Abstract. Introduction. Cryocompression therapy after knee surgery is widely utilised for post-operative rehabilitation. Skin temperature should be reduced to 10–15°C to maximise the therapeutic benefits while avoiding risks of adverse events. Some cryocompression devices offer control over the temperature of the ice-water circulated through a cuff. The degree to which this corresponds to the achieved skin temperature during a treatment is unknown. Methods. 30 healthy participants volunteered for this prospective randomised crossover trial involving the use of a cryocompression device. Each underwent a 30-minute test in all of five conditions: A, B, C, D and Control. Conditions corresponded to device temperature settings of 6, 8, 10, 12°C and no ice-water circulation, respectively. Skin temperature was measured prior to the cuff being applied, then every 5 minutes during a test. Results. Groups A, B, C and D significantly reduced skin temperature relative to the Control condition (p<0.05). Mean baseline skin temperatures did not significantly differ between groups. Mean skin temperatures after 30 minutes were 13.2 ± 1.9°C (Group A), 14.4 ± 1.5°C (Group B), 16.3 ± 1.8°C (Group C), 18.3 ± 1.7°C (Group D), and 30.8 ± 2.3°C (Control). Conclusions. The cryocompression device successfully reduced the skin temperature to within the therapeutic range. However, temperature settings did not correspond to skin temperatures achieved. To optimise the therapeutic benefit of treatment with this device, the 6°C setting is recommended. (Note: these are preliminary results from on an ongoing study, comprising 72% of the final dataset. Full results will be presented at BASK 2022)

Purpose. The purpose was to determine if the use of cold irrigation fluid in routine knee arthroscopy leads to a reduction in post operative pain. Background. Some surgeons use cooled irrigation fluid in knee arthroscopy in the hope that it may lead to a reduction in post operative pain and swelling. There is currently no evidence for this, although there is some evidence to support the use of cold therapy post operatively in knee surgery. Methodology. We conducted a blind randomised controlled trial comparing the use of cooled (4°C) and room temperature irrigation fluid in routine arthroscopic knee surgery. Pain was recorded on a numerical scale (0 to 10) hourly for 3 hours post-operatively, at discharge and daily for 1 week. A detailed record of analgesic consumption was recorded. Patients were randomised into the cooled group (mean age 50.1 years) and the room temperature group (mean age of 46.1 years). Results. The average hourly difference in pain score for the first 3 hours post operatively was 0.12, 0.57, and 0.23 with reduced pain scores in the cooled fluid group, but this did not reach statistical significance. Total analgesic administration in theatre, recovery and the ward was lower in the cooled fluid group, as was the self administration of analgesia for the week after discharge. No increased complications where seen. Conclusion. No significant difference in patient reported pain scores has been demonstrated after the use of cooled irrigation fluid in routine knee arthroscopy. The tendency to a slight reduction in analgesic consumption in the cooled fluid group may have more significant benefits in complex arthroscopic knee surgery such as ligament reconstruction, this requires further study

Aims. The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups. Methods. This prospective randomized controlled trial included 30 patients with osteoarthritis of the knee undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localized knee temperature were collected preoperatively and postoperatively at six hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned postioning of the components in both groups. Results. Patients undergoing conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory and localized thermal response at six hours, day 1, day 2, and day 28 after surgery. Robotic TKA had significantly reduced levels of interleukin-6 (p < 0.001), tumour necrosis factor-α (p = 0.021), ESR (p = 0.001), CRP (p = 0.004), lactate dehydrogenase (p = 0.007), and creatine kinase (p = 0.004) at day 7 after surgery compared with conventional TKA. Robotic TKA was associated with significantly improved preservation of the periarticular soft tissue envelope (p < 0.001), and reduced femoral (p = 0.012) and tibial (p = 0.023) bone trauma compared with conventional TKA. Robotic TKA significantly improved the accuracy of achieving the planned limb alignment (p < 0.001), femoral component positioning (p < 0.001), and tibial component positioning (p < 0.001) compared with conventional TKA. Conclusion. Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (< 48 hours) or late (day 28) postoperative systemic inflammatory response compared with conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced femoral and tibial bone trauma, and improved accuracy of component positioning compared with conventional TKA. Cite this article: Bone Joint J 2021;103-B(1):113–122

