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Introduction: The results of primary total knee replacement (TKR) using hinge implants performed in the Indian population with post-polio residual paresis (PPRP) are unknown. The purpose of this study was to report the outcome of primary rotating hinge TKR in Indian patients with PPRP at a minimum follow-up of 12 months., Materials and Methods: We retrospectively reviewed the clinical and radiological records of six patients treated with primary rotating hinge TKR. Pre-and post-operative (at final follow-up) knee range of motion (ROM), knee sagittal deformity, knee society score (KSS), and Oxford knee score (OKS) were compared to determine improvement in function., Results: Six rotating hinge TKRs (five female and one male patient) were analyzed for this study. At a mean follow-up of 27 ± 22 months (range, 12-71 months), the mean pre-operative KSS of 50.6 ± 2.5 significantly improved (P < 0.0001) to 72.5 ± 1.6, and the mean pre-operative OKS of 23.6 ± 1.6 significantly improved (P < 0.0001) to 35.3 ± 1.7. The mean pre-operative knee ROM of 94° ± 10° changed to 92° ± 4° (P = 0.64) and the mean pre-operative sagittal deformity of 7° ± 23.5° changed to -3° ± 2.5° (P = 0.32) at final follow-up. None of the knees had any intra- or post-operative complications or showed radiologic evidence of post-operative loosening, subsidence, or periprosthetic radiolucent lines at the final follow-up., Conclusion: Rotating hinge TKR gave excellent clinical and radiological results at a mean follow-up of 27 months in the present study. Despite TKR being a technically challenging procedure in patients with poliomyelitis-affected limbs, a rotating hinge design, along with meticulous surgical technique, can significantly improve function in such patients., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Several finite element (FE) studies reported performances of various lumbar fusion surgical approaches. However, comparative studies on the performance of Open Laminectomy plus Posterolateral Fusion (OL-PLF) and Open Laminectomy plus Transforaminal Interbody Fusion (OL-TLIF) surgical approaches are rare. In the current FE study, the variation in ranges of motions (ROM), stress-strain distributions in an implanted functional spinal unit (FSU) and caudal adjacent soft structures between OL-PLF and OL-TLIF virtual models were investigated. The implanted lumbar spine FE models were developed from subject-specific computed tomography images of an intact spine and solved for physiological loadings such as compression, flexion, extension and lateral bending. Reductions in the ROMs of L1-L5 (49 % to 59 %) and L3-L4 implanted FSUs (91 % to 96 %) were observed for both models. Under all the loading cases, the maximum von Mises strain observed in the implanted segment of both models exceeds the mean compressive yield strain for the vertebra. The maximum von Mises stress and strain observed on the caudal adjacent soft structures of both the implanted models are at least 22 % higher than the natural spine model. The findings indicate the risk of failure in the implanted FSUs and higher chances of adjacent segment degeneration for both models., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interests., (Copyright © 2024 IPEM. Published by Elsevier Ltd. All rights reserved.)

Purpose: This study aimed to report changes in sexual activity and related difficulties and concerns among Indian patients at the end of 1-year after primary total hip arthroplasty (THA)., Materials and Methods: A detailed questionnaire related to sexual difficulty, frequency, position, satisfaction, stress, and concerns pre- and postoperatively was administered through an in-person interview at 1-year post-THA., Results: Preoperatively, 77% of patients reported difficulties in sexual activities, which reduced significantly (p < 0.0001) to 30% at the end of 1-year post-operatively. A majority of patients reported no change in the frequency (56.5%) or satisfaction with their sexual activity (54%), and moderate to severe stress (53%) related to sexual activity at 1 year postoperatively. A significantly higher percentage (p = 0.01) of female patients (63%) reported changing their coital position postoperatively due to difficulty in leg positioning when compared to male patients (37.5%). Most patients (69%) were not able to procure information on sexual activity after THA surgery. and only 17.5% of patients discussed the topic with their surgeon., Conclusion: Although THA significantly reduced difficulty in sexual activity, most patients reported no change in the frequency of sexual activity or sexual satisfaction, had moderate to severe stress regarding sex, and were primarily concerned about safety of coital position and fear of dislocation at the end of 1-year postoperatively. Pre- and postoperative counselling by their surgeons will provide the patient with relevant information and help reduce anxiety and stress, improve satisfaction, and enhance the overall sexual health of the patient undergoing primary THA., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Despite increased usage of telemedicine to deliver treatment during the coronavirus disease 2019 (COVID-19) pandemic, the efficacy of telerehabilitation for spine pain is unknown. This study aimed to investigate the effect of telerehabilitation on pain and disability in patients with spine pain treated during the COVID-19 pandemic and compare the results to in-clinic rehabilitation., Materials & Methods: In this propensity score-matched analysis, 428 patients with spine pain who underwent telerehabilitation during the 6 months of COVID-19 pandemic lockdown and 428 patients who underwent in-clinic multimodal rehabilitation treatment during the 6-month period prior to lockdown were compared. Propensity score matching was done based on gender, age, pre-treatment pain, and disability. Post-treatment numerical pain rating scale (NPRS), Oswestry or Neck disability index (ODI or NDI), and minimal clinical important difference (MCID) achieved for NPRS and ODI/NDI scores were compared between the 2 groups., Results: Post-treatment, the mean NPRS (mean difference - 1, p  < 0.0001) and ODI/NDI (mean difference - 5.8, p  < 0.0001) scores, were significantly lower in the telerehabilitation group when compared to control group. Similarly, the percentage of patients who achieved MCID of ≥ 2 for NPRS (mean difference - 6%, p  = 0.0007) and MCID of ≥ 10 for ODI/NDI (mean difference - 7.5%, p  = 0.005) scores were significantly higher in the telerehabilitation group., Conclusions: Telerehabilitation achieved significant reduction in pain and disability among patients with spine pain, better than in-clinic rehabilitation. These encouraging results during the COVID-19 pandemic indicate the need to further explore and test the efficacy and wider application of telerehabilitation for treating spine pain.IMPLICATIONS FOR REHABILITATIONTelerehabilitation can help achieve significant reduction in pain and disability among patients with spine pain.These encouraging results indicate the need to further explore a wider application of telerehabilitation for treating patients with spine pain during non-pandemic times.

Background: Although many studies have investigated the physical and ergonomic risks of spine pain in specific occupation groups, the literature is lacking on occupation-based clinical and psychological presentation in patients with spine pain., Objective: To analyze occupation-based variation in demographic, clinical, and psychological presentation in patients with spine pain., Methods: This retrospective study analyzed the clinical data of 71727 patients with spine pain visiting a chain of spine rehabilitation clinics. Demographic and clinical variables such as gender, age, affected site, symptom duration, clinical symptoms and presentation, pain intensity, disability, and STarT Back Screening Tool (SBT) risk were compared between 9 occupational groups., Results: The service and sales workers (44%) and students (43.5%) groups had the highest percentage of patients who presented with central spine pain; military personnel had the highest percentage of patients who presented with unilateral radicular pain (51.5%); and the retired or unemployed group had the highest percentage of patients who presented with severe myotomal loss (grade≤3) (6%). Homemakers had significantly higher pain intensity and disability (p < 0.001) and had the highest percentage of patients who presented with severe pain (47%), severe and crippled disability (59.5%), and medium to high risk (59%) with SBT when compared to other occupational groups., Conclusion: Patients with spine pain showed variation in demographic, clinical, and psychological presentation based on their occupation. The findings of this study can be the basis for identifying risk factors for spine pain and helping plan preventive and treatment measures based on their occupation.

