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Wautier D, Thienpont E. Appearance and evolution of radiolucent lines below the tibial implant in primary total knee arthroplasty. Arch Orthop Trauma Surg 2024; 144:1333-1344. [PMID: 37878076 DOI: 10.1007/s00402-023-05100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/30/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND The aim of this study was to evaluate total knee arthroplasty (TKA) radiographically to detect the occurrence of radiolucent lines (RLL) under the tibial base plate and to determine what type of RLL may have a correlation with aseptic loosening (AL). The study had two hypotheses: (1) RLLs may have different radiological aspects and evolutions in time depending of different factors (2) Signs of micro- and/or macro-mobility of the implant are necessary before diagnosing aseptic loosening of the tibial component. METHODS Retrospective cohort study of 774 patients operated with a Vanguard TKA (Zimmer Biomet, Warsaw, IN, US) from 2007 to 2015. RLLs were recorded in a database and described according to their radiological aspect, localization, time of apparition, progression and eventual evolution to AL. Other collected parameters were pre- and post-operative HKA angles, amount of post-operative HKA correction, surgical, clinical and demographic data. RESULTS 178/774 TKAs (23%) showed RLLs under the tibial base plate including 9 (1.2%) tibial implants needing revision for AL. Three different types and two aspects of RLLs were observed. Important deformity corrections or undercorrected implants were recognized as a mechanical risk factor for loosening. Elderly women with osteoporosis and young men with important pre-operative deformities were identified as clinical risk factors for RLLs. CONCLUSIONS RLLs are frequently present at the epiphyseal bone/implant interface after total knee arthroplasty, but do not mean the implant is loose. They can be considered a sign of reduced epiphyseal surface fixation due to micro mobility of the tibial implant. Aseptic loosening can be observed radiologically when signs of macro-mobility of the implant are present at the metaphyseal level. LEVEL OF EVIDENCE III.
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Affiliation(s)
- D Wautier
- Department of Orthopedic Surgery, CHU UCL Namur, Godinne, Avenue Docteur Gaston Therasse 1, 5530, Yvoir, Belgium.
| | - E Thienpont
- Department of Orthopedic Surgery, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Flury A, Hoch A, Cirigliano G, Hodel S, Kühne N, Zimmermann SM, Vlachopoulos L, Fucentese SF. Excessive femoral torsion is not associated with patellofemoral pain or instability if TKA is functionally aligned and the patella denervated. Knee Surg Sports Traumatol Arthrosc 2023; 31:3665-3671. [PMID: 36114342 PMCID: PMC10435632 DOI: 10.1007/s00167-022-07162-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Recent data suggest that individual morphologic factors should be respected to restore preoperative patellofemoral alignment and thus reduce the likelihood of anterior knee pain. The goal of this study was to investigate the effect of excessive femoral torsion (FT) on clinical outcome of TKA. METHODS Patients who underwent TKA and complete preoperative radiographic evaluation including a long-leg radiograph and CT scan were included. 51 patients showed increased FT of > 20° and were matched for age/sex to 51 controls (FT < 20°). Thirteen patients were lost to follow-up. Thirty-eight matched pairs were compared after a 2 year follow-up clinically (Kujala and patellofemoral score for TKA) and radiographically (FT, frontal leg axis, TT-TG, patellar thickness, patellar tilt, and lateral displacement of patella). Functional alignment of TKA was performed (hybrid-technique). All patellae were denervated but no patella was resurfaced. RESULTS There was no significant difference between clinical scores two years after surgery between patients with normal and excessive FT (n.s.). Kujala score was 64.3 ± 16.7 versus 64.8 ± 14.4 (n.s.), and patellofemoral score for TKA was 74.3 ± 21 versus 78.5 ± 20.7 (n.s.) for increased FT group and control group, respectively. There was no correlation between preoperative FT and clinical scores. Other radiographic parameters were similar between both groups. No correlations between clinical outcomes and preoperative/postoperative frontal leg axis or total leg axis correction were found (n.s.). CONCLUSION If the leg axis deformity is corrected to a roughly neutral alignment during cemented TKA, including patellar denervation, then excessive FT was not associated with patellofemoral pain or instability. LEVEL OF EVIDENCE Prospective comparative study, level II.
