Postoperative WOMAC Research Articles

Extended Trochanteric Osteotomy Does Not Compromise Functional and Radiographic Outcomes of Femoral Stem Revisions with the Use of an Uncemented Modular Conical Stem.

Background: Stem revisions in revision total hip arthroplasty (THA) with proximal bone stock loss may be dealt with utilizing modular, uncemented conical stems. During stem extraction, surgeons may resort to extended trochanteric osteotomy (ETO). However, ETO is associated with extensive blood loss and infections. This study compared the clinical outcomes, radiographic results and complications in THA revisions utilizing conical modular stem with and without ETO. Methods: Patients who underwent revision THA with or without ETO were assessed retrospectively. The minimal follow-up was 3 years. The functional evaluation included Harris Hip Score (HHS) and Short Form 36 (SF-36) as well as Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Numerical Rating Scale for pain assessment. The radiographic evaluation comprised bone defect assessment, osteotomy healing, stem migration and position, presence of radiolucent lines and stress shielding. Results: In total, 73 patients (80 hips) were included in the final analysis. The ETO group comprised 48 hips, and the no-ETO group comprised 32 hips. In the ETO group, pre-operative WOMAC scores were lower than in the no-ETO group (p = 0.012). No significant differences were found in terms of post-operative HHS, WOMAC, and NRS scores between groups, except worse results were found in the case of claw plate implantation. Patients in the no-ETO group exhibited better results in SF-36 than in the ETO-group. Osteotomy non-union was observed in four hips (9.5%). Stam varus/valgus position was within ±1.5 degrees (85.9%). Conclusions: ETO does not adversely impact outcomes in patients undergoing femoral stem revisions with modular conical stems. The invasive nature of these procedures prompts careful consideration in each case individually.

Does the femoral component design modified in consideration of Asian anatomical characteristics fit better than the conventional design for Korean femora in reality?

We aimed to investigate the anatomical and clinical advantages of an Asian-specific femoral component design with a high femoral aspect ratio, compared with the conventional femoral component design. A retrospective analysis of the operation and outpatient clinic records of 239 knees operated on using an anatomically modified femoral component design (MFCD, Group A) and 153 knees operated on using a conventional femoral component design (CFCD, Group B) in Korean patients was performed. Three subgroups were created based on the mediolateral size of the two different femoral component designs. The geometric accommodation of each femoral component was assessed using intraoperatively measured femoral posterior condylar resection and posterior condylar trimming amounts. Clinical outcomes were assessed using a range of motion (ROM) and patient-reported outcome measurements. In the comparison between Groups A and B, the mean combined bilateral posterior condylar trimming (XPCT) was 2.91 [2SD: -4.12-9.94] and 1.45 [2SD: -5.89-8.80], and the median XPCT was 3 and 1.5. In the largest subgroup (subgroup 2), Groups A and B included 100 and 112 patients, all six posterior condylar resection and trimming parameters were significantly larger in Group A. Preoperative and postoperative ROM and Hospital for Special Surgery scores were similar between the two groups. Preoperative Western Ontario and McMaster Universities Arthritis Index (WOMAC) was higher in Group A. However, postoperative WOMAC was similar between the groups. Perioperative improvement in WOMAC index was significantly greater in Group B. The Asian-specific femoral component design resulted in more resection and trimming of the femoral posterior condyle than the conventional design despite it was not associated with different clinical outcomes. Surgeons should be aware of unexpected excessive posterior condylar resection and formation of large flexion gap when using femoral component design with high femoral aspect ratio.

Comparative study of total knee arthroplasty assisted by robot and remote sensing navigation system

