A Novel Approach to Total Ankle Arthroplasty with Simultaneous Structural Tibial Cut Autograft for Anterior Tibial Bone Defects.

Severe bone defects pose a clinical challenge in total ankle arthroplasty (TAA) and are frequently considered contraindicated. We introduce an innovative approach that utilizes a structural tibial cut autograft to address anterior distal tibia bone defects during TAA. This technique is a viable alternative to employing revision TAA systems or resorting to excessively high tibial cuts. Furthermore, it facilitates achieving favorable sagittal alignment and ensures adequate fixation strength of the tibial component.

Clinical outcomes of guider-assisted osteotomy compared to conventional pendulum-saw osteotomy in open wedge high tibial osteotomy: a propensity score-matched cohort study.

PURPOSE: We developed a novel guider-assisted osteotomy (GAO) procedure to improve the safety of open wedge high tibial osteotomy (OWHTO) and aimed to compare its efficacy and complications with the conventional pendulum-saw osteotomy (PSO). METHODS: This is a retrospective cohort study of patients undergoing either GAO or PSO procedure in the OWHTO to treat varus knee osteoarthritis, who had a minimum of 2 years of follow-up. Patients were propensity score matched (PSM) in a 1:1 ratio based on demographic and clinical data with a caliper width of 0.02. The outcomes assessed involved the hospital for special surgery (HSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and the Intraoperative and postoperative complications. RESULTS: 199 patients were included in each group after PSM. The mean duration of follow-up was 38.3 ± 8.9 months. The GAO group had a shorter operation duration (104.5 ± 35.7 vs. 112.1 ± 36.0 min, p = 0.027) and fewer times of intraoperative fluoroscopy (4.2 ± 1.4 vs. 6.0 ± 1.4, p < 0.001). At the last follow-up, clinical scores for knee achieved significant improvements in both GAO and PSO groups: HSS (67.5 ± 10.5 vs. 90.2 ± 7.0, p < 0.001; 69.4 ± 8.2 vs. 91.7 ± 6.8, p < 0.001) and WOMAC (65.7 ± 11.6 vs. 25.2 ± 10.4, p < 0.001; 63.3 ± 12.2 vs. 23.8 ± 9.5, p < 0.001). However, no significant difference was observed between groups for any measures (p > 0.05). In addition, the intraoperative complications (0.5% vs. 3.5%, p = 0.068) and the postoperative bone delayed union and nonunion (1.0% vs. 4.5%, p = 0.032) were marginally or significantly reduced in the GAO versus PSO group. CONCLUSION: GAO demonstrates improvements in intraoperative radiation exposure and complications, with comparable short-term efficacy to PSO, and could be considered a viable alternative in clinical practice.

Changes in the anteroposterior position of the femur relative to the tibia impact patient satisfaction in total knee arthroplasty.

BACKGROUND: In this study, we aimed to investigate the preoperative and postoperative anteroposterior position (AP) of the femur relative to the tibia in total knee arthroplasty (TKA) and assess the influence of change in the AP position on clinical outcomes. METHODS: We evaluated 49 knees that underwent bi-cruciate-substituted TKA using a navigation system. The preoperative and postoperative AP position of the femur relative to the tibia at maximum extension, 15°, 30°, 45°, 60°, 90°, 105°, and 120° and maximum flexion angles were calculated. The 2011 Knee Society Score was evaluated preoperatively and 1 year postoperatively. The Wilcoxon signed rank and Spearman's rank correlation tests were performed, with statistical significance set at P < 0.05. RESULTS: The postoperative AP position was significantly correlated with the preoperative AP position at each measured angle. The postoperative AP positions were statistically more anterior than those preoperatively. Furthermore, the changes in the AP position after TKA negatively correlated with the symptom (P = 0.027 at 30°, P = 0.0018 at 45°, P = 0.0003 at 60°, P = 0.01 at 90°, and P = 0.028 at 105°) and patient satisfaction (P = 0.018 at 60° and P = 0.009 at 90°) scores at 1 year postoperatively. CONCLUSION: The postoperative AP position of the femur relative to the tibia was strongly influenced by the preoperative those in TKA. Postoperative anterior deviation of the femur relative to the tibia from mid-flexion to deep flexion could worsen clinical outcomes.

