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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 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.

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.

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.

Robotic-arm-assisted total hip arthroplasty (RoTHA) offers the opportunity to improve the implant positioning and restoration of native hip mechanics. The concept of individualised, functional implant positioning and how it relates to spinopelvic imbalance is an important yet rather novel consideration in THA. There is mounting evidence that a significant percentage of dislocations occur within the perceived “safe zones”; hence, in the challenging subset of patients with a stiff spinopelvic construct, it is imperative to employ individualised component positioning based on the patients’ phenotype. Restoring the native centre of rotation, preserving offset, achieving the desired combined anteversion and avoiding leg length inequality are all very important surgeon-controlled variables that have been shown to be associated with postoperative outcomes. The latest version of the software has a feature of virtual range of motion (VROM), which preoperatively identifies potential dynamic causes of impingement that can cause instability. This review presents the workflow of RoTHA, especially focusing on pragmatic solutions to tackle the challenge of spinopelvic imbalance. Furthermore, it presents an overview of the existing evidence concerning RoTHA and touches upon future direction.

IntroductionRobotic-assisted knee replacement systems have been introduced to healthcare services worldwide in an effort to improve clinical outcomes for people, although high-quality evidence that they are clinically, or cost-effective remains sparse. Robotic-arm systems may improve surgical accuracy and could contribute to reduced pain, improved function and lower overall cost of total knee replacement (TKR) surgery. However, TKR with conventional instruments may be just as effective and may be quicker and cheaper. There is a need for a robust evaluation of this technology, including cost-effectiveness analyses using both within-trial and modelling approaches. This trial will compare robotic-assisted against conventional TKR to provide high-quality evidence on whether robotic-assisted knee replacement is beneficial to patients and cost-effective for healthcare systems.Methods and analysisThe Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial-Knee is a multicentre, participant-assessor blinded, randomised controlled trial to evaluate the clinical and cost-effectiveness of robotic-assisted TKR compared with TKR using conventional instruments. A total of 332 participants will be randomised (1:1) to provide 90% power for a 12-point difference in the primary outcome measure; the Forgotten Joint Score at 12 months postrandomisation. Allocation concealment will be achieved using computer-based randomisation performed on the day of surgery and methods for blinding will include sham incisions for marker clusters and blinded operation notes. The primary analysis will adhere to the intention-to-treat principle. Results will be reported in line with the Consolidated Standards of Reporting Trials statement. A parallel study will collect data on the learning effects associated with robotic-arm systems.Ethics and disseminationThe trial has been approved by an ethics committee for patient participation (East Midlands—Nottingham 2 Research Ethics Committee, 29 July 2020. NRES number: 20/EM/0159). All results from the study will be disseminated using peer-reviewed publications, presentations at international conferences, lay summaries and social media as appropriate.Trial registration numberISRCTN27624068.

Introduction : Effective postoperative pain management is imperative in total hip arthroplasty (THA) to enable early mobilization and accelerate recovery pathways. This study investigated the patterns of inpatient opioid consumption following THA and identified the factors associated with increased opioid usage. Methods : In this large-scale, single-institution study, we analyzed data from 1,867 primary THAs between April 2019 and July 2023. We collected data on demographics, length of stay (LOS), type of anaesthesia, Post Anaesthesia Care Unit (PACU) admissions, 30-day readmissions, total opioid consumption (MME; morphine milligram equivalents), implant fixation techniques, surgical characteristics and pre- and postoperative haemoglobin (Hb) levels. Factors associated with increased opioid consumption (patients in the ≥ 75th percentile of inpatient opioid consumption; MME ≥ 211.9 mg) were identified through univariate and multivariate logistic regression models. Results : The cohort included 1150 women (61.6%) and 717 men (38.4%). The median inpatient opioid use was 88 mg (IQR = 39.3–211.9). In the univariate model, significant predictors included age, American Society of Anaesthesiologists (ASA) score, manual THA technique, general anaesthesia, pre- and postoperative Hb levels, need for PACU admission and year of surgery. After adjusting for baseline demographics in the hierarchical multivariate logistic regression model, significant predictors of higher opioid utilization were age (OR 0.989 [95% CI 0.981–0.997], p  = 0.01), general anaesthesia (OR 2.386 [95% CI 1.865–3.054], p  < 0.001), PACU admission (OR 2.098 [95% CI 1.310–3.358], p  = 0.002), ASA score (OR 1.492 [95% CI 1.193–1.866], p  < 0.001), postoperative Hb levels (OR 0.981 [95% CI 0.970–0.992], p  < 0.001), and year of surgery (OR 0.638 [95% CI 0.579–0.703], p  < 0.001) indicating that later years were associated with lower odds of high opioid consumption). Discussion : Younger age, higher ASA scores, lower postoperative haemoglobin, the need for PACU admission and general anaesthesia were significantly associated with increased opioid consumption following THA. Recognizing these factors can facilitate the development of tailored postoperative pain management protocols, enabling targeted interventions that minimize opioid reliance while enhancing recovery.

