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Purpose The aim of this study was to investigate the clinical and radiological results of the MAKO CT-based robotic-assisted system for total knee arthroplasty (TKA). Methods A PRISMA systematic review was conducted using four databases (MEDLINE, EMBASE, Pubmed, GOOGLE SCHOLAR) to identify all clinical and radiological studies reporting information regarding the use and results of the CT-based robotic-assisted system to perform TKA between 2016 and 2020. The main investigated outcome criteria were postoperative pain, analgesia requirements, clinical scores, knee range of motion, implant positioning and the revision rate. The ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions) was used to evaluate the quality of included studies and the risk of bias. Results A total of 36 studies were identified, of which 26 met inclusion criteria. Of these 26 studies, 14 were comparative. The follow-up varied from 30 days to 17 months. This CT-based, saw cutting Robotic TKA is associated with a significantly lower postoperative pain score (2.6 versus 4.5) and with significantly reduced time to hospital discharge (77 h versus 105), compared with conventional TKA. The two comparative studies assessing functional outcomes at 1 year reported significantly better functional scores with CT-based robotic TKA compared with conventional TKA (WOMAC score: 6 ± 6 versus 9 ± 8 ( p  < 0.05); KSS function score: 80 versus 73 ( p  = 0.005)). Only three comparative studies assessed implant positioning, and these reported better implant positioning with CT-based robotic-assisted TKA. Conclusion The CT-based robotic-assisted system for TKA reduced postoperative pain and improved implant positioning with equal or slightly superior improvement of the functional outcomes at one year, compared to conventional TKA. Level of evidence Systematic review level IV.

SARS-CoV-2 is the causative virus responsible for the COVID-19 pandemic. This pandemic has necessitated that all professional and elite sport is either suspended, postponed or cancelled altogether to minimise the risk of viral spread. As infection rates drop and quarantine restrictions are lifted, the question how athletes can safely resume competitive sport is being asked. Given the rapidly evolving knowledge base about the virus and changing governmental and public health recommendations, a precise answer to this question is fraught with complexity and nuance. Without robust data to inform policy, return-to-play (RTP) decisions are especially difficult for elite athletes on the suspicion that the COVID-19 virus could result in significant cardiorespiratory compromise in a minority of afflicted athletes. There are now consistent reports of athletes reporting persistent and residual symptoms many weeks to months after initial COVID-19 infection. These symptoms include cough, tachycardia and extreme fatigue. To support safe RTP, we provide sport and exercise medicine physicians with practical recommendations on how to exclude cardiorespiratory complications of COVID-19 in elite athletes who place high demand on their cardiorespiratory system. As new evidence emerges, guidance for a safe RTP should be updated.

Background There is debate around how to treat patients with periprosthetic joint infection of the hip. When there is an ingrown component on one side of the arthroplasty and a loose component on the other, treatment is typically revision of the entire construct. There is an argument to retain an ingrown implant in instances in which removal would result in severe bone damage. However, little has been reported on the likelihood of success with this approach. Questions/purposes Among carefully selected patients presenting with an infected total hip arthroplasty (THA) who were treated with joint débridement and at least partial implant retention: (1) What proportion remained apparently free of infection at a minimum of 5 years of followup? (2) What were the Harris hip scores of patients thus treated? Methods Between January 2000 and December 2010, a total of 293 patients were treated surgically at one hospital for a periprosthetic joint infection of the hip. Of these, 18 (2.9%) were treated with an approach that retained either the femoral component or the acetabular component (the removed component was exchanged at this same single-stage procedure). During that time, the general indications for this approach were patients who had complex THAs with ingrown femoral stems or complex acetabular components that were well fixed with no evidence of loosening on radiographs and CT. Patients had to be free from chronic debilitating diseases, had not developed a tracking sinus, and had a positive microbial growth from the hip aspirate. In 12 of these patients, the ingrown cementless femoral component was kept in situ and the femoral head and acetabular component were exchanged. In six patients, complex acetabular reconstructions including augments and/or cages were left in situ, and femoral revision with liner exchange was performed. The technique included removal of the loose component, thorough débridement, synovectomy, and extensive lavage. The ingrown component, be it femoral or acetabular, was thoroughly cleaned, lavaged, and scrubbed. Once there was a clear field, redraping was carried out and new instruments were used to reimplant the other side. In all patients, intravenous antibiotics were used postoperatively for a minimum of 5 days and oral antibiotics for a minimum of 6 weeks based on serology, wound healing, and nutritional markers. None of the patients were lost to followup. Minimum followup was 5 years; median followup was 7.1 years (range, 5–9.9 years). Results Reinfection occurred in three patients at 3, 9, and 10 months; all were treated by two-stage revision. No reinfection was noted in the other cases. At latest followup, the mean Harris hip score was 78 (range, 46–89). Conclusions In some patients, staged revision of large and well-fixed components will result in bone damage and compromised function. These results suggest that partial implant retention and joint débridement may be an alternative for those patients who have complex well-fixed acetabular or femoral components, are not immunocompromised, have not developed sinus formation, and we were able to obtain a positive hip aspirate. We caution this technique should not be applied when patients have chronic illness such as diabetes or rheumatoid disease, have a negative hip aspirate for microorganisms, or show any signs of loosening on radiography, CT, or on intraoperative assessment. These results at a minimum of 5 years are reassuring in this small single-center series, but we suggest that the technique not be widely adopted until or unless larger groups of patients with longer term data have been studied. Level of Evidence Level IV, therapeutic study.

