Comparison of Time Taken in Conventional versus Active Robotic-Assisted Total Knee Arthroplasty.

Background: Computer- and robotic-assisted total knee replacement procedures have been shown to improve the accuracy of the implant size. It also allows dynamic confirmation of the implant and limb alignment during total knee arthroplasty (TKA). The major inhibition of the arthroplasty surgeon in adapting to the robotic-assisted TKA (RA-TKA) is the extra time spent during the registration process and milling of the bone with the robot. The aim of the study was to ascertain the extra time spent during these 2 steps as compared to the conventional TKA (C-TKA). Methods: It is a prospective study involving 30 patients each in the conventional TKA and RA-TKA operated by the same surgical team. The patients were given a choice between the C-TKA and RA-TKA and consecutive 30 cases in each group were studied by an independent observer. In the C-TKA group, the time for the application of appropriate zigs and execution of the bone cuts and soft-tissue release was recorded whereas in the RA-TKA group, the time taken for fixation of the tibial and femoral arrays and bone registration and bone milling with robot and required soft-tissue release was measured. Results: The preoperative patient characteristics were the same in both groups. The time taken in the C-TKA and RA-TKA groups was 24.77 ± 1.92 minutes and 25.03 ± 3.27 minutes, respectively, which is statistically insignificant (p = 0.709). Conclusions: The study findings show that RA-TKA does not take additional time than C-TKA.

An Early Experience with a Novel Technique of Total Knee Arthroplasty for Osteoarthritic Knee with Coexistent Traumatic Tibia Diaphysis Fracture.

BACKGROUND: Treatment of tibia (upper third and diaphysis) fracture together with severe osteoarthritis (OA) poses challenge to an orthopedic surgeon. Traditionally, it is treated through three-stage surgeries, first fracture fixation followed by implant removal and finally surgery of total knee arthroplasty (TKA). Herein, we describe a novel TKA procedure using long-stemmed tibia component. This one-step technique not only addresses arthritis of the knee joint but also helps in assisting fixation of the fracture. MATERIALS AND METHODS: We reported outcomes of three female non-diabetic patients with OA who developed tibia shaft fracture following trauma. Range of motion and quadriceps strengthening exercise were initiated immediately after the procedure. X-rays anteroposterior and lateral views of the operated limbs were obtained at post-operative week-6 and week-12. We allowed the patients' toe touch weight-bearing immediately after the surgery. The patients were progressed to full weight-bearing after confirming radiological union on the X-rays. RESULTS: At follow-up, all treated patients were able to mobilize with good range of motion of the operated knee and with union of the fracture. The American Knee society scores and WOMAC pain and stiffness scores improved significantly. CONCLUSION: This novel technique offers one-stage solution to the complex situation of osteoarthritis of the knee with associated tibia shaft fracture, thereby reducing future hospital admissions/surgeries and associated costs and complications. Further, it allows faster rehabilitation.

What do patients want out of their Total Knee Arthroplasty?: An Indian perspective.

INTRODUCTION AND AIM: Total Knee Arthroplasty surgery is one of the most successful operations in orthopaedics. Still a sizable percentage of patients remain dissatisfied. Various studies have been conducted to analyse the red flags associated with poor outcome. In this study we tried to have insight on actual requirements of Indian patients from TKA operation. MATERIAL & METHODS: 300 patients undergoing TKA were studied by way of patient expectation feedback form. The form had various patient related capture points. It had a leading question: What are your expectations from TKA? They were asked to rank the 5 most important options in the order of importance. The patient expectation form was distributed and collected by an independent observer. RESULTS: 70% of patients ranked relief of pain as the most important expectation. 20% reported improvement in walking as the number one expectation. Nearly equal number listed improvement in walking and ease of doing day-to-day activities as the second most important expectation. This was followed by improvement in climbing the stairs and improvement in quality of life. Correction of deformity and no pain while squatting and getting up from sitting position ranked at the bottom. CONCLUSION: Our study shows that the primary expectations of Indian population from their TKA are relief from pain and improvement in walking. Secondary expectations include ease of doing day-to-day activities and improvement in quality of life.

Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty.

Background: One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur. Materials and methods: This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2 years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48 h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5 mcg/h was applied at the beginning of surgery and was continued 2 weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14 days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any. Results: Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group. Conclusion: TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

Unusual Occurrence of Incarceration and Breakage of the Coiled Shaft of the Intramedullary Reamer during Closed Intramedullary Nailing of Tibia.

