Mako versus ROSA: comparing surgical accuracy in robotic total knee arthroplasty.

There is increasing adoption of robotic surgical technology in Total Knee Arthroplasty. The ROSA® knee system can be used in either image-based mode (using pre-operative calibrated radiographs) or imageless modes (using intra-operative bony registration). The Mako knee system is an image-based system (using a pre-operative CT scan). This study aimed to compare surgical accuracy between the ROSA and Mako systems with specific reference to joint line height, patella height, posterior condylar offset and tibial slope. This was a retrospective review of a prospectively collected data of the initial 50 consecutive ROSA TKAs and the initial 50 consecutive Mako TKAs performed by two high-volume surgeons. To determine the accuracy of component positioning, the immediate post-operative radiograph was reviewed and compared with the immediate pre-operative radiograph with regards to joint line height (JLH), patella height (PH), tibial slope (TS) and posterior condylar offset (PCO). Mean difference between pre- and post-operative radiographs using the ROSA knee system of joint line height was 0.47 mm (SD 0.95) posterior condylar offset 0.16 mm (SD 0.76), tibial slope 0.9 degrees (SD 1.6) and patella height 0.01 (SD 0.05). Mean difference using the MAKO knee system of joint line height was 0.26 (SD 1.08), posterior condylar offset -0.26 mm (SD 0.78), tibial slope 1.8 degrees and patella height 0.03. No significant difference was demonstrated between the accuracy of component positioning of the ROSA or MAKO knee systems. Our study is the first study to compare the accuracy of the ROSA and MAKO knee systems in total knee arthroplasty. Both systems are highly accurate in restoring native posterior condylar offset, joint line height, tibial slope and patella height in TKA with no significant difference demonstrated between the two groups.

The ROSA robotic-arm system reliably restores joint line height, patella height and posterior condylar offset in total knee arthroplasty.

INTRODUCTION: There is growing interest in the use of robotic TKA to improve accuracy of component positioning in Total Knee Arthroplasty (TKA). The aim of this study was to investigate the accuracy of implant component position using the ROSA® knee system with specific reference to Joint Line Height, Patella Height and Posterior Condylar Offset (PCO). METHODS: This was a retrospective review of a prospectively-maintained database of the initial 100 consecutive TKAs performed by a high volume surgeon using the ROSA® knee system. Both the image-based and imageless workflow were used and two prosthesis types were implanted. To determine the accuracy of component positioning, the immediate post-operative radiograph was reviewed and compared with the immediate pre-operative radiograph with regards to Joint Line Height, Patella Height and Posterior Condylar Offset. RESULTS: 100 consecutive patients undergoing TKA using the ROSA system were included; mean age 70 years (range 49-95 years). Mean change in joint line height was 0.2 mm, patella height (Insall-Salvati ratio) 0.01 and posterior condylar offset 0.02 mm; there was no statistically significant difference between the pre and post-operative values. No difference was demonstrated between image-based or imageless workflows, or between implant design (Persona versus Vanguard) regarding joint line height, patella height and PCO. CONCLUSION: This study validates the use of the ROSA® knee system in accurately restoring Joint Line Height, Patella Height and Posterior Condylar Offset in TKA surgery. No significant differences were found between imageless and image-based groups, or between implant designs (Persona versus Vanguard).

Robotic technology in total knee arthroplasty.

Key factors for successful total knee arthroplasty include accurate implant positioning with precise tibial and femoral resection, combined with appropriate soft tissue balancing to achieve the desired alignment. Robotic-assisted total knee arthroplasty allows surgeons to execute pre-planned strategies with precision, with growing evidence suggesting that robotic-assisted-total knee arthroplasty reduces radiological outliers. This has yet to be proven to translate into long-term improvements in patient-reported outcomes and implant survivorship. Robotic-assisted-total knee arthroplasty systems can be divided into fully autonomous and semi-autonomous systems. While fully autonomous systems showed initial promise, semi-autonomous systems are gaining popularity with encouraging early outcomes suggesting improved radiological and clinical outcomes, although concerns remain regarding a significant learning curve, installation costs, radiation exposure and cost associated with preoperative imaging. The future of total knee arthroplasty seems certain to involve robotic technology, although to what degree and in what capacity will depend on further high-quality studies assessing long-term outcomes, complications, survivorship and cost-benefit analyses.

The Environmental Impact and Sustainability of Total Hip and Knee Arthroplasty.

