Patient-reported outcome measures (PROMs) have failed to highlight differences in function or outcome when comparing knee replacement designs and implantation techniques. Ankle-worn inertial measurement units (IMUs) can be used to remotely measure and monitor the bi-lateral impact load of patients, augmenting traditional PROMs with objective data. The aim of this study was to compare IMU-based impact loads with PROMs in patients who had undergone conventional total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and robotic-assisted TKA (RA-TKA). 77 patients undergoing primary knee arthroplasty (29 RA-TKA, 37 TKA, and 11 UKA) for osteoarthritis were prospectively enrolled. Remote patient monitoring was performed pre-operatively, then weekly from post-operative weeks two to six using ankle-worn IMUs and PROMs. IMU-based outcomes included: cumulative impact load, bone stimulus, and impact load asymmetry. PROMs scores included: Oxford Knee Score (OKS), EuroQol Five-dimension with EuroQol visual analogue scale, and the Forgotten Joint Score. On average, patients showed improved impact load asymmetry by 67% (p=0.001), bone stimulus by 41% (p<0.001), and cumulative impact load by 121% (p=0.035) between post-operative week two and six. Differences in IMU-based outcomes were observed in the initial six weeks post-operatively between surgical procedures. The mean change scores for OKS were 7.5 (RA-TKA), 11.4 (TKA), and 11.2 (UKA) over the early post-operative period (p=0.144). Improvements in OKS were consistent with IMU outcomes in the RA-TKA group, however, conventional TKA and UKA groups did not reflect the same trend in improvement as OKS, demonstrating a functional decline. Our data illustrate that PROMs do not necessarily align with patient function, with some patients reporting good PROMs, yet show a decline in cumulative impact load or load asymmetry. These data also provide evidence for a difference in the functional outcome of TKA and UKA patients that might be overlooked by using PROMs alone

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand. Patient reported outcome measures (PROMs) are predictors of knee arthroplasty revision. Unicompartmental knee arthroplasty (UKA) is effective for patients with the correct indications, however has higher revision rates than total knee arthroplasty (TKA). Different revision thresholds for the procedures have been postulated. Our aims were to investigate: 1) if PROMs could predict knee arthroplasty revision within two years of the score at six months, five years and ten years follow-up, and 2) if revision ‘thresholds’ differed between TKA and UKA. All TKAs and UKAs captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months (TKA n=27,708, UKA n=8,415), five years (TKA n=11,519, UKA n=3,365) or ten years (TKA n=6,311, UKA n=1,744) were included. were propensity-score matched 2:1 with UKAs for comparison of revision thresholds. Logistic regression indicated that for every one-unit decrease in OKS, the odds of TKA and UKA revision decreased by 10% and 11% at six months, 10% and 12% at five years and 9% and 5% at ten years. Fewer TKA patients with ‘poor’ outcomes (≤25) subsequently underwent revision compared with UKA at six months (5.1% vs. 19.6%, p<0.001), five years (4.3% vs. 12.5%, p<0.001) and ten years (6.4%vs. 15.0%, p=0.02). Compared with TKA, UKA patients were 2.5 times more likely to undergo revision for ‘unknown’ reasons, bearing dislocations and disease progression. The OKS is a strong predictor of subsequent knee arthroplasty revision within two years of the score from early to late term. A lower revision threshold was found with UKA when compared with a matched TKA cohort. Higher revision rates of UKA are associated with both lower clinical thresholds for revision and additional modes of UKA failure

