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The impact of fulfillment of patient expectations throughout recovery on satisfaction in total knee arthroplasty (TKA) is not well understood. Utilizing a standardized TKA method with a robotically assisted (RA) platform, we investigated the impact of expectation fulfillment at 3-month (M) and 6-M on 1-year (Y) and 2-Y satisfaction. We hypothesize that early fulfillment of patient expectations is associated with improved midterm patient satisfaction. We also compare improvements in outcomes with RA-TKA to those of a recent large national TKA cohort study to determine whether RA-TKA meets or exceeds the current standard of care. One hundred six patients were prospectively enrolled and underwent robotic-assisted TKA by a single surgeon using the OMNIBotics system. Patients completed KOOS and New Knee Society Score (KSS) preoperatively and at 3M, 6M, 1Y, and 2Y postoperatively. Expectation fulfillment was subdivided into patients who were below or above the average expectation score pre-operatively, or fulfillment of expectation score at 3M and 6M post TKA. The satisfaction of each group was then compared at 1Y and 2Y post TKA. Study cohort outcomes were compared to contemporary literature from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE–TJR) database. Patients with greater than average KSS expectation fulfillment at 3M reported significantly higher KSS satisfaction scores at 1Y (34.9 ± 5.3 vs 30.6 ± 6.7, p = 0.0012), and patients with greater than average 6M expectation fulfillment reported improved satisfaction at 1Y (33.9 ± 5.9 vs 31.1 ± 6.7, p = 0.0330) and 2Y (35.2 ± 4.8 vs 32.4 ± 6.8, p = 0.0323). When compared to the FORCE-TJR database, no significant differences in post-operative KOOS outcomes were observed except for Sports and Recreation, for which the RAS group demonstrated higher scores (65.5 ± 30.0 vs 53.0 ± 27.1 p

A well-balanced knee is a critical goal for total knee arthroplasty (TKA) across all surgical technique. Some controversy exists however about the method in which various techniques achieve soft tissue balance. Technology for balancing gaps in the tibia first approach has progressed from manual tensioners and laminar spreaders to digital tensioning tools integrated with robot-assisted navigation platforms, however there has been no comparison between femur first measured resection and tibia first techniques with this new technology. Our objective was to prospectively investigate joint balance accuracy and precision between a femur first measured resection and tibia first gap balancing technique utilizing a digital gap balancing tool.A consecutive series cohort undergoing TKA were investigated. The cohort was divided in to 4 groups: 1) Femur First Blinded to gap data, 2) Femur First Non-Blinded to gap data, 3) Tibia first Blinded to gap data, 4) Tibia first Non-Blinded to gap data. Implanted medio-lateral (ML) gap difference was used to calculate joint balance.94 patients were enrolled. No significant difference was found between the average ML gaps, however, the frequency of outlier balance throughout flexion, was significantly reduced in Group 4. Significant differences in the variance of the post-operative gap balance were also found, in which Group 4, reported reduced variance compared to group 3 and 2 throughout flexion and compared to group 1 at 90°.Ideal joint balance may remain a controversial topic, nonetheless a tibia first approach with digital balancing allows surgeons to accurately achieve a desired joint balance target.

This study reports on the one-year clinical results and patient reported outcomes (PROMs) associated with a new ‘predictive balance’ tibia-cut first total knee arthroplasty (TKA) technique that uses a robotic ligament tensioner. PROMs are compared to registry data and historical results in the literature.Five hundred and thirty-three patients were prospectively enrolled and underwent robotic TKA (mean age: 67.7±8.4; females: 320; BMI: 31.2±4.9). Pre-op, three, six and 12-month WOMAC, UCLA activity scale, and HSS-Patient satisfaction assessments were completed by 533, 352, 314, and 256 patients, respectively, and compared to WOMAC registry data from the Shared Ortech Aggregated Repository (SOAR) and to historical satisfaction reports in the literature.Despite having equivalent baseline PROM scores, predictive balance patients had significantly higher WOMAC scores at all post-operative timepoints (pLimitations to this study include the lack of a closely matched control group. Nonetheless, first year results are promising with improved objective measures compared to large registry databases and recently reported patient satisfaction measures.

