Background
Ideal component sizing is difficult to achieve in unicompartmental knee arthroplasty (UKA). Anatomic variants, incremental implant size, and a minimized surgical exposure may lead to over- or under-sizing of the components. The purpose was to compare the accuracy of UKA sizing with robotic-assisted techniques versus a conventional technique.
Methods
Three groups of 93 medial UKA were assessed. The first group was performed by a conventional technique, the second group with an image-free robotic-assisted system (Image-Free group), and the last group with an image based robotic arm-assisted system, using on pre-operative CT scan (Image-Based group). There were no demographic differences between groups. We compared six parameters on postoperative radiographs to assess UKA sizing. Incorrect sizing was defined by an over- or under-sizing greater than 3mm.
Results
There was a higher rate of tibial under-sizing posteriorly in the conventional group compared to robotic-assisted groups (47.3% in conventional group, 29% in Image-Free group, 6.5% in Image-Based group; p<0.0001), as well as a higher rate of femoral under-sizing posteriorly (30.1% in conventional group, 7.5% in Image-Free group, 12.9% in Image-Based group; p<0.001). The posterior femoral offset was more often increased in conventional group, especially in comparison to the Image-Based group (43% in conventional group, 30.1% in Image-Free group, 8.6% in Image-Based group; p<0.0001). There was no significant overhang of the femoral or tibial implant in any groups.
Conclusion
Robotic-assisted surgical techniques for medial UKA decrease the risk of tibial and femoral under-sizing, particularly with an image-based system using a pre-operative CT scan.

Introduction: This study aims to evaluate the clinical safety and efficacies of Mesh-hold bone filling container(MHFC) vertebroplasty in the treatment of osteoporotic vertebral compression fractures (OVCFs) with posterior wall injury. Methods: From October 2017 to July 2019, 17 patients with OVCFs and posterior wall injury were admitted in our hospital, All patients underwent MHFC vertebroplasty using a unipedicular approach. After implanting the Mesh-hold bone filling container into a space formed by bone expander dilatation, bone cement is filled into the MHFC, a small amount of bone cement can be infiltrated into the trabecular space through the meshes to form a microscopic twist lock and to strengthen the vertebral body. Preoperative clinical and neurologic evaluations were done. Clinical efficacy of MHFC vertebroplasty treatment was evaluated by kyphotic Cobb’s angle, ODI and VAS score. Bone cement leakage and postoperative complications were also observed. Results: Operations were successfully completed in all 17 patients without pulmonary embolism and other complications. Asymptomaticbone cement leakage into other sites was seen in 5 vertebrae (29.41%). The ODI results before operation and at 1 day, 1 month, and 6 months after the operation were 83.215 ± 8.341, 28.125 ± 8.461, 16.195 ± 6.543, and 11.311 ±5.670, respectively.The VAS results before operation and at 1 day, 1 month, and 6 months after the operation were 7.815 ±0.501, 2.115 ± 0.511, 1.726 ± 0.421, and 1.630 ±0.112, respectively. Conclusion: MHFC vertebroplasty for treating OVCFs with posterior wall injury can relieve pain effectively and effectively prevent bone cement leakage.

BACKGROUND: Accelerometer-based handheld navigation systems(HHNS) for TKA do not require the large consoles needed for computer-assisted navigation systems (CAS) and have shown to decrease component malalignment in Total Knee Arthroplasty(TKA). The purpose of this study is to compare the radiological evaluation and functional outcome of TKA using HHNS with conventional instrumentation.
MATERIALS AND METHODS: This study is a multi-surgeon, prospective, assessor-blinded comparative study of 70 patients who were randomly allotted two groups HHNS group and conventional group based on instrumentation used for TKA. Postoperative radiographic evaluation was done using tibial and femoral alignment angle, posterior tibial slope, tibiofemoral angle, and functional outcome was evaluated using Oxford knee score (OKS) and Knee society score(KSS) with serial follow-up of up to 2 years. The data obtained were compared between two groups using appropriate statistical methods.
RESULTS: The mean tibial alignment angle and the posterior tibial slope was 0.82±1.17°, 3.58±0.96° respectively in the HHNS cohort versus 1.59±1.19°, 2.52±1.92° in the conventional cohort which is statistically significant (p-value < 0.001). There was no statistically significant difference in femoral alignment angle. The overall alignment using the mean tibiofemoral angle was 179.21±1.55 in the HHNS group as compared to the Conventional group 178.68±1.71 and was statistically significant (p-value =0.002). No statistical difference was found in KSS and OKS at 2-year follow-up among two groups.
CONCLUSIONS: The use of HHNS in TKA significantly increases accuracy in limb and implant alignment but there was no difference in `functional outcomes at the end of 2 years follow-up.

