Sex Differences in Complications Following Total Hip Arthroplasty: A Population-Based Study.

BACKGROUND: The relationship between sex and outcomes, especially complications, after total hip arthroplasty (THA) has not been well established. This study aimed to identify if patient biological sex significantly impacted complications after THA in Ontario, Canada. METHODS: A population-based retrospective cohort study of patients undergoing primary THA in Ontario from April 1, 2015 to March 31, 2020 was conducted. The primary outcome was major surgical complications within a year postsurgery (a composite of revision, deep infection requiring surgery, and dislocation). Secondary outcomes included the individual component of the composite primary outcome and major medical complications within 30 days. Proportional hazards regression calculated the adjusted hazards ratio for major surgical complications in men relative to women, adjusting for age, comorbidities, neighborhood income quintile, surgeon and hospital volume, and year of surgery. RESULTS: A total of 67,077 patients (median age 68 years; 54.1% women) from 61 hospitals were included; women were older with a higher prevalence of frailty. Women had a higher rate of major surgical complications within 1 year of surgery compared to men (2.9 versus 2.5%, adjusted odds ratio 1.19, 95% confidence interval 1.08 to 1.33, P = .0009). Conversely, men had a higher risk for medical complications within 30 days (6.3 versus 2.7%, P < .001). CONCLUSIONS: Observable sex disparities exist in post-THA complications; women face surgical complications predominantly, while medical complications are more prevalent in men. These insights can shape preoperative patient consultations. LEVEL OF EVIDENCE: Level III.

Does the accelerometer-based navigation system reduce blood loss and transfusion in one-stage sequential bilateral total knee arthroplasty? A randomized double-blind controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is associated with significant blood loss and postoperative transfusion. The accelerometer-based navigation (ABN) system guides the bone cutting plane without breaching the intramedullary canal, which may reduce bleeding. This study aimed to investigate blood loss and transfusion compared between the ABN system and the conventional procedure in patients undergoing one-stage sequential bilateral TKA (SBTKA). METHODS: A total of 66 patients scheduled for SBTKA were randomly allocated to either the ABN or conventional group. Postoperative hematocrit (Hct) level, drainage blood loss, transfusion rate, and amount of packed red cell transfusion were collected. Total red blood cell (RBC) loss was then calculated for the primary outcome. RESULTS: The mean calculated total RBC loss in the ABN and conventional group was 669.7 and 630.0 mL, respectively (p = 0.572). There was no significant difference between groups for other evaluated outcome parameters, including postoperative Hct level, drainage blood loss, or packed red cell transfusion volume. All patients in the conventional group required postoperative blood transfusion while 96.8% of patients in the ABN group were transfused. CONCLUSIONS: The total RBC loss and volume of packed red cells transfusion were not significant difference between interventions, which suggest no benefit of the ABN system in reducing blood loss and transfusion in patients undergoing SBTKA. TRIAL REGISTRATION: The protocol of this study was registered in the Thai Clinical Trials Registry database no. TCTR20201126002 on 26/11/2020.

No association between different in tibial resection level and clinical outcomes six months after Oxford unicompartmental knee arthroplasty: a prospective cohort study.

BACKGROUND: Localized tibial strain is one of the hypotheses to explain residual pain after Oxford UKA. We evaluate whether the depth of the vertical cut during tibial resection correlates with medial knee pain. We aimed to investigate the association between the depth of tibial resection and medial knee pain after OUKA. METHODS: This prospective cohort study enrolled 85 patients (mean age: 64.5 ± 7.7 years) who underwent cemented OUKA at our institute during October 2018-June 2019. The depth of tibial resection was measured intraoperatively as the thickness of the anterior, middle, and posterior parts. The greatest of the three thicknesses was recorded. Medial knee pain was assessed at 6 weeks and followed to 6 months. Patients were divided into the pain (P) and no pain (NP) groups. Preoperative and postoperative radiographic findings and OKS were compared between groups. We used logistic regression to analyze the independent association. RESULTS: The mean preoperative Oxford Knee Score (OKS) was 27.2 ± 7.6. The incidence of medial knee pain was 23.5% at 6 weeks after OUKA. The P group had a significantly lower OKS at 6 weeks compared to the NP group (28.9 ± 9.7 vs 33.7 ± 6.5, p = 0.049). There was no significant difference in the depth of tibial resection between groups. Medial knee pain had resolved by 6 months in all patients, and the 6-month OKS was similar between groups. CONCLUSION: Medial knee pain was found to be common in the early postoperative period after OUKA, but this pain spontaneously resolved by 6 months. As a range of tibial resection level, post-operative pain is not associated with tibial resection thickness in this study. LEVEL OF EVIDENCE: Level II. TRIAL REGISTRATION: The study was approved by the Institutional review board of Siriraj Hospital, Mahidol university. [SIRB 691/2560(EC4)].

