Application of virtual reality technology in postoperative rehabilitation following total knee arthroplasty: A scoping review.

BACKGROUND: With the advent of an ageing era, the number of elderly patients undergoing knee joint replacement is increasing. Postoperative long-term standardized functional exercise is a focal point and difficulty in the recovery of joint function for patients after knee replacement. Virtual reality (VR) is increasingly considered a potentially effective option that can provide patients with a relaxed and enjoyable exercise method. OBJECTIVE: The primary objective of the scoping review to systematically evaluates the impact of virtual reality (VR) technology the movement and functional recovery, psychological state, pain levels, and quality of life of patients after total knee arthroplasty (TKA). It summarises and synthesises VR's effects and feasibility in TKA rehabilitation training, offering a scientific basis and reference for the professional advancement of orthopaedic practice nurses and future research in this domain. METHODS: We employed the Joanna Briggs Institute's scoping review guidelines as our methodological framework. The literature search spanned from January 2018 to December 31, 2023, encompassing databases such as PubMed, Web of Science, The Cochrane Library, Embase, CNKI, Wanfang, CQVIP, and the China Biomedical Literature Database. RESULTS: An initial search yielded 2708 articles, with 17 studies meeting the inclusion criteria after stringent screening. The findings indicate that VR equipment primarily comprises VR goggles, handheld controllers, and sensor technology. Interventions typically occurred 3 to 5 times weekly, lasting 20-30 min per session. The principal assessment metrics included pain levels, psychological state, joint function, and quality of life. CONCLUSION: VR technology proves feasible in the rehabilitation of TKA patients, effectively alleviating pain, enhancing psychological states, and improving joint function and quality of life. However, discrepancies exist regarding VR's effect on bolstering lower limb muscle strength. Future research should focus on evidence-based medical practices, optimising VR intervention strategies, developing customised plans tailored to individual patient differences, and potentially extending intervention durations to amplify VR technology's application effects in TKA patient rehabilitation.

The impact of metabolic syndrome on clinical outcomes following total knee arthroplasty in osteoarthritis patients.

Background: Metabolic syndrome (MetS) is a combination of interconnected conditions, including insulin resistance, abdominal obesity, high blood pressure, and abnormal blood lipid levels. The objective of this research was to investigate the impact of MetS on the quality of life and clinical outcomes following total knee arthroplasty (TKA) in patients with osteoarthritis (OA). Methods: A retrospective descriptive study was conducted to enroll OA patients who underwent primary TKA at Zhongda Hospital, Southeast University from January 2015 to August 2019. A total of 83 OA patients who did and 144 (MetS group) who did not have MetS (non-MetS group) were included. An analysis was conducted on the patient's clinical data. Results: The two groups had similar results in terms of lengths of stay (P=0.93), hospital costs (P=0.24), and overall complication rates (P=0.99). There was no significant difference in the average erythrocyte sedimentation rate and C-reactive protein levels between the groups. However, the MetS group exhibited notably lower Hospital for Special Surgery knee scores and Short Form [36] health survey (SF-36) scores compared to the non-MetS group (both P>0.05) during the one-year follow-up period. Conclusions: OA patients who have MetS had significantly worse knee joint function and quality of life after TKA. There are certain constraints in the current research. First, it belongs to a single-center retrospective study. Further study will be necessary to determine the generality of this conclusion. Second, this study is retrospective, and the number of patients included is not large. Third, due to the diverse clinical groups in our hospital, it is challenging to comprehensively document all the clinical data of the patients involved in this study. Forth, this study did not compare the preoperative differences between the two groups, as well as analyze the postoperative improvement changes in depth. We will compare the preoperative and postoperative differences between the two groups in more depth in future large sample studies.

Impact of systemic lupus erythematosus (SLE) on outcomes following aseptic and septic revision total knee arthroplasty: an analysis of the 2005-2018 nationwide inpatient sample.