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Affiliation(s)
- Andreas Flury
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland.
| | - Armando Hoch
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Gabriele Cirigliano
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Sandro Hodel
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Nathalie Kühne
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Stefan M Zimmermann
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
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Grabherr M, Dimitriou D, Schraknepper J, Helmy N, Flury A. Hybrid fixation of unicompartmental knee arthroplasty shows equivalent short-term implant survivorship and clinical scores compared to standard fixation techniques. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04710-z. [PMID: 36459235 DOI: 10.1007/s00402-022-04710-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION There is a paucity of data regarding hybrid-fixated unicompartmental knee arthroplasty (UKA), and no study directly compared all three available fixation techniques (cementless, cemented, and hybrid). The hypothesis was that hybrid fixation might have a lower incidence of radiolucent lines (RLL) than cemented UKA, with equivalent outcomes to uncemented UKA. MATERIALS AND METHODS A total of 104 UKA with a minimal follow-up of 1 year were retrospectively included, of which 40 were cemented, 41 cementless, and 23 hybrid prostheses. The functional outcomes scores included the Oxford Knee (OKS), Subjective Knee (SKS), and Forgotten Joint scores (FJS). RLLs, subsidence, and component positioning were assessed on radiographs. RESULTS At a mean follow-up of 28 months, the survival rate was 95% for cemented UKA and 100% for the cementless and hybrid UKA (n.s.), respectively. Postoperative FJS (93 vs. 82 points, p = 0.007) and SKS (4.7 vs. 4.1 points, p = 0.001) were better in cementless than cemented UKA, with hybrid-fixated UKA in between the two (90 and 4.4 points, n.s.). Improvement of OKS preoperatively to postoperatively did not differ between the groups (n.s.). RLLs were more frequent in cemented (23%) compared to cementless (5%, p = 0.021) and hybrid UKA (9%, n.s.). With an incidence of 12%, subsidence occurred more commonly in cementless UKA compared to cemented (5%) and hybrid (0%) (n.s.) UKA. CONCLUSION Hybrid fixation achieves equivalent results to standard UKA fixation techniques regarding implant survival and functional and radiological outcomes. Therefore, the hybrid fixation technique seems to be a valuable alternative as it combines the advantages of cemented tibial components with those of uncemented femoral components. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael Grabherr
- Orthopaedic and Traumatology Department, Bürgerspital Solothurn, Schöngrünstrasse 38, 4500, Solothurn, Switzerland.
| | - Dimitris Dimitriou
- Orthopaedic and Traumatology Department, Bürgerspital Solothurn, Schöngrünstrasse 38, 4500, Solothurn, Switzerland.,Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Johannes Schraknepper
- Orthopaedic and Traumatology Department, Bürgerspital Solothurn, Schöngrünstrasse 38, 4500, Solothurn, Switzerland
| | - Näder Helmy
- Orthopaedic and Traumatology Department, Bürgerspital Solothurn, Schöngrünstrasse 38, 4500, Solothurn, Switzerland
| | - Andreas Flury
- Orthopaedic and Traumatology Department, Bürgerspital Solothurn, Schöngrünstrasse 38, 4500, Solothurn, Switzerland.,Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Pan Y, Jiang B, Li Y, Yu Y, Chen Y. Alignment analysis of Brainlab knee 3 navigation-guided total knee arthroplasty using the adjusted mechanical method. Front Surg 2022; 9:1040025. [DOI: 10.3389/fsurg.2022.1040025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/18/2022] [Indexed: 11/10/2022] Open
Abstract
PurposeWith the application of navigation technology in Total Knee Arthroplasty (TKA), TKA procedures have become various. Studies have shown that navigation can improve the alignment of patients' lower limbs. To verify this conclusion, we collected the clinical data from patients who underwent Brainlab knee 3 navigation-guided TKA. Brainlab knee 3 is a completely new software that takes a different approach to address the current challenges of navigated TKA. During the procedure, we applied the Adjusted Mechanical Alignment (AMA) principle and took soft tissue balance as a priority. We aim to explore the patients’ lower limb alignment changes who underwent the Brainlab knee 3 navigation-guided TKA using the AMA method.MethodsFifty consecutive patients who underwent total knee arthroplasty using the Brainlab knee3 knee navigation system (Smith&Nephew) from January to August 2021 by the same doctor (Yunsu Chen) in the Department of Joint Surgery of the Shanghai Sixth People's Hospital were included. Hip-Knee-Ankle Angle (HKAA), anatomic Femur Tibia Angle (FTA), Lateral Distal Femoral Angle (LDFA), and medial proximal tibia angle (MPTA) were measured on preoperative and postoperative full-length lower-limbs x-ray films or weight-bearing anterior and lateral knee radiographs for observational and descriptive study. The preoperative and postoperative knee alignment changes were analyzed through paired t-test or nonparametric Wilcoxon test using SPSS 25.0 softwareResultsPre-operative and post-operative HKAA both obeyed normal distribution. The mean preoperative HKAA was 169.8° (154.9–178.7°) with a standard deviation of 5.41; the postoperative HKAA was 175.7° (168.4–180.0°) with a standard deviation of 2.81. Using the two-sample paired t-test to analyze, the result showed P = 0.000 < 0.05; a statistically significant difference exists. The preoperative and postoperative FTA obeyed normal distribution as well. The mean preoperative FTA was 174.7° (163.4–179.9°) with a standard deviation of 3.90; postoperative 175.6° (167.0–179.9°) with a standard deviation of 2.77. Using the two-sample paired t-test to analyze, the result showed P = 0.140 > 0.05, the difference was not statistically significant. The preoperative LDFA was normally distributed, while postoperative LDFA was not. The mean preoperative LDFA was 90.7° (83.5–99.6°) with a standard deviation of 3.83; the median of postoperative LDFA was 91.6° (86.0–103.2°) with an interquartile range of 2.93. Using the two-sample paired Wilcoxon test, the result showed P = 0.052 > 0.05; the difference was not statistically significant. Preoperative MPTA obeyed normal distribution, while postoperative MPTA did not. The mean preoperative MPTA was 83.5° (72.7–92.9°), with a standard deviation of 3.66; the median of postoperative MPTA was 89.3° (84.6–95.6°), with an interquartile range of 1.45. Using the two-sample paired Wilcoxon test, the result shows P = 0.000 < 0.05; a statistically significant difference exists.ConclusionIn our study, AMA alignment was applied in Brainlab Knee3 computer navigation-assisted total knee arthroplasty. The femoral and tibial osteotomy angles were minimally adjusted according to soft tissue situations to reduce soft tissue release. We found AMA alignment provides good control of knee alignment in the coronal plane of the lower limbs, which is a reliable technique.
