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In recent years, day-case hip and knee arthroplasty has emerged as a potential solution to the elective backlog within the NHS. While international literature on this topic is extensive, only a handful of single-centre studies have been conducted in the United Kingdom. This study aimed to examine the safety and efficacy of day-case hip and knee arthroplasty in the UK using a 20-year linked national NHS dataset. A cohort study was conducted using the Clinical Practice Research Datalink (CPRD), linked to Hospital Episode Statistics (HES) and the Office for National Statistics death registry. Adults undergoing primary hip or knee arthroplasty between 1998 and 2021 were included. Procedures were classified as day-case or inpatient, using two distinct approaches: patient classification and length of stay. Day-case is defined as discharge on the same day of the procedure, while inpatient procedures involve undergo at least one overnight stay in hospital. The primary outcomes assessed were A&E attendance, readmission, and critical care admission within 90-days post-operatively. Secondary outcomes included 90-day complication rates and survival analysis. Propensity score matching was implemented to adjust outcomes for age, gender, comorbidity burden, deprivation index, and ethnicity. In total, 1,822 (0.16%) procedures were classified as day-case, while 4,355 (0.37%) had a recorded length of stay of 0&#xa0;days. On average, patients undergoing day-case arthroplasty were younger, more often male, and had fewer comorbidities than their inpatient counterparts. Higher rates of A&E attendance (12% vs 9.1%; P&#x2009;=&#x2009;0.001) and readmission (5.7% vs 3.7%; P&#x2009;<&#x2009;0.001) were observed in the day-case cohort. In contrast, deep vein thrombosis (0.5% vs 0.9%; P&#x2009;=&#x2009;0.010) and infection rates (1.0% vs 1.9%; P&#x2009;=&#x2009;0.014) were lower in this patient group. Survival analyses demonstrated significantly higher adjusted survival probabilities associated with day-case arthroplasty (HR: 0.84; [95% CI: 0.72-0.99]; P&#x2009;=&#x2009;0.034) over a 20-year follow-up period. Day-case hip and knee arthroplasty has been demonstrated to be &#xa0;safe and&#xa0;feasible, with comparable complication rates to the traditional inpatient setting. However, within the context of the NHS, it is currently associated with higher rates of 90-day A&E attendance and readmission. While increasing day-case volumes may help address elective backlogs, it is important to ensure that the appropriate patient selection criteria, optimised peri-operative care, and post-discharge support are in place before this approach is expanded in the UK.

Knee arthroplasty is an established treatment for degenerative and inflammatory knee disorders. Effective perioperative analgesia is essential for early mobilisation and same-day discharge. This study evaluated the relationship between different regional anaesthesia techniques, postoperative pain, and same-day discharge rates in knee arthroplasty patients. We evaluated 100 consecutive patients as part of a service evaluation of our established knee arthroplasty pathway. Four regional anaesthesia strategies were used: adductor canal block (ACB) only, ACB&#x2009;+&#x2009;genicular, ACB&#x2009;+&#x2009;IPACK (infiltration of popliteal artery and capsule of the knee), and no block. Pain was assessed using a verbal rating scale (0&#x2013;3) at 2, 6, 12, and 24&#xa0;h postoperatively. Patient demographics, anaesthetic technique, surgical type and discharge status were recorded. Group comparisons were statistically analysed and predictors of same-day discharge were assessed adjusting for age, gender, BMI, and mean 24-h pain score and surgical type. Mean 24-h pain score for the cohort was 1.05&#x2009;&#xb1;&#x2009;0.81, with women reporting higher scores than men (p-value 0.023). Higher pain scores were independently associated with reduced odds of same-day discharge (OR 0.32, p-value 0.002). Across the four block modalities, mean pain scores did not differ significantly (p-value 0.968). Using no block as the reference, ACB&#x2009;+&#x2009;genicular was associated with higher odds of same-day discharge (OR 5.29, p-value 0.035). Younger age (p-value 0.022) and higher BMI (p-value 0.044) were also significant predictors; gender and ASA grade were not. While overall pain scores were similar between block types, higher pain was independently associated with lower likelihood of same-day discharge. In this observational cohort, ACB&#x2009;+&#x2009;genicular was independently associated with same-day discharge following adjustment for confounders. Further work is needed to determine whether these associations are reproducible across centres and patient populations. Evaluates the effect of four regional anaesthesia strategies (ACB only, ACB + genicular, ACB + IPACK, no block) on pain and same-day discharge after knee arthroplasty. Finds no significant difference in 24-hour mean pain scores between ACB only, ACB + genicular, ACB + IPACK, and no block. Identifies higher pain scores as independently associated with reduced likelihood of same-day discharge. ACB + genicular was independently associated with higher odds of same-day discharge compared with no block. Reports younger age and higher BMI as significant predictors of same-day discharge, while gender and ASA grade were not.

