Robotic arthroplasty software training improves understanding of total knee arthroplasty alignment and balancing principles: a randomized controlled trial.

Understanding alignment and gap balancing in Total Knee Arthroplasty (TKA) can be challenging for trainee and experienced orthopedic surgeons. Traditional learning methods may not effectively translate to real-life scenarios. The advent of advanced technologies like robotic surgery and navigation systems has revolutionized intraoperative understanding of gap balancing techniques. This trial aims to investigate the effectiveness of robotic TKA planning software in educating trainees about alignment and ligament balancing. We hypothesize that a single session with the software will significantly enhance trainees' understanding of these techniques. This UK-based single-center, two-arm, group parallel randomized controlled trial was conducted during a national robotic arthroplasty symposium. It aims to evaluate the effect of robotic knee arthroplasty software training on understanding TKA alignment and gap balancing principles using Multiple Choice Questions (MCQs). The MCQ test was crafted based on established guidelines from a different institution with expert consensus in the field. Our study revealed that baseline knowledge of gap balancing and alignment principles was generally low among all participants. However, the intervention group, which received comprehensive robotic software training, demonstrated a significant improvement in their MCQ scores compared to the control group, which did not undergo the training. In conclusion, our study demonstrates that robotic arthroplasty software training significantly improves the understanding of TKA alignment and balancing principles among orthopedic trainees. Level of Evidence II.

Burnout in trauma and orthopaedics: a cross-sectional study of surgeons from across the United Kingdom.

INTRODUCTION: Improving psychological wellbeing in healthcare professionals has demonstrable links with improvements in system-performance and patient outcomes. The aims of this study were to determine the prevalence of burnout among orthopaedic surgeons within the United Kingdom (UK) and to identify any influencing factors. METHODS: This prospective, cross-sectional nationwide study used the Oldenburg Burnout Inventory to assess burnout among orthopaedic registrars, middle grades and consultants from across the UK. In total, 369 participants completed an anonymised online survey. Reasons for burnout were assessed using a list of 20 stressors followed by a white-space box for elaboration. RESULTS: Respondents included 204 (55.3%) consultants, 100 (27.1%) registrars and 65 (17.6%) who were an associate specialist, trust grade or fellow. Some 252 (68.3%) participants experienced moderate-level burnout and 81 (22.0%) high-level burnout. There was no significant association between burnout and grade (p = 0.283), gender (p = 0.433), marital status (p = 0.932), years since graduation (p = 0.397), overseas training (p = 0.642), hours worked (p = 0.601), region (p = 0.699) or hospital type (p = 0.813). A high level of disengagement and exhaustion were identified, with the latter being a greater contributory factor. The most common reasons for burnout were insufficient staff numbers, an overload of administrative work and limited time to see patients. CONCLUSION: There was a moderate to high level of burnout among orthopaedic surgeons within the UK. Clinical and management teams should focus on improving staff numbers, reducing administrative work and increasing clinic consultation times to limit any further disengagement and exhaustion from surgeons. Reducing burnout may help to improve mental wellbeing, work satisfaction and workforce productivity.

A meta-analysis assessing time for return to sport following hip resurfacing.

BACKGROUND: Hip resurfacing arthroplasty (HRA) is associated with excellent functional outcomes and return to pre-disease level of activity. The time for return to sport (RTS) following HRA remains unknown. The aim of this meta-analysis was to establish the time for RTS following HRA. METHODS: A search was performed on PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trials on HRA and RTS, in the English language, published from the inception of the database to October 2020. In addition, a manual search was performed of relevant sports medicine and orthopaedic journals, and the bibliographies reviewed for eligible trials. All clinical trials reporting on time to RTS following HRA were included. Data relating to patient demographics, methodological quality, operation type, RTS, clinical outcomes, and complications were recorded by two independent reviewers. The PRISMA guidelines for reporting meta-analyses was used to undertake this study. RESULTS: The initial literature search identified 1559 studies and nine further studies were found. Of these, 11 studies with a total of 659 patients matched the inclusion criteria. Two studies involving a total of 94 patients demonstrated an overall pooled proportion of 91.8% (95% CI 71.8-100) of patients RTS by three months post-operatively. Four studies including a total of 265 patients determined a pooled proportion of 96.8% (95% CI 91.0-99.7) of patients able to RTS by the 6-month post-operative stage. Pooled proportion analysis from all 11 studies comprising 659 patients showed 90.9% (95% CI 82.2-96.9) of patients were able to RTS by final follow up of 3 years. CONCLUSION: Pooled proportion analysis showed an increasing number of patients were able to RTS after HRA over the first one year after surgery. There remains marked inter and intra-study variations in time for RTS but the pooled analysis shows that over 80% of patients were able to RTS at 6 to 12 months after HRA. The findings of this meta-analysis will enable more informed discussions between patients and healthcare professionals about time for RTS following HRA.

