Total knee replacement (TKR) design aims to restore normal kinematics with emphasis on flexion range. The survivorship of a TKR is dependent on the kinematics in six-degrees-of-freedom (6-DoF). Stepping up, such as stair ascent is a kinematically demanding activity after TKR. The debate about design choice has not yet been informed by 6-DoF in vivo kinematics. This prospective randomised controlled trial (RCT) compared kneeling kinematics in three TKR designs.

68 participants were randomised to receive either cruciate retaining (CR-FB), rotating platform (CR-RP) or posterior stabilised (PS-FB) prostheses. Image quality was sufficient for 49 of these patients to be included in the final analysis following a minimum 1-year follow-up. Patients completed a step-up task while being imaged using single-plane fluoroscopy. Femoral and tibial computer-aided design (CAD) models for each of the TKR designs were registered to the fluoroscopic images using bespoke software OrthoVis to generate six-degree-of-freedom kinematics. Differences in kinematics between designs were compared as a function of flexion.

There were no differences in terminal extension between the groups. The CR-FB was further posterior and the CR-RP was more externally rotated at terminal extension compared to the other designs. Furthermore, the CR-FB designs was more posteriorly positioned at each flexion angle compared to both other designs. Additionally, the CR-RP design had more external femoral rotation throughout flexion when compared with both fixed bearing designs. However, there were no differences in total rotation for either step-up or down. Visually, it appears there was substantial variability between participants in each group, indicating unique patient-specific movement patterns.

While use of a specific implant design does influence some kinematic parameters, the overall patterns are similar. Furthermore, there is high variability indicating patient-specific kinematic patterns. At a group level, none of these designs appear to provide markedly different step-up kinematic patterns. This is important for patient expectations following surgery. Future work should aim to better understand the unique patient variability.

Introduction

Reverse total shoulder arthroplasty (RTSA) is rapidly being adopted as the standard procedure for a growing number of shoulder arthropathies. Though short-term outcomes are promising, mid- and long-term follow-ups present a number of complications – among them, humeral stem and glenosphere component loosening. Though not the primary complication, previously reported aseptic loosening required revision in 100% of cases. As the number of patients undergoing RTSA increases, especially in the younger population, it is important for surgeons to identify and utilize prostheses with stable long-term fixation. It has previously been shown in the hip and knee literature that implant migration in the first two years following surgery is predictive of later failure due to loosening in the 5=10-year postoperative window. The purpose of this study is to, for the first time, evaluate the pattern and total magnitude of implant migration in reverse shoulder arthroplasty using the gold standard imaging technique radiostereometric analysis (RSA).

Introduction

Total shoulder arthroplasty is the fastest growing joint replacement in recent years, with projected compound annual growth rates of 10% for 2016 through 2021 – higher than those of both the hip and knee combined. Reverse total shoulder arthroplasty (RTSA) has gained particular interest as a solution for patients with irreparable massive rotator cuff tears and failed conventional shoulder replacement, for whom no satisfactory intervention previously existed. As the number of indications for RTSA continues to grow, so do implant designs, configurations, and fixation techniques. It has previously been shown that continuous implant migration within the first two years postoperatively is predictive of later loosening and failure in the hip and knee, with aseptic loosening of implant components a guaranteed cause for revision in the reverse shoulder. By identifying implants with a tendency to migrate, they can be eliminated from clinical practice prior to widespread use. The purpose of this study is to, for the first time, evaluate the pattern and magnitude of implant component migration in RTSA using the gold standard imaging technique radiostereometric analysis (RSA).

Background

The purpose of this multi-center, randomized clinical trial was to compare static and articulating spacers in the treatment of PJI complicating total knee arthroplasty TKA.

Background

The purpose of this multicenter, randomized clinical trial was to determine the optimal dosing regimen of tranexamic acid (TXA) to minimize perioperative blood loss for revision total hip arthroplasty (THA).