Objective  To determine the correlation between posttreatment trunk range of motion (ROM) and isometric strength (TIS) and pain and disability in patients who underwent multimodal rehabilitation for low back pain (LBP). Methods  In this prospective cohort study, 122 patients undergoing multimodal rehabilitation for LBP were analyzed. The pre- and posttreatment numerical pain rating scale (NPRS) and the Oswestry disability index (ODI) scores, as well as trunk ROM and TIS were compared. The Pearson correlation was used to determine correlation between posttreatment clinical outcomes and ROM and TIS. Results  At the end of treatment, the mean NPRS ( p  < 0.0001) and ODI ( p  < 0.0001) scores, mean trunk extension ( p  < 0.0001), and flexion ( p  < 0.0001) ROMs improved significantly. Similarly, posttreatment, the mean extension ( p  < 0.0001) and flexion ( p  < 0.0001) TISs improved significantly. There was a weak correlation between the NPRS score and ROM extension (r = -0.24, p  = 0.006) and flexion strength (r = -0.28, p  = 0.001), as well as between the ODI score and TIS extension (r = -0.30, p  = 0.0007) and flexion (r = -0.28, p  = 0.001). Conclusion  Despite significant improvement in pain, disability, trunk ROM, and TIS with multimodal treatment, there was a weak correlation between posttreatment pain and function and trunk ROM and TIS. Improvement in pain and function with physical rehabilitation treatment for LBP is a complex phenomenon and needs further investigation., Competing Interests: Conflito de Interesses Os autores não têm conflito de interesses para declarar., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Purpose: The outcomes of the constrained condylar knee (CCK) implant used during primary total knee arthroplasty (TKA) in knees with severe varus in patients from low- and middle-income countries (LMICs) such as Iraq are not known. Hence, this study aimed to analyze and report the functional outcome of CCK TKA in patients with severe varus deformities at the end of 5 years in Iraqi patients., Methods: In this prospective study, pre- and post-operative (at the end of 5 years) clinical outcome using Knee Society Score (KSS) and radiological deformity using hip-knee-ankle (HKA) angle was analyzed in 76 CCK TKAs (20 bilateral and 36 unilateral TKAs) performed in 56 patients with severe varus deformity (> 15°)., Results: At a mean follow-up of 60.3 months (range 60-68 months), the mean preoperative KSS knee score of 6.6 ± 4.5 improved significantly (p < 0.0001) to 87.2 ± 6.6 and the mean preoperative KSS function score of 7.1 ± 6.4 improved significantly (p < 0.0001) to 70.4 ± 7.8. The function score was good to excellent in 64.3% (36 patients), fair in 28.5% (16 patients), and poor in 7.1% (4 patients) at the end of 5 years. The mean preoperative HKA angle significantly improved (p < 0.001) from 25.5° ± 6° varus (range 17°-37°) to 3° ± 2.5° varus (range 0°-7.5°) at final follow-up., Conclusion: The CCK implant significantly improved pain and function in patients with severe varus deformity at the end of 5 years. The CCK implant is a good option during primary TKA in severe varus knees in patients from LMICs and can help achieve clinical outcomes similar to patients from high-income countries., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Surgery is often prescribed to patients with significant reduction in standing time (ST) and walking time (WT) due to degenerative lumbar spondylolisthesis (DLS). The efficacy of a multimodal physical rehabilitation protocol (MPRP) in improving ST and WT in patients with DLS is not known., Objective: To investigate the effect of MPRP on ST and WT in patients with DLS and compare the results with similar patients treated with other physiotherapy treatment (OPT) methods., Methods: Outcomes including numerical pain rating scale (NPRS) and Oswestry disability index (ODI) scores, ST and WT were compared in patients in the MPRP and OPT groups., Results: Data from 25 patients in MPRP group and 10 patients in OPT group were analyzed. In the MPRP group, the mean NPRS and ODI scores, ST, and WT improved significantly ( p < .0001) after MPRP at a mean follow-up of 328 days. The mean NPRS score was significantly lower ( p = .0001); mean ST ( p = .03), and mean WT ( p = .03) were significantly higher; and the mean NPRS improvement ( p < .0001), mean ST improvement ( p = .001), and mean WT improvement ( p = .008) were significantly higher in MPRP group when compared to the OPT group at final follow-up., Conclusion: Patients with low-grade DLS showed significant improvement in ST and WT after MPRP when compared to similar patients who underwent other physiotherapy treatments. These encouraging results indicate that MPRP can be utilized as a primary treatment option in patients with significantly reduced ST and WT due to DLS.

Anterior Cervical Discectomy and Fusion (ACDF) is the most popular and effective procedure for patients with intervertebral disc degeneration, where the degenerated disc is replaced with an interbody implant (widely known as cage). The design of the cage plays a vital role since it has to provide stability for the anterior cervical column without any side-effects. We designed a novel S-type dynamic cage for C4-C5 level, using Polyetheretherketone (PEEK) material considering four different shapes namely: square, circle, rectangle and elliptical, for the central window to occupy bone graft. The major design constrain for a successful cage is minimized cage stress, in order to avoid subsidence. Finite Element (FE) analysis results revealed that the cage stress values obtained during the physiological motion varied depending upon the shape of the central window provided for bone graft. The objective of this study is to optimize the central window shape using the Teaching Learning Based Optimization (TLBO) algorithm. It was found that square and elliptical shape bone graft cavity resulted in better outcomes. Additional experimental study was also conducted with a six-axis spine simulator. Based on the optimization results, we manufactured two PEEK cage models with square and elliptical shaped central window using additive manufacturing. A prototype model of the C4-C5 level made of Polyvinylchloride (PVC) was used for experiment due to the existing constraints for using a cadaveric model. The experimental results were cross-verified using FE analysis. Thus, we would like to conclude that square and elliptical shape of the central window were the better design factor for our novel dynamic cage., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 IPEM. Published by Elsevier Ltd. All rights reserved.)

Aim: This survey of spine surgeons aimed to determine the prevalence of neck pain and identify the associated risk factors. The prevalence of neck pain has been reported in various medical sub-specialities including laparoscopy surgeons, dentists, plastic surgeons, ophthalmologist, urologist and orthopaedic surgeons. However, the literature is lacking on prevalence and risk factors for neck pain in spine surgeons., Methods: A survey questionnaire containing demographic, Neck pain and work practice details was administered to 300 spine surgeons (members of an online group) via text message and e-mail., Results: One hundred and eighty surgeons responded to the survey (response rate, 60%). Three spine surgeons had previous cervical spine surgeries. The 1-month prevalence rate of neck pain was 74.4% (134/180 surgeons). One hundred and eighteen surgeons (88%) reported only neck pain, 16 surgeons (11.9%) had neck pain with radicular arm pain. Only 20.5% of surgeons used a loupe, 18% of surgeons used a microscope, and 24% of surgeons used operating table height at umbilicus during surgery. There was no significant difference between the mean age (p = 0.65), work experience (p = 0.8), time spent in surgery (p = 0.7), and operating table height preference (p = 0.4) when symptomatic and asymptomatic groups were compared. However, a significantly greater percentage of surgeons had a sedentary lifestyle (p = 0.002) & used loupes as compared to microscopes (p = 0.04) in the symptomatic group. There was significant correlation between the surgeon's lifestyle & use of loupe and the incidence of neck pain., Conclusion: Spine surgeons have a higher prevalence of neck pain than general populations and surgeons from other specialties. Considering the high prevalence of neck pain, general health, work, and ergonomic guidelines and recommendations must be formulated to help prevent and decrease the burden of neck pain among spine surgeons., (© 2022 Delhi Orthopedic Association. All rights reserved.)

