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Purpose To determine whether patient-specific instrumentation (PSI), computer-assisted surgery (CAS) or robot-assisted surgery (RAS) enable more accurate rotational alignment of the tibial baseplate in primary total knee arthroplasty (TKA) compared to conventional instrumentation, in terms of deviation from the planned target and the proportion of outliers from the target zone. Methods The authors independently conducted three structured electronic literature searches using the PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases from 2007 to 2020. Studies were included if they compared rotational alignment of the tibial baseplate during TKA using conventional instrumentation versus PSI, CAS, and/or RAS, and reported deviation from preoperatively planned rotational alignment of the tibial baseplate in terms of absolute angles and/or number of outliers. Methodological quality of eligible studies was assessed by two researchers according to the Downs and Black Quality Checklist for Health Care Intervention Studies. Results Fifteen studies, that reported on 2925 knees, were eligible for this systematic review, of which 6 studies used PSI, and 9 used CAS. No studies were found for RAS. Of the studies that reported on angular deviation from preoperatively planned rotational alignment, most found smaller deviations using PSI (0.5° to 1.4°) compared to conventional instrumentation (1.0° to 1.6°). All studies that reported on proportions of outliers from a target zone (± 3°), found lower rates of outliers using PSI (0 to 22%) compared to conventional instrumentation (5 to 96%). Most studies reported smaller angular deviation from preoperatively planned rotational alignment using CAS (0.1° to 6.9°) compared to conventional instrumentation (1.1° to 7.8°). Of the studies that reported on proportions of outliers from a target zone (± 3°), most found fewer outliers using CAS (10 to 61%) compared to conventional instrumentation (17 to 78%). Conclusion This systematic review and meta-analysis revealed that both CAS and PSI can improve the accuracy of rotational alignment of the tibial baseplate by decreasing angular deviation from the preoperatively planned target and reducing the proportion of outliers from the target zone. The clinical relevance is that PSI and CAS can improve alignment, though the thresholds necessary to grant better outcomes and survival remain unclear. Level of evidence IV.

Sensor technology was introduced to intraoperatively analyse the differential pressure between the medial and lateral compartments of the knee during primary TKA using a sensor to assess if further balancing procedures are needed to achieve a “balanced” knee. The prognostic role of epidemiological and radiological parameters was also analysed. A consecutive series of 21 patients with primary knee osteoarthritis were enrolled and programmed for TKA in our unit between 1 September 2020 and 31 March 2021. The VERASENSE Knee System (OrthoSensor Inc., Dania Beach, FL, USA) has been proposed as an instrument that quantifies the differential pressure between the compartments of the knee intraoperatively throughout the full range of motion during primary TKA, designed with a J-curve anatomical femoral design and a PS “medially congruent” polyethylene insert. Thirteen patients (61.90%) showed a “balanced” knee, and eight patients (38.10%) showed an intra-operative “unbalanced” knee and required additional procedures. A total of 13 additional balancing procedures were performed. At the end of surgical knee procedures, a quantitatively balanced knee was obtained in all patients. In addition, a correlation was found between the compartment pressure of phase I and phase II at 10° of flexion and higher absolute pressures were found in the medial compartment than in the lateral compartment in each ROM degree investigated. Moreover, those pressure values showed a trend to decrease with the increase in flexion degrees in both compartments. The “Kinetic Tracking” function displays the knee’s dynamic motion through the full ROM to evaluate joint kinetics. The obtained kinetic traces reproduced the knee’s medial pivot and femoral rollback, mimicking natural knee biomechanics. Moreover, we reported a statistically significant correlation between the need for soft tissue or bone resection rebalancing and severity of the initial coronal deformity (>10°) and a preoperative JLCA value >2°. The use of quantitative sensor-guided pressure evaluation during TKA leads to a more reproducible “balanced” knee. The surgeon, evaluating radiological parameters before surgery, may anticipate difficulties in knee balance and require those devices to achieve the desired result objectively.

