BACKGROUND:Robotic systems are being increasingly used to assist with total knee replacement (TKR). Whether robotic systems improve outcomes after TKR is uncertain. We aimed to ascertain the clinical efficacy and cost-effectiveness of the Mako robotic-arm system compared with conventional instruments for TKR. METHODS:We conducted a participant-masked and assessor-masked pragmatic, superiority, randomised controlled trial at ten hospitals in Great Britain involving 33 surgeons. Patients with advanced knee osteoarthritis underwent TKR with conventional instruments (cTKR) or with the Mako robotic-arm-assisted system (rTKR). Key exclusion criteria were inflammatory arthropathy, previous fracture, or the need for complex implants. Participants were randomly assigned (1:1) through a remote computer system using minimisation by age, BMI, centre, surgeon, and primary knee compartment involved. Participants and assessors were masked through methods including using sham incisions, additional draping, and masked operation notes. The primary outcome was the Forgotten Joint Score (FJS) at 12 months after randomisation according to the intention-to-treat principle using a linear mixed-effects model. The prespecified target difference was 12 points. The trial is registered with ISRCTN (ISRCTN27624068), and long-term follow-up is ongoing. FINDINGS:Between Dec 21, 2021, and Dec 13, 2023, 807 patients were screened and 339 were randomly assigned: 168 to rTKR and 171 to cTKR. The median age was 68·8 years (IQR 61·3-75·2), 167 (49%) were female, and 172 (51%) were male. At 12 months, the mean FJS was 49·2 (SD 28·4; n=154) in the rTKR group and 50·2 (29·9; n=158) in the cTKR group. The adjusted mean difference was -1·5 (95% CI -7·5 to 4·5; p=0·62,) favouring cTKR. 16 participants in each group had one serious adverse event. INTERPRETATION:In this pragmatic trial, rTKR as delivered in routine practice was more costly than cTKR and did not provide a clinically meaningful patient benefit at 12 months after randomisation. The two groups had similar safety (ie, harms) profiles. FUNDING:UK National Institute for Health and Care Research Health Technology Assessment Programme.

Aims:Bi-unicompartmental knee arthroplasty (Bi-UKA) is a bone-conserving, cruciate-sparing alternative to total knee arthroplasty (TKA). Patient-reported outcome measures (PROMs) do not differ between procedures. Conflicting data exist on gait preservation, and little is known about physical activity (PA) outcomes. PA is understudied in arthroplasty, despite its links with all-cause mortality. We compared PA volume and intensity in patients randomized to Bi-UKA or TKA. Methods:We analyzed 38 TKA and 31 Bi-UKA patients from a prospective randomized controlled trial. A triaxial accelerometer was worn on the surgical thigh for seven days, with a three-day minimum wear criterion. Data were collected preoperatively, and at one and two years postoperatively. Outcomes were PA energy expenditure (PAEE), moderate-to-vigorous intensity PA (MVPA), light-intensity PA (LPA), and sedentary time (ST), plus proportional PAEE by intensity. Group differences were assessed with mixed-effects models including baseline PA and biphasic gait as covariates. Spearman's rank correlation between PROMs and PA was performed. Results:Preoperative characteristics were comparable. Activity levels were higher following surgery, but postoperative differences in PAEE, MVPA, LPA, or ST between groups failed to reach statistical significance. Baseline PAEE (β =+ 0.27, p = 0.037) and MVPA (β =+ 0.25, p = 0.024) were associated with improvements in postoperative activity. Postoperative correlations between PROMs and objective PA were weak across groups, and appeared to diminish over time. Conclusion:Although free-living PA improved following Bi-UKA and TKA, differences between groups failed to reach statistical significance. Across both procedures, habitual and behavioural factors appear to be stronger determinants of postoperative PA than surgical procedure, as reflected by the limited correlation between PROMs and objective PA. Larger, long-term randomized studies are needed to confirm these findings.

