Operating room efficiency for a high-volume surgeon in simultaneous bilateral robotic-assisted total knee arthroplasty: a prospective cohort study.

Robotic-assisted total knee arthroplasty (RATKA) has been shown to achieve more accurate component positioning and target alignment than conventional jig-based instrumentation; however, concerns remain regarding its adoption since it is associated with steep learning curves, higher operational costs, and increased surgical time. This study aims to compare the operating times of three cohorts of patients undergoing simultaneous bilateral TKA, i.e., first 50 RATKA, last 50 RATKA (at the end of 1 year), and 50 conventional TKA. This prospective cohort study was conducted at a single high-volume tertiary care center by a single experienced surgeon on 150 patients (300 knees), who were allotted into three equal cohorts of 50, between February 2020 and December 2021. Simultaneous bilateral TKAs were done in all three groups and operative times recorded. We describe the technique for optimizing the surgical time of SB-RATKA for efficient operative room logistics. The operating times of the two robotic-assisted TKA cohorts were compared with the operating times of the conventional SB-TKA cohort. The mean age of the study population was 59(±6.2) years with the majority of females (82%). The mean coronal deformity was comparable between the cohorts. The mean operating time in the conventional CTKA, initial 50 RATKA, and final 50 RATKA cohorts were 115.56 (±10.7), 127.8 (±26), and 91.66 (±13.5) min, respectively, all of which showed a statistically significant difference (p < 0.001). The mean operating times of the final 50 RATKA at the end of 1 year improved by about 36 min with all the SB-RATKA cases being completed in under 120 min. The efficiency of SB-RATKA improved significantly with time and experience, resulting in shorter operational times within a year, revealing the potential of robotic-assisted surgery to surpass conventional approaches in TKA in terms of operating room efficiency.

Adoption of robotics in arthroplasty- a survey of perceptions, utilization and challenges with technology amongst Indian surgeons.

Introduction: Total joint replacement surgeries are standard procedures for managing end-stage hip or knee arthritis. Despite advances in technology, some patients experience dissatisfaction after total knee arthroplasty (TKA). Robotic technology has evolved significantly and has shown promise in improving component positioning, alignment, and surgical outcomes. However, the widespread adoption of robotics in arthroplasty faces challenges such as high costs, a steep learning curve, and limited evidence on long-term outcomes. Methods: This cross-sectional observational study used a structured self-administered online survey to assess the perceptions of Indian arthroplasty surgeons regarding robotic technology. The survey included questions about the surgeon's background, experience, perceptions of robotic joint replacement, and limiting factors for robotic usage. A total of 417 responses were collected from practising arthroplasty surgeons. Results: Most participants(78.1 %) expressed a willingness to adopt robotics in their arthroplasty practice if the cost of installation was reduced. Robotic users were more convinced about the benefits of robotics, including improved alignment, reduced pain, faster rehabilitation, and better outcomes. High-volume robotic surgeons demonstrated a greater belief in the broader potential of robotics beyond implant positioning and alignment. The major barriers to adoption were the high cost of installation and limited insurance coverage for robotic-assisted procedures. Lack of formal robotic training opportunities, resistance from corporate management, patient acceptance issues, and limited published literature supporting robotic advantages were also cited as limiting factors. Conclusion: Robotic technology is increasingly being adopted in India for TKA. The main obstacle to widespread adoption is the high cost of installation. As technology costs decrease, we can expect a rise in the number of installations across the country. Advocacy from national orthopaedic organizations may be needed to address insurance reimbursement challenges. Overall, this study provides valuable insights into the perceptions and challenges associated with the adoption of robotic technology in arthroplasty in India.

Erosion and Failure of the Tibial Post after Posterior-stabilized Total Knee Replacement: A Case Report.

