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Purpose Achieving a balanced knee is accepted as an important goal in total knee arthroplasty; however, the deinition of ideal balance remains controversial. This study therefore endeavoured to determine: (1) whether medio-lateral gap balance in extension, midlexion, and lexion are associated with improved outcome scores at one-year post-operatively and (2) whether these relationships can be used to identify windows of optimal gap balance throughout lexion. Methods 135 patients were enrolled in a multicenter, multi-surgeon, prospective investigation using a robot-assisted surgical platform and posterior cruciate ligament sacriicing gap balancing technique. Joint gaps were measured under a controlled tension of 70-90 N from 10°-90° lexion. Linear correlations between joint gaps and one-year KOOS outcomes were investigated. KOOS Pain and Activities of Daily Living sub-scores were used to deine clinically relevant joint gap target thresholds in extension, midlexion, and lexion. Gap thresholds were then combined to investigate the synergistic efects of satisfying multiple targets. Results Signiicant linear correlations were found throughout extension, midlexion, and lexion. Joint gap thresholds of an equally balanced or tighter medial compartment in extension, medial laxity ± 1 mm compared to the inal insert thickness in midlexion, and a medio-lateral imbalance of less than 1.5 mm in lexion generated subgroups that reported signiicantly improved KOOS pain scores at one year (median ∆ = 8.3, 5.6 and 2.8 points, respectively). Combining any two targets resulted in further improved outcomes, with the greatest improvement observed when all three targets were satisied (median ∆ = 11.2, p = 0.002). Conclusion Gap thresholds identiied in this study provide clinically relevant and achievable targets for optimising soft tissue balance in posterior cruciate ligament sacriicing gap balancing total knee arthroplasty. When all three balance windows were achieved, clinically meaningful pain improvement was observed. Level of Evidence Level II.

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Introduction: Although technology-assisted total hip arthroplasty (TA-THA) may improve implant positioning, it remains unknown whether TA-THA confers improved clinical outcomes. We sought to examine national TA-THA utilization trends and compare clinical outcomes between TA-THA and unassisted THA (U-THA). Methods: Patients who underwent primary, elective THA from 2010 to 2018 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Demographic, perioperative, and 30-day outcomes were queried and collected. Patients were stratified based on whether they underwent TA-THA, which included computer navigation or robotics, and U-THA. Propensity score matching paired patients undergoing TA-THA or U-THA on a 1:1 basis. Results: Of the 238,755 THA patients, 3,149 cases (1.3%) were done using TA-THA. Comparing the unmatched TA-THA and U-THA groups, race distribution (P , 0.001) and baseline functional status (P , 0.001) differed. Propensity score matching yielded 2,335 TA-THA and U-THA pairs. Perioperatively, the TA-THA cohort had longer mean surgical times (101.0 6 34.0 versus 91.9 6 38.8 minutes, P , 0.001), but lower transfusion rates (5.7% versus 7.8%, P = 0.005). As compared with the U-THA group, the TA-THA group had a shorter mean hospital length of stay (2.0 6 1.1 versus 2.5 6 2.0 days, P , 0.001) and a higher proportion of patients discharged home (85.8% versus 75.7%, P , 0.001). Notably, the TA-THA cohort had higher readmission rates (3.8% versus 2.4%, P , 0.001). Major complication and revision surgery rates did not markedly differ between groups. Discussion: TA-THA utilization rates remain low among orthopaedic surgeons. As compared with U-THA, TA-THA yield mixed perioperative and 30-day outcomes. Surgeons must consider the clinical benefits and drawbacks of TA-THA when determining the proper surgical