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand. The Oxford Knee Score (OKS) is a 12-item questionnaire used to track knee arthroplasty outcomes. Validation of such patient reported outcome measures is typically anchored to a single question based on patient ‘satisfaction’, however risk of subsequent revision surgery is also an important outcome measure. The OKS can predict subsequent revision risk within two years, however it is not known which item(s) are the strongest predictors. Our aim was to identify which questions were most relevant in the prediction of subsequent knee arthroplasty revision risk. . All primary TKAs (n=27,708) and UKAs (n=8,415) captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months, five years or ten years post-surgery were included. Logistic regression and receiver operating characteristics (ROC) curves were used to assess prediction models at six months, five years and ten years. Q1 ‘overall pain’ was the strongest predictor of revision within two years (TKA: 6 months, odds ratio (OR) 1.37; 5 years, OR 1.80; 10 years, OR 1.43; UKA: 6 months, OR 1.32; 5 years, OR 2.88; 10 years, OR 1.85; all p<0.05). A reduced model with just three questions (Q1, Q6 ‘limping when walking’, Q10 ‘knee giving way’) showed comparable or better diagnostic ability with the full OKS (area under the curve (AUC): TKA: 6 months, 0.77 vs. 0.76; 5 years, 0.78 vs. 0.75; 10 years, 0.76 vs. 0.73; UKA: 6 months, 0.80 vs. 0.78; 5 years: 0.81 vs. 0.77; 10 years, 0.80 vs. 0.77). The three questions on overall knee pain, limping when walking, and knee ‘giving way’ were the strongest predictors of subsequent revision within two years. Attention to the responses for these three key questions during follow-up may allow for prompt identification of patients most at risk of revision

Increased collection of patient-reported outcome measures (PROM) in registries enables international comparison of patient-centered outcomes after knee and hip replacement. We aimed to investigate 1) variations in PROM improvement, 2) the possible confounding factor of BMI, and 3) differences in comorbidity distributions between registries. Registries affiliated with the International Society of Arthroplasty Registries (ISAR) or OECD membership countries were invited to report aggregate EQ-5D, OKS, OHS, HOOS-PS and KOOS-PS values. Eligible patients underwent primary total, unilateral knee or hip replacement for osteoarthritis within three years and had completed PROMs preoperatively and either 6 or 12 months postoperatively, excluding patients with subsequent revisions. For each PROM cohort, Chi-square tests were performed for BMI distributions across registries and 12 predefined PROM strata (male/female, age 20-64/65-74/>75, high or low preoperative PROM scores). Comorbidity distributions were reported for available comorbidity indexes. Thirteen registries from 9 countries contributed data, n~130000 knee (range 140 to 79848) and n~113000 hip (range 137 to 85281). Mean EQ-5D index values (10 registries) ranged from 0.53 to 0.71 (knee) and 0.50 to 0.70 (hips) preoperatively and 0.78 to 0.85 (knee) and 0.83 to 0.87 (hip) postoperatively. Mean OKS (6 registries) ranged from 19.3 to 23.6 preoperatively and 36.2 to 41.2 postoperatively. Mean OHS (7 registries) ranged from 18.0 to 23.2 preoperatively and 39.8 to 44.2 postoperatively. Four registries reported KOOS-PS and three reported HOOS-PS. Proportions of patients with BMI >30 ranged from 35 to 62% (10 knee registries) and 16 to 43% (11 hip registries). For both knee and hip registries, distributions of patients across six BMI categories differed significantly among registries (p30 were for patients in the youngest age groups (20 to 64 and 65 to 74 years) with the lowest baseline scores. Additionally, females with lowest preoperative PROM scores had highest BMI. These findings were echoed for the OHS and OKS cohorts. Proportions of patients with ASA scores ≥3 ranged from 7 to 42% (9 knee registries) and 6 to 35% (8 hip registries). PROM-score improvement varies between international registries, which may be partially explained by differences in age, sex and preoperative scores. BMI and comorbidity may be relevant to adjust for

