Similar complications and outcomes with simultaneous versus staged bilateral total hip arthroplasty with the direct anterior approach: A comparative study.

INTRODUCTION: Simultaneous bilateral total hip arthroplasty (THA) has demonstrated similar clinical outcomes to staged bilateral THA. However, there is scarce data regarding the early postoperative complications. This study compares simultaneous to staged bilateral THA with the direct anterior approach (DAA) regarding early complications and revision surgeries. METHODS: This retrospective case-control study included all bilateral THAs, performed by DAA between 2013 and 2021 with a minimum follow-up of 6 months. A total of 264 THAs (132 patients) were identified [simultaneous group (1T): 58 patients; staged group (2T): 74] with a mean follow-up of 54 months. Complications and revisions, clinical outcomes, and days off work were assessed at the last follow-up. Moreover, blood loss was evaluated by the modified method of Mercuriali and Inghilleri. RESULTS: Blood loss was higher in the 1T group (1003 mL 1T vs. 740 mL 2T; p < 0.001) but there was no significant difference in transfusion rates (5% 1T vs. 3% 2T; p = 0.4). There were no complications in 1T, while the complication rate was 5.2% (n = 6) in 2T (p = 0.012). There were 5 revisions in the 2T group, including 2 debridements with polyethylene exchange and implant retention for early infections, 2 revisions for aseptic loosening in the same patient, and 1 revision due to fracture. Postoperative pain on D3 was equivalent in both groups (4.2 1T vs. 4.3 2T; p = 0.79). The improvement in function according to the HHS at 2 months was better in the 1T group, but not significant (36.8 1T vs. 32.9 2T; p = 0.05). The total number of days off work was significantly higher in the 2T group (82.6 days vs. 178.8; p = 0.025). DISCUSSION: Simultaneous bilateral THA with the DAA seems to be a safe procedure, with no risk of increased early postoperative complications when compared to the staged procedure with similar functional outcomes and significantly fewer complications and days off work.

Ten-year minimal follow-up of lateral opening wedge distal femoral osteotomy for lateral femorotibial osteoarthritis: Good survivorship and high patient satisfaction.

PURPOSE: This study aimed (1) to determine complications and survival rates of lateral opening wedge distal femoral osteotomy (LOW-DFO) in the long term, (2) to assess their clinical outcomes in the long term and (3) to identify risk factors of failure. METHODS: Between 1991 and 2011, 62 LOW-DFOs were performed in the same department. Inclusion criteria were all isolated LOW-DFO performed for isolated lateral tibiofemoral osteoarthritis and valgus malalignment, with a minimum 10-year follow-up. Thirty-eight patients were included, with a mean age of 48 ± 9 years. All patients had clinical and radiological assessments. The survival curves were calculated based on the following endpoints: unicompartmental or total knee arthroplasty. RESULTS: The mean follow-up was 15.2 ± 4.4 [10-29] years. The mean preoperative mechanical FemoroTibial Axis (mFTA) was 188.8° ± 3.2° [184°-197°], primarily due to femur deformity (mean lateral distal femoral axis [LDFA] 83.2° ± 2.8°). Bone union was achieved in 89.5% of patients (n = 34) at a mean delay of 6.5 ± 6.7 months. The complication rate was 26% (five stiffness, one nonunion, three secondary displacements and one deep vein thrombosis). Nine revision surgeries (24%) were recorded. Survival rates at 5 and 10 years were 92.1% and 78.9%, respectively. The mean delay between DFO and total knee arthroplasty (TKA) was 11.6 ± 5.7 [1-27] years. Nineteen patients (50%) were free of TKA at the last follow-up. KSS scores were improved significantly. Return to sports was obtained in 92% of cases (n = 35), with a mean delay of 11 ± 8 months. Seventy-four per cent of patients were satisfied or very satisfied with the surgery. Eighty-four per cent would be willing to undergo the surgery again. Older age (p = 0.032) was a significant risk factor for TKA conversion. CONCLUSION: LOW-DFO is an efficient procedure to manage lateral knee osteoarthritis in young patients with valgus deformity, with a good survival rate at 10 years and high patient satisfaction. LEVEL OF EVIDENCE: Level III.

