Effectiveness of virtual reality compared to video training on acetabular cup and femoral stem implantation accuracy in total hip arthroplasty among medical students: a randomised controlled trial.

PURPOSE: Virtual reality (VR) training effectiveness in improving hip arthroplasty surgical skills requires further evaluation. We hypothesised VR training could improve accuracy and the time taken by medical students compared to a control group with only video teaching. METHODS: This single-centre randomized controlled clinical trial collected data from March to June 2023. Surgically naïve volunteer undergraduate medical students performed three sessions on a VR training platform, either cup (VR-Cup=Control-Stem) or stem (VR-Stem=Control-Cup) implantation. The primary outcome was the mean difference between predefined cup inclination (60°) and stem anteversion (20°) compared to the actual implanted values in sawbones between VR and control groups. Secondary outcomes were task completion time and mistake number between the groups. RESULTS: A total of 101 students participated (VR-Cup 47, VR-Stem 54). Groups did not significantly differ concerning age (p = 0.879), gender (p = 0.408), study year (p = 0.938), previous VR use (p = 0.269) and baseline medical and procedural knowledge. The VR-Cup implanted the cup closer to the intended target (p < 0.001) and faster than the Control-Cup group (p = 0.113). The VR-Stem implanted the stem closer to the intended target (p = 0.008) but not faster than the Control-Cup group (p = 0.661). Stem retroversion was commoner in the Control-Stem than in the VR-Stem group (p = 0.016). CONCLUSIONS: VR training resulted in higher rates of accurate procedure completion, reduced time and fewer errors compared to video teaching. VR training is an effective method for improving skill acquisition in THA. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05807828.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review.

PURPOSE: Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data. METHODS: Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs. RESULTS: One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies. CONCLUSIONS: This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

The ROSA knee robotic system demonstrates superior precision in restoring joint line height and posterior condylar offset compared to conventional manual TKA: a retrospective case-control study.

PURPOSE: Variations in total knee arthroplasty (TKA) joint line height may lead to complications such as pain and altered joint mechanics, while posterior condylar offset (PCO) can influence knee stability. METHODS: Single-centre, single-surgeon retrospective analysis from December 2019 to May 2023 investigated primary unilateral TKA (Nexgen Legacy, Zimmer Biomet) in patients with knee osteoarthritis, using ROSA robotic system (raTKA) or conventional manual technique (mTKA). Joint line height and PCO were measured and compared in 182 raTKA and 144 mTKA patients. RESULTS: The groups were matched in age (p = 0.847) and sex distribution (p = 0.2). Excellent interobserver agreement (ICC ≥ 0.9). RaTKA mean joint line height difference was - 0.0001 mm (± 3.48, 95% CI - 0.509, 0.509) (p = 0.523), - 0.951 mm for mTKA (± 4.33, 95% CI - 1.664, - 0.237) (p = 0.009). RaTKA mean PCO difference was 0.52 mm (± 2.45, 95% CI 0.160, 0.880) (p = 0.005), 1.15 mm for mTKA (± 4.01, 95% CI - 1.496, 1.818) (p < 0.001). Mean difference in joint line height of 0.95 mm between groups was significant (p = 0.027), and for PCO, it was 0.63 mm, demonstrating tendency towards significance (p = 0.08). Mean absolute value in joint line height difference between groups was not significant (p = 0.235) but highly significant for PCO (p < 0.001). CONCLUSION: The ROSA knee robotic system can more accurately restore joint line height and PCO compared to conventional manual TKA. The improved degree of precision raTKA offers may be a vehicle for better Patient-Reported Outcome Measures, but further correlational studies are required.

The learning curve to ROSA: cases needed to match the surgery time between a robotic-assisted and a manual primary total knee arthroplasty.

PURPOSE: Limited published data regarding the ROSA (Robotic Surgical Assistant) learning curve exist. This study evaluated the number of cases needed for an expert orthopaedic surgeon to master the ROSA system and match the operative time of robotic (raTKAs) and manual primary total knee arthroplasties (mTKAs). METHODS: This retrospective comparative cohort study included two hundred patients with primary knee osteoarthritis. The study group consisted of an expert surgeon's first 100 raTKAs. The control group included 100 patients that underwent mTKAs from the same surgeon during the same period. The consecutive cases in each group were divided into ten subgroups, each of 10 cases. The groups were comparable concerning age, sex, BMI and Kellgren-Lawrence classification. We compared each subgroup's operative time and complications in mTKA and raTKA groups. We performed a cumsum analysis to construct the ROSA learning curve. RESULTS: The first non-significant difference between the mTKAs and raTKAs operative times was observed in the subgroup of 62 to 71 cases. Till then, the operative time has been significantly lower for the mTKA than the raTKA group. The following groups of tens analysis (8th, 9th and 10th) showed no operative time difference between groups. The learning curve analysis demonstrated that the surgeon switched to the mastering phase from case 73 onwards. The two groups had no complication rate differences. CONCLUSION: Our study demonstrated that about 70 cases are necessary for a senior surgeon to balance operative time between mTKAs and raTKAs using the ROSA system.

