PROBLEM. Since the COVID-19 pandemic of 2020, there has been a marked rise in the use of telemedicine to evaluate patients following total knee arthroplasty (TKA). Telemedicine is helpful to maintain patient contact, but it cannot provide objective functional TKA data. External monitoring devices can be used, but in the past have had mixed results due to patient compliance and data continuity, particularly for monitoring over numerous years. This novel stem is a translational product with an embedded sensor that can remotely monitor patient activity following TKA. SOLUTION. The Canturio™ TE∗ System (Canary Medical) functions structurally as a tibial extension for the Persona® cemented tibial plate (Zimmer Biomet). The stem is instrumented with internal motion sensors (3-D accelerometer and gyroscope) and telemetry that collects and transmits kinematic data. Raw data is converted by analytics into clinically relevant gait metrics using a proprietary algorithm. The Canturio™ TE∗ will monitor the patient's gait daily for the first year and then with lower frequency thereafter to conserve battery power enabling the potential for 20 years of longitudinal data collection and analysis. A base station in the OR activates the device and links the stem and data to the patient. A base station in the patient's home collects and uploads data to the Cloud Based Canary Data Management Platform (Canary Medical). The Canary Cloud is structured as an FDA regulated and HIPPA-compliant database with cybersecurity protocols integrated into the architecture. A third base station is an accessory used in the health care professional's office to perform an on-demand gait analysis of a patient. A dashboard allows the health care professional and patient to monitor objective data of the patient's activity and progress post treatment. MARKET. The early target market for this device includes total joint surgeons who are early adopters of technology and currently utilize technology in their practice. The kinematic data provided by the Canturio™ TE∗ System will enable clinicians to augment patient care by reviewing their objective gait metrics. In the future, this data has the potential to be integrated with other Zimmer Biomet technologies, such as the Rosa™ Knee robotic platform, mymobility™, and sensored devices like iAssist™, to provide the surgeon with a complete pre-surgical functional assessment, intraoperative data, and post-operative functional data. PRODUCT. Persona IQ will be the combination of the proven Persona personalized total knee system with the Canary Medical Canturio™ TE∗. TIMING AND FUNDING. The Canturio™ TE is currently under De Novo FDA review for market clearance; it is not yet available for commercial distribution. The plan is to launch the product in 2021 pending regulatory De Novo grant. This effort is a partnership between Zimmer Biomet and Canary Medical. ∗ The Canturio™ - TE is currently under De Novo FDA review for market clearance; it is not yet available for commercial distribution

BACKGROUND. Trochlear geometry of modern femoral implants is designed for the mechanical alignment (MA) technique for Total Knee Arthroplasty (TKA). The biomechanical goal is to create a proximalised and more valgus trochlea to better capture the patella and optimize tracking. In contrast, Kinematic alignment (KA) technique for TKA respects the integrity of the soft tissue envelope and therefore aims to restore native articular surfaces, either femoro-tibial or femoro-patellar. Consequently, it is possible that current implant designs are not suitable for restoring patient specific trochlea anatomy when they are implanted using the kinematic technique. This could cause patellar complications, either anterior knee pain, instability or accelerated wear or loosening. The aim of our study is therefore to explore the extent to which native trochlear geometry is restored when the Persona. ®. implant (Zimmer, Warsaw, USA) is kinematically aligned. METHODS. A retrospective study of a cohort of 15 patients with KA-TKA was performed with the Persona. ®. prosthesis (Zimmer, Warsaw, USA). Preoperative knee MRIs and postoperative knee CTs were segmented to create 3D femoral models. MRI and CT segmentation used Materialise Mimics® and Acrobot Modeller® software, respectively. Persona. ®. implants were laser-scanned to generate 3D implant models. Those implant models have been overlaid on the 3D femoral implant model (generated via segmentation of postoperative CTs) to replicate, in silico, the alignment of the implant on the post-operative bone and to reproduce in the computer models the features of the implant lost due to CT metal artefacts. 3D models generated from post-operative CT and pre-operative MRI were registered to the same coordinate geometry. A custom written planner was used to align the implant, as located on the CT, onto the pre-operative MRI based model (figure 1). In house software enabled a comparison of trochlea parameters between the native trochlea and the performed prosthetic trochlea (figure 2). Parameters assessed included 3D trochlear axis and anteroposterior offset from medial facet, central groove, and lateral facet. Sulcus angle at 30% and 40% flexion was also measured. Inter and intra observer measurement variabilities have been assessed. RESULTS. Varus-valgus rotation between the native and prosthetic trochleae was significantly different (p<0.001), with the prosthetic trochlear groove being on average 7.9 degrees more valgus. Medial and lateral facets and trochlear groove were significantly understuffed (3 to 6mm) postoperatively in the proximal two thirds of the trochlear, with greatest understuffing for the lateral facet (p<0.05). The mean medio-lateral translation and internal-external rotation of the groove and the sulcus angle showed no statistical differences, pre and postoperatively (figure 3). CONCLUSION. Kinematic alignment of Persona. ®. implants poorly restores native trochlear geometry. The clinical impact of this finding remains to be defined. For figures/tables, please contact authors directly.