Systemic lupus erythematosus (SLE) can adversely affect surgical outcomes, and the impact on revision total knee arthroplasty (TKA) outcomes is unclear. This study aimed to explore the impact of SLE on in-patient outcomes of revision TKA. The Nationwide Inpatient Sample (NIS) database from 2005 to 2018 was searched for patients aged ≥ 18 years old who received revision TKA. Patients with and without SLE were propensity score matched (PSM) at a 1:4 ratio. Associations between SLE and in-hospital outcomes were examined using regression analyses. The study included 133,054 patients, with 794 having SLE. After 1:4 PSM, data of 3,970 patients were analyzed (SLE, 794; non-SLE, 3,176). Multivariate-adjusted analyses revealed that SLE patients had a significantly higher risk of postoperative complications (adjusted odds ratio [aOR] = 1.23, 95% confidence interval [CI]: 1.05-1.44, p = 0.011), non-routine discharge (aOR = 1.22, 95% CI: 1.02-1.46, p = 0.028), major blood loss (aOR = 1.19), respiratory failure/mechanical ventilation (aOR = 1.79), acute kidney injury (AKI) (aOR = 1.47), and wound dehiscence (aOR = 2.09). SLE patients also had a longer length of hospital stay (aBeta = 0.31) and greater total hospital costs (aBeta = 6.35) compared to non-SLE patients. Among those with aseptic failure, SLE patients had a significantly higher risk of postoperative complications (aOR = 1.23) and non-routine discharge (aOR = 1.36). SLE is independently associated with worse in-hospital outcomes in patients undergoing revision TKA. This study highlights the importance of heightened vigilance and tailored perioperative management for patients undergoing major surgeries in the background of SLE. Key Points • SLE significantly increases the risk of non-routine discharge, major blood loss, respiratory failure, acute kidney injury, and wound dehiscence, in patients undergoing aseptic and septic revision TKA. • Patients with SLE experience longer hospital stays and higher hospital costs compared to those without SLE. • The study's findings highlight the necessity for healthcare providers to consider the presence of SLE as a critical factor in preoperative planning and postoperative care to improve outcomes in revision TKA patients.

The Investigation of Preoperative Factors Associated With Postoperative Outcomes Following Total Knee Arthroplasty for Osteoarthritis: A Scoping Review.

This study aimed to investigate preoperative factors associated with non-home discharges from acute care hospitals in patients undergoing total knee arthroplasty (TKA) due to osteoarthritis. It was a scoping review focused on patients who received their first unilateral TKA for osteoarthritis. The research targeted observational studies that examined the destinations of patients post-surgery based on preoperative factors, with a literature search conducted in April 2023. Out of 3,255 identified papers, 28 met the eligibility criteria. A total of 26 preoperative factors were identified as potentially related to discharge destinations, including age, gender, comorbidities, and obesity. By selecting an appropriate discharge destination based on preoperative factors, there may be potential for more efficient use of medical resources. Future studies should consider preoperative factors in the context of national healthcare systems and lengths of hospital stay.

Femoral cartilage thickness measured on MRI varies among individuals: Time to deepen one of the principles of kinematic alignment in total knee arthroplasty. A systematic review.

PURPOSE: Kinematically aligned total knee arthroplasty (KA TKA), as a pure resurfacing procedure, is based on matching implant thickness with bone cut and kerf thickness, plus cartilage wear. However, the assumption of a consistent 2 mm femoral cartilage thickness remains unproven. This study aimed to systematically review the available literature concerning magnetic resonance imaging (MRI) assessment of femoral cartilage thickness in non-arthritic patients. Our hypothesis was that cartilage thickness values would vary significantly among individuals, thereby challenging the established KA paradigm of 'one-cartilage-fits-all'. METHODS: Systematic literature searches (Pubmed, Scopus and Cochrane Library) followed PRISMA guidelines. English-language studies assessing distal and posterior femoral cartilage thickness using MRI in non-arthritic adults were included. Studies lacking numerical cartilage thickness data, involving post-operative MRI, considering total femoro-tibial cartilage thickness, or failing to specify the compartment of the knee being studied were excluded. RESULTS: Overall, 27 studies comprising 8170 MRIs were analysed. Weighted mean femoral cartilage thicknesses were: 2.05 ± 0.62 mm (mean range 1.06-2.6) for the distal medial condyle, 1.95 ± 0.4 mm (mean range 1.15-2.5) for the distal lateral condyle, 2.44 ± 0.5 mm (mean range 1.37-2.6) for the posterior medial condyle and 2.27 ± 0.38 mm (mean range 1.48-2.5) for the posterior lateral condyle. DISCUSSION: Femoral cartilage thickness varies significantly across patients. In KA TKA, relying on a fixed thickness of 2 mm may jeopardize the accurate restoration of individual anatomy, leading to errors in implant coronal and rotational alignment. An intraoperative assessment of cartilage thickness may be advisable to express the KA philosophy at its full potential. LEVEL OF EVIDENCE: Level IV.

