Analysis of robot-specific operative time and surgical team anxiety level and its effect on alignment during robot-assisted TKA.

Adapting to robotic-assisted (RA) total knee arthroplasty (TKA) is hindered by the surgeon's fear of extra time. The main purpose of this study was to determine the robot's operative time, and the secondary goals were to assess the surgical team's anxiety, implant location and size, and limb alignment. From February to April 2022, 40 participants participated in prospective research. The study included primary Cuvis joint active RA-TKA patients for end-stage arthritis, but conversion of unicompartmental knee arthroplasty to TKA, and patients with prior knee surgery were excluded. The active RA-TKA surgical time included surgeon-dependent and surgeon-independent/active robot time. The surgeon's anxiety was measured using the state-trait anxiety inventory (STAI). The implant size/position and limb alignment were checked by post-operative weight-bearing lateral, anteroposterior, and full-length scanograms. Operative time specifically related to active RA-TKA was higher in the first 10 cases as against 10-20, 20-30 and 30-40 cases which was observed to lower from cohort 2. A similar trend was observed for the surgical team's anxiety levels which seem to lower from cohort 2 (case 10-20). Cumulative experience of active RA-TKA showed no effect on the precision of implant alignment/ size, limb alignment and complications. The study showed progressive improvement in the surgical anxiety scores and reduction in operating time indicating the proficiency gained by the surgical team. Further no learning curve was involved in achieving the implant positioning and sizing, limb alignment with the absence of complications.

Early Results of Bone-Conserving High Flexion Posterior-Stabilized Total Knee System in Indian Population.

Background: A number of total knee arthroplasty (TKA) systems are used across a variety of markets in which outcome will be influenced by patient factors, surgical technique and implant characteristics. The aim of the current study was to report the early functional results of a primary TKA system in support of the component design characteristics adapted for achieving increased functional expectations of the patients. Materials and Methods: A prospective, continuous series of 304 primary posterior-stabilized (PS) TKAs were performed in 208 patients by a single surgeon. Inclusion criterion was patients undergoing primary TKA with Freedom Total Knee system and willing to participate in the study. Exclusion criteria were patients undergoing revision TKA, patients not willing to participate and patients who were lost to follow-up. Patients were clinically and radiologically assessed for a minimum of 5 years post-operatively. Oxford Knee score (OKS) and range of motion (ROM) were assessed for the entire study population and by gender. Results: There were no patients who were lost to follow-up. Two patients (Two knees) required incision and secondary suturing for superficial skin wound complication. At minimum 5-year follow-up, there was no radiographic evidence of component loosening/failure. Clinical evaluation at 5 years post-operatively showed statistically significant increase in the OKS and ROM as compared to pre-operative values (OKS pre-operative 19.27 ± 1.86, post-operative 38.76 ± 1.5, p value < 0.001, ROM pre-operative 94.57 ± 3.49, post-operative 127.69 ± 3.65, p value < 0.001). There was no statistically significant difference in the clinical outcome between male and female genders as well as between unilateral and bilateral TKA. Conclusion: The study showed encouraging early results for the bone-conserving high flexion TKA system in 208 patients at minimum 5-year follow-up. The adapted design characteristics for improved functional expectations are confirmed in this reported Indian population study group cohort. Further continued evaluation is warranted for this primary TKA system across Indian and other ethnic population.

An early experience of the use of dual mobility cup uncemented total hip arhroplasty in young patients with avascular necrosis of the femoral head.

Introduction: THA (Total hip arthroplasty) in advanced grade (grade 4) avascular necrosis (AVN) is a challenge to the treating surgeon as it affects young patients who have high functional demands and increased dislocation risk. The aim of the study was to evaluate the efficacy, survivorship, and dislocation rate of uncemented dual mobility cups (DMC) in advanced grade IV AVN young patients. Methods: Retrospective cohort study involving 204 DMC THA for advanced grade IV AVN from January 2013 to December 2015. The sample size of the study was estimated to be 188 hips with an α error of 0.05 and ß error of 0.2. Inclusion criterion was patients less than 55 years of age with advanced grade IV AVN. Patients >55 years of age, patients diagnosed with primary osteoarthritis of the hip and hip fracture were excluded from the study. 172 patients (32 with bilateral & 140 with unilateral affection) with 204 DMC THA were evaluated clinically by Harris Hip Score (HHS) and radiologically at a follow up of 60 months. P value < 0.05 was considered significant. Results: Mean age of the patients was 42.5 ± 5.3. Preoperative HHS was 50.6 ± 10.5. Postoperative HHS at 5 years follow up was 96.4 ± 2.6. None of the operated patient had any dislocation episode or had undergone hip revision surgery (statistically significant against historical control of 2%, p value = 0.042). The radiological evaluation at 5 years showed no signs of radiolucent lines, periprosthetic osteolysis, polyethylene wear and signs of displacement or migration of the DMC. Cumulative survivorship rate at 5 years follow up was 100% without any revision/dislocation. Conclusion: Use of DMC THA in young, advanced grade IV AVN patients was found to be a reliable option showing excellent early functional results with no dislocation. Ongoing follow up of this cohort is required to confirm the maintenance of these excellent functional results at follow up in the long term.

Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty.

Background: One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur. Materials and methods: This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2 years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48 h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5 mcg/h was applied at the beginning of surgery and was continued 2 weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14 days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any. Results: Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group. Conclusion: TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

An Early Experience with a Novel Technique of Total Knee Arthroplasty for Osteoarthritic Knee with Coexistent Traumatic Tibia Diaphysis Fracture.

BACKGROUND: Treatment of tibia (upper third and diaphysis) fracture together with severe osteoarthritis (OA) poses challenge to an orthopedic surgeon. Traditionally, it is treated through three-stage surgeries, first fracture fixation followed by implant removal and finally surgery of total knee arthroplasty (TKA). Herein, we describe a novel TKA procedure using long-stemmed tibia component. This one-step technique not only addresses arthritis of the knee joint but also helps in assisting fixation of the fracture. MATERIALS AND METHODS: We reported outcomes of three female non-diabetic patients with OA who developed tibia shaft fracture following trauma. Range of motion and quadriceps strengthening exercise were initiated immediately after the procedure. X-rays anteroposterior and lateral views of the operated limbs were obtained at post-operative week-6 and week-12. We allowed the patients' toe touch weight-bearing immediately after the surgery. The patients were progressed to full weight-bearing after confirming radiological union on the X-rays. RESULTS: At follow-up, all treated patients were able to mobilize with good range of motion of the operated knee and with union of the fracture. The American Knee society scores and WOMAC pain and stiffness scores improved significantly. CONCLUSION: This novel technique offers one-stage solution to the complex situation of osteoarthritis of the knee with associated tibia shaft fracture, thereby reducing future hospital admissions/surgeries and associated costs and complications. Further, it allows faster rehabilitation.

What do patients want out of their Total Knee Arthroplasty?: An Indian perspective.

INTRODUCTION AND AIM: Total Knee Arthroplasty surgery is one of the most successful operations in orthopaedics. Still a sizable percentage of patients remain dissatisfied. Various studies have been conducted to analyse the red flags associated with poor outcome. In this study we tried to have insight on actual requirements of Indian patients from TKA operation. MATERIAL & METHODS: 300 patients undergoing TKA were studied by way of patient expectation feedback form. The form had various patient related capture points. It had a leading question: What are your expectations from TKA? They were asked to rank the 5 most important options in the order of importance. The patient expectation form was distributed and collected by an independent observer. RESULTS: 70% of patients ranked relief of pain as the most important expectation. 20% reported improvement in walking as the number one expectation. Nearly equal number listed improvement in walking and ease of doing day-to-day activities as the second most important expectation. This was followed by improvement in climbing the stairs and improvement in quality of life. Correction of deformity and no pain while squatting and getting up from sitting position ranked at the bottom. CONCLUSION: Our study shows that the primary expectations of Indian population from their TKA are relief from pain and improvement in walking. Secondary expectations include ease of doing day-to-day activities and improvement in quality of life.

Effect of Preoperative Diabetes on the Achievement of Forgotten Knee Status in Patients with Total Knee Arthroplasty.