Infection remains as one of the major challenges of total joint surgery. One-stage irrigation, debridement and reimplantation or two-stage revision surgery with a temporary implantation of antibiotic eluting bone cement spacer followed by reimplantation are two methods often used to treat infected patients with mixed outcomes. Like bone cement, ultra-high molecular weight polyethylene (UHMWPE) can also be used as a carrier for antibiotics. Recently, we demonstrated that vancomycin and rifampin can be successfully delivered from UHMWPE implants at therapeutic levels to eradicate Staphylococcus aureus biofilm in a lupine animal model. There are regulatory challenges in translating these types of combination devices in to clinical use. One approach is to follow a stepwise strategy, with the first step of seeking clearance for a temporary UHMWPE spacer containing gentamicin sulfate. In this study, we explored the effect of gentamicin sulfate (GS) content in UHMWPE on GS elution rate and antimicrobial activity against methicillin-sensitive S. aureus(MSSA). We also assessed the effect of spacer fabrication on the activity of gentamicin sulfate. We prepared and consolidated UHMWPE/GS blends in varying concentrations. After consolidation, we fabricated test samples with surface area (350mm2) to volume (300mm3) ratio of 1.2 for elution in 1.5ml phosphate buffered saline at body temperature for up to six months and quantified eluted GS content using liquid chromatography – mass spectrometry (LCMS). We assessed the antibacterial activity of the obtained samples in vitro against various concentrations of MSSA (103–106 CFU/ml). Furthermore, we quantified the probability of bacterial colonization of UHMWPE impregnated with GS compared to GS containing bone cement. We assessed any detectable changes in activity of eluted GS caused by spacer fabrication by screening m/z peaks of GS isomers in mass spectra obtained from LC-MS. Gentamicin sulfate activity was not compromised by the elevated temperature and pressure used during spacer fabrication. Elution rate of GS increased with increasing GS content in the blends studied. At comparable elution rates, the GS-loaded UHMWPE was either equivalent or better in terms of antibacterial and anticolonization properties when compared with gentamicin containing bone cement. GS-impregnated UHMWPE is a promising material for temporary spacers

We compared inflammation in the knee after total knee replacement (TKR) for primary osteoarthritis between two groups of patients undergoing joint replacement with and without synovectomy. A total of 67 patients who underwent unilateral TKR were randomly divided into group I, TKR without synovectomy, and group II, TKR with synovectomy. Clinical outcomes, serial serum inflammatory markers (including interleukin-6 (IL-6), CRP and ESR) and the difference in temperature of the skin of the knee, compared with the contralateral side, were sequentially evaluated until 26 weeks after surgery. Pre-operatively, there were no statistically different clinical parameters between groups I and II. At the 26-week follow-up, both groups had a similarly significantly improved American Knee Society clinical score (p < 0.001) and functional score (p < 0.001) with no differences between the groups. Similar changes in serial inflammatory markers were found in both groups, including mean peak levels of IL-6 (189 pg/ml (. sd. 53.4) versus 201 pg/ml (. sd. 49.4) for groups I and II, respectively) and CRP (91 mg/L (. sd. 24.1) versus 88 mg/L (. sd. 23.4), respectively) on the first post-operative day, returning to pre-operative values at two and six weeks, respectively. The mean peak level of ESR for the respective two groups was 46 mm/hr versus 48 mm/hr at two weeks, which had still not returned to its pre-operative mean value at 26 weeks. The elevation in the skin temperature appeared to mirror the peak elevation of the ESR, with a range of 2.5° C to 4.5° C with some reduction at 26 weeks but still exceeding the pre-operative value. We concluded that synovectomy at the time of TKR does not provide any benefit to the clinical outcome or shorten the duration of the inflammatory response after surgery

