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AimsAlternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment.MethodsA total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019.ResultsMean overall patient satisfaction for the entire cohort was 4.7 (SE 0.1) on a 5-point Likert scale, with 93% being either very satisfied or satisfied compared with a Likert of 4.3 and patient satisfaction of 81% in the mechanical alignment group (p < 0.001 and p < 0.006 respectively). At mean follow-up of 17 months (11 to 27), the mean overall Likert, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and Knee Society Knee and Function Scores were significantly better in the kinematic group than in the neutral mechanical alignment group. The most common complication in both groups was contracture requiring manipulation under anaesthesia, involving seven knees (6.1%) in the kinematic group and nine knees (7.8%) in the mechanical alignment group.ConclusionWith the advent of advanced technology, and the ability to obtain accurate bone cuts, the target limb alignment, and soft-tissue balance within millimetres, using a restricted kinematic alignment concept demonstrated excellent patient satisfaction following primary TKA. Longer-term analysis is required as to the durability of this method. Cite this article: Bone Joint J 2021;103-B(6 Supple A):59–66.

Aims Robotic-assisted total knee arthroplasty (RA-TKA) has been introduced to provide accurate bone cuts and help achieve the target knee alignment, along with symmetric gap balancing. The purpose of this study was to determine if any early clinical benefits could be realized following TKA using robotic-assisted technology. Methods In all, 140 consecutive patients undergoing RA-TKA and 127 consecutive patients undergoing conventional TKA with minimum six-week follow-up were reviewed. Differences in visual analogue scores (VAS) for pain at rest and with activity, postoperative opiate usage, and length of stay (LOS) between the RA-TKA and conventional TKA groups were compared. Results Patients undergoing RA-TKA had lower average VAS pain scores at rest (p = 0.001) and with activity (p = 0.03) at two weeks following the index procedure. At the six-week interval, the RA-TKA group had lower VAS pain scores with rest (p = 0.03) and with activity (p = 0.02), and required 3.2 mg less morphine equivalents per day relative to the conventional group (p < 0.001). At six weeks, a significantly greater number of patients in the RA-TKA group were free of opioid use compared to the conventional TKA group; 70.7% vs 57.0% (p = 0.02). Patients in the RA-TKA group had a shorter LOS; 1.9 days versus 2.3 days (p < 0.001), and also had a greater percentage of patient discharged on postoperative day one; 41.3% vs 20.5% (p < 0.001). Conclusion Patients undergoing RA-TKA had lower pain levels at both rest and with activity, required less opioid medication, and had a shorter LOS.

Background Isolated patellofemoral joint arthritis has been identified in 10% of the population presenting with symptomatic knee osteoarthritis. Patient selection is important in order to improve survivorship following PF arthroplasty. The purpose of this study is to compare the use of a preoperative bone scan vs a magnetic resonance imaging (MRI) to identify the patient with isolated PF arthritis. Methods This is a retrospective review of 32 patients undergoing isolated PF arthroplasty for PF arthritis using the same implant design. Sixteen consecutive patients received a preoperative bone scan to confirm isolated PF arthritis. These patients were matched by age and gender to patients where an MRI was used to determine isolated PF arthritis. The bone scan cohort contained 13 females and three males with an average age of 48 years and average follow-up of 52 months. There was no significant difference in age, body mass index, follow-up, or preoperative range of motion between the groups. The MRI and bone scan results were reported by a radiologist specializing in orthopedic radiology. Results Survivorship was 100% in the PF arthroplasty group selected using a preoperative bone scan. Revision surgery with conversion to TKA was required in 5 of 16 patients (31%) when an MRI was used to identify isolated PF arthritis. Revision in all patients in the MRI group was due to progression of knee arthritis in the tibial-femoral joint. There were no cases of implant-related failures. Conclusion Patellofemoral arthroplasty using a modern design implant demonstrated 100% survivorship when a preoperative bone scan was used for patient selection to confirm isolated PF arthritis. In the group where only an MRI was used, there was a 31% failure due to progression of the disease. Based on this study, we would recommend the use of a bone scan as a tool in the selection criteria for patients undergoing PF arthroplasty.

