Addition of Surgeon-Administered Adductor Canal Infiltration to the Periarticular Infiltration in Total Knee Arthroplasty: Effect on Pain and Early Outcomes.

BACKGROUND: Our aim was to study the additive effect of surgeon-administered adductor canal infiltration (SACI) over routine periarticular infiltration (PAI) on pain control [morphine consumption and pain score by the visual analog scale (VAS)] and early function [flexion and Timed Up and Go (TUG) test] post-total knee arthroplasty (TKA). METHODS: We prospectively randomized 60 patients into 2 groups. Group I patients received the standard PAI, whereas in Group II, the patients received a SACI in addition to the PAI. The total volume of the injected drug and the postoperative pain management protocol were the same for all. The number of doses of patient-controlled analgesia (PCA) used for breakthrough pain was recorded as PCA consumption. For early function, flexion and the TUG test were used. The VAS score and PCA consumption were compared between the 2 groups by using analyses of variance with post hoc tests as indicated. The TUG test and flexion were compared using Student t tests. The level of significance was set at 0.05. RESULTS: The PCA consumption in the first 6 hours was significantly higher in Group I (P = .04). The VAS at 6 hours was significantly lower in Group II (P = .042). The TUG test was comparable between the 2 groups preoperatively (P = .72) at 24 hours (P = .60) and 48 hours (P = .60) post-TKA. The flexion was comparable between the 2 groups preoperatively (P = .85) at 24 hours (P = .48) and 48 hours (P = .79) post-TKA. CONCLUSIONS: Adding a SACI to PAI provides improved pain relief and reduces opioid consumption without affecting early function post-TKA. A SACI avoids the need for an anesthesiologist or specialized equipment with no added operating time and minimal added cost. We recommend routine use of SACI for all patients undergoing TKA.

Decreased Femoral Trochlear Length Associated With Increased Anterior Knee Pain Following Total Knee Arthroplasty: A New Anatomical Perspective.

BACKGROUND: Anterior knee pain (AKP) and patello-femoral crepitus (PFCr) continue to plague total knee arthroplasty patients despite advances and modifications to implant design and surgical techniques. We present our study of the femoral trochlear length measurement preimplantation and postimplantation and its association with AKP/PFCr and clinical scores. METHODS: Using computer navigation, we obtained several measurements in 263 total knee arthroplasty (posterior-stabilized) patients, which included femoral native trochlear measurement (NTM) and difference in trochlear length between implant and native trochlea. We report their association with Knee Society Score, Western Ontario McMaster University Arthritic Index, and AKP/PFCr at 1 year postoperatively. RESULTS: Mean Knee Society Score and Western Ontario McMaster University Arthritic Index scores were significantly worse in patients who had AKP (P = .005 and P = .002 respectively). Receiver operating characteristic curve showed a statistically significant association between NTM and AKP (Area under the curve = 0.609, P = .014). Lower the NTM, greater was the incidence of AKP. Analysis of the receiver operating characteristic curve identified the cutoff value of NTM to be ≤25.5 with sensitivity of 76.7(95% confidence interval - 57.7 - 90.1) and specificity of 46.9 (95% confidence interval - 41.9 - 55.1). Patients who had NTM of ≤25.5 had an odds ratio of 3.09 to have AKP. The difference in trochlear length ranged from 7.4 to 32.1 millimeters, indicating that postimplantation there was lengthwise overstuffing along the trochlea in every patient. CONCLUSION: We found that the shorter the native femoral trochlea and greater the difference between implanted and native trochlea, the higher was the occurrence of AKP. A mismatch in trochlear measurement preimplantation and postimplantation resulted in lengthwise overstuffing in the anterior knee causing AKP and PFCr.

Does Postoperative Intravenous Ferric Carboxymaltose Hasten the Recovery of Hemoglobin in Patients Post Total Knee Arthroplasty?