Efficacy of epinephrine in local infiltration analgesia on pain relief and opioid consumption following total knee arthroplasty: a randomized controlled trial.

BACKGROUND AND PURPOSE: Local infiltration analgesia (LIA) is one of the effective regimens to reduce pain after total knee arthroplasty (TKA). Epinephrine is a commonly used sympathetic adjunct in LIA. It is expected to enhance the intensity and extend the duration of LIA. The primary aim of the study was to evaluate the efficacy of epinephrine on postoperative pain control after primary TKA. PATIENTS AND METHODS: A total of 80 patients who underwent primary TKA were randomized into an epinephrine (EN) and a control (C) group. Postoperative visual analogue pain score (VAPS) and morphine consumption were recorded every 6 hours until 48 hours after operation. The VAPS 6-48 hours were compared using repeated measure statistics. The range of motion (ROM) on discharge and complications were also compared between these 2 groups. RESULTS: The study showed that although VAPS differed statistically between the 2 groups at 12 hours (C higher) and 48 hours (C lower) postoperatively (p = 0.04 and 0.02, respectively), repeated measures analysis revealed that there were no significant differences in 6-48 hours VAPS (p = 0.6). Total morphine consumption in the EN and C groups was 3.4 (SD 3.7) and 4.2 (SD 4.4) mg, respectively (p = 0.4). ROM on discharge was also similar between the groups. No complications were detected in this study. CONCLUSION: Our study showed that additional epinephrine in LIA had a statistically significant reduction in VAPS at 12 hours and morphine usage during 6-12 hours when compared with the control group. However, the magnitude of difference did not reach minimal clinically importance difference (MCID) value for TKA.

Clinical and radiological outcomes of robotic-assisted versus conventional total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND PURPOSE: Robotic-assisted total knee arthroplasty (RATKA) is an alternative surgical treatment method to conventional total knee arthroplasty (COTKA) that may deliver better surgical accuracy. However, its impact on patient outcomes is uncertain. The aim of this systematic review of randomized controlled trials (RCTs) is to evaluate whether RATKA could improve functional and radiological outcomes compared with COTKA in adult patients with primary osteoarthritis of the knee. METHODS: We searched Ovid MEDLINE, EMBASE, Scopus, and the Cochrane Library to identify published RCTs comparing RATKA with COTKA. 2 reviewers independently screened eligible studies, reviewed the full texts, assessed risk of bias using the Risk of Bias 2.0 tool, and extracted data. Outcomes were patient-reported outcomes, range of motion, and mechanical alignment (MA) deviation and outliers, and complications. RESULTS: We included 12 RCTs involving 2,200 patients. RATKA probably results in little to no effect on patient-reported outcomes (mean difference (MD) in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of -0.35 (95% confidence interval [CI] -0.78 to 0.07) and range of motion (MD -0.73°; CI -7.5° to 6.0°) compared with COTKA. However, RATKA likely results in a lower degree of MA outliers (risk ratio 0.43; CI 0.27 to 0.67) and less deviation from neutral MA (MD -0.94°; CI -1.1° to -0.73°). There were no differences in revision rate or major adverse effects associated with RATKA. CONCLUSION: Although RATKA likely results in higher radiologic accuracy than COTKA, this may not be clinically meaningful. Also, there is probably no clinically important difference in clinical outcomes between RATKA and COTKA, while it is as yet inconclusive regarding the revision and complication rates due to insufficient evidence.

Alignment accuracy and functional outcomes between hand-held navigation and conventional instruments in TKA: a randomized controlled trial.