Purpose Postoperative instability represents one of the most common complications following primary total knee arthroplasty (TKA). To prevent this outcome, valgus deformities have been historically treated using more constrained implants. The purpose of this study was to evaluate the outcome of treating a moderate valgus deformity by combining a surgical technique used to release the postero-lateral soft tissue envelope with the use of a medially congruent (MC) TKA design without using classical, semi-constrained inserts. Methods Seventy-nine MC TKAs were performed by three surgeons at three institutions between 2016 and 2018 as part of a multicenter, international study. Inclusion criteria were: radiographic late-stage osteoarthritic knees with Ranawat’s type 1 or 2 classification of valgus deformity and integrity of the medial capsular–ligament complex (less than 10 mm of medial opening during valgus stress test at 10° of knee flexion). Exclusion criteria were: BMI > 40; neuromuscular, metabolic, or immunologic disorders; or the inability to complete outcome measures or radiographic assessment. Results Seventy-seven patients (79 knees), 59 males and 18 females, were evaluated at 2-year minimum follow-up according to the Knee Society Score (KSS) and Forgotten Joint Score (FJS). Mean age at surgery was 70 years (range 48–91). The mean range of motion (ROM) improved from 110° (range 85°–130°) preoperatively to 121° (range 105°–135°) ( p  < 0.001) at the time of the last follow-up. Preoperative knee extension significantly improved from 3° (range − 15° to 20°) to 1° (range − 5° to 5°) of flexion at the last follow-up in all the patients. KSS and KSS Functional scores were 89 (range 65–100) and 82 points (range 55–100), respectively. The FJS obtained at the last follow-up was 72 (range 49–88). Two patients (2.5%) had major postoperative complications (one periprosthetic joint infection; one postoperative patellar fracture) requiring surgical interventions. Conclusions In different surgeon’s hands, the use of a modern medially congruent TKA design yielded good clinical outcomes at 2 years in a consecutive series of TKA in valgus arthritic knees. Postoperative instability was not recorded in this series and this finding was related to the high conformity design of the MC polyethylene insert, which significantly differs from classical posterior-stabilized (PS) designs. Level of evidence IV.

Introduction: Periprosthetic joint infections (PJI) represent a devastating consequence following total joint arthroplasty (TJA). In this study, the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure (DAIR) to improve the possibilities of retaining an acutely infected TJA. Materials and Methods: This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads in a setting of acute (<4 weeks from symptoms onset) PJI with pathogen identification. The combination of three different surgical techniques (tumor-like synovectomy, argon beam/acetic acid application and chlorhexidine gluconate brushing) aims to remove the bacterial biofilm from the implant without explanting the original hardware. Results: In total, 62 patients met the acute infection criteria (<4 weeks of symptoms); there were 57 males and five females. The patients’ average age at the time of treatment was 71 years (62–77) and the average BMI was 37 kg/m2. The micro-organism, always identified through synovial fluid analysis (culture, multiplex PCR or Next Generation Sequencing), was an aerobic Gram + in 76% (S. Coag-Neg 41%; S. aureus 16%), Gram—in 10% (E. coli 4%) and anaerobic Gram + in 4%. The DAPRI treatment was performed at an average of 3 days from symptoms onset (1–7 days). All patients underwent a 12-week course of post-operative antibiotic therapy (6 weeks I.V. and 6 weeks oral). All patients were available at the 2-year minimum FU (24–84 months). A total of 48 (77.5%) patients were infection-free at the final FU, while 14 patients underwent 2-stage revision for PJI recurrence. In total, four patients (6.4%) had a prolonged drainage from the wound after placement of the calcium sulphate beads. Conclusions: This study suggests that the DAPRI technique could represent a valid alternative to the classic DAIR procedure. The current authors do not recommend this procedure outside of the main inclusive criteria (acute scenario micro-organism identification).

Anterior cruciate ligament (ACL) injuries are common in sports and often require surgical intervention, e.g., ACL reconstruction (ACLR), aimed at restoring knee stability and enabling a return to pre-injury activity levels. The choice of graft is crucial, impacting biomechanical properties, clinical outcomes, and complication rates, and is especially important in revision surgeries after graft failure. Over the past 30 years, trends in graft selection have evolved towards more individualized approaches, considering factors such as patient activity level, prior injuries, and tissue availability. In Europe, autografts like hamstring tendon (HT), bone-patellar tendon-bone (BTB), and quadriceps tendon (QT) are preferred, with the increasing use of QT grafts. This review synthesizes the current literature on graft selection and its influence on ACLR outcomes.

