Background: Neutral postoperative alignment is crucial for total knee arthroplasty. Several alignment theories can achieve accurate alignment. This research aims to radiologically quantify the difference in the amount of tibial bone resection that is necessary to execute a mechanical alignment (MA) vs an anatomic alignment (AA)TKA. AA requires a greater amount of resection than MA TKA. Methods: Two observers performed a retrospective review of the long leg radiographs of one 100 patients who were listed for TKA, with the goal of determining the amount of tibial bony resection necessary to achieve either MA/AA during TKA. Results The overall lower limb mechanical axis of radiographs varied from 16degrees varus to 17.6degrees valgus, with a mean of 4.4degrees varus and a standard deviation of 6.64degrees. When measured from the normal side of the tibial plateau, the mean resection required is 7.6mm in the mechanical alignment measurement, and 5.2 millimetres in the anatomical alignment measurement (p 0.0001 for both). 17% of all MA cuts will need tibial cut more than 10 millimetres (mean12.382 mm). No measurement of AA is more than 10mm. The Medial Proximal Tibial Angle is a better predictor of deformity than the mechanical axis when a virtual tibial cut of more than 10 mm is necessary. Conclusions: AA tibial cut is more bone-conserving on the tibia than a MA. It may also lead to reduced asymmetry of the bony cuts and higher bony preservation, although the clinical correlation is still required for these findings.

Purpose: to predict the most important preoperative factor affecting the patient satisfaction after total Knee arthroplasty (TKA) in trial to improve patient counseling process. Methods: we retrospectively reviewed all patients who underwent primary TKA from 1st of January 2018 to 31st of January 2019 with minimum one year follow up for the previously collected patient reported outcome measures (PROMs) as Oxford Knee Score (OKS) and Knee Injury and Osteoarthritis Outcome Score for joint replacement (KOOS, JR) preoperative, 6 months and 12 months postoperative. Results: By using Oxford knee score at 12 months as dependent variable, we found a negative moderate spearman correlation between age and oxford score at 12 months postoperative. Moderate negative spearman correlation was also found between oxford score at 12 months postoperative and KOOS pain, stiffness and function scores at preoperative and 6 months postoperative, denoting higher satisfaction at 12 months with less perceived stiffness, pain and limited function at baseline and 6 months postoperative. A multivariate regression analysis was done using the oxford knee score at 12 months as dependent variable to detect the predictors of oxford knee score at 12 months postoperatively and showed that younger age and less perception of stiffness at baseline were significant predictors of higher oxford score; higher satisfaction at 12 months postoperative. Conclusion: Preoperative stiffness can predict the postoperative satisfaction score more than any other factor. We also address the importance of combining more than one PROM in assessing patients as OKS and KOOS, JR. KEYWORDS: knee arthroplasty, PROMs.

Total knee arthroplasty (TKA) is a common surgical procedure for patients with severe knee osteoarthritis or other knee conditions that limit their mobility and quality of life. In recent years, there has been a debate over the optimal alignment technique in TKA, with some surgeons preferring anterior referencing (AR) and others preferring posterior referencing (PR). To determine which technique is superior, a meta-analysis of relevant studies was conducted.Methods: A systematic literature search was performed using PubMed, Embase, and Cochrane Library databases to identify randomized controlled trials (RCTs) and observational studies comparing AR versus PR in TKA. The primary outcome was the difference in postoperative pain scores and the knee range of motion between the two techniques. Secondary outcomes included functional outcomes, complications, and radiographic outcomes.Results:A total of 6 studies  were included in the meta-analysis, with a total of 784 knees (318 AR and 448 PR). The meta-analysis showed no significant difference in postoperative alignment between AR and PR (mean difference 0.09 degrees, 95% confidence interval [CI] -0.29 to 0.47 degrees; p = 0.64). There was also no significant difference in functional outcomes or complications between the two techniques.Conclusion:This meta-analysis suggests that there is no significant difference in postoperative alignment, functional outcomes, or complications between AR and PR in TKA. , which could potentially lead to early loosening or instability of the implant. Therefore, surgeons should carefully consider the benefits and risks of each technique and choose the one that is best suited for their patient's individual needs and characteristics.