Multimodal analgesia based on ultrasound-guided regional block is widely used after total knee arthroplasty (TKA). The goal of this study was to investigate the analgesic efficiency and knee motor function of programmed intermittent infusion combined with adductor hiatus block in total knee arthroplasty. This prospective randomized controlled trial was approved by the Medical Ethics Committee of the First Affiliated Hospital of Chongqing Medical University (ethical approval number: 2024-302-01) and was registered in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn , ChiCTR2400090031); the study was conducted from October 2024 to March 2025. A total of 148 patients undergoing unilateral total knee arthroplasty with general anesthesia were assigned to the continuous adductor canal block (CACB) group (G1, n&#x2009;=&#x2009;50), the continuous adductor hiatus block (CAHB) group (G2, n&#x2009;=&#x2009;50), or the programmed intermittent adductor hiatus block (PIAHB) group (G3, n&#x2009;=&#x2009;48). The main outcome was the active flexion angle of the knee joint. The secondary outcomes were performance on the timed up-and-go (TUG) test; the muscle strength of the quadriceps femoris, ankle dorsiflexors, and metatarsal flexor; and Visual Analogue Scale (VAS) scores of anterior and posterior sides of the knee at rest and during active 30-degree flexion. The PIAHB group had a significantly greater active knee flexion angle than the CAHB and CACB groups on the 1st, 2nd, and 3rd post-operative days (F&#x2009;=&#x2009;14.313, p&#x2009;<&#x2009;0.001; F&#x2009;=&#x2009;16.793, p&#x2009;<&#x2009;0.001; and F&#x2009;=&#x2009;18.097, p&#x2009;<&#x2009;0.001, respectively); the TUG times in the PIAHB group were shorter than those in the CAHB and CACB groups on the 1st and 2nd post-operative days (F&#x2009;=&#x2009;26.059, p&#x2009;<&#x2009;0.001) (F&#x2009;=&#x2009;18.102, p&#x2009;<&#x2009;0.001), but there was no difference in TUG test results on the 3rd post-operative day. There was no significant difference in the muscle strength of lower limb; VAS scores of the posterior side of the knee at rest and during active flexion were significantly lower in the PIAHB group than in the CAHB and CACB groups (F&#x2009;=&#x2009;5.860, p&#x2009;=&#x2009;0.004; F&#x2009;=&#x2009;80.015, p&#x2009;<&#x2009;0.001), but there was no difference in the VAS scores of the anterior side of the knee. The number of patients receiving remedial analgesia within 72&#xa0;h was reduced in the PIAHB group (F&#x2009;=&#x2009;7.405, p&#x2009;=&#x2009;0.030), and the consumption of ropivacaine was significantly reduced in that group (F&#x2009;=&#x2009;24.995, p&#x2009;<&#x2009;0.001), but there was no difference in the incidence of postoperative complications or in HSS (post-operativeHospital for Special Surgery) scores 6&#xa0;months post-operatively. PIAHB increased the analgesic effect on the popliteal fossa without decreasing the strength of the quadriceps femoris, resulting in improved ROM on the 1st and 2nd post-operative days in patients who underwent TKA.

Enhanced Recovery After Surgery (ERAS) was introduced in hip and knee arthroplasty to expedite recovery, shorten inpatient stay, and reduce costs. This study aims to investigate the safety and efficacy of implementing a universal standardized non-selective ERAS service for all patients admitted for primary hip and knee arthroplasty in a single high-volume tertiary orthopaedic centre. All patients who underwent primary hip or knee arthroplasty under ERAS from April 2023 to March 2024 were compared with a matched cohort between January 2018 and December 2019. Patients were matched at a 2:1 ratio based on procedure, age, sex, ASA grade, and BMI (ERAS&#x2009;=&#x2009;1811, Standard Care&#x2009;=&#x2009;3549 patients). Outcomes included Length of Stay (LOS), 30-day readmission, overall infection, superficial infection, deep infection, 30- and 90-day mortality rates. The median LOS was 1&#xa0;day (IQR 1-2) in the ERAS group versus 3&#xa0;days (IQR 2-4) in the Standard Care group (W&#x2009;=&#x2009;5,415,769, P&#x2009;<&#x2009;0.001). Rates of 30-day readmission (1.7% vs. 2.1%), overall infection (0.66% vs. 1.15%), deep infection (0.39% vs. 0.68%), superficial infection (0.28% vs. 0.48%), 30-day mortality (0.11% vs. 0.20%), and 90-day mortality (0.22% vs. 0.37%) were all higher in the Standard Care group. However, these differences were not statistically significant, with P-values of 0.41, 0.11, 0.26, 0.38, 0.70, and 0.52, respectively. The estimated cost reduction per patient with the ERAS pathway, considering only the difference in LOS, is &#xa3;718.60(95%CI &#xa3;602.56 to &#xa3;832.64). The subgroup analysis for patients&#x2009;&#x2265;&#x2009;80 revealed a statistically significant difference in LOS, which was more pronounced with a median difference of 3&#xa0;days (5&#xa0;days in standard care versus 2&#xa0;days in ERAS, P&#x2009;<&#x2009;0.001). Non-selective ERAS was safe and effective in reducing LOS for patients undergoing primary THA and TKA across all age groups and varying comorbidity statuses. Although perioperative morbidity and mortality were less in ERAS, these changes did not reach statistical significance.

