Introduction: Follow-up protocols after total knee arthroplasty (TKA) are highly variable and not standardised. In literature, several regimens, from none to every 3-5 years for an inconsistent number of years are recommended.
In our hospital long-term follow-up is done every 5 years.
An orthopaedic resident runs a weekly clinic for arthroplasty follow-up. Initially started for total hip arthroplasty in 1998, in 2004 TKA were included.
Case: A 91 year-old female presented to our emergency department with exacerbation of lower leg pain with persistent swelling.
X-rays showed implant failure of the TKA ( primary implantation 1998) with fracturing of the lateral tibia plateau and proximal fibula.
During surgery, we found the inlay to be completely used up, the femoral shield was fractured. A revision prosthesis was implanted.
The patient recovered well from surgery. Closed mobilisation was performed after two weeks due to limited flexion. After six months we saw a content and pain free patient.
This particular patient was followed-up only until one year after TKA. 6 years later a TKA on the left side was performed.
Due to other health issues the patient was lost to follow-up three months after TKA on the left.
Conclusion: With the population ageing, we see an increased number of elderly patients after TKA; many biologically younger.
We highly recommend continuous follow-up after TKA also in elderly patients.
In our understanding, it is important to set neither a distinctive cut-off age nor time after surgery as to when follow-up should be stopped.

Introduction: we aimed to identify the potential risk factors for malalignment in coronal plane following TKA . Second, to develop a model for guiding surgeons to predict the probability of postoperative malalignment. Methods: We retrospectively reviewed prospectively collected data on 550 knees that underwent conventional primary TKA from 2017 to 2019 from our institutional joint registry. pre- and intraoperative clinical, radiological, and technical factors which may affect postoperative alignment were studied. Pre- and post-operative Hip-knee-Ankle(HKA)angle , mechanical lateral distal femoral angle(LDFA) , mechanical medial proximal tibial angle(MPTA) and joint line congruency angle(JLCA) were calculated based on the full-length anteroposterior standing radiograph. In addition femoral and tibial bowing and Caput-Column-Diaphyseal(CCD) angle was measured. Multiple logistic regression was used to develop a model for predicting coronal malalignment in TKA. Results: 402 TKAs were analyzed that 172(42.79%) were outside the acceptable postoperative HKA angle(180°±3°) range. Of the 17 factors studied, Multiple logistic regression analysis showed that flexion contracture>10°(odds ratio[OR]=2.95,P <0.001), Femoral bowing>4.9°(OR=1.89,P =0.006),tibial-bowing>2.2°(OR=2.00,P =0.002),preoperative MPTa≤85°(OR=1.68,P=0.037) or HKA≥20° varus(OR=5.07,P=0.017) , preoperative JLCA(range,4°-10°) (OR=2.49,P=0.023) and CCD angle≤131°(OR=1.62,P=0.044) were statistically associated with a greater chance of post operative malalignment . The findings were almost the same, when the analyses performed after excluding the extreme outliers(greater than 6° varus or valgus) . Conclusion: Findings indicate that postoperative malalignment is more likely to occur in some patients undergoing primary TKA,so modifying risk factors or using advanced methods should be considered.

Introduction: Stiff knees are defined as those with an arc of motion less than 50 degrees. They pose a considerable surgical challenge to the operating surgeon. Based on our experience to deal with these complex cases, we have developed a working classification that outlines a flowchart to manage the stiff/ankylosed knees.Material & Methods: It was a retrospective study conducted in our department. Out of 570 TKA performed in last 5 yrs, 57 had stiffness and 4 had bony ankylosis(total 61 knees). Patients were classified based upon the fibrous or bony ankylosis and preoperative ROM.Results: Patients were followed for an average 2.4 years (1.8 to 5.5 years). KSS pain scores improved from an av. 32 preop (18-64) to av. 76 post operatively(61-90).The KSS function scores improved from a preoperative value of 36 (16-56) to an av.78 (52-90) post-operatively. ROM improved from an average of 35.60 (0 -440 ) pre operatively to an average of 95.60 (ROM 730 to 1180) post operatively. Extension lag was an av. 8 degrees(30-120) and was seen in 13 patients postoperatively. Residual fixed flexion deformity was an av. 7 degrees (30-140) and seen in 17 patients. The stiff knees (type 1 and type 2 ) fared better than ankylosed knees(type 3) in all aspects. Complication rate was high (24%) in our series. Conclusion: Our classification of stiff /ankylosed knees guides the surgeon to decide upon which approach to take, which implants to keep handy and has a predictive and prognostic value.