Introduction. John Insall described medial release to balance the varus knee; the release he described included releasing the superficial MCL in severe varus cases. However, this release can create instability in the knee. Furthermore, this conventional wisdom does not correct the actual pathology which normally exists at the joint line, and instead it focuses on the distal end of the ligament where there is no pathology. We have established a new protocol consisting of 5 steps to balance the varus knee without releasing the superficial MCL and we tried this algorithm on a series of 115 patients with varus deformity and compared it to the outcome with a similar group that we have performed earlier using the traditional Insall technique. Material and method. 115 TKR were performed by the same surgeon using Zimmer Persona implant in varus arthritic knees. The deformities ranged from 15 to 35 degrees. First, the bony resection was made using Persona instrumentation as recommended by the manufacturer. The sequential balancing was divided into 5 steps (we will show a short video demonstrating the surgical techniques for each step) as follows:. Step 1: Releasing of deep MCL Step 2: Excising of osteophyte. Step 3: Excising of scarred tissue in the posteromedial corner soft phytes Step 4: Excision of the posteromedial capsule in case of flexion contracture Step 5: Releasing the semi-membranous (in gross deformity). We used soft tissue tensioner to balance the medial and lateral gaps. When the gaps are balanced at early step, there was no need to carry on the other steps. We used only primary implant and we did not have to use any constrained implant. We have compared this group with a similar group matched for deformity from previous 2 years where the conventional medial release as described by Insall. Results. We could balance all knees without releasing the superficial MCL ligament as follows:. -In[H1] 31 cases, we were able to balance the knees performing step 1 and step 2 only. -In 35 cases, we had to do step three in addition to 1 and 2 to achieve balance of cases. -In 25 cases, we performed step 4- those cases had pre-operative flexion contracture. -We had to proceed to step 5 only in 14 cases. These patients had the worst deformity in the group. We have used primary TKR in all cases; in 83 cases, we used a CR implant and in the rest, we used PS implant. Comparing this to the earlier conventional release we had to use 11 CCK implant on severe cases. Patient satisfaction was better with the new algorithm group when compared with the traditional release. Preserving the superficial MCL allowed us to maintain stability post-operatively and allowed us to use minimum constraint such as CR in severe deformity. Discussion. Many literatures have confirmed that cutting superficial MCL causes major medial instability after TKA. Releasing or pie crusting the superficial MCL can cause MCL insufficiency. Our protocol enable the surgeon to tackle the pathology rather than take a short-cut and releasing the superficial MCL. Reserving the superficial MCL allowed us to use minimal constraint even in severe deformity of 40 degrees of varus deformity. The conventional release has resulted in some cases instability, forcing us to use higher constraint such as CCK. Conclusion. Although releasing the superficial MCL has been described in different ways in multiple literature, little attention has been paid to the pathology of the posteromedial corner. This paper clearly shows that the complex anatomy of the posteromedial corner require us to pay better attention and this paper present better algorithm reserving the superficial MCL and enabling us to correct the deformity and balancing the soft tissue without instability. We strongly recommend surgeons not to release the superficial MCL because this will create instability in some cases

