Arthroscopic Meniscal Repair and Meniscectomy for Adult Discoid Lateral Meniscus Results in Progression to Valgus Alignment and Lateral Compartment Degeneration Compared With Nonoperative Treatment and Nondiscoid Lateral Meniscus.

PURPOSE: To analyze the effect of the arthroscopic meniscal procedure in adult discoid lateral meniscus (DLM) according to the age and meniscal-preserving by making comparisons with the nondiscoid lateral meniscus (N-DLM). METHODS: From March 2014 to October 2020, a comparative analysis was performed in adults with DLM who underwent arthroscopic meniscal procedures (operative DLM: 134 knees), nonoperative treatment (nonoperative DLM: 56 knees), and adult N-DLM who underwent arthroscopic meniscal procedures (operative N-DLM: 64 knees). These patients were between 20 and 65 years old and completed a minimum follow-up of 2 years. Patients with DLM who underwent arthroscopic procedure were divided into subgroups according to age and extent of the meniscal-preserving. The following parameters were assessed and compared between the groups: (1) coronal limb alignment, (2) osteoarthritis grade, and (3) clinical outcomes and the minimal clinically important difference. RESULTS: The coronal limb alignment was significantly changed to valgus in the order of operative DLM, N-DLM, and nonoperative DLM (Δ mechanical hip-knee-ankle angle: 3.23 ± 1.85 vs 1.35 ± 1.03° vs -0.57 ± 1.88°; P < .05). Operative DLM showed most prominent osteoarthritic change in the lateral compartment, followed by the N-DLM and nonoperative DLM groups (40.3% vs 17.2% vs 5.3%; P < .05). These changes in operative DLM were more prominent in older adults who underwent meniscal-sacrificing procedures and resulted in less-satisfactory clinical outcomes (all P < .05). CONCLUSIONS: Arthroscopic surgery for adult DLM resulted in progression to valgus alignment and lateral compartment degeneration compared with nonoperative treatment and arthroscopic surgery of the adult N-DLM. Old ager and having a meniscal-sacrificing procedure showed more rapid radiographic changes and lower clinical outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparison study.

Retro-tubercular Biplanar Medial Opening-Wedge High Tibial Osteotomy Results in Superior Patellofemoral Alignment Versus Supra-tubercular Osteotomy.

PURPOSE: To compare the changes in patellofemoral (PF) joint alignment, focusing on multiple planes, between two different types of biplanar medial opening-wedge high tibial osteotomy (OWHTO). METHODS: Patients who underwent biplanar OWHTO between July 2017 and May 2021 were retrospectively evaluated. They were allocated to either the supra-tubercular (ST)- or retro-tubercular (RT)-OWHTO group. The following radiologic parameters were compared between the two groups: 1) weight-bearing line ratio (WBLR), 2) patellar height, 3) posterior tibial slope (PTS), 4) tibial tubercle-trochlear groove (TT-TG) distance, 5) TT-TG angle, and 6) femoral shaft-patellar tendon (FS-PT) angle. Clinical outcomes and the minimal clinically important difference (MCID) were also evaluated. RESULTS: In total, 104 knees that underwent ST-OWHTO and 105 knees that underwent RT-OWHTO were evaluated. The patellar height significantly decreased only after ST-OWHTO (P < .001). The TT-TG distance and FS-PT angle significantly increased, more after ST-OWHTO than RT-OWHTO (mean change value: 5.72 mm vs 1.91 mm; P < .001 for TT-TG distance; and 4.72° vs 1.80°; P < .001 for FS-PT angle). The TT-TG angle increased significantly after ST-OWHTO (mean change value: 7.62°; P < .001) but decreased after RT-OWHTO mean change value: -4.30°; P < .001). The PTS more increased after RT-OWHTO than after ST-OWHTO (mean change value: 0.91° vs 1.69°; P = .003). Clinical outcomes in both groups improved postoperatively, and no significant differences were observed between the groups. CONCLUSIONS: RT-OWHTO resulted in lesser changes in multiplane PF joint alignment than ST-OWHTO. However, no difference was observed in clinical outcomes between both groups, and PTS increased after RT-OWHTO. Therefore, these aspects of RT-OWHTO should also be considered. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Postoperative Intravenous Iron Supplementation Increases Hemoglobin Level in Total Knee Arthroplasty.

