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Purpose The purpose of this study was to compare radiographic and clinical outcomes of robotic-assisted and conventional manual techniques in restricted kinematically aligned TKA. Methods Patients who underwent either manual or robotic-assisted restricted kinematically aligned TKA between 2019 and 2020 were included in this retrospective comparative study. Radiographic outcomes comprised coronal plane measurements performed through standing full-length anteroposterior radiographs. The Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford score, Visual Analog Scale pain and satisfaction score, and Forgotten Joint Score were used to determine the clinical outcome. The continuous data were compared by Student’s t test according to the Kolmogorov‒Smirnov normality test. Results The manual group consisted of 46 patients (38 females, eight males) with a mean age of 68.1 years, and the robotic group consisted of 70 patients (58 females, 12 males) with a mean age of 65.7 years (n.s.). Preoperatively, no significant difference was observed between groups concerning demographic characteristics, radiographic measurements, and clinical scores except for the symptom and pain domains of the KOOS score, which was significantly worse in the manual group ( p  = 0.011 and 0.035, respectively). At the postoperative 2-year follow-up, we observed significant differences between groups with respect to the mean HKA angle, mMPTA, and mLDFA ( p  = 0.034, 0.041, and 0.005, respectively). A comparison of clinical scores at the postoperative 2-year follow-up demonstrated no significant differences between groups. Conclusion The current study demonstrated that using robotic-assisted technique for restricted kinematically aligned total knee arthroplasty (TKA) resulted in significantly better outcomes compared to the conventional manual technique in achieving normal ranges of lower extremity coronal alignment measurements. While the robotic-assisted group demonstrated better clinical scores, there was no statistically significant difference in clinical outcomes between the robotic-assisted group and the control group at the two-year follow-up. Concerning clinical relevance, the restoration of original anatomy and coronal alignment, a crucial concern in restricted kinematically aligned TKA, may be better achieved by the robotic-assisted technique. Level of evidence Level III (Retrospective cohort study).

Purpose This study aimed to investigate functional outcome and complications after primary and revision modular H-TKA using hybrid fixation with cementless stems. Methods Between 2015 and 2018, 48 patients with 50 implants were included after hybrid implantation of a single design H-TKA system using cementless osseointegrating stems and modular components. Complications and clinical outcome were analysed using Knee Society Score (KSS), the Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) and the Short-Form Health Survey 12 (SF-12) score. Results Indications for implantation were aseptic revision ( n  = 29, 58%), primary TKA ( n  = 19, 38%) and two-stage septic revisions ( n  = 2, 4%). Complications were reported in 26% ( n  = 12), whereas complications associated with hybrid fixation occurred in 5 (10%) cases, with 2 (4%) requiring revision surgery for aseptic loosening and 3 (6%) treated with an adapted postoperative protocol for perioperative fractures. Implant survivorship was 84% after a mean follow-up of 54 months. Postoperative KSS significantly improved from 51.50 (12–100) to 78.36 (41–99; p  < 0.001). The mean WOMAC score was 19.26 (0–55), SF-12 PCS was 41.56 points (22.67–57.66) and SF-12 MCS was 49.21 points (23.87–63.21). Conclusion Hybrid modular implantation in H-TKA provides satisfactory clinical and functional results in primary and revision TKA. Clinical outcomes significantly improve with reduced pain, increased mobility, and good-to-excellent functional scores after implantation. Whilst implant survival is comparable to previous studies and complications associated with hybrid fixation are low, general complication rates are comparably high.