This study evaluates the effect of an orthopaedic department's full transition from the use of a cemented polished tapered stem (PTS) to a cemented composite beam femoral component (CB) on periprosthetic fracture rates up to ten years after primary surgery. A ten-year, prospective observational study was conducted on patients undergoing cemented hip arthroplasty. There were 542 patients in the PTS group and 534 in the CB femoral component group. There were 333 and 285 hemiarthroplasties in the PTS and CB groups, respectively. The mean age of participants was 82 years (SD 8.1). The majority of patients were classified as American Society of Anesthesiologists (ASA) grade III to IV and were female, comprising 71.2% in the PTS group and 74.5% in the CB group. Most patients, 827, underwent hip arthroplasty due to fractures (76.9%). Cognitive dysfunction was present in 27% (n = 142) to 29% (n = 159) of patients. Cox regression analysis was performed to adjust for confounders such as age, sex, ASA grade, and cognitive dysfunction. The PTS group had a higher rate of periprosthetic fractures (6.5%) compared with the CB group (1.3%) over the study period from November 2011 to December 2015. The reoperation rate for the PTS groups was 9.7% and 5.2% for the CB group, respectively. The dislocation rates were 4.9% for the PTS and 1.3% for the CB group. The periprosthetic joint infection rate was 3.5% in the PTS and 2.0% in the CB group. In the regression model female sex (HR 2.0, 95% CI 1.2 to 3.1), ASA grade (HR 3.2, 95% CI 1.1 to 8.3), cognitive dysfunction (HR 1.9, 95% CI 1.2 to 3.2), and the type of femoral component (PTS vs CB, HR 0.2, CI 0.1 to 0.3) were correlated with outcome. CB femoral components were associated with a reduction in adverse events compared with PTS in cemented hip arthroplasty in an older population. These findings support the use of CB femoral components in order to improve patient outcomes and minimize complications in selected cases.

Geriatric femoral neck fracture (FNF) represents a pressing global health challenge, imposing substantial burdens on medical resources while being associated with high complication rates and suboptimal clinical outcomes. In recent years, the direct anterior approach (DAA) has emerged as a mainstream surgical strategy for hip joint arthroplasty (HJA) in developed countries, owing to its minimally invasive nature, neuromuscular-sparing anatomical interval, preservation of soft tissue integrity, and alignment with enhanced recovery after surgery principles, collectively contributing to significant improvements in clinical outcomes of HJA for elderly patients with FNF. However, no unified consensus exists regarding standardized techniques and procedural protocols for DAA-HJA in this specific patient population. Consequently, there is an urgent need to develop an evidence-based expert consensus to address key clinical dilemmas inherent to DAA-HJA in geriatric FNF. Sponsored by the Joint Surgery Group of the Chinese Medical Association, this expert consensus builds upon the foundational Chinese Expert Consensus on Direct Anterior Approach Hip Arthroplasty for the Surgical Treatment of Geriatric Femoral Neck Fracture (2023 Edition). A multidisciplinary expert panel was convened to standardize core issues and procedural norms for DAA-HJA in geriatric FNF. Two rounds of modified Delphi questionnaires and one consensus conference were conducted for voting, with a predefined consensus threshold of&#x2009;&#x2265;&#x2009;70%. A total of 12 clinical recommendations were formulated, covering critical concerns including surgical indications, approach selection, operative timing, anesthesia management, patient positioning, prosthesis choice, fixation methods, drainage strategies, postoperative mobilization, and the application of navigation/robotic technologies. These recommendations are stratified by strength: Recommendations 4, 8, and 12 are classified as strong; Recommendations 1, 3, 5, and 9 are moderate; and Recommendations 2, 6, 7, 10, and 11 are limited. By providing systematic, evidence-based, and operationally feasible guidance for the clinical application of DAA in geriatric FNF, this consensus aims to promote standardized, systematic, and individualized diagnosis and treatment paradigms-ultimately optimizing patients' functional prognosis. Video Abstract.