Purpose: To determine predictors of failure to achieve minimal clinical important difference (MCID) for pain and disability at discharge after mechanical diagnosis and therapy (MDT)-based multimodal rehabilitation for neck pain (NP)., Methods: Pre- and post-treatment numerical pain rating scale (NPRS) and neck disability index (NDI) in patients with mechanical NP were analysed in this retrospective study. Multivariate analysis was performed to investigate the effect of covariates such as age, gender, lifestyle, body mass index, presentation, diabetes, osteoporosis, response to repeated movement testing, treatment sessions, compliance rate, and pre-treatment NPRS and NDI scores on failure to achieve MCID of ≥ 30% for NPRS and NDI scores post-treatment., Results: In the 4998 patients analysed for this study, 7% and 14.5% of patients failed to achieve MCID for NPRS and NDI scores, respectively, at the end of treatment. Age > 70 years, diabetes, osteoporosis, partial or non-response to repeated movements, lesser treatment sessions, and lower compliance rate were associated with increased risk for failure to achieve MCID for NPRS and NDI scores. A higher pre-treatment NDI score was associated with failure to achieve MCID for NPRS score, whereas lower pre-treatment NPRS and NDI scores were associated with failure to achieve MCID for NDI score., Conclusion: Although MDT-based multimodal rehabilitation helped to achieve significant reduction in pain and disability in mechanical NP, several baseline risk factors were associated with failure to achieve MCID for pain and disability after treatment. Identifying and modifying these factors as part of rehabilitation treatment may help to achieve better outcomes in mechanical NP., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Dislocation after total hip arthroplasty (THA) partly under the surgeon's control, by appropriate placement of the components. We aimed in this study to determine the accuracy of using intra-operative smartphone applications (Apps) to place the acetabular cup within the safe abduction angle by less experienced surgeons during THA surgery when compared to the conventional freehand technique for cup placement., Methods: Sixty primary THAs were performed, 30 using the conventional freehand technique (control group) and 30 using the smartphone app technique (study group) to determine the acetabular cup abduction angle by the same young surgeon with less than one year of experience. Postoperative mean cup abduction angle, mean cup anteversion angle, and the percentage of cups within the safe abduction zone as measured on radiographs were compared between the two groups., Results: In the study group, the mean cup abduction angle was significantly lower ( P=0.0008 ), and the acetabular cup was placed within the safe zone in a significantly higher ( P<0.001 ) percentage of patients (93% vs 63%) when compared to the control group. However, there was no significant difference ( P=0.40 ) between the two groups when the mean cup anteversion angle was compared., Conclusion: The smartphone app technique may help achieve an accurate acetabular cup abduction angle and a higher percentage of cups placed within the safe zone of abduction by a less experienced surgeon when compared to the conventional freehand technique. Using tools such as the smartphone app to measure the acetabular cup position can reduce intraoperative errors by young and less experienced surgeons during THA surgery.

Background: Although many studies have investigated the prevalence of low back pain (LBP) among Indian subjects, no meta-analysis has been conducted to determine the comprehensive epidemiological point, annual, lifetime prevalence of LBP among Indian subjects., Objective: The purpose of this systematic review and meta-analysis was to investigate the point, annual, and lifetime prevalence of LBP in the Indian population., Methods: We searched PubMed, Embase, Science Direct, and Cochrane Library databases for relevant studies that reported point, annual, or lifetime prevalence of LBP among Indian subjects. Pooled point, annual and lifetime prevalence rates were calculated. Meta-analysis, subgroup analysis, sensitivity analysis and publication bias assessment were performed., Results: Ninety-seven studies were included in this review. Fifty-four studies included in the review (55.5%) were found to be of higher methodological quality. The pooled point, annual, and lifetime prevalence of LBP in India was 48% (95% CI 40-56%); 51% (95% CI 45-58%), and 66% (95% CI 56-75%), respectively. The pooled prevalence rates were highest among females, the rural population, and among elementary workers., Conclusion: The point, annual, and lifetime prevalence rates of LBP in the Indian population is higher compared to global and other ethnic populations affecting a large proportion of the population, especially among women, rural population and in elementary workers. The findings of this study can be the basis for formulating policy regarding the prevention and treatment of LBP in a large part of the global population.

Purpose: In navigated TKA, the risk of notching is high if femoral component sagittal positioning is planned perpendicular to the sagittal mechanical axis of femur (SMX). We intended to determine if, by opting to place the femoral component perpendicular to distal femur anterior cortex axis (DCX), notching can be reduced in navigated TKA., Methods: We studied 171 patients who underwent simultaneous bilateral computer-assisted TKA. Femoral component sagittal positioning was planned perpendicular to SMX in one knee (Femur Anterior Bowing Registration Disabled, i.e. FBRD group) and perpendicular to DCX in the opposite knee (Femur Anterior Bowing Registration Enabled, i.e. FBRE group). Incidence and depth of notching were recorded in both groups. For FBRE knees, distal anterior cortex angle (DCA), which is the angle between SMX and DCX, was calculated by the computer., Results: Incidence and mean depth of notching was less (p = 0.0007 and 0.009) in FBRE versus FBRD group, i.e. 7% versus 19.9% and 0.98 mm versus 1.53 mm, respectively. Notching was very high (61.8%) in FBRD limbs when the anterior bowing was severe (DCA > 3°) in the contralateral (FBRE) limbs., Conclusion: Notching was less when femoral component sagittal positioning was planned perpendicular to DCX, in navigated TKA., Level of Evidence: Therapeutic level II., (© 2021. The Author(s).)

Background: A combination of immune-mediated vascular damage and routine use of systemic corticosteroid (CS) therapy in COVID-19 may significantly increase the risk and burden of osteonecrosis (ON) after COVID-19. This narrative review explores the pathogenesis, risk factors, and possible preventive and early treatment measures for ON in COVID-19., Methods: For this narrative review, an extensive literature search was performed using the PubMed, Medline, and Science Direct databases from January 2000 to August 2021 for relevant articles on etiopathogenesis, epidemiology, clinical manifestations, and treatment of severe acute respiratory syndrome coronavirus (SARS-CoV) infection and steroid-induced ON (SION)., Results: Pathogenesis of COVID-19, utility of corticosteroids in the treatment of COVID-19, pathogenesis of SION vis-a-vis SARS-CoV infection, associated risk factors, and early diagnosis and treatment of ON following CS therapy of SARS-CoV infection were discussed., Conclusion: Preliminary data of COVID-19 and similar trends from the SARS 2003 epidemic indicate that the "angiocentric" pathogenesis of SARS-CoV-2 and treatment with high-dose CS may increase the risk of ON in COVID-19 patients. Risk stratification based on CS intake during COVID-19 treatment can help identify subjects at moderate to high-risk for ON where early preventive and follow-up plans can be initiated., Competing Interests: Conflict of InterestThe author declares that he has no conflict of interest., (© Indian Orthopaedics Association 2021.)