Tranexamic acid (TXA) is a well-known antifibrinolytic developed in 1962.
For last 2 decades it's potential for bleeding control in various branches of medicine was recognised.
Side effects are rare, but there are a number of relative and absolute contraindications for its usage.
There is currently no global consensus on protocols or recommendations for the usage of TXA.
Our Clinic started to use TXA over 7 years ago, but all patients with relative contraindications were excluded. Therefore this study was designed to see if it is possible to use TXA topically with similar effect and how those results will compare to systemic administration.
This study was conducted over a period of 12 months. 50 patients operated by indiviual surgeon using same implant divided into 2 groups were included in this study. TXA for 25 patients was administered intravenously and 25 topically using our protocols.
We defined excluding criteria.
All patient had one vacuum drainage during 24 hours.
Parameters observed were blood loss during 24 hours, red blood cell count after 6 and 24 hours postop, hemoglobin level after 6 and 24 hours postop, need for BT and DVT/embolism incidence.
Results showed a statistically significant difference in total blood loss in the comparison of the two groups (545 ml systemic vs. 684 ml topically). As for hemoglobin levels and red blood cell count, there was no statistically significant difference at 6 and 24 hours postop.
Two patients from each group needed BT.
Patients in both groups didn't have DVT or embolism.

Introduction: Anecdotal reports suggest some cementless Oxford Unicompartmental Knee Replacements (OUKRs) have painful early tibial subsidence with valgus rotation and/or posterior tilting. The true incidence of subsidence and its association with pain is unknown. This radiographic study aimed to evaluate the incidence of cementless tibial subsidence and its relation to five-year patient reported outcome measures (PROMs). Methods: Cementless OUKRs from a high-volume centre with acceptable post-operative and five-year radiographs were included in the study. Subsidence was determined by measuring the tibial tray/tibial axis angle and distance between the tibial tray axis and fibula head on anteroposterior and lateral radiographs using a custom MATLAB program. Analysis of 5-year PROMs assessed the relationship between subsidence and pain. Radiographs indicating tibial subsidence were validated by two observers. Results: Radiographs of 94 cementless OUKRs were analysed of which five (5%) tibial components had subsided with an average of 1.9 varus rotation and 3.0 posterior tilt. Subsidence appeared to occur early within the first post-operative year with all tibial components fixed securely at 5 years. Two subsiders had moderate pain (ICOAP=20.5&15.9, AKSS Pain=20&45) and lower Oxford Knee Scores (OKS=26&31) compared to the cohort means (ICOAP=3.91, AKSS Pain=45.9, OKS = 43.6). These two subsiders had BMIs greater than 30. Conclusion: This study found 5% of cementless tibial components had early subsidence before becoming securely fixed. 2 of the 5 cases with subsidence had moderate pain at 5 years, which may be associated with obesity. A larger study is needed to study subsidence in greater detail.

There is a significant dissatisfaction rate in patients undergoing total knee arthroplasty (TKA), and poor mental health in patients is increasingly recognized as a major contributor to dissatisfaction. The aim was to review the effectiveness of cognitive behavioural therapy (CBT) in improving pain and functional outcomes of patients undergoing TKA and highlight important aspects that may be crucial for improvement. A systematic search was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were included if they were randomized control trials that included patients undergoing unilateral or bilateral TKA, with CBT as an intervention compared against usual care, and reported outcomes in pain, knee function and any psychological outcomes as measured. Eight RCTs were selected which included 683 participants. The timings of CBT delivery, profiles of therapists, and outcome measures reported varied across the studies. Overall, 3 studies reported significant improvement in pain outcomes, 3 studies reported significant improvement in functional outcomes and 5 studies reported significant improvements in psychological outcomes. While there is some evidence for the efficacy of CBT in TKA, current data in literature is too heterogenous. Further studies with homogenous CBT methods are required to further ascertain the true relationship between CBT and postoperative outcomes of TKA. Future studies should consider the points set out in this review, such as the importance of revisiting CBT skills, providing individualized therapy, having a supervisory team to support the fidelity of interventions, and identifying which group of patients would best benefit from CBT.

Introduction: The Oxford Unicompartmental Knee Replacement’s (OUKR) fully-congruent mobile bearing design minimises linear polyethylene wear. Consequently, wear is a rare failure mechanism. This study aimed to measure bearing wear at 10 years in a randomised trial comparing cemented and cementless OUKR and investigate factors that may affect wear. Methodology: Bearing thickness was determined using radiostereometric analysis at regular intervals up to 10 years. Data for 39 and 29 OUKRs was available at 5 and 10 years, respectively. As creep occurs early, wear rate was calculated using linear regression between 6 months and 10 years. Relationships between wear and patient factors, fixation method, Oxford Knee Score (OKS), bearing position, and component position were analysed. Results: The wear rate was constant after 6 months, with the mean wear rate being 0.06mm/year. Fixation method, age, OKS, component size, and bearing size had no correlation with wear. A higher BMI was associated with lower wear (p=0.01). Bearings more than 4mm from the wall had significantly more wear (p=0.04) than those less than 4mm from the wall. There was a negative correlation between the femoral component contact area on the bearing and wear (p=0.04). Conclusions: Phase-3 OUKR bearing linear wear rate is low, constant and not influenced by the method of fixation. It is however higher than Phase-2 OUKR. To minimise the risk of wear-induced bearing fracture in the long-term 4mm bearings should be used in young active patients and surgeons should position components appropriately. The use of highly crosslinked polyethylene should also be considered.