Introduction: Posterior-stabilized (PS) total knee arthroplasty (TKA) prostheses are characterized by an articulation between the polyethylene tibial post and the cam of the femoral component. Tibial post-fractures, traumatic and non-traumatic, are uncommon but catastrophic complications. We report a rare and unusual case of complete atraumatic erosion of the tibial post after PS-TKA. Case Report: We present a case of atraumatic tibial post-failure (complete erosion) in a 73-year-old female after primary TKA. The patient presented with chronic pain, effusion, and instability both in the coronal and sagittal plane over a period of 1 year. There were no signs of component loosening on plain radiography, no fractures, and revealed medial extension laxity on valgus stress views. During revision surgery, polyethylene insert retrieval revealed a completely eroded tibial post, without any obvious fracture. There was no fractured tibial post lying freely in the joint cavity. The patient was subsequently revised with a hinged component due to gross bi-planar instability. Conclusion: In a post-TKR (PS knee) patient with chronic pain and instability, one should consider tibial post-complications after ruling out infection. Chronic instability can cause progressive erosion of the tibial post, which can fail without an obvious fracture. Revision surgery with constrained implants may be needed to manage such cases.

Functional alignment is associated with increased incidence of pre-balance, reduced soft-tissue release, and post-operative pain compared to mechanical alignment in patients undergoing simultaneous bilateral robotic-assisted TKA.

This study aimed to compare two alignment strategies in the same patient undergoing simultaneous bilateral robotic-assisted TKA (SB-RATKA): mechanical alignment (MA), the gold-standard, and functional alignment (FA), a balance-driven, personalized alignment strategy. The outcome measures included quantitative assessment of soft-tissue release, incidence of knee balance, and post-operative pain. This was a prospective, self-controlled, randomized-controlled trial involving 72 patients who underwent SB-RATKA using the MAKO® robotic system with comparable grades of deformity and pain in both knees. 65 patients were finally included with one alignment strategy done per knee, with the patients blinded to the strategy used. The study recorded the additional soft-tissue releases required, incidence of pre-balance, and daily post-operative VAS pain scores. The mean age of the study population was 57.95 years, with a female preponderance (N = 53, 81.6%). MA group had significantly more medial compartment tightness in both flexion (MA-15.6 ± 1.8; FA-17 ± 1.3) and extension (MA-14.9 ± 1.9; FA-17 ± 1.1) (p < 0.0001) compared to the FA group after dynamic balancing. 66% of knees in the FA group (N = 43) achieved pre-balance compared to 32.3% in the MA group (N = 21) (p < 0.0001). VAS scores showed a significant reduction in pain in the FA group up to 72 h post-surgery (p < 0.0001). The requirement for posteromedial release (PM), posterior capsular (PC) release, tibial reduction osteotomy (TRO), and superficial MCL pie crusting (sMCL) were significantly lower in FA (PM-22, PC-13, TRO-8, sMCL-2) compared to MA (PM-44, PC-29, TRO-18, sMCL-8). Functional alignment strategy consistently resulted in a higher incidence of knee balance with a significant reduction in soft-tissue releases and immediate post-operative pain when compared to MA in the same patient undergoing SB-RATKA. Therapeutic Level 1.

Patella non-resurfacing in primary total knee arthroplasty provides good functional results-a retrospective review of nine thousand three hundred forty six knees.

PURPOSE: Patellar resurfacing has long been a contentious subject in TKA with no consensus and the literature yielding disparate results. The aim of this study was to evaluate the long-term functional outcomes and complications of patients undergoing primary TKA without patellar resurfacing (non-resurfacing). METHODS: This study retrospectively analysed 9346 patients who underwent primary manual jig-based TKA without patellar resurfacing at a single high-volume arthroplasty centre between 2010 and 2018. Patients with a minimum three year follow-up irrespective of disease etiology and implant manufacturer were included in the study. Primary outcome was measured using Oxford knee score and patellofemoral Feller score. Secondary outcomes included determining the incidence of patellofemoral complications and re-operation rates following TKA. RESULTS: A total of 8695 knees were eligible for final evaluation having a mean follow-up of 6.6 years. Mean age of the patients was 62.6 (SD-7.5) years with female predominance of (N-6619, 70.8%). The majority of the patients had primary OA (N-8792, 94.1%) with varus deformity (N-8642, 92.46%). Depuy was the most used manufacturer (n = 2592, 26.4%) with the posterior stabilised (N-4127, 44.2%) design being the most predominant. The mean Feller score of the study population was 24.5 (SD = 3) with a majority of patients having good to excellent outcomes (86.95%, N-8424) and mean Oxford knee score was 36.9 (SD-6.9) with a majority of the patients having an OKS greater than 30 (87.1%, N-8133) with anterior knee pain (AKP) reported in only 4.8% patients (N-418). Most common complications included patellar clunk (N-56, 0.7%), traumatic patellar fractures (N-62, 0.8%), quadriceps tendon tear (N-54, 0.7%) and patellar dislocation (N-4, 0.05%) CONCLUSION: Patellar non-resurfacing has no detrimental impact on functional outcomes and incidence of AKP. We conclude that it is a safe, cost-effective and satisfactory approach in primary TKA with no significant complications.

