This scoping review aims to map and evaluate the current body of literature on the use of extended reality (XR), including virtual reality (VR), augmented reality (AR) and mixed reality (MR), in the field of knee arthroplasty. There is a high global prevalence of knee osteoarthritis, and the frequency of knee replacement surgeries is increasing. The integration of XR technologies with surgery has the potential to improve patient care, surgical precision and medical education. This review seeks to understand the current landscape of XR applications in knee arthroplasty and identify gaps in knowledge to guide future research and clinical innovation. A systematic search of four databases-PubMed, Cochrane Central Register for Controlled Trials, National University of Singapore Libraries and Google Scholar-was conducted in December 2023 and updated in April 2024. Only English-language articles published from 2004 onwards were included. Editorials, case reports and articles not related to the knee joint were excluded. Eligible studies involved the use of XR/VR/AR/MR technologies specifically in the context of knee arthroplasty. Included articles were categorised under three major themes: (1) Clinical Practice (encompassing surgery, anaesthesia and rehabilitation), (2) Education (targeting both surgeons and nursing staff) and (3) Research (including applications in artificial intelligence and robotic-assisted surgery). Data from each study were extracted and summarised in a thematic table. Out of 236 articles retrieved from databases and 5 identified through reference screening, 54 articles met the inclusion criteria. VR was the most commonly studied modality (n = 42), followed by AR (n = 21), MR (n = 5), and XR (n = 2), with some overlap (n = 9) across technologies. Most articles focused on clinical practice (n = 45), while fewer addressed educational uses (n = 9) and research applications (n = 2). Two studies were classified under multiple themes. XR technologies were applied across preoperative training, intraoperative surgical navigation, anaesthesia techniques and postoperative rehabilitation. XR technologies in knee arthroplasty are diverse and show promising applications across clinical, education and research domains. While surgery, anaesthesia and education-related applications appear practical and beneficial, rehabilitation-related studies report mixed outcomes. Further high-quality research is needed to evaluate effectiveness and support broader clinical implementation across all identified subthemes. Level V.
Limb deformities have a close pathological link with peripheral nerve injuries; however, there is currently a lack of analysis and summary of research trends in this field aimed at elucidating the close relationship between limb deformities and peripheral nerve repair. Based on the Web of Science Core Collection database, this study retrieved 897 articles published between 2001 and 2025. A bibliometric analysis using CiteSpace and VOSviewer was therefore conducted to comprehensively map the research landscape, hotspots, and evolving trends in this field, revealing a sustained annual upward trend in research output. The University of Washington (UW, Seattle) was the institution with the most publications and the greatest impact. The Journal of Pediatric Orthopaedics was the journal with the most publications, while the Journal of Bone and Joint Surgery-American Volume was the journal with the greatest academic impact. Keyword analysis identified two major clusters of interest: diabetic peripheral neuropathy and foot deformities, involving studies on Charcot neuroarthropathy, diabetic foot ulcers, and amputation prevention; and birth-related brachial plexus palsy and its secondary shoulder and elbow deformities, focusing on functional reconstruction strategies such as tendon transfer and osteotomy. Burst keyword analysis revealed a clear shift in the research focus. From 2003 to 2013 (the early period), studies primarily focused on single-site functional impairments and conservative treatments (such as botulinum toxin). From 2014 to 2025 (the recent period), the focus shifted toward investigating "prevalence" and "risk factors," as well as conducting in-depth studies on "reconstructive" surgery, diabetic foot ulcers, and molecular mutation mechanisms. Current research in this field focuses on the bidirectional relationship between "malformations" and "nerves," exploring how nerve injuries cause malformations and investigating secondary nerve compression and damage following malformations. Peripheral neuropathies, such as diabetic peripheral neuropathy, Charcot-Marie-Tooth disease, and obstetric brachial plexus palsy, are the key direct or indirect causes of specific limb deformities (such as foot deformities, talipes, and forearm supination deformities). Research on the mechanical effects of deformities on nerves focuses on how skeletal deformities (such as elbow valgus/varus or knee valgus) result in or exacerbate nerve entrapment syndromes (such as ulnar nerve or common peroneal nerve injuries) through abnormal biomechanical mechanisms (such as excessive traction or dynamic compression). During surgeries for correcting complex deformities, the use of intraoperative nerve monitoring provides real-time early warning to avoid iatrogenic brachial plexus injuries and ensure patient safety, which has become a prominent technical focus. Previous studies have established the criteria for early monitoring of shoulder deformities and Mallet functional assessment following obstetric paralysis. Research over the past 5 years has focused on the mechanisms by which deformities exert mechanical effects on nerves, as well as the application of precision surgical techniques and intraoperative nerve monitoring. Surgical repair strategies for cubital tunnel syndrome and ulnar nerve palsy-induced claw hand are also among the key clinical areas of interest. Overall, these findings indicate that research on limb deformities associated with peripheral neuropathy and injury repair has evolved into two major research domains, focusing on nerve repair for deformities caused by diabetic peripheral neuropathy and limb deformities resulting from obstetric paralysis. Current research trends are moving toward precision, minimally invasive approaches, and multidimensional efficacy assessments. Future research should deepen the understanding of the "deformity-nerve" interaction mechanisms, focus on early warning systems, intraoperative nerve monitoring, and individualized functional reconstruction, and thereby improve patient outcomes and surgical safety.
