No Difference in Limb Alignment Between Kinematic and Mechanical Alignment Robotic-Assisted Total Knee Arthroplasty.

BACKGROUND: Individualized alignment techniques have gained major interest in an effort to increase satisfaction among total knee arthroplasty patients. This study aimed to compare postoperative alignment between kinematic alignment (KA) and mechanical alignment (MA) and assess whether KA significantly deviates from the principle of aligning the limb as close to neutral alignment as possible. METHODS: There were 234 patients who underwent robotic-assisted total knee arthroplasty using an unrestricted KA and a strict MA technique (KA: 145, MA: 89). The lateral distal femoral angle, medial proximal tibia angle, and the resultant arithmetic hip-knee-ankle angle (aHKA) were measured. The aHKA < 0 indicated varus alignment, while the aHKA > 0 indicated valgus knee alignment. The primary outcome was the frequency of cases that resulted in an aHKA of ± 4° of neutral (0°), as assessed on full-leg standing radiographs obtained at 6 weeks postoperatively. The secondary outcome was the change in coronal plane alignment of the knee classification type from preoperative to postoperative between the MA and KA groups. RESULTS: The mean preoperative aHKA was similar between the 2 groups (P = .19). The KA group had a mean postoperative aHKA of -1.4 ± 2.4°, while the MA group had a mean postoperative aHKA of -0.5 ± 2.1°. No significant difference in limb alignment was identified between KA and MA cases that resulted in hip-knee-ankle angle of ± 4° being neutral (91.7 versus 96.6%, P = .14). There were 97.2% of cases in the KA group that fell within the ± 5° range. The MA group was associated with a significantly higher rate of coronal plane alignment of the knee classification type change from preoperatively to postoperatively (P < .001). CONCLUSIONS: Kinematic alignment achieved similar postoperative aHKA compared to MA, and thus did not significantly deviate from the principle of aligning the limb as close to neutral alignment as possible. Surgeons should feel comfortable starting to introduce individualized alignment techniques. Without being restricted by boundaries, postoperative alignment will be within 5 degrees of neutral 97% of the time.

Decreased Instability in High-Risk (Hip-Spine 2B) Patients After Modifications of Surgical Planning and Technique.

BACKGROUND: Patients undergoing primary total hip arthroplasty (THA) who have spinal deformity and a stiff spine are the highest-risk group for instability. Despite the increasing use of dual-mobility cups and large femoral heads, dislocation remains a major complication after THA. Preoperative planning becomes a critical aspect of ensuring precise component positioning within a safe zone. The purpose of this study was to investigate dislocation rates over a 9-year period. METHODS: A retrospective review of 4,731 THAs performed by 3 orthopaedic surgeons between January 2014 and March 2023 was performed. Spinopelvic measurements were conducted to determine the hip-spine classification group for each patient. Only patients classified as 2B (pelvic incidence-lumbar lordosis > 10° and Δsacral slope < 10°) were eligible. Both absolute and relative dislocation frequencies were then analyzed using time-series analysis techniques and Fisher's exact tests. RESULTS: A total of 281 hip-spine 2B patients undergoing primary THA were eligible for analysis (57% women; mean age, range: 66 years, 23 to 87; mean body mass index, range: 28, 16 to 45). The overall dislocation rate was 4.3%. Use of femoral head sizes ≥ 40 mm increased from 4% in 2014 to 2019 to 37% in 2020 to 2023 (P < .001), while the use of dual-mobility cups decreased from 100% in 2014 to 2019 to 37% in 2020 to 2023 (P < .001). Acetabular component planning was changed from the supine plane to the standing plane in February 2020. Those changes in surgical practice were notably correlated with a significant decrease in dislocation rates from 6.8% in 2014 to 2019 to 1.5% in 2020 to 2023 (P = .03). CONCLUSIONS: Our study demonstrates that the introduction of advanced preoperative THA planning to the standing plane, coupled with precise intraoperative technology for implant placement, can significantly reduce the risk of instability in high-risk THA patients. Notably, we observed a significant decrease in dislocation rates, which aligned with the shift in surgical practice. LEVEL OF EVIDENCE: IV.