Patella is rarely resurfaced during primary total knee arthroplasty in clinical trials conducted in Greece: a systematic review.

PURPOSE: The aim of the present study was to report the approach of Greek surgeons regarding patellar management and provide the outcomes and the rate of the need for secondary patella resurfacing. METHODS: Following the PRISMA guidelines, PubMed, Scopus, and The Cochrane Central Register of Controlled Trials (CENTRAL) databases were accessed in January 2024. Clinical studies evaluating the outcomes of patients undergoing primary TKA were considered eligible for this systematic review if the following predefined criteria were fulfilled: (1) published in English, (2) were conducted in Greece, and had a minimum of 2-year follow-up. The methodological quality and publication bias were assessed using the Modified Coleman Methodology Score (mCMS) and ROBIS tool, respectively. Data was presented in tables using absolute values from individual studies. Pooled data were presented as means, ranges, and percentages. RESULTS: Six clinical studies with a total of 1084 TKAs were included. Four studies were retrospectives, and two studies were prospective. Patella was only resurfaced in 0.6% of total TKAs. TKA without patellar resurfaced, which resulted in an improvement in functional outcome. Among studies, the overall need for revision incidence was 7.6% (68 out of 892 TKAs). Additionally, Aseptic loosening (2.4%) was the most common reason for revision due to patellofemoral joint complications, followed by secondary patellar resurfacing (2.1%) and deep infection (1.3%). The mean mCMS demonstrated a fair methodological quality level, and the ROBIS toll a low risk of bias in all four domains. CONCLUSION: The available evidence supports that Greek surgeons mainly do not resurface the patella. However, patellar non-resurfacing yields good functional outcomes and presents relatively low revision rates for secondary patellar resurfacing. LEVEL OF EVIDENCE: IV.

Valgus stress knee radiographs accurately anticipate the bone resection in medial unicompartmental knee arthroplasty: Protocol validation using an image-based robotic system.

PURPOSE: The objective of this study was to describe a planning method for medial unicompartmental knee arthroplasty (UKA) implantation using preoperative stress radiographs to measure the thickness of tibial and femoral bone resections and to validate this method with data from an image-based robotic surgery system. Having such method for preoperative planning would be of interest for surgeons performing UKA in order to anticipate optimal bone resection on both tibia and femoral sides. METHODS: A new planning method for medial UKA based on valgus stress knee radiographs validated it with an image-based robotic surgery system (Restoris MCK, MAKO®, Stryker Corporation) was proposed. This retrospective study involved radiographic measurements of 76 patients who underwent image-based robotic medial UKA between April 2022 and February 2023. Preoperative anteroposterior stress radiographs of the knee were used to simulate UKA implantation. The UKA technique was based on Cartier's angle and aimed at restoring the joint line. The total dimension measured was 14 mm (8 mm for minimal tibial component and polyethylene insert + 4 mm for femoral component + 2 mm for safety laxity). Bone resections were measured in the preoperative valgus stress radiographs and then against the intraoperative bone resection data provided by the robotic system. Inter- and intra-observer reliability was assessed using 25 measurements. RESULTS: The mean planned tibial resection measured in the radiographs was 4.3 ± 0.4 [2.9-5.8], while the mean robotic resection was 4.2 ± 0.5 [2.7-5.8] (mean difference = 0.15 mm, 95% confidence interval [CI] [-0.27 to 0.57]). There was a strong correlation between these two values (Pearson's rank R = 0.79, p < 0.001). Intra- and inter-observer reliability were also very strong (Pearson's rank R = 0.91, p < 0.001, and Pearson's rank R = 0.82, p < 0.001, respectively). The mean planned femoral bone resection measured in the radiographs was 2.7 ± 0.7 mm [1-4.5], while the mean robotic resection was 2.5 ± 0.9 [1-5] (mean difference = 0.21 mm, 95% CI [-0.66 to 1.08]). There was a strong correlation between these two values (Pearson's rank R = 0.82, p < 0.001). Intra- and inter-observer reliability were also strong (Pearson's rank R = 0.88, p < 0.001, and Pearson's rank R = 0.84, p < 0.001, respectively). CONCLUSION: This study describes and validates with robotic information a simple and reproducible preoperative planning method to determine femoral and tibial bone resection for medial UKA implantation using antero-posterior valgus stress knee radiographs, leaving a medial safety laxity of 2 mm. It represents a very valuable contribution to the understanding of UKA principles, which can serve to extend its indications and increase reproducibility of the surgical technique. LEVEL OF EVIDENCE: III. Retrospective cohort study.