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials.

PURPOSE: The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA. METHODS: A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate. RESULTS: 14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7-5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1-3.1) with an OR of 1.9 (95% CI = 1.1-3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12-0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4-5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10-0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7-9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50-19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60-3.60, p = 0.36) did not differ between the two groups. CONCLUSION: Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use. LEVEL OF EVIDENCE: meta-analysis, Level II.

Time for return to sport following total knee arthroplasty: a meta-analysis.

INTRODUCTION: The frequency of total knee arthroplasty (TKA) is increasing, particularly in younger and more active patients. In these patients, there may be greater functional demands, with an expectation to return to sporting activities (RTS) following TKA. There is a paucity of data on the time to RTS following TKA and the aim of this meta-analysis is to determine the time to RTS following TKA. METHODS: Using the PRISMA guidelines, an electronic search of PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trails was performed on TKA and RTS in English language, published since the inception of the database to 31st October 2020. Data evaluating the time to RTS and functional outcomes were recorded by two authors independently that were included in the analysis. Pooled analysis using random effect model on overall proportions at the different time intervals and at the end of the follow-up was carried out for all studies. RESULTS: In total, 1,611 studies were retrieved from literature search. Of these, nine studies met the inclusion criteria with 1,307 patients. Two studies with 148 patients demonstrated an overall pooled proportion of 18.7% (95% CI 8.2-32.3%) of patients RTS at 3 month post-TKA; Three studies reported RTS rate at 6 months 70.% (95% CI 48-88.4). Two studies with 123 patients demonstrated an overall pooled proportion of 84.0% (95% CI 77.1-89.9%) patients RTS at 12 months. 986 patients returned to sport from total of 1307, with an overall adjusted proportion return to sport of 87.9 (95% CI 80.5-93.8%) at the end of follow-up; mean 14 months (range 3-36 months). CONCLUSION: Patients undergoing TKA were found to successfully RTS, pooled proportion analysis showed an increasing rate of RTS with time, at a mean of 14 months following TKA, where 87.9% of patients had returned to sports. The findings of this study will enable more informed discussions and rehabilitation planning between patients and clinicians on RTS following TKA.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway.

INTRODUCTION: We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. METHODS: An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. FINDINGS: Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. CONCLUSION: We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

Artificial intelligence and surgical innovation: lower limb arthroplasty.

The number of patients requiring hip and knee arthroplasty continues to rise each year. Patients are living longer and expecting to remain active into later life following joint replacement. Developments in computer-assisted surgery and robotic technology may optimise surgical outcomes and patient satisfaction following lower limb arthroplasty. The use of artificial intelligence in healthcare is rapidly growing and has gained momentum in lower limb arthroplasty. This article reviews the use of artificial intelligence and surgical innovation in lower limb arthroplasty, with a particular focus on robotic-assisted surgery in total knee arthroplasty.

Outcomes of repeat two-stage exchange hip arthroplasty for prosthetic joint infection.

AIMS: The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI). PATIENTS AND METHODS: We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years. RESULTS: A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years' follow-up. CONCLUSION: The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110-115.

An assessment of early functional rehabilitation and hospital discharge in conventional versus robotic-arm assisted unicompartmental knee arthroplasty: a prospective cohort study.