Introduction. The objectives of this study were to compare the systemic inflammatory reaction, localised thermal response and macroscopic soft tissue injury outcomes in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic total knee arthroplasty (robotic TKA). Methods. This prospective randomised controlled trial included 30 patients with symptomatic knee osteoarthritis undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localised knee temperature were collected preoperatively and postoperatively at 6 hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned limb alignment and implant positioning in both treatment groups. Results. Conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory reaction and localised thermal response at 6 hours, day 1, day 2 and day 28 after surgery. Robotic TKA had reduced levels of interleukin-6 (p<0.001), tumour necrosis factor-α (p=0.021), erythrocyte sedimentation rate (p=0.001), C-reactive protein (p=0.004), and creatine kinase (p=0.004) at day 7 after surgery compared to conventional TKA. Robotic TKA was associated with improved intraoperative preservation of the periarticular soft tissue envelope (p<0.001) and reduced bone trauma (p=0.015) compared to conventional TKA. Robotic TKA improved accuracy of achieving the planned limb alignment (p<0.001), femoral component positioning (<0.001), and tibial component positioning (<0.001) compared to conventional TKA. Conclusion. Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (<48 hours) or late (day 28) postoperative systemic inflammatory responses compared to conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced bone trauma and improved accuracy of implant positioning compared to conventional TKA

This study evaluates high power low frequency ultrasound transmitted via a flat vibrating probe tip as an alternative technology for meniscal debridement in the knee. A limitation of this technology is thermal damage in residual meniscal tissue. An experimental force controlled testing rig was constructed using a 20kHz ultrasonic probe suspended vertically from a load cell. Ex-vivo bovine meniscus samples were harvested from knee joints and cut into uniform 16mm discs. Effect of variation in force (2.5-4.5N) and amplitude of distal tip displacement (242-494μm peak-peak) settings on tissue removal rate (TRR) and penetration rate (PR) was analysed. Temperature elevation in the residual meniscus was measured by embedded thermocouples and residual meniscus histological analysis. The experiment was designed using a response surface quadratic model with input variables treated as continuous, using Design-Expert v.8.0 (Stat-Ease Inc., Minneapolis, MN). Statistical analysis was conducted using PASW Statistics v.18.0 (IBM SPSS Inc., Chicago, IL). As either force or amplitude increases, there is a linear increase in TRR (Mean±SD: 0.9±0.4 to 11.2±4.9mg/s). A corresponding increase is observed in PR (Mean±SD: 0.08±0.04 to 0.73±0.18mm/s). Maximum mean temperatures of 84.6±12.1°C and 52.3±10.9°C were recorded in residual tissue at 2mm and 4mm from the ultrasound probe-tissue interface. Minimum depth of the zone of thermal alteration in residual tissue was 177.4μm. There is an inverse relationship between both amplitude and force, and temperature elevation, with higher amplitude and force settings resulting in less thermal damage. Ultrasonic debridement shows comparable thermal damage to existing meniscal debridement technologies

Aims. This aim of this study was to assess the feasibility of designing and introducing generic 3D-printed instrumentation for routine use in total knee arthroplasty. Materials and Methods. Instruments were designed to take advantage of 3D-printing technology, particularly ensuring that all parts were pre-assembled, to theoretically reduce the time and skill required during surgery. Concerning functionality, ranges of resection angle and distance were restricted within a safe zone, while accommodating either mechanical or anatomical alignment goals. To identify the most suitable biocompatible materials, typical instrument shapes and mating parts, such as dovetails and screws, were designed and produced. Results. Before and after steam sterilization, dimensional analysis showed that acrylonitrile butadiene styrene could not withstand the temperatures without dimensional changes. Oscillating saw tests with slotted cutting blocks produced debris, fractures, or further dimensional changes in the shape of Nylon-12 and polymethylmethacrylate (MED610), but polyetherimide ULTEM 1010 was least affected. Conclusion. The study showed that 3D-printed instrumentation was technically feasible and had some advantages. However, other factors, such as whether all procedural steps can be accomplished with a set of 3D-printed instruments, the logistics of delivery, and the economic aspects, require further study. Cite this article: Bone Joint J 2019;101-B(7 Supple C):115–120

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As has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA).