To compare clinical efficacy of robot-assisted (RA) and remote sensing navigation alignment (RSNA) system-assisted total knee arthroplasty (TKA). From March 2023 to June 2023, 60 patients who underwent the first unilateral TKA due to severe knee osteoarthritis (KOA) were admitted and divided into RSNA group and RA group according to different treatment methods, with 30 patients in each group. There were 5 males and 25 females in RSNA group, aged from 56 to 81 years old with an average of(66.33±7.16) years old;body mass index(BMI) ranged from 19.87 to 38.54 kg·m-2 with an average of (28.40±6.18) kg·m-2;the courses of disease ranged from 5 to 36 months with an average of (18.20±8.98) months; RSNA system was used to assist the positioning of osteotomy. There were 7 males and 23 females in RA group, aged from 55 to 82 years old with an average of (67.83±8.61) years old;BMI ranged from 19.67 to 37.25 kg·m-2 with an average of (28.01±4.89) kg·m-2; the courses of disease ranged from 3 to 33 months with an average of (17.93±9.20) months;RA was performed. Operation time, incision length, latent blood loss at 2 weeks after operation and incidence of lower extremity thrombosis were compared between two groups. Hip-knee ankle angle (HKAA), HKAA deviation, lateral distal femoral angle ( LDFA), medial proximal tibial angle (MPTA) and posterior tibial slope (PTS) were compared between two groups;Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and Knee Society score (KSS) were used to evaluate functional recovery before operation, 3 and 6 months after operation. The operation was performed successfully in both groups, and there were no serious complications such as vascular and nerve injury during operation. The wound healed well at stageⅠafter operation, and the follow-up time was 6 months. The operation time, latent blood loss at 2 weeks after operation and incision length in RSNA group were (94.35±5.75) min, (130.54±17.53) ml and (14.73±2.14) cm, respectively;while (102.57±6.88) min, (146.33±19.47) ml and (16.78±2.32) cm in RA group, respectively. RSNA group was better than RA group (P<0.05). No deep vein thrombosis occurred in both groups at 2 weeks after operation, 5 patients occurred intermuscular vein thrombosisin in RSNA group and 8 patients in RA group, the difference was not statistically significant (P>0.05). In RSNA group, HKAA, LDFA and MPTA were (173.00±5.54) °, (86.96±3.45) °, (82.79±3.35) ° before operation, and (178.34±1.85) °, (89.92±0.42) °, (89.84±0.73) ° at 1 week after operation, respectively. In RA group, HKAA, LDFA and MPTA were (173.31±6.48) °, (87.15±3.40) ° and (82.99±3.05) ° before operation, and (178.52±1.79) °, (90.03±0.39) ° and (90.15±0.47) ° at 1 week after operation, respectively. HKAA, LDFA and MPTA were significantly improved in both groups at 1 week after operation (P<0.05). There were no significant difference in HKAA, LDFA, MPTA and PTS between two groups before operation and 1 week after operation (P>0.05). There was no significant difference in deviation distribution of HKAA at 1 week after operation (χ2=2.611, P=0.456). There were no significant difference in WOMAC and KSS between two groups before operation, 3 and 6 months after operation (P>0.05), and postoperative WOMAC and KSS at 3 and 6 months between two groups were improved compared with those before operation (P<0.05). Both RA and RSNA system assisted TKA could obtain accurate osteotomy, RA has higher surgical accuracy, RSNA system assisted operation has less trauma, and operation is simpler.

Analysis of Patients Who Undergo Index Arthroscopy With Biopsy but Not Implantation for Staged Chondrocyte Cell Transplantation.

Autologous chondrocyte implantation (ACI) and matrix-induced autologous chondrocyte implantation (MACI) are 2-stage procedures requiring an index full-thickness cartilage biopsy. Only a portion of patients ultimately undergo second-stage ACI/MACI. To identify patients with articular cartilage defects who underwent arthroscopic debridement with biopsy for ACI/MACI and compare those who did with those who did not proceed with implantation within 2 years after biopsy. Additionally, the authors sought to identify why patients did not proceed with implantation. Case-control study; Level of evidence, 3. Patients who underwent arthroscopy and autologous chondrocyte biopsy from January 1, 2015, to December 31, 2019, and who had minimum 2-year follow-up data were grouped into those who proceeded with second-stage ACI/MACI (implant group; n = 97) and those who did not (biopsy group; n = 63). Demographic factors, cartilage defect characteristics, and preoperative International Knee Documentation Committee (IKDC) scores were analyzed. Patients in both groups were evaluated postoperatively using the IKDC, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) for pain, and patients who did not undergo implantation were asked for their reasoning. Body mass index (BMI) (P < .001) and Outerbridge grades at index arthroscopy (P = .047) were significantly higher for the implant group than the biopsy group. Both groups had significantly improved IKDC scores from their initial presentation to final follow-up (implant group: 46.4 ± 16.2 preoperative vs 69.6 ± 20.6 postoperative [P < .001]; biopsy group: 47.2 ± 15.9 preoperative vs 70.7 ± 19.1 postoperative [P < .001]); however, the level of improvement did not differ significantly between groups. Postoperative WOMAC, SANE, and VAS pain scores were also similar between groups. In the biopsy group, 23 patients (37%) cited symptom resolution or activity level improvement after initial arthroscopy as the reason for not proceeding with implantation. Patients who proceeded to the second stage of chondrocyte implantation via either ACI or MACI had higher-grade articular defects and higher BMI compared with those who underwent biopsy with concomitant debridement chondroplasty alone. Postoperative outcomes were similar between the groups.