BACKGROUND: This study assessed surgical accuracy and functional outcomes using hand-held accelerometer-based navigation following total knee arthroplasty (TKA). QUESTION: (1) Does hand-held navigation (the iAssist system) improve surgical accuracy (assessed with five parameters commonly used to evaluate surgical alignment: the hip-knee-ankle angle (HKA), femoral coronal angle (FCA), tibial coronal angle (TCA), femoral sagittal angle (FSA), and tibial slope angle (TSA)) compared to conventional instruments in TKA? (2) Which surgical alignment parameters among HKA, FCA, TCA, FSA, and TSA can obtain the most advantage from the iAssist system? (3) Does the iAssist system lead to better functional outcomes at two years of follow-up after TKA? METHODS: This parallel-group double-blinded randomized controlled trial recruited 60 patients (30 patients each in the iAssist and conventional group) with osteoarthritis who underwent primary TKA by a single surgeon at Siriraj Hospital. There was no loss to follow-up in the study. All procedures in both groups were performed using similar surgical exposure, prosthesis implant, perioperative and postoperative protocols. Participants in the iAssist group received the iAssist system as an assistive technique, while those in the conventional group only had conventional instruments. Surgical alignments (HKA, FCA, TCA, FSA, and TSA) were recorded using CT scan at six weeks post-operation. Functional outcomes were assessed with knee ROM, KSS, and EQ-5D at 6 months, 1 year and 2 years post-operation. Baseline characteristics including age, sex, the affected knee side, and body mass index were comparable between the two groups, similar to preoperative ROM, KSS, and EQ-5D. RESULTS: The mean operative time was relatively longer in the iAssist than the conventional group, although not statistically significant (88.1 ± 13.7 versus 83.4 ± 21.3; p = 0.314). Among the surgical alignment parameters evaluated, FCA was the only radiographic parameter with a statistically significant difference between the two groups and was closer to 90º in the iAssist group (89.4 ± 2.2 in the iAssist versus 87.2 ± 2.1 in the conventional group; p = 0.003). Also, there was a higher proportion of outliers in the conventional than the iAssist group (23.3% versus 10%; p = 0.086). Nonetheless, HKA and TCA did not differ between the two groups (p = 0.25 and 0.096, respectively), although the percentages of outliers were higher in the conventional than the iAssist group (HKA: 26.7% vs. 13.3%; p = 0.101 and TCA: 6.7% versus 0%; p = 0.078). Likewise, we observed other radiographic parameters had no significant group differences, including FSA and TSA. Furthermore, at two years post-operation, we found no differences between the iAssist and the conventional group in knee ROM (106.7 ± 14.6 versus 108.2 ± 12.7; p = 0.324), KSS (82.5 ± 6.4 versus 83.8 ± 3.4; p = 0.324), and EQ-5D (0.9 ± 0.2 versus 1.0 ± 0.1; p = 0.217). All functional outcomes were also comparable at 6 months and 12 months of follow-up postoperatively. CONCLUSION: The iAssist technology increase surgical precision by allowing for a more precise FCA with fewer outliers than conventional equipment. iAssist had longer operative time. Functional outcomes and quality of life were not different. LEVEL OF EVIDENCE: I.

Efficacy of adding an interspace block to the posterior knee for perioperative pain in total knee arthroplasty: a randomized controlled trial.

BACKGROUND AND PURPOSE: The interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block is a novel anesthetic technique for total knee arthroplasty (TKA). Our objective was to compare the effect of IPACK and adductor canal block (ACB) and periarticular injection (PAI), relative to ACB and PAI only, from baseline to postoperative day 3, in patients undergoing unilateral primary TKA. PATIENTS AND METHODS: This was a single-center, double-blinded, randomized controlled trial. Adults over the age of 50 who were scheduled for unilateral primary TKA were enrolled. They were randomly assigned to ACB and PAI block (control group), or ACB, PAI, and IPACK block (IPACK group). The primary outcome was mean pain at rest during 24-48 hours post-operation using a numerical rating scale (0-10). We also investigated opioid use and ambulation pain. RESULTS: 89 patients were evaluated, 45 from the control group and 44 from the IPACK group. Despite slightly higher mean pain score at rest in the control group, no statistically significant difference was found during 0-24 hours (0.13; 95% CI -0.19 to 0.46), 24-48 hours (0.42; CI -0.06 to 0.89), and 48-72 hours (0.35; CI 0.00 to 0.69) postoperatively as well as in maximum pain scores at rest. Neither pain during ambulation nor the number of opioids used differed between the trial groups at any given time point. CONCLUSION: The addition of the IPACK block to ACB and PAI did not reduce postoperative pain intensity or opioid usage. Therefore, IPACK block may not offer any benefit for pain management in patients undergoing unilateral primary TKA who are already receiving ACB and PAI.

Accuracy of empirical distal femoral valgus cut angle of 4° to 6° in total knee arthroplasty: a randomized controlled trial.