AIMS: The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA. PATIENTS AND METHODS: This prospective cohort study included 146 patients with symptomatic medial compartment knee osteoarthritis undergoing primary UKA performed by a single surgeon. This included 73 consecutive patients undergoing conventional jig-based mobile bearing UKA, followed by 73 consecutive patients receiving robotic-arm assisted fixed bearing UKA. All surgical procedures were performed using the standard medial parapatellar approach for UKA, and all patients underwent the same postoperative rehabilitation programme. Postoperative pain scores on the numerical rating scale and opiate analgesia consumption were recorded until discharge. Time to attainment of predefined functional rehabilitation outcomes, hospital discharge, and postoperative complications were recorded by independent observers. RESULTS: Robotic-arm assisted UKA was associated with reduced postoperative pain (p < 0.001), decreased opiate analgesia requirements (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001), and increased maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based UKA. Mean time to hospital discharge was reduced in robotic UKA compared with conventional UKA (42.5 hours (sd 5.9) vs 71.1 hours (sd 14.6), respectively; p < 0.001). There was no difference in postoperative complications between the two groups within 90 days' follow-up. CONCLUSION: Robotic-arm assisted UKA was associated with decreased postoperative pain, reduced opiate analgesia requirements, improved early functional rehabilitation, and shorter time to hospital discharge compared with conventional jig-based UKA.

Indications for a single-stage exchange arthroplasty for chronic prosthetic joint infection: a systematic review.

AIMS: Prosthetic joint infections (PJIs) of the hip and knee are associated with significant morbidity and socioeconomic burden. We undertook a systematic review of the current literature with the aim of proposing criteria for the selection of patients for a single-stage exchange arthroplasty in the management of a PJI. MATERIAL AND METHODS: A comprehensive review of the current literature was performed using the OVID-MEDLINE, EMBASE, and Cochrane Library databases and the search terms: infection and knee arthroplasty OR knee revision OR hip arthroplasty OR hip revision, and one stage OR single stage OR direct exchange. All studies involving fewer than ten patients and follow-up of less than two years in the study group were excluded as also were systematic reviews, surgical techniques, and expert opinions. RESULTS: The initial search revealed 875 potential articles of which 22 fulfilled the inclusion and exclusion criteria. There were 16 case series and six comparative studies; five were prospective and 14 were retrospective. The studies included 962 patients who underwent single stage revision arthroplasty of an infected hip or knee joint. The rate of recurrent infection ranged from 0% to 18%, at a minimum of two years' follow-up. The rate was lower in patients who were selected on the basis of factors relating to the patient and the local soft-tissue and bony conditions. CONCLUSION: We conclude that single-stage revision is an acceptable form of surgical treatment for the management of a PJI in selected patients. The indications for this approach include the absence of severe immunocompromise and significant soft-tissue or bony compromise and concurrent acute sepsis. We suggest that a two-stage approach should be used in patients with multidrug resistant or atypical organisms such as fungus.

Assuring the long-term total joint arthroplasty: a triad of variables.

OBJECTIVES: The primary objective of this study was to compare accuracy in restoring the native centre of hip rotation in patients undergoing conventional manual total hip arthroplasty (THA) versus robotic-arm assisted THA. Secondary objectives were to determine differences between these treatment techniques for THA in achieving the planned combined offset, component inclination, component version, and leg-length correction. MATERIALS AND METHODS: This prospective cohort study included 50 patients undergoing conventional manual THA and 25 patients receiving robotic-arm assisted THA. Patients undergoing conventional manual THA and robotic-arm assisted THA were well matched for age (mean age, 69.4 years (sd 5.2) vs 67.5 years (sd 5.8) (p = 0.25); body mass index (27.4 kg/m2 (sd 2.1) vs 26.9 kg/m2 (sd 2.2); p = 0.39); and laterality of surgery (right = 28, left = 22 vs right = 12, left = 13; p = 0.78). All operative procedures were undertaken by a single surgeon using the posterior approach. Two independent blinded observers recorded all radiological outcomes of interest using plain radiographs. RESULTS: The correlation coefficient was 0.92 (95% confidence interval (CI) 0.88 to 0.95) for intraobserver agreement and 0.88 (95% CI 0.82 to 0.94) for interobserver agreement in all study outcomes. Robotic THA was associated with improved accuracy in restoring the native horizontal (p < 0.001) and vertical (p < 0.001) centres of rotation, and improved preservation of the patient's native combined offset (p < 0.001) compared with conventional THA. Robotic THA improved accuracy in positioning of the acetabular component within the combined safe zones of inclination and anteversion described by Lewinnek et al (p = 0.02) and Callanan et al (p = 0.01) compared with conventional THA. There was no difference between the two treatment groups in achieving the planned leg-length correction (p = 0.10). CONCLUSION: Robotic-arm assisted THA was associated with improved accuracy in restoring the native centre of rotation, better preservation of the combined offset, and more precise acetabular component positioning within the safe zones of inclination and anteversion compared with conventional manual THA.