Introduction

Unstable ankle fractures are routinely managed operatively. Due to soft-tissue and implant related complications, there has been recent literature reporting on the non-operative management of well-reduced medial malleolus fractures following fibular stabilisation, but with limited evidence supporting routine application. This trial assessed the superiority of internal fixation of well-reduced (displacement ≤2mm) medial malleolus fractures compared with non-fixation following fibular stabilisation.

To compare 24-month patient-reported outcomes after surgical treatment or casting in patients age 60 years of age or older with unstable distal radius fractures (DRF's).

The Wrist and Radius Injury Surgical Trial (WRIST), is the largest randomized, multicenter trial in Hand Surgery, which enrolled 304 adults with isolated, unstable DRF's at 24 institutions. WRIST participants were followed for 24 months- longest follow-up among prospective studies comparing four treatment methods. Patients who agreed to surgical treatment (n=187) were randomized to internal fixation with volar plate (VLPS), external fixation, or percutaneous pinning; patients who preferred conservative management (n=117) received casting. The primary outcome was 24-month Michigan Hand Outcomes Questionnaire (MHQ) Summary score. Secondary outcomes were MHQ Domain scores.

At 24-month assessment, participants' mean MHQ Summary score was 86 (95% CI: 83,88), representing good hand function. Participants reported good return of their Activities of Daily Living (ADLs) with a mean MHQ ADL score of 88 (95% CI: 85,91). Finally, participants were satisfied, with a mean MHQ Satisfaction score of 84 (95% CI: 80,88). There were no significant differences in score by treatment group in any MHQ domain at 24 months. Six weeks after surgery, VLPS participants scored significantly higher than the other three groups on (ADLs) and Satisfaction (both p<0.0001), whereas participants who received external fixation scored significantly lower than the casting and VLPS groups on the same domains. By the 3-month assessment, the gap between VLPS and casting had disappeared but external fixation participants continued to report significantly worse scores. External fixation participants did not report comparable ADL scores to the other three groups until 12 months after surgery.

Participants reported good outcomes 24 months after DRF regardless of treatment. Casting and VLPS are both acceptable treatments for older adults. The decision between the two treatments should be made considering patient goals regarding recovery speed and desire to avoid surgical risks. External fixation should be avoided because of worse outcomes in the year after surgery and the risk of pin site infections.

Introduction

Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA that is associated with greater blood loss. The purpose of this multi-center randomized trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA.

The purpose of this study was to quantify tibial tunnel enlargement at 3-, 6- and 12-months post-anterior cruciate ligament reconstruction (ACLR), and evaluate the magnitude of tunnel widening with use of a Poly (L-lactic Acid) interference screw (PLLA (Bioscrew XtraLok, Conmed, New York)) compared to a Poly (L-lactic Acid) + tricalcium phosphate interference screw (PLLA+TCP (GENESYS Matryx screw comprised of microTCP and 96L/4D PLA, Conmed, New York)).

This was a prospective randomized controlled trial with two parallel groups. Eighty unilateral ACL-deficient participants awaiting ACLR surgery were recruited between 2013 and 2017 from the clinic of a sole fellowship trained orthopaedic surgeon. Patients had to be skeletally mature and less than 45 years old, with no concomitant knee ligament injuries requiring surgery, chondromalacia, or previous history of ipsilateral knee joint pathology, surgery or trauma to the knee.

Participants were randomized intra-operatively into either the PLLA or PLLA+TCP tibial interference screw fixation group. Study time points were pre-, 3-, 6-, and 12-months post ACLR. Participants underwent x-rays with a 25 mm calibration ball, IKDC knee assessment, and completed the ACL-Quality of Life score (ACL-QOL) at each visit.

Measurement (mm) of the most proximal and distal extents as well as the widest point of the tibial tunnel were taken using efilm (IBM Watson Health) and were standardized relative to the calibration ball. A contrast inverter was used to determine clear borders based on contrast between normal and drilled bone. In addition, a subjective evaluation of the tunnel was conducted looking for bowing of the borders of the tunnel or change in tunnel shape, categorizing the tunnel as widened or not widened.