BACKGROUND: Timely and effective iron supplementation may help reduce the incidence of postoperative anemia and its associated problems. In this study, we aim to assess the efficacy of intravenous ferric carboxy maltose (FCM) on improving hemoglobin(Hb) level posttotal knee arthroplasty (TKA). METHODS: We retrospectively reviewed 263 patients who had undergone unilateral TKA with 157 patients in the study group (year 2019) and 106 in the control group (year 2016). Patients in the study group received FCM (500 mg IV) on postoperative day 1, whereas patients in the control group did not receive FCM or any other iron supplementation postoperatively. Hb levels were recorded preoperatively (Pr-Hb), postoperatively on day 3 (Day3-Hb) and postoperatively at 5(+1) weeks (Week5-Hb). Statistical analysis was performed using student's paired and unpaired t-tests. RESULTS: Pr-Hb and Day3-Hb levels were comparable in the control and study group, while Week5-Hb levels were significantly higher (P < .001) in the study group. The drop in Hb at Day3 from preoperative values was comparable between the two groups (P = 1.0). The rise in Hb from Day3 to 5 weeks was significantly higher in the study group as compared to the control group (P < .001). The difference between Pr-Hb and Week5-Hb was significantly lower (P < .001) in the study group compared to the control group. However, Week5-Hb in both groups remained lower than Pr-Hb (P < .001) in all patients. CONCLUSION: Intravenous FCM (500 mg) was found to be a safe method of iron supplementation to improve hemoglobin levels rapidly and consistently, post-TKA. We need to further study the additive effect of higher dose FCM (1000 mg) on hemoglobin recovery.

What Is the Normal Trajectory of Interleukin-6 and C-reactive Protein in the Hours and Days Immediately After TKA?

BACKGROUND: Some patients with early periprosthetic joint infection (PJI) can be treated successfully using open débridement with polyethylene exchange rather than two-stage revision; however, the challenge is to diagnose PJI early. In late infection, C-reactive protein (CRP) and interleukin-6 (IL-6) are elevated, but shortly after surgery, CRP is difficult to interpret because it may be elevated even in the absence of infection, and we know little about the normal trajectory of IL-6 immediately after arthroplasty. If a deviation of biomarkers from their normal trajectory is seen, it may help guide the clinician toward early knee aspiration. QUESTIONS/PURPOSES: We studied the normal trajectories of IL-6 and CRP in the immediate hours and days after uncomplicated TKA and examined whether one or the other normalizes more quickly. METHODS: We studied serum IL-6 and CRP levels in 50 patients undergoing primary TKA at five time points: 12 hours preoperatively and postoperatively at 12 hours, 48 hours, 4 days, and 2 weeks. One surgeon operated on all patients using the same approach and postoperative management. The same laboratory methods were used each time. Results are presented as median and range. Repeated-measures analysis was done using Friedman's (nonparametric) test. No patient showed any clinical sign of infection during our study period. All patients were followed up until 1 year with no evidence of infection and good knee scores. RESULTS: IL-6 showed a sharp rise from its baseline with a preoperative median value of 6 pg/mL (range, 3-17 pg/mL) to a peak of median value of 133 pg/mL (range, 15-359 pg/mL) at 12 hours postoperatively. At 48 hours, IL-6 had declined to a median value of 82 pg/mL (range, 12-309 pg/mL). At 4 days, it had further declined to a median value of 22 pg/mL (range, 5-67 pg/mL). At 2 weeks, IL-6 reached a median value of 7 pg/mL (range, 3-14 pg/mL), which was not different from the baseline median value with the numbers available (p = 0.455). CRP showed a gradual rise from its baseline preoperative median value of 2 mg/L (range, 1-17 mg/L) to a median value of 15 mg/L (range, 2-111 mg/L) at 12 hours postoperatively, which peaked at 48 hours to a median value of 125 mg/L (range, 22-247 mg/L). At 4 days postoperatively, CRP levels had declined to a median value of 69 mg/L (range, 21-234 mg/L). At 2 weeks, CRP had reached a median value of 12 mg/L (range, 1-72 mg/L), which was still higher than the baseline median value with available numbers (p < 0.001). CONCLUSIONS: We found that after uncomplicated TKA, IL-6 showed a sharp rise to peak at 12 hours, then fell rapidly to near baseline levels by 4 days and returned to the baseline level at 2 weeks. CRP showed a gradual rise to peak at 48 hours, then fell gradually, remaining elevated at 4 days and higher than baseline level at 2 weeks. Future studies can help define more definitive thresholds for IL-6 and CRP; ideally, these should derive from large, multicenter studies. With such data, any deviation from a known normal trajectory can facilitate a quicker decision to perform knee aspiration to diagnose early PJI more promptly. LEVEL OF EVIDENCE: Level III, diagnostic study.