Background: Operating room waste is disposed of in landfill sites, recycled, or undergoes costly, energy-intensive incineration processes. By assessing the quantity and recyclability of waste in primary hip (THA) and knee arthroplasty (TKA), we aim to identify strategies to improve sustainability. Methods: A prospective waste audit of 15 primary THA and 16 primary TKA cases was conducted at a tertiary orthopedic hospital between April and July 2022. Waste was categorized into nonhazardous, hazardous, recycling, sharps, and linens. Each category was weighed. Items disposed as nonhazardous waste were cataloged for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined using packaging. Results: Average total waste generated for THA and TKA was 14.46 kg and 17.16 kg, respectively. TKA generated significantly greater waste (P < .05). Of all waste, 5.4% was recycled in TKA and just 2.9% in THA cases. The mean amount of recycled waste was significantly greater in TKA cases than that in THA cases, 0.93 kg and 0.42 kg, respectively.Hazardous waste made up the largest proportion for both TKA (69.2%) and THA (73.4%). Nonhazardous waste made up 15.1% and 11.3% of total waste for TKA and THA, respectively. In the nonhazardous waste, only 2 items (scrub-brush packaging and towel packaging) were recyclable. Conclusions: We estimate hip and knee arthroplasty generates over 2.7 million kg of waste in the United Kingdom annually. Currently, only a small percentage of waste is recycled in hip and knee arthroplasty, which could improve through increased use of recyclable plastics and clear labeling of items as recyclable by medical suppliers.

The Linear Coronal Knee Offset (LCKO)-Preliminary Study of New Method of Measuring Knee Varus/Valgus Malalignment.

Introduction Considerable attention is focused on preoperative templating of radiological images in patients undergoing total knee arthroplasty to obtain optimal alignment and outcome. Several radiological measurements have been described. Purpose In this study, we illustrate a new linear measurement: The linear coronal knee offset (LCKO) that can be used to analyze the coronal configuration on long leg alignment radiographs commonly undertaken during preoperative templating. Methods A retrospective search was performed of our Picture Archiving and Communication System and Radiology Information System to identify 100 lower limbs anteroposterior, weight bearing, long leg alignment view radiographs of patients referred to knee clinics over 1 year with knee pain. Demographic details, clinical indication, standard radiological measurement of the anatomical tibiofemoral angle, and the LCKO were measured and data were analyzed using Student's t -test. In addition, intraclass correlation coefficient was used to analyze for intraclass reliability. Results The average age of patients was 36.3 years (range: 12-80 years) with a male predominance. The LCKO was statistically significant between the three cohorts of patients. The mean LCKO in normal cohorts was 0.24 cm, varus was -0.6 cm, and valgus was 1.72cm. There was good inter and interobserver reliability (Kappa of 0.8 and 0.8, respectively). Conclusion The novel LCKO measurement provides a simpler method in assessing coronal lower limb malalignment and can easily identify a normal, varus, or valgus knee deformity.

Lateral sesamoid position in hallux valgus: correlation with the conventional radiological assessment.

BACKGROUND: We aimed to quantify the severity of the hallux valgus based on the lateral sesamoid position and to establish a correlation of our simple assessment method with the conventional radiological assessments. METHODS: We reviewed one hundred and twenty two dorso-plantar weight bearing radiographs of feet. The intermetatarsal and hallux valgus angles were measured by the conventional methods; and the position of lateral sesamoid in relation to first metatarsal neck was assessed by our new and simple method. RESULTS: Significant correlation was noted between intermetatarsal angle and lateral sesamoid position (Rho 0.74, p < 0.0001); lateral sesamoid position and hallux valgus angle (Rho 0.56, p < 0.0001). Similar trends were noted in different grades of severity of hallux valgus in all the three methods of assessment. CONCLUSIONS: Our method of assessing hallux valgus deformity based on the lateral sesamoid position is simple, less time consuming and has statistically significant correlation with that of the established conventional radiological measurements.

Outcomes of distally un-threaded screw fixation of slipped capital femoral epiphysis at skeletal maturity: a matched cohort study.

