Millions adults worldwide have knee osteoarthritis (OA), a life-altering disease associated with pain. Different pharmacologic and non-pharmacologic drugs and agents are recommended for treatment of pain , and to improve their daily adult life. The use of viscosupplementation with hyaluronic acid (HA) injections can benefit to restore synovial fluid properties in the knee, can relief pain and improved the function. Arthroplasty of the knee either partial or total usually is considered as the last option. This study to show the use of HA injections in delaying knee arthroplasty in patients with knee OA.
Methods: A retrospective study of 85 patients with degenerative knee disease of at least two compartments seen in our OPD from Jan 2020 till March 2023 ( 55 female & 30 males). Excluding those with obvious deformities. All patients receive HA injections 4ml single and Intensive quadriceps build up and stretching exercises for two months, then follow clinically and radiologicaly.
Result: There was a well defined response curve with such model of treatment in 69 case very well improved and the reduction of NSADs use, 10 cases slight improvements and 6 cases with minimal satisfaction
Conclusion: The results support the effectiveness of hyaluronic acid injections associated with good physiotherapy program in delaying total knee replacement and show that patients treated with hyaluronic acid and the reduction of the direct medical costs

Introduction: We aim to analyse the clinical and radiological outcomes of TKA in neuropathic joints. Methods: A final cohort of 17 patients (21 knees) with the diagnosis of neuropathic joint undergoing primary TKA between January 2013 to January 2019 were included in the study. The preoperative ambulatory status, range of motion, prosthesis used, level of constraint and any augmentation were retrieved from medical records. Radiological evaluation includes Koshino’s staging, magnitude of deformity, and any progressive loosening were evaluated. Results: The mean follow up was 40.2 months (range, 15 to 75 months). The mean HKA angle in valgus knees was 23.60 (range, 11.10 to 42.50) and for the varus knees was 19.30 (range, 4.90 to 39.60). The prosthesis used were posterior stabilized in 7 knees (33.3%), varus-valgus constrained in 5 knees (23.8%) and rotating hinge was required in 9 knees (42.8%). The mean arc of motion improved from 102.4±22.7 degrees to 105.7±15.5 degrees postoperatively (p>0.05). The knee society and knee society functional score improved from 23.3±9.3 and 28.3±12.2 preoperatively to 81.1±5.4 and 80.4±8.5 during the follow up respectively (p<0.05). There were no progressive radiolucent lines noted in the final follow up. One patient had medial collateral ligament injury, one patient had deep vein thrombosis and another had postoperative periprosthetic tibial shaft fracture. Conclusion: TKA in neuropathic joint will lead to improved functional and radiological outcomes compared to the preoperative disability. The diagnosis of non-syphilitic neuroarthropathy, modern constrained prosthesis and early rehabilitation lead to improved clinical outcomes in these high-risk patients.

Background: TKA has estimated blood loss from 700-1,500 ml. Postoperative changes in hemoglobin (Hb) can evoke a stress response in patients and increase morbidity. While monitoring Hb levels and clinical is standard postoperative care, existing literature lacks a standardized guideline for postoperative blood concentration monitoring. This leading to the question what the appropriate timing and frequency for blood collection. this could reduce the cost of investigations and alleviate the discomfort associated with blood collections.
Methods: A total of 203 patients undergoing unilateral TKA, and 130 patients undergoing simultaneous bilateral TKA were enrolled in a prospective observational study. All patients received tranexamic acid and underwent tourniquet. Preoperative Hb levels were obtained and subsequent measurements were taken at 24 and 48 hours postoperatively. A correlation between pre- and post-operative of hemoglobin level and blood transfusion rate was analyzed. Blood was transfused when Hb level <8.0 or patient had anemic symptoms.
Results: The mean difference in Hb levels between preoperative and 24 hours postoperative was 2.1 g/dL in unilateral and 2.78 g/dL in bilateral TKA. The most significant decrease in Hb levels was observed at 24 hours postoperative compared to the previous day. The overall blood transfusion rate was 6.4% in unilateral and 37.6% in bilateral TKA. From the results, in unilateral patients with hemoglobin levels of 13.1 (± 1.3) g/dL and 12.99 (± 1.13) g/dL in bilateral TKA, no blood transfusions were administered. The first-day blood transfusion rate was 46% in unilateral and 48.9% in bilateral TKA groups.