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Accuracy of the Tibial Component Alignment by Extramedullary System Using Simple Radiographic References in Total Knee Arthroplasty. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091212. [PMID: 36143888 PMCID: PMC9505503 DOI: 10.3390/medicina58091212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/26/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: The tibial component alignment is an important issue for the longevity of total knee arthroplasty (TKA). The purpose of our study was to investigate the usefulness of proximal tibial references determined by pre-operative radiography and intraoperative C-arm-guided hip and ankle center marking for the extramedullary guided tibial cut in mild (<10°) and severe (≥10°) varus knee TKA. Materials and Methods: A total of 150 consecutive patients (220 cases) who underwent total knee arthroplasty who were recruited from July 2011 to April 2017 were reviewed retrospectively. Before surgery, the proximal tibial reference point and medio-lateral cut thickness difference were identified. Then, hip and ankle centers were checked using a C-arm intensifier intraoperatively. The hip−knee−ankle (HKA) alignment and medial proximal tibial angle (MPTA) were assessed pre-operatively and post-operatively. More than 3° varus or valgus of HKA alignment or tibial component angle was defined as an outlier. Results: Mean follow-up duration was 26.9 months. Among 220 cases, 111 cases are classified as mild varus group and 109 cases are classified as severe varus group. The HKA alignment is significantly improved (p < 0.001). The average tibial component angle after surgery is 90.1°. A total of 21 cases (9.5%) and 3 cases (1.4%) are classified as outliers of HKA alignment and MPTA, respectively. Among MPTA outliers, one case is in the mild varus group and two cases are in the in severe varus group (p = 0.62). Conclusion: Measurement of proximal tibial radiographic references and checking the C-arm-guided intraoperative hip and ankle center could be helpful to obtain the favorable coronal position of the tibial component in the extramedullary guided tibial cut.
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Lv SJ, Wang XJ, Huang JF, Mao Q, He BJ, Tong PJ. Total knee arthroplasty in Ranawat II valgus deformity with enlarged femoral valgus cut angle: A new technique to achieve balanced gap. World J Clin Cases 2022; 10:6406-6416. [PMID: 35979319 PMCID: PMC9294892 DOI: 10.12998/wjcc.v10.i19.6406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/10/2021] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nearly 10% of patients undergoing primary total knee arthroplasty (TKA) have valgus deformity (VD) of the knee. For severe VD of the knee, a more lateral structural release is needed to achieve balance between medial and lateral space and neutral femorotibial mechanical axis (FTMA), which is challenging and technical.
AIM To introduce a new surgical technique of resection, soft tissue release, and FTMA for Ranawat type-II VD with a 5-year follow-up.
METHODS A retrospective study was conducted on patients who underwent TKA from December 2011 to December 2014. Hip-knee-ankle (HKA), range of motion (ROM), Oxford knee score (OKS), and knee society score (KSS) were used to assess the joint activity of patients in the new theory TKA group (NT-TKA) and were compared with those of the conventional TKA group (C-TKA).
RESULTS A total of 103 people (103 knees) were included in this study, including 42 patients with an average follow-up period of 83 mo in the C-TKA group and 61 patients with an average follow-up period of 76 mo in the NT-TKA group. Six patients had constrained prosthesis, one had common peroneal nerve injury, and two had joint instability in the C-TKA group, but none of these occurred in the NT-TKA group. There were significant statistical differences in constrained prosthesis usage and complications between the groups (P = 0.002 and P = 0.034, respectively). The KSS at 1 mo post-operation for the C-TKA and NT-TKA groups were 11.2 ± 3.8 and 13.3 ± 2.9, respectively, with a significant difference (P = 0.007). However, the data of HKA, ROM, OKS KSS, and prosthesis survival rate were insignificant (P > 0.05) in both the preoperative and follow-up periods.