Is Tibial Bone Mineral Density Related to Sex, Age, Preoperative Alignment, or Fixation Method in Primary Total Knee Arthroplasty?

BACKGROUND: Cementless total knee arthroplasty (TKA) has regained interest for its potential for long-term biologic fixation. The density of the bone is related to its ability to resist static and cyclic loading and can affect long-term implant fixation; however, little is known about the density distribution of periarticular bone in TKA patients. Thus, we sought to characterize the bone mineral density (BMD) of the proximal tibia in TKA patients. METHODS: We included 42 women and 50 men (mean age 63 years, range: 50 to 87; mean body mass index 31.6, range: 20.5 to 49.1) who underwent robotic-assisted TKA and had preoperative computed tomography scans with a BMD calibration phantom. Using the robotic surgical plan, we computed the BMD distribution at 1 mm-spaced cross-sections parallel to the tibial cut from 2 mm above the cut to 10 mm below. The BMD was analyzed with respect to patient sex, age, preoperative alignment, and type of fixation. RESULTS: The BMD decreased from proximal to distal. The greatest changes occurred within ± 2 mm of the tibial cut. Age did not affect BMD for men; however, women between 60 and 70 years had higher BMD than women ≥ 70 years for the total cut (P = .03) and the medial half of the cut (P = .03). Cemented implants were used in 1 86-year-old man and 18 women (seven < 60 years, seven 60 to 70 years, and four ≥ 70 year old). We found only BMD differences between cemented or cementless fixation for women < 60 years. CONCLUSIONS: To our knowledge, this is the first study to characterize the preoperative BMD distribution in TKA patients relative to the intraoperative tibial cut. Our results indicate that while sex and age may be useful surrogates of BMD, the clinically relevant thresholds for cementless knees remain unclear, offering an area for future studies.

Low early complication rates after arthroscopic meniscus repair and meniscectomy.

PURPOSE: To evaluate the 30-day complication rates after arthroscopic meniscus repair and meniscectomy using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, with subgroup analysis of patients aged > 40 years. METHODS: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing arthroscopic meniscus repair (CPT 29882, 29883) and meniscectomy (29880, 29881). The following 30-day complications were assessed: pulmonary embolism (PE), venous thromboembolism (VTE), surgical site infection (SSI), reoperation, and readmission. Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and smoking/dyspnoea/COPD. A subgroup analysis was performed for patients aged > 40 years. RESULTS: A total 6354 meniscus repairs and 99,372 meniscectomies were identified. Complication rates were < 1% for both meniscus repair and meniscectomy. Meniscus repair was associated with significantly higher rates of PE, VTE, and readmission compared to meniscectomy: PE (0.2% vs 0.1%, p < 0.001), VTE (0.8% vs 0.4%, p < 0.001), superficial SSI (0.1% vs 0.2%, n.s), deep SSI (0.07% vs 0.1%, n.s), reoperation (0.5% vs 0.4%, n.s), and readmission (0.9% vs 0.8%, p = 0.003). Among patients aged > 40 years, complication rates were < 1.3% for both meniscus repair and meniscectomy. Similar trends and rates were found in patients aged > 40 years undergoing meniscus repair versus meniscectomy: PE (0.38% vs 0.12%, p < 0.001), VTE (1.07% vs 0.46%, p < 0.001), superficial SSI (0.03% vs 0.19%, n.s), deep SSI (0.1% vs 0.06%, n.s), reoperation (0.48% vs 0.43%, n.s), and readmission (1.2% vs 0.85%, p = 0.01). CONCLUSION: Arthroscopic meniscus repair and meniscectomy are both low-risk procedures with 30-day complication rates < 1% overall and < 1.3% among patients aged > 40 years. These findings support meniscus repair whenever feasible in the setting of preserved articular cartilage. Understanding of the short-term complication rates after arthroscopic meniscus repair and meniscectomy can aid surgeons in providing comprehensive preoperative counselling to patients considering such treatments, specifically when discussing the risks and benefits of meniscus repair. LEVEL OF EVIDENCE: III.

