperatively, the group with a looser gap (3-6 mm) had higher mean PROMs when compared with the group with a gap of 2-3 mm. There were no differences detected in any other outcomes at 2 years. A total of 70.9% of patients in the group with a 3-6 mm gap reported being able to walk down a flight of stairs 'easily', compared with 56.7% in the 2-3 mm group and 54% in the <2 mm group (p = 0.04). CONCLUSION: The study shows that a loose lateral flexion gap in functionally aligned CR TKA does not adversely affect outcomes in the short term. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Re-operation rates of arthroscopic management versus arthrotomy in treatment of septic arthritis of native shoulder joint in adults. A systematic review and meta-analysis.

AIMS: Previous studies have reported concern regarding high reoperation rates when septic arthritis of the native shoulder is treated arthroscopically, compared to open arthrotomy. We aimed to compare re-operation rate between the two strategies. PATIENTS AND METHODS: The review was registered prospectively at PROSPERO, (CRD42021226518). We searched common databases and references lists (8 February 2021). The inclusion criteria included interventional or observational studies of adult patients with a confirmed diagnosis of native shoulder joint septic arthritis and had either arthroscopy or arthrotomy. The exclusion criteria included patients with periprosthetic or post-surgical infections, patients who had atypical infections, and studies that did not report re-operation rate. Cochrane Collaboration's tool for assessing risk of bias (ROBINS-I) was used. RESULTS: Nine studies (retrospective cohort studies) were included that involved 5,643 patients (5,645 shoulders). Mean age ranged from 55.6 to 75.5 years, and follow-up time ranged from 1-41 months. Mean duration of symptoms prior to presentation ranged from 8.3-23.3 days. Metanalysis observed a higher re-operation rate for reinfection at any time point following initial arthroscopy in comparison to arthrotomy, odds ratio 2.61 (95% confidence interval 1.04, 6.56). There was marked heterogeneity (I2 = 78.8%) among studies including surgical techniques and missing data. CONCLUSION: This metanalysis observed a higher reoperation rate in arthroscopy in comparison to arthrotomy for the treatment of native shoulder septic arthritis in adults. The quality of the included evidence is low and the heterogeneity among included studies is marked. Higher quality evidence is still needed that address limitations of previous studies.

Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review.

BACKGROUND: Lauge-Hansen supination external rotation (SER)-type ankle fractures are very common and account for up to 75% of all ankle fractures. Assessing deltoid integrity is key for surgical decision making. Ultrasound has been used recently to assess the integrity of the deltoid ligament and differentiate between SER II and SER IV fractures. The aim of this article is to review the literature for studies assessing the diagnostic accuracy of ultrasound in this group of patients. METHODS: After registering the protocol with PROSPERO, Embase, Ovid MEDLINE, Web of Science Core Collection, and Google Scholar were systematically searched. Studies that satisfied the following inclusion criteria were assessed: (1) Adult patients (>16 years), (2) Acute SER-type ankle fractures assessed within 2 weeks of the injury, (3) Diagnostic accuracy studies. Risk of bias assessment was conducted and a narrative synthesis of the results presented. RESULTS: A total of five studies satisfied our inclusion criteria and were included for review. These had a total of 175 patients studied. All studies showed a sensitivity of 100% and specificity of 90-100% for detecting a complete tear of the deltoid. All papers had a significant risk of bias inherent to the design. Only patients undergoing surgery were exposed to the gold standard of operative intervention. CONCLUSION: Ultrasound scan has shown excellent diagnostic accuracy for detecting complete deltoid ruptures in SER ankle fractures. These results however should be interpreted with caution. Perhaps a different approach is needed to assess the efficacy of ultrasound scans in patient with SER type fractures.

COVID-19 - Changes in the presentation and management of shoulder and elbow trauma in a UK district general hospital orthopaedic department.

INTRODUCTION: COVID-19 has had a significant impact on healthcare systems. We aim to quantify the impact of this outbreak on shoulder and elbow trauma in our institution. METHODS: We prospectively collected data on patients presenting to our hospital with shoulder and elbow injuries during COVID-19. This included the number of attendances to the emergency department, fracture clinic, inpatient admissions and operative treatments. This was compared to a pre-COVID-19 period. We also assessed the efficacy of telephone clinics. RESULTS: There has been a noticeable decrease in the number of emergency department and fracture clinic attendances with upper limb complaints. The number of in-person fracture clinic reviews also decreased, with a reciprocal exponential increase in telephone consultations. We recorded a decrease in the number of shoulder and elbow trauma procedures performed. There was a small increase in the proportion of injuries treated conservatively during COVID-19. Our telephone clinics yielded a diagnosis and management plan in many cases and patient perspective appeared favourable. CONCLUSION: We have noted significant change in the upper limb caseload. Certain injuries have reduced, likely due to COVID-19 lockdown. Moreover, we consider several changes to current practices could be taken forward after the pandemic.

Redeployment of the trainee orthopaedic surgeon during COVID-19: a fish out of water?