Purpose The purpose of this study was to demonstrate closer-to-normal knee kinematics following primary total knee arthroplasty (TKA) performed establishing asymmetric gap balancing intraoperatively. Material and method Two age-, sex-, BMI-matched groups of patients underwent medially stabilized TKA because of isolated knee disease. Group A (12 patients) underwent “unrestricted” kinematic alignment (uKA) according to Howell while group B (15 patients) received robot-assisted “simplified” KA (sKA) with an alignment goal (Hip-Knee-Ankle axis-HKA) ± 5° respect to the mechanical axis. Intraoperatively, in group B, the flexion gap at 90° was first set at an average of 1.5 mm (0–5 mm; SD 4.4 mm) tighter in the medial compartment with respect to the lateral; in the same way, the extension gap was then set at an average of 2.0 mm (0–4.5 mm; SD 3.1 mm) tighter in the medial compartment with respect to the lateral. All patients, including a non-arthritic cohort (group C: 5 controls) underwent gait analysis using an instrumented treadmill (WalkerView–WV) equipped with an instrumented belt armed with a 3D video camera. The WV software evaluated multiple spatiotemporal and kinematic parameters, including: (1) contact time (s); (2) knee ROM during gait cycle; (3) step length percentage with respect to total gait (%) and pure step length (cm). Statistical analyses included t -Test and ANOVA and were conducted by using SPSS. Results At the final FU, significant differences were noted during gait between the two TKA groups (uKA-sKA) and the controls. Both TKA groups showed superior mean contact time on the surgical knee (uKA 1 s; sKA 0.97 s) as compared to the controls (0.72 s) ( P  = 0.002) while no differences were found between them ( P  = 0.11). TKA groups showed a lower, maximum ROM in the surgical knee (mean uKA 36º; mean sKA 49º) relative to the controls (mean 57º) ( P  < 0.05) but a statistical difference was found between them ( P  = 0.003). Both TKA groups showed a higher step length percentage with respect to the total gait and a shorter step length on the surgical side (uKA: mean 8.28% and mean step length 35.5 cm; sKA: mean 8.38% and mean step length 34.6 cm) in comparison to the controls (mean 3.38%; mean step length 71.4 cm) ( P  < 0.05) while no statistical differences were found between them. Conclusion To our knowledge, this was the first study to exhibit the kinematic advantages of a slightly asymmetric gap balancing during KA TKA. Combining a medially-stabilized implant design and a surgical technique aiming to obtain a tighter medial compartment represents a promising approach to improve outcomes after TKA. Graphical Abstract

Background: Periprosthetic joint infection (PJI) represents a devastating consequence of total joint arthroplasty (TJA) because of its high morbidity and its high impact on patient quality of life. The lack of standardized preventive and treatment strategies is a major challenge for arthroplasty surgeons. The purpose of this article was to explore the potential and future uses of nanotechnology as a tool for the prevention and treatment of PJI. Methods: Multiple review articles from the PubMed, Scopus and Google Scholar databases were reviewed in order to establish the current efficacy of nanotechnology in PJI preventive or therapeutic scenarios. Results: As a prevention tool, anti-biofilm implants equipped with nanoparticles (silver, silk fibroin, poly nanofibers, nanophase selenium) have shown promising antibacterial functionality. As a therapeutic tool, drug-loaded nanomolecules have been created and a wide variety of carrier materials (chitosan, titanium, calcium phosphate) have shown precise drug targeting and efficient control of drug release. Other nanotechnology-based antibiotic carriers (lipid nanoparticles, silica, clay nanotubes), when added to common bone cements, enhanced prolonged drug delivery, making this technology promising for the creation of antibiotic-added cement joint spacers. Conclusion: Although still in its infancy, nanotechnology has the potential to revolutionize prevention and treatment protocols of PJI. Nevertheless, extensive basic science and clinical research will be needed to investigate the potential toxicities of nanoparticles.