Partial versus total knee arthroplasty for isolated antero-medial osteoarthritis - An analysis of PROMs and satisfaction.

AIM: This study aimed to compare the patient-reported functional outcomes and patient satisfaction after medial Unicompartmental Knee Arthroplasty (UKA) versus Total Knee Arthroplasty (TKA), performed for anteromedial osteoarthritis (AMOA) of the knee in patients from an Indian population, at a minimum 3-year follow-up. METHODS: This is a prospective matched cohort study (1:2 ratio). One hundred and one UKA cases were matched to 206 TKA cases by propensity score matching for age, body mass index (BMI), gender distribution, and the Charlson Comorbidity Index (CCI). The primary outcome (Oxford knee score, OKS) was assessed at a 3-year follow-up, along with secondary outcomes (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] Score, Forgotten Joint Score (FJS), Anterior Knee Pain (Kujala) score, patient satisfaction, and revision rate at the final follow-up). RESULTS: The UKA group was superior to the TKA group in patient-reported functional outcomes based on the OKS (p = 0.004). Using the FJS score, UKA was more likely to be a forgotten joint compared to TKA (p < 0.001). However, differences in the OKS and FJS did not meet the reported minimal clinically important difference (MCID) thresholds. Quality of life (EuroQol-5D VAS scale) was found to be significantly higher in the UKA group (p < 0.001). Patients in the UKA group were more likely to be very satisfied (75.2%) versus the TKA group (62.1%, p = 0.023). CONCLUSION: For AMOA, UKA was associated with improved patient satisfaction compared to TKA. Although patient-reported outcome measures were statistically in favour of UKA over TKA, the differences were not clinically significant. Multicenter and randomized studies comparing the two procedures are warranted. EVIDENCE: Level-II Therapeutic.

Radiological Evaluation of the Phenotype of Indian Osteoarthritic Knees based on the Coronal Plane Alignment of the Knee Classification (CPAK).

Background: Understanding constitutional alignment of the lower limb is essential to optimize alignment strategies during total knee arthroplasty. The coronal plane alignment of knee (CPAK) classification system was proposed as a comprehensive assessment tool based on coronal alignment and variations in joint line obliquity (JLO). This prospective observational cross-sectional study aimed to evaluate the phenotype of knees in the Indian population based on the CPAK system. Methods: Two cohorts of individuals (250 young healthy volunteers and 250 elderly patients with knee osteoarthritis) underwent radiological assessment with long-leg radiographs and were classified based on the CPAK system. Measurements included the mechanical and arithmetic hip-knee-ankle angles (mHKA, aHKA), joint line obliquity (JLO), lateral distal femoral angle (mLDFA) and medial proximal tibial angle (mMPTA). Knees were grouped into 9 CPAK phenotypes based on aHKA and JLO. Results: A total of 1000 knees were evaluated. In cohort-1 of healthy young adults, most knees were distributed in the CPAK class II phenotype (128 knees, 25.6%) followed by CPAK Type I (106 knees, 21.2%). In cohort-2 of elderly arthritic adults, most knees were distributed in Type I (294 knees, 58.8%) with constitutional varus and apex-distal joint line orientation. Conclusion: The majority of the study population was found to have constitutional varus alignment. In addition, a high proportion of patients in both categories, especially arthritic patients undergoing TKA, were found to have varus alignment with an apex-distal oblique joint line. This classification may help optimize component positioning to restore constitutional alignment and joint line orientation during TKA.