RoBi-UKA is a bone-conserving, cruciate-sparing alternative to TKA. Patient-reported outcome measures (PROMs) do not differentiate the procedures, and conflicting data exists on physiological gait preservation. Physical activity (PA) is an understudied phenomenon in arthroplasty, especially given its strong causal link with cardiometabolic disease and all-cause mortality. The World Health Organization (WHO) recommends at least 150–300minutes of moderate-intensity PA or 75–150minutes of vigorous-intensity PA per week to maintain health. We compared levels of PA using a highly reliable and valid objective measure device in patients randomised to RoBi-UKA or TKR. We analysed 55 patients from a prospective, single centre, RCT. 33 received TKA and 22 underwent RoBi-UKA. The ActivPal accelerometer was worn on their dominant thigh for 24 hours per day for seven days. Data for three consecutive days was analysed at pre-op, one-year post-op and at two years. EQ-5D-3L, EuroQol, Forgotten Joint Score, New Knee Society Score, Oxford Knee Score, and UCLA scores were also collected. Moderate-to-Vigorous Physical Activity (MVPA) increased from 26.6mins/day to 28.6mins/day at one-year postop and 29.3 mins/day at two-years postop for RoBi-UKA. MVPA for TKA initially fell from 24.5mins/day to 24.2mins/day at one-year but rose to 26.6mins/day at two-years, also reflected in PROMs. No statistically significant differences in PA were seen between the two groups at any time point. RoBi-UKA offers a faster recovery to PA levels which are within the weekly WHO recommendations. TKA patients drop PA to lower than arthritic levels at one-year postop but reach RoBi-UKA levels at two years.

AimsThe aim of this study was to perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted medial unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).MethodsTen-year follow-up of patients who were randomized to rUKA (n = 64) or mUKA (n = 65) was performed. Patients completed the EuroQol five-dimension health questionnaire preoperatively, at three months, and one, two, five, and ten years postoperatively, which was used to calculate quality-adjusted life years (QALY) gained and the incremental cost-effectiveness ratio (ICER). Costs for the index and additional surgery and healthcare costs were calculated.ResultsmUKA had a lower survival for reintervention (84.8% (95% CI 76.2 to 93.4); p = 0.001), all-cause revision (88.9% (95% CI 81.3 to 96.5); p = 0.007) and aseptic revision (91.9% (95% CI 85.1 to 98.7); p = 0.023) when compared to the rUKA group at ten years, which was 100%. The rUKA group had a greater QALY gain per patient (mean difference 0.186; p = 0.651). Overall rUKA was the dominant intervention, being cost-saving and more effective with a greater health-related quality of life gain. On removal of infected reinterventions (n = 2), the ICER was £757 (not discounted) and £481 (discounted). When including all reintervention costs, rUKA was cost-saving when more than 100 robotic cases were performed per year. When removing the infected cases, rUKA was cost-saving when undertaking more than 800 robotic cases per year.ConclusionrUKA had lower reintervention and revision risks at ten years, which was cost-saving and associated with a greater QALY gain, and was the dominant procedure. When removing the cost of infection, which could be a random event, rUKA was a cost-effective intervention with an ICER (£757) which was lower than the willingness-to-pay threshold (£20,000).Cite this article: Bone Joint J 2025;107-B(1):72–80.

PURPOSE:The objective of this study was to compare the clinical outcomes 2 years following surgery between robotic-arm assisted bi-unicompartmental knee arthroplasty (bi-UKA) compared with conventional mechanically aligned total knee arthroplasty (TKA). METHODS:This is a single-centre, double-blinded, randomised controlled trial comparing bi-UKA and TKA. Patient-reported outcome measures (PROMs) were collected from 60 patients (27 bi-UKA and 33 TKA patients) 2 years following surgery, including Oxford Knee Score (OKS), New Knee Society Score (NKSS), Forgotten Joint Score, EQ-5D-3L, UCLA activity scale, Hospital Anxiety and Depression Scale, Pain and Stiffness Visual Analogue Scales, Satisfaction and Range of Motion. Complications were also recorded at each visit. RESULTS:TKA and bi-UKA continue to offer comparable PROMs. The clinical NKSS demonstrated a significant difference between the two interventions, TKA 59.5 (37-65) versus bi-UKA 26.0 (22-40) (p < 0.001). There were no significant differences shown between the interventions across all time points and remaining outcome measures (OKS at 2-year follow-up; TKA-42.0 [34.0-45.5] vs. bi-UKA-41.0 [28.0-45.0]) or the proportion of participant achieving bi-phasic gait at 2 years following surgery (p = 0.429). There was no difference in complication rates following surgery at 2 years. CONCLUSION:Robotic arm-assisted, cruciate-sparing bi-UKA and mechanically aligned TKA offer similar clinical outcomes 2 years following surgery with no difference in complication rates. Further, follow-up is required to monitor patients as they enter mid/long-term follow-up and determine whether patients will gain long-term benefits from the cruciate-sparing bi-UKA approach. LEVEL OF EVIDENCE:Level I.

