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2.
Trials ; 21(1): 194, 2020 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-32070406

RESUMO

BACKGROUND: Total knee arthroplasty (TKA) with mechanical alignment (MA) aims to achieve neutral limb alignment in all patients, whereas TKA with functional alignment (FA) aims to restore native, patient-specific anatomy and knee kinematics by manipulating bone resections and fine-tuning implant positioning. The objective of this study is to determine the optimal alignment technique in TKA by comparing patient satisfaction, functional outcomes, implant survivorship, complications, and cost-effectiveness in MA TKA versus FA TKA. Robotic technology will be used to execute the planned implant positioning and limb alignment with high-levels of accuracy in all study patients. METHODS AND ANALYSIS: This prospective double-blinded randomised control trial will include 100 patients with symptomatic knee osteoarthritis undergoing primary robotic arm-assisted TKA. Following informed consent, patients will be randomised to MA TKA (the control group) or FA TKA (the investigation group) at a ratio of 1:1 using an online random number generator. Blinded observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to postoperative rehabilitation, clinical progress, functional outcomes, accuracy of implant positioning and limb alignment, gait, implant stability, cost-effectiveness, and complications. A superiority study design will be used to evaluate whether FA TKA provides superior outcomes compared to MA TKA. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Surrey Research Ethics Committee, UK. The study is sponsored by University College London, UK. DISCUSSION: This is the first study to describe the use of robotic technology to achieve FA TKA, and the only existing clinical trial comparing robotic MA TKA versus robotic FA TKA. The findings of this study will enable an improved understanding of the optimal alignment technique in TKA for achieving high-levels of patient satisfaction, improving functional outcomes, increasing implant survivorship, improving cost-effectiveness, and reducing complications. REGISTRATION: Clinical Trials.gov, NCT04092153. Registered on 17 September 2019.

4.
Hip Int ; : 1120700019889334, 2019 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-31838874

RESUMO

BACKGROUND: Robotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning and orientation during total hip arthroplasty (THA). The objective of this study was to assess the surgical team's learning curve for robotic-arm assisted acetabular cup positioning during THA. METHODS: This prospective cohort study included 100 patients with symptomatic hip osteoarthritis undergoing primary total THA performed by a single surgeon. This included 50 patients receiving conventional manual THA and 50 patients undergoing robotic-arm assisted acetabular cup positioning during THA. Independent observers recorded surrogate markers of the learning curve including operative times, confidence levels amongst the surgical team using the state-trait anxiety inventory (STAI) questionnaire, accuracy in restoring native hip biomechanics, acetabular cup positioning, leg-length discrepancy, and complications within 90 days of surgery. RESULTS: Cumulative summation (CUSUM) analysis revealed robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for achieving operative times (p < 0.001) and surgical team confidence levels (p < 0.001) comparable to conventional manual THA. There was no learning curve of robotic-arm assisted THA for accuracy of achieving the planned horizontal (p = 0.83) and vertical (p = 0.71) centres of rotation, combined offset (p = 0.67), cup inclination (p = 0.68), cup anteversion (p = 0.72), and correction of leg-length discrepancy (p = 0.61). There was no difference in postoperative complications between the two treatment groups. CONCLUSIONS: Integration of robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for operative times and surgical team confidence levels but there was no learning curve effect for accuracy in restoring native hip biomechanics or achieving planned acetabular cup positioning and orientation.

7.
Expert Rev Med Devices ; 16(12): 1063-1070, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31752561

RESUMO

Introduction: Although a relatively rare complication, the incidence and prevalence of prosthetic joint infection (PJI) is certainly rising. This is mainly due to the number of arthroplasties performed each year and our ability to capture more cases. There is currently no consensus in the optimal diagnosis and management of the infected total hip arthroplasty. Various management techniques have been described in literature.Areas covered: We discuss and summarize the literature in diagnosing prosthetic joint infection (PJI) including next-generation sequencing. An in-depth critical analysis of the biomarkers and the novel tests available in the market is reviewed including the evolving nature of the diagnostic criteria for PJI. The key issues in managing infected THA are identified.Expert commentary: The senior authors' expert opinion on diagnostic criteria is discussed. We also stress the importance of tissue/fluid analysis of microbiology and histology being key to diagnosis of PJI. The indications of one-stage versus two-stage revision arthroplasty is examined, including techniques for successful one-stage revision.