Background Genicular artery embolization (GAE) is an emerging minimally invasive therapy for osteoarthritis (OA)-related knee pain. Traditional embolic agents such as imipenem-cilastatin and permanent microspheres have distinct limitations. Rapidly resorbable gelatin-based microspheres (RRGMs), designed specifically for GAE, may offer a promising alternative. Purpose To evaluate the safety and clinical outcomes of GAE using RRGMs in participants with OA-related knee pain. Materials and Methods This prospective, single-center observational study included consecutive participants with OA-related knee pain refractory to conservative treatment who underwent GAE using RRGMs between July and November 2024. Safety, the numeric rating scale (NRS) score (range, 0-10), and the Knee Injury and Osteoarthritis Outcome Score (KOOS) (range, 0-100) were assessed at 6 weeks and 3, 6, and 12 months after treatment. Clinical benefits were evaluated using the minimum clinically important difference (MCID). Descriptive statistics were used, and changes over time were assessed with the Friedman nonparametric repeated-measures test. Results A total of 194 participants (median age, 69 years; IQR, 60.5-75 years; 114 female) underwent 239 GAE procedures using RRGMs. The follow-up rates were 94% at 6 weeks (183 of 194 participants), 89% at 3 months (172 of 194 participants), 89% at 6 months (171 of 194 participants), and 79% at 12 months (154 of 194 participants). All the procedures (239 of 239) were technically successful. Transient skin discoloration occurred after 15 procedures (6.3%), and one participant developed a superficial groin hematoma (0.4%), all of which resolved without sequelae. No moderate or severe adverse events were observed. The median NRS pain score decreased from 7 (IQR, 6-8) at baseline to 3 (IQR, 2-5) at 12 months (P < .001), corresponding to a median reduction of 4 points (95% CI: 3.5, 4.0). At 12 months, 55%-80% of participants achieved improvements exceeding the MCID across all KOOS subscores. Conclusion GAE using RRGMs is safe and is associated with clinically meaningful improvement in participants with OA-related knee pain. © The Author(s) 2026. Published by the Radiological Society of North America under a CC BY 4.0 license.
This study examines outcomes and resource utilization of rTKA with a gradually reducing radius knee implant (GRRK) compared to all other revision knee implants. This study utilized the Premier Healthcare Database to analyze patients who underwent a single-stage revision with GRRK vs. all other revision implants from January 1, 2017, to October 31, 2024. Study variables included patient and hospital demographics and procedural characteristics. The primary endpoint was knee-related readmission rate within 90 days. Secondary outcomes included surgical time, length of stay and discharge status. Propensity score fine stratification was utilized for covariate balancing, followed by analysis through generalized linear models. 43,072 rTKAs were analyzed (2,203 for GRRK and 40,869 for all other revision implants) between January 2017 and October 2024. At 90-day follow-up, there were significantly lower knee-related readmissions for GRRK compared to all other revision implants (4.07% vs. 6.41%), with a mean difference of -2.35% (95 CI %: -3.23% to -1.47%, p < 0.001). At 30-day (2.08% vs. 2.94%) and 365-day (9.01% vs. 12.82%) follow-up, knee-related readmissions were also lower. All-cause readmission rates were also lower during the 30-, 90-, and 365-day follow-up period for GRRK compared to all other revision implants. Patients undergoing revision surgery with GRRK had higher rates of discharge to home (83.48% vs. 80.85%) and had shorter average surgical time (191 vs. 200 min) compared to other revision implants. GRRK was associated with significantly lower 90-day knee-related readmissions versus other revision implants, supporting its use in revision knee arthroplasty and future research to improve outcomes and resource use.
