Introduction: Approximately 20% of patients feel unsatisfied 12 months after primary total knee arthroplasty (TKA). We have developed the SMART Choice (Knee) tool using logistic regression and machine learning methods to predict improvement / no significant improvement based on utility score change at 12 months post-surgery in TKA patients.

Methods: Patients who underwent primary TKA for osteoarthritis between 2006 and 2019 from the St. Vincent's Melbourne Arthroplasty Outcomes (SMART) Registry were analysed. Patients were split into improvement / no significant improvement groups. Potential predictors included demographic information, body mass index, co-morbidity status, and pre-operative patient reported outcome measures (VR12 and WOMAC). Logistic regression and 3 machine learning algorithms were used to develop the predictive models. Models were evaluated using discrimation (AUC [area under the receiver operating characteristic curve]) and calibration (gradient, intercept, Brier Score) metrics. Furthermore, predictive outcomes were categorised into deciles; from 1 being the least likely to improve to 10 being the most likely to improve.

Results: 3703 eligible patients were included in the analysis. The logistic regression model performed best out-of-sample in both discrimination (AUC = 0.712) and calibration (gradient = 1.176, intercept = -0.116, Brier score = 0.201). Using the (final) logistic regression model, patients in the lowest decile had a 29% probability for improvement and patients in the highest decile had an 86% probability for improvement.

Conclusions: In this study, the logistic regression model outperformed machine learning algorithms. The optimal calibration performance allowed the final model to accurately predict improvement after TKA using probability deciles.

Introduction:We describe a reproducible, economical, All arthroscopic anchorless transosseous rotator cuff repair technique using a arthroscopic PCL jig.
This technique involves two bone tunnels and four high-strength nonabsorbable polyethylene sutures and is suitable for medium-to-large rotator cuff tears that would alternatively need multiple anchors.In addition to these issues, suture anchors are expensive, particularly if used in a DR or suture-bridge configuration, and may have limited efficacy in cases of revision wherein multiple anchors have previously been implanted.
Materials & Methods:In this prospective cohort study, we analyzed 20 cases in which non absorbable mattress sutures were used. Sample size was limited owing to COVID-19 pandemic. Three 2-mm Kirshner wires with perforated tips were inserted through the inferior margin of the greater tuberosity into the medial edge of the footprint using and arthroscopic pCL jig. Four threads were passed through 2 bone tunnels using the perforated tips of the Kirshner wires. The surgery was completed by inserting 2 mattress sutures and 2 bridging sutures. In addition to functional ROM post operatively, retear rates & the surgical cost of other arthroscopic methods was investigated.
Results: We found that out of 20 patients,18 patients had excellent functional rom and return to activities of daily living. Surgical cost of the procedure was found to be significantly low as compared to other arthroscopic and open methods.
Conclusion: This technique of RC repair has big advantage of being inexpensive & hardware free which is very much cost effective and economical in an Indian set up.

The aim of this study was to compare long-term survivorship and clinical outcomes of two options in algorithm of osteoarthritis management in a young patient: HTO first with later TKA versus TKA as index procedure.
Methods : This monocentric case-control study included 73 primary posterior-stabilized TKA for osteoarthritis between 1996 and 2010 with a previous HTO. The minimum follow-up was 10 years after TKA. Each case was matched with a primary TKA without previous HTO (1:1) based on BMI, gender, and age at the time of HTO in the study group.
Results : Mean follow-up was 13 years after TKA in both groups. Follow-up since HTO was 24.4 years, with mean delay between HTO and TKA of 11.1 years. Survival rate free from any revision was 91.8% at the last follow-up in the TKA post HTO group and 94.5% in the control group. The 20-year Kaplan Meier survival estimate was 98.6% (95% CI, 90.4% to 99.8%) in the TKA post HTO group (HTO as timing reference) and 81.4% (95% CI, 45.1% to 94.8%) in the control group (TKA as timing reference) (p=0.03). There was no significant difference in clinical, radiological outcomes, and complications between groups at last follow-up.
Conclusion : At same delay from index surgery (HTO or TKA), a strategy of HTO with later TKA had superior survivorship compared to primary TKA without HTO at long term. HTO should continue to be part of osteoarthritis treatment strategy in this population group.