Comparative outcomes between a new robotically assisted and a manual technique for total knee arthroplasty in patients with osteoarthritis: a prospective matched comparative cohort study.

PURPOSE: Studies comparing clinical outcomes between manual (mTKA) and robotic-assisted TKA (raTKA) are limited. This prospective comparative cohort study aimed to compare early postoperative outcomes, satisfaction, and patient-reported outcome measures (PROMS) between patients undergoing mTKA and ROSA raTKA (Zimmer Biomet, Warsaw, IN) performed by one surgeon. METHODS: Thirty ROSA raTKAs and 30 mTKAs performed by one surgeon during 2020-2021 were prospectively evaluated. Groups were matched for age, sex, and body mass index. All procedures were primary unilateral TKAs using the same posterior-stabilized prosthesis (Nexgen Legacy, Zimmer Biomet, Warsaw, IN). Length of hospital stay (LOS) and blood transfusion rate were recorded. Complications, visual analogue scale score (VAS), and Oxford Knee Score (OKS) were assessed preoperatively and for six postoperative months. The Forgotten Joint Score (FJS) and patient satisfaction were evaluated 6 months postoperatively. RESULTS: No complications and similar blood transfusion rate were recorded between groups (p = 0.228). The LOS was non-significantly shorter in raTKA than in the mTKA group (p = 0.120). Mean preoperative and third-month OKS and VAS scores were comparable between groups. However, the mean 6-month OKS (p = 0.006) and VAS score (p = 0.025) were significantly better for the raTKA group. The 6-month FJS was significantly greater for raTKA than the mTKA group (p < 0.001). One patient was unhappy in raTKA, and three in the mTKA group (p = 0.301). Significantly more raTKA patients answered that they would undergo surgery again (p = 0.038). CONCLUSION: raTKA was associated with the same complication risk, less pain level, better patient satisfaction, and PROMs on 6-month follow-up than the mTKA group.

Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA. METHODS: A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I2-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies. RESULTS: Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I2 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I2 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I2 42.99%). CONCLUSION: Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.

A roadmap to develop clinical guidelines for open surgery of acute and chronic tears of hip abductor tendons.

PURPOSE: Abductor tendon tears are increasingly recognised as a common cause of lateral hip pain. Surgical treatment of these tears has been recommended, but the indications and types of open surgery have not been precisely elucidated yet. This manuscript aimed to critically review the literature concerning all open treatment options for this condition while identifying knowledge gaps and introducing a treatment algorithm. METHODS: Literature search was conducted, including PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE from 2000 to May 2020. Inclusion criteria were set as: (i) clinical studies reporting outcomes following open surgical treatment of acute or chronic hip abductor tendon tears, (ii) studies reporting an open direct or augmented suturing or muscle transfer procedure, (iii) acute or chronic tears found in native or prosthetic hips. RESULTS: A total of 34 studies published between 2004 and 2020 were included. The vast majority of studies were uncontrolled case series of a single treatment method. A total of 970 patients (76% women) with an age range between 48 and 76 years were involved. Women between 60 and 75 years old were most commonly treated. Preoperative evaluation of patients and reporting of open surgical technique and outcomes are inconsistent. All studies reported variable improvement of pain, functional outcomes and gait of patients. Overall, complication rates ranged from 0 to 31.2%. CONCLUSION: The current literature on this topic is highly heterogeneous, and the overall level of the available evidence is low. A roadmap to develop practical guidelines for open surgery of acute and chronic tears of abductor tendons is provided. The anatomy and chronicity of the lesion, the extent of fatty infiltration and neurologic integrity of hip abductor muscles may influence both treatment choice and outcome. Further high-quality studies with standardisation of preoperative evaluation of patients and reporting of outcomes will help delineate best treatments. LEVEL OF EVIDENCE: IV.

Type 2 Diabetes Mellitus is Associated with Increased Risk of Sarcopenia: A Systematic Review and Meta-analysis.

