Introduction: The purpose of this study was to compare not only the radiological results, but also postoperative patient-reported outcomes measures (PROMs) of Bicruciate stabilized (BCS) and posterior stabilized (PS) total knee arthroplasty (TKA) in the same patients.
Methods: A prospective, randomized controlled trial was performed in 48 patients who received bilateral TKAs. One knee was randomly assigned to receive a BCS TKA, and the other knee was scheduled for a PS TKA from the same company knee system. The static anteroposterior (AP) stability was evaluated using 20° flexion radiographs with anterior drawer stress and 90° flexion radiographs with posterior drawer stress at 1 year postoperatively. Postoperative PROMs were compared using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and preference of operation side. Forgotten joint score (FJS) was also evaluated in both group.
Results: There was no significant difference with regard to the demographics and preoperative measures. No Significant difference in static AP laxity was seen (8.2mm in the BCS group vs 8.7mm in the PS group, p>0.05). There were no significant differences in the all WOMAC subscores between the two groups at preoperatively and 1 year postoperatively (all p>0.05). There was no difference of preference (p>0.05) and FJS (53.5 in the BCS group vs 50.4 in the PS group, p>0.05) between BCS and PS group.
Conclusion: Despite theoretical advantages of BCS prosthesis, there was no significant differences in radiological outcomes and PROMs including preference and WOMAC scores between groups with BCS and PS TKAs at 1 year postoperatively.

Introduction: The purpose of this study was to compare the early postoperative pain patterns in both knees after same-day and staggered bilateral total knee arthroplasty (TKA) in Central sensitization (CS) patients. Methods: Thirty-six patients in each group corresponding to CS were compared. For staggered bilateral TKA, only those with a one-week interval were included. CS was assessed using a Central Sensitization Inventory preoperatively. Postoperative pain was investigated 1st, 3rd, 5th, and 7th postoperative day using pain visual analogue scale(VAS) in resting, walking, night, and 24 hours average. The amounts of patient-controlled analgesia(PCA) were also investigated. The first and second knees in staggered bilateral TKA were compared with the knee on the same operating side in bilateral TKA. Results: There was no significant difference in pain VAS between the first knee of staggered TKA and the knee of the same surgical site in same-day TKA (all p>0.05). However, all pain VAS scores were higher in the second knee of the staggered TKA compared to the same side in same-day TKA (all p<0.05). The amount of PCA usage was also significantly more in 2nd knee of staggered bilateral TKA patients even compared to patients with simultaneous TKA (p<0.05). Conclusion: When staggered bilateral TKA was performed in CS patients, early postoperative pain in the 2nd knee was more severe than the pain amount of the same side knee in same-day bilateral TKA. If medical comorbidity is not a matter, performing same-day bilateral TKA is more advantageous in postoperative pain control in CS patients.

introduction: About one-third of knee replacement patients have bilateral OA symptoms, necessitating joint replacement surgeries in both knees, encouraging patients and surgeons to consider simultaneous bilateral total knee arthroplasty instead of twice admissions.

Aim of the study: To Compare The Mortality, Perioperative Morbidity And Clinical Results Between Simultaneous Bilateral And Staged Bilateral Total Knee Arthroplasty (TKA).

Methods: It Is A Non-Randomized Comparative Prospective Study Done On 53 Patients All Of Them Complaining Of Disabling Degenerative Osteoarthritis Of The Knee. 26 Patients Treated With Staged Bilateral Total Knee Arthroplasty, And The Other 27 Patients Were Treated With Simultaneous Total Knee Arthroplasty.

Results: A Total Of Ten Systemic Complications Occurred In Nine Patients (33.0%) In The Simultaneous Bilateral TKA As Compared With Three Systemic Complications In Two Patients (7.7%) In The Staged Bilateral TKA. The Difference Between The Two Groups In The Total Number Of Systemic Complications Was Significant (P Value <0.021). The Systemic Complications Were Correlated With ASA Grading System 3 Or More. Statistically Significant Differences Were Found In The Complication Rate For Patients Who Were Over 65 Year (P < 0.05).

In Conclusion, Simultaneous Bilateral TKA Is A Reasonably Safe And Acceptable Choice For Patients Whose Symptoms Necessitate Bilateral TKA. However, The Incidence Of Systemic Complications Rises In The Elderly And High-Risk Population.