The coronal plane alignment of the knee (CPAK) classification classifies coronal knee alignment based on the arithmetic hip knee angle and joint line obliquity. With increasing prevalence of robot-assisted total knee arthroplasty (TKA), surgeons are equipped to assess gap balancing intra-operatively and fine tune implant placement prior to making saw cuts, to achieve the “ideal” lower limb alignment. Hence, this study aims to evaluate how pre- vs post-operative CPAK classification changes for patients undergoing robot-assisted TKA, and its impact on patient reported outcome measures (PROMs). We retrospectively analysed 250 consecutive knees in patients who underwent Stryker Mako robot-assisted TKAs. Gap balancing was performed intra-operatively with all surgeons opting for a restricted kinematic alignment strategy. The most common pre-operative CPAK phenotypes were 37% CPAK I, 27% CPAK IV and 16% CPAK II, which changed post-operatively to 28.7% CPAK IV and 70.5% CPAK V post-operatively. In terms of functional outcomes, patients with pre-operative CPAK IV or V had a better Knee Society Score at 6 months post-operatively compared to all other CPAK phenotypes (p<0.001), but there was no difference at 2 years (p=0.74). These findings illustrate how CPAK phenotypes change with robot-assisted TKA, but with no significant difference in long-term PROMs.

Introduction: The coronal plane alignment of knee (CPAK) classification system has been proposed as a pragmatic, comprehensive classification for coronal knee alignment, based on constitutional alignment and JLO. This study aimed to evaluate the phenotype of knees in the Han Chinese population based on the CPAK system. Methods Randomly chosen 300 osteoarthritic knees of Han Chinese patients underwent radiological assessment with long-leg radiographs and were classified based on the CPAK system. Measurements included the arithmetic hip–knee–ankle angles (aHKA), joint line obliquity (JLO), lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA). Knees were grouped into 9 CPAK phenotypes based on aHKA and JLO. Results Most knees were distributed in Type I (37%) with constitutional varus and apex-distal joint line orientation. followed by type IV (26.7%), type II (13%), type III (10%), and type V (5.3%), types VII (3.7%), type VI(3%), type VIII (1.3 %), type IX was not distributed. Conclusion The majority of Han Chinese population was found to have constitutional varus alignment and apex-distal joint line orientation.

Introduction: We aimed to provide a comprehensive overview of current Asian joint arthroplasty registries, highlighting their strengths and weaknesses, and providing a case for the
need to establish such registries nationwide.
Methods: A broad search on Google, PubMed and Scopus using the keywords “joint registry Asia” without limits on language or date was conducted. The search was then conducted with keywords in English using Boolean operators, ("arthroplasty registry" OR "joint registry" OR " knee registry" OR "arthroplasty database" OR "joint database" OR "joint arthroplasty registry" OR "knee arthroplasty registry" OR "hip registry" OR "hip arthroplasty registry" OR "joint arthroplasty database" OR "hip database" OR "hip arthroplasty database" OR "knee arthroplasty database"). Results: A total of six registries in Asia were identified. Only three, Indian Joint Registry, Japanese Orthopaedic Association National Registry and Pakistan National Joint Registry have developed official websites and published annual reports. The majority of both hip surgeries in India and Pakistan were carried out on men,
osteoarthritis in contrary to in Japan. The majority of knee surgeries were conducted in women. Osteoarthritis was the primary indication for knee surgery, whereas osteonecrosis was the main indication for hip surgery in India and Pakistan compared to osteoarthritis in Japan. Conclusions: Although many countries in Asia have attempted to report data on joint arthroplasties, very little information on nationwide registries can be found. Only three countries in Asia, Japan, India and Pakistan have made available their joint registry data to the public.

Introduction: A well-known postoperative complication of the standard midline approach used in Total Knee Arthroplasty (TKA) is an injury to the infrapatellar branch of the saphenous nerve (IPBSN), which results in hypoesthesia of the anterior skin around the knee.

Method: As part of the present study, 66 knees undergoing primary TKA with a standard anterior midline incision were evaluated. The length of the incision and the area of numbness were measured in complete knee extension and 90° of flexion. The area of numbness was marked by the patient using a sketch pen. It was also determined by an independent observer using monofilament testing. The “ImageJ” software was also used for calculating the area of numbness. All measurements were done at 2 weeks, 3 months, and 6 months postoperatively.