Study Design: Retrospective., Objective: The aim of this study was to investigate the effect of body mass index (BMI) on pain and disability in patients with chronic mechanical low back pain (LBP) treated with multimodal rehabilitation., Summary of Background Data: Despite being a well-known risk factor for developing LBP, there is minimal data on the effect of BMI on pain and disability in patients with chronic mechanical low back pain (LBP) treated with multimodal rehabilitation., Methods: Data from patients with chronic mechanical LBP who underwent multimodal rehabilitation treatment at a chain of spine rehabilitation outpatient clinics in one of the three BMI groups-1564 patients in normal body weight (BMI ≥18.5-24.9), 1990 patients in overweight (BMI ≥25-29.9), and 891 patients in obese (BMI ≥ 30) groups-were retrospectively analyzed. Pre- and post-treatment Numerical Pain Rating Scale (NPRS) and Oswestry Disability Index (ODI) scores, and final treatment outcomes were compared between the three groups. Multivariate analysis was used to determine the association between pre-treatment covariates and post-treatment clinical outcomes., Results: Post-treatment, the mean NPRS (P = 0.005) and mean ODI (P < 0.001) scores were significantly higher with a significantly lower percentage of full success outcome (P = 0.009) in the obese group when compared to normal and overweight groups. However, multivariate analysis showed a significant correlation between age, the number of treatment sessions, pre-treatment NPRS and ODI scores, and post-treatment NPRS and ODI scores and treatment failure, and no correlation with patient BMI., Conclusion: Patient BMI may not affect pain and disability outcomes in patients undergoing a multimodal rehabilitation treatment for chronic LBP. In contrast to BMI, other covariates such as age, treatment sessions, and pre-treatment NPRS and ODI scores may be associated with increased risk for poor treatment outcome. Obese individuals can expect clinical outcomes similar to normal or overweight individuals with multimodal physical rehabilitation for chronic LBP.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Variations in cage design, material, and graft shape can affect osteointegration and adjacent segment range of motion (ROM) and stress after anterior cervical discectomy and fusion (ACDF) surgery. This study aimed to evaluate the biomechanical properties of a novel dynamic cervical cage design in both titanium (Ti) and polyether ether ketone (PEEK) with variations in bone graft shape using a single level ACDF (FE) model., Methods: A 3-dimensional C3-C6 FE model was developed using computed tomography scan data from a healthy male subject. The novel S-shaped dynamic interbody fusion cage with a zero-profile fixation was inserted at the C4-C5 level with 4 different bone graft shapes (square, circular, rectangular, and elliptical). Changes in segmental ROM and maximum von Mises stresses at the fusion and adjacent segments were analyzed., Results: Both Ti and PEEK cages showed decreased ROM at the fusion and adjacent levels for all shapes of bone graft when compared with the intact spine model. The elliptical graft, for both Ti and PEEK cages, showed a lower percentage of reduction in segmental ROM at the fusion and adjacent levels (0%-5.6%) when compared with other graft shapes (0%-12%). Maximum stresses at the fusion level were lowest in Ti cage with elliptical graft (229.8-347.6 MPa) when compared with other shapes (241.2-476.2 MPa) in flexion, extension, and lateral bending. For the bone graft, maximum stresses were highest on the elliptical-shaped bone graft in flexion and extension in the Ti cage, and in flexion and lateral bending in the PEEK cage., Conclusions: Both Ti and PEEK cages showed decreased ROM at the fusion and adjacent levels for all shapes of bone graft when compared with the intact spine model. In the Ti and PEEK dynamic cages, the elliptical shape bone graft showed decreased stress on the cage and increased stress on the bone graft. Further experimental and clinical studies are needed to confirm these encouraging biomechanical results of this novel dynamic, zero-profile fusion device with elliptical bone graft in ACDF surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To determine normative reference values for trunk range of motion (ROM) and isometric strength (TIS) in asymptomatic young, Indian adults., Methods: Age, gender, body mass index, lifestyle, and dynamometer-based device measurements of trunk ROM and TIS in extension (EXT), flexion (FLX), and rotation (ROT) were recorded and analysed in 80 asymptomatic subjects between 20 and 40 years of age. Correlation analysis was performed to determine factors influencing EXT and FLX ROM and TIS., Results: The normative reference values for mean trunk EXT, FLX, right ROT, and left ROT ROM were 23° (95th percentile 31.9°), 40.2°(95th percentile 51.5°), 36.8°(95th percentile 57.7°), and 35.4° (95th percentile 55.7°), respectively; and for mean EXT, FLX, right ROT, and left ROT TIS were 118.1 Nm (95th percentile 278.8 Nm), 63.8 Nm (95th percentile 159.4 Nm), 39.9 Nm (95th percentile 113.6 Nm), and 42.8 Nm (95th percentile 108.9 Nm), respectively. The mean EXT (p = 0.0002), right ( p  = 0.02), and left ROT ROM ( p  = 0.01), and the mean EXT, FLX, and ROT TIS ( p  < 0.0001) were significantly greater in males compared to females. The FLX, EXT, and ROT TIS showed significant strong correlation with EXT and FLX TIS. Mean TIS values in Indian subjects were lower when compared to subjects from other countries., Conclusion: This study established normative reference values for trunk ROM and TIS in asymptomatic young Indian adults. These reference values can be helpful to diagnose trunk ROM and TIS deficits, identify subjects at risk for LBP and disability, and individualise rehabilitation treatment in them., Competing Interests: Conflict of InterestOn behalf of all the authors, the corresponding author states that there is no conflict of interest., (© Indian Orthopaedics Association 2021.)

Background: The literature is lacking on the incidence and management of pyogenic spondylodiscitis (PS) following routine elective surgical procedures. This study aimed to analyze the presentation and treatment outcome in patients with PS following nonspinal surgeries at a tertiary care center with a minimum follow-up of 12 months., Methods: The demographic, clinical-radiologic features, and treatment outcomes in 40 patients with a diagnosis of PS following nonspinal surgical procedures were retrospectively reviewed and analyzed., Results: The mean age at presentation was 36.4 ± 11.8 years, with 80% of patients being female. The common surgical procedures associated with PS were cesarean delivery (30%), gastric sleeve surgery (12.5%), and dilatation and curettage (12.5%). The tissue biopsy culture was positive in 82.5% of patients. A total of 26 patients (65%) were treated with conservative management and 14 patients (35%) were treated surgically. The mean pretreatment Core Outcome Measure Index score significantly decreased at 12 months ( P < .0001) after treatment. The mean pretreatment erythrocyte sedimentation rate ( P < .0001) and C-reactive protein ( P < .0001) levels significantly decreased at 12 months after treatment., Conclusions: With most patients with PS following nonspinal surgeries treated with conservative management, excellent clinical outcomes were achieved in all patients at 12 months after treatment. The diagnosis of PS should be considered in patients presenting with low back pain (LBP) with a recent history of undergoing a nonspinal surgical procedure. Patients who undergo surgical procedures are an important "at-risk" patient population, and early diagnosis and treatment can help achieve excellent clinical outcomes. Further studies are required to determine risk factors and possible perioperative precautions that can be taken to prevent PS in patients who undergo nonspine surgeries., Level of Evidence: 3., Clinical Relevance: Pyogenic spondylodiscitis should be suspected in patients presenting with LBP after a recent non-spinal surgical procedure. Early diagnosis and treatment can help achieve excellent clinical outcomes in these patients., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2021 ISASS.)

Objective: In obese patients, thick subcutaneous tissue can introduce errors during registration and leg weight can influence gap balancing in navigated TKA. Present study is done to determine if computer navigated TKA using a gap balancing technique can achieve consistent accuracy for limb and component alignment, and similar clinical and functional results in obese patients like in non-obese patients., Methods: We prospectively compared the radiological, clinical, and functional results of 78 knees in 57 non-obese patients and 79 knees in 58 obese patients who underwent computer-assisted TKA. Non-obese individuals were defined as those having BMI of <30 kg/m 2 and obese individuals as BMI ≥30 kg/m 2 . The degree of knee deformity was calculated by Hip - Knee - Ankle (HKA) angle and clinical and functional assessment was done using the Knee Society Score - clinical knee score and Knee Society Score - function score, respectively. All these were documented before and at 6 months, 2 year, and 5 years after TKA., Results: The outlier rate of postoperative limb alignment (HKA angle) was 8.9% in the obese group which was not significantly different (p =1.00) from that of the non-obese group (7.7%). Mean clinical knee scores were not significantly different between the non-obese and obese groups preoperatively (58.8 vs 57.4, p = 0.14) and at 6 months (92.7 vs 91, p = 0.06), 2 years (91.4 vs 90, p = 0.07), and 5 years (92.4 vs 91.3, p = 0.1) post-surgery. Similarly, mean functional scores were not significantly different between the non-obese and obese groups preoperatively (50.9 vs 49.9, p = 0.31) and at 6 months (92.7 vs 90.9, p = 0.06), 2 years (91.3 vs 92, p = 0.44), and 5 years (90.6 vs 91.1, p = 0.51) post-surgery., Conclusion: Obesity has no influence on mid-term clinical, functional, and radiological results after computer navigated TKA, done by gap balancing technique., Level of Evidence: Therapeutic level II., Competing Interests: None., (© 2021 Delhi Orthopedic Association. All rights reserved.)

Objectives: To evaluate the efficacy of adjuvant frequency-specific microcurrent (FSM) application on pain and disability in patients treated with physical rehabilitation for mechanical low back pain (LBP) and neck pain (NP)., Methods: In this retrospective case-control study, pre- and post-treatment numerical pain rating scale (NPRS) score, Oswestry disability index (ODI) score, neck disability index (NDI) score, disability categories, and treatment outcome categories were compared between 213 patients in the FSM group (167 patients with LBP, 46 patients with NP) and 78 patients in the control group (61 patients with LBP, 17 patients with NP)., Results: In LBP patients, mean post-treatment NPRS score was significantly lower (p = 0.02) and a significantly higher percentage of patients were in the ≤3 NPRS score (p = 0.02), in the minimal disability (p = 0.01), and the full success (p = 0.006) categories post-treatment in the FSM group when compared to the control group. In NP patients, there was no significant difference in the post-treatment pain intensity, disability or treatment outcome when the 2 groups were compared., Conclusions: The use of adjuvant FSM application in patients treated with physical rehabilitation for LBP significantly improved pain and disability when compared to patients in the control group. Frequency specific microcurrent could be a useful adjuvant in the rehabilitation treatment of patients with low back pain., Competing Interests: Declaration of competing interest There are no conflicts of interest with any financial organization regarding the material discussed in the manuscript and this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: This retrospective study aimed to determine the efficacy of an integrated active, rehabilitation protocol in patients ≥ 65 years of age with chronic mechanical low back pain and compare the results in similar patients in 50-64 years age group., Methods: Pre- and post-treatment mean numerical pain rating scale (NPRS) score, mean Oswestry disability index (ODI) score, treatment outcome category and minimal clinically important difference (MCID) thresholds achieved for NPRS and ODI scores post-treatment were compared among 697 patients in the 50-64 years and 495 patients in the ≥ 65 years age groups., Results: At a mean treatment duration of 57 days (range, 30-90 days), both mean NPRS score (p < 0.0001) and mean ODI score (p < 0.0001) were significantly higher in the ≥ 65 years age group when compared to the 50-64 years age group. However, post-treatment outcome categories (p = 0.17) and percentage of patients who achieved MCID thresholds for NPRS score (p = 0.13) and ODI score (p = 0.18) were not significantly different between the two groups. There was a significant correlation between post-treatment NPRS score and patient age and pre-treatment NPRS score and between post-treatment ODI score and incidence of osteoporosis and pre-treatment ODI score., Conclusion: Although mean NPRS and ODI scores achieved were significantly better in patients of 50-64 years of age, our integrated active, rehabilitation protocol helped achieve significant improvement in NPRS score, MCID thresholds for NPRS and ODI scores and treatment outcomes in patients ≥ 65 years of age, similar to patients in the 50-64 years of age group, at the end of 3 months of treatment. These slides can be retrieved under Electronic Supplementary Material.

