Robotic-assisted differential total knee arthroplasty with patient-specific implants: surgical techniques and preliminary results.

OBJECTIVE: In total knee arthroplasty (TKA), achieving soft-tissue balance while retaining acceptable lower limb alignment is sometimes difficult and may lead to patient dissatisfaction. Theoretically, patient-specific implants can bring great benefits, while the lack of precise surgical tools may hinder the improvement of outcomes. The objective of this study was to illustrate surgical techniques and evaluate kinematics and early clinical outcomes of robotic-assisted TKA using patient-specific implants. METHODS: Based on preoperative CT scan, femoral and tibial components were 3D printed. Medial and lateral tibial liners were separate with different thicknesses, posterior slopes and conformity. TiRobot Recon Robot was used for surgery, and was armed with smart tools that quantify gap, force and femoral-tibial track. We collected data on demographics, intraoperative gap balance and femoral-tibial motion. In the follow-up, we evaluated the range of motion, Visual Analogue Scale (VAS), forgotten joint score (FJS), Knee injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) score. Radiological data were also harvested. RESULTS: Fifteen patients (17 knees) were enrolled with a mean age of 64.6 ± 6.4 (53-76) years. In 5 knees, we used symmetric tibial liners, the rest were asymmetric. After surgery, the average alignment was 1.6 ± 2.0 (-3-5) degrees varus. The average follow-up lasted 6.7 ± 4.2 (1-14) months. The mean visual analogue scale was 0.8 ± 0.7 (0-2), FJS was 62.4 ± 25.3 (0-87), KOOS was 86.5 ± 9.4 (57-97). 11 patients were "very satisfied", 3 were "satisfied" with the result, and one patient was neutral due to restricted extension and unsatisfactory rehabilitation at five months' follow-up. CONCLUSIONS: With patient-specific implants and robotics, TKA could be performed by a mathematical way, which was dubbed a "differential" TKA. Intraoperative kinematics was excellent in terms of gap-force balancing and femoral-tibial relative motion. Preliminary clinical outcomes were overall satisfactory.

Patient-perceived knee enlargement after total knee arthroplasty: prevalence, risk factors, and association with functional outcomes and radiological analysis.

PURPOSE: In clinical practice, many patients complained that their knees became larger after total knee arthroplasty (TKA), yet no studies have described this phenomenon. We named this as "patient-perceived enlargement of knee" (PPEK). This study aimed to investigate the prevalence of PPEK after TKA; assess the association between PPEK and demographics, surgical options, or component size; assess the influence of PPEK on patient satisfaction and functional outcomes; and determine whether there was radiological difference between patients with or without PPEK. METHODS: We reviewed patients that underwent unilateral primary TKA between May 2018 and April 2019. We investigated the prevalence of PPEK and acquired functional scores and satisfaction. Patients were divided into two groups according to whether they complained of PPEK. In radiological evaluation, we measured anterior and posterior condyle offset (ACO and PCO) of the femur, tibial coverage lines, tibial overhanging lines, and femoral overhanging lines. RESULTS: A total of 389 patients were enrolled and 101 patients felt their knee became "larger" after TKA. Patients with PPEK had significantly shorter height and lower weight, yet component size distribution showed no statistical difference. Patients with PPEK had significantly lower functional scores and satisfaction. Patients with PPEK had significantly larger ACO, shorter postoperative PCO, more ACO increase, and less anterior underhang of the tibia. CONCLUSION: PPEK is common in TKA patients, especially in individuals with smaller height and weight. PPEK is associated with poor satisfaction and lower functional scores. In radiology, post-operative ACO, PCO, and anterior underhang of the tibial component were correlated with PPEK.

Treatment and outcomes of Vancouver type B periprosthetic femoral fractures.

AIMS: Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF. METHODS: A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications. RESULTS: In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications. CONCLUSION: The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection bias in undertaking surgical intervention. In our whole cohort, younger patient age was a risk factor for postoperative complications in Vancouver type B PFF. Cite this article: Bone Joint J 2020;102-B(3):293-300.

Retrospective Cohort Study Comparing Complications, Readmission, Transfusion, and Length of Stay of Patients Undergoing Simultaneous and Staged Bilateral Total Hip Arthroplasty.