Results: All patients developed numbness around the knee after TKA. Pearson correlation coefficient showed a statistically significant correlation between the length of skin incision and the area of numbness in both flexion and extension at 2 weeks (p<0.001) and 3 months (p<0.001). However, there was a weak positive correlation at 6 months (p=0.217) and it was statistically not significant.

Conclusion: The skin incision length used for TKA positively correlates with the area of numbness postoperatively in the short-term period. However, there is no significant correlation 6 months after the surgery. Numbness involving the lateral skin flap is a significant notable complication after TKA and patients should be counseled regarding this complication before surgery. The occurrence of numbness should be documented postoperatively.

Introduction Multiple strategies, used either in isolation or combination, are available to reduce the need for post-operative blood transfusion in joint replacements. Amongst them, the use of tranexamic acid (TXA) has been rising and this study was conducted to compare the efficacy of topical and intravenous TXA in bilateral total knee replacement patients. Materials and methods Randomised prospective study with 120 patients (male: female: 25:95) undergoing bilateral TKA. Patients were divided into two groups A and B after computer randomization, who received intravenous or topical (intra-articular) TXA respectively. Results The average haemoglobin loss in intravenous group was 90.2379 g/L as compared to 39.137 g/L in topical group (p < 0.005). Moreover, there was reduction in blood loss in topical (330.1602 ml) as compared to intravenous group (764.9622 ml). The blood transfusion rate was more for the intravenous group (average 1.73 units) than for the topical group (average 0.75, unit). WOMAC score at 6 weeks in the intravenous group was 12.50, and in the topical group was 7.23 (p value < 0.001). Conclusion Topical TXA is better than intravenous TXA for reduction of blood loss, which also reduces the need for blood transfusion in bilateral TKA patients.

Background: The position of knee flexion during wound closure in total knee arthroplasty (TKA) can influence postoperative outcomes such as pain, knee function, and patellar height. This study compares the effects of 45-degree versus 90-degree knee flexion. Methods: A randomized sample of 58 patients undergoing TKA with posterior-stabilized prostheses was divided into two groups: 45-degree knee flexion (29 patients) and 90-degree knee flexion (29 patients). Outcomes assessed at 3 months postoperatively included pain, patellar height, knee function, and complications. Results: At 3 months post-TKA, there were no significant differences in pain scores, patellar height (measured by the modified Insall-Salvati ratio and Blackburne-Peel index), knee function (assessed by the Forgotten Joint Score-12 Thai version and Oxford Knee Score Thai version), or range of motion between the two groups. No postoperative complications were observed. Conclusions: Knee flexion at 45 degrees and 90 degrees during wound closure in TKA showed no significant differences in pain, patellar height, knee function, or complications at 3 months postoperatively

Introduction:Posterior cruciate ligament(PCL) is a key structure in balancing the gaps in TKA;but the effect of its resection on the gaps are controversial and inconclusive. This study aims to understand the changes in the flexion and extension gaps in both medial and lateral compartments following PCL resection in TKA with Stryker-Mako robot. Materials and methods:Prospective study which included 50 patients with osteoarthritis of the knee with varus deformity who underwent Stryker Mako robot assisted TKA(RA-TKA) from July2023 to Dec2023. Valgus deformity, post traumatic arthritis, previous ligament surgeries, rheumatoid arthritis are excluded. Medial and lateral compartment are distracted to the physiological limits in full extension and 90° flexion with curved osteotome before and after PCL release and gaps are documented. Results:PCL resection led to greater increase in medial flexion gap(mean 3.1mm(sd 2.0),p-0.009) compared to lateral flexion gap(mean 1.8mm(sd 1.2),p-0.003). PCL resection increased medial extension gap by mean of 0.9mm(p-0.004) and lateral extension gap by mean of 1mm(p-0.03). There was no significant improvement in the varus angle(mean 1.20 p-0.6)and flexion deformity angle(improved by mean of 1.20) following PCL resection. Discussion:Kayani et al have shown asymmetrical flexion gap opening which is more in lateral compartment. Lucian et al claim that the pattern of opening up of gaps following PCL release is inconsistent. The behaviour of PCL may differ based on the CPAKtype and in Indian scenario most common is CPAKtype 1, unlike the western population. Conclusion:In Indian varus knees PCL resection creates flexion extension mismatch with greater increase in medial flexion gap.