Differences between groups at each time point were evaluated using independent t-tests corrected for multiple comparisons. Tunnel width was also compared as a percentage of actual screw size at 12-months post-operative. Categorical data were compared using Fisher's Exact Test. Forty participants were randomized to each group with mean age (SD) of 29.7 (7.6) and 29.8 (9.1), for PLLA and PLLA+TCP, respectively. There were no differences between groups in age, gender or ACL-QOL.

There were no differences found between groups at any time point in either tunnel width measurements or tunnel width as a percentage of actual screw size. The greatest difference between groups was noted in the measurement of the widest point on lateral x-ray view with a mean difference of 11%. Based on subjective evaluation of tunnel shape, three participants had visible widening in the PLLA group, and two in the PLLA+TCP group (p=NS).

No differences in tunnel widening were identified between ACL reconstruction patients using a PLLA interference screw compared to a PLLA+TCP screw for tibial fixation up to 12-months post-operative.

PURPOSE: The purpose of this study was to compare the level of post operative sport activity in a randomized study of SRA and THA.

INTRODUCTION: Return to high activity level has been proposed has an advantage of hip resurfacing (SRA) compared to THA. However, patient selection for SRA favours higher demand individuals, thus leading to a biased comparison of both techniques.

MATERIALS AND METHODS: Patients were randomized to THA or SRA. At minimum one year follow-up, the patients were asked about the activities they have resumed, the level of satisfaction regarding return to sports and the factors limiting full return to intense activities. 80 THA and 85 SRA with a mean follow-up of 16 months were analyzed.

RESULTS: The postoperative UCLA activity score was significantly higher in the SRA group (6.3 versus 7.1, p< 0.05). 77% of the SRA patients returned to high or moderate activity level vs 39% in the THA group (p=0.007). In the THA group, the activity level was mostly restricted due to concern about instability. However, some THA patients were still able to perform high demand activities.

DISCUSSION AND CONCLUSION: This study suggests that SRA allows return to higher activity level when compared to THA. This may be due in part to the larger diameter head of SRA which improves stability and suction-fit (reducing micro separation of the bearing during activities). Enhanced proprioception due to the retained femoral neck may also be involved in the bias towards SRA. Further follow-up is will determine if higher activity level is detrimental to implant survivorship

Patients with moderate to severe osteoarthritis of the knee, on a waiting list for total knearthroplasty, were recruited to a double-blind, randomized clinical trial evaluating neoprene knee braces containing high-power static magnets or sham magnets. Patients wore the brace for a minimum of six hours per day and were evaluated at baseline, two, six, twelve and twenty-four weeks. The subjective outcomes (MACTAR, WOMAC, KOOS, SF-36) and functional outcomes (six minute walk, thirty second stair climb) showed no statistically significant differences between the groups at any of the follow-up time periods.

The purpose of this study was to compare the effectiveness of neoprene knee braces containing high-power static magnets to sham magnets in the management of osteoarthritis of the knee

No statistically significant difference in patient-related quality-of-life and objective functional evaluation was found between groups.

This study provides patients and doctors with evidence as to the efficacy of this type of therapy. It will allow those individuals on fixed incomes to utilize their resources to the best advantage to minimize their symptoms related to osteoarthritis of the knee.

A prospective double-blinded randomized clinical trial was conducted. Ninety-five patients with moderate to severe osteoarthritis of the knee were randomized to receive a Magnet (M) or Sham (S) knee brace. Both groups were equal with regards to age (M = 71.1 yrs, S = 66.8yrs), severity of disease, gender and all baseline measures. No statistically significant difference in patient-related quality-of-life and objective functional evaluation was found between groups at any time interval.

All study patients were recruited from a knee arthroplasty waiting list. At baseline and at two, six, twelve and twenty-four weeks each patient completed a WOMAC, MACTAR, KOOS quality-of-life questionnaire, SF–36 global health measure, and six minute walk and thirty second stair climb after which they were asked to determine their general fatigue, pain and shortness of breath on a 100mm VAS scale. Patients were instructed to wear their brace at least six hours per day and when active (walking, shopping, golfing).