The most common treatment for slipped capital femoral epiphysis worldwide is in situ fixation with a threaded screw. Un-threaded screws are designed to prevent slip progression without hindering residual growth of the proximal femur. This study aimed to compare growth, remodelling and long-term outcomes after fixation with un-threaded screws and a matched cohort of patients treated with a standard screw. Six patients (nine hips) treated with un-threaded screws and 16 patients (21 hips) treated with standard screws matched for age, skeletal maturity, sex and Southwick angle were recruited. Clinical records were reviewed for patient demographics, medical history and complications. Radiographs were reviewed for residual growth and time to physeal closure. Growth velocity was calculated. Absence of cam deformity signified complete remodelling. Clinical assessment was graded from excellent to poor and patient-reported outcomes were recorded. There was significantly more growth recorded in the un-threaded screw group in femoral neck length (7.6 mm, P = 0.003), articulo-lesser trochanter distance (5.3 mm, P = 0.028), pin-joint ratio (7.439%, P = 0.006) and pin-physis ratio (8.244%, P = 0.001). The probability of revision operations due to ongoing growth was higher in this group (risk ratio: 6.57, P = 0.0008). Time to physeal closure was not significantly different, but growth velocity was significantly higher in the un-threaded group. The lower probability of cam deformity was not significant. Functional and clinical results were not significantly different at average 11.2 years' follow-up. Un-threaded screws allow for significantly more growth than standard threaded screws. The un-threaded screw could not be recommended due to the higher re-operation rates, without any proven benefit.

Review of total hip arthroplasty in patients younger than 30 years: mid- to long-term results.

BACKGROUND: Data on the outcome of THA in patients under the age of 30 years is sparse. There is a perceived reluctance to offer surgery to young patients on the basis of potential early failure of the implant. The aim of this study was to review clinical and radiological outcomes of THA in patients under the age of 30 years in a high-volume specialist arthroplasty unit. METHODS: A retrospective review of patients between 1989 and 2009 was undertaken. 95 patients (118 THAs) were identified but 17 patients were excluded for lack of clinical records or for follow-up under 5 years. Clinical records were reviewed for demographics, underlying pathology, details of operation and failures. Radiographs were reviewed for evidence of loosening and wear of the components. Functional assessment was carried out using the modified Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score and EQ-5D-5L. RESULTS: Mean age was 25 (16-30) years and 65% patients were females. The most common underlying pathologies were development dysplasia of the hip (29%) and juvenile rheumatoid arthritis (25%). Mean follow-up was 12.6 (5-24) years, during which 19 patients (25%) were revised. The majority of the revisions were for aseptic loosening of the acetabular component. CONCLUSIONS: Surgeons are cautious when considering THA in very young patients despite the significant documented improvement in function and quality of life after THA. This study reports on the mid- to long-term results of THA which will be valuable when advising young patients on the prospects of revision surgery at the time of primary THA.

Methicillin-resistant Staphylococcus aureus in hip fracture.

AIMS: Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization and surgical site infection (SSI). This paper reports the impact of routine MRSA screening and the "cleanyourhands" campaign on rates of MRSA SSI and patient outcome. METHODS: A total of 13,503 patients who presented with a hip fracture over 17 years formed the study population. Multivariable logistic regression was performed to determine risk factors for MRSA and SSI. Autoregressive integrated moving average (ARIMA) modelling adjusted for temporal trends in rates of MRSA. Kaplan-Meier estimators were generated to assess for changes in mortality. RESULTS: In all, 6,189 patients were identified before the introduction of screening and 7,314 in the post-screening cohort. MRSA infection fell from 69 cases to 15 in the post-screening cohort (p < 0.001). The ARIMA confirmed a significant reduction in MRSA SSI post-screening (p = 0.043) but no significant impact after hand hygiene alone (p = 0.121). Overall SSI fell (2.4% to 1.5%), however deep infection increased slightly (0.89% to 1.06%). ARIMA showed neither intervention affected overall SSI ("cleanyourhands" -0.172% (95% confidence interval (CI) -0.39% to 0.21); p = 0.122, screening -0.113% per year, (95% CI -0.34 to 0.12); p = 0.373). One-year mortality after deep SSI was unchanged after screening (50% vs 45%; p = 0.415). Only warfarinization (OR 3.616 (95% CI 1.366 to 9.569); p = 0.010) and screening (OR 0.189 (95% CI 0.086 to 0.414); p < 0.001) were significant covariables for developing MRSA SSI. CONCLUSION: While screening and decolonization may reduce MRSA-associated SSI, the benefit to patient outcome remains unclear. Overall deep SSI remains an unsolved problem that has seen little improvement over time. Preventing other hospital-associated infections should not be forgotten in the fight against MRSA. Cite this article: Bone Joint J 2021;103-B(1):170-177.

Deep infection after hip hemiarthroplasty: risk factors for infection and outcome of treatments.

AIMS: Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. METHODS: Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. RESULTS: A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. CONCLUSION: Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958-965.