Objective Robot‐assisted surgery has been promoted worldwide in recent years. The development of a domestic orthopaedic robot and its clinical application are therefore of great significance. This study aimed to compare the early clinical and radiographic outcomes of domestic robot‐assisted total knee arthroplasty (RA‐TKA) with conventional manual total knee arthroplasty (CM‐TKA). Methods A total of 77 patients who underwent primary single‐sided TKA from June to December 2020 were prospectively enrolled; resulting in the inclusion of 72 patients. The patients were randomly divided into the RA‐TKA group (37 cases, with TKA being assisted by the Yuanhua Orthopaedic Robotic System) and the CM‐TKA group (35 cases, with TKA being performed using conventional tools). Knee function was evaluated by the knee range of motion (ROM), the American Knee Society Score (KSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Postoperative radiographic results were evaluated by full‐length weight‐bearing X‐rays of the lower limb and anteroposterior and lateral X‐rays of the knee were obtained preoperatively and at 90 days postoperative. The operative duration, blood loss, postoperative knee function, radiographic outcomes, and incidence of complications were compared by Student's t‐test, Mann–Whitney U test, or chi‐square test. Serum levels of inflammatory markers before the operation and 1, 3, and 30 days after the operation were recorded and compared between the two groups. Results The operation was significantly longer in the RA‐TKA group than in the CM‐TKA group (154.3 vs 115.2 min, p < 0.001). There was no significant difference in blood loss (933 vs 863 ml, p = 0.519) between the two groups. The knee ROM, KSS, and WOMAC were significantly improved in both groups 90 days after the operation compared with before the operation (p < 0.05), but there were no significant differences between the two groups (p > 0.05). The incidence of postoperative deep vein thrombosis was not statistically different between the two groups. In the radiographic findings at 90 days postoperatively we found the frequency of lateral tibial component (LTC) angle outliers was significantly lower in the RA‐TKA group (3.0% vs 29.4%, p = 0.003). The neutrophil‐to‐lymphocyte ratio (NLR) was significantly lower in the RA‐TKA group than in the CM‐TKA group on day 1 after surgery (9.9 vs 12.7, p = 0.024). Conclusions RA‐TKA requires more time than CM‐TKA, which may be related to the learning curve and intraoperative registration. The short‐term postoperative knee functional outcomes had no differences between the two groups, and RA‐TKA improved the accuracy of tibial component alignment. Further follow‐up studies are required to investigate the long‐term outcomes. We compared the early clinical outcomes of the RA‐TKA and CM‐TKA groups through a prospective study. The advantages of RA‐TKA in terms of radiographic results as well as inflammatory indicators and the disadvantages of prolonging the surgery are described.

Purpose The present study assessed the effect of insert articular surface geometry (anatomical versus conventional insert design) on anteroposterior (AP) translation and varus-valgus (VV) laxity in balanced posterior cruciate ligament (PCL) retaining total knee arthroplasty (TKA). Secondly, we evaluated if the AP translation and VV laxity in the reconstructed knee resembled the stability of the native knee. Methods Nine fresh-frozen full-leg cadaver specimens were used in this study. After testing the native knee, anatomical components of a PCL-retaining implant were implanted. The knee joints were subjected to anteriorly and posteriorly directed forces (at 20° and 90° flexion) and varus-valgus stresses (at 20°, 45° and 90° flexion) in both non-weightbearing and weightbearing situations in a knee kinematics simulator. Measurements were performed in the native knee, TKA with anatomical insert geometry (3° built-in varus, medial concave, lateral convex), and TKA with symmetrical insert geometry. Results In weightbearing conditions, anterior translations ranged between 2.6 and 3.9 mm at 20° flexion and were < 1 mm at 90° flexion. Posterior translation at 20° flexion was 2.7 mm for the native knee versus 4.0 mm ( p  = 0.047) and 7.0 mm ( p  = 0.02) for the symmetrical insert and the anatomical insert, respectively. Posterior translation at 90° flexion was < 1.1 mm and not significantly different between the native knee and insert types. In non-weightbearing conditions, the anterior translation at 20° flexion was 5.9 mm for the symmetrical and 4.6 mm for the anatomical insert (n.s.), compared with 3.0 mm for the native knee ( p  = 0.02). The anterior translation at 90° flexion was significantly higher for the reconstructed knees (anatomical insert 7.0 mm; symmetrical insert 9.2 mm), compared with 1.6 mm for the native knee (both p  = 0.02). Varus-valgus laxity at different flexion angles was independent of insert geometry. A valgus force in weightbearing conditions led to significantly more medial laxity (1°–3° opening) in the native knee at 45° and 90° flexion compared with the reconstructed knee for all flexion angles. Conclusions Insert geometry seems to have a limited effect with respect to AP translation and VV laxity, in the well-balanced PCL-retaining TKA with an anatomical femoral component. Secondly, AP translation and VV laxity in the reconstructed knee approximated the laxity of the native knee.