Introduction: Uncemented unicompartmental knee replacement offers a minimally invasive approach, faster rehabilitation and good levels of function, supported by evidence reporting low intra-operative fracture rate and mid-term stability with no implant migration at 5-years. Our aim was to examine the clinical outcomes in 289 consecutive Oxford unicompartmental knee arthroplasties (257 patients), five years post-operatively.
Methods: A retrospective study of patients treated in a non-inventor centre by a single surgeon was performed. Patients with anteromedial bone on bone uni-compartmental arthritis were included. Oxford Knee Scores (OKSs) at last follow-up were recorded, intra-operative complications reported with commentary on revision cases.
Results: Mean age of patients was 66 years (SD 9.6, 45e88 years). The average oxford knee score was 40.1 (n 1⁄4 232, Range 06 to 48, SD 8.46) at an average 6 years and 3 months from surgery, including revised patients. Six patients had their prosthesis revised within five-years of the index sur- gery. Five-year cumulative implant survival rate was 97.8% (95% CI 97.62 to 97.98, SE 0.09). Indications for revision were: lateral side wear (n 1⁄4 1); dislocated spacer (n 1⁄4 4); instability and spacer subluxation (n 1⁄4 1). Thirteen patients died within five years of surgery Five-year cumulative survival rate was 94.9% (95% CI 94.87 to 94.925, SE 0.013).
Conclusion: The proportion of patients requiring revision at five-years is lower than that generally re- ported for UKR. These findings add support for the use of the cementless oxford UKR outside the design centre.

Introduction: Osteoarthritis of Knee with Tibial stress fracture is not so common entity. It poses additional challenges for doing Total Knee Arthroplasty. We studied the radiological and functional outcome of Single-stage total knee arthroplasty with long stem components for patients with grade4 of knee osteoarthritis and proximal tibia stress fractures. Materials and Methods: We analysed 15 patients with proximal tibia stress fractures associated with Grade 4 knee osteoarthritis. The mean age was 66 years (range-52–80) and included seven men and eight women. Diagnosis of stress fractures was seen on x rays and clinical examination. Standing X-Ray views were obtained for all patients preoperatively and postoperatively. All patients were treated with TKA with long stem (PCL sacrificing). Union of the fracture site studied using anteroposterior and lateral leg x-rays at intervals. Results: The mean follow-up period was 17.2 weeks (range of 12–24) months. All patients experienced reduction in pain and improvement in functional status. The range of motion of the knee improved significantly. Flexion of knee improved from mean of 88 degrees (60-110) to 122 degrees (100-140). The fixed flexion deformity also decreased from mean of 10 degrees (5-15) to mean of 1 degree (0-5) The Knee Society score and Knee Society functional score had excellent improvements of approximately 825 and 83% respectively. All proximal tibia stress fractures were united till with an average time of 10 weeks (8-12 weeks). Conclusion: Single- stage Long stem TKR is a good and reliable surgical option for proximal tibial stress fractures with grade 4OA

Background: Tranexamic acid has proven to reduce bleeding after total knee arthroplasty without an increase in adverse events. However, it is still controversial whether its intravenous or periarticular delivery is preferable. Methods: We performed a prospective cohort study comparing intravenous and periarticular tranexamic acid in total knee arthroplasty, and specifically the differences in the clinical evaluation of the knee after one year. Two groups of 37 patients received either 2 doses of intravenous tranexamic acid (25mg/kg) or a periarticular infiltration of 2g in 40cc of saline. The blood level of haemoglobin was recorded after 24 hours as well as clinical and functional data one year after the surgery. Results: Patients in the iv group showed a reduction in haemoglobin level after 24 hours of 2.1 mg/dL (±0,97) and the second group of 2,14 mg/dL (±0,79) showing no statistical difference in the t-test (t=0.8671). The visual analogue scale (VAS) score, flexion and extension at one year follow-up showed a value of 2.65, 106.97 and 0 in the iv group, and 2.69, 106.63 and 0 in the periarticular infiltration group. The Oxford Knee Score at follow up was 34.04 and 33.82, respectively. None of the results regarding pain and range of motion showed statistical differences between the two groups. Conclusion: Both intravenous and periarticular delivery of tranexamic acid in total knee arthroplasty provide equal functional results at one year follow-up.