Iwuchukwu, Chijioke; Wright, David; Sofine, Anna; Schwarzkopf, Ran
Given the steady increase in the number of primary and revision total knee arthroplasties (TKAs) performed in the United States, we wanted to determine if an evidence-based TKA perioperative surgical home could close the perioperative morbidity gap between primary and revision TKAs. We conducted a prospective cross-sectional cohort study comparing outcomes of patients who had primary TKA (n = 235) with outcomes of patients who had revision TKA (n = 50). We measured several perioperative outcomes: length of stay, discharge disposition, 30-day readmission rate, and 30-day reoperation rate. Mean length of stay was 2.55 days for primary TKA and 2.92 days for revision TKA (P = .061). Eighty (34%) of the 235 primary TKA patients and 21 (41%) of the 51 revision TKA patients were discharged to a subacute nursing facility (P = .123). One primary TKA patient (0.4%) and 2 revision TKA patients (4%) were readmitted within 30 days after surgery (P = .081). None of the primary TKAs and 2 (4%) of the revision TKAs underwent reoperation (P = .993). There was no difference in perioperative outcomes between the primary and revision TKA groups in our Total Joint Replacement Perioperative Surgical Home (TJR-PSH) cohort. Advances in multidisciplinary co-management of TKA patients are highlighted in the TJR-PSH. The similarity in primary and revision TKA outcomes has significant implications regarding costs and potential increased patient satisfaction.
Long, Gong; Zhang, Guo Qiang
Functional exercise after total knee arthroplasty (TKA) is necessary. However, it may be a difficult and painful process for the patient. Desirable methods of relieving the patient's pain are worth exploring. Oral supplement of adenosine triphosphate (ATP) is a potential option. In the present study, we decide to investigate whether short-term administration of ATP benefits patients undergoing TKA. A total of 244 subjects were randomized to receive 120mg ATP or placebo each day for 4weeks. Significant differences in quadriceps strength, pain scores at postoperative days 7, 14, 21, and 28 and total opioid consumption were detected. It follows that oral supplement of ATP could benefit patients recovering from TKA.
Gradišnik, Lidija; Gorenjak, Mario; Vogrin, Matjaž
Background Cartilage tissue engineering is a fast-evolving field of biomedical engineering, in which the chondrocytes represent the most commonly used cell type. Since research in tissue engineering always consumes a lot of cells, simple and cheap isolation methods could form a powerful basis to boost such studies and enable their faster progress to the clinics. Isolated chondrocytes can be used for autologous chondrocyte implantation in cartilage repair, and are the base for valuable models to investigate cartilage phenotype preservation, as well as enable studies of molecular features, nature and scales of cellular responses to alterations in the cartilage tissue. Methods Isolation and consequent cultivation of primary human adult articular chondrocytes from the surgical waste obtained during total knee arthroplasty (TKA) was performed. To evaluate the chondrogenic potential of the isolated cells, gene expression of collagen type 2 (COL2), collagen 1 (COL1) and aggrecan (ACAN) was evaluated. Immunocytochemical staining of all mentioned proteins was performed to evaluate chondrocyte specific production. Results Cartilage specific gene expression of COL2 and ACAN has been shown that the proposed protocol leads to isolation of cells with a high chondrogenic potential, possibly even specific phenotype preservation up to the second passage. COL1 expression has confirmed the tendency of the isolated cells dedifferentiation into a fibroblast-like phenotype already in the second passage, which confirms previous findings that higher passages should be used with care in cartilage tissue engineering. To evaluate the effectiveness of our approach, immunocytochemical staining of the evaluated chondrocyte specific products was performed as well. Discussion In this study, we developed a protocol for isolation and consequent cultivation of primary human adult articular chondrocytes with the desired phenotype from the surgical waste obtained during TKA. TKA is a common and very
Halewood, Camilla; Traynor, Alison; Bellemans, Johan; Victor, Jan; Amis, Andrew A
The purpose of this study was to examine whether a bicruciate retaining (BCR) TKA would yield anteroposterior (AP) laxity closer to the native knee than a posterior cruciate ligament retaining (CR) TKA. A BCR TKA was designed and compared to CR TKA and the native knee using cadaver specimens. AP laxity with the CR TKA was greater than the native knee (P=0.006) and BCR TKA (P=0.039), but no difference was found between the BCR TKA and the native knee. No significant differences were found in rotations between the prostheses and the native knee. BCR TKA was shown to be surgically feasible, reduced AP laxity versus CR TKA, and may improve knee stability without using conforming geometry in the implant design. Copyright © 2015 Elsevier Inc. All rights reserved.
Gong, Long; Wang, ZhenHu; Fan, Dong
This study examined the effects of sleep quality on early recovery after total knee arthroplasty. A total of 148 patients were randomized 1:1 to receive either zolpidem or placebo for 2 weeks. VAS pain scores (rest, ambulation and night), range of motion (ROM), total amount of opioid analgesics and antiemetics taken, postoperative nausea and vomiting (PONV), sleep efficacy and satisfaction were recorded. It was found that patients taking zolpidem achieved greater improvement in quality of life and reported better satisfaction. Patients in the intervention group had lower pain score and took less antiemetics. Moreover, a significant correlation between sleep quality and ROM was detected. These results demonstrated that improved sleep quality is beneficial to patients' post-TKA recovery. Copyright © 2015. Published by Elsevier Inc.
Corbett, Kelly L; Reichmann, William M; Katz, Jeffrey N; Beagan, Carolyn; Corsello, Paul; Ghazinouri, Roya; Dang, Bachyen; Mikulinsky, Regina; Losina, Elena; Wright, John
Introduction: Over 500,000 total knee arthroplasties (TKAs) are performed annually in the US, yet postoperative pain management varies widely. In patients managed with epidural analgesia, the epidural catheter is generally removed on the second postoperative day. We compared in-hospital outcomes associated with removing the epidural catheter on postoperative day 1 (POD1-group) vs on postoperative day 2 (POD2-group) among patients undergoing TKA. Methods: We identified 89 patients who had TKA performed by a single surgeon from January through July 2007, and who were managed with epidural analgesia. This study took advantage of a change of policy from removing the epidural on the second postoperative day prior to March 2007 (n = 34) to removing the epidural on the first postoperative day thereafter (n = 55). Data were obtained by medical record review and analyzed with bivariate and multivariate techniques. Outcomes included knee range of motion (ROM), pain (0-10 scale), distance walked, narcotic usage, and length of stay. Results: The mean patient age was 68 ± 10 years. We did not identify clinically important differences in preoperative characteristics across groups. Patients in the POD1- group had a shorter length of stay (median of 3 vs 4 days in the POD2-group, p<0.001). The POD1-group also walked a greater distance on the second postoperative day (mean of 38 feet vs 9 feet in the POD2-group, p < 0.002). We did not observe a difference between the two groups with respect to change in passive ROM, pain on the second postoperative day, or narcotic usage. The POD1-group had more restricted continuous passive motion settings on the second postoperative day than the POD2-group (50° vs 65°, p = 0.031), and the POD1-group had somewhat worse passive range of motion at discharge (e.g. passive flexion 82o vs 76o in the POD2- group, p = 0.078). Conclusion: The balance between a shorter hospital stay and earlier walking achievement with the POD1-strategy-- vs better ROM
Fan, Lin; Zhu, Chunyan; Zan, Pengfei; Yu, Xiao; Liu, Jin; Sun, Qi; Li, Guodong
Total knee arthroplasty (TKA) is usually associated with severe post-operative pain, which can prevent rehabilitation of patients' knee function and influence the satisfaction of surgery. Local infiltration analgesia (LIA) is a method that has been applied in clinical practice recently. However, the clinical use of this method is still under discussion. In this paper, we systematically reviewed randomized clinical trails (RCTs) comparing LIA with peripheral nerve block (PNB) to verify the efficacy and safety of LIA. During the analysis, we strictly filtered papers and chose ones that had fewer disturbance variables. We also analyzed the heterogeneity. We conclude that when compared with PNB, pain control with LIA is at least comparable.
Risitano, Salvatore; Sabatini, Luigi; Giachino, Matteo; Agati, Gabriele; Massè, Alessandro
Interest for uncemented total knee arthroplasty (TKA) has greatly increased in recent years. This technique, less used than cemented knee replacement in the last decades, sees a revival thanks an advance in prosthetic design, instrumentation and operative technique. The related literature in some cases shows conflicting data on survival and on the revision’s rate, but in most cases a success rate comparable to cemented TKA is reported. The optimal fixation in TKA is a subject of debate with the majority of surgeons favouring cemented fixation. PMID:27162779
Bjerke, Joakim; Öhberg, Fredrik; Nilsson, Kjell G; Foss, Olav A; Stensdotter, Ann K
Reduced peak knee flexion during stair descent (PKSD) is demonstrated in subjects with total knee arthroplasty (TKA), but the underlying factors are not well studied. 3D gait patterns during stair descent, peak passive knee flexion (PPKF), quadriceps strength, pain, proprioception, demographics, and anthropometrics were assessed in 23 unilateral TKA-subjects ~19 months post-operatively, and in 23 controls. PKSD, PPKF and quadriceps strength were reduced in the TKA-side, but also in the contralateral side. A multiple regression analysis identified PPKF as the only predictor (57%) to explain the relationship with PKSD. PPKF was, however sufficient for normal PKSD. Deficits in quadriceps strength in TKA-group suggest that strength is also contributing to smaller PKSD. Increased hip adduction at PKSD may indicate both compensatory strategy and reduced hip strength.
Revision Total Knee Arthroplasty Because of; Loosening; Instability; Impingement; or Other Reasons Accepted as Indications for TKA Exchange.; The Focus is to Determine the Precision of Joint Line Restoration in Navigated vs. Conventional Revision Total Knee Arthroplasty
Wodowski, Andrew J; Swigler, Colin W; Liu, Hongchao; Nord, Keith M; Toy, Patrick C; Mihalko, William M
Proprioceptive mechanoreceptors provide neural feedback for position in space and are critical for three-dimensional interaction. Proprioception is decreased with osteoarthritis of the knees, which leads to increased risk of falling. As the prevalence of osteoarthritis increases so does the need for total knee arthroplasty (TKA), and knowing the effect of TKA on proprioception is essential. This article reviews the literature regarding proprioception and its relationship to balance, aging, osteoarthritis, and the effect of TKA on proprioception. Knee arthroplasty involving retention of the cruciate ligaments is also reviewed, as well the evidence of proprioception in the posterior cruciate ligament after TKA.
Rakel, Barbara; Zimmerman, M. Bridget; Geasland, Katharine; Embree, Jennie; Clark, Charles R; Noiseux, Nicolas O; Callaghan, John J; Herr, Keela; Walsh, Deirdre; Sluka, Kathleen A
This study evaluated the efficacy of TENS in reducing pain and hyperalgesia and increasing function following total knee arthroplasty (TKA). We hypothesized participants using TENS during rehabilitation exercises would: 1) report significantly lower pain during range-of-motion (ROM) and fast walking but not at rest; 2) have less hyperalgesia; and, 3) have better function than participants receiving Placebo-TENS or Standard Care. We also hypothesized that change in ROM pain would differ based on psychological characteristics (trait anxiety, pain catastrophizing and depression) and treatment group. This prospective, randomized study used intent-to-treat analyses on 317 subjects after primary, unilateral TKA. Assessors, blinded to treatment allocation, measured pain, function (ROM and gait speed), and hyperalgesia (quantitative sensory tests) postoperatively and 6 weeks after surgery. Analgesic intake, anxiety, depression, and pain catastrophizing were also assessed. TENS participants used it 1–2 times/day at 42 mA (on average) and had less pain postoperatively during active knee extension (p=0.019) and fast walking (p=0.006) than Standard Care participants. TENS and Placebo-TENS were not significantly different. TENS participants who scored low on anxiety and pain catastrophizing had a greater reduction in ROM pain at 6 weeks than those scoring high on these factors (p=0.002 and 0.03). Both TENS and Placebo-TENS participants had less postoperative mechanical hyperalgesia (p=0.03 – 0.01) than Standard Care participants. Supplementing pharmacologic analgesia with TENS during rehabilitation exercises reduces movement pain postoperatively but a placebo influence exists and the effect is gone by 6 weeks. Patients with low anxiety and pain catastrophizing may benefit most from TENS. PMID:25270585
Baratta, Jaime L; Gandhi, Kishor; Viscusi, Eugene R
Pain management following total knee arthroplasty (TKA) can be challenging. Inadequate pain management following TKA may inhibit rehabilitation, increase morbidity and mortality, decrease patient satisfaction, and lead to chronic persistent postsurgical pain. Traditionally the mainstay of postoperative pain management was opioids; however, the current recommendations to pain management emphasize a multimodal approach and minimizing opioids whenever possible. With careful planning and a multimodal analgesic approach instituted perioperatively, appropriate pain management following TKA can be achieved. Utilizing an extensive review of the literature, this article discusses the analgesic techniques available for the perioperative management of TKA.
Atzori, Francesco; Salama, Wael; Sabatini, Luigi; Mousa, Shazly; Khalefa, Abdelrahman
Total knee arthroplasty (TKA) with a medial pivot design was developed in order to mimic normal knee kinematics; the highly congruent medial compartment implant should improve clinical results and decrease contact stresses. Clinical and radiographic mid-term outcomes are satisfactory, but we need other studies to evaluate long-term results and indications for unusual cases.
Rodriguez-Merchan, E Carlos
Background Knee prosthesis instability (KPI) is a frequent cause of failure of total knee arthroplasty. Moreover, the degree of constraint required to achieve immediate and long-term stability in total knee arthroplasty (TKA) is frequently debated. Questions This review aims to define the problem, analyze risk factors, and review strategies for prevention and treatment of KPI. Methods A PubMed (MEDLINE) search of the years 2000 to 2010 was performed using two key words: TKA and instability. One hundred and sixty-five initial articles were identified. The most important (17) articles as judged by the author were selected for this review. The main criteria for selection were that the articles addressed and provided solutions to the diagnosis and treatment of KPI. Results Patient-related risk factors predisposing to post-operative instability include deformity requiring a large surgical correction and aggressive ligament release, general or regional neuromuscular pathology, and hip or foot deformities. KPI can be prevented in most cases with appropriate selection of implants and good surgical technique. When ligament instability is anticipated post-operatively, the need for implants with a greater degree of constraint should be anticipated. In patients without significant varus or valgus malalignment and without significant flexion contracture, the posterior cruciate ligament (PCL) can be retained. However, the PCL should be sacrificed when deformity exists particularly in patients with rheumatoid arthritis, previous patellectomy, previous high tibial osteotomy or distal femoral osteotomy, and posttraumatic osteoarthritis with disruption of the PCL. In most cases, KPI requires revision surgery. Successful outcomes can only be obtained if the cause of KPI is identified and addressed. Conclusions Instability following TKA is a common cause of the need for revision. Typically, knees with deformity, rheumatoid arthritis, previous patellectomy or high tibial osteotomy, and
Parcells, Bertrand W; Tria, Alfred J
The early knee replacements were hinge designs that ignored the ligaments of the knee and resurfaced the joint, allowing freedom of motion in a single plane. Advances in implant fixation paved the way for modern designs, including the posterior-stabilized (PS) total knee arthroplasty (TKA) that sacrifices both cruciate ligaments while substituting for the posterior cruciate ligament (PCL), and the cruciate-retaining (CR) TKA designs that sacrifice the anterior cruciate ligament but retain the PCL. The early bicruciate retaining (BCR) TKA designs suffered from loosening and early failures. Townley and Cartier designed BCR knees that had better clinical results but the surgical techniques were challenging.Kinematic studies suggest that normal motion relies on preservation of both cruciate ligaments. Unicompartmental knee arthroplasty retains all knee ligaments and closely matches normal motion, while PS and CR TKA deviate further from normal. The 15% to 20% dissatisfaction rate with current TKA has renewed interest in the BCR design. Replication of normal knee kinematics and proprioception may address some of the dissatisfaction.
Akbari Shandiz, Mohsen; Boulos, Paul; Saevarsson, Stefan Karl; Yoo, Sam; Miller, Stephen; Anglin, Carolyn
Total knee arthroplasty (TKA) changes the knee joint in both intentional and unintentional, known and unknown, ways. Patellofemoral and tibiofemoral kinematics play an important role in postoperative pain, function, satisfaction and revision, yet are largely unknown. Preoperative kinematics, postoperative kinematics or changes in kinematics may help identify causes of poor clinical outcome. Patellofemoral kinematics are challenging to record since the patella is obscured by the metal femoral component in X-ray and moves under the skin. The purpose of this study was to determine the kinematic degrees of freedom having significant changes and to evaluate the variability in individual changes to allow future study of patients with poor clinical outcomes. We prospectively studied the 6 degrees of freedom patellofemoral and tibiofemoral weightbearing kinematics, tibiofemoral contact points and helical axes of rotation of nine subjects before and at least 1 year after total knee arthroplasty using clinically available computed tomography and radiographic imaging systems. Normal kinematics for healthy individuals were identified from the literature. Significant differences existed between pre-TKA and post-TKA kinematics, with the post-TKA kinematics being closer to normal. While on average the pre-total knee arthroplasty knees in this group displayed no pivoting (only translation), individually only five knees displayed this behaviour (of these, two showed lateral pivoting, one showed medial pivoting and one showed central pivoting). There was considerable variability postoperatively as well (five central, two lateral and two medial pivoting). Both preop and postop, flexion behaviour was more hinge-like medially and more rolling laterally. Helical axes were more consistent postop for this group. An inclusive understanding of the pre-TKA and post-TKA kinematics and changes in kinematics due to total knee arthroplasty could improve implant design, patient diagnosis and
Vertullo, C J; Easley, M E; Scott, W N; Insall, J N
Mobile-bearing knee arthroplasty (MBKA) has potential advantages compared with conventional fixed-bearing total knee arthroplasty (TKA). By allowing unconstrained axial rotation, MBKA can offer greater articular conformity without an increased probability of loosening due to increased axial torque. Increased articular conformity minimizes polyethylene contact stresses, thereby reducing linear wear and subsurface fatigue failure. Axial rotation of the platform also enables self-correction of tibial component malrotation. Despite these advantages, the long-term clinical results obtained with current MBKA devices are similar to those obtained with well-designed fixed-bearing TKA prostheses, with no data suggesting their superiority. The disadvantages of MBKA include bearing dislocation and breakage, soft-tissue impingement, a steep technique learning curve, and concerns about volumetric wear. Hypothetically, longer-term follow-up of MBKA results may reveal a significant difference from fixed-bearing TKA results as the fatigue failure threshold of incongruent polyethylene is exceeded.
Bytyqi, Dafina; Shabani, Bujar; Cheze, Laurence; Neyret, Philippe; Lustig, Sebastien
Patients with knee osteoarthritis tend to modify spatial and temporal parameters during walking to reduce the pain. Total knee arthroplasty (TKA) is considered the gold standard treatment for end-stage knee osteoarthritis. However, reduced physical function of the knee is partly, but apparently not fully, remedied by surgery. The purpose of this study was to investigate the in vivo, three dimensional knee kinematics during gait at the patients with knee osteoarthritis and the influence of "third condyle" psoterior stabilized (PS) total knee arthroplasty on restoration of normal kinematics. Twenty patients with medial knee osteoarthritis and a control group with age-matched subjects were prospectively collected for this study. The same group of 20 patients were re-assessed 10 months after total knee arthroplasty with "third condyle" PS prosthesis. All subjects were assessed with a 3D, optoelectric knee assessement device, while walking on a treadmill at a self-selected speed. For each participant, knee flexion-extension, abduction-adduction, internal-external rotation and anterior-posterior displacement, were calculated. The range of flexion/extension was improved significantly (39.9° ± 5.5° vs 44.8° ± 5.1°, p < 0.05) after TKA but it still remained lower than control group (6.9° ± 5.5° vs 2.2° ± 3.9°, p < 0.05). The range of motion in internal-external rotation did not change pre- and post-arthroplasty, but remained lower than the matched control group (6.7° ± 2.4° vs 9.3° ± 2.4, p < 0.05). The maximum posterior displacement during swing phase was significantly higher at post-arthroplasty group comparing with control group (-9.5 ± 2.2 vs -5.7 ± 3 mm, p < 0.05). Following "third condyle" PS-TKA, patients had better clinical, spatiotemporal and kinematic parameters. Despite improvements, the knee kinematics during gait in TKA group differed from healthy control group. TKA group had a lower extension lower range
Jung, Myung-Chul; Chung, Jun Young; Son, Kwang-Hyun; Wang, Hui; Hwang, Jaejin; Kim, Jay Joong; Kim, Joon Ho; Min, Byoung-Hyun
The purpose of this study was to compare knee kinematics during stair walking in patients with simultaneous total knee arthroplasty (TKA) and unicompartmental knee arthroplasties (UKA). It was hypothesized that UKA would reproduce more normalized knee kinematics than TKA during stair ascent and descent. Six patients who received UKA in one knee and TKA in the other knee were included in the study. For this study, a four-step staircase was assembled with two force platforms being positioned at the centre of the second and third steps. Each patient was attached with 16 reflective markers at both lower extremities and was asked to perform five roundtrip trials of stair climbing. Kinematic parameters including stance duration, knee angle, vertical ground reaction force (GRF), joint reaction force, and moments were obtained and analysed using a10-camera motion system (VICON, Oxford, UK). Nonparametric Friedman test was used to compare the results between two arthroplasty methods and between stair ascent and descent. Compared to TKA, UKA knees exhibited significantly greater degree of rotation in transverse planes (5.0 degrees during ascent and 6.0 degrees during descent on average), but showed no difference in terms of the other parameters. When comparing the results during stair ascent with descent, overall greater knee angle, vertical GRF, joint reaction force, and moment were observed during stair descent. Both UKA and TKA knees have shown overall similar knee kinematics, though UKA knee may allow greater degree of rotation freedom, which resembles normal knee kinematics during stair walking.
Haase, Elisabeth; Lange, Toni; Lützner, Jörg; Kopkow, Christian; Petzold, Thomas; Günther, Klaus-Peter; Schmitt, Jochen
Joint replacement surgery is one of the most often performed routine procedures for the treatment of knee osteoarthritis in Germany. Currently, there is no consensus on indication criteria for total knee arthroplasty (TKA). The topic indication for TKA was processed using six guiding questions concerning: 1) Common practice in determining the indication for TKA; 2) Inclusion criteria in clinical trials; 3) Treatment goals/goal criteria; 4) Predictors for goal attainment; 5) Economic aspects of determining a TKA indication; 6) Guidelines of the "Working Group of Scientific Medical Societies" (AWMF) in other areas. The evidence mapping was conducted by systematically searching Medline via Ovid, the Cochrane Library, through hand searching national guidelines and selected journals as well as the AWMF guideline portal. 1) In Germany there is currently no consented guideline regarding indications for TKA surgery. 2) Indication criteria for clinical trials are: diagnosed osteoarthritis of the knee, limitations of age and BMI. The most common criteria for exclusion include rheumatoid/inflammatory arthritis, secondary diagnoses and allergies. 3) As yet, no international initiatives have been identified which, by involving all relevant stakeholders, have reached consensus regarding the indication criteria for TKA. 4) A variety of predictors were identified with effects on individual treatment goals acting in different directions. 5) Very few studies were identified concerning economic aspects of determining TKA indication. 6) Comparable AWMF guidelines are currently not available. The findings of this study suggest that specific systematic reviews are needed to explore the following questions: What are the treatment goals of a TKA intervention? For whom are these relevant? And how are they measured? Continuous analyses are recommended in the field of predictors for a positive TKA outcome. Copyright © 2015. Published by Elsevier GmbH.
O'Connor, Mary I
As efforts continue to improve the results of TKA, the potential influence of sex and gender on long-term survival of implants, knee function, pain relief, and patient satisfaction remains relevant, particularly given the increased incidence of osteoarthritis of the knee in women and reports that women derive equal benefit from TKA. This article reviews the literature pertinent to the question of whether long-term survival, knee function, pain relief, and patient satisfaction after TKA differ between men and women. Large clinical series (> 1000 patients) published in the last 10 years were identified in PubMed and reviewed. Men may be at higher risk of revision surgery than women. Sex/gender has been consistently shown to impact both function and pain relief both before and after TKA. Although women achieve at least the same degree of functional improvement as men, women have worse preoperative physical function and do not reach the same final level of physical function as men. Likewise women may have similar or even greater improvement in pain after arthroplasty than men but still have final pain scores that are less favorable. Further research is required to understand the sex and gender differences contributing to implant survival, physical function, and pain relief after TKA. Strategies need to be developed to identify any patient who is at higher risk of implant failure, suboptimal postoperative function, and incomplete pain relief.
Cheuy, Victor A; Foran, Jared R H; Paxton, Roger J; Bade, Michael J; Zeni, Joseph A; Stevens-Lapsley, Jennifer E
Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function. Copyright © 2017 Elsevier Inc. All rights reserved.
O'Donnell, Turlough M P; Abouazza, Omar; Neil, Michael J
We compared a cohort of patients undergoing revision of a minimal resection resurfacing unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) with a cohort of patients undergoing primary TKA. Both cohorts were matched in terms of age, sex, and body mass index. We collected data on preoperative and postoperative range of motion, International Knee Society scores, and radiologic data. We also collected data on the modes of failure of the primary UKA. There were 55 patients in each cohort. The average time the UKA was in place was 48.3 months. The average follow-up period from the time of revision was 39.2 months. The most common reason for revision was subsidence of the tibial base plate (58%). Forty percent of patients required particulate bone grafting for contained defects. Two patients required metal augments, and 1 required stems. There was no significant difference between the 2 groups in terms of range of motion, functional outcome, or radiologic outcomes. Revision of these types of implants to TKA is associated with similar results to primary TKA and is superior to revision of other forms of UKA.
Comparison of continuous femoral nerve block (CFNB/SA) and continuous femoral nerve block with mini-dose spinal morphine (CFNB/SAMO) for postoperative analgesia after total knee arthroplasty (TKA): a randomized controlled study.
Sundarathiti, Petchara; Thammasakulsiri, Jadesadha; Supboon, Supawadee; Sakdanuwatwong, Supalak; Piangjai, Molruedee
Unsatisfactory analgesia for major knee surgery with femoral nerve block (FNB) alone was reported and the additional benefit of sciatic block to continuous femoral nerve block (CFNB) was not conclusive. The aim of the present study was to find the benefit of the additional mini-dose spinal morphine (0.035 mg) to CFNB for postoperative pain control and to compare their associated side effects after total knee arthroplasty (TKA). After written informed consent and with Institutional Ethics Committee approval, 68 American Society of Anesthesiologists (ASA) Physical Status I-III patients scheduled for elective unilateral TKA under spinal anesthesia (SA) were included in the present prospective, randomized controlled study. The patients were allocated into two groups. CFNB was placed in all patients by the inguinal paravascular approach with 20 ml of 0.25 % levobupivacaine. Group I (named CFNB/SA group), SA was administered with 2.8 ml levobupivacaine and Group II (named CFNB/SAMO group), SA with 2.8 ml levobupivacaine plus morphine 0.035 mg. At Post Anesthesia Care Unit (PACU), pain and other adverse effects were recorded. Pain was assessed by visual analog scale (VAS) 0-10. Tramadol 50 mg intravenous (IV) was given if the VAS > 4. In the ward, all patients were maintained by continuous femoral infusion of 0.125 % levobupivacaine rate 7 ml/hr and then reduced to 5 ml/hr if VAS ≤3. Patient's demographics data in each group were not different. At post-operative (PO) 12-24 h, the VAS scores were significantly lesser in the CFNB/SAMO group. Cumulative tramadol IV requirement for PO48h were also significantly lesser in the CFNB/SAMO group. Nausea, vomiting and numbness were significantly greater in the CFNB/SAMO group during early postoperative period (PO1-6 h). Though in some patients CFNB was inadequate, a mini-dose of intrathecal morphine (0.035 mg) in addition to CFNB was found to be effective with minimal side effects. Thai Clinical Trial Registry
Alves, Wilson Mello; Migon, Eduardo Zaniol; Zabeu, Jose Luis Amim
Total knee arthroplasty (TKA) is known to be a successful procedure. The aging of the population and the growing demand for quality of life have greatly increased the indications for the procedure. Nonetheless, TKA presents some complications that still lack definitive resolution. Pain after TKA is caused by a myriad of reasons that need to be systematically studied in order to reach the correct diagnosis and treatment. History, physical examination, laboratory tests and imaging examinations must all be included in the workup and repeated until a plausible reason has been identified, since if pain is the only indication for TKA revision, the results may be catastrophic. PMID:27022583
Bayne, Christopher O; Bayne, Omar; Peterson, Michael; Cain, Eric
Arterial thrombosis is a rare complication of total knee arthroplasty (TKA). The overall incidence of arterial complications after TKA, including arterial occlusion, arteriovenous fistula, arterial aneurysm, and arterial severance, varies between 0.03% and 0.17% in reports published in the orthopedic literature (J Vasc Surg 1994;20:927-932). We report a case of acute popliteal artery thrombosis and its sequelae immediately following bilateral TKA performed sequentially under the same anesthesia. This is the first reported case of a post-TKA popliteal artery thrombosis in a patient younger than 60 years without the commonly accepted risk factors.
Gupta, Ryan; Phan, Duy; Schwarzkopf, Ran
Metal hypersensitivity is an uncommon complication after total knee arthroplasty (TKA) that can lead to significant functional impairment and aseptic prosthesis failure. We describe a 70-year-old patient who presented with persistent pain, swelling, and instability 2 years after a primary TKA. The patient had a history of metal hypersensitivity following bilateral metal-on-metal total hip arthroplasty (THA) that was revised to ceramic-on-polyethylene implants. Knee radiographs showed severe osteolysis with implant loosening. Serum cobalt was elevated and serum chromium was significantly elevated, while joint aspiration and inflammatory marker levels ruled out a periprosthetic infection. Revision TKA was performed, with intraoperative tissue pathology and postoperative leukocyte transformation testing confirming metal hypersensitivity as the cause for aseptic implant failure. This case report demonstrates the clinical and laboratory signs that suggest metal hypersensitivity in total knee arthroplasty and the potential for joint function restoration with revision surgery.
Pancio, Steven I; Sousa, Paul L; Krych, Aaron J; Abdel, Matthew P; Levy, Bruce A; Dahm, Diane L; Stuart, Michael J
The risk of major complications and revision arthroplasty after TKA in patients who previously underwent multiligament knee surgery have been poorly characterized. Is multiligament knee surgery before TKA associated with (1) worse implant survival, (2) increased use of TKA design constraint, (3) a greater risk for major complications, and (4) poorer scores for pain and function compared with similar patients receiving TKA for primary osteoarthritis? Fifty-nine TKAs were performed at our institution between 1985 and 2014 in 59 patients (36 men, 23 women; mean age, 53 years) with a history of previous multiligament knee surgery (≥ two ligaments). Of those, we had followup for 39 (66%), 18 (31%), and six (10%) patients at 5, 10, and 15 years, respectively; mean followup was 5.4 years (range, 1-25 years). A two-to-one matched control group consisting of patients undergoing primary TKA for the diagnosis of osteoarthritis was selected for comparison. Patients were matched based on gender, age at primary TKA (within 5 years), and date of the TKA (within 5 years). Medical records were reviewed for survivorship, TKA design, complications (reoperation, revision, infection, manipulation under anesthesia, and periprosthetic joint infection), TKA design, and clinical outcomes (Knee Society Scores [KSS], Knee Society Function Score [KSS-F]). The overall 15-year revision-free survival in patients with prior multiligament knee surgery was decreased in comparison to the matched controls (42% [95% CI, 16%-73%] vs 94% [95% CI, 81%-99%]; p < 0.001). Varus-valgus constraint implant design was used for more patients in the multiligament cohort at index TKA than in the matched control group (9/59 [15%] vs 0/110 [0%], respectively; odds ratio [OR], 45; 95% CI, 3-781; p = 0.009). Patients with a history of multiligament knee surgery also were at increased risk of reoperation for any cause (14/59 [24%] vs 7/118 [6%]; OR, 5; 95% CI, 2-14; p = 0.001). With the numbers available, there was
Abdul, Nicole; Dixon, David; Walker, Andrew; Horabin, Joanna; Smith, Nick; Weir, David J; Brewster, Nigel T; Deehan, David J; Mann, Derek A; Borthwick, Lee A
Total knee arthroplasty (TKA) is one of the most successful orthopaedic procedures that alleviates pain and restores function in patients with degenerative knee joint diseases. Arthrofibrosis, abnormal scarring in which dense fibrous tissue prevents normal range of motion, develops in ~3-10% of TKA patients. No prophylactic intervention is available and treatment is restricted to aggressive physiotherapy or revision surgery. Tissue was collected from patients undergoing primary (n = 30) or revision (n = 27) TKA. Revision patients were stratified as non-arthrofibrotic and arthrofibrotic. Tissue was macroscopically and histologically compared to improve our understanding of the pathophysiology of arthrofibrosis. Macroscopically, tissue from primary TKA presents as homogenous, fatty tissue whereas tissue from revision TKA presents as dense, pigmented tissue. Histologically, there was dramatic tissue remodelling, increased collagen deposition and increased (myo)fibroblast staining in tissue from revision TKA. Significantly, tissue architecture was similar between revision patients regardless of clinically diagnosis. There are significant differences in architecture and composition of tissue from revision TKA over primary TKA. Surprisingly, whether revision TKA were clinically diagnosed as arthrofibrotic or non-arthrofibrotic there were still significant differences in fibrotic markers compared to primary TKA suggesting an ongoing fibrotic process in all revision knees.
Abdul, Nicole; Dixon, David; Walker, Andrew; Horabin, Joanna; Smith, Nick; Weir, David J.; Brewster, Nigel T.; Deehan, David J.; Mann, Derek A.; Borthwick, Lee A.
