Introduction: A total knee replacement is a surgical procedure to treat severe arthritis in the knee joint. The cruciate-sacrificing prosthetic design is one of the most frequently used in total knee replacement (TKR). There has been debate regarding whether metal-backed tibia (MB) or all-polyethylene (AP) tibial components are better for implants in terms of lifespan, clinical results, and complication rates. The big role played by selecting appropriate knee joint implants for osteoarthritis in developing countries is with economic constraints. Metal and all-polyethylene monoblock essentially can serve this purpose in knees without defects in bones that do not require modularity like stem extensions or augments. The aim of this study was to compare the long-term clinical and radiological results of metal-backed vs all-polyethylene cruciate-sacrificing total knee replacements. Long-term application of all-polyethylene tibial implants against the backdrop of better-designed implants/instrumentation coupled with an increasing use of TKR and continuous economic pressures on health care could represent a potential for enormous cost savings without jeopardizing patient clinical outcomes. Materials and methods: This prospective study involves 200 TKR procedures using Depuy PFC AP implants and MB implants 100 in each group, conducted between January 2011 and January 2012, with 12-years follow-up. Patients age > 50 years with a definite diagnosis of osteoarthritis, severe knee pain or dysfunction disabling normal work and life, ineffectiveness of conservative treatment, and TKRs that did not necessitate bone grafting, modular stems or augments, or more constrained designs were included. Functional outcomes were assessed using the Knee Society Score (KSS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and range of motion (ROM). Radiological assessments were performed to check for signs of loosening and malalignment. Implant survival was measured by revision surgery rates. Results: The study cohort included 130 females and 70 males, with an average age of 61.3 years. Both the MB and AP groups showed significant improvement in KSS, WOMAC, and ROM over 12-years, with no statistically significant difference between the two groups. The implant survival rate was 96% for AP and 94% for MB. Aseptic loosening occurred in 2 AP and 3 MB cases, with polyethylene wear observed in the MB group due to micromotion, while the AP group showed only minimal poly wear. Conclusion: The long-term outcomes of both AP and MB tibial components in TKR show comparable clinical and radiological success, with both designs significantly improving pain relief and functional outcomes in patients with severe knee arthritis. AP implants, in particular, demonstrated similar functional improvements and radiological stability, while offering the added benefit of reduced polyethylene wear. Given the lower cost of AP components, they represent a cost-effective solution in resource-limited settings without sacrificing patient outcomes.

Background: Efficient operating room (OR) management reduces the potential for extended OR days. Surgical schedulers play a key role in generating OR schedules, despite unfamiliarity with specific case considerations that may affect case length. We evaluated the correlation between a single surgeon's subjective preoperative complexity scoring system and the resulting total knee arthroplasty (TKA) procedure time, and secondarily to assess the financial losses generated from unaccounted OR time. Methods: All patients at the index institution who received a primary, unilateral TKA from February 2014 to November 2019 with a documented tourniquet time and assigned complexity score were included (n = 551). Patient and surgery-specific characteristics were recorded, including the score that was assigned at the preoperative visit. Case length was determined by tourniquet time. The rate of underestimating room duration was estimated from the booking time. Average supply and labor costs as well as surgical and anesthesia charges were tabulated across four providers (one utilizing the score and three not utilizing the score). Results: Preoperative complexity score was positively correlated with tourniquet time (p < 0.001, ρ = 0.196). Operations with complexity scores of 1, 2, and 3 had a mean tourniquet time of 59 minutes, 64.2 minutes, and 76 minutes, respectively (p < 0.001). The surgical assistant training level did not correlate with a longer tourniquet time (p = 0.492). The attending utilizing the score only underestimated the booking time at a rate of 4% with a significantly shorter room duration (131 minutes) while the remaining attendings underestimated the required booking time at a rate of 72% with a longer room duration (151 minutes; p < 0.05). The average cost savings per case between attendings that did not use the complexity score and the attending that did was $4,462.17 ($223.11 per minute). Conclusion: Our complexity score correlated with OR time and may aid in enhancing OR efficiency by incorporating it into scheduling algorithms, and reducing the direct variable operating cost burden of primary TKAs.