Hip and knee arthroplasty in one surgical session: early morbi-mortality study.

INTRODUCTION: Bilateral prosthetic hip or knee replacement in one surgical session is a procedure that has been widely validated in the literature, whereas hip and knee replacement in one surgical session remains poorly documented. This study reports on the results of these procedures by analyzing early post-operative complications in a retrospective multicenter study. MATERIAL AND METHODS: Between 2009 and 2023, 51 patients underwent hip and knee replacement surgery in a single surgical session at 4 French centers. They were 24 men and 27 women, with a mean age of 68.8 years (36-87); 7 patients were ASA 1, 30 were ASA 2 and 14 ASA 3. Prosthetic hip replacement was always performed first, associated 33 times with the ipsi-lateral knee and 18 times with the contralateral knee. All early complications, within the first 90 days post-operatively, were recorded: death, phlebitis, pulmonary embolism, myocardial infarction, surgical site infection (SSI), knee stiffness treated by mobilization under general anesthesia, urinary tract infection, acute urine retention or any other adverse event related to care. Transfusion rates were also reported. RESULTS: The rate of early complications was 9.8% (5/51). No deaths, no phlebitis, no pulmonary embolism and no SSI were observed. Complications included one myocardial infarction, one urinary tract infection, one superficial infection, one haematoma treated by surgical evacuation and one recurrent instability requiring revision surgery (hip arthroplasty). The transfusion rate was 17.6% (9/51). The complication rate of ASA 3 patients was higher than that of ASA 1 and 2 patients, while there was no difference related to age or BMI. DISCUSSION: Our results confirm the feasibility of single-stage hip and knee replacement, with a low complication rate in ASA 1 and 2 patients. This study adds to the few published works on the subject and reports comparable results. The small sample size and the heterogeneity of patients and centers limit the scope of the results, these limitations being relative to the volume expected for a rare procedure. CONCLUSION: Single-session hip and knee arthroplasty should be reserved for patients selected according to comorbidities: ASA score, age and body mass index. ASA 3 patients have a higher risk of complications. LEVEL OF EVIDENCE: IV; retrospective.

Restoration of the anterior compartment after robotic total knee arthroplasty significantly improves functional outcome and range of motion at 1 year.

PURPOSE: This study aims to assess the functional outcomes based on restoring the anterior compartment after total knee arthroplasty (TKA). METHODS: This retrospective study included 96 primary TKAs performed between 2021 and 2022. Functional positioning principles were applied using an image-based robotic-assisted system. The mean age was 69.2 ± 7.9 years. Knee Society Score (KSS), Kujala score, Forgotten Joint Score (FJS) and knee flexion were collected preoperatively and at 1 year. The depth difference between native and prosthetic trochlea was measured to assess anterior compartment restoration at full extension, 30°, 70° and 90° flexion. The global anterior compartment restoration combined the anterior compartment restoration and the patellar thickness restoration. RESULTS: The trochlear offset was mostly understuffed after TKA compared to the native anatomy, mainly for medial and lateral condyles at 30° and 70° of flexion. The global anterior compartment restoration was understuffed in full extension (-0.7 mm ± 2), at 30° (-4.4 mm ± 2) and 70° of flexion (-3.6 mm ± 2.5). At 90°, the global anterior compartment restoration was overstuffed (2.2 mm ± 1.8). Functional scores were not significantly influenced by the anterior compartment stuffing at 0° and 30° (n.s.). The anterior compartment overstuffing at 70° and 90° was associated with decreased KSS function score (p = 0.009) and flexion (p = 0.04). CONCLUSION: Moderate anterior understuffing was frequently observed after TKA performed with functional positioning and an image-based robotic-assisted system. This understuffing did not influence the functional outcomes. The overstuffing of the anterior compartment led to a reduction in KSS function score and flexion measurements at 1 year. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Robotic assessment of patella tracking in total knee arthroplasty.