Purpose. Various alignment philosophies for total knee arthroplasty (TKA) have been described, all striving to achieve excellent long-term implant survival and good functional outcomes. In recent years, in search of higher functionality and patient satisfaction, a shift towards more patient-specific alignment is seen. Robotics is the perfect technology to tailor alignment. The purpose of this study was to describe ‘inverse kinematic alignment’ (iKA) technique, and to compare clinical outcomes of patients that underwent robotic-assisted TKA performed by iKA versus adjusted mechanical alignment (aMA). Methods. The authors analysed the records of a consecutive series of patients that received robotic assisted TKA with iKA (n=40) and with aMA (n=40). Oxford Knee Score (OKS) and satisfaction on a visual analogue scale (VAS) were collected at a follow-up of 12 months. Clinical outcomes were assessed according to patient acceptable symptom state (PASS) thresholds, and uni- and multivariable linear regression analyses were performed to determine associations of OKS and satisfaction with 6 variables (age, sex, body mass index (BMI), preoperative hip knee ankle (HKA) angle, preoperative OKS, alignment technique). Results. The iKA and aMA techniques yielded comparable outcome scores (p=0.069), with OKS respectively 44.6±3.5 and 42.2±6.3. VAS Satisfaction was better (p=0.012) with iKA (9.2±0.8) compared to aMA (8.5±1.3). The number of patients that achieved OKS and satisfaction PASS thresholds was significantly higher (p=0.049 and p=0.003, respectively) using iKA (98% and 80%) compared to aMA (85% and 48%). Knees with preoperative varus deformity, achieved significantly (p=0.025) better OKS using iKA (45.4±2.0) compared to aMA (41.4±6.8). Multivariable analyses confirmed better OKS (β=3.1; p=0.007) and satisfaction (β=0.73; p=0.005) with iKA. Conclusions. The results of this study suggest that iKA and aMA grant comparable clinical outcomes at 12-months follow-up, though a greater proportion of knees operated by iKA achieved the PASS thresholds for OKS and satisfaction. Notably. in knees with preoperative varus deformity, iKA yielded significantly better OKS and satisfaction than aMA

Aims. The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales. Methods. We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents’ full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson’s correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments’ minimal clinically important difference (MCID). Results. The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson’s correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient’s CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire. Conclusion. Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy. Cite this article: Bone Jt Open 2022;3(10):786–794

Introduction. This study assessed outcomes of total knee joint replacements (TKJR) in patients who had undergone previous periarticular osteotomy compared with unicompartmental knee replacement (UKR). Establishing a difference in the results of total knee joint replacements following these operations may be an important consideration in the decision-making and patient counselling around osteotomy versus UKR for the management of single-compartment osteoarthritis. Method. Using data from the New Zealand Joint Registry, we identified 1,895 total knee joint replacements with prior osteotomy and 1,391 with prior UKR. Revision rates and patient-reported outcomes, as measured by the Oxford Knee Score (OKS), between these two groups were compared. Adjusted hazard ratios were also calculated to compare the groups. Results. The revision rate for total knee joint replacement following osteotomy was significantly lower than TKJR following UKR (0.88 per 100 component years versus 1.38 per 100 component years, respectively). Adjusted hazard ratio calculations found that those with TKJR with prior UKR had more than double the risk of requiring revision than those with prior osteotomy. Additionally, there was a statistically significant difference in the mean adjusted OKS scores between the two groups, with improved outcomes in the group with prior osteotomy. Conclusion. Our findings suggest that total knee joint replacement following periarticular osteotomy have a lower risk of revision and improved OKS when compared to those with prior UKR. Previous studies assessing New Zealand Joint Registry have not found a statistically significant difference between the two groups however, these results are no longer in keeping with more contemporary literature. Our study confirms the New Zealand population to be comparable with international studies with TKJR after osteotomy performing significantly better compared with prior UKR

Contemporary indications for unicompartmental knee replacement (UKR) include bone on bone radiographic changes in the medial compartment with relatively preserved lateral and patellofemoral compartments. The role of MRI in identifying candidates for UKR is commonplace. The aim of this study was to assess the relationship between radiographic and MRI pre-operative grade and outcome following UKR. A retrospective analysis of medial UKR patients from 2017 to 2021. Inclusion criteria were medial UKR for osteoarthritis with pre-operative and post-operative Oxford Knee Scores (OKS), pre-operative radiographs and MRI. 89 patients were included. Whilst all patients had grade 4 ICRS scores on MRI, 36/89 patients had grade 3 KL radiographic scores in the medial compartment, 50/89 had grade 4 KL scores on the medial compartment. Grade 3 KL with grade 4 IRCS medial compartment patients had a mean OKS change of 17.22 (Sd 9.190) meanwhile Grade 4 KL had a mean change of 17.54 (SD 9.001), with no statistical difference in the OKS change score following UKR between these two groups (p=0.873). Medial bone oedema was present in all but one patient. Whilst lateral compartment MRI ICRS scores ranged from 1 to 4 there was no association with MRI score of the lateral compartment and subsequent change in oxford score (P value 0.458). Patellofemoral Compartment (PFC) MRI ICRS ranged from 0 to 4. There was no association between PFC ICRS score and subsequent change in oxford knee score (P value .276). Radiographs may under report severity of some medial sided knee osteoarthritis. We conclude that in patients with grade 3 KL score that would normally not be considered for UKR, pre-operative MRI might identify grade 4 ICRS scores and this subset of patients have equivalent outcomes to patients with radiographic Grade 4 KL medial compartment osteoarthritis