Iron supplementation provides iron storage and facilitates effective production of hemoglobin. The purpose of this study was to investigate the effect of early postoperative intravenous (IV) iron supplementation in different types of total knee arthroplasty (TKA) surgery. We retrospectively analyzed 863 patients who underwent TKA between September 2017 and September 2021. The IV iron (I) and non-IV iron (NI) groups were compared. Hemoglobin responders, defined as patients who showed a change in hemoglobin level of ≥2 g/dL at 6 weeks of surgery compared to the baseline immediate postoperative hemoglobin level, were identified and they were compared with the nonresponders. After logistic regression analysis, the patients were classified according to the type of surgery (unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA). A subgroup analysis was performed according to the comorbidity as Charlson Comorbidity Index (CCI). The type of surgery and the rate of hemoglobin responders differed between the I and NI groups. The surgery type and iron supplementation significantly affected the hemoglobin responder in the logistic regression model. In each surgery type, hemoglobin drop in the I group was generally lower in the second and sixth weeks than that in the NI group. It was also effective in reducing hemoglobin drop on the first day of the second surgery in staged bilateral TKA. In addition, the number of hospital days was lower in the IV iron supplementation group who underwent a staged bilateral TKA. CCI did not affect hemoglobin responder, hemoglobin drop, and transfusion rate in both the I and NI groups. Postoperative IV iron supplementation affected the outcome of hemoglobin responders. In addition, it reduced early postoperative hemoglobin drop. However, iron supplementation did not affect the transfusion rate, complications, and clinical outcome, regardless of the type of surgery. LEVEL OF EVIDENCE: Level III, case-control study.

Constitutional alignment predicts medial ligament balancing in mechanically aligned total knee arthroplasty for varus knees.

PURPOSE: The aim of this study was to identify if constitutional alignment and preoperative radiologic parameters determined whether medial gap balancing was required in mechanically aligned total knee arthroplasty (TKA). METHODS: Two hundred and sixty three patients with 394 consecutive knees who underwent primary TKAs were retrospectively analysed in this study. Selective sequential multiple needle puncturing (MNP) was performed for medial ligament balancing when required. Constitutional alignment, which was determined using the Coronal Plane Alignment of the Knee (CPAK) classification, as well as preoperative and postoperative radiologic parameters was evaluated to identify factors which predicted the need for MNP. RESULTS: One hundred and fifty eight (40.1%) knees required medial ligament balancing with MNP. Patients who required MNP during surgery had significantly more constitutional varus, more varus preoperative mechanical Hip-Knee-Ankle angle (mHKA), smaller preoperative medial proximal tibial angle (MPTA) and a larger change in mHKA and MPTA after surgery than those who did not. Patients with constitutional varus also had a higher incidence of having had MNP to both anterior and posterior superficial medial collateral ligament (sMCL) fibres. There was no significant difference in preoperative lateral distal femoral angle (LDFA), posterior tibial slope (PTS) and varus-valgus difference (VVD) between groups. CONCLUSION: Ligament balancing using MNP was determined by constitutional alignment rather than medial soft tissue contracture. Patients with constitutional varus who had a larger medio-lateral gap difference in extension also had a higher incidence of having had MNP to both anterior and posterior sMCL fibres. LEVEL OF EVIDENCE: Retrospective comparative study, level IV.

Prior tuberosity screw fixation of the osteotomized tubercle can lead to favorable outcomes in retro-tubercular bi-planar opening wedge high tibial osteotomy.

BACKGROUND: Exact information regarding fixing the tuberosity screw during retro-tubercular opening-wedge high tibial osteotomy (RT-OWHTO) is still lacking. The purpose of this study was to determine whether prior tuberosity screw fixation before plate fixation of main osteotomy fragment can prevent complications associated with tuberosity screw. METHODS: From 2019 to 2021, patients who underwent RT-OWHTO were divided into two groups (group I, prior tuberosity screw fixation; group II, later tuberosity screw fixation). A total of 49 and 44 knees were included in groups I and II, respectively. Plain radiographs and computed tomography (CT) were used to analyze the parameters of tuberosity screw fixation, neurovascular (NV) safety and osteotomy configurations. Clinical outcomes and post-operative complications were assessed. RESULTS: The delta (Δ) of the deformation angle of the tuberosity (P = 0.002), delta (Δ) of the posterior tibial slope (PTS) (P < 0.001), extruded screw length (P < 0.001), and retro-tuberosity tip distance (P < 0.001) of group I were significantly smaller than those of group II. All tuberosity screws were fixed medially to the NV structures. Post-operative tuberosity fracture occurred in one knee (2%) in group I and in 10 knees (23%) in group II (P = 0.003). CONCLUSIONS: RT-OWHTO with prior tuberosity screw fixation can minimize the risk of tuberosity fracture and an increase in the PTS. It can also prevent NV injuries by reducing extruded tuberosity screw length and fixing it medially from the NV structures.