INTRODUCTION: Currently, the best and simplest way that used to select the distal femoral valgus cut (DFVC) angle in total knee arthroplasty (TKA) is standing long leg radiograph. However, this kind of film is still not available in all hospitals. The purpose of this study is to compare the accuracy of different empirical DFVC angles in the restoration of the neutral mechanical alignment of the femoral component after TKA. METHOD: 125 patients who diagnosed primary osteoarthritic knee and underwent unilateral TKA were randomly assigned into three groups: A, B, and C, according to the use of an intramedullary guide with the DFVC angle of 4°, 5°, and 6°, respectively. At three months after surgery, anteroposterior hip-to-ankle computed tomography (CT) scanograms were evaluated. Mechanical axis angle (MAA), mechanical lateral distal femoral angle (LDFA), femoral bowing, femoral neck-shaft angle (FNSA), and outliers of femoral component position were measured and compared among three groups. Independent influencing factors for the outliers > ±3° were determined using binary logistic regression analysis. RESULTS: Group B was older than group A. There were no significant differences of postoperative MAA, LDFA, femoral bowing, and FNSA among three groups. Outliers > ±3° of femoral component position in each group were 14.6%, 19.0%, and 16.7%, respectively (p = 0.865). When considering the outliers > ±2°, group C (35.7%) had a trend to have fewer outliers than groups A and B (41.5 and 42.9%). However, this finding was not reached the statistical significance (p = 0.778). Femoral bowing was only significantly influencing factors that related to the outliers > ±3° (p = 0.003). CONCLUSION: This study demonstrates that there are no significant differences in coronal femoral component alignment among using the DFVC angle of 4°, 5°, and 6°. The use of the DFVC angle of 6° had a trend to reduce the outliers. Nevertheless, femoral bowing is the crucial influencing factor for selecting the degree of DFVC angle.

Risk factors of early periprosthetic femoral fracture after total knee arthroplasty.

BACKGROUND: Periprosthetic femoral fracture (PFF) is a serious complication after total knee arthroplasty (TKA). However, the risk factors of PFF in the early postoperative setting are not well documented. This study determines the risk factors of early PFF after primary TKA. METHODS: This study recruited 24 patients who had early PFF within postoperative 3 months and 96 control patients. Demographic data (age, gender, weight, height, body mass index, Deyo-Charlson comorbidity index, diagnosis, operated side, underlying diseases and history of steroid usage intraoperative outcomes), intraoperative outcomes (operative time, surgical approach, type and brand of the prosthesis), and radiographic outcomes (distal femoral width; DFW, prosthesis-distal femoral width ratio; PDFW ratio, anatomical lateral distal femoral angle; LDFA, the change of LDFA, femoral component flexion angle; FCFA and anterior femoral notching; AFN) were recorded and compared between groups. Details of PFF, including fracture pattern, preoperative deformity, and time to PFF were also documented. RESULTS: In univariate analysis, the PFF group had significantly older, right side injury, rheumatoid, dyslipidemia, Parkinson patients than the control group (p < 0.05). No cruciate-retaining design was used in PFF group (p = 0.004). Differences between the prosthetic brand used were found in this study (p = 0.049). For radiographic outcomes, PFF group had significantly lower DFW but higher PDFW ratio and postoperative LDFA than the control group (p < 0.05). While the change of LDFA, FCFA and AFN were similar between groups. The fracture patterns were medial condylar (45.8%), lateral condylar (25.0%) and supracondylar fracture (29.2%). The mean overall time to PFF was 37.2 ± 20.6 days (range 8-87 days). Preoperative deformity was significantly different among the three patterns (p < 0.05). When performed multivariate analysis using the logistic regression model, age was only an independent risk factor for early PFF. The cut-off point of age was > = 75 years, with a sensitivity of 75.0% and specificity of 78.1%. CONCLUSION: This study determined that age was the independent risk factors for early PFF. However, further well-controlled studies with a larger sample size were needed to address this issue.

Cosmetic outcomes and patient satisfaction compared between staples and subcuticular suture technique for wound closure after primary total knee arthroplasty: a randomized controlled trial.