9.
EFORT Open Rev ; 4(11): 618-625, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31754468

RESUMO

Robotic total hip arthroplasty (THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA.Robotic THA improves precision and reduces outliers in restoring the planned centre of hip rotation compared to conventional manual THA.Improved accuracy in restoring hip biomechanics and acetabular cup positioning in robotic THA have not translated to any differences in early functional outcomes, correction of leg-length discrepancy, or postoperative complications compared to conventional manual THA.Limitations of robotic THA include substantive installation costs, additional radiation exposure, steep learning curves for gaining surgical proficiency, and compatibility of the robotic technology with a limited number of implant designs.Further higher quality studies are required to compare differences in conventional versus robotic THA in relation to long-term functional outcomes, implant survivorship, time to revision surgery, and cost-effectiveness. Cite this article: EFORT Open Rev 2019;4:618-625. DOI: 10.1302/2058-5241.4.180088.

10.
EFORT Open Rev ; 4(10): 611-617, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31754467

RESUMO

Robotic total knee arthroplasty (TKA) improves the accuracy of implant positioning and reduces outliers in achieving the planned limb alignment compared to conventional jig-based TKA.Robotic TKA does not have a learning curve effect for achieving the planned implant positioning. The learning curve for achieving operative times comparable to conventional jig-based TKA is 7-20 robotic TKA cases.Cadaveric studies have shown robotic TKA is associated with reduced iatrogenic injury to the periarticular soft tissue envelope compared to conventional jig-based TKA.Robotic TKA is associated with decreased postoperative pain, enhanced early functional rehabilitation, and decreased time to hospital discharge compared to conventional jig-based TKA. However, there are no differences in medium- to long-term functional outcomes between conventional jig-based TKA and robotic TKA.Limitations of robotic TKA include high installation costs, additional radiation exposure, learning curves for gaining surgical proficiency, and compatibility of the robotic technology with a limited number of implant designs.Further higher quality studies are required to compare differences in conventional TKA versus robotic TKA in relation to long-term functional outcomes, implant survivorship, time to revision surgery, and cost-effectiveness. Cite this article: EFORT Open Rev 2019;4:611-617. DOI: 10.1302/2058-5241.4.190022.

11.
Hip Int ; : 1120700019882922, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31615288

RESUMO

INTRODUCTION: Hip resurfacing arthroplasty (HRA) is an alternative to conventional total hip arthroplasty (THA) with potential advantages of preserving femoral bone stock and the ability to participate in higher impact activities. This study compares outcomes, satisfaction and preference in patients who underwent HRA in 1 hip and THA on the contralateral side. METHODS: 62 Patients with an HRA in 1 hip and a contralateral THA were retrospectively identified at 3 centres, consisting of 38 males and 24 females with 53 patients (85.5%) undergoing HRA first. A survey regarding satisfaction and preference for each procedure and outcome scores were obtained. RESULTS: Patients were younger (51.5 vs. 56.6 years, p = 0.002) and had longer follow-up on the HRA hip (11.0 vs. 6.0 years, p < 0.001). HRA was associated with larger increase in Harris Hip Score from preoperative to final follow-up (35.8 vs. 30.6, p = 0.035). 18 Patients (29.0%) preferred HRA, 19 (30.6%) preferred THA and 25 (40.3%) had no preference (p = 0.844). When asked what they would choose if they could only have 1 surgery again, 41 (66.1%, p < 0.001) picked HRA. Overall satisfaction (p = 0.504), willingness to live with their HRA versus THA for the rest of their life (p = 0.295) and recommendation to others (p = 0.097) were similar. CONCLUSIONS: Although HRA is associated with risks related to metal-on-metal bearings, it showed greater increase in patient-reported outcomes and a small subjective preference amongst patients who have undergone both conventional and resurfacing arthroplasty.