Patient reported outcome measures (PROMs) after total knee arthroplasty (TKA) are typically used to assess longitudinal change in pain and function after total knee arthroplasty (TKA). The Patient's Knee Implant Performance (PKIP) score was developed to evaluate outcomes more broadly including function, stability, confidence, and satisfaction. Although validated in patients having a primary TKA, the PKIP has not been evaluated as an outcome measure for patients having revision TKA. This study examined patient outcomes at one year following primary and revision TKA measured using the PKIP, compared to Oxford Knee Scores. A retrospective analysis of pre-operative and one-year post-operative outcomes was completed for 39 patients (21 female) who had primary (n=27) or revision (n=12) TKA with a single surgeon between 2017 and 2020. The mean age was 69.2±7.4 years, and mean weight 87.4± 5.1kg. The change over time and correlation between the self-reported outcome measures was evaluated. There was a significant improvement in the PKIP overall score at the 12-month follow-up (32± 13 v 69± 15, p= <0.001), with no significant difference between groups (3.3 points, p=0.50). Among the PKIP sub-scores, there was a significant improvement in knee confidence (3.5±2 vs 7.7±2; p<0.001), stability (3.4±2 vs 7.4±3; p<0.001) and satisfaction (2.5±1.7 vs 6.6±3, p<0.001). Between group differences in PKIP sub-scores one year after surgery were small and non-significant. For all patients, the OKS and PKIP scores were moderately correlated before surgery (r=0.64, p=<0.05), and at 1 year after surgery (r=0.61, p= <0.001). Significant improvements in knee confidence, stability, and satisfaction one year after TKA were identified from the PKIP responses, with no significant difference between primary and revision surgery. The moderate correlation with the OKS suggests these questionnaires measure difference constructs and may provide complementary outcome information in this patient cohort

Most studies comparing medial pivot to the posterior stabilised (PS) systems sacrifice the PCL. It is unknown whether retaining the PCL in the Medial Congruent (MC) system may provide further benefit compared to the more commonly used PS system. A retrospective review of a single-surgeon's registry data comparing 44 PS and 25 MC with PCL retained (MC-PCLR) TKAs was performed. Both groups had similar baseline demographics in terms of age, gender, body mass index, and American Society for Anaesthesiology score. There was no significant difference in their preoperative range of motion (ROM) (104º±20º vs. 102º±20º,p=0.80), Oxford Knee Score (OKS) (27±6 vs. 26±7,p=0.72), and Knee Society Scoring System (KS) Function Score (KS-FS) (52±24 vs. 56±24,p=0.62). The preoperative KS Knee Score (KS-KS) was significantly lower in the PS group (44±14 vs. 54 ± 18,p<0.05). At 3-months postoperation, the PS group had significantly better OKS (38±6 vs. 36±6,p=0.02) but similar ROM (111º±14º vs. 108º±12º,p=0.25), KS-FS (73±20 vs. 68±23, p=0.32) and KS-KS (87±10 vs. 86±9,p=0.26). At 12-months postoperation, both groups had similar ROM (115º±13º vs. 115º±11º,p=0.99), OKS (41±5 vs. 40±5,p=0.45), KS-FS (74±22vs.78±17,p=0.80), and KS-KS (89±10vs.89±11,p=0.75). There was statistically significant improvement in all parameters at 1-year postoperation (p<0.05). The PS group had significant improvement in all parameters from preoperation to 3-month postoperation (p<0.05), but not from 3-month to 1-year postoperation (p≥0.05). The MC-PCLR group continued to have significant improvement from 3-month to 1-year postoperation (p<0.05). The MC provides stability in the medial compartment while allowing a degree of freedom in the lateral compartment. Preserving the PCL when using MC may paradoxically cause an undesired additional restrain that slows the recovery process of the patients after TKA. In conclusion, compared to MC-PCLR, a PS TKA may expect significantly faster improvement at 3 months post operation, although they will achieve similar outcomes at 1-year post operation