Background and purpose - COVID-19 has had a significant impact on health services and the entire healthcare sector, including trauma and orthopaedics, has been compelled to adapt. At the heart of this was the redeployment of the orthopaedic trainees to support "frontline specialties". This paper sheds light on the experience of orthopaedic trainees in redeployment. Methods - In this retrospective study, we asked orthopaedic trainees in the KSS (Kent, Surrey, Sussex) and London Deaneries to complete a survey regarding their experience in redeployment during the COVID-19 outbreak. The study took place in the Kent, Surrey, Sussex, and London regions of the United Kingdom over a period of 8 weeks from 15th of March 2020 until 15th of May 2020. The study was based at East Kent Hospitals University NHS Foundation Trust and participants were recruited from a number of secondary and tertiary care centres across the region. 120 orthopaedic trainees were contacted, working in 21 teaching hospitals. Of these, 40 trainees (30%) from 13 hospitals responded and completed the survey. Results - 50% of the surveyed trainees were redeployed to other specialties. Trainees spent varying amounts of time in the redeployed speciality and gave differing views on how comfortable they felt and how useful they felt the experience was. One-third of trainees experienced symptoms and/or tested positive for COVID-19 and the majority of these were redeployed to other specialties. Interpretation - Orthopaedic training appears to have taken a temporary back seat at this time but trainees have made a significant contribution to reinforcing key front-line specialties in the fight against COVID-19.

Change in practice due to COVID-19 - Early experiences of a United Kingdom district general hospital in trauma & orthopaedics.

COVID-19 is a significant worldwide challenge to many healthcare systems. In Trauma and Orthopaedics, there has been a significant change in the workload but departments have been compelled to change their practice in order to match the demand, as well as respond to the escalating situation of COVID. Some guidance is available on these changes from bodies such as the National Health Service (NHS), Public Health England and the British Orthopaedic Association (BOA). We have implemented certain changes in our university district general hospital trauma and orthopaedic department with regard to staff roles, outpatient and inpatient care and operative protocols. We aim to present some of these changes and their effects on patient care in an attempt to share these with colleagues who may face similar pressures and make some recommendations to help others prepare for a possible second wave of COVID-19.

Management of periprosthetic distal femur fractures using distal femoral arthroplasty and fixation - Comparative study of outcomes and costs.

PURPOSE: Our study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing) in the management of distal femur peri-prosthetic fractures. METHODS: We reviewed our database for patients admitted with peri-prosthetic distal femoral fractures between 2005 and 2013 (n = 61). The patients were stratified into 2 groups based on management method. The Distal Femoral Arthroplasty group (Group A) had 21 patients and the Fixation group (Group B) had 40 patients. Outcome & cost were compared. Minimum follow-up was 3 years. RESULTS: The mean length of stay in group A was 9 days whereas in group B was 32 days. All patients were fully weight bearing by day 3 in group A, compared to a mean of 11 weeks in group B. Mean OKS was 28 and KSS score was 70 in group A compared to 27 and 68 in group B. In group A, there were 2 deaths, 1 superficial infection, and 1 DVT. In group B, there were 6 deaths, 1 failure of fixation, 6 mal-unions, 1 non-union and 2 infections. Overall, the distal femoral arthroplasty procedure costs approximately £9600 and the fixation group costs were on average of £9800. CONCLUSION: Distal femoral arthroplasty appears to provide good clinical results, with comparable overall costs to fixation.

Short-term outcome of unicompartmental knee arthroplasty in the octogenarian population.

PURPOSE: Unicompartmental knee arthroplasty (UKA) provides significant benefits to patients with anteromedial osteoarthritis, with good long-term results. Morbidity and mortality rates are lower, and recovery is quicker. These benefits would be advantageous to the octogenarian population whom carry significant comorbidities. The primary aim was to compare the short-term functional outcome at 2 years of UKA in the octogenarian population against a stratified younger cohort of patients. We hypothesised that the octogenarian population would have equally significant improved patient-reported outcome measures. METHODS: Prospective patient-reported outcome measures, including Oxford Knee Score (OKS), satisfaction rates and Euro-Quol (EQ-5D) scores at 1-year and 2-year post-operative data, were collected and analysed. Three hundred and ninety-five medial Oxford Phase 3 UKA implants were evaluated. Mean follow-up was 4.7 years (range 2.1-7.7). Secondary outcomes including revision rates, length of stay, complications and mortality were recorded. Our patient population was stratified into three cohort groups based on age: 60-69, 70-79 and 80-89 years. RESULTS: The OKS and EQ-5D score improved significantly in all three groups at all post-operative time periods and maintained at 2 years. The OKS at 2 years post-operatively by age was 39.5 (SD 18.6), 39.2 (SD 17.7) and 39.3 (SD 15.9), respectively. No significant difference of implant survival was found between the groups. The overall revision rate was 28/395 (7%). The 90-day mortality in the present series was one patient. CONCLUSION: The 2-year short-term functional outcome, revision rates and satisfaction of UKA in the octogenarian population did not differ statistically from other age groups. LEVEL OF EVIDENCE: III.