INTRODUCTION: Staples and subcuticular suture are commonly used wound closure techniques after total knee arthroplasty (TKA). To date, only a few studies have investigated the differences between these two wound closure methods in TKA. Accordingly, this study aimed to compare cosmetic outcome and patient satisfaction between staples and subcuticular suture for post-TKA wound closure. MATERIALS AND METHODS: This prospective randomized controlled trial included patients scheduled to undergo TKA at the Department of Orthopaedic Surgery of Siriraj Hospital (Bangkok, Thailand) during June 2018-March 2019. Patients were randomized into the staples or subcuticular suture groups. Hollander Wound Evaluation Scale (HWES), cosmetic-visual analogue scale (VAS), and patient satisfaction-VAS were evaluated at the 6-week and 3-month follow-ups. Functional outcome by the modified Knee Society Knee Scoring System and wound complications were also assessed. RESULTS: Sixty-two patients (31 per group) were included. There were no significant differences in the HWES, cosmetic-VAS, patient satisfaction-VAS, or wound complication rate between groups at the 6-week or 3-month follow-ups. Wound closure time was significantly shorter in the staples group (p < 0.001), but the total operative time was not significantly different between groups. Modified knee score was significantly better in the suture group at 6 weeks (p = 0.024), but there was no significant difference between groups at 3 months. Significant association was observed between patient satisfaction-VAS and cosmetic-VAS at the 6-week (p = 0.03) and 3-month (p = 0.021) follow-ups. CONCLUSION: Subcuticular suture and staples were found to be comparable wound-closure options after TKA relative to cosmetic outcome, patient satisfaction, functional outcome, and wound complication rate at 3-months post-operation.

Validity and Responsiveness of the Two-Minute Walk Test for Measuring Functional Recovery After Total Knee Arthroplasty.

BACKGROUND: The 2-minute walk test (2mwt) is a performance-based test that evaluates functional recovery after total knee arthroplasty (TKA). This study evaluated its validity compared with the modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), modified Knee Score, Numerical Pain Rating Scale, and Timed Up and Go test, and its responsiveness in assessing functional recovery in TKA patients. METHODS: This prospective cohort study included 162 patients undergoing primary TKA between 2013 and 2015. We used patient-reported outcome measures (modified WOMAC, OKS, modified Knee Score, Numerical Pain Rating Scale) and performance-based tests (2mwt and Timed Up and Go test) at baseline and 3, 6, and 12 months postoperatively. The construct validity of 2mwt was determined between the 2mwt distances walked and other outcome measurements. To assess responsiveness, effect size and standardized response mean were analyzed. Minimal clinically important difference of 2mwt at 12 months after TKA was also calculated. RESULTS: All outcome measurements improved significantly from baseline to 3, 6, and 12 months postoperatively. Bivariate analysis revealed mild to moderate associations between the 2mwt and modified WOMAC function subscales, and moderate to strong associations with OKS. Mild to moderate correlations were found for pain and stiffness between 2mwt and other outcome measurements. The effect size and standardized response mean at 12 months were large, with a minimal clinically important difference of 12.7 m. CONCLUSION: 2mwt is a validated performance-based test with responsiveness properties. Being simple and easy to perform, it can be used routinely in clinical practice to evaluate functional recovery after TKA.

Modified Robert Jones bandage can not reduce invisible blood loss after total knee arthroplasty: a randomized-controlled trial.

INTRODUCTION: To compare the efficacy and safety of modified Robert Jones bandage (MRJB) and non-compressive dressing (NCD) on reducing invisible blood loss (IBL) after total knee arthroplasty (TKA). MATERIALS AND METHODS: Eighty patients who underwent unilateral TKA were randomly assigned into two groups: MRJB and NCD groups. Pre- and post-operative hematocrit levels, amount of drained blood and transfused blood were measured and calculated into IBL. Pain score, amount of morphine usage, range of motion (ROM) at discharge, blood transfusion rate, and complications were also recorded and compared between both groups. RESULTS: There was no significant difference in the mean IBL between MRJB (221.2 ± 233.3 ml) and NCD groups (158.5 ± 186.7 ml) (p = 0.219). Post-operative pain score at rest and during ambulation, amount of morphine usage, ROM at discharge, blood transfusion rate, and complications were also similar between two groups. CONCLUSIONS: This study cannot determine the benefit of MRJB over NCD. The use of MRJB may not be necessary after primary TKA.

Survivorship of medial opening wedge high tibial osteotomy in the elderly: two to ten years of follow up.