There is a lack of evidence as to the best way to deliver rehabilitation following TKA. Previous work has suggested that postoperative physiotherapy applied to all patients is not effective at improving one-year post-surgical outcomes. The aim of this study was to target physiotherapy to those at risk of poor outcome following TKA, and to determine if a therapist-led intervention offered superior results compared to a home-exercise based protocol in this ‘at risk’ group. The Targeted Rehabilitation to Improve Outcomes (TRIO) study was a prospective randomised controlled trial run at 15-centres in the UK. Patients were identified as ‘potential poor outcome’ based on an Oxford Knee Score (OKS) classification at 6-weeks post-surgery and randomised to either therapist-led or home-exercise based protocols. Patients were reviewed by a physiotherapist and commenced 18-exercise sessions over 6-weeks. The therapist-led group undertook a progressive functional protocol (modified weekly in 1-1 contact sessions) in contrast to the static home-exercise based regime. Evaluation took place following rehabilitation intervention, then at 6-months and 1-year post-surgery. Primary outcome was comparative group OKS at 1-year. Secondary outcomes included, ‘worst’ and ‘average’ pain scores, OXS and EQ-5D, and satisfaction questionnaire. Health economic (cost-utility) analysis was undertaken from NHS perspective up to 1-year post-surgery. Incremental cost per Quality Adjusted Life Years (QALYs) were calculated from intervention costs, patient reported primary and secondary care usage, and EQ-5D data. 4264 patients were screened, 1296 were eligible, 334 patients were randomised, 8 were lost to follow-up, therapy compliance was >85%. Clinically meaningful improvement in OKS (between baseline and 1-year) was seen in both arms (p < 0 .001). Between group difference in 1-year OKS was 1.91 (95%CI, −0.17–3.99) points favouring the therapist-led arm (p=0.07). Incorporating all time point data, between group difference in OKS was 2.25 points (95%CI, 0.61–3.90, p=0.008). Small, non-significant reductions (< 5 %) in both worst and average pain scores were observed favouring the therapist-led group. Enhanced satisfaction with pain relief (OR 1.65, p < 0 .02), ability to perform daily functional tasks (OR 1.66, p < 0 .02), and perform heavy functional tasks (OR 1.6, p=0.04) was reported in the therapist-led group. There was a small non-significant difference of 0.02 points (95%CI −0.02–0.06) between groups in EQ-5D, resulting in a £12,125 cost per QALY of delivering the therapist led intervention with a 57% chance of being cost-effective at the standard UK policy threshold of £20,000 per QALY. TRIO is the largest randomised trial of physiotherapy following TKA, and the first to target rehabilitation to patients at risk of poor outcomes. Both therapist-led and home-exercise based rehabilitation groups made clinically meaningful improvements in outcome by 1-year. We observed a modest difference in OKS in favour of therapist-led rehabilitation compared to the home-exercises which was not statistically significant. The relatively tight confidence intervals suggests that any difference which might exist is too small to be clinically relevant. Patient satisfaction with outcome was however higher in those that received greater physiotherapist contact. While cost per QALY estimates were below UK policy threshold, this result is uncertain and insufficient to make accept-decline recommendations