This randomized clinical trial utilizing the validated rotator cuff disease specific quality of life outcome measure (RC-QOL) and adequate power demonstrates no difference in outcome for full thickness rotator cuff tears comparing open to mini-open surgical techniques.

The purpose of the study was to compare standard open rotator cuff repair versus mini-open rotator cuff repair by measuring the disease specific quality of life in patients with rotator cuff injury.

This randomized clinical trial utilizing a validated disease specific outcome measure and adequate power demonstrates no difference in outcome for full thickness rotator cuff tears comparing open to mini-open surgical techniques.

The miniopen approach utilizing an arthroscoic acromioplasty provides no additional beneifit to the patient undergoing a rotator cuff repair.

The mean one year RC-QOL score for the open and mini-open groups were 85.3 (SD = 15.6) and 87.4 (SD = 12.0) out of a maximum of one hundred, respectively. This difference was not statistically significant (p = 0.572).

Seventy-two patients (forty-eight males/twenty-four females) with an average age of 56.4 years (thirty-three to eighty-two years) consented to participate in the study. Inclusion criteria involved: unremitting pain, failed conservative treatment of at least three months, weakness of rotator cuff, and positive diagnostic imaging indicating a full-thickness rotator cuff tear. Massive rotator cuff tears were excluded.

Prior to surgery, patients were randomized to either open or mini-open rotator cuff repair. Patients were assessed and outcomes were collected at three, six and twelve months after surgery. Primary Outcome Measure: Patient quality of life was quantified using the validated disease specific, reliable and responsive Rotator Cuff Quality of Life Questionnaire (RC-QOL) measured on a one hundred point visual analogue scale format. Secondary Outcomes: Range of motion, strength, American Shoulder and Elbow Surgeons Score, and the Shoulder Rating Questionnaire.

Aim

This was a multicenter, randomized, clinical trial to compare the 90-day 1) incidence of surgical site complications (SSC); 2) health care utilization (the number of dressing changes, readmission, and reoperation); and 3) the patient-reported outcomes (PRO) in high-risk patients undergoing revision total knee arthroplasty (rTKA) with postoperative closed incision negative pressure wound therapy (ciNPT) versus a standard of care (SOC) silver-impregnated occlusive dressing.

Introduction Venous thromboembolic disease is a serious complication of total hip replacement (THR). Use of low-molecular-weight heparin (LMWH) has been shown to reduce the occurrence of deep-vein thrombosis (DVT) significantly, but side effects such as bleeding and thrombocytopenia are frequent. Pneumatic compression with foot-pumps seems to provide the best balance of effectiveness and safety. However, a recent meta-analysis showed that the overall number of patients investigated in randomised clinical trials is too small to draw evidence-based conclusions regarding mechanical prophylaxis of DVT. This trial is a contribution in comparing the effectiveness and safety of mechanical versus chemical prophylaxis of DVT in patients managed with THR.

Methods Inclusion criteria were hip osteoarthritis, age less than 80 years, and uninterrupted use of a foot-pump. Exclusion criteria were a history of thromboembolic disease, heart disease, malignancy and bleeding diatheses. Two hundred and sixteen consecutive patients were considered for inclusion in the trial and were randomized either for management with (LMWH) (Fraxiparin, Sanofi -Synthelabo, France) or with the A-V Impulse foot-pump (Orthofix Vascular Novamedix, UK). All patients started mobilisation on crutches with partial weight-bearing on day two using compression stockings. The foot-pump was applied on both feet in the recovery room and was used until patient discharge. Management with the foot-pump was interrupted only during physiotherapy and toileting. A reverse Trendelenburg position (head-high, feet-low) was applied at rest to enhance the pneumatic effect of the pumps. Patients were monitored for DVT using serial duplex sonography (Sonoline Elegra, Siemens, Germany) at day three, 10 and 45 after surgery.