This study compares health-related quality of life (HRQoL) between patients undergoing primary total hip arthroplasty (THA) for osteoarthritis (OA) and a propensity-matched general population cohort. We also aimed to clarify the relationship between BMI and postoperative improvements, mediated via preoperative HRQoL. In this retrospective study using the Edinburgh Arthroplasty database (1 January 2013 to 31 December 2022; n = 3,495) and Health Survey for England data (2010 to 2012; n = 25,320), propensity score matching (1:1) was performed based on age, sex, and BMI. The primary outcome was EuroQol five-dimension three-level questionnaire (EQ-5D-3L) index score. Secondary outcomes included EuroQol-visual analogue scale (EQ-VAS) and mediation analysis examining how preoperative EQ-5D-3L mediated the relationship between BMI and postoperative improvement. Preoperatively, THA patients had significantly lower EQ-5D-3L scores compared with matched general population (median difference: 0.280, bootstrapped 95% CIs; 0.258 to 0.306; p < 0.001). At one-year follow-up, THA patients exceeded population norms (THA median: 0.814 vs general population: 0.796, p = 0.014). Patients aged > 85 years showed the greatest magnitude of improvements, restoring EQ-5D-3L scores equivalent with their age-matched general population peers (preoperative: 0.189 vs postoperative: 0.796, general population: 0.696). Mediation analysis revealed that BMI's negative direct effect on improvements in EQ-5D-3L was counterbalanced by stronger indirect effects transmitted through preoperative scores (indirect effects: obesity I (30 to 34.9 kg/m2): &#x3b2; = 0.038, p < 0.001; obesity II (35 to 39.9 kg/m2): &#x3b2; = 0.086, p < 0.001; obesity III (&#x2265; 40 kg/m2): &#x3b2; = 0.123, p < 0.001). THA was shown to restore HRQoL to that expected of a matched normal population, but in younger patients this was less than expected. Patients aged > 85 years had the greatest magnitude of restoration. Postoperative HRQoL improvement was predominantly influenced by preoperative functional status, rather than BMI alone. These findings challenge current BMI-based eligibility thresholds and support surgical prioritization based on functional impairment severity.

The learning curve refers to the relationship between a learner's execution of a task and the number of attempts or time necessary to perform it in a predictable, reliable, and optimal fashion. The learner's competence in a task should improve over time as they execute the job more frequently. The present investigation aims to clarify the learning curve associated with robotic-assisted total knee arthroplasty (TKA). Consecutive patients undergoing total knee arthroplasty at the Department of Orthopaedic Surgery, Eifelklinik St. Brigida, Simmerath, Germany, between 2021 and 2025 were prospectively screened for participation in this clinical study. All procedures were performed through a medial parapatellar approach, following a functional alignment strategy. Implantation was performed in accordance with the manufacturer's recommendations using the Smith & Nephew Legion Genesis II system with a posterior-stabilised polyethylene insert. Both femoral and tibial components were cemented with Palacos cement (Heraeus Medical GmbH, Wehrheim, Germany). Postoperative physiotherapy followed the standard institutional protocol. At hospital admission, demographic variables including age, body mass index (BMI), and sex were recorded. Operative time was documented for each procedure and defined as the interval from skin incision to completion of wound closure. The first 200 robotic-assisted TKAs were monitored. 66% (112 of 200 patients) were women, and 47.5% (95 of 200 TKAs) were performed on the right side. The mean age of the patients was 68.6 &#xb1; 8.1 years, and their BMI was 28.6 kg/m&#xb2;. The exponential decay model revealed a characteristic learning curve, characterised by initial rapid gains followed by a plateau. The estimated asymptotic operative time was approximately 89.2 minutes, with a learning rate coefficient of 0.035. This implies that the majority of efficiency improvements occur early, but meaningful reductions persist beyond the 20th case. Block-wise comparisons supported the existence of an earlier functional learning threshold. Statistically significant reductions in operative time, compared with the first 10 cases, were observed from the 41st to 50th procedure block (p = 0.02), with stabilisation in the 90-minute range thereafter. The most efficient gains occur early, and operative times stabilise at around 90 minutes after approximately 40 procedures. German Registry of Clinical Trials (ID DRKS00030614).

