Robotic-assisted unicompartmental knee arthroplasty is associated with earlier discharge from physiotherapy and reduced length-of-stay compared to conventional navigated techniques.

INTRODUCTION: Computer-assisted surgery (CAS) has been used to improve intraoperative accuracy to restore patient's anatomy and joint kinematics. It is not yet known whether robotic systems provide significant benefits over established navigation techniques. MATERIALS AND METHODS: Thirty-one patients underwent robotic-assisted UKA (RA-UKA) over a 14-month period. Length of operation, transfusion requirements, time to discharge, range-of-motion and analgesia requirements were compared to a similar cohort of 31 patients who had received UKA using computer-assisted surgery (CAS-UKA). RESULTS: All patients in the RA-UKA and CAS-UKA groups underwent surgery without conversion to conventional techniques. Both cohorts were similar apart from mean BMI (RA-UKA-group 28.5 vs 32.2; p < 0.05). There was a higher percentage of females in the CAS-UKA group (68% vs 45%, p = 0.12). Minor complication rates were the same in both groups (4/31, 12.9%). Mean operating time was longer in the RA-UKA group (104.8 vs 85.6 min; p < 0.001). No patients required post-operative transfusion in either group and there was no significant difference in haemoglobin level drop or analgesia requirements at any time point. Patients in the RA-UKA group achieved straight leg raise without lag sooner (23 vs 37.5 h; p = 0.004) and demonstrated increased range-of-motion on discharge (81.4° vs 64.5°; p < 0.001). Patients in the RA-UKA group were discharged from physiotherapy services earlier than the CAS-UKA group (42.5 vs 49 h; p = 0.02) and discharged from hospital significantly sooner (46 vs 74 h; p = 0.005). CONCLUSIONS: RA-UKA is safe and reproducible, comparable to traditional navigation. Patients undergoing RA-UKA achieve straight leg raise and discharge from physiotherapy sooner than with navigation alone. LEVEL OF EVIDENCE: III (Therapeutic) Retrospective Cohort Study.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Predictors of extended length of stay after unicompartmental knee arthroplasty.

PURPOSE: To identify factors that independently predict extended length of stay after unicompartmental knee arthroplasty (UKA) surgery (defined as length of stay longer than 3 days), and to identify factors predicting early post-operative complications. METHODS: A retrospective analysis of all patients undergoing UKA from January 2016-January 2019 at our institution was performed. Clinical notes were reviewed to determine the following information: Patient age (years), gender, American Society of Anesthesiologists (ASA) grade, weight (kg), height (meters), body mass index (BMI), co-morbidities, indication for surgery, surgeon, surgical volume, surgical technique (navigated or patient-specific instrumentation), implant manufacturer, estimated blood loss (ml), application of tourniquet during the surgery, application of drain, hospital length of stay (days) and surgical complications. RESULTS: Multivariate regression analysis showed that ASA 3-4 vs. ASA 1-2 [OR 4.4 (CI; 1.8-10.8, p = 0.001)] and a history of cardiovascular disease [OR 2.8 (CI; 1.4-5.5), p = 0.004)] were significant independent predictors of prolonged length of stay. Hosmer-Lemeshow goodness of fit of the model showed a p-value of 0.214. Nagelkerke R-Square was 0.2. For complications, multivariate regression analysis showed that ASA 3-4 vs. ASA 1-2 [OR 5.8 (CI; 1.7-20.7)] and high BMI (BMI >30) [OR 4.3 (CI; 1.1-17.1)] were significant independent predictors of complications. Hosmer-Lemeshow goodness of fit was 0.89 and Nagelkerke R-Square was 0.2. Patients treated with robotics (Navio) techniques had shorter length of stay median 51 h (IQR; 29-96) when compared to other techniques 72 h (IQR; 52-96), p = 0.008. CONCLUSION: Based on the results of our study, high ASA grade (≥3) appears to be the most important factor excluding eligibility for fast-track UKA. Any number of co-morbidities may increase ASA, but in and of themselves, apart from a history of cardiovascular disease, they should not be seen as contraindications. Appropriate patient selection, technical tools and details during the surgery could facilitate fast track surgery.

Achieving discharge within 24 h of robotic unicompartmental knee arthroplasty may be possible with appropriate patient selection and a multi-disciplinary team approach.