Mechanical varus or valgus alignment measures have been demonstrated to be closely related to knee osteoarthritis (KOA) development, but few attempts have been made to correlate the Coronal Plane Alignment of the Knee (CPAK) classification and disease development. This study hypothesized that certain CPAK types or deviations in CPAK parameters might enhance the risk of KOA development. KOA was defined as a Kellgren-Lawrence grade of 2 or higher. Data from 2,541 knees without KOA at baseline from the Multicenter Osteoarthritis Study (MOST) over five years of follow-up were examined. Differences in baseline CPAK types and parameters were analyzed between knees that developed KOA and those that did not. The association of CPAK type, arithmetic hip-knee-ankle angle (aHKA), and joint line obliquity (JLO) with the risk of disease development and joint line convergence angle (JLCA) changes were assessed. Knees that developed KOA (480 knees; 18.9%) had significantly lower JLO (p = 0.022) and aHKA (p = 0.008) values than those that did not (2,061 knees; 81.1%). JLO was significantly associated with KOA development (odds ratio 1.048 (95% CI 1.001 to 1.098)). For knees with JLO values under the cut-off value of 171.6°, the risk of KOA development was 1.36 times higher than for those with values over the cut-off value (95% CI 1.053 to 1.770). aHKA showed a significant negative correlation with JLCA change (regression coefficient -0.139 (95% CI -0.241 to -0.036); p = 0.008). However, CPAK type itself showed no significant correlation with KOA development. CPAK parameters, rather than types, were significantly associated with KOA development. Importantly, significant obliquity to the constitutional joint line might be as impactful as lower limb alignment. By potentially adjusting cut-off values, CPAK classification might be applied for predicting KOA development and investigating alignment-related aspects of KOA pathophysiology.
Introduction: Currently, there is an ongoing debate regarding the benefits of kinematic alignment (KA) versus mechanical alignment (MA) in total knee arthroplasty (TKA). Robotic-assisted TKA has been shown to improve implant positioning and precision of the KA technique, enabling successful kinematic alignment. However, its impact on early postoperative and functional outcomes remains unclear. This study aims to examine how imageless, table-mounted, robotic-assisted KA-TKA compares with conventional MA-TKA. Methods: Registry data of all primary TKAs using ATTUNE™ cruciate-retaining implants (January 2021-December 2024) performed by a single, experienced surgeon in a high-volume arthroplasty center were retrospectively reviewed. A total of 64 patients who underwent robotic-assisted KA-TKA were compared to 39 patients who underwent conventional MA-TKA. The mean age was 70.3 ± 7.71 and 69.3 ± 9.47 in the KA-TKA group and the MA-TKA group, respectively, while the male proportion was 32.8% and 30.7%, respectively. Early postoperative outcomes (static/dynamic pain score, ambulation distance, length of stay) and 6-month functional outcomes (range of motion, Knee Society Score, Oxford Knee Score, SF-36, patient expectation/satisfaction scores) were analyzed. Delta changes in outcome scores and proportion of patients attaining a minimum clinically important difference (MCID) were studied. Results: Robotic-assisted KA-TKA displayed benefits in the majority of the early postoperative outcomes, with significant improvements in ambulation distance (23.3 vs. 14.7 m, p = 0.002) compared to conventional MA-TKA. Both groups showed significant improvements in the majority of the functional outcomes at 6 months. Robotic-assisted KA-TKA also shows significant improvements in selected mental health aspects of SF-36, namely vitality (p = 0.001), mental health (p = 0.048), mental component summary (MCS) (p = 0.004), and a larger proportion attaining SF-36 vitality MCID (p = 0.045). Following false discovery rate correction for multiple comparisons, postoperative ambulation distance, SF-36 vitality, and MCS remained statistically significant between groups. No significant differences in KSS, OKS, and satisfaction/expectation fulfillment were noted. Conclusions: Robotic-assisted KA-TKA demonstrated early rehabilitation and select mental health-related quality of life improvements compared to conventional MA-TKA. Further studies are needed to examine its long-term clinical outcomes.
Postoperative pain management is crucial for optimising recovery after total knee arthroplasty. Adequate pain control facilitates early rehabilitation, enhances quadriceps muscle recovery, improves knee function and improves patient satisfaction. Corticosteroids are widely used for postoperative pain management. However, studies comparing the efficacy of periarticular (PA) and intravenous (IV) corticosteroid injection are limited. Therefore, this study aimed to evaluate the effect of PA and IV corticosteroid injections on quadriceps strength (QS) recovery in patients undergoing total knee arthroplasty. A total of 59 patients were included in this study. Patients were randomly assigned to two groups: the PA triamcinolone group (n = 29) and the IV hydrocortisone group (n = 30). Patients were followed up for 6 months and their QS, Visual Analogue Scale score, Modified Timed Up and Go (MTUGT) score, Western Ontario and McMaster Universities Osteoarthritis Index score, Knee Society Score and inflammatory marker levels were assessed. On postoperative day 3, the PA group exhibited a significantly lower reduction in QS (-43.11% ± 23.36% versus -63.7% ± 17.67%, p = 0.02) and significantly lower changes in MTUGT scores than the IV group (153.3% versus 301.3%, p < 0.01). Additionally, the knee flexion angle was significantly greater in the PA group than in the IV group on postoperative day 3 (91° ± 11° versus 82.6° ± 10.9°, p < 0.01) and at week 2 (103.2° ± 12.2° versus 97.4° ± 8.7°, p = 0.04). C-reactive protein levels were significantly lower in the PA group than in the IV group on postoperative day 1 (10.4; IQR: 5.3-17.2 versus 15.4; IQR: 9.4-28.6, p = 0.01), on day 3 (65.5; IQR: 38.3-96 versus 119.1; IQR: 69.6-146.1, p < 0.01) and at week 2 (3.9 versus 8.9, p = 0.01). On postoperative day 3, the PA group had significantly higher glucose levels than the IV group (115; IQR: 106-127 versus 106; IQR: 93-122, p = 0.02). No wound complications were observed in both groups. PA corticosteroid injection improves knee function in terms of muscle recovery, faster ambulation, increased knee flexion and reduced inflammation for up to 2 weeks after surgery compared with IV corticosteroid injection. A transient increase in serum glucose was observed but is unlikely to be clinically significant.