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Mid-level constraint designs for total knee arthroplasty (TKA) are intended to reduce coronal plane laxity. Our aims were to compare kinematics and ligament forces of the Zimmer Biomet Persona posterior-stabilized (PS) and mid-level designs in the coronal, sagittal, and axial planes under loads simulating clinical exams of the knee in a cadaver model.

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Adenosine, lidocaine, and Mg²⁺ (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery.

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The diagnosis of periprosthetic joint infection (PJI) continues to present a significant clinical challenge. New biomarkers have been proposed to support clinical decision-making; among them, synovial fluid alpha-defensin has gained interest. Current research methodology suggests reference methods are needed to establish solid evidence for use of the test. This prospective study aims to evaluate the diagnostic accuracy of high-performance liquid chromatography coupled with the mass spectrometry (LC-MS) method to detect alpha-defensin in synovial fluid.

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One of the main causes of tibial revision surgery for total knee arthroplasty is aseptic loosening. Therefore, stable fixation between the tibial component and the cement, and between the tibial component and the bone, is essential. A factor that could influence the implant stability is the implant design, with its different variations. In an existing implant system, the tibial component was modified by adding cement pockets. The aim of this experimental in vitro study was to investigate whether additional cement pockets on the underside of the tibial component could improve implant stability. The relative motion between implant and bone, the maximum pull-out force, the tibial cement mantle, and a possible path from the bone marrow to the metal-cement interface were determined.

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The aim of this study was to investigate whether wear and backside deformation of polyethylene (PE) tibial inserts may influence the cement cover of tibial trays of explanted total knee arthroplasties (TKAs).

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The main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray.

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The objective of this study is to assess the use of ultrasound (US) as a radiation-free imaging modality to reconstruct 3D anatomy of the knee for use in preoperative templating in knee arthroplasty.

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The anterior cruciate ligament (ACL) is known to have a poor wound healing capacity, whereas other ligaments outside of the knee joint capsule such as the medial collateral ligament (MCL) apparently heal more easily. Plasmin has been identified as a major component in the synovial fluid that varies among patients. The aim of this study was to test whether plasmin, a component of synovial fluid, could be a main factor responsible for the poor wound healing capacity of the ACL.

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The aim of this study was to compare the ability of tantalum, 3D porous titanium, antibiotic-loaded bone cement, and smooth titanium alloy to inhibit staphylococci in an in vitro environment, based on the evaluation of the zone of inhibition (ZOI). The hypothesis was that there would be no significant difference in the inhibition of methicillin-sensitive or methicillin-resistant Staphylococcus aureus (MSSA/MRSA) between the two groups.

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We propose a state-of-the-art temporary spacer, consisting of a cobalt-chrome (CoCr) femoral component and a gentamicin-eluting ultra-high molecular weight polyethylene (UHMWPE) tibial insert, which can provide therapeutic delivery of gentamicin, while retaining excellent mechanical properties. The proposed implant is designed to replace conventional spacers made from bone cement.

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It is increasingly appreciated that coordinated regulation of angiogenesis and osteogenesis is needed for bone formation. How this regulation is achieved during peri-implant bone healing, such as osseointegration, is largely unclear. This study examined the relationship between angiogenesis and osteogenesis in a unique model of osseointegration of a mouse tibial implant by pharmacologically blocking the vascular endothelial growth factor (VEGF) pathway.