Alignment after total knee arthroplasty (TKA) plays an important role with respect to patient satisfaction and implant survivorship. In patients undergoing ipsilateral TKA with prior total hip arthroplasty (THA), the femoral intramedullary (IM) guide cannot be fully inserted into the femoral canal because of the prior THA. The purpose of this study was to determine the effect of femoral component alignment using a shorter IM guide during TKA in patients with an ipsilateral THA. We identified 42 patients undergoing ipsilateral TKA with the use of a short IM guide in the setting of a prior THA. A matched cohort group was identified from our total joint registry that included 42 patients who underwent primary TKA. The surgical goal was to achieve 5 degrees of valgus on the femoral side and 0 degree on the tibial side with an overall postoperative tibial–femoral angle of 5 degrees of valgus. Patients were evaluated clinically using Knee Society pain scores (KSSs), function scores, and with radiography. Both the tibial–femoral limb alignment and the femoral component alignment were compared using Student's t-test. There were no significant differences between the two groups with respect to sex, age, body mass index (BMI), pre- and postoperative KSSs. There was a statistically significant difference between the two groups with respect to radiographic tibial–femoral limb alignment, 4.33 degrees of valgus in the short stem THA–TKA group versus 5.4 degrees of valgus in the TKA group (p

Background Obese and morbidly obese patients undergoing primary total knee arthroplasty (TKA) place significant stress at the bone-cement-implant interface over the life of the patient. The purpose of this study is to evaluate results of cemented, posterior-stabilized TKA in obese and morbidly obese patients at an average follow-up of 10 years. Methods Retrospective study of 181 patients who had a cemented, posterior-stabilized TKA between 2000 and 2013 with body mass index >35 at the time of surgery was conducted. Clinical data and radiographs were evaluated along with survivorship, complications, and revisions. Minimum follow-up was 5 years with an average follow-up of 10 years. Results There were 135 women and 46 men in the study, with mean age of 60.2 years (range 43-80), mean body mass index of 42.0 (range 35.1-66.1), and an average follow-up of 10 years (range 5-18). There were a total of 39 failures (22%) that underwent revision TKA surgery with mean time to revision of 8 years. Failures included 25 (14%) cases of aseptic loosening; 9 (5%) polyethylene wear; 2 (1%) prosthetic joint infection; and 3 additional revisions for instability, pain, and stiffness. There were a total of 11 cases of isolated tibial component loosening and 13 for both tibial and femoral loosening. Survivorship at 15 years with aseptic loosening as the endpoint was 86.7%, and for all causes 79.6% at 15 years. Conclusion Aseptic loosening is the leading cause of failure following TKA in obese and morbidly obese patients with decreasing survivorship from 96.1% to 91.2% and 86.7% at 5, 10, and 15 years, respectively.

Aims:Approximately 20% of patients are dissatisfied with their total knee arthroplasty (TKA). Purpose of this study was to determine if patient satisfaction could be improved following TKA using computer technology to obtain the target alignment and precisely balanced gaps.Patients & Methods:75 consecutive patients undergoing primary robotic-arm assisted TKA (RA-TKA) with real-time intraoperative alignment and gap balancing information were compared with a prospective cohort of 75 consecutive patients undergoing primary TKA with manual jig-based instruments during the same time period. There were no differences between groups with age, gender, BMI, and ASA scores. TKA’s were performed by a single surgeon using same implant design, anesthesia and surgical protocols. Patient satisfaction survey using Knee Society (KSS) and Likert scoring system was obtained at 1-year follow-up.Results:Likert scoring system demonstrated 95% of patients in the computer technology group were either very satisfied or satisfied versus 75% in the manual instruments TKA group (p=0.005) at 1-year follow-up. Second question of the KSS which deals with pain at rest was significantly better in RA-TKA group (p=0.04). Fifth question which deals with recreational activities was also significantly improved in the RA-TKA group, p=0.02. RA-TKA group had a better average overall satisfaction score of 7.1 versus 6.4 in the manual instrument group, p=0.03.Conclusion:Using intraoperative computer technology to achieve the target alignment with flexion/extension gap balancing to within 1mm, a significant improvement in patient satisfaction was demonstrated compared to TKA using conventional manual jig-based instruments.