Background. Multiple retrospective studies have compared UC with traditional bearings and shown comparable results and outcomes when looking at clinical and radiologic variables, complications rates, and implant survivorship; however, debate still exists regarding the optimum bearing surface. The present study seeks to determine whether there are any preoperative patient demographic or medical factors or anatomic variables including femoral condylar offset and tibial slope that may predict use of a UC bearing when compared to a standard CR group. Methods. The study cohort consisted of 117 patients (41 males, 76 females) who underwent primary TKA with the senior author. The implants utilized were either the CR or UC polyethylene components of the Zimmer Persona Total Knee System. Insert selection was based on intraoperative assessment of PCL integrity and soft tissue balancing. Patient demographics (age, gender, BMI) and co-morbidities (hypertension, diabetes, depression, cardiac disease, and lung disease) were recorded. Intraoperative variables of interest included extension and flexion range of motion, estimated blood loss (EBL), tourniquet time, and polyethylene and femoral component sizes. We calculated change in tibial slope and femoral condylar offset from pre- to post-surgery and computed the percentage of patients for whom an increase in tibial slope or femoral condylar offset was determined. Postoperative variables, including length of stay, complication rates and reoperation rates, were recorded. All dependent variables were compared between patients who received the UC component and patients who received the CR component. Continuous variables were assessed using independent samples t-tests, while categorical variables were compared using the chi-square test of independence. Results. There were 39 patients who received a UC insert and 78 patients who received CR insert. Patient age (p = 0.58), BMI (p = 0.34), or sex distribution (p = 0.84) did not differ between the UC and CR groups. Mean LOS (3.59 vs. 3.08; p = 0.017), EBL (54.5 vs. 46.7; p=0.021), and tourniquet time (61.2 vs. 57.4; p=0.032) were greater for the UC group. Intraoperative implant variables, including polyethylene component (p = 0.49), femoral component (p = 0.56), use of a narrow femoral component (p = 0.85), and patellar component size (p = 0,83), were similar between groups. Additionally, preoperative (p = 0.46) and postoperative (p = 0.19) condylar offset and preoperative (p = 0.66) and postoperative (p = 0.23) tibial slope were not different between the groups. However, the proportion of patients for whom tibial slope increased postoperatively was greater for the UC group compared to the CR group (43.6 vs. 21.8% respectively, p=0.018). Conclusions. Our results showed that no preoperative medical co-morbidities or demographic factors predicted use of the UC bearing; however, postoperative tibial slope was increased for a greater number of patients who received the UC implant. Patients who have an increase in their slope from their native anatomy during tibial preparation may require additional balancing of the flexion gap, and use of a UC component may be beneficial in this particular group of patients

Introduction. Early complication post total knee replacement reported to be higher in obese patient in general. Also the outcome of cruciate retaining and PS knee has been fully discussed before and there was no major difference in the outcomes for all the patients overall regardless of their weight. However, the purpose of this paper is to find out if the CR knee has superiority over PS knee in terms of clinical and functional outcomes and if early complication postTKR such as fracture and instability is more common in PS implant than in CR knee. This is a retrospective study comparing two groups of obese patients. The first using PS implant and the other using CR implant. These two groups were matched for age, body mass and severity of deformity. Materials & Methods. At our institution we have been using Persona implant which has the option of using PS insert or a CR. The decision to proceed with CR or PS mainly depends on the availability of the implant and also the ability to well balance the knee in patients. In most patients we try to proceed with CR implant. However, the flow of implant sometime sometimes limit us from using CR or the imbalance in the ligament force us to process with PS implant. We have reviewed a chart of over 200 patients in each group of obese patient they were done within the last three years. All cases had a minimum follow up of 6 months. Those groups were matched for body mass, age and severity of deformity. After matching the groups we documented Knee Society Score (KSS), Knee Society Function Score (KSFS), blood loss, post – operative pain and complications. All surgeries were performed by the same surgeon. Results. Our study showed that the clinical scores (KSS) in both groups were very close while significant differences were observed in functional scores (KSFS) for the CR knee. We had 8 cases of per-prosthetic fracture in the PS group and one in the CR implant. We had 4 revisions in the PS group for instability and MCL