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Xinhuan Lei, Jie Xiang, Hailan Yang, Hongya Bao, Zhong Zhu, and Hua Luo


  • Surgical site infection (SSI) is a rare and serious complication of total knee arthroplasty (TKA), which causes a poor prognosis for patients. The purpose of this study was to explore the effect of intraosseous (IO) antibiotics in preventing infection and complications after TKA compared with intravenous (IV) antibiotics and to provide a certain theoretical basis for clinical treatment.


  • The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, Embase, Ovid, Web of Science, and the Cochrane Central Register of Controlled Trials databases about trials on IO antibiotics (into the proximal tibia before skin incision) to prevent infections in TKA from the respective inception dates to September 30, 2022. The infection occurred within 3 months after surgery. Both researchers individually screened the studies in accordance with the inclusion and exclusion criteria, performed the literature quality evaluation and data extraction, and used Stata 17 software for data analysis.


  • Five studies that enrolled 3801 patients were included in this meta-analysis. The results showed that IO antibiotics were effective in reducing the incidence of SSI (OR: 0.25, P = 0.001) and periprosthetic joint infections (OR: 0.16, P = 0.004) relative to IV. Moreover, the percentage of infection due to Gram-positive bacteria (OR: 0.18, P = 0.025) was reduced in the IO group compared with that in IV group, but Gram-negative bacteria levels were not significantly reduced (P = 0.14). There was no difference between the two groups for other systemic adverse effects of the drug.


  • IO antibiotics in TKA are safe and effective alternatives to IV antibiotics. Large randomized clinical studies comparing infection rates and related complications with IO and IV antibiotics are required.

E Carlos Rodríguez-Merchán and Carlos Kalbakdij-Sánchez

  • Parkinson’s disease (PD) is a common neurodegenerative disorder.

  • When patients with PD undergo total knee arthroplasty (TKA) for knee osteoarthritis, poorer knee function and poorer quality of life are obtained than in matched cohorts (MCs). However, the degree of patient satisfaction is usually high.

  • The mean length of stay is 6.5% longer in patients with PD than in MCs.

  • Compared with MCs, patients with PD undergoing TKA have a 44% higher risk of complications.

  • In patients with PD, the overall complication rate is 26.3% compared with 10.5% in MCs; the periprosthetic joint infection rate is 6.5% in patients with PD vs 1.7% in MCs; and the periprosthetic fracture rate is 2.1% in patients with PD vs 1.7% in MCs.

  • The 90-day readmission rate is 16.29% in patients with PD vs 12.66% in MCs. More flexion contractures occur in patients with PD.

  • The rate of medical complications is 4.21% in patients with PD vs 1.24% in MCs, and the rate of implant-related complications is 5.09% in patients with PD vs 3.15% in MCs. At 5.3 years’ mean follow-up, the need for revision surgery is 23.6%.

  • The 10-year implant survival, taking revision of any of the components as an endpoint, is 89.7% in patients with PD vs 98.3% in MCs.

Elena Gálvez-Sirvent, Aitor Ibarzábal-Gil, and E Carlos Rodríguez-Merchán

  • Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis.

  • The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA.

  • Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection.

  • In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage).

  • Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

Claudio Legnani, Andrea Parente, Franco Parente, and Alberto Ventura


  • It is debatable whether or not previous high tibial osteotomy (HTO) has negative effects on the results of subsequent medial unicompartmental knee replacement (UKR). The purpose of this study is to report, through a systematic review of the literature, the outcomes of medial UKR after failed HTO. It was hypothesized that this procedure would be safe and effective in providing satisfactory postoperative functional outcomes.


  • A systematic review was performed by searching Pubmed/MEDLINE, Embase and CINAHL. Only studies in English pertaining to all levels of evidence reporting on subjects undergoing UKR following HTO were considered. Review articles and expert opinion or editorial pieces were excluded. Outcomes of interest included indications, surgical technique and associated procedures, type of prosthesis, clinical and functional outcomes, rate of complications, revision surgery and failure rate.