Background: This prospective study aimed to verify the efficacy of a novel, hand-held, iPod-based navigation system in comparison to traditional navigation system for total knee arthroplasty (TKA)., Methods: Limb alignment, tibial and distal femoral bone cut thickness and plane were recorded intraoperatively using both iPod-based and traditional navigation system in 36 knees undergoing primary TKAs., Results: Intraoperatively, the iPod-based navigation system showed good to excellent correlation and reliability for tibial and distal femoral bone cut thickness, plane of the femoral cut and limb alignment when compared to the traditional navigation system., Conclusions: Despite its quick registration feature, the iPod-based system has an efficacy similar to traditional navigation system and is a positive step towards making navigation systems for TKA more compact, user-friendly, time and cost-effective.

Purpose: Recurrent patellar dislocation is often associated with genu valgum. The purpose of this study was to analyze the short-term results of single-incision, closing-wedge distal femoral osteotomy (CWDFO) combined with medial reefing and lateral release for recurrent patellar instability with genu valgum., Materials and Methods: Combined CWDFO/medial reefing/lateral release was performed on 10 knees. Clinical evaluation was based on pre- and postoperative Knee Society Score (KSS) and Kujala patellofemoral score. Radiographic evaluation was performed with reference to the weight-bearing line (WBL), the femorotibial angle (FTA), and the mechanical lateral distal femoral angles in the knee-standing view., Results: At a mean follow-up of 20±11.7 months (range, 12-42 months), KSS scores improved significantly, from 46.7±5.2 preoperatively to 87±4.4 postoperatively (p<0.001), as did the Kujala score, from 44±8 preoperatively to 86.6±6.8 postoperatively (p<0.001). The WBL decreased significantly, from 76±7% preoperatively to 41±11% postoperatively (p<0.001). The FTA was improved significantly, from 12.7±1.7° preoperatively to 4±4° postoperatively (p<0.001), as was the mLDFA, from 83±4° preoperatively to 91±1.3° postoperatively (p<0.001)., Conclusion: Use of single-incision CWDFO combined with medial reefing and lateral release prevents patellar dislocation, corrects deformity, and improves clinical outcomes., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2017)

Purpose: The purpose of this prospective study was to determine correlation between coronal mechanical alignment measured on preoperative standing full-length radiographs and navigation during total knee arthroplasty (TKA) in the presence of an associated sagittal deformity (hyperextension and flexion deformity)., Materials and Methods: Coronal mechanical alignment measured on preoperative, standing, full-length, hip-to-ankle anteroposterior radiographs was compared with intraoperative measurements recorded with computer navigation in 200 primary navigated TKAs., Results: The mean difference in mechanical alignment between the two techniques was significantly greater (p=0.001) in patients with an associated flexion deformity >10° when compared to knees with associated flexion deformity ≤10°; 48% of knees with a flexion deformity >10° had a difference of ≥3° between the full-length radiograph and navigation alignment measurements. There was a strong correlation between the radiographic and navigation measurement techniques., Conclusions: The mean difference in coronal mechanical alignment between the two techniques was significantly higher in patients with an associated flexion deformity >10°. Hence, surgeons should take caution when relying on preoperative full-length radiographs for determining coronal mechanical alignment in patients with an associated flexion deformity >10° where using navigation may be more reliable.

Purpose: The purpose of this retrospective comparative study was to evaluate and compare, radiographically and clinically, progression of osteoarthritis (OA) in the patellofemoral (PF) compartment after open-wedge high tibial osteotomy (OWHTO), and unicompartmental knee arthroplasty (UKA) over a minimum follow-up of 5 years., Methods: In this study, 42 knees in an OWHTO group were compared with 59 knees in a UKA group in terms of radiographic parameters, such as the grading system for OA progression in the PF compartment, and clinical parameters, such as the PF pain and function scores over a minimum follow-up of 5 years., Results: There was no significant difference of OA progression in the PF compartment between the two groups on knee radiography. Compared with the preoperative grades, the UKA group showed significant progression of OA in the medial PF compartment at the final follow-up, whereas the medial PF compartment showed significant stepwise progression by only one grade when compared to the OWHTO group. The PF pain and function scores showed no statistical differences between the two groups at the final follow-up, regardless of OA progression., Conclusions: There was no significant difference between OWHTO and UKA in terms of progression of OA in the PF compartment or deterioration of PF function score over a minimum follow-up of 5 years. However, the medial PF compartment of the UKA group was minimal, and worsened or progressed by only one grade., Level of Evidence: III.

Background and purpose - Medial unicompartmental knee arthroplasty (UKA) is undertaken in patients with a passively correctable varus deformity. We investigated whether restoration of natural soft tissue tension would result in a lower limb alignment similar to that of the contralateral unaffected lower limb after mobile-bearing medial UKA. Patients and methods - In this retrospective study, hip-knee-ankle (HKA) angle, position of the weight-bearing axis (WBA), and knee joint line obliquity (KJLO) after mobile-bearing medial UKA was compared with that of the unaffected (clinically and radiologically) contralateral lower limb in 123 patients. Results - Postoperatively, HKA angle was restored to within ±3° of the contralateral lower limb in 87% of the patients and the WBA passed within ±1 Kennedy and White's tibial zone of the unaffected contralateral lower limb in 95% of the patients. The mean KJLO in the operated limbs was not significantly different from that in the unaffected lower limbs (p = 0.07) and the KJLO in the operated limb was restored to within ±3° of that in the contralateral lower limb in 96% of the patients. Interpretation - Lower limb alignment and knee joint line obliquity after mobile-bearing medial UKA were comparable to that of the unaffected contralateral limb in most patients. Comparison with the contralateral unaffected lower limb is a reliable method for evaluation and validation of limb mechanical alignment after mobile-bearing medial UKA.

Purpose: This study was to determine the efficacy of iliac crest reconstruction using bone cement in reducing pain and morbidity at the donor site in patients undergoing open wedge high tibial osteotomy (OWHTO) with tricortical iliac crest autologous graft., Materials and Methods: Thirty-three patients who underwent iliac crest reconstruction using polymethyl methacrylate (PMMA) bone cement (group A) and thirty patients who had no iliac crest reconstruction (group B) were enrolled in this study. All patients were evaluated for pain and functional disability related to graft harvesting using the pain and functional visual analogue scale (VAS) score during hospital stay and at 6 weeks, 3 months, and 6 months postoperatively., Results: There was significant difference between the two groups in terms of pain and function. The pain VAS score was significantly lower in group A than group B during the first 2 weeks postoperatively (p=0.04) and the functional VAS score was also significantly lower in group A during the first 2 weeks postoperatively (p<0.001) in terms of breathing, sitting up from the supine position, and standing up with crutches from the sitting position., Conclusions: Iliac crest donor site reconstruction using PMMA bone cement in patients undergoing OWHTO significantly decreased pain and improved function during the first 2 weeks postoperatively when compared to patients who underwent OWHTO without iliac crest reconstruction.