insufficiency and non in the CR implant. Infection, wound complication, blood loss, and patient satisfaction were same in both groups. Discussion. This study suggests a significant difference in functional outcomes, especially walking, stair climbing and the use of walking aids, between CR and PS that favors CR implant which may be related to the CR knee retaining proprioception and ligaments tension with balance. In addition, PS knee have more varus-valgus and mid-flexion laxity than CR knee throughout the range of motion which appear clearly in obese patient. On the other hand, the study clearly shows that the decrease incidence of peri-prosthetic fracture in the CR implant which could be easily explained by the fact that a good cortical bone is resected in order to make room for the PS spine. Also, the fact that resecting the posterior cruciate ligament might cause more stress on the implant versus the CR. Instability also were more common in the PS group. We believe this has to do with the fact that the PCL serve as a secondary constraint to the MCL. The presence of the PCL help maintain the stability in case of incidental injury to the MCL during surgery which was reported to be higher in obese patients. Conclusion. There is clear advantage of improving the outcomes or knee scores and decreasing the early postoperative complications in obese patient using CR knee and we strongly recommend using CR implant in obese patients in order to restore functionality faster and reduce the incidence of peri-prosthetic fracture and the revision for instability

Introduction. Early complication post total knee replacement reported to be higher in obese patient in general. Also the outcome of cruciate retaining and PS knee has been fully discussed before and there was no major difference in the outcome. However, the purpose of this paper is to find out if early complication postTKR such as fracture and instability is more common in PS implant than in CR knee. This is a retrospective study comparing two groups of obese patients. The first using PS implant and the other using CR implant. These two groups were matched for age, body mass and severity of deformity. We clearly showed that there is significant increase in peri-prosthetic fracture and instability in the group that use PS implant. Materials & Methods. At our institution we have been using Persona implant which has the option of using PS insert or a CR. The decision to proceed with CR or PS mainly depends on the availability of the implant and also the ability to well balance the knee in patients. In most patients we try to proceed with CR implant. However, the flow of implant sometime sometimes limit us from using CR or the imbalance in the ligament force us to process with PS implant. We have reviewed a chart of over 200 patients in each group of obese patient they were done within the last three years. All cases had a minimum follow up of 6 months. Those groups were matched for body mass, age and severity of deformity. After matching the groups we documented knee score, blood loss, post – operative pain and complications. All surgeries were performed by the same surgeon. Results. We had 7 cases of per-prosthetic fracture in the PS group and non in the CR implant. We had 3 revisions in the PS group for instability and MCL insufficiency. We had non in the CR implant. Infection, wound complication, blood loss, knee score and patient satisfaction were same in both groups. Discussion. Our study clearly show that the decrease incidence of peri-prosthetic fracture in the CR implant which could be easily explained by the fact that a good cortical bone is resected in order to make room for the PS spine. Also, the fact that resecting the posterior cruciate ligament might cause more stress on the implant versus the CR. Instability also were more common in the PS group. We believe this has to do with the fact that the PCL serve as a secondary constraint to the MCL. The presence of the PCL help maintain the stability in case of incidental injury to the MCL during surgery which was reported to be higher in obese patients. Practically the same in both group shows there is no apparent advantage of either implant. Conclusion. There is clear advantage of decreasing the early postoperative complications in obese patient using CR knee and we strongly recommend using CR implant in obese patients in order to reduce the incidence of peri-prosthetic fracture and the revision for instability