Geographic Variation in Knee Phenotypes Based on the Coronal Plane Alignment of the Knee Classification: A Systematic Review.

BACKGROUND: The extent of geographic variation in knee phenotypes remains unclear. The Coronal Plane Alignment of the Knee (CPAK) Classification proposes 9 coronal plane phenotypes based on constitutional limb alignment and joint line obliquity. This systematic review aims to examine differences in the distributions of CPAK types across geographic regions. METHODS: A systematic review of the literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting distributions of knee phenotypes according to the CPAK classification for healthy and/or arthritic knees were included. RESULTS: There were 7 studies included, accounting for 5,964 knees in 3,917 subjects. Among healthy knees (n = 1,214), CPAK type II was the most common type in Belgium (39.2%), Taiwan (39.3%), and India (25.6%). Among arthritic knees (n = 2,804), CPAK type I was the most common in France (33.4%), India (58.8%), and Japan (53.8%), whereas CPAK type II was the most common in Australia (32.8%). The proportion of CPAK type I and II knees varied significantly across geographic regions among healthy (P < .01) and arthritic knees (P < .01). CONCLUSION: Significant variation in CPAK distributions exists between countries. Further work is needed to delineate racial and sexual differences in CPAK types, which were not explored in this article. A better understanding of population-level variability in knee phenotypes may enable orthopaedic surgeons to offer a more personalized approach to knee arthroplasty.

Current Concepts in Alignment in Total Knee Arthroplasty.

BACKGROUND: In an effort to increase satisfaction among total knee arthroplasty (TKA) patients, emphasis has been placed on implant positioning and limb alignment. Traditionally, the aim for TKA has been to achieve a neutral mechanical alignment (MA) to maximize implant longevity. However, with the recent spike in interest in individualized alignment techniques and with the advent of new technologies, surgeons are slowly evolving away from classical MA. METHODS: This review elucidates the differences in alignment techniques for TKA, describes the concept of knee phenotypes, summarizes comparative studies between MA and individualized alignment, and provides a simple way to incorporate the latter into surgeons' practice. RESULTS: In order to manage patients by applying these strategies in day-to-day practice, a basic understanding of the aforementioned concepts is essential. Transition to an individualized alignment technique should be done gradually with caution in a stepwise approach. CONCLUSION: Alignment and implant positioning are now at the heart of the debate and surgeons are investigating a more personalized approach to TKA.

Anatomic study of an anterior portal for percutaneous internal fixation of capitellum fractures.