To clarify the impact of lower limb and hindfoot alignment and its changes on foot and ankle-related quality of life (QOL) over a 4-year period in patients with rheumatoid arthritis (RA). A total of 258 RA patients (516 feet) who underwent plain X-ray examination with hip-to-calcaneal (HC) view at baseline and a 4-year follow-up, along with Self-Administered Foot Evaluation Questionnaire (SAFE-Q) data at the follow-up were analyzed after excluding patients with prior lower limb surgery or severe ankle destruction (Larsen classification ≥ III or Takakura-Tanaka classification ≥ IIIa). Radiographic parameters representing lower limb and hindfoot alignment were measured using HC view, including hip-knee-ankle angle (HKA), tibio-calcaneal angle (TCA), talar tilt angle (TTA), and the changes of these angles. Clinical and laboratory factors collected included age, sex, BMI, autoantibody titer and positivity, methotrexate (MTX) use, biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) use, cumulative glucocorticoid dose, and Clinical Disease Activity Index. The primary outcome was the association between clinical and radiographic factors and ankle-related QOL. A generalized linear mixed model was used for statistical analysis. The mean age was 62.4 years, 87.2% were female, and 89.9% were seropositive. Over 4 years, hindfoot valgus (TCA) progressed from 4.3° to 6.0°. GLMM showed that age and cumulative glucocorticoid dose negatively affected QOL, while male sex, methotrexate dose, and b/tsDMARDs use were positively associated. Among radiographic parameters, valgus progression of TCA was significantly associated with poorer SAFE-Q outcomes in the "Shoe-related" and "General Health Perception" domains. Baseline HKA predicted valgus progression of TCA, whereas higher BMI, male sex, and larger baseline TCA predicted varus progression. Progressive hindfoot valgus deformity over 4 years, rather than static alignment, negatively impacts foot- and ankle-related QOL in RA patients, particularly in shoe-related function and general health perception. Baseline knee varus deformity predicts longitudinal hindfoot valgus progression.
Glucagon-like peptide 1 receptor agonists (GLP-1RAs) facilitate weight loss and reduce pain among individuals with knee osteoarthritis (OA). We investigated attitudes and barriers influencing GLP-1RA use among individuals with knee OA and excess weight to draw distinctions in perspectives between patients with and without GLP-1RA experience. In this cross-sectional qualitative study guided by the Framework Analysis method, we conducted structured interviews with persons with knee OA and excess weight. The moderator's guide included questions about health, weight loss history, and thoughts and experiences related to GLP-1RAs. Of the 286 patients prescreened, 30 completed an interview, after which saturation was reached. Interview transcripts were coded by research assistants using Dedoose software, and themes were identified using inductive analysis, charting, and memo writing. The 30 individuals interviewed were majority female and most self-identified as White. Fifteen participants had current or prior GL-P1RA use, and fifteen had never taken GLP-1RAs. We identified four major themes: (1) health care providers were the primary GLP-1RA information source; (2) most participants recognized that weight loss could contribute to knee pain relief; (3) "ever users" reported overall positive experiences and found GLPA-1RAs helped facilitate healthy lifestyle changes, whereas "never users" more often described medications as a last resort after lifestyle changes fail; and (4) cost was the most significant barrier to GLP-1RA use. We found that perceptions both differed and overlapped among participants with and without prior GLP-1RA use. Clinicians should address potential concerns regarding GLP-1RAs when discussing treatment options with patients with excess weight and knee OA.