12.
J Bone Joint Surg Am ; 101(19): 1713-1723, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31577676

RESUMO

BACKGROUND: Implant malalignment may predispose patients to prosthetic failure following total knee arthroplasty (TKA). A more thorough understanding of the surgeon-specific factors that contribute to implant malalignment following TKA may uncover actionable strategies for improving implant survival. The purpose of this study was to determine the impact of surgeon volume and training status on malalignment. METHODS: In this retrospective multicenter study, we performed a radiographic analysis of 1,570 primary TKAs performed at 4 private academic and state-funded centers in the U.S. and U.K. Surgeons were categorized as high-volume (≥50 TKAs/year) or low-volume (<50 TKAs/year), and as a trainee (fellow/resident under the supervision of an attending surgeon) or a non-trainee (attending surgeon). On the basis of these designations, 3 groups were defined: high-volume non-trainee, low-volume non-trainee, and trainee. The postoperative medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured. Outlier measurements were defined as follows: DFA, outside of 5° ± 3° of valgus; PTA, >±3° deviation from the neutral axis; and PSA, <0° or >7° of flexion for cruciate-retaining or <0° or >5° of flexion for posterior-stabilized TKAs. "Far outliers" were defined as measurements falling >± 2° outside of these ranges. The proportions of outliers were compared between the groups using univariate and multivariate analyses. RESULTS: When comparing the high and low-volume non-trainee groups using univariate analysis, the proportions of knees with outlier measurements for the PTA (5.3% versus 17.4%) and PSA (17.4% versus 28.3%) and the proportion of total outliers (11.8% versus 20.7%) were significantly lower in the high-volume group (all p < 0.001). The proportions of DFA (1.9% versus 6.5%), PTA (1.8% versus 5.7%), PSA (5.5% versus 12.6%), and total far outliers (3.1% versus 8.3%) were also significantly lower in the high-volume non-trainee group (all p < 0.001). Compared with the trainee group, the high-volume non-trainee group had significantly lower proportions of DFA (12.6% versus 21.6%), PTA (5.3% versus 12.0%), PSA (17.4% versus 33.3%), and total outliers (11.8% versus 22.3%) (all p < 0.001) as well as DFA (1.9% versus 3.9%; p = 0.027), PSA (5.5% versus 12.6%; p < 0.001), and total far outliers (3.1% versus 6.4%; p = 0.004). No significant differences were identified when comparing the low-volume non-trainee group and the trainee group, with the exception of PTA outliers (17.4% versus 12.0%; p = 0.041) and PTA far outliers (5.7% versus 2.6%; p = 0.033). Findings from multivariate analysis accounting for the effects of patient age, body mass index, and individual surgeon demonstrated similar results. CONCLUSIONS: Low surgical volume and trainee status were risk factors for outlier and far-outlier malalignment in primary TKA, even when accounting for differences in individual surgeon and patient characteristics. Trainee surgeons performed similarly, and certainly not inferiorly, to low-volume non-trainee surgeons. Even among high-volume non-trainees, the best-performing cohort in our study, the proportion of TKA alignment outliers was still high. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

13.
Bone Joint J ; 101-B(10): 1230-1237, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31564152

RESUMO

AIMS: The aim of this study was to assess the effect of posterior cruciate ligament (PCL) resection on flexion-extension gaps, mediolateral soft-tissue laxity, fixed flexion deformity (FFD), and limb alignment during posterior-stabilized (PS) total knee arthroplasty (TKA). PATIENTS AND METHODS: This prospective study included 110 patients with symptomatic osteoarthritis of the knee undergoing primary robot-assisted PS TKA. All operations were performed by a single surgeon using a standard medial parapatellar approach. Optical motion capture technology with fixed femoral and tibial registration pins was used to assess gaps before and after PCL resection in extension and 90° knee flexion. Measurements were made after excision of the anterior cruciate ligament and prior to bone resection. There were 54 men (49.1%) and 56 women (50.9%) with a mean age of 68 years (sd 6.2) at the time of surgery. The mean preoperative hip-knee-ankle deformity was 4.1° varus (sd 3.4). RESULTS: PCL resection increased the mean flexion gap significantly more than the extension gap in the medial (2.4 mm (sd 1.5) vs 1.3 mm (sd 1.0); p < 0.001) and lateral (3.3 mm (sd 1.6) vs 1.2 mm (sd 0.9); p < 0.01) compartments. The mean gap differences after PCL resection created significant mediolateral laxity in flexion (gap difference: 1.1 mm (sd 2.5); p < 0.001) but not in extension (gap difference: 0.1 mm (sd 2.1); p = 0.51). PCL resection significantly improved the mean FFD (6.3° (sd 4.4) preoperatively vs 3.1° (sd 1.5) postoperatively; p < 0.001). There was a strong positive correlation between the preoperative FFD and change in FFD following PCL resection (Pearson's correlation coefficient = 0.81; p < 0.001). PCL resection did not significantly affect limb alignment (mean change in alignment: 0.2° valgus (sd 1.2); p = 0.60). CONCLUSION: PCL resection creates flexion-extension mismatch by increasing the flexion gap more than the extension gap. The increase in the lateral flexion gap is greater than the increase in the medial flexion gap, which creates mediolateral laxity in flexion. Improvements in FFD following PCL resection are dependent on the degree of deformity before PCL resection. Cite this article: Bone Joint J 2019;101-B:1230-1237.


