Influence of Preoperative Deformity on Flexion Gap Asymmetry in Measured Resection Technique: A Theoretical Study in Navigated Gap Balancing Total Knee Arthroplasties, Done for Varus Knee Osteoarthritis.

INTRODUCTION: Disagreement exists on (a) achieving a symmetrical flexion gap and (b) the influence of varus deformity on the flexion gap asymmetry (FGA) in measured resection (MR) total knee arthroplasty (TKA). We aimed to determine the FGA and influence of preoperative deformity on the FGA, based on the MR technique, in varus knee osteoarthritis. METHODS: In 321 navigated TKAs, we released the soft tissues in extension. In 90° flexion, with the tensioner in situ, we calculated the FGA, the angle between the posterior femoral cut (planned 3° external rotation to the posterior condylar line, parallel to the surgical transepicondylar axis, or perpendicular to the Whiteside line) and the proximal tibial resection plane. RESULTS: The FGA values varied widely, and the risk of >2° and >3° FGA was present in at least 60% and 40% knees, respectively. These risks were high in knees with moderate and severe varus deformity. CONCLUSIONS: In varus knee osteoarthritis, the risk of FGA (based on the MR technique) was high, especially when the deformity was moderate to severe. Caution is required in MR TKA, and surgeons must consider safer alternatives (gap balancing or hybrid technique) to achieve a symmetrical flexion gap in these knees.

Cruciate retaining total knee arthroplasty has a better 10 year survival than posterior stabilized total knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: There has been a long standing debate regarding superiority of cruciate retaining total knee arthroplasty over posterior stabilized total knee arthroplasty regarding the short-term outcomes as well as long-term survivorship. The proponents of both the techniques have published vast evidence in favor of their respective surgical method and early outcome in meta-analyses does not seem to be significantly different. The decision to select either design should depend on their long-term survivorship but the literature comparing their long-term survival is sparse.This meta-analysis was conducted in order to answer the following questions: (1) Does cruciate retaining total knee arthroplasty has a better long-term survival beyond 10 years.compared to posterior stabilized total knee arthroplasty? (2) Does cruciate retaining knee arthroplasty has higher complication rates compared to posterior stabilized total knee arthroplasty? METHODS: The present systematic review and meta-analysis study was carried out following PRISMA guidelines. The following databases: Embase, Web of Science, PubMed, Scopus, the Cochrane Library, Google Scholar, and CINAHL were used to search potentially interesting articles published from database inception until January 2022. Inclusion criteria for articles were: (1) retrospective comparative studies; (2) patients who had undergone a total knee arthroplasty; (3) publications evaluating the long-term survival of cruciate-retaining (CR) versus posterior stabilizing (PS) at a minimum 10 years' follow-up; (4) publications evaluating complications of cruciate-retaining (CR) versus posterior stabilizing (PS) at a minimum 10 years' follow-up; and (5) publications reporting sufficient data regarding the outcomes. We used a fixed-effects design in the case of I2 < 50% and P > 0.05; if not, we adopted a random-effects design [4]. We also performed subgroups and sensitivity analysis in order to assess the possible source of heterogeneity. RESULTS: Database searching identified 597 studies to be screened, of which 291 abstracts were revealed as potentially eligible and finally 7 articles were included. The forest plot showed that CR had significantly better survival than PS (OR = 2.17; 95% CI: 1.69-2.80) after 10 years. However, complication rate was not significantly different between CR and PS groups (OR = 0.86; 95% CI: 0.52-1.44; P = 0.57). Subgroup analysis showed that only the period of publication constituted a source of heterogeneity in survivorship outcome. Sensitivity analysis revealed that outcomes did not differ markedly, which indicates that the meta-analysis had strong reliability. CONCLUSION: The results of this meta-analysis showed that cruciate retaining prosthesis may be preferred over the posterior stabilized design in view of longer survivorship it offers However, further randomized controlled trials are recommended to confirm this finding.

Efficacy of telerehabilitation for spine pain during the Coronavirus pandemic lockdown: a retrospective propensity score-matched analysis.