Background: Periprosthetic joint infections (PJIs), a significant complication of total knee replacement surgery, are influenced by patient, surgeon, and healthcare system factors. Natural disasters can disrupt healthcare services and alter microbiological factors in the hospital environment. The impact of natural disasters on pathogen distribution in periprosthetic joint infection (PJI) is unclear. Therefore, this study investigated the association between the 2023 Kahramanmaraş-centered earthquakes in Türkiye and changes in microbiological patterns of PJI after knee arthroplasty. Methods: This retrospective cohort study included patients who developed PJI following total knee arthroplasty at the study center. The patients were divided into two groups based on the timing of their PJI diagnosis: pre-earthquake and post-earthquake. The demographic characteristics, comorbid diseases, and perioperative characteristics of each patient were recorded, and their microbiological profiles were analyzed. Logistic regression analysis examined the relationships between patient-related factors and causative agents. Results: 56 patients were studied and divided into two groups: 26 patients in the pre-earthquake group and 30 in the post-earthquake group. Furthermore, 79 bacterial isolates were obtained from these patients. Demographic, metabolic, and preoperative characteristics were similar between the two groups. No significant difference was found in the overall distribution of bacterial isolates. However, Gram-negative organisms, primarily Acinetobacter baumannii and Pseudomonas aeruginosa, increased in the isolate distribution after the earthquake. Patient analysis revealed that polymicrobial PJIs were significantly more frequent after the earthquake (56.7% vs. 23.1%; p = 0.011). Diabetes mellitus (DM) and smoking were associated with an increased risk of polymicrobial infection; the association was not statistically significant. Conclusions: In the post-earthquake period, patients who had undergone total knee arthroplasty and developed PJI showed a higher proportion of polymicrobial infections and a numerical increase in Gram-negative pathogens, along with more complex infection patterns compared to the pre-earthquake period. Although both patient groups demonstrated similar characteristics regarding patient-related and surgical factors, the observed changes indicate that the pressure on the healthcare system after a natural disaster can affect a hospital's microbiological ecology. Identifying these indirect effects is crucial for guiding microbiological surveillance and infection control during post-disaster recovery periods, even for elective patients.
There is conflicting evidence regarding the merits of patellar resurfacing during total knee replacement (TKR), as previous randomised controlled trials (RCTs) have been under-powered and with follow-up of ten years or less. A pragmatic, multicentre, open-label RCT was initiated in 1999 in the UK. Within a partial-factorial design, participants were randomly allocated to receive or not receive patellar resurfacing during primary TKR and were followed up for 20 years. Adult (aged ≥18 years) patients due to have a primary TKR under the care of a collaborating surgeon were eligible. Participants were allocated (1:1) using an automated telephone service stratified by surgeon, with minimisation according to the patients' age (<60 years, 60-79 years, ≥80 years), sex, and location of d isease. The primary outcome measure was the Oxford Knee Score (OKS), analysed using repeated measures mixed-effects linear regression analysis with marginal differences reported. Secondary measures included the 12-Item Short Form Health Survey (SF-12), the European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L), costs, cost-effectiveness, and subsequent knee surgery. This trial is registered with ISRCTN Registry, ISRCTN45837371. Between April 8, 1999, and Jan 13, 2003, 1715 participants (955 female and 760 male; mean age 70 years [SD 8], mean BMI 29·7 kg/m2) were randomly assigned: 861 to patellar resurfacing and 854 to no resurfacing. At the 20-year follow-up, 132 participants in the patellar resurfacing group and 110 participants in the non-resurfacing group provided outcome data, although marginal differences included earlier data for participants who died or had missing 20-year data. The marginal difference in OKS over the whole 20-year follow-up was 0·76 (95% CI -0·08 to 1·59; p=0·076) in favour of patellar resurfacing. During the 20-year follow-up period, although not significant, differences in OKS, SF-12, and EQ-5D-3L, readmissions, minor or intermediate operations, patella-related operations, major operations, and complications all favoured patellar resurfacing. At 20 years, the resurfaced group accrued significantly more quality-adjusted life-years (QALYs) than the non-resurfaced group (7·295 vs 6·884; difference 0·380, 95% CI 0·061 to 0·700; p=0·020). However, QALY differences were smaller in a sensitivity analysis assuming no difference in mortality (7·209 vs 6·964; difference 0·183, 95% CI -0·034 to 0·400; p=0·10). The cost of readmissions was non-significantly lower in the resurfaced group and offset the higher cost of primary TKR; therefore, overall 20-year health-care costs per participant were similar (£10 825 vs £10 889; difference -£6, 95% CI -£721 to £708; p=0·99). There was no significant difference in primary outcome (OKS) or other clinical endpoints. However, as clinical differences tend to support patellar resurfacing, the resurfacing group had significantly higher QALYs. There was no difference in costs over the 20-year period, and patellar resurfacing had a 99% probability of being cost-effective at any threshold above £10 000 per QALY gained. The evidence is therefore weighted towards resurfacing being the approach of first choice. UK National Institute for Health and Care Research Health Technology Assessment Programme.