Total knee arthroplasty (TKA) is one of the most successful orthopaedic procedures that alleviates pain and restores function in patients with degenerative knee joint diseases. Arthrofibrosis, abnormal scarring in which dense fibrous tissue prevents normal range of motion, develops in ~3–10% of TKA patients. No prophylactic intervention is available and treatment is restricted to aggressive physiotherapy or revision surgery. Tissue was collected from patients undergoing primary (n = 30) or revision (n = 27) TKA. Revision patients were stratified as non-arthrofibrotic and arthrofibrotic. Tissue was macroscopically and histologically compared to improve our understanding of the pathophysiology of arthrofibrosis. Macroscopically, tissue from primary TKA presents as homogenous, fatty tissue whereas tissue from revision TKA presents as dense, pigmented tissue. Histologically, there was dramatic tissue remodelling, increased collagen deposition and increased (myo)fibroblast staining in tissue from revision TKA. Significantly, tissue architecture was similar between revision patients regardless of clinically diagnosis. There are significant differences in architecture and composition of tissue from revision TKA over primary TKA. Surprisingly, whether revision TKA were clinically diagnosed as arthrofibrotic or non-arthrofibrotic there were still significant differences in fibrotic markers compared to primary TKA suggesting an ongoing fibrotic process in all revision knees. PMID:26553967
Nazzal, Mahmoud I.; Bashaireh, Khaldoon H.; Alomari, Mahmoud A.; Nazzal, Mohammad S.; Maayah, Mikhled F.; Mesmar, Mohammad
The aim of this study was to examine patient satisfaction with rehabilitation after total knee arthroplasty (TKA). Fifty-six patients, aged 45-77 years, were enrolled in a post-TKA comprehensive therapy program focusing on knee strengthening and functional activities. The program lasted 3 months and was conducted for 1 h, twice a day, 5 days per…
Nazzal, Mahmoud I.; Bashaireh, Khaldoon H.; Alomari, Mahmoud A.; Nazzal, Mohammad S.; Maayah, Mikhled F.; Mesmar, Mohammad
The aim of this study was to examine patient satisfaction with rehabilitation after total knee arthroplasty (TKA). Fifty-six patients, aged 45-77 years, were enrolled in a post-TKA comprehensive therapy program focusing on knee strengthening and functional activities. The program lasted 3 months and was conducted for 1 h, twice a day, 5 days per…
Pianigiani, Silvia; Labey, Luc; Pascale, Walter; Innocenti, Bernardo
Total knee arthroplasty (TKA) is a very successful surgical procedure. However, implant failures and patient dissatisfaction still persist. Sometimes surgeons are not able to understand and explain these negative performances because the patient's medical images "look good", but the patient "feels bad". Apart from radiograph imaging and clinical outcome scores, conventionally used follow-up methods are mainly based on the analysis of knee kinematics. However, even if kinematics remains close to the "normal" range of motion, the patient may still complain about pain and functional limitations. To provide more insight into this paradox, a better quantitative understanding of TKA mechanics must be developed. For this purpose, improved techniques for clinical follow-up, combining kinetics and kinematics analysis, should be introduced to help surgeons to assess and understand TKA performance. An analysis on four TKA designs was performed, and the changes in kinematics and in kinetics induced by several implant configurations (simulating implant malalignment and different knee anatomy) were compared. More specifically, analysed tibio-femoral and patello-femoral contact forces and tibio-femoral kinematics were analysed during a squat task up to 120°. The results from this study show that contact forces (with changes up to 67 %) are more heavily affected by malconfigurations than kinematics, for which maximum deviations are of the order of 5 mm or 5°, similar to the simulated surgical errors. The results present a similar trend for the different designs. The results confirm the hypothesis that kinematics is not the only and also not the most relevant parameter to predict or explain knee function after TKA. In the future, techniques to analyse knee kinetics should be integrated in the clinical follow-up.
Carulli, Christian; Villano, Marco; Bucciarelli, Giovanni; Martini, Caterina; Innocenti, Massimo
Summary Total Knee Arthroplasty (TKA) is one of the most successful procedures in Orthopaedic Surgery, with good clinical results and high survival rate in more than 90% of the cases at long-term follow-up. Since the increase of population’s mean age, worsening of articular degenerative alterations, and articular sequelae related to previous fractures, there is a persistent growing of the number of knee arthroplasties in every country each year, with expected increase of complications rates. Painful TKA is considered an unusual complication, but several reports focus on this challenging clinical issue. Common causes of painful TKA may be divided as early or late, and in referred, periarticular or intra-articular. Among the early, we recall implant instability (related to surgical and technical mistakes) and problems of extensor mechanism (patella not resurfaced, malalignment of femoral, tibial, or patellar component, tendons failure or degeneration). Late causes of painful TKA are almost related to aseptic loosening and infection, but also, even if unusual, reflex sympathetic dystrophy, synovitis, and hypersensitivity to metal implants are represented. Hypersensitivity to metal is a clinical issue with significative increase, but to date without a specific characterization. The Authors report about incidence, clinical features, and diagnostic pathways of hypersensitivity to metal implants, focusing on the prevention of this challenging problem. PMID:22461811
Total knee arthroplasty (TKA) is one of the most successful and effective surgical options to reduce pain and restore function for patients with severe osteoarthritis. The purpose of this article was to review and summarize the recent literatures regarding patient satisfaction after TKA and to analyze the various factors associated with patient dissatisfaction after TKA. Patient satisfaction is one of the many patient-reported outcome measures (PROMs). Patient satisfaction can be evaluated from two categories, determinants of satisfaction and components of satisfaction. The former have been described as all of the patient-related factors including age, gender, personality, patient expectations, medical and psychiatric comorbidity, patient's diagnosis leading to TKA and severity of arthropathy. The latter are all of the processes and technical aspects of TKA, ranging from the anesthetic and surgical factors, type of implants and postoperative rehabilitations. The surgeon- and patient-reported outcomes have been shown to be disparate occasionally. Among various factors that contribute to patient satisfaction, some factors can be managed by the surgeon, which should be improved through continuous research. Furthermore, extensive discussion and explanation before surgery will reduce patient dissatisfaction after TKA. PMID:26955608
Jacobs, Cale A; Christensen, Christian P; Karthikeyan, Tharun
Although the relationship between pain and bone marrow edema (BME) in the osteoarthritic knee has been established, little is known about the effect of preoperative BME on postoperative outcomes after knee arthroplasty or if the influence of BME on postoperative outcomes differs between medial unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The purpose of this study was to compare pain, patient satisfaction, and revision rates between medial UKA and TKA patients with and without magnetic resonance imaging evidence of BME in the proximal tibia. We identified 71 patients (72 knees) from our prospective outcomes database with magnetic resonance images taken before undergoing either medial UKA or TKA and recorded the absence or presence of tibial BME. We then compared preoperative and postoperative Knee Society pain scores, patient satisfaction, and revisions between groups of UKA and TKA patients with or without preoperative tibial BME. Pain scores for UKA patients with BME were worse both before and after surgery, whereas TKA patients with BME demonstrated greater postoperative improvements in pain scores when compared to TKA patients without BME. Similarly, significantly fewer UKA patients with BME were satisfied with their procedure than those without BME (8/11, 73% vs 17/17, 100%; P = .05), but BME did not affect patient satisfaction after TKA. Preoperative BME did not influence TKA outcomes; however, pain scores for UKA patients with BME were worse both before and after surgery and fewer UKA patients with preoperative tibial BME were satisfied with their surgery. Copyright © 2016 Elsevier Inc. All rights reserved.
Schroer, William C; Diesfeld, Paul G; LeMarr, Angela R; Morton, Diane J; Reedy, Mary E
Liposomal bupivacaine periarticular injection (PAI) offers sustained bupivacaine release after TKA, but few prospective independent studies exist. In this prospective, blinded study, liposomal bupivacaine was randomized against bupivacaine and incorporated into a comprehensive multimodal pain management protocol. 111 primary TKAs were randomized to receive PAI: 58 patients received 266 mg (20cc) liposomal bupivacaine mixed with 75 mg (30cc) 0.25% bupivacaine, and 53 patients received 150 mg (60cc) 0.25% bupivacaine. Visual analog pain scores and narcotic use were determined. No pain score differences occurred between study and control patients: Day 1: 4.5/4.6 (P=0.73); Day 2: 4.4/4.8 (P=0.27); or Day 3: 3.5/3.7 (P=0.58). Narcotic use was similar during hospitalization, 51.8/54.2 (P=0.34). The study medication costs $285, and the control medication costs $2.80. This finding does not justify the routine use of liposomal bupivacaine.
Lachiewicz, Paul F; Watters, Tyler Steven; Jacobs, Joshua J
Metal hypersensitivity in patients with a total knee arthroplasty (TKA) is a controversial topic. The diagnosis is difficult, given the lack of robust clinical validation of the utility of cutaneous and in vitro testing. Metal hypersensitivity after TKA is quite rare and should be considered after eliminating other causes of pain and swelling, such as low-grade infection, instability, component loosening or malrotation, referred pain, and chronic regional pain syndrome. Anecdotal observations suggest that two clinical presentations of metal hypersensitivity may occur after TKA: dermatitis or a persistent painful synovitis of the knee. Patients may or may not have a history of intolerance to metal jewelry. Laboratory studies, including erythrocyte sedimentation rate, C-reactive protein level, and knee joint aspiration, are usually negative. Cutaneous and in vitro testing have been reported to be positive, but the sensitivity and specificity of such testing has not been defined. Some reports suggest that, if metal hypersensitivity is suspected and nonsurgical measures have failed, then revision to components fabricated of titanium alloy or zirconium coating can be successful in relieving symptoms. Revision should be considered as a last resort, however, and patients should be informed that no evidence-based medicine is available to guide the management of these conditions, particularly for decisions regarding revision. Given the limitations of current testing methods, the widespread screening of patients for metal allergies before TKA is not warranted.
Lachiewicz, Paul F.; Watters, Tyler Steven; Jacobs, Joshua J.
Metal hypersensitivity in patients with a total knee arthroplasty (TKA) is a controversial topic. The diagnosis is difficult, given the lack of robust clinical validation of the utility of cutaneous and in vitro testing. Metal hypersensitivity after TKA is quite rare and should be considered after eliminating other causes of pain and swelling, such as low-grade infection, instability, component loosening or malrotation, referred pain, and chronic regional pain syndrome. Anecdotal observations suggest that two clinical presentations of metal hypersensitivity may occur after TKA: dermatitis or a persistent painful synovitis of the knee. Patients may or may not have a history of intolerance to metal jewelry. Laboratory studies, including erythrocyte sedimentation rate, C-reactive protein level, and knee joint aspiration, are usually negative. Cutaneous and in vitro testing have been reported to be positive, but the sensitivity and specificity of such testing has not been defined. Anecdotal reports suggest that, if metal hypersensitivity is suspected and nonsurgical measures have failed, then revision to components fabricated of titanium alloy or zirconium coating can be successful in relieving symptoms. Revision should be considered as a last resort, however, and patients should be informed that no evidence-based medicine is available to guide the management of these conditions, particularly for decisions regarding revision. Given the limitations of current testing methods, the widespread screening of patients for metal allergies before TKA is not warranted. PMID:26752739
da Silva, Robson Rocha; Santos, Ayrton André Melo; de Sampaio Carvalho Júnior, José; Matos, Marcos Almeida
To review the literature on quality of life among patients who underwent total knee arthroplasty (TKA) and assess the impact of various associated factors. this was a systematic review of the literature in the Medline, Embase, Lilacs and SciELO databases, using the terms: TKA (total knee arthroplasty); TKR (total knee replacement); quality of life; and outcomes. There were no restrictions regarding study design. 31 articles addressing this topic using various quality-of-life evaluation protocols were selected. SF-36/SF-12, WOMAC and Oxford were the ones most frequently used. The studies made it possible to define that TKA is capable of making an overall improvement in patients' quality of life. Pain and function are among the most important predictors of improvement in quality of life, even when function remains inferior to that of healthy patients. The factors associated negatively were obesity, advanced age, comorbidities, persistence of pain after the procedure and a lengthy wait for surgery.
Alghamdi, Ahmed; Rahmé, Michel; Lavigne, Martin; Massé, Vincent; Vendittoli, Pascal-André
Osteoarthritis of the knee is associated with deformities of the lower limb. Tibia valga is a contributing factor to lower limb alignment in valgus knees. We evaluated 97 valgus knees and 100 varus knees. Long-leg films were taken in weight bearing with both knees in full extension. For valgus knees, 52 knees (53%) had a tibia valga deformity. Average tibia valgus deformation was 5.0°. For varus knees, there was only 1 case of tibia valga (1%), with a deformation of 2.5°. The aim of this study was to assess the prevalence of primary tibia valga in valgus and varus knees and understand how it affects our approach to total knee arthroplasty (TKA). We recommend having full-leg length films when planning for TKA in valgus knees.
Young, Kathryn L; Dunbar, Michael J; Richardson, Glen; Astephen Wilson, Janie L
Surgical navigation systems for total knee arthroplasty (TKA) surgery are capable of capturing passive three-dimensional (3D) angular joint movement patterns intraoperatively. Improved understanding of patient-specific knee kinematic changes between pre and post-implant states and their relationship with post-operative function may be important in optimizing TKA outcomes. However, a comprehensive characterization of the variability among patients has yet to be investigated. The objective of this study was to characterize the variability within frontal plane joint movement patterns intraoperatively during a passive knee flexion exercise. Three hundred and forty patients with severe knee osteoarthritis (OA) received a primary TKA using a navigation system. Passive kinematics were captured prior to (pre-implant), and after prosthesis insertion (post-implant). Principal component analysis (PCA) was used to capture characteristic patterns of knee angle kinematics among patients, to identify potential patient subgroups based on these patterns, and to examine the subgroup-specific changes in these patterns between pre- and post-implant states. The first four extracted patterns explained 99.9% of the diversity within the frontal plane angle patterns among the patients. Post-implant, the magnitude of the frontal plane angle shifted toward a neutral mechanical axis in all phenotypes, yet subtle pattern (shape of curvature) features of the pre-implant state persisted.
Li, Chunbao; Hosseini, Ali; Tsai, Tsung-Yuan; Kwon, Young-Min; Li, Guoan
Accurate knowledge of tibiofemoral articular contact kinematics of the knee after total knee arthroplasty (TKA) is important for understanding the intrinsic knee biomechanics and improving the longevity of the components. The objective of this study was to compare the in vivo articular contact kinematics of the knees with end-stage medial osteoarthritis (OA) during a weight-bearing, single leg lunge activity before and after a posterior cruciate retaining TKA (CR-TKA) using a dual fluoroscopic imaging technique. We found that the CR-TKA resulted in more posterior contact positions on the tibial surface and a reduced range of motion in the medial and lateral compartments. The distances between medial and lateral contact locations in the CR-TKA knees were statistically larger than the OA knees. The articular contact centers have shifted from medial side of the tibial plateau pre-operatively to the lateral side after operation. This study indicated that the CR-TKA resulted in significant changes in contact kinematics of the knees in both anteroposterior and mediolateral directions. Further studies are needed to determine the influence of the altered in vivo contact kinematics on the longevity of polyethylene liner and long term clinical outcomes of the TKA. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Paxton, Roger J; Melanson, Edward L; Stevens-Lapsley, Jennifer E; Christiansen, Cory L
Total knee arthroplasty (TKA) is the most commonly performed elective surgery in the United States. TKA typically improves functional performance and reduces pain associated with knee osteoarthritis. Little is known about the influence of TKA on overall physical activity levels. Physical activity, defined as “any bodily movement produced by skeletal muscles that results in energy expenditure”, confers many health benefits but typically decreases with endstage osteoarthritis. The purpose of this review is to describe the potential benefits (metabolic, functional, and orthopedic) of physical activity to patients undergoing TKA, present results from recent studies aimed to determine the effect of TKA on physical activity, and discuss potential sources of variability and conflicting results for physical activity outcomes. Several studies utilizing self-reported outcomes indicate that patients perceive themselves to be more physically active after TKA than they were before surgery. Accelerometry-based outcomes indicate that physical activity for patients after TKA remains at or below pre-surgical levels. Several different factors likely contributed to these variable results, including the use of different instruments, duration of follow-up, and characteristics of the subjects studied. Comparison to norms, however, suggests that daily physical activity for patients following TKA may fall short of healthy age-matched controls. We propose that further study of the relationship between TKA and physical activity needs to be performed using accelerometry-based outcome measures at multiple post-surgical time points. PMID:26396937
Paxton, Roger J; Melanson, Edward L; Stevens-Lapsley, Jennifer E; Christiansen, Cory L
Total knee arthroplasty (TKA) is the most commonly performed elective surgery in the United States. TKA typically improves functional performance and reduces pain associated with knee osteoarthritis. Little is known about the influence of TKA on overall physical activity levels. Physical activity, defined as "any bodily movement produced by skeletal muscles that results in energy expenditure", confers many health benefits but typically decreases with endstage osteoarthritis. The purpose of this review is to describe the potential benefits (metabolic, functional, and orthopedic) of physical activity to patients undergoing TKA, present results from recent studies aimed to determine the effect of TKA on physical activity, and discuss potential sources of variability and conflicting results for physical activity outcomes. Several studies utilizing self-reported outcomes indicate that patients perceive themselves to be more physically active after TKA than they were before surgery. Accelerometry-based outcomes indicate that physical activity for patients after TKA remains at or below pre-surgical levels. Several different factors likely contributed to these variable results, including the use of different instruments, duration of follow-up, and characteristics of the subjects studied. Comparison to norms, however, suggests that daily physical activity for patients following TKA may fall short of healthy age-matched controls. We propose that further study of the relationship between TKA and physical activity needs to be performed using accelerometry-based outcome measures at multiple post-surgical time points.
Lum, Z. C.; Lombardi, A. V.; Hurst, J. M.; Morris, M. J.; Adams, J. B.; Berend, K. R.
Aims Since redesign of the Oxford phase III mobile-bearing unicompartmental knee arthroplasty (UKA) femoral component to a twin-peg design, there has not been a direct comparison to total knee arthroplasty (TKA). Thus, we explored differences between the two cohorts. Patients and Methods A total of 168 patients (201 knees) underwent medial UKA with the Oxford Partial Knee Twin-Peg. These patients were compared with a randomly selected group of 177 patients (189 knees) with primary Vanguard TKA. Patient demographics, Knee Society (KS) scores and range of movement (ROM) were compared between the two cohorts. Additionally, revision, re-operation and manipulation under anaesthesia rates were analysed. Results The mean follow-up for UKA and TKA groups was 5.4 and 5.5 years, respectively. Six TKA (3.2%) versus three UKAs (1.5%) were revised which was not significant (p = 0.269). Manipulation was more frequent after TKA (16; 8.5%) versus none in the UKA group (p < 0.001). UKA patients had higher post-operative KS function scores versus TKA patients (78 versus 66, p < 0.001) with a trend toward greater improvement, but there was no difference in ROM and KS clinical improvement (p = 0.382 and 0.420, respectively). Conclusion We found fewer manipulations, and higher functional outcomes for patients treated with medial mobile-bearing UKA compared with TKA. TKA had twice the revision rate as UKA although this did not reach statistical significance with the numbers available. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):28–33. PMID:27694513
Toliopoulos, Panagiota; LeBlanc, Marc-Andre; Hutt, Jonathan; Lavigne, Martin; Desmeules, Francois; Vendittoli, Pascal-Andre
Objectives: The purpose of this study was to compare the intra-operative benefits and the clinical outcomes from kinematic or mechanical alignment for total knee arthroplasty (TKA) in patients undergoing revision of failed unicompartmental kneel arthroplasty (UKA) to TKA. Methods: Ten revisions were performed with a kinematic alignment technique and 11 with a mechanical alignment. Measurements of the hip-knee-ankle angle (HKA), the lateral distal femoral angle (LDFA), and the medial proximal tibial angle (MPTA) were performed using long-leg radiographs. The need for augments, stems, and constrained inserts was compared between groups. Clinical outcomes were compared using the WOMAC score along with maximum distance walked as well as knee range of motion obtained prior to discharge. All data was obtained by a retrospective review of patient files. Results: The kinematic group required less augments, stems, and constrained inserts than the mechanical group and thinner polyethylene bearings. There were significant differences in the lateral distal femoral angle (LDFA) and the medial proximal tibial angle (MPTA) between the two groups (p<0.05). The mean WOMAC score obtained at discharge was better in the kinematic group as was mean knee flexion. At last follow up of 34 months for the kinematic group and 58 months for the mechanical group, no orthopedic complications or reoperations were recorded. Conclusion: Although this study has a small patient cohort, our results suggest that kinematic alignment for TKA after UKA revision is an attractive method. Further studies are warranted. PMID:27563365
Kahn, Timothy L; Schwarzkopf, Ran
Total knee arthroplasty (TKA) is associated with improved patient-reported pain levels, function, and quality of life; however, it is poorly understood whether there is increased physical activity following TKA. Using data from the Osteoarthritis Initiative (OAI), we compare physical activity, as measured using an accelerometer, and patient-reported outcome measures of 60 patients who had already received a TKA with 63 patients who eventually received a TKA during the OAI study. There was no significant difference in activity levels between the two groups as measured by the accelerometer. Total WOMAC, KOOS Quality of Life, KOOS Knee Pain, and KOOS Function scores improved in the post-TKA compared to the pre-TKA group. In both pre-TKA and post-TKA groups, physical activity guidelines were met in only 5% or less. Copyright © 2015 Elsevier Inc. All rights reserved.
Cho, Kye-Youl; Song, Sang-Jun; Bae, Dae-Kyung
Background Cruciate-retaining (CR) prostheses have been considered to produce more physiologic femoral rollback, provide better proprioception, and result in better quadriceps recovery than posterior-stabilized (PS) prostheses after total knee arthroplasty (TKA). However, there are very few studies demonstrating these benefits in an objective manner. We investigated whether CR-TKA could result in (1) better quadriceps recovery; (2) a greater proportion of patients with beyond the preoperative level of recovery; and (3) better clinical outcomes than PS-TKA. Methods This was a prospective non-randomized comparative study on the results of CR-TKA and PS-TKA. CR prostheses were used in 51 knees and PS prostheses in 51 knees. Quadriceps force was measured with a dynamometer preoperatively and at postoperative 6 weeks, 3 months, and 6 months consecutively. The Knee Society score (KSS) and range of motion (ROM) were also evaluated. Results There were no differences between two groups in terms of the objective quadriceps force during the follow-up period. The proportion of patients with beyond the preoperative level of recovery was similar between groups. Moreover, the KSS and ROM were not significantly different between two groups. Conclusions CR-TKA did not result in better quadriceps recovery than PS-TKA during the 6-month follow-up. In other words, PS-TKA could lead to comparable quadriceps recovery despite greater preoperative weaknesses such as more restricted ROM and more severe degenerative changes of the knee. PMID:27904719
Bala, Abiram; Penrose, Colin Thomas; Seyler, Thorsten Markus; Mather, Richard Chad; Wellman, Samuel Secord; Bolognesi, Michael Paul
Computer-navigated total knee arthroplasty (CN-TKA) has been used to improve component alignment, though the evidence is currently mixed on whether there are clinically significant differences in long-term outcomes. Given the established increased costs and operative time, we hypothesized that the utilization rate of CN-TKA would be decreasing relative to standard TKA in the Medicare population given the current health care economic environment. We queried 1,914,514 primary TKAs performed in the entire Medicare database from 2005 to 2012. Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify and separate CN-TKAs. Utilization of TKA was compared by year, gender, and region. Average change in cases per year and compound annual growth rate (CAGR) were used to evaluate trends in utilization of the procedure. We identified 30,773 CN-TKAs performed over this time period. There was an increase in utilization of CN-TKA per year from 984 to 5,352 (average = 572/year, R (2) = 0.85, CAGR = 23.58%) from 2005 to 2012. In contrast, there was a slight decrease in overall TKA utilization from 264,345 to 230,654 (average = 4297/year, R (2) = 0.74, CAGR = - 1.69%). When comparing proportion of CN-TKA to all TKAs, there was an increase from 0.37 to 2.32% (average 0.26%/year, R (2) = 0.88, CAGR = 25.70%). CN-TKA growth in males and females was comparable at 24.42 and 23.11%, respectively. The South region had the highest growth rate at 28.76%, whereas the Midwest had the lowest growth rate at 15.51%. The Midwest was the only region that peaked (2008) with a slow decline in utilization until 2012. Despite increased costs with unclear clinical benefit, CN-TKA is increasing in utilization among Medicare patients. Reasons could include patient preference, advertising, proper of coding the procedure, and increased publicly available information about
NiemeläInen, Mika J; MäKelä, Keijo T; Robertsson, Otto; W-Dahl, Annette; Furnes, Ove; Fenstad, Anne M; Pedersen, Alma B; Schrøder, Henrik M; Huhtala, Heini; Eskelinen, Antti
Background and purpose - The annual number of total knee arthroplasties (TKAs) has increased worldwide in recent years. To make projections regarding future needs for primaries and revisions, additional knowledge is important. We analyzed and compared the incidences among 4 Nordic countries Patients and methods - Using Nordic Arthroplasty Register Association (NARA) data from 4 countries, we analyzed differences between age and sex groups. We included patients over 30 years of age who were operated with TKA or unicompartmental knee arthroplasty (UKA) during the period 1997-2012. The negative binomial regression model was used to analyze changes in general trends and in sex and age groups. Results - The average annual increase in the incidence of TKA was statistically significant in all countries. The incidence of TKA was higher in women than in men in all 4 countries. It was highest in Finland in patients aged 65 years or more. At the end of the study period in 2012, Finland's total incidence was double that of Norway, 1.3 times that of Sweden and 1.4 times that of Denmark. The incidence was lowest in the youngest age groups (< 65 years) in all 4 countries. The proportional increase in incidence was highest in patients who were younger than 65 years. Interpretation - The incidence of knee arthroplasty steadily increased in the 4 countries over the study period. The differences between the countries were considerable, with the highest incidence in Finland. Patients aged 65 years or more contributed to most of the total incidence of knee arthroplasty.
Lo, JiaHsuan; Müller, Otto; Dilger, Torsten; Wülker, Nikolaus; Wünschel, Markus
This study investigated passive translational and rotational stability properties of the intact knee joint, after bicruciate-retaining bi-compartmental knee arthroplasty (BKA) and after posterior cruciate retaining total knee arthroplasty (TKA). Fourteen human cadaveric knee specimens were used in this study, and a robotic manipulator with six-axis force/torque sensor was used to test the joint laxity in anterior-posterior translation, valgus-varus, and internal-external rotation. The results show the knee joint stability after bicruciate-retaining BKA is similar to that of the native knee. On the other hand, the PCL-retaining TKA results in inferior joint stability in valgus, varus, external rotation, anterior and, surprisingly, posterior directions. Our findings suggest that, provided functional ligamentous structures, bicruciate-retaining BKA is a biomechanically attractive treatment for joint degenerative disease. Copyright © 2010 Elsevier B.V. All rights reserved.
Kulshrestha, Vikas; Datta, Barun; Kumar, Santhosh; Mittal, Gaurav
With increasing number of patients with early osteoarthritis of knee opting for total knee arthroplasty (TKA), there has been increase in patients dissatisfied with surgical outcomes. It is being presumed that offering unicondylar knee arthroplasty (UKA) to them would improve outcomes. Primary objective of our study was to look for any difference in patient-reported outcome and function at 2-year follow-up in patients undergoing UKA as compared to TKA. Our study was a randomized study with parallel assignment conducted at a high-volume specialized arthroplasty center. Eighty patients with bilateral isolated medial compartment knee arthritis were randomized into simultaneous 2-team bilateral TKA (n = 40) and UKA (n = 40) group. We finally analyzed 36 patients in each group. Main outcome measure was improvement in Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and High Activity Arthroplasty Score (HAAS) obtained at 2-year follow-up. Improvement in KOS-ADLS and HAAS at 2 years was similar (P = .2143 and .2010) in both groups. Performance as assessed with Delaware index was also similar. Length of hospital stay was less in UKA group (6.6 days as against 5.4 days). Complications and readmission rates were more in TKA group (nil in UKA group; 08 in TKA group). At 2-year follow-up, UKA provides similar improvement in patient-reported outcomes, function, and performance as compared to TKA when performed in patients with early arthritis. However, UKA patients have shorter hospital stay and fewer complications. Copyright © 2016 Elsevier Inc. All rights reserved.
Schroer, William C; Diesfeld, Paul J; Reedy, Mary E; LeMarr, Angela
This study reviewed 747 consecutive posterior stabilized total knee arthroplasty (TKA) to explain the increased incidence of patella clunk syndrome that occurred when the surgeon switched from a medial parapatellar arthrotomy to a mini-subvastus (MIS) TKA technique. The incidence of patella clunk syndrome increased with increased postoperative knee flexion. Six weeks after surgery, knees that developed patella clunk had a mean flexion of 124 degrees vs 117 degrees for knees that did not develop this syndrome (P = .016). As the MIS approach resulted in increased knee flexion, this approach was indirectly associated with the increased incidence of patella clunk. Knee flexion at 6 weeks postoperatively was 117 degrees for the MIS knees vs 108 degrees for traditional medial parapatellar arthrotomy knees (P < .001). The effect of increased knee flexion achieved with the MIS approach, which resulted in an increase in patella clunk, was mitigated by using a new posterior stabilized femoral component designed to minimize soft tissue entrapment.
Sugaya, Hisashi; Kubota, Shigeki; Onishi, Mio; Kanamori, Akihiro; Sankai, Yoshiyuki; Yamazaki, Masashi
The knee range of motion is an important outcome of total knee arthroplasty (TKA). According to previous studies, the knee range of motion temporarily decreases for approximately 1 month after TKA due to postoperative pain and quadriceps dysfunction following surgical invasion into the knee extensor mechanism. We describe our experience with a knee-extension training program based on a single-joint hybrid assistive limb (HAL-SJ, Cyberdyne Inc., Tsukuba, Japan) during the acute recovery phase after TKA. HAL-SJ is a wearable robot suit that facilitates the voluntary control of knee joint motion. A 76-year-old man underwent HAL-SJ-based knee-extension training, which enabled him to perform knee function training during the acute phase after TKA without causing increased pain. Thus, he regained the ability to fully extend his knee postoperatively. HAL-SJ-based knee-extension training can be used as a novel post-TKA rehabilitation modality. PMID:27774330
Pichonnaz, Claude; Bassin, Jean-Philippe; Currat, Damien; Martin, Estelle; Jolles, Brigitte M
Electrical bioimpedance spectroscopy (BIS) allows the evaluation of limb extracellular fluid (R0) and total fluid (Rinf). BIS could facilitate post-surgical oedema evaluation after total knee arthroplasty (TKA), as it is easily performed and is non-invasive. However, neither its applicability in this context nor the influence of metallic implants on measurement has been evaluated. The aim of this study was to evaluate the influence of TKA implants on the BIS R0 and Rinf variables used for oedema evaluation. This was a prospective non-randomized comparative clinical trial. One oedema-free group of patients with TKA was compared with a group presenting similar characteristics except for the arthroplasty, to assess the influence of the implant on BIS measurement in the absence of oedema. The TKA group included 15 patients who had undergone surgery more than a year previously, and the control group included 19 patients awaiting TKA surgery. Volume and perimeter measurements served as reference criterions. The lower limb percentage differences for BIS, knee perimeter and volume were calculated. The significance of differences between groups was calculated for all measurement methods, using the Mann-Whitney test. The setting was a Department of Orthopedic Surgery and Traumatology in a university hospital. The differences between groups were not significant for R0, Rinf, volume and perimeter. R0 showed the smallest mean difference in limb percentage difference between groups [means (SD): TKA 3.98 (8.09), controls 3.97 (5.16)]. The lower-leg percentage difference in the TKA group is comparable with that of healthy subjects. R0 can be used for oedema evaluation following TKA surgery, as there was no sign of alteration from the metallic implant. These findings indicate the potential for early oedema evaluation after TKA. More research is warranted to extensively validate the application of BIS for oedema evaluation after TKA. Copyright © 2012 John Wiley & Sons, Ltd.
Dan, Michael; Martinez Martos, Sara; Beller, Elaine
A perioperative blood management program is one of a number of important elements for successful patient care in total knee arthroplasty (TKA) and surgeons should be proactive in its application. The aims of blood conservation are to reduce the risk of blood transfusion whilst at the same time maximizing hemoglobin (Hb) in the postoperative period, leading to a positive effect on outcome and cost. An individualized strategy based on patient specific risk factors, anticipated blood loss and comorbidities are useful in achieving this aim. Multiple blood conservation strategies are available in the preoperative, intraoperative and postoperative periods and can be employed in various combinations. Recent literature has highlighted the importance of preoperative Hb optimization, minimizing blood loss and evidence-based transfusion guidelines. Given TKA is an elective procedure, a zero allogenic blood transfusion rate should be the aim and an achievable goal. PMID:27595070
Vaishya, Raju; Panthi, Sagar; Vijay, Vipul; Vaish, Abhishek
Patellar instability is a known but catastrophic complication after total knee arthroplasty (TKA). The occurrence of bilateral dislocation of the patella after TKA is exceedingly rare. It may present as anterior knee pain, and diagnosis can easily be made clinically or by plain radiographs. Early diagnosis with surgical realignment and repair of the extensor mechanism can provide good outcomes after this complication. PMID:28409075
McClelland, Jodie A; Webster, Kate E; Ramteke, Alankar A; Feller, Julian A
Computer-assisted navigation in total knee arthroplasty (TKA) reduces variability and may improve accuracy in the postoperative static alignment. The effect of navigation on alignment and biomechanics during more dynamic movements has not been investigated. This study compared knee biomechanics during level walking of 121 participants: 39 with conventional TKA, 42 with computer-assisted navigation TKA and 40 unimpaired control participants. Standing lower-limb alignment was significantly closer to ideal in participants with navigation TKA. During gait, when differences in walking speed were accounted for, participants with conventional TKA had less knee flexion during stance and swing than controls (P<0.01), but there were no differences between participants with navigation TKA and controls for the same variables. Both groups of participants with TKA had lower knee adduction moments than controls (P<0.01). In summary, there were fewer differences in the biomechanics of computer-assisted navigation TKA patients compared to controls than for patients with conventional TKA. Computer-assisted navigation TKA may restore biomechanics during walking that are closer to normal than conventional TKA. Copyright © 2017 Elsevier B.V. All rights reserved.