Cementless fixation is an alternative to cemented unicompartmental knee replacement (UKR), with several advantages over cementation. This study reports on the 15-year survival and 10-year clinical outcomes of the cementless Oxford unicompartmental knee replacement (OUKR). This prospective study describes the clinical outcomes and survival of first 693 consecutive cementless medial OUKRs implanted in New Zealand. The sixteen-year survival was 89.2%, with forty-six knees being revised. The commonest reason for revision was progression of arthritis, which occurred in twenty-three knees, followed by primary dislocation of the bearing, which occurred in nine knees. There were two bearing dislocations secondary to trauma and a ruptured ACL, and two tibial plateau fractures. There were four revisions for polyethylene wear. There were four revisions for aseptic tibial loosening, and one revision for impingement secondary to overhang of the tibial component. There was only one revision for deep infection and one revision where the indication was not stated. The mean OKS improved from 23.3 (7.4 SD) to 40.59 (SD 6.8) at a mean follow-up of sixteen years. In conclusion, the cementless OUKR is a safe and reproducible procedure with excellent sixteen-year survival and clinical outcomes

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Little information exists regarding optimal tibial stem usage in revision total knee arthroplasty (rTKA) utilising a tibial trabecular metal (TM) cone. The purpose of this study was to compare 1) functional outcomes, 2) radiographic outcomes, and 3) implant survivorship in rTKA utilising TM cones combined with either short stems (SS) or long stems (LS) at minimum two-years clinical follow-up. In this retrospective, multi-centre study, patients undergoing TM cone utilising rTKA between 2008 and 2019 were included. Patients were divided into: SS group (no diaphyseal engagement), and LS group (diaphyseal engagement). All relevant clinical charts and post-operative radiographs were examined. Oxford Knee Score (OKS) and EuroQol-5D (EQ-5D-5L) data were collected at most recent follow-up. In total, 44 patients were included: 18 in the SS group and 26 in the LS group. The mean time of follow-up was 4.0 years. Failure free survival was 94.5% for the SS group and 92.3% for the LS group. All failures were for prosthetic joint infections managed with debridement, antibiotics, and implant retention. At most recent follow-up, 3 patients demonstrated radiographic signs of lucency (1 SS 2 LS, p = 1) and the mean OKS were 37 ± 4 and 36 ± 6 (p = 0.73) in the SS and LS groups, respectively. Tibial SS combined with TM cones performed as well as LS in rTKA at minimum two-years follow-up. A tibial SS in combination with a TM cone is a reliable technique to achieve stable and durable fixation in rTKA

Abstract. Introduction. We aimed to compare the outcomes of elderly patients with periarticular distal femur or supracondylar periprosthetic fractures treated with either open reduction internal fixation or distal femoral replacement. Methods. A retrospective review of patients over 65 years with AO Type B and C fractures of the distal femur or Su type I and II periprosthetic fractures treated with either a DFR or ORIF was undertaken. Outcomes including Length of Stay, PROMs (Oxford Knee Score and EQ 5D), infection, union, mortality, complication and reoperation rates were assessed. Data on confounding variables were also collected for multivariate analysis. Patients below 65 years and extra articular fractures were excluded. Results. 23 patients (11 in DFR group and 12 in ORIF group) fulfilled inclusion criteria and were included in the analysis. There was no difference between the DFR and ORIF groups with respect to SDI, demographic variables, ASA grade, FCI, preoperative Hb and renal function. There was no difference in 30 day mortality, reoperation rates, 30 day readmission rates and LOS between the two groups. Mean follow up was 12.7 and 15.9 months respectively in the DFR and ORIF groups. At final follow up after accounting for all confounding variables on multivariate analysis, functional outcomes using OKS (adjusted mean: 29.5 vs 15.8) and Health related Quality of Life outcomes using EQ 5D (adjusted mean: 0.453 vs −0.07) were significantly better in the DFR group. Conclusion. DFR for periarticular and periprosthetic distal femoral fractures in the elderly are associated with better patient reported outcomes