Results DVT was detected in three of 100 patients managed with the foot-pump compared with six of 100 patients who received chemical prophylaxis. Sixteen patients did not tolerate continuous use of the foot-pump and were excluded from the study. The average post-operative drainage was 259 ml in the foot-pump group and 328 ml in the control group (p=0.05). Patients with foot-pump had less swelling of the thigh (10 mm compared with 15 mm) (p=0.05). One patient developed heparin-induced thrombocytopenia.

Conclusions This study confirms the effectiveness and safety of mechanical prophylaxis of DVT in THR, confirming the outcomes of previous randomized clinical trials. Some patients cannot tolerate the foot-pump, mostly because of sleep disturbance.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

The aim of tissue sparing surgery in total knee arthroplasty is to reduce surgical invasivity to the entire knee joint. Surgical invasion should not be limited only toward soft tissues but also toward bone. The classic technique for total knee arthroplasty implies intramedullary canal invasion for proper femoral component positioning. This phase is associated to fat embolism, activation of coagulation, and occult bleeding from the reamed canal. The purpose of our study was to validate a new extramedullary device which relies on templated data.

Two-hundred patients in four different orthopaedics centres were randomized to undergo primary total knee arthroplasty either using standard intramedullary femoral instruments (IM group) or using a new extramedullary device (EM group). A new set of instruments was developed to control the sagittal and coranl plane of the distal femoral resection. The extramedullary instrument was calibrated referencing to templated data obtained from the preoperative long-limb radiograph (Fig 1, 2). Varus-valgus orientation of the resection were established by moving the two paddles according to templated data. An L-shaped sliding tool (5 centimetres long) over the anterior cortex controls the flexion-extension parameter of the resection and is intended to allow a cut flush with the anterior cortex at 0° of angulation with the distal aspect of the femoral diaphysis on the sagittal plane

Femoral component coronal alignment was within 0±3° of the mechanical axis in 86% of the IM group and 88% of the EM group. Sagittal alignment of the femoral component was 0±3° in 80% of the IM group and 94% of the EM group. There was no difference in the average operative time between the two groups. The EM group showed a trend toward less postoperative blood loss

Extramedullary reference with careful preoperative templating can be safely utilized during total knee arthroplasty.

Introduction

The application of artificial intelligence (A.I) using patient reported outcomes (PROs) to predict benefits, risks, benefits and likelihood of improvement following surgery presents a new frontier in shared decision-making. The purpose of this study was to assess the impact of an A.I-enabled decision aid versus patient education alone on decision quality in patients with knee OA considering total knee replacement (TKR). Secondarily we assess impact on shared decision-making, patient satisfaction, functional outcomes, consultation time, TKR rates and treatment concordance.

Background

The reductions of perioperative blood loss and inflammatory response are important in total knee arthroplasty. Tranexamic acid reduced blood loss and the inflammatory response in several studies. However, the effect of epinephrine administration plus tranexamic acid has not been intensively investigated, to our knowledge. In this study, we evaluated whether the combined administration of low-dose epinephrine plus tranexamic acid reduced perioperative blood loss or inflammatory response further compared with tranexamic acid alone.

Purpose: To comapre the clinical results and costs of a non-modular, all-polyethylene tibial component versus a modular tibial component in patients older than 70.

Methods: A multi-center (London, Ontario; Halifax, Nova Scotia) prospective randomized clinical trial was designed to compare modular metal-backed versus an all polyethylene tibial component in patients over 70 years. Primary outcome measures include Knee Society Clinical Rating System, WOMAC, SF-12, Kaplan-Meier Survivorship.

Results: Between September 1995 and August 1997, 127 total knee replacements (Genesis I, Smith & Nephew) were randomized to receive either a non-modular (all-polyethylene) tibial baseplate or a modular (metal-backed) baseplate. Minimum follow-up was 8 years. Excluding patients who died or became disabled due to medical problems, no consistent significant differences have been seen in regard to the WOMAC, SF-12, and Knee Society scores between the two groups. Kaplan-Meier Survivorship is 93% with a mean survival time of 9.36 years for the non-modular group and 94.1% with a mean survival time of 9.49 years for the modular group. The cost saving in the non-modular group was approximately $800 per TKR without any compromise in clinical outcome.