Association Between Overhang of the Posterior Femoral Condyle and Restricted Postoperative Knee Flexion Related to Patient-Reported Stiffness in Medial-Pivot Total Knee Arthroplasty

BackgroundThe primary aim of this study was to investigate the association between the posterior longitudinal overhang in the femoral condyle (PLOF) in medial-pivot total knee arthroplasty (TKA) and a change in knee flexion angle (change in flexion). MethodsThis retrospective cohort study included 148 knees undergoing medial-pivot TKA for medial knee osteoarthritis. The primary outcome was the change in flexion (c-flexion) preoperatively and 1-year postoperatively. The component positions were evaluated using 3-dimensional measurements, where the PLOF was measured for each medial and lateral femoral condyle. The secondary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index scores taken preoperatively and 2 years postoperatively. A multivariate regression analysis was performed to determine predictors of c-flexion and risk factors for negative c-flexion (less than 0°). Furthermore, a receiver operating characteristic curve was utilized to determine the threshold for negative c-flexion. ResultsThe mean c-flexion was −3.2° ± 8.7, and lateral PLOF was significantly associated with c-flexion (β = −0.52; P < 0.001). Larger preoperative flexion angles (odds ratio, 1.10; P < 0.001) and larger lateral PLOF (odds ratio, 1.69; P = 0.001) were risk factors for negative c-flexion, with thresholds of 129° and 1.1 mm, respectively (sensitivity, 0.79; specificity, 0.72). Additionally, patients who had negative c-flexion (n = 91) demonstrated less improvement in preoperative and 2-year postoperative Western Ontario and McMaster Universities Osteoarthritis Index stiffness subscores than patients who had positive c-flexion (0° or more; n = 57) (P = 0.01). ConclusionsA larger lateral PLOF was associated with decreased and negative c-flexion after medial-pivot TKA. Patients who had negative c-flexion demonstrated less improvement in knee stiffness. Surgical strategies aimed at minimizing lateral PLOF may enhance postoperative knee flexion and overall patient outcomes in medial-pivot TKA.

Functional Outcome after Direct Anterior Approach Total Hip Arthroplasty (DAA-THA) for Coxa Profunda and Protrusio Acetabuli-A Retrospective Study.

Objective: The direct anterior approach (DAA) is a recognized technique for total hip arthroplasty (THA) that spares soft tissue. Functional and clinical outcomes following THA via the DAA in patients with complex acetabular deformities, specifically coxa profunda (CP) and protrusio acetabuli (PA), have yet to be determined. Methods: A retrospective analysis was conducted on 188 primary THA cases, including 100 CP hips and 88 PA hips, performed via the DAA. Functional and clinical outcomes were evaluated by means of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Harris Hip Score (HHS) preoperatively and at a mean follow-up of 46 ± 14 months. Furthermore, potential complications were assessed. Results: From the preoperative to the latest postoperative visit, a significant improvement in the WOMAC total score was observed (CP: -34.89 ± 20.66; PA: -40.38 ± 21.11). The length of stay (LOS) was the only parameter predictive of the postoperative WOMAC total score, with each day of LOS increasing the postoperative WOMAC by a mean of 1.77 points (p < 0.01). The HHS improved by 38.37 ± 14.23 (PA-group) and 32.79 ± 14.89 points (CP-group). No significant difference in the patient-reported outcome measures (PROMs) between the CP- and PA-group was found. The survival rate for any revision was 97.70% (PA-group) and 92.80% (CP-group). Conclusion: The results of this study indicate that the minimally invasive DAA was not predictive of the functional and clinical outcome following DAA-THA in patients with CP and PA. Improvements in the mean WOMAC and HHS scores were above or within the reported MCID. Additionally, revision rates were well below those reported in the literature for short and intermediate follow-up periods.

Forgotten joint score associated with prosthesis weight in cementless total hip arthroplasty: a prospective clinical study.

This prospective study aimed to investigate the influence of weight difference between implanted prosthesis and removed bone in cementless total hip arthroplasty (THA) on hip awareness and patient-reported outcomes. A total of 48 patients (56 hips) who underwent primary THA were prospectively enrolled. Implanted prosthesis and removed bone were weighed intraoperatively. Forgotten Joint Score (FJS) and Western Ontario and McMaster Universities (WOMAC) scores were obtained before and at 1 and 3 months after surgery. Patients were divided into groups A, B, and C according to the percentile of the weight difference. The mean weight difference of the implanted prosthesis and removed bone was 117.97 ± 47.35 g. A negative correlation was found among the weight differences of the three groups and 1- and 3-month postoperative FJS (correlation coefficients, -0.331 and -0.734, respectively). A positive correlation was found among the weight difference of the three groups and 3-month postoperative WOMAC (correlation coefficient, 0.403). A significant difference in 3-month postoperative FJS and WOMAC scores was found among the three groups. The mean 3-month postoperative FJS (79.00) of group C was significantly lower than that of group A (93.32) (P < 0.05). The mean WOMAC score (15.83) of group A was significantly lower than that of group C (23.67) (P < 0.05). The implanted prosthesis is larger than the removed bone in cementless THA. The weight difference is negatively correlated with hip function. The weight difference should be minimized to achieve optimal hip joint awareness.