What is the Responsiveness and Respondent Burden of the New Knee Society Score?

BACKGROUND: Although the new Knee Society score (NKSS) has been validated by a task force, a longitudinal study of the same cohort of patients to evaluate the score's responsiveness and respondent burden has not been reported, to our knowledge. QUESTIONS/PURPOSES: We analyzed the NKSS for (1) responsiveness; (2) respondent burden; and (3) convergent validity in 148 patients studied longitudinally during more than 1 year. METHODS: During an 8-month period, 165 patients underwent TKA by the same surgeon at our institution, of whom 148 (90%) completed this study; the others were excluded because of distance to travel or loss to followup at the specified time. The NKSS, WOMAC, and SF-12 were completed by each patient 1 day before surgery and at 3 and 12 months postoperatively. At the same times, the original KSS (OKSS) which is designed as an observer's assessment, was completed by the same orthopaedic fellow for all patients. Responsiveness of the NKSS was assessed by determining effect size, standardized response mean (SRM), and ceiling and floor effects. Respondent burden was assessed through time to completion recorded in minutes and ease of completion which was measured objectively on a Likert scale of 1 to 5 by the patients. Convergent validity was assessed by correlating the NKSS with the WOMAC, SF-12, and OKSS (current, widely used scales) by Pearson's correlation coefficient. RESULTS: Effect size was largest (2.83 and 3.38) and SRM was highest (2.29 and 2.68) for the NKSS at 3 and 12 months respectively, indicating the NKSS to be the most-responsive score followed by the OKSS, WOMAC, and SF-12. The NKSS exhibited no ceiling and floor effects. The NKSS took a longer time to complete (5.49 ± 3.56 minutes) compared with the WOMAC (4.64 ± 3.19 minutes) and SF-12 (4.35 ± 3.27 minutes). The mean difference in time taken for the NKSS versus the WOMAC was 0.85 minutes (95% CI, 0.54-1.17 minutes; p < 0.001) and the mean difference for the NKSS versus the SF-12 was 1.14 minutes (95% CI, 0.76-1.15 minutes; p < 0.001). Its ease of completion generally was comparable to that of the WOMAC and SF-12. Convergent validity showed a strong correlation (r > 0.6; p < 0.001) of the NKSS with the WOMAC at all times and moderate to strong correlation (r = 0.4-0.6; p < 0.001) with the SF-12 and OKSS at the first two assessments, which became strong (r > 0.6; p < 0.001) at 12 months. CONCLUSIONS: The NKSS exhibited greater responsiveness than the WOMAC, SF-12, and OKSS scales and showed no ceiling effect, indicating adequate potential for recording future improvement. The NKSS also showed reliable convergent validity when correlated with these other scores. However, it posed a greater respondent burden in terms of time to completion. CLINICAL RELEVANCE: As independent nondevelopers of the NKSS, we found it to be a responsive tool for assessment of TKA outcomes. We have confirmed that the NKSS can be used interchangeably for this purpose with the WOMAC scale and that it correlates positively with other established scales of the SF-12 and OKSS. Further study of the short-form version will establish whether it also can be used effectively while reducing the respondent burden.

Ten- to 13-Year Results of Mobile Bearing Posterior-Stabilized Rotating-Platform Knee Implants, Reported by Nondesigner Surgeon.