Diabetes mellitus (DM) is associated with an increased risk of fractures, mainly due to impaired bone architecture and microvascular complications. Whether DM is also associated with increased risk of sarcopenia is not yet known, with studies yielding inconclusive results. The aim of this study was to systematically review and synthesize the best available evidence regarding the association between DM and sarcopenia risk. A comprehensive search was conducted in PubMed, CENTRAL and Scopus databases. Data are expressed as odds ratio (OR) with 95% confidence intervals (CI). The I2 index was employed for heterogeneity. Only studies which had implemented at least two of the three criteria for sarcopenia diagnosis (low muscle mass, muscle strength and/or muscle performance), as defined by the international studying groups, were included. Fifteen studies fulfilled eligibility criteria, yielding a total of 1832 patients with type 2 DM (T2DM) and 1159 cases of sarcopenia. Patients with T2DM demonstrated a higher risk of sarcopenia compared with euglycemic subjects (OR 1.55, 95% CI 1.25-1.91, p < 0.001; I2 34.6%). This risk remained significant when analysis was restricted to studies matched for age and sex. Sarcopenia risk was independent of disease definition or study design. Notably, T2DM patients presented lower muscle performance and strength compared with euglycemic subjects, whereas no difference in muscle mass was observed between groups. Patients with T2DM have an increased risk of sarcopenia compared with euglycemic subjects.

Genetic Predisposition to Developmental Dysplasia of the Hip.

BACKGROUND: The etiopathogenesis of developmental dysplasia of the hip (DDH) has not been clarified. This systematic review evaluated current literature concerning all known chromosomes, loci, genes, and their polymorphisms that have been associated or not with the prevalence and severity of DDH. METHODS: Following the established methodology of Meta-analysis of Observational Studies in Epidemiology guidelines, MEDLINE, EMBASE, and Cochrane Register of Controlled Trials were systematically searched from inception to January 2019. RESULTS: Forty-five studies were finally included. The majority of genetic studies were candidate gene association studies assessing Chinese populations with moderate methodological quality. Among the most frequently studied are the first, third, 12th,17th, and 20th chromosomes. No gene was firmly associated with DDH phenotype. Studies from different populations often report conflicting results on the same single-nucleotide polymorphism (SNP). The SNP rs143384 of GDF5 gene on chromosome 20 demonstrated the most robust relationship with DDH phenotype in association studies. The highest odds of coinheritance in linkage studies have been reported for regions of chromosome 3 and 13. Five SNPs have been associated with the severity of DDH. Animal model studies validating previous human findings provided suggestive evidence of an inducing role of mutations of the GDF5, CX3CR1, and TENM3 genes in DDH etiopathogenesis. CONCLUSION: DDH is a complex disorder with environmental and genetic causes. However, no firm correlation between genotype and DDH phenotype currently exists. Systematic genome evaluation in studies with larger sample size, better methodological quality, and assessment of DDH patients is necessary to clarify the DDH heredity. The role of next-generation sequencing techniques is promising.

The Outcome of 69 Recemented Hip Femoral Prostheses Performed by One Surgeon 22-40 Years Ago.

BACKGROUND: There is a lack of long-term data on cement-in-cement technique in revision of failed hip femoral stem. METHODS: We present the outcome of 69 consecutive recemented femoral prostheses, performed by one surgeon (GH) 22-40 years ago. Four patients (4 hips) were lost to follow-up. Sixty-three patients (65 hips) were followed for their lifetime or until the time of the preparation of the study. The study population consisted of 18 failed hemiarthroplasties and 47 failed total hip arthroplasties. RESULTS: The 23-year probability of survival for the recemented femoral components, with re-revision for any reason and resection arthroplasty as the end point, was 73.6% (61.8%-85.4%) and, with re-revision for aseptic loosening as the end point, was 82.2% (71.4%-93%). CONCLUSION: Our follow-up study at 22-40 years, after recemented hip femoral prostheses, shows that recementing works well in selected cases.

The effect of smoking on clinical and radiographic variables, and acute phase reactants in patients with ankylosing spondylitis.

To investigate the association between smoking and clinical, inflammatory and radiographic parameters in patients with ankylosing spondylitis (AS). One hundred and six tumour necrosis factor inhibitor naïve patients with AS were included in the study. The erythrocyte sedimentation rate, C-reactive protein, Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI) and modified Stroke AS Spine Score (mSASSS) were assessed cross-sectionally for each patient. Smoking history was obtained, and smoking pack years were calculated. Current smokers had significantly higher BASDAI (p < 0.001) and a trend for higher BASFI (p = 0.059). Ever smokers had significantly higher BASFI (p = 0.035) and a trend for higher mSASSS (p = 0.063) compared to never smokers. Pack years (smoking intensity) were positively correlated with duration of inflammatory back pain (r = 0.628, p < 0.001), BASFI (r = 0.443, p < 0.001) and mSASSS (r = 0.683, p < 0.001). Multivariate regression analyses showed that current smoking was independently associated with a higher BASDAI score [regression coefficient (B) = 14.75, p < 0.001] and increasing pack years were independently associated with higher mSASSS (B = 0.26, p = 0.005). In patients with AS, current smoking was strongly and independently associated with higher disease activity, and cumulative smoking exposure with more radiographic spinal damage. In AS smokers, smoking cessation should be strongly recommended.