Hamstrings autograft has been a preferred choice for the primary Anterior Cruciate Ligament (ACL) reconstruction for last couple of decades. However, thigh weakness and hypotrophy has also been reported when followed for the functional outcomes. We report a better functional outcome with the use of Peroneus Longus Autograft having less thigh weakness, better functional outcomes at knee and limited morbidity at ankles. METHODS: A total of 136 patients, 128 Male (94.11%) & 8 females (5.88%) with mean age 39 ranging from 21 -56 years, who met the inclusion criteria (Isolated ACL injury) were followed prospectively for 3 years. Functional scores(Lysholm, IKDC) were recorded preoperatively in both groups (PL:68, Hamstring:68), at 6 Months, 1 year, 2 year and 3 years of follow up. Donor site morbidity was assessed by measuring thigh circumference at knee and AOFAS score at ankles. RESULTS: There were no significant differences in Knee functional scores between hamstrings and peroneus longus group at 3 years of follow up. Mean postoperative Lysholm score at knee was 89.8 + 3.1 (Range 45-100) in hamstring group and 91.7 + 1.1 was calculated in peroneus longus group. Mean Pre-operative AOFAS was 98 + 3.92 and post-operative score was 95+ 3.3 in peroneus longus group with a significant decrease in thigh circumference & muscle strength in hamstring group. (p= 0.03) CONCLUSION:
Peroneus longus autograft is an effective autograft for primary ACLR with improved functional outcomes at knee, less thigh weakness as compared to hamstrings and limited morbidity at ankle.

The aim of this prospective study is to assess the effectiveness in terms of pain relief, functional outcomes, life quality, need to conversion to total knee arthoplasty (TKA) and complications of the percutaneous Subchondroplasty under fluoroscopic guidance and arthroscopic assistance in the treatment of osteoarthritis-related bone marrow lesions of the knee (BMLs). 19 patients with knee osteoarthritis and BMLs, with previous failure of conservative treatment, underwent Subchondroplasty. The main variables were visual analog scale (VAS), International Knee Documentation Committee (IKDC), Knee Society Score (KSS), Function Score (FSS), range of motion (ROM) and EuroQol5 (EQ-5D) preoperatively and at 1 year of follow-up. We observed significant improvements in both pain and function. The results were excellent in 78.9% and 68.4% of patients in the KSS and FSS respectively (p=0.016). It was statistically significantly associated in KSS to Kellgren-Lawrence osteoarthritis grade 0 in external compartment, Outerbridge osteoarthritis grade 1 in internal compartment and normal axis. In FSS, it was linked to younger ages and grade 1 of Outerbridge osteoarthritis in internal compartment (p<0.05). The ROM remained without differences in 84.2% of patients. In EQ-5D there was a significant improvement of 0.74 (0.55 - 0.84) (p=0.0002). Only 1 patient (5.3%) required TKA at the median follow-up of 31,0(16,0-0,0) months. Subchondroplasty represents a safe and effective therapeutic alternative in knee osteoarthritis-related BMLs with significant improvement in pain and function. The low medium term conversion rate to arthroplasty suggests that Subchondroplasty may play a role in delaying more invasive and expensive procedures as represents the TKA.

Introduction: Detecting loosening of total knee arthroplasty (TKA) implants is a challenging process, even for experienced clinicians, and may not always be available, potentially delaying diagnosis. The purpose of this study was to investigate whether the loosening of TKA implant could be detected on plain radiograph using deep convolution neural network (CNN). Methods: An analysis was conducted on 100 patients who underwent revision TKA due to loosening at one institution from 2012 to 2020. 100 patients who underwent primary TKA without loosening were extracted through propensity score matching for age, gender, body mass index, and operation side. We implemented training acceleration in a pre-trained CNN model called VGG19 through a transfer learning method that gradually changes the freezing layer. Training and testing were conducted in a ratio of 8:2. Results: In the first model that trained only the last layer of the classification layer, the accuracy in diagnosing loosening of TKA implant was 87.5% and the accuracy for no-loosening was 56.3%. However, as the trained learning layer was gradually increased to the feature learning part, the accuracy in diagnosing loosening increased to 100%, and the accuracy for the non-loosening increased to 95%. Conclusion: CNN algorithm through transfer learning shows high accuracy in detecting loosening of TKA implant through plain radiograph. These results can be expected to be utilized as an auxiliary tool in the decision making process in diagnosing loosening of TKA implant by orthopedic surgeons.