OBJECTIVES: Robotic tools have been developed to improve planning, accuracy and outcomes in total knee arthroplasty (TKA). The purpose of this study was to describe and illustrate a novel technique for assessing the patellofemoral (PFJ) in TKA using an imageless robotic platform. METHODS: A consecutive series of 30 R-TKA was undertaken by a single surgeon utilising the described technique. A technique to dynamically assess the PFJ intra-operatively, pre- and post-implantation was developed. A full set of data from 9 cases was then collected and reviewed for analysis. A series of dynamic PFJ tracks collected intra-operatively pre- and post-implantation are presented. Furthermore, a full assessment of PFJ over and under-stuffing through a 90° arc of flexion is illustrated. Finally, a pre- and post-centre of rotation for the PFJ was defined and measured. RESULTS: The described technique was defined over a series of 30 R-TKA using the described robotic platform. Nine cases were analysed to determine what data could be measured using the robotic platform. Intra-operative real-time data allowed a visual assessment of PFJ tracking through a range of motion of 0°-90° flexion pre- and post-implantation. PFJ over and under-stuffing was also assessed intra-operatively through a range of motion of 0°-90° flexion. Post-operative analysis allowed a more detailed study to be performed, including defining a pre- and post-implantation centre of rotation (COR) for the patella. Defining the COR allowed the definition of a patella plane. Furthermore, patella mediolateral shift in full extension, and end flexion could be measured. CONCLUSION: Intra-operative assessment of the PFJ in TKA is challenging. Robotic tools have been developed to improve measurement, accuracy of delivery and outcomes in TKA. These tools can be adapted in novel ways to assess the PFJ, which may lead to further refinements in TKA techniques.

Physiopathology of patello-femoral osteoarthritis: current concepts.

Patellofemoral osteoarthritis (PFOA) is the result of degeneration and loss of articular cartilage of the patella and trochlea, and is a common cause of anterior knee pain. PFOA is triggered by insufficient adaptation to overload of the articular cartilage of the PF joint created by abnormal biomechanics. It is important to understand the pathophysiology and natural history to make the diagnosis and to plan treatment. Innate factors including malalignment, patellar instability, kinematic disorders, and acquired factors like trauma, obesity, and endocrine diseases have been found to be causes of PFOA. Genetic predisposition is also described as a contributing cause but without much scientific evidence. The diagnosis will be based on clinical manifestations, such as anterior knee pain aggravated by overloading activities, identification of risk factors, and exclusion of referred pain from other pathologies, followed by a systematic and structured physical examination. Imaging will be useful for assessing the presence of early osteoarthritis in the other compartments, for classification of the PFOA, and to identify features to establish an adequate treatment. This paper discusses varying management options for different causes of patellofemoral disease and explains the complexity of the PF joint and its often poorly understood biomechanics.

Nonanatomical femoral tunnel positioning in isolated MPFL reconstruction is not associated with an increased risk of patellofemoral osteoarthritis after a minimum follow-up of 10 years.