Analysis of kinematic changes of hip joint after total hip arthroplasty

To analyze the kinematic changes of the hip joint after total hip arthroplasty (THA) through three-dimensional gait analysis. Patients with hip joint diseases admitted between October 2022 and June 2023 were selected as the subjects. The patients who met the selective criteria were finally included in the THA group. The healthy volunteers matched with the THA group in the same age were included as the control group. Baseline data including age, gender, body mass index (BMI), and laterality were compared between the two groups. The Harris hip score (HHS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were recorded preoperatively and at last follow-up in the THA group. Three-dimensional motion capture system was utilized to collect spatiotemporal parameters and kinematic data during walking, including stride length, cadence, and maximum/minimum values, range of motion (ROM) in hip joint abduction/adduction, external/internal rotation, and flexion/extension, as well as gait scores. Differences between the two groups were analyzed. Additionally, the correlation between gait scores and postoperative HHS and WOMAC scores were analyzed in the THA group. Finally, the kinematic data of each degree of freedom (DOF) were fitted into a gait diagram, and the dynamic changes of the 3-DOF of the hip joint during the gait cycle were quantitatively analyzed. There was no significant difference in gender, age, laterality, and BMI between the two groups ( n=20, P>0.05). The mean follow-up time in the THA group was 9.9 months (range, 6-12 months). The HHS and WOMAC scores at last follow-up in the THA group showed significant improvement when compared with preoperative scores ( P<0.05). Gait scores were positively correlated with postoperative HHS score ( r=0.585, P=0.007) and negatively correlated with WOMAC score ( r=-0.619, P=0.004). There was no significant difference in stride length and cadence between the THA and control groups ( P>0.05), but gait score was significantly lower in the THA group than in the control group ( P<0.05). There was no significant difference in maximum and minimum values of flexion/extension, external/internal rotation, and abduction/adduction between the two groups ( P>0.05); however, ROM in the THA group was significantly lower than that in the control group ( P<0.05). There were significant differences between the two groups of flexion/extension in multiple phases of the gait cycle ( P<0.05). Early post-THA hip joint kinematics exhibit relative adduction, external rotation, and flexion during the gait cycle compared to normal individuals, with incomplete recovery of kinematic parameters in three degrees of freedom. Significant differences in flexion are observed at multiple phases of the gait cycle compared to normal individuals.

Comparison of Alignment Accuracy and Clinical Outcomes between a CT-Based, Saw Cutting Robotic System and a CT-Free, Jig-guided Robotic System for Total Knee Arthroplasty.

The different cutting mode of robot-assisted TKAs may influence the accuracy of alignment. The purpose of this study was to compare alignment accuracy and early clinical outcomes between a CT-based, saw cutting robotic system (MAKO) and a CT-free, jig-guided robotic system (ROSA) for total knee arthroplasty (TKA). A total of 20 MAKO TKAs and 20 ROSA TKAs from June 2021 to June 2022 were retrospectively analyzed. Differences in the postoperative hip-knee-ankle (HKA) angle, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), posterior tibial slope (PTS) and 3° outlier frequency of the HKA, LDFA, MPTA and PTS were studied at 3 months and 1 year of follow-up. The operative time and total blood loss (TBL) were compared between these two groups. Clinical outcomes at 1 year after surgery, including range of motion (ROM), Western Ontario McMaster University Osteoarthritis Index (WOMAC) score, and Knee Society Score-2011 (KSS-2011), were also compared between these two groups. The baseline characteristics of the two groups were comparable. There were no significant differences in the mean deviations of postoperative HKA, LDFA, MPTA or PTS between the two groups at 3 months or 1 year (all ps > 0.05). Moreover, there was no significant difference in the percentage of 3° outliers for HKA, LDFA, MPTA, or PTS between the two groups at 3-month or 1-year follow-up (all ps > 0.05). The mean operation time of MAKO was longer than that of ROSA (112.7 ± 12.8 min vs 94.8 ± 23.0 min, p = 0.001), but the mean TBL (1356.7 ± 648.5 mL vs 1384.5 ± 676.3 mL) and transfusion rate (15.0% vs 5.0%) were not significantly different between the two groups (all ps > 0.05). No significant differences were found in postoperative ROM, WOMAC score or KSS score at 1 year (all ps > 0.05). The MAKO and ROSA had similar accuracy and precision in TKA alignment. The clinical outcomes at 1 year after surgery were also comparable.