Achieving a balanced knee is a critical aspect of Total Knee Arthroplasty (TKA). Coronal and axial boundaries for femoral component placement to achieve balance however, are not well defined. Our aim is to investigate the effect of femoral component and long leg coronal and axial alignment on patient outcomes when using a tibia-first gap balancing technique.All surgeries were performed using the OMNIBotics robot-assisted TKA platform and BalanceBot device. A total of 197 patients were prospectively enrolled into this study and received TKA surgery using the OMNIBotics platform and completed 1-year KOOS outcome scores. Femoral component and tibiofemoral alignment were categorized as inliers or outliers in the coronal and axial planes. Knee Injury and Osteoarthritis Outcome Score (KOOS), and University of California at Los Angeles Activity Scale (UCLA) was collected at 1-year post-op.No significant differences were found between the KOOS subscores or UCLA outcome and femoral coronal or tibiofemoral coronal and axial alignment. Significant differences were found between the KOOS pain and sports sub-scores and femoral axial alignment (∆ = 5.4, p = 0.007, ∆ = 8.3, p = 0.03 respectively), in which outlier femoral rotation reported higher scores.Component alignment limits for improved survival and patient outcomes are a source of ongoing debate. The data presented here indicates that when utilizing a tibia-first gap balancing technique, small deviations outside of traditional ±3°alignment boundaries did not negatively affect KOOS or UCLA outcomes, indicating balance may have a stronger link to patient outcome than alignment.

A poorly balanced, unstable or stiff joint is a leading cause of dissatisfaction and revision after surgery. The quantitative definition of a well-balanced joint, however, remains a source of controversy. This study investigates joint gaps measured by a digitally-controlled ligament tensioning device throughout flexion and its effect on post- operative outcome.Surgeries were performed using the OMNIBotics robot-assisted TKA platform and BalanceBot device. Joint gaps were recorded by the BalanceBot throughout flexion during trialing. Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected at 1-year post-op. Correlations between joint gaps and KOOS outcome were investigated.Knees that reported: a medial gap ≤ lateral gap in extension (p = 0.007, median ∆ = 8.3); an average joint gap of between 1 mm tighter and 1 mm looser than the final insert thickness in midflexion (p = 0.006, median ∆ = 5.5); and an imbalance of less than 1.5 mm in flexion (p = 0.012, median ∆ = 2.8) reported significantly improved pain scores. Patients which satisfied both extension and flexion criteria, or midflexion and flexion criteria reported improved outcomes compared to those which satisfied only one or neither criterion (p = 0.0002, median ∆ = 9.7, p = 0.0019, median ∆ = 8.4 respectively).KOOS Pain scores correlated with joint gap measurements across all flexion angles investigated. Combining joint gap windows, subgroups of patients were found that reported a change in the median KOOS Pain outcome beyond the minimally clinically important difference.

Joint balance in total knee arthroplasty (TKA) has traditionally focused on achieving a tight symmetric extension gap and rectangular or trapezoidal gaps in flexion. This study sought to investigate the effect of femoral and tibial coronal rotation and femoral axial rotation on midflexion coronal joint balance and patient outcomes.A prospective multi-center study was performed with a mixture of tibia-first gap-balancing and femur-first approaches were performed using the Corin OMNIBotics robot-assisted TKA platform with APEX implant components. Coronal and axial femoral and tibial resections were recorded by the platform. Medial and lateral joint gaps were recorded while applying a computer-controlled load to the joint throughout flexion during trialing using the Corin BalanceBot device. In addition, 1-year Knee Injury and Osteoarthritis Outcome Score (KOOS) and PROMIS-10 global health scores were collected.231 surgeries were identified: 66.9±8.1 years, 31.4±4.8 kg/m2 and 57% female (121) with a mean pre-operative HKA angle of 4.5±5.2° varus. A significant correlation was found between the medio-lateral (ML) joint gap difference in midflexion and both extension and flexion joint line (p=0.003, r2=-0.20, p=0.001, r2=-0.22, respectively). A significant correlation was found between midflexion ML imbalance and KOOS stiffness questions at 3 M and 6 M post-op (r2=-0.15, p=0.036, r2=-0.18, p=0.013), in which a more balanced knee correlated with improved outcomes.Treating flexion and extension joint balance in isolation may not capture the effect on midflexion laxity. Component placement should take in to account the effect on joint gaps throughout flexion to target optimal joint balance.

Soft tissue releases are often required to correct deformity and achieve balance in total knee arthroplasty (TKA). However, releasing soft tissues can be subjective, highly variable and is perceived as an ‘art’ in TKA. The objective of this study was to compare the rate of soft tissue release required to achieve a balanced knee in tibial-first gap- balancing versus conventional, measured resection TKA, and its effect on outcomes.Soft tissue releases were documented and reviewed in 1256 robotic-assisted gap- balancing and 85 robotic-assisted measured-resection TKAs. Knees were stratified by coronal deformity (varus: >2° varus; valgus: >2° valgus). Rates of releases were compared between the two groups and literature. A subset of these patients were also enrolled in a prospective study. KOOS outcomes were captured pre-operatively and at 6M post TKA.The frequency of soft tissue release was significantly lower in the robotic gap- balancing group, with 21% of knees requiring release versus 40% (p=0.001) in the robotic measured resection group and 67% (pRobotic assisted TKA with predictive gap balancing was found to reduce the number of releases across all coronal angles compared to conventional instruments. Furthermore, performing a soft tissue release rather than bone resection to achieve balance, correlated with worse outcomes. Further research is required to understand when imbalance should be corrected with bone resection adjustment versus soft tissue release.