Purpose: We aimed to determine variation in femoral valgus correction angle (VCA) between the two limbs in a patient with windswept deformity undergoing total knee arthroplasty (TKA)., Methods: Femoral VCA was measured on full-length, hip-to-ankle, standing radiographs and was compared between the varus and the valgus limbs in 66 patients with windswept deformities., Results: The mean VCA in varus knees was significantly higher compared to mean VCA in valgus knees ( p  = 0.002)., Conclusion: Significant difference in VCA is present between the varus and the valgus limbs in most patients with windswept deformity undergoing TKA.

Purpose: Simultaneous bilateral total knee arthroplasty (TKA) is associated with excessive blood loss and morbidity arising from postoperative reduction in hemoglobin (Hb). The purpose of this prospective randomized study was to determine if drains have any effect on blood loss, postoperative reduction in Hb levels and transfusion rates compared to no drainage in simultaneous bilateral TKAs., Materials and Methods: Two hundred and thirty patients who underwent simultaneous bilateral TKA by a single surgeon were randomly allotted to drain or no-drain group (n=115 in each group). Postoperative Hb level, blood loss volume and transfusion rate were compared between the two groups., Results: The mean postoperative Hb level (p=0.38), blood loss volume (p=0.33) and transfusion rate (p=0.52) in the drain group were not significantly different compared to the no-drain group. No statistical difference was found in terms of complications, readmissions and mortality rates between the two groups., Conclusions: No significant difference was observed in the two groups with respect to blood loss and blood transfusion. Non-drainage does not offer an advantage over drainage with respect to conserving blood in simultaneous bilateral TKA., Competing Interests: No potential conflict of interest relevant to this article was reported.

Purpose: The purpose of this study was to analyze clinical outcomes in patients who underwent posterior cruciate ligament reconstruction (PCLR) with and without remnant preservation., Methods: A search of the literature was performed with the established medical databases Medline, Embase, and the Cochrane Register. Two authors screened the selected articles for title, abstract, and full text in accordance with predefined inclusion and exclusion criteria. The inclusion criteria were as follows: English-language articles on isolated posterior cruciate ligament injury; clinical trials with a clear description of surgical technique; outcome evaluation using a well-defined knee score, arthrometry, and posterior stress radiography; follow-up longer than 2 years; and a Coleman Methodology Score (CMS) of 65 points or greater. The methodologic quality of all articles was assessed by 2 authors according to the CMS., Results: Eleven studies were included, with a mean CMS of 78.9 points (SD, 5.37 points). There was no direct comparative study between remnant-preserving PCLR and standard PCLR. At final follow-up, the knees of 72% to 100% of patients who underwent remnant-preserving PCLR and 41% to 95% of patients who underwent standard PCLR were rated as normal or nearly normal on the International Knee Documentation Committee subjective knee assessment. Patients who underwent remnant-preserving PCLR showed an increase of 16.4 to 47 points in Lysholm scores, and patients who underwent standard PCLR showed an increase of 22 to 29 points. The ranges of mean postoperative side-to-side differences on KT-1000 (MEDmetric, San Diego, CA) testing were 0.7 to 2.8 mm in patients who underwent remnant-preserving PCLR and 1 to 3.5 mm in patients who underwent standard PCLR. The ranges of mean postoperative side-to-side differences on stress radiography were 2.2 to 5 mm in patients who underwent remnant-preserving PCLR and 4.7 to 6 mm in patients who underwent standard PCLR., Conclusions: All studies on PCLR with remnant preservation showed satisfactory outcomes despite using numerous surgical techniques, graft types, intervals from injury to surgery, and follow-up periods., Level of Evidence: Level IV, systematic review of Level II through IV studies., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

[Purpose] Device based therapy for low back pain (LBP) involves quantitative assessment of muscle strength, resistance and lumbar motion and tailoring the rehabilitation protocol based on this objective assessment. The purpose of this study was to determine the effectiveness of device based therapy for LBP. [Subjects and Methods] In this retrospective study, clinical data of 235 patients who underwent device-based physiotherapy for low back pain was reviewed. Pre and post-treatment outcome measures for pain (visual analogue scale or VAS score), disability (Oswestry disability index) and functional ability were compared to determine effectiveness of device-based physiotherapy at the end of 6 weeks of treatment. [Results] All outcome measures including VAS Score and mean Oswestry Disability Score showed significant improvement at the end of 6 weeks of device-based physical therapy. Before treatment, 73% of patients had moderate to severe disability which reduced to 28% after treatment. [Conclusion] Device-based therapy is effective in relieving pain, improving function and reducing disability in patients with low back pain in the short term. Device-based therapy may help to objectively evaluate the function of the spine and paraspinal muscles and help the therapist tailor treatment accordingly.

Objectives: The aim of this retrospective study was (1) to evaluate the radiographic features to differentiate arthroscopically confirmed complete and incomplete discoid lateral meniscus (DLM) (2) to determine the cutoff values for any parameter that was found to differentiate complete from incomplete DLM., Materials and Methods: We retrospectively analyzed plain knee radiographs of 130 arthroscopically proven DLM. Seventy-nine patients had complete DLM and 51 patients incomplete DLM. Knee radiographs from 52 patients with arthroscopically proven normal lateral meniscus acted as control group. Radiographic parameters measured included fibular height, lateral joint space, condylar cutoff sign, height of lateral tibial spine, obliquity of lateral tibial spine, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau., Results: Among radiographic parameters, high fibular head, widening of the lateral joint space and femoral condylar cutoff sign showed statistically significant (p<0.0001) differences between complete and incomplete DLM. At specific threshold points of fibular height<11 mm, lateral joint space>6 mm and condylar cutoff sign<0.80, the diagnosis of complete DLM revealed 87.3% sensitivity, 81.6% specificity and 78.4% positive predictive value (PPV) for the fibular height, 81.0% sensitivity, 86.6% specificity and 83.1% PPV for the lateral joint space, and 86.1% sensitivity, 83.5% specificity and 80% PPV for the condylar cutoff sign., Conclusions: Radiographic features of fibular height, lateral joint space and condylar cut off sign can be used for screening of a complete type of DLM. However, radiographs are not a reliable screening tool for an incomplete DLM., Level of Evidence: IV, Case Series., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Purpose: This retrospective study aimed to determine if computer navigation provides consistent accuracy for limb and component alignment during TKA irrespective of body mass index (BMI) by comparing limb and component alignment and the outlier rates in obese versus non-obese individuals undergoing computer-assisted TKA., Methods: Six hundred and thirty-five computer assisted total knee arthroplasties (TKAs) performed in non-obese individuals (BMI<30 kg/m(2)) were compared with 520 computer-assisted TKAs in obese individuals (BMI ≥ 30 kg/m(2)) for postoperative limb and component alignment using full length standing hip-to-ankle radiographs., Results: No significant difference in postoperative limb alignment (179.7° ± 1.7° vs 179.6° ± 1.8°), coronal femoral (90.2° ± 1.6° vs 89.8° ± 1.9°) and tibial component (90.2° ± 1.6° vs 90.3° ± 1.7°) alignment and outlier rates (6.2% vs 7.5%) was found between non-obese and obese individuals. Similarly, alignment and the outlier rates were similar when non-obese individuals and a subgroup of morbidly obese individuals (BMI >40 kg/m(2)) were compared., Conclusions: Computer navigation can achieve excellent limb and component alignment irrespective of a patient's BMI. Although obesity may not be an indication per se for using computer navigation during TKA, it will help achieve consistently accurate limb and component alignment in obese patients., Level of Evidence: Level II., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Successful outcomes following high tibial osteotomy (HTO) require precise realignment of the mechanical axis of the lower extremity. The present study investigated whether the weight-bearing limb scanogram (WBS) technique provided a more accurate mechanical axis realignment than the navigation technique in open high tibial osteotomy (OHTO)., Methods: This prospective study involved 80 knees (78 patients) undergoing OHTO. The WBS technique was used in 40 knees and the navigation technique in 40 knees. Each technique was performed by a different surgeon in a different hospital. Postoperative coronal limb alignment was assessed using the weight-bearing line (WBL) ratio on full-length standing hip-to-ankle radiographs., Results: We found that the mean postoperative WBL ratio was greater in the WBS compared to the navigation group (p=0.001), and hence the ratio for the WBS group was closer to the ratio target of 62%. There was a greater proportion of WBL ratio outliers in the navigation group than the WBS group (25% vs. 10%, p=0.034)., Conclusion: We conclude that the WBS technique was more accurate than the navigation technique for restoration of coronal leg alignment in OHTO., Level of Evidence: Level II., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Purpose: This prospective study aimed to evaluate radiographically, mechanical or hip-knee-ankle (HKA) axis in healthy, asymptomatic, Asian (Indian and Korean) adults between 20 and 40 years of age to determine the incidence of inherent varus (mechanical limb alignment of >3° varus) and the factors influencing it., Methods: Three hundred and eighty-eight lower limbs were evaluated using full length, standing hip-to-ankle radiographs in 198 healthy, asymptomatic, Asian (Indian and Korean) adults between 20 and 40 years of age to assess the hip-knee-ankle (HKA) angle, medial proximal tibial angle (MPTA), femoral bowing and femoral neck-shaft angle to determine the incidence of inherent varus (mechanical limb alignment of >3° varus) and the factors influencing it., Results: Overall, the mean HKA angle was 177.6°±2.6° with 34.5% of limbs in inherent varus (mean HKA angle 174.9°±1.8°). The incidence of inherent varus was significantly higher (p=0.01) in males (40%) compared to females (28%) but similar among Indian (34%) and Korean subjects (35%). The hip-knee-ankle (HKA) angle showed significant positive correlation (r=0.82, p<0.001) with only the medial proximal tibial angle (MPTA)., Conclusions: Inherent varus alignment of the lower limb is fairly common among asymptomatic, Asian adults. These results raise several pertinent questions regarding the role of inherent varus in the aetiopathogenesis of knee osteoarthritis and in lower limb realignment procedures., (© 2013 Elsevier B.V. All rights reserved.)