Background: Patients undergoing unicompartmental knee arthroplasty (UKA) often want to return to sport (RTS) after surgery. However, the time taken to RTS and proportion of patients who RTS after UKA remain unknown. Purpose: To determine the time to RTS and proportion of patients who RTS after UKA. Study Design: Systematic review; Level of evidence, 4. Methods: A search was performed using PubMed, Medline, Embase, SPORTDiscus and the Cochrane Library databases for clinical trials reporting on RTS after UKA published between database inception and September 2021. In addition, a manual search was performed of relevant sports medicine and orthopaedic journals, and bibliographies were reviewed for eligible trials. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to undertake this study. Results: This meta-analysis included 11 studies (749 patients) that reported on RTS after UKA. The proportion of patients returning to sports increased over time: 6 studies (432 patients) demonstrated an overall pooled proportion of 48.1% (95% CI, 36.3%-60.2%) of patients who returned to sport at 3 months after surgery, while 7 studies (443 patients) demonstrated an overall pooled proportion of 76.5% (95% CI, 63.9%-87.1%) of patients who returned to sport at 6 months after surgery. Overall, 92.7% (95% CI, 85.8%-97.4%) of 749 patients were able to RTS at 4 years after surgery. Overall excellent patient-reported functional outcomes scores and low risk of complications with RTS after UKA were reported. Conclusion: The authors found that 48.1% of patients were able to RTS at 3 months after surgery and 76.5% were able to RTS at 6 months after UKA. Pooled proportion analysis showed that >90% of patients undergoing UKA were able to RTS at 48 months after surgery. The majority of patients who were able to RTS after UKA did so at a lower level of intensity than their preoperative level. RTS after UKA was associated with good patient-reported functional outcomes scores and a low risk of complications.

Background Robotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning during total hip arthroplasty. The objective of this study is to compare the accuracy of implant positioning, restoration of hip biomechanics, patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications in conventional manual total hip arthroplasty (CO THA) versus robotic-arm assisted total hip arthroplasty (RO THA). Preoperative pelvic computerised tomography (CT) scans will be used to create patient-specific, virtual, three-dimensional reconstructions for surgical planning in both treatment groups. Methods and analysis This prospective randomised controlled trial will include 60 patients with symptomatic hip osteoarthritis undergoing primary THA. Following informed consent, patients will be randomised to CO THA (control group) or RO THA (investigation group) at a ratio of 1:1 using an online random number generator. Observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to the accuracy of implant positioning, hip biomechanics, postoperative rehabilitation, clinical progress, functional outcomes, cost-effectiveness, and complications. 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. Intention to treat relates to the allocated treatment (CO THA or RO THA), and per-protocol refers to the actual treatment received by the patient. 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-Bromley Research Ethics Committee, UK. The study is sponsored by University College London, UK. Discussion This study compares a comprehensive and robust range of clinical, functional, and radiological outcomes in CT-planned CO THA versus CT-planned RO THA. The findings of this study will enable an improved understanding of the differences in CO THA versus RO THA with respect to patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications. Trial registration ClinicalTrials.gov NCT04095845 . Registered on 19 September 2019