Background: As COVID-19 restricts operative opportunities for orthopaedic trainees, there is an urgent need for simulation training. The aim of this study is to assess the potential effectiveness of low fidelity simulation at improving arthroscopic skills. The feasibility of delivering a structured simulation training program for students will also be examined. Methods: Twenty two medical students completed pre- and post-training tests on Probing (Task 1) and Maze (Task 2) exercises from the Fundamentals of Arthroscopy Surgery Training (FAST) program. Between the two tests, participants were given a combined total of 25 minutes practice over a period of days. Test completion times and frequency of errors were measured. Additionally, pre- and post-training questionnaires assessed participants’ views on the usefulness of the program. Adherence rate and mean number of days between tests were calculated to assess feasibility. Results: Program adherence was 96% and mean interval between tests 3.4 days. Test completion time significantly decreased by a mean of 83 seconds for Task 1 (p = 0.001) and 105 seconds for Task 2 (p = 0.00007). Frequency of errors also decreased significantly by a mean of 1.0 errors for Task 1 (p = 0.04) and 0.8 errors for Task 2 (p=0.04). The number of participants answering ‘Yes’ to the incorporation of FAST into formal training increased from 57% to 82%. Conclusions: The results of this pilot study suggest low fidelity arthroscopic simulators have the feasibility and potential to improve basic arthroscopic skills in medical students, and may be incorporated into formal training.

Introduction: The COVID-19 pandemic has provided new challenges for surgical training. Junior surgical trainees are often redeployed to intensive care units (ICU) or medical wards to provide support. This study aims to evaluate whether junior trainees had received prior simulation teaching, assess their confidence in basic clinical skills and to review their confidence levels prior to and after an orthopaedic simulation session (DHS and basic arthroscopy simulation).
Methods: A retrospective questionnaire was sent to junior surgical trainees (senior house officer / junior resident level) after completion of the simulation session.
Results: 82% (9/11) had no prior experience of orthopaedic simulation teaching whilst 73% (8/11) had attended practical workshops. 91% (10/11) felt that the pandemic had affected their theatre time; redeployment to ICU was stated as the most common factor. 82% (9/11) felt their confidence in practical skills had been affected during COVID and the majority felt nervous about achieving benchmark operating numbers for progression in training. 91% (10/11) felt there was a lack of simulation teaching in the current curriculum. Confidence levels were higher post-simulation session, individually, for both DHS and arthroscopy simulators. 82% (9/11) felt simulation should be a part of e-logbook to supplement but not replace theatre operating time.
Conclusion: The confidence of junior trainees in completion of clinical tasks has been affected by the pandemic. Simulation training is a useful educational platform likely to increase trainee confidence. Future studies should aim to evaluate long-term implications of incorporating simulation into the surgical curriculum.