Aims The aim of this study was to perform an incremental costutility analysis and assess the impact of differential costs and case volume on the costeffectiveness of robotic arm- assisted medial unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA). Methods Ten- year follow- up of patients who were randomized to rUKA (n = 64) or mUKA (n = 65) was performed. Patients completed the EuroQol five- dimension health questionnaire preoperatively, at three months, and one, two, five, and ten years postoperatively, which was used to calculate quality- adjusted life years (QALY) gained and the incremental costeffectiveness ratio (ICER). Costs for the index and additional surgery and healthcare costs were calculated. Results mUKA had a lower survival for reintervention (84.8% (95% CI 76.2 to 93.4); p = 0.001), all- cause revision (88.9% (95% CI 81.3 to 96.5); p = 0.007) and aseptic revision (91.9% (95% CI 85.1 to 98.7); p = 0.023) when compared to the rUKA group at ten years, which was 100%. The rUKA group had a greater QALY gain per patient (mean difference 0.186; p = 0.651). Overall rUKA was the dominant intervention, being costsaving and more effective with a greater health- related quality of life gain. On removal of infected reinterventions (n = 2), the ICER was 757 pound (not discounted) and 481 pound (discounted). When including all reintervention costs, rUKA was costsaving when more than 100 robotic cases were performed per year. When removing the infected cases, rUKA was costsaving when undertaking more than 800 robotic cases per year. Conclusion rUKA had lower reintervention and revision risks at ten years, which was costsaving and associated with a greater QALY gain, and was the dominant procedure. When removing the cost of infection, which could be a random event, rUKA was a costeffective intervention with an ICER (757) pound which was lower than the willingness- to- pay threshold (20,000) pound.

Summary: Background: Selenium is an essential trace element and its deficiency can lead to dysfunction in multiple areas. Selenium status is commonly assessed by its measurement in plasma but this may be an unreliable marker in patients with systemic inflammatory response (SIR). Erythrocyte selenium is an alternative marker that appears not to be perturbed by the SIR. Objectives: Examine the effect of the magnitude of acute and chronic SIR on plasma and erythrocyte selenium concentrations. Methods: Acute inflammation: Blood samples were collected in patients (n=16) undergoing elective knee arthroplasty pre-operatively and post-operatively (24 and 48 hours and 3 months). Chronic inflammation: Blood samples were collected in patients receiving nutritional support who presented for routine micronutrient screening (n = 3798). CRP was used as a marker of inflammation. Plasma and erythrocyte selenium concentrations were divided into 3 inflammatory groups: minor, moderate and major defined as CRP<10, 11–80, >80 mg/L. Results: Plasma selenium concentrations reduced with increasing CRP concentrations from minor to moderate to major inflammation (P<0.001), whereas erythrocyte selenium concentrations only reduced in chronic major inflammation. In both acute and chronic inflammation, median plasma selenium concentrations were within the local laboratory defined reference interval (0.75–1.50 μmol/L) with minor and moderate inflammation, whereas in major inflammation they were below the reference interval. In contrast, median erythrocyte selenium concentrations remained within the local laboratory defined reference interval (3.0–9.0 nmol/g haemoglobin) in the context of minor, moderate and major inflammation in both acute and chronic inflammation cohorts. Furthermore, in the chronic inflammation cohort, concordance between plasma and erythrocyte selenium concentrations at the lower limit of the reference intervals decreased from 84% of patients with minor inflammation, to 66% and 44% in patients with moderate and major inflammation respectively. Conclusion: In both acute and chronic inflammation, plasma selenium concentrations fell significantly with rising CRP, whereas erythrocyte selenium concentrations were less affected. IRAS: 225557. ClinicalTrials.gov: NCT03554668.