A New Arthroscopic Classification for Chondrolabral Disease in Patients Undergoing Surgery for Developmental Dysplasia of the Hip.

Current classification systems for intra-articular pathology intraoperatively have been described for patients with femoroacetabular impingement rather than dysplasia. To (1) describe intra-articular findings in dysplastic hips undergoing combined hip arthroscopy and periacetabular osteotomy (PAO); (2) propose a new chondrolabral classification system for dysplastic hips based on these findings; and (3) correlate patient-reported outcome measures (PROM) with the newly proposed classification. Case series; Level of evidence, 4. A total of 46 hips underwent combined hip arthroscopy and PAO at our institution between September 2013 and December 2014, irrespective of symptoms or radiographic findings. PROMs were evaluated preoperatively and at 2 years postoperatively. At the time of hip arthroscopy, the chondrolabral junction was classified as normal without tear (1 hip, type 1); hypertrophic labrum without chondrolabral disruption (19 hips, type 2); chondrolabral disruption on the articular side, not extending into the capsular side (16 hips, type 3A); chondrolabral disruption extending through the capsular side (3 hips, type 3B); and exposed acetabular subchondral bone (7 hips, type 4). There was a significant difference in postoperative modified Harris Hip Score (mHHS) (P = .020), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores (P = .037), and WOMAC total scores (P = .049) between chondrolabral junction types. Post hoc analyses demonstrated significant differences between type 2 (84.9 ± 12.9) and type 3A (67.8 ± 20.7; P = .198), and between type 2 and type 4 (59.3 ± 24.3; P = .011) in postoperative mHHS scores; and between type 2 (83.9 ± 12.9) and type 3A (68.9 ± 23.7; P = .045) in postoperative WOMAC total scores. In multivariate analysis, chondrolabral type 3 or type 4, age >35 years, and previous surgery were significantly correlated with worse mHHS scores at 2 years. This new chondrolabral classification is proposed to describe intra-articular pathology seen during combined hip arthroscopy and PAO, specifically in dysplastic hips. More advanced chondrolabral disease was associated with worse PROMs at 2 years.

Effect of lower limb alignment on outcome after lateral unicompartmental knee arthroplasty: a retrospective study

PurposeThe objective of this study was to investigate the correlation between lower limb alignment and patient outcomes after lateral unicompartmental knee arthroplasty (LUKA).MethodsIn this retrospective study, the information of 51 patients who underwent lateral UKA was collected after an average of 27months of follow-up (13 to 60 months). Evaluation indicators include the AKS and WOMAC score. The Kellgren-Lawrence grade is used to evaluate the severity of osteoarthritis, while the hip-knee-ankle (HKA) angle is utilized to measure the valgus angle of lower limb alignment.ResultPatients with postoperative valgus (≥ 3°) alignment had the best outcomes, while those with varus (≤-3°) alignment had the worst outcomes (p < 0.001). Furthermore, it was noted that patients with preoperative mild valgus (≤ 4°) alignment had worse postoperative outcomes than those with severe valgus (≥ 7°) alignment (p < 0.05). The study also revealed a positive correlation between postoperative valgus and WOMAC scores (p < 0.001), whereas a negative correlation was observed between the change in valgus angle and WOMAC scores (p = 0.005).ConclusionDuring follow-ups, we found that lower limb alignment seems to be an independent predictor of postoperative outcomes. It is recommended that more than 3° of valgus alignment should be maintained after LUKA. Surgeons performing lateral UKA should be cautious of overcorrecting alignment, particularly in patients with preoperative mild valgus alignment.

Controlled posterior condylar milling technique for unicompartmental knee arthroplasty minimises tibia resection during gap balancing: Short-term clinical results.

The purpose of this study was to demonstrate the clinical utility of controlled posterior condylar milling (CPCM) in gap balancing while minimally resecting the tibia during fixed-bearing unicompartmental knee arthroplasty (UKA). This study is a retrospective cohort study. Patients who underwent medial UKA for isolated medial compartment osteoarthritis with a minimum follow-up of 2 years were included. The patients were divided into two groups: the conventional group (n = 56) and the CPCM group (n = 66). In the CPCM group, the proximal tibia was resected at the level of the distal end of the subchondral bone. If the flexion gap was tighter than extension, the posterior condyle was additionally milled to adjust gap tightness. Standing knee X-ray and scanogram were used to evaluate alignment and tibia resection amount. Range of motion (ROM) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores were used to evaluate clinical outcomes. The CPCM group showed significantly smaller tibia resection (3.6 ± 1.9 mm) compared to the conventional group (5.2 ± 2.7 mm) (p < 0.001). Postoperative ROM (133.0 ± 8.3°, 135.2 ± 7.2°, n.s.) and WOMAC (19.3 ± 13.6, 23.6 ± 17.7, n.s.) were not significantly different between the two groups. Postoperative periprosthetic fractures occurred in two patients in conventional group, while the CPCM group had no periprosthetic fractures. The CPCM technique may be a simple and useful intraoperative technique that can achieve minimal tibia resection and promising clinical outcomes while easily adjusting gap tightness between flexion and extension during medial fixed-bearing UKA. Level III.