BACKGROUND: Fractures of the capitellum are uncommon and difficult to treat surgically. Capitellar open reduction-internal fixation uses a lateral open approach with posterior-to-anterior or anterior-to-posterior screw fixation. We investigated the use of an anterior portal for placement of anterior-to-posterior screw fixation through cadaveric measurement of the anatomic relationships from an anteriorly to posteriorly placed Kirschner wire (K-wire) to anterior elbow structures and calculated the percentage of articular surface accessed from the anterior portal. METHODS: Eight fresh-frozen cadaveric elbows without radiographic or cutaneous evidence of prior trauma or surgery were used for this study. An arthroscopic proximal anteromedial portal was cannulized, and the radiocapitellar joint was evaluated. A single 1-cm portal was placed 1 cm distal to the elbow flexion crease and based lateral to the biceps tendon. The location of the portal was confirmed with a spinal needle, and blunt dissection with a hemostat was performed down to capsular tissue and for arthrotomy. A spinal needle sheath was threaded over a blunt switching stick and served as a cannula for placement of a 0.062 K-wire. Articular mapping was performed with cartilage scraping by the K-wire; the K-wire was then placed at the perceived center along the proximal-to-distal and radial-to-ulnar axis of the capitellum. Fluoroscopic confirmation of the wire's location was performed. Under loupe magnification, anatomic dissection was performed and the shortest distance measurements were recorded with digital calipers from the K-wire to the dissected structures. Capitellar articular measurements were recorded, in addition to the articular area defined by the K-wire. Data analysis was performed, and the average distance and standard deviation (in millimeters) were calculated. For structures that were pierced by or touching the K-wire, the distance was recorded as 0.1 mm. RESULTS: The average distance from the K-wire to the radial, lateral antebrachial cutaneous, and median nerves was 1.8 mm, 11.5 mm, and 28.0 mm, respectively. The average distance from the median cubital vein and biceps tendon was 3.7 mm and 13.4 mm, respectively. The pin track pierced the brachioradialis and supinator muscles in all but 1 specimen. The average capitellar articular surface marked was 39.1% of the calculated articular footprint of the capitellum. CONCLUSIONS: The anterior portal to the capitellum is directly adjacent to the radial nerve and lateral antebrachial cutaneous nerve, where each is susceptible to injury. We recommend blunt dissection and insertion of a cannula to allow drilling and placement of internal fixation in a relatively safe manner with respect to neurovascular structures.

Highly cross-linked polyethylene in primary total knee arthroplasty is associated with a lower rate of revision for aseptic loosening: a meta-analysis of 962,467 cases.

BACKGROUND: The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA. METHODS: The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: "cross-linked", "polyethylene", "HXLPE", "conventional", "total knee arthroplasty", "TKA", "total knee replacement" and "TKR" combined with Boolean operators AND and OR. RESULTS: Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39-1.18; I2: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20-1.49; I2: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31-0.39; I2: 0.0%). CONCLUSION: The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.

Use of elevated liners in primary total hip arthroplasty: a systematic review of the literature.

PURPOSE: Instability remains one of the most frequent complications requiring revision surgery after primary total hip arthroplasty (THA). Elevated liners are often utilized to reduce the risk of dislocation; however, the literature is inconclusive, with no systematic reviews summarizing the data. Thus, this systematic review aimed to establish a consensus for the efficacy of elevated liners in primary THA by determining rates of overall revision and revision specifically for recurrent dislocation. MATERIALS AND METHODS: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies reporting on the use of elevated liners in primary total hip arthroplasty were identified through May 2020. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity. RESULTS: Eight studies met inclusion criteria, and overall, 26,507 patients undergoing primary THA with use of an elevated liner were included. In aggregate, the most common cause of revision was recurrent hip dislocation (1.3%, N = 82/6,267) followed by joint infection (1.2%, N = 45/3,772) and acetabular loosening (0.3%, N = 10/3,772). Notably, elevated liners were associated with a lower risk of revision for recurrent dislocation compared to neutral liners (HR: 0.74; 95% CI: 0.55-1.00; p = 0.048). CONCLUSION: This review found that after primary THA with the use of elevated liners, hip dislocation and prosthetic joint infection continued to be the most frequent reasons for revision surgery. However, elevated liners had a lower risk of revision for recurrent dislocation compared to neutral liners.

Does Ureteral Stenting Increase the Risk of Metachronous Upper Tract Urothelial Carcinoma in Patients with Bladder Tumors? A Systematic Review and Meta-analysis.