BACKGROUND AND PURPOSE: Medial opening wedge high tibial osteotomy (MOWHTO) is a well-accepted procedure, which has been widely used for pain relief and varus deformity correction in the osteoarthritic (OA) knee, especially in the young patient. However, in the elderly patient, the efficacy of this procedure is still unknown. Therefore, this study aims to evaluate the survivorship of MOWHTO in elderly patients as the primary outcome. The secondary outcome is to evaluate the loss of correction angle that is the common complication after MOWTHO. MATERIALS AND METHOD: A retrospective study of 50 elderly patients (≥ 60 years) was conducted to track survivorship of MOWHTO. All patients were diagnosed with varus OA knee and underwent MOWHTO at our institute. The patients who had previous knee surgery or incomplete data were excluded. Medical records and radiographs of eligible patients were reviewed for recruiting the data. Survivorship of MOWHTO was analyzed using Kaplan-Meier curves. The starting point was the time of operation and the end point was the time of subsequent TKA. The loss of correction angle was defined as the change of medial proximal tibial angle (MPTA) between three months and one year post-operatively. RESULTS: The mean age of patients was 66 ± 5.0 years. The majority of patients were female (74%). The mean correction angle was 10.6 ± 3.6 degrees. The union rate of osteotomy site was 100%. In survival analysis, the median follow-up time was 6.0 ± 3.0 years. Two patients required subsequent conversions to TKA. The survivorship of MOWHTO at four years was 95.5% (95%CI, 96.0 to 98.0). For radiographic assessment, the loss of correction angle was 1.0 ± 0.5 degrees at one year post-operatively. CONCLUSION: This study proved that MOWHTO in patient ≥60 years had good mid-term survivorship with acceptable complications. This procedure can be the alternative option for the treatment of varus OA knee in the elderly.

Effectiveness Testing of Combined Innovative Pressurized Carbon Dioxide Lavage and Pulsatile Normal Saline Irrigation to Enhance Bone Cement Penetration in Total Knee Replacement: A Cadaveric Study.

Background: The cementing technique in total knee arthroplasty (TKA) is essential for a successful outcome. Previous studies have shown that deeper cement penetration results in greater tensile and shear strength between the bony part and the prosthetic parts. Objective: Objective: To investigate the effectiveness of combined innovative pressurized carbon dioxide lavage and pulsatile normal saline irrigation for enhancing cement penetration into cancellous bone, as compared with standard pulsatile normal irrigation alone. Material and Method: An intra-individual comparative cadaveric study was conducted at the Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University in April 2015. Ten fresh cadavers underwent TKA via the medial parapatellar approach. The proximal tibia was cut perpendicular to its anatomical axis at a point nine millimeters inferior to the lateral plateau. After randomization of knees, the proximal tibia of one side was prepared with pulsatile normal saline irrigation followed by innovative pressurized carbon dioxide lavage. The contralateral side was then prepared using standard pulsatile normal saline irrigation alone. After completing bilateral cemented TKA, the tibial prostheses were removed from both knees. The proximal tibia was then cut on three planes. The posterior coronal plane cut, the medial sagittal oblique plane cut, and the lateral sagittal oblique plane cut facilitated visualization and measurement of the depth of cement penetration into the posterior, middle, and lateral columns, respectively. A bone sample from each column was measured by digital vernier caliper to evaluate bone cement penetration. Results: Combined innovative pressurized carbon dioxide lavage and pulsatile normal saline irrigation produced significantly deeper cement penetration into cancellous bone, as compared with pulsatile normal irrigation alone (1.90±0.39 mm vs. 1.21±0.21 mm, p = 0.04). Conclusion: Combined innovative pressurized carbon dioxide lavage and pulsatile normal saline irrigation produced significantly deeper bone cement penetration than pulsatile normal saline irrigation alone.

Sterility verification of innovative pressurized carbon dioxide lavage for bone surface preparation in cemented knee arthroplasty.

OBJECTIVE: To verify sterility of innovative pressurized carbon dioxide (CO) lavage for bone surface preparation in cemented knee arthroplasty. MATERIAL AND METHOD: Twenty-five 500 L. air samples from the innovative pressurized CO, lavage were laboratory tested to verify the presence or absence of either bacteria or fungi in microbial air samplings taken in a biological safety cabinet. CO2 gas was delivered though a pressure regulator, a sterile delivery tube, a hand piece, and a microbial air filter with a pressure level of 50 psi, according to the medical standard. Contamination samples for bacteria and fungi were taken by using Tryptic Soy Agar and SabouraudAgar as the culture media and were then analyzed at 48 hours and 10 days, respectively. RESULTS: Twenty-five samples of microbial culture showed no bacterial or fungal growth on either Tryptic Soy Agar or Sabouraud Agar CONCLUSION: The sterility of the innovative pressurized carbon dioxide lavage was confirmed by laboratory test results and was approved for application for bone surface preparation in cemented total knee arthroplasty.