Surgeon-Applied Stress and a Ligament Tensor Instrument Provide a Similar Assessment of Preresection Flexion Laxity During Robotic Total Knee Arthroplasty.

Background: Robotic-assisted total knee arthroplasty (RA-TKA) allows surgeons to perform intraoperative soft tissue laxity assessments prior to bone resections and is used to alter resections to achieve gap balance. This study compared 2 techniques for flexion gap laxity assessment during RA-TKA. Methods: A prospective study of 50 primary RA-TKAs performed by a single surgeon was conducted between February and October 2023. Following full exposure, anterior tibial dislocation, and osteophyte removal, maximal medial and lateral compartment flexion laxity was quantified to the nearest 0.5 mm by the robotic system using a dynamic, surgeon-applied stress (SURGEON). This data was used to plan a balanced flexion gap by adjusting the femoral component size, rotation, and anterior-posterior translation. Flexion laxity was quantified again after distal femoral and proximal tibial resections using a ligament tensor instrument (TENSOR). These new data were used to plan for the same desired flexion gap using the same variables. Paired-samples t-tests and a simple linear regression were used for analysis. Results: Both methods produced near-identical recommendations for femoral component sizing (mean deviation 0.06 sizes, range -1 to +1 size; P = .569), rotation (deviation mean 1.0°, range -3.0° to +3.0°; P = .741), and anterior-posterior translation (deviation mean 0.13 mm, range -0.5 to +0.5 mm, P = .785). SURGEON femoral component rotation predicted TENSOR rotation (R2 = 0.157; 95% confidence interval = 0.124, 0.633; P = .004). Conclusions: Assessing flexion laxity with a surgeon-applied stress vs a ligament tensor produced near-identical laxity data in RA-TKA, suggesting surgeons may comfortably choose either technique as a reliable method. Level of Evidence: Level III.

Current Evidence Does Not Support the Use of Tibial Stem Extension in Total Knee Arthroplasty of Obese Patients: A Systematic Review.

BACKGROUND: Obesity rates have been increasing globally, leading to a higher incidence of knee osteoarthritis and a surge in primary and revision total knee arthroplasty (TKA). The debate continues on the impact of obesity on TKA success, particularly regarding the use of stemmed tibial components in obese patients. This systematic review aimed to compare the effectiveness of stemmed tibial components versus standard keeled tibial components in obese patients undergoing TKA, hypothesizing that stemmed components would yield better clinical and radiological outcomes. METHODS: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Databases including PubMed, Embase, Scopus, and Web of Science were searched from inception to December 2023. The eligibility criteria were based on the PICO framework; Participants: Patients who have obesity undergoing TKA, Intervention: stemmed TKA, Comparator: standard keeled tibial TKA, Outcome: aseptic loosening, Patient-Reported Outcome Measures (PROMs), and overall revision. Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane risk-of-bias tool for randomized trials. RESULTS: The search yielded 470 studies, with 10 studies (42,533 knees) meeting the inclusion criteria. These studies included three randomized clinical trials and seven retrospective cohorts. The primary outcomes measured were aseptic loosening and overall revision rates, while secondary outcomes included PROMs. Results indicated mixed findings, with some studies suggesting improved outcomes with stemmed components in cases of aseptic loosening and mechanical failure, while others showed no significant difference. The PROMs did not show a significant difference between groups post-TKA. The certainty of the evidence was graded as "very low" using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. CONCLUSION: Current literature does not provide conclusive evidence to support the routine use of stemmed tibial components in TKA for obese patients. The decision to use stem extensions should not solely rely on the patient's obesity status. Further high-quality studies are needed to clarify the role of stemmed components in TKA for this patient population.