Introduction: Single-stage TKA with long-stem is a viable option to treat tibial stress fracture in advance knee Osteoarthritis. But in patients with late presentation, mal-united fracture or fractures having sclerotic margins; treatment becomes complicated. Therefore, focus in this study is to monitor clinical and radiological outcome in patients presenting early or late treated with different surgical interventions.
Methods: This retrospective study includes 24 consecutive patients, all were female. Patients with recent and mobile stress fracture (Group-A) were treated with close reduction and long-stem Tibial component. But in patients with old, sclerotic or mal-united fractures (Group-B); open reduction, partial fibulectomy and plating with bone grafting was also done. Outcome was monitored by Tibiofemoral angle, Functional Knee Society Score (KSS) and time taken for union. Results: The mean age of patients was 62.34 years. There were 13 patients in group-A and 11 in Group-B. KSS improved from 29.83 +/- 6.10 to 91.57 +/- 4.89 in group-A and from 27.21 +/- 3.32 to 89.87 +/- 3.89 in group-B. Tibiofemoral angle improved from 20.57 o +/- 3.00 to 0.80 +/- 0.46 in 21varus whereas it improved from 22.33 o +/- 4.61 to 0.83 o +/- 0.28 in three valgus knees. Iatrogenic perforation of tibial cortex occurred in one case. Union of stress fracture was achieved in all cases with a mean duration of 4.70 months. Conclusion: Excellent results were obtained in both groups but were slightly low in patients presenting late, therefore efforts must be made to treat such cases as early as possible.

Background: Patient safety after bilateral total knee arthroplasty(BTKA) has been a much debated topic world over. While many studies have quoted high complication rates with simultaneous BTKA, others have proven its safety provided proper patient selection. What about staggered BTKA (done at 3-7 day interval)? The purpose of this study was to analyse the complications of patients undergoing bilateral staggered TKA and compare it to existing literature. Methods : It is a retrospective study. Data was collected from medical records and through phone calls to patients. All surgeries done by a single surgeon between 2016 to 2020 were included. The study population was 562 patients(1,124 knees). Complications were divided into major and minor based on previous studies from literature. These were evaluated during hospital stay, 2 month follow-up period and 1 year follow-up period.Results: The overall rate of complications during hospital stay was 9.25% with major complications comprising 0.9% and minor complications comprising 8.36%. ICU requirement during hospital stay 0.35%. At 1 year, mortality rate was 0.47% and re-admission rate was 2.336%. The rate of pulmonary embolism was 0.2% and deep infection was 1.16% at 1 year. Conclusion : After analysing our data and comparing it to existing literature, we conclude that staggered bilateral total knee arthroplasty is safe.

Introduction: Recently, poor patient satisfaction after total knee arthroplasty (TKA) has gained attention mainly in osteoarthritis (OA) patients, however satisfaction after TKA remains to be understood in rheumatoid arthritis (RA) patients. This study aimed to examine satisfaction and function after RA-TKA as compared to those the of OA-TKA.
Methods: This study enrolled 120 TKAs of 98 patients consisting of 26 TKAs of 20 RA patients and 94 TKAs of 78 OA patients between January 2017 to December 2020. Serial radiographs and new Knee Society Score 2011 (KSS) were done at regular intervals till one year follow-up. Statistical analysis was performed with KSS satisfaction score in order to clarify factors affecting patient satisfaction. Principle component analysis was performed, and satisfaction and function components were compared between RA and OA.
Results: Patient satisfaction scores were significantly better in RA-TKA than in OA-TKA whereas, activity scores were significantly lower in RA-TKA than in OA-TKA. Scores for symptom, expectation, basic activity, and discretional activity positively affected patient satisfaction (p < 0.001), while PCS negatively did (p=0.021). RA-TKA patients achieved significantly higher satisfaction component (p=0.001), but lower functional component (p<0.0001) compared to OA-TKA. There were no major complications and no evidence of any loosening on follow-up radiographs.
Conclusion: Patient satisfaction was significantly better but functional activity was lower in RA than in OA. As poor functional activity was evident postoperatively and on follow-up in RA patients, to improve functional outcome should be future challenge for RA-TKA.

INTRODUCTION: This study strives to establish a link amongst intraoperative perception of the surgeon and the post-operative functional outcome of the patient undergoing bilateral total knee arthroplasty (B/L TKA) performed in a single sitting. This is an attempt to steer towards a more reliable result by identifying the parameters that hold much influence over the desired result.

MATERIAL AND METHODS: A total of 50 patients underwent B/L TKA were studied according to inclusion and exclusion criteria, in between May2017 – May2021 by using New Knee Society Scoring System and in-house made surgeon questionnaire. The results were obtained according to Freidman’ test with p<0.05 considered to be statistically significant.