Introduction: Tibial plateau fractures are complex, peri-articular fractures that can have poor outcomes resulting in conversion to total knee arthroplasty (TKA). This study evaluates the 10-year survival of tibial plateau fractures treated with open reduction and internal fixation and identifies risk factors associated with conversion to TKA. Methods: This retrospective cohort study evaluates the outcomes of 126 patients undergoing tibial plateau ORIF from January 2011 to December 2012 at Glasgow Royal Infirmary. As well as patient factors, radiographic assessments were analysed including the degree of articular depression, medial proximal tibial angle, and femoral width ratio preoperatively, peri-operatively and at the time of union. Patients requiring further surgical intervention, including TKA, were evaluated further. Results: A bell-shaped distribution of patient age was observed. Schatzker II fractures were most prevalent (48%). Pre-operative articular depression averaged 6.9 mm ranging from 0.0 - 36.0 mm. Operative reduction was generally satisfactory (mean articular depression 1.3 mm, femoral width 0.96, mPTA 89.6(0)), with 82% achieving an anatomical reduction. 12 patients (9.3%) required TKA during follow-up with Kaplan-Meier calculated as 91.9% at 5 years and 87.4% at 10 years. Articular depression > 4 mm (HR = 16.2), femoral width ratio > 1.05 (HR = 14.7) and age > 50 years (HR = 4.2) at time for fracture union were independently associated with progression to TKA. Conclusion: 9.3% of patients required TKA within 10 years of tibial plateau ORIF, Kaplan Meier 10-year survivorship was 87.4%. Joint depression and increased tibial width at time of union and age were independent risk factors associated with need for TKA. Particular care must be taken during operative intervention to ensure adequate reduction to lower this risk. Crown Copyright (c) 2024 Published by Elsevier B.V. All rights reserved.

Objectives: Anterior cruciate ligament (ACL) repair for proximal tears, where the ligament is re-attached and augmented with suture tape, can negate the need for graft harvest, thereby maintaining native anatomy. Autograft harvest has been associated with persistent deficits in lower limb muscle strength after recovery from ACL reconstruction. The aim of this study is to compare lower limb muscle strength following ACL repair and reconstruction. Methods: Nineteen ACL repair patients augmented with suture tape and nineteen ipsilateral semitendinosusgracilis autograft ACL reconstruction patients (both mean 4 years postoperatively) were recruited, along with twenty healthy volunteers. Patient-reported outcome measures (PROMs) were obtained using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner scores. Maximal isometric quadriceps and hamstring strength at 90 degrees knee flexion were measured using a fixed Myometer after a warm-up and three maximal-effort contractions. Results: Mean hamstring strength of the reconstructed legs was lower than that of healthy volunteers by 0.29 Nm/ kg. The hamstring strength ratio of the operated side to the uninjured side was greater in the repair (95% +/- 13) than in the reconstruction (81% +/- 18) group. There were no statistically significant differences between sides for quadriceps peak torque or for hamstrings in the volunteer or repair group. PROMs scores for the reconstruction group were significantly lower than volunteers across all domains and lower than repair for KOOS activities of daily living and Lysholm scores. Conclusion: Hamstring weakness seen following ACL reconstruction is not evident following ACL repair with suture tape augmentation. Strength asymmetry could contribute to re-injury risk and influence functional performance, while altered loads affect knee biomechanics and may lead to osteoarthritis progression. The absence of these deficits in the repair group demonstrates a potential benefit of this technique when used in appropriate patients. Level of evidence: II.