Clinical, functional, and radiological outcomes of robotic assisted versus conventional total hip arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

This systematic review of randomized controlled trials (RCTs) aims to compare important clinical, functional, and radiological outcomes between robotic-assisted total hip arthroplasty (RATHA) and conventional total hip arthroplasty (COTHA) in patients with hip osteoarthritis. We identified published RCTs comparing RATHA with COTHA in Ovid MEDLINE, EMBASE, Scopus, and Cochrane Library. Two reviewers independently performed study screening, risk of bias assessment and data extraction. Main outcomes were major complications, revision, patient-reported outcome measures (PROMs), and radiological outcomes. We included 8 RCTs involving 1014 patients and 977 hips. There was no difference in major complication rate (Relative Risk (RR) 0.78; 95% Confidence Interval (CI) 0.22 to 2.74), revision rate (RR 1.33; 95%CI 0.08 to 22.74), and PROMs (standardized mean difference 0.01; 95%CI - 0.27 to 0.30) between RATHA and COTHA. RATHA resulted in little to no effects on femoral stem alignment (mean difference (MD) - 0.57 degree; 95%CI - 1.16 to 0.03) but yielded overall lower leg length discrepancy (MD - 4.04 mm; 95%CI - 7.08 to - 1.0) compared to COTHA. Most combined estimates had low certainty of evidence mainly due to risk of bias, inconsistency, and imprecision. Based on the current evidence, there is no important difference in clinical and functional outcomes between RATHA and COTHA. The trivial higher radiological accuracy was also unlikely to be clinically meaningful. Regardless, more robust evidence is needed to improve the quality and strength of the current evidence.PROSPERO registration: the protocol was registered in the PROSPERO database (CRD42023453294). All methods were carried out in accordance with relevant guidelines and regulations.

The pre-anesthetic period is the best time to evaluate the knee flexion angle for predicting the flexion angle after total knee arthroplasty: A prospective cohort study.

INTRODUCTION: Knee flexion angle (KFA) is one of the most critical factors for evaluating patient functional outcomes after total knee arthroplasty (TKA). Preoperative KFA and intraoperative drop leg test are both accepted as predictors of postoperative KFA after TKA. Preoperative testing performed after anesthesia helps overcome pain-related limitations; however, the KFA measurement timepoint that best predicts KFA at 6 months after TKA has not yet been established. METHODS: This prospective cohort study recruited patients who underwent unilateral primary TKA at Siriraj Hospital (Bangkok, Thailand) during August 2012 to August 2017. We recorded KFA at the pre-anesthetic phase, post-anesthetic phase, intraoperation using drop leg test, and at 6-months post-operation. Pearson's correlation coefficient was used to evaluate correlation between different measurement timepoints and 6 months after surgery. Those same relationships were evaluated for overall patients, and for patients with KFA <90° (poor KFA), 90-120° (average KFA), and >120° (high KFA). RESULTS: A total of 165 patients with a mean age of 68.7 years were recruited. Pre-anesthetic KFA measurement had the highest positive correlation with the 6-month KFA (r = 0.771, p<0.05). Post-anesthetic measurement and intraoperative drop leg KFA measurement had moderate positive correlation (r = 0.561, p<0.05) and low positive correlation (r = 0.368, p<0.05) with the 6-month KFA, respectively. The average KFA group had the highest positive correlation between pre-anesthetic KFA measurement and the 6-month KFA (r = 0.711, p<0.05). Predicted 6-month KFA (degrees) adjusted for pre-anesthetic KFA is 45.378 + [0.596 x pre-anesthetic KFA (degrees)] (r = 0.67, p <0.05). CONCLUSIONS: Pre-anesthetic KFA demonstrated the highest correlation with the final KFA at six months after unilateral primary TKA, especially in the patients who had a preoperative KFA within 90-120°.

The association between perception of patients and their actual ability to do floor activities after mobile-bearing unicompartmental knee arthroplasty: A prospective, cross-sectional study.

