Background: Nearly 20% of Total knee Arthroplasty patients remain dissatisfied. This is a major concern in twenty-first century arthroplasty practice. Accurate implant sizing is shown to improve the implant survival, knee balance and patient reported outcome. Aim of the current study is to assess the efficacy of pre-operative three-dimensional (3D) CT scan templating in a robot-assisted TKA in predicting the correct implant sizes and alignment.
Materials and methods: Prospectively collected data in a single center from 30 RA-TKAs was assessed. Inclusion criterion was patients with end stage arthritis (both osteoarthritis and rheumatoid arthritis) undergoing primary TKA. Patients undergoing revision TKA and patients not willing to participate in the study were excluded. Post-operative radiographs were assessed by an independent observer with respect to implant size and position. The accuracy of femoral and tibial component sizing in the study was compared with the historic control with Chi-squared test.
Results: The pre-operative CT scan 3D templating accuracy was 100% (30 out of 30 knees) for femoral component and 96.67% (29 out of 30 knees) for tibial component. The implant position and limb alignment was accurate in 100% of patients. The accuracy of femoral component and tibial component sizing is statistically significant.
Conclusion: The study results show the effectiveness of pre-operative 3D CT scan planning in predicting the implant sizes and implant positioning. This may have a potential to improve the implant longevity, clinical outcomes and patient satisfaction.

Background: Proper patella tracking is one of the most important goals while performing Total Knee Replacement (TKR) to ensure good functional outcome. Intraoperative patellar maltracking acts as a red flag and necessitates reassessment of components’ position and soft tissue balance.
Methods: In 50 consecutive patients with varus osteoarthritis knees scheduled for TKR in a high-volume arthroplasty institution between January 2021 and December 2022, Patellar tracking and lateral retinaculum tightness were assessed throughout full range of movement of the knee by “No Thumb Test” and “Vertical Patella Test” after performing all the femoral and tibial bone cuts, appropriate sizing, and finalizing soft tissue releases and gap balancing and achieving full range of motion.
This evaluation was done twice: firstly, while using trial components and then after cementing final components. In all cases, the curve-on-curve method was used for rotational positioning of the tibial component while femoral component external rotation was adjusted based on the average rotation axis of the trans epicondylar axis and the axis perpendicular to the Whiteside’s line.
All surgeries were done by one high-volume total knee arthroplasty surgeon, using subvastus approach, cemented posterior stabilized prosthesis, and symmetrical tibial components.
Results: “No Thumb Test” and “Vertical Patella Test” were negative in all of the cases. Lateral patellar retinacular release was not required in any case.
Conclusions: Preserving the vastus medialis obliqus attachment to the patella by operating with subvastus approach while performing TKR improves intraoperative patellofemoral tracking and decreases the need to perform lateral patellar retinacular release in TKR.

Background
We aimed to assess the diagnostic parameters for different indications for aseptic revision and different periprosthetic pathologic findings. What were the synovial WBC count and synovial PMN% levels, and what proportion of values were above the 2018 International Consensus Meeting (ICM) cutoff (3000 cells/ mL, 70%)?
Methods We retrospectively studied preoperative synovial fluid cell counts in patients who underwent aseptic revision TKA. Cell count and PMN % were analyzed using automated analyzer. Clinical findings, preoperative radiographs and surgical reports were used to establish diagnoses of revision surgery. We evaluated 552 knees considering the recommendations of the 2018 ICM (WBC count of 3000 cells/mL, PMN% of 70% and Alpha defensin 1) to see what proportion of them would have been characterized as likely having PJI on basis of those cutoff values.
Results
Of 552 aseptic revision TKA, 1.4% (8/544) had Alpha-Defensin>1 and 1.3% had combination of WBC > 3000 cells/mL and PMN >70%. Aseptic loosening cases had a significant higher WBC count compared to other failure causes (p=0.01). No significant difference of PMN % and Alpha defensin were reported for different failure causes. Of note, patients with wear induced synovitis, osteolysis and metallosis had also higher WBC count (p<0.001) than patients who had not.
Conclusion
Using automated cell counting, we found that WBC count values can significantly differ across different pathologies. In contrast, PMN% and Alpha-Defensin were not affected by the cause of failure and seems more reliable in interpreting aspiration results. Isolated elevated WBC count should be interpreted carefully.