Background Total knee arthroplasty (TKA) with mechanical alignment (MA) aims to achieve neutral limb alignment in all patients, whereas TKA with functional alignment (FA) aims to restore native, patient-specific anatomy and knee kinematics by manipulating bone resections and fine-tuning implant positioning. The objective of this study is to determine the optimal alignment technique in TKA by comparing patient satisfaction, functional outcomes, implant survivorship, complications, and cost-effectiveness in MA TKA versus FA TKA. Robotic technology will be used to execute the planned implant positioning and limb alignment with high-levels of accuracy in all study patients. Methods and analysis This prospective double-blinded randomised control trial will include 100 patients with symptomatic knee osteoarthritis undergoing primary robotic arm-assisted TKA. Following informed consent, patients will be randomised to MA TKA (the control group) or FA TKA (the investigation group) at a ratio of 1:1 using an online random number generator. Blinded observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to postoperative rehabilitation, clinical progress, functional outcomes, accuracy of implant positioning and limb alignment, gait, implant stability, cost-effectiveness, and complications. A superiority study design will be used to evaluate whether FA TKA provides superior outcomes compared to MA TKA. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Surrey Research Ethics Committee, UK. The study is sponsored by University College London, UK. Discussion This is the first study to describe the use of robotic technology to achieve FA TKA, and the only existing clinical trial comparing robotic MA TKA versus robotic FA TKA. The findings of this study will enable an improved understanding of the optimal alignment technique in TKA for achieving high-levels of patient satisfaction, improving functional outcomes, increasing implant survivorship, improving cost-effectiveness, and reducing complications. Registration Clinical Trials.gov , NCT04092153 . Registered on 17 September 2019.

Total hip arthroplasty (THA) has been quoted as one of the most successful and cost-effective procedures in Orthopaedics. The last decade has seen an exponential rise in the number of THAs performed globally and a sharp increase in the percentage of young patients hoping to improve their quality of life and return to physically demanding activities. Hence, it is imperative to review the various applications of technology in total hip arthroplasty for improving outcomes. The development of state-of-the-art robotic technology has enabled more reproducible and accurate acetabular positioning, while long-term data are needed to assess its cost-effectiveness. This opinion piece aims to outline and present the advances and innovations in total hip arthroplasty, from virtual reality and three-dimensional printing to patient-specific instrumentation and dual mobility bearings. This illustrates and reflects the debate that will be at the centre of hip surgery for the next decade.

Background The increasing number of patients experiencing periprosthetic total knee arthroplasty (TKA) infections and the cost of treating them suggest that we seek alternatives to two-stage revision. Single-stage revision is a potential alternative to the standard two-stage procedure because it involves only one surgical procedure, so if it is comparably effective, it would be associated with less patient morbidity and lower cost. Questions/purposes We compared (1) the degree to which our protocol of a highly selective single-stage revision approach achieved infection control compared with a two-stage revision approach to TKA infections; and (2) Knee Society scores and radiographic evidence of implant fixation between the single-stage and two-stage patients who were treated for more complicated infections. Methods Between 2004 and 2009, we treated 102 patients for chronic TKA infections, of whom 28 (27%) were treated using a single-stage approach and 74 (73%) were treated using a two-stage approach. All patients were available for followup at a minimum of 3 years (mean, 6.5 years; range, 3–9 years). The indications for using a single-stage approach were minimal/moderate bone loss, the absence of immunocompromise, healthy soft tissues, and a known organism with known sensitivities for which appropriate antibiotics are available. Participants included 38 men and 64 women with a mean age of 65 years (range, 45–87 years). We used the Musculoskeletal Infection Society definition of periprosthetic joint infection to confirm infection control at the last followup appointment. Radiographs were evaluated for signs of loosening, and patients completed Knee Society Scores for clinical evaluation. Results None of the patients in the single-stage revision group developed recurrence of infection, and five patients (93%) in the two-stage revision group developed reinfection (p = 0.16). Patients treated with a single-stage approach had higher Knee Society scores than did patients treated with the two-stage approach (88 versus 76, p < 0.001). However, radiographic findings showed a well-fixed prosthesis in all patients with no evidence of loosening at last followup in either group. Conclusions Our data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. However, larger, multicenter, prospective trials are called for to validate our findings. Level of Evidence Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The increasing numbers of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), combined with the rapidly growing repertoire of surgical techniques and interventions available have put considerable pressure on surgeons and other healthcare professionals to produce excellent results with early functional recovery and short hospital stays. The current economic climate and the restricted healthcare budgets further necessitate brief hospitalization while minimizing costs. Clinical pathways and protocols introduced to achieve these goals include a variety of peri-operative interventions to fulfill patient expectations and achieve the desired outcomes. In this review, we present an evidence-based summary of common interventions available to achieve enhanced recovery, reduce hospital stay, and improve functional outcomes following THA and TKA. It covers pre-operative patient education and nutrition, pre-emptive analgesia, neuromuscular electrical stimulation, pulsed electromagnetic fields, peri-operative rehabilitation, modern wound dressings, standard surgical techniques, minimally invasive surgery, and fast-track arthroplasty units.