Multiplex PCR in septic arthritis and periprosthetic joint infections microorganism identification: Results from the application of a new molecular testing diagnostic algorithm.

Purpose: Pathogen identification is key in the treatment of septic arthritis (SA) and periprosthetic joint infections (PJI). This study evaluates the outcome of the application of a new, score-based SA and PJI diagnostic algorithm, which includes the execution of molecular testing on synovial fluid. Methods: A score-based diagnostic algorithm, which includes serologic and synovial fluid markers determination using multiplex PCR (mPCR) and Next Generation Sequencing (NGS) molecular testing, has been applied to a consecutive series of patients with clinically suspected SA or PJI. Patients with a score ≥6 underwent synovial fluid molecular testing, together with traditional culture, to identify the pathogen and its genetically determined antibiotic resistance. Results: One hundred and seventeen joints in 117 patients (62.5% women; average age 73 years) met the criteria for possible SA/PJI. The affected joint was the knee in 87.5% (joint replacement 66.5%; native joint 21%) and the hip in 12.5% (all replaced joints). 43/117 patients (36.7%) were ultimately diagnosed with SA/PJI. Among the various testing technologies applied, mPCR was the main determinant for pathogen identification in 63%, standard culture in 26%, and mNGS in 11%. Staphylococcus aureus and Enterococcus faecalis were the top two microorganisms identified by mPCR, while Staphylococcus epidermidis was the prevalent organism identified by NGS. mPCR detected the presence/absence of the genetically determined antibiotic resistance of all identified microorganisms. The average timeframe for pathogen identification was 3.13 h for mPCR, 4.5 days for culture, and 3.2 days for NGS. Conclusions: Molecular diagnostic technologies represent an innovative screening for fast microorganism identification when a joint infection is clinically suspected. Level of Evidence: Level IV, case series.

Comparing Different Multimodal Analgesia Protocols for Primary Total Knee Arthroplasty-A Retrospective Cohort Analysis.

Background: Several local regional anesthesia regimes have been described in the literature to reduce post-surgical pain following total knee arthroplasty (TKA), but it is unclear which regime has the best analgetic effect combined with the best motor function. The aim of this study was to determine if patients with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) combined with an adductor canal block (SACB) had less pain, better motor function, and less opioid consumption after TKA than patients with a femoral nerve block (FNB) combined with a popliteal sciatic nerve block (PSB). Methods: In a retrospective cohort analysis, 342 patients following primary TKA were examined; 175 patients were treated with an IPACK combined with a SACB, and 167 patients with a femoral FNB combined with a PSB. The outcome parameters postoperative pain (visual analogue scale (VAS) for mobilization and at rest, functional recovery, opioid consumption, hospital discharge, and complications were analyzed and compared between both groups. Results: The IPACK/SACB group had a higher postoperative need for opioids despite higher doses of ropivacaine compared to the FNB/PSB group, accompanied by higher VAS scores. Patients' satisfaction was equal between the groups. Both groups showed comparable mobilization rates and walking distances following TKA. Conclusions: IPACK/SACB showed equal results compared to FNB/PSB for mobilization rates and patients' satisfaction following TKA without a reduction in opioid consumption.

Mechanically aligned total knee arthroplasty does not yield uniform outcomes across all coronal plane alignment of the knee (CPAK) phenotypes.