Background and Objectives: The objective of the study was to evaluate the epidemiology of slope-related accidents in a high-volume trauma center during the winter season. In addition, this study aims to analyze patient-related, equipment-related, and environment-related characteristics. Materials and Methods: A questionnaire containing 22 items was distributed to all adult patients admitted to the emergency department of the Brixen Hospital (Italy) during the 2023/24 winter season because of a ski/snowboard-related injury. Results: The final database included 579 questionnaires from 579 patients who ultimately entered the study: 285 were females and 294 were males. The analysis of risk factors for fractures revealed that patients with fractures were generally older (50.7 ± 16.0 years) compared to those without fractures (45.4 ± 17.2 years, p = 0.0021). Thirty-six percent of injuries were considered as joint sprain/ligament strain: patients in this group were younger (45.5 ± 16.2 years) compared to all patients (48.3 ± 17.3 years, p = 0.0151). Conclusions: In conclusion, this study identified significant risk factors associated with skiing and snowboarding injuries. Fractures were more common among older and more experienced skiers, particularly those who described themselves as experts. Ligamentous distortions were more common among younger and less experienced skiers. Fatigue is generally underestimated, and the general physical preparation is often lacking for sports like skiing and snowboarding. Additionally, the absence of significant correlations between weather conditions, snow quality, equipment type, and the difficulty of the slope with injury risk suggests that individual factors such as age and skill level are more critical determinants of injury risk than environmental or equipment-related factors.

Background: Traditional total knee implants designs, usually, are not able to reproduce the physiological kinematics of the knee, leaving almost 20% of the patients, those who underwent a total knee arthroplasty (TKA), not fully satisfied. Modern inserts are nowadays designed with a fully congruent medial compartment to reproduce the normal medial pivoting biomechanics of the knee. The aim of this article was to evaluate preliminary clinical improvement using the Medial Congruent (MC) insert as specific level of constraint. Materials and methods: A total of 10 consecutive patients have been enrolled in this study and treated using an MC tibial polyethylene insert. The Oxford Knee Score (OKS) and the Knee Society Score (KSS) have been assessed preoperatively and at 3-month, 6-month, and 1-year follow-up (FU) and used as validated measurements to evaluate early clinical improvements. Postoperative radiological examination was reviewed looking for radiolucent lines or loosening of the components. Results: Average improvement in OKS was from 19.5 to 41.2, whereas KSS improved with an average score from 64.7 preoperatively to 167.5 at the final FU showing good to excellent results in 95% of the treated knees. Evaluating the range of motion, the average maximum active movement was 124° and none of the patients needing for a revision surgery or manipulation under anesthesia. No complications were observed at the final FU as septic or aseptic loosening or vascular or neurologic injury. Discussion and conclusions: Medial Congruent insert showed good to excellent clinical results at 1-year FU. Range of motion and subjective outcomes were satisfying and comparable with results obtained in literature using traditional TKA design.

Background Total knee arthroplasty (TKA) is one of the most performed orthopedic procedures worldwide. While excellent efficacy has been reported, about 20% of patients are not satisfied with the result. A potential cause is the problematic reproduction of knee kinematics. This systematic review examines gait analysis studies in primary medial pivot (MP) and posterior stabilized (PS) TKAs to investigate the differences between the two prosthesis designs. Methods A systematic review was conducted by following PRISMA guidelines. Five databases (PubMed, Medline, Embase, Scopus and the Cochrane Database of Systematic Reviews) were analyzed, and eligible articles were evaluated in terms of the levels of evidence. The methodological quality of the articles was assessed by using the MINORS scoring. This review was registered in PROSPERO. Results Nine studies were included. Gait analysis was performed in 197 MP TKA and 192 PS TKA patients. PS TKA cases showed ( P  < 0.05) a significantly higher peak of knee flexion angle during the swing phase, greater knee flexion angle at toe-off, an increased knee adduction angle, higher knee flexion and extension moment, increased anterior femoral roll during knee flexion and anterior translation on medial and lateral condyle during knee flexion compared to MP TKA. MP TKA showed statistically significant ( P  < 0.05) higher knee rotational moment and greater tibiofemoral external rotation motion during knee flexion than PS TKA. No statistically significant difference ( P  > 0.05) was reported regarding gait spatial–temporal parameters. The Forgotten Joint Score (FJS) and Western Ontario and McMaster Universities Comparison in terms of Arthritis Index (WOMAC) score (mean stiffness) showed that MP TKA yielded significantly better results than PS TKA. Conclusions This systematic review revealed significant kinematic and kinetic differences between MP and PS TKA at all gait analysis phases. Furthermore, the considerable difference between TKA design and the kinematics of healthy knee were highlighted in this study. Level of evidence III.