Arthritic knees with genu recurvatum pose unique challenges during Total knee arthroplasty (TKA). The aim of this study was to compare clinical outcomes between Cruciate Retaining (CR) or Posterior Stabilized (PS) implants in patients with pre-operative recurvatum undergoing TKA for osteoarthritis. Prospectively collected registry data of primary total knee arthroplasties carried out by 3 specialist Orthopaedic surgeons between 2000 and 2018 were analysed. Baseline characteristics, clinical assessments with detailed measurements of start and end range of motion were collected. Results: 3960 primary TKAs were performed in total, of which 109 knees had physiological pre-operative recurvatum (mean -7.3, range -22 to -5). 62 knees underwent CR TKA and 47 underwent PS TKA. At baseline, there were no statistically significant differences in either group. At 2-year follow up, there was no significant difference in range of motion (CR: 119.3 vs PS: 123.4; p= .17) International Knee Score functional scores (CR: 73.9 vs PS: 71.9; p = .59), knee scores (CR: 82.6 vs PS: 81.8; p = .76) or improvement in oxford scores (CR: 16.3 vs PS: 17.0; p=.71). Satisfaction scores were not significantly different (CR: 92.3 vs PS: 90.3; p=.77). However, PS knees exhibited greater end range flexion (CR: 116.4 vs PS: 121.9; p=.05). Conclusion: Patients in both groups were able to achieve significant correction of their recurvatum at 6 months and were able to maintain significant correction at 2-years. Clinical and functional outcomes did not differ, although PS knees showed an average of 5.5° greater end range flexion at 2 years.

Background: The diagnosis of periprosthetic joint infection (PJI) is challenging, especially in the setting of early infection. We aimed to determine the role of neutrophils to lymphocytes ratio (NLR) and monocytes to lymphocytes ratio (MLR) in the diagnosis of acute PJI of the hip and hip. Methods: A total of 78 consecutive patients within 90 days after index arthroplasty, who were treated with acute PJI according to the ICM criteria were enrolled. From the same time interval, we selected 102 patients with the diagnosis of erysipelas as controls, since PJI were ruled out by joint aspiration. We evaluated the C-reactive protein (CRP), NLR and MLR in all cases. Receiver operating characteristic (ROC) curve and the area under the curve (AUC) analysis were used to evaluate the optimal cutoff values of each test. Results: We obtained an MLR value  0.439 (optimal cutoff value). The sensitivity and specificity of MLR with this cutoff value were demonstrated as 0.74 and 0.58 respectively. For NLR, we obtained a value  3.1 (optimal cutoff value).These cutoff reported a sensitivity and specificity of 0.82 and 0.60 respectively. For CRP, we obtained a value 45.95 mg/L (best cutoff value; 75 % sensitivity and 77% specificity).Conclusion: MLR and NLR offer a reasonable diagnostic accuracy in detecting an acute periprosthetic joint infection. However, the determination of NLR and MLR should be used as an adjunct diagnostic test.

The aim of this study is to compare the short and medium term functional results, the quality of life between total knee arthroplasty (TKA) and (UKA) for the treatment of isolated osteoarthritis. of the medial compartment.
This is a prospective, randomized, comparative and single-centre study of two groups of patients, the 1st group comprising 20 fixed bearing cemented UKAs, the 2nd group 30 cemented, postero-stabilized TKAs, for the treatment of medial unicompartmental knee osteoarthritis.
The average age of the patients was 57.5 years (44-70 years). The revision rate with an average follow-up of 24 months was nil. The clinical data were analyzed according to the HSS and Oxford scores.
The analysis showed that UKA improved the general function of the knee, moreover, it reduced postoperative pain and a complication rate less than TKA. There were no significant differences in postoperative revision rate and knee functional scores between the two techniques.
The present study showed that patients in the UKA group recovered better postoperative knee function, less pain and fewer complications than those in the group including TKA. This is probably attributed to the characteristics of the UKA surgical procedure which replaces only the affected compartment of the knee with the prosthesis, protects the cruciate ligament and does not affect other compartments. The past decade has seen an increasing interest in UKA implantation for the treatment of isolated medial osteoarthritis of the knee. However, arthroplastic surgeons have preferred TKA due to the long learning curve of UKAs compared to previous ones.