Shervin, David; Pratt, Katelyn; Healey, Travis; Nguyen, Samantha; Mihalko, William M; El-Othmani, Mouhanad M; Saleh, Khaled J
Despite improvements in technique and technology for total knee arthroplasty (TKA), anterior knee pain impacts patient outcomes and satisfaction. Addressing the prosthetic and surgical technique related causes of pain after TKA, specifically as it relates to anterior knee pain, can aid surgeons in addressing these issues with their patients. Design features of the femoral and patellar components which have been reported as pain generators include: Improper femoral as well as patellar component sizing or designs that result in patellofemoral stuffing; a shortened trochlear groove distance from the flange to the intercondylar box; and then surgical technique related issues resulting in: Lateral patellar facet syndrome; overstuffed patella/flange combination; asymmetric patellar resurfacing, improper transverse plane component rotation resulting in patellar subluxation/tilt. Any design consideration that allows impingement of extensor mechanism anatomical elements has the possibility of impacting outcome by becoming a pain generator. As the number of TKA procedures continues to increase, it is increasingly critical to develop improved, evidence based prostheses that maximize function and patient satisfaction while minimizing pain and other complications. PMID:26601061
Sarraf, Khaled M; Konan, Sujith; Pastides, Philip S; Haddad, Fares S; Oussedik, Sam
Using the National Joint Registry (UK) database, we compared the thickness of polyethylene (PE) and the level of constraint used during primary total knee arthroplasty (TKA) versus the revision of unicondylar knee arthroplasty (UKA) to TKA. A total of 251,803 TKA procedures and 374 revision UKA-TKA procedures between 2003 and 2009 were reviewed. The commonest PE size used in TKA was 10mm, compared to 12.79 mm in the revision group. The use of constrained knee implant was required in 2.15% of primary TKA and 4.19% of UKA to TKA revisions. The revision of UKA to TKA is a more complex procedure compared to primary TKA, with a higher incidence of using constrained implants and thicker PE inserts. These findings may be useful for surgeons in their decision making.
Hagedorn, Jonathan; Levine, Brett R
Knee dislocation after revision total knee arthroplasty (TKA) is a dangerous, albeit rare, injury that can lead to neurovascular compromise and permanent disability. A paucity of peer-reviewed literature exists regarding this complication after revision TKA. Tibiofemoral dislocation commonly occurs with minimal trauma, such as rising from a seated position, and is commonly associated with a flexion-extension gap mismatch. Prompt diagnosis and expedited treatment of this complication is necessary to minimize the risk of adjacent neurovascular structures. Acute management involves attempted reduction, knee stabilization, and thorough neurovascular workup. Long-term management may require revision surgery, with the level of articular constraint necessary being determined intraoperatively. This article describes 2 cases of relatively atraumatic knee dislocations after revision TKA involving the same semiconstrained components. Patient 1 was a 68-year-old man who sustained an atraumatic posterior knee dislocation 2 months after revision TKA. Patient 2 was a 55-year-old woman who presented after an atraumatic posterior knee dislocation 6 months after revision TKA. In both patients, a semiconstrained construct was used with corresponding revision components prior to dislocation. This article includes a synopsis of solutions for flexion-extension gap balancing and a review of the literature regarding this uncommon complication. Copyright 2012, SLACK Incorporated.
Tantavisut, Saran; Tanavalee, Aree; Ngarmukos, Srihatach; Limtrakul, Arak; Wilairatana, Vajara; Wangroongsub, Yongsak
Popliteus-tendon injury during total knee arthroplasty (TKA) may result in imbalanced soft-tissue tension; however, it is unclear whether complete popliteus-tendon resection is a factor which contributes to knee instability following TKA. We performed an isolated complete resection of the popliteus tendon during a standard posterior stabilised TKA (PS-TKA) in 14 normal knees of Thai female cadavers and measured gap differences in both knee flexion and extension. In addition, we measured the distance from the femoral attachment of the popliteus tendon to the femoral condyles including the distance from the most distal femoral attachment of the popliteus tendon to the distal lateral femoral condyle (DFa-DLFC), and the distance from the most posterior femoral attachment of the popliteus tendon to the posterior lateral femoral condyle (PFa-PLFC). After completion of bone cuts, static flexion and extension gaps were measured with a tension of 98 N under intact and complete tendon resection, respectively. The mean DFa-DLFC and PFa-PLFC distances were 8.9 mm (range, 6.4-10.5mm) and 11.5mm (range, 9.5-14.0mm), respectively. Of 14 cadaveric knees, 35.7% had a DFa-DLFC distance <9 mm. Flexion and extension gaps significantly increased in both medial and lateral sides after complete popliteus resection with a similar mean increased value of 1.85 mm. The clinical evaluation of gap changes after popliteus resection on knee stability should be further investigated. A routine 9-mm distal femoral bone cut may injure the popliteus tendon during TKA conducted on small knees.
Bhave, Anil; Corcoran, James; Cherian, Jeffery J; Mont, Michael A
Knee stiffness is a common complication after total knee arthroplasty (TKA). Despite studies published on the surgical management of reduced range of motion (ROM) after TKA, there is limited evidence on the nonoperative management of joint and soft tissue imbalances possibly contributing to reduced knee ROM. This report assesses changes in ROM, pain, function, and patellar tendon length after Astym® joint mobilization use. A 38-year-old male professional skier had a right TKA 3 months before presentation with 2 subsequent manipulations under anesthesia secondary to persistent knee stiffness. He had patellar baja on radiograph, a reduced arc of ROM, reduced patellar mobility and muscular extensibility, and pain to palpation along the patellar tendon. He had 12 visits of physical therapy with the use of Astym®, patellar mobilization, and tibio-femoral mobilizations with movement. The patient also used a customized knee device at home for prolonged knee extension stretching. The patient was treated for 12 visits, along with home use of customized bracing for knee extension. Significant improvements were seen in pain, function, and ROM. He returned to work full-time, ambulated prolonged distances, and negotiated stairs pain-free. He also demonstrated resolution of patellar baja radiographically. Conservative management of recalcitrant knee joint stiffness after primary TKA can be effective in restoring knee mobility and reducing pain and activity limitation. A multimodal approach using Astym® treatment, customized knee bracing, and targeted joint mobilization can be effective in resolving knee joint stiffness.
Amanatullah, Derek F; Trousdale, Robert T; Sierra, Rafael J
Below knee amputation protects the ipsilateral knee from osteoarthritis and overloads the contralateral knee predisposing it to symptomatic osteoarthritis. We retrospectively reviewed 13 primary total knee arthroplasty (TKAs) in 12 patients with a prior lower extremity amputation. Twelve TKAs were performed on the contralateral side of the amputated limb while only one TKA was performed on the ipsilateral side. The average clinical follow-up was 6.8 ± 4.8 years. Knee Society Scores improved from 30.4 ± 11.8 to 88.5 ± 4.2 after TKA with a prior contralateral amputation. Three (23.1%) patients with TKA after contralateral amputation had aseptic loosening of the tibial component. Patients experience clinically significant improvement with TKA after lower extremity amputation. Augmentation of tibial fixation with a stem may be advisable during TKA after contralateral amputation.
Greidanus, Nelson V; Peterson, Richard C; Masri, Bassam A; Garbuz, Donald S
The purpose of this study was to evaluate and compare the quality of life and satisfaction outcomes of patients undergoing primary and revision total knee arthroplasty (TKA). Sixty revision and 199 primary TKA patients were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford-12 Knee Score, Short Form-12, and patient-reported satisfaction. Baseline preoperative scores demonstrate that revision TKA patients have inferior quality of life across all measures (WOMAC, Oxford-12, and Short Form-12) in comparison with primary TKA patients (P < .05). At follow-up revision, TKA patients continue to have inferior outcomes (P < .05) in comparison with primary TKA patients. When adjusting for confounding factors in regression analyses, revisions are inferior to primary TKA by 8.6 (95% confidence interval, 2.7-14.6) normalized WOMAC units. Copyright © 2011 Elsevier Inc. All rights reserved.
Hwang, Youn Soo; Moon, Kyu Pill; Kim, Kyung Taek; Kim, Jin Wan; Park, Won Seok
Flexion contracture deformities, as well as severe varus and valgus deformities of the knee joint, accompany osteoarthritis or rheumatoid arthritis (RA). In particular, severe flexion contracture deformity of the knee joint is often found in patients with RA, which renders them nonambulatory. This report describes a 26-year-old female patient diagnosed with RA 10 years ago. She had chronic joint pain, severe flexion contracture, valgus deformity in both knees, and limited range of motion in both knees and became nonambulatory. She underwent a total knee arthroplasty (TKA) and serial casting and physical therapy to restore stable joint movement and correct knee joint deformity. Her pain was successfully relieved, and she was able to walk after surgery. Here, we report the excellent results of TKA in this RA patient with severe flexion contracture of both knees. PMID:27894181
Babazadeh, Sina; Stoney, James D.; Lim, Keith; Choong, Peter F.M.
The Charcot knee - or neuropathic arthropathy - presents a considerable challenge to the orthopaedic surgeon. Caused by a combination of sensory, motor and autonomic neuropathy, it was originally described as an arthritic sequelae of neurosyphilis. In today's western orthopaedics it is more often caused by diabetes. A Charcot knee is often symptomatically painful and unstable. Traditional management has usually been conservative or arthrodesis, with limited success. Arthroplasty of a Charcot joint has commonly been avoided at all costs. However, in the right patient, using the right technique, arthroplasty can significantly improve the symptoms of a Charcot joint. This article explores the evidence surrounding the role of arthroplasty in the management of a Charcot knee. Arthroplasty is compared to other forms of treatment and specific patient demographics and surgical techniques are explored in an attempt to define the role of arthroplasty in the management of a Charcot knee. PMID:21808708
Vanlommel, L; Luyckx, T; Vercruysse, G; Bellemans, J; Vandenneucker, H
Flexion in a stiff total knee arthroplasty (TKA) can be improved by manipulation under anaesthesia (MUA). Although this intervention usually results in an improvement in range of motion, the expected result is not always achieved. The purpose of this study is to determine which factors affect range of motion after manipulation in patients with a stiff total knee. After exclusion (n = 22), the data of 158 patients (138 knees) with a stiff knee after TKA who received a manipulation under anaesthesia between 2004 and 2014 were retrospectively analysed. Pre-, peri- and post-operative variables were identified and examined for their influence on flexion after the manipulation using Kruskal-Wallis and Mann-Whitney U tests and Spearman correlations. After MUA, a mean improvement in flexion of 30.3° was observed at the final follow-up. Preoperative TKA flexion, design of TKA and interval between TKA procedure and MUA were positive associated with an increase in flexion after MUA. MUA performed 12 weeks or more after TKA procedure deteriorated the outcome. Three factors, pre-TKA flexion type of prosthesis and interval between TKA procedure and manipulation under anaesthesia, were found to have impact on flexion after TKA and MUA were identified. Results are expected to be inferior in patients with low flexion before TKA procedure or with a long interval (>12 weeks) between the TKA procedure and the manipulation under anaesthesia. IV.
Lee, Aenon; Park, Junhyuck; Lee, Seungwon
[Purpose] The purpose of this study was to investigate ability and muscle activities of elderly women after total knee arthroplasty (TKA) and compare them with those of healthy ones. [Subjects and Methods] Fifteen female patients with TKA due to advanced degenerative arthritis of the measured on knee joint and 19 healthy elderly females participated. Tibiofemoral angles of TKA patients were using a gait analysis system anterioposterior X-rays of the weight-bearing knee. The knee flexion angle and gait parameters were measured. Muscle activities and prolongation time were EMG system. The gait of the treated limb of each participant was evaluated in three consecutive trials at fast speed and comfortable speed. [Results] The knee flexion angle %stance phase, stride length, step length, speed, cadence, and gait cycle significantly decreased at both the fast speed and comfortable speeds, and the onset and duration time of rectus femoris activity was significantly increased at the comfortable speed in the TKA group. [Conclusion] In conclusion, elderly women who received TKA showed decreased gait ability and muscle activity compared to the healthy elderly women.
Lee, Aenon; Park, Junhyuck; Lee, Seungwon
[Purpose] The purpose of this study was to investigate ability and muscle activities of elderly women after total knee arthroplasty (TKA) and compare them with those of healthy ones. [Subjects and Methods] Fifteen female patients with TKA due to advanced degenerative arthritis of the measured on knee joint and 19 healthy elderly females participated. Tibiofemoral angles of TKA patients were using a gait analysis system anterioposterior X-rays of the weight-bearing knee. The knee flexion angle and gait parameters were measured. Muscle activities and prolongation time were EMG system. The gait of the treated limb of each participant was evaluated in three consecutive trials at fast speed and comfortable speed. [Results] The knee flexion angle %stance phase, stride length, step length, speed, cadence, and gait cycle significantly decreased at both the fast speed and comfortable speeds, and the onset and duration time of rectus femoris activity was significantly increased at the comfortable speed in the TKA group. [Conclusion] In conclusion, elderly women who received TKA showed decreased gait ability and muscle activity compared to the healthy elderly women. PMID:25931687
Wünschel, Markus; Leasure, Jeremi M; Dalheimer, Philipp; Kraft, Nicole; Wülker, Nikolaus; Müller, Otto
Posterior cruciate ligament (PCL) retaining (CR) and -sacrificing (PS) total knee arthroplasties (TKA) are widely-used to treat osteoarthritis of the knee joint. The PS design substitutes the function of the PCL with a cam-spine mechanism which may produce adverse changes to joint kinematics and kinetics. CR- and PS-TKA were performed on 11 human knee specimens. Joint kinematics were measured with a dynamic knee simulator and motion tracking equipment. In-situ loads of the PCL and cam-spine were measured with a robotic force sensor system. Partial weight bearing flexions were simulated and external forces were applied. The PS-TKA rotated significantly less throughout the whole flexion range compared to the CR-TKA. Femoral roll back was greater in the PS-TKA; however, this was not correlated with lower quadriceps forces. Application of external loads produced significantly different in-situ force profiles between the TKA systems. Our data demonstrate that the PS-design significantly alters kinematics of the knee joint. Our data also suggest the cam-spine mechanism may have little influence on high flexion kinematics (such as femoral rollback) with most of the load burden shared by supporting implant and soft-tissue structures. Copyright © 2013 Elsevier B.V. All rights reserved.
Sur, Yoo-Joon; Koh, In-Jun; Park, Se-Wook; Kim, Hyung-Jin; In, Yong
The Triathlon condylar-stabilizing (CS) lipped insert is designed to provide anteroposterior (AP) stability of the posterior-stabilized (PS) insert, without a post. The purpose of this study was to compare the AP stability of the knee in patients with Triathlon CS and PS total knee arthroplasty (TKA) with midterm follow-up. Thirty-one patients received a Triathlon PS TKA in one knee and a Triathlon CS TKA in the contralateral knee, and 28 patients were followed up with a minimum duration of 5years. Although there was no difference in functional outcomes, the posterior displacement was significantly greater in the CS TKA group than in the PS TKA group (P<0.001). The Triathlon CS lipped insert could not restore posterior stability with PCL sacrifice.
Arnold, John B; Mackintosh, Shylie; Olds, Timothy S; Jones, Sara; Thewlis, Dominic
Total knee arthroplasty (TKA) in people with knee osteoarthritis increases knee-specific and general physical function, but it has not been established if there is a relationship between changes in these elements of functional ability. This study investigated changes and relationships between knee biomechanics during walking, physical activity, and use of time after TKA. Fifteen people awaiting TKA underwent 3D gait analysis before and six months after surgery. Physical activity and use of time were determined in free-living conditions from a high resolution 24-h activity recall. After surgery, participants displayed significant improvements in sagittal plane knee biomechanics and improved their physical activity profiles, standing for 105 more minutes (p=0.001) and performing 64 min more inside chores on average per day (p=0.008). Changes in sagittal plane knee range of motion (ROM) and peak knee flexion positively correlated with changes in total daily energy expenditure, time spent undertaking moderate to vigorous physical activity, inside chores and passive transport (r=0.52-0.66, p=0.005-0.047). Restoration of knee function occurs in parallel and is associated with improvements in physical activity and use of time after TKA. Increased functional knee ROM is required to support improvements in total and context specific physical activity. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Ares, Oscar; Seijas, Roberto; Hernandez, Alberto; Castellet, Enric; Sallent, Andrea
The aim of this study is an attempt to clarify the productive time of drainages as we find that the use of drains in knee arthroplasty is controversial, and there is no consensus regarding their length-time maintenance. We analysed the survival curve of bleeding within three surgical techniques for knee arthroplasty and the effect of two variables on survival curve. One hundred and eighty-eight out of 234 knees were included in the study, and patients were divided into three groups according to the surgical technique: conventional total knee arthroplasty (TKA), subvastus TKA and unicompartmental knee arthroplasty. Variables of study were type of surgery, number and placement of drains. Mean of survival curve for postoperative bleeding time was 16 h (95 % CI: 15.4; 16.6). The risk for longer bleeding increased 1.38-fold with each additional drain used (95 % CI 1.1; 1.8). According to the present study, drains can be safely removed at around 17 h postoperative. Bleeding time reduces as less drains are applied. Therapeutic study, Level III.
Breugem, Stéfanus Jacob Martinus; Haverkamp, Daniël
Total Knee Arthroplasty has been shown to be a successful procedure for treating patients with osteoarthritis, and yet approximately 5%-10% of patients experience residual pain, especially in the anterior part of the knee. Many theories have been proposed to explain the etiology of this anterior knee pain (AKP) but, despite improvements having been made, AKP remains a problem. AKP can be described as retropatellar or peripatellar pain, which limits patients in their everyday lives. Patients suffering from AKP experience difficulty in standing up from a chair, walking up and down stairs and riding a bicycle. The question asked was: “How can a ‘perfectly’ placed total knee arthroplasty (TKA) still be painful: what can cause this pain?”. To prevent AKP after TKA it is important to first identify the different anatomical structures that can cause this pain. Greater attention to and understanding of AKP should lead to significant pain relief and greater overall patient satisfaction after TKA. This article is a review of what pain is, how nerve signalling works and what is thought to cause Anterior Knee Pain after a Total Knee Arthroplasty. PMID:25035818
Sharma, Vineet; Tsailas, Panagiotis G.; Maheshwari, Aditya V.; Ranawat, Chitranjan S.
Several proponents of minimally invasive surgery-total knee arthroplasty (MIS-TKA) have suggested patellar eversion during a standard exposure of the knee may cause shortening of the patellar tendon and poorer outcomes secondary to acquired patella baja. To explore this suggestion, we retrospectively reviewed 135 consecutive TKAs in 110 patients to ascertain the effect of TKA on the postoperative Insall-Salvati ratio. All surgeries were performed using standard TKA techniques with a midline incision, medial parapatellar arthrotomy, partial excision of the fat pad, and routine eversion of the patella. One patient developed a postoperative patella baja, defined as an Insall-Salvati ratio of less than 0.8. The Knee Society score for knee and function in this patient was 75 and 70, respectively. Five additional patients had a decrease in Insall-Salvati ratio by 10% or more but without patella baja. Mean Knee Society score for knee and function in these five patients was 94 (range, 73–99) and 96 (range, 90–100), respectively, as compared with 93 (range, 37–99) and 94 (range, 40–100) in the remaining 104 patients. Our data suggest the incidence of patella baja is low after TKA despite routine patellar eversion. Furthermore, a 10% or more decrease in the Insall-Salvati ratio without patella baja was not associated with a worse clinical outcome. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:18568378
Hamilton, William G; Reeves, James D; Fricka, Kevin B; Goyal, Nitin; Engh, Gerard A; Parks, Nancy L
The purpose of this study was to determine the rate of thromboembolic and bleeding complications when using mechanical prophylaxis with preoperative risk stratification following total knee arthroplasty (TKA). Between 1994 and 2007, 4037 TKAs were performed on 3144 patients at our institution. Mechanical VTE prophylaxis was used for standard risk patients, which included AV impulse foot pumps, thigh high stockings, and early mobilization. Chemoprophylaxis was only given to patients who were at increased thromboembolic risk. The incidence of DVT identified by ultrasound following TKA was 2.1%. A retrospective review showed 1 patient had a fatal pulmonary embolism, and 5 patients had bleeding complications in the knee. We conclude that mechanical thromboembolic prophylaxis using risk stratification is safe and effective following TKA. Copyright © 2014 Elsevier Inc. All rights reserved.
Boyd, Jason A; Gradisar, Ian M
Several orthopedic registries have described the incidence of total knee arthroplasty (TKA) in patients who have undergone knee arthroscopy. Patient risk factors may play a role in the conversion rate from knee arthroscopy to TKA. This study quantifies the incidence of conversion of knee arthroscopy to TKA from a US mixed-payer database and describes some common patient risk factors for conversion. The medical records of more than 50 million patients who were treated between 1998 and 2014 were mined with a commercially available software platform. During the study period, a total of 68,090 patients older than 50 years underwent knee arthroscopy for partial meniscectomy, chondroplasty, or debridement. Reported rates of TKA at 1, 2, and 3 years after arthroscopy were 10.1%, 13.7%, and 15.6%, respectively. Obesity, depressive disorder, rheumatoid arthritis, diabetes, and age 70 years and older were associated with increased relative risk of conversion to TKA at 2 years. When obesity was combined individually with the top 5 other risk factors, no combination produced a higher relative risk than that of obesity alone. Patients who were 50 to 54 years of age had the lowest incidence of conversion to TKA (8.3%, P<.001). Men had a lower incidence of conversion to TKA (11.3%) than women (15.8%, P<.001). This information can help surgeons to counsel patients on the incidence of TKA after knee arthroscopy and identify preoperative risk factors that increase risk. [Orthopedics. 2016; 39(6):e1041-e1044.].
Pérez-de la Fuente, T.; Sandoval, E.; Alonso-Burgos, A.; García-Pardo, L.; Cárcamo, C.; Caballero, O.
Lower limb lymphorrhea secondary to a surgical procedure is a rare but difficult-to-solve complication. In lower limb, this entity is frequently associated with vascular procedures around the inguinal area. We report on a case of a knee lymphocutaneous fistula secondary to a knee revision arthroplasty. To our knowledge, no previous reports regarding this complication have been published. PMID:25580333
Steinhaus, Michael E; Christ, Alexander B; Cross, Michael B
Total knee arthroplasty (TKA) is generally accepted as the definitive treatment for advanced knee arthritis after patients fail nonoperative treatments; however, the safety and efficacy of TKA compared to continued nonoperative treatment has never been proven in high-quality, randomized controlled trials. Recently, a 2015 Danish study published a 12-month follow-up on a cohort of patients randomized to either a TKA or continued nonsurgical management for advanced knee osteoarthritis (OA). The authors reported significantly greater improvement in the TKA group in functional outcome scores such as the overall Knee Injury and Osteoarthritis Outcome Score (KOOS4 score), the KOOS subscales, EQ-5D descriptive index, and timed get up-and-go and 20-m walk tests; however, patients in the TKA did suffer significantly more serious adverse events (SAE). The authors concluded that TKA combined with additional nonoperative care postoperatively is more efficacious than nonsurgical treatment alone in terms of improving pain, function, and quality of life at 12 months but is associated with more SAE. The purpose of this review is to identify the strengths and weaknesses of this trial, interpret its outcomes within the context of prior literature, and evaluate the validity of its conclusions.
Baldini, A; Castellani, L; Traverso, F; Balatri, A; Balato, G; Franceschini, V
Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella. Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes. When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.
Tian, Y.; Tanaka, Y.; Kuriyama, S.; Ito, H.; Furu, M.; Matsuda, S.
Objectives Little biomechanical information is available about kinematically aligned (KA) total knee arthroplasty (TKA). The purpose of this study was to simulate the kinematics and kinetics after KA TKA and mechanically aligned (MA) TKA with four different limb alignments. Materials and Methods Bone models were constructed from one volunteer (normal) and three patients with three different knee deformities (slight, moderate and severe varus). A dynamic musculoskeletal modelling system was used to analyse the kinematics and the tibiofemoral contact force. The contact stress on the tibial insert, and the stress to the resection surface and medial tibial cortex were examined by using finite element analysis. Results In all bone models, posterior translation on the lateral side and external rotation in the KA TKA models were greater than in the MA TKA models. The tibiofemoral force at the medial side was increased in the moderate and severe varus models with KA TKA. In the severe varus model with KA TKA, the contact stress on the tibial insert and the stress to the resection surface and to the medial tibial cortex were increased by 41.5%, 32.2% and 53.7%, respectively, compared with MA TKA, and the bone strain at the medial side was highest among all models. Conclusion Near normal kinematics was observed in KA TKA. However, KA TKA increased the contact force, stress and bone strain at the medial side for moderate and severe varus knee models. The application of KA TKA for severe varus knees may be inadequate. Cite this article: S. Nakamura, Y. Tian, Y. Tanaka, S. Kuriyama, H. Ito, M. Furu, S. Matsuda. The effects of kinematically aligned total knee arthroplasty on stress at the medial tibia: A case study for varus knee. Bone Joint Res 2017;6:43–51. DOI: 10.1302/2046-3758.61.BJR-2016-0090.R1. PMID:28077396
Kuchinad, Raul; Fourman, Mitchell S; Fragomen, Austin T; Rozbruch, S Robert
Patients with multiple failures of total knee arthroplasty (TKA) are challenging limb salvage cases. Twenty one patients over the last 10 years were referred to our service for knee fusion by arthroplasty surgeons who felt they were not candidates for revision TKA. Active infection was present in 76.2% and total bone loss averaged 6.6 cm. Lengthening was performed in 7/22 patients. Total time in Ilizarov frames was 9 months, with 93.3% union. Patients treated with IM fusion nails had 100% union. Average LLD increased from 3.6 to 4.5 cm following intervention, while those with concurrent lengthening improved to 1.6 cm. Findings suggest that bone loss and the soft-tissue envelope dictate knee fusion method, and multiple techniques may be needed. A treatment algorithm is presented.
Can, Ata; Erdogan, Fahri; Erdogan, Ayse Ovul
Tibiofemoral instability is a common complication after total knee arthroplasty (TKA), accounting for up to 22% of all revision procedures. Instability is the second most common cause of revision in the first 5 years after primary TKA. In this study, 13 knees with tibiofemoral instability after TKA were identified among 693 consecutive primary TKA procedures. Patient demographics, body mass index, clinical symptoms, previous deformity, previous knee surgery, complications, interval between index TKA and first tibiofemoral instability, causes of instability, and interval between index TKA and revision TKA were retrospectively reviewed. Clinical outcomes were assessed with the Lysholm Knee Scoring Scale. All patients were women, and mean body mass index was 37.7 kg/m(2) (range, 27.2-52.6 kg/m(2)). Mean interval between index TKA and first tibiofemoral instability was 23.4 months (range, 9-45 months), and mean interval between index TKA and revision TKA was 25.6 months (range, 14-48 months). All patients had posterior cruciate ligament-retaining implants. Of the 13 knees, 11 had flexion instability and 2 had global instability. In all patients, instability was caused by incompetence of the posterior cruciate ligament; additionally, 1 patient had undersized and malpositioned implants. In 4 knees, the polyethylene insert was broken as well. All patients underwent revision TKA. Lysholm Knee Scoring Scale score had improved from a mean of 35.8 (range, 30-46) to a mean of 68.3 (range, 66-76). All patients included in this study were female and obese. The main cause of instability was secondary posterior cruciate ligament rupture and incompetence. The use of posterior-stabilized implants for primary TKA may prevent secondary instability in obese patients. [Orthopedics. 201x; xx(x):xx-xx.]. Copyright 2017, SLACK Incorporated.
Trinler, Ursula K; Baty, Florent; Mündermann, Annegret; Fenner, Verena; Behrend, Henrik; Jost, Bernhard; Wegener, Regina
Joint biomechanics during stair walking may contain important information on functional deficits in patients with orthopaedic conditions but depend on the stair dimension. The goal of this study was to compare knee kinematics and kinetics between patients with good outcome 2 years after total knee arthroplasty (TKA) and age-matched controls during stair ascent and descent at two different stair heights. Principal component analysis was used to detect differences in gait mechanics between 15 patients and 15 controls at different stair conditions. Linear mixed models showed differences in knee kinematic and kinetic patterns (in flexion/extension and abduction/adduction) between stair heights. The knee adduction angle was more affected by stair heights in stair ascending whereas knee adduction moment and knee power were more affected during stair descent. Some stair by height and subject effects were small but not significant. Overall, good outcome after TKA is reflected in close-to-normal knee biomechanics during stair walking. Specific stair configuration must be considered when comparing joint biomechanics between subject groups and studies. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1753-1761, 2016.
Losina, Elena; Walensky, Rochelle P.; Kessler, Courtenay L.; Emrani, Parastu S.; Reichmann, William M.; Wright, Elizabeth A.; Holt, Holly L.; Solomon, Daniel H.; Yelin, Edward; Paltiel, A. David; Katz, Jeffrey N.
Background Total knee arthroplasty (TKA) relieves pain and improves quality of life for persons with advanced knee osteoarthritis. However, to our knowledge, the cost-effectiveness of TKA and the influences of hospital volume and patient risk on TKA cost-effectiveness have not been investigated in the United States. Methods We developed a Markov, state-transition, computer simulation model and populated it with Medicare claims data and cost and outcomes data from national and multinational sources. We projected lifetime costs and quality-adjusted life expectancy (QALE) for different risk populations and varied TKA intervention and hospital volume. Cost-effectiveness of TKA was estimated across all patient risk and hospital volume permutations. Finally, we conducted sensitivity analyses to determine various parameters’ influences on cost-effectiveness. Results Overall, TKA increased QALE from 6.822 to 7.957 quality-adjusted life years (QALYs). Lifetime costs rose from $37 100 (no TKA) to $57 900 after TKA, resulting in an incremental cost-effectiveness ratio of $18 300 per QALY. For high-risk patients, TKA increased QALE from 5.713 to 6.594 QALY, yielding a cost-effectiveness ratio of $28 100 per QALY. At all risk levels, TKA was more costly and less effective in low-volume centers than in high-volume centers. Results were insensitive to variations of key input parameters within policy-relevant, clinically plausible ranges. The greatest variations were seen for the quality of life gain after TKA and the cost of TKA. Conclusions Total knee arthroplasty appears to be cost-effective in the US Medicare-aged population, as currently practiced across all risk groups. Policy decisions should be made on the basis of available local options for TKA. However, when a high-volume hospital is available, TKAs performed in a high-volume hospital confer even greater value per dollar spent than TKAs performed in low-volume centers. PMID:19546411
Peng, Hui-ming; Weng, Xi-sheng; Zhai, Ji-liang; Bian, Yan-yan; Lin, Jin; Jin, Jin; Qian, Wen-wei; Zhao, Li-juang
To describe the microbiology, antimicrobial susceptibility of patients proven prosthetic joint infection (PJI) after primary total knee arthroplasty (TKA)and to provide reference for the diagnosis and treatment of this complication. The medical data of the patients with infected knee arthroplasty, who were managed with revision surgery between January 1995 to December 2011 were reviewed. Twenty-nine cases were identified and majority of the patients were female (23/29). Diagnosis of PJI after primary TKA was between 1 week and 10 years (average 24.3 months). The microbiology and antimicrobial susceptibility were analyzed. The overall positive rate of cultures was 65.5% (19/29). The most common organisms identified were Coagulase-negative Staphylococcus (CNS) (7/19) and Staphylococcus Aureus (SA) (5/19). Rare pathogens of Mycobacterium (2/19) and fungi (1/19) were also identified. Vancomycin was the most effective antibiotics with overall sensitivity rates of 100%.Resistant and rare pathogens were all in type IV infection. Gram-positive bacterias are the main pathogen, resistant and rare pathogens should be payed attention to. Antibiotic treatment for infected TKA should be based on the results of drug susceptibility. Vancomycin allows infected knee arthroplasties before the result.
Kitchen, Brock; Sanchez, Hugo B; Wagner, Russell A
Juvenile Rheumatoid Arthritis (JRA) is a progressive disease characterized by pain, swelling, and loss of motion in the joints of adolescents. Total knee arthroplasty (TKA) can be indicated, during the adolescent years, in patients with advanced JRA to alleviate pain and improve function. Because of the relative infrequency of TKA in patients with JRA, evaluation of the type of TKA performed and the results merit review. This case report present two distinct operations performed to obtain full extension. 1. Distal femoral resection with conversion to hinged arthroplasty. 2. Femoral shortening osteotomy with resurfacing TKA.
Kitchen, Brock; Sanchez, Hugo B.; Wagner, Russell A.