Morbidity and mortality in patients undergoing lower limb arthroplasty surgery during the initial surge of the COVID-19 pandemic in the UK at a single-speciality orthopaedic hospital.

AIMS: The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic. METHODS: Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months. RESULTS: There were 167 elective procedures performed in the first three weeks of the study period, prior to the first national lockdown, and 57 emergency procedures thereafter. Three patients (1.3%) were readmitted within 30 days of discharge. There was one death (0.45%) due to SARS-CoV-2 infection after an emergency procedure. None of the patients developed complications of SARS-CoV-2 infection after elective arthroplasty. There was no observed spike in complications during in-hospital stay or in the early postoperative period. There was no statistically significant difference in survival between pre-COVID-19 and peri-COVID-19 groups (p = 0.624). We observed a higher number of emergency procedures performed during the pandemic within our institute. CONCLUSION: An international cohort has reported 30-day mortality as 28.8% following orthopaedic procedures during the pandemic. There are currently no reports on clinical outcomes of patients treated with lower limb reconstructive surgery during the same period. While an effective vaccine is developed and widely accepted, it is very likely that SARS-CoV2 infection remains endemic. We believe that this report will help guide future restoration planning here in the UK and abroad. Cite this article: Bone Jt Open 2021;2(5):323-329.

Landmark Technique for a Wrist Block.

Effective anesthesia of the hand and wrist has many uses inside and outside the operating room. In the emergency department or fracture clinic, a wrist block may be used for closed reductions of dislocations and fractures or for effective inspection and treatment of wounds. In the operating room, surgery may be carried out under a wrist block alone or a wrist block may be used as an adjunct to general anesthesia as the block is an opiate-sparing option to facilitate outpatient surgery and to provide many hours of postoperative analgesia, particularly if administered prior to the commencement of surgery. The landmark technique for distal peripheral nerve blocks at the wrist is a well-recognized method and is described for the median nerve, ulnar nerve, superficial branch of the radial nerve, and dorsal branch of the ulnar nerve at the wrist. To make this technique more effective for carpal surgery, blocks of the posterior interosseous and anterior interosseous nerves are added.Step 1: The patient is counseled about the procedure and the expected outcomes.Step 2: Drug allergies are checked.Step 3: The maximum safe dose of the chosen local anesthetic agent is calculated using the weight of the patient.Step 4: The drug ampules are checked for the name and concentration of the drug as well as the expiration date.Step 5: The drug is drawn up into a 10-mL syringe, and a needle is fitted for injection.Step 6: For each of the 6 nerves to be blocked, the anatomical landmarks are identified along with surrounding structures at risk.Step 7: The skin is prepared with an antiseptic agent.Step 8: The nerve block injections are administered using the techniques in the accompanying video, while checking that there are no signs of intraneural or intravascular injection. The landmark technique for wrist block is an effective method in the situations described above. However, there are occasional failures to provide sufficient analgesia as with all peripheral nerve block techniques. There is a possibility of intraneural injection, which must be avoided. There is also a risk of direct nerve fascicular injury with the needle, which therefore requires a thoughtful technique. There is little if any motor block, which makes the technique particularly suitable when intraoperative active motion is required or when physiotherapy is started directly postoperatively. The technique is very rapid to administer, and it does not require any equipment other than a syringe and needle, making it very inexpensive and suitable for austere environments.

Outcome following use of the Achillon jig for the repair of acutely ruptured Achilles tendons.

We report a series of 143 patients who underwent limited open Achilles tendon repair using the Achillon device at a mean follow-up of 25 months. All patients attending our institution with a diagnosis of acute Achilles tendon rupture were considered for operative repair using the Achillon jig unless they declined surgery or met the exclusion criteria. Following surgery patients were contacted and asked to complete an Achilles Tendon Rupture Score (ATRS). The clinical records were reviewed for evidence of complications, demographic information and evidence of re-rupture. Statistical analysis of subgroups including age at presentation, delay to surgery and patients with complications was carried out using the Kruskal Wallis non-parametric test. We report no re-ruptures at a mean of 25 months (minimum 12 months) following surgery. The mean ATRS score was 84/100 (range 15-100). There was no statistical significance between any of the subgroups analyzed. In conclusion, acute Achilles repair using the Achillon jig is safe, with a low re-rupture rate, excellent ATRS scores at a minimum of 12 months post-operatively and low complications. The incidence of sural nerve injury is much lower than published series of percutaneous Achilles tendon repair without the use of a jig.

Scarf-Akin osteotomy for hallux valgus in juvenile and adolescent patients.