RESULTS: The study has yielded a conclusion of congruency upto 93.3% with statistically highly significant (p<0.001) between the assessment of the surgeon, done intra-operatively and the feedback provided by the patient, at one year follow up. It further threw light on the importance of key influencers such as patello-femoral alignment (40%), joint motion (40%) and soft tissue release (20%), which is of importance in about 20% of the unsatisfied patients despite a perfectly done procedure.

CONCLUSION: Our study shows that the in house derived surgeon based questionnaire positively correlates postoperative functional outcome and satisfaction of the patient. We identified the important parameters influencing the functional outcome and also validated the surgeons in-house derived questionnaire. This could be rectified at the time of surgery with more concentration, meticulous technique and parameters to counter check to make it 100% to minimize the human errors.

Postoperative knee instability is one of the major underlying causes of unsatisfactory outcomes after total knee arthroplasty (TKA), but the thresholds between stable and unstable TKA knees remain difficult to quantify, particularly using manual clinical assessment. With the goal of fully understanding subjectively reported joint instability, the aim of this study was to develop a passive testing approach that is sufficiently accurate to establish the thresholds between stable and unstable knees after TKA. Eight self-reported unstable (age:68.9±8.3, 3M/5F) and ten stable (age:62.6±6.8, 7M/3F) TKA knees (ultra-congruent inlay, cruciate-retaining design) were assessed in this study using fluoroscopic imaging to accurately assess the passive relative tibiofemoral rotation under the application of internal/external torques using a custom-made rotometer device. In addition, anteroposterior (A-P) and mediolateral laxity were measured using stress radiography with a modified Telos® device. No differences between groups were observed in rotational tests at 90° or in external rotation at 30° knee flexion or resulting from varus-valgus, anterior-drawer, as well as anterior Lachman tests. However, our results did reveal that unstable TKA knees exhibit increased A-P translation in the posterior Lachman test compared to stable knees. Moreover, unstable knees presented greater rotational laxity during the initial phase of internal rotation (torque 1-3Nm at 30° of knee flexion), although a comparable stiffness between the two groups was observed from 3 to 5Nm. Using a linear combination of A-P and rotational laxity, the two groups could be clearly classified, hence demonstrating excellent potential to differentiate between stable and unstable knees.

Introduction: The study intended to evaluate the efficacy of periarticular drug cocktail injection in managing postoperative pain in total knee arthroplasty in terms of pain and morphine consumption. Methods: Patients who were diagnosed with primary osteoarthritis of the knee were enrolled in this study. The intervention group received a cocktail injection of bupivacaine, adrenaline, morphine sulfate, and diclofenac sodium in the periarticular region during the operation. Both groups were started on PCA morphine postoperatively. Pain scores at 6, 12, and 24-hour post-operative periods were evaluated, and total morphine consumption was recorded. Results: There were 54 patients recruited with 27 subjects in each arm. The mean age of the patients is 63.59 years old. There were 34 female and 20 male participants. The mean visual analog score in the intervention group during the 6-hour post-operative period is statistically significant compared to the control group. The mean visual analog score at 12 hours period is lower in the intervention group but is not significant. There is no difference in visual analog score in both groups at 24 hours post-operation. Total morphine consumption in the first 24-hour period post-operation is lower in the intervention group and is statistically significant. Conclusion: Periarticular injection of bupivacaine, adrenaline, morphine sulfate, and diclofenac sodium in periarticular the region during total knee arthroplasty is effective to reduce post-operative pain and to reduce total morphine consumption in the early post-operative period.

Introduction: The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA.

Methods: A systematic search was performed on Pubmed, Embase, and Cochrane up to May 2021. RCTs were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes were superficial and deep infection, skin blistering, and transfusion rate.

Results: 14 RCTs with 1,329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI=2.7-5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI=1.1-3.1) with an OR of 1.9 (95% CI=1.1–3.76, p=0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12 – 0.54), P=0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4 - 5.3, P=<0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of in-hospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10 – 0.38, P=<0.01). The incidence of skin blistering (OR 2.6, 95% CI=0.7-9.9, p=0.17), skin necrosis (OR 3.0, 95% CI=0.50-19.3, p=0.25), and DVT rates (OR 1.5, 95% CI=0.60- 3.60, p=0.36) did not differ between the two groups.

Conclusion: The data showed tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this systematic review and meta-analysis do not support the routine use of tourniquet in TKA.