Abstract Aim This study represents one of the largest clinical case series' evaluating long-term outcomes following surgical fixation of tibial plateau fractures over a 10-year follow-up. The primary aim is to evaluate the incidence of TKR and risk-factors associated with poor outcomes. Method Patients receiving surgical fixation of tibial plateau fractures between 2008 – 2012 were included. Those requiring arthroplasty or endoprosthesis post-injury were excluded. PACs was used to analyse case notes and radiographic imaging. Articular reduction and alignment (mPTA) were measured using pre-operative radiographs. Comparisons were made with radiographs post-fracture union (6-weeks to 6-months), assessing fracture reduction maintenance. Long-term outcomes were assessed for patients receiving imaging thereafter. Patients were checked using the Scottish National Imaging Archive. Results 130 patients presented various fractures (Schatzker I-III n = 78, IV n = 12, V n = 9, VI n = 29) and 2 open-fractures. 32 patients required further surgery, 13 required multiple operations - resulting in 47 operations. These included metalwork removal (n = 28, 21.5%), TKR (n = 12, 9.2%), washout for infection (n = 3, 2.3%), osteotomy (n = 2, 1.5%), sequestrectomy (n = 1, 0.8%), and above knee amputation (n = 1, 0.8%). ≥ 2mm articular reduction was maintained in the majority (84%); however, good articular reduction did not prevent progression to arthroplasty (average step 1.4mm in TKR versus 1.8mm in non-TKR). Good alignment correlated with favourable outcomes - average mPTA being 90.8° in non-TKR versus 93.5° in TKR. Conclusions These findings support previous literature in this field demonstrating that malalignment, rather than articular depression, increases the risk for post-traumatic arthritis requiring arthroplasty. The incidence of TKR after tibial plateau fracture fixation at 10-years was 9.2%.

PurposeThis study was to evaluate the survivorship of HTO for the treatment of medial compartment osteoarthritis (OA) in young and active patients from two teaching hospitals in a single city.MethodsThis is a retrospective cohort multicenter study looking at HTO for treatment of medial compartment OA. We analyzed a case series of HTO's performed by four surgeons in two centres over a 14-year period. Failure was defined as conversion to total knee replacement (TKR). All cases where additional procedures for instability of the knee were performed at the time of the index surgery were excluded. Time to failure was recorded, and a Kaplan-Meir (KM) analysis was performed to evaluate survivorship. Univariate binary regression analysis was undertaken to identify associations between risk factors and failure.ResultsA total of 96 patients were included in the study with a median age was 45 years. The survivorship at five years post-op was 90.3%, and at ten years post-op, it was 82%. Patients that were 14 years after surgery had a survivorship of 65%. Also, 18.8% of patients required the removal of their metalwork. The overall complication rate was 6.3%. The univariate regression analysis showed that higher age (p = 0.02) and larger corrections requiring the use of bone graft increased the risk of failure (p = 0.02). There was no statistically significant correlation between laterality, gender, complication rate, and pre-operative alignment to survivorship.ConclusionThis is one of the largest reported case series of HTO's with comparable survivorship at five and ten year follow-up compared to the reported literature. There was an association found between increasing age and larger corrections requiring bone graft at index procedure to increasing failure rate.

Computer-assisted surgery (CAS) total knee arthroplasty (TKA) remains a controversial area of surgical practice. The aim of this study is to report the ten-year revision rates and patient-reported outcome measures (PROMS) of a single-blinded, prospective, randomised controlled trial comparing electromagnetically (EM) navigated and conventional TKA. 199 patients were randomised to receive either EM navigated or conventional TKA where the aim of implantation was neutral mechanical alignment in all cases. Ten-year revision rates were collated and compared between the two intervention groups. Longitudinal PROMS data was collected prospectively at various time points up to 10 years post-operatively. Over the ten-year period, there were 23 deaths (22.8

AimsTo perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).MethodsThis was a five-year follow-up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ-5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated.ResultsrUKA was associated with a relative 0.012 QALY gain at five years, which was associated with an incremental cost per QALY of £13,078 for a unit undertaking 400 cases per year. A cost per QALY of less than £20,000 was achieved when ≥ 300 cases were performed per year. However, on removal of the cost for a revision for presumed infection (mUKA group, n = 1) the cost per QALY was greater than £38,000, which was in part due to the increased intraoperative consumable costs associated with rUKA (£626 per patient). When the absolute cost difference (operative and revision costs) was less than £240, a cost per QALY of less than £20,000 was achieved. On removing the cost of the revision for infection, rUKA was cost-neutral when more than 900 cases per year were undertaken and when the consumable costs were zero.ConclusionrUKA was a cost-effective intervention with an incremental cost per QALY of £13,078 at five years, however when removing the revision for presumed infection, which was arguably a random event, this was no longer the case. The absolute cost difference had to be less than £240 to be cost-effective, which could be achieved by reducing the perioperative costs of rUKA or if there were increased revision costs associated with mUKA with longer follow-up.Cite this article: Bone Jt Open 2023;4(11):889–899.