BACKGROUND: Posterior-stabilized rotating-platform (PSRP) knee was designed with the purpose of improving postoperative flexion and stability. Its long-term performance has limited reports, which could show whether this purpose has been realized without deleterious effect. We report its long-term results at 10-13 years, of a previously studied cohort, evaluated longitudinally. METHODS: A total of 133 consecutive PSRP implants, selected for 118 patients were studied. Twenty-one patients (24 knees) were deceased and 11 patients (12 knees) were lost to follow-up after 10 years. Eighty patients (97 knees) completed clinical evaluation, of whom 78 patients (88 knees) also completed radiological evaluation. RESULTS: Mean flexion improved from 106.8° (30°-150°) to 127° (90°-155°). Forty-three percent patients could sit crosslegged, 32.5% could sit on floor, and 3.4% could squat. Mean knee subscore of Knee Society Score improved from 28 (1-59) to 96 (67-100). Mean function subscore improved from 53 (5-81) to 78 (-10 to 100). After 10 years, 5 patients had zero function score because of developing other debilitating medical illnesses. Twenty-one dead patients (24 knees), at their last follow-up (7.7 years), had satisfactory scores. No patient had spinout or revision. Radiologically, alignment was satisfactory and there was no osteolysis. Kaplan-Meier analysis showed 100% implant survival. CONCLUSION: PSRP design, evaluated after 10 years of implantation in selected patients, had 100% survival with good flexion. Addition of post and cam to the original rotating platform design has provided good stability without untoward effects of wear or osteolysis at 10-13 years.

A prospective randomized study in 20 patients undergoing bilateral TKA comparing midline incision to anterolateral incision.

BACKGROUND: Lateral flap numbness is a known side-effect of midline skin incision in total knee arthroplasty (TKA) and a cause of patient dissatisfaction. Anterolateral incision is an alternative approach which preserves the infrapatellar branches of the saphenous nerve and avoids numbness. Studies have compared both incisions, but in different patients. However, different patients may assess the same sensory deficit dissimilarly, because of individual variations in anatomy and healing responses. We compared the two incisions in the same patient at the same time, using an anterolateral incision on one knee and a midline incision on the other knee in simultaneous bilateral TKA. Other surgical steps including medial arthrotomy were idential. We also correlated subjective and objective findings. MATERIALS AND METHODS: Twenty patients were prospectively randomized. Sensory loss and skin healing were assessed at 6, 12 and 52 weeks. Subjective preference for the knee with less numbness was charted on Wald's Sequential Probability Ratio Test. Sensation scores for touch, vibration, static and moving two-point discrimination were measured. Scar healing was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). Functional scores were measured. RESULTS: A statistically significant difference favoring knees with anterolateral incision was observed in patient preference at all assessment points and this correlated with sensation scores. A statistically significant difference was observed in POSAS score favoring knees with anterolateral incision at 6 and 12 weeks which became statistically insignificant at 1 year. Functional scores remained comparable. CONCLUSION: We recommend anterolateral incision as a safe and effective method to circumvent the problem of lateral flap numbness with midline incision. LEVEL OF EVIDENCE: I.

Expert Consensus on Best Practices for Optimal Wound Closure in Total Knee Arthroplasty: A STRIDE Initiative for Orthopedic Surgeons of India.

Background: Wound closure in joint replacement surgeries is crucial for postoperative rehabilitation. Despite substantial advances in total knee arthroplasty (TKA), no guidelines/recommendation or consensus practice statement available internationally or nationally around the optimal method of wound closure. The study aimed to develop evidence-based consensus on current practices, and proposed adoption of advanced wound closure initiatives. Methods: From Nov 2020 to Jan 2021, a group of 12 leading orthopedic surgeons from India met virtually under the Success in Total joint replacement through Recommendation In wounD closure (STRIDE) initiative. Expert committee used Delphi method to evaluate definitional statements that were identified through a comprehensive review of the published literature. Over three rounds of iterative voting, revision, and exclusion, the expert panel provided recommendations based on their clinical expertise and scientific evidence. Statements that reached ≥ 80% agreement was considered as "consensus". A survey poll was conducted following each round to add or suggest changes to the statements. Results: General recommendations include marking the arthrotomy before incision, placing the knee in flexion (less than 90°) for re-approximation during arthrotomy closure. The barbed suture can be a good alternative to traditional sutures for providing water-tight capsule closure and topical skin adhesives (TSAs) to staples for minimizing hospital visits and improving patient satisfaction. Conclusion: This consensus provides interim guidance and practical references to orthopedic surgeons of India enabling easy access to evidence-based healthcare solutions for TKA wound closure. These recommendations need to be periodically reviewed in light of emerging evidence.

Surgical technique: Lateral retinaculum release in knee arthroplasty using a stepwise, outside-in technique.