High Prevalence of Isolated Antero-medial Osteoarthritis (AMOA) in Indian Patients Undergoing Primary Total Knee Arthroplasty.

Background: Isolated antero-medial osteoarthritis (AMOA) of the knee is a distinct pattern of arthritis. Medial arthritis of the knee in select patients can be managed with uni-compartmental arthroplasty (UKA), with studies showing shorter hospital stay, faster rehabilitation and reduced medical complications in the post-operative period compared to TKA. However, the prevalence of AMOA in Indian patients with osteoarthritis of the knee is unknown. The aim of this study was to evaluate the prevalence of AMOA in patients undergoing primary TKA for OA. Methods: This was a prospective evaluation of 2518 knees in 1936 patients who were selected for primary TKA. Pre-operative radiographs were screened based on the Oxford UKA Radiological decision aid and diagnosis of AMOA was established. All 2518 knees underwent primary total knee arthroplasty and cases of AMOA were confirmed intra-operatively based on ACL integrity, lateral compartment wear and medial compartment wear pattern. Cases with AMOA arthritic wear pattern were considered amenable for UKA if radiographs showed intact lateral joint space, intra-operatively those with intact and functional ACL, acceptable patellofemoral wear (Outerbridge I-II). Results: We report a prevalence of 46.94% of AMOA, who were amenable for UKA. Obese patients were more likely to have a damaged or non-functional ACL and more likely to have a high degree of wear, not amenable for UKA (p < 0.05). Non-functional ACL was associated with higher prevalence of posterior extension of arthritic wear. Conclusion: This study demonstrated a high prevalence (46.94%) of antero-medial osteoarthritis (AMOA), amenable for UKA. Patient selection is important for improving outcomes after TKA or UKA. Future studies are warranted to compare outcomes of both UKA and TKA in patients with isolated AMOA of the knee.

Comparison of patient reported outcomes after robotic versus manual total knee arthroplasty in the same patient undergoing staged bilateral knee arthroplasty.

Background: Robotic-assisted total knee arthroplasty (RATKA) has been proven to improve accuracy of component positioning and reducing alignment target outliers. However, the clinical benefit of robotics is often debated. Recent studies have shown reduced pain and faster recovery in the immediate post-operative period and may be associated with improved PROMs and satisfaction. The aim of this study was to assess PROMs and satisfaction in a unique patient population undergoing bilateral staged TKA to compare manual (MTKA) and RATKA in the same patient. Methods: 55 patients underwent bilateral staged TKA, performed by a single surgeon at a single institute. Patients who underwent TKA for the first knee with manual technique and RATKA for the second side, were eligible for inclusion in the study. Primary outcome assessed was the Oxford Knee Score and secondary outcomes included the Forgotten Joint Score (FJS), patient satisfaction, mean duration for independent ambulation after TKA, and patient perspectives on recovery evaluated with a questionnaire. Results: Both RATKA and MTKA were associated with comparable PROMs. Though RATKA was associated with improved joint perception (Mean FJS after MTKA surgery was 70.3 (SD = 10.66) and significantly lower than the mean FJS after RATKA (73, SD = 10.95, p-value < 0.01), but the difference was not clinically relevant. A higher proportion of patients were more likely to be very satisfied or satisfied after RATKA. A significant proportion of patients felt the knee operated with RATKA was less painful and felt more natural compared to MTKA at final follow-up (p < 0.01). Majority of patients would undergo RATKA again and recommend robotic-TKA to others. Conclusion: Robotic-assisted surgery was associated with improved patient satisfaction, faster independent ambulation compared to manual techniques. PROMs however, were comparable without clinically significant differences. Patients preferred robotic-assisted surgery, with a significantly higher proportion perceiving knee operated by RATKA felt more natural.

Pre-operative planning and templating with 3-D printed models for complex primary and revision total hip arthroplasty.