Achieving proper soft tissue balance during total knee arthroplasty (TKA) can reduce post- operative instability and stiffness as well as improve patient reported outcomes. The objective of this study was to compare final intra-operative coronal balance throughout the knee range of motion in navigated robotic-assisted TKA when performed with quantifiable feedback from a robotic ligament tensioning tool versus with standard trials and navigation measurements alone.The study included a prospective cohort of 52 patients undergoing robotic-assisted TKA using a measured resection technique. The cohort was divided into two sequential groups: a non-sensor-assisted group (n=25) and a subsequent sensor-assisted group (n=27). Once bony cuts and soft tissue balancing was performed in the non-sensor cohort, the final tibiofemoral gaps were measured throughout the knee range of motion using a robotic-assisted tensioner with the surgeon blinded to the measurements. For the sensor cohort, the surgeon preformed soft-tissue releases or re-cuts in order to balance the knee using the gap measurement data from the robotic tensioner. The robotic-assisted tensioner was then used to measure the final medial and lateral gap measurements.The average mediolateral gap difference throughout the range of flexion was 1.9 ± 0.7 mm with maximum difference of 7.8 mm for the non-sensor cohort. The sensor cohort had an average mediolateral difference of 1.5 ± 0.6 mm and a maximum difference of 3.8 mm. The difference between the two groups was statistically significant from 60 to 90 degrees of flexion. 38-41% of knees were balanced to within 1 mm mediolaterally in the non-sensor group compared to 48-70% for the sensor group when measured at various flexion angles. 65-76% of knees were balanced to within 2 mm for the non-sensor group compared to 78-86% for the sensor-assisted group. The number of knees requiring subsequent soft tissue releases was similar in each group. Soft tissue balancing with the aid of a robotic tensioning tool resulted in significantly more accurate soft tissue balance than when using navigation measurements and standard trials alone in this single surgeon study.

Total knee arthroplasty is a successful procedure. However, there is still area for improvement as up to 15-20% of patients remain unsatisfied. Robotic-assisted surgery (RAS) may improve patient outcomes by providing a reproducible way of obtaining neutral mechanical alignment of the limb, which has been shown to reduce early revisions and correlate with patient reported outcomes after surgery.We prospectively enrolled 106 patients undergoing robotic-assisted TKA by a single surgeon performing a measured-resection femur-first technique using the OMNIBotic system. Patients completed a KOOS and New Knee Society Score (KSS) pre-operatively and at 3, 6, 12, and 24 months (M) postoperatively. Changes in the five KOOS sub-scales were compared to available literature data from the FORCE – TJR cohort, as well as to individual studies reporting on conventional and computer-assisted TKA.When compared to FORCE-TJR 6-month (M) and 2-year (Y) data, the RAS cohort had significantly higher improvements at 6M for pain (40.5 vs. 31.1, pDespite having poorer joint function and higher pain pre-operatively, robotic-assisted TKA patients achieved excellent self-reported outcomes, with significantly higher levels of improvement through two years post-surgery when compared with large national cohort studies. Further controlled clinical studies are warranted to determine if these results translate to other groups of surgeons, centers and patients.

Despite the advantages of real time alignment assessment and visual feedback while balancing offered by robotic assisted total knee arthroplasty, few clinical studies have reported patient outcomes. The purpose of this study is to report the midterm patient reported outcomes and survivorship of a computer-navigated TKA system with a robotic cutting guide. This patient cohort is the first IRB approved series of patients treated in the United States with this robotic knee system. This study serves as a midterm follow-up study on for this cohort, upon which learning curve, intra-operative efficiency, and deformity management were previously reportedRecipients of 152 consecutive total knee arthroplasties using a computer- navigated TKA system performed by a single surgeon between June 2010 and January 2012 were surveyed between 5-7 years post-operatively. 94 patients were reachable for outcome measures and survivorship data was obtained in 98 patients. Mean patient age at follow up was 74.6 +/- 8.6 years. Implant survivorship was 99.0% at an average of 6.5 years. Mean patient reported knee outcome scores were 62.7 (KSS-SF) and 79.5 (KOOS-JR). Overall satisfaction rate was reported as “satisfied or very satisfied” in 80.2%, “neutral” in 11.0%, and “dissatisfied or very dissatisfied” in 7.7% of patients.Robotic assisted total knee arthroplasty using a computer-navigated TKA system with a robotic cutting guide appears to provide a durable outcome with sustainable midterm patient reported outcomes and excellent survivorship. Further follow up is required to determine if there are long term outcome and survivorship benefits of robotic assisted total knee arthroplasty.