CONCLUSION Adopting 5°-7° valgus cut angle for VD and sacrificing 2° neutral FTMA for severe VD which cannot be completely corrected during TKA can reduce the need for soft tissue release, maintain early joint stability, reduce the use of constrained prostheses, and minimize postoperative complications.
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Affiliation(s)
- Shuai-Jie Lv
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xiao-Jian Wang
- The First Clinical Medical School, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Jie-Feng Huang
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Qiang Mao
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Bang-Jian He
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Pei-Jian Tong
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
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Su S, Lei P, Wang C, Gao F, Zhong D, Hu Y. Mixed Reality Technology in Total Knee Arthroplasty: An Updated Review With a Preliminary Case Report. Front Surg 2022; 9:804029. [PMID: 35495740 PMCID: PMC9053587 DOI: 10.3389/fsurg.2022.804029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Augmented reality and mixed reality have been used to help surgeons perform complex surgeries. With the development of technology, mixed reality (MR) technology has been used to improve the success rate of complex hip arthroplasty due to its unique advantages. At present, there are few reports on the application of MR technology in total knee arthroplasty. We presented a case of total knee arthroplasty with the help of mixed reality technology. Case Presentation We presented a case of a 71-year-old woman who was diagnosed with bilateral knee osteoarthritis with varus deformity, especially on the right side. After admission, the right total knee arthroplasty was performed with the assistance of MR technology. Before the operation, the three-dimensional virtual model of the knee joint of the patient was reconstructed for condition analysis, operation plan formulation, and operation simulation. During the operation, the three-dimensional virtual images of the femur and tibia coincided with the real body of the patient, showing the osteotomy plane designed before the operation, which can accurately guide the completion of osteotomy and prosthesis implantation. Conclusions As far as we know, this is the first report on total knee arthroplasty under the guidance of mixed reality technology.
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Affiliation(s)
- Shilong Su
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
- Department of Orthopedics, The First Hospital of Changsha, Changsha, China
| | - Pengfei Lei
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chenggong Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Fawei Gao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Da Zhong
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Da Zhong
| | - Yihe Hu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Makram AM, Makram OM, Youssef M, Hafez MA. Comparison of the logistics between the conventional instruments and patient-specific templating in total knee replacement in the low-income setting. HEALTH POLICY AND TECHNOLOGY 2021. [DOI: 10.1016/j.hlpt.2021.100581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rossi SMP, Ivone A, Ghiara M, Jannelli E, Sangaletti R, Perticarini L, Benazzo F. A ligament tensor-guided extramedullary alignment technique for distal femoral cut in total knee replacement: results at a minimum 3 years follow-up. Arch Orthop Trauma Surg 2021; 141:2295-2302. [PMID: 34386837 DOI: 10.1007/s00402-021-04115-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 08/05/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Femoral intramedullary canal referencing is used by most knee arthroplasty systems for distal femoral cut; to avoid the opening of the femoral canal different solutions have been presented such as navigation, patient-specific instruments (PSI) or the use of an extramedullary device. The FuZion® system is a tensor device, created to merge the two main techniques for performing a total knee arthroplasty: the ligament balancing and measured resection techniques. Our idea was to use the tensor as an extramedullary cutting guide for the distal femoral cut, based on a 90° tibial resection. METHODS A total of 110 patients were operated on with this technique. Patients were evaluated with weight-bearing long-standing X-rays, knee a-p and lateral views, validated PROMs (Oxford Knee Score, EQ-5D and EQ-VAS), the Knee Society Scoring System (KSS) and the Forgotten Joint Score (FJS). Minimum follow up was 3 years (range 38-50 months). RESULTS Complete results were available for 104 patients (5 were lost in follow up and 1 died). Significant improvements were registered for all the evaluated scores from pre-op to the final follow up. Pre-op long-standing X-rays showed 21 valgus knees (20%) with a mean HKA of 187.6° (± 3.2°), 70 varus knees (62%) with a mean 172.2° (± 3.7°) HKA and 19 neutrally aligned knees, with a mean HKA of 179.5° (0 ± 2°). The radiographic evaluation at 3 months post-op showed 20 valgus knees (mean HKA 183.7° ± 1.5°), 67 varus knees (mean HKA 176.1° ± 1.8°) and 23 neutrally aligned knees with a mean HKA of 179.3° (0 ± 2°). At final follow up the survival rate was 100% for revision of the implant as the endpoint. With any reoperation as the endpoint Kaplan-Meier survival estimate showed a survival rate of 95.1% at 3 years. CONCLUSIONS This technique for performing a ligament driven alignment in total knee arthroplasty showed encouraging clinical outcomes at mid-term follow up leaving a residual deformity on the coronal plane.