Background: Complex primary and revision THR requires comprehensive understanding of abnormal bony anatomy. Evaluation and classification of acetabular bone defects is essential to manage them appropriately. It is difficult to appreciate complex defects using conventional 2-Dimensional radiological modalities. 3D printed models can provide both visual and tactile reproduction of the bony anatomy, with potential for better pre-operative planning and making these complex surgeries more precise and accurate. Materials and methods: Anatomical 3D models of pelvis and femur were made based on CT scans of 27 patients undergoing complex primary THR/Revision THR by FDM (Fusion Deposition Modeling) technology using Flash Forge-Dreamer 3D printer with ABS (plastic) material. Models were used for pre-operative planning and simulation of surgery. Aims of the study were to study the accuracy of 3D models in predicting the implant sizes, accuracy in evaluation of acetabular bone defects and validating the utility of 3 D models through surgeon feedback. Results: The acetabular cup size and placement was accurate in 25 (92.6%) patients. Preoperative acetabular bone defect was accurately estimated in all the patients. There were no neurovascular complications at early and 1-year follow-up in this case series. Model realism and reliability survey response from five surgeons was graded, with average overall usefulness of 3D models of 4.86/5, average model realism was 4.9/5, average usefulness for planning was 4.74/5 and usefulness for teaching was 5/5. Conclusion: 3D models are accurate and help in assessing acetabular bone deficiencies reliably in complex and revision THR. Anatomical models help in surgical planning and simulation, enabling surgeons in predicting the correct implant sizes and importantly placement of acetabular cup and for management of bone defects. The safe trajectory of acetabular screws can be simulated and determined, thereby avoiding penetration into pelvis and neuro-vascular injuries.

Enhanced Mid-Resection Workflow Technique for Severe Varus Deformity Correction Using Robotic-Arm Assisted Total Knee Arthroplasty.

INTRODUCTION: Robotic technology in total knee arthroplasty has been proven to improve accuracy of component positioning, achieve alignment targets, and balance the knee objectively. However, the utility of robotics in correction of severe varus deformities of the knee has not been investigated in detail. The aim of this paper was to establish the utility and describe the technique of robotic-arm assisted total knee arthroplasty (RA-TKA) in achieving pre-balance in severe varus deformities of the knee. MATERIALS AND METHODS: Among the existing Mako (Stryker, Kalamazoo, Michigan) RA-TKA workflows, pre-resection workflow is limited to knees which can be pre-balanced by component positioning according to functional alignment. Mid-resection workflow (distal femur/tibia first) is reserved for complex cases, whereby the extension gap is balanced first. In our experience, both workflows could not achieve pre-balance in severe varus deformities, necessitating the need to develop a novel technique. The ability of the robot to execute precise bone cuts allows for a provisional postero-medial femoral bone cut in flexion, giving access to remove large inaccessible posterior osteophytes and the tight posterior capsule, thus balancing the knee in extension. The flexion gap is subsequently matched to the extension gap by alterations in axial component positioning. CONCLUSION: This novel "enhanced mid-resection workflow" technique establishes the utility of the RA-TKA in balancing severe varus deformities of the knee. We also propose an algorithm which simplifies and helps surgeons choose between the three workflows to pre-balance knees irrespective of the severity of the varus deformity.

Avoiding Lateral Laxity in Robotic Arm-Assisted Total Knee Arthroplasty-A Surgical Technique Describing a New Method of Gap Capture and Balancing Strategy.

INTRODUCTION: Optimal flexion-extension gap balancing is an important factor in outcomes after total knee arthroplasty. Knees with varus deformities are commonly associated with a greater degree of lateral laxity both in extension and flexion. Residual lateral laxity could be encountered by surgeons during component trialling after robotic-assisted total knee arthroplasty (RATKA), necessitating additional medial soft tissue release for a thicker insert. This study describes a new technique of gap assessment during RATKA and we propose a functional alignment based balancing strategy to avoid residual lateral laxity. MATERIALS AND METHODS: This surgical technique was prospectively employed in 105 patients undergoing primary MAKO® (Stryker, Kalamazoo, Michigan) RATKA for osteoarthritis of the knee with varus deformity, between January 2021 and July 2021. Patients included had an initial lateral extension laxity of more than 24mm. Surgical data points collected consisted of characterization of the laxity profile of the knee using the medial and lateral extension and flexion initial gap captures, final gap captures after dynamic balancing with a functional alignment strategy, and residual lateral extension gap laxity in millimeters at the end of implantation. RESULTS: The mean initial lateral extension gap was 25.76mm (standard deviation [SD]=1.47) and the mean lateral flexion gap was 24.4mm (SD=1.94). Balance was achieved in all the patients with a 9 or 11mm insert, with a mean residual lateral laxity of 0.51mm (SD=0.73, range 0-2mm). The majority of patients (n=66, 62.85%) had zero lateral laxity at the end of final implantation while 24 patients (22.8%) had 1mm of residual lateral laxity. CONCLUSION: Residual lateral joint laxity can be avoided consistently and predictably in RATKA cases with initial gap capture of up to 30mm in lateral extension and flexion with this new technique of gap capture and employing various steps of balancing strategy described.