BACKGROUND: Forgotten knee is the terminology which is used to describe a post-TKA patient who is completely unaware of his knee implant. The aim of the study is to determine whether preoperative diabetes negatively influences the achievement of forgotten knee status. METHODS: This is a retrospective cohort study. 300 patients (240 F:60 M) were studied. Patients were evaluated by an independent observer with FJS-12 score 2 weeks preop and at 6 weeks and 12 months after the operation. The patients with a FJS-12 score of ≥ 55 were considered to have achieved forgotten knee status. Out of 240 females, 96 had diabetes and out of 60 males, 18 had diabetes. Preoperative factors such as preop HBA1c, ROM, degree of deformity, VAS score and other associated co morbidities and postoperative factors such as HBA1c, ROM and hip-knee-ankle alignment were studied. Study was started with null hypothesis. The statistical difference was measured with Binominal proportion test and comparison of means t test. RESULTS: 96 out of 144 non-diabetic females (66.67%) and 51 out of 96 diabetic females (53%) achieved forgotten knee status (statistically significant, p value = 0.0336, Binominal proportion test). 27 out of 42 (65%) non-diabetic males and 12 out 18 diabetic males (66%) achieved forgotten knee status (p value = 0.9411). The FJS-12 score at 1 year for non-diabetic females and diabetic females was 58.6 mean ± 12.6 SD and 53.8 ± 17.6, respectively, which is statistically significant, p value 0.0145. The FJS-12 at 1 year in non-diabetic and diabetic males was 60.1 ± 14.8 and 59.6 ± 17.3, respectively, p value = 0.9097. CONCLUSION: Diabetic females have less chance of achieving a forgotten knee status than non-diabetic females. This understanding will help the operating surgeon in the preoperative patient counseling and modify the patient expectations.

Education, engagement and provision of empathy by trained counselor enhances the patient satisfaction after Total Knee Arthroplasty.

BACKGROUND: One of the major concerns following Total Knee Arthroplasty (TKA) surgery is patient satisfaction. Hence, this study sought to assess the effect of patient education, engagement and provision of empathy delivered by trained counselor on patient satisfaction. METHODS: All the patients included in the study were randomly allocated to two groups: Patients who received counseling from trained personnel during pre-, peri- and post-TKA phase constituted group-A (n = 100) whereas patients who were advised by the surgeon before the procedure constituted group-B (n = 100). All the patients who were counseled by trained personnel continued to receive counseling up to six months following TKA surgery. Patients belonging to group-A were provided counseling pertaining to education related to TKA procedure, the modalities of pain management and post-TKA ambulation regimen. Patient satisfaction was measured with Forgotten Joint Score-12 (FJS-12) and consumer gap (defined as the difference between patient perception and expectation) was recorded by an independent observer after 52-week of the TKA procedure. RESULTS: Patients belong to group-A had higher satisfaction as compared to those in group-B as evident by statistically higher FJS-12 score (64.5 ± 16.4 vs. 59.4 ± 17.9; p = 0.0369). There was statistically significant difference observed in consumer gap between group-A (6%) and group-B (16%) (p = 0.0242). CONCLUSIONS: The results of the study are encouraging to employ counseling by trained personnel during pre-, peri- and post-TKA phases as to improve patient satisfaction and reduce consumer gap.

The influence of the internet on the patients' choice of surgeon for their total knee replacement surgery.

BACKGROUND: To study the influence of the internet on the patient's choice about Total Knee Replacement surgery and about their choice of surgeon for their Total Knee Replacement procedure. SIGNIFICANCE: Insight into patient's decision making will help the surgeon to increase his/her visibility and also will help in providing true and reliable information about the patient's ailment. MATERIALS AND METHODS: We studied 200 patients who were operated by a single surgeon. They were given a questionnaire which had various questions regarding their name, age, sex, date of operation. It also had leading questions like did you or your relative searched the net about the operation and the operating surgeon? The information was collected by self filled questionnaire form. RESULTS: There were 166 females and 34 males. 70% of to be operated patients or their relatives searched the net before undergoing the Total knee replacement. Also 36% of patient relatives (mainly son or daughter) searched the surgeon on the net before finalizing the operation. 10% of patients searched the operating surgeon on the internet. 15% of patients or their relatives chose the operating surgeon based on their net search. CONCLUSION: Our study shows that a sizable number of decision makers (patients and their children) search the information about the operation and about their operating surgeon. Hence it is recommended that the surgeon should have an information portal to increase his/her visibility, patient reach and imparting proper information to the prospective patients regarding the operative procedure.

Discrepant histological diagnoses: A cause of early low FJS-12 score and if untreated, unhappy Total Knee Arthroplasty patient.