PURPOSE. Total knee arthroplasty (TKA) is a successful technique for treating painful osteoarthritic knees. However, the patients' satisfaction is not still comparable with total hip arthroplasty. Basically, the conditions with operated joints were anterior cruciate ligament (ACL) deficient knees, thus, the abnormal kinematics is one of the main reason for the patients' incomplete satisfaction. Bi-cruciate stabilized (BCS) TKA was established to reproduce both ACL and posterior cruciate ligament (PCL) function and expected to improve the abnormal kinematics. However, there were few reports to evaluate intraoperative kinematics in BCS TKA using navigation system. Hence, the aim in this study is to reveal the intraoperative kinematics in BCS TKA and compare the kinematics with conventional posterior stabilized (PS) TKA. Materials and Methods. Twenty five consecutive subjects (24 women, 1 men; average age, 77 years; age range, 58–85 years) with varus osteoarthritis undergoing navigated BCS TKA (Journey II, Smith&Nephew) were enrolled in this study. An image-free navigation system (Stryker 4.0 image-free computer navigation system; Stryker) was used for the operation. Registration was performed after minimum medial soft tissue release, ACL and PCL resection, and osteophyte removal. Then, kinematics including tibiofemoral rotational angles from maximum extension to maximum flexion were recorded. The measurements were performed again after implantation. We compared the kinematics with the kinematics of paired matched fifty subjects who underwent conventional posterior stabilized (PS) TKA (25 subjects with Triathlon, Stryker; 25 subjects with PERSONA, ZimmerBiomet) using navigation statistically. Results. Preoperative tibiofemoral rotational kinematics were almost the same between the three implants groups. Kinematics at post-implantation found that tibia was significantly internally rotated compared to the kinematics at registration in all three implants at maximum extension position (p<0.05), however the tibial rotational position with BCS TKA was significantly externally rotated at maximum extension position, compared to the other two implant position (p<0.05). The tibial rotational position with Triathlon PS TKA was externally rotated at 60 degrees of flexion compared to the other two implant position, however the results were not statistically significant. Discussion and Conclusion. Previous study found that PCL resection changed tibial rotational position and the amount of tibial internal rotation, affecting postoperative maximum flexion angles. This study found that BCS TKA can reduce the amount of rotational changes, compared to conventional PS TKA. Further studies are needed to investigate the kinematic changes in BCS TKA affect the postoperative clinical outcomes

Purpose. Analysis of the morphology of the distal femur, and by extension of the femoral components in total knee arthroplasty (TKA), has been related to the aspect ratio, which represents the width of the femur. Little is known about variations in trapezoidicity (i.e whether the femur is more rectangular or more trapezoidal). This study aimed to quantify additional morphological characteristics of the distal femur and identify anatomical features associated with higher risks of over- or under-sizing of components in TKA. Method. We analyzed the shape of 114 arthritic knees at the time of primary TKA using the pre-operative CT scans. The maximum AP dimension was measured. The mediolateral dimensions were measured on the theoretical distal resection slice at three levels: the posterior region (MLP), the central region (MLC) and the anterior region (MLA) (Fig 1). The ‘aspect’ ratio (MLC/AP) ratio quantified how wide or narrow the shape is. The ‘trapezoidicity’ ratio (MLP/MLA) ratio quantified how rectangular or trapezoidal the shape is. We also quantified the medial and lateral ‘narrowing angles’ in the anterior and central zones (α and β) (Fig 2). The post-operative prosthetic overhang was calculated from CT-scan. We compared the morphological characteristics with those of twelve TKA models scanned using a three-dimensional optical scanning machine (ATOS II, GOM mbH, Braunschweig, Germany) and its photogrammetric analysis software (TRITOP, GOM mbH, Braunschweig, Germany). Results. There were significant variations in both the aspect ratio (1.16±0.07; range 0.98–1.31) and the trapezoidicity ratio (1.21±0.08; range 1.06– 1.46). Femoral trapezoidicity was mostly due to an inward curve of the medial cortex. The multivariate analysis indicated that prosthetic overhang was