Aims To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).Methods This was a five year follow up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ- 5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated.Results rUKA was associated with a relative 0.012 QALY gain at five years, which was associated with an incremental cost per QALY of 13,078 pound for a unit undertaking 400 cases per year. A cost per QALY of less than 20,000 pound was achieved when >= 300 cases were performed per year. However, on removal of the cost for a revision for presumed infection (mUKA group, n = 1) the cost per QALY was greater than 38,000 pound, which was in part due to the increased intraoperative consumable costs associated with rUKA (626 pound per patient). When the absolute cost difference (operative and revision costs) was less than 240 pound, a cost per QALY of less than 20,000 pound was achieved. On removing the cost of the revision for infection, rUKA was cost-neutral when more than 900 cases per year were undertaken and when the consumable costs were zero.Conclusion rUKA was a cost-effective intervention with an incremental cost per QALY of 13,078 pound at five years, however when removing the revision for presumed infection, which was arguably a random event, this was no longer the case. The absolute cost difference had to be less than 240 pound to be cost-effective, which could be achieved by reducing the perioperative costs of rUKA or if there were increased revision costs associated with mUKA with longer follow up.

Background: Anterior cruciate ligament reconstructions (ACLR) fail at a rate of 10-15%, with graft impingement often a cause. In this study we investigate the prevalence and causes of impingement seen during ACLR surgery. Methods: We reviewed consecutive primary ACLR from 2012-2018. Graft impingement was estimated intraoperatively by placing the arthroscope through the tibial tunnel and passively extending the knee, observing how much was obscured by the lateral femoral condyle from an anterior and lateral direction. Preoperative MRI scans were used to measure the intercondylar notch; Notch Width Index (NWI) and Notch Depth Index (NDI). Positioning of the tunnels was determined on postoperative radiographs. Results: There were 283 ACLRs performed with 33 failures diagnosed on MRI (11.7%). 257 patients had complete imaging and follow up (91%). The mean age was 28 (+/- 9) years and mean follow-up 5.3 (+/- 1.8) years. The mean NWI was 0.26(+/- 0.03), and NDI was 0.49(+/- 0.06). The tibial tunnel aperture was located 42(+/- 6) % of the way from anterior-posterior and 39 (+/- 6) % from medial-lateral. Impingement requiring a notchplasty was observed in 80% of cases, with lateral impingement more prominent. Conclusions: The amount of impingement did not correlate with tunnel position, which was located within the recommended area. There was a weak negative correlation between NWI and lateral impingement (r(s) = -0.16, p = 0.01), and NDI and anterior impingement (r(s) = -0.12, p = 0.04), therefore a smaller notch is associated with greater impingement. Despite optimal tunnel positioning, impingement still occurs in a significant number of cases therefore notchplasty should always be considered to keep revision rates low. (C) 2022 Elsevier B.V. All rights reserved.