Does referencing system affect the selection of implant size, position and gap balance in total knee arthroplasty?

BACKGROUND: (1) To evaluate if referencing system affects selection of implant size, position, and gap balance in total knee arthroplasty (TKA) with the use of contemporary implant designs and (2) to describe the authors' intraoperative sizing strategy using anterior referencing (AR) and posterior referencing (PR) systems. METHODS: This was a retrospective review of 270 consecutive patients (397 knees) who underwent primary TKA with an AR or PR system. Selection of implant size, mediolateral and anteroposterior alignment of the femoral component, as well as gaps were compared between groups. RESULTS: In the AR group, more patients had femoral components which were upsized or downsized compared to those in the PR group (29.5% vs 12.0% respectively) and in patients who underwent bilateral TKA, 49.4% of those in the AR group had femur component size asymmetry. The AR group had better medio-lateral (ML) fit over the distal cutting surface area, smaller change in anterior offset but higher incidence of anterior notching when compared to the PR group. Posterior condylar offset (PCO) was restored in both groups and gap differences in flexion-extension and ML were comparable. There was also no difference in clinical scores and ROM between groups at 2-years follow-up. CONCLUSION: In this study, conventional implications related to referencing system were not observed. In practice, AR systems can restore PCO while PR systems do not result in increased anterior notching or anterior overstuffing. Differences observed in this study are most likely related to implant design specifics and surgical technique.

Constitutional and postoperative joint line obliquity can predict serial alignment change after opening-wedge high tibial osteotomy: analysis using coronal plane alignment of the knee classification.

PURPOSE: The purposes of this study were (1) to clarify the distribution of the Coronal Plane Alignment of the Knee (CPAK) phenotype in patients who underwent medial opening-wedge high tibial osteotomy (OWHTO) and (2) to identify the predictive factors for postoperative serial alignment changes after OWHTO by analyzing constitutional phenotypes. METHODS: Patients who underwent OWHTO between March 2014 and December 2019 were retrospectively evaluated. Those who completed a minimum follow-up of 3 years were divided into three groups based on the direction of alignment changes from postoperative 3 months to the final follow-up: Group 1 (varus direction) when the weight-bearing line ratio (WBLR) change was less than - 4%, Group 2 (maintained) when the WBLR change was between - 4% and 4%, and Group 3 (valgus direction) when the WBLR change was greater than 4%. The following parameters were assessed serially and compared between the groups: (1) radiologic parameters of coronal limb alignment such as joint line obliquity (JLO), (2) CPAK phenotypes, and (3) clinical outcomes. RESULTS: In total, 163 knees were included, and the average duration of follow-up was 4.8 ± 1.6 years. More apex distal JLO was observed in the order of Group 1, 2, and 3 at all times (all p < 0.05). The most common CPAK type was type (I + II) (constitutional: apex distal JLO) + type (V + VI) (postoperative 3 months: neutral JLO) in Group 1 (29.4%; p = 0.000); otherwise, the most common CPAK type was type (IV + V) (constitutional: neutral JLO) + type (VIII + IX) (postoperative 3 months: apex proximal JLO) in Group 3 (11.7%; p = 0.000). Clinical outcomes did not differ between the groups. CONCLUSION: Constitutional and postoperative JLO were predictive factors of postoperative alignment changes after OWHTO. Constitutional apex distal and postoperative neutral JLO had a tendency for varus alignment progression, whereas constitutional neutral and postoperative apex proximal JLO had a tendency for valgus alignment progression. LEVEL OF EVIDENCE: Retrospective cohort study; Level III.

The use of an anatomic tibial baseplate in total knee arthroplasty optimizes coverage without compromising rotation: A propensity-matched evaluation.