Conclusions: There was no difference found in the clinical outcome scores between an all polyethylene tibial baseplate and a modular tibial component in patients over 70 years of age. Non-modular tibial baseplates have a list price of 23–65% the cost of their modular counterparts. A high mortality rate exists in this age group limiting the numbers available for longer term review. The use of an all polyethylene tibial component is a cost effective and clinically successful alternative in the older patient requiring total knee replacement.

115 patients undergoing primary unilateral THA were randomized to either DAA or MPA. Groups did not differ in mean age, sex, or mean body mass index. Functional results included time to discontinue gait aids, discontinue all narcotics, and independence with various activities of daily living. Activity in study subjects was measured with 5 wearable activity monitoring sensors with tri-axial MEMS accelerometers and validated custom algorithms and conducted over three days at pre-op, 2 weeks, 8 weeks, and one year. SF-12, WOMAC, and HHS scores to one year were also tabulated.

Early functional recovery slightly favoured DAA compared to MPA; time to discontinue walker (10 vs. 14.5 days), time to discontinue all gait aids (17.3 vs 23.6 days), ascend stairs with gait aid (5.4 vs. 10.3 days), and to walk 6 blocks (20.5 vs. 26.0 days). There were no other differences in early functional milestones. Activity monitoring at two weeks postoperatively slightly favoured DAA; mean steps per day were 3897 versus MPA 2,235, percent of day active, DAA 10.5% versus MPA 6.9%. There was no difference in activity monitoring pre-operatively, at two months, or at one year. There was no difference at one year with the SF-12. There was no difference in the SF-12 mental component or the HOOS at any time point. There was no loosening or subsidence of any of the components in any hip.

Both the direct anterior and posterior approach provided excellent early postoperative recovery with a low complication rate. The direct anterior patients had slightly faster recovery than the mini-posterior approach patients, with slightly shorter times to achieve milestones of function and as measured by advanced, quantitative activity monitoring at 2 weeks postoperatively.

Purpose: Surface replacement arthroplasty is being increasingly offered as the treatment of choice to young and active patients with hip arthritis with proposed advantages including bone conservation and better functional outcome. Excellent outcome has been reported in the few recent short-term clinical series of surface replacement arthroplasty. However they have an inbuilt patient selection bias. There are no direct prospective randomized studies comparing the newer generation of surface replacement arthroplasty with conventional total hip arthroplasty. Our study addresses this issue.

Method: 210 hips in 194 patients were randomized to receive either an uncemented total hip arthroplasty or a hybrid metal-on-metal surface replacement arthroplasty. Complications, functional outcomes, along with patient satisfaction and radiographic evaluation were compared at a minimum of two years follow up.

Results: Patients in both groups demonstrated a very high satisfaction rate and achieved similar functional scores. Four dislocations occurred in the THA group (one needing acetabular cup revision) and none in the SRA group. There were no femoral neck fractures in the surface replacement arthroplasty group. However, two surface replacement arthroplasty cases underwent revision for late head collapse and one needed a femoral neck osteoplasty for persisting femoro-acetabular impingement. Better biomechanical restoration was attained with surface replacement arthroplasty. All the components were considered to be stable after an average follow up of 45 months.

Conclusion: Although surface replacement arthroplasty of the hip offer similar patient satisfaction, functional outcome and complication rate as an uncemented total hip arthroplasty in a young and active group of patients, different complications were associated to each procedure. Better patient selection could avoid some of the complications in the surface replacement arthroplasty group. One main advantage that remains for the surface arthroplasty technique it is the proximal femoral bone stock preservation. However, long term survival analysis is necessary to determine the true advantage of these implants over total hip arthroplasty.