Artificial intelligence (AI) is becoming increasingly integrated into orthopaedic surgery for tasks such as implant positioning, dislocation risk prediction, and surgical decision-making. However, the current evidence varies widely across anatomical regions and applications. A structured narrative review was conducted using PubMed and Web of Science Core Collection to identify studies applying machine learning or deep learning in orthopaedic procedures, focusing on parameters such as the anatomical region addressed, data types used, primary AI tasks, evaluation designs, and validation strategies. Reviews and meta-analyses were excluded. Study selection was summarized using a PRISMA-style flow diagram, and included studies were narratively synthesized according to anatomical region, AI task, imaging modality, validation strategy, and clinical relevance. We identified three main application areas: (1) AI in imaging-driven planning and implant positioning, often linked with navigation or robotic systems; (2) postoperative evaluation related to implants; and (3) prediction of clinically relevant outcomes such as dislocation risk. The strongest evidence is found in hip arthroplasty, where AI improves measurement accuracy and workflow efficiency, whereas applications in knee, shoulder, and spine surgery are less developed and often supported by smaller studies. Although existing risk prediction models demonstrate good performance, their generalizability is hindered by limited external validation and inconsistent reporting. Overall, while AI shows significant promise in enhancing various aspects of orthopaedic surgery, stronger links between technical advancements and patient outcomes are needed. Future research should prioritize extensive validations, workflow-aware evaluations, failure analysis, and adherence to AI-specific reporting guidelines to facilitate safe and effective clinical implementation.
To evaluate 1 year mortality, complication rates, and functional outcomes after internal fixation of femoral periprosthetic knee fractures following total knee arthroplasty, and to identify predictors of adverse outcomes and increased healthcare resource utilization. This retrospective cohort study included 102 consecutive patients with femoral periprosthetic knee fractures classified as UCPF VB3 and VC3 treated with internal fixation at a single tertiary center between 2010 and 2023. Interprosthetic fractures and combined fixation techniques were excluded. Primary outcomes were 1 year mortality and postoperative complications. Secondary outcomes included length of stay, discharge destination, and ambulatory status at follow up. Patients were markedly frail, with a mean age of 82.4 ± 10.8 years and mean Charlson Comorbidity Index of 5.6. One year mortality was 16.7% and was associated with older age, higher ASA class, higher Charlson index, impaired pre fracture ambulation, and fracture related infection. Overall complication rate was 29.4%, including 15.7% infections and 13.7% mechanical failures. Open reduction was more frequent in plate fixation and resulted in longer operative times, without increasing complication rates. Median hospital stay was 18 days, 66.3% required discharge to nursing facilities, and only 7.8% regained independent ambulation. Outcomes were worse in patients who developed complications. Outcomes after internal fixation of femoral periprosthetic knee fractures are driven primarily by patient frailty rather than fixation technique. Functional recovery is limited and resource utilization is substantial, underscoring the need for improved risk stratification and perioperative care pathways.
To investigate the effects of gait modification on the knee lever arm (KLA) in individuals with obesity. This study was designed as a retrospective, cross-sectional, observational study to investigate the impact of gait modifications on knee joint loading in individuals with obesity. A convenience sample was used, and no formal sample size calculation was performed. Single university hospital. Fifty-three individuals (N=53) with obesity who had no history of lower-limb surgery, musculoskeletal disorders, or neuromuscular diseases affecting gait. Interventions: Not applicable. Three-dimensional gait analyses were performed in individuals with obesity under 3 conditions: walking at a comfortable speed, with their toes outward (toe-out gait), and with a wider step width (wide-base gait). The peak knee adduction moment (KAM), area under the curve of KAM during stance (KAM impulse), and KLA were measured. Considering the relative position between foot placement and the center of gravity by gait modifications, the KLA was divided into the mediolateral shift of the center of pressure (center of pressure component of KLA [KLA-COP]) and the mediolateral tilt of the ground reaction force vector (tilt component of KLA [KLA-tilt]). Wide-base gait significantly reduced peak KAM, KAM impulse, KLA, and KLA-COP but increased the KLA-tilt, whereas the toe-out gait did not significantly reduce these parameters compared with other conditions. In the wide-base gait, the change in peak KAM was significantly correlated with changes in the hip abduction angle (r=-.66). The results show that reducing the KLA-COP and increasing the KLA-tilt with a lateral shift in foot placement acted as abduction and adduction moments, respectively. In particular, changing the hip kinematics can enhance the effects of gait modification in individuals with obesity.