The Addition of Hydroxyapatite Nanoparticles on Implant Surfaces Modified by Zirconia Blasting and Acid Etching to Enhance Peri-Implant Bone Healing.

This study investigated the impact of adding hydroxyapatite nanoparticles to implant surfaces treated with zirconia blasting and acid etching (ZiHa), focusing on structural changes and bone healing parameters in low-density bone sites. The topographical characterization of titanium discs with a ZiHa surface and a commercially modified zirconia-blasted and acid-etched surface (Zi) was performed using scanning electron microscopy, profilometry, and surface-free energy. For the in vivo assessment, 22 female rats were ovariectomized and kept for 90 days, after which one implant from each group was randomly placed in each tibial metaphysis of the animals. Histological and immunohistochemical analyses were performed at 14 and 28 days postoperatively (decalcified lab processing), reverse torque testing was performed at 28 days, and histometry from calcified lab processing was performed at 60 days The group ZiHa promoted changes in surface morphology, forming evenly distributed pores. For bone healing, ZiHa showed a greater reverse torque, newly formed bone area, and bone/implant contact values compared to group Zi (p < 0.05; t-test). Qualitative histological and immunohistochemical analyses showed higher features of bone maturation for ZiHa on days 14 and 28. This preclinical study demonstrated that adding hydroxyapatite to zirconia-blasted and acid-etched surfaces enhanced peri-implant bone healing in ovariectomized rats. These findings support the potential for improving osseointegration of dental implants, especially in patients with compromised bone metabolism.

Lateral Tibial Plateau Reconstruction Using Tricortical Iliac Crest Autograft as the Weight-Bearing Surface.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/lateral-tibial-plateau.

Extra-articular Osteotomy for the Management of Intra-articular Tibial Plateau Valgus Malunion.

OBJECTIVES: To report a case series of extra-articular osteotomies for the management of intra-articular tibial plateau malunions and to assess the ability to correct deformity and improve knee range of motion (ROM). METHODS: . DESIGN: Retrospective case series. SETTING: Academic, tertiary, referral center. PATIENT SELECTION CRITERIA: Adult patients with tibial plateau fracture malunion treated with extra-articular osteotomy of the femur and/or tibia between 2014 and 2023. OUTCOME MEASURES AND COMPARISON: Mechanical axis deviation (MAD), medial proximal tibia angle (MPTA), lateral distal femoral angle (LDFA), and posterior proximal tibia angle (PPTA) correction; knee ROM; and time to weight bearing. RESULTS: There were 7 patients included, 6 (85.7%) were female and 1 (14.3%) were male. The median age was 43.5 years (IQR 38.5-51, range 32-62). Four (57.1%) patients were treated with a high tibial osteotomy (HTO), and 3 (42.9%) patients were treated with an HTO and distal femoral osteotomy. One patient had concomitant supramalleolar osteotomy with HTO to address distal tibia procurvatum and valgus. Four were treated with hexapod frames, and 3 were treated with plates and screws. Median follow-up was 22.5 months (IQR 10.5-107 months, range 7-148 months). Surgical intervention corrected median radiographic measures of valgus malalignment preoperatively relative to postoperative values. This included MAD (42.5 mm-0 mm), valgus angle (12.5 degrees-1.5 degrees), MPTA (95 degrees-88.0°), and LDFA (86.0°-87.3 degrees). Surgical intervention increased maximal knee range of motion preoperatively to postoperatively. Median time to full weight bearing was 81.5 days (IQR 46-57 days, range 41-184 days). Two patients were converted to total knee arthroplasty after 5 and 10 years following HTO with hexapod frame. CONCLUSIONS: Extra-articular osteotomy is an effective treatment for addressing intra-articular malunion after tibia plateau fractures. It is effective in correcting the MAD, valgus deformity, MPTA, LDFA, PPTA, and improving knee ROM (measured through knee extension and flexion). LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of accelerated postoperative rehabilitation after tibial tubercle distalisation: A randomised controlled trial protocol.