Restricted kinematically aligned total knee arthroplasty with an anatomically designed implant can restore constitutional coronal lower limb alignment.

Restricted kinematically aligned total knee arthroplasty (rKA-TKA) may not restore the constitutional varus alignment in most patients with knee osteoarthritis. This study aimed to investigate (1) the extent to which constitutional lower limb alignment can be restored by rKA-TKA using an anatomically designed implant and (2) which lower limb alignment parameters are associated with patient-reported outcome measures (PROMs). This study included 60 patients who underwent rKA-TKA using an anatomically designed implant. Radiographic alignment parameters, including mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), coronal hip-knee-ankle angle (HKA), coronal joint line obliquity (JLO), posterior tibial slope (PTS), single-leg standing knee flexion angle (KFA), sagittal JLO, and arithmetic HKA (aHKA), were evaluated preoperatively and postoperatively. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used for clinical evaluation. The mLDFA, MPTA, and aHKA showed no significant differences before and after surgery. Coronal HKA and PTS have significantly changed from 8.1 ± 8.7° and 9.9 ± 8.6° preoperatively to 3.5 ± 3.1° and 2.5 ± 2.0° postoperatively, respectively (p < 0.001 for each comparison). The postoperative WOMAC total score was significantly correlated with the KFA (r = 0.4063, p = 0.0034) and sagittal JLO (r = -0.3435, p = 0.0157). Postoperative KFA is a causal factor for the increased postoperative WOMAC total score (r = 1.416, 95% confidence interval: 0.491-2.342, p = 0.003). rKA-TKA using an anatomically designed implant can restore constitutional coronal lower limb alignment, while postoperative KFA and sagittal JLO were associated with poor PROMs. Care should be taken for the postoperative KFA because it is a risk factor for poor PROMs. Level III, case-control study.

No Superior Bone Union Outcomes with Allografts Compared to No Grafts and Autografts Following Medial Opening Wedge High Tibial Osteotomy: A Retrospective Cohort Study.

There has been long-standing debate about whether a medial opening wedge high tibial osteotomy (MOWHTO) gap should be filled with autologous bone graft or any other filler to expedite the healing process. The main purpose of this study was to compare the clinical and radiological outcomes of MOWHTO with an opening gap ≥10 mm, utilizing autograft, allograft, or no graft at 1 year postoperatively. A total of 68 patients were included in this retrospective study and divided into three treatment groups: Group A (no bone graft), Group B (autologous iliac crest graft), and Group C (allogenous tibia plateau graft). At postoperative 1-year follow-up, the area of callus filling in the most medial side of the knee was measured using anteroposterior radiographs, and a modified van Hemert scoring system was used to evaluate bone union outcomes in five mediolaterally divided zones. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and relevant complications were assessed. The correlations between the gap width and bone union scores were evaluated. Patients in the autograft group demonstrated better bone union progression (p = 0.031) and higher bone union scores (p < 0.01) compared to patients in the allograft or no graft groups. There were no significant differences in terms of postoperative WOMAC scores and incidence of complications among the three groups. No discernible linear relationships between the width of the opening gap and the bone union score were found. For MOWHTOs with an average gap opening width of 12.1 mm, autografts resulted in superior bone union outcomes compared to allografts and no graft at 1 year postoperatively. However, no bone graft achieved similar outcomes to allografts, suggesting that routine use of allografts should not be recommended.

Total Knee Replacement in Nonambulant Patients: Osteoporosis, Severe Fixed Flexion Deformity, and Weak Extensor Mechanism “the Terrible Triad”

Abstract Background: Knee osteoarthritis is among the most disabling disorders in elderly. With delay in proper management, muscular weakness, progressive flexion deformity (FD), and disuse osteoporosis “the terrible triad” are serious consequences, which could be major obstacles for the planned total knee replacements (TKRs). High risk for iatrogenic fractures, difficult gap balancing and failure to promote the patient activity are common expectations. Materials and Methods: A retrospective analysis of all TKRs that were done in a university specialized unit between January 2015 and January 2021 searching for nonambulant-patients was done. Twenty-two replacements for 15 patients who were unable to walk at least 3 months before surgery were found. The median fixed FD (FFD) before anesthesia was 45°. Osteopenia was evident on X-rays and bone thickness intraoperatively. Quadriceps muscle strength was not more than grade four. The median preoperative functional KSS was 0°. The median preoperative WOMAC score was 90.63. Results: Twelve knees had remaining FFD 1 year after surgery with a median of 5°. Ten had iatrogenic fractures mostly affected the medial femoral condyle. One patient could not regain walking capability and 11 patients could not walk without assistance. The median postoperative functional KSS and WOMAC scores were 61 and 21.36, respectively. Conclusion: TKRs in nonambulant patients with evident terrible triad (muscle weakness, osteoporosis, and FFD) is a risky procedure. Common complications include iatrogenic fractures and inability to regain normal physical capabilities. Despite the magnificent improvement in function, we do not recommend performing TKRs in such patients without strict patient counseling with possible drawbacks.