Unusual Failure of Modular TKA Prosthesis and Screw Migration following Revision Total Knee Arthroplasty.

Introduction: The use of modular implants for revision TKA are ever increasing in number due to their definitive advantage over their monoblock counterparts by providing the surgeon with the versatility needed to achieve equal gaps and manage bone defects. This superiority comes at the cost of certain unique complications attributable to its modular design such as loosening and fractures at the areas of component coupling that are prone to fatigue failure with suboptimal fixation. Case Report: We present a case of modular femoral component failure in a 59-year man of Asian decent after revision TKA secondary to disengagement and migration of the extension stem locking bolt of a Total Condylar-III prosthesis. Patient presented with pain, effusion, and instability 2.5 years after stage-2 revision TKA. Radiographs revealed migration of the femur-stem locking bolt into the joint cavity. The femoral component and stem were loose. The locking bolt was extracted, and he underwent re-revision surgery with revised femoral components. Conclusion: Stem-condylar junction of modern modular TKA implants are prone to early loosening and failure. This diagnosis should be anticipated on serial follow-up radiographs and in patients who complain of sudden onset of instability following revision surgery.

Analgesic efficacy of single-shot adductor canal block versus adductor canal block combined with intra-articular ropivacaine infusion after total knee arthroplasty.

AIMS: Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone. METHODS: This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain. RESULTS: The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014). CONCLUSION: Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA. Cite this article: Bone Jt Open 2021;2(12):1082-1088.

Does Early Debridement, Antibiotic Therapy and Implant Retention (DAIR) have a Role in Managing Periprosthetic Joint Infection of the Knee in Indian Scenario: A Retrospective Analysis of Outcomes.

PURPOSE: To report outcomes of Debridement, Antibiotic therapy and Implant Retention (DAIR) for periprosthetic knee joint infections (PJI) in the Indian population and to study factors influencing outcomes. METHODS: This was a Retrospective study of 80 cases of acute PJI after total knee arthroplasty who were treated by DAIR, within 2 weeks of onset of infection. A standardised institutional management protocol was applied to all cases. Patients were followed up for a minimum 1 year. Outcomes of DAIR were classified as successful or unsuccessful based on resolution or persistence of infection, and subsequent requirement of revision surgery. Influence of factors, like comorbidities, culture status and microbiological characteristics of causative organism, on outcomes was assessed. RESULTS: Overall 55 patients (68.75%) had successful eradication of infection after DAIR. 27 (33.7%) patients were culture negative and 53 (66.2%) patients grew organisms on culture. There was no statistically significant difference in outcomes (p = 0.082) between culture-positive cases (69.8% success rate) and (66.7% success rate) in culture negative cases. Furthermore, no difference in outcomes was observed in culture-positive patients between those who grew Gram-positive organisms versus Gram-negative organisms (p = 0.398) Similarly, patient comorbidities did not significantly alter the outcomes after DAIR (p = 0.732). CONCLUSION: Our study demonstrates that early DAIR within 2 weeks of onset of infection using a standard protocol during surgery and postoperatively can result in good outcomes. Patient comorbidities, culture status (positive versus negative), Gram staining characteristics of organisms and the identity of pathogenic bacteria did not influence outcomes of DAIR for acute PJI.

Impact of COVID-19 Pandemic on Orthopaedic Trauma Volumes: a Multi-Centre Perspective From the State of Telangana.