PURPOSE: Ureteral stenting in patients with bladder cancer may become necessary in order to protect the ureteral orifice during transurethral resection of the tumor or for relief of upper urinary tract obstruction. However, it is believed to increase metachronous upper tract urothelial carcinoma risk. MATERIALS AND METHODS: We performed a systematic review and meta-analysis of studies comparing ureteral stenting versus nephrostomy or no drainage with regard to the risk of metachronous upper tract urothelial carcinoma. Records were identified through database searches and sources of grey literature up to October 2020 (PROSPERO: CRD42020178298). RESULTS: Five studies (3,309 individuals) were included. Overall, 278 ureteral stents were placed and 20 (7.2%) patients developed metachronous upper tract urothelial carcinoma, while 131 patients were treated with nephrostomy and 3 (2.3%) cases of metachronous upper tract urothelial carcinoma occurred. Patients treated with ureteral stents had a higher likelihood of metachronous upper tract urothelial carcinoma compared to no stents (OR: 3.49, 95% CI: 1.43-8.48, I2=52%) and no upper urinary tract drainage (OR: 3.37, 95% CI: 1.49-7.63, I2=45%). No difference with regard to metachronous upper tract urothelial carcinoma was observed between stent and nephrostomy (OR: 3.07, 95% CI: 0.41-22.98, I2=54%). For the same outcomes, no difference was noted for patients with hydronephrosis. The level of evidence for all measures was evaluated as low. CONCLUSIONS: Stenting as a preventive measure after resection of tumors involving the orifice should be avoided, when possible, as it increases the risk of metachronous upper tract urothelial carcinoma. In cases of hydronephrosis, drainage with either nephrostomy or stent is recommended depending on individual patient cases as both interventions do not differ regarding metachronous upper tract urothelial carcinoma risk.

Platelet-Rich Plasma Combined With Hyaluronic Acid Improves Pain and Function Compared With Hyaluronic Acid Alone in Knee Osteoarthritis: A Systematic Review and Meta-analysis.

PURPOSE: To evaluate the efficacy of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) injections versus HA injections alone for the management of knee osteoarthritis (OA). METHODS: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies directly comparing combined PRP-HA injections with HA injections alone were identified through a search of PubMed, Scopus, and Cochrane Central databases from inception to May 2020. A random effects model meta-analysis was conducted and the I2 statistic was used to assess for heterogeneity. RESULTS: Four studies comprising 377 patients (PRP-HA: 193, HA: 184) with knee OA ranging from I-IV Kellgren-Lawrence grading scale were included. The final follow-up was 12 months in 3 studies and 6 months in 1 study. Patients who received PRP combined with HA had significantly greater improvements compared with those injected with HA alone in terms of visual analog scale scores at 3-month (standardized mean difference [SMD] 1.13; 95% confidence interval [CI] 0.56-1.70; I2 = 56.7%; P < .001), 6-month (SMD 1.08; 95% CI 0.54-1.62; I2 = 67.9%; P < .001), and 12-month (SMD 1.13; 95% CI 0.74-1.52; I2 = 0.0%; P < .001) and 12-month Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical functioning (SMD 0.91; 95% CI 0.65-1.17; I2 = 0.0%; P < .001) and 12-month WOMAC stiffness (SMD 1.09; 95% CI 0.80-1.38; I2 = 0.0%; P < .001) scores. No difference was identified in terms of 12-month WOMAC pain score (SMD 0.36; 95% CI -0.19 to 0.91; I2 = 74.1%; P = .195). CONCLUSIONS: Symptomatic patients with knee OA who were injected with a combination of PRP and HA demonstrated greater improvement in pain and function compared with patients who received HA injections only, as assessed by 3-, 6-, and 12-month visual analog scale scores and 12-month WOMAC physical function and stiffness scores. This study provides encouraging evidence for the use of the combined PRP-HA injections in the management of symptomatic patients with knee OA. LEVEL OF EVIDENCE: III (meta-analysis of randomized and non-randomized comparative trials).

Endovascular reconstruction of extracranial traumatic internal carotid artery dissections: a systematic review.