Juvenile Rheumatoid Arthritis (JRA) is a progressive disease characterized by pain, swelling, and loss of motion in the joints of adolescents. Total knee arthroplasty (TKA) can be indicated, during the adolescent years, in patients with advanced JRA to alleviate pain and improve function. Because of the relative infrequency of TKA in patients with JRA, evaluation of the type of TKA performed and the results merit review. This case report present two distinct operations performed to obtain full extension. 1. Distal femoral resection with conversion to hinged arthroplasty. 2. Femoral shortening osteotomy with resurfacing TKA. PMID:25972704
Lim, Hong-An; Seon, Jong-Keun; Park, Kyung-Soon; Shin, Young-Joo; Yang, Hong-Yeol
Background Persistent pain after total knee arthroplasty (TKA) is dissatisfying to the patient and frustrating to the surgeon. The purpose of this study is to evaluate the aseptic causes and clinical course of intractable pain following TKA. Methods Of the total 2,534 cases of primary TKA reviewed, 178 cases were classified as having aseptic persistent pain that was not resolved within 1 year after surgery. Except for the cases with periprosthetic fracture (56 knees), 122 cases of aseptic painful TKA were divided into two groups: intra-articular group (83 knees) and extra-articular group (39 knees). Results In the intra-articular group, the main reasons for pain were aseptic loosening (n = 40), polyethylene wear (n = 16), instability (n = 10), recurrent hemarthrosis (n = 5), patellar maltracking (n = 4), tendon ruptures (n = 4), and stiffness (n = 2). In the extraarticular group, 10 knees (25.6%) were found to have nerve entrapment in the spine, 6 knees (15.4%) were found to have hip osteoarthritis or femoral head avascular necrosis. The reasons for persistent knee pain in the remaining 23 knees (59.0%) still remain elusive. Conclusions Persistent pain after TKA originated from pathology of extra-articular origin in a considerable number of cases in this study. Therefore, it is important to perform thorough preoperative evaluations to reduce pain resulting from extra-articular causes. Furthermore, meticulous surgical procedures and optimal alignment are required to reduce pain of intra-articular origin related to implant wear, instability, and patellar maltracking. PMID:28261427
Bin Abd Razak, Hamid Rahmatullah; Yeo Jin, Seng; Chong Chi, Hwei
We compared postoperative flexion contracture in navigated total knee arthroplasty (TKA) versus conventional TKA. Two groups (Group 1: conventional, Group 2: navigated) of 235 consecutive patients matched for age and gender were retrospectively compared. Range of motion, mechanical axes, Knee Society Scores, Oxford Knee Scores and Short Form-36® (SF-36) scores were collected prospectively and compared preoperatively and at 2years following TKA. At 2years, patients who underwent navigated TKA averaged significantly lesser flexion contracture of 1 degree compared to 6 degrees in patients who underwent conventional TKA. There were a significantly larger proportion of outliers in the conventional group. Computer navigation results in less severe flexion contracture and less frequent flexion contracture of more than 5 degrees as compared to conventional techniques. Copyright © 2014 Elsevier Inc. All rights reserved.
Spinarelli, Antonio; Petrera, Massimo; Vicenti, Giovanni; Pesce, Vito; Patella, Vittorio
Often in daily practice the choice of a prosthesis does not rise out of considerations about literature evidences, but it seems to be related to the personal experience and "surgical philosophy" of surgeon. The choice of prosthesis in total joint replacement is usually justified by biological and mechanical parameters that the surgeon considers before surgery. Osteoporosis is a disease characterized by a reduced bone mass and a degeneration of the bone tissue; it leads to bone fragility, so to a higher risk of fractures. Bone resistance, as all the changes in the microarchitecture of the bone tissue, is linked to bone density. Because of the bone density variation and/or the changes in the bone micro-architecture, as the bone strength decreases, the risk of fractures increases. It is important to understand all the factors taking part in both normal and abnormal bone remodelling. Osteoporosis does not imply a concrete bone loss, but a change of the bone micro-architecture itself. In these cases the choice of the patient and implant design are very important. In the period between March 1997-July 2002, we implanted 100 consecutive TKA (total knee arthroplasty) Genesis II in 97 subjects (79 female); mean age was 77.1 years old. All TKA were performed because of primary osteoarthritis of the knee. All patients had complete pain relief and excellent knee score. The surgical and medical complications were in accordance with the published literature. We must consider all existing medical conditions, the state of the knee and local needs of the elderly patient. Thus, within these limits, the total knee can improve the ability of patients to manage the activities of daily living and improve their quality of life.
Choi, Nam-Yong; Sohn, Jong-Min; Cho, Sung-Gil; Kim, Seung-Chan
Purpose Primary total knee arthroplasty (TKA) can be an alternative method for treating distal femoral fractures in elderly patients with knee osteoarthritis. The purpose of this study was to evaluate the clinical and radiographic results in patients with knee osteoarthritis who underwent TKA with the Medial Pivot prosthesis for distal femoral fractures. Materials and Methods Eight displaced distal femoral fractures in 8 patients were treated with TKA using the Medial Pivot prosthesis and internal fixation. The radiographic and clinical evaluations were performed using simple radiographs and Hospital for Special Surgery (HSS) knee scores during a mean follow-up period of 49 months. Results All fractures united and the mean time to radiographic union was 15 weeks. The mean range of motion of the knee joint was 114.3° and the mean HSS knee score was 85.1 at the final follow-up. Conclusions Based on the radiographic and clinical results, TKA with internal fixation can be considered as an option for the treatment of simple distal femoral fractures in elderly patients who have advanced osteoarthritis of the knee with appropriate bone stock. PMID:24032103
NiemeläInen, Mika J; MäKelä, Keijo T; Robertsson, Otto; W-Dahl, Annette; Furnes, Ove; Fenstad, Anne M; Pedersen, Alma B; Schrøder, Henrik M; Huhtala, Heini; Eskelinen, Antti
Background and purpose The annual number of total knee arthroplasties (TKAs) has increased worldwide in recent years. To make projections regarding future needs for primaries and revisions, additional knowledge is important. We analyzed and compared the incidences among 4 Nordic countries Patients and methods Using Nordic Arthroplasty Register Association (NARA) data from 4 countries, we analyzed differences between age and sex groups. We included patients over 30 years of age who were operated with TKA or unicompartmental knee arthroplasty (UKA) during the period 1997–2012. The negative binomial regression model was used to analyze changes in general trends and in sex and age groups. Results The average annual increase in the incidence of TKA was statistically significant in all countries. The incidence of TKA was higher in women than in men in all 4 countries. It was highest in Finland in patients aged 65 years or more. At the end of the study period in 2012, Finland’s total incidence was double that of Norway, 1.3 times that of Sweden and 1.4 times that of Denmark. The incidence was lowest in the youngest age groups (< 65 years) in all 4 countries. The proportional increase in incidence was highest in patients who were younger than 65 years. Interpretation The incidence of knee arthroplasty steadily increased in the 4 countries over the study period. The differences between the countries were considerable, with the highest incidence in Finland. Patients aged 65 years or more contributed to most of the total incidence of knee arthroplasty. PMID:28056570
Lahav, Amit; Hofmann, Aaron A
We present an exposure technique, the "banana peel," that has been used exclusively for revision total knee arthroplasty (TKA) for more than 20 years. We retrospectively reviewed use of this technique in 102 consecutive patients (mean age, 62 years; range, 41-92 years) who underwent tibial-femoral stemmed revision TKA. There were 5 deaths, leaving 97 patients (98 knees) for the study. The technique involves peeling the patella tendon as a sleeve off the tibia, leaving the extensor mechanism intact with a lateral hinge of soft tissue. A quadriceps "snip" is also done proximally. Patients with a minimum follow-up of 24 months were included. Telephone interviews and chart reviews were conducted, and Knee Society scores were obtained. Mean follow-up was 39 months (range, 24-56 months). No patient reported disruption of the extensor mechanism or decreased ability to extend the operative knee. Mean Knee Society score was 176 (range, 95-200). Mean postoperative motion was 106 degrees. No patient reported pain over the tibial tubercle. The banana-peel technique for exposing the knee during revision TKA is a safe method that can be used along with a proximal quadriceps snip and does not violate the extensor mechanism, maintaining continuity of the knee extensors.
Freed, Ryan D; Simon, Jacqueline C; Knowlton, Christopher B; Orozco Villaseñor, Diego A; Wimmer, Markus A; Lundberg, Hannah J
It is not known if the loads and motions reported for instrumented knees are generalizable to a larger population of total knee arthroplasty (TKA) patients. The purpose of this study is to (1) report axial implant force data for chair and stair activities for a population of cruciate-retaining TKA patients and (2) compare the population forces to those measured with instrumented TKAs. Twenty-three subjects with a cruciate-retaining TKA underwent motion analysis during stair ascending, stair descending, chair sitting, and chair rising activities after informed consent in this institutional review board approved study. Axial TKA forces were calculated using a previously validated computational model. Differences between the mean and variability of population instrumented TKA peak forces and force impulses were tested using t tests and Levene test. Peak axial forces were 3.06, 2.74, 2.65, and 2.60 kN for stair ascent, stair descent, chair rising, and chair sitting, respectively. Force impulses were 123.3, 123.4, 153.5, and 154.0 kN*% activity cycle for stair ascent, stair descent, chair sitting, and chair rising, respectively. Population TKA and instrumented TKA peak forces were different for stair ascent (P = .03) and stair descent (P = .03) in the second half of the activity cycles. The variability of the peak forces and impulses were not different (P = .106 to P = .99). The forces and motions presented in this study represent cruciate-retaining TKA patients and could be used for displacement-driven knee wear testing. The forces are similar to those in the literature from instrumented prostheses of an ultracongruent cruciate-sacrificing TKA. Copyright © 2017 Elsevier Inc. All rights reserved.
Wilke, Benjamin K; Wagner, Eric R; Trousdale, Robert T
Semi-constrained implants provide stability in the setting of soft-tissue deficiency in revision total knee arthroplasty (TKA). This study evaluated our institution's long-term survival results with a semi-constrained implant used in the revision TKA setting. 234 semi-constrained revision total knee arthroplasties were performed in 209 patients. The average follow-up was 9 years. Forty repeat revisions were performed. 5-year survival was 91% and 10-year survival was 81%. Male gender significantly increased the risk of revision. At 10 years the average range of motion, pain level, and Knee Society score improved significantly (P < 0.001). Ninety percent of patients reported an improvement in their knee. The semi-constrained implant used in revision knee arthroplasty has acceptable implant survival and functional outcomes in the long-term follow-up period.
Vahtrik, Doris; Gapeyeva, Helena; Ereline, Jaan; Pääsuke, Mati
The aim of the present study was to evaluate an isometric maximal voluntary contraction (MVC) force of the leg extensor muscles and its relationship with knee joint loading during gait prior and after total knee arthroplasty (TKA). Custom-made dynamometer was used to assess an isometric MVC force of the leg extensor muscles and 3-D motion analysis system was used to evaluate the knee joint loading during gait in 13 female patients (aged 49-68 years) with knee osteoarthritis. Patients were evaluated one day before, and three and six months following TKA in the operated and non-operated leg. Six months after TKA, MVC force of the leg extensor muscles for the operated leg did not differ significantly as compared to the preoperative level, whereas it remained significantly lower for the non-operated leg and controls. The knee flexion moment and the knee joint power during mid stance of gait was improved six months after TKA, remaining significantly lowered compared with controls. Negative moderate correlation between leg extensor muscles strength and knee joint loading for the operated leg during mid stance was noted three months after TKA. The correlation analysis indicates that due to weak leg extensor muscles, an excessive load is applied to knee joint during mid stance of gait in patients, whereas in healthy subjects stronger knee-surrounding muscles provide stronger knee joint loading during gait. III (correlational study). Copyright © 2013 Elsevier B.V. All rights reserved.
Eickmann, Tom; Quane, Erika
Bidirectional barbed sutures, which do not require the tying of knots, have the potential to reduce closure times of total knee arthroplasty (TKA) wounds without adverse effect to wound security, cosmesis, or infection risk. In this retrospective study, data were reviewed from TKAs performed between January 2007 and September 2008. For 88 of these procedures, conventional absorbable sutures were used for interrupted closure of the retinacular and subcutaneous layers and for running closure of the subcuticular layer. For 90 procedures, bidirectional barbed absorbable sutures were used for running closure of the retinacular and subcutaneous layers. Surgeries performed with barbed sutures were significantly faster than those performed with conventional sutures (mean times of 74.3 minutes and 85.8 minutes, respectively, p < 0.001) with no detrimental clinical effects.
Goh, Graham Seow-Hng; Liow, Ming Han Lincoln; Mitra, Amit Kanta
To compare the outcome following total knee arthroplasty (TKA) in obese and non-obese Asian patients. 27 obese patients were compared with 27 non-obese controls matched for age, gender, diagnosis (osteoarthritis), prosthesis, preoperative Knee Society knee and function scores, preoperative Oxford Knee Score, and follow-up duration. All TKAs were performed by a single surgeon. Patients were assessed at 6 months and 2 years for the range of motion, Knee Society knee and function scores, Oxford Knee Score, and Short Form-36 Health Survey (SF-36). The obese and non-obese groups did not differ significantly in pre- and post-operative variables: range of motion, Knee Society knee and function scores, Oxford Knee Score, and SF-36 score. Using revision as an end-point, implant survival was 100%. There were no intra- or post-operative complications in either group. Obese and non-obese Asian patients achieved a comparable outcome following TKA.
Softness, Kenneth A; Murray, Ryan S; Evans, Brian G
Tibial plateau fractures are common injuries that occur in a bimodal age distribution. While there are various treatment options for displaced tibial plateau fractures, the standard of care is open reduction and internal fixation (ORIF). In physiologically young patients with higher demand and better bone quality, ORIF is the preferred method of treating these fractures. However, future total knee arthroplasty (TKA) is a consideration in these patients as post-traumatic osteoarthritis is a common long-term complication of tibial plateau fractures. In older, lower demand patients, ORIF is potentially less favorable for a variety of reasons, namely fixation failure and the need for delayed weight bearing. In some of these patients, TKA can be considered as primary mode of treatment. This paper will review the literature surrounding TKA as both primary treatment and as a salvage measure in patients with fractures of the tibial plateau. The outcomes, complications, techniques and surgical challenges are also discussed. PMID:28251061
Tsujimoto, Ryu; Matsumoto, Tomoyuki; Takayama, Koji; Kawakami, Yohei; Kamimura, Masato; Matsushita, Takehiko; Kuroda, Ryosuke; Kurosaka, Masahiro
Acute arterial occlusions are a rare complication of total knee arthroplasty (TKA). However, in revision TKA, the risk of such complications is higher and these complications can lead to amputation if not adequately treated. We describe a case of acute popliteal artery occlusion 4 hours after second revision TKA in a patient with a history of several surgical procedures because of periprosthetic infection at a previous hospital. Revascularization was achieved via bypass grafting and amputation was narrowly avoided despite time lag after symptom onset to revascularization. In this case, it was possible that the arterial disease that accompanied the vascular endothelium injury such as pseudoaneurysm had existed since the previous surgery at another hospital and was destroyed by the surgical procedure, which led to the formation of thrombosis and arterial occlusion. Preoperative evaluation of the arterial condition should be considered to avoid acute arterial occlusive disease, especially in patients who had several previous surgical procedures.
Bonnin, M; Lustig, S; Huten, D
Extensor tendon rupture is a rare but serious complication after total knee arthroplasty (TKA) that impairs active knee extension, thereby severely affecting knee function. Surgery is usually required. Surgical options range from simple suturing to allograft reconstruction of the entire extensor mechanism and include intermediate methods such as reconstruction using neighbouring tendons or muscles, synthetic ligament implantation, and partial allograft repair. Simple suturing carries a high failure rate and should therefore be routinely combined with tissue augmentation using a neighbouring tendon or a synthetic ligament. After allograft reconstruction, outcomes are variable and long-term complications common. Salvage procedures for managing the most severe cases after allograft failure involve reconstruction using gastrocnemius or vastus flaps. Regardless of the technique used, suturing must be performed under tension, with the knee fully extended, and rehabilitation must be conducted with great caution. Weaknesses of available case-series studies include small sample sizes, heterogeneity, and inadequate follow-up duration. All treatment options are associated with substantial failure rates. The patient should be informed of this fact and plans made for a salvage option. Here, the main techniques and their outcomes are discussed, and a therapeutic strategy is suggested.
Huang, Adrian; Ryu, Jae-Jin; Dervin, Geoffrey
Background With diminishing reimbursement rates and strained public payer budgets, a high-volume inpatient procedure, such as total knee arthroplasty (TKA), is a common target for improving cost efficiencies. Methods This prospective case–control study compared the cost-minimization of same day discharge (SDD) versus inpatient TKA. We examined if and where cost savings can be realized and the magnitude of savings that can be achieved without compromising quality of care. Outcome variables, including detailed case costs, return to hospital rates and complications, were documented and compared between the first 20 SDD cases and 20 matched inpatient controls. Results In every case–control match, the SDD TKA was less costly than the inpatient procedure and yielded a median cost savings of approximately 30%. The savings came primarily from costs associated with the inpatient encounter, such as surgical ward, pharmacy and patient meal costs. At 1 year, there were no major complications and no return to hospital or readmission encounters for either group. Conclusion Our results are consistent with previously published data on the cost savings associated with short stay or outpatient TKA. We have gone further by documenting where those savings were in a matched cohort design. Furthermore, we determined where cost savings could be realized during the patient encounter and to what degree. In carefully selected patients, outpatient TKA is a feasible alternative to traditional inpatient TKA and is significantly less costly. Furthermore, it was deemed to be safe in the perioperative period. PMID:28234591
Elkassabany, Nabil M; Abraham, Daniel; Huang, Stephanie; Kase, Brandon; Pio, Finnah; Hume, Eric; Israelite, Craig; Liu, Jiabin
Spinal anesthesia (SA) for Total Knee Arthroplasty (TKA) may be associated with better patients' outcomes. This study aims to assess the association between preoperative education about the advantage of SA over general anesthesia (GA) for TKA and the likelihood of patient choice of NA. Patients undergoing unilateral primary TKA were identified. Type of anesthesia (GA or SA), attendance of the (joints class), patient demographics, ASA status, anticoagulation status, and diagnosis of back problems were recoded. Regression analysis was used to assess the association between the type of anesthesia and attendance of the joints class. 1010 patients were identified to have unilateral primary TKA. 31% of patients attended the joint class. Patients who attended the joints class were more likely to receive SA when compared to those who did not attend (OR=1.7, CI: 1.2-2.5, P=0.004) after adjusting for other variables. Preoperative education about advantages of SA may be associated with an increase in patients receiving SA for TKA. Increase in patients receiving SA for TKA may improve outcomes. Copyright © 2017 Elsevier B.V. All rights reserved.
Lass, Richard; Kubista, Bernd; Holinka, Johannes; Pfeiffer, Martin; Schuller, Spiro; Stenicka, Sandra; Windhager, Reinhard; Giurea, Alexander
Cementless total knee arthroplasty (TKA) implants were designed to provide long-term fixation without the risk of cement-associated complications. The purpose of this study was to evaluate the outcome of titanium-coated cementless implants compared with hybrid TKA implants with a cemented tibial and a cementless femoral component. The authors performed a case-control, single-center study of 120 TKAs performed between 2003 and 2007, including 60 cementless and 60 hybrid cemented TKAs. The authors prospectively analyzed the radiographic and clinical data and the survivorship of the implants at a minimum follow-up of 5 years. Ninety patients who underwent TKA completed the 5-year assessment. Knee Society Scores increased significantly in both groups (P<.001). In both groups, 2 patients underwent revision due to aseptic tibial component loosening, resulting in a 96% implant survival rate. Radiographs showed significantly less radiolucent lines around the tibial baseplate in the cementless group (n=12) than in the hybrid cemented group (n=26) (P=.009).At 6-year mean follow-up, no significant difference existed between the cementless and hybrid cemented tibial components in TKA in terms of clinical and functional results and postoperative complications. The significantly smaller number of radiolucent lines in the cementless group is an indicator of primary stability with the benefit of long-term fixation durability of TKA.
Whitchelo, Tara; McClelland, Jodie A; Webster, Kate E
People with knee osteoarthritis (OA) report ongoing limitations in climbing stairs, even after total knee arthroplasty (TKA). The aim of this systematic review was to synthesise the available evidence of factors affecting stair climbing ability in patients with knee OA before and after TKA. A systematic search was conducted of common electronic databases. All English language abstracts where stair-climbing was assessed in patients with either knee OA or at least 6 months after TKA, and a relationship to any physical, psychological or demographic factors was reported. Thirteen studies were included in the final review, nine investigated a knee OA population, and four investigated a TKA population. For patients with knee OA there was consistent and convincing evidence that greater stair-climbing ability was related to stronger lower limb muscles and less knee pain. For patients with TKA there was much less research, and no conclusions could be reached. For people with knee OA there is evidence that some physical, demographic and psychosocial factors are related to stair-climbing ability. However, the evidence for similar relationships in the TKA population is scarce and needs more extensive research. Implications for Rehabilitation People with knee osteoarthritis experience difficulty when climbing stairs, and this remains challenging even after knee replacement. For people with knee osteoarthritis, a range of physical, demographic and psychosocial factors contribute to stair-climbing ability, however, evidence for similar relationships in the TKA population is scarce. Rehabilitation that is multi-faceted may be the best approach to improve stair-climbing in people with knee osteoarthritis.
Astephen Wilson, Janie L; Dunbar, Michael J; Hubley-Kozey, Cheryl L
The future of total knee arthroplasty (TKA) surgery will involve planning that incorporates more patient-specific characteristics. Despite known biological, morphological, and functional differences between men and women, there has been little investigation into knee joint biomechanical and neuromuscular differences between men and women with osteoarthritis, and none that have examined sex-specific biomechanical and neuromuscular responses to TKA surgery. The objective of this study was to examine sex-associated differences in knee kinematics, kinetics and neuromuscular patterns during gait before and after TKA. Fifty-two patients with end-stage knee OA (28 women, 24 men) underwent gait and neuromuscular analysis within the week prior to and one year after surgery. A number of sex-specific differences were identified which suggest a different manifestation of end-stage knee OA between the sexes.
Ota, Susumu; Nakashima, Takeshi; Morisaka, Ayako; Omachi, Takaaki; Ida, Kunio; Kawamura, Morio
Diminished range of motion (ROM) of the knee joint after total knee arthroplasty (TKA) is thought to be related to reduced patellar mobility. This has not been confirmed clinically due to a lack of quantitative methods adequate for measuring patellar mobility. We investigated the relationship between patellar mobility by a reported quantitative method and knee joint ROM after TKA. Forty-nine patients [osteoarthritis--OA: 29 knees; rheumatoid arthritis--RA: 20 knees] were examined after TKA. Respective medial and lateral patellar mobility was measured 1 and 6 months postoperatively using a patellofemoral arthrometer (PFA). Knee joint ROM was also measured in each of those 2 sessions. Although the flexion and extension of the knee joints improved significantly from 1 to 6 months after TKA, the medial and lateral patellar displacements (LPDs) failed to improve during that same period. Moreover, only the changes in knee flexion and medial patellar displacement (MPD) between the two sessions were positively correlated (r = 0.31, p < 0.05). However, our findings demonstrated that medial and lateral patellar mobility had no sufficient longitudinal relationship with knee ROM after TKA.
Smith, Webb A; Zucker-Levin, Audrey; Mihalko, William M; Williams, Michael; Loftin, Mark; Gurney, James G
Obese patients are more likely to have osteoarthritis and total knee arthroplasty (TKA). This investigation sought to evaluate physical function, activity level, and quality of life (QOL). Obese participants near 1-year postsurgical follow-up appointment were recruited. Evaluation included QOL and activity questionnaire, medical histories, anthropometrics, strength, and aerobic capacity. Sixty participants completed assessments. Obese TKA patients have physical performance limitations and low physical activity levels 1 year after surgery and completion of postoperative rehabilitation.
Baker, Paul N; Petheram, Timothy; Dowen, Daniel; Jameson, Simon S; Avery, Peter J; Reed, Mike R; Deehan, David J
Patella resurfacing during primary total knee arthroplasty (TKA) remains controversial. Variation in published results for patella resurfacing may potentially be explained by differences in design between TKA brands. We interrogated NJR-PROMs data to ascertain whether there is an early functional benefit to resurfacing the patella, both overall and for each of the five most popular primary knee designs through use of the Oxford Knee Score. A total of 8103 resurfaced TKAs and 15,290 nonresurfaced TKAs were studied. There was a large variation in the proportion of knees undergoing patella resurfacing by brand (Nexgen=16% versus Triathlon=52%). Patellar resurfacing did not significantly influence the magnitude of improvement in overall knee function or anterior knee-specific function irrespective of TKA brand or for cruciate retaining versus sacrificing designs. Copyright © 2014 Elsevier Inc. All rights reserved.
Volkmann, Elizabeth R; FitzGerald, John D
Gender disparities in total knee arthroplasty utilization may be due to differences in perceptions and expectations about total knee arthroplasty outcomes. This study evaluates the impact of a decision aid on perceptions about total knee arthroplasty and decision-making parameters among patients with knee osteoarthritis. Patients with moderate to severe knee osteoarthritis viewed a video about knee osteoarthritis treatments options, including total knee arthroplasty, and received a personalized arthritis report. An adapted version of the Western Ontario and McMaster Universities Osteoarthritis Index was used to assess pain and physical function expectations following total knee arthroplasty before/after the intervention. These scores were compared to an age- and gender-adjusted means for a cohort of patients who had undergone total knee arthroplasty. Decision readiness and conflict were also measured. At baseline, both men and women had poorer expectations about post-operative pain and physical outcomes compared with observed outcomes of the comparator group. Following the intervention, women's mean age-adjusted expectations about post- total knee arthroplasty pain outcomes improved (Pre: 27.0; Post: 21.8 [p =0.08; 95% CI -0.7, 11.0]) and were closer to observed post-TKA outcomes; whereas men did not have a significant change in their pain expectations (Pre: 21.3; Post: 19.6 [p = 0.6; 95% CI -5.8, 9.4]). Women also demonstrated a significant improvement in decision readiness; whereas men did not. Both genders had less decision conflict after the intervention. Both women and men with osteoarthritis had poor estimates of total knee arthroplasty outcomes. Women responded to the intervention with more accurate total knee arthroplasty outcome expectations and greater decision readiness. Improving patient knowledge of total knee arthroplasty through a decision aid may improve medical decision-making and reduce gender disparities in total knee arthroplasty utilization.
Urish, Kenneth L; Conditt, Michael; Roche, Martin; Rubash, Harry E
Although current total knee arthroplasty (TKA) is considered a highly successful surgical procedure, patients undergoing TKA can still experience substantial functional impairment and increased revision rates as compared with those undergoing total hip arthroplasty. Robotic-assisted surgery has been available clinically for almost 15 years and was developed, in part, to address these concerns. Robotic-assisted surgery aims to improve TKA by enhancing the surgeon's ability to optimize soft tissue balancing, reproduce alignment, and restore normal knee kinematics. Current systems include a robotic arm with a variety of different navigation systems with active, semi-active, or passive control. Semi-active systems have become the dominant strategy, providing a haptic window through which the surgeon consistently prepares a TKA based on preoperative planning. A review of previous designs and clinical studies demonstrates that these robotic systems decrease variability and increase precision, primarily with the mechanical axis and restoration of the joint line. Future design objectives include precise planning and consistent intraoperative execution. Preoperative planning, intraoperative sensors, augmenting surgical instrumentation, and biomimetic surfaces will be used to re-create the 4-bar linkage system in the knee. Implants will be placed so that the knee functions with a medial pivot, lateral rollback, screw home mechanism, and patellar femoral tracking. Soft tissue balancing will become more than equalizing the flexion and extension gaps and will match the kinematics to a normal knee. Together, coupled with advanced knee designs, they may be the key to a patient stating, "My knee feels like my natural knee." [Orthopedics. 2016; 39(5):e822-e827.].
Mihalko, William M; Ali, Mounawar; Phillips, Matthew J; Bayers-Thering, Mary; Krackow, Kenneth A
The change in coronal plane deformity throughout a range of flexion before and after total knee arthroplasty (TKA) has not been reported. Unlike most alignment assessments traditionally reporting coronal plane alignment in a standing position under static conditions, this study reports deformity throughout the flexion arc before and after deformity correction. One hundred fifty-two TKA patients using the anteroposterior axis for femoral component rotation and computer navigation techniques were included in the study. Deformity before TKA ranged from 17.5 degrees varus (deformity apex away from the midline) to 20.5 degrees valgus (deformity apex toward the midline) in full extension. Before TKA, deformity was not constant through an arc of motion and significantly decreased with flexion of 60 degrees and more (P < .01). The deformity after performing a TKA was not different (P = .478) throughout the flexion arc. The data determined that deformity is not constant throughout flexion in osteoarthritic knees preoperatively and that deformity throughout flexion can be corrected with the use of conventional alignment techniques during TKA.
Kim, Kyung Tae; Lee, Song; Ko, Dong Oh; Seo, Bong Soo; Jung, Woo Shik; Chang, Byung Kwon
To identify the modes of failure after total knee arthroplasty (TKA) in patients >55 years of age and to compare with those >55 years of age in patients who underwent revision TKA. We retrospectively reviewed 256 revision TKAs among patients who underwent TKA for knee osteoarthritis between January 1992 and December 2012. The causes of TKA failure were analyzed and compared between the groups. Thirty-one revision TKAs were performed in patients ≤55 years of age at the time of primary TKA, whereas 225 cases were in those >55 years of age at primary TKA. In the ≤55 years of age group, the most common cause of TKA failure was polyethylene wear (45%) followed by infection (26%) and loosening (17%). The interval from primary TKA to revision was 8.6 years (range, 1 to 17 years). There were relatively lower infection rate and higher loosening rate in patients ≤55 years of age, but the difference was not statistically significant. The main causes of failure after TKA in patients ≤55 years of age were polyethylene wear, infection and loosening, and there was no significant difference in the modes of failure after TKA between the two groups.
Patil, Shantanu; Bunn, Adam; Bugbee, William D; Colwell, Clifford W; D'Lima, Darryl D
Nearly 14% to 39% TKA patients report dissatisfaction causing incomplete return of function. We proposed that the kinematics of knees implanted with patient-specific prostheses using patient-specific cutting guides would be closer to normal. Eighteen matched cadaver lower limbs were randomly assigned to two groups: group A was implanted with patient-specific implants using patient-specific cutting guides; group B, the contralateral knee, was implanted with a standard design using intramedullary alignment cutting guides. Knee kinematics were measured on a dynamic closed-kinetic-chain Oxford knee rig, simulating a deep knee bend and in a passive rig testing varus-valgus laxity. The difference from normal kinematics was lower for group A compared to group B for active femoral rollback, active tibiofemoral adduction, and for passive varus-valgus laxity. Our results support the hypothesis that knees with patient-specific implants generate kinematics more closely resembling normal knee kinematics than standard knee designs. Restoring normal kinematics may improve function and patient satisfaction after total knee arthroplasty. Copyright © 2015 Elsevier B.V. All rights reserved.
Kumar, Nishikant; Yadav, Chandrashekhar; Raj, Rishi; Anand, Sumit
Today, total knee arthroplasty (TKA) is one the most commonly performed surgeries worldwide. The purpose of this article is to review the appearance of normal post-TKA roentgenographs and describe the correct sequence for their interpretation. It is unwise to depend solely on patients' symptoms when diagnosing TKA complications because serial radiographs can foresee failures well before they manifest clinically. Ideal post-TKA radiographs comprise whole lower extremity anteroposterior and lateral views taken under weight bearing conditions along with a skyline view of the patellofemoral joint. Among other things, weight bearing exposes the true alignment, ligamentous laxity and polyethylene wear. On the basis of follow-up of our TKA cases, we have drawn up a protocol for assessing postoperative X-ray films after TKAs. Following the proposed sequence, surgeon can easily decide how to proceed with follow-up and foresee complications. Careful interpretation of postoperative radiographs after TKA is essential to careful monitoring of patients and implant survival.
Lee, Wei Ting; Chin, Pak Lin; Lo, Ngai Nung; Yeo, Seng Jin
To compare the short-term functional outcome after computer-assisted total knee arthroplasty (TKA) versus conventional TKA. 23 men and 67 women aged 48 to 80 years were randomised to undergo (1) conventional TKA using an intramedullary guide, (2) conventional TKA using an extramedullary guide, or (3) computer-assisted TKA. Two senior surgeons performed all the TKAs using the same TKA system and the standard anteromedial arthrotomy with eversion of the patella. Patients were assessed by physiotherapists before and 6 months and 2 years after TKA using the Short Form-36 Health Survey, Oxford Knee Score, and Knee Society Score. Of the 90 patients, 67 and 70 were assessed at 6 months and 2 years after TKA, respectively. No patient developed deep infection or required revision surgery. Functional outcomes of the 3 groups did not differ significantly at the corresponding follow-ups. Significant improvement in the functional outcome was not shown in patients treated with computer-assisted TKA, compared with conventional TKA. Thus, computer-assisted TKA has limited additional short-term benefits. Further studies with longer follow-up are required to examine the benefits of computer-assisted TKA.
Kazemi, Seyyed Morteza; Daftari Besheli, Laleh; Eajazi, Alireza; Miniator Sajadi, Mohammad Reza; Okhovatpoor, Mohammad Ali; Farhang Zanganeh, Ramin; Minaei, Reza
One of the complications of total knee arthroplasty (TKA) which has not yet been directly addressed is pseudo-patella baja (PPB). True patella baja (PB) is present when the length of the patellar tendon becomes shorter. PPB is present when the patella tendon is not shortened, but the level of the joint line is elevated. This study was conducted to assess PPB in TKA. Sixty patients who had had a primary TKA at our center between 1995 and 2005 were included. The average follow-up was 27.5 months. The Knee Society Scoring (KSS), lateral knee x-rays and the Blackburne-Peel index were used for assessments. Out of the 60 patients, 43 (72%) demonstrated no joint line elevation or patellar tendon shortening (group A). Fifteen patients (25%) had joint line elevation (group B), and both PB and PPB were present in 2 (3%) patients (group C). KSS was lower in groups B and C compared with group A, but this difference was not statistically significant. The average range of motion (ROM) in group A was significantly higher compared with either group B or C, and patients in groups B and C showed significantly more severe pain compared with group A (P<0.001). PPB is not an uncommon finding after TKA and is associated with a statistically significant decrease in ROM and an increase in pain. Furthermore, KSS in the PPB group was less than in patients without PPB, although the difference was not statistically meaningful.