BACKGROUND: Lateral release of a tight lateral retinaculum in a TKA is intended to correct patellar maltracking but the widely used inside-out technique has associated risks. We describe an alternate stepwise outside-in technique, with titrated release intended to maximize the chance of preserving the superior lateral genicular artery (SLGA). DESCRIPTION OF TECHNIQUE: Patellar maltracking was judged by a no-thumb technique and graded as I and Ia: normal and near normal tracking; II: patella tilted; III: patella subluxed; or IV: patella dislocated. Outside-in release was performed in three progressive steps. Step-1 release was from the midpatella to the upper tibial border, Step-2 release was from the midpatella to the proximal pole of the patella, and Step-3 release was proximal to the superior pole of the patella with sectioning of the SLGA. METHODS: We retrospectively reviewed records of 1884 patients operated on between 2002 to 2008. Two hundred five patients (11%) had lateral release performed, and 177 of those 205 patients (86%) were reviewed. Patellofemoral function was assessed clinically by The Knee Society score. Radiographs were examined for patellar tilt, shift, and avascular necrosis. The minimum followup was 22 months (median 48 months; range, 22-105 months). RESULTS: The SLGA was preserved in 155 (76%) patients. At last followup, no patient had patellar maltracking, patellar fracture, or avascular necrosis. Six of 177 (3%) patients had anterior knee pain. Female patients and high-flex components had a higher incidence of release and midvastus arthrotomy had a lower incidence of release. CONCLUSIONS: Stepwise release of the lateral retinaculum by an outside-in technique allowed minimum necessary retinacular release, preserving the SLGA in 76% of patients. No complications were seen at followup with functional and radiographic examinations. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients.

BACKGROUND: The antifibrinolytic tranexamic acid reduces surgical blood loss, but studies have not identified an optimal regimen. QUESTIONS/PURPOSES: We studied different dosages, timings, and modes of administration to identify the most effective regimen of tranexamic acid in achieving maximum reduction of blood loss in TKA. METHODS: We prospectively studied five regimens (four intravenous, one local; 40 patients each) with a control group (no tranexamic acid). The four intravenous (10-mg/kg dose) regimens included (1) intraoperative dose (IO) given before tourniquet deflation, (2) additional preoperative dose (POIO), (3) additional postoperative dose (IOPO), and (4) all three doses (POIOPO). The fifth regimen was a single local application (LA). Two independent parameters of drain loss and total blood loss, calculated by the hemoglobin balance method, were evaluated statistically. RESULTS: Both parameters were reduced in all five regimens as against the control. A significant reduction in drain loss was seen in the POIO, IOPO, and POIOPO groups whereas total blood loss was significantly reduced in the POIO, POIOPO, and LA groups. The POIOPO group had the least drain loss (303 mL) and least total blood loss (688 mL). The IO group had the greatest drain loss and the IOPO group the greatest total blood loss. CONCLUSIONS: Single-dose tranexamic acid did not give effective results. The two-dose regimen of POIO was the least amount necessary for effective results. When compared against the control, this regimen produced reduction of drain loss and total blood loss, whereas the IOPO regimen did not. The three-dose regimen of POIOPO produced maximum effective reduction of drain loss and total blood loss.

High-flex rotating platform knee implants: two- to 6-year results of a prospective study.

We prospectively enrolled 48 patients (53 knees), scheduled for high-flex posterior-stabilized rotating platform knee implant arthroplasty (PFCΣRPF) to our study. Performance of this implant, introduced in 2005, has been reported upon only up to 2 years. We report its 2- to 6-year postoperative clinical and radiographic results in 47 patients (52 knees). Mean Knee Society score improved from 35.7 to 96. Mean function score improved from 55.2 to 90.6. Postoperative knee flexion averaged 130° (95°-155°), 81% patients could sit cross legged, 53% could sit on floor, and 21% could squat. Kaplan-Meier survival rate was 100% at average 50.2 months (26-72 months). No patient had any spin-out of rotating bearing. Supervised radiographs were analyzed, which showed no osteolysis or component loosening.

To use or not to use continuous passive motion post-total knee arthroplasty presenting functional assessment results in early recovery.