BACKGROUND: The aims of this study were (1) to compare in vivo coverage and rotational alignment of 2 tibial component designs: anatomic and symmetrical; and (2) to determine if coronal deformity and tibial torsion were related to rotation and coverage. METHODS: Postoperative CT scans of 200 propensity score-matched patients who underwent TKA with either an anatomic (ATC) or symmetrical tibia component (STC) were analyzed. Rotation was measured using four axes: surgical transepicondylar axis (sTEA), Berger's protocol, medio-lateral (ML) axis and posterior borders of the tibial plateau, while coverage was assessed by measuring fit and surface area. The relationship between coronal deformity, tibial torsion, rotation, and coverage was investigated. RESULTS: Overall, STCs had more internal rotation when measured using the sTEA (-0.6° ± 3.5 vs 0.5° ± 3.6, p = 0.03), Berger's protocol (-21.6° ± 7.1 vs -17.9° ± 6.2, p = 0.000) and ML axes (2.9° ± 3.9 vs 8.1° ± 5.1, p = 0.000) compared to ATCs. STCs also had more posteromedial underhang (-3.3 mm ± 2.4 mm vs -1.7 mm ± 2.5 mm, p = 0.000) but smaller change in tibial torsion postoperatively (-18.4° ± 9.9° vs -13.1° ± 9.4°, p = 0.000). Tibial torsion was more pronounced in valgus than varus knees both preoperative (-25.4° ± 6.5° vs -20.2° ± 9.3°, p = 0.02) and postoperatively (-19.7° ± 7.2° vs -14.7° ± 10.3°, p = 0.04), but there was no difference in postoperative tibial torsion between ATCs and STCs in this subgroup. CONCLUSION: The use of an anatomic tibial baseplate optimizes coverage by reducing posterolateral overhang and posteromedial underhang. It also achieved better rotational profiles compared to STCs. However, it resulted in a larger change in tibial torsion after TKA.

The development of machine learning algorithms that can predict patients satisfaction using baseline characteristics, and preoperative and operative factors of total knee arthroplasty.

BACKGROUND: Patient satisfaction following primary total knee arthroplasty (TKA) is a crucial part to evaluate the success of the procedure. The purpose of this study was to develop to predict patient satisfaction following TKA. METHODS: Satisfaction outcome data after 435 consecutive conventional TKAs performed between August 2020 and December 2021 were retrospectively collected. The total 26 input data were collected. The most favorable algorithm was first found using logistic regression (LR) and machine learning (ML) algorithms. To evaluate the predictive performance of the models, both area under curve (AUC) and F1-score were used as the primary metrics. The shapley additive explanations (SHAP) feature explanation in XGBoost and LR analysis were performed to interpret the model. RESULTS: The performance of extreme gradient boosting classifier (XGBoost) was only higher than that of conventional LR in AUC (0.782 vs. 0.689). Comparing the F-1 score, only XGBoost showed better performance than LR (0.857 vs. 0.800). The most predictive feature in XGBoost was Short Form-36 physical and mental component summary scores (SF-36 MCS), followed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, Bone mineral density (BMD). In the LR analysis, lumbar spine disease, WOMAC pain, and BMD were statistically significant. CONCLUSION: XGboost showed the best performance and was superior to conventional LR in the prediction of patient satisfaction after TKA. The SF-36 MCS was the most important feature in the ML model. WOMAC pain and BMD were meaningful variables and demonstrated a linear relationship with satisfaction in both the LR and ML models. LEVEL OF EVIDENCE: Retrospective cohort study; Level of evidence 3.

Outcomes of Geriatric Hip Fractures in a Tertiary Referral Center in Malaysia During the COVID-19 Pandemic.