Background
No algorithm or predictive model have been published to anticipate the surgical time for the TKA procedure. The aim of this study was to analyze the predictive demographic factors of surgical time during a robotic-assisted TKA and to determine if the CT scan data impacts the prediction of surgical time.
Methods
It was a retrospective study using a large database of TKA performed with image-based robotic-assisted system. 1061 robotic-assisted TKA were included. Demographic data included patient age, BMI, gender, height, weight, surgery side and a surgeon label. The femoral and tibial mechanical axis and the osteophyte volume were collected from this database. A predictive model was created from these data and aimed to predict surgical time defined as incision to close, based on: 1) Demographic data only, and 2) Demographic and 3D patient anatomy data. The mean surgical time was 70.9 ±18.9 minutes.
Results
The most important features to predict the surgical time were: surgeon and patient weight, followed by 10 anatomical parameters derived from 3D CT scan, particularly the osteophytes volume. This model with demographic data and CT scan data (including osteophytes volume) showed that 94% of predictions were within 15 minutes of actual surgical time; with 88% within 10 minutes and 78% within 5 minutes.
Conclusion
The prediction of TKA surgical time was based mainly on the surgeon, the patient weight and the osteophytes volume. A preoperative CT scan brought several data allowing to improve the prediction of the surgical time of TKA.

Back ground and objectives:
The study was designed to study the advantage of robotic assistance in improving the functional outcome following total knee replacement (TKR) in comparison with the manual method.

Methods:
A single center observational comparative functional outcome study was conducted between september 2019 and april 2020 with a minimum one year follow up period. The patients were divided into two groups, group A included patient who underwent TKR using robotic assistance and group B included patients who underwent TKR using manual method. Knee society score (KSS) was used to assess the functional outcome after robotic and manual total knee replacement at the 3months, 6 months and one year. preoperative patient selection, pain management and post operative physio rehabilitation were identical for both the groups expect for the intra operative execution using robotic assistance and manual method.


Results:
The mean functional scores of robotic TKA at the end of 3 months was 37.8, 6 months was 47.0 and one year was 91.3 in comparison to manual TKA in the end of 3 months was 37.83, 6 months was 46.33 and one year was 91.3 with insignificant P value > 0.05.


Conclusion:

Though knee functional score in Robotic group showed better score in the early follow up ,but the final outcome in the both groups showed no difference at the end of one year. We hypothesize that this early benefit could be attributed to very minimal soft tissue release and Improved alignment.

Introduction: Amputation of an extremity is a life-changing event for each patient and has a negative impact on their quality of life (QoL) due to physical barriers and psychological distress. Until recently, no study had compared the quality of life of persons with transfemoral amputation treated with osseointegration to socket prosthesis users.
Objectives: Comparison of quality of life in two types of prostheses users: a cohort of patients with osseointegration and patients equipped with a socket prosthesis who were group-matched for age, body mass index and mobility grade. Study design: A cross-sectional study that compared
Methods: The quality of life of 39 participants (22 in the osseointegration group and 17 in the socket prosthesis group) was measured using the Questionnaire for Persons with Transfemoral Amputation (Q-TFA) and European Questionnaire 5-dimension 3-level (EQ-5D-3L) surveys.
Results: Compared with the socket prosthesis group, the osseointegration group had a significantly higher ‘Global’ score (p = 0.022) and a significantly lower ‘Problem’ score (p < 0.001) of the Q-TFA. The ‘Mobility’ (p = 0.051) and ‘Use’ scores (p=0.146) of the Q-TFA, the EQ-5D-3L index (p=0.723), and EQ-5D visual analog scale (p=0.497) showed no significant differences between groups.
Conclusions: Patients with osseointegration experienced less prosthesis-associated problems than socket prosthesis users and had a higher prosthesis-associated quality of life when assessed with the Q-TFA. General quality of life, as assessed with the EQ-5D-3L, was not different between groups.