PURPOSE: Patient dissatisfaction rates following total knee arthroplasty (TKA) reported in the literature reach 20%. The optimal coronal alignment is still under debate. The aim of this retrospective study was to compare clinical outcomes in different coronal plane alignment of the knee (CPAK) phenotypes undergoing mechanically aligned (MA) TKA. The hypothesis was that knees with preoperative varus arithmetic hip-knee-ankle angle (aHKA) would achieve inferior clinical outcomes after surgery compared to other aHKA categories. Additionally, another objective was to assess CPAK phenotypes distribution in the study population. METHODS: A retrospective selection was made of 180 patients who underwent MA TKA from April 2021 to December 2022, with a 1-year follow-up. Coronal knee alignment was classified according to the CPAK classification. Clinical outcome evaluations were measured using the Knee Society Score (KSS), Oxford Knee Score (OKS), Short Form Survey 12 and Forgotten Joint Score (FJS). Differences in clinical outcomes were considered statistically significant with a p value <0 .05. RESULTS: Patients with varus aHKA achieved significantly inferior outcomes at final follow-up compared to other aHKA categories in KSS pt. 1 (79.7 ± 17.2 vs. 85.6 ± 14.7; p = 0.028), OKS (39.2 ± 9.2 vs. 42.2 ± 7.2; p = 0.019) and FJS (75.4 ± 31.0 vs. 87.4 ± 22.9; p =0 .003). The most common aHKA category was the varus category (39%). The most common CPAK phenotypes were apex distal Types I (23.9%), II (22.8%) and III (13.3%). CONCLUSION: MA TKA does not yield uniform outcomes across all CPAK phenotypes. Varus aHKA category shows significantly inferior results at final follow-up. The most prevalent CPAK categories are varus aHKA and apex distal JLO, with phenotypes I, II and III being the most common. However, their gender distribution varies significantly. LEVEL OF EVIDENCE: Level IV.

Prediction of Distal Femoral and Posterior Articular Surfaces in Total Knee Arthroplasty With Severe Bone Defects Using Computed Tomography-Based Templating Software.

Introduction Optimal repair of the joint line (JL) in total knee arthroplasty (TKA) is critical for knee joint motion reconstruction and ligament balance. Identification of JL may be difficult, particularly in revision or primary cases of severe femoral condylar bone loss. We aimed to define the relationship between the epicondyles and the articular surface (AS) of the femur using computed tomography-based three-dimensional digital templating software. Methods The study included 127 knees with osteoarthritis of the knee below grade 2 on the Kellgren-Lawrence index. A perpendicular line was drawn from the medial and lateral femoral epicondylar processes to the most distal point of the AS, and the distance was measured in the axial and coronal planes. Femoral width was measured as the distance between the medial and lateral epicondyles. All distances described above were converted to a ratio by division with femoral width. Results On the axial plane, the distance from epicondyles to the posterior ASs was 29.4 ± 2.2 mm medially and 21.3 ± 2.1 mm laterally. The width of the distal femur was 75.2 ± 4.2 mm. On the coronal plane, the distances from epicondyles to the distal ASs were 25.2 ± 2.9 mm on the medial side and 21.3 ± 2.5 mm on the lateral side. The ratio of the distance from epicondyles to the distal and posterior ASs divided by the width of the femur was 0.39 ± 0.02, 0.28 ± 0.03, 0.34 ± 0.03, and 0.28 ± 0.03. Conclusions The distance from the epicondyles to the distal and posterior JLs correlates with the distal femur width. These findings may be useful in determining an appropriate JL.

Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

BACKGROUND: Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success. METHODS: This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices. RESULTS: The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care. CONCLUSIONS: Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success.

Effects of implant precoating and fat contamination on the stability of the tibial baseplate.

BACKGROUND: Approximately 5% of primary total knee arthroplasty patients require revision within 10 years, often due to distal component loosening. Application of a thin layer of PMMA cement as precoating on the tibial component aims to prevent aseptic loosening. This study investigates the impact of precoating and fat contamination on tibial baseplate stability. METHODS: Two groups of NexGen® stemmed tibial implants (size 4) were studied: Option implants (N = 12) and PMMA Precoat implants (N = 12). Each implant design was divided into two subgroups, (N = 6), with one subgroup featuring bone marrow fat at the implant-cement interface and the other without contamination. In a mechanical testing machine, the implants underwent uniaxial loading for 20,000 cycles, while recording vertical micromotion and migration of the tibial baseplates. Subsequently, a push-out test assessed fixation strength at the cement interfaces. Results were compared using non-parametric statistics and presented as median and min-to-max ranges. RESULTS: Option implants exhibited higher micromotion in dry conditions compared to precoated implants (p = 0.03). Under contamination, both designs demonstrated similar micromotion values. Fixation strength did not significantly differ between designs under dry, uncontaminated conditions (p > 0.99). However, under contaminated conditions, the failure load for the non-coated Option implant was nearly half that of the uncontaminated counterparts (3517 N, 2603-4367 N vs 7531 N, 5163-9000 N; p = 0.002). Precoat implants displayed less susceptibility to fat contamination (p = 0.30). CONCLUSION: NexGen® implant PMMA precoating might reduce the risk of aseptic loosening and revision surgery in case of eventual bone-marrow fat contamination.