Patella alta is a clinical condition where the patella is positioned too proximal in relation to the femoral trochlea. Such an abnormality may cause patellar instability and predispose to recurrent patellofemoral dislocations and patellofemoral pain. There are no conclusive guidelines for determining a threshold for too high positioned patella, as several different methods have been described to measure patellar height. As a surgical solution, distalising tibial tubercle osteotomy has been described to correct excessive patellar height. In the early phase of the distalising tibial tubercle osteotomy postoperative protocol, weightbearing and knee flexion are limited with a brace commonly for 4-8 weeks to avoid potential implant failure leading to displacement of the osteotomy or non-union. The potential risks for adverse effects associated with the limitation rehabilitation protocol include a delay in regaining knee range of motion, stiffness and muscle weakness. As a result, recovery from surgery is delayed and may lead to additional procedures and long-term morbidity in knee function. This is a prospective, randomised, controlled, single-blinded, single centre trial comparing a novel accelerated rehabilitation protocol with the traditional, motion restricting rehabilitation protocol. All skeletally mature patients aged 35 years and younger, referred to as the distalising tibial tubercle osteotomy procedure group, are eligible for inclusion in the study. Patients will be randomised to either the fast rehabilitation group or the traditional rehabilitation group. Patients with patellar instability will be additionally treated with medial patellofemoral ligament reconstruction. The hypothesis of the trial is that the novel accelerated rehabilitation protocol will lead to faster recovery and improved functional outcome at 6, 12 and 24 weeks compared with the conservative rehabilitation protocol. A secondary hypothesis is that the complication rate will be similar in both groups. The study will document short-term recovery and the planned follow-up will be 3 years. After the 1-year follow-up, the trial results will be disseminated in a major peer-reviewed orthopaedic publication. Protocol version 3.6, date 28/11/2023.

A high precision laser scanning system for measuring shape and volume of transtibial amputee residual limbs: Design and validation.

Changes in limb volume and shape among transtibial amputees affects socket fit and comfort. The ability to accurately measure residual limb volume and shape and relate it to comfort could contribute to advances in socket design and overall care. This work designed and validated a novel 3D laser scanner that measures the volume and shape of residual limbs. The system was designed to provide accurate and repeatable scans, minimize scan duration, and account for limb motion during scans. The scanner was first validated using a cylindrical body with a known shape. Mean volumetric errors of 0.17% were found under static conditions, corresponding to a radial spatial resolution of 0.1 mm. Limb scans were also performed on a transtibial amputee and yielded a standard deviation of 8.1 ml (0.7%) across five scans, and a 46 ml (4%) change in limb volume when the socket was doffed after 15 minutes of standing.

Surgical Bone Implantation Technique for Rat Tibia Models of Diabetes and Osteoporosis.

The rat has long served as a valuable animal model in implant dentistry and orthopedics, particularly in studying the interactions between biomaterials and bone tissue. The rat's tibia is frequently chosen due to its easy surgical access through thin tissue layers (skin and muscle) and the flattened shape of its medial face, facilitating the surgical insertion of intraosseous devices. Additionally, this model enables the induction of specific diseases, mimicking various clinical conditions to assess biological responses to different implant conditions like geometry, surface texture, or biological cues. However, despite its robust cortical structure, certain intraosseous devices may require adaptations in design and size for successful implantation. Therefore, establishing standardized surgical methods for manipulating both soft and hard tissues in the implantation region is essential for ensuring proper implant or screw device placement, particularly in fields like implant dentistry and orthopedics. This study included eighty Sprague Dawley rats divided into two groups based on their respective diseases: Group 1 with osteoporosis and Group 2 with Type 2 Diabetes. Implantations were performed at 4 weeks and 12 weeks, with the same surgeon following a consistent surgical technique. A positive biological response was observed, indicating complete osseointegration of all implants placed. These results validate the success of the surgical protocol, which can be replicated for other studies and serve as a benchmark for the biomaterials community. Notably, osseointegration values remained stable at both 4 weeks and 12 weeks for both disease models, demonstrating a durable integration of the implant over time and emphasizing the establishment of an intimate bone connection as early as 4 weeks.

Development and clinical validation of a deep learning-based knee CT image segmentation method for robotic-assisted total knee arthroplasty.