Galasso, Olimpio; Jenny, Jean-Yves; Saragaglia, Dominique; Miehlke, Rolf K
The use of a keel in the tibial component during modern primary total knee arthroplasty (TKA) has become common, and its cementation may affect the future performance of the prosthesis. Although proponents of cementing the entire tibial component argue that this technique provides better initial fixation and may prevent aseptic loosening, reasons exist to apply cement only to the tibial baseplate. In this study, 232 patients who underwent TKA using full or surface cementation of the tibial baseplate were evaluated at an average 5.6-year follow-up to assess survivorship and clinical results. The cumulative survival rate at 8 years was 97.1%. With revision of either component for any reason considered the endpoint, no significant difference was noted between full and surface cemented groups. Knee Society Score, range of motion, and femoro-tibial mechanical angle significantly increased postoperatively. Multivariate analysis revealed that good preoperative range of motion and Knee Society Scores were related to good postoperative range of motion and Knee Society Scores. Follow-up length was a negative predictor of postoperative Knee Society Score. The use of full or surface cementation of the baseplate was unrelated to the postoperative clinical outcomes. Clinical outcomes did not differ according to the tibial component cementation technique. The results of this study suggest that cementing the keel of the tibial component during primary TKA has no advantage for patients. Longer-term follow-up and proper patient randomization are required to confirm these findings.
Chen, Antonia F; Choi, Lisa E; Colman, Matthew W; Goodman, Mark A; Crossett, Lawrence S; Tarkin, Ivan S; McGough, Richard L
Current methods of fixing periprosthetic fractures after total knee arthroplasty (TKA) are variable, and include open reduction and internal fixation (ORIF) via plating, retrograde nailing, or revision using standard revision TKA components or a distal femoral arthroplasty (DFA). The purpose of this study is to compare patients who failed plating techniques requiring subsequent revision to DFA to patients who underwent primary DFA. Of the 13 patients (9.2%) who failed primary ORIF, causes included nonunion (53.8%), infection (30.8%), loosening (7.7%), and refracture (7.7%). There were significantly more surgical procedures for ORIF revision to DFA compared to primary DFA. Complications for patients who underwent primary reconstruction with DFAs included extensor mechanism disruption (8.3%), infection (5.6%), and dislocation (2.8%). Primary reconstruction via ORIF is beneficial for preserving bone stock, but primary DFA may be preferred in osteopenic patients, or those at high risk for nonunion.
Tahmasebi, Mohammad Naghi; Amjad, Gholamreza Ghorbani; Kaseb, Mohammad Hassan; Bashti, Kaveh
Multiplanar or global laxity in arthritic knee is rare, most of this patients have neuromuscular disorder (post poliomyelitis, spinal dystrophy) or history of knee trauma. Ligament insufficiency and severe bone loss is significant in this patient. The estimated prevalence for the concurrence of charcot marie-tooth (CMT) with myasthenia gravis (MG) suggests an extremely rare event. We have presented a 54-year-old female patient with CMT and MG complaining of progressive pain, swelling, and crepitation of the knee joints who had been undergone total knee arthroplasty (TKA) with rotating hinge prosthesis. She had an acute myasthenia crisis soon after operation with prolonged intubation and intensive care unit admission. Radiographies and physical examination revealed bilateral severe unstable arthritic knee joints and left knee posterior dislocation. Short-term postoperative follow-up revealed improved knee function and resolution of all symptoms in the operated side. PMID:28271089
Jaroma, Antti; Soininvaara, Tarja; Kröger, Heikki
Background and purpose Total knee arthroplasty (TKA) may cause postoperative periprosthetic bone loss due to stress shielding. Bone also adapts to mechanical alterations such as correction of malalignment. We investigated medium-term changes in bone mineral density (BMD) in tibial periprosthetic bone after TKA. Patients and methods 86 TKA patients were prospectively measured with dual-energy X-ray absorptiometry (DXA), the baseline measurement being within 1 week after TKA and the follow-up measurements being at 3 and 6 months, and at 1, 2, 4, and 7 years postoperatively. Long standing radiographs were taken and clinical evaluation was done with the American Knee Society (AKS) score. Results The baseline BMD of the medial tibial metaphyseal region of interest (ROI) was higher in the varus aligned knees (25%; p < 0.001). Medial metaphyseal BMD decreased in subjects with preoperatively varus aligned knees (13%, p < 0.001) and in those with preoperatively valgus aligned knees (12%, p = 0.02) between the baseline and 7-year measurements. No statistically significant changes in BMD were detected in lateral metaphyseal ROIs. No implant failures or revision surgery due to tibial problems occurred. Interpretation Tibial metaphyseal periprosthetic bone is remodeled after TKA due to mechanical axis correction, resulting in more balanced bone stock below the tibial tray. The diaphyseal BMD remains unchanged after the initial drop, within 3–6 months. This remodeling process was related to good component survival, as there were no implant failures or revision operations due to tibial problems in this medium-term follow-up. PMID:27120266
Jaroma, Antti; Soininvaara, Tarja; Kröger, Heikki
Background and purpose - Total knee arthroplasty (TKA) may cause postoperative periprosthetic bone loss due to stress shielding. Bone also adapts to mechanical alterations such as correction of malalignment. We investigated medium-term changes in bone mineral density (BMD) in tibial periprosthetic bone after TKA. Patients and methods - 86 TKA patients were prospectively measured with dual-energy X-ray absorptiometry (DXA), the baseline measurement being within 1 week after TKA and the follow-up measurements being at 3 and 6 months, and at 1, 2, 4, and 7 years postoperatively. Long standing radiographs were taken and clinical evaluation was done with the American Knee Society (AKS) score. Results - The baseline BMD of the medial tibial metaphyseal region of interest (ROI) was higher in the varus aligned knees (25%; p < 0.001). Medial metaphyseal BMD decreased in subjects with preoperatively varus aligned knees (13%, p < 0.001) and in those with preoperatively valgus aligned knees (12%, p = 0.02) between the baseline and 7-year measurements. No statistically significant changes in BMD were detected in lateral metaphyseal ROIs. No implant failures or revision surgery due to tibial problems occurred. Interpretation - Tibial metaphyseal periprosthetic bone is remodeled after TKA due to mechanical axis correction, resulting in more balanced bone stock below the tibial tray. The diaphyseal BMD remains unchanged after the initial drop, within 3-6 months. This remodeling process was related to good component survival, as there were no implant failures or revision operations due to tibial problems in this medium-term follow-up.
Mittal, Amber; Bhosale, Pradeep B; Suryawanshi, Ashish V; Purohit, Shaligram
PURPOSE. To evaluate the outcome of one-stage long-stem total knee arthroplasty (TKA) for patients with arthritic knees and tibiofemoral stress fractures. METHODS. Records of 11 men and 18 women aged 47 to 78 (mean, 66) years who underwent fixed-bearing posterior-stabilised TKA for osteoarthritis or rheumatoid arthritis of the knee with tibial (n=31) and femoral (n=3) stress fractures were reviewed. All the tibial fractures involved the proximal half. There were 7 associated fibular stress fractures. Of the 31 knees with tibial stress fractures, 26 and 5 manifested varus and valgus deformity, respectively. RESULTS. The mean follow-up period was 51 (range, 24-96) months. The mean tibiofemoral angle improved from 23.2 to 1.9 degrees varus. The mean Knee Society knee score improved from 38.5 (range, 15- 63) to 89.6 (range, 80-95) [p<0.05]. The mean Knee Society functional score improved from 25.5 (range, 0-40) to 86.5 (range, 60-100) [p<0.05]. All fractures were united at the last follow-up. No complications were encountered. CONCLUSION. One-stage long-stem TKA restores limb alignment and facilitates fracture healing, with excellent outcome.
Fuchs, Mathijs C H W; Janssen, Rob P A
The primary aim of the study was to evaluate the range of motion and complications after Genesis II total knee arthroplasty with high-flexion tibia insert (TKA-HF). Furthermore, difference in knee flexion between high flexion and standard inserts was compared. The hypothesis was that knee flexion is better after high-flexion TKA. A total of 292 TKA-HF were retrospectively reviewed. Mean follow-up was 24.3 months. The range of motion was compared between TKA-HF (high-flexion group) and a comparable cohort of 86 Genesis II TKA with a standard tibia insert (control group). Surgeries were performed by one experienced knee orthopedic surgeon. Knee flexion in the high-flexion group increased from 114.8° preoperatively to 118.0° postoperatively (P < 0.01). Knee extension in the high-flexion group increased from -4.5° preoperatively to -0.4° after surgery (P < 0.01). Mean knee flexion was 5.52° (± 1.46°) better in the high-flexion group compared with the control group (P < 0.01). Preoperative range of motion, body mass index, diabetes mellitus and patellofemoral pain significantly influenced range of motion. Few complications occurred after TKA-HF. The Genesis II TKA-HF showed good short-term results with limited complications. Knee flexion after Genesis II TKA-HF was better compared with a standard tibia insert.
Chiang, Chih-Yen; Chen, Kun-Hui; Liu, Kai-Chun; Hsu, Steen Jun-Ping; Chan, Chia-Tai
Total knee arthroplasty (TKA) is the most common treatment for degenerative osteoarthritis of that articulation. However, either in rehabilitation clinics or in hospital wards, the knee range of motion (ROM) can currently only be assessed using a goniometer. In order to provide continuous and objective measurements of knee ROM, we propose the use of wearable inertial sensors to record the knee ROM during the recovery progress. Digitalized and objective data can assist the surgeons to control the recovery status and flexibly adjust rehabilitation programs during the early acute inpatient stage. The more knee flexion ROM regained during the early inpatient period, the better the long-term knee recovery will be and the sooner early discharge can be achieved. The results of this work show that the proposed wearable sensor approach can provide an alternative for continuous monitoring and objective assessment of knee ROM recovery progress for TKA patients compared to the traditional goniometer measurements.
Chiang, Chih-Yen; Chen, Kun-Hui; Liu, Kai-Chun; Hsu, Steen Jun-Ping; Chan, Chia-Tai
Total knee arthroplasty (TKA) is the most common treatment for degenerative osteoarthritis of that articulation. However, either in rehabilitation clinics or in hospital wards, the knee range of motion (ROM) can currently only be assessed using a goniometer. In order to provide continuous and objective measurements of knee ROM, we propose the use of wearable inertial sensors to record the knee ROM during the recovery progress. Digitalized and objective data can assist the surgeons to control the recovery status and flexibly adjust rehabilitation programs during the early acute inpatient stage. The more knee flexion ROM regained during the early inpatient period, the better the long-term knee recovery will be and the sooner early discharge can be achieved. The results of this work show that the proposed wearable sensor approach can provide an alternative for continuous monitoring and objective assessment of knee ROM recovery progress for TKA patients compared to the traditional goniometer measurements. PMID:28241434
van der Woude, J A D; Wiegant, K; van Heerwaarden, R J; Spruijt, S; Emans, P J; Mastbergen, S C; Lafeber, F P J G
Knee joint distraction (KJD) is a relatively new, knee-joint preserving procedure with the goal of delaying total knee arthroplasty (TKA) in young and middle-aged patients. We present a randomised controlled trial comparing the two. The 60 patients ≤ 65 years with end-stage knee osteoarthritis were randomised to either KJD (n = 20) or TKA (n = 40). Outcomes were assessed at baseline, three, six, nine, and 12 months. In the KJD group, the joint space width (JSW) was radiologically assessed, representing a surrogate marker of cartilage thickness. In total 56 patients completed their allocated treatment (TKA = 36, KJD = 20). All patient reported outcome measures improved significantly over one year (p < 0.02) in both groups. At one year, the TKA group showed a greater improvement in only one of the 16 patient-related outcome measures assessed (p = 0.034). Outcome Measures in Rheumatology-Osteoarthritis Research Society International clinical response was 83% after TKA and 80% after KJD. A total of 12 patients (60%) in the KJD group sustained pin track infections. In the KJD group both mean minimum (0.9 mm, standard deviation (sd) 1.1) and mean JSW (1.2 mm, sd 1.1) increased significantly (p = 0.004 and p = 0.0003). In relatively young patients with end-stage knee osteoarthritis, KJD did not demonstrate inferiority of outcomes at one year when compared with TKA. However, there is a high incidence of pin track infection associated with KJD. Cite this article: Bone Joint J 2017;99-B:51-8. ©2017 The British Editorial Society of Bone & Joint Surgery.
Carvalho, Rogério Teixeira de; Canté, Jonny Chaves Lima; Lima, Juliana Hoss Silva; Tavares, Luiz Alberto Barbosa; Takano, Marcelo Itiro; Tavares, Fernando Gomes
The volume of knee arthroplasty procedures has increased over the last decade. The aim of this study was to estimate the frequency of these procedures performed within the public healthcare system of the state of São Paulo between 2003 and 2010. Cross-sectional study conducted in the state of São Paulo by researchers at Hospital do Servidor Público do Estado de São Paulo. A sample of 10,952 patients (7,891 females and 3,061 males) who underwent primary total knee arthroplasty (TKA) and revision of total knee arthroplasty (RTKA) in the state of São Paulo between 2003 and 2010 was evaluated. The patients were cataloged using the public healthcare service's TABNET software. All of the patients presented primary osteoarthritis of the knee. The variables of gender, number of primary TKA procedures and number of RTKA procedures were evaluated. A total of 10,952 TKA procedures were performed (annual average of 1369), of which 9,271 (85%) were TKA and 1,681 (15%), RTKA. Of the TKA procedures, 72% were carried out on females (P < 0.0001), while 70% of the RTKA procedures were on females (P < 0.0001). The average ratio of TKA to RTKA was 5.5:1 (P < 0.0001); the ratios in 2003 and 2010 were 9.0:1 and 4.4:1 (P < 0.0001), respectively. The number and frequency of TKA and RTKA procedures increased in the state of São Paulo between 2003 and 2010. This increase was relatively greater in RTKA than in TKA and was predominantly in female patients.
Innocenti, Massimo; Vieri, Berti; Melani, Tommaso; Paoli, Tommaso; Carulli, Christian
Hypersensitivity to metals in the general population has an incidence of about 15%, and in rising also for the higher number of joint replacements in the last decades. Total Knee Arthroplasty (TKA) represents the most performed orthopaedic procedure during last years, and it seems to be particularly associated with sensitization after surgery. On the other hand, there is a rising amount of patients with painful but well implanted and functioning TKAs: in certain cases, after the exclusion of the most frequent causes of failure, a condition of hypersensitivity may be found, and a revision with anallergic implants is mandatory. The present study is a review of the potential problems related to hypersensitivity in TKA, its possible diagnostic procedures, and the surgical options to date available. Medical history, patch testing, and other specific laboratory assays are useful to assess a status of metals hypersensitivity before surgery in subjects undergoing a knee replacement, or even after TKA in patients complaining pain in otherwise well implanted and aligned prostheses. However, few groups worlwide deal with such condition, and all proposed diagnostic protocols may be considered still today conjectural. On the other hand, these represent the most updated knowledge of this condition, and may be useful for both the patient and the orthopaedic surgeon. Once assessed a possible or ascertained allergy to metals, several options are available for primary andr revision knee surgery, in order to avoid the risk of hypersensitivity. A review of the recent publications on this topic and an overview of the related aspects has been made to understand a condition to date considered negligible. Hypersensitivity to metals has not to be nowadays considered a "fiction", but rather a possible preoperative risk or a postoperative cause of failure of TKA. Crucial is the information of patients and the medical history, associated in suspect cases to laboratory testings. Today in the
Hatfield, Gillian L; Stanish, William D; Hubley-Kozey, Cheryl L
Objective To determine if baseline 3-dimensional (3-D) biomechanical gait patterns differed between those patients with moderate knee osteoarthritis (OA) who progressed to total knee arthroplasty (TKA) and those that did not, and whether these differences had predictive value. Methods Fifty-four patients with knee OA had ground reaction forces and segment motions collected during gait. 3-D hip, knee, and ankle angles and moments were calculated over the gait cycle. Amplitude and temporal waveform characteristics were determined using principal component analysis. At followup 5–8 years later, 26 patients reported undergoing TKA. Unpaired t-tests were performed on baseline demographic and waveform characteristics between TKA and no-TKA groups. Receiver operating curve analysis, stepwise discriminate analysis, and logistic regression analysis determined the combination of features that best classified TKA and no-TKA groups and their predictive ability. Results Baseline demographic, symptomatic, and radiographic variables were similar, but 7 gait variables differed (P < 0.05) between groups. A multivariate model including overall knee adduction moment magnitude, knee flexion/extension moment difference, and stance–dorsiflexion moment had a 74% correct classification rate, with no overtraining based on cross-validation. A 1-unit increase in model score increased by 6-fold the odds of progression to TKA. Conclusion In addition to the link between higher overall knee adduction magnitude and future TKA, an outcome of clear clinical importance, novel findings include altered sagittal plane moment patterns indicative of reduced ability to unload the joint during midstance. This combination of dynamic biomechanical factors had a 6-fold increased odds of future TKA; adding baseline demographic and clinical factors did not improve the model. PMID:25708360
Behrend, Henrik; Zdravkovic, Vilijam; Giesinger, Johannes; Giesinger, Karlmeinrad
We recently developed the forgotten joint score 12 (FJS-12), a tool to assess joint awareness in everyday life. It is unknown whether patient factors predicting the outcome of the FJS-12 after total knee arthroplasty (TKA) exist. Five hundred forty cases of TKA were analyzed. Objective clinical results were obtained for range of motion, stability, and alignment. Patient-reported outcome was assessed using the FJS-12. Baseline data and complications were recorded. Cluster analysis based on FJS-12, postoperative flexion, and age resulted in 3 groups: poor outcome (88 patients), good outcome (340 patients), and excellent outcome (118 patients). The characteristics of "poor" compared to "excellent" clusters were studied more closely using bivariate comparative tests and logistic regression. We could find that male patients around 63 years with a lower body mass index were most likely to be allocated to the cluster "excellent" (defined as high FJS-12 and high postoperative flexion). Preoperative extension and flexion, stability, varus/valgus alignment, surgery prior TKA, or comorbidities were not predictive for the FJS-12 at 1 year follow-up. We identified 3 preoperative patient-related factors that may predict the FJS-12 after TKA: body mass index, age, and gender. These findings can be used to guide decision-making and important preoperative discussions on expectations after TKA. Copyright © 2016 Elsevier Inc. All rights reserved.
Miner, Andrew L; Lingard, Elizabeth A; Wright, Elizabeth A; Sledge, Clement B; Katz, Jeffrey N
We investigated the relationship of knee range of motion (ROM) and function in a prospective, observational study of primary total knee arthroplasty (TKA). Preoperative and 12-month data were collected on 684 patients, including knee ROM, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function questionnaire scores, patient satisfaction, and perceived improvement in quality of life (QOL). Only modest correlations were found between knee ROM and WOMAC function (r<0.34). At 12 months we found significantly worse WOMAC function scores for patients with <95 degrees flexion compared with patients with > or =95 degrees (mean, 61.9 vs 75.0; P<.0001). In linear regression models, WOMAC pain and function scores at 12 months were both correlates of patient satisfaction and perceived improvement in QOL (standardized beta>3.5; P<.0001), but knee flexion was not. For assessment of these outcomes, WOMAC function appears to be more important than knee flexion.
Frisch, Nicholas B; Pepper, Andrew M; Rooney, Edward; Silverton, Craig
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common and successful orthopedic procedures, and as their frequency continues to increase substantially, the focus on limiting perioperative complications heightens. Intraoperative normothermia is recommended to minimize additional complications, but limited evidence exists regarding the effect of hypothermia on orthopedic patients. The purpose of this retrospective study was to determine the incidence of perioperative hypothermia in the setting of TKA and THA, and to evaluate its impact on complications and outcomes. The clinical records of 2580 consecutive patients who underwent TKA or THA at a single institution between January 1, 2011, and December 31, 2013 were reviewed. After excluding patients with complex or revision procedures, a total of 2397 patients comprised the study population. Patient demographic data, surgery-specific data, postoperative complications, length of hospital stay, and 30-day readmission were recorded. Patients with a mean intraoperative temperature less than 36°C were identified as hypothermic. Statistical analysis evaluated associations with hypothermia and the effect on complications and outcomes. The incidence of mean intraoperative hypothermia was 37%, 43.9%, and 32.6% for arthroplasty, THA, and TKA, respectively. General anesthesia was significantly associated with hypothermia (P<.001). Women and THA patients were at higher risk for hypothermia. In the arthroplasty and THA cohorts, longer operating room time and re-warmer use were associated with hypothermia (P=.010). Overall, hypothermia was associated with increased estimated blood loss, but no increase in associated transfusion was demonstrated (P=.006). Hypothermia was not associated with postoperative complications. [Orthopedics. 2017; 40(1):56-63.]. Copyright 2016, SLACK Incorporated.
Huang, Rongying; Liu, Yanqiang; Zhu, Jun
Knee injury is a common medical issue. A full understanding of the kinematics and mechanical properties of knees following total knee arthroplasty (TKA) repair utilizing patellar replacement (only the base of the patella is replaced) versus patellar retaining surgical techniques is still lacking. In the current paper, we investigated magnetic resonance (MR) imaging data from knees repaired by these two methods and evaluated total knee models created using imaging reconstruction technology that simulated gait conditions. Results revealed that patellar replacement had little influence on tibiofemoral kinematics, although the tibia-surface equivalent stress increased slightly. By contrast, patellar replacement had a significant influence on the patellofemoral joint; patellar internal rotation, external rotation, and medial-lateral translation were all increased. Moreover, the stress distribution on patellar prostheses was altered, resulting in an increased surface maximal equivalent stress on the corresponding area. Moreover, during the gait cycle, we found that the area with maximal equivalent stress shifted its position. Finally, the patellofemoral joint showed decreased motion stability. From the view of kinematics and mechanics, this paper suggests that patella should be retained during TKA if it is possible. The present study presented approaches and technologies for evaluating kinematics and mechanical properties of total knee joint after TKA under gait loads. PMID:27057134
Frisch, Nicholas B; Wessell, Nolan M; Charters, Michael A; Yu, Stephen; Jeffries, James J; Silverton, Craig D
Perioperative patient optimization can minimize the need for blood transfusions in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to determine predictors and complications of transfusions. This retrospective review analyzed 1795 patients who underwent primary THA and TKA at our institution between January 2011 and December 2012. Of the 1573 patients ultimately included the rates of transfusion were 9.27% in TKA and 26.6% in THA. Significant predictors for transfusion include: preoperative hemoglobin, age, female gender, body mass index, creatinine, TKA, operating room time, operative blood loss, and intra-operative fluids. The DVT rate was comparable, but deep surgical site infection rate among transfused patients was 2.4% compared to 0.5% in non-transfused patients (P = 0.0065). Copyright © 2014 Elsevier Inc. All rights reserved.
Poultsides, Lazaros A; Ghomrawi, Hassan M K; Lyman, Stephen; Aharonoff, Gina B; Mancuso, Carol A; Sculco, Thomas P
The objective of this study was to compare preoperative expectation scores between stages in patients with bilateral total knee arthroplasty (TKA) and total hip arthroplasty (THA) using intraclass correlation coefficients (ICCs). For patients with TKA (57), ICC was 0.449, indicating fair agreement between stages; expectations did not change for 31% of patients, whereas 40% had higher and 29% had lower expectations. For patients with THA (55), ICC was 0.663, indicating moderate agreement; expectations did not change for 42% of patients, whereas 38% had higher and 20% had lower expectations. In multivariable analyses controlling for first expectation score, second expectation score was associated with better Western Ontario McMaster Universities Osteoarthritis Index stiffness score for TKA and with worse Western Ontario McMaster Universities Osteoarthritis Index function score for patients with THA. For most patients, expectations changed between staged bilateral TKA and THA, but the direction of change was not uniform.
de Beer, Justin; Petruccelli, Danielle; Adili, Anthony; Piccirillo, Liz; Wismer, David; Winemaker, Mitch
A 42-item survey was developed and administered to determine patient perception of and satisfaction with total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A total of 153 patients who had both primary THA and TKA for osteoarthritis with 1-year follow-up were identified. Survey response rate was 72%. Patients were more satisfied with THA meeting expectations for improvement in function and quality of life (P < .05), whereas pain relief expectations were equivalent. Most patients (70.9%) reported that TKA required more physiotherapy. One-year Oxford score and improvement in Oxford score from preoperative to 1 year were superior for THAs (P = .000). Despite equivalent pain relief, THAs trend toward higher satisfaction compared with TKAs. THA is more likely to "feel normal" with greater improvement in Oxford score. Recovery from TKA requires more physiotherapy and a longer time to achieve a satisfactory recovery status. Patients should be counseled accordingly.
Dion, Neil T; Bragdon, Charles; Muratoglu, Orhun; Freiberg, Andrew A
This article reviews the history of the development of highly cross-linked polyethylene and provides an in-depth review of the clinical results regarding the durability of highly cross-linked polyethylene (HXLPE) used in total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of polyethylene as a bearing surface has contributed to the success of THA and TKA; however, polyethylene wear and osteolysis can lead to failure. Ongoing clinical and retrieval studies are required to analyze outcomes at longer-term follow-up.
Dimitriou, Dimitris; Tsai, Tsung-Yuan; Park, Kwan Kyu; Hosseini, Ali; Kwon, Young-Min; Rubash, Harry E; Li, Guoan
An equal knee joint height during flexion and extension is of critical importance in optimizing soft-tissue balancing following total knee arthroplasty (TKA). However, there is a paucity of data regarding the in-vivo knee joint height behavior. This study evaluated in-vivo heights and anterior-posterior (AP) translations of the medial and lateral femoral condyles before and after a cruciate-retaining (CR)-TKA using two flexion axes: surgical transepicondylar axis (sTEA) and geometric center axis (GCA). Eleven osteoarthritis (OA) knee patients were studied during a weight-bearing single leg lunge, using a validated dual fluoroscopic imaging system (DFIS) based tracking technique. Eight healthy subjects were recruited as controls. The results demonstrated that following TKA, the medial and lateral femoral condyle heights were not equal at mid-flexion (15-45°, medial condyle lower then lateral by 2.4mm at least, p<0.01), although the knees were well-balanced at 0° and 90°. While the femoral condyle heights increased from the pre-operative values (>2mm increase on average, p<0.05), they were similar to the intact knees except that the medial sTEA was lower than the intact medial condyle between 0° and 90°. At deep flexion (>90°), both condyles were significantly higher (>2mm, p<0.01) than the healthy knees. Anterior femoral translation of the TKA knee was more pronounce at mid-flexion, whereas limited posterior translation was found at deep flexion. These data suggest that a well-balanced knee intra-operatively might not necessarily result in mid-flexion and deep flexion balance during functional weight-bearing motion, implying mid-flexion instability and deep flexion tightness of the knee.
Storey, Ava S.T.; Myrah, Ainslie M.; Bauck, Robyn A.; Brinkman, Danielle M.; Friess, Shawn N.
ABSTRACT Purpose: To determine the relationship between indoor and outdoor mobility capacity in older adults with unilateral total knee arthroplasty (TKA) and, secondarily, to determine walking intensity in the same population and to compare all outcomes to a control group of older adults without knee pathology. Method: In this cross-sectional study, participants (TKA=16, mean 22.9 (SD 9.7) mo post TKA; control=22) completed indoor walking tests and a 580 m outdoor course that included varying terrain (e.g., curbs, grass, sidewalk) and frequent changes in direction. Walking capacity was assessed using stopwatches, global positioning system watches and accelerometers. Results: Outdoor walking time was moderately correlated (p<0.05) with the timed up-and-go (TUG) test (r=0.65), stair-climb test (SCT) (r=0.67 ascending, r=0.79 descending), 10 m walk test (10 mWT) (r=0.73), and 6-minute walk test (6 MWT) (r=−0.75). Based on activity counts, walking intensity levels for participants in both groups were moderate (outdoor walk and 6 MWT). There was no significant difference in walking capacity between groups (TUG, SCT, 10 mWT, 6 MWT, outdoor walk). Conclusions: Common clinical walking tests are moderately correlated with outdoor mobility. Mobility capacity of individuals post TKA was similar to controls in both indoor and outdoor environments, and participants in both groups achieved moderate physical activity levels with walking. PMID:24403699
Song, Sang Jun; Kim, Kang Il; Lee, Chung Hwan
Clinical results of high tibial osteotomy (HTO) deteriorate over time despite the initial satisfactory results. Several knees may require a conversion to total knee arthroplasty (TKA) because of failure such as the progression of degenerative osteoarthritis and the loss of the correction angle. It is important to know the long-term survival rate and common reason of failure in HTO to inform patients of postoperative expectations before surgery and to prevent surgical errors during surgery. In addition, it has been reported that clinical and radiological results, revision rate, and complication rate were poorer than those in patients without a previous HTO. There are few review articles that describe why conversion TKA after HTO is surgically difficult and the results are poor. Surgeons have to avoid the various complications and surgical errors in this specific situation. We would like to present the considering factors and technical difficulties during conversion TKA after HTO with a review of the literature. We could conclude through the review that the correction of deformity, lower amount of tibial bone resection, and sufficient polyethylene insert thickness, restoration of the joint line height, and adequate ligament balancing can be helpful in overcoming the technical challenges encountered during TKA following HTO. PMID:27274465
Willis-Owen, Charles A; Brust, Klaus; Alsop, Helen; Miraldo, Marisa; Cobb, Justin P
The viability of unicondylar knee arthroplasty (UKA) as a stand-alone or temporising option for the management of gonarthrosis is a topic of considerable contention. Despite recent advances in prosthesis design and surgical technique, as well as mounting evidence of long-term survivorship, UKA remains infrequently used, accounting for just 8-15% of all knee arthroplasties. Instead this group is more typically managed using total knee arthroplasty (TKA). For UKA to warrant increased usage the candidacy for UKA must be prevalent, the outcome must be equivalent or superior to that of TKA, and the costs should be comparatively low. Here we address three issues regarding UKA: 1) a prospective assessment of the proportion of knees needing arthroplasty that are candidates for UKA; 2) retrospective outcome measures comparing TKA, UKA and controls; and 3) an estimation of the difference in costs between TKA and UKA from a hospital perspective. We show in a series of 200 knees that candidacy for UKA is widespread; representing 47.6% of knees. Furthermore, we also show for the first time, that not only is UKA functionally superior to TKA (based on Total Knee Questionnaire (TKQ) scores), but scores in medial and lateral UKA knees do not differ significantly from normal, non-operative age- and sex-matched knees (t=1.14 , p=0.163; and t=1.16 , p=0.255 respectively). Finally, we report that UKA offers a substantial cost saving over TKA ( pound 1761 per knee) indicating that UKA should be considered the primary treatment option for unicompartmental knee arthritis.
Hiyama, Y; Wada, O; Nakakita, S; Mizuno, K
There is a growing interest in the use of patient-reported outcomes to provide a more patient-centered view on treatment. Forgetting the artificial joint can be regarded as the goal in joint arthroplasty. The goals of the study were to describe changes in joint awareness in the artificial joint after total knee arthroplasty (TKA), and to determine which factors among pain, knee range of motion (ROM), quadriceps strength, and functional ability affect joint awareness after TKA. Patients undergoing TKA demonstrate changes in joint awareness and joint awareness is associated with pain, knee ROM, quadriceps strength, and functional ability. This prospective cohort study comprised 63 individuals undergoing TKA, evaluated at 1, 6, and 12 months postoperatively. Outcomes included joint awareness assessed using the Forgotten Joint Score (FJS), pain score, knee ROM, quadriceps strength, and functional ability. Fifty-eight individuals completed all postoperative assessments. All measures except for knee extension ROM improved from 1 to 6 months. However, there were no differences in any measures from 6 to 12 months. FJS was affected most greatly by pain at 1 month and by quadriceps strength at 6 and 12 months. Patients following TKA demonstrate improvements in joint awareness and function within 6 months after surgery, but reach a plateau from 6 to 12 months. Quadriceps strength could contribute to this plateau of joint awareness. Prospective cohort study, IV. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Tsukeoka, Tadashi; Tsuneizumi, Yoshikazu
Retrospective studies demonstrated inadequate soft tissue balance is associated with the long-term outcome of total knee arthroplasty (TKA). However, most of these studies have evaluated the joint laxity only postoperatively without anesthesia. Therefore information about the effect of anesthesia on knee laxity is important for soft tissue balancing at the time of surgery. This study was conducted to determine how anesthesia affects the varus and valgus stress tests after TKA. A consecutive series of 26 patients undergoing staged bilateral TKA was evaluated. Varus and valgus laxity of the knee with the TKA implant was measured a few days before the contralateral TKA without anesthesia and again immediately after the contralateral TKA under spinal anesthesia. The laxity was significantly increased from 3.0° to 3.6° (p = 0.005) and from 4.7° to 5.7° (p = 0.007) in medial and lateral side, respectively, when the stress tests were performed under anesthesia in comparison to the laxity measured without anesthesia. The major change in laxity (≥3°) was measured in 6 (23%) patients tested without anesthesia. Anesthesia significantly influenced knee joint laxity after TKA. The findings of this study suggest that muscular forces impart a stabilizing force across the joint.