Patient-specific knee alignment is regarded as a major target for improving total knee arthroplasty (TKA) outcomes. The Coronal Plane Alignment of the Knee (CPAK) classification has been proposed to capture the native patient-specific knee alignment, according to the Joint Line Obliquity (JLO) and arithmetic Hip Knee Ankle angle (aHKA), themselves based on the Lateral Distal Femoral Angle (LDFA) and Medial Proximal Tibial Angle (MPTA). This study aims to evaluate intra-operator, inter-operator, and test-retest reliability of the CPAK classification and associated angles in both knees with osteoarthritis (KOA) and TKA. From our local arthroplasty registry, patients who sequentially underwent TKA on both knees within 18&#xa0;months, with long-leg X-rays before and after each surgery between 2018 and 2023, were retrospectively selected. The contralateral knees before the 1st and 2nd TKA were used as test-retest for KOA and TKA knee, respectively. Four operators with increasing experience performed two measures of MPTA and LDFA for each image. The intra-operator, inter-operator, and test-retest reliability were assessed with Intraclass Correlation Coefficient (ICC(3,1)), Smallest Detectable Change (SDC), and Cohen's Kappa. The study included 34 patients. Angles showed good to excellent ICC apart from JLO in the KOA condition (moderate). Measures of LDFA on KOA and all TKA angles presented good to excellent SDC (<&#x2009;3&#xb0;), including test-retest conditions. MPTA, JLO, and aHKA on KOA showed moderate SDC (<&#x2009;4.2&#xb0;). CPAK classification was moderate to substantial for KOA (Kappa of 0.5 to 0.64) and substantial to almost perfect for TKA (Kappa of 0.69 to 0.81). Reliability increased with experience. For experienced operators, CPAK classification and associated angles demonstrated levels of inter-rater reliability acceptable for clinical use in knees with TKA but at the limit of acceptability for knees with severe OA. In severe OA, one should interpret CPAK types cautiously, and angles may be preferable. MPTA in the knees with OA appeared as the main factor undermining reliability. Clarification on this angle may be needed to improve reliability, especially when using philosophies aiming at restoring the native alignment. Finally, test-retest reliability levels suggested that these measures are appropriate for longitudinal assessment.

This study compared the learning curves and clinical outcomes of osteotomy guide robot and guide plate-based robot-assisted total knee arthroplasty (TKA). From January to May 2023, 100 patients were prospectively enrolled to receive either a guide plate-based robot or an osteotomy guide robot-assisted total knee arthroplasty. The thickness of the osteotomy planned by the robot and the actual thickness were recorded in real time during the operation, as was the time taken for each step in the operation, including bone registration and osteotomy. The SF-12, HSS score, and FJS of the patients before surgery and 6&#xa0;weeks and 24&#xa0;months after surgery were also collected. For surgeon 1, the average operating time with the guide plate-based robot and osteotomy guide robot was 98.16&#x2009;&#xb1;&#x2009;9.68 and 118.52&#x2009;&#xb1;&#x2009;15.95&#xa0;min, respectively; the difference was significant. The average time of the last 10 cases was shorter than that of the first 10 cases. The inflection points of the osteotomy learning curve of surgeon 1 with two robotic systems were at case 5 and case 9. The average operative times for Surgeon 2's two robotic surgery groups were 104.52&#x2009;&#xb1;&#x2009;12.65&#xa0;min and 105.76&#x2009;&#xb1;&#x2009;33.03&#xa0;min, respectively. The inflection points of the osteotomy learning curves using the two robotic systems occurred at case 13, respectively. Patients who underwent guide plate-based robot or osteotomy guide robot-assisted TKA had similarly improved knee recovery, reflected in the SF-12, HSS score, and FJS. There was no significant difference in the osteotomy learning curve between the two robotic systems. The improvement in knee functional recovery was similar after the guide plate-based robot and the osteotomy guide robot-assisted TKA. Level II.