PURPOSE: The association between the prevalence of patellofemoral arthritis (PFA) and femoral tunnel positioning following isolated medial patellofemoral ligament reconstruction (MPFLr) has not been well described. The aim of this study was to analyse the relationship between femoral tunnel positioning and the prevalence of PFA. METHODS: This was a single-centre study of patients undergoing an isolated MPFLr between 2006 and 2011 with a minimum of 10 years of follow-up. Outcomes assessed were the presence of PFA on radiographs, recurrence of instability requiring revision surgery and patient-reported outcomes, including Kujala, Tegner and IKDC scores. Tunnel positioning was assessed on postoperative radiographs using two radiographic methods: Schöttle's point and the grid method to localise the femoral tunnel. Patients were grouped based on tunnel positioning and compared. RESULTS: Fifty patients were analysed at a mean follow-up of 12.4 years. Thirty-three patients (66%) had a femoral tunnel position within 7 mm of Schöttle's point and 39 (78%) within the anatomic quadrant, with the most common location according to the grid method in D4 (28%) and E4 (26%), respectively. Thirty-seven patients (74%) had a satisfactory (>80 versus <80) Kujala score at long-term follow-up. None of the examined tunnel assessment methods demonstrated a significant relationship with Tegner, Kujala or International Knee Documentation Committee scores. Patients with a femoral tunnel position >7 mm outside Schöttle's point or were considered to be in a nonanatomic position were not significantly more likely to result in unsatisfactory Kujala scores at the last follow-up. Tunnel positioning and the other tested parameters were not found to be significantly associated with the development of PFA. CONCLUSION: No correlation between femoral tunnel position and risk of PFA or poor outcomes was observed in patients undergoing isolated MPFLr at long-term follow-up. The impact of femoral tunnel placement on long-term outcomes in patients with PFI may be less significant than originally considered. LEVEL OF EVIDENCE: Level IV.

Enhancing soft tissue balance: Evaluating robotic-assisted functional positioning in varus knees across flexion and extension with quantitative sensor-guided technology.

PURPOSE: Functional implant positioning (FIP) for total knee arthroplasty (TKA) is an evolution of kinematic alignment based on preoperative CT scan and robotic-assisted technology. This study aimed to assess the ligament balancing of image-based robotic-assisted TKA in extension, mid-flexion and flexion with an FIP using intraoperative sensor-guided technology. The hypothesis was that image-based robotic-assisted TKA performed by FIP would achieve ligament balancing all along the arc of knee flexion. METHODS: This prospective monocentric study included 47 consecutive patients with varus knees undergoing image-based robotic-assisted TKA performed with FIP. After robotic-assisted bone cuts, trial components were inserted, and soft tissue balance was assessed using sensor-guided technology at 10°, 45° and 90° of knee flexion. A mediolateral balanced knee was defined by an intercompartmental pressure difference (ICPD) ≤ 15 lbf and medial and lateral compartment pressure ≤60 lbf. The mean age was 71.6 years old ±6.7, the mean BMI was 29.0 kg/m2 ± 4.9 and the mean preoperative HKA was 174° ± 5 [159; 183]. RESULTS: The mean postoperative knee alignment was 177.0° ± 2.2° [172; 181]. There were 93.6% of balanced knees (n = 44) at 10 and 90° of knee flexion versus 76.6% (n = 36) at 45° of knee flexion with a significant difference (p = 0.014). Median ICPD at 10, 45 and 90° of knee flexion were, respectively, 7.0 (interquartile range [IQR]: 9), 11.0 (IQR: 9.5) and 8.0 (IQR: 9.0). Pairwise analyses revealed differences for ICPD at 45° versus ICPD at 10° (p = 0.003) and ICPD at 90° versus ICPD at 45° (p = 0.007). CONCLUSION: FIP with an image-based robotic-assisted system allowed the restoration of a well-balanced knee at 10° and 90° of flexion in varus knees. Nevertheless, some discrepancies occurred in midflexion, and more work is needed to understand ligament behaviour all along the arc of knee flexion. LEVEL OF EVIDENCE: Level II.

Enhancing robotic precision in medial UKA: Image-based robot-assisted system had higher accuracy in implant positioning than imageless robot-assisted system across 292 knees.