Background: Reduction osteotomy (removing the posteromedial tibial bony flare) is one step to aid in achieving deformity correction in varus arthritic knees during TKA. However, the amount of deformity correction achieved with reduction osteotomy during TKA is unclear., Questions/purposes: We therefore addressed the following questions: (1) What is the amount of deformity correction achieved with reduction osteotomy during TKA in varus knees? (2) What is the correlation of amount of deformity correction achieved to the amount of bone osteotomized and the degree of varus deformity?, Methods: We prospectively collected and analyzed intraoperative data on the degree of varus deformity before and after reduction osteotomy (using computer navigation) and the amount of reduction osteotomy performed (using a measuring scale) in 71 primary, computer-assisted TKAs., Results: For a mean reduction osteotomy of 7.5 ± 2 mm, a mean correction of 3.5° ± 1° was achieved; a mean osteotomy of 2 mm was required (confidence interval, 1.7-2.6 mm) for every 1° correction of varus deformity. Degree of varus correction achieved correlated positively with the amount of osteotomy performed, especially in knees with preoperative varus deformity of < 15° (r = 0.77, p < 0.001) and the preosteotomy residual varus deformity correlated positively with the amount of correction achieved (r = 0.81, p < 0.001)., Conclusions: Reduction osteotomy can achieve deformity correction in a predictable 2 mm for 1° in most varus arthritic knees during TKA. Further studies are required to ascertain its effectiveness as a soft tissue-sparing step when performed early on during TKA to achieve deformity correction.

Background: Extensive posteromedial release to correct severe varus deformity during TKA may result in mediolateral or flexion instability and may require a constrained implant. We describe a technique combining computer navigation and medial condylar osteotomy in severe varus deformity to achieve a primary goal of ligament balance during TKA., Description of Technique: The goal of this procedure was to achieve mediolateral gap balance in varus knees with rigid, recalcitrant medial contracture, with or without excessive lateral laxity, not amenable to extensive medial soft tissue releases. A sliding medial condylar osteotomy (SMCO) was performed under navigation guidance and the condylar block internally fixed using cancellous screws., Methods: We prospectively evaluated mediolateral laxity, Knee Society scores, and knee ROM after SMCO in 12 varus arthritic knees in 11 patients (five men, six women) undergoing TKA with a minimum followup of 2 years (mean, 2 years; range, 2-2.5 years)., Results: The degree of mediolateral knee laxity improved from Grade 2 (in four knees) and Grade 3 (in eight knees) preoperatively to Grade 1 (< 5 mm) in all knees at last followup. Mean Knee Society score improved from 30 (range, 10-54) to 92 (range, 86-100). Mean knee flexion improved from 106° (range, 90°-120°) to 112° (range, 100°-124°), and no knee had any extensor lag or residual flexion deformity (> 5°). Three knees had asymptomatic fibrous union at the osteotomy site., Conclusions: Computer-assisted SMCO in varus knees with recalcitrant medial contracture achieves improved mediolateral stability and knee function after TKA. Our technique uses navigation to accurately reposition the medial condylar block to equalize medial and lateral gaps, thereby ensuring a stable well-aligned knee without deploying constrained implants.

Purpose: The purpose of this cadaveric study was to study the effect of plane of osteotomy on incidence of lateral cortex fracture and to define a "safe zone" through which medial open-wedge high tibial osteotomy (HTO) could be performed with minimal risk of lateral cortex fracture., Methods: Medial open HTO was performed in nine fresh frozen human cadavers (18 knees) with each specimen randomly assigned to a "safe zone" osteotomy (group A, between the tip of the fibular head and the circumference line of the fibular head), or a lower level osteotomy (group B, distal to the circumference line of the fibular head)., Results: Six out of nine knees developed lateral cortex fracture in group B compared to none in group A (P = 0.009) when the osteotomy site was distracted to a maximum of 20 mm., Conclusion: Directing the plane of the osteotomy toward the "safe zone" significantly reduces the risk of lateral cortex fracture compared to an osteotomy, which is directed at a lower level. Confining the plane of a medial open HTO to within the "safe zone" can prevent lateral cortex fracture and subsequent loss of correction.

We prospectively studied variations in valgus correction angle (VCA) and the influence of preoperative limb deformity on VCA in 503 consecutive total knee arthroplasties done in 393 patients. The percentage of limbs that had VCA values less than 5° was 10.9%, and that with VCA values greater than 7° was 44.9%. The percentage of limbs with VCA greater than 7° was significantly more in varus knees, and that with VCA less than 5° was significantly more in valgus knees; preoperative deformity showed a significant correlation with VCA. Choosing a fixed-routine VCA of 5° to 7° may cause an unacceptable planning error that may be minimized by individualizing VCA or using computer navigation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this prospective, randomized, computed tomography-based study was to investigate whether the press-fit technique reduces tunnel volume enlargement (TVE) and improves the clinical outcome after anterior cruciate ligament reconstruction at a minimum follow-up of 1 year compared with conventional technique., Methods: Sixty-nine patients undergoing primary ACL reconstruction using hamstring autografts were randomly allocated to either the press-fit technique group (group A) or conventional technique group (group B). All patients were evaluated for TVE and tunnel widening using computed tomography scanning, for functional outcome using International Knee Documentation Committee and Lysholm scores, for rotational stability using the pivot-shift test, and for anterior laxity using the KT-2000 arthrometer at a minimum of 1-year follow-up., Results: There were no significant differences in TVE between the 2 groups. In group A, in which the press-fit technique was used, mean volume enlargement in the femoral tunnel was 65% compared with 71.5% in group B (P = .84). In group A, 57% (20 of 35) of patients developed femoral TVE compared with 67% (23 of 34) of patients in group B (P = .27). Both groups showed no significant difference for functional outcome (mean Lysholm score P = .73, International Knee Documentation Committee score P = .15), or knee laxity (anterior P = .78, rotational P = .22) at a minimum follow-up of 1 year., Conclusions: In a comparison of press-fit and conventional techniques, there were no significant differences in TVE and clinical outcome at short-term follow-up., Level of Evidence: Level II, therapeutic study, prospective randomized clinical trial., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Computer navigation has improved accuracy and reduced the percentage of alignment outliers in TKA. However, the characteristics of outliers and the risk factors for limb malalignment after TKA are still unclear., Questions/purposes: We therefore addressed the following questions: (1) What is the incidence and characteristics of outliers for postoperative limb mechanical axis (hip-knee-ankle [HKA] angle outside the conventional 180° ± 3° range) and component alignment in TKA? And (2) what are the preoperative clinical or radiographic risk factors for limb mechanical axis malalignment in TKA?, Methods: We retrospectively reviewed the clinical and radiographic records of 1500 computer-assisted TKAs to identify outliers for postoperative HKA axis and component alignment and determined risk factors for malalignment. Full-length hip-to-ankle and knee radiographs were used to measure preoperative HKA angle, femoral coronal bowing, joint divergence angle, tibial subluxation, and tibial bone loss and postoperative HKA angle and femoral and tibial component angle., Results: The incidence of outliers for postoperative limb mechanical axis, femoral component alignment, and tibial component alignment was 7% (112 of 1500 TKAs), 7%, and 8%, respectively, with 70% of limbs placed in excessive varus and 30% in excessive valgus. Preoperative varus deformity of more than 20° and femoral bowing of more than 5° were associated with increased risk of placing the limb mechanical axis outside the acceptable ± 3° range after computer-assisted TKA., Conclusions: The presence of preoperative radiographic risk factors should alert the surgeon to increased chance of malalignment and every measure should be undertaken in such at-risk knees to ensure proper limb and component alignment and soft tissue balance.