IntroductionThe impact of fulfillment of patient expectations throughout recovery on satisfaction in total knee arthroplasty (TKA) is not well understood. Utilizing a standardized TKA method with a robotically assisted (RA) platform, we investigated the impact of expectation fulfillment at 3-month (M) and 6-M on 1-year (Y) and 2-Y satisfaction. We hypothesize that early fulfillment of patient expectations is associated with improved midterm patient satisfaction. We also compare improvements in outcomes with RA-TKA to those of a recent large national TKA cohort study to determine whether RA-TKA meets or exceeds the current standard of care. Materials and methods One hundred six patients were prospectively enrolled and underwent robotic-assisted TKA by a single surgeon using the OMNIBotics system. Patients completed KOOS and New Knee Society Score (KSS) preoperatively and at 3M, 6M, 1Y, and 2Y postoperatively. Expectation fulfillment was subdivided into patients who were below or above the average expectation score pre-operatively, or fulfillment of expectation score at 3M and 6M post TKA. The satisfaction of each group was then compared at 1Y and 2Y post TKA. Study cohort outcomes were compared to contemporary literature from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) database. Results Patients with greater than average KSS expectation fulfillment at 3M reported significantly higher KSS satisfaction scores at 1Y (34.9 ± 5.3 vs 30.6 ± 6.7, p = 0.0012), and patients with greater than average 6M expectation fulfillment reported improved satisfaction at 1Y (33.9 ± 5.9 vs 31.1 ± 6.7, p = 0.0330) and 2Y (35.2 ± 4.8 vs 32.4 ± 6.8, p = 0.0323). When compared to the FORCE-TJR database, no significant differences in post-operative KOOS outcomes were observed except for Sports and Recreation, for which the RAS group demonstrated higher scores (65.5 ± 30.0 vs 53.0 ± 27.1 p < 0.0001); however, the study cohort reported significantly greater improvements in KOOS Pain, Symptoms, Sports and Recreation, and Quality of Life at multiple time points up to 2 years post TKA. Conclusion High early-expectation fulfillment was associated with improved satisfaction at 1Y and 2Y, indicating the importance of managing patient-specific post-operative care to ensure patients reach their pre-operative goals. Greater improvements in all KOOS sub-scores and in absolute Sports and Recreation at 1Y and 2Y were observed in this roboticassisted cohort compared to a large contemporary database, indicating that RAS meets or exceeds current standard of care benchmarks for patient-reported outcomes.

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Total knee arthroplasty is a successful procedure. However, there is still area for improvement as up to 15-20% of patients remain unsatisfied. Robotic-assisted surgery (RAS) may improve patient outcomes by providing a reproducible way of obtaining neutral mechanical alignment of the limb, which has been shown to reduce early revisions and correlate with patient reported outcomes after surgery.We prospectively enrolled 106 patients undergoing robotic-assisted TKA by a single surgeon performing a measured-resection femur-first technique using the OMNIBotic system. Patients completed a KOOS and New Knee Society Score (KSS) pre-operatively and at 3, 6, 12, and 24 months (M) postoperatively. Changes in the five KOOS sub-scales were compared to available literature data from the FORCE – TJR cohort, as well as to individual studies reporting on conventional and computer-assisted TKA.When compared to FORCE-TJR 6-month (M) and 2-year (Y) data, the RAS cohort had significantly higher improvements at 6M for pain (40.5 vs. 31.1, p&lt;.001) and at 2Y for all five KOOS sub-scores. The larger improvement was due to the RAS cohort having lower baseline KOOS scores than the FORCE-TJR cohort, except for the Sports-Recreation sub-score, which was similar pre- operatively but significantly higher post-operatively for the robotic cohort. Rates of dissatisfaction with knee pain level and function using the KSS after RAS were 3.0%, 1.0%, and 2.7% at 6, 12, and 24M postoperatively, respectively.Despite having poorer joint function and higher pain pre-operatively, robotic-assisted TKA patients achieved excellent self-reported outcomes, with significantly higher levels of improvement through two years post-surgery when compared with large national cohort studies. Further controlled clinical studies are warranted to determine if these results translate to other groups of surgeons, centers and patients.