Lateral Subvastus Lateralis versus Medial Parapatellar Approach for Total Knee Arthroplasty: Patient Outcomes and Kinematics Analysis.

The conventional approach for total knee arthroplasty (TKA) is a medial parapatellar approach (MPA). We aimed to study patient outcomes and kinematics with a quadriceps sparing lateral subvastus lateralis approach (SLA). Patients with neutral/varus alignment undergoing primary TKA were consented to undergo the SLA. At 1-year postoperative, patients underwent radiostereometric analysis. Patients were administered the Short Form 12 (SF-12), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee Society Score (KSS). Kinematics and outcome data were compared to a group undergoing TKA via conventional MPA. Fourteen patients underwent TKA via SLA with a mean age 71.5 ± 8.0 and mean body mass index (BMI) 31.0 ± 4.5. The MPA group had 13 patients with mean age 63.4 ± 5.5 (p = 0.006) and mean BMI 31.2 ± 4.6 (p = 0.95). The SLA resulted in a significantly more posterior medial contact point at 0 (p = 0.011), 20 (p = 0.020), and 40 (p = 0.039) degrees of flexion. There was no significant difference in medial contact point from 60 to 120 degrees, lateral contact point at any degree of flexion, or axial rotation. There was no difference in improvement in postoperative WOMAC, SF-12, KSS function, and total KSS knee scores between groups. The MPA group had a significantly greater improvement in KSS knee scores at 3 months (p < 0.001), 1 year (p = 0.003), and 2 years (p = 0.017). The SLA resulted in increased medial femoral rollback early in flexion. Although both approaches resulted in improved postoperative outcomes, the MPA group showed significantly greater improvements in KSS knee scores at 3 months, 1 year, and 2 years. Further studies are required to identify any benefits that the SLA may offer. LEVEL OF EVIDENCE: Therapeutic Level II.

Comparison of Clinical Signs Associated with Lumbar Spine in Patients with Simultaneous Knee Osteoarthritis and Lumbar Spine Osteoarthritis before and after Knee Arthroplasty

Background: Knee osteoarthritis (OA) and low back pain (LBP) are common and co-occur in the elderly. The LBP in patients who are candidates for knee arthroplasty affects the outcome and prognosis after surgery. In this study, we investigated the LBP in patients with simultaneous knee and lumbar spine OA after total knee arthroplasty.&#x0D; Methods: In this cross-sectional study, 41 candidates for knee arthroplasty suffering from LBP were included. Demographic and visual analogue scale (VAS) questionnaires for LBP and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire for knee pain and function were completed by patients before surgery. Patients were graded according to VAS index. They were followed up for at least six months to two years.&#x0D; Results: The mean age of 41 patients was 64.30 ± 6.46 years. The mean of the preoperative VAS index was 5.15 ± 2.75, while postoperative VAS decreased to 4.34 ± 3.53 (P = 0.024). Of the total number of patients in preoperative evaluation, 24.4% were in low grades based on the VAS index, followed by moderate (41.5%) and severe (34.1%) grades. The greatest improvement in the VAS index was related to those in mild and moderate grades before surgery. The mean preoperative WOMAC index was 55.1 ± 23.7, while it was postoperatively reduced to 42.9 ± 30.6 (P &lt; 0.001). Postoperative WOMAC was found to be correlated with postoperative VAS (P = 0.004).&#x0D; Conclusion: In patients with mild to moderate LBP and knee OA, their back pain would improve if they had knee arthroplasty. However, in patients with severe LBP and knee OA, the spine should be examined further.