Introduction With the advancing age of the population, there are an increasing number of patients with geriatric hip fractures. Despite the advancement of surgical knowledge and improvement of implant designs to treat geriatric hip fractures, mortality and morbidity remain high among these frail patients. In conjunction with the COVID-19 pandemic, the collateral damage dealt to these patients remains unknown as scarce resources are funneled to deal with the pandemic. This study is geared to investigate the surgical outcomes of patients with geriatric hip fractures who were admitted during the initial phase of the COVID-19 pandemic. Methods This retrospective study was carried out at Hospital Kuala Lumpur, the largest public hospital in the capital of Malaysia, from March 1, 2020, to March 1, 2021. All patients of age 60 years and above were screened for suitability. Only patients who had undergone surgical intervention during the study period were included in this study. Patients' demographic data, mechanism of injury, waiting time for surgery, type of surgery, complications and ambulatory status were obtained from the medical records. Univariate analysis was performed to determine the factors associated with complications as well as the post-operative ambulatory status of the patients. Results A total of 52 patients were included in this study, with a median age of 72 years. The majority of the patients were Chinese (n=21, 40.4%). This was followed by Malay and Indian (n=14, 26.9% each) and other ethnicity (n=3, 5.8%). More than three-quarters of the patients had a trivial injury such as a fall due to a miss-step (n=16, 30.8%) and slip (n=16, 30.8%) and a fall due to dizziness (n=8, 15.4%). Only 12 patients (23.1%) sustained hip fractures due to trauma. The median time to surgery for these patients was 5 days (interquartile range: 4 days). Most of these patients underwent total hip replacement (n=30, 57.7%). This was followed by unipolar hemiarthroplasty (n=11, 21.2%), bipolar hemiarthroplasty (n=10, 19.2%) and internal fixation (n=1, 1.9%). Among these patients, six of them had documented complications. There were periprosthetic joint infection (n=2, 3.8%), dislocation (n=2, 3.8%), hematoma formation (n=1, 1.9%) and seroma (n=1, 1.9%). Six months after the surgery, most of the patients were able to ambulate, albeit some patients required walking aid such as walking stick and walking frame. Univariate analysis showed that all the factors were not associated with the complications and the post-operative ambulatory status of the patients. Conclusion  The incidence of geriatric hip fractures remains high during the COVID-19 pandemic despite the movement control order (MCO) being enforced in Malaysia. With prompt surgical intervention, most of the patients can regain ambulatory status, albeit with a walking aid.

Association Between Tunnel Position, Tunnel Angle, Graft Signal Intensity, and Graft Thickness in the Reconstructed Posterior Cruciate Ligament.

Background: An appropriate tunnel position, tunnel angle, and tunnel-graft angle are important factors for maintaining the stability and mechanical properties of a posterior cruciate ligament (PCL) graft. Purpose: To evaluate the association between tunnel position, tunnel angle, graft signal intensity ratio (SIR), and graft thickness after remnant-preserving PCL reconstruction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were patients who had undergone remnant-preserving single-bundle PCL reconstruction using a tibialis anterior allograft between March 2014 and September 2020 and who had minimum 12-month postoperative magnetic resonance imaging scans. Tunnel position and angle were evaluated via 3-dimensional computed tomography, and their association with graft SIR on both the femoral and the tibial sides was determined. Graft thickness and SIR at 3 areas of the graft were evaluated and compared, and their association with tunnel-graft angle was also determined. Results: Overall, 50 knees (50 patients; 43 male, 7 female) were included. The mean time to postoperative magnetic resonance imaging was 25.8 ± 15.8 months. The mean SIR of the graft's midportion was higher compared with that of the proximal and distal portions (P = .028 and P < .001, respectively), and the SIR of the proximal portion was higher compared with that of the distal portion (P = .002). The femoral tunnel-graft angle was more acute than the tibial tunnel-graft angle (P = .004). A more anteriorly and distally located femoral tunnel led to a less acute femoral tunnel-graft angle (P = .005) and a decreased SIR of the proximal portion (P = .040), and a more laterally located tibial tunnel was associated with a less acute tibial tunnel-graft angle (P = .024) and a reduced SIR of the distal portion (P = .044). The mean thicknesses of the graft's midportion and distal portion were larger than that of the proximal portion (P < .001). The SIR of the graft's midportion was positively correlated with its thickness (r = 0.321; P = .023). Conclusion: The SIR of the proximal portion of the graft around the femoral tunnel was higher than that of the distal portion around the tibial tunnel. An anteriorly and distally positioned femoral tunnel and a laterally positioned tibial tunnel resulted in less acute tunnel-graft angles that were associated with decreased signal intensity.

Preoperative education on realistic expectations improves the satisfaction of patients with central sensitization after total knee arthroplasty: a randomized-controlled trial.