The use of rotating hinge (RH) prostheses for severe primary as well as revision arthroplasty is widely established. Aim of this study was to investigate long term results of a new RH prosthesis (EnduRo®, B Braun, Germany), which uses carbon-fiber reinforced poly-ether-ether-ketone (CFR PEEK) as a new bearing material, first time used in knee arthroplasty. Fifty-six consecutive patients, who received the EnduRo® RH prosthesis were included in this prospective study: 21 patients (37.5%) received the prosthesis as a primary total knee arthroplasty (TKA) and 35 patients (62.5%) underwent revision total knee arthroplasties (rTKA). Clinical and radiographic examinations were performed preoperatively as well as postoperatively after 3 and 12 months and annually thereafter. Min. Follow up was 7 and mean follow up 9,3 years. Clinical examination included Knee Society Score (KSS), Western Ontario and McMaster Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), and range of motion (ROM). Competing risk analysis was assessed for survival with respect to indication and failure mode. KSS, WOMAC, OKS, and ROM significantly improved from the preoperative to the follow up investigations (p < 0.0001). There was no difference in clinical outcome between the primary and the revision group. The overall cumulative incidence for revision for any reason was 23.6% and the cumulative incidence for complications associated with failure of the prothesis was 5.6% at 7 years, respectively. Complications occurred more frequently in the revision group (p = 0.002). The evaluated RH prosthesis provided reliable and durable results with a minimum follow-up of 7 years. Prosthesis survival was successful considering the complexity of cases. The use of this RH system in primary patients showed high survival rates. Long-term functional and clinical results proved to be satisfying in both revision and primary cases. No adverse events were associated with the new bearing material CFR-PEEK

This study aimed to analyze the effect of two different techniques of cement application: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term effect of radiolucent lines (RLL) in primary fully cemented total knee arthroplasties (TKA) with patella resurfacing. 379 fully cemented TKAs (318 patients) were included in this monocentric study. Preoperative and postoperative at week 4 and 12 month after surgery all patients had a clinical and radiological examination and were administered the Oxford Knee Score (OKS). Cement was applied in two different ways among the two study groups: cement on bone surface (CoB group) or cement on bone surface and implant surface (CoBaI group). The evaluation of the presence of RLL or osteolysis was done as previously described using the updated Knee Society Radiographic Evaluation System. The mean OKS and range of motion improved significantly in both groups at the 4-week and 12-month follow-up, with no significant difference between the groups (CoB vs. CoBaI). RLL were present in 4.7% in the whole study population and were significantly higher in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up RLL were seen in 29.8% of the TKAs in the CoBaI group, whereas the incidence was lower in the CoB group (24.0% (n.s.)). There were two revisions in each group. None of these due to aseptic loosening. Our study indicated that the application of bone cement on bone surface only might be more beneficial than onto the bone surface and onto the implant surface as well in respect to the short-term presence of RLL in fully cemented primary TKA. The long-term results will be of interest, especially in respect to aseptic loosening and might guide future directions of bone cement applications in TKA

Introduction. Schatzker V & VI tibial plateau fractures are serious life-changing injuries often resulting in significant complications including post-traumatic arthritis. Reported incidence of secondary TKA following ORIF of all tibial plateau fractures is 7.3% and 13% for Schatzker V & VI tibial. This study reports a 15-year single centre experience of CEF of Schatzker V & VI fractures including PROMs and incidence of secondary TKA. This study was approved by the local Institutional board. Materials & Methods. All patients from 2007 – 2022 with Schatzker V or VI fractures treated with CEF were identified from a departmental limb reconstruction registry and included in this retrospective study. Patients’ demographics were collected from electronic institutional patient system. Further data was collected for secondary intervention, adverse events, and alignment at discharge. All deceased patients at the time of the study were excluded. Each participant completed a questionnaire about secondary intervention, EQ-5D-3L and Oxford Knee Score (OKS). Results. 90 patients (from 130 eligible) with an average age of 58.3 years completed the questionnaire. At an average follow up of 7.4 years (SD=3.8) the incidence of secondary TKA was 7.8%. There was no significant correlation between articular incongruity and the incidence of secondary TKA. The mean OKS score was 31.7 (SD=13.3). The mean EQ-VAS was 69.3 (SD=23.3) and the mean EQ-5D Index was 0.595 (SD=0.395), both were significantly lower than UK normal population means. Conclusions. This study is probably one of the largest and with the longest follow-up reporting the outcomes of Schatzker V and VI fractures treated with CEF. It appears that articular incongruity has no significant correlation with secondary TKA. Patients reported EQ-5D-3L scores were significantly lower than those for the normal UK population, and the average EQ-VAS has deteriorated with time. This study would be relevant in counselling and consenting patients with this severe injury