Background/Objectives: Alignment philosophy in total knee arthroplasty (TKA) may affect joints beyond the knee. Mechanical alignment (MA) targets a neutral mechanical axis, whereas kinematic alignment (KA) aims to restore native alignment and joint line obliquity (JLO). This study compares the effects of MA and KA on hip and ankle radiographic parameters and investigates the propagation of coronal correction along the lower limb. Methods: A retrospective comparative study evaluated 63 TKAs performed for varus deformity (KA: n = 32; MA: n = 31). Pre- and postoperative full-length standing radiographs were used to calculate changes (Δ), defined as the difference between postoperative and preoperative values, in hip offsets, mechanical and arithmetic hip-knee-ankle angles (mHKA, aHKA), medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), JLO, and ankle ground-referenced angles. Between-group differences and correlations were analysed. Interobserver reliability was assessed for all variables. Results: MA produced significantly greater limb correction than KA (ΔmHKA: 8.89° vs. 4.82°, p < 0.001), primarily due to increased tibial valgus correction (ΔMPTA: 6.26° vs. 2.41°, p < 0.001). JLO increased substantially with MA (+4.10°) but was preserved with KA (+0.30°, p < 0.001). MA resulted in significant valgus shifts at the ankle (ground talar dome angle (GTDA) -3.01°, ground tibial plafond angle (GTPA) -3.02°; p = 0.006 for both), whereas KA produced no significant ankle changes. Correlation analysis demonstrated limited knee-ankle biomechanical coupling, with a moderate negative correlation in MA (ΔmHKA vs. ΔGTDA: ρ = -0.479, p = 0.006) and a weak correlation in KA (ΔaHKA vs. ΔGTDA: ρ = -0.360, p = 0.043). Hip parameters remained unchanged in both groups. Conclusions: Mechanical alignment induces larger tibial-driven coronal corrections, increases joint line obliquity, and produces measurable valgus shift at the ankle. In contrast, kinematic alignment preserves native alignment and joint-line obliquity while minimising distal ankle compensatory changes.
Background: Autologous adipose-derived stromal vascular fraction (SVF) is increasingly used for symptomatic knee osteoarthritis (OA), but it remains uncertain whether patient age should influence candidacy. We examined whether age was related to 12-month pain response after intra-articular SVF administration. Methods: This retrospective knee-level analysis included 357 knees from 266 patients with Kellgren-Lawrence grade II-IV OA treated with adipose-derived SVF and followed for at least 12 months. Pain was assessed with the visual analog scale (VAS). Group comparisons and Spearman correlation analyses were used to explore relationships between age, baseline variables, injected cell number, and pain outcomes. Results: VAS scores improved from 6.5 ± 1.2 before treatment to 3.1 ± 1.6 at final assessment (p < 0.01). Age did not show a significant association with baseline pain (p = 0.128), final pain (p = 0.088), or measured baseline factors. Higher body mass index, more severe radiographic OA, and lower SVF cell number were associated with less favorable final pain scores. No serious treatment-related adverse event was identified. Conclusions: SVF injection was followed by significant pain reduction at 12 months. In this cohort, chronological age was not a meaningful determinant of response, whereas metabolic burden, structural OA severity, and delivered cell dose were more relevant clinical factors. These results argue against excluding patients from SVF treatment solely because of age.
Unicompartmental knee arthroplasty (UKA) has become an effective treatment for medial compartment osteoarthritis of the knee. However, its use in patients who also have patellofemoral joint osteoarthritis (PFOA) before surgery remains controversial. Restoring postoperative lower limb alignment and achieving accurate implant positioning are also important factors for the success of UKA, but there is still a lack of studies that combine both patient-related factors and surgical technique-related factors in the Chinese population. This study retrospectively analyzed 69 Chinese patients (79 knees) with medial compartment osteoarthritis who underwent Oxford UKA between May 2017 and December 2020. The severity and location of PFOA were assessed by MRI. Postoperative coronal alignment was categorized by the femorotibial angle (FTA) into neutral, mild varus, moderate varus, and extreme/out-of-range groups. Implant positioning was classified as ideal or non-ideal according to established radiographic target ranges for aLDFA, aMPTA, PTS, and component alignment angles. Functional outcomes were evaluated using VAS, KSS, WOMAC, and Kujala scores, with multifactorial interactions analyzed via multivariate analysis of covariance (MANCOVA). At a mean follow-up of 66.5 ± 9.6 months, Oxford UKA markedly improved overall patient function. While no cases of prosthesis loosening or revision were observed, three patients reported persistent postoperative pain and two presented with valgus deformity. Postoperative functional scores did not differ by PFOA severity or lesion location. Regarding lower-limb alignment, neutral and mild varus (< 6°) knees had higher KSS function scores than moderate varus and extreme/out-of-range knees and lower WOMAC scores. KSS knee scores were higher in neutral and mild varus than in the extreme group. Implant positioning (ideal vs non-ideal) was not associated with postoperative scores. Mid-term follow-up showed that Oxford UKA achieved satisfactory clinical outcomes. The severity and location of PFOA before surgery did not significantly affect postoperative knee function. Maintaining postoperative alignment within the target range (neutral to slight varus; within 6° of varus) may be associated with better functional recovery.