Extracranial internal carotid artery dissection (ICAD) is a potential source of morbidity and mortality in trauma patients and requires high degree of suspicion for diagnosis after the initial presentation. Occasionally, if standard therapy is contraindicated, endovascular reconstruction is a treatment option. The aim of this systematic review was to report clinical and radiographic outcomes following endovascular repair of ICAD of traumatic and iatrogenic etiology. A comprehensive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed and Cochrane Library databases were searched. Twenty-four studies comprising 191 patients (204 lesions) were included; 179 underwent traditional carotid artery stenting (CAS), whereas 12 patients underwent flow diversion with the pipeline embolization device (PED). In total, 75.7% of the CAS group and 66.6% of the PED group presented with ICAD-related symptomatology. Concomitant pseudoaneurysms were identified in 61.9% and 78.5% of lesions in the CAS and PED group, respectively. Adverse event rates among CAS-treated lesions after 30-day follow-up were below 2.2% for stroke, transient ischemic attack, and mortality. During follow-up in the CAS group, there was no incidence of ICAD-related stroke or death and 2.2% of patients underwent a repeat CAS procedure. In the PED group, no patient suffered stroke or death in the reported follow-up. In the PED cohort, there was an adequate occlusion rate and no patient had to be retreated. Endovascular reconstruction of traumatic or iatrogenic ICAD appears safe. This approach demonstrated acceptable short- and long-term clinical and radiographic outcomes in both groups.

Meniscofibular ligament: how much do we know about this structure of the posterolateral corner of the knee: anatomical study and review of literature.

PURPOSE: The present study is a systematic review of a relatively unknown structure of the posterolateral corner of the knee, the meniscofibular ligament (MFL), aiming at summarizing and broadening current scientific knowledge regarding this ligament anatomy, function, imaging and injury. MATERIALS AND METHODS: A systematic review was performed according to the PRISMA guidelines. Medline (PubMed) and Cochrane Library databases were reviewed for every kind of study reporting on the MFL through December 2019. Due to between-study differences in (anatomy, function, imaging, injury) examining the ligament, the findings were summarized from each study, but the results were not pooled. RESULTS: The MFL is a ligament extending between the inferolateral portion of lateral meniscus, just anterior to the popliteus tendon, and the fibular head. It provides stability to the posterolateral corner of the knee joint, it can be demonstrated in magnetic resonance imaging and magnetic resonance arthrography and has a potential role in lateral meniscus injuries. Further research is required to clearly understand the prognosis and management of MFL injury. CONCLUSION: The current systematic review, focusing only on the MFL of the knee, summarizes the existing knowledge on anatomy, gross morphology, histology, function, biomechanics and imaging and contributes to the further understanding of the MFL.

A meta-analysis of randomized trials comparing bovine pericardium and other patch materials for carotid endarterectomy.