PURPOSE: Despite increased usage of telemedicine to deliver treatment during the coronavirus disease 2019 (COVID-19) pandemic, the efficacy of telerehabilitation for spine pain is unknown. This study aimed to investigate the effect of telerehabilitation on pain and disability in patients with spine pain treated during the COVID-19 pandemic and compare the results to in-clinic rehabilitation. MATERIALS & METHODS: In this propensity score-matched analysis, 428 patients with spine pain who underwent telerehabilitation during the 6 months of COVID-19 pandemic lockdown and 428 patients who underwent in-clinic multimodal rehabilitation treatment during the 6-month period prior to lockdown were compared. Propensity score matching was done based on gender, age, pre-treatment pain, and disability. Post-treatment numerical pain rating scale (NPRS), Oswestry or Neck disability index (ODI or NDI), and minimal clinical important difference (MCID) achieved for NPRS and ODI/NDI scores were compared between the 2 groups. RESULTS: Post-treatment, the mean NPRS (mean difference - 1, p < 0.0001) and ODI/NDI (mean difference - 5.8, p < 0.0001) scores, were significantly lower in the telerehabilitation group when compared to control group. Similarly, the percentage of patients who achieved MCID of ≥ 2 for NPRS (mean difference - 6%, p = 0.0007) and MCID of ≥ 10 for ODI/NDI (mean difference - 7.5%, p = 0.005) scores were significantly higher in the telerehabilitation group. CONCLUSIONS: Telerehabilitation achieved significant reduction in pain and disability among patients with spine pain, better than in-clinic rehabilitation. These encouraging results during the COVID-19 pandemic indicate the need to further explore and test the efficacy and wider application of telerehabilitation for treating spine pain.IMPLICATIONS FOR REHABILITATIONTelerehabilitation can help achieve significant reduction in pain and disability among patients with spine pain.These encouraging results indicate the need to further explore a wider application of telerehabilitation for treating patients with spine pain during non-pandemic times.

Notching is less, if femoral component sagittal positioning is planned perpendicular to distal femur anterior cortex axis, in navigated TKA.

PURPOSE: In navigated TKA, the risk of notching is high if femoral component sagittal positioning is planned perpendicular to the sagittal mechanical axis of femur (SMX). We intended to determine if, by opting to place the femoral component perpendicular to distal femur anterior cortex axis (DCX), notching can be reduced in navigated TKA. METHODS: We studied 171 patients who underwent simultaneous bilateral computer-assisted TKA. Femoral component sagittal positioning was planned perpendicular to SMX in one knee (Femur Anterior Bowing Registration Disabled, i.e. FBRD group) and perpendicular to DCX in the opposite knee (Femur Anterior Bowing Registration Enabled, i.e. FBRE group). Incidence and depth of notching were recorded in both groups. For FBRE knees, distal anterior cortex angle (DCA), which is the angle between SMX and DCX, was calculated by the computer. RESULTS: Incidence and mean depth of notching was less (p = 0.0007 and 0.009) in FBRE versus FBRD group, i.e. 7% versus 19.9% and 0.98 mm versus 1.53 mm, respectively. Notching was very high (61.8%) in FBRD limbs when the anterior bowing was severe (DCA > 3°) in the contralateral (FBRE) limbs. CONCLUSION: Notching was less when femoral component sagittal positioning was planned perpendicular to DCX, in navigated TKA. LEVEL OF EVIDENCE: Therapeutic level II.

No influence of obesity on mid-term clinical, functional, and radiological results after computer-navigated total knee arthroplasty using a gap balancing technique.

OBJECTIVE: In obese patients, thick subcutaneous tissue can introduce errors during registration and leg weight can influence gap balancing in navigated TKA. Present study is done to determine if computer navigated TKA using a gap balancing technique can achieve consistent accuracy for limb and component alignment, and similar clinical and functional results in obese patients like in non-obese patients. METHODS: We prospectively compared the radiological, clinical, and functional results of 78 knees in 57 non-obese patients and 79 knees in 58 obese patients who underwent computer-assisted TKA. Non-obese individuals were defined as those having BMI of <30 kg/m2 and obese individuals as BMI ≥30 kg/m2. The degree of knee deformity was calculated by Hip - Knee - Ankle (HKA) angle and clinical and functional assessment was done using the Knee Society Score - clinical knee score and Knee Society Score - function score, respectively. All these were documented before and at 6 months, 2 year, and 5 years after TKA. RESULTS: The outlier rate of postoperative limb alignment (HKA angle) was 8.9% in the obese group which was not significantly different (p =1.00) from that of the non-obese group (7.7%). Mean clinical knee scores were not significantly different between the non-obese and obese groups preoperatively (58.8 vs 57.4, p = 0.14) and at 6 months (92.7 vs 91, p = 0.06), 2 years (91.4 vs 90, p = 0.07), and 5 years (92.4 vs 91.3, p = 0.1) post-surgery. Similarly, mean functional scores were not significantly different between the non-obese and obese groups preoperatively (50.9 vs 49.9, p = 0.31) and at 6 months (92.7 vs 90.9, p = 0.06), 2 years (91.3 vs 92, p = 0.44), and 5 years (90.6 vs 91.1, p = 0.51) post-surgery. CONCLUSION: Obesity has no influence on mid-term clinical, functional, and radiological results after computer navigated TKA, done by gap balancing technique. LEVEL OF EVIDENCE: Therapeutic level II.