Sahasthara (SHT), a traditional Thai herbal remedy used for anti-inflammatory and musculoskeletal disorders, lacks clinical evaluation as a topical formulation employing microemulsion (ME) technology. This study aimed to assess the efficacy and safety of a Sahasthara microemulsion (SHT-ME) compared with a diclofenac microemulsion (DF-ME) in patients with primary knee osteoarthritis (OA). Eighty-four patients aged 40-70 years were randomized to receive either 1% SHT-ME or 2% DF-ME, applied three times daily for 28 days. Efficacy was evaluated using the pain visual analogue scale (VAS), 100-m walking time, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and global assessments. Safety assessments included physical examinations, laboratory tests, and adverse-event monitoring. Both formulations significantly reduced VAS pain scores, improved walking time, and decreased WOMAC scores at days 14 and 28 compared with baseline (P < 0.05). No significant efficacy differences were observed between groups (P > 0.05). Liver and renal function, blood pressure, and biochemical parameters remained within normal ranges, and no severe or skin-related adverse events occurred in either group. SHT-ME provided efficacy comparable to DF-ME in relieving pain and improving mobility in knee OA. Both treatments were well tolerated and safe. These findings suggest that SHT-ME, a natural herbal alternative, and DF-ME, a synthetic drug formulation, are equally effective topical microemulsions for knee osteoarthritis management.
The choice of fixation for total knee arthroplasty (TKA) remains controversial. Cementless designs incorporating highly porous titanium surfaces may achieve durable biological fixation and mitigate cement-related complications. However, little has been written comparing the methods of fixation for robotic-assisted (RA) TKA. The aim of this study was to compare the implant survival and complication rates between cemented and cementless RA-TKA using a single robotic system and uniform implant design. This retrospective review involved 2,647 consecutive primary RA-TKAs undertaken by 27 surgeons at a high-volume academic centre, between 2016 and 2024, using a single CT-based robotic platform and implant design (Triathlon). Patients aged > 18 years with primary osteoarthritis and at least one year of follow-up were included. The method of fixation was determined by the operating surgeon. This resulted in 1,289 cemented and 1,358 cementless RA-TKAs. The mean follow-up was 3.5 years (SD 2.1). Outcomes included Kaplan-Meier survival free from revision (overall, septic, and aseptic), all-cause further surgery, and 90-day readmissions and nonoperative complications. Multivariable Cox regression analysis adjusted for age, BMI, sex, race, ethnicity, and operating time was performed to identify independent predictors. The five-year revision-free survival was 98.0% (95% CI 97.1 to 98.9) and 98.5% (95% CI 97.4 to 99.6) for cemented and cementless fixation, respectively (p = 0.137, log-rank test). Cementless fixation was associated with a significantly decreased risk of septic revision (hazard ratio 0.21 (95% CI 0.03 to 0.71); p = 0.021), whereas there were no differences between the groups for aseptic revision. The five-year survival free from any reoperation was 96.6% (95% CI 95.5 to 97.7) in the cemented group and 97.1% (95% CI 95.9 to 98.4) in the cementless group (p = 0.472, log-rank test). The most common indication for reoperation was stiffness, followed by periprosthetic joint infection. The 90-day readmission and nonoperative complication rates were similar between the groups (p = 0.999 and p = 0.290, respectively). Cementless RA-TKA showed excellent five-year survival with a significantly decreased risk of septic revision compared with cemented RA-TKA. These findings suggest a decreased infection-related risk of failure with cementless fixation, without compromising the short-term implant survival.
Bicruciate-retaining (BCR) total knee arthroplasty (TKA) was developed to better replicate native knee biomechanics by preserving both cruciate ligaments. First-generation BCR implants were notorious for technical challenges and suboptimal survivorship. However, advancements in implant design and surgical techniques have renewed interest in second-generation BCR TKA systems. This study aimed to evaluate the overall survivorship of contemporary (second-generation) BCR primary TKA implants. A systematic review of PubMed, Scopus, Embase, Web of Science, and Cochrane databases was conducted from inception to January 3, 2025. Inclusion criteria were studies that reported the number of revisions following second-generation BCR TKA. We excluded case reports, review articles, and studies that evaluated first-generation BCR TKA. A total of 1046 articles were retrieved; ultimately, 13 were included. Events per person-years pooled analysis was performed to estimate the incidence of all-cause revision, adjusting for duration of follow-up. Heterogeneity was measured using I2 test. A p-value < 0.05 was considered statistically significant. A total of 1,087 BCR TKA implants among 13 studies were analyzed. The mean follow-up was 2.6 years. A total of 62 (5.7%) knees were revised. The overall pooled rate of all-cause revision was 1.6 per 100 person-years (95% confidence interval [CI] 0.009-0.023) Heterogeneity among the analyzed studies was significant (I2 = 75.5%, p < 0.001). Contemporary BCR TKA implants showed improved survivorship compared to historical reports, with a low pooled all-cause revision rate of 1.6 per 100 person-years, corresponding to a 1.6% chance of revision per year of follow-up. Despite the associated heterogeneity, these findings suggest that modern BCR designs offer durable outcomes and support their continued use. Further long-term comparative data are needed to better define their role relative to modern knee implants.