OBJECTIVE: Patch angioplasty during carotid endarterectomy is commonly used to treat symptomatic and asymptomatic carotid artery stenosis. The objective of the present study was to compare the different patch materials that are currently available (synthetic vs venous vs bovine pericardium) in terms of short- and long-term outcomes. METHODS: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and eligible randomized control trials were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until September 2017. A meta-analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. The primary study end point was the incidence of long-term restenosis. Secondary study end points were 30-day stroke, transient ischemic attack (TIA), myocardial infarction, neck wound infection, local hematoma, carotid artery thrombosis, cranial nerve injury, long-term stroke incidence, and death. RESULTS: Eighteen studies and 3234 patients were included. The risk of 30-day stroke (relative risk [RR], 1.00; 95% confidence interval [CI], 0.45-2.19; I2 = 0%), TIA (RR, 1.14; 95% CI, 0.41-3.19; I2 = 0%), myocardial infarction (odds ratio, 0.75; 95% CI, 0.14-3.97; I2 = 0%), death (RR, 0.53; 95% CI, 0.21-1.34; I2 = 0%), wound infection (RR, 1.84; 95% CI, 0.43-7.81; I2 = 0%), carotid artery thrombosis (RR, 1.47; 95% CI, 0.44-4.97; I2 = 0%), cranial nerve palsy (RR, 1.21; 95% CI, 0.53-2.77; I2 = 0%), and long-term stroke (RR, 2.33; 95% CI, 0.76-7.10; I2 = 0%), death (RR, 1.09; 95% CI, 0.65-1.83; I2 = 0%) and restenosis of greater than 50% (RR, 0.48; 95% CI, 0.19-1.20; I2 = 0%) were similar between the synthetic vs venous patch groups. Also, no differences in terms of 30-day stroke (RR, 0.31; 95% CI, 0.02-5.16; I2 = 63.1%), TIA (RR, 0.49; 95% CI, 0.14-1.76; I2 = 0%), death (RR, 0.74; 95% CI, 0.05-10.51; I2 = 31.7%), carotid artery thrombosis (RR, 0.13; 95% CI, 0.02-1.07; I2 = 0%), and long-term restenosis of greater than 70% (RR, 0.15; 95% CI, 0.01-2.29; I2 = 70.9%) were detected between the synthetic polytetrafluoroethylene and Dacron patch groups. The comparison between the bovine pericardium vs synthetic patch did not yield any statistically significant results in terms of 30-day stroke (RR, 1.44; 95% CI, 0.19-10.79; I2 = 12.7%), TIA (RR, 1.05; 95% CI, 0.11-10.27; I2 = 0%), local neck hematoma (RR, 4.01; 95% CI, 0.46-34.85; I2 = 0%), and death (RR, 4.01; 95% CI, 0.46-34.85; I2 = 0%). CONCLUSIONS: Closure of the carotid arteriotomy with any of the studied patch materials seems to be similar in terms of short- and long-term end points. However, additional randomized trials with adequate follow-up periods are needed to compare bovine pericardium patches with other patch materials.

Spinopelvic Motion: A Simplified Approach to a Complex Subject.

Knowledge of the relationship between the hip and spine is essential in the effort to minimize instability and improve outcomes following total hip arthroplasty (THA). A detailed yet straightforward preoperative imaging workup can provide valuable information on pelvic positioning, which may be helpful for optimum placement of the acetabular cup. For a streamlined preoperative assessment of THA candidates, classification systems with a capacity for providing a more personalized approach to performance of THA have been introduced. Familiarity with these systems and their clinical application is important in the effort to optimize component placement and reduce the risk of instability. Looking ahead, the principles of the hip-spine relationship are being integrated using emerging innovative technologies, promising further streamlining of the evaluation process.

Comparison of Early Complication Rates After High Tibial Osteotomy Versus Unicompartmental Knee Arthroplasty for Knee Osteoarthritis.

Background: Although both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) can be utilized to treat unicompartmental osteoarthritis (OA) in select patients, the early complication rates between the 2 procedures are not well understood. Understanding of the complication profiles for both procedures would help clinicians counsel patients with unicompartmental knee OA who may be eligible for either treatment option. Purpose: To compare the 30-day complication rates after HTO versus UKA for the treatment of knee OA using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Study Design: Cohort study; Level of evidence, 3. Methods: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing HTO and UKA for knee OA. Patients >60 years of age were excluded. Patient demographics, preoperative comorbidities, and intraoperative data were collected. Postoperative 30-day complications, including venous thromboembolism (VTE), urinary tract infection (UTI), transfusion, surgical-site infection (SSI), and reoperations were recorded. Complication rates between treatment groups were compared using a multivariate logistic regression model adjusted for sex, age, body mass index, steroid use, respiratory status (smoking/dyspnea/chronic obstructive pulmonary disease), diabetes, and hypertension. Results: A total of 156 patients treated with HTO and 4755 patients treated with UKA for knee OA were identified. Mean patient ages were 46 years for the HTO group and 53.4 years for the UKA group. Operative time was significantly longer in the HTO group versus the UKA group (112 minutes vs 90 minutes; P < .001). Multivariate analyses found no significant differences in VTE (1.3% vs 0.6%), UTI (0.6% vs 0.3%), transfusion (0.6% vs 0.2%), deep SSI (0.6% vs 0.1%), and reoperation (1.3% vs 1%) rates between HTO and UKA groups. The HTO group had a higher rate of superficial SSI compared with the UKA group (2.6% vs 0.6%; P = .006) (adjusted odds ratio, 4.2; 95% CI, 1.4-12.5; P = .01). Conclusion: There were no differences in 30-day VTE, UTI, transfusion, deep SSI, and reoperation rates for HTO versus UKA in the treatment of knee OA. HTO was associated with a higher rate of superficial SSI compared with UKA. These findings serve to guide clinicians in counseling patients regarding the early risks after HTO and UKA.