PURPOSE: Total Knee Arthroplasty (TKA) is one of the most successful operations in orthopedics. Still, a sizable percentage of patients (20%) remain dissatisfied after a well-executed TKA. The study aims to examine the excised synovium from the suprapatellar region in osteoarthritic knees during TKA and evaluate the histopathology (HP) report to know whether discrepant diagnoses affect the Forgotten Joint Score-12 at various time intervals. METHODS: This is a prospective cohort study. Two hundred (160 female; 40 male) end-stage osteoarthritis patients who underwent primary TKA were studied. An inclusion criterion was patient with end-stage osteoarthritis. Clinically and serologically proven rheumatoid arthritis patients were excluded from the study. The synovium excised during the TKA procedure was sent for the HP examination. The statistical significance was measured with the Chi-square test and two-sample t-test. RESULTS: A total of 184 out of the 200 patients (92%) knee synovium showed HP features of osteoarthritis. The discordant diagnoses and discrepant diagnosis rate was 8% and 7%, respectively, which is statistically significant by Chi-square test (p value < 0.0001 and p value = 0.0001). 14 of the patients (12 F:2 M) showed histological features of inflammatory/rheumatoid arthritis who were treated, two patients (all female) showed HP features of villonodular synovitis. The mean (SD) improvement in FJS-12 at six weeks in the concordant group (25.3 [17.6]) is significantly more than the discrepant group (15.3 [12.5]), p-value 0.0385. CONCLUSION: 8% of our patients exhibited unexpected results. The study showed a 7% rate of discrepant diagnosis. This discrepant diagnosis if missed and untreated, would have affected the function and long-term survival of the implanted TKA.

Home physiotherapy with vs. without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty.

The aim of this retrospective cohort study was to compare home physiotherapy with or without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. METHODS: A total of 900 patients (including 810 females and 90 males) who had undergone total knee arthroplasty were divided into group A (n = 300) and group B (n = 600). Patients in group A had home physiotherapy on their own after discharge from hospital. The physiotherapist did not visit them at home. Patients in group B received home physiotherapy under supervision of physiotherapist for 6 weeks after discharge from hospital. Patients' age, range of motion of the knee, and forgotten joint score-12 were assessed. A p < 0.05 was considered statistically significant. RESULTS: In group A, the mean age was 69.1 ± 14.3 years (range: 58 to 82 years); in group B, the mean age was 66.5 ± 15.7 years (range: 56 to 83 years) (p > 0.05). Preoperatively, the mean range of motion of the knee in group A and B was 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p > 0.05). The mean forgotten joint score-12 of group A and B were 11.90 ± 11.3 and 11.72 ± 12.1 (p > 0.05), respectively. Six weeks after total knee arthroplasty, the mean ROM of the knee in group A and B was 109.7° ± 22.3° and 121° ± 21.5°, respectively (p < 0.05). The mean postoperative forgotten joint score-12 of the group A and B was 24.5 ± 16.4 and 25.6 ± 17.4, respectively (p > 0.05). The rate of manipulation under anaesthesia was 3% in group A and 0.2% in group B (p < 0.05). CONCLUSION: After total knee arthroplasty, frequent physiotherapist's instruction helps the patients improve knee exercises and therefore decrease the risk of revision surgery. The home physiotherapy under supervision of physiotherapist lowers the rate of manipulation under anaesthesia. LEVEL OF EVIDENCE: Therapeutic study, Level IIa.

Understanding the apprehension and concern haunting patients before a total knee arthroplasty.

PURPOSE: The aim of this prospective study was to understand the fear and apprehension factors that play on patient's mind before total knee arthroplasty. METHODS: This retrospective cohort study included 500 consecutive patients (375 females and 125 males) who were scheduled to undergo total knee arthroplasty the next day. The patients were asked to list the most important fear in their mind regarding the operation in descending order of importance. They were given a questionnaire form which contained several capture points, including age, gender, educational background, occupation, and provision of help at home. Preoperative pain was measured by using the visual analog score, and its influence on the patients' fear and apprehension factors was also measured. RESULTS: In this study, 58% of patients (50 males, 40%; 240 females, 64%) were fearful of the pain that they would experience after surgery and during the postoperative physiotherapy. The female patients showed more fear of pain than their male counterparts (P < 0.05). 18% of the patients (40 males, 32%; 50 females, 13%) listed whether they will be able to walk and perform activities of daily living after surgery as the most important fear. The male patients had more fear of returning to normal walking (P < 0.05). 20% of the patients (30 males, 24%; 70 females, 19%) were fearful about getting adequate home help after discharge from hospital (P > 0.05). 4% of patients were concerned about withstanding such a major operation. There was no difference between male and female patients (P > 0.05). CONCLUSION: The majority of the patients experience apprehension of pain in the perioperative period of TKA. Preoperative counseling benefits pain management by alleviating the patient's concerns about the fear of postoperative pain and apprehension of returning to normal walking.