OBJECTIVES: To determine whether the rates of postoperative complications, rate of readmission, cumulative transfusion volume, and length of stay (LOS) differ between simultaneous total hip arthroplasty (THA) and staged bilateral THA and to assess whether the length of the interval between staged procedures influences surgery outcome. METHODS: This was a retrospective cohort study comparing the rate of postoperative complications, readmission, cumulative transfusion volume, and LOS between simultaneous THA and staged bilateral THA in our hospital's registration database. The inclusion criteria is listed as follows: patients who underwent bilateral primary THA between January 2011 and January 2015 with minimum 3-month follow-up; simultaneous bilateral THA; staged bilateral THA; postoperative complications, readmission, cumulative transfusion volume, length of stay of the patients and the influence of the interval between stages of bilateral THA on the outcome above; and retrospective cohort study. Finally, a total of 1145 patients, including simultaneous bilateral THA in 863 patients (1726 hips) and staged bilateral THA in 282 patients (564 hips), were eligible for the present study. The patients were divided into three groups according to the interval time (≤30 days, 30-90 days, >90 days) between the two stages of bilateral THA and we compared postoperative complications, readmission rates, cumulative transfusion volume, and LOS for the three groups. All patients' medical records and outpatient notes were reviewed to extract preoperative data, perioperative complications, readmission, cumulative transfusion, and LOS. Preoperative information included patients' age, sex, diagnosis, body mass index, and American Society of Anesthesiologists (ASA) classification. Perioperative complications were sorted into two groups: (i) medical complications included cardiovascular, pulmonary, neurological, digestive, and urologic system complications, along with other miscellaneous issues; and (ii) surgical complications included dislocation, superficial wound infection, hematoma, deep periprosthetic joint infection, and nerve palsy. Patients who failed to come back to visit our hospital in the postoperative 3 months were followed up by telephone, at which point we inquired about any postoperative complications and readmission. RESULTS: Simultaneous THA was performed more often in younger men, and patients in the simultaneous group had fewer major medical complications (excluding venous thromboembolism), fewer surgical complications, and shorter hospital stays; however, patients in the simultaneous group were likelier to have a higher transfusion rate than patients in the staged group. Among patients in the staged group, there were no differences for differing time intervals, except that patients with a between-stage interval of ≤30 days required more blood transfusions. CONCLUSION: With careful patient assessment and selection, simultaneous bilateral THA is a safe procedure, and has lower rates of surgical and major medical complications than staged bilateral THA.

Outcome of posterior wall blowout in anterior cruciate ligament (ACL) reconstruction via anteromedial portal approach: A retrospective research in 20 patients with 6 years follow-up.

PURPOSE: To evaluate the clinical outcome in patients who received anterior cruciate ligament (ACL) reconstruction via anteromedial portal with or without posterior wall blowout. METHODS: Twenty patients with ruptured ACL, who have received ACL reconstruction via anteromedial portal between Apr 2012 and Oct 2013 were enrolled. According to the conditions of posterior wall, the patients were divided into 2 groups: posterior wall blowout group (10 patients) and posterior wall intact group (10 patients). The median follow up time were 63 (range 19-75) months and 60.5 (range 25-64) months in the 2 groups respectively. The clinical outcome was evaluated by knee joint physical examination, magnetic resonance imaging (MRI), the International Knee Documentation Committee (IKDC) 2000 subjective score, Lysholm score, Tenger score, difference of thigh circumference, KT-2000 and Biodex isokinetic dynamometer system. RESULTS: No significant differences were found in terms of the IKDC score, Lysholm score, Tegner score, Lachman test positive rate or Pivot Shift test positive rate between the two groups. In KT-2000 and Biodex isokinetic dynamometer tests, the difference of muscle strength between affected knees and unaffected knees in posterior wall blowout group was not significant less than that of posterior wall intact group (p > 0.05). In addition, there is no statistical difference between the two groups in signal/noise quotient (SNQ) of the graft (p > 0.05) in post operative MRI. CONCLUSION: Blowout of posterior wall in ACL reconstruction via anteromedial portal does not affect the clinical outcome as long as reliable fixation is taken intraoperatively.

Burnout Among Chinese Adult Reconstructive Surgeons: Incidence, Risk Factors, and Relationship With Intraoperative Irritability.

BACKGROUND: Burnout is a major concern in human service occupations, mainly characterizing in emotional exhaustion and depersonalization. There is very limited research dealing with burnout in orthopedic surgeons. Exploring burnout prevalence, risk factors, and intraoperative irritability-related incidences is necessary to improve the quality of life for surgeons. METHODS: The study population consisted of 202 registered adult reconstructive doctors in China. Burnout was measured using a normalized translated version of the Maslach Burnout Inventory-Human Service Survey. Demographics, professional characteristics, and intraoperative irritability-related questions were also collected by electronic questionnaires. Statistical analysis was performed using SPSS 22.0. RESULTS: The overall rate of burnout was 85.1%. Variables significantly associated with high emotional exhaustion scores included poor sleeping time per day (P = .008), more nights on call per week (P = .048), and absence of research (P = .014). For depersonalization, absence of marriage (P < .001) and more nights on call per week (P < .001) were selected as risk factors. The incidence of losing temper in operation is 58.9%, significantly higher in senior surgeons (P = .001). Three major reasons for irritation during operations included delays by companies providing operative devices, poor coordination of assistants, and slow movements of instrument nurses. Intraoperative irritability was found to be significantly correlated with burnout, especially in emotional exhaustion. Residents were the population having the least opportunities to lose temper in operation. CONCLUSION: Burnout is highly prevalent in Chinese adult reconstructive surgeons, and it had some correlations with irritability. Further research is needed to determine more risk factors and reduce intraoperative irritability-related incidences.