Introduction: ruptures of the patellar tendon are one of the most severe complications of knee arthroplasty. The use of allografts leads to a high frequency of infection, and the strength of autografts is often not enough to withstand the load in this area.
Methods: we proposed a method for the patellar tendon autoplasty using the tendons of the long peroneal muscles on both sides. These tendons were harvested from both sides. In the middle and lower parts of the patella, two transverse holes were made with a drill. The tendons were passed through these holes so that equal parts of the grafts remained on both sides. At a distance of 5 - 10 mm medially and laterally from the tibial tuberosity, two through holes were made obliquely distally with the passage of the opposite cortical bone. The ends of both tendons were passed through these holes, stretched with threads, and fixed with screws with a diameter equal to the diameter of the holes.
Results: since 2018 we used this method in knee revision arthroplasties in 9 patients. There were no infectious complications and no reoperations in this group. In 7 patients, full active extension in the knee joint was noted, in 2 patients there was a deficit of active extension up to 10 degrees.
Conclusion: the use of two tendons of the long peroneal muscles showed good results in patellar tendon plasty during revision knee arthroplasty.

Backround : Due to the increase in average life expectancy, the number of arthroplasty surgeries performed in elderly patient groups is also increasing. The increase in arthroplasty surgeries in the elderly population brings with it the increase in periprosthetic joint infections. There is no consensus about septic exchange in elderly patients.

Methods: The study was conducted on patients aged 80 and over who underwent one stage septic exchange and two stage septic excahnge between January 2011 and September 2018. Re-infection rates and intra-hospital complications of the patients were evaluated and recorded for each patient separately.

Results: Thirty-six patients who underwent one stage septic exchange and 24 patients who underwent two stage septic exchange were included in the study. The length of hospital stay, the amount of blood transfusion and the risk of pulmonary embolism complications were found to be higher in the two stage septic exchange group.

Conclusion: One-stage septic exchange can be a better option for the management of PJI in patients aged 80 years and over, since the procedure involves a lower risk of in-hospital complications, less need for a blood transfusion and shorter length of stay at the hospital in addition to requiring less surgical intervention

Background:Complex primary Total Knee Arthroplasty (TKA) in the setting of sever varus and lateral femoral bowing (LFB) is increasing especially in Asian and Middle Eastern populations. The aim of this study is to evaluate the correlation between the femoral bowing and the degree of arthritis, varus deformity and the distal femoral cut angle (VCA).Methods:This is a single-center observational cross-sectional study. All patients who met the inclusion criteria within the time interval between March 2018 to March 2021 were included. Out of 562 knees Scheduled for TKA 124 knees were excluded leaving 438 knees eligible for the study. The following angles were assessed: Femoral bowing angle (FBA), mHKA mLDFA,MPTA, VCA.Results:The study population’s mean age was 60±5.9 years. LFB was more in older age group(p=0.005), in females(p<0.001), and in grade 4 OA,(p<0.001). Also, there was a significant positive correlation between FBA and age and increasing varus mHKA, and with varus orientation of the distal femur and the tibial plateau. The mean and the 95% confidence interval of the VCA angle for the medial bowing group was 3.43(3.01-3.85°), for the normal bowing group was 5.42(5.15-5.68°), for the mild lateral bowing was 6.74(6.47-7°), and for the sever bowing group was 9.23(8.89-9.55°).Conclusion:There is no single safe zone for the VCA to reproduce postoperative neutral coronal alignment especially in cases of sever LFB in TKA. However, the VCA should be analyzed in term of how much femoral bowing exists. In other words, for each subset of femoral bowing there is a safe zone for the VCA.

Purpose: This study aimed to compare distal femur morphology in different age and gender groups using the Citak classification.

Methods: Retrospective review of knee anteroposterior radiographs from 2010 to 2020 was conducted on patients divided into three age groups: young adults (Group I, <50 years), middle-aged adults (Group II, 51-73 years), and elderly (Group III, >74 years). From each age group, 80 patients (40 males / 40 females) were randomly selected using age-stratified sampling. Exclusions included patients <18 years, history of fracture/surgery, fixation implants/prosthesis, and lower limb abnormalities. Measurements were performed by an experienced orthopedic surgeon familiar with the Citak classification, and all variables were compared between age and gender groups.