Background and Objectives Total knee arthroplasty (TKA) is a standard treatment for end‐stage knee osteoarthritis (KOA). While conventional TKA (cTKA) is widely used, robotic‐assisted TKA (rTKA) has gained attention for its potential precision and improved outcomes. However, the comparative efficacy and safety of rTKA versus cTKA remain unclear due to inconsistent findings in existing studies. This study aims to systematically review and compare the efficacy and safety of rTKA and cTKA in patients with KOA. Methods A total of seven databases were searched. Only randomized controlled trials (RCTs) were included in this systematic review. Subgroup analysis, sensitivity analysis, and trial sequential analysis (TSA) were used to evaluate the stability of the results. Results Twenty‐five RCTs involving 3156 patients with KOA were included. The only statistically significant clinical difference between patients who received rTKA and cTKA was that the rTKA group was associated with a longer operative duration (MD = 22.38 mins; 95% confidence interval [CI] [12.86, 31.91]; p < 0.00001; I 2 = 98%). As for functional parameters, the two groups had similar results in postoperative Knee Society Score (KSS), the Western Ontario and McMaster Universities (WOMAC), and Hospital for Special Surgery Score (HSS). Regarding the tibiofemoral angle and the coronal femoral component angle, no significant difference was observed between the two groups. Patients in the rTKA group had a higher hip–knee–ankle angle (HKA) (MD = 0.63; 95% CI [0.23, 1.03]; p = 0.002; I 2 = 52%), lower HKA deviation (MD = −0.99; 95% CI [−1.24, −0.74]; p < 0.00001; I 2 = 0%), and a higher coronal tibial component angle (MD = 0.46; 95% CI [0.07, 0.85]; p = 0.02; I 2 = 81%) after the surgery. Conclusions While rTKA appears to be a feasible and safe alternative to cTKA, the mixed evidence from our study highlights the need for further research to fully understand its clinical implications and long‐term outcomes. Trial Registration: PROEPERO: CRD42024541052 Compared to the conventional total knee arthroplasty (cTKA) group, patients in the robotic‐assisted TKA (rTKA) group had similar clinical outcomes except for longer operative duration. There was no significant difference in functional outcomes between two groups. rTKA could achieve more accurate anatomical positions and may pose potential benefits.

Purpose In this prospective study, we determined whether corrective surgery for isolated rotational malalignment of femoral prosthesis components would benefit patients previously treated with total knee arthroplasty. The symptoms, amount of malrotation and type of constraint necessary for the revision prosthesis were investigated. Methods Seventy-two patients were screened with computed tomography; of these, 14 had isolated internal malrotation of the femoral component with no other malpositions and were included in the study. A complete exchange arthroplasty with the correction of the malrotated femoral component was performed within 3 years of primary arthroplasty. Mean follow-up was 57 months. Results At the time of revision, patients suffered either from instability in flexion with good range of motion (ROM) (flexion ≥90°) and pain on the lateral side of the distal femur and proximal tibia ( n  = 8) or from stiffness with pain on the medial side of the proximal tibial and poor ROM (flexion <90°) ( n  = 6). One patient showed no patellar maltracking, six patients, patellar tilt and six patients, patellar subluxation. Median internal rotation of the femoral component was 7.1° (4.1–10.0°). A condylar-type revision implant with a posterior-stabilized insert was used in all patients. The corrective surgery resulted in an increase in the mean Knee Society Score from 52/65 to 85/84 points and an improvement in the mean Hospital for Special Surgery knee score from 63 to 83 points. Conclusions Correction of isolated internal malrotation of the femoral component ≥4° improves patient outcome.

Purpose Total knee arthroplasty with functional alignment uses pre-resection balancing to determine component position within the soft tissue envelope to achieve balance and restoration of native joint obliquity. The purpose of this study was to assess the balance achievable with a mechanical axis alignment and kinematic axis alignment plan, and the subsequent balance achievable after adjustment of the component position to functional alignment. Methods A prospective cohort of 300 knees undergoing cruciate retaining total knee arthroplasty were included in this study. Of these, 130 were initially planned with mechanical alignment (MA) and 170 with kinematic alignment (KA). Maximal stressed virtual gaps were collected using an optical tracking software system. The gaps were measured medially and laterally in flexion and extension. Following assessment of balance, implant position was adjusted to balance the soft tissues in functional alignment (FA) and the maximal gaps reassessed. Gaps were considered to be balanced when within 2 mm of equality. Incidence of balance within each cohort was compared to independent samples proportions test. Results Functional alignment obtained significantly better balance in extension, medially and overall than both MA and KA alignment without soft tissue release ( p  < 0.001). Overall balance was observed in 97% of FA knees, 73% of KA knees and in 55% of MA knees. The difference between KA and MA was also significant ( p  = 0.002). Whilst there was no difference observed in balanced achieved or limb alignment when FA was planned with either MA or KA, the joint line obliquity was maintained with an initial KA plan. Conclusion Functional alignment more consistently achieves a balanced total knee arthroplasty than either mechanical alignment or kinematic alignment prior to undertaking soft tissue release. Utilising an individualised KA plan allows FA to best achieve the stated goals of maintaining joint line plane and obliquity. Level of evidence Level III: retrospective cohort study.