A Novel Infrapatellar Fat Pad Preservation Technique in Total Knee Arthroplasty Reduced Postoperative Pain and Wound Complications.

OBJECTIVE: The management of the infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) remains controversial. This study aimed to evaluate a novel IPFP preservation technique-"the medially pedicled IPFP flap"-for reducing postoperative pain, wound complications, and improving functional recovery after TKA. METHODS: A retrospective analysis was conducted on TKA cases at our institution from 2018 to 2021, including those with IPFP preservation (medially pedicled flap) versus IPFP complete resection. Patient demographics, perioperative parameters (blood loss, operative time, length of hospital stay, visual analogue scale [VAS] score, white cell count [WBC], C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], and wound oozing), and postoperative follow-up data (VAS, Knee Society [KSS], or Knee Society functional assessment [KSFA] scores) were compared between groups. Independent sample t-tests were used to compare continuous data and chi-squared tests were used to compare categorical data between groups. RESULTS: Six hundred thirty patients were included, with 278 in the medial pedicled IPFP flap group (preservation group) and 352 in the IPFP resection group (resection group). The operative time was significantly shorter in the preservation versus resection group (125.5 ± 23.2 vs 130.3 ± 28.7 mins, p = 0.03), as was the length of hospital stay (8.4 ± 2.7 vs 9.2 ± 2.3 days, p < 0.01). Regarding pain, the preservation group had significantly lower VAS scores on postoperative day 2 (2.0 ± 0.8 vs 2.4 ± 1.2, p < 0.001) and day 3 (1.5 ± 0.5 vs 1.8 ± 1.0, p < 0.001). CRP and ESR levels on postoperative day 5 were also significantly lower in the preservation group. Wound oozing rates were significantly lower in the preservation versus resection group (0.7% vs 2.8%, p = 0.04). No significant differences existed in VAS, KSS, or KSFA scores at the last follow-up. CONCLUSION: The novel IPFP preservation technique significantly improved surgical exposure, shortened operative time and length of hospital stay. It also reduced wound pain and oozing compared to IPFP resection.

Total Knee Arthroplasty in Human Immunodeficiency Virus Patients: A Literature Review.

Background: Total knee arthroplasty (TKA) has become a common surgical intervention for human immunodeficiency virus (HIV)-positive patients who develop osteonecrosis of the knee. This paper summarized existing literature regarding the outcomes of HIV-positive patients undergoing TKA in 4 subsections: (1) complications; (2) survivorship analyses; (3) patient-reported outcomes; and (4) infections. Methods: A review of PubMed was performed, searching for articles focused on HIV-positive patients undergoing TKA. There were 6 reports selected, containing 4765 HIV-positive patients, and data regarding the various domains was tabulated and analyzed. To ensure article quality, a methodology score and level of evidence were determined for selected studies. Results: Complication rates for HIV-positive patients were low, with a larger study reporting that 7.8% of HIV-positive patients developed a complication in comparison to 8% of HIV-negative patients. Survivorship analyses showed similar results, with a study reporting implant survivorship of 98% for HIV-positive and 99% for HIV-negative patients. There were no differences in patient-reported outcomes; HIV-positive patients improved from baseline with respect to the mean Knee Society objective and mean Knee Society functional scores, and the University of California, Los Angeles self-reported activity levels. The infection rate for HIV-positive patients was low, with a larger database study reporting that 0.6% of HIV-positive patients developed a wound infection in comparison to 0.4% of HIV-negative patients. Conclusions: A TKA is an effective treatment for HIV-positive patients who develop osteonecrosis of the knee. Results showed similar patient-reported outcomes, implant survivorships, revisions, and complication rates when compared to non-HIV patients.