Assuntos
Artroplastia do Joelho/métodos , Instabilidade Articular/prevenção & controle , Osteoartrite do Joelho/cirurgia , Ligamento Cruzado Posterior/cirurgia , Amplitude de Movimento Articular/fisiologia , Procedimentos Cirúrgicos Robóticos/métodos , Fatores Etários , Idoso , Análise de Variância , Artroplastia do Joelho/efeitos adversos , Estudos de Coortes , Feminino , Seguimentos , Humanos , Prótese do Joelho , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Cuidados Pós-Operatórios/métodos , Estudos Prospectivos , Melhoria de Qualidade , Medição de Risco , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Fatores Sexuais , Resultado do Tratamento
15.
J Orthop Case Rep ; 9(3): 68-71, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31559232

RESUMO

Introduction: Surgical excision of fat fractures is often reserved for patients with large chronic deformities to improve cosmetic appearance. To our knowledge, the acute surgical management of a traumatic fat fracture has not been previously reported. Case Report: This case report describes the management of a professional soccer player that developed a traumatic fat fracture over the lateral thigh. The patient presented with persistent pain, reduced range of movement, and inability to participate in sporting activity. Symptoms were refractory to non-operative treatment. Following acute surgical excision of the fat fracture, the patient was able to make an early return to sporting activity with no complications at short-term follow-up. Conclusion: Acute surgical excision of a traumatic fat fracture may be used as an avenue for improving pain, enhancing functional rehabilitation, and facilitating early return to pre-injury level of function.

16.
J Dance Med Sci ; 23(3): 91-96, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31500690

RESUMO

Inadequate levels of vitamin D may lead to poor performance in professional dancers. Therefore, dietary supplementation may be essential in this population. This longitudinal pilot study to a randomized controlled trial assessed dancer compliance with self-directed oral vitamin D supplementation. Seventy-one dancers, 41 females and 30 males with a mean age of 31.1 years, were recruited from The Royal Ballet, London. Baseline serum 25(OH)D levels were measured and dancers were interviewed, examined, and provided with oral supplements for the winter period, November 2011 to March 2012. Dancers with normal serum 25(OH)D levels were provided with maintenance supplements (1,000 IU/ day) and those with insufficient or deficient serum 25(OH)D levels were given a loading dose of 60,000 IU weekly for 2 and 6 weeks, respectively. Serum 25(OH) D levels were measured at 1 and 2 years and dancers were sampled for compliance with instructions. Mean compliance during loading and maintenance was 86% and 50%, respectively. Mean serum 25(OH)D levels at start and end of the study period were 79.3 ± 31.6 nmol/L and 78.68 ± 19.8 nmol/L, respectively. Only one-third of dancers with insufficient (N = 5) and deficient (N = 5) serum vitamin D levels improved to normal values. It is concluded that professional ballet dancers demonstrate good compliance with self-directed loading doses of vitamin D supplementation but poor compliance with maintenance doses. Poor maintenance compliance may have accounted for the low rates of serum vitamin D level improvement among dancers with insufficient or deficient levels.

18.
Surgeon ; 2019 Aug 10.
Artigo em Inglês | MEDLINE | ID: mdl-31409532

RESUMO

BACKGROUND: Allogeneic blood transfusion has been linked with an increase in the risk of surgical site infections (SSIs) through the mechanism of immunomodulation. However, no studies to date have investigated the direct relationship between blood conserving strategies including antifibrinolytics and wound complications after total hip arthroplasties (THA). METHODS: A systematic review and meta-analysis of published randomised controlled trials (RCTs) to investigate the effect of tranexamic acid (TXA) on wound complications after THAs has been conducted. RESULTS: We identified 25 clinical trials which were suitable for detailed data extraction. There were no trials which utilised TXA in revision THA. All studies reported on wound complications including a total of 1608 patients. Using TXA led to a 2% reduction in the risk of developing wound complications compared to the control group with no significant statistical heterogeneity among the study groups (Risk Difference -0.02, 95%, confidence interval CI -0.04 to -0.00, P = 0.01, Heterogeneity I2 = 0%). However, there was no significant difference in clinical outcomes in terms of antibiotic treatment or surgical intervention among the study groups. TXA also reduced intraoperative, postoperative and total blood loss and led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion with no significant differences in deep venous thrombosis, pulmonary embolisms, or other complications between the study groups. CONCLUSION: TXA reduced blood loss and transfusion rates after primary THA surgery. It also reduced wound complication rates but the clinical significance of this needs further investigation through well designed and adequately powered RCTs.

20.
Bone Joint J ; 101-B(7_Supple_C): 1-2, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31256652
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