BACKGROUND: This study aimed to develop a novel deep convolutional neural network called Dual-path Double Attention Transformer (DDA-Transformer) designed to achieve precise and fast knee joint CT image segmentation and to validate it in robotic-assisted total knee arthroplasty (TKA). METHODS: The femoral, tibial, patellar, and fibular segmentation performance and speed were evaluated and the accuracy of component sizing, bone resection and alignment of the robotic-assisted TKA system constructed using this deep learning network was clinically validated. RESULTS: Overall, DDA-Transformer outperformed six other networks in terms of the Dice coefficient, intersection over union, average surface distance, and Hausdorff distance. DDA-Transformer exhibited significantly faster segmentation speeds than nnUnet, TransUnet and 3D-Unet (p < 0.01). Furthermore, the robotic-assisted TKA system outperforms the manual group in surgical accuracy. CONCLUSIONS: DDA-Transformer exhibited significantly improved accuracy and robustness in knee joint segmentation, and this convenient and stable knee joint CT image segmentation network significantly improved the accuracy of the TKA procedure.

Influence of zoledronic acid and low-intensity laser on collagen fibers during the bone repair process.

PURPOSE: To evaluate collagen fibers during the bone repair process in critical defects created in the tibias of rats, treated with zoledronic acid (AZ) associated with low-level laser therapy (LLLT). METHODS: Ten rats were distributed according to treatment: group 1) saline solution; group 2) LLLT; group 3) AZ; group 4) AZ and LLLT. AZ was administered at the dose of 0.035 mg/kg at fortnightly intervals over eight weeks. Next, 2-mm bone defects were created in the tibias of all animals. The bone defects in groups 2 and 4 were irradiated LLLT in the immediate postoperative period. After periods 14 and 28 of application, the animals were euthanized, and birefringence analysis was performed. RESULTS: Approximately 90% of the total area was occupied by collagen fibers within the red color spectrum, this area being statistically larger in relation to the area occupied by collagen fibers within the green and yellow spectrum, in the four groups. Over the 14-day period, there was no statistically significant difference between the groups. In the 28-day period, group 2 (14.02 ± 15.9%) was superior in quantifying green birefringent fibers compared to group 1 (3.06 ± 3.24%), with p = 0.009. CONCLUSIONS: LLLT associated with ZA is effective in stimulating the neoformation of collagen fibers. The LLLT group without the association with ZA showed a greater amount of immature and less organized matrix over a period of 28 days.

Endoprosthetic replacement with preservation of the epiphysis for proximal tibial reconstruction after osteosarcoma resection in children: a case report.

BACKGROUND: Limb salvage surgery is an important method for treating malignant tumors of the bone involving the adjacent parts of the major joints in children. This technique allows for preservation of limb function, especially in the lower limb. However, the reconstruction of the proximal end of the tibia after removing the tumor mass with a rational scale to preserve the total knee joint and reduce limb length discrepancy presents a challenge. CASE PRESENTATION: We present a case of osteosarcoma of the proximal tibia. After being treated with an extended tumor resection, the proximal tibia of the child was restructured using endoprosthetic replacement with epiphyseal preservation. This procedure preserves the entire articular surface and growth plate of the knee joint of the affected limb and provides a feasible alternative protocol for retaining the function and growth potential of the affected limb. The patient remained disease-free and normal limb motor function was observed during the 3.5 year follow-up since the initial surgery. CONCLUSIONS: Preservation of the epiphysis enabled our patient to perform better limb function after limb-saving surgery as a result of his undamaged knee joint and minimized limb-length discrepancy. We believe that endoprosthetic replacement with preservation of the epiphysis can provide the best strategy for reconstruction after resection of focal malignant tumors in long bones without epiphytic involvement.

Applying 3D-printed prostheses to reconstruct critical-sized bone defects of tibial diaphysis (> 10 cm) caused by osteomyelitis and aseptic non-union.