Bilateral fused hip and knee joints are not uncommon in patients with chronic inflammatory conditions such as ankylosing spondylitis and rheumatoid arthritis. The generalized osteoporosis, the ambiguous identity of the joint line, the pelvic obliquity, the weakness and contracture of the hip abductors, and the quadriceps muscle make it difficult for ankylosed joints conversion to quadruple joint replacement. There is no uniform surgical technique, and the sequence of joint replacement have described till now. We present a series of three patients with ankylosed bilateral hip and knee joints managed by staged quadruple arthroplasty. Of the two patients with ankylosing spondylitis, one patient had features of trabecular bridging of multiple joints with hip and knee fusion at 900 abduction and 1100 flexion, respectively. The other patient had a history of fracture fixation in the fused knee prior to arthroplasty. The third case was seropositive rheumatoid arthritis with features of erosive arthritis of multiple joints, fusion, and windswept deformity of lower extremities. The preoperative assessment, the surgical steps with novel techniques, the sequence of joint replacement, and the significance of staged joint replacement in these rare cases are discussed. At 2year follow-up, the staged quadruple joint arthroplasty had shown improved functional outcome and quality of life in all three patients.

Background: Physical rehabilitation after total knee arthroplasty (TKA) promotes functional recovery in the long term. Sensor-based home rehabilitation is a promising option as it bridges the gap between increased accessibility and structured monitoring and guidance during rehabilitation. Given the advent of new wearable sensor systems, we aimed to perform a systematic review of the effectiveness of wearable sensor-based rehabilitation on post-TKA outcomes. Methods: We performed a systematic search of three electronic databases from beginning of record to 12th March 2021. Primary outcome was patient-reported outcome measures (PROMs) after rehabilitation, namely Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS). Secondary outcomes were physical activity levels and functional performance including range of motion (ROM) and Time Up and Go Test (TUG). Results: A total 16 studies involving 1321 subjects were included. All wearable sensors in our included studies involved a combination of accelerometers, gyroscopes and magnetometers as functional units. Studies reported favourable outcomes across all three PROMs measurements, although the extent of improvement in specific domains is varied across studies. Physical activity levels in terms of daily steps and time spent on physical activity increased post-rehabilitation. Similarly, there was improvements in ROM and TUG that were consistent with favourable post-operative trajectory during rehabilitation. Conclusion: Senor-based rehabilitation is effective in improving subjective and objective outcomes post-TKA. The role of sensor-based rehabilitation should be in evaluated in dedicated cost-benefit analysis to facilitate wider adoption in healthcare systems.

Background: Pain management following TKA must be on the forefront of every surgeon’s mind which provides patient comfort, along with the initiation of physiotherapy. The role of peripheral nerve blocks in post-operative TKA analgesia has been studied in abundance, but outcomes of administering combined capsular block and peripheral nerve block are not known. The object of this study was to compare the efficacy of adding ACB in patients receiving Capsular block in post-operative analgesia. Methods: The study was conducted in a single hospital over three years where 140 patients undergoing primary TKA were randomly assigned into two groups. Group A received the capsular block while Group B received both capsular and the ACB. Using the VAS Score, the primary parameter assessed in all 140 patients was pain. A secondary parameter which was added for the latter 70 patients was the pain free interval immediately following surgery. Results: There was a statistically significant difference in the median pain scores of patients in Group B (2 and 3) at the 4th and 12th hour respectively. In the second batch of 70 patients, there was a statistically significantly longer pain free interval experienced in Group B patients. Conclusion: Our study shows that ACB in combination with capsular block offers a longer pain free interval following surgery. ACB also provides better pain control up to 12 hours post-operatively and up to 24 hours during mobilization.

Introduction: Investigate the effect of semi-rigid extension bracing after TKA on articular pain and function. Methods: The present randomized clinical trial included 72 patients undergoing unilateral primary TKA from April 2018 to September 2019. The case group underwent post-surgical semi-rigid extension-locked knee bracing for 8 days, while the control group did not receive such intervention. The outcomes assessed preoperatively and on the 1st, 9th, 30th day, and 1-year postoperatively; included the knee society score(KSS), functional KSS(FKSS), VAS pain score, amount of opiate painkiller usage, and range of motion (ROM). Results: The case group had a significantly lower flexion ROM on postoperative day 9 compared to the control group (95.3° vs. 100.8°, p=0.03), while it became significantly higher one month(114.1° vs. 104.7°,p=0.03) and one year postoperative(128.0° vs. 120.5°,p=0.002). Also, FKSS was significantly higher in the case group than in the controls in the one-month postoperative assessment(37.0 vs. 32.6, p=0.009) but not in the one-year postoperative assessment.
The case group patients had a significantly lower pain than the control group on days 1(5.8 vs. 7.2, p=0.02) and 9 postoperative(4.1 vs. 5.2, p=0.048), but not at later assessments. The amount of 1 month postoperative opium (oxycodone) consumption was significantly lower in the brace group (12.4 vs. 14.1 tablets, P=0.03). The KSS were not significantly different between the groups 1 and 12 months after the surgery. Conclusion: Extension-locked splinting immediately after TKA is a non-invasive, non-pharmacological, and inexpensive intervention with possible promising effects on knee ROM, short-term functional improvement, and acute postoperative pain management.