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Affiliation(s)
- Stefano Marco Paolo Rossi
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello sport, U.O Ortopedia e Traumatologia Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy.
| | - Alessandro Ivone
- Clinica Ortopedica e Traumatologica, Fondazione IRCCS Policlinico San Matteo, P.le Golgi 19, 27100, Pavia, Italy
| | - Matteo Ghiara
- Clinica Ortopedica e Traumatologica, Fondazione IRCCS Policlinico San Matteo, P.le Golgi 19, 27100, Pavia, Italy
| | - Eugenio Jannelli
- Clinica Ortopedica e Traumatologica, Fondazione IRCCS Policlinico San Matteo, P.le Golgi 19, 27100, Pavia, Italy
| | - Rudy Sangaletti
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello sport, U.O Ortopedia e Traumatologia Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy.,Clinica Ortopedica e Traumatologica, Fondazione IRCCS Policlinico San Matteo, P.le Golgi 19, 27100, Pavia, Italy.,Università degli Studi di Pavia, 27100, Pavia, Italy
| | - Loris Perticarini
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello sport, U.O Ortopedia e Traumatologia Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy
| | - Francesco Benazzo
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello sport, U.O Ortopedia e Traumatologia Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy.,Clinica Ortopedica e Traumatologica, Fondazione IRCCS Policlinico San Matteo, P.le Golgi 19, 27100, Pavia, Italy.,Università degli Studi di Pavia, 27100, Pavia, Italy
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Rajgopal A, Kumar S, Aggarwal K. Recognizing the Role of the Posterolateral Corner in Patients Undergoing Total Knee Arthroplasty for Fixed Varus Deformity. Orthop Res Rev 2021; 13:171-177. [PMID: 34675694 PMCID: PMC8519409 DOI: 10.2147/orr.s329367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/24/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Varus deformity is the commonest presentation of the arthritic knee requiring surgical intervention. While correctable deformities lend themselves to realignment options like unicompartmental replacement, fixed deformities often need a total knee replacement. Current treatment options for patients with fixed coronal varus malalignment undergoing total knee arthroplasty include varying degrees of medial soft tissue releases, often leading to infringement of the medial collateral ligament complex and increased use of constrained options. We describe the role of the posterolateral (PL) tether in a select subgroup of patients needing release to achieve correction and minimising use of constrained options. Patients and Methods A total of 384 patients with fixed varus deformity were retrospectively evaluated and categorised on the basis of weight bearing x-rays into four groups, namely, knees with angulation (F1), angulation with subluxation and torsion (F2), medial translation (F3) and deformity with major medial bone loss (F4). From this cohort, we identified patients with a tight PL tether that needed release to achieve good correction. These were predominantly in the F2 and F3 subgroups. Functional scores and outcomes were evaluated at a mean follow-up of 120.23 months. Results F1 cohort achieved good correction with medial soft tissue release, while F2 and F3 cohorts often needed a PL release. While functional outcomes and scores were comparable in both groups, survivorship was better in the group where release was done. Conclusion We recognise the role of the PL tether in a subgroup of patients with recalcitrant fixed varus deformities. Sequential release helped achieve good outcomes with minimal use of constrained options. Level of Evidence Three.
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Affiliation(s)
- Ashok Rajgopal
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta- The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Sumit Kumar
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta- The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Kalpana Aggarwal
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta- The Medicity Hospital, Gurugram, Haryana, 122001, India
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Asvadi A, Dardenne G, Troccaz J, Burdin V. Bone surface reconstruction and clinical features estimation from sparse landmarks and Statistical Shape Models: a feasibility study on the femur. Med Eng Phys 2021; 95:30-38. [PMID: 34479690 DOI: 10.1016/j.medengphy.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 11/16/2022]
Abstract
In this study, we investigated a method allowing the determination of the femur bone surface as well as its mechanical axis from some easy-to-identify bony landmarks. The reconstruction of the whole femur is therefore performed from these landmarks using a Statistical Shape Model (SSM). The aim of this research is therefore to assess the impact of the number, the position, and the accuracy of the landmarks for the reconstruction of the femur and the determination of its related mechanical axis, an important clinical parameter to consider for the lower limb analysis. Two statistical femur models were created from our in-house dataset and a publicly available dataset. Both were evaluated in terms of average point-to-point surface distance error and through the mechanical axis of the femur. Furthermore, the clinical impact of using landmarks on the skin in replacement of bony landmarks is investigated. The predicted proximal femurs from bony landmarks were more accurate compared to on-skin landmarks while both had less than 3.5∘ degrees mechanical axis angle deviation error. The results regarding the non-invasive determination of the mechanical axis are very encouraging and could open very interesting clinical perspectives for the analysis of the lower limb either for orthopedics or functional rehabilitation.