PURPOSE: The aim of this study was to investigate whether an additional module on realistic expectations following total knee arthroplasty (TKA) would lead to a higher proportion of satisfied patients compared to existing preoperative education. METHODS: This was a single-center, randomized-controlled trial. A total of 172 patients who were scheduled for TKA between September 2020 and October 2021 were enrolled. Patients were randomized to receive either only standard preoperative education, or an additional module on realistic expectations following TKA. The primary outcome was patient satisfaction. Secondary outcomes were Short Form-36, Western Ontario and McMaster Universities Osteoarthritis Index, crepitus score, and range of motion. Subgroup analysis was performed based on central sensitization inventory (CSI) score stratification. Assessment was performed at the 3-month, 6-month, and > 1-year follow-up. RESULTS: At more than 1 year, 65/78 (83.3%) patients in the intervention group and 52/80 (65.0%) patients in the control group were satisfied (P = 0.03). The mean satisfaction score was measured as 4.2 ± 0.9 in the intervention and 3.9 ± 0.9 in the control at > 1 year (P = 0.01). There were significant differences in Short Form-36 physical and mental component summary scores and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and stiffness scores at 6 months (P = 0.02, P = 0.02, P = 0.04, P = 0.04). The frequency of satisfaction and mean satisfaction score in the top 25 percentile CSI group were 15/16 (93.8%) and 4.6 ± 0.6 in those who received intervention and 12/19 (63.2%) and 3.8 ± 0.8 in those who did not (P = 0.01, P = 0.01). CONCLUSIONS: Thorough preoperative education on realistic expectations following TKA showed effects on WOMAC pain and satisfaction at > 1 year after surgery. It was more prominent in the group with a higher CSI score at > 1-year follow-up. LEVEL OF EVIDENCE: Level I.

Graft impingement increases anterior cruciate ligament graft signal more than acute graft bending angle: magnetic resonance imaging-based study in outside-in anterior cruciate ligament reconstruction.

PURPOSE: In this study, the relationship between patient-specific geometric factors and tunnel placement in graft impingement was identified by using magnetic resonance imaging (MRI) signal intensity of anterior cruciate ligament (ACL) grafts. METHODS: Ninety-two patients, who were treated between 2014 and 2020, were included retrospectively. These patients underwent primary remnant-preserving outside-in ACL reconstruction (ACLR) and were followed up with postoperative MRI at least one year after surgery. Plain radiographs and computed tomography (CT) were used to analyze tibial and femoral tunnel positions. Postoperative MRI was performed, at 32.8 ± 17.5 months after surgery, to evaluate the graft signal intensity, the ACL/posterior cruciate ligament (PCL) ratio (APR), ACL/muscle ratio (AMR), tunnel positions, and graft impingement. Clinical and stability outcomes were analyzed using the International Knee Documentation Committee (IKDC) subjective and objective scores, Lysholm scores, and side-to-side differences (SS-D). RESULTS: The mean APR and AMR of the proximal third of the grafts were significantly lower than those of the middle third of the grafts (p = 0.017 and p = 0.045, respectively). Multivariate regression analysis showed that there was a negative association between the mean APR and AMR of entire intra-articular ACL graft and the distance from the anterior end of the intercondylar roof to the center of the tibial tunnel in the sagittal plane (p < 0.001 and p < 0.001, respectively) and the notch width index (p < 0.001 and p = 0.002, respectively). No significant correlations were found between tunneling and geometric factors, and clinical scores or SS-D. CONCLUSIONS: Graft impingement on the anterior tibial tunnel relative to the end of the intercondylar roof and narrow notch was a more significant contributing factor on increased signal intensities of the ACL graft, compared with the acute femoral bending angle in remnant-preserving outside-in ACLR. Therefore, surgeons should focus on intercondylar notch anatomy during tibial tunnel placement to avoid roof impingement. LEVEL OF EVIDENCE: Level III.

Mobility and Hip Function Among Geriatric Patients With Displaced Neck of Femur Fractures Treated With Arthroplasty.