BACKGROUND: Clinical repair of critical-sized bone defects (CBDs) in the tibial diaphysis presents numerous challenges, including inadequate soft tissue coverage, limited blood supply, high load-bearing demands, and potential deformities. This study aimed to investigate the clinical feasibility and efficacy of employing 3D-printed prostheses for repairing CBDs exceeding 10 cm in the tibial diaphysis. METHODS: This retrospective study included 14 patients (11 males and 3 females) with an average age of 46.0 years. The etiologies of CBDs comprised chronic osteomyelitis (10 cases) and aseptic non-union (4 cases), with an average defect length of 16.9 cm. All patients underwent a two-stage surgical approach: (1) debridement, osteotomy, and cement spacer implantation; and (2) insertion of 3D-printed prostheses. The interval between the two stages ranged from 8 to 12 weeks, during which the 3D-printed prostheses and induced membranes were meticulously prepared. Subsequent to surgery, patients engaged in weight-bearing and functional exercises under specialized supervision. Follow-up assessments, including gross observation, imaging examinations, and administration of the Lower Extremity Functional Scale (LEFS), were conducted at 3, 6, and 12 months postoperatively, followed by annual evaluations thereafter. RESULTS: The mean postoperative follow-up duration was 28.4 months, with an average waiting period between prosthesis implantation and weight-bearing of 10.4 days. At the latest follow-up, all patients demonstrated autonomous ambulation without assistance, and their LEFS scores exhibited a significant improvement compared to preoperative values (30.7 vs. 53.1, P < 0.001). Imaging assessments revealed progressive bone regeneration at the defect site, with new bone formation extending along the prosthesis. Complications included interlocking screw breakage in two patients, interlocking screw loosening in one patient, and nail breakage in another. CONCLUSIONS: Utilization of 3D-printed prostheses facilitates prompt restoration of CBDs in the tibial diaphysis, enabling early initiation of weight-bearing activities and recovery of ambulatory function. This efficacious surgical approach holds promise for practical application.

Conventional vs. endoscopic-assisted curettage of benign bone tumours. An experimental study.

BACKGROUND: This experimental study aimed at directly comparing conventional and endoscopic-assisted curettage towards (1) amount of residual tumour tissue (RTT) and (2) differences between techniques regarding surgical time and surgeons' experience level. METHODS: Three orthopaedic surgeons (trainee, consultant, senior consultant) performed both conventional (4x each) and endoscopic-assisted curettages (4x each) on specifically prepared cortical-soft cancellous femur and tibia sawbone models. "Tumours" consisted of radio-opaque polyurethane-based foam injected into prepared holes. Pre- and postinterventional CT-scans were carried out and RTT assessed on CT-scans. For statistical analyses, percentage of RTT in relation to total lesion's volume was used. T-tests, Wilcoxon rank-sum tests, and Kruskal-Wallis tests were applied to assess differences between surgeons and surgical techniques regarding RTT and timing. RESULTS: Median overall RTT was 1% (IQR 1 - 4%). Endoscopic-assisted curettage was associated with lower amount of RTT (median, 1%, IQR 0 - 5%) compared to conventional curettage (median, 4%, IQR 0 - 15%, p = 0.024). Mean surgical time was prolonged with endoscopic-assisted (9.2 ± 2.9 min) versus conventional curettage (5.9 ± 2.0 min; p = 0.004). No significant difference in RTT amount (p = 0.571) or curetting time (p = 0.251) depending on surgeons' experience level was found. CONCLUSIONS: Endoscopic-assisted curettage appears superior to conventional curettage regarding complete tissue removal, yet at expenses of prolonged curetting time. In clinical practice, this procedure may be reserved for cases at high risk of recurrence (e.g. anatomy, histology).

Evaluation of distal tibia slope in pilon fractures after surgical fixation.

INTRODUCTION: Alteration of sagittal alignment during fracture fixation directly impacts ankle motion in dorsiflexion and plantarflexion. Previously research measured the anterior distal tibia angle (ADTA) in a normal healthy population. The null hypothesis for this study is that ADTA is restored to normal range following unstable pilon fractures. The aim of this study is to identify the range of the ADTA in distal tibia fractures after surgical fixation, compared to a previously published normal population. MATERIAL AND METHODS: A retrospective review of operative distal tibia fractures (AO/OTA classification 43A and 43C - 43B were excluded due to lower likelihood of fracture changing the ADTA) was performed. ADTA on lateral radiograph was measured as the angle relative to the tibia shaft. RESULTS: 100 patients with post-operative radiographs that met inclusion criteria were analyzed. The average ADTA was 6.9° (⌠=4.62°) with a maximum slope of 19.2° (i.e. anterior orientation) and a minimum of -3.3° (i.e. posterior orientation). The uninjured population had an average ADTA of 6.0° (range -2.0°-14°, ⌠=3.0°). CONCLUSION: This analysis shows the average distal tibia sagittal alignment in the post-surgical group is similar to a normal, uninjured population. Large alterations in ADTA would directly impact the ankle in the plane of motion (i.e. negative ADTA would decrease ankle dorsiflexion). Considering ADTA as an objective intra-operative parameter optimizes sagittal plane alignment.