Background: Total knee arthroplasty(TKA) has been known as a definitive treatment of advanced knee osteoarthritis. Both intra-(IM) and extramedullary(EM) tibial guides have been used to restore the desired extremity alignment. However, controversy exists regarding the superiority of either technique. We aimed to compare their functional outcomes and accuracy in providing neutral alignment after TKA. Methods: In a randomized, double-blinded clinical trial, we studied 98 patients undergoing primary TKA in two groups of IM and EM. We measured the medial proximal tibial angle(MPTA), varus angle(VA), and joint-line convergence angle with normal ranges of 90°±3°, 0-2°, and 0±3°, respectively, on a three-joint alignment view after three months. We also assessed functional outcomes at the last follow-up. Finally, we compared these outcomes between groups. Results: Eighty-four patients (IM=42, EM=42) were included in the final analysis(16 males, 68 females; mean age: 63.9±8.6 years; mean follow-up: 13±2.9 months). The mean postoperative alignment angles showed no significant difference, although MPTA outliers were significantly more frequent in the EM group(26.2% vs. 9.5% in IM, P=0.04). None of the functional outcomes showed a significant difference between groups. However, the mean ROM increase was significantly higher in VAs within ±3° of normal than those outside it(30.8 vs. 27.4, respectively; P=0.039). Conclusion: We conclude that both techniques were not different in terms of the mean alignment angles and functional outcomes. However, fewer MPTA outliers can be seen with IM. A postoperative mechanical axis within ±3° of neutral can result in a more ROM increase after one year.

Introduction: Spino-pelvic harmony and balance is crucial to a good working and walking posture, and pathology in any segment leads to poor balance. The present study investigates the changes found in spino-pelvic parameters in relation to severe Knee Osteoarthritis (OA) and associated symptoms of back pain in the Indian population. Methods: Whole Body standing EOS imaging was done for 146 patients with Kellgren Lawrence grade 3 and 4 knee OA and 46 controls. Sagittal alignment of the spine, pelvis, hip, and proximal femur were quantified. Sagittal balance was measured by the relative anterior translation of C7 plumb line. The presence of chronic low back pain (LBP) was documented. Comparisons were made between the two groups with independent samples t-test or chi-squared test. Results: Patients with severe OA showed significant backward femoral inclination (FI), hip flexion, anterior C7 plumb line translation (average of 3.4 mm) compared to controls (89.6% versus 4.2 % p< 0.001). 119 patients had FI>10 degrees, with significant pelvic anteversion, reduced lumbar lordosis and hip flexion. Those with FI <10 degrees (n=27) showed no significant differences. FI had a positive correlation with flexion deformity of knee (Pearson’s coefficient 0.85, p<0.001). 60.5% patients (FI> 10) had symptoms of LBP. LBP had no correlation with sagittal parameters. Conclusion: Sagittal alignment of spino-pelvic axis was significantly influenced with FI. Hip flexion, Pelvic anteversion and FI were found to be increased in patients with flexion deformities of knees. LBP could not be correlated to a change in sagittal parameters due to OA.

Background: Resecting or retaining the Posterior cruciate ligament (PCL) during total knee arthroplasty is still controversial and widely debated. PCL substituting (PS) implant design was introduced to alleviate problems associated with the PCL retaining design. However, PS implants have complications due to the inherent post-cam mechanism. Resection of PCL and using deep-dished polyethylene insert has been proven to provide clinical success for PCL substituting TKA. Our study aims to analyze and evaluate the functional outcome of this design.
Methods: This is a retrospective study of 86 patients who underwent PS TKA with metal-backed deep dished polyethylene. All patients with prior tibial or femoral fractures, osteotomies, and revision knee arthroplasty cases were excluded. Functional outcome was measured both preoperatively and postoperatively using the Knee society score. Follow-up radiographs were analyzed for alignment and component loosening.
Results: In our study, we had 47 female and 39 male patients. Mean follow-up of 10.6 years. Knee society score improved from 40.80 preoperatively to 88.45 postoperatively at the final follow-up. 2 patients who were obese (BMI>35) were noted to have mid-flexion instability intra-operatively, hence required to be replaced with a posterior stabilized design. 1 patient with rheumatoid arthritis and severe osteoporosis had intra-operative tibial fracture which required fixation with screws. 1 patient had tibial component loosening which required revision after 8 years.
Conclusion: We conclude that a deep-dished polyethylene insert provides a good functional outcome without the need for additional bone resection and avoids complications related to the post-cam mechanism in a PCL substituting TKA.

Purpose: Proper sizing of the femoral and tibial components is an important step in total knee replacement (TKA). When performing bilateral TKA, there is often an opinion that the same size prosthesis as the opposite side will suffice, even though there are reports of anatomical differences between sides. In this study, we quantify the incidence of asymmetry in femoral and tibial component sizes in staged bilateral TKA in a Middle East population. Methods: This is a retrospective observational study of all patients who underwent uncomplicated bilateral TKA with the same type of prosthesis by two surgeons at the same institute, between January 2013 and January 2019. Results: There were 123 patients, femoral and tibial component size variationswerepresent in 42 patients (34.1%) and 30 patients (24.4%) respectively. The variation was evident in both posterior substituting (PS) and cruciate retaining (CR) designs. The femoral components had a higher variation in size between the sides for both PS and CR designs than the tibial components for both designs. The percentage variation in the size of the femoral component was similar for PS and CR subgroups (32.7% and 33.3% respectively). For the tibial component, the size variation was higher for PS design (24.5%) than for CR design (18.7%). 7.3% had side-to-side variation by 2 or more sizes in both femoral and tibial components. Conclusion: Variations in size of femoral and tibial components is common in patients undergoing bilateral TKA. Contralateral component size alone should not be used during TKA.