Background: Obesity has also been recognized as the most important modifiable risk factor for osteoarthritis. Total knee replacement (TKR) in obese patients presents additional challenges with increased risk of component malpositioning and component loosening. Navigation in TKR results in accurate alignment, titrated soft tissue balancing, reduced blood loss, early rehabilitation, and reduced chances of embolism by not entering the intramedullary space. Whether it actually improves outcomes and reduces complications in obese was the research question of our study. Materials and methods: It was a prospective randomized comparative observational study conducted at our institute between December 2017 and March 2019. Obese patients between ages 50 and 75 years undergoing primary TKR for osteoarthritis were included in the study after an internal review board approval and after prior informed consent. A hundred knees in obese patients [Body mass index (BMI) > 30 kg/m²)] with varus deformation undergoing TKR were randomized into a navigated group (NG, n = 50) and a non-navigated group (NNG, n = 50). Results: Patients were followed for a minimum of 2 years. The average follow-up was 4.6 years (2–6.5 years). Two of the patients (four knees) in NG were lost to follow-up and three of the patients (6 knees) had died in the NNG leaving us with a total of 46 knees in NG and 44 knees in NNG at final follow-up. The NG showed better outcomes in terms of alignment, component positioning, range of motion (ROM), deformity correction, blood loss, return to activity, and complications. Conclusion: Computer navigation-assisted TKR significantly improves alignment with marginal functional improvement and reduces perioperative complications in obese patients.

Introduction: The cut surface of anterior cortex of the femur during a mechanically aligned total knee replacement resembles the top surface of a grand piano. It is said to be a reliable marker for correct rotational alignment of the femur. Robotics and CT-based 3D planning have sophisticated tools for manipulating the 3D bony template of the femur. Moreover, CT-based robotics and CT-based 3D planning require CT scans for all patients undergoing surgery. Previous studies have mentioned that the grand piano sign is a good indicator of the femoral component rotation, but is the change of shape significant and predictable for all changes in alignments and rotations? Materials and methods: A retrospective study was conducted using 200 CT scans of patients undergoing total knee replacement surgery with CT-based 3D planning. A proprietary, interactive, surgery-planning and execution software developed by the lead author (MS) (Kne3wiz by Arthro 3D LLP, http://www.arthro3d.com) was used for 3D reconstruction and planning. The system created a 3D bone model using AI segmentation. Results: A sizable percentage (>40%) of the knees had a single peak. When the single peaks were excluded from the analysis, the ratios dropped across all alignments and with varying degrees of flexion of the femoral component. These were tested for statistical significance using ANOVA. The ratios were found to be significant with a change in flexion of more than 2°. The p-values for flexion in the intramedullary axis at +3 and +5 were both significant (p = 0.003 and p = 0.001, respectively). The difference in lateral peaks was highly significant for all changes in the flexion of the femoral component; whereas a change of 3 or more degrees of flexion of the femoral component was significant for the medial peak. Conclusion: The ratios of the lengths of medial and lateral columns of the grand piano sign vary across different alignments. The changes in ratios and measurements are more a function of the femoral component flexion than varus-valgus or rotations of the femoral component. The difference in measurements among different alignments for the length of the lateral column is highly significant. This makes it a possible tool for validation for implant position in femur with preoperative CT-based 3D planning.

Total knee replacement (TKR) is a surgical procedure to alleviate pain and restore function in patients with severe knee arthritis or other debilitating knee conditions. The success of TKR is influenced by various factors, such as component position, alignment, implant size, soft tissue balance, and the surgeon's technique, expertise, and experience. Computer-aided techniques like navigation and robotics have been increasingly adopted to enhance precision. Augmented reality (AR), which integrates real-world information with virtual data, is emerging to enhance surgeons’ capabilities by providing augmented medical information, leveraging deep learning and artificial intelligence. Augmented reality is believed to increase precision and improve patient outcomes. The article discusses AR technology's potential benefits, applications, and challenges in TKR. While AR shows promise and could revolutionize orthopedic surgery by improving the understanding of 3D anatomical relationships and precise implant positioning, it is still not widely used. Future advancements are necessary to address existing challenges, and well-designed randomized trials with standardized outcomes are needed to compare AR technology with current navigational systems in knee replacements.