Background: Neck of femur fractures result in impaired function for older people. Despite surgery, many patients experience a decrease in functional level and poorer health status after the injury. The objectives of this study were (1) to determine the short-term mobility and hip function of geriatric patients who underwent hip replacement surgery for a displaced neck of femur fracture in our local population and (2) to identify factors which affect the functional outcome of these patients. Methods: Patients aged 60 years and above, who were admitted for neck of femur fracture from January 2017 to December 2020, and treated surgically with arthroplasty, were included. Information on patient demography, comorbidities, perioperative data, mobility, hip function and complications were retrospectively collected. Outcome measures used were independent ambulation and recovery of pre-fracture mobility at 1 year after surgery while hip function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total, pain, stiffness, and physical function scores. Factors associated with these outcomes were analyzed. Results: 168 patients with a mean age of 75.2 (SD 8.4) years met the inclusion criteria. 32.1% of patients regained their pre-fracture mobility and 59.6% remained independent 1 year after surgery. Logistic regression analysis identified age, gender, surgical procedure, and time to surgery as significant contributors to recovery of pre-fracture mobility. Older age and increasing requirement for postoperative ambulatory aid resulted in worse WOMAC total and physical function scores. No significant differences were observed in patient-reported hip function between those who had a total hip arthroplasty and those who had a hemiarthroplasty. Conclusion: Most geriatric patients with displaced neck of femur fractures did not regain pre-fracture mobility despite surgical treatment with arthroplasty.

Key-Point Detection Algorithm of Deep Learning Can Predict Lower Limb Alignment with Simple Knee Radiographs.

(1) Background: There have been many attempts to predict the weight-bearing line (WBL) ratio using simple knee radiographs. Using a convolutional neural network (CNN), we focused on predicting the WBL ratio quantitatively. (2) Methods: From March 2003 to December 2021, 2410 patients with 4790 knee AP radiographs were randomly selected using stratified random sampling. Our dataset was cropped by four points annotated by a specialist with a 10-pixel margin. The model predicted our interest points, which were both plateau points, i.e., starting WBL point and exit WBL point. The resulting value of the model was analyzed in two ways: pixel units and WBL error values. (3) Results: The mean accuracy (MA) was increased from around 0.5 using a 2-pixel unit to around 0.8 using 6 pixels in both the validation and the test sets. When the tibial plateau length was taken as 100%, the MA was increased from approximately 0.1, using 1%, to approximately 0.5, using 5% in both the validation and the test sets. (4) Conclusions: The DL-based key-point detection algorithm for predicting lower limb alignment through labeling using simple knee AP radiographs demonstrated comparable accuracy to that of the direct measurement using whole leg radiographs. Using this algorithm, the WBL ratio prediction with simple knee AP radiographs could be useful to diagnose lower limb alignment in osteoarthritis patients in primary care.

The Relationship of Transepicondylar Width with the Distal and Posterior Femoral Condyles and Its Clinical Implications: A Three-Dimensional Study.

BACKGROUND: Restoration of the anatomical joint line, while important for clinical outcomes, is difficult to achieve in revision total knee arthroplasty (rTKA) due to distal femoral bone loss. The objective of this study was to determine a reliable method of restoring the anatomical joint line and posterior condylar offset in the setting of rTKA based on three-dimensional (3D) reconstruction of computed tomography (CT) images of the distal femur. METHODS: CT scans of 50 lower limbs were analyzed. Key anatomical landmarks such as the medial epicondyle (ME), lateral epicondyle, and transepicondylar width (TEW) were determined on 3D models constructed from the CT images. Best-fit planes placed on the most distal and posterior loci of points on the femoral condyles were used to define the distal and posterior joint lines, respectively. Statistical analysis was performed to determine the relationships between the anatomical landmarks and the distal and posterior joint lines. RESULTS: There was a strong correlation between the distance from the ME to the distal joint line of the medial condyle (MEDC) and the distance from the ME to the posterior joint line of the medial condyle (MEPC) (p < 0.001; r = 0.865). The mean ratio of MEPC to MEDC was 1.06 (standard deviation [SD]: 0.07; range: 0.88-1.27) and that of MEPC to TEW was 0.33 (SD: 0.03; range: 0.25-0.38). CONCLUSIONS: Our findings suggest that the fixed ratios of MEPC to TEW (0.33) and that of MEPC to MEDC (1.06) provide a reliable means for the surgeon to determine the anatomical joint line when used in combination.

COVID-19 Collateral Damage: Management of Periprosthetic Joint Infection in Malaysia.

