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Robotic-assisted total knee arthroplasty (rTKA) has been developed to improve knee kinematics and functional outcomes, expedite recovery, and improve implants long-term survivorship. Robotic devices are classified into active, semi-active, and passive, based on their degree of freedom. Their capacity to provide increased accuracy in implants positioning with reduced radiographic outliers has been widely proved. However, these early advantages are yet to be associated with long-term survivorship. Moreover, multiple drawbacks are still encountered including a variable learning curve, increased setup and maintenance costs, and potential complications related to the surgical technique. Despite recent technologies applied to TKA have failed to prove substantial improvements, robotic-assisted surgery seems to be here to stay and revolutionize the field of TKA. To support its consistent usage on a daily basis, long-term results are still awaited, and further improvements are necessary to reduce the expenses related to it.

Background: C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality. Methods: We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio. Results: The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%. Conclusions: Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.

Background Several studies have evaluated the outcomes of tantalum cones in revision knee arthroplasty with moderate-to-severe metaphyseal bone defects. However, recent innovations have led to the development of 3-D printed titanium cones to better adapt to host bone, there remains no consensus on their overall performance. Objective We therefore performed a systematic review of the literature to examine short-term survivorship and complication rates of their usage in revision TKAs. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords. Results In all, 7 articles met the inclusion criteria. A total of 687 cones were implanted in 557 revision TKAs. The all-cause revision-free survivorship of the implants was 95.3% (26 revisions), and of the cones was 95.5% (31 cones revised) at mean 24 months follow-up. The cones revision-free survivorship from aseptic loosening was 99.7%. The overall complication rate was 19.7% with infection as the most common complications observed and the most frequent reason for revision with an incidence of 10.4% and 4.1%, respectively. Overall, functional outcomes improved as documented by postoperative knee scores. Conclusion 3-D printed metal cones represent a reliable option in metaphyseal bone defects reconstruction that provides high fixation, good short-term survivorship, and complications rates in line with similar devices. In addition, they are associated with lower intraoperative complications, and higher survivorship from aseptic loosening.

Purpose Knee instability is considered one of the most frequent cause of failure after primary total knee arthroplasty (TKA). In order to address intraoperative instability, varus-valgus constrained knee implants (VVC) are increasingly utilized in primary TKA. Despite an increased risk of mechanical failure, short to mid-term results seem to be encouraging, but long-term results are still lacking. Methods A systematic review of prospective and retrospective studies that reported clinical outcomes of patients with VVC systems in primary TKAs between 1990 and 2020 was performed. Results In all, 28 articles met our inclusion criteria. A total of 2798 VVC implants were used in primary TKA. The all-cause revision-free survivorship was 95.2% at a mean follow-up of 7 years. Infection and aseptic loosening were the most common reasons for reoperation with an incidence of 1.8% and 1.7%, respectively. Overall complication rate was 9.6%, the most common complications were knee stiffness and infection with an incidence of 2.8% and 2.5%, respectively. Conclusions VVC implants in primary TKA are associated with improved functional outcomes and good mid-term survivorship, comparable to lower level of constraint implants. Non-modular stemless seem to be reliable implants at mid-term follow-up. However, given the lack data coming from long-term studies, VVC implants should be used cautiously in primary TKA.

Introduction Medial Pivot Total Knee Arthroplasty was introduced in clinical practice in 1990s to reproduce the in vivo-natural knee kinematics. This design is characterized by an asymmetric constraint profile, with aa highly congruent medial compartment, and a less congruent lateral compartment. Short-term outcomes of the medial pivot systems in primary knee arthroplasty have been widely reported in the current literature, however, only few studies have described results beyond 5-year follow-up. Objectives The primary objectives of this systematic review of the literature is to analyze the mid-term studies on medial pivot total knee arthroplasty focusing on the reoperation rate, survivorship and clinical outcome scores. Methods The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to December 2019 utilizing the following keywords: “medial pivot”, “medial stabilized”, “medial rotating”, “medial congruent”, medial ball and socket”, “arthroplasty”, “TKA”, “TKR”, and “knee surgery”. Results 18 articles met the inclusion criteria for the present study. The average quality was 11.4 for non-comparative studies and 21.7 for comparative studies based on MINORS criteria. A total 2832 knee arthroplasties were included for the final analysis with an average age of 69 years, and an average follow-up of 8.1 years (minimum 5 years). The overall reoperation rate was 2.4%, with periprosthetic joint infection as the leading cause of revision in 0.9% of cases, followed by aseptic loosening in 0.4% of cases. The average Knee Society Score improved to a mean preoperative score of 40.1 to a mean postoperative score of 89.2. The functional knee society score improved from a mean preoperative score of 44.8 to an average postoperative score of 82.9. The global range of motion improved from 104.8° preoperatively to 115.6° postoperatively. Conclusion We found that medial pivot system in primary total knee arthroplasty provide overall mid-term survivorship comparable to other standard implasnts. In addition, medial pivot system is associated with better high-end function compared to standard implants.