Introduction: The aim of this study was to evaluate the patient demographics, revision risk and death of simultaneous sequential bilateral total knee arthroplasty (TKA) procedures, comparing them to staged bilateral procedures < 1 year apart (A1 and A2), > 1 year apart (B1 and B2), and to unilateral procedures using data from 83734 TKAs in the Norwegian Arthroplasty Register (NAR) between 2012-2019.
Materials and Methods: The analysis of simultaneous procedures consisted of 487 patients with 974 TKA procedures from 2012-2019. Kaplan–Meier survival analysis evaluated time to first revision surgery with a maximum follow-up of 8 years. Cox regression analysis was used to calculate hazard ratio (HR) comparing simultaneous sequential TKA to the 5 different groups.
Results: The Kaplan-Meier 5 year survival was 98.4% for simultaneous and 95.1% for unilateral TKA. Staged TKA (A) had 98.1% survival for the A1 and 97.2% for the A2 procedure. The adjusted Cox regression analysis with simultaneous TKA as reference showed HR 2.5 (1.35-4.74), p=0.004 for unilateral TKA. Staged TKA (A1) had HR 1.1 (0.53-2.14), p=0.856, whereas staged TKA (B1) had HR 2.0 (1.04-3.84), p=0.038. There were no deaths within 90 days in the simultaneous TKA group. Among the unilateral TKA there were 46 deaths (19 in 10,000 operations) in the same period.
Conclusion: This study demonstrates that simultaneous sequential bilateral TKA procedures had a similar risk of revision compared to patients with staged bilateral TKAs done with less than 1 year apart, and no deaths within 90 days were recorded in the former group.

Introduction: In Malawi, pediatric trauma is a significant and rising public health concern, and access to musculoskeletal trauma and surgical care is limited. We sought to identify patient- and injury-specific characteristics associated with operative treatment of children with fractures entered in the Malawi Fracture Registry. Methods: From the Registry, we reviewed patients younger than 20 years who presented to 2 urban central hospitals and 2 rural district hospitals in Malawi. We used multivariate Poisson regression to evaluate association between operative treatment and patient-, injury-, and treatment-related covariates. Results: 11,041 patients were included. Most injuries were due to falls (80.0%), and fractures were most commonly of the wrist (31.5%), elbow (19.6%), and forearm (19.5%). There were 193 (1.7%) open fractures, 27.5% of the tibia/fibula. Non-physician orthopaedic clinical officers (OCO) managed 97.4% of patients. Surgery was performed on 632 (5.7%) patients. Surgical treatment was independently associated with older age (RR:1.06 [1.04, 1.08]), initial evaluation by an orthopaedic surgeon (RR:2.86 [2.38, 3.45]), hospital admission (RR:2.38 [2.13, 2.70]), open fracture (RR:10.00 [7.14, 12.50]), and the following fracture locations: shoulder, scapula, humerus, elbow, forearm, hand, pelvis, knee, and ankle. Surgery was less likely for fractures related to a fall and those being referred by another health facility (RR:1.35 [1.01, 1.79]). P-value <0.05 determined significance. Conclusion: In Malawi, the vast majority of children with fractures are treated non-operatively, cared for by non-physician clinicians. The association of non-operative treatment with referral from another facility possibly indicates inadequate referral systems and lack of care standardization.

Background: Large chronic osteochondral fractures (OCFs) of the lateral femoral condyle of the knee can be diagnostically and therapeutically challenging. Historically, management has involved removal of the fragment, leaving a large area of bone devoid of articular cartilage on the weight-bearing surface. This study assessed open reduction and internal fixation of the osteochondral fragments with use of Herbert Compression Screws (HCS).
Methods: Twenty-one patients, with a large (>4 cm2) osteochondral fracture of the femoral condyle of more than 6 weeks of injury were treated with ORIF using HCS. Each patient was evaluated at more than two years (mean; 6-years). The mode of injury, size of the osteochondral fragment, knee function with Kajula scoring were examine. Radiological assessment was done by X-rays and MRI scans.
Results: Twenty-one patients, with a mean age of 19-years with chronic OCF of femur were enrolled. The mean time from trauma to presentation was 7-weeks. The mean pre-operative Kujala score improved from 36, to 84.8 at 6months and 92.6 at 2years, post-operative. Intraoperatively, the lesion was at the medial aspect of the lateral femoral condyle in 15 patients; 6 had lesions in the medial condyle. The mean size was 52mm2. Three patients underwent implant removal for mechanical symptoms.
Conclusions: OCFs of the femur are often missed, and present as chronic injuries. Open reduction and internal fixation using HCS is simple, reliable and reproducible and demonstrates that late presenting cases can also be successfully managed by ORIF with HCS with an excellent outcome.