Conventional robotic-assisted total knee arthroplasty (RA-TKA) relies on rigid limb fixation to suppress intra-operative motion, adding complexity and potential inefficiency. A novel motion-following control system dynamically compensates for limb movement, allowing real-time adjustment of the tool-bone relationship without immobilization. This study evaluated whether motion-following improves efficiency and osteotomy accuracy while preserving alignment and early function. Sixty consecutive primary RA-TKA cases performed with the SkyWalker robotic platform (MicroPort, Shanghai, China) between September 2022 and August 2024 were retrospectively reviewed. Thirty procedures used conventional rigid fixation (control group) and thirty employed motion-following tracking (motion-Following group). Primary endpoints were operative time and resection thickness error, measured intraoperatively with a caliper. Secondary outcomes included coronal alignment assessed by HKA (hip-knee-ankle angle), CFCA (coronal femoral component angle), and CTCA (coronal tibial component angle), as well as functional recovery assessed by WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) at 6&#xa0;months. Values are expressed as mean&#x2009;&#xb1;&#x2009;standard deviation unless otherwise specified. Mean operative time was shorter with motion-following (118.8&#x2009;&#xb1;&#x2009;9.3&#xa0;min) than with conventional fixation (133.9&#x2009;&#xb1;&#x2009;11.9&#xa0;min; p&#x2009;<&#x2009;0.001). Mean resection-thickness error was lower with motion-following (0.53&#xa0;mm vs 0.82&#xa0;mm), with 93.9% versus 68.3% of cuts within&#x2009;&#x2264;&#x2009;1&#xa0;mm. At the plane level, motion-following achieved smaller errors on all six surfaces, with four planes: DF-M (distal femur medial), distal femur lateral (DF-L), posterior femur medial (PF-M), and tibial plateau lateral (TP-L) reaching statistical significance (p&#x2009;<&#x2009;0.05). Post-operative coronal alignment closely reproduced the pre-operative plan in both groups, with mean deviations of approximately 1&#xb0; across all parameters and no statistically significant between-group differences. WOMAC scores improved substantially in both groups, with no significant between-group difference (&#x394;WOMAC 32.8&#x2009;&#xb1;&#x2009;8.5 vs 30.1&#x2009;&#xb1;&#x2009;7.9; p&#x2009;=&#x2009;0.21). Motion-following robotic control streamlines TKA by eliminating rigid fixation, improving workflow efficiency, and slightly enhancing osteotomy precision without compromising alignment or recovery. This dynamic, real-time tracking approach refines execution of the surgical plan and may represent a meaningful evolution toward more efficient, surgeon-friendly robotic arthroplasty.

Medial pivot total knee arthroplasty (TKA) was designed to replicate physiological tibiofemoral kinematics, yet the role of posterior cruciate ligament (PCL) management in this setting remains controversial. This systematic review and meta-analysis aimed to compare the clinical and functional outcomes, as well as revision rates, between PCL retention and resection in medial pivot TKA. A comprehensive search of PubMed, Web of Science, Embase, and Google Scholar was conducted in August 2025, following the PRISMA guidelines. Comparative and non-comparative clinical studies reporting outcomes of medial pivot TKA with either PCL retention or resection were included. Outcomes of interest were Knee Society Score (KSS) and its functional subscale (KSS-F), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS), range of motion (ROM), and revision rates. Twenty-seven studies involving 3380 patients were included, of whom 1209 underwent medial pivot total knee arthroplasty (TKA) with posterior cruciate ligament (PCL) retention and 2171 with PCL resection. Baseline characteristics were comparable, except for follow-up duration and sex distribution. At the final follow-up, both groups achieved similar outcomes for the Knee Society Score (KSS), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS), and range of motion (ROM). The PCL-retained cohort exhibited slightly higher functional and clinical scores, yet the magnitude of difference remained below the threshold of minimal clinical significance. Revision rates were low and comparable between the two groups. PCL retention and resection in medial pivot TKA yield statistically different but clinically equivalent results. The small numerical advantages observed for the retained group in certain functional outcomes do not appear to represent a meaningful clinical improvement. Both strategies can therefore be considered viable, and adequate alignment, balancing, and soft-tissue management remains pivotal. Further high-quality comparative studies involving well-matched populations are warranted to clarify whether subtle functional trends associated with PCL retention have consistent long-term clinical significance. Level III.

The indications for reverse shoulder arthroplasty (RSA) have expanded beyond the primary design philosophy of an implant used to deal with rotator cuff deficiency. Its application in the cuff intact shoulder is growing in clinical practice. Despite this, there is little understanding of how surgeons decide between implants, specifically RSA and total shoulder arthroplasty (TSA) in this clinical scenario. Trauma & Orthopaedic Consultants specializing in shoulder surgery were recruited to participate in semistructured interviews by the research team. Using grounded theory methodology, the transcribed interviews were analyzed to generate themes and theories on factors affecting the decision-making between RSA and TSA. Collection and analysis was concluded when data saturation had been reached. Patients characteristics, specifically 'physiological age', a term incorporating age, comorbid status, and preoperative function played a key role in decision-making. Anatomical factors specifically glenoid morphology and retroversion angle significantly contributed to implant choice; however, specific cut-offs for determining implants were not universal. Other themes identified included revision profiles of the implants, functional outcomes, and surgical training and experience. The decision-making between RSA and TSA for osteoarthritis and cuff intact patients is complex and multifactorial. The main factors surgeons consider are physiological age, patient anatomy, and functional outcomes. Within these factors however, there is no uniform agreement on which implant is best for which patients.