Collared versus collarless hydroxyapatite-coated stems for primary cementless total hip arthroplasty; a systematic review of comparative studies. Is there any difference in survival, functional, and radiographic outcomes?

INTRODUCTION: This systematic review aims to critically assess the literature comparative studies investigating collared and collarless Corail stem in primary total hip arthroplasty (THA) to find differences in revision rates, radiographic and clinical outcomes, and postoperative complications between these two types of the same stem. METHODS: Eligible studies were found by searching PubMed, Science Direct/Scopus, and the Cochrane Database of Systematic Reviews from conception till May 2023. The PRISMA guidelines were followed. The investigation encompassed randomized controlled trials, case series, comparative, cohort, and observational studies that assessed at least one comparative outcome or complication between collared and collarless Corail stems. RESULTS: Twelve comparative studies with 90,626 patients undergoing primary THA were included. There were 40,441 collared and 58,543 collarless stems. The follow-up ranged from 12 to 360 months. Our study demonstrated no significant difference in stem revision relative risk (RR = 0.68; 95% confidence interval (CI), 0.23, 2.02; p = 0.49), number of radiolucent lines (RR = 0.3; 95% CI, 0.06, 2.28; p = 0.29) and overall complication risk (RR = 0.62; 95% CI, 0.22, 1.76; p = 0.37) between collared and collarless stems. The collared stems demonstrated significantly lesser subsidence (mean difference: 1.01 mm; 95% CI, -1.77, -0.25; p = 0.009) and risk of periprosthetic fractures (RR = 0.52; 95% CI, 0.29, 0.92; p = 0.03). CONCLUSION: The comparative studies between collared and collarless stem groups showed similar survival and overall complication rates and functional outcomes. The similar revision rates between groups make the impact of higher subsidence for collarless stems uncertain. The lower risk of periprosthetic fractures in the collared stems group must be clarified further but could be related to increased rotational stability.

Acetabular Reconstruction in a Rare Case of Ligamentum Teres Tenosynovial Giant Cell Tumour (TGCT) Causing Extensive Destruction.

Tenosynovial giant cell tumour (TGCT), previously called pigmented villonodular tenosynovitis (PVNS), is a rare benign, locally aggressive condition that primarily affects the synovial lining of large joints, such as the knee, the hip, and the ankle. TGCT of the hip joint is a relatively scarce entity, and its diagnosis is often challenging. This article reports a case of TGCT affecting the left acetabulum, the left femoral head, and the ligamentum teres of the hip joint in a 39-year-old woman who presented to our clinic three months after the onset of symptoms. The patient underwent a biopsy, computer tomography (CT), and magnetic resonance imaging (MRI). All tests were inconclusive. Total hip arthroplasty (THA) was subsequently performed, leading to healing of the lesion previously present. Following surgery, a second biopsy classified this lesion as TGCT. By sharing our experience with this rare manifestation, we aim to contribute to the growing body of knowledge on the diagnosis and management of TGCT, specifically when it occurs in the hip joint.

Primary Staged Bilateral Total Hip Arthroplasty in a Patient With Short Stature and Hartofilakidis Type I Developmental Dysplasia of the Hip.

Syndromes associated with osteochondrodysplasia, short stature, and DDH are rarely reported in the literature. Total hip arthroplasty (THA) in such cases is a complex procedure with a high rate of complications and difficulties. In this case report, we describe the staged bilateral complex primary THA of a patient with the rare occurrence of a syndrome involving osteochondrodysplasia and DDH, highlighting the surgical challenges and importance of the right prosthesis selection.

Complex Primary Total Knee Arthroplasty in a Young Patient With Neurofibromatosis Type One and Multidirectional Knee Instability: Technical Tips and Outcome.

Neurofibromatosis is an inherited disorder that causes skin discoloration and tumors. The musculoskeletal symptoms are specific, including bone deformities, dysplasia, joint instability, and osteoporosis. We present a rare case of a young patient with neurofibromatosis and multidirectional knee instability who underwent a successful complex primary knee replacement surgery. Stress right knee radiographs showed global joint instability with permanent anterior knee dislocation, excessively hypoplastic femoral condyles and patella, joint surfaces incongruency, and hypoplastic varus tibia, with intraluminal midshaft bone bridge causing severe stenosis. The patient could not walk, had an unstable recurvatum right knee, and used a wheelchair for her professional activities. The surgery involved a fully cemented rotating-hinged total knee arthroplasty with tibial and femoral stems. After three years of follow-up, the patient remains pain-free, fully ambulatory with no walking aids, a stable knee, a full range of motion, and no signs of aseptic loosening. This case highlights the decision-making difficulties and the significant surgical challenges faced during the operation.