Introduction: Intramedullary (IM) nailing is a well-established method of treating closed tibia shaft fracture. We hereby describe an unusual incidence of the incarceration of the flexible IM reamer in the distal fracture fragment with breakage of the coiled shaft of the reamer in the proximal third of tibia during closed IM nailing. This case report highlights the usefulness of making a small window in the tibia to aid retrograde removal of incarcerated reamer. Case Presentation: A 26-year-old male patient had road traffic accident and sustained a close fracture of the right distal 3rd tibia along with segmental fracture of the adjacent fibula. The tibia nailing was done under combined spinal and epidural anesthesia. The proximal tibia was approached by a midline incision with splitting of the patellar tendon. The reduction of the fracture fragments was done and the guide wire was inserted. The medullary canal was narrow and hence the initial reaming was started with the smallest available, that is, 8 mm reamer. After crossing the fracture site, we noticed that reamer coiled shaft got broken into multiple pieces in the medullary cavity at proximal 3rd tibia. The fracture site was exposed and a linear osteotomy was done in distal tibial fragment. Through this window, the broken reamer was pushed in the retrograde manner and was delivered out. Most of the broken metal pieces of the reamer shaft were removed with pituitary rongeur. An 8 mm solid IM nail was passed in antegrade manner across the fracture site and was locked distally and proximally. The operative wounds were irrigated and closure was done in layers. The patient was allowed partial weight bearing at 3 weeks post-surgery with gradually progressing to full weight bearing at 10 weeks after confirming clinical and radiological union. Conclusion: To handle this unusual occurrence one needs to stay calm, make a small window to aid retrograde removal of reamer and remove the fragmented pieces of the coiled shaft of the reamer. In tight medullary canal, it is desirable to have smaller diameter reamers, that is, 6 mm during the surgery.

Rare Presentation of Ulnar Nerve Palsy in Closed Both Bone Forearm Fracture in Pediatric Population.

Introduction: Ulnar nerve injury in closed both bone forearm fracture is rare. Most nerve injuries are neuropraxia and rarely the nerve is trapped or is transected. Most of the time recovery is spontaneous but sometimes requires surgical exploration. We are reporting a case of a 14-year-old boy with closed both bone forearm fracture with ulnar nerve palsy due to entrapment and laceration between ulnar bone fracture fragment. Case Report: A 14-year-old boy presented in emergency department elsewhere with a left forearm closed injury due to fall while playing where he was diagnosed with both bone forearm shaft fracture with ulnar nerve palsy and was given an above elbow slab. After 3 days, the patient presented to our outpatient department (OPD) with completely absent sensation over little finger, ulnar aspect of ring finger, and ulnar clawing. No signs of compartment syndrome in the form of tense swelling or stretch pain were seen. There was a suspected ulnar nerve injury for which patient was admitted and posted for fracture fixation and exploration of the nerve in emergency which showed lacerated ulnar nerve trapped in fracture fragment. Open reduction and internal fixation with ulnar plating and radius titanium elastic nailing was done by orthopedic surgeon while ulnar nerve neurolysis and micro repair was subsequently done by plastic surgeon. There was no neurological recovery immediately post-operatively. Patient was discharged after 48 h and called for regular follow-up in OPD to assess fracture union and neurological recovery. There was gradual neurological recovery over the period of time. Complete motor and sensory recovery took place in 4 months. Conclusion: Ulnar nerve injury associated with close both bone forearm fracture is uncommon. They are usually associated with a contusion for which the treatment is basically conservative. Immediate nerve exploration and fracture fixation should be reserved for suspicious nerve laceration or entrapment within displaced fracture fragments on radiographs. This prevents delay and also avoids nerve sequelae to occur. Hence, high index of suspicion and complete neurological examination of the patient at first presentation is important to recognize and diagnose the type of nerve lesion early to decide upon the plan of management.

Short-term results of a novel management of supracondylar fracture with coexisting osteoarthritis with bifold fixation and total knee arthroplasty.

PURPOSE: Presence of supracondylar and periarticular femoral fracture with associated arthritis of knee poses a challenging situation to the orthopaedic surgeon. The results of fixation of fracture in osteoporosis are not very satisfactory and have complications. With fixation alone, they still cannot bear weight on affected leg due to severe disability of osteoarthritis. To make patient walk, conventionally three surgeries in the form of fracture fixation, removal of implant and total knee arthroplasty (TKA) needs to be done in staged manner. We propose a novel management in form of bifold fixation and simultaneous TKA. METHODS: Eight cases (6 females, 2 males) of supracondylar femoral fractures with severe osteoarthritis of the knee and osteoporosis were primarily fixed with bifold fixation using SIGN nail ( www.signfracturecare.org ) and locking plate together with simultaneous total knee arthroplasty. There were five cases (2 males and 3 females) of grade 4 (Kellgren-Lawrence grading) osteoarthritis (OA) and three cases (all females) of severe rheumatoid arthritis (RA). RESULTS: The mean age was 68 years and average time for full weight bearing was 6 days. Radiographic evidence of fracture union was achieved in 16.25 weeks. The mean Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 26 months was 83.13 and 22.13 respectively. CONCLUSIONS: Single stage combined bifold osteosynthesis with interlocking nail and locking plate together with total knee arthroplasty helps in one time management of these difficult injuries. It is a cost-effective and economically sound option and gives excellent results with good patient satisfaction.

Effect of Preoperative Diabetes on the Achievement of Forgotten Knee Status in Patients with Total Knee Arthroplasty.