Continuous passive motion (CPM), though of doubtful value, is yet routinely practiced post-total knee arthroplasty (TKA). We prospectively distributed 84 patients with TKA to 1 of the 3 standard rehabilitation regimes: no-CPM, 1-day-CPM, and 3-day-CPM. We recorded a unique "Timed up and go" test besides pain, Western Ontario and McMaster Universities (WOMAC), short form-12 (SF-12), range of motion, knee and calf swelling, and wound healing parameters. Our standardized and elaborate measurements preoperatively and on postoperative days 3, 5, 14, 42, and 90 showed no statistically significant difference among the 3 groups in each parameter. We concluded that CPM gives no benefit in immediate functional recovery post-TKA, and in fact, the postoperative knee swelling persisted longer. We have since then discontinued its use in our patients without any untoward effect.

Ten- to 14-Year Results of a High-Flex Rotating Platform Knee Implant: A Follow-Up Report of a Prospective Cohort.

BACKGROUND: High-flex posterior stabilised rotating platform (PSRP) implant was introduced to provide for deep knee flexion. Few short-term results have been reported, but there are no long-term outcomes reported. METHODS: We prospectively followed 48 patients (53 knees) implanted with one such design. Inclusion criteria for implantation were patients with good pre-operative flexion and wishing to perform activities requiring deep knee flexion post-operatively, with femorotibial varus angle < 15° and having good flexion stability at trialling stage. Previously, we reported their outcomes at 2-6 years (FU-1). We now report their functional and radiological results at a minimum follow-up of 10 years (FU-2) in 39 patients (43 knees); 5 patients having died and 4 lost to follow-up. RESULTS: The mean pre-operative flexion of 124° improved to 130° at FU-1 and to 134° at FU-2. Flexion of 130° or more was seen in 59.6% knees at FU-1 and 74.42% knees at FU-2. At FU-2 mean Knee score was 90.5 and Function score was 67.8. Incidence of patellofemoral symptoms increased from 7.7% at FU-1 to 11.36% at FU-2. There were no cases of bearing spin out, osteolysis or revision surgeries. CONCLUSION: At a minimum 10-year follow-up, high-flexion PSRP design in selected patients yielded 100% survival. We recorded good knee flexion and knee society scores, with no case of spin out, implant loosening, osteolysis or revision surgery. Although deep knee flexion improved at longer follow-up, its use in ADL had reduced due to other age-related factors. There was increased incidence of patellofemoral symptoms.

Margin of error in alignment: a study undertaken when converting from conventional to computer-assisted total knee arthroplasty.

We analyzed alignment of 300 knees, divided equally into groups according to total knee arthroplasty technique: Conventional, CAS-Early (computer-assisted surgery during the surgeon's learning curve), and CAS-Late (after experience with CAS). With the margin of error for alignment of the mechanical axis and femoral and tibial components each within ±3°, the Conventional group's success rate was only 66%; but the rate for the CAS-Early group was 94%. The CAS-Late group's rate was 100%, with no outliers; moreover, the margin of error was reduced to within ±2° in 92% of patients and within ±1° in 52%. For the Conventional group's success rate to be 100%, the margin of error would have to be statistically relaxed to an unacceptable ±8°. Computed-assisted surgery improves alignment even early in the learning curve.

Five- to eight-year results of a prospective study in 118 arthroplasties using posterior-stabilized rotating-platform knee implants.

We prospectively enrolled 118 patients (133 knees) whose arthroplasties were performed using posterior-stabilized rotating-platform knee implants. Introduced in year 2000, this implant's performance beyond 5 years is not reported on, to date. We present 5- to 8-year (average, 6.5 years) results of 118 posterior-stabilized rotating-platform knee arthroplasties. Kaplan-Meier survival rate was 100%, considering revision or the need for it as the end point. Mean Knee Society Score improved from 27 (range, 1-54) to 96 (range, 54-100). Mean function score improved from 51 (range, 5-81) to 83 (range, 0-100). No patient had spin-out of rotating bearing or osteolysis. Postoperatively, knee flexion averaged 120° (range, 80°-155°), 34% patients achieved more than 130° flexion, and 67% patients could sit cross legged. Only 5% patients presented with patellofemoral symptoms.