Background: Spinopelvic mobility is comprised of interactions among the knee, hip, pelvis, and spine. For arthroplasty surgeons, understanding this interaction is crucial because a growing number of patients will have both knee or hip pathologies as well as spinal pathologies. A spinopelvic sagittal balance can be determined if the difference between PI (Pelvic Incidence) and LL (Lumbar Lordosis) is less than 10 degrees. For this purpose, it is necessary to determine the PI (or SS (Sacral Slope) and PT (Pelvic Tilt)) and LL angles and calculate their differences (PI-LL). Method: the angle along the line passing through the center of the femoral head and the middle of the upper surface of the sacrum with along the upper surface of the first lumbar vertebra is determined, which we call our novel angle (pelvico-sacro-L1 angle), this angle (pelvico-sacro-L1) will be equal to 90 ± (PI-LL mismatch) degrees. Results: we validated the angle with 100 patients who were candidates for Total hip arthroplasty between January 2019 and January 2020. Conclusion: Therefore, without determining the angles of SS, PT, PI and LL, we can be ensured quickly and accurately the spinopelvic sagittal balance before total hip and knee arthroplasty.

INTRODUCTION:
The joint line orientation angle (JLOA) is the angle between the knee joint line and the horizontal line parallel to the floor. It has been reported to be one of the key factors related to postoperative outcomes after Total knee arthroplasty (TKA).
Studies have shown that extreme outliers of JLOA have unsatisfactory outcomes in TKA. However, no study reports
the impact of JLOA on patient-reported outcome measures (PROMs) in fixed-bearing UKA. UKA can restore horizontal JLOA, thereby leading to greater satisfaction over TKA. Our study aims to evaluate the relationship between JLOA and PROMs after fixed-bearing UKA.
METHODS:
This is a single-center retrospective study approved by the institutional review board. The study included 56 knees in 56 patients with medial compartment osteoarthritis who underwent unilateral fixed-bearing UKA with almost normal opposite knee. Patients were selected as per standard radiological decision aid. Their postoperative JLOAs were measured by full-leg length standing coronal radiographs. The opposite normal knee was taken as control. PROMs were measured in terms of Oxford knee score (OKS).
RESULTS: Postoperative JLOA in the normal and operated knee were 0.3 ± 2.4° and 0.7 ± 2.6°, respectively. The JLOA
either horizontal or mildly tilted medially which was statistically not significant. The JLOA significantly positively correlated with the improvement of the PROMs (Oxford Knee Score (OKS), P < 0.0001).
DISCUSSION AND CONCLUSION: The JLOA after fixed-bearing UKA was either horizontal or mildly medially tilted which
was statistically not significant and positively correlated with PROMs.

Introduction: Intra-operative joint line determination during revision Total Knee Arthroplasty (TKA) is crucial. The aim of this study was to determine the medial and lateral joint line level and the transepicondylar width (TEW) ratio in the Malay population. Methods: Images of MRI knees performed without bony anomalies between July 2019 and July 2021 were obtained. Two senior radiologists measured the transepicondylar width (TEW), distance between the medial epicondyle to the distal articular surface (DMAD) and the distance between the lateral epicondyle to the distal articular surface (DLAD). We then measured the transepicondylar width ratio (DMAD/TEW & DLAD/TEW). Results: We identified 85 suitable MRI knees. Forty-six (54.1%) were males and 39 (45.9%) were females. The mean age was 33.4 (range,16-70) years. The mean DMAD in males was 2.51cm and 2.31cm in females. The DLAD in males was 2.10cms and 1.91cm in females. The mean TEW distance in males was 7.97cm and 6.79cm in females. The mean DMAD/TEW ratio was 0.31 in males and 0.34 in females. Conclusion: To our knowledge this is the first study looking at DMAD, DLAD and transepicondylar width ratio in the Malay population in Malaysia. The mean value for all 3 parameters (DMAD, DLAD, TEW) is smaller than in the published literature. The Malay population have smaller DMAD, DLAD and TEW measurements. The measurement is smaller in Malay females compared to Malay males. This needs to be taken into consideration when performing revision TKA in this population to obtain accurate anatomical joint line restoration.