Total Knee Arthroplasty (TKA) is an effective surgery performed for knee osteoarthritis. Despite this success up to 20% of patients are less than fully satisfied. Rotating platform (RP) bearings have demonstrated significant reduction in rates of wear in laboratory studies but thus far have failed to demonstrate a clinical difference compared to fixed bearing (FB) arthroplasty in patients. This may be due to studies limited by small sample size and single centre design. Additionally, no studies have utilised modern patient-reported outcome measures (PROMs) such as PKIP to investigate differences between these bearings. A non-randomised, prospective, multi-centre study was conducted across centres in Australia, United Kingdom and the United States from November 2012 to May 2015. Knee prosthesis included were the RP and FB models of the PFC Sigma Knee (Depuy, Synthes) and the ATTUNE Knee (Depuy, Synthes). Data was collected on pre-arthroplasty interventions, demographics and PROMs. PROMs included were the KOOS, OKS, EQ53DL and PKIP. Participants were followed-up for 2 years. A total of 1,718 patients were recruited across 27 centres. 959 participants underwent a FB TKA, 759 participants underwent a RP TKA. No significant difference was found between RP and FB in change from baseline at 2 years across any parameter in all PROMs investigated at 2 years. Body Mass Index pre-operatively was the biggest indicator of change from baseline at 2 years. Our data demonstrates similar improvements in the short-term in both RP and TKA across all PROMs. Patients reported similar scores in satisfaction, confidence, mobility and stability in the PKIP PROM for both RP and FB groups. We have not found any evidence to suggest that RP TKA is disadvantageous at 2 years, and this is reassuring for any surgeon looking to utilise this bearing type in practice. Our data does not demonstrate a clinical advantage in RP TKA over FB TKA at 2 years in any PROM

Introduction. Robotic-assisted total knee arthroplasty (TKA) has demonstrated significant benefits, including improved accuracy of component positioning compared to conventional jig-based TKA. However, previous studies have often failed to associate these findings with clinically significant improvements in patient-reported outcome measures (PROMs). Inertial measurement units (IMUs) provide a more nuanced assessment of a patient's functional recovery after TKA. This study aims to compare outcomes of patients undergoing robotic-assisted and conventional TKA in the early postoperative period using conventional PROMS and wearable sensors. Method. 100 patients with symptomatic end-stage knee osteoarthritis undergoing primary TKA were included in this study (44 robotic-assisted TKA and 56 conventional TKA). Functional outcomes were assessed using ankle-worn IMUs and PROMs. IMU- based outcomes included impact load, impact asymmetry, maximum knee flexion angle, and bone stimulus. PROMs, including Oxford Knee Score (OKS), EuroQol-Five Dimension (EQ-5D-5L), EuroQol Visual Analogue Scale (EQ-VAS), and Forgotten Joint Score (FJS-12) were evaluated at preoperative baseline, weeks 2 to 6 postoperatively, and at 3-month postoperative follow-up. Results. By postoperative week 6, when compared to conventional TKA, robotic-assisted TKA was associated with significant improvements in maximum knee flexion angle (118o ± 6.6 vs. 113o ± 5.4; p=0.04), symmetrical loading of limbs (82.3% vs.22.4%; p<0.01), cumulative impact load (146.6% vs 37%; p<0.01), and bone stimulus (25.1% vs 13.6%; p<0.01). Whilst there were no significant differences in PROMs (OKS, EQ-5D-5L, EQ-VAS, and FJS-12) at any time point between the two groups, when comparing OKS subscales, significantly more robotic-assisted TKA patients achieved an ‘excellent’ outcome at 6 weeks compared to conventional (47% vs 41%, p= 0.013). Conclusions. IMU-based metrics detected an earlier return to function among patients that underwent robotic-assisted TKA compared to conventional TKA that PROMs were unable to detect within the first six weeks of surgery