Ultrasound Evaluation of Subsartorial Spread Following Adductor Canal Block: A Case Series.

Adductor canal block is a widely used regional anesthesia technique for total knee arthroplasty that helps in reducing post-surgical pain and opioid use. Anatomically, the adductor canal extends from the apex of the femoral triangle proximally to the adductor hiatus distally and is roofed by the sartorius and vasto-adductor fascia. All these serve as a potential path for the spread of the local anesthetic when it is injected inside the adductor canal during the block. Subsartorial space is of unique interest as it lies between the sartorius and vasto-adductor fascia, carrying the subsartorial plexus that can provide additional analgesia to the knee when the adductor canal block injectate spreads into it. While the spread can be variable, ultrasound can be a useful tool to evaluate this spread. This is a case series of patients who underwent total knee arthroplasty under spinal anesthesia and adductor canal blocks. We present the findings of ultrasound evaluation of the injectate spread following adductor canal blocks and evaluation of their analgesia effects.

Tranexamic acid may benefit patients with preexisting thromboembolic risk undergoing total joint arthroplasty: a systematic review and meta-analysis.

Purpose: This study sought to determine if the use of tranexamic acid (TXA) in preexisting thromboembolic risk patients undergoing total joint arthroplasty (TJA) was linked to an increased risk of death or postoperative complications. Methods: We conducted a comprehensive search for studies up to May 2023 in PubMed, Web of Science, EMBASE, and the Cochrane Library. We included randomized clinical trials, cohort studies, and case-control studies examining the use of TXA during TJA surgeries on high-risk patients. The Cochrane Risk of Bias instrument was used to gauge the excellence of RCTs, while the MINORS index was implemented to evaluate cohort studies. We used mean difference (MD) and relative risk (RR) as effect size indices for continuous and binary data, respectively, along with 95% CIs. Results: Our comprehensive study, incorporating data from 11 diverse studies involving 812 993 patients, conducted a meta-analysis demonstrating significant positive outcomes associated with TXA administration. The findings revealed substantial reductions in critical parameters, including overall blood loss (MD = -237.33; 95% CI (-425.44, -49.23)), transfusion rates (RR = 0.45; 95% CI (0.34, 0.60)), and 90-day unplanned readmission rates (RR = 0.86; 95% CI (0.76, 0.97)). Moreover, TXA administration exhibited a protective effect against adverse events, showing decreased risks of pulmonary embolism (RR = 0.73; 95% CI (0.61, 0.87)), myocardial infarction (RR = 0.47; 95% CI (0.40-0.56)), and stroke (RR = 0.73; 95% CI (0.59-0.90)). Importantly, no increased risk was observed for mortality (RR = 0.53; 95% CI (0.24, 1.13)), deep vein thrombosis (RR = 0.69; 95% CI (0.44, 1.09)), or any of the evaluated complications associated with TXA use. Conclusion: The results of this study indicate that the use of TXA in TJA patients with preexisting thromboembolic risk does not exacerbate complications, including reducing mortality, deep vein thrombosis, and pulmonary embolism. Existing evidence strongly supports the potential benefits of TXA in TJA patients with thromboembolic risk, including lowering blood loss, transfusion, and readmission rates.

Analysis of the Initial Learning Curve for Robotic-Assisted Total Knee Arthroplasty Using the ROSA® Knee System.