Introduction: Wound healing after surgery is of utmost importance after total knee replacement, as it enables early rehabilitation and mobilization of the patient. We compared the outcomes of wound closure with Polypropylene versus subcuticular Polyglactin 910 suture in patients undergoing total knee arthroplasty (TKA). Methods: A randomized control trial enrolling 40 patients was conducted at The Indus Hospital, Karachi, Pakistan. In each patient, one knee wound was closed by polypropylene suture and the other by polyglactin 910 suture. Baseline demographics, Hollander score, and rate of skin complications were compared between both suture types. Results: We enrolled 27 women and 13 men, with a median age of 58 years, mean weight of 73.6 kg, mean height of 157 cm and mean ASA score of 1.9. The mean Hollander score was 6.0 (p>0.05) in both suture groups. The polyglactin 910 group saw a delayed presentation of post-operative erythema compared to the polypropylene group (p>0.05), 16 vs 21 patients on day 3 and 2 vs 0 on day 30, respectively. In the Polyglactin 910-group 1 patient developed wound dehiscence and 2 patients developed a surgical site infection, for which sutures were removed. Conclusion: There is no clinically significant difference in post-op complication rate among patients undergoing TKA and wound closure by polyglactin 910 or polypropylene. Both sutures can be used for event-free wound closure after TKA, with a preference for polyglactin 910 in low-resource settings because of its self-absorbable nature, which eliminates the need for post-operative suture requirement.

Patient satisfaction(recovery) in broad range of BMI in post subvastus approach in Early follow up
Abstract
Background : patient satisfaction (early recovery) is one of the most important factor for early mobilization (back to routine life style) in large scale of BMI
Aim : 1. Duration of surgery
2. post operative pain score & Requirement of Analgesics
3. length of hospital stay
4. Ease of doing physiotherapy
Material and method : serial study of 647 patients (male - 349, female – 298) with BMI of 18 to 54 kg/m2. All patients were prospectively evaluated pre- and also postoperatively at 2nd week, 6th weeks, and 12th weeks, The Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC) was used. The average follow-up was 3 months (range from 1 to 6 months)
Results : The approach provided adequate exposure in all knees, with average surgical time of 60 minutes. The average WOMAC SCORE at pre operatively 78/96 reduced post operatively at 2nd week 38/96, at 6th week 20/96 and at 12th week 12/96, The complications included maltracking of patella in 12 cases and partial patella tendon avulsion in 6 cases, infection in 5 cases and pulmonary embolism in 6 cases
Conclusion : our results favorably show fast recover, early mobilization, less requirements of analgesics and physiotherapy, Average hospital stay for unilateral 3.5 days and bilateral (same sitting) 4.5 days.

a. Background: High Tibial osteotomy is a surgical procedure to reposition the mechanical axis of a painful varus knee into a slightly valgus one, which minimizes joint tenderness and also decreases the rate of cartilage degeneration so the joint replacement surgery can be postponed. b. Materials & Methods: 500 knees were evaluated during the period 2008 to 2017. An X-ray scanogram was done pre-operatively & post-operatively to assess the correction. Visual analogue and Knee Society scores are used to evaluate the functional outcome. c. Results: The mean follow-up was 5 years. The mean age of the patients in our study at the time of surgery was 46.7 & sex distribution was 55.6% and 44.4% in Females & Males respectively. 44.4 % and 55.6 % of the patients underwent left-sided and right HTO respectively. The overall complication rate was 4.8%. These complications include Delayed Union (2.4%), Stiffness of the knee (1.6%) and only 4 patients required revision to TKR (0.8%) at 5 years follow-up. The most extended follow-up was 14 years. The VAS and KSS significantly improved after surgery (P < 0.001). The Knee Society score at 5 years of follow-up was excellent at 22.8%, good at 55.6%, Fair at 16.2% and poor at 5.4% d.Conclusions: HTO alleviates pain, enhances activities of daily living, and improves the function and quality of life of patients suffering from symptomatic medial compartmental osteoarthritis of the knee. The success of HTO depends on the correct selection of patients, proper osteotomy, and precise surgical techniques.

Total knee replacement is one of the most common elective surgeries worldwide. There has been ongoing debate about the patellar mobilization technique in total knee replacement surgery. Some authors are in favour of patellar retraction while others are in favour of patellar eversion. Thus, we designed this study to compare the functional outcomes between two groups of patients; one group operated through patellar retraction and the other operated through patellar eversion. This study is introspective and included 40 patients. All patients were operated by the same surgeon in El-Hadra University Hospital centre for orthopaedic surgery between January and June 2021. The patients were simply randomised in an alternating manner with half of them operated through patellar retraction and the other half operated through patellar eversion. Only patients with end stage arthritis and those with varus or valgus deformity < 20 degrees were included in the study. Patients with previous ipsilateral knee surgery and those undergoing revision surgery were excluded. The patients were followed up at 6 months post-operatively. Knee range of motion, extension lag, flexion contracture, oxford knee score and visual analogue score for anterior knee pain were assessed. The results were statistically compared between the two groups. We found that the patellar retraction group scored better with the results being statistically significant in range of motion, visual analogue scale for anterior knee pain and oxford knee score. We came to the conclusion that patellar retraction technique is better for the function of the extensor mechanism.