The volume of shoulder arthroplasties in the United Kingdom continues to rise, with 8221 cases recorded in the National Joint Registry (NJR) in 2023. Amid increasing demand and pressure on NHS resources, reducing hospital length of stay (LOS) is a key priority for improving efficiency. This study aimed to identify independent predictors of prolonged LOS following shoulder arthroplasty. NJR data from April 2012 to March 2022 were linked with Hospital Episode Statistics (HES) for England. Prolonged LOS was defined as >2 nights (above the cohort median). Variables analysed included age, sex, Charlson comorbidity index (CCI), comorbidities, surgical indication, implant type, operating surgeon volume, and day of surgery. Univariable and multivariable logistic regression models were used to identify predictors. Among 47,145 patients, older age, higher CCI, and ASA grades 3 and 4 were significantly associated with extended LOS. Male patients had a 45% reduced risk of prolonged stay. Trauma-related procedures and surgeries conducted Friday-Sunday were associated with increased LOS. Patients treated by high-volume surgeons had a 19% lower risk of prolonged LOS. Several comorbidities were independently predictive; however, differed across implants. Both patient-level and system-level factors contribute to prolonged LOS. Optimising perioperative care and scheduling may reduce LOS and improve NHS resource utilisation.

Fixation choice (polymethyl-methacrylate bone cement or cementless implants) in total knee arthroplasty (TKA) varies widely across surgeons, reflecting differences in clinical judgment. While traditional statistical approaches are commonly used to study surgical decision-making, they may be limited in capturing complex and multifactorial relationships inherent in such data. This study evaluates how different supervised machine learning (SML) algorithms characterize fixation choice and prioritize predictors, rather than developing a clinical decision-support tool. We analyzed data from the multicenter Patient-Centered Outcomes Research Institute (PCORI)-funded Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement (PEPPER) trial, linked with the American Hospital Association Annual Survey. Adult patients undergoing elective primary TKA for osteoarthritis between December 2016 and May 2024 were included. The primary outcome was the binary classification of cemented versus cementless fixation. Five models were evaluated (logistic regression, LASSO, support vector machine, XGBoost, and Random Forest). Model performance was assessed using discrimination, precision&#x2013;recall performance, calibration, and F1 score within a nested cross-validation framework. All confidence intervals were estimated using surgeon-clustered bootstrap resampling. Permutation importance was used for cross-model feature comparison, and SHapley Additive exPlanations (SHAP) were applied to interpret the best-performing model. Among 7848 patients treated by 140 surgeons at 29 hospitals, 85.8% underwent cemented TKA. RF achieved the highest discriminatory performance (AUROC&#x2009;=&#x2009;0.868; 95%CI:0.826&#x2013;0.891, F1&#x2009;=&#x2009;0.944; 95%CI:0.927&#x2013;0.951) and the lowest Brier score (0.080; 95%CI: 0.072&#x2013;0.091). In the RF model, patient BMI and age emerged as the most influential predictors of fixation choice, with SHAP analyses indicating an inverse association between BMI and cemented fixation and a non-linear relationship between age and the likelihood of cemented TKA. In contrast, non-tree-based models more frequently prioritized hospital-level and geographic characteristics over patient factors. Tree-based SML models, particularly RF, showed the highest performance in this cohort and prioritized patient-level predictors more consistently than non&#x2013;tree-based models. Substantively, fixation choice within this study cohort was more strongly associated with patient-specific factors such as BMI and age. These findings may help inform understanding of how patient characteristics are associated with fixation choice in current clinical practice.

Staphylococcus aureus is the most common pathogen in periprosthetic joint infections (PJIs), capable of biofilm formation and resistance mechanisms, complicating diagnosis and treatment. PJIs remain a leading cause of total joint arthroplasty failure and are associated with significant morbidity, mortality, and healthcare and economic burdens. Biofilm formation by S. aureus on prosthetic materials is central to PJI persistence and antibiotic resistance. Novel treatment strategies, including copper-coated implants, show promise as adjunct therapies but require further clinical validation.