A Simple, Stepwise, Outside-in Technique for Lateral Retinacular Release for Management of Patellar Maltracking During Total Knee Arthroplasty.

Lateral retinacular release is done to correct patellar maltracking in total knee arthroplasty. The inside-out technique is widely used but has associated risks. Our video describes a simple outside-in technique, done stepwise, and titrated according to the grade of maltracking that maximizes preservation of the superior lateral geniculate artery and preserves the synovium, avoiding complications such as hematoma formation, skin tenting, and wound discolouration. The technique is also effective in all severities of maltracking and with all types of implants.

Vitamin D Trajectory after Total Knee Arthroplasty: A Method for Quick Correction in Deficient Patients.

BACKGROUD: It has been widely reported that vitamin D (vit D) affects preoperative, postoperative, and long-term outcomes after total knee arthroplasty (TKA). Our aim was to study vit D trajectory after TKA and compare effects of oral versus intramuscular (IM) supplementation in insufficient patients and assess its effects on immediate functional recovery in the first 2 weeks after TKA. METHODS: Vit D levels < 30 ng/mL are considered insufficient. We prospectively enrolled 60 patients (20 per group): group I, vit D sufficient patients; group II, vit D insufficient patients given IM supplementation (cholecalciferol 6,00,000 IU); and group III, vit D insufficient patients given oral supplementation (cholecalciferol 600,000 IU). Vit D levels, knee flexion, Timed Up and Go (TUG) test results, and visual analog scale (VAS) score were recorded preoperatively and postoperatively on day 3 and 14. RESULTS: In group I, mean preoperative vit D significantly dropped at postoperative day (POD) 3 and POD 14 (p = 0.001). In group II, mean preoperative vit D rose at POD 3 and rose significantly at POD 14 (p = 0.001). In group III, mean preoperative vit D increased significantly at both POD 3 and POD 14 (p < 0.001). Also, in group III, the rise in vit D was significantly higher than that in group II both at POD 3 and POD 14 (p < 0.05). In group III, 19 of 20 insufficient patients became sufficient on POD 3 and all 20 by POD 14. In group II, even by POD 14, only 11 of 20 insufficient patients became sufficient. Functional parameters (flexion, change in flexion, TUG test results, and VAS score) were comparable (p > 0.05) in all groups. Changes in TUG test showed a significant increase in group II (48.5 seconds) when compared to group I (35.5 seconds) at POD 3 (p < 0.05), suggesting a slower recovery. It remained comparable (p > 0.05) between group III and group I. CONCLUSIONS: We found that vit D insufficient patients can be rapidly supplemented on the morning of surgery with a large dose of oral cholecalciferol 600,000 IU, and the effect was consistent over 2 weeks after surgery. Orally supplemented vit D insufficient patients also showed functional recovery comparable to vit D sufficient patients. IM supplementation increased vit D levels only at 2 weeks and the rise was significantly lower than oral supplementation. Interestingly, approximately 25% of vit D sufficient patients who were not supplemented after TKA became insufficient in the first 2 weeks postoperatively.

Forgotten Joint Score Post Total Knee Arthroplasty and Its Correlation with the New Knee Society Score.

BACKGROUND/PURPOSE: Forgotten Joint Score (FJS) is designed to asses patient recovery post Total Knee Arthroplasty (TKA) in a new dimension. It assess the ability to forget the operated joint as artificial during activities of daily living. New Knee Society Score (NKSS) is developed to encompass objective and subjective outcome as well as an assessment of patient expectation and satisfaction. Our purpose was (1) to determine FJS at 1 year post TKA in Indian Patients, and (2) to assess convergent validity between FJS and the NKSS. We hypothesised that FJS should strongly correlate with the Satisfaction (SS) and Knee perception(KPS) sub-component of NKSS. METHODS: We enrolled 181 patients who underwent primary TKA during an 8-month duration. They were prospectively followed up at 1-year review clinic when FJS and NKSS were administered. 169 patients completed the assessment forms and 13 patients were lost to follow-up. Statistical evaluation was done with Spearman correlation test. RESULTS: Mean FJS at 1 year was 66.6 ± 25.9 with 14% ceiling and 1% floor effects. There was a mild to moderate correlation of FJS with NKSS (p < 0.001, r = 0.47) and its sub-scores (p < 0.001; r = 0.43 and r = 0.44). There was a weak correlation of FJS with NKSS sub-components of SS and KPS (p < 0.001; r = 0.37 and 0.25, respectively). CONCLUSION: Mean FJS at 1 year post TKA showed convergent validity with NKSS; however, the correlation was not strong enough to use them interchangeably. Hypothesis that FJS should strongly correlate with the NKSS sub-components of satisfaction and joint perception was refuted. We conclude, FJS provides unique evaluation in recovery post TKA, different from NKSS. LEVEL OF EVIDENCE: Level III.