INTRODUCTIONRupture of the anterior cruciate ligament (ACL) often occurs in conjunction with meniscal tears. In this study, we investigate the rates and outcomes of meniscal repair surgery performed with ACL reconstruction compared with acute ACL repair surgery.MATERIALS AND METHODSData was collected for all patients undergoing surgery for ACL ruptures between 2012 and 2018, including ACL reconstruction with hamstring autograft and primary ACL repair augmented with suture tape. Patients undergoing multi-ligament surgery were excluded. Meniscal injury was evaluated intraoperatively and the treatment was determined by type of tear, reducibility, and quality of meniscal tissue. If possible, tears were repaired using all-inside anchors and all others were resected.RESULTSThere were 272 ACL reconstructions and 134 ACL repairs, and mean age was 28 (±9) and 35 (±14) years, respectively (p <0.01). The mean Tegner activity score was 6.6 in both groups. The mean interval from injury to surgery was longer in the reconstruction group (26.2 vs. 1.3 months, p <0.01). Fifty-five percent of reconstructions and 43% of ACL repairs required meniscal surgery at the time of their ACL procedure. In the reconstruction group, 123 (70%) were meniscectomies and 53 (30%) were meniscal repairs, compared to 31 (50%) of each in the ACL repair group. Meniscal repair was more likely to be possible when carried out as part of acute ACL repair surgery, c2(1, n=238)=7.94, p <0.01. The success rate of meniscal repair was 97% in both groups.CONCLUSIONSThe rate of meniscal repair is 67% higher when performed early with ACL repair. When ACL reconstruction is performed, meniscal resection was more likely. Rates of post-traumatic osteoarthritis are high after ACL reconstruction when performed with meniscal resection. Furthermore, the success rate of meniscal repair in conjunction with ACL surgery is high (97%). Therefore, meniscal repair should be encouraged whenever possible to improve long-term outcomes.

Purpose The aim of this study was to determine the frequency of secondary surgery following anterior cruciate ligament (ACL) repair with suture tape augmentation in comparison to conventional hamstring ACL reconstruction. We hypothesised that there would be no differences between the groups.Methods This was a retrospective comparison study of patients undergoing ACL surgery between September 2011 and April 2018. Two hundred and 73 patients underwent ACL reconstruction using hamstring autograft. During the same timeframe, 137 patients with an acute proximal ACL rupture underwent ACL repair with suture tape augmentation. One patient was lost to follow-up in the ACL reconstruction group leaving 272 patients (99.6%) for the final analysis. In the ACL repair group, three patients were lost to follow-up leaving 134 patents (97.8%) for the final analysis. Secondary surgery was identified by contacting the patients by email/telephone and reviewing patient notes at the time of this analysis.Results Re-rupture occurred in 32 patients (11.8%) in the ACL reconstruction group compared to 22 patients (16.4%) in the ACL repair group (p = 0.194). Contralateral ACL rupture occurred in four patients (1.5%) in the ACL reconstruction group compared to three patients (2.2%) in the ACL repair group (p = 0.224). In the ACL reconstruction group, nine patients (3.3%) required secondary meniscal surgery whilst five patients (3.7%) required meniscal surgery in the ACL repair group (p = 0.830). Seven other operations were performed in the ACL reconstruction group (2.6%) compared to three other operations in the ACL repair group (2.2%) (p = 0.374). The overall number of patients undergoing secondary surgery in the ACL reconstruction group was 52 (19.1%) in comparison to 30 (22.4%) in the ACL repair group (p = 0.114).Conclusion ACL repair with suture tape augmentation for acute proximal ruptures demonstrated comparable rates of secondary surgery with hamstring ACL reconstruction.

Background: Primary repair of anterior cruciate ligament (ACL) ruptures has re-emerged as a treatment option for proximal tears, with internal brace augmentation often utilised. The aim of this study is to provide an overview of the current evidence presenting outcomes of ACL repair with internal bracing to assess the safety and efficacy of this technique.Methods: All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears, augmented with internal bracing from 2014-2021 were included. Primary outcome was failure rate and secondary outcomes were subjective patient reported outcome measures (PROMs) and objective assessment of anteroposterior knee laxity.Results: Nine studies were included, consisting of 347 patients, mean age 32.5 years, mean minimum follow up 2 years. There were 36 failures (10.4%, CI 7.4% -14.1%). PROMs reporting was variable across studies. KOOS, Lysholm and IKDC scores were most frequently used with mean scores > 87%. The mean Tegner and Marx scores at follow-up were 6.1 and 7.8 respectively. The mean side to side difference measured for anteroposterior knee laxity was 1.2mm. Conclusions: This systematic review with meta-analysis shows that ACL repair with internal bracing is a safe technique for treatment of proximal ruptures, with a failure rate of 10.4%. Subjective scores and clinical laxity testing also revealed satisfactory results. This suggests that ACL repair with internal bracing should be considered as an alternative to ACL reconstruction for acute proximal tears, with the potential benefits of retained native tissue and proprioception, as well as negating the need for graft harvest.(c) 2022 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