correlated to the ‘aspect ratio’ (more overhang in narrow femurs, p=0.002), to the ‘trapezoidicity ratio’ (more overhang in trapezoidal femurs, p=0.002), and to the Tibio Femoral Angle (more overhang in valgus knees, p=0.035). The geometries of the twelve specimen components can be compared directly with the morphological findings of this study. Some components had excessively low trapezoidicity ratios (i.e. were too rectangular) such as DePuy LCS and Stryker Scorpio. Other designs had trapezoidicity ratios closer to anatomic values such as Zimmer Nexgen, Zimmer Persona, DePuy Attune and Smith and Nephew Journey (Fig 3). Several components had excessively low anterior lateral narrowing angle (αL) such as DePuy LCS, Stryker Scorpio. All had insufficiently low medial narrowing angles. Conclusion. This study shows that rectangular/trapezoidal variability of the distal femur cannot be ignored. Most of the femoral components, which were tested appeared to be excessively rectangular when compared with the bony contours of the distal femur. These findings suggest that the design of TKA should be more concerned with matching the trapezoidal/rectangular shape of the native femur

Introduction. Previous studies of long-term CoCr alloy femoral components for TKA have identified 3rd body abrasive wear and inflammatory cell induced corrosion (ICIC). The extent of femoral condyle surface damage in contemporary CoCr femoral components is currently unclear. The purpose of this study was to investigate the prevalence and morphology of damage (3rd body scratches and ICIC) at the bearing surface in retrieved TKA femoral components from contemporary designs. Methods. 308 CoCr femoral TKA components were collected as part of an ongoing, multi-institutional orthopedic implant retrieval program. The collection included contemporary designs from Stryker (Triathlon n=48, NRG n=10, Scorpio n=31), Depuy Synthes (PFC n=27) and Zimmer (NexGen n=140, Persona n=1) and Biomet (Vanguard n=51). Hinged knee designs and unicondylar knee designs were excluded. Components were split into groups based on implantation time: short-term (1–3y, n=134), intermediate-term (3–5y, n=73) and long-term (6–15y, n=101). Each grouping was mainly revised for instability, infection and loosening. Third-body abrasive wear of CoCr was evaluated using a semi-quantitative scoring method similar to the Hood method (Figure 1). A score of 1 had minimal damage and a score of 4 corresponded to damage covering more than 50% of the evaluated area. ICIC damage was reported as location of affected area. A white light interferometer (Zygo New View 5000) was also used to analyze the topography of severe damage of the bearing surface. For this analysis, three representative components from each cohort were selected and analyzed in three locations on the apex of the bearing surface. We analyzed the following roughness parameters: Ra, Rsk, and Rku. Results. On the CoCr bearing surface, the primary damage mechanisms were large scratches, small random scratches, and ICIC damage (Figure 2). Mild to severe damage (Damage Score ≥ 2) was observed in 96% of the short-term, 98% intermediate-term and 94% of long-term components. Severe damage (Damage Score = 4) was observed in 43% of the short-term, 50% intermediate-term and 56% of long-term components. ICIC damage observed on a portion of the bearing surface was detected in 43% of the short-term components, 30% of the intermediate-term components and 26% of the long term components. Apparent ICIC damage on the bearing and/or a non-bearing region of the component was observed in 85% of the short-term components, 75% of the intermediate-term components and 80of long-term TKA components. The Ra, Rsk, and Rku were similar between cohorts (Table 1). Discussion. Abrasive wear of the femoral components was frequently observed in retrieved contemporary femoral components for TKA, regardless of their implantation time, and can most likely be attributed to third body damage caused by bone or bone cement debris. The prevalence of severe CoCr damage scores was highest in the long-term cohort, while the appearance of ICIC damage was lowest in the long-term cohort. Surface roughness parameters were similar in all three cohorts suggesting that the mechanism for this damage is comparable throughout the first 15 years of service. Future work is necessary to quantify the in vivo release of CoCr from abrasive wear and corrosion mechanisms, and the effects of increased surface roughness on wear of the polyethylene counter face