Background and objective Periprosthetic joint infection (PJI) is one of the dreaded complications in patients after arthroplasty surgeries, owing to the risk of morbidity and arduous investigations and management associated with it. Nevertheless, as Malaysia is currently battling against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) pandemic head-on, the treatment for other non-life-threatening diseases including PJI has taken a backseat. In this study, we present a case series of 11 patients with PJI who were managed surgically at the largest tertiary hospital in Malaysia and we hope to shed some light on the difficulties we have encountered during this trying period. Patients and methods Patients with PJIs who underwent surgical intervention during the ongoing COVID-19 pandemic (March 1, 2020, to June 30, 2021) were reviewed and included in this study. The demographic profile of the patients, presenting complaints, prosthesis topography, biochemical investigative findings, surgical interventions, and short-term outcomes were summarized. Results A total of 11 patients were treated surgically at Hospital Kuala Lumpur for PJI. Among them, five patients are still awaiting their second-stage surgeries despite the completion of their antibiotic regimes, and they are fit for the procedure. Conclusion The COVID-19 pandemic has wreaked havoc on the treatment of patients with PJI. In a setting with scarce resources, surgeons should strongly consider single-stage revision surgeries for the treatment of patients with PJI.

Tibia vara in Asians: Myth or fact? Verification with three-dimensional computed tomography.

BACKGROUND: There is a common perception among surgeons that Asian tibiae are significantly more varus compared to non-Asians, contributed both by an acute medial tibial proximal angle (MPTA) and diaphyseal bowing. Insight into the normative morphology of the tibia allows generation of knowledge towards disease processes and subsequently planning for corrective surgeries. METHODS: Computed tomography (CT) scans of 100 normal adult knees, aged 18 years and above, were analysed using a 3-dimensional (3D) analysis software. All tibiae were first aligned to a standard frame of reference and then rotationally aligned to the tibial centroid axis (TCAx) and the transmalleolar axis (tmAx). MPTA was measured from best-fit planes on the surface of the proximal tibia for each rotational alignment. Diaphyseal bowing was assessed by dividing the shaft to three equal portions and establishing the angle between the proximal and distal segments. RESULTS: The mean MPTA was 87.0° ± 2.2° (mean ± SD) when rotationally aligned to TCAx and 91.6° ± 2.7° when aligned to tmAx. The mean diaphyseal bowing was 0.1° ± 1.9° varus when rotationally aligned to TCAx and 0.3° ± 1.6° valgus when aligned to tmAx. The mean difference when the MPTA was measured with two different rotational alignments (TCAx and tmAx) was 4.6° ± 2.3°. No statistically significant differences were observed between males and females. Post hoc tests revealed statistically significant difference in MPTA between different ethnic sub-groups. CONCLUSION: The morphology of the proximal tibiae in the disease-free Asian knee is inherently varus but not more so than other reported populations. The varus profile is contributed by the MPTA, with negligible diaphyseal bowing. These implications are relevant to surgical planning and prosthesis design.

Distal Femoral Rotation Correlates With Proximal Tibial Joint Line Obliquity: A Consideration for Kinematic Total Knee Arthroplasty.

BACKGROUND: We hypothesized that there is a correlation between the distal femoral rotation and proximal tibial joint line obliquity in nonarthritic knees. This has significance for kinematic knee arthroplasty, in which the target knee alignment desired approximates the knee before disease. METHODS: Fifty computed tomography scans of nonarthritic knees were evaluated using three-dimensional image processing software. Four distal femoral rotational axes were determined in the axial plane: the transepicondylar axis (TEA), transcondylar axis (TCA), posterior condylar axis (PCA), and a line perpendicular to Whiteside's anterior-posterior axis. Then, angles were measured relative to the TEA. Tibial joint line obliquity was measured as the angle between the proximal tibial plane and a line perpendicular to the axis of the tibia. RESULTS: There was a strong positive correlation between PCA-TEA and tibial joint line obliquity (r = 0.68, P < .001) as well as TCA-TEA and tibial joint line obliquity (r = 0.69, P < .001). In addition, the tibial joint line obliquity and TCA-TEA angles were similar, 3.7° ± 2.2° (mean ± standard deviation) and 3.5° ± 1.7°, respectively (mean difference, 0.2° ± 0.2°; P = .369). CONCLUSION: Both PCA-TEA and TCA-TEA strongly correlated with proximal tibial joint line obliquity indicating a relationship between distal femoral rotational geometry and proximal tibial inclination. These findings could imply that the native knee in flexion attempts to balance the collateral ligaments toward a rectangular flexion space. A higher tibial varus inclination is matched with a more internally rotated distal femur relative to the TEA.