Demey, Guillaume; Nover, Luca; Dejour, David
Background The study aimed to compare trochlear profiles in recent total knee arthroplasty (TKA) models and to determine whether they feature improvements compared to their predecessors. The hypothesis was that recent TKA models have more anatomic trochlear compartments and would display no signs of trochlear dysplasia. Methods The authors analyzed the geometry of the 6 following TKA models using engineering software: PFC and Attune (DePuy), NexGen and Persona (Zimmer), Noetos and KneeTec (Tornier). The mediolateral trochlear profiles were plotted at various flexion angles (0°, 15°, 30° and 45°) to deduce the sulcus angle. Results Analysis of sulcus angles reveals general convergence of recent designs towards anatomic values. At 0° of flexion, sulcus angles of recent implant models were between 156.0–157.4°, while those of previous generation models between 154.5–165.5°. At 30° of flexion, sulcus angles of recent models also lie within 145.7–148.6°, but those of previous models are between 149.5–152.0°. All three manufacturers deepened their trochlear profile at 30° of flexion in recent models compared to earlier designs. Sulcus angles converge towards anatomic values but still exceed radiologic signs of dysplasia by 2–5°. Conclusions Recent TKA designs have more anatomic trochlear geometries than earlier TKA models by the same manufacturers, but trochlear compartments still exceed radiologic signs of trochlear dysplasia by 2° to 5°. The hypothesis that recent TKA models display no signs of trochlear dysplasia is therefore refuted. Surgeons should be aware of design limitations to optimize choice of implant and extensor mechanisms alignment. Level of evidence: IV geometric implant analysis. PMID:26855943
Hocker, Austin D; Boileau, Ryan M; Lantz, Brick A; Jewett, Brian A; Gilbert, Jeffrey S; Dreyer, Hans C
Total knee arthroplasty (TKA) is the most common remediation for knee pain from osteoarthritis (OA) and is performed 650,000 annually in the U.S. A tourniquet is commonly used during TKA which causes ischemia and reperfusion (I/R) to the lower limb but the effects of I/R on muscle are not fully understood. Previous reports suggest upregulation of cell stress and catabolism and downregulation of markers of cap-dependent translation during and after TKA. I/R has also been shown to cause endoplasmic reticulum (ER) stress and induce the unfolded protein response (UPR). We hypothesized that the UPR would be activated in response to ER stress during TKA. We obtained muscle biopsies from the vastus lateralis at baseline, before TKA; at maximal ischemia, prior to tourniquet deflation; and during reperfusion in the operating room. Phosphorylation of 4E-BP1 and AKT decreased during ischemia (−28%, P < 0.05; −20%, P < 0.05, respectively) along with an increase in eIF2α phosphorylation (64%, P < 0.05) suggesting decreased translation initiation. Cleaved ATF6 protein increased in ischemia (39%, P = 0.056) but returned to baseline during reperfusion. CASP3 activation increased during reperfusion compared to baseline (23%, P < 0.05). XBP1 splicing assays revealed an increase in spliced transcript during ischemia (31%, P < 0.05) which diminished during reperfusion. These results suggest that in response to I/R during TKA all three branches of the ER stress response are activated. PMID:24159375
Caton, Jacques H; Prudhon, Jean Louis; Aslanian, Thierry; Verdier, Régis
We described in 1981 a method to evaluate patellar height in normal and symptomatic knees on sagittal X-ray view. This index is a frequently used method, yet it is not suitable after a total knee arthroplasty (TKA). The original method measures the distance between the distal margin of the articular surface of the patella (point A) and the anterosuperior angle of the tibial plateau (point T), then the length of the patellar articular surface (AP). The index is AT/AP ratio (normal values range from 0.8 to 1.2). After TKA, the T landmark is no longer available, so we must define a new T' landmark. This point is situated at the intersection between the line perpendicular to the tibial posterior cortex elevated at the tip of the fibular head and the tibial anterior cortex. This remarkable landmark can be identified before and after TKA, with a new relative index AT'/AP ratio. This modified method allows the comparison of patella height before and after TKA. We have used this modified index with the collaboration of several authors during the testing of different models of TKA, with an accurate reproducibility. Repeatability (usually called intra-observer reliability) was good, with intra-class correlation coefficients (ICCs) between 0.58 and 0.75 among the observers. Reproducibility (usually called inter-observer reliability) was also considered as good, with ICC ranging from 0.64 to 0.72. Patella height measurement has to be assessed with the original method (AT/AP) to detect patella infera that could influence the surgical approach. The correlation between original and modified indexes has to be assessed. The modification of patella height after TKA could be evaluated through the modified index and compared with functional results.
Milandt, Nikolaj; Nymark, Tine; Jørn Kolmos, Hans; Emmeluth, Claus; Overgaard, Søren
Background and purpose - Iodine-impregnated incision drapes (IIIDs) are used to prevent surgical site infection (SSI). However, there is some evidence to suggest a potential increase in SSI risk as a result of IIID use, possibly from promotion of skin recolonization. A greater number of viable bacteria in the surgical field of an arthroplasty, and surgery in general, may increase the infection risk. We investigated whether IIID use increases bacterial recolonization compared to no drape use under conditions of simulated total knee arthroplasty (TKA). Methods - 20 patients scheduled for TKA were recruited. Each patient had 1 knee randomized for draping with IIID, while the contralateral knee was left bare. The patients thus served as their own control. The operating room conditions and perioperative procedures of a TKA were simulated. Cylinder samples were collected from the skin of each knee prior to disinfection, and again on 2 occasions after skin preparation-75 min apart. Quantities of bacteria were estimated using a spread plate technique under aerobic conditions. Results - We found similar quantities of bacteria on the intervention and control knees immediately after skin disinfection and after 75 min of simulated surgery. These quantities had not increased at the end of surgery when compared to baseline, so no recolonization was detected on the draped knees or on the bare knees. Interpretation - The use of IIIDs did not increase bacterial recolonization in simulated TKA. This study does not support the hypothesis that IIIDs promote bacterial recolonization and postoperative infection risk.
Matsui, Yoshio; Minoda, Yukihide; Fumiaki, Inori; Nakagawa, Sigeru; Okajima, Yoshiaki; Kobayashi, Akio
Joint gap balancing during total knee arthroplasty (TKA) is important for ensuring postoperative joint stability and range of motion. Although the joint gap should be balanced to ensure joint stability, it is not easy to achieve perfect balancing during TKA. In particular, relative extension gap shortening can induce flexion contracture. Intraoperative manipulation is often empirically performed. This study evaluated the tension required for this manipulation and investigated the influence of intraoperative manipulation on the joint gap in cadaveric knees. Total knee arthroplasty was performed in 6 cadaveric knees from whole body cadavers. Flexion contracture was induced using an insert that was 4 mm thicker than the extension gap, and intraoperative manipulation was performed. Study measurements included the changes in the joint gap after manipulation at 6 positions, with the knee bending from extension to 120° flexion, and the manipulation tension that was required to create a 4-mm increase in the gap. The manipulation tension needed to create a 4-mm increase in the extension gap was 303±17 N. The changes in the joint gap after manipulation were 0.4 mm, 0.6 mm, 0.2 mm, -0.2 mm, -0.4 mm, and -0.6 mm at 0°, 30°, 45°, 60°, 90°, and 120° flexion, respectively. Therefore, the joint gap was not significantly changed by the manipulation. Intraoperative manipulation does not resolve flexion contracture. Therefore, if flexion contracture occurs during TKA, treatment with additional bone cutting and soft tissue release is likely more appropriate than manipulation. [Orthopedics. 2016; 39(6):e1070-e1074.].
Rorabeck, Cecil H; Mehin, Ramin; Barrack, Robert L
There are numerous options that need to be considered by the surgeon at the time of revision total knee arthroplasty (TKA). One needs to consider the reason for the revision, the type of patella in place, and the length of time the patella has been in place. The surgeon also needs to consider the status of the patellar bone stock, the stability of the patellar component (well-fixed or loose), and the component type (cemented or metal-backed). Assuming that the existing prosthesis is not metal-backed and has minimal PE wear, then it is preferable to retain a well-fixed all-PE cemented patellar button. However, if the button is metal-backed, then it probably is best to remove the button and replace it with an all-PE domed patellar component. Assuming more than 8 mm of patellar bone stock is remaining, it usually is best to cement an all-PE dome-shaped patella. However, if less than 8 mm is remaining, then that patient can be left with a patelloplasty, recognizing that this individual is going to continue with a high likelihood of anterior knee pain, subluxation, and poor functional results. In that situation, it may be preferable to consider a bone stock augmentation.
Henry, Richard; Cahill, Catherine M; Wood, Gavin; Hroch, Jennifer; Wilson, Rosemary; Cupido, Tracy; VanDenKerkhof, Elizabeth
BACKGROUND: Knee pain is one of the major sources of pain and disability in developed countries, particularly in aging populations, and is the primary indication for total knee arthroplasty (TKA) in patients with osteoarthritis (OA). OBJECTIVES: To determine the presence of myofascial pain in OA patients waitlisted for TKA and to determine whether their knee pain may be alleviated by trigger point injections. METHODS: Following ethics approval, 25 participants were recruited from the wait list for elective unilateral primary TKA at the study centre. After providing informed consent, all participants were examined for the presence of active trigger points in the muscles surrounding the knee and received trigger point injections of bupivacaine. Assessments and trigger point injections were implemented on the first visit and at subsequent visits on weeks 1, 2, 4 and 8. Outcome measures included the Timed Up and Go test, Brief Pain Inventory, Centre for Epidemiologic Studies Depression Scale, State-Trait Anxiety Inventory and Short-Form McGill Pain Questionnaire. RESULTS: Myofascial trigger points were identified in all participants. Trigger point injections significantly reduced pain intensity and pain interference, and improved mobility. All participants had trigger points identified in medial muscles, most commonly in the head of the gastrocnemius muscle. An acute reduction in pain and improved functionality was observed immediately following intervention, and persisted over the eight-week course of the investigation. CONCLUSION: All patients had trigger points in the vastus and gastrocnemius muscles, and 92% of patients experienced significant pain relief with trigger point injections at the first visit, indicating that a significant proportion of the OA knee pain was myofascial in origin. Further investigation is warranted to determine the prevalence of myofascial pain and whether treatment delays or prevents TKA. PMID:23061082
Mullaji, Arun; Shetty, Gautam M
Forty extra-articular deformities (22 femoral and 18 tibial) in 34 patients (mean age, 63.1 years) were studied. Mean coronal extra-articular deformity was 9.3 degrees ; mean preoperative limb alignment was 166.7 degrees . Three limbs underwent simultaneous corrective osteotomy; the rest were treated with intra-articular correction during computer-assisted total knee arthroplasty (TKA). Mean postoperative limb alignment was 179.1 degrees . At a mean follow-up of 26.4 months, the Knee Society knee score improved from a mean preoperative score of 49.7 to 90.4 points postoperatively; function score improved from 47.3 to 84.9 points. Computer-assisted TKA is a useful alternative to conventional TKA for knee arthritis with extra-articular deformity where accurate restoration of limb alignment may be challenging because of the presence of a deformed tibia or femur or in the presence of hardware.
“Increased aseptic tibial failures in patients with a BMI ≥35 and well-aligned total knee arthroplasties” published in The Journal of Arthroplasty on July 2, 2015 draws the conclusion that the risk of revision total knee arthroplasties (TKA) due to aseptic tibial component loosening is two times greater in patients with a BMI ≥35 kg/m2, independent of age or limb alignment. This result confirms that obese patients are at a higher risk of mechanical complications after performing TKA, independently from the risk of infection. This study suggests that the management of obese patients for TKA must be meticulous, careful, and should inspire from great bone deformations in valgus of varus when choosing implants. PMID:26697470
Von Keudell, Arvind G.; Thornhill, Thomas S.; Katz, Jeffrey N.; Losina, Elena
Background: The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown. Methods: We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation. Results: If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals. Conclusion: Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year. PMID:28144380
Zha, Guo-Chun; Sun, Jun-Ying; Dong, Sheng-Jie
Anterior knee pain is a major cause of complaint in total knee arthroplasty (TKA) without patellar resurfacing. The concept of improved patellar tracking and decreased retropatellar contact pressure for lateral retinacular release theoretically suggests that patients with lateral retinacular release in TKA would achieve a lower incidence of anterior knee pain when compared without lateral retinacular release. We sought to determine (1) whether those patients who received a routine lateral retinacular release in TKA would attain lower incidence of anterior knee pain as compared to patients who received TKA without lateral retinacular release and (2) whether lateral retinacular release would increase the lateral retinacular release-related complications. A total of 148 patients who underwent TKA with the use of the Gemini MK II mobile bearing were randomized to receive either routine lateral retinacular release (intervention group) or not (control group). Patients were assessed by the visual analogue scale for anterior knee pain, the Knee Society clinical scoring system of knee score and function score, and patellar score for clinical function. Patients' satisfaction and lateral retinacular release-related complications were also evaluated. The overall incidence of anterior knee pain in the intervention group at 18 months follow-up was 5.6%, while that of the control group was 20.6% (p = 0.009). No statistical difference was detected between the two groups in terms of lateral retinacular release-related complications (n.s.), patients' satisfaction (n.s.), knee score (n.s.), function score (n.s.), and patellar score (n.s.) at 18 months follow-up. The present study suggests that routine lateral retinacular release can reduce anterior knee pain and does not increase lateral retinacular release-related complications, in TKA with the use of the Gemini MK II mobile bearing without patellar resurfacing. Therapeutic, Level I.
Daniilidis, Kiriakos; Skwara, Adrian; Vieth, Volker; Fuchs-Winkelmann, Susanne; Heindel, Walter; Stückmann, Volker; Tibesku, Carsten O
The use of highly conforming polyethylene inlays in total knee arthroplasty (TKA) provides improved anteroposterior stability. The aim of this fluoroscopic study was to investigate the in vivo kinematics during unloaded and loaded active extension with a highly conforming inlay and a flat inlay after cruciate retaining (CR) total knee arthroplasty (TKA). Thirty one patients (50 knees) received a fixed-bearing cruciate retaining total knee arthroplasty (Genesis II, Smith & Nephew, Schenefeld, Germany) for primary knee osteoarthritis. Twenty two of them received a flat polyethylene inlay (PE), nine a deep dished PE and 19 were in the control group (physiological knees). The mean age at the time of surgery was 62 years. Dynamic examination with fluoroscopy was performed to assess the "patella tendon angle" in relation to the knee flexion angle (measure of anteroposterior translation) and the "kinematic index" (measure of reproducibility). Fluoroscopy was performed under active extension and flexion, during unloaded movement, and under full weight bearing, simulated by step climbing. No significant difference was observed between both types of polyethylene inlay designs and the physiological knee during unloaded movement. Anteroposterior (AP) instability was found during weight-bearing movement. The deep-dish inlay resulted in lower AP translation and a non-physiological rollback. Neither inlay types could restore physiological kinematics of the knee. Despite the fact that deep dished inlays reduce the AP translation, centralisation of contact pressure results in non-physiological rollback. The influence of kinematic pattern variability on clinical results warrants further investigation.
Moretti, Biagio; Vitale, Elsa; Esposito, Antonio; Colella, Antonio; Cassano, Maria; Notarnicola, Angela
Total knee arthroplasty (TKA) was a well-established procedure that had shown excellent long-term results in terms of reduced pain and increased mobility. Pain was one of the most important outcome measures that contributed to patient dissatisfaction after TKA. After a computerized search of the Medline and Embase databases, we considered articles from January 1st, 1997 to October 31st, 2009 that underlined the impact on patient pain perception of either standard open total knee arthroplasty or minimally invasive total knee arthroplasty. We included articles that used the visual analog scale (VAS), Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), Knee Score, Hospital for Special Surgery Score (HSS), Oxford Knee Score (OKS) as postoperative pain indicators, and we included studies with a minimum follow-up period of two months. We excluded studies that monitored only functional postoperative knee activities. It was shown that TKA with the open technique was a better treatment for knees with a positive effect on pain and function than the minimally invasive technique. PMID:21042568
Tilbury, Claire; Holtslag, Maarten J; Tordoir, Rutger L; Leichtenberg, Claudia S; Verdegaal, Suzan H M; Kroon, Herman M; Fiocco, Marta; Nelissen, Rob G H H; Vliet Vlieland, Thea P M
Background and purpose There is no consensus on the impact of radiographic severity of hip and knee osteoarthritis (OA) on the clinical outcome of total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed whether preoperative radiographic severity of OA is related to improvements in functioning, pain, and health-related quality of life (HRQoL) 1 year after THA or TKA. Patients and methods This prospective cohort study included 302 THA patients and 271 TKA patients with hip or knee OA. In the THA patients, preoperatively 26% had mild OA and 74% had severe OA; in the TKA patients, preoperatively 27% had mild OA and 73% had severe OA. Radiographic severity was determined according to the Kellgren and Lawrence (KL) classification. Clinical assessments preoperatively and 1 year postoperatively included: sociodemographic characteristics and patient-reported outcomes (PROMs): Oxford hip/knee score, hip/knee injury and osteoarthritis outcome score (HOOS/KOOS), SF36, and EQ5D. Change scores of PROMs were compared with mild OA (KL 0–2) and severe OA (KL 3–4) using a multivariate linear regression model. Results Adjusted for sex, age, preoperative scores, BMI, and Charnley score, radiographic severity of OA in THA was associated with improvement in HOOS “Activities of daily living”, “Pain”, and “Symptoms”, and SF36 physical component summary (“PCS”) scale. In TKA, we found no such associations. Interpretation The decrease in pain and improvement in function in THA patients, but not in TKA patients, was positively associated with the preoperative radiographic severity of OA. PMID:26484651
Dao Trong, Mai Lang; Helmy, Näder
Osteoarthritis of the knee is one of the most common problems in the orthopedic practice and its surgical technique is still challenging. This Mini-Review presents patient specific cutting blocks for the implantation of a total knee arthroplasty.
Robertsson, O.; Ranstam, J.; Sundberg, M.; W-Dahl, A.; Lidgren, L.
We are entering a new era with governmental bodies taking an increasingly guiding role, gaining control of registries, demanding direct access with release of open public information for quality comparisons between hospitals. This review is written by physicians and scientists who have worked with the Swedish Knee Arthroplasty Register (SKAR) periodically since it began. It reviews the history of the register and describes the methods used and lessons learned. Cite this article: Bone Joint Res 2014;3:217–22. PMID:24986492
Keshmiri, Armin; Maderbacher, Günther; Baier, Clemens; Sendtner, Ernst; Schaumburger, Jens; Zeman, Florian; Grifka, Joachim; Springorum, Hans R
Postoperative anterior knee pain is one of the most frequent complications after total knee arthroplasty (TKA). Changes in patellar kinematics after TKA relative to the preoperative arthritic knee are not well understood. We compared the patellar kinematics preoperatively with the kinematics after ligament-balanced navigated TKA. We measured patellar tracking before and after ligament-balanced TKA in 40 consecutive patients using computer navigation. Furthermore, the influences of different femoral and tibial component alignment on patellar kinematics were analyzed using generalized linear models. After TKA, the patellae shifted statistically significantly more laterally between 30° and 60°. The lateral tilt increased at 90° of flexion whereas the epicondylar distance decreased between 45° and 75° of flexion. Sagittal component alignment, but not rotational component alignment, had a significant influence on patellar kinematics. There are major differences in patellar kinematics between the preoperative arthritic knee and the knee after TKA. Combined sagittal component alignment in particular appears to have a major effect on patellar kinematics. Surgeons should be especially aware of altering preoperative sagittal alignment until the possible clinical relevance has been investigated.
Keshmiri, Armin; Maderbacher, Günther; Baier, Clemens; Sendtner, Ernst; Schaumburger, Jens; Zeman, Florian; Grifka, Joachim; Springorum, Hans R
Background and purpose Postoperative anterior knee pain is one of the most frequent complications after total knee arthroplasty (TKA). Changes in patellar kinematics after TKA relative to the preoperative arthritic knee are not well understood. We compared the patellar kinematics preoperatively with the kinematics after ligament-balanced navigated TKA. Patients and methods We measured patellar tracking before and after ligament-balanced TKA in 40 consecutive patients using computer navigation. Furthermore, the influences of different femoral and tibial component alignment on patellar kinematics were analyzed using generalized linear models. Results After TKA, the patellae shifted statistically significantly more laterally between 30° and 60°. The lateral tilt increased at 90° of flexion whereas the epicondylar distance decreased between 45° and 75° of flexion. Sagittal component alignment, but not rotational component alignment, had a significant influence on patellar kinematics. Interpretation There are major differences in patellar kinematics between the preoperative arthritic knee and the knee after TKA. Combined sagittal component alignment in particular appears to have a major effect on patellar kinematics. Surgeons should be especially aware of altering preoperative sagittal alignment until the possible clinical relevance has been investigated. PMID:25582349
Background Simultaneous osteoarthritis (OA) of the ankle joint complicates primary total knee arthroplasty (TKA). In such cases, rehabilitation of TKA is limited by debilitating ankle pain, but varus or valgus ankle arthritis may even compromise placement of knee prosthetic components. Case presentation We present a patient with simultaneous bilateral valgus and patellofemoral OA of the knees and bilateral varus OA of the ankle joints that equally contributed to overall disability. This 63 years old, motivated and otherwise healthy patient was treated by simultaneous bilateral total knee and ankle arthroplasty (quadruple total joint arthroplasty, TJA) during the same anesthesia. Two years outcome showed excellent alignment and function of all four replaced joints. Postoperative time for rehabilitation, back to work (6th week) and hospital stay (12 days) of this special patient was markedly reduced compared to the usual course of separate TJA. Conclusions Simultaneous quadruple TJA in equally disabling OA of bilateral deformed knees and ankles resulted in a better functional outcome and faster recovery compared to the average reported results after TKA and TAA in literature. However, careful preoperative planning, extensive patient education, and two complete surgical teams were considered essential for successful performance. To the best of our knowledge this is the first case report in literature about quadruple major total joint arthroplasty implanted during the same anesthesia in the same patient. PMID:21995682
Frye, Benjamin M; Najim, Amjad A; Adams, Joanne B; Berend, Keith R; Lombardi, Adolph V
Previous reports have stated that MRI is less accurate than CT for patient specific guide creation in total knee arthroplasty (TKA). Twenty-three TKAs were performed with CT-based guides and 27 with MRI-based guides. A mechanical axis through the central third of the knee was achieved in 88.9% of MRI-guided TKA versus 69.6% of CT-guided TKA (p=0.07). There were nine component outliers in the CT group (39.1%) and two in the MRI group (7.4%, p=0.00768). The relative risk of having an outlier using a CT-based guide was 5.28 times that of an MRI-based guide. Superior overall alignment and fewer outliers were achieved with the use of MRI compared with CT. MRI is the best imaging modality for surgeons wishing to utilize patient specific guides for TKA.
Camp, Christopher L; Yuan, Brandon J; Wood, Adam J; Lewallen, David G
Occurring in either a localized or diffuse form, pigmented villonodular synovitis (PVNS) is a disease of unknown etiology that typically presents with insidious onset of pain, swelling, stiffness, or mechanical symptoms as a result of synovial tissue proliferation. PVNS preferentially affects large joints, most commonly the knee. Currently there is no known association with PVNS and total knee arthroplasty (TKA), and to date, there are only a few cases reported in the orthopedic literature in which PVNS was diagnosed after primary TKA. To our knowledge, this is the first case of diffuse PVNS that was discovered at the time of revision TKA for flexion instability and patellar fracture. In this patient, with no known history of PVNS, the diagnosis of diffuse PVNS was made at the time of surgery. She underwent revision TKA, partial patellectomy, and extensive synovectomy. Level of evidence: V, Case Report.
Zhou, Zhihong; Yew, Khye Soon Andy; Arul, Earnest; Chin, Pak-Lin; Tay, Keng Jin Darren; Lo, Ngai-Nung; Chia, Shi-Lu; Yeo, Seng Jin
The primary aim of this study was to identify the time point at which improvements in knee range of motion reach a plateau, if any. The secondary aim of this study was to investigate the correlation between the improvements in knee range of motion and patient-reported outcomes [Oxford knee score (OKS) and SF-36]. The hypothesis is that there is a time point at which the recovery in the knee range of motion after total knee arthroplasty (TKA) plateaus. A prospective study of 145 patients who underwent TKA was conducted. All TKAs were performed by the same surgeon. OKS and SF-36 scores were measured preoperatively and at 6, 12, and 24 months. Range of motion was measured preoperatively and at 1, 3, 6, 12, and 24 months postoperatively. This study shows that for surgeon/therapist reported range of motion, a plateau in recovery was reached at 12 months after TKA. It was also found that range of extension is significantly correlated with OKS, whereas range of flexion was not significantly correlated with OKS. Knowledge of when patients fully recover after TKA will allow appropriate counseling of patients during preoperative consultation. Also, this knowledge will enable surgeons/therapists to better monitor the rehabilitation progress of TKA patients, and make adjustments to the rehabilitation protocol. In addition, our study shows that objective surgeon-/therapist-measured outcome (range of motion) has a significant correlation with subjective patient-reported outcomes (OKS). Hence, both outcome measures should be employed in the postoperative monitoring of patient progress. Prospective case series, Level IV.
Background Patellofemoral complications are one of the main problems after Total Knee Arthroplasty (TKA). Retropatellar pressure distribution after TKA can contribute to these symptoms. Therefore we evaluated retropatellar pressure distribution subdivided on the ridge, medial and lateral surface on non-resurfaced patella before and after TKA. Additionally, we analyzed axial femorotibial rotation and quadriceps load before and after TKA. Methods Seven fresh frozen cadaver knees were tested in a force controlled knee rig before and after TKA (Aesculap, Tuttlingen, Germany, Columbus CR) while isokinetic flexing the knee from 20° to 120° under weight bearing. Ridge, medial and lateral retropatellar surface were defined and pressure distribution was dynamically measured while quadriceps muscles and hamstring forces were applied. Aside axial femorotibial rotation and quadriceps load was recorded. Results There was a significant change of patella pressure distribution before and after TKA (p = 0.004). In physiological knees pressure distribution on medial and lateral retropatellar surface was similar. After TKA the ridge of the patella was especially in higher flexion grades strongly loaded (6.09 +/−1.31 MPa) compared to the natural knee (2.92 +/−1.15 MPa, p < 0.0001). Axial femorotibial rotation showed typical internal rotation with increasing flexion both before and after TKA, but postoperatively it was significantly lower. The average amount of axial rotation was 3.5° before and after TKA 1.3° (p = 0.001). Mean quadriceps loading after implantation of knee prosthesis did not change significantly (575 N ±60 N in natural knee and after TKA 607 N ±96 N; p = 0.28). Conclusions The increased retropatellar pressure especially on the ridge may be one important reason for anterior knee pain after TKA. The trochlea of the femoral component might highly influence the pressure distribution of the non-resurfaced retropatellar surface. Additionally
Bennett, Damien; Hanratty, Brian; Thompson, Neville; Beverland, David E
Pain is the predominant symptom of degenerative knee arthritis and the main reason patients undergo total knee arthroplasty (TKA). Variation in patient response to pain has proved difficult to quantify. The effect of removing pain by testing TKA patients' range of motion (ROM) before and after the administration of anesthesia has not previously been analyzed. This study objectively quantifies the effect of eliminating pain on knee joint ROM for a typical group of TKA patients with osteoarthritis. We prospectively recruited 141 patients with osteoarthritis admitted for TKA to assess the inhibitory effect of pain on ROM. Passive maximum flexion, extension, and ROM were measured preoperatively before and after administration of anesthesia (spinal anesthetic followed by femoral and sciatic regional nerve blocks). Following pain abolition, passive maximum flexion increased by an average of 13.4 degrees (SD=11.9 degrees), passive maximum extension improved by an average of 3.0 degrees (SD=4.2 degrees), and passive ROM increased by an average of 16.4 degrees (SD=13.1 degrees). The change in each parameter was statistically significant (P<.0001). Improvements in flexion (P=.01) and ROM (P=.005) were significantly greater in women. Measurements taken before anesthesia reflect knee ROM that the patient will tolerate before pain becomes the limiting factor, while measurements taken after anesthesia is achieved suggest the knee ROM possible once pain is eliminated. Abolition of pain led to significant increases in knee flexion, extension, and ROM, suggesting that pain has a significant inhibitory effect on knee motion.
Bakırhan, Serkan; Unver, Bayram; Karatosun, Vasfi
The study aims to determine body weight ratios between extremities in patients with unilateral total knee arthroplasty (TKA) at 12 months postoperatively at the static-standing position at 30, 60 and 90 degrees of knee flexion. The study included 52 female patients (mean age 65.6±10.6 years; range 40 to 83 years) who underwent unilateral primary TKA. The force-platform was used to calculate the body-weight ratios of the patients. Body weight ratios on the operated and non-operated limbs of the unilateral TKA patients were examined at standing-static position at 30, 60 and 90 degrees of knee flexion on the force-platform according to their age and body mass index (BMI). The pain levels of the patients were evaluated using the visual analog scale. It was found that unilateral TKA patients placed their body weight on the non-operated limb more at the standing-static position, and 30, 60 and 90 degrees of knee flexion at 12 months postoperatively (p<0.05). It was also found that as the knee flexion degree increased with age, so did TKA patients place their body weight on the nonoperated limb more (p<0.05), and that BMI had no effect on the load distribution difference over the two extremities (p>0.05). During the postoperative period, load asymmetry between the two extremities in patients with unilateral TKA remains the same due to advancing age. This accelerates the osteoarthritis process on the non-operated knee. It is concluded that the age factor should be taken into account while planning physiotherapy and rehabilitation programs for unilateral TKA patients and knee exercise programs aiming to place load over the operated limb should be arranged.
Standifird, Tyler W; Saxton, Arnold M; Coe, Dawn P; Cates, Harold E; Reinbolt, Jeffrey A; Zhang, Songning
This study compared biomechanics during stair ascent in replaced and non-replaced limbs of total knee arthroplasty (TKA) patients with control limbs of healthy participants. Thirteen TKA patients and fifteen controls performed stair ascent. Replaced and non-replaced knees of TKA patients were less flexed at contact compared to controls. The loading response peak knee extension moment was greater in control and non-replaced knees compared with replaced. The push-off peak knee abduction moment was elevated in replaced limbs compared to controls. Loading and push-off peak hip abduction moments were greater in replaced limbs compared to controls. The push-off peak hip abduction moment was greater in non-replaced limbs compared to controls. Future rehabilitation protocols should consider the replaced knee and also the non-replaced knee and surrounding joints.
Baldini, Andrea; Balato, Giovanni; Franceschini, Vincenzo
Revision total knee arthroplasty (TKA) represents a technically challenging procedure. The use of an offset stem extension can help in addressing some of the difficulties that can be encountered during surgery and, in particular, anatomical mismatch, malalignment, and gap balancing. Different offset stem extensions are available and can be classified according to four parameters: modularity, location of the offset, direction, and size of the displacement. Offset stem extensions can assist with implant alignment on the metaphysis if there is an offset diaphysis, can avoid medial-lateral or anterior-posterior component overhang, can reduce the incidence of coronal or sagittal malalignment, and can help in balancing the flexion and extension spaces by effectively translating the components. The aim of this study is to give an overview of the currently available evidence regarding the use of offset stem extensions in revision TKA as well as some useful surgical tips.
Graceffa, Angelo; Marcucci, Massimiliano; Baldini, Andrea
Many surgical techniques, correlated to different anatomical landmarks, have been proposed to allow a satisfactory rotational alignment of the tibial component in primary total knee arthroplasty (TKA). Unfortunately, an accurate landmark has not yet been established although many computer models using CT reconstructions and standard radiologic studies have been performed. In this review article, the authors propose a new anatomical rotational reference for a correct positioning of the tibial component during primary TKA; the authors compared the results of their studies with the current literature on rotational alignment references and previously proposed surgical techniques. The authors also analyzed the correlation between classic and newer tibial baseplate designs and different tibial rotational landmarks. PMID:26855939
Giaquinto, S; Ciotola, E; Dall'Armi, V; Margutti, F
The study evaluated the subjective functional outcome following total knee arthroplasty (TKA) in participants who underwent hydrotherapy (HT) six months after discharge from a rehabilitation unit. A total of 70 subjects, 12 of which were lost at follow-up, were randomly assigned to either a conventional gym treatment (N=30) or HT (N=28). A prospective design was performed. Participants were interviewed with Western-Ontario McMasters Universities Osteoarthritis Index (WOMAC) at admission, at discharge and six months later. Kruskal-Wallis and Wilcoxon tests were applied for statistical analysis. Both groups improved. The WOMAC subscales, namely pain, stiffness and function, were all positively affected. Statistical analysis indicates that scores on all subscales were significantly lower for the HT group. The benefits gained by the time of discharge were still found after six months. HT is recommended after TKA in a geriatric population. Copyright 2009 Elsevier Ireland Ltd. All rights reserved.
Nodzo, Scott R; Westrich, Geoffrey H; Henry, Michael W; Miller, Andy O
Propionibacterium acnes is a common cause of upper extremity arthroplasty infection and usually presents in an indolent subacute fashion. It is not well described how total knee arthroplasty (TKA) patients infected with P acnes present. We retrospectively compared patients undergoing revision TKA for infection from P acnes and methicillin-sensitive Staphylococcal aureus (MSSA) in our institutional infection database. Patients were classified as having a periprosthetic joint infection based on the Musculoskeletal Infection Society criteria and were excluded if they had a polymicrobial culture. Patient demographics, preoperative laboratory values, microbiology data, and synovial fluid white blood cell (WBC) counts were analyzed. Sixteen patients with a P acnes and 30 with an MSSA TKA periprosthetic joint infection were identified. Median erythrocyte sedimentation rate was significantly higher in the MSSA group compared to the P acnes group (56.0 mm/h; interquartile range [IQR], 44.3-72.9 vs 23.0 mm/h; IQR, 18.5-52.0; respectively, P = .03) as were C-reactive protein levels (5.9 mg/dL; IQR, 3.7-26.9 vs 2.0 mg/dL; IQR, 0.5-14.0; respectively, P = .04). WBC count, synovial fluid WBC, and percentage of synovial polymorphonuclear cells were similar between groups. Mean time to culture was 8.3 ± 2.0 days in the P acnes group and 1.8 ± 0.8 days in the MSSA group. P acnes TKA infections are associated with more acute inflammatory symptoms than typically appreciated, and long hold anaerobic cultures up to 14 days are necessary to accurately identify this organism as the causative agent of TKA periprosthetic infection. Copyright © 2016 Elsevier Inc. All rights reserved.