Background: Decreasing length of stay (LOS) following primary total knee arthroplasty (TKA) has been an important focus by all the stakeholders involved in the delivery of care. LOS is dictated by both the patient and hospital-related factors. The purpose of this study was to determine if early mobilization on post-operative day 0 (POD 0) following primary TKA has an effect on hospital LOS and discharge to home vs. rehabilitation facilities. Methods: An analysis was performed of consecutive primary TKAs performed at a single institution over one year. Patients were assigned to two groups: POD 0 or POD 1, based on their day of mobilization. Patients were mobilized following surgery based on time of arrival to the orthopaedic floor and availability of physical therapy (PT) resources. The two groups were compared for LOS and discharge disposition using univariate analysis. A total of 408 consecutive TKAs were evaluated and from this group, a total of 143 patients who were mobilized on POD 0 were then matched to 143 patients mobilized on POD 1. There were no significant differences in age, sex, American Society of Anesthesiologists score, or body mass index (BMI) between POD 0 and POD 1 groups. Results: There was a significant difference in LOS between POD 0 and POD 1 groups, 2.44 vs. 2.80 days (P=0.002). There were also differences in discharge to home vs. rehabilitation, 70.63% of the POD 0 cohort were discharged home compared to 58.74% in POD 1 (P=0.035). Conclusions: There was a significant reduction in LOS and there were differences in discharge disposition between patients who mobilized on POD 0 vs. POD 1, with more patients mobilized on POD 0 discharged home. Hospitals should work with their total joint arthroplasty programs to mobilize close to 100% of the patients undergoing primary TKA on POD 0 in order to decrease LOS and healthcare expenditure.

The purpose of this study was to determine the risk factors associated with reinfection in patients treated with irrigation and debridement (I&D) with liner exchange for an acute (less than 3 months) prosthetic joint infection following the index primary total knee arthroplasty (TKA). Medicare claims database was queried to identify patients with periprosthetic joint infection within 3 months of their index TKA who underwent I&D with tibial polyethylene liner exchange. Exclusion criteria included age 85 years old (p 6 weeks after index procedure compared with those performed within 2 weeks. Patients older than 85 years, diabetics, or treated with I&D with liner exchange > 14 days following the primary TKA had a significantly higher risk of reinfection within 1 year. Patients should be cautioned on the risk of reinfection prior to proceeding with I&D with liner exchange > 2 weeks following the index procedure.

The purpose of this study was to evaluate the efficacy and safety profiles of topical tranexamic acid (TXA) in patients undergoing elective total knee arthroplasty (TKA) with comorbid conditions precluding them from intravenous (IV) TXA use. A total of 104 patients were divided into two groups: 47 in the normal-risk group and 57 in the high-risk group, with the latter representing those with one or more risk factors for venous thromboembolism (VTE). Demographics were similar between groups, and there were no differences with regard to postoperative changes in hemoglobin (− 3.42 g/dL ± 1.07 and − 3.68 g/dL ± 1.07, p = 0.214), total drain output (630.2 mL ± 331.6 and 566.9 mL ± 343.9, p = 0.344), postoperative transfusion rate (2.1 and 3.5%, p = 0.675), or total number of complications 3 (6.5%) and 5 (8.8%) for the normal- and high-risk groups, respectively (p = 0.671). Topical TXA exhibited a similar safety and efficacy profile in reducing postoperative blood loss in a group of patients at increased thromboembolic risk, without a significant increase in complications or thromboembolic events. Topical TXA appears to represent a safe and efficacious alternative to IV TXA in patients at high risk for VTE undergoing TKA.

Background Primary total knee arthroplasty (TKA) in morbidly obese patients has been associated with greater postoperative complications. Cementless TKA has the potential for biologic fixation which may provide more durable long-term stability. Methods This was a multicenter review of 298 TKAs in 292 morbidly obese patients (body mass index, >40) undergoing TKA, with 154 TKAs (149 patients) in the cemented and 144 TKAs (143 patients) in the cementless group. Results There were significantly more revisions in the cemented group (n = 20) than in the cementless group (n = 1; 13.0% vs 0.7%). There was a significantly higher incidence of aseptic loosening in the cemented cohort vs the cementless cohort (9 vs 0 TKAs). All revisions in the cementless cohort were due to infection (0.7%). Conclusion Cementless fixation may be an alternative in the morbidly obese patient undergoing primary TKA.