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Affiliation(s)
- Alireza Asvadi
- University of Western Brittany, UBO, Brest France; Laboratory of Medical Information Processing (LaTIM), INSERM U 1101, Brest, France.
| | - Guillaume Dardenne
- University Hospital of Brest, Brest, France; Laboratory of Medical Information Processing (LaTIM), INSERM U 1101, Brest, France
| | - Jocelyne Troccaz
- Univ. Grenoble Alpes, CNRS, Grenoble INP, TIMC, Grenoble F-38000, France
| | - Valérie Burdin
- IMT Atlantique, Mines Telecom Institute, Brest, France; Laboratory of Medical Information Processing (LaTIM), INSERM U 1101, Brest, France
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12
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Mardani-Kivi M, Leili EK, torfeh N, Azari Z. Bilateral total knee arthroplasty: Simultaneous versus staging in the same or in twice hospitalization. J Clin Orthop Trauma 2020; 14:59-64. [PMID: 33717897 PMCID: PMC7920008 DOI: 10.1016/j.jcot.2020.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/18/2020] [Accepted: 09/20/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Arthroplasty is the main treatment in patients with advanced knee osteoarthritis. In bilateral lesions, it is frequently performed in two simultaneous or separate surgical procedures. In this regard, the present study aimed to compare the results of knee arthroplasty in two joints simultaneously at two different times. METHOD In general, all 40-70 years old patients in need of complete bilateral total knee arthroplasty (BTKA) were enrolled in this descriptive cross-sectional study during 2009-2016. They were included in three groups of BTKA as simultaneously (n = 272), staging in the same hospitalization (146), and staging in different hospitalizations (245). To assess the quantitative and qualitative function of the knees, patients' knees were evaluated before the surgery, and one month, three months, and two years after the surgery using the Knee Society Score (KSS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC). Finally, hospitalization time, anesthesia duration, and medical costs were compared between the three groups. RESULTS Based on the results, knee function improved based on WOMAC and KSS scales in all groups after arthroplasty although no significant differences were observed between the three groups. Patients' satisfaction in simultaneous BTKA was significantly higher compared to the other two groups (P = 0.013). Eventually, complications demonstrated no significant differences between the three groups except for pulmonary and cerebral embolism which were more prevalent in old patients with a high body mass index in the simultaneous BTKA group (P = 0.035 and P = 0.043, respectively). CONCLUSION Overall, simultaneous BTKA is a useful approach for reducing costs while increasing patients' function and satisfaction although it has certain complications such as embolism in older overweight patients.
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Affiliation(s)
- Mohsen Mardani-Kivi
- Ghaem Clinical Research Development Unit, Guilan University of Medical Sciences, Rasht, Iran
| | - Ehsan Kazemnejad Leili
- Statistics Department, School of Health, Guilan University of Medical Sciences, Rasht, Iran
| | - Nazanin torfeh
- Ghaem Clinical Research Development Unit, Guilan University of Medical Sciences, Rasht, Iran
| | - Zoleikha Azari
- Department of Anatomical Sciences & Cell Biology, Mashhad University of Medical Sciences, Mashhad, Iran,Corresponding author. Mashhad University of medical sciences, Mashhad, Iran..
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Hadi H, Jabal Ameli M, Bagherifard A, Behrouzi A, Safi F, Azimi A, Ghanbari M, Azarnia Samarin G. The Effect of Total Knee Arthroplasty on Hindfoot Alignment in Patients with Severe Genu Varum and Genu Valgum. THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:413-419. [PMID: 32766401 DOI: 10.22038/abjs.2019.33735.1883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The maintenance of deformity in the ankle and hindfoot after correction of knee deformity following knee arthroplasty may cause abnormal tension in the knee and patient dissatisfaction. The aim of this study was to determine the effect of knee arthroplasty on the hindfoot alignment in patients with severe genu varum and valgum. Methods A total of 84 patients with primary osteoarthritis, were enrolled in the study. The knee deformity was measured using a long leg film before surgery. The long axial radiographic view of hindfoot was taken in the standing position for all patients, before and six months after surgery. Comparisons were made on changes in the hindfoot angles measured before and after surgery. Results A total of 84 patients with mean age of 62.28 ± 7.77 years, 77 (92%) and seven patients (eight percent) had knee varus and valgus deformity, respectively. In the knee varus group, the mean preoperative hindfoot angle was + 5.32 ± 6.12 ° (valgus) which was changed to - 0.25 ± 4.91 ° (varus) in the postoperative phase. In the knee valgus group, the mean pre and postoperative hindfoot angles were - 7.71 ± 7.06° (varus) and - 2.14 ± 5.92 ° (varus), respectively. The mean preoperative hindfoot angle in severe and very severe varus knee groups were + 5.45 ± 3.30 and + 5.28 ± 6.86 °, respectively. These angles were changed to + 0.21± 5.17 and -1.60 ± 3.89° six months after surgery, respectively. The mean preoperative hindfoot angle in severe and very severe valgus knee deformity groups were - 7.00 ± 4.69 and -8.66 ± 10.69 °, respectively. These angles were changed to - 2.00 ± 5.71 and - 2.33 ± 7.50 °after surgery, respectively. There was no significant difference between patients with severe and very severe deformity in terms of pre and post-operative hindfoot angle. Conclusion The hindfoot alignment is significantly corrected after knee arthroplasty. The severity of knee deformity does not correlate with the severity of the hindfoot deformity before and after surgery.