  • Overall, six studies met all the inclusion criteria for this review. All were published between 2006 and 2021. The search resulted in one prospective comparative study, four retrospective comparative cohort studies, and one retrospective cohort study. Average follow-up periods ranged from 1 to 13 years. From these studies, 115 patients (117 knees) were identified. Overall, most studies reported satisfying postoperative clinical and functional outcomes. Implant survivorship ranged from 66 to 97.6%. In 15 patients, revision surgery was performed due to persistent pain.


  • Medial UKR performed after failed HTO appears as a feasible procedure providing satisfying outcomes and limited complications in most cases. Further prospective comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are lacking.

E Carlos Rodríguez-Merchán

  • The current applications of the virtual elements of artificial intelligence (AI), machine learning (ML), and deep learning (DL) in total knee arthroplasty (TKA) are diverse.

  • ML can predict the length of stay (LOS) and costs before primary TKA, the risk of transfusion after primary TKA, postoperative dissatisfaction after TKA, the size of TKA components, and poorest outcomes. The prediction of distinct results with ML models applying specific data is already possible; nevertheless, the prediction of more complex results is still imprecise. Remote patient monitoring systems offer the ability to more completely assess the individuals experiencing TKA in terms of mobility and rehabilitation compliance.

  • DL can accurately identify the presence of TKA, distinguish between specific arthroplasty designs, and identify and classify knee osteoarthritis as accurately as an orthopedic surgeon. DL allows for the detection of prosthetic loosening from radiographs.

  • Regarding the architectures associated with DL, artificial neural networks (ANNs) and convolutional neural networks (CNNs), ANNs can predict LOS, inpatient charges, and discharge disposition prior to primary TKA and CNNs allow for differentiation between different implant types with near-perfect accuracy.

David Constantinescu, William Pavlis, Michael Rizzo, Dennis Vanden Berge, Spencer Barnhill, and Victor Hugo Hernandez


  • Commercially available smartphone apps and wearable devices have proven valuable in a variety of clinical settings, yet their utility in measuring physical activity and monitoring patient status following total knee arthroplasty (TKA) remains unclear.


  • A systematic review was performed to assess the evidence supporting the use of smartphone apps and wearable devices to assist rehabilitation interventions following TKA. A search was conducted in the PubMed, Cochrane, Medline, and Web of Science databases in September 2021.


  • One hundred and seventy-six studies were retrieved, of which 15 met inclusion criteria, including 6 randomized control trials. Four of these studies utilized smartphone apps, seven utilized wearable devices, and four utilized a combination of both. A total of 1607 TKA patients participated in the included studies. For primary outcomes, three reported on device accuracy, three on recovery prediction, two on functional recovery, two on physical activity promotion, two on patient compliance, two on pain control, and one on healthcare utilization.


  • Commercially available smartphone apps and wearable devices were shown to capably monitor physical activity and improve patient engagement following TKA, making them potentially viable adjuncts or replacements to traditional rehabilitation programs. Components of interventions such as step goals, app-based patient engagement platforms, and patient-specific benchmarks for recovery may improve effectiveness. However, future research should focus on the economics of implementation, long-term outcomes, and optimization of compliance and accuracy when using these devices.

Reha N Tandogan, Esref Terzi, Enrique Gomez-Barrena, Bruno Violante, and Asim Kayaalp

  • Native patellar tendon injuries are seen in younger patients compared to quadriceps tendon ruptures.

  • Up to a third of the patients may have local (antecedent tendinopathy and cortisone injections) or systemic risk factors (obesity, diabetes, hyperparathyroidism, chronic renal failure, fluoroquinolone or statin use) of injury, these are more frequent in bilateral disruptions.

  • Complete extensor mechanism disruptions should be repaired surgically. Although isolated primary repair has been reported to have good outcomes in younger patients with acute tears and good tendon quality, augmentation of the repair with autograft, allograft or synthetic material should be considered in patients with poor tendon quality, chronic tears or tendon defects.