Purpose: This prospective study aimed to evaluate radiographically, change in joint line and femoral condylar offset with the optimized gap balancing technique in computer-assisted, primary, cruciate-substituting total knee arthroplasties (TKAs)., Methods: One hundred and twenty-nine consecutive computer-assisted TKAs were evaluated radiographically using pre- and postoperative full-length standing hip-to-ankle, antero-posterior and lateral radiographs to assess change in knee deformity, joint line height and posterior condylar offset., Results: In 49% of knees, there was a net decrease (mean 2.2mm, range 0.2-8.4mm) in joint line height postoperatively whereas 46.5% of knees had a net increase in joint line height (mean 2.5mm, range 0.2-11.2mm). In 93% of the knees, joint line was restored to within ± 5 mm of preoperative values. In 53% of knees, there was a net increase (mean 2.9 mm, range 0.2-12 mm) in posterior offset postoperatively whereas 40% of knees had a net decrease in posterior offset (mean 4.2mm, range 0.6-20mm). In 82% of knees, the posterior offset was restored within ± 5 mm of preoperative values., Conclusions: Based on radiographic evaluation in extension and at 30° flexion, the current study clearly demonstrates that joint line and posterior femoral condylar offset can be restored in the majority of computer-assisted, cruciate-substituting TKAs to within 5mm of their preoperative value. The optimized gap balancing feature of the computer software allows the surgeon to simulate the effect of simultaneously adjusting femoral component size, position and distal femoral resection level on joint line and posterior femoral offset., (Copyright © 2011 Elsevier B.V. All rights reserved.)

This study aimed to determine the accuracy and reliability of visual estimation of limb alignment and knee flexion by orthopaedic surgeons when compared to recordings done by computed navigation. Orthopaedic surgeons attending a national conference were asked to place a lower limb synthetic bone model in 6 positions of the knee in the coronal and sagittal planes. These were simultaneously quantified and recorded by a computer navigation system. In the sagittal plane, 44%, 54% and 60% of the surgeons deviated by more than 5 degrees when positioning the knee in 0 degrees flexion, 10 degrees flexion and 90 degrees flexion respectively. In the coronal plane, 15%, 12% and 8% of the surgeons deviated by more than 5 degrees when positioning the knee in 0 degrees varus/valgus, 5 degrees varus and 5 degrees valgus respectively. Only 25% of the surgeons could position the knee both within 3 degrees of neutral varus/valgus and within 5 degrees of neutral flexion. Accuracy of visual estimation was not different when surgeons were compared based on time since residency, experience with TKA and experience with computer-assisted TKA. Visual estimation of knee alignment in both the sagittal and coronal plane is prone to error and may lead to inaccurate limb alignment during procedures such as TKA.

This study aimed to determine limb and component alignment after computer-assisted total knee arthroplasty in 30 patients (32 limbs) with an altered hip center due to a prior hip implant or deformed femoral head. There were no outliers greater than ±3° in the postoperative coronal alignment of the limb and the femoral component in relation to the altered hip center. Two limbs (8%) were more than ±3° for coronal alignment of the femoral component in relation to the anatomical hip center and 96% of limbs had less than 2° deviation in relation to the altered hip center. Computer-navigated total knee arthroplasty results in accurate restoration of lower limb and component alignment in patients with prior hip implants or deformed femoral heads where accurate restoration of alignment may be challenging due to altered hip center., (Copyright © 2011 Elsevier Inc. All rights reserved.)

One hundred twenty-two consecutive minimally invasive Oxford phase 3 medial unicompartmental knee arthroplasties in 109 patients were evaluated for postoperative limb alignment and the influence of factors such as preoperative limb alignment, age, body mass index, sex, insert thickness, and surgeon's experience. The mean mechanical preoperative hip-knee-ankle (HKA) angle of 172.2° ± 3.1° improved to 177.1° ± 2.9° postoperatively. In 75% of the limbs, the HKA angle was restored to within an acceptable alignment of 177° ± 3°, 14% of the limbs were in excessive varus (<174°), and 11% were in valgus (>180°). Only preoperative HKA angle was predictive of postoperative HKA angle. Although most of the limbs had acceptable limb alignment after unicompartmental knee arthroplasty, limbs with more severe preoperative varus deformity had a tendency to remain in excessive varus, and limbs with lesser preoperative varus deformity had a greater tendency to go into valgus postoperatively., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Despite several advantages of medial opening wedge high tibial osteotomy, this procedure has been noted to have a high rate of complications especially with the use of a spacer plate for fixation. We retrospectively evaluated the early complications of 138 medial opening wedge high tibial osteotomies done using autologous tricortical iliac bone graft and T-plate fixation(AO locking compression T-plate, Ti/3H 4.5-5.0 mm, Synthes, Switzerland, Model No. 440.131 in 30 and low-profile locking T-plate and low-profile locking T-plate in 128 patients. At a mean follow-up of 36.8 months (13 to 78), 26 knees (18.8%) developed complications. Complications varied from osteotomy site infection, loss of correction, broken screws and lateral tibial plateau fracture to joint fluid leakage, pseudoaneurysm and iliac bone fractures. Using the "safe zone" technique and penetrating the lateral cortex with Steinmann pins may help to avoid complications such as loss of correction and lateral tibial plateau fractures. The results of this study indicate that medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation may be a technically demanding procedure associated with a moderate rate of complications. However, these complications could be minimized with proper planning, adequate intra-operative precautions and few modifications to avoid technical error., (Crown Copyright © 2010. Published by Elsevier B.V. All rights reserved.)

Background: The weightbearing axis of the limb goes from the pelvis to the ground and includes the hindfoot. However, the influence of hindfoot alignment on mechanical axis and overall limb alignment after TKA is unclear., Questions/purposes: We therefore addressed the following questions: (1) Does hindfoot alignment change after TKA for knee osteoarthritis? (2) What factors influence hindfoot alignment after TKA? (3) Does deviation of the mechanical axis from the center of the knee vary when the hindfoot is considered (ground mechanical axis) as compared with when it is not (conventional mechanical axis) after TKA?, Patients and Methods: We prospectively reviewed the radiographs of 125 patients who underwent 165 TKAs. We evaluated the preoperative and postoperative hip-knee-ankle (HKA) angle, conventional mechanical axis deviation, ground mechanical axis (mechanical axis which included the hindfoot) deviation, and tibiocalcaneal angle., Results: The preoperative hindfoot valgus alignment decreased after TKA. Preoperative hindfoot alignment was the only factor that influenced hindfoot alignment after TKA. The conventional mechanical axis showed less deviation from the center of the knee when compared with ground mechanical axis which showed lateral deviation after TKA. Despite limb alignment being restored to within 3° of neutral of the conventional mechanical axis after TKA, 29% of limbs had a postoperative ground mechanical axis deviation of 10 mm or greater., Conclusions: Accurate restoration of limb alignment after TKA may be associated with persistent hindfoot valgus alignment with the ground mechanical axis passing lateral to the center of the knee. This could have implications on long-term survival of the implant owing to possible excessive loading laterally and needs further investigation.