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Affiliation(s)
- Hosseinali Hadi
- Orthopedic Department, Arak University of Medical Sciences, Arak, Iran
| | - Mahmood Jabal Ameli
- Bone and Joint Reconstruction Research Center, Shafa Yahyaian Hospital, Iran University of Medical Science, Tehran, Iran
| | - Abolfazl Bagherifard
- Bone and Joint Reconstruction Research Center, Shafa Yahyaian Hospital, Iran University of Medical Science, Tehran, Iran
| | | | - Fatemeh Safi
- Radiology Department, Faculty of Medicine, Arak University of Medical Sciences, Arak, Iran
| | - Amir Azimi
- Orthopedic Department, Arak University of Medical Sciences, Arak, Iran
| | - Mahtab Ghanbari
- Nursing Department, Qom University of Medical Sciences, Qom, Iran
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14
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León-Muñoz VJ, Parrinello A, López-López M, Martínez-Martínez F, Santonja-Medina F. Revision of total knee arthroplasty with the use of patient-specific instruments: an alternative surgical technique. Expert Rev Med Devices 2020; 17:795-806. [PMID: 32729346 DOI: 10.1080/17434440.2020.1803737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Accuracy in the placement of components in revision total knee arthroplasty (R-TKA) surgery is sometimes challenging. The applicability of patient‑specific instruments (PSI) in knee surgery has progressively expanded to types of surgery other than primary arthroplasty. Could this assistive technology be used to facilitate accurate R-TKA surgery? The aim of the current manuscript is to describe this new application of PSI for revision of TKA-to-TKA and to provide a step-by-step technical guideline for use. AREAS COVERED We will describe the application and a detailed description of PSI technology to TKA revision surgery, step-by-step, from CT images acquisition for preoperative planning and PSI blocks production to the surgery. EXPERT COMMENTARY The system can facilitate the accomplishment of the bony cuts for optimal implant placement and that can be useful in minimally altering the femoral and the tibial joint line. It is obvious that technology alone will not replace surgical skill and that accuracy of the system will also depend on the quality of the CT images and the ability of the software to prevent metal artifacts. Despite that, our initial results are promising and prove that the concept of applying PSI technology to the R-TKA surgery is feasible.
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Affiliation(s)
- Vicente J León-Muñoz
- Orthopaedic Surgery and Traumatology Department, Hospital Clínico Universitario Virgen de la Arrixaca , Murcia, Spain
| | | | - Mirian López-López
- Subdirección General de Tecnologías de la Información. Servicio Murciano de Salud , Murcia, Spain
| | - Francisco Martínez-Martínez
- Orthopaedic Surgery and Traumatology Department, Hospital Clínico Universitario Virgen de la Arrixaca , Murcia, Spain.,Faculty of Medicine, University of Murcia , Murcia, Spain
| | - Fernando Santonja-Medina
- Orthopaedic Surgery and Traumatology Department, Hospital Clínico Universitario Virgen de la Arrixaca , Murcia, Spain.,Faculty of Medicine, University of Murcia , Murcia, Spain
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Zahn RK, Graef F, Conrad JL, Renner L, Perka C, Hommel H. Accuracy of tibial positioning in the frontal plane: a prospective study comparing conventional and innovative techniques in total knee arthroplasty. Arch Orthop Trauma Surg 2020; 140:793-800. [PMID: 32124032 PMCID: PMC7244465 DOI: 10.1007/s00402-020-03389-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Indexed: 12/05/2022]
Abstract
BACKGROUND Coronal alignment of the tibial component determines functional outcome and survival in total knee arthroplasty (TKA). Innovative techniques for tibial instrumentation have been developed to improve accuracy and reduce the rate of outliers. METHODS In a prospective study, 300 patients were allocated to four different groups using a randomization process (two innovative and two conventional) techniques of tibial instrumentation (conventional: extramedullary, intramedullary; innovative: navigation and patient-specific instrumentation (PSI); n = 75 for each group). The aims were to reconstruct the medial proximal tibial angle (MPTA) to 90° and the mechanical tibio-femoral axis (mTFA) to 0°. Both angles were evaluated and compared between all groups three months after the surgery. Patients who presented with a postoperative mTFA > 3° were classified as outliers. RESULTS The navigation and intramedullary technique both demonstrated that they were significantly more precise in reconstructing a neutral mTFA and MPTA compared to the other two techniques. The odd's ratio (OR) for producing outliers was highest for the PSI method (PSI OR = 5.5, p < 0.05; extramedullary positioning OR = 3.7, p > 0.05; intramedullary positioning OR = 1.7, p > 0.05; navigation OR = 0.04, p < 0.05). We could only observe significant differences between pre- and postoperative MPTA in the navigation and intramedullary group. The MPTA showed a significant negative correlation with the mTFA in all groups preoperatively and in the extramedullary, intramedullary and PSI postoperatively. CONCLUSION The navigation and intramedullary instrumentation provided the precise positioning of the tibial component. Outliers were most common within the PSI and extramedullary technique. Optimal alignment is dependent on the technique of tibial instrumentation and tibial component positioning determines the accuracy in TKA since mTFA correlated with MPTA pre- and postoperatively.