  • High rates of return to work/sports have been reported in native patellar and quadriceps tendon tears, with re-rupture rates <5%.

  • Extensor mechanism disruptions in patients with a total knee arthroplasty are challenging due to older age, systemic co-morbidities and poor local conditions, resulting in inferior outcomes compared to native extensor mechanism injuries. Some form of augmentation with autograft, allograft or synthetics is advisable in all cases. Salvage procedures such as whole extensor mechanism allografts provide acceptable outcomes in multiply operated knees with extensive bone and soft tissue deficits.

Andrea Ferrera and Jacques Menetrey

  • Osteotomies around the knee represent a valid surgical treatment in young active patients affected by unicompartmental osteoarthritis and/or knee ligament instability.

  • This review article describes the main osteotomies performed around the knee and their optimization, with particular attention to indications and surgical technique in light of the most recent literature and author experience.

  • Further developments have to be expected from technological advances, focusing particularly on surgical planning and the control of intraoperative deformity correction by pre-shaped cutting blocks.

R J M Morrison, W G Fishley, K S Rankin, and M R Reed


Vitamin D deficiency has been linked to poorer outcomes following hip (THR) and knee (TKR) replacement. We review the effect of peri-operative supplementation on clinical and patient-reported outcomes following THR/TKR.


This study was registered with PROSPERO (CRD42021238086). Searches of electronic databases were performed from inception to March 2021. All randomised, cohort, or case-controlled studies reported in English of adults undergoing THR/TKR where vitamin D supplementation was given peri-operatively and at least one outcome was reported were included. Studies reporting on vitamin D in relation to osteoporosis and hip fracture were excluded, as were conference abstracts and those involving preclinical models. Risks of bias were performed using the RoB-2 and ROBINS-I tools.


Three studies comprising 413 TKR patients were identified; two were randomised controlled trials and one was a prospective cohort study. No studies meeting the inclusion criteria reported on the outcomes following THR. Supplementation was associated with a statistically significant reduction in the IL6:IL10 ratio at 24- and 48h following surgery, but no effect was noted on Western Ontario and McMaster Universities Osteoarthritis Index scores or the rates of falls. All studies were judged to be limited by bias, with heterogeneity in the supplementation dose and timing of administration, as well as the reported outcome measures used.


Further adequately powered randomised-controlled trials using vitamin D supplementation and a specific clinically relevant or patient-reported outcome measure are required to assess if pre-operative vitamin D insufficiency is a modifiable risk factor to improve outcomes following THR/TKR.

Joost van Tilburg and Mikkel Rathsach Andersen


Due to substantial increase in obesity, the demand for total knee arthroplasty (TKA) in obese and morbidly obese patients is higher than ever. This review aims to investigate mid- to long-term complications, revision rates, and outcome for morbidly obese, compared with non-obese after TKA.


A systematic search was conducted in May 2021. Included studies reported revision rates for morbidly obese and non-obese with a mean follow-up of at least 2 years. Reported knee society score (KSS) has been used to compare the functional outcome. PRISMA protocol was followed, and PROSPERO registered (ID: CRD42021254119).


From 12 studies that met the inclusion criteria, a total of 1031 cases of morbidly obese and 9797 cases of non-obese controls were included. The risk ratio for revision was 1.48 for the morbidly obese, compared with non-obese (95% CI: 0.98 to 2.24; P = 0.06). Regarding aseptic and septic revision, the risk ratio was 1.44 (95% CI: 0.64 to 3.25; P  = 0.37) and 2.22 (95% CI: 0.89 to 5.57; P  = 0.09), respectively. The morbidly obese scored lower in Objective Knee Society Score (OKSS) and Functional Knee Society Score (FKSS) both preoperatively and postoperatively, compared with the non-obese; however, the two groups improved equally in function scores OKSS (P= 0.967) and FKSS (P  = 0.834). Overall risk ratio for complications was 1.56 (95% CI: 0.98 to 2.48; P  = 0.06).


The gained benefit in functional outcome surpasses the increase in risk of revision and complications for the morbidly obese in TKA surgery.