AIMS: There has been significant interest in day-case and rapid discharge pathways for unicompartmental knee replacements (UKR). Robotic-assisted surgery has the potential to improve surgical accuracy in UKR. However, to date there are no published studies reporting results of rapid-discharge pathways in patients receiving UKR using the NAVIO ◊ robotic system. METHODS: A retrospective analysis identified 19 patients who were safely discharged within 24 h following UKR using the NAVIO ◊ robotic system between June 2017 and October 2019. All patients went through a standardised UKR pathway protocol. Pre-operatively patients underwent education sessions and anaesthetic assessment, with selected patients undergoing occupational/physiotherapy assessment prior to surgery. All patients received a general anaesthetic with local anaesthetic infiltration prior to closure; nerve blocks were not used routinely. A multi-modal analgesic regime was utilised. Patients were discharged home once they were safe to mobilise on ward, had normal vital signs and pain was adequately controlled. Patients were discharged with outpatient physiotherapy referral and consultant follow up at 6 weeks. RESULTS: All patients were discharged within 24 h; there were no post-operative complications and no readmissions to hospital. The mean length of stay was 19.5 h (SD = 6.8), with patients seen twice on average by physiotherapy post-operatively. Active range of motion at 6 weeks was 105.8°, with all patients mobilising independently. The median 6-month post-operative Oxford Knee Score was 44 out of 48. CONCLUSION: This initial feasibility study suggests that patients may be safely discharged within 24 h of UKR using the NAVIO robotic system. Appropriate patient selection will ensure successful discharge. Further prospective studies are needed.

Should we routinely perform a post-operative hemoglobin check following unicompartmental knee arthroplasty?

OBJECTIVES: To study the significance of checking post-operative hemoglobin and hematocrit following unicompartmental knee arthroplasty (UKA). SETTING: Single center. Multiple surgeons. DESIGN: Retrospective case series. Level of evidence IV. MATERIALS AND METHODS: Following institutional approval, a retrospective analysis of all patients undergoing UKA at our level one academic university hospital was conducted. Operative records of all patients undergoing primary UKA were reviewed between March 2016 and March 2019. Patients' pre-operative hemoglobin and hematocrit, BMI, co-morbidities, application of tourniquet, tourniquet time, administration of tranexamic acid, need for post-operative blood transfusion, hospital length of stay, complications, and re-admission were all recorded. Blood loss was estimated using the post-operative hematocrit. RESULTS: A total number of 155 patients were included. There were 70 females (45%) and 85 males (55%). The mean age was 66 ±â€¯10 years. Median pre-op blood volume was 4700 mLs (interquartile range (IQR); 4200-5100). Median blood loss was 600 mLs (IQR; 400-830). Mean pre-op hemoglobin was 135 ±â€¯14 g/L and mean post-op hemoglobin was 122 ±â€¯13 g/L. No patient had a post-op hemoglobin under 80 g/L (range 93-154). No patients in our study needed transfusion. CONCLUSION: The results of our study indicated that post-operative hemoglobin and hematocrit check proved unnecessary in all of our patients and could have been omitted from post-operative routines. We conclude that routine post UKA check of hemoglobin and hematocrit can be avoided and be saved for special circumstances depending on patient's physiology.

Extracervical Approaches to Thyroid Surgery: Evolution and Review.

Over the last two decades, advances and adaptation of technology have led to a variety of endoscopic thyroidectomy procedures being performed. The drive for extracervical procedures has been predominantly influenced by the desire for improved cosmesis via avoidance of visible scars. Extracervical techniques have shown considerable evolution with approaches that have included transaxillary, breast, postauricular, and transoral routes. There has been a varied evidence base for each of these approaches with regard to technical feasibility, safety, patient satisfaction, and cost-effectiveness. In recent years, robotic-assisted thyroid surgery has gained increased popularity worldwide with the introduction of the da Vinci Robot. Reports of improved postoperative outcomes and patient satisfaction have been in contrast to the financial burden, longer operative time, and increased training required which, to date, have limited widespread application. The aim of this review is to describe the evolution of extracervical procedures including surgical approaches, outcomes, advantages, and disadvantages. Consideration is also given to the future direction of extracervical thyroid surgery with regard to the safety, feasibility, and application of robotic systems.