Joint line obliquity after lateral closing-wedge high tibial osteotomy does not adversely affect clinical and radiological outcome: a 5-year follow-up study

PurposeTo analyze the association between change in knee joint line obliquity (KJLO) and patient-reported outcome, radiological progression of osteoarthritis, and surgical survival after lateral closing-wedge high tibial osteotomy (HTO).MethodsA cohort of 180 patients treated in one single hospital with lateral closing-wedge HTO was examined. KJLO was defined by the medial proximal tibial angle (MPTA). To assess the association between KJLO and patient-reported outcome, radiological progression of osteoarthritis, and surgical survival, patient groups were defined: I, postoperative MPTA < 95.0°; II, postoperative MPTA ≥ 95.0°; A, MPTA change < 8.0°; B, MPTA change ≥ 8.0°. Propensity score matching was used for between-groups (I and II, A and B) covariates matching, including age, gender, preoperative lower limb alignment, preoperative medial joint space width (mJSW), preoperative Western Ontario and McMaster Universities osteoarthritis Index (WOMAC) score, wedge size, and postoperative follow-up time. Patient-reported outcome was assessed by the WOMAC questionnaire, radiological progression of osteoarthritis by mJSW and Kellgren–Lawrence (KL) grade progression (≥ 1) preoperatively and at follow-ups (> 2 years). Failure was defined as revision HTO or conversion to knee arthroplasty.ResultsAfter propensity score matching, groups I and II contained 58 pairs of patients and groups A and B contained 50 pairs. There were no significant differences in postoperative WOMAC score or surgical failure rate between groups I and II or between groups A and B (p > 0.05). However, the postoperative mJSW was significantly lower in group I than group II (3.2 ± 1.6 mm vs 3.9 ± 1.8 mm; p = 0.018) and in group A than group B (3.0 ± 1.7 mm vs 3.7 ± 1.5 mm; p = 0.040). KL grade progression rate was significantly higher in group I than group II (53.4% vs 29.3%; p = 0.008) and in group A than group B (56.0% vs 28.0%; p = 0.005).ConclusionIncreased KJLO (postoperative MPTA ≥ 95.0°) or MPTA change ≥ 8.0° after lateral closing-wedge HTO does not adversely affect patient-reported outcome, radiological progression of osteoarthritis, or surgical survival at an average 5-year follow-up.Level of evidenceIII, retrospective cohort study.

MODELING TO PREDICT THE PATIENTS’ POSTOPERATIVE WOMAC SCORE BY FEATURES ENGINEERING AND GRADIENT BOOST TREE

This research studies factors and creates a model to predict the patients’ postoperative WOMAC score after total knee replacement. First, the influencing factors were found by feature engineering, using several techniques such as Generalized Linear Models, Support Vector Machines, Deep Learning, and Gradient Boost Trees. Afterwards, the model was created by the Gradient Boost Tree technique which groups different attributes from feature engineering. Models were compared to find the model with the best predictability. RapidMiner Studio software version 9.9 was used in this work. The results demonstrate that the model created by the Gradient Boost Tree technique with attributes originating from feature engineering on the Gradient Boost Tree performs most efficiently with root mean square error (RMSE), mean absolute deviation (MAD) and square error (SE) of \mathbf{5}.\mathbf{311}\pm\mathbf{0}.\mathbf{538}, \mathbf{3}.\mathbf{550}\pm\mathbf{0}.\mathbf{376}, and \mathbf{28}.\mathbf{472}\pm\mathbf{5}.\mathbf{811} respectively.

Moonlight surgery: no influence of moon phase or Friday 13th on outcomes of total knee arthroplasty.

The purpose of the present study was to investigate associations between revision-free survival and functional scores of total knee arthroplasty (TKA) and moon phase on the day of surgery, as well as operations performed on a Friday 13th. The data of all patients that received TKA between 2003 and 2019 were extracted from the Tyrol arthroplasty registry. Patients that had undergone previous total or partial knee arthroplasty as well as patients that had missing pre- or post-operative WOMAC were excluded. Patients were allocated to one of the following four groups according to moon phase on the day of surgery: new, waxing, full and waning. Patients operated on a Friday 13th were also identified and compared to patients operated on any other days/dates. A total of 5923 patients met the inclusion criteria, with mean age of 69 ± 9years, and comprising 62% women. There were no significant differences in revision-free survival among the four moon phase groups (p = 0.479), and no significant differences in preoperative and postoperative total WOMAC (p = 0.260, p = 0.122), There were no significant differences in revision-free survival patients operated on Friday 13th vs. other days/dates (p = 0.440). The preoperative total WOMAC was significantly worse for patients operated on a Friday 13th (p = 0.013), which was observed in the pain (p = 0.032) and function (p = 0.010) subscales. There were no significant differences in postoperative total WOMAC at 1year follow-up (p = 0.122). Neither moon phase on the day of surgery nor Friday 13th were associated with revision-free survival or clinical scores of TKA. Patients operated on a Friday 13th had significantly worse preoperative total WOMAC but similar postoperative total WOMAC at 1-year follow-up. These findings could help reassure patients that TKA renders consistent outcomes regardless of the preoperative pain or function, and in spite of bad omens or moon phases.