Background
There is growing literature showing that robotic-arm assisted knee arthroplasty is associated with improved accuracy of implant positioning, better short- to mid-term functional scores and reduced revision rates compared with conventional jig based TKA.

The aim of this study is to detect differences in gait between robotic assisted and conventional knee arthroplasty. We hypothesised that patients after robotic TKA would reach higher walking speeds and inclines compared with conventional TKA and would enable a more natural gait.

Study Design & Methods
This prospective randomised controlled trial included 34 patients with symptomatic knee osteoarthritis undergoing conventional TKA versus robotic TKA. This study included 15 male patients and 19 female patients.

Gait analysis was performed with an instrumented dual-belt treadmill, with force plates underneath both belts to record the kinetics of each step, left and right, independently at increasing speed and inclination.

Results
There were no differences in baseline demographics or preoperative radiological deformity between the two groups. Mean age 68.7 in the conventional TKA group and 67.9 in the robotic TKA group.

Gait studies were performed at mean follow up at 27.8 months. No difference was found in the two groups at low walking speed. With increasing walking speed, the robotic TKA group reached a higher speed compared with conventional TKA. Gait analysis revealed significantly better cadence, walking speed, stride length and stance time in the robotic TKA group.

Conclusions
Robotic assisted surgery in total knee arthroplasty improves outcomes of gait performed under increased physical demand.

Purpose: Total knee arthroplasty (TKA) and unicompartment knee arthroplasty (UKA) are among the most important treatment options for end-stage knee osteoarthritis. Previous papers have noted the importance of knowing the type of medial tibial wear in deciding to manage varus knee osteoarthritis patients with TKA vs UKA. But few studies have delineated the pre-operative variables predicting the type of tibia wear. Method: This study assessed individuals with varus knee osteoarthritis planned for knee arthroplasty. After recording the demographic variables, hip-knee-ankle joint alignment views were taken from all patients. Finally, the type of tibial wear encountered during the surgery (posteromedial, non-posteromedial) was documented. Results: A total of 325 knees and 301 participants were evaluated in the study. Participants aged 67.12 (± SD 8.14) and the male to female ratio was 0.20. Between either non posteromedial/posteromedial wear or insufficient/sufficient ACL cases, there was a statistically significant difference with regard to MPTA, LDFA, VA, and JCA (P value < 0.05). Sixty-three percent of knees had non-posteromedial wear in the tibia plateau and 37% had posteromedial wear. Posteromedial wear was associated with 95% chance of ACL tear. Non-posteromedial knee had nearly 50% chance of having ACL insufficiency. Among non-posteromedial cases, VA of 14.5 as cut-off value had 65% sensitivity, 90% specificity, 73% negative predictive value, 87% positive predictive value, and 78% accuracy in detecting ACL insufficiency. Conclusion: Posteromedial tibial wear is associated with ACL insufficiency. However, regarding non-posteromedial cases, varus angle > 14.5 is highly predictive of ACL tear (87% positive predictive value).

Introduction: Metaphyseal Sleeves (MS) was introduced to address tibial and femoral metaphyseal defects. The aim of this study was to look at the outcome of MS (Depuy,Warsaw, Indiana) in our institute. Methods: This study was a retrospective study. Patient`s bone defects were evaluated intra-operatively based on the Anderson Orthopedic Research Institute (AORI) classification. Results: There were 15 (7 males, 8 females) patients who had MS between 2017 and 2022. Eleven cases were done for revision TKA and four were complex primary TKA. There were three AORI 2A, five AORI 2B and seven AORI 3. All revision cases were done as part of a 2-stage surgery for infection except for one patient who had a one stage MS after sustaining a periprosthetic fracture around the medial tibial plateau. As for the primary cases they were severe osteoarthritis with deformity and metaphyseal defects. The mean follow-up was 33 months. Two patients passed away at final follow-up due to unrelated causes. All MS integrated at final follow-up and there were no surgical related post-operative complications. All our patients were either independently mobile or walking with a single stick at final follow-up. The mean pre-operative Oxford Knee Scorewas 22.84 and post-operatively was 34.84 (p <0.00001). Conclusion: Our patients have had significant functional outcome improvement in the short to medium term follow-up. Our study shows that MS is a good option in patients who have tibial or/and femoral metaphyseal defects in both primary and revision arthroplasty cases.