Lateral unicompartmental arthroplasty (UKA-L) is a bone- and cruciate-preserving procedure in the treatment of isolated lateral compartment gonarthrosis, but relatively little is known of its associated gait characteristics and patient-reported outcomes. A total of 20 individuals, at a mean 35 months (SD 37) post UKA-L, were measured on an instrumented treadmill. They were compared to age-, sex-, and BMI-matched healthy controls (n = 22) and individuals with unilateral total knee arthroplasty (TKA, n = 28) mean 44 months (SD 46) post-surgery (p = 0.382). Top walking speed, temporospatial parameters, and vertical ground reaction forces of gait were analyzed. Oxford Knee Scores (OKS) and EuroQol five-dimension questionnaire (EQ-5D) scores were compared. The UKA-L group walked at a mean speed of 7.0 km/hour (SD 0.6), which was 0.2 km/hour (3%) slower than the healthy control group (7.2 km/hour (SD 0.7); p = 0.681) but 26% faster than the TKA group (5.5 km/hour (SD 0.7), p < 0.001). UKA-L displayed nearer normal vertical ground reaction forces throughout the stance phase. TKA demonstrated significantly reduced maximum weight acceptance, increased mid-stance, and reduced push-off forces compared to healthy and UKA-L subjects (all p < 0.05). UKA-L recorded similar step and stride lengths to healthy controls, and were 12% and 10% longer than TKA, respectively (p < 0.05). UKA-L was associated with a mean OKS of 44 (SD 3) compared to 36 (SD 6) for TKA (p < 0.001), and mean EQ-5D of 0.90 (SD 0.09) vs 0.78 (SD 0.14) for TKA (p = 0.003). UKA-L restores healthy gait characteristics at top walking speeds. Compared to TKA, faster walking speeds, nearer-normal vertical ground reaction forces, longer stride lengths, and a more consistent gait pattern demonstrate the importance of functional cruciate ligaments to gait. UKA-L is associated with high patient satisfaction and good quality of life in the treatment of isolated lateral compartment arthrosis.

Timely publication of preregistered study outcomes is not self-evident. Discrepancies can lead to significant research waste. To assess timely (within 7 years) and consistent publication of preregistered primary outcomes and associated factors of total knee arthroplasty (TKA) studies registered between 2000 and 2017 over time. An observational study. ClinicalTrials.Gov, MEDLINE, Embase, Cochrane Library, Web of Science, PubMed and Google Scholar. Registered TKA trials at ClinicalTrials.Gov between 2000 and 2017. ClinicalTrials.Gov's required and optional data elements for registering a study and the preregistered and published primary outcome, defined as the outcome stated in the primary outcome field on ClinicalTrials.Gov. We used descriptive statistics, Kaplan-Meier curves and Cox regression analyses. 1352 registered TKA (1072 interventional; 280 observational) studies were included, with 967 (811 interventional; 156 observational) unique references. Regarding the publication of preregistered primary outcomes within 7 years, the results for interventional trials were 0% (2000), which increased to 59.6% (2017). Observational studies were timely published in 0% (2000) and 37.5% (2017). Interventional trials and observational studies not funded by industry were more likely to have timely and consistent publication of their primary outcomes. Drug intervention trials were more likely to be timely and consistently published than procedure-focused trials. Phase 3 interventional trials were more likely, while phase 1 trials were less likely to be consistently published on time. Despite ongoing efforts to improve publication rates, over a third of interventional trials remain unpublished within 7 years. For observational studies, the rate is even lower, with only two-fifths published on time, contributing to significant research waste. CRD42021246599.

Valgus knee deformity, which is less common, is not a mirror image of varus knee deformity and poses unique technical challenges in total knee arthroplasty (TKA). Although the lateral parapatellar approach may be advantageous for severe valgus knee, the medial approach is often preferred due to surgeons' limited familiarity with valgus TKA and the lateral approach. Recently, robotic technology has demonstrated superior accuracy in bone resection and soft-tissue balancing during TKA. Hence, we introduce the application of robotic technology for valgus knees via the lateral approach in TKA. As the standard patella drill template of the onlay oval patellar implant was designed for the medial approach, we created a reversed-asymmetric patella drill template for the lateral approach. In the recent cases, patellar tracking following prosthesis implantation was also evaluated using robotic technology. We included cases of primary TKA performed for Ranawat classification types II and III with uncorrectable valgus knee alignment, as well as for valgus deformity&#x2009;>&#x2009;20&#xb0;. In TKA, arthrotomy was performed via the lateral approach, and the patella was retracted medially. After soft-tissue balancing was adjusted, bone resection was performed using the Mako robotic system. The patella was replaced with an onlay oval patellar implant using our novel patella drill template in the lateral approach. Patellar tracking on the femoral trochlear groove after implantation was visualized and assessed using robotic technology. The surgical procedures were performed smoothly in 10 knees of 9 patients. The pre-operative limitations of knee extension, Visual Analog Scale scores, and radiographic knee alignment significantly improved following TKA. Pre-operatively, the tibiofemoral joint gaps were tighter laterally in both extension and flexion; post-operative medial laxity was effectively corrected. The accuracy and precision of prostheses positioning were confirmed radiographically. Patellar tracking was found to be appropriate after replacement with the oval patellar implant. The combination of robotic assistance, the lateral approach, and onlay oval patellar implants using our originally developed patella drill template showed feasibility for precise bone resection, optimal soft-tissue balancing, and proper patellar tracking for TKA in cases of valgus knee deformity.