Annual Trends of High Tibial Osteotomy: Analysis of an Official Registry in Italy.

Background and Objectives: Knee osteoarthritis is a serious burden for modern countries. Timing of surgery and treatment choice are still a matter of controversy in the orthopedic literature. The purpose of this study was to ascertain the incidence and hospitalization trends of high tibial osteotomy in Italy from 2001 to 2016. Materials and Methods: Data are sourced from the National Hospital Discharge Reports (SDO) of the Italian Ministry of Health between 2001 and 2016. Results: A total of 34,402 high tibial osteotomies were performed over the study period in Italy. The cumulative incidence was 3.6 cases per 100,000 residents. The age classes 50-54, 55-59 showed the higher number of procedures. In pediatric patients (0-19 years), high tibial osteotomies are also largely performed. The majority of patients having surgery were men with a M/F ratio of 1.5. The mean age of patients was 44.2 ± 19.2 years. Males were significantly younger than females (43.3 ± 20.7 vs. 45.6 ± 17.7). The average length of hospitalization was 6.1 ± 7.3 days. Over the course of the analysis, a declining trend in hospital stay length was seen. The main primary diagnosis codes were "Varus knee" (736.42 ICD-9-CM code, 33.9%), "Osteoarthrosis, localized, primary, leg region" (715.16 ICD-9-CM code, 9.5%). Conclusions: Over the study period, high tibial osteotomies in Italy almost halved. Varus deformity and knee osteoarthritis are the leading causes requiring high tibial osteotomy. Except for the pediatric setting, results showed that from the 20-24 age class to the 50-54 age class, there was an increasing request for knee osteotomy, whereas in those aged >60 years, the incidence progressively decreased. The evident decline in HTO performed over the years in Italy seems to reflect a minor role for knee osteotomy in the management of knee OA, as it seems to be primarily reserved for younger male patients.

The Overlay, a New Solution for Volume Variations in the Residual Limb for Individuals with a Transtibial Amputation.

BACKGROUND: The company Ethnocare has developed the Overlay, a new pneumatic solution for managing volumetric variations (VVs) of the residual limb (RL) in transtibial amputees (TTAs), which improves socket fitting. However, the impact of the Overlay during functional tasks and on the comfort and pain felt in the RL is unknown. METHODS: 8 TTAs participated in two evaluations, separated by two weeks. We measured compensatory strategies (CS) using spatio-temporal parameters and three-dimensional lower limb kinematics and kinetics during gait and sit-to-stand (STS) tasks. During each visit, the participant carried out our protocol while wearing the Overlay and prosthetic folds (PFs), the most common solution to VV. Between each task, comfort and pain felt were assessed using visual analog scales. RESULTS: While walking, the cadence with the Overlay was 105 steps/min, while it was 101 steps/min with PFs (p = 0.021). During 35% and 55% of the STS cycle, less hip flexion was observed while wearing the Overlay compared to PFs (p = 0.004). We found asymmetry coefficients of 13.9% with the Overlay and 17% with PFs during the STS (p = 0.016) task. Pain (p = 0.031), comfort (p = 0.017), and satisfaction (p = 0.041) were better with the Overlay during the second visit. CONCLUSION: The Overlay's impact is similar to PFs' but provides less pain and better comfort.

Infiltration of local anesthetic in the Interspace between the popliteal artery and capsule of the posterior knee "IPACK block" versus adductor canal block "ACB" for pain relief after open wedge high tibial osteotomy: a randomized clinical trial.

BACKGROUND: A high tibial osteotomy is usually associated with severe postoperative pain. Both adductor canal block (ACB) and interspace between the popliteal artery and capsule of the posterior knee (IPACK) have been described as effective block techniques for providing analgesia after knee surgeries, with few comparisons in wedge osteotomy cases. We aim to compare the postoperative analgesic profile of the previously mentioned two block techniques in patients undergoing tibial osteotomies. METHODS: Sixty patients were enrolled in this randomized prospective trial (30 received IPACK and 30 received ACB). Both blocks were installed before the spinal anesthesia after infiltration of 2 mL lidocaine 2%. Twenty mL of bupivacaine 0.25% mixed with dexamethasone as anesthetic adjuvant were used for both blocks. The postoperative analgesic profiles were compared between the two groups. RESULTS: Postoperative pain scores were lower in the IPACK group, and that decrease was evident throughout the first 10 hours postoperatively. Additionally, the duration of analgesia was much prolonged with the same block (487.50±82.39 vs. 301.93±92.06 minutes with ACB). There was a significant decline in postoperative analgesic consumption (1.27±0.45 vs. 1.8±0.61 gm, P=0.000), and a significant increase in the ambulation distance (19.10±0.60 vs. 17.73±0.45 m, P=0.000) with a significant decline in the duration of hospitalization (43.27±7.61 vs. 54±8.35 hours) in the IPACK group compared to the ACB group. CONCLUSIONS: IPACK is a superior block technique compared to ACB in patients undergoing high tibial osteotomy regarding postoperative analgesia, ambulation distance, and patient satisfaction with little rate of adverse events in both groups.