Results: The study included 240 patients (120 males / 120 females) with a mean age of 59.6±20.4 (range 18-95). The distal femur morphology index was similar (p:0.811), and morphological types were equally distributed among age groups (p:0.819). There was no significant difference between genders in measured variables (p>0.05 for all variables), and Citak classification types were similarly distributed between genders (p:0.153). No correlation was found between age and Citak index in either gender (p:0.967 and p:0.633, respectively).

Conclusion: In conclusion, distal femoral morphology classified by the Citak index was not dependent on age or gender. Type C, which is typically associated with a wider diaphyseal diameter and considered more common in elderly subjects, was equally distributed across all age groups.

Background: Antifibrinolytic property of Tranexamic acid plays a prominent role in reucing chances of bleeding after major surgical procedures. Intra venous injection of tranexamic acid in Total knee repalcement is the commonest pracitse, however it has its won side effects in certain patients with systemic usage. Our study is mainly to focus on intra articular vs intravenous tranexamic acid usage in Total knee arthroplasty cases. Methods: Our study includes in total of 200 patients of which 100 with intra articular application of tranexamic acid and 100 with intavenous application, both genders were included in our study. Blood loss transfusion rates are assessed and evaluated from day 1 till 1 month of surgery by using Nadlers formula. Results:Male : Female ratio of our study was 1:2.5. Mean age group of our study was 64.5 years. Mean Hb drop in intra articular group is 1.2 and intravenous group is 1.31 (p value= 0.45) mean haematocrit drop in intraarticular group is 2.6 where as in the other group is 2.9 ( p value=0.35) mean post operative Hb 10.5 in intraarticular group and 10.2 in intravenous group. (p value=0.66).Conclusion: Intraarticular and intravenous tranexamic acid administration results are comparable in the both groups.

Background: Single stage sequential bilateral total knee arthroplasty(TKA) is becoming a popular option nowadays due to reduced cost,improved anaesthetic techniques , availability of improved perioperative care,application of multimodal analgesia, rehabilitation techniques and awareness of benefits of total knee replacement surgery in the general population. Correct implant sizing is essential to prevent soft tissue irritation, misbalance, osteolysis from wear debris and component subsidence.Methods:This is a retrospective study of prospectively collected data of 362 patients who have underwent single stage sequential bilateral TKA for osteoarthritis at out centre to analyse the incidence, factors affecting and the outcome in patients who had asymmetry of component sizes. Results and Conclusion: All surgeons should be aware of the possibility of phenomenon of asymmetry of component size during a single stage sequential bilateral TKA.Each knee must be sized independently and not rely on the sizing of contralateral knee during a bilateral TKA surgery. Incidence of an asymmetry rate of 9%,8% and 2% for femoral ,tibial and patellar component respectively is found in our study. Polyethylene insert of size 10-14 mm was used in all patients. Variation in knee morphology, degree of Varus deformity(more than 10 degree),anterior referencing technique, femoral component flexion angle and amount of reduction osteotomy statistically contribute to this phenomenon of component asymmetry .Patients having asymmetry of component size had no statistical difference between left and right knees with respect to knee score, pain, function, range of motion, incidence of lateral release or complications.

INTRODUCTION: Total knee replacement (TKR) surgery is arguably one of the most successful operations performed worldwide this day-and-age. Patellar clunk syndrome(PCS) is a known post-operative complication, after TKR, that may arise due to various factors. The origin of PCS and its relationship to patella resurfacing or non-resurfacing is a matter of much debate. This systematic review aims to study the incidence of PCS in relation to patellar resurfacing versus non-resurfacing in TKR.
METHODS: We conducted a systematic review following the PRISMA recommendations by looking for PCS cases using the following MeSH search phrases: "patellar OR patella" AND "catch" OR "clunk" OR "crepitus" in PubMed, Cochrane, and Google Scholar. We included 32 articles, from the initial search, that met the inclusion criteria. To identify the cause of PCS and its relationship with patella resurfacing or non resurfacing, we collected data on the outcomes in individuals suffering from the condition.
RESULTS: We found that in the incidence of patellar clunk syndrome, prosthesis design was the most frequently implicated factor. Patellar resurfacing does play a part in decreasing the incidence of PCS; however, according to our study, the difference in incidence of PCS between the non- resurfaced patella and resurfaced patella is insignificant.
CONCLUSION: Due to numerous variables that can affect a patient's outcome, it is challenging to make a definitive conclusion whether or not to resurface the patella. Our study clearly confirms that patellar resurfacing or non-resurfacing, in TKR surgeries has no significant influence on the incidence of PCS.