BACKGROUND: Forgotten knee is the terminology which is used to describe a post-TKA patient who is completely unaware of his knee implant. The aim of the study is to determine whether preoperative diabetes negatively influences the achievement of forgotten knee status. METHODS: This is a retrospective cohort study. 300 patients (240 F:60 M) were studied. Patients were evaluated by an independent observer with FJS-12 score 2 weeks preop and at 6 weeks and 12 months after the operation. The patients with a FJS-12 score of ≥ 55 were considered to have achieved forgotten knee status. Out of 240 females, 96 had diabetes and out of 60 males, 18 had diabetes. Preoperative factors such as preop HBA1c, ROM, degree of deformity, VAS score and other associated co morbidities and postoperative factors such as HBA1c, ROM and hip-knee-ankle alignment were studied. Study was started with null hypothesis. The statistical difference was measured with Binominal proportion test and comparison of means t test. RESULTS: 96 out of 144 non-diabetic females (66.67%) and 51 out of 96 diabetic females (53%) achieved forgotten knee status (statistically significant, p value = 0.0336, Binominal proportion test). 27 out of 42 (65%) non-diabetic males and 12 out 18 diabetic males (66%) achieved forgotten knee status (p value = 0.9411). The FJS-12 score at 1 year for non-diabetic females and diabetic females was 58.6 mean ± 12.6 SD and 53.8 ± 17.6, respectively, which is statistically significant, p value 0.0145. The FJS-12 at 1 year in non-diabetic and diabetic males was 60.1 ± 14.8 and 59.6 ± 17.3, respectively, p value = 0.9097. CONCLUSION: Diabetic females have less chance of achieving a forgotten knee status than non-diabetic females. This understanding will help the operating surgeon in the preoperative patient counseling and modify the patient expectations.

Early experience with the use of trochanteric reattachment plate for the treatment of Vancouver type B 1 periprosthetic hip fractures.

OBJECTIVE: The purpose of our study is to study the usefulness of trochanteric reattachment plate in the management Vancouver type B 1 periprosthetic femur fractures. METHODS: We describe a case series of 15 (12 F: 3 M) Vancouver type B 1 fracture fixed with trochanteric reattachment plate with 3 years follow up. Patients with Vancouver A, B2, B3 and C fractures were excluded in the study. Clinical and radiological assessment of patients was done at 1, 3, 6, 9, 12, 24 and 36 months. The parameters evaluated were fracture union, Harris hip score and post-operative complications if any. RESULTS: Patients mean age was 74 years (range 58-84). Eleven patients were operated with cemented hemiarthroplasty while 4 patients had total hip arthroplasty done before. Operation time mean was 137.2 min and mean surgical blood loss was 522.66 ml. All the patients achieved radiological union of the fracture at mean of 14.13 weeks. Mean Harris hip Score was 82 at 36 months follow up. 13 out of 15 hips (86.67%) showed good clinical results and 2 patients (13.33%) showed fair result. All the patients returned to their pre injury activities of daily living. CONCLUSION: Operative fixation of Vancouver type B 1 periprosthetic fractures is a challenge for an orthopedic surgeon. Open reduction and internal fixation of these fractures using of trochanteric reattachment plate incorporating screws and cerclage wires through the plate provides good outcome in these patients. Use of this plate offers the surgeon stability against shearing as well as rotational forces.

Comparison of local pain and tissue reaction between conventional pneumatic tourniquet and disposable silicone ring tourniquet during Total Knee Arthroplasty.

BACKGROUND: To study the comparison of conventional pneumatic and disposable silicone ring tourniquet in Total Knee Arthroplasty. MATERIAL AND METHODS: This is a prospective randomized control trial. We used conventional pneumatic tourniquet on one side of leg and disposable silicone ring tourniquet on the other side in consecutive 50 simultaneous bilateral TKR patients. Patients having peripheral vascular disease of the lower limb were excluded from the study. The patient demographics & characteristics are identical being the same patient with two different legs. We started the study with null hypothesis. An independent observer assessed the local tourniquet site pain (VAS score 1-10) and local tourniquet site skin reaction at 24 h and 48 h after the TKA. P value < 0.05 was considered significant. RESULTS: There were no local skin complication with disposable tourniquet (0%). 8 out of 50 patients in whom the conventional tourniquet was applied showed local bruising, and two patients had blister formation making the local skin site complication rate 20% (statistically significant, p value0.0196, chi-squared test). The VAS score at 24 h was 4.3 ± 1.5 for disposable tourniquet group as against 5.6 ± 2.1 for conventional tourniquet group (statistically significant, p value = 0.0152, t statistic test for comparison of means). The VAS score at 48 h was 2.1 ± 1.5 and 3.3 ± 1.2 for disposable tourniquet group and conventional tourniquet group respectively (statistically significant p value = 0.003, student's t-test). CONCLUSION: Use of disposable tourniquet has better outcome than the conventional tourniquet with minimal or no local complications. The advantages of the disposable tourniquet are: 1 less local pain, 2. no local skin problems, 3. accurate tourniquet pressure at the application site, 4.0% local contamination. Hence, we recommend use of the disposable tourniquet during the Total Knee Arthroplasty.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.