AIMS:The aim of this study was to compare any differences in the primary outcome (biphasic flexion knee moment during gait) of robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) at one year post-surgery.METHODS:A total of 76 patients (34 bi-UKA and 42 TKA patients) were analyzed in a prospective, single-centre, randomized controlled trial. Flat ground shod gait analysis was performed preoperatively and one year postoperatively. Knee flexion moment was calculated from motion capture markers and force plates. The same setup determined proprioception outcomes during a joint position sense test and one-leg standing. Surgery allocation, surgeon, and secondary outcomes were analyzed for prediction of the primary outcome from a binary regression model.RESULTS:Both interventions were shown to be effective treatment options, with no significant differences shown between interventions for the primary outcome of this study (18/35 (51.4%) biphasic TKA patients vs 20/31 (64.5%) biphasic bi-UKA patients; p = 0.558). All outcomes were compared to an age-matched, healthy cohort that outperformed both groups, indicating residual deficits exists following surgery. Logistic regression analysis of primary outcome with secondary outcomes indicated that the most significant predictor of postoperative biphasic knee moments was preoperative knee moment profile and trochlear degradation (Outerbridge) (R2 = 0.381; p = 0.002, p = 0.046). A separate regression of alignment against primary outcome indicated significant bi-UKA femoral and tibial axial alignment (R2 = 0.352; p = 0.029), and TKA femoral sagittal alignment (R2 = 0.252; p = 0.016). The bi-UKA group showed a significant increased ability in the proprioceptive joint position test, but no difference was found in more dynamic testing of proprioception.CONCLUSION:Robotic arm-assisted bi-UKA demonstrated equivalence to TKA in achieving a biphasic gait pattern after surgery for osteoarthritis of the knee. Both treatments are successful at improving gait, but both leave the patients with a functional limitation that is not present in healthy age-matched controls. Cite this article: Bone Joint J 2022;103-B(4):433-443.

Aims This systematic review aims to compare the precision of component positioning, patient-reported outcome measures (PROMs), complications, survivorship, cost-effectiveness, and learning curves of MAKO robotic arm-assisted unicompartmental knee arthroplasty (RAUKA) with manual medial unicompartmental knee arthroplasty (mUKA). Methods Searches of PubMed, MEDLINE, and Google Scholar were performed in November 2021 according to the Preferred Reporting Items for Systematic Review and Meta-­Analysis statement. Search terms included “robotic”, “unicompartmental”, “knee”, and “arthroplasty”. Published clinical research articles reporting the learning curves and cost-effectiveness of MAKO RAUKA, and those comparing the component precision, functional outcomes, survivorship, or complications with mUKA, were included for analysis. Results A total of 179 articles were identified from initial screening, of which 14 articles satisfied the inclusion criteria and were included for analysis. The papers analyzed include one on learning curve, five on implant positioning, six on functional outcomes, five on complications, six on survivorship, and three on cost. The learning curve was six cases for operating time and zero for precision. There was consistent evidence of more precise implant positioning with MAKO RAUKA. Meta-analysis demonstrated lower overall complication rates associated with MAKO RAUKA (OR 2.18 (95% confidence interval (CI) 1.06 to 4.49); p = 0.040) but no difference in re-intervention, infection, Knee Society Score (KSS; mean difference 1.64 (95% CI -3.00 to 6.27); p = 0.490), or Western Ontario and McMaster Universities Arthritis Index (WOMAC) score (mean difference -0.58 (95% CI -3.55 to 2.38); p = 0.700). MAKO RAUKA was shown to be a cost-effective procedure, but this was directly related to volume. Conclusion MAKO RAUKA was associated with improved precision of component positioning but was not associated with improved PROMs using the KSS and WOMAC scores. Future longer-term studies should report functional outcomes, potentially using scores with minimal ceiling effects and survival to assess whether the improved precision of MAKO RAUKA results in better outcomes. Cite this article: Bone Joint J 2022;104-B(5):541–548.