Introduction:To explore the clinical efficacy and safety of a novel steerable percutaneous balloon kyphoplasty (S-PKP) for treatment of thoracolumbar osteoporotic vertebral compression fractures (OVCFs).Methods: From April 2018 to October 2019, a total of 29 patients (32 vertebrae) with thoracolumbar OVCFs were treated with a novel steerable percutaneous balloon kyphoplasty (S-PKP). The injured vertebrae were distributed as follows: T11 in 6 case, T12 in 10 cases, L1 in 8 cases, L2 in 4 cases, L3 in 4 cases. All patients underwent S-PKP procedure using a unipedicular approach. Introduced the novel steerable curved bone expander from the puncture side, expansion and bending to the contralateral side then inserted and inflated the curved balloon tamp. After vertebral body reduction, the bone cement was injected into the vertebral body. Clinical efficacy of S-PKP treatment was evaluated by kyphot¬ic Cobb’s angle, ODI and VAS score. Bone cement leakage and postoperative complications were also observed.
Results:The anterior vertebral body height of the fractured vertebrae, Cobb’s angle was a significant improvement between pre-operative and post-operative values without spinal cord or nerve root injury. The VAS was 8.2±0.3 at pre-operative, 2.1±0.5 at post-operative, 1.8±0.3 at final follow-up; and the ODI was 86.3±2.2 at pre-operative, 32.1±2.9 at post-operative, 27.1±2.3 at final follow-up. There was statistically significant improvement in the VAS and ODI at the post-operative assessment compared with the pre-operative assessment. Asymptomatic leakage was seen in 3 vertebrae.Conclusion:The novel S-PKP technology is a safe and efficient way for the treatment of thoracolumbar OVCFs.

Background: 15% of diabetics develop a foot ulcer. Offloading the ulcers leads to rapid healing. Various modalities include total contact coasting (TCC), irremovable/removable walker casts, therapeutic shoes, and conventional therapy. Studies show that TCC has better outcomes. A pilot study was conducted to calculate the cost analysis of TCC versus conventional therapy in the NHS at a district general hospital level. Methods: The sample size of 5 patients was calculated after incidence was found to be 25 patients/year in the region. The first 5 patients to receive TCC were recruited into the study. Data was collected with the help of the coding department. The cost of services before and after the intervention was analyzed, in the following categories: inpatient care, antibiotics cost, orthotics used, outpatient appointments, MDT appointments, and district nurse appointments. Patients received a change of TCC every 2 weeks with wound check. Results: The patients had diabetic foot ulcers for a period ranging from 6 to 140 weeks, despite using orthotics. They were admitted on numerous occasions for intravenous antibiotics, requiring multiple wound checks and input from different clinics. After TCC application their ulcers healed within 3 to 16 weeks. Only two patients needed oral antibiotics, with one of them being admitted to the hospital. Patients did not require reviews in other clinics. Before TCC, treatment costs varied from £2000 to £2,00,000, averaging at £40,022.46/patient. After TCC, it ranged from £600 to £14,000, averaging at £2739.18/patient. Conclusion: TCC is significantly economical than conventional therapy, with better outcomes.

Introduction: This study aims to explore the incidence, demographics, inpatient stay, use of imaging and outcomes of patients who have non-operatively managed NOF fractures.
Method: A 6-year retrospective review (2013-2019) of all non-operatively managed NOF fractures at a tertiary teaching hospital was conducted. Electronic patient records, radiographs and National Hip Fracture Database (NHFD) data were used to obtain information.
Results: 3.2% (99/3132) of NOF fractures were managed non-operatively. 52% (51/99) of these were minimally displaced subcapital fracture (AO Classification 31-B1.1). The two commonest reasons for non-operative management were either ‘comfortable mobilisation’(n=45) or ‘patient frailty/medically unwell’(n=50). The mean length of stay (LOS) was 10.1 days. 1-year mortality was 66.7% (66/99) for the overall cohort, 24.4% (11/45) for the ‘comfortable mobilisation’ subgroup. 74% (37/50) of the patients deemed too frail for operative management died within the 30 days of admission; 92% 1-year mortality (46/50). Of the “comfortable mobilisation” subgroup, 60% (27/45) presented at time of injury with an average delay in presentation of 7.9 days (range: 2 days- 6 weeks). 10.1% (10/99) required surgical intervention for failed non-operative management. 80% (36/45) of the comfortably mobilising subgroup had a successful trial of mobilisation.
Conclusion: For a select group of patients who are mobilising comfortably, non-operative management resulted in a 24.4% 1-year mortality rate. This is comparable to statistics for overall NOF fracture management in the literature and according to the NHFD 2019 report. Further analysis is necessary to assess the functional outcomes of this subgroup, as well as the potential cost implications.