Early Complication Rates Are Equivalent Between Isolated Cartilage Restoration and Concomitant Cartilage Restoration and Osteotomy of the Knee.

OBJECTIVE: Realignment osteotomy performed concomitantly with cartilage restoration typically requires early restricted weightbearing and can add significant morbidity, potentially leading to an increased risk of early perioperative complications. The purpose of this study was to compare the 30-day complication rates after isolated cartilage restoration (ICR) versus concomitant cartilage restoration and osteotomy (CRO) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. DESIGN: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing ICR (autologous chondrocyte implantation, osteochondral autograft transfer, or osteochondral allograft transplantation) and CRO (with concomitant high tibial osteotomy, distal femoral osteotomy, and/or tibial tubercle osteotomy). Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and respiratory status. RESULTS: A total of 773 ICR and 97 CRO surgical procedures were identified. Mean patient ages were 35.9 years for the ICR group and 31.2 years for the CRO group. Operative time was significantly longer in the CRO group (170.8 min) compared with the ICR group (97.8 min). Multivariate analysis demonstrated no significant differences in rates of PE, VTE, and all-cause readmission between the ICR and CRO groups. No events of wound disruption, SSI and reoperation were found in the CRO group, while the ICR group was characterized by low rates of wound disruption, reoperation, and SSI (<1.1%). CONCLUSIONS: These findings further support concomitant osteotomy with cartilage restoration when appropriate and aid surgeons in the preoperative counseling of patients undergoing cartilage restoration treatment.

Definitions and consequences of current alignment techniques and phenotypes in total knee arthroplasty (TKA) - there is no winner yet.

Dissatisfaction following total knee arthroplasty (TKA) has been extensively documented and it was attributed to numerous factors. In recent years, significant focus has been directed towards implant alignment and stability as potential causes and solutions to this issue. Surgeons are now exploring a more personalized approach to TKA, recognizing the importance of thoroughly understanding each individual patient's anatomy and functional morphology. A more comprehensive preoperative analysis of alignment and knee morphology is essential to address the unresolved questions in knee arthroplasty effectively. The crucial task of determining the most appropriate alignment strategy for each patient arises, given the substantial variability in bone resection resulting from the interplay of phenotype and the alignment strategy chosen. This review aims to comprehensively present the definitions of different alignment techniques in all planes and discuss the consequences dependent on knee phenotypes.Level of evidence V.

Salvage Fixation With a Single Nitinol Compression Staple for a Lateralized Fibular Tunnel in Posterolateral Corner Reconstruction of the Knee.

Recognition and treatment of injuries to the posterolateral (PLC) corner of the knee have increased in recent decades. Despite advancements in surgical technique, complications can occur in up to 20% of PLC reconstructions. Lateralization of the fibular tunnel during drilling is a common intraoperative pitfall and can lead to cortical breach or fibular head fracture after graft tensioning. Compression staples have been increasingly used for fracture fixation in the hand, foot, and ankle. Because of its pseudo-elastic properties, insertion of a low-profile, compressive Nitinol staple could serve as an intraoperative salvage technique to reinforce and prevent failure through a thin lateral cortex of the fibular head. The purpose of this Technical Note is to describe a reproducible technique for the implementation of a Nitinol staple for reinforcement of a lateralized fibular tunnel in posterolateral corner reconstruction.