Preoperative CT-Based Three-Dimensional Templating in Robot-Assisted Total Knee Arthroplasty More Accurately Predicts Implant Sizes than Two-Dimensional Templating.

Patient dissatisfaction after total knee arthroplasty (TKA) is a concern. Surgical error is a common, avoidable cause of failed TKA. Correct femoral and tibial component sizing improves implant longevity, clinical outcomes, knee balance, and pain scores. We hypothesized that preoperative three-dimensional (3D) templating for robot-assisted TKA (RA-TKA) is more accurate than two-dimensional (2D) digital templating. Prospectively collected data from 31 RA-TKAs were assessed to determine accuracy pertaining to implant sizing and positioning. All cases undergoing RA-TKA undergo preoperative CT-scans as per protocol. Three blinded observers retrospectively templated these knees for TKA using standard radiographs. We compared whether 2D templating was as accurate as CT-guided templating. Postoperative radiographs were then evaluated for sizing and positioning. Intraclass correlation coefficients (ICCs) and the effect of learning curve were assessed. Preoperative femoral component 3D templating and retrospective blinded 2D templating accuracies were 96.6% and 52.9%, respectively (χ 2: 17.965; odds ratio [OR]: 24.957, 3.250-191.661; p < 0.001). Tibial component 3D and 2D templating accuracies were 93.1% and 28.7%, respectively (χ 2: 36.436; OR: 33.480, 7.400-151.481; p < 0.001). ICC for the three radiograph observers was 0.920 (95% confidence interval [CI]: 0.652-0.890; p < 0.001) for the femur and 0.833 (0.717-0.911; p < 0.001) for the tibia, showing excellent agreement. We conclude that preoperative CT-based templating for RA-TKA more accurately predicts the size of implants compared with traditional 2D digital templating. This may improve operating room efficiency and cost containment.

The learning curve associated with robotic-arm assisted unicompartmental knee arthroplasty: a prospective cohort study.

Aims: The primary aim of this study was to determine the surgical team's learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA. Patients and Methods: This prospective single-surgeon cohort study included 60 consecutive conventional jig-based UKAs compared with 60 consecutive robotic-arm assisted UKAs for medial compartment knee osteoarthritis. Patients undergoing conventional UKA and robotic-arm assisted UKA were well-matched for baseline characteristics including a mean age of 65.5 years (sd 6.8) vs 64.1 years (sd 8.7), (p = 0.31); a mean body mass index of 27.2 kg.m2 (sd 2.7) vs 28.1 kg.m2 (sd 4.5), (p = 0.25); and gender (27 males: 33 females vs 26 males: 34 females, p = 0.85). Surrogate measures of the learning curve were prospectively collected. These included operative times, the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire to assess preoperative stress levels amongst the surgical team, accuracy of implant positioning, limb alignment, and postoperative complications. Results: Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time (p < 0.001) and surgical team confidence levels (p < 0.001). Cumulative robotic experience did not affect accuracy of implant positioning (p = 0.52), posterior condylar offset ratio (p = 0.71), posterior tibial slope (p = 0.68), native joint line preservation (p = 0.55), and postoperative limb alignment (p = 0.65). Robotic-arm assisted UKA improved accuracy of femoral (p < 0.001) and tibial (p < 0.001) implant positioning with no additional risk of postoperative complications compared to conventional jig-based UKA. Conclusion: Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time and surgical team confidence levels but no learning curve for accuracy of implant positioning. Cite this article: Bone Joint J 2018;100-B:1033-42.

Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty: a prospective cohort study.