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Affiliation(s)
- R. K. Zahn
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - F. Graef
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany ,Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
| | - J. L. Conrad
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - L. Renner
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - C. Perka
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - H. Hommel
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany ,Department of Orthopaedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
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Mazzotti A, Perna F, Golinelli D, Quattrini I, Stea S, Bordini B, Faldini C. Preoperative valgus deformity has twice the risk of failure as compared to varus deformity after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:3041-3047. [PMID: 30539306 DOI: 10.1007/s00167-018-5331-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/07/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this study was to assess whether preoperative valgus or varus deformity affected survivorship after total knee arthroplasty (TKA) and to quantify the risk factors for implant failure in a registry-based population. METHODS The Emilia-Romagna Registry of Prosthetic Orthopedic Implants was examined regarding TKAs performed on patients with a preoperative diagnosis of valgus or varus deformity. Demographics, implant characteristic and survivorships were investigated and compared. A total of 2327 TKA procedures performed from 2000 to 2016 were included in the study. Six hundred and forty primary TKAs with a diagnosis of valgus deformity were evaluated with a median follow-up of 3.3 years; 1687 primary TKAs with a diagnosis of varus deformity were evaluated with a median follow-up of 2.5 years. RESULTS Bi-compartmental, cemented posterior stabilised fixed-bearing implants were preferred. For both diagnoses, the implant survivorship rate was greater than 98% in the first year. However, the survival curve of the TKAs implanted for valgus deformity showed a greater slope in the first 3 years as compared to the survival curve of those implanted for varus deformity. Valgus deformity had a 2.1-fold higher risk for revision as compared with varus deformity. Infection was a major cause of implant failure in TKAs for varus deformity, 9/24 (37.5%), while its incidence was lower for valgus deformity, 1/21 (4.8%). CONCLUSIONS Preoperative valgus alignment showed a twofold risk of failure as compared to varus alignment after TKA. This should be considered in daily practice, and surgeons are called on to pay more attention when performing TKAs on such patients. Prospective randomised controlled trials are, therefore, necessary to better understand the role of preoperative coronal knee deformity in implant failure. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Antonio Mazzotti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Fabrizio Perna
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Davide Golinelli
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Via San Giacomo 12, 40126, Bologna, Italy.
| | - Irene Quattrini
- IRCCS Istituto Ortopedico Rizzoli, via di Barbiano 1/10, 40136, Bologna, Italy
| | - Susanna Stea
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, via di Barbiano 1/10, 40136, Bologna, Italy
| | - Barbara Bordini
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, via di Barbiano 1/10, 40136, Bologna, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
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Vaishya R, Vijay V, Vaish A, Agarwal AK. Computed tomography based 3D printed patient specific blocks for total knee replacement. J Clin Orthop Trauma 2018; 9:254-259. [PMID: 30202158 PMCID: PMC6128807 DOI: 10.1016/j.jcot.2018.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/17/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES 3D printing is an emerging technology and its use in orthopaedics is being explored. We discuss the role of computed tomography based 3D printed patient specific jigs in total knee replacement. We also discuss the various advantages of 3D printed patient specific jigs and the future scope of their use in total knee replacement. METHODS A search of English literature was done and articles discussing the role of CT scan based 3D printed patient specific jigs in total knee replacement were included in the study. RESULTS The role of 3D printed jigs in total knee replacement have been found in the prediction of femoral valgus angle, component sizing and in retained hardware. They have shown promise with studies suggesting they might improve the overall mechanical alignment of the knee. There are studies which have also studied the combined role of patient specific instruments with navigation. CONCLUSION 3D printed jigs hold promise in total knee replacement. Their use in total knee replacement in the presence of retained hardware is useful for the surgeon. They have also showed promise in improving prediction of component sizing and improving mechanical alignment of the knee. Further studies with longer follow up and larger sample size will help in establishing their role in total knee replacement.
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Affiliation(s)
| | - Vipul Vijay
- Indraprastha Apollo Hospital, New Delhi, India
| | - Abhishek Vaish
- Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India
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