OBJECTIVES: This study aims to evaluate the association between patients' perception and their ability to perform floor activities after mobile-bearing unicompartmental knee arthroplasty (MB-UKA). PATIENTS AND METHODS: This prospective, cross-sectional study included a total of 63 knees of 63 patients (7 males, 56 females; mean age: 65.6±6.2 years; range, 51 to 79 years) with anteromedial osteoarthritis knee who had MB-UKA with a follow-up period of at least one year postoperatively. Each participant was asked to rate their perception of their ability to perform six floor activities. Their actual abilities were measured by using a five-category anchored scale. The primary outcome was the association between participants' perception and their actual ability. The secondary outcome was to evaluate factors affecting patients' actual ability. RESULTS: More than 60% of the patients could achieve good actual ability scores in performing chair kneeling, floor kneeling, and sitting side-legged regardless of their perception. Chair kneeling at 90 degrees had the most patients (69.8%) with good actual ability scores. Standing up from the floor was the activity with the highest positive perception rate of 84.1%. However, relatively lower actual activity scores were observed in floor squatting, cross-legged sitting, and standing up from the floor. Floor squatting yielded the lowest rate of positive perception and actual ability scores (39.1% and 20.6%, respectively). The Oxford Knee Score and knee flexion angle had moderate positive correlations with the actual ability scores (r=0.44 and 0.40, respectively). CONCLUSION: Patients' perception and their actual ability may differ for each floor activity after MB-UKA. An appropriate sequence of activities based on their difficulties along with positive reinforcement and appropriate patient education may yield favorable functional outcomes following MB-UKA.

To resurface or not to resurface? Investigating the impact of patellar resurfacing on anterior knee pain in rheumatoid arthritis patients undergoing total knee replacement.

BACKGROUND: Routine patellar resurfacing is a controversial issue in total knee replacement (TKR), especially for rheumatoid arthritis (RA). Anterior knee pain (AKP) is a common complaint after TKR that may be related to patellofemoral joint condition. The aim of this study was to investigate the prevalence and factors associated with AKP after TKR for RA compared between non-resurfaced patella (NRP) and resurfaced patella (RP). METHODS: This retrospective study included RA patients who underwent TKR at our institute from 2002 to 2019. All included patients had at least 1 year of follow up. Patients were divided into the NRP and RP groups. At the last follow up visit, the prevalence of AKP, and the severity of AKP, including visual analogue pain score (VAPS) and Kujala score, were compared between groups. Univariate and multivariate logistic regression analysis was performed to identify independent predictors of AKP. RESULTS: A total of 141 RA patients (median age: 60 years, 90% female, 219 knees) were included. There was no significant difference in AKP between the NRP and RP groups (12.7% vs. 7.3%, P = 0.185). Regarding AKP severity, there was no significant difference in VAPS or Kujala score between groups (P = 0.147 and P = 0.067, respectively). No independent predictors of AKP were identified. CONCLUSION: Although patellar resurfacing is recommended in TKR for RA, this study found no significant difference in prevalence of AKP, VAPS and Kujala score between those with and without patellar resurfacing during TKR.

No Effect of Oral Mecobalamin on Skin Numbness at 3 Months After Total Knee Arthroplasty: A Randomized, Double-Blinded, Placebo-Controlled Superiority Trial.

Background: An area of skin numbness (AON) around an incision commonly occurs following total knee arthroplasty (TKA). Mecobalamin has been shown to facilitate peripheral nerve recovery in various conditions; accordingly, the present study aimed to investigate the ameliorative effect of mecobalamin on AON following TKA, as compared with a placebo. Methods: This superiority study was a double-blinded, randomized controlled trial. All patients undergoing primary TKA were assessed for eligibility. Included patients were randomized to receive either mecobalamin (500 µg, twice daily) or placebo (corn starch powder; 500 µg, twice daily) for 3 months. The primary outcome was the change in the AON around the surgical site from 2 weeks to 3 months after TKA. Secondary outcomes included the rates of different adverse events, functional outcomes, and visual analogue scale patient satisfaction scores. Results: A total of 154 patients were enrolled, with 77 patients each in the mecobalamin and placebo groups. The mean AON among patients in the mecobalamin group was 61.6 cm2 at baseline (2 weeks) and 29.1 cm2 at 3 months, compared with 55.9 cm2 and 33.2 cm2 among patients in the placebo group, respectively. Intention-to-treat analysis showed no significant difference in the change in AON around the surgical site between the 2 groups (mean difference, 7.5; 95% confidence interval, -4.2 to 25.3; p = 0.159). The rates of adverse events, functional outcomes, and visual analogue scale patient satisfaction score were also not significantly different between groups. Conclusions: Mecobalamin did not demonstrate superiority over a placebo in reducing the AON around the surgical site at 3 months after primary TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.