Isolated Renal Mucormycosis.

Mucormycosis in humans has been described as early as 1885 in literature. Isolated renal mucormycosis is rare as it has been mainly described in developing countries like India and China. It is rarer still to find this entity in immunocompetent young males without any risk factors. Specific guidelines on the treatment is not yet known but combined surgical and medical therapy is considered the best modality for its management. We describe a young male who presented with bilateral hydroureteronephrosis. He was initially treated as a case renal tuberculosis which is relatively more common in TB endemic country like ours. However when he did not respond to the anti-tuberculosis drug (ATT), a biopsy revealed mucormycosis. He was treated with nephrectomy and liposomal amphotericin B and oral posaconazole. On follow up of 2 years he is healthy and leading his normal life.

Patellofemoral arthroplasty in a bilateral Syme's amputee.

We present the case of a 50-year-old woman, who is a bilateral Syme's amputee and subsequently underwent patellofemoral arthroplasty (PFA) for osteoarthritis primarily involving the patellofemoral (PF) joint. History and physical examination were suggestive of severe PF arthritis without patellar instability of the right knee. The diagnosis was confirmed by roentgenogram and a PFA was performed. A slightly modified rehabilitation program was implemented and the patient was followed until 6 years after surgery. In comparison to the preoperative scores, the Oxford, the Western Ontario and McMaster Universities (WOMAC), the Knee Society, and the Hospital for Special Surgery Knee Scores improved significantly (p < 0.05) at the time of final follow-up. PF problems specific to below-knee amputees, factors to be considered before performing PFA, and the drawbacks of other treatment modalities in these patients have been discussed.

The influence of preoperative deformity on valgus correction angle: an analysis of 503 total knee arthroplasties.

We prospectively studied variations in valgus correction angle (VCA) and the influence of preoperative limb deformity on VCA in 503 consecutive total knee arthroplasties done in 393 patients. The percentage of limbs that had VCA values less than 5° was 10.9%, and that with VCA values greater than 7° was 44.9%. The percentage of limbs with VCA greater than 7° was significantly more in varus knees, and that with VCA less than 5° was significantly more in valgus knees; preoperative deformity showed a significant correlation with VCA. Choosing a fixed-routine VCA of 5° to 7° may cause an unacceptable planning error that may be minimized by individualizing VCA or using computer navigation.

Postoperative limb alignment and its determinants after minimally invasive Oxford medial unicompartmental knee arthroplasty.

One hundred twenty-two consecutive minimally invasive Oxford phase 3 medial unicompartmental knee arthroplasties in 109 patients were evaluated for postoperative limb alignment and the influence of factors such as preoperative limb alignment, age, body mass index, sex, insert thickness, and surgeon's experience. The mean mechanical preoperative hip-knee-ankle (HKA) angle of 172.2° ± 3.1° improved to 177.1° ± 2.9° postoperatively. In 75% of the limbs, the HKA angle was restored to within an acceptable alignment of 177° ± 3°, 14% of the limbs were in excessive varus (<174°), and 11% were in valgus (>180°). Only preoperative HKA angle was predictive of postoperative HKA angle. Although most of the limbs had acceptable limb alignment after unicompartmental knee arthroplasty, limbs with more severe preoperative varus deformity had a tendency to remain in excessive varus, and limbs with lesser preoperative varus deformity had a greater tendency to go into valgus postoperatively.

Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty:a prospective, randomized trial.

We evaluated the efficacy of periarticular infiltration of corticosteroid, opioid, and a local anesthetic by comparing pain scores, knee flexion, and quadriceps function on the day of surgery, first postoperative day, day of discharge, and 2 and 4 weeks after surgery between the infiltrated and the noninfiltrated knee in 40 patients undergoing simultaneous bilateral computer-assisted total knee arthroplasty who were randomized to receive the injection in the right or left knee. In comparison to the noninfiltrated side, the infiltrated knee showed significantly lower pain scores, significantly greater active flexion up to 4 weeks, and superior quadriceps recovery up to 2 weeks after surgery. This simple and inexpensive technique can significantly reduce pain and hasten functional recovery in the first month after total knee arthroplasty.

Variability in the range of inter-anterior superior iliac spine distance and its correlation with femoral head centre. A prospective computed tomography study of 200 adults.

PURPOSE: The anterior superior iliac spine (ASIS) is commonly used to estimate the centre of the femoral head and assess limb alignment during surgical procedures. This study aimed to determine the range of inter-anterior superior iliac spine distances (IADs) and inter-femoral head centre distances (IFDs) among individuals and ascertain whether there is correlation between the IFD and the IAD. We also sought to determine whether gender, height and body mass index (BMI) had any influence on IAD and IFD. MATERIALS AND METHODS: We prospectively measured IAD and IFD in 200 adults, using transverse computed tomography (CT) scans done for medical causes. We also calculated the distance between the pelvic midline and the centre of the femoral head (XY distance) from the measured IFD. The influence of gender, height and body-mass index on IAD and IFD, and the correlation of IAD with IFD, were also studied. RESULTS: The overall mean IAD, IFD and XY distances were 22.7+/-1.6 cm, 16.0+/-0.8 cm and 8.0+/-0.4 cm, respectively. There was wide variation within the IAD range with 50% (100/200) of the subjects having their IAD within +/-10 mm of the mean compared to 75.5% (151/200) of the subjects with IFD within +/-10 mm of the mean. The probability that the mean XY distance would fall within 10 mm of the true femoral head centre in all subjects was 100%. The gender difference in IAD and IFD was statistically significant (P=0.03 and P<0.001, respectively), height and BMI had no influence, and the correlation of IAD with IFD was weak (0.35). CONCLUSION: Although the range of IADs showed wide variation among subjects, this study clearly demonstrated the narrow range of the XY distance and IFD in the study population and provides a useful and accurate basis for a new method to determine the femoral head centre clinically and intraoperatively.

Quantification of effect of sequential posteromedial release on flexion and extension gaps: a computer-assisted study in cadaveric knees.

A novel sequence of posteromedial release consistent with surgical technique of total knee arthroplasty was performed in 15 cadaveric knees. Medial and lateral flexion and extension gaps were measured after each step of the release using a computed tomography-free computer navigation system. A spring-loaded distractor and a manual distractor were used to distract the joint. Posterior cruciate ligament release increased flexion more than extension gap; deep medial collateral ligament release had a negligible effect; semimembranosus release increased the flexion gap medially; reduction osteotomy increased medial flexion and extension gaps; superficial medial collateral ligament release increased medial joint gap more in flexion and caused severe instability. This sequence of release led to incremental and differential effects on flexion-extension gaps and has implications in correcting varus deformity.

Comparison of limb and component alignment using computer-assisted navigation versus image intensifier-guided conventional total knee arthroplasty: a prospective, randomized, single-surgeon study of 467 knees.

Total knee arthroplasty was performed in 282 knees with image-free navigation (group A) and in 185 with optimized conventional technique (group B). Mean postoperative mechanical axis of the limb was 179.7 degrees in group A and 179.1 degrees in group B (P < .002). There was a higher percentage of knees in group A that had restoration of mechanical axis to +/-1 degrees, +/-2 degrees, and +/-3 degrees of neutral (P < .0001). There were 9.2% outliers (+/-3 degrees) in group A and 21.6% outliers in group B (P < .0001). For knees exceeding 20 degrees varus, there was no significant difference between the mean mechanical axes in the 2 groups. Both components were aligned within 3 degrees of neutral in 90.8% of the knees in group A and 76.2% of the knees in group B (P < .0001).