PURPOSE: The objective of this study was to compare the degree of accuracy in implant positioning and limb alignment offered by two robot-assisted (RA) systems: an image-based robot-assisted (IBRA) versus an imageless robot-assisted (ILRA) system for the treatment of medial knee osteoarthritis with unicompartmental knee arthroplasty (UKA). METHODS: This retrospective radiographic study included medial UKAs performed between 2011 and 2023. Radiographic measurements taken preoperatively and at 1-year postoperative control visit focusing on hip-knee-ankle angle (HKA), posterior tibial slope (PTS), tibial component coronal alignment relative to Cartier's angle and restoration of proper joint line (JL) height were analyzed. Outliers for postoperative measurements were defined as follows: HKA <175° or >180°, PTS <2° or >8°, >3° or <-3° alterations in Cartier's angle and ±2 mm changes in the height of the joint line. RESULTS: The final sample consisted of 292 medial UKAs: 95 (32.5%) with an IBRA system and 197 (67.5%) with an ILRA system. Implant positioning and limb alignment were more accurate in the group of patients treated with IBRA, HKA (77.9% vs. 67.5%, p = 0.07), PTS (93.7% vs. 82.7%, p = 0.01), restoration of tibial varus relative to Cartier's angle (87.4% vs. 65%, p < 0.001) and restoration of JL height (81.1% vs. 69.5%, p = 0.04). CONCLUSION: Medial UKA surgery using an IBRA system was associated with a higher degree of accuracy in implant positioning and postoperative limb alignment as compared to an ILRA system. This is a valuable contribution to help communicate the advantages of using this surgical technique and improve its reproducibility. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Long-term functional success and robust implant survival in lateral unicompartmental knee arthroplasty: A case series with a mean follow-up of twenty two and a half years.

PURPOSE: Lateral unicompartmental knee arthroplasty (UKA) is an accepted treatment option in cases of end-stage lateral osteoarthritis. While lateral UKA has many proposed advantages compared to total knee arthroplasty, its technical challenges and relatively small number of cases make this an uncommon procedure. The aim of this study was to report the survivorship and functional outcomes beyond 20 years of follow-up of isolated UKA. METHODS: Between January 1988 and October 2003, 54 lateral UKAs were performed in a single center. The fitted prosthesis was a fixed plate and cemented polyethylene (PE). All patients had isolated lateral tibiofemoral osteoarthritis, including five open meniscectomies, three arthroscopies, and three open reductions of lateral tibial plateau fractures. Patients with a minimum of 20 years of follow-up were included in the final analysis. RESULTS: Of the 54 UKA, 22 died before reaching the minimum follow-up period and four were lost to follow-up. Twenty-eight were included in the final analysis. Among them, 21 patients remained alive and an additional seven were deceased after 20 years. The mean age at the last follow-up was 84.8 ± 11.9 years with a mean follow-up duration of 22.5 ± 2.1 years. Of the 28 knees, eight underwent revision surgery (5 for the progression of osteoarthritis; 2 for aseptic loosening; 1 for PE wear). Kaplan-Meier survival analysis revealed a survival rate at 20 and 25 years of 72.3% (CI 59.1; 88.6). The average time to revision was 14.9 ± 4.9 years. At the last follow-up, the mean function Knee Society Score (KSS) was 41.5 ± 32.9 and the mean objective KSS score was 79.4 ± 9.7. In the unrevised population, 94.7% of patients (n = 18) reported being satisfied or very satisfied with the surgery. CONCLUSION: Lateral UKA remains a viable treatment option for patients with isolated lateral tibiofemoral osteoarthritis, providing satisfactory 20-year implant survivorship and high patient satisfaction.

Surgical factors play a critical role in predicting functional outcomes using machine learning in robotic-assisted total knee arthroplasty.