BACKGROUND: The COVID-19 outbreak reached pandemic proportions in March 2020, and the government of India declared a nationwide lockdown on 24th March, 2020. All vehicular movement, construction work, industries, national highways, etc. remained closed during lockdown. The aim of this study was to assess the impact of lockdown on the case load and epidemiology of orthopaedic trauma cases in the state of Telangana. METHODS: This study was a multi-centre, retrospective observational study. Data were collected from 8 teaching hospitals, 8 corporate hospitals, 1 dedicated industrial trauma, and hand injury center and 56 consultants with individual practice. Data were collected in two groups, pre-lockdown period (23rd Feb to 24th March) and lockdown period (25th march to 25th April). Patient demographics, type of injury, and cause of injury were collected. This was done using an online survey form and retrieval of case data from health records. RESULTS: There was a significant decrease in total trauma numbers during lockdown by 1266 cases (pre-lockdown n = 2020 and lockdown n = 754), amounting to a decrease by 62.7% (p < 0.01). RTA was the leading cause of trauma in all age groups except in elderly and we found a reduction of 77.9% cases during lockdown (n = 1343 vs. n = 298). The numbers of fragility fractures in elderly were unaffected due to lockdown. CONCLUSION: RTA was the major cause of injuries in young adults and adults. Though they cannot be eliminated, RTA numbers can be reduced by strict implementation of traffic rules and better road infrastructure. Lockdown had no effect on incidence of fragility fractures in elderly. With changes in life style and more people working from home there may be a reduction in overall injuries in future.

Simultaneous bilateral neck of femur fractures in an adolescent secondary to hypocalcaemic seizure.

We present a rare case of a previously healthy 16-year-old boy who sustained simultaneous bilateral femoral neck fractures after a single first-time seizure episode. He was diagnosed to have severe vitamin D deficiency and secondary hyperparathyroidism. Symptomatic hypocalcemia was the cause of seizures. Both fractures were treated surgically and united at 3 months. Bilateral femoral neck fractures after seizures are very rare, especially in children. Severe vitamin D deficiency may cause seizures and also weakening of bone, predisposing to fractures without significant trauma. We recommend that paediatric cases of femoral neck fractures after seizures should be investigated for underlying metabolic disease.

Bilateral Solitary Glomus Tumour of Thumb: A Case Report.

Glomus tumours are benign neoplastic lesions of glomus body, a thermoregulatory apparatus of cutaneous microvasculature. These tumours can arise at any location of the body but most commonly seen in subungual region of fingers. Bilateral solitary glomus tumour of hand is a rare entity. We report a case of 54-year-old female who presented with complaints of pain in the right thumb since three years and left thumb pain since 20 years. Clinical examination revealed acute tenderness of both the thumbs. Love's pin test and Hildreth's test were positive. MRI revealed characteristic features of glomus tumour. Excision of both the lesions was done and proceeds forwarded to histopathology which confirmed diagnosis. Patient was symptom free immediately following surgery. No nail deformities were noticed and there was no recurrence of symptoms in one year follow up. Glomus tumours of the hand are a rare entity and often missed.

Flexible Ag-C60 nano-biosensors based on surface plasmon coupled emission for clinical and forensic applications.

The relatively low sensitivity of fluorescence detection schemes, which are mainly limited by the isotropic nature of fluorophore emission, can be overcome by utilizing surface plasmon coupled emission (SPCE). In this study, we demonstrate directional emission from fluorophores on flexible Ag-C60 SPCE sensor platforms for point-of-care sensing, in healthcare and forensic sensing scenarios, with at least 10 times higher sensitivity than traditional fluorescence sensing schemes. Adopting the highly sensitive Ag-C60 SPCE platform based on glass and novel low-cost flexible substrates, we report the unambiguous detection of acid-fast Mycobacterium tuberculosis (Mtb) bacteria at densities as low as 20 Mtb mm(-2); from non-acid-fast bacteria (e.g., E. coli and S. aureus), and the specific on-site detection of acid-fast sperm cells in human semen samples. In combination with the directional emission and high-sensitivity of SPCE platforms, we also demonstrate the utility of smartphones that can replace expensive and cumbersome detectors to enable rapid hand-held detection of analytes in resource-limited settings; a much needed critical advance to biosensors, for developing countries.