Background Successful treatment of an infected joint arthroplasty depends on correctly identifying the responsible pathogens. The value of a preoperative biopsy remains controversial. Questions/purposes We (1) compared the sensitivity and specificity of both tests separately and in combination, and (2) asked whether the combination of tissue biopsy and aspiration would improve our diagnostic yield in the evaluation of periprosthetic joint infections. Patients and Methods We prospectively followed 120 patients with suspected infection of a total joint arthroplasty: 64 with THAs and 56 with TKAs. All patients had aspiration with culture and biopsy. Results The sensitivity was 83% for aspiration, 79% for biopsy, and 90% for the combination of both techniques. The specificity was 100% for aspiration and biopsy and the combination. The overall accuracy was 84%, 81%, and 90%, respectively. Conclusions Our data suggest tissue biopsy alone offers no clear advantage over joint aspiration. However, the combination of both techniques provides improved sensitivity and accuracy. We recommend the use of tissue biopsy as an adjunct to joint aspiration in the diagnosis of total joint infection. Level of Evidence Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Introduction Accurate implant positioning, tailored to the phenotype and unique biomechanics of each patient is the single most important objective in achieving stability in THA and maximise range of motion. The spine-pelvis-hip construct functions as a single unit adapting to postural changes. It is widely accepted in the literature that no universaltarget exists and variations in spinopelvic mobility mandate adjustments to the surgical plan; thus bringing to the fore the concept of personalised, functional component positioning. Methods This manuscript aims to outline the challenges posed by spinopelvic imbalance and present a reproducible, stepwise approach to achieve functional-component positioning. We also present the one-year functional outcomes and Patient Reported Outcome Measures of a prospective cohort operated with this technique. Results and Conclusion Robotic-arm assisted Total Hip Arthroplasty has facilitated enhanced planning based on the patient’s phenotype and evidence suggests it results in more reproducible and accurate implant positioning. Preservation of offset, avoiding leg-length discrepancy, accurate restoration of the centre of rotation and accomplishing the combinedversion target are very important parameters in Total Hip Arthroplasty that affect post-operative implant longevity, patient satisfaction and clinical outcomes.

ObjectiveFindings from individual anterior cruciate ligament reconstruction (ACLR) registry studies are impactful, but how various registries from different countries compare with different patient populations and surgical techniques has not been described. We sought to describe six ACLR registry cohorts to understand variation across countries.MethodsFive European registries and one US registry participated. For each registry, all primary ACLR registered between registry establishment through 31December 2014 were identified. Descriptive statistics included frequencies, proportions, medians and IQRs. Revision incidence rates following primary ACLR were computed.Results101 125 ACLR were included: 21 820 in Denmark, 300 in Luxembourg, 17 556 in Norway, 30 422 in Sweden, 2972 in the UK and 28 055 in the US. In all six cohorts, males (range: 56.8%–72.4%) and soccer injuries (range: 14.1%–42.3%) were most common. European countries mostly used autografts (range: 93.7%–99.7%); allograft was most common in the US (39.9%). Interference screw was the most frequent femoral fixation in Luxembourg and the US (84.8% and 42.9%), and suspensory fixation was more frequent in the other countries (range: 43.9%–75.5%). Interference was the most frequent tibial fixation type in all six cohorts (range: 64.8%–98.2%). Three-year cumulative revision probabilities ranged from 2.8% to 3.7%.ConclusionsSimilarities in patient demographics and injury activity were observed between all cohorts of ACLR. However, graft and fixation choices differed. Revision rates were low. This work, including >100 000 ACLR, is the most comprehensive international description of contemporary practice to date.