PURPOSE: Predictive models help determine predictive factors necessary to improve functional outcomes after total knee arthroplasty (TKA). However, no study has assessed predictive models for functional outcomes after TKA based on the new concepts of personalised surgery and new technologies. This study aimed to develop and evaluate predictive modelling approaches to predict the achievement of minimal clinically important difference (MCID) in patient-reported outcome measures (PROMs) 1 year after TKA. METHODS: Four hundred thirty robotic-assisted TKAs were analysed in this retrospective study. The mean age was 67.9 ± 7.9 years; the mean body mass index (BMI) was 32.0 ± 6.8 kg/m2. The following PROMs were collected preoperatively and 1-year postoperatively: knee injury and osteoarthritis outcome score for joint replacement, Western Ontario and McMaster Universities osteoarthritis index (WOMAC) Function, WOMAC Pain. Demographic data, preoperative CT scan, implant size, implant position on the robotic system and characteristics of the joint replacement procedure were selected as predictive variables. Four machine learning algorithms were trained to predict the MCID status at 1-year post-TKA for each PROM survey. 'No MCID' was chosen as the target. Models were evaluated by class discrimination (F1-score) and area under the receiver operating characteristic curve (ROC-AUC). RESULTS: The best-performing model was ridge logistic regression for WOMAC Function (area under the curve [AUC] = 0.80, F1 = 0.48, sensitivity = 0.79, specificity = 0.62). Variables most strongly contributing to not achieving MCID status were preoperative PROMs, high BMI and femoral resection depth (posterior and distal), supporting functional positioning principles. Conversely, variables contributing to a positive outcome (achieving MCID) were medial/lateral alignment of the tibial component, whether the procedure was an outpatient surgery and whether the patient received managed Medicare insurance. CONCLUSION: The most predictive variables included preoperative PROMs, BMI and surgical planning. The surgical predictive variables were valgus femoral alignment and femoral rotation, reflecting the benefits of personalised surgery. Including surgical variables in predictive models for functional outcomes after TKA should guide clinical and surgical decision-making for every patient. LEVEL OF EVIDENCE: Level III.

Optimized decision algorithm for the microbiological diagnosis of osteoarticular infections in adults using synovial fluid samples: a prospective study in two French hospitals including 423 samples of synovial fluid.

No consensus exists about the techniques to use for microbiological diagnosis of bone and joint infections (BJIs). The objective herein was to define an algorithm to optimize BJI diagnosis in adults using various bacteriological methods on synovial fluid samples. This prospective multi-center study included 423 synovial fluids collected from adult patients with suspected BJIs. Culture (using five solid media, an enrichment broth, and blood culture bottles), universal 16S rRNA PCR followed by Sanger sequencing, and seven specific bacterial PCRs were systematically performed. Combinations of methods were compared to arrive at the optimized algorithm. Among 423 synovial fluids, 242 infections were diagnosed (57.2 %): 213 mono- and 29 poly-microbial for a total of 284 bacteria (staphylococci at 54.6 %, streptococci-enterococci at 16.5 %, Gram-negative bacilli at 15.5 %, anaerobic species at 8.8 %). Comparing culture techniques, blood culture bottles had the highest sensitivity (67.6 % for pediatric and 63.9 % for anaerobic bottles) but are not sufficient alone and require being combined with solid media. The 16S rDNA PCR detected only 52.3 % of the bacteria, whereas specific PCRs had a higher sensitivity (Staphylococcus spp. at 66.2 %, S. aureus at 85.2 %, Streptococcus spp. at 91.2 %). Based on these results, an algorithm was proposed associating three solid media; inoculation into blood culture bottles; and 16S, Staphylococcus spp., and Streptococcus spp. PCRs, which would have detected 90.5 % of bacteria in the present cohort versus 79.2 % using all culture techniques on synovial fluid. This prospective study shows that a combination of culture and molecular methods on synovial fluids allows the optimization of bacterial detection.

Gender does not influence outcomes and complications in medial unicompartmental knee arthroplasty.