Study of Patients with Bilateral Knee Osteoarthritis Undergoing Total Knee Replacement Procedure with Coexisting Lumbar Spondylosis Symptoms.

STUDY DESIGN: This is a prospective cohort study involving patients who were followed for 2 years after total knee replacement (TKR) to determine changes in lumbar spine and knee symptoms. PURPOSE: The objectives of this study were to determine the percentage of patients undergoing bilateral TKR who present with coexisting lumbar spine problems and determine if TKR relieves lumbar spine symptoms. OVERVIEW OF LITERATURE: No studies quantify the percentage of TKR patients who experience relief of lumbar spine symptoms after TKR surgery. METHODS: The study included 200 patients (164 females, 36 males) undergoing primary TKR. Follow-up was performed at 4 weeks, 3, 6, 12, and 24 months. Lumbar spine and knee symptom improvements were assessed using the Oswestry Disability Index (ODI) and Oxford Knee Score, respectively. RESULTS: All 200 patients undergoing bilateral TKR presented with radiographic lumbar spine degenerative pathology; 60% (n=120) of the patients presented with moderate to severe clinical symptoms of lumbar spondylosis, including 54% (n=108) with degenerative lumbar spondylosis and lumbar canal stenosis and 6% (n=12) with degenerative spondylolisthesis. Of the 120 patients who presented with lumbar spine problems, 90% (n=108) reported improvement in their symptoms; the ODI score improved from 42.5%±4.1% preoperative score to 15.6%±2.3% postoperative score (p-value<0.001). Of the 12 patients with no improvement, 10 patients underwent percutaneous procedures for their lumbar spine pathology with good results, one patient underwent surgery, and one declined any intervention. CONCLUSIONS: A significant number of patients (60%) undergoing bilateral TKR also present with symptomatic lumbar spine problems. Patients with mild to moderate lumbar spine degenerative symptoms and no associated severe radiating pain on activity are more likely to experience relief of their symptoms post-TKR.

CRP (C Reactive Protein) level after total knee replacement in Indian population--- does it follow Anglo-Saxon trend?

BACKGROUND: This study was to determine how C-reactive protein (CRP) responds after total knee replacement (TKR), including both unilateral and simultaneous bilateral TKR in Indian population and if it follows Anglo-Saxon trend. Published literature from North America and Europe shows CRP value peaks on the 2nd post-operative day and drops to normal by 6-8 weeks. We started the study with null hypothesis. MATERIAL AND METHODS: This is a prospective study, with 50 patients (all females, 25 received unilateral operations and 25 bilateral ones) included. CRP levels were measured, on the 2nd day, 8, 12 and 16 weeks after operation. RESULTS: In both groups, CRP level rose the 2nd post-operative day. The rise in CRP level was significantly higher in the simultaneous bilateral TKR group than in the unilateral TKR group. In unilateral cases, CRP on the 2nd postoperative day ranged from 65 to 110 mg/l with average level of 80 mg/ml. In bilateral TKR cases, CRP level on the 2nd postoperative day was between 110 and 180 mg/l with a mean of 140 mg/ml. The CRP level returned to normal in about 40% of unilateral TKR patients 8 weeks after operation, while in 92% (23 out of 25) of bilateral simultaneous TKR patients it stayed at a high level 8 weeks post-op and did not come back to normal. At 12 weeks CRP decreased to normal in all 100% of unilateral TKR patients and 32% of bilateral TKR patients. At 16 weeks, CRP was normal in all bilateral TKR patients. CONCLUSION: 60% of our unilateral TKR patients and 92% of our simultaneous bilateral TKR patients did not achieve a normal CRP 8 weeks after operation. These findings are significant as CRP is commonly used as a very sensitive indicator of postoperative joint infection. Hence we conclude that in the Indian TKR patients the CRP values take longer time to return to normal than in their Anglo-Saxon counterparts. Published results regarding the normal levels of CRP in unilateral TKR should not be extrapolated to simultaneous bilateral TKR patients.