BackgroundThe purpose of this study was to evaluate (1) the reoperation rates and survivorship for septic and aseptic causes, (2) radiographic outcomes, and (3) clinical outcomes of condylar-constrained knee (CCK) implants used in primary total knee arthroplasty (TKA) with severe coronal deformity and/or intraoperative instability.Materials and methodsA consecutive series of CCK implants in primary TKA was retrospectively evaluated in patients with severe coronal deformities. Forty-nine patients (54 knees) were included with a mean follow-up of 9 years (range 6–12). All patients were treated with a single-design, second-generation CCK implant. The primary diagnosis was osteoarthritis in 36 knees, post-traumatic arthritis in 7 knees, and rheumatoid arthritis in 4 knees. Preoperatively, standing femorotibial alignment was varus in 22 knees and valgus in 20 knees.ResultsAt a mean follow-up of 9 years, overall survivorship was 93.6%. Two knees (4.3%) required revision for periprosthetic joint infection. One knee (2.1%) required subsequent arthroscopy due to patellar clunk syndrome. At final follow-up, no evidence of loosening or migration of any implant was reported, and the mean Knee Society knee scores improved from 43 to 86 points (p p ConclusionCCK implants in primary TKA with major coronal deformities and/or intraoperative instability provide good midterm survivorship, comparable with less constrained implants. In specific cases, CCK implants can be considered a viable option with good clinical and radiographic outcomes. However, a higher degree of constraint should be used cautiously, leaving the first choice to less constrained implants.Level of evidenceTherapeutic study, level IV.

Background: The aim of this study is to update the 10-year follow-up survivorship and metal ions levels of a cohort of metal-on-metal (MoM) hip resurfacing (HR) and large-diameter-head (LDH) total hip arthroplasty (THA). Methods: The study is a retrospective analysis of prospectively collected data that compared the outcomes of 24 MoM HR (21 patients) and 15 (11 patients) modular LHD MoM THA at >10 years follow-up. Baseline characteristics as well as intraoperative and postoperative information were collected, including complications, revisions, clinical and radiographic outcomes, and serum metal ions level (Cobalt, Chromium). Metal ion levels were compared using a two-tailed unpaired t-test and Wilcoxon signed-rank test (jamovi v2.3.3.0, Sydney, NSW, AU). Results: No significant differences were detected in gender, BMI, and ASA score between the two groups. Patients in the modular THA group were significantly older (57 years vs. 46 years; p < 0.05). The HR overall survivorship was 91.7% (22 of 24 hips) with survivorship from implant failure and/or aseptic loosening and/or metal debris related 100% of problems. The modular THA overall survivorship was 86.7% (13 of 15 hips) with survivorship from implant aseptic loosening and metal ions complications of 93.4% (14 of 15 hips). No significant difference was noted when comparing clinical outcomes. Metal ions were significantly lower in the HR group (Co 25.8 nmol/L vs. 89 nmol/L; p < 0.001–Cr 33.5 nmol/L vs. 55.2 nmol/L; p = 0.026). Conclusion: Both implants reported excellent and comparable clinical outcomes at >10 years follow-up. The Adept HR reported remarkable survivorship, in line with the registry data, proving once again its reliability in young active males. The modular LDH THA, despite being discontinued, presented higher reliability and a lower failure rate when compared with similar withdrawn MoM implants. Trunnionosis did not appear to be a significant problem in this particular modular design.

Background Starting in January 2020, the SARS-CoV-2 pandemic caused changes in the nation’s health systems. The hospital’s reorganization led to a near-total stop of non-urgent, elective surgeries across all specialties, including hip and knee arthroplasty. However, in May 2020, a gradual elective surgery restarting was possible. Considering the risk of COVID-19 infections, the European Knee Associates suggest the need to implement specific protocols for a safe return to orthopaedic elective surgery. Methods A retrospective analysis regarding all patients who underwent primary knee arthroplasty (TKA) between March 1st and October 1st, 2020 using an institutional database was performed. The study time was divided into 2 periods: Pandemic (from March 2020 to May 2020), Post Pandemic (from June 2020 to October 2020). A specific protocol was designed to safeguard the health of patients and healthcare workers during the SARS-CoV-2 pandemic. Results A total of 147 patients underwent total knee replacement surgery in the analyzed period. The mean surgical time was 77.6 (+/-18.9). The intraoperative mean blood loss was 54 (+/-28) ml. The mean hospital stay was 3-4 days. Among the treated patients no case of COVID-19 infection was observed. Conclusion The use of our protocol, developed ad hoc for the management of elective orthopedic patients, allowed the restart of elective orthopedic surgery in a safe and reproducible way with an average increase of 374% on surgical activity between the pandemic and post-pandemic periods without record cases of contagion among the treated patients

Background Clinical outcomes of cemented femoral stems revisions using the cement-in-cement technique in aseptic conditions after total hip arthroplasty have been widely described. Methods The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried. Results Twelve articles were included (620 revision THA). Revision rate for complications related to the femoral side was 1.4% at mid-term follow-up (5.4 years). Periprosthetic femoral fracture rate was 1.1%, aseptic loosening of the femoral component 0.3%. Conclusions Cement-in-cement revision technique of the femoral component is associated with a high mid-term success rates (98.6%) and is potentially less challenging than other revision techniques.