PURPOSE: The impact of gender on the outcomes of unicompartmental knee arthroplasty (UKA) remains a topic of active discussion with limited exploration thus far. The study aims to elucidate the gender effect on clinical outcomes, complications, pre- and postoperative radiological outcomes following the implantation of a medial UKA at mid-term follow-up in a large section of patients. METHODS: This was a single-centre, retrospective cohort study encompassing patients undergoing medial UKA between 2011 and 2019. The International Knee Society (IKS) Knee and Function score, patient satisfaction, complications, revisions, pre- and postoperative radiological outcomes (coronal plane alignment, femoral and tibial component positioning, posterior tibial slope) were evaluated. Survival rate at the time of the last follow-up was also recorded. RESULTS: Of the 366 knees that met the inclusion criteria, 10 were lost to follow-up, accounting for a 2.7% loss. Mean follow-up was 5.2 ± 2 years [2.1-11.3]. Out of the total population, 205 patients were females (57.6%, 205/356) and 151 were males (42.4%, 151/356). Men exhibited superior pre- and postoperative IKS function scores (p = 0.017). However, no significant differences were observed between women and men regarding improvements of IKS Knee and Function scores, radiographic outcomes and implant survivorship. CONCLUSION: At a mean follow-up of 5 years, this study revealed no significant impact of gender on clinical outcomes and complications in patients undergoing medial UKA. Furthermore, no significant differences were evident in radiographic outcomes, implant positioning and knee phenotype. LEVEL OF EVIDENCE: Level III.

Role of the Gut Microbiota in Osteoarthritis, Rheumatoid Arthritis, and Spondylarthritis: An Update on the Gut-Joint Axis.

Dysregulation of the gut microbiota and their metabolites is involved in the pathogenic process of intestinal diseases, and several pieces of evidence within the current literature have also highlighted a possible connection between the gut microbiota and the unfolding of inflammatory pathologies of the joints. This dysregulation is defined as the "gut-joint axis" and is based on the joint-gut interaction. It is widely recognized that the microbiota of the gut produce a variety of compounds, including enzymes, short-chain fatty acids, and metabolites. As a consequence, these proinflammatory compounds that bacteria produce, such as that of lipopolysaccharide, move from the "leaky gut" to the bloodstream, thereby leading to systemic inflammation which then reaches the joints, with consequences such as osteoarthritis, rheumatoid arthritis, and spondylarthritis. In this state-of-the-art research, the authors describe the connections between gut dysbiosis and osteoarthritis, rheumatoid arthritis, and spondylarthritis. Moreover, the diagnostic tools, outcome measures, and treatment options are elucidated. There is accumulating proof suggesting that the microbiota of the gut play an important part not only in immune-mediated, metabolic, and neurological illnesses but also in inflammatory joints. According to the authors, future studies should concentrate on developing innovative microbiota-targeted treatments and their effects on joint pathology as well as on organizing screening protocols to predict the onset of inflammatory joint disease based on gut dysbiosis.

Management of fixed flexion contracture in primary total knee arthroplasty: recent systematic review.

INTRODUCTION: This study aimed to systematically review the literature and identify the surgical management strategy for fixed flexion contracture in primary total knee arthroplasty (TKA) surgery, pre-, intra-, and post-operatively. Secondary endpoints were etiologies and factors favoring flexion contracture. MATERIALS AND METHODS: Searches were carried out in November 2023 in several databases (Pubmed, Scopus, Cochrane, and Google Scholar) using the following keywords: "flexion contracture AND TKA", "fixed flexion deformity AND TKA", "posterior capsular release AND TKA", "posterior capsulotomy in TKA", "distal femoral resection AND TKA". Study quality was assessed using the STROBE checklist and the Downs and Black score. Data concerning factors or strategies leading to the development or prevention of flexion contracture after TKA were extracted from the text, figures, and tables of the included references. The effect of each predictive factor on flexion contracture after TKA was recorded. RESULTS: Thirty-one studies were identified to meet the inclusion and exclusion criteria. These studies described a variety of preoperative and intraoperative factors that contribute to the development or correction of postoperative flexion contracture. The only clearly identified predictor of postoperative flexion contracture was preoperative flexion contracture. Intraoperative steps described to correct flexion contracture were: soft-tissue balancing (in posterior and medial compartments), distal femoral resection, flexion of the femoral component, and posterior condylar resection. However, no study has investigated these factors in a global model. DISCUSSION: This review identified various pre-, intra-, and post-operative factors predictive of post-operative flexion contracture. In practice, these factors are likely to interact, and it is therefore crucial to further investigate them in a comprehensive model to develop an algorithm for the management of flexion contracture. LEVEL OF EVIDENCE: IV.