Biomechanical analysis of patient specific cone vs conventional stem in revision total knee arthroplasty.

BACKGROUND: In revision total knee arthroplasty, addressing significant bone loss often involves the use of cemented or press-fit stems to ensure implant stability and long-term fixation. A possible alternative to stem was recently introduced utilizing custom-made porous metaphyseal cones, designed to reconstruct the missing tibial and femoral geometries. Early clinical and radiological assessments have shown promising results. The objective of this research was to biomechanically evaluate the performances of these custom-made cones. METHODS: The biomechanical study was conducted using a validated finite element model. The bone geometries of a patient (selected for their history of four knee revisions due to infection and periprosthetic fractures, followed by a successful treatment with custom-made 3D-printed metaphyseal cones) were employed for the study. On these bone models, different revision scenarios were simulated and examined biomechanically: (A) custom-made cementless metaphyseal cones; (B) cemented stems; (C) press-fit stems; (D) distal femoral reconstruction with press-fit stem. All the models were analyzed at 0 °and 90 °of flexion, under physiological load conditions simulating daily activities; stress distribution, average Von-Mises stresses and risk of fracture were then analyzed and compared among configurations. RESULTS: The use of custom-made 3D-printed cones exhibited the most favorable stress distribution in both femoral and tibial bones. Tibial bone stress was evenly distributed in custom-made cone configurations, while stress concentration was observed in distal regions for the other scenarios. Additionally, custom-made cones displayed overall homogeneity and lower stress levels, potentially contributing to limit pain. Symmetrical stress distribution was observed between the lateral and medial proximal tibia in custom-made cone models, whereas other scenarios exhibited uneven stress, particularly in the anterior tibial bone. CONCLUSIONS: The biomechanical analysis of porous custom-made metaphyseal cones in re-revision arthroplasties is in agreement with the positive clinical and radiological outcomes. These findings provide valuable insights into the potential benefits of using custom-made cones, which offer more uniform stress distribution and may contribute to improve patient outcomes in revision TKA procedures. Further studies in this direction are warranted to validate these biomechanical findings.

The AERO prosthetic liner: socket pressure distribution, comfort and material composition.

PURPOSE: This study aimed to evaluate the pressure distribution and comfort of transtibial prosthesis wearers using an affordable ethyl-vinyl acetate (EVA) roll-on (AERO) liner. METHOD: Fifteen unilateral transtibial prosthesis users wore patella tendon bearing (PTB) sockets with a polyethylene foam (PE-lite) liner were enrolled this study. AERO liners were provided to all participants. Six force sensors were applied to the residual limb to evaluate pressure distribution during treadmill walking, and the socket comfort score (SCS) was used to evaluate comfortability. Fourier transform infrared (FT-IR) spectroscopy was performed on the EVA and PE-lite liners. RESULTS: Eleven participants used prefabricated AERO liners and four participants used custom-made AERO liners. The pressure distribution was analysed by the coefficient of variation (CV): PE-lite was 75.7 ± 6.0 and AERO liner 83.3 ± 4.1. Residual limb pressure was significantly decreased when using the AERO liner (p = .0007), with a large effect size (r = 0.87). Mean SCS was 7.5 ± 1.3 and 8.9 ± 1.1 for PE-lite and AERO liner respectively. CONCLUSION: Better pressure distribution and comfort were observed when the participants used the AERO liner. AERO had a greater proportion of calcium carbonate (CaCO3). These findings suggest that the AERO liner is a better off-the-shelf option for persons using traditional prosthetic sockets and liners.