Background: Lumbar spinal stenosis is a condition caused by narrowing of spinal canal. Steroid injections either lumbar or caudal do improve the functional outcome and reduce low back pain.
Objective: The objective of the study was to compare the outcome of caudal epidural steroid injection with lumbar epidural steroid injection in treating spinal stenosis in patients suffering from sciatica due to spinal stenosis.
Material and methods: In this prospective study 338 patients having low backache due to spinal stenosis with sciatica were included from June 2013 to December 2014. Patients were randomly divided into two groups, group I and II. Patients in Group I (160 patients) received caudal epidural steroid injections while the patients in Group II (178 patients) received lumbar epidural steroid injections. Visual analog scale (VAS) and Oswestry Disability Index (ODI) was used to assess outcome of the Caudal and Lumbar steroid injections and was measured at 2 weeks, at
3 months, and improvement was declared if VAS decrease >50% of baseline and Oswestry disability index decrease > 40% at 3 months.
DISSCUSSION
This randomized controlled trail of injecting steroid for managing lumbar spinal stenosis either
by caudal approach or by lumbar translaminar approach showed the efficacy of both approach at
the end of 3 months. However, the lumbar translaminar approach was superior to caudal epidural at 3 months. 89.33% patients of group II showed more than 50% decrease in VAS while only 75% patients of group I showed improvement at 3 months after the procedure

Introduction: Lumbar disc herniation (LDH) was generally treated with a conservative therapy or surgery so far. Condoliase, powerful chemonucleolytic drug that degrades the herniated disc, has been becoming a novel minimally-invasive therapeutic option for LDH since 2018 in Japan. This study assessed the shot-term clinical outcome of condoliase therapy in patients with LDH.
Methods: A total of 40 consecutive patients that we followed up for more than three months were retrospectively reviewed. All patients (mean age, 52.6 years) underwent the condoliase injection treatment for lumbar disc herniation. We evaluated clinical outcomes (symptom duration, affected intervertebral space, change in disc height, disc degeneration, JOA score, JOABPEQ (Japanese Orthopedic Association Back Pain Evaluation Questionnaire) and Visual analogue scale (VAS) (low back pain, leg pain, leg paresthesia)) at three months status after injection. VAS of leg pain improvement of 50% or more at three months after injection was judged as effective.
Results: Thirty-two patients (80.0%) were judged as effective at 3-month status after injection. The mean VAS of low back pain and leg paresthesia, JOA score and JOABPEQ were also significantly improved from baseline to the 3-month follow-up. Surgical treatment was required in one patient. The average duration since the onset of disease was 3.9months. 37.5% of the patients developed disc degeneration of Pfirrmann grade 1 or more at the injected disc level.
Conclusions: Chemonucleolysis with condoliase improved symptoms and physical function of patients with LDH. Condoliase is an effective therapeutic option for LDH patients who do not respond to conservative therapy.

Introduction: It is estimated that 28.9% (17.8 million) people have Musculoskeletal conditions in the United Kingdom. A study has shown one-third of patients presenting at general practice with musculoskeletal problems get knee steroid injections. Up to 2.4% of the population of adults aged 18 years or older needs anticoagulation therapy, with about 1.25 million people currently prescribed oral anticoagulants in the UK. With the given risk of bleeding complications, there is a lack of consensus on how Intraarticular injections and arthrocentesis to be performed in patients on novel oral anticoagulants. The aim of this study was to analyze the risk of bleeding complications in people on Novel Oral Anticoagulants who underwent joint injections and arthrocentesis, to help physicians in the decision making and consenting process Methods: A literature search of 3 online databases was conducted by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study that reported bleeding complication rates in adult patients on Novel oral anticoagulants undergoing injection/aspiration. Results: The search of databases resulted in a total of 284 articles. After screening, a total of 4 articles were deemed suitable to be included in the analysis. These described a total of 668 patients with injections/aspiration procedures. Only 1 joint had a bleeding complication on Dabigatran. None of the patients on Apixban or Rivaroxban showed any complications. Conclusions: The results of this systematic review show that it is relatively safe to perform intraarticular injections and arthrocentesis while continuing Novel Oral anticoagulants.