Abstractobjective To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania, where audit results have been disappointing 2 years after its introduction.methods Qualitative study involving participative observation of audit sessions, followed by 23 indepth interviews with health workers and managers. Knowledge and perceptions of audit were assessed and suggestions for improvement of the audit process explored.results During the observational period, audit sessions were held irregularly and only when the head of department of obstetrics and gynaecology was available. Cases with evident substandard care factors were audited. In-depth interviews revealed inadequate knowledge of the purpose of audit, despite the fact that participants regarded obstetric audit as a potentially useful tool. Insufficient staff commitment, managerial support and human and material resources were mentioned as reasons for weak involvement of health workers and poor implementation of recommendations resulting from audit. Suggestions for improvement included enhancing feedback to all staff and managers to attend sessions and assist with the effectuation of audit recommendations.

Aims Although bone cement is the primary mode of fixation in total knee arthroplasty (TKA), cementless fixation is gaining interest as it has the potential of achieving lasting biological fixation. By 3D printing an implant, highly porous structures can be manufactured, promoting osseointegration into the implant to prevent aseptic loosening. This study compares the migration of cementless, 3D-printed TKA to cemented TKA of a similar design up to two years of follow-up using radiostereometric analysis (RSA) known for its ability to predict aseptic loosening. Methods A total of 72 patients were randomized to either cementless 3D-printed or a cemented cruciate retaining TKA. RSA and clinical scores were evaluated at baseline and postoperatively at three, 12, and 24 months. A mixed model was used to analyze the repeated measurements. Results The mean maximum total point motion (MTPM) at three, 12, and 24 months was 0.33 mm (95% confidence interval (CI) 0.25 to 0.42), 0.42 mm (95% CI 0.33 to 0.51), and 0.47 mm (95% CI 0.38 to 0.57) respectively in the cemented group, versus 0.52 mm (95% CI 0.43 to 0.63), 0.62 mm (95% CI 0.52 to 0.73), and 0.64 mm (95% CI 0.53 to 0.75) in the cementless group (p = 0.003). However, using three months as baseline, no difference in mean migration between groups was found (p = 0.497). Three implants in the cemented group showed a > 0.2 mm increase in MTPM between one and two years of follow-up. In the cementless group, one implant was revised due to pain and progressive migration, and one patient had a liner-exchange due to a deep infection. Conclusion The cementless TKA migrated more than the cemented TKA in the first two-year period. This difference was mainly due to a higher initial migration of the cementless TKA in the first three postoperative months after which stabilization was observed in all but one malaligned and early revised TKA. Whether the biological fixation of the cementless implants will result in an increased long-term survivorship requires a longer follow-up. Cite this article: Bone Joint J 2020;102-B(8):1016–1024.

Background: Recent short-term studies of total knee arthroplasty (TKA) have claimed improved clinical outcomes and implant survival when aiming to restore constitutional joint kinematics, as compared with neutral mechanical axis alignment. However, implant durability may be compromised when aligned in varus or valgus. With use of data pooled from 3 long-term radiostereometric analysis (RSA) studies, the aim of the present study was to assess the effects of coronal alignment on tibial component migration. Methods: Coronal alignment parameters from full-leg radiographs were measured and the constitutional leg alignment was determined for each patient. We evaluated the effect of the postoperative hip-knee-ankle angle, relative to both the mechanical axis and the constitutional alignment, on tibial component migration. In-range knees were defined as within ±3° of either the neutral mechanical axis or constitutional alignment of the patient. Analysis was performed with a linear mixed-effects model, corrected for study, age, sex, preoperative alignment, diagnosis, and body mass index. Results: A total of 85 cemented TKAs were included, of which 3 were revised for aseptic loosening and another 4 were considered loose. The median follow-up was 11 years. No loose tibial components were observed in mechanically in-range knees, whereas all loose tibial components were out of range. Mechanically varus knees showed the highest mean migration (maximum total point motion) of 1.55 mm (95% confidence interval [CI], 1.16 to 2.01 mm) after 5 years, compared with 1.07 mm (95% CI, 0.63 to 1.64 mm) and 0.77 mm (95% CI, 0.53 to 1.06 mm) for valgus and in-range knees, respectively (p < 0.001). In contrast, looking at constitutional alignment, loose tibial components were found among both constitutionally in-range and out-of-range knees. Mixed-model analysis showed comparable migration among constitutionally in-range, more-in-varus, and more-in-valgus aligned knees. Conclusions: Mechanically out-of-range alignment, especially mechanical varus, led to higher tibial component migration. However, matching the constitutional alignment of the patient did not preclude high implant migration. RSA trials randomizing different alignment techniques are needed to confirm the results of the present study. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The tibial components of PA-coated TKAs showed more overall migration compared with the tibial components of cemented TKAs. However, analysis showed that this difference was caused by higher migration of PA-coated components in the first three months, after which a stable migration pattern was observed. Clinically, there was no significant difference in outcome between the groups. Cite this article: 2017;99-B:1467-76.