Tilbury, C; Kuijer, PPFM; Verdegaal, SHM; Wolterbeek, R; Nelissen, RGHH; Frings-Dresen, MHW; Vliet Vlieland, TPM
Introduction A substantial number of patients undergoing total hip or knee arthroplasty (THA or TKA) do not or only partially return to work. This study aimed to identify differences in determinants of return to work in THA and TKA. Methods We conducted a prospective, observational study of working patients aged <65 years undergoing THA or TKA for osteoarthritis. The primary outcome was full versus partial or no return to work 12 months postoperatively. Factors analysed included preoperative sociodemographic and work characteristics, alongside the Hip Disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS), and Oxford Hip and Knee Scores. Results Of 67 THA and 56 TKA patients, 9 (13%) and 10 (19%), respectively, returned partially and 5 (7%) and 6 (11%), respectively, did not return to work 1 year postoperatively. Preoperative factors associated with partial or no return to work in THA patients were self-employment, absence from work and a better HOOS Activities of Daily Living (ADL) subscale score, whereas only work absence was relevant in TKA patients. Type of surgery modified the impact of ADL scores on return to work. Conclusions In both THA and TKA, absence from work affected return to work, whereas self-employment and better preoperative ADL subscale scores were also associated in THA patients. The impact of ADL scores on return to work was modified by type of surgery. These results suggest that strategies aiming to influence modifiable factors should consider THA and TKA separately. PMID:27138849
Leichtenberg, C S; Tilbury, C; Kuijer, Ppfm; Verdegaal, Shm; Wolterbeek, R; Nelissen, Rghh; Frings-Dresen, Mhw; Vliet Vlieland, Tpm
Introduction A substantial number of patients undergoing total hip or knee arthroplasty (THA or TKA) do not or only partially return to work. This study aimed to identify differences in determinants of return to work in THA and TKA. Methods We conducted a prospective, observational study of working patients aged <65 years undergoing THA or TKA for osteoarthritis. The primary outcome was full versus partial or no return to work 12 months postoperatively. Factors analysed included preoperative sociodemographic and work characteristics, alongside the Hip Disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS), and Oxford Hip and Knee Scores. Results Of 67 THA and 56 TKA patients, 9 (13%) and 10 (19%), respectively, returned partially and 5 (7%) and 6 (11%), respectively, did not return to work 1 year postoperatively. Preoperative factors associated with partial or no return to work in THA patients were self-employment, absence from work and a better HOOS Activities of Daily Living (ADL) subscale score, whereas only work absence was relevant in TKA patients. Type of surgery modified the impact of ADL scores on return to work. Conclusions In both THA and TKA, absence from work affected return to work, whereas self-employment and better preoperative ADL subscale scores were also associated in THA patients. The impact of ADL scores on return to work was modified by type of surgery. These results suggest that strategies aiming to influence modifiable factors should consider THA and TKA separately.
Suggs, Jeremy F; Hanson, George R; Park, Sang Eun; Moynihan, Angela L; Li, Guoan
Even though posterior substituting total knee arthroplasty has been widely used in surgery, how the cam-post mechanism (posterior substituting mechanism) affects knee joint kinematics and function in patients is not known. The objective of the present study was to investigate posterior femoral translation, internal tibial rotation, tibiofemoral contact, and cam-post engagement of total knee arthroplasty patients during in vivo weight-bearing flexion. Twenty-four knees with a PS TKA were investigated while performing a single leg weight-bearing lunge from full extension to maximum flexion as images were recorded using a dual fluoroscopic system. The in vivo knee position at each targeted flexion angle was reproduced using 3D TKA models and the fluoroscopic images. The kinematics of the knee was measured from the series of the total knee arthroplasty models. The cam-post engagement was determined when the surface model of the femoral cam overlapped with that of the tibial post. The mean maximum flexion angle for all the subjects was 112.5 +/- 13.1 degrees . The mean flexion angle where cam-post engagement was observed was 91.1 +/- 10.9 degrees . The femur moved anteriorly from 0 degrees to 30 degrees and posteriorly through the rest of the flexion range. The internal tibial rotation increased approximately 6 degrees from full extension to 90 degrees of flexion and decreased slightly with further flexion. Both the medial and lateral contact point moved posteriorly from 0 degrees to 30 degrees , remained relatively constant from 30 degrees to 90 degrees , and then moved further posterior from 90 degrees to maximum flexion. The in vivo cam-post engagement corresponded to increased posterior translation and reduced internal tibial rotation at high flexion of the posterior substituting total knee arthroplasty. The initial cam-post engagement was also mildly correlated with the maximum flexion angle of the knee (R = 0.51, p = 0.019). A later cam-post engagement might
Bastiani, Denise; Ritzel, Cintia Helena; Bortoluzzi, Silvia Manfrin; Vaz, Marco Aurelio
The inflammatory manifestations of knee osteoarthritis (OA) lead to muscle inhibition and hypotrophy, resulting in a reduction in total muscle work and muscle power. Total knee arthroplasty (TKA) is the most adequate surgery for the treatment of advanced OA. However, its effects on muscle functional behavior have not been well understood. To compare the total work and power of the knee flexor and extensor muscles in patients with OA (20) and in patients post-TKA (12) at two angular velocities (60º/sec and 240º/sec). An isokinetic Biodex dynamometer was used to assess muscle power and total work during isokinetic contractions. Two-way ANOVA for repeated measures was used to compare total muscle work and muscle power between the groups (SPSS software, version 13.0; significance level, P < 0.05). There was no difference between the OA and TKA groups for the total work of both knee extensors and flexors at the two angular velocities (P > 0.05). In addition, no difference was observed in the muscle power of the knee extensors and flexors (P > 0.05). Total work and power were similar in the OA and TKA groups, suggesting that TKA did not improve functional capacity, which was similar in both groups.
Nagura, Takeo; Otani, Toshiro; Suda, Yasunori; Matsumoto, Hideo; Toyama, Yoshiaki
The purpose of this study was to indicate the mechanical loads and the flexion angle at the knee during rise from maximal flexion following total knee arthroplasty (TKA). Twenty three knees were evaluated using skin marker-based motion analysis system during four different activities of daily living. The average maximum flexion was 90 degrees (34 degrees less than passive flexion) and all subjects required support for their weight to rise from maximal flexion. The external moments and the external forces at the knee during the maximal flexion were smaller than those during the stair descending activity. The results indicate that capable flexion angle for the patients following TKA is approximately 90 degrees which has smaller mechanical loads at the knee than the stair descending activity.
Hochreiter, Bettina; Strahm, Carol; Behrend, Henrik
Treatment strategies for advanced knee osteoarthritis with coexistent joint infection are not well established. While in periprosthetic joint infection the two-stage approach has been studied extensively, only few case reports on two-stage total knee arthroplasty (TKA) for knee osteoarthritis with coexistent joint infection have been published. The purpose of this paper was to report on our method of implementing a two-stage TKA with intervening antibiotic-loaded articulating cement spacers and a short interval between first- and second-stage procedures to treat two patients with Staphylococcus aureus-infected end-stage knee osteoarthritis. Consistent infection eradication was found at a 1-year follow-up with postoperative range of motion and knee scores comparing favourably with those of other case series. Level of evidence V.
Nishio, Yusuke; Onodera, Tomohiro; Kasahara, Yasuhiko; Takahashi, Daisuke; Iwasaki, Norimasa; Majima, Tokifumi
The aim of this study was to evaluate the relationship between clinical results including patient-reported outcomes and intraoperative knee kinematic patterns after total knee arthroplasty (TKA). A cross-sectional survey of forty consecutive medial osteoarthritis patients who had a primary TKA using a CT-based navigation system was conducted. Subjects were divided into two groups based on intraoperative kinematic patterns: a medial pivot group (n = 20) and a non-medial pivot group (n = 20). Subjective outcomes with the new Knee Society Score and clinical outcomes were evaluated. The functional activities, patient satisfaction and the knee flexion angle of the medial pivot group were significantly better than those of the non-medial pivot group. An intraoperative medial pivot pattern positively influences deep knee flexion and patient-reported outcomes.
Levine, Brett; Fabi, David; Deirmengian, Carl
The use of digital radiography is becoming more prevalent in orthopedics. This transition impacts the ability to preoperatively plan for implants in total hip arthroplasty (THA) and total knee arthroplasty (TKA). This article reports on the clinical success of digital templating using the Advanced Case Plan (Stryker Imaging, Flower Mound, Texas) system in primary THA and TKA. Digital radiographs of 269 consecutive patients undergoing primary THA (93 cases) or TKA (176 cases) were templated using the Advanced Case Plan digital software package. A 25.4-mm metallic sphere was used as a calibrating marker. Anteroposterior hip and lateral knee radiographs were digitally templated preoperatively and compared to the actual size of the implants at the time of surgery. The accuracy of calibrating images using the metallic sphere was validated by measuring the diameter of femoral heads on 25 postoperative hip radiographs. Digital templating was accurate in predicting the correct implant size in 58.5% of THAs and 66% of TKAs. In 93% of THAs and 98.5% of TKAs, preoperative templating was within 1 size of the final implant. There were no cases in which the predicted implant size varied from the final components by >2 sizes. Calibrating the image using the metallic sphere marker was found to be highly accurate, predicting the correct femoral head size within 1.5 mm in all 25 cases (7 hemiarthroplasties and 18 THAs). Digital templating is an effective means for predicting the size of THA and TKA components, thus remaining a viable option as we transition into the modern era of digital radiography. Future studies will evaluate interobserver reliability and the impact of level of training on templating accuracy. Copyright 2010, SLACK Incorporated.
Barretto, João Maurício; Malta, Márcio; e Albuquerque, Rodrigo Pires; de Assis, Daniel Pinho; Campos, André Siqueira
Objective: This study assessed 47 patients who underwent total knee arthroplasty (TKA) with implants manufactured in Brazil, with a mean follow-up of five years. Methods: This was a retrospective study at Santa Casa de Misericordia Hospital in Rio de Janeiro, from January 1993 to December 2002. The sample comprised 47 patients (44 females and three males) who underwent TKA, totaling 58 knees. The patients’ ages ranged from 46 to 83 years. A diagnosis of osteoarthritis or rheumatic disease was confirmed in all the patients. Results: In this investigation, all the patients underwent cemented TKA with preservation of the posterior cruciate ligament. The length of follow-up ranged from 5 to 17 years. The functional assessment criterion used was the one of the Hospital for Special Surgery (HSS), and this yielded an average of 87 points after the operation. The radiographic criterion used was the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. We had three cases with a radiolucent line without implant loosening, which were asymptomatic from a clinical standpoint. Conclusion: The total knee arthroplasty procedures using an implant made in Brazil were performed by a trained and experienced team. To date, over the clinical follow-up on these patients with knee osteoarthritis or rheumatoid arthritis, the results have been seen to be satisfactory. PMID:27027051
Zietek, P; Dobiecki, K
The clinical management of paraplegic patients is more complex than in able-bodied subjects. Spinal cord injury (SCI) affects younger, active people more often than the elderly during high-energy fall or traffic accidents. In order to return to work after suffering an SCI, patients need to regain their functional independence, especially their ability to drive. The literature lacks strong evidence addressing the surgical solutions in severe knee arthrosis in paralyzed patients after SCI. We present a favourable outcome of total knee arthroplasty (TKA) of a stiff knee in extension in a man with T12 grade C paraplegia after SCI. We describe an effective rehabilitation protocol after knee arthroplasty in patient with damage to the spinal cord. Several factors should be taken into account before performing surgery: 1. ability of regaining some of spinal cord locomotor function through intensive gait rehabilitation in SCI patients, 2. presence of muscle imbalance and knee contractures combined with a risk of bone fracture resulting from intensive postoperative rehabilitation, 3. the impaired microvasculature of the skin and subcutaneous tissues and increased risk of occlusion occurrence of the capillaries and small vessels of the leg, 4. higher prevalence of secondary infections via urinary entry sites in patients after SCI, 5. patient's strong determination and willingness to undergo the arthroplasty procedure. TKA might be considered in selected paralyzed patients after SCI, especially in those with severe arthrosis as well as significant knee contractures. Our study reveals the advantage of performing TKA in improving functional state in patients with cord injury.
Gatha, Nehal M; Clarke, Henry D; Fuchs, Robin; Scuderi, Giles R; Insall, John N
One hundred thirty five patients with osteoarthritis who underwent total knee arthroplasty (TKA) were evaluated to determine whether specific pre- and postoperative variables were correlated with the postoperative range of motion. Age, sex, pre- and postoperative range of motion, pre- and postoperative Knee Society scores, intraoperative patellar thickness before and after resurfacing, pre- and postoperative radiographic patellar height (as determined by the Insall-Salvati and Blackburn-Peel ratios), and preoperative radiographic alignment were recorded for each patient. Regression analysis was performed to identify whether any variables were correlated with the postoperative range of motion or Knee Society scores. The only variable that was significantly correlated with postoperative range of motion was the preoperative range of motion. This study suggests that among the variables evaluated, the preoperative range of motion was the only significant predictor of postoperative range of motion.
Murtha, Andrew S; Johnson, Anthony E; Buckwalter, Joseph A; Rivera, Jessica C
United States military personnel frequently suffer knee injuries. The resulting progressive post-traumatic osteoarthritis (PTOA) causes significant disability in these young high-demand patients for which total knee arthroplasty (TKA) is the only effective treatment of their pain and impairment. Yet the use of this option for treatment of PTOA has not been studied. This retrospective review identified 74 knees in 64 U.S. military personnel who underwent TKA at ≤ 50 years-of-age during an eight year period at a tertiary-care, academic, military medical center. Fifty-five knees (74.3%) experienced one or more prior ligamentous, meniscal, or chondral injuries prior to arthroplasty. Only one subject had a history of osteochondral intra-articular fracture. The average at injury was 29.2 years (95% CI of ± 2.50) with an average age at arthroplasty of 44.3 years (± 1.11). The most common injury was anterior cruciate ligament rupture (n = 19) with a mean time to TKA of 23.1 years (± 10.54) and 18.8 years (± 7.01) when concomitant meniscal pathology was noted. Nineteen patients were noted to have radiographic and symptomatic end-stage osteoarthritis without a specified etiology at 41.4 years (± 1.47) and underwent subsequent TKA. This is the first study to evaluate treatment of end-stage PT OA in young people treated with TKA, finding that the incidence of PTOA as an indication for arthroplasty is significantly higher than among civilians. In this otherwise healthy, high-demand patient population, the rate of OA progression following knee injury is accelerated and the long term implications can be career and life-altering. This article is protected by copyright. All rights reserved.
de Jesus, Christopher; Stacey, Dawn; Dervin, Geoffrey F
Many patients with isolated medial compartment osteoarthritis are candidates for either unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). A novel patient decision aid (PDA) was developed to educate patients on both interventions and prepare them for making the decision with their surgeon. The study objective was to evaluate the acceptability and usefulness of a PDA for informing and helping patients reach a surgical preference without increasing decisional conflict. A PDA was developed in accordance with the criteria listed by Ottawa Decision Support Framework and prospectively tested in UKA and TKA patients, who were mailed the PDAs to complete at home along with outcome measures before surgeon consultation. Of 50 patients who consented to participate, 45 patients (26 men, 19 women) used the PDA. Quantitative analysis of acceptability, decisional conflict, knowledge, and preferred surgical option was then performed. Mean patient age was 64.6 years (range, 50-80 years). Patients rated the PDA as acceptable: 84.4% indicated balanced presentation of information and 77.8% asserted that PDA helped them to make decisions between UKA and TKA. Mean knowledge score was 86.6% and total decisional conflict was 19.7 out of 100. Of 45, 33 stated a preferred option (24 UKA; 9 TKA; 12 unsure). Patients understood the majority of the benefits and risks for each surgical option without increasing decisional conflict. The decision aid for advanced medial compartment osteoarthritis is shown to be acceptable and useful for choosing between UKA and TKA. Copyright © 2017 Elsevier Inc. All rights reserved.
Husted, Henrik; Jørgensen, Christoffer C; Gromov, Kirill; Troelsen, Anders
Postoperative joint stiffness following total knee arthroplasty (TKA) may compromise the outcome and necessitate manipulation. Previous studies have not been in a fast-track setting with optimized pain treatment, early mobilization, and short length of stay (LOS), which may have influenced the prevalence of joint stiffness and subsequent manipulation. We investigated the prevalence of manipulation following fast-track TKA and identified patients at risk of needing manipulation. 3,145 consecutive unselected elective primary unilateral TKA patients operated in 6 departments with well-defined fast-track settings were included in the study. Demographic data, prevalence, type and timing of manipulation, and preoperative and postoperative ROM were recorded prospectively, ensuring complete 1-year follow-up. 70 manipulations were performed within 1 year (2.2%) at a mean of 4 months after index surgery. Younger age and not using walking aids preoperatively were associated with a higher risk of manipulation. LOS ≤ 4 days (as opposed to a longer LOS) was not associated with an increased risk of manipulation. The prevalence of manipulation was lower or comparable to that in most published studies following more conventional pathways. Inherent patient demographics were identified as risk factors for manipulation whereas LOS ≤ 4 days was not. Thus, fast-track TKA does not result in increased risk of manipulation-despite a shorter LOS. Optimized pain treatment and early mobilization may contribute to these favorable results that support the use of fast-track.
Mistry, Jaydev B; Elmallah, Randa D K; Bhave, Anil; Chughtai, Morad; Cherian, Jeffrey Jai; McGinn, Tanner; Harwin, Steven F; Mont, Michael A
Rehabilitation following total knee arthroplasty (TKA) continues to pose a challenge for both patients and providers. In addition, guidelines vary considerably between institutions, which often leave therapy regimens to the discretion of the provider. The lack of clear guidelines for rehabilitation may contribute to inadequate recovery of strength and range-of-motion, resulting in less optimal functional outcomes. Therefore, the aim of this review was to highlight and discuss a variety of post-TKA rehabilitative modalities currently available and to provide evidence regarding efficacy and practicality. Specifically, we assessed the role of and evidence for exercise therapy, aquatic therapy, balance training, continuous passive motion, cold therapy and compression, neuromuscular electrical stimulation, transcutaneous electrical nerve stimulation, and instrument-assisted soft-tissue therapy. Additionally, we proposed general recommendations for rehabilitation after TKA, and as we specifically described active and obese patients, we have included guidelines for these subsets as well. Our review examines the various rehabilitative modalities to offer suggestions for recovery of strength and range-of-motion after TKA, with a focus on the early incorporation of exercise therapy, balance training, aquatic therapy, cryopneumatic therapy, neuromuscular electrical stimulation, and transcutaneous electrical nerve stimulation. Dedication and commitment to rehabilitation may help patients attain and exceed their preoperative activity levels.
Ajwani, Sanil Harji; Charalambous, Charalambos P.
Purpose To provide information on the type of “hypersensitivity-friendly” components available for primary total knee arthroplasty (TKA) in the current market. Materials and Methods Implant manufactures were identified using the 2013 National Joint Registries of the United Kingdom and Sweden and contacted to obtain information about the products they offer for patients with metal hypersensitivity. Results Information on 23 TKA systems was provided by 13 implant manufacturers. Of these, 15 systems had options suitable for metal hypersensitivity patients. Two types of “hypersensitivity-friendly” components were identified: 10 implants were cobalt chrome prostheses with a “hypersensitivity-friendly” outer coating and 5 implants were made entirely from non-cobalt chrome alloys. Conclusions The results of this study suggest that several hypersensitivity TKA options exist, some of which provide the same designs and surgical techniques as the conventional implants. The information in this study can guide TKA surgeons in making informed choices about implants and identifying implants that could be examined in future controlled studies comparing outcomes between “hypersensitivity-friendly” and conventional implants. PMID:27894179
Higuchi, Hiroshi; Hatayama, Kazuhisa; Shimizu, Masaki; Kobayashi, Atsushi; Kobayashi, Tsutomu; Takagishi, Kenji
The objective of this study was to investigate the range of motion (ROM) of the knee before and four years after total knee arthroplasty (TKA) with a mobile or fixed type of platform and to prospectively evaluate whether there was a difference in ligament balance between the platform types. The subjects were 68 patients involving 76 joints. The mobile type was used in 31 joints and fixed type in 45 joints by employing a prospective randomised method. The passive maximum ROM was measured using a goniometer before and four years after surgery. Also, the intraoperative knee ligament balance was measured. The postoperative extension ROM was significantly improved after TKA using a mobile bearing type compared with that employing a fixed bearing type. In TKA using the former, the intraoperative gap difference was not related to the postoperative flexion angle of the knee. However, they were related in TKA using a fixed bearing type, with a positive correlation regarding the flexion gap.
Unicondylar knee arthroplasty implantation is extremely demanding as the prosthesis needs to be integrated in the natural anatomy of the knee. It ensures the integrity of the natural knee kinematic. Some studies and registries data have shown lower success rate in comparison with total knee arthroplasty, and patient-related factors may have an impact on outcome. While, better results have been published by high volume centres. The indications for surgery should be reconsidered critically, even if medial osteoarthritis of the knee remains the most common. This article sets out the diagnostic, and surgical steps in order to fine tuning the unicompartmental replacement of the knee. PMID:26605256
Healy, William L; Rana, Adam J; Iorio, Richard
The hospital cost of total knee arthroplasty (TKA) in the United States is a major growing expense for the Centers for Medicare & Medicaid Services (CMS). Many hospitals are unable to deliver TKA with profitable or breakeven economics under the current Diagnosis-Related Group (DRG) hospital reimbursement system. The purposes of the current study were to (1) determine revenue, expenses, and profitability (loss) for TKA for all patients and for different payors; (2) define changes in utilization and unit costs associated with this operation; and (3) describe TKA cost control strategies to provide insight for hospitals to improve their economic results for TKA. From 1991 to 2009, Lahey Clinic converted a $2172 loss per case on primary TKA in 1991 to a $2986 profit per case in 2008. The improved economics was associated with decreasing revenue in inflation-adjusted dollars and implementation of hospital cost control programs that reduced hospital expenses for TKA. Reduction of hospital length of stay and reduction of knee implant costs were the major drivers of hospital expense reduction. During the last 25 years, our economic experience with TKA is concerning. Hospital revenues have lagged behind inflation, hospital expenses have been reduced, and our institution is earning a profit. However, the margin for TKA is decreasing and Managed Medicare patients do not generate a profit. The erosion of hospital revenue for TKA will become a critical issue if it leads to economic losses for hospitals or reduced access to TKA. Level III, Economic and Decision Analyses. See Guidelines for Authors for a complete description of levels of evidence.
Roberts, Timothy D; Clatworthy, Mark G; Frampton, Chris M; Young, Simon W
The objective of this study was to determine whether computer assisted navigation in total knee arthroplasty (TKA) improves functional outcomes and implant survivability using data from a large national database. We analysed 9054 primary TKA procedures performed between 2006 and 2012 from the New Zealand National Joint Registry. Functional outcomes were assessed using Oxford Knee Questionnaires at six months and five years. On multivariate analysis, there was no significant difference in mean Oxford Knee Scores between the navigated and non-navigated groups at six months (39.0 vs 38.1, P=0.54) or five years (42.2 vs 42.0, P=0.76). At current follow-up, there was no difference in revision rates between navigated and non-navigated TKA (0.46 vs 0.43 revisions 100 component years, P=0.8).
Komnik, Igor; Peters, Markus; Funken, Johannes; David, Sina; Weiss, Stefan; Potthast, Wolfgang
After knee arthroplasty (KA) surgery, patients experience abnormal kinematics and kinetics during numerous activities of daily living. Biomechanical investigations have focused primarily on level walking, whereas walking on sloped surfaces, which is stated to affect knee kinematics and kinetics considerably, has been neglected to this day. This study aimed to analyze over-ground walking on level and sloped surfaces with a special focus on transverse and frontal plane knee kinematics and kinetics in patients with KA. A three-dimensional (3D) motion analysis was performed by means of optoelectronic stereophogrammetry 1.8 ± 0.4 years following total knee arthroplasty (TKA) and unicompartmental arthroplasty surgery (UKA). AnyBody™ Modeling System was used to conduct inverse dynamics. The TKA group negotiated the decline walking task with reduced peak knee internal rotation angles compared with a healthy control group (CG). First-peak knee adduction moments were diminished by 27% (TKA group) and 22% (UKA group) compared with the CG during decline walking. No significant differences were detected between the TKA and UKA groups, regardless of the locomotion task. Decline walking exposed apparently more abnormal knee frontal and transverse plane adjustments in KA patients than level walking compared with the CG. Hence, walking on sloped surfaces should be included in further motion analysis studies investigating KA patients in order to detect potential deficits that might be not obvious during level walking.
Komnik, Igor; David, Sina; Weiss, Stefan; Potthast, Wolfgang
After knee arthroplasty (KA) surgery, patients experience abnormal kinematics and kinetics during numerous activities of daily living. Biomechanical investigations have focused primarily on level walking, whereas walking on sloped surfaces, which is stated to affect knee kinematics and kinetics considerably, has been neglected to this day. This study aimed to analyze over-ground walking on level and sloped surfaces with a special focus on transverse and frontal plane knee kinematics and kinetics in patients with KA. A three-dimensional (3D) motion analysis was performed by means of optoelectronic stereophogrammetry 1.8 ± 0.4 years following total knee arthroplasty (TKA) and unicompartmental arthroplasty surgery (UKA). AnyBody™ Modeling System was used to conduct inverse dynamics. The TKA group negotiated the decline walking task with reduced peak knee internal rotation angles compared with a healthy control group (CG). First-peak knee adduction moments were diminished by 27% (TKA group) and 22% (UKA group) compared with the CG during decline walking. No significant differences were detected between the TKA and UKA groups, regardless of the locomotion task. Decline walking exposed apparently more abnormal knee frontal and transverse plane adjustments in KA patients than level walking compared with the CG. Hence, walking on sloped surfaces should be included in further motion analysis studies investigating KA patients in order to detect potential deficits that might be not obvious during level walking. PMID:28002437
Yan, Denglu; Yang, Jing; Pei, Fuxing
This study aims to explore the technique of soft tissue balance and joint tension maintenance in total knee arthroplasty (TKA) for the rheumatoid arthritis (RA) patients with flexion contracture of the knee. This retrospective study reviewed flexion contracture deformity of RA patients who underwent primary TKA and ligament and soft tissue balancing. Based on the flexion contracture deformity, the remaining 76 patients available for analysis were divided into two groups, i.e., severe flexion group (SF) and moderate flexion group (MF). There were no intraoperative complications in this study. All patients had improved Knee Society Rating System scores and range of motion. The flexion contracture was completely corrected in MF and SF patients. There were no cases of patellar dislocation, but three cases had mild mediolateral instability in severe flexion group. Four knees (two knees in SF versus two knees in MF) had transient peroneal nerve palsy but recovered after conservative therapy. TKA can be performed successfully in the RA knees with severe flexion contracture. It is very important in TKA to maintain the joint stability in the condition of severe flexion contracture deformity of the RA knee.
Background This study aims to explore the technique of soft tissue balance and joint tension maintenance in total knee arthroplasty (TKA) for the rheumatoid arthritis (RA) patients with flexion contracture of the knee. Methods This retrospective study reviewed flexion contracture deformity of RA patients who underwent primary TKA and ligament and soft tissue balancing. Based on the flexion contracture deformity, the remaining 76 patients available for analysis were divided into two groups, i.e., severe flexion group (SF) and moderate flexion group (MF). Results There were no intraoperative complications in this study. All patients had improved Knee Society Rating System scores and range of motion. The flexion contracture was completely corrected in MF and SF patients. There were no cases of patellar dislocation, but three cases had mild mediolateral instability in severe flexion group. Four knees (two knees in SF versus two knees in MF) had transient peroneal nerve palsy but recovered after conservative therapy. Conclusions TKA can be performed successfully in the RA knees with severe flexion contracture. It is very important in TKA to maintain the joint stability in the condition of severe flexion contracture deformity of the RA knee. PMID:24229435
da Mota e Albuquerque, Roberto Freire
Navigation was the most significant advance in instrumentation for total knee arthroplasty over the last decade. It provides surgeons with a precision tool for carrying out surgery, with the possibility of intraoperative simulation and objective control over various anatomical and surgical parameters and references. Since the first systems, which were basically used to control the alignment of bone cutting referenced to the mechanical axis of the lower limb, many other surgical steps have been incorporated, such as component rotation, ligament balancing and arranging the symmetry of flexion and extension spaces, among others. Its efficacy as a precision tool with an effective capacity for promoting better alignment of the lower-limb axis has been widely proven in the literature, but the real value of optimized alignment and the impact of navigation on clinical results and the longevity of arthroplasty have yet to be established. PMID:27026979
Vissers, M M; Bussmann, J B; de Groot, I B; Verhaar, J A N; Reijman, M
Our previous study showed that 6 months after total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients reported having less difficulty with daily activities, showed better functional capacity, and performed activities in their natural environment faster compared to preoperatively. However, their actual daily activity level was not significantly improved. Six months is a rather short follow-up period and the discrepancy in recovery among different aspects of functioning might be explained by this limited duration of follow-up. The objective of the present study was to examine the recovery of different aspects of physical functioning at a follow-up nearly 4 years after THA/TKA. Special attention was given to the actual daily activity level, and whether it had increased 4 years after THA/TKA compared to 6 months postoperatively. Seventy-seven (35 hip, 42 knee) patients who were measured preoperatively and postoperatively (6 months after surgery) in a previous study were invited to participate; 44 patients (23 hip, 21 knee) agreed to participate. The 4-year follow-up data were compared with the preoperative and 6-month postoperative data. The daily activity level after 4 years was found to be actually lower than at 6 months post-surgery (128 min vs. 138 min activity per 24h; p-value 0.48). However, the patients continued to improve in other aspects of physical functioning. In conclusion, 4-year post-surgery patients continued to improve on perceived physical functioning, capacity, and performance of activities in daily life. However, even in this relatively healthy study population, patients did not adopt a more active lifestyle 4 years after surgery.
Sebastian, Arjun S; Wilke, Benjamin K; Taunton, Michael J; Trousdale, Robert T
Diaphyseal bowing may compromise axial alignment in revision total knee arthroplasty (TKA). 277 patients undergoing revision TKA were evaluated for coronal bowing and hip-knee-ankle (HKA) axis. The mean femoral bow was 1.52° ± 0.18° varus (-10.1° to +8.4°). The mean tibial bow was 1.25° ± 0.13° valgus (-5.9° to +10°). HKA axis averaged 3.08° ± 0.35° varus preoperatively compared to 0.86° ± 0.25° varus postoperatively. Inter-rater and intra-rater reliability was high. Femoral bow greater than 4° significantly correlated with postoperative HKA axis malalignment (r = 0.402, P = 0.008). 39.7% of patients deviated 3° or greater from a neutral mechanical axis with a significant difference in femoral bow (0.94° ± 0.31°, P = 0.003). Diaphyseal bowing clearly has an important effect on postoperative limb alignment in revision TKA.
Namba, Robert S; Cafri, Guy; Khatod, Monti; Inacio, Maria C S; Brox, Timothy W; Paxton, Elizabeth W
Using a Total Joint Replacement Registry, patient, operative, implant, surgeon, and hospital risk factors associated with aseptic revision after primary total knee arthroplasty (TKA) were evaluated. From 04/2001 to 12/31/2010 64,017 primary TKA cases, followed for a median time of 2.9 years, were registered and included in the analysis. Patients were predominantly female, white, with osteoarthritis, and obese. The crude aseptic revision rate is 1.3% (N=826). The cumulative survival for aseptic revision at 8 years is 97.6% (95% CI 97.3%-97.8%). Adjusted models revealed that age, race, body mass index, diabetic status, bilateral procedures, high-flex implants, and the LCS mobile bearing knee are associated with risk of revision. Gender, general health status, diagnosis, surgeon fellowship training, surgeon volume, hospital volume, fixation, and bearing surface material were not associated with risk of aseptic revision. Recognition of surgical factors associated with TKA failures can help the surgeons with their choices of surgical techniques and implants.
Kazemi, Seyyed Morteza; Besheli, Laleh Daftari; Eajazi, Alireza; Sajadi, Mohammad Reza Miniator; Okhovatpoor, Mohammad Ali; Zanganeh, Ramin Farhang; Minaei, Reza
Summary Background One of the complications of total knee arthroplasty (TKA) which has not yet been directly addressed is pseudo-patella baja (PPB). True patella baja (PB) is present when the length of the patellar tendon becomes shorter. PPB is present when the patella tendon is not shortened, but the level of the joint line is elevated. This study was conducted to assess PPB in TKA. Material/Methods Sixty patients who had had a primary TKA at our center between 1995 and 2005 were included. The average follow-up was 27.5 months. The Knee Society Scoring (KSS), lateral knee x-rays and the Blackburne-Peel index were used for assessments. Results Out of the 60 patients, 43 (72%) demonstrated no joint line elevation or patellar tendon shortening (group A). Fifteen patients (25%) had joint line elevation (group B), and both PB and PPB were present in 2 (3%) patients (group C). KSS was lower in groups B and C compared with group A, but this difference was not statistically significant. The average range of motion (ROM) in group A was significantly higher compared with either group B or C, and patients in groups B and C showed significantly more severe pain compared with group A (P<0.001). Conclusions PPB is not an uncommon finding after TKA and is associated with a statistically significant decrease in ROM and an increase in pain. Furthermore, KSS in the PPB group was less than in patients without PPB, although the difference was not statistically meaningful. PMID:21525812
Zeng, Yirong; Feng, Wenjun; Qi, Xinyu; Li, Jie; Chen, Jinlun; Lu, Lu; Deng, Peng; Zeng, Jianchun; Li, Feilong
Objectives To monitor knee skin temperature changes for 12 months following total knee arthroplasty (TKA) and identify potential reasons for any differences in skin temperature and to investigate if there is a relationship between the differential temperature and clinical outcome. Methods Patients who attended for a unilateral TKA due to primary osteoarthritis between August 2012 and August 2014 were eligible for this prospective study. The skin temperature of both knees was monitored preoperatively and postoperatively using an infrared thermometer. Serum indices and Hospital for Special Surgery (HSS) knee scores were assessed. Results Thirty-nine patients were involved in the study. The skin temperature of both knees as well as the differential temperature increased following TKA. Serum haemoglobin, haematocrit and days from surgery showed inverse correlations with the differential temperature, while body mass index and American Society of Anesthesiologists scores showed positive correlations. There was a strong inverse correlation between the differential temperature and HSS. score. Conclusions Differential knee skin temperature elevation 12 months post-TKA may be a normal surgical response.