Background Implant malalignment in total knee arthroplasty (TKA) correlates with poor outcomes, and robotic-assisted systems aim to improve precision. While closed-platform robotic systems dominate the market, their restriction to proprietary implants limits surgical flexibility. This study evaluates the radiological accuracy of an open-platform robotic system (Yuanhua KUNWU) across four TKA implant designs. Methods A multi-centre retrospective analysis of 129 robotic-assisted TKAs (Zhengtian Irene, n  = 60; DePuy Synthes Attune, n  = 32; Zimmer Biomet Persona, n  = 20; Smith & Nephew Legion, n  = 17) was conducted. Patients with end-stage osteoarthritis (Kellgren-Lawrence grade 3–4) were included, while those with prior knee surgery or complex anatomy were excluded ( n  = 15). A total of 114 pre-operative and post-operative alignment (hip-knee-ankle angle [HKA], femoral and tibial component coronal angles [FCCA, TCCA], posterior tibial slope [PTS]) were measured on radiographs by two independent reviewers. Interobserver reliability (intra-class correlation [ICC], Cronbach’s α) and deviations from planned alignment (paired t -tests) were analysed. Acceptability was defined as ≤ 3° deviation. Results Interobserver reliability was excellent (ICC > 0.77, Cronbach’s α > 0.87 for all parameters). Mean post-operative deviations from planned alignment were clinically small: HKA (+1.32°, P  < 0.001), FCCA (−0.55°, P  < 0.001), TCCA (+0.19°, P  = 0.097), and PTS (−0.42°, P  = 0.018). All mean differences were within the 3° acceptability threshold. Subgroup analysis of pre- and post-operative alignment between implant types also showed deviations of < 3°. Conclusions The KUNWU open-platform robotic system achieved high radiological accuracy across four implant designs, with alignment deviations < 1.5°. This suggests open-platform robotics can provide implant versatility without compromising precision. Further studies regarding the assessment of long-term clinical and patient-reported outcomes and comparison with closed-platform systems are warranted.

Purpose The primary aim of this study was to compare postoperative short-term patient reported outcome measurements (PROMs) and rotational mismatch between femoral and tibial following conventional jig-based total knee arthroplasty (Conv-TKA) versus robotic-assisted TKA (RA-TKA) using three-dimensional computed tomography (3DCT) measurements. Methods This retrospective, consecutive case–control trial included 83 patients with varus osteoarthritis of the knee undergoing Conv-TKA versus RA-TKA using bi-cruciate stabilized TKA. The rotational mismatch of the femoral and tibial components between the two groups were compared using 3DCT measurements. PROMs (2011 Knee Society Score (KSS), forgotten joint score-12 (FJS-12), patella score were compared in patients between 1 and 2 years postoperatively. Results The two groups did not exhibit significant differences in any of the following preoperative factors: age at surgery, body mass index (BMI), preoperative range of motion (ROM), hip-knee-ankle (HKA) angle. There were no significant differences in postoperative HKA angle and tibial rotation angle, the absolute values of the femoral rotational angle and rotational mismatch were significantly smaller in the RA-TKA group than in the Conv-TKA group (both p  < 0.01). Neither Postoperative PROMs (2011 KSS: pain, patient satisfaction, patient expectation, advanced activities score) nor patella score differed significantly between the groups, but FJS-12 was significantly better in the Conv-TKA group than in the RA-TKA group ( p  < 0.01). Conclusions RA-TKA did not improve FJS-12 compared to Conv-TKA, but did result in more accurate rotational alignment of femoral component and rotational mismatch between the femoral and tibial components. Level of evidence IV.

BackgroundDespite continued advances in techniques and implant designs, a population of patients who are dissatisfied after total knee arthroplasty (TKA) remains. During robotic-assisted arthroplasty, real-time intraoperative assessment of patient knee alignment is performed. Here, we assess the prevalence of an under-appreciated deformity, reverse coronal deformity (RCD), and the benefits of utilizing robotic-assisted knee arthroplasty to help correct this dynamic deformity.MethodsA retrospective study evaluating patients undergoing robotic-assisted cruciate-retaining TKA was performed. Intraoperative measurements were obtained using tibial and femoral arrays to assess coronal plane deformity at full extension and at 90° flexion. RCD was defined as ≥ 2° varus in knee extension that reversed to ≥ 2° valgus in flexion, or vice-versa. Coronal plane deformity was then reassessed after robotic-assisted bony resection and implant placement.ResultsOf 204 patients that underwent TKA, 16 patients (7.8%) were found to have RCD, with 14 patients (87.5%) transitioning from varus in extension to valgus in flexion. The average coronal deformity was 7.75°, with a maximum of 12°. These improved to an average coronal change of 0.93° post-TKA. Final medial and lateral gaps were all balanced to within 1° in extension and flexion. Another 34 patients (16.7%) had ≥ 5° change in coronal plane deformity from extension to flexion (average 6.39°), however, did not experience a reversal of their coronal deformity. Outcomes were assessed with KOOS Jr. scores postoperatively.ConclusionComputer and robotic assistance were utilized to demonstrate the prevalence of RCD. We also demonstrated accurate identification and successfully balancing of RCD utilizing robotic-assisted TKA. An increased awareness of these dynamic deformities could aid surgeons in proper gap balancing even in the absence of navigation and robotic-assisted surgery.