Hallux valgus (HV) has been reported to affect 22-36% of adolescents, with a recurrence rate of around 30-40%. Operative treatment may be indicated in symptomatic deformities where conservative management has failed to halt progression of the deformity. There remains genuine concern with respect to high complication rates including recurrence and stiffness of the metatarsophalangeal joint following operative treatment in adolescents. We report the clinical, functional and radiological outcomes of the Scarf-Akin procedure in the treatment of juvenile and adolescent HV. A review of single surgeon series was carried out of all children who underwent Scarf and Akin osteotomies as a combined procedure for HV between February 2001 and 2010. The preoperative and postoperative intermetatarsal angle (IMA1-2), hallux valgus angle, distal metatarsal articular angle and ratio of the length of first metatarsal to that of the second metatarsal were determined. The American Orthopaedic Foot and Ankle Score was used for functional assessment. Twenty-nine patients (47 feet) underwent Scarf-Akin osteotomies for moderate to severe HV. The average age of the patients at surgery was 11.7 years. The 6-week postoperative radiographs confirmed a significant improvement in the IMA, hallux valgus angle and distal metatarsal articular angle, in all the 47 feet, but 10 patients (14 feet, 29.8%) reported recurrence of hallux valgus at subsequent reviews. The radiological recurrence rate in our series was 29.8%, with 21.3% of patients symptomatic enough to require a revision operation. We report a high recurrence rate in hallux valgus operation in children and hence recommend postponement of correction until skeletal maturity.

Type II Monteggia injury in a toddler: an unusual presentation.

Monteggia type fracture dislocations of the elbow are a common occurrence in children. Bado types I and III are the most common types comprising 70 and 23%, respectively, and type II injuries account only for 6%. We present an interesting case of Monteggia type II fracture dislocation in an 11-month-old child, which has not been described before in a child younger than 11 years of age. Any ulnar fracture, especially in a child, should be evaluated carefully. Closed reduction is the mainstay of treatment in Monteggia type II fracture dislocation in children.

A unique orthogeriatric model: a step forward in improving the quality of care for hip fracture patients.

BACKGROUND: In August 2010, a unique model of shared care for hip fracture patients was implemented in our hospital. In this model, patients are allocated to an orthogeriatric team within 48 h of surgery, who review patients daily to manage medical complications and coordinate multidisciplinary rehabilitation, with orthopaedic input if necessary. AIM: To compare the new model to the previous model of care as perceived by members of staff and compare clinical outcomes. METHODS: Prospective data were collected using questionnaires given to medical, nursing and allied health professionals. Their opinions were rated using the Likert scaling system and analysed with the Mann Whitney U-test. Clinical outcomes were obtained from the hip fracture database and subsequently analysed. RESULTS: 59 responses (100%); 21 doctors and 38 allied health professionals. The majority of staff believed that quality of patient care was better in the newer model and preferred to work in this model. The median length of stay in the previous model (274 patients) was 25 days compared to 19.5 days in the new model (249 patients) (p = 0.22). 56.8% patients returned to their source of admission in the previous model compared to 72.7% in the new model (p = 0.00007). The inpatient mortality rates improved from 12.4% in the previous model to 8.4% in the new model (p = 0.26). CONCLUSION: This unique model improved care for hip fracture patients and was cost effective. Furthermore, it highlighted excellent staff satisfaction. This can pioneer a change in the management of hip fracture patients nationally and internationally.

Traction splint: to use or not to use.

Traction splints are widely used for immobilisation of fractures of the lower limb. There is brevity of evidence-based research on their efficacy. We present a case of skin complication following traction splint for spiral fracture of femur. It is prudent to identify patients at higher risk of developing complications of immobilisation. In circumstances where delays are inevitable, the indication and appropriateness of continuation of traction splint should be re-evaluated.

Medial and lateral rotatory dislocations of the ankle after trivial trauma--pathomechanics and management of two cases.

Pure frontal plane rotatory dislocation of the ankle joint without an associated fracture is an extremely rare injury. We report one such case of an eversion rotatory dislocation and one case of an inversion rotatory dislocation. To our knowledge, this is the first report of an eversion injury resulting in dislocation of the ankle without fracture. Both patients had low energy trauma, predisposing ligamentous injuries, and recurrent sprains. In the patient with lateral rotatory dislocation, medial malleolar hypoplasia was also a contributing factor. Both patients healed the presenting index injury with nonoperative treatment, whereas the lateral rotatory dislocation had a lateral ankle stabilization to prevent subsequent injury.