Purpose Simultaneous bilateral unicompartmental knee arthroplasty (BUKA) is considered safe and effective. We performed a systematic review to assess the postoperative outcomes. Methods The US National Library of Medicine (PubMed/MEDLINE), Google Scholar, and the Cochrane Database of Systematic Reviews were queried for publications. Results Ten articles were included with 765 simultaneous BUKA. Overall complication rate was 7.0%, survivorship was 97.6% at mean 17 months follow-up. No differences were reported between simultaneous and staged BUKA. Conclusion Simultaneous BUKA is as safe as staged BUKA, it is associated with decreased length of stay and operative time, although it has an increased rate of blood transfusion.

Revision total hip arthroplasty in the setting of acetabular bone loss is a challenging procedure and requires a solid understanding of current acetabular reconstruction options. Despite major developments in the field of revision hip surgery in recent decades, reconstruction of acetabular defects remains a major problem in order to achieve primary stability and durable fixation without sacrificing additional bone stock. Although there are several ways to classify acetabular bone defects, the Paprosky classification system is the most commonly used to describe the defects and guide treatment strategy. An understanding of the bone defects associated with detailed pre-operative assessment and planning are essential elements in order to achieve satisfactory outcomes. Multiple acetabular reconstructive options are currently available including impaction bone grafting with metal mesh, reinforcement rings and antiprotrusio cage, structural allografts, cementless hemispherical cups, extra-large “jumbo cups”, oblong cups, modular porous metal augments, cup-cage constructs, custom- made triflange cups, and acetabular distraction. To date, debate continues as to which technique is most effective due to the lack of long-term studies of modern reconstruction systems. Further long-term studies are necessary to assess the longevity of the different implants. The purpose of this study was to review the current literature and provide a comprehensive understanding of the available reconstruction options with their clinical outcomes.

Total hip arthroplasty (THA) is considered the most successful orthopedic surgical procedure of the last century with excellent survivorship up to 20-years. However, instability remains a major issue representing the most common reason for revision after THA. Hip-spine relationship has gained progressive interest between arthroplasty surgeons and its understanding is crucial in order to identify high-risk patients for postoperative dislocation. Spinal deformity and abnormal spinopelvic mobility have been associated with increased risk for instability, dislocation and revision THA. Preoperative workup begins with standing anteroposterior pelvis x-ray and lateral spinopelvic radiographs in the standing and sitting position. Hip-spine stiffness needs to be addressed before THA in consideration of adapting the preoperative planning to the patient’s characteristics. Acetabular component should be implanted with different anteversion and inclination angles according to the pattern of hip-spine motion in order to reduce the risk of impingement and consequent dislocation. Different algorithmic approaches have been proposed in case of concomitant hip-spine disease and in case of altered sagittal balance and pelvic mobility. The aim of this review is to investigate and clarify the hip-spine relationships and evaluate the impact on modern total hip arthroplasty.

Total knee arthroplasty (TKA) is a highly successful operation that improves patients’ quality of life and functionality. Yet, up to 20% of TKA patients remain unsatisfied with the functional outcomes. Robotic TKA has gained increased attention and popularity in order to improve patient satisfaction and implant survivorship by increasing accuracy and precision of component implantation. The current systematic review was run in order to compare implant survivorship, complication rates, clinical outcomes, and radiological outcomes between robotic-assisted TKA (RA) and conventional manual TKA (CM). Articles were referenced from the US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews. Nine comparative studies with 1199 operated knees in 1159 patients were included, 614 underwent active or semiactive robotic-assisted TKA compared to 585 CM-TKA. Improvements in the RA group were reported for early functional outcomes, radiographic outliers (RA 16% vs CM 76%) and radiolucent lines (RA 0% vs CM 35%). No significant differences between the two groups were reported in overall survivorship (RA 98.3% vs CM 97.3%), complication rate (RA 2.4% vs CM 1.4%) and operative time (RA 88 min vs CM 79 min). Despite higher costs, roboticassisted TKA offers better short-term clinical outcomes when compared to conventional manual technique with reduction in radiographic outliers and reduced risks of iatrogenic soft tissues injuries (reduced blood loss and postoperative drainage). Further high-quality long-term studies of modern robotic systems are required in order to evaluate how the increased accuracy and reduced outliers affect the long-term survivorship of the implants and the clinical outcomes.