Accurate and topical spatial datasets representing human populations are foundational to solving humanitarian issues. This paper provides unique solutions to accurately map human settlements both at scale and across remote areas. A method of village boundary extraction from very high resolution optical satellite imagery is proposed. Furthermore, the supplement of a crowd-sourced validation process to filter the detections for higher accuracy and the automated mosaic techniques are detailed. To demonstrate the computational and informational scalability of the process, four distinct geographic locations in Nigeria, Somalia, Pakistan, and Afghanistan were analyzed for a total processed area of 592 000 km 2 , comprised of 1159 high-resolution DigitalGlobe images. The geographic variability of the locations and the scale of the projects required dynamic and automated solutions, respectively. The curated results exhibit high recall and precision of human settlement data in remote as well as urban areas. Crowdsourced validation allows complete control over the precision of the final village boundary layer, and given time, an effective 100% precision can be achieved. This highly scalable and precise system is perfectly adequate for processing regional and country-scale areas, with minimal human effort.

Background Diabetes mellitus has been associated with significant perioperative complications in joint arthroplasty. In addition, many patients are unaware of their dysglycemic status, and the prevalence of undiagnosed dysglycemia in joint arthroplasty patients is unknown. Methods Several years ago, we began routine hemoglobin A1c (HbA1c) level screening in all our patients planning to undergo elective total hip and total knee arthroplasties. We retrospectively reviewed the HbA1c levels in our initial 663 patients. Results Forty-eight percent of these patients were found to be nondiabetic; 19% percent had a previous history of some level of dysglycemia. Most significantly, over one third, 33.6% of these patients were previously undiagnosed dysglycemic patients; 31% were diagnosed as prediabetic and 2.6% as diabetic. Conclusion Owing to the high prevalence of prediabetic patients who go on to develop diabetes and to the high correlation of poor glucose control with perioperative complications, we feel that it is imperative to identify this large number of previously undiagnosed dysglycemic patients. We recommend the routine screening of all patients planning to undergo major orthopedic procedures. Likewise, we recommend that identified patients be referred for diabetic counseling. We also recommend that patients with markedly elevated HbA1c levels have their elective surgery postponed until better glycemic control can be achieved.

To gain widespread acceptance, robotic-assisted surgery must add value to total joint arthroplasty by demonstrating improved outcomes and reduced overall costs associated with the episode of care. We review the surgical technique as well as clinical and economic results associated with the introduction of a commercially available robotic-assisted total knee arthroplasty system (OMNIBotics®) in both an academic teaching and a community hospital setting. Clinical results demonstrate highly accurate and reproducible component placement and overall leg alignment, high patient satisfaction and knee functional outcomes as measured by the new Knee Society and KOOS scores, as well as a shortened length of stay and reduced 90-day readmission rates and overall episode of care costs when compared with manual intramedullary-based instrumentation.

An overview is presented of robotic and computer-assisted surgical (CAS) technologies, which have remarkable potential to enhance the precision and the quality of total knee arthroplasty (TKA). A detailed description is given of an exemplary imageless CAS TKA system that is based on bone-morphometric planning software combined with miniature robotic cutting-guide technology. The application of this technology in the clinical setting is discussed as it pertains to surgical accuracy and efficiency, surgeon learning curve, clinical utility in complex cases and severe deformities, and minimally invasive surgical (MIS) techniques.

We analyze the following question associated with flexible outsourcing under imperfect domestic labour market: How does the implementation of profit sharing influence flexible outsourcing? We show that in general profit sharing has a negative effect on low skilled wage and thus an outsourcing decreasing character. However due to labour union determination of effort a constant effort level will result so that in this case firm’s optimal choice of profit sharing is zero.

We analyze the following questions associated with flexible outsourcing under partly imperfect dual domestic labour markets, where high skilled workers participate in firm’s profit via profit sharing: How does the implementation of profit sharing influence flexible outsourcing? What is the relationship between outsourcing cost, profit sharing and wages? We show that profit sharing has a positive effect on low skilled wage and thus an outsourcing enhancing character. The wages of both types of labour are negatively correlated and lower outsourcing cost can increase the wage dispersion by decreasing the low skilled wage and raising the high skilled wage. The overall effect of profit sharing on high skilled wage is ambiguous due to a positive direct effect and a negative indirect effect via the low skilled wage.