Aims: The objective of this study was to compare early postoperative functional outcomes and time to hospital discharge between conventional jig-based total knee arthroplasty (TKA) and robotic-arm assisted TKA. Patients and Methods: This prospective cohort study included 40 consecutive patients undergoing conventional jig-based TKA followed by 40 consecutive patients receiving robotic-arm assisted TKA. All surgical procedures were performed by a single surgeon using the medial parapatellar approach with identical implant designs and standardized postoperative inpatient rehabilitation. Inpatient functional outcomes and time to hospital discharge were collected in all study patients. Results: There were no systematic differences in baseline characteristics between the conventional jig-based TKA and robotic-arm assisted TKA treatment groups with respect to age (p = 0.32), gender (p = 0.50), body mass index (p = 0.17), American Society of Anesthesiologists score (p = 0.88), and preoperative haemoglobin level (p = 0.82). Robotic-arm assisted TKA was associated with reduced postoperative pain (p < 0.001), decreased analgesia requirements (p < 0.001), decreased reduction in postoperative haemoglobin levels (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001) and improved maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based TKA. Median time to hospital discharge in robotic-arm assisted TKA was 77 hours (interquartile range (IQR) 74 to 81) compared with 105 hours (IQR 98 to 126) in conventional jig-based TKA (p < 0.001). Conclusion: Robotic-arm assisted TKA was associated with decreased pain, improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based TKA. Cite this article: Bone Joint J 2018;100-B:930-7.

Metal-on-polyethylene versus metal-on-metal bearing surfaces in total hip arthroplasty: a prospective randomised study investigating metal ion levels and chromosomal aberrations in peripheral lymphocytes.

The long term biological effects of wear products following total hip arthroplasty (THA) are unclear. However, the indications for THA are expanding, with increasingly younger patients undergoing the procedure. This prospective, randomised study compared two groups of patients undergoing THA after being randomised to receive one of two different bearing surfaces: metal-on-polyethylene (MoP) n = 22 and metal-on-metal (MoM) n = 23. We investigated the relationship between three variables: bearing surface (MoP vs MoM), whole blood levels of chromium (Cr) and cobalt (Co) and chromosomal aberrations in peripheral lymphocyte pre-operatively and at one, two and five years post-surgery. Our results demonstrated significantly higher mean cobalt and chromium (Co and Cr) blood levels in the MoM group at all follow-up points following surgery (p < 0.01), but there were no significant differences in the chromosomal aberration indices between MoM and MoP at two or five years (two years: p = 0.56, p = 0.08, p = 0.91, p = 0.51 and five years: p = 0.086, p = 0.73, p = 0.06, p = 0.34) for translocations, breaks, loss and gain of chromosomes respectively. Regression analysis showed a strong linear relationship between Cr levels and the total chromosomal aberration indices in the MoM group (R(2) = 0.90016), but this was not as strong for Co (R(2) = 0.68991). In the MoP group, the analysis revealed a poor relationship between Cr levels and the total chromosomal aberration indices (R(2) = 0.23908) but a slightly stronger relationship for Co (R(2) = 0.64292). Across both groups, Spearman's correlation detected no overall association between Co and Cr levels and each of the studied chromosomal aberrations. There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. While THA continues to be very successful at alleviating pain and restoring function, the long-term biological implications of the procedure still require further scrutiny.

A review of the surgical management of sacral chordoma.

BACKGROUND: Sacral chordomas are rare low-to-intermediate grade malignant tumours, which arise from remnants of the embryonic notochord. This review explores prognostic factors in the management of sacral chordomas and provides guidance on the optimal treatment regimens based on the current literature. PATIENTS AND METHODS: Electronic searches were performed using MEDLINE, Embase and the Cochrane library to identify studies on prognostic factors in the management of sacral chordomas published between January 1970 and December 2013. The literature search and review process identified 100 articles that were included in the review article. This included both surgical and non-surgical studies on the management of sacral chordomas. RESULTS: Sacrectomy with wide resection margins forms the mainstay of treatment but is associated with high risk of disease recurrence and reduced long-term survival. Adequate resection margins may require sacrifice of adjacent nerve roots, musculature and ligaments leading to functional compromise and mechanical instability. Large tumour size (greater than 5-10 cm in diameter), dedifferentiation and greater cephalad tumour extension are associated with increased risk of disease recurrence and reduced survival. Chordomas are poorly responsive to conventional radiotherapy and chemotherapy. CONCLUSION: Operative resection with wide resection margins offers the best long-term prognosis. Inadequate resection margins, large tumour size, dedifferentiation, and greater cephalad chordoma extension are associated with poor oncological outcomes. Routine long-term follow-up is essential to enable early detection and treatment of recurrent disease.