The purpose of this study was to compare the efficacy of topical Tranexamic Acid (TXA) versus Intravenous (IV) Tranexamic Acid for reduction of blood loss following primary total knee arthroplasty (TKA). This prospective randomized study involved 89 patients comparing topical administration of 2.0g TXA, versus IV administration of 10mg/kg. There were no differences between the two groups with regard to patient demographics or perioperative function. The primary outcome measure, perioperative change in hemoglobin level, showed a decrease of 3.06 ± 1.02 in the IV group and 3.42 ± 1.07 in the topical group (P = 0.108). There were no statistical differences between the groups in preoperative hemoglobin level, lowest postoperative hemoglobin level, or total drain output. One patient in the topical group required blood transfusion (P = 0.342). Based on our study, topical Tranexamic Acid has similar efficacy to IV Tranexamic Acid for TKA patients.

Background The use of cementless femoral components has become the standard in younger patients due to increased implant survivorship and decreased loosening. However, it remains controversial whether these femoral stems can provide comparable results in elderly patients. Therefore, our purpose was to compare the (1) incidence of revisions; (2) clinical outcomes; (3) incidence of postoperative blood transfusions; and (4) differences in complications between the 2 cohorts. Methods Seventy-four consecutive patients (78 hips) aged 80 years or older, who underwent primary total hip arthroplasty using a cementless, tapered, femoral stem were retrospectively compared with a matched cohort of 76 patients (78 hips) who were less than 80 years. Mean age was 83 years (range, 80-91 years) vs 59 years (range, 17-79 years) for the matched group. Minimum follow-up was 2 years. Revision rates, clinical outcomes using the Harris Hip Score, incidences of complications, and postoperative transfusion rates were evaluated. Results In the octogenarian cohort, the aseptic survivorship was 99%, compared with 95% in the matched group. There were 2 aseptic loosenings (2.6%): 1 femoral implant loosening (1.3%) and 1 acetabular loosening, but only 1 revision was performed, as one of the patients declined revision surgery. In the matched cohort, there were 6 revisions (7.7%). There were no significant differences in revision rates between the 2 cohorts, and no significant differences in final Harris Hip Score scores. The incidence of blood transfusion in the study group was 42% vs 19% in control group ( P Conclusion The use of cementless, tapered, femoral stems yielded excellent results in the octogenarian group, although adequate patient preoperative optimization is necessary given the significantly higher transfusion incidence.

Tranexamic acid (TXA) has been used successfully in primary total knee arthroplasty (TKA) to minimize blood loss and transfusions. The purpose of this study is to determine its efficacy in patients undergoing revision TKA. In a retrospective review of 111 patients (68 control and 43 TXA), treatment patients receiving a single intravenous TXA dose of 10mg/kg required less transfusions ( P =0.03) and less total blood units consumed than controls ( P =0.03). When stratified by type of revision, treatment patients undergoing femoral and tibial component revision had lower transfusion rates than the controls ( P =0.03). Given the drawbacks of allogenic blood transfusion, we highly recommend the use of TXA in revision TKA, especially when both components are being revised.

Bicondylar tibial plateau fractures can be difficult to treat due to the extent of articular cartilage, metaphyseal bone, and soft tissue injury. The purpose of this study was to compare the outcomes of open reduction and locked plating vs fine-wire external fixation of 58 consecutive bicondylar tibial plateau fractures at a level I trauma center. All bicondylar tibial plateau fractures were classified as Schatzker V/VI or AO/OTA type 41C. Twenty-eight patients in one group were treated using a locked plating system, and 30 patients in another group were treated with a hybrid or circular external fixation frame. The 2 groups were similar demographically. When compared with external fixation, locked plating was associated with a decreased time to union (5.9 vs 7.4 months), decreased incidence of articular malunion (7% vs 40%; P=.003), decreased knee stiffness (4% vs 13%), and decreased overall complications (27% vs 48%). The Schatzker VI subgroup accounted for 25 of the 27 complications (93%) in the locked plating group and 40 of the 48 complications (83%) in the external fixation group. We reserve the use of external fixation devices in the treatment of tibial plateau fractures to span the fracture site until the patient is amenable to definitive fixation with locked plating.

The purpose of this study was to determine whether the use of a periarticular injection using liposomal bupivacaine could decrease pain and improve outcomes after total knee arthroplasty. Fifty consecutive patients received no periarticular injections (group A). Another 50 consecutive patients received a periarticular injection of liposomal bupivacaine (group B). There were no differences in the groups with respect to gender, age, body mass index (BMI), or comorbidities. There was a significant reduction in the amount of narcotics used in the liposomal bupivacaine group (60.97-mg oral morphine equivalent vs 89.74 mg, P = 0.009). Patients in group B with a BMI