Background: The incidence of femoral neck fractures is increasing among the geriatric population due to longer life expectancy, necessitating effective management strategies. Bipolar hemiarthroplasty is commonly used for intracapsular fractures in elderly or neglected cases, despite well-documented complications such as infection, implant loosening, and dislocation. Methods: This case series presents four patients with an unusual complication: Late spontaneous dissociation of bipolar hemiarthroplasty components. The inner articulating component separated from the outer implant after 7–14 years postsurgery, causing compromised hip function and requiring revision surgery. Clinical presentations, radiographic findings, and management strategies, including conversion to total hip arthroplasty (THA) are detailed. Results: Radiographic evaluations confirmed dissociation of the bipolar components in all cases, prompting surgical intervention. Postoperative recoveries were generally uneventful, with patients experiencing significant pain relief and improved mobility. Conclusion: Late spontaneous dissociation of bipolar hemiarthroplasty components is an extremely rare complication, rarely reported in the literature. This series highlights its clinical significance, discusses potential risk factors, and underscores the necessity of rigorous postoperative care and follow-up. Not many cases of late bipolar dissociation have been described in the literature worldwide.

Introduction: Acromegalic arthropathy, a rare complication of acromegaly caused by excessive growth hormone (GH) production, primarily affects large joints, leading to pain, stiffness, and functional impairment. Unlike degenerative arthropathy, which is typically due to wear and tear over time, acromegalic arthropathy is driven by the overproduction of GH and insulin-like growth factor 1 (IGF-1), resulting in abnormal cartilage and bone growth. Effective management requires a multidisciplinary approach involving endocrinologists, rheumatologists, and orthopedic surgeons. With a prevalence of 40 to 70 cases per million and diagnosis typically between ages 40 and 50, treatment ranges from conservative early-stage measures to surgical interventions like total knee arthroplasty (TKA) in advanced cases. Despite extensive research, gaps exist in understanding long-term outcomes and treatment efficacy. Case description: We present a unique and rare case of a 64-year-old female who was diagnosed with acromegalic arthropathy of both knees and managed with bilateral TKA. This case, due to its rarity, provides a valuable opportunity to delve into the complexities of this condition and its management. Conclusion: Acromegalic arthropathy is a rare joint disorder. Successful outcomes following TKA highlight the effectiveness of surgery in severe cases, emphasizing the need for timely intervention. This underscores the importance of early diagnosis, empowering both patients and healthcare professionals to take proactive steps in managing this condition. The surgical steps and postoperative care are similar to those for other end-stage knee arthritis. A multidisciplinary approach is crucial for effective management.

Background: Ankylosing spondylitis (AS) presents with hip and spine stiffness at total hip arthroplasty (THA) with mobility restriction. Reduced spinopelvic mobility is associated with spine stiffness, especially bilateral fused hips. Case report: We present a rare case of bilateral fused hips due to AS with a traumatic subtrochanteric fracture of the right femur—preoperative planning with anesthetic considerations included risk assessment for bilateral vs unilateral and mobilization after the procedure. Simultaneous bilateral cementless THA using a modified Hardinge approach with modular femoral component (SROM, Depuy USA) to achieve fracture stabilization was done, followed by gradual mobilization. Care was taken to ensure correct femoral and acetabular component positioning, considering spine stiffness and loss of spinopelvic mobility. The patient is doing well at 3 years with a stiff spine in extension, walking independently, the ability to sit comfortably, and a good functional outcome. Conclusion: Simultaneous bilateral THA had to be considered in this unusual case of AS, although not ideal, with risk consent for achieving mobility following significant stiffness and disability.