Background/Objectives: Total knee arthroplasty (TKA) is a frequent procedure in orthopedic surgery. Advances in TKA include the development of robotic-assisted systems. Training in raTKA entails a learning curve to achieve proficiency comparable to conventional manual TKA (maTKA). Methods: We conducted a prospective study of the learning curve in raTKA using the Robotic Surgical Assistant (ROSA) Knee System. The study included 180 patients (90 raTKAs; 90 maTKAs) and three surgeons (one with >15 years of experience in maTKA). The cumulative sum control chart method (CUSUM) was used to define the transition from the learning phase to the mastered phase in raTKA. Results: The learning curves were 43 cases (experienced surgeons) and 61 cases (all surgeons). Mean operative times for both phases in raTKA were longer than in maTKA (p < 0.001). In raTKA, operative times in the learning phase were longer compared to those in the mastered phase (p < 0.001). Operative times in the learning and mastered phases for all surgeons in raTKA were significantly longer compared to those in maTKA (p < 0.001); however, operative times of the experienced surgeon in the mastered phase of raTKA and in maTKA showed no differences. Conclusions: The learning curve in raTKA is dependent upon the surgeon's previous experience in maTKA.

2-Octyl-Cyanoacrylate Mesh Dressings for Total Joint Arthroplasty: Dressing Design Influences Risks of Wound Complications.

BACKGROUND: Recent liquid adhesive skin closure systems with a mesh patch and a 2-octyl cyanoacrylate liquid formula have shown promising results in total joint arthroplasty. Chemical accelerators are typically included to promote the rapid polymerization of 2-octyl cyanoacrylate. The goal of the study is to distinguish designs and wound complication differences between 2 similar systems. METHODS: An 18-week retrospective study was conducted from July to December 2023, including 207 total hip arthroplasty and 212 total knee arthroplasty cases from 4 attending surgeons at 1 institution that used 1 of 2 dressing designs. Both dressings had a 2-octyl cyanoacrylate liquid adhesive formula that applied topically to a polyester-based mesh overlaying the wound. Mesh A (used in 274 cases) included an accelerator, a quaternary ammonium salt, on the mesh patch, whereas Mesh B (used in 145 cases) included a similar accelerator within the adhesive applicator. RESULTS: Wound complications (3.2 versus 7.6%; X2 = 3.86; df = 1; P = .049), early periprosthetic joint infections (0 versus 2.8%; X2 = 7.63; df = 1; P = .006), and 90-day reoperations for wound complications (0.4 versus 3.4%; X2 = 6.39; df = 1; P = .011) were significantly lower in patients who received Mesh A versus B, respectively. There was no difference in superficial surgical site infections (0.7 versus 0%; X2 = 1.06; df = 1; P = .302) or allergy rates (3.3 versus 4.1%; X2 = 0.12; df = 1; P = .655) between Mesh A and B. CONCLUSIONS: We observed significantly different performance in wound complications, early postoperative periprosthetic joint infections, and 90-day reoperation between the 2 designs. Having the accelerator in the applicator rather than on the mesh patch may lead to premature polymerization before bonding appropriately with the mesh to create the desired wound closure and seal. LEVEL OF EVIDENCE: Level III.

Adductor Canal Block Versus Local Infiltration Analgesia for Postoperative Pain Management in Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a common surgical procedure for patients with knee osteoarthritis, often associated with postoperative pain. Effective pain management strategies are essential for improving patient outcomes and satisfaction. This study aimed to compare the efficacy of two analgesic modalities, local infiltration analgesia (LIA) and adductor canal block (ACB), in providing postoperative pain relief for patients undergoing TKA. METHODS: This prospective randomized comparative study included 60 patients undergoing TKA for knee osteoarthritis under subarachnoid block (spinal anaesthesia). Patients were divided into two groups: LIA group (local wound infiltration with periarticular injection of bupivacaine 0.125% + dexmedetomidine 1 mcg/kg) and ACB group (ACB with bupivacaine 0.125% + 1 mcg/kg dexmedetomidine). Pain relief was assessed using the Numerical Rating Scale (NRS) score, time to first rescue analgesic requirement (NRS > 3), and total amount of analgesic needed in the first 24 hours post-surgery. RESULTS: The time to first perception of pain with NRS > 3 was 11.30±0.8 hours in the ACB group and 9.40 ± 1.1 hours in the LIA group, with a statistically significant difference (p < 0.001). Additionally, the total number of rescue analgesic doses given in the first 24 hours post-operatively differed significantly between the two groups (p = 0.046). CONCLUSION: The study concludes that ACB is an effective postoperative analgesic modality, superior to local infiltration analgesia, for patients undergoing TKA.