WHO Class of Obesity Influences Functional Recovery Post-TKA.

BACKGROUND: No study in the literature has compared early functional recovery following total knee arthroplasty (TKA) in the obese with the nonobese using World Health Organization (WHO) classes of obesity. Our aim was to compare functional scores and flexion post-TKA in each class of obesity as per WHO classification against a matched control group of nonobese patients. METHODS: Records of 885 consecutive primary TKA patients (919 knees) operated by a single surgeon were reviewed. The first 35 knees in each class I, class II and class III obesity group during the study period were then matched with a similar number of knees in nonobese TKA patients during the same period. Functional scores recorded pre- and postoperatively at 3 months and 1 year were Western Ontario and McMaster Osteoarthritis Index (WOMAC), Short-Form Health Survey (SF-12) score, and Knee Society Score (KSS). RESULTS: There was no difference in any parameter between the class I obese and matched nonobese at any assessment point. In the class II obese, as compared to the nonobese, there was no difference in any parameter preoperatively and 3 months postoperatively. However, 1 year postoperatively, the SF-12 physical subscore was lower in the class II obese than the nonobese (44.7 vs. 48.6, p = 0.047) and the WOMAC score was significantly higher (15.8 vs. 9.7, p = 0.04). In the class III obese, the WOMAC score was significantly higher than the nonobese (58.1 vs. 44.3, p < 0.001 preoperatively; 15.7 vs. 8.1, p = 0.005 at 1 year) and KSS was significantly lower (83.5 vs. 96.5, p = 0.049 preoperatively; 172 vs. 185; p = 0.003 at 1 year). Knee flexion was significantly lower in the class III obese than the nonobese (95 vs. 113; p < 0.001 preoperatively; 120 vs. 127; p = 0.002 at 1 year). CONCLUSIONS: The class I obese can expect good early and late functional recovery as the nonobese. The class II obese can expect comparable early functional recovery as the nonobese but their late function may be lesser. The class III obese would have poorer functional scores and lesser knee flexion postoperatively compared to the nonobese. However, compared to their own preoperative status, there is definite improvement in function and knee flexion.

Optimizing effectivity of tranexamic acid in bilateral knee arthroplasty - A prospective randomized controlled study.

INTRODUCTION: Tranexamic acid (TEA) is used in reducing surgical blood loss. Literature shows no optimal regimen recommended for Bilateral Total Knee Arthroplasty (TKA). We evaluated three TEA regimens differing in dosage, timing and mode of administration in bilateral TKA to identify the most effective regimen to reduce blood loss. METHODS: We prospectively studied three TEA regimens (25 patients each) as follows: (1) two intraoperative, intravenous doses (IOIO), (2) two intraoperative local applications (LALA), and (3) one preoperative plus two intraoperative, intravenous doses (POIOIO). Two independent parameters of drain loss and total blood loss, calculated by the hemoglobin balance method were statistically evaluated. RESULTS: Mean drain loss was least (412.9ml) in the POIOIO group, greatest (607.2ml) in the IOIO group and LALA group in between (579.4ml), with a statistically significant difference among them (p=0.0022). On paired evaluation, the drain loss in the POIOIO group was significantly less as compared to the other two groups, whereas the difference between IOIO and LALA was not significant. Mean total blood loss was least in the POIOIO group (1207ml) and greatest in LALA group (1270ml). The difference among the groups was not statistically significant (p=0.80). There was no incidence of any thromboembolic phenomenon. On correlation with our study on Most Effective Regimen in Unilateral TKA, both results were found to substantiate each other.