Barsoum, Wael K; Lee, Ho H; Murray, Trevor G; Colbrunn, Robb; Klika, Alison K; Butler, S; van den Bogert, Antonie J
Pain secondary to instability in total knee arthroplasty (TKA) has been shown to be major cause of early failure. In this study, we focused on the effect of instability in TKA on the proximal tibio-fibular joint (PTFJ). We used a robotics model to compare the biomechanics of the PTFJ in the native knee, an appropriately balanced TKA, and an unbalanced TKA. The tibia (n = 5) was mounted to a six-degree-of-freedom force/torque sensor and the femur was moved by a robotic manipulator. Motion at the PTFJ was recorded with a high-resolution digital camera system. After establishing a neutral position, loading conditions were applied at varying flexion angles (0°, 30°, and 60°). These included: internal/external rotation (0 Nm, ±5 Nm), varus/valgus (0 Nm, ±10 Nm), compression (100 N, 700 N), and posterior drawer (0 N, 100 N). With respect to anterior displacement, external rotation had the largest effect (coefficient = 0.650; p < 0.0001). Polyethylene size as well as the interaction between polyethylene size and flexion consistently showed substantial anterior motion. Flexion and mid-flexion instability in TKA have been difficult to quantify. While tibio-femoral kinematics is the main aspect of TKA performance, the effects on adjacent tissues should not be overlooked. Our data show that PTFJ kinematics are affected by the balancing of the TKA. Copyright © 2010 Orthopaedic Research Society.
Kim, Dong-Kyoon; Seo, Min-Chul; Song, Sang-Joon
Most of the implants used for total knee arthroplasty (TKA) in Asian patients have been produced based on anthropometry of Western people. Since anatomic features and life styles are different between Western and Eastern people, there would be ethnic differences in terms of conformity of implants to the patient's anatomy or clinical results after TKA. Therefore, surgeons in Asia are particularly interested in related surgical techniques and implant designs used in TKA for improved clinical results and patient satisfaction. In this review, we investigated the anthropometric differences of Koreans from Westerners. Koreans are of shorter stature, less weight, and smaller skeletal structure and have a higher incidence of constitutional varus alignment of the lower extremity. Moreover, compared to Westerner TKA populations, the proportion of female patients was large and primary osteoarthritis was prevalent in preoperative diagnosis in Korean TKA patients. Culturally, Koreans have life styles that demand high flexion positions of the knee such as squatting, kneeling, and cross-legged sitting. Although there were no notable differences in the complication and revision rates following TKA between Westerners and Koreans, the incidence of postoperative deep vein thrombosis and pulmonary thromboembolism was lower in Koreans than Westerners. We hope that further research on implant designs and more interest in TKA will improve outcomes in Korean patients. PMID:26675374
Objective This study investigated the effect of the knee position during wound closure on early knee function recovery after total knee arthroplasty (TKA). Methods This study included 80 primary total knee arthroplasties due to osteoarthritis. The patients were randomized according to the type of wound closure: extension group for full extension and flexion group for 90° flexion. The incision of articular capsule was marked for precise wound alignment. In the flexion group, the knee was kept in high flexion for 1 to 2 min after wound closure. The two groups were treated with the same postoperative rehabilitation exercises. The range of motion (ROM), visual analogue scale (VAS) score of anterior knee pain, Knee Society Score (KSS) and postoperative complications were assessed at 6 weeks, 3 months and 6 months, postoperatively. Results At 6 weeks and 3 months postoperatively, the ROM in flexion group was 98.95 ± 10.33° and 110.05 ± 4.93° respectively, with 87.62 ± 8.92° and 95.62 ± 6.51° in extension group, respectively; The VAS score of anterior knee pain in flexion group was 2.02 ± 1.38 and 2.21 ± 0.87, respectively, with 2.57 ± 1.07 and 2.87 ± 0.83 in extension group, respectively. The ROM and VAS pain score of the two groups were significantly different at these two time points, with no significant difference at 6 months postoperatively. The two groups were not significantly different in KSS, and no apparent complication was observed at three time points. Conclusion Marking the articular capsule incision, wound closure in flexion and high flexion after wound closure can effectively decrease anterior knee pain after TKA and promote the early recovery of ROM. PMID:25149657
Anania, Andres; Abdel, Matthew P; Lee, Yuo-yu; Lyman, Stephen; González Della Valle, Alejandro
We investigated the incidence, natural history, and functional consequences of a newly developed flexion contracture after total knee arthroplasty (TKA). Forty patients with full knee extension preoperatively who developed a postoperative flexion contracture were match-paired 1:2 with 80 patients who had full extension. The incidence of a newly developed flexion contracture, ROM, and Knee Society scores (KSS) at six weeks, four months, and one year were analysed. The incidence of a new flexion contracture at six weeks was 14%, but diminished to 5% and 0.3% at four months and one year, respectively. One year after surgery, there was no difference in the KSS (p = 0.5). This study showed that the majority of patients who developed a new flexion contracture after TKA have full knee extension one year postoperatively. Moreover, knee extension and KSS at one year are equivalent to those patients who did not developed a flexion contracture.
Kohl, Sandro; Evangelopoulos, Dimitrios S; Hartel, Maximilian; Kohlhof, Hendrik; Roeder, Christoph; Eggli, Stefan
Total knee arthroplasty (TKA) disturbs patellar blood flow, an unintended accompaniment to TKA that may be a cause of postoperative anterior knee pain. We examine whether disrupted patellar blood flow correlates with anterior knee pain following TKA. In 50 patients (21 men, 29 women) undergoing TKA, we compared patellar blood flow at flexions 0° to 30°, 60°, 90°, and 110° before and after medial parapatellar arthrotomy to pre- and postoperative anterior knee pain scores by means of a laser Doppler flowmeter (LDF) probe. Anterior knee pain was assessed using the pain intensity numeric rating scale (NRS) of 0-10 (0-no, 10-worst pain). Based on the NRS pain values, patients were divided into two main groups: group A (n = 34) with no pain or discomfort (NRS range 0-4) and group B (n = 16) with anterior knee pain (NRS range 5-10). Patients of group B demonstrated a significant decrease in blood flow before arthrotomy at flexions from 0° to 90°, and 110° and from 0° to 60°, 90°, and 110° after arthrotomy. For group A, a significant decrease in blood flow was detected at flexions from 0° to 90°, and 110° before and after arthrotomy. For both groups, medial arthrotomy did not have a statistically significant influence on patellar blood flow (margin of significance P < 0.05). Prior to TKA, 16 of the 50 patients of group B (32%) complained of anterior knee pain (mean NRS 7.1 ± 1.7). At 2-year follow-up, pain significantly decreased (NRS 3.1 ± 2.1) and only 4 of the 16 patients (25%) complained of moderate anterior pain (average NRS 5.7 ± 0.5), while 8 of 16 (50%) patients reported discomfort (mean NRS 3.5 ± 1.8) around the patella. Patients in group A also demonstrated a significant decrease in pain intensity (from NRS 1.5 ± 1.4 preoperatively to NRS 0.4 ± 1.5 at 2-year follow-up). Statistical analysis demonstrated no statistically significant correlation between pre-arthrotomy/post-arthrotomy patellar blood flow and the presence of preoperative and
Jakobsen, Thomas Linding; Christensen, Malene; Christensen, Stine Sommer; Olsen, Marie; Bandholm, Thomas
Two of the most utilized outcome measures to assess knee joint range of motion (ROM) and intra-articular effusion are goniometry and circumference, respectively. Neither goniometry nor circumference of the knee joint have been examined for both intra-tester and inter-tester in patients with total knee arthroplasty (TKA). The purpose of this study was to determine the intra-tester and inter-tester reliability of active and passive knee joint ROM and circumference in patients with TKA when administered by physiotherapists (testers) with different clinical experience. The design was an intra-tester, inter-tester and intra-day reliability study. Nineteen outpatients (10 females) having received a TKA were examined by an inexperienced and an experienced physiotherapist. Following a standardized protocol, active and passive knee joint ROM and circumference measurements were obtained using a universal goniometer and a tape measure, respectively. To establish reliability, intraclass correlation coefficients (ICC(2,1)) and smallest real difference (SRD) were calculated. The knee joint ROM and circumference measurements were generally reliable (ICC > 0.8) within and between physiotherapists (except passive knee extension). Changes in knee joint ROM of more than 6.6 degrees and 10 degrees (except active knee flexion) and knee joint circumference of more than 1.0 cm and 1.63 cm represent a real clinical improvement (SRD) or deterioration for a single individual within and between physiotherapists, respectively. Generally, the experienced tester recorded larger knee joint ROM and lower circumference values than that of the inexperienced tester. In clinical practice, we suggest that repeated knee goniometric and circumferential measurements should be recorded by the same physiotherapist in individual patients with TKA. Tester experience appears not to influence the degree of reliability. (c) 2009 John Wiley & Sons, Ltd.
Macheras, George A; Galanakos, Spyridon P; Lepetsos, Panagiotis; Anastasopoulos, Panagiotis P; Papadakis, Stamatios A
The ideal total knee arthroplasty (TKA) should provide maximum range of motion and functional stability for all desired daily activities and, if possible, to replicate normal knee kinematics and function. The ADVANCE® Medial Pivot (AMP) Knee System was designed with a highly congruent medial compartment and a less conforming lateral compartment to more closely mimic the kinematics of the normal knee and to offer more stability through out of range of motion (ROM). The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of this TKA system. Three hundred and twenty-five (325) patients (347 knees) with knee osteoarthritis underwent a TKA using the AMP prosthesis in our Department. For evaluation, objective and subjective clinical rating systems along with radiograph series were used. The average follow-up was 15.2years. All patients showed a statistically significant improvement (p<0.0005) in the Knee Society clinical rating system, Western Ontario and McMaster Universities Osteoarthritis Index questionnaire, SF-12® questionnaire, and Oxford knee score. The majority of patients (94%) were able to perform age-appropriate activities with a mean knee flexion of 120° (range, 105°-135°) at final follow-up. Survival analysis showed a cumulative success rate of 98.8% at 17years. The obtained results demonstrate excellent long-term clinical outcome for this knee design. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.
Ostermeier, S; Hurschler, C; Stukenborg-Colsman, C
The purpose of this in vitro study was to investigate the amount of quadriceps force required to extend the knee during an isokinetic extension cycle before and after total knee arthroplasty. The magnitude of the extension torque used in simulating a constant moment extension exercise was derived from tests made using a dynamometer on patients who had received a total knee arthroplasty. Quadriceps force needed to extend the knee was measured. Human knee specimens (n=8, mean age=65 SD 7 years, all male) were tested in a kinematic knee simulating machine untreated and after implantation of two different knee prosthesis. During simulation, a hydraulic cylinder applied sufficient force to the quadriceps tendon to produce an extension moment of 31 Nm about the knee. The quadriceps forces needed to extend the knee during the physiologic simulation reached levels as high as 1238.9 N (SD 46.6). After implantation the Interax-prosthesis, quadriceps force increased up to 13.9% (P=0.003), in conjunction with resurfacing of the patella 11.9% (P=0.01). With the LCS-prosthesis implanted, quadriceps force showed a somewhat smaller increase of up to 6.6% (P=0.007). The following study helps to clarify postoperative problems related to the extensor mechanisms of the knee after implantation of total knee arthroplasty.
Ali, Abdulemir; Lindstrand, Anders; Nilsdotter, Anna; Sundberg, Martin
Background and purpose Knee pain after total knee arthroplasty (TKA) is not uncommon. Patellar retention in TKA is one cause of postoperative knee pain, and may lead to secondary addition of a patellar component. Patellar resurfacing in TKA is controversial. Its use ranges from 2% to 90% worldwide. In this randomized study, we compared the outcome after patellar resurfacing and after no resurfacing. Patients and methods We performed a prospective, randomized study of 74 patients with primary osteoarthritis who underwent a Triathlon CR TKA. The patients were randomized to either patellar resurfacing or no resurfacing. They filled out the VAS pain score and KOOS questionnaires preoperatively, and VAS pain, KOOS, and patient satisfaction 3, 12, and 72 months postoperatively. Physical performance tests were performed preoperatively and 3 months postoperatively. Results We found similar scores for VAS pain, patient satisfaction, and KOOS 5 subscales at 3, 12, and 72 months postoperatively in the 2 groups. Physical performance tests 3 months postoperatively were also similar in the 2 groups. No secondary resurfacing was performed in the group with no resurfacing during the first 72 months Interpretation Patellar resurfacing in primary Triathlon CR TKA is of no advantage regarding pain, physical performance, KOOS 5 subscales, or patient satisfaction compared to no resurfacing. None of the patients were reoperated with secondary addition of a patellar component within 6 years. According to these results, routine patellar resurfacing in primary Triathlon TKA appears to be unnecessary. PMID:27212102
Schirm, Andreas C; Jeffcote, Benjamin O; Nicholls, Rochelle L; Jakob, Hilaire; Kuster, Markus S
Restricted range of motion and excessive laxity are both potential complications of total knee arthroplasty (TKA). During TKA surgery, the surgeon is frequently faced with the question of how tightly to implant the prosthesis. The most common method of altering implantation tightness is to vary the thickness of the polyethylene inlay after the bone cuts have been made and the trial components inserted. We have sought to quantify how altering the polyethylene thickness may affect post-operative soft tissue tension for a range of prosthetic designs. Four different prosthetic designs were implanted into fresh-frozen cadaveric knee joints. All four designs were implanted in the standard manner, with a 100 Newton distraction force used to set soft tissue balance. The tibiofemoral force was then recorded at 15° intervals throughout the passive flexion range. After the standard implantation of each prosthesis, the tibial component was raised or lowered to mimic increasing and decreasing the polyethylene thickness by 2mm and the force measurements repeated. Tibiofemoral force in extension correlated with implantation tightness for all prosthesis designs. Between 15° and 90° of knee flexion, all four designs were insensitive to changes in implantation tightness. Beyond 90° the effect was more notable in rotating platform mobile-bearing and cruciate-retaining prostheses than in posterior-stabilised mobile-bearing designs. The findings of this research may be useful in assisting surgical decision-making during the implantation of TKA prostheses.
Patients undergoing surgery for total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at particularly high risk for developing venous thromboembolism (VTE). Despite the existence of effective therapies for VTE prevention, THA/TKA patients remain at risk for developing thrombi. Furthermore, the incidence of VTE is predicted to increase as an aging and increasingly obese population experiences joint damage necessitating THA and TKA. Current guidelines recommend the use of a wide range of antithrombotic agents in patients undergoing THA and TKA. These agents include vitamin K antagonists, low-molecular-weight heparins, fondaparinux, and the new oral anticoagulants. However, adherence to guidelines in clinical practice is disappointingly low. The limitations of traditional anticoagulants present management challenges following orthopedic surgery. Vitamin K antagonists present a number of drawbacks, including a narrow therapeutic window and unpredictable pharmacokinetics and pharmacodynamics. The subcutaneous route of administration of fondaparinux and low-molecular-weight heparins may make them unacceptable to patients in the outpatient setting. The introduction of a new generation of anticoagulants promises to address many of the drawbacks associated with the traditional agents. Clinical studies have shown the new oral anticoagulants to be as effective as traditional thromboprophylaxis, with good tolerability profiles. Clinical knowledge of these new agents will be essential to ensure that patients receive appropriate care following orthopedic surgery. This article will discuss the prevention of VTE after THA and TKA based on current evidence-based practice guidelines, the limitations of conventional anticoagulants, and the promise of new therapeutics.
Renaud, Alexandre; Fuentes, Alexandre; Hagemeister, Nicola; Lavigne, Martin; Vendittoli, Pascal-André
Background: Various implants of total knee arthroplasty (TKA) are used in clinical practice and each presents specific design characteristics. No implant managed this day to reproduce perfectly the biomechanics of the natural knee during gait. Objectives: We therefore asked whether (1) differences in tridimensional (3D) kinematic data during gait could be observed in two different designs of TKA on the same patients, (2) if those gait kinematic data are comparable with those of asymptomatic knees and (3) if difference in clinical subjective scores can be observed between the two TKA designs on the same patient. Methods: We performed knee kinematic analysis on 15 patients (30 TKAs) with two different TKA implant designs (Nexgen, Zimmer and Triathlon, Stryker) on each knee and on 25 asymptomatic subjects (35 knees). Clinical evaluation included range of motion, weight bearing radiographs, questionnaire of joint perception, KOOS, WOMAC and SF-12. Results: Comparison between TKAs and asymptomatic knees revealed that asymptomatic knees had significantly less knee flexion at initial contact (p < 0.04) and more flexion for most of the swing phase (p between 0.004 and 0.04). Asymptomatic knees also had less varus at loading response, during stance phase and during most of the swing phase (p between 0.001 - 0.05). Transverse plane analysis showed a tendency for asymptomatic knees to be more in internal rotation during stance phase (p 0.02 - 0.04). Comparing both TKA designs, NexgenTM implant had significantly more flexion at the end of swing phase (p = 0.04) compared to knees with the TriathlonTM implant. In frontal plane, from initial contact to maximum mid stance angle and between the mean mid stance angle and initial contact NexgenTM TKA had significantly more adduction (varus, p =0.02 – 0.03). Clinical scores of both TKAs did not have significant difference. Conclusions: TKA with the tested implants did not reproduce natural knee kinematics during gait. In our cohort
Robbins, Shawn M; Rastogi, Ravi; McLaughlin, Terry-Lyne
The objective was to explore predictors of physical function during acute in-patient rehabilitation within a few days after TKA. Physical function status of participants (n = 72) three days after total knee arthroplasty (TKA) was measured using the Timed Up and Go Test (TUG) and the function subscale of the Western Ontario McMaster Universities Index of Osteoarthritis (WOMAC-function). Potential predictors of physical function were measured day one post-TKA. Their relationship with physical function was examined using backward elimination, multiple regression analyses. Older age and increased comorbidity were associated (R(2) = 0.20) with worse TUG times. Increased pain severity was associated (R(2) = 0.08) with worse WOMAC-function scores. Age, comorbidity, and pain severity should be considered when predicting which patients will struggle with acute recovery post-TKA.
Choi, Ho-Rim; Bedair, Hany
We report the medium-term mortality after septic versus aseptic revision total knee arthroplasty (TKA) and factors that can contribute to mortality in revision TKA. Mortality rates of 88 patients undergoing septic revision (septic group) were compared with age- and year of surgery-matched 88 patients of aseptic revision (aseptic group). The overall mortality after revision TKA was 10.7% at a median of 4 years of follow-up (range, 2-7 years). However, the mortality after septic revision (18%, 16/88) was six times higher than that of aseptic revision (3%, 3/88) (P = 0.003). Infections with Staphylococcus aureus and/or methicillin resistance was not associated with higher mortality rates. Multivariate analysis indicated that increased age (P < 0.001), higher ASA class (P = 0.002), and septic revision (P < 0.001) were identified as independent predictors of increased mortality after revision TKA.
Lee, Thay Q
The capacity to perform certain activities is frequently compromised after total knee arthroplasty (TKA) due to a functional decline resulting from decreased range of motion and a diminished ability to kneel. In this manuscript, the current biomechanical understanding of hyperflexion and kneeling before and after TKA will be discussed. Patellofemoral and tibiofemoral joint contact area, contact pressure, and kinematics were evaluated in cadaveric studies using a Tekscan pressure measuring system and Microscribe. Testing was performed on intact knees and following cruciate retaining and posterior stabilized TKA at knee flexion angles of 90°, 105°, 120°, and 135°. Three loading conditions were used to simulate squatting, double stance kneeling, and single stance kneeling. Following TKA with double stance kneeling, patellofemoral contact areas did not increase significantly at high knee flexion angle (135°). Kneeling resulted in tibial posterior translation and external rotation at all flexion angles. Moving from double to single stance kneeling tended to increase pressures in the cruciate retaining group, but decreased pressures in the posterior stabilized group. The cruciate retaining group had significantly larger contact areas than the posterior stabilized group, although no significant differences in pressures were observed comparing the two TKA designs (p < 0.05). If greater than 120° of postoperative knee range of motion can be achieved following TKA, then kneeling may be performed with less risk in the patellofemoral joint than was previously believed to be the case. However, kneeling may increase the likelihood of damage to cartilage and menisci in intact knees and after TKA increases in tibiofemoral contact area and pressures may lead to polyethyelene wear if performed on a chronic, repetitive basis.
The capacity to perform certain activities is frequently compromised after total knee arthroplasty (TKA) due to a functional decline resulting from decreased range of motion and a diminished ability to kneel. In this manuscript, the current biomechanical understanding of hyperflexion and kneeling before and after TKA will be discussed. Patellofemoral and tibiofemoral joint contact area, contact pressure, and kinematics were evaluated in cadaveric studies using a Tekscan pressure measuring system and Microscribe. Testing was performed on intact knees and following cruciate retaining and posterior stabilized TKA at knee flexion angles of 90°, 105°, 120°, and 135°. Three loading conditions were used to simulate squatting, double stance kneeling, and single stance kneeling. Following TKA with double stance kneeling, patellofemoral contact areas did not increase significantly at high knee flexion angle (135°). Kneeling resulted in tibial posterior translation and external rotation at all flexion angles. Moving from double to single stance kneeling tended to increase pressures in the cruciate retaining group, but decreased pressures in the posterior stabilized group. The cruciate retaining group had significantly larger contact areas than the posterior stabilized group, although no significant differences in pressures were observed comparing the two TKA designs (p < 0.05). If greater than 120° of postoperative knee range of motion can be achieved following TKA, then kneeling may be performed with less risk in the patellofemoral joint than was previously believed to be the case. However, kneeling may increase the likelihood of damage to cartilage and menisci in intact knees and after TKA increases in tibiofemoral contact area and pressures may lead to polyethyelene wear if performed on a chronic, repetitive basis. PMID:24900891
Skou, Søren T; Roos, Ewa M; Laursen, Mogens B; Rathleff, Michael S; Arendt-Nielsen, Lars; Simonsen, Ole; Rasmussen, Sten
Clinical decision-making in total knee arthroplasty (TKA) is a complex process needing further clarification. The aim of this study was to compare TKA eligibility criteria considered most important by orthopedic surgeons (OSs) to characteristics of patients with knee osteoarthritis (OA) eventually found eligible for TKA. Nine OSs chose the five criteria most important when deciding on TKA eligibility. Cross-sectional data from 200 patients found either eligible (n=100) or not eligible (n=100) for TKA by one of the nine OS, were analyzed in a regression analyses with TKA eligibility as the dependent variable. Radiographic severity (n=8), pain (n=9), functional disability (n=8) and not responding to the recommended non-surgical treatment (n=7) were considered most important by OSs. Associations (P<0.25) between TKA eligibility and criteria found important by the OS were demonstrated for worse radiographic severity and more functional limitations, but not for pain and not responding to the recommended non-surgical treatment. Furthermore, more comorbidities and higher Body Mass Index (BMI) were associated with TKA-eligibility, but not found important for TKA eligibility by the OS. Radiographic severity and functional limitations were confirmed as drivers for TKA eligibility, while pain was not. Not responding to non-surgical treatment was not included in the decision-making, suggesting low uptake of clinical guidelines in clinical practice. This study highlights the complexity of the decision-making with some overlap between the criteria that OSs think they apply and what is actually applied in clinical practice. Copyright © 2015 Elsevier B.V. All rights reserved.
Finch, E; Walsh, M; Thomas, S G; Woodhouse, L J
A comparison of function of individuals 1 year after total knee arthroplasty (TKA) with healthy control subjects (controls) meaningfully describes outcome in these patients. Perception of function measured by two questionnaires, the Lower Extremity Activity Profile (LEAP) and the Western Ontario McMaster Osteoarthritis Index (WOMAC), and walking and stair performance was compared between 29 patients, 1 year after TKA, and 40 controls. There was significantly greater perceived difficulty with function in patients with TKA than in controls. In TKA men, LEAP and WOMAC scores correlated respectively with self-paced walk speed (r = -.71 and -.55) and stair performance time (r = 0.70 and 0.68). In TKA women, LEAP difficulty score correlated with self-paced walk speed (r = -.41) and stair performance time (r = -0.71). By 1 year, TKA subjects regained 80% of the function of controls. Perception of function after TKA can be measured by either questionnaire in men; however, the LEAP is the preferable questionnaire with women.
Merican, Azhar M; Ghosh, Kanishka M; Baena, Ferdinando Rodriguez Y; Deehan, David J; Amis, Andrew A
To study the effect of increasing patellar thickness (overstuffing) on patellofemoral kinematics in total knee arthroplasty and whether subsequent lateral retinacular release would restore the change in kinematics. The quadriceps of eight fresh-frozen knees were loaded on a custom-made jig. Kinematic data were recorded using an optical tracking device for the native knee, following total knee arthroplasty (TKA), then with patellar thicknesses from -2 to +4 mm, during knee extension motion. Staged lateral retinacular releases were performed to examine the restoration of normal patellar kinematics. Compared to the native knee, TKA led to significant changes in patellofemoral kinematics, with significant increases in lateral shift, tilt and rotation. When patellar composite thickness was increased, the patella tilted further laterally. Lateral release partly corrected this lateral tilt but caused abnormal tibial external rotation. With complete release of the lateral retinaculum and capsule, the patella with an increased thickness of 4 mm remained more laterally tilted compared to the TKA with normal patellar thickness between 45° and 55° knee flexion and from 75° onwards. This was on average by 2.4° ± 2.9° (p < 0.05) and 2.°9 ± 3.0° (p < 0.01), respectively. Before the release, for those flexion ranges, the patella was tilted laterally by 4.7° ± 3.2° and 5.4° ± 2.7° more than in the TKA with matched patellar thickness. Patellar thickness affects patellofemoral kinematics after TKA. Although lateral tilt was partly corrected by lateral retinacular release, this affected the tibiofemoral kinematics. IV.
Harato, Kengo; Yoshida, Hiroki; Otani, Toshiro
Unilateral total knee arthroplasty (TKA) would produce asymmetric changes of lower extremity in patients with bilateral varus deformity. Our purpose was to investigate whether asymmetry of the leg alignment would affect trunk bending in the coronal plane after unilateral TKA. Twenty patients (mean 76 years old) with bilateral end-stage knee osteoarthritis (OA) participated. Spine images during relaxed standing were obtained on pre- and postoperative day 21. As a result, the shoulder tilted more to the TKA side and the pelvis inclined more to the contralateral OA side. These results suggested that the trunk would bend away from the contralateral OA side after unilateral TKA in patients with bilateral end-stage knee OA and varus deformity. Asymmetry of the leg alignment led to asymmetric trunk bending.
Shah, Siddharth Mahesh; Dutton, Andrew Quoc; Liang, Shen; Dasde, Shamal
Severe medio-patellofemoral osteoarthritis (MPFOA) is often managed with a total knee arthroplasty (TKA). Bicompartmental knee arthroplasty (BKA), as compared with TKA can offer a bone and ligament preserving solution for MPFOA. We aimed to compare the early clinical and functional outcomes of modular BKA (n = 16) with TKA (n = 20) in MPFOA. Knee Society Score (KSS-clinical and function scores) and Knee injury & Osteoarthritis Outcome Score (KOOS-pain, symptoms, stiffness, and function scores) were recorded at 6, 12 and 24 months postoperatively and compared between the two groups. Pre- and postoperative radiographs were evaluated for alignment and radiolucencies. We found that none of the outcome scores were significantly different (p ≥ 0.137) between the two groups at any point in time. Postoperative knee range of motion (ROM) was significantly greater in the BKA group at all points in time (p ≤ 0.007). None of the patients in either group were revised or pending revision at the end of 24 months. To conclude, modular BKA resulted in better knee ROM but similar clinical and functional scores than TKA in MPFOA at short term. Modular BKA is a viable option for MPFOA but may not necessarily result in significant superior functional outcomes than with TKA. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Miller, Emily J; Pagnano, Mark W; Kaufman, Kenton R
For total knee arthroplasty (TKA), neutral mechanical alignment produces balanced static knee loading. Dynamically, knee loading is affected by more than limb static alignment. We compared static and dynamic knee loading following TKA. Fifteen TKA patients were evaluated pre-operatively and 2 months and 2 years post-operatively. Tibiofemoral angles and medial tibial plateau loading were calculated. Pre-operatively, static medial load was greater for varus than valgus knees. Post-operatively, no relationship existed between tibiofemoral angle and static medial plateau load. Pre-operatively and post-operatively, dynamic medial load was not dependent on tibiofemoral angle. While all patients achieved equal static plateau load distributions at 2 years, only 47% had dynamic medial load distributions of 50 ± 10%. Static tibiofemoral alignment alone does not predict dynamic tibial loading.
ten Ham, Arno M; Wymenga, Ate B; Jacobs, Wilco C H
In revision total knee arthroplasty (TKA), control of the patellar height and the joint line is difficult. Therefore, we developed an adjustable flexion-extension spacer, the Knee Joint-line Balancer (KJB(R)). This device simulates femur component sizes, polyethylene sizes, the joint-line level, and distal femur wedges. The goal of this study is to evaluate the use of an adjustable knee spacer to control patellar height and joint-line during revision total knee surgery. The subjects of the study were the first 10 consecutive patients who had undergone revision of a primary TKA where the KJB was used. A reference group composed of the last 10 patients treated without the use of the KJB was also evaluated. The joint-line position and the patellar height were determined before and after revision TKA. The method described by Figgie et al. was used. The patellar height in the reference group averaged 7.7 mm. Seven of 10 patients had a patella baja, and two of these patients had patellar impingement. One patient needed a proximalisation of the tuberositas. The patellar height in the KJB group averaged 14.6 mm after revision, with only one patient having a patella baja. This new device, adjustable kneespacer for revision TKA ("the KJB"), seems to provide better control of the patellar position in total knee revision.
Chan, Ferdinand J; Schwartz, Andrew M; Wong, Jason; Chen, Cynthia; Tiwari, Bharat; Kim, Sun Jin
A subset of patients who undergo total knee arthroplasty (TKA) are on methadone maintenance. They require more and often unpredictable quantities of opioids to function as effective painkillers. This study aims to compare the opioid requirements and the immediate postoperative course for patients on methadone maintenance with those who are not, after a TKA. A retrospective, case-control study was performed. From 2005 to 2010, 36 patients, who underwent a unilateral TKA, on chronic methadone maintenance were identified. A control group matched for age, gender, and body mass index comprised patients from the same period, who did not self-report taking methadone. Chart review and analysis of patient demographics, type of anesthesia used, preoperative methadone use, inpatient opioid use (converted to oral morphine equivalent doses), need for in-house pain management consult, length of hospital stay, and need for reoperation were performed. Patients on chronic methadone maintenance used significantly more opioids than patients not on methadone during their entire inpatient stay (P < .001). This was demonstrated by a higher median daily usage of opioids and higher patient-controlled analgesia usage. Patients on methadone maintenance had a significantly longer postoperative inpatient hospitalization (P < .001). Finally, these patients required significantly more inpatient pain management referrals (P = .025). There is a significantly higher opioid requirement, length of stay, and pain management consults in patients on methadone maintenance compared with those who are not after a TKA. These patients may benefit from a nonroutine approach to perioperative care in TKA. Copyright © 2017 Elsevier Inc. All rights reserved.
Struelens, Bernard; Claes, Steven; Bellemans, Johan
Although articulated cement spacers are frequently used in a staged approach of an infected total knee arthroplasty (TKA), no data are available on the incidence and type of spacer-related problems in these patients. A retrospective analysis of 154 patients who underwent a two-stage revision procedure for an infected TKA was performed. All patients received an articulating cement spacer at the implant removal procedure; their radiographs were analyzed for spacer-related issues such as spacer dislocation, fracture, tilting or translation, and knee subluxation. In 43% of the patients, the spacer was considered as optimal. The main finding of this study is the large incidence (57%) of spacer-specific problems in two-stage revision knee arthroplasty for infected TKA. Spacer tilting and mediolateral translation were found to be the most frequent spacer-specific problems, in 24% and 21% of the cases respectively. These were considered as minor problems. Major problems were seen in 12 % : in 3% of the knees the spacer had dislocated, in 5% the spacer fractured and in 4%, although the spacer seemed to be adequately positioned relative to the femoral and tibial bone, frank knee subluxation could be noted. The impact of spacer-specific problems with articulating cement spacers on final outcome in two-stage revision knee surgery will be further investigated.
Pinto, Patrícia R; McIntyre, Teresa; Ferrero, Ramón; Araújo-Soares, Vera; Almeida, Armando
This study compares the incidence, nature, and impact of persistent post-surgical pain after total knee arthroplasty (TKA) and total hip arthroplasty (THA) and investigates differences between these procedures, with the focus on potential presurgical and post-surgical issues that could be related to the distinct persistent post-surgical pain outcomes between these two groups. A consecutive sample of 92 patients was assessed prospectively 24 hours before, 48 hours, and 4–6 months after surgery. The data show that TKA patients had a higher likelihood of developing persistent post-surgical pain, of reporting higher pain levels, and of using more neuropathic descriptors when classifying their pain. In addition, TKA patients more often reported interference from pain on functional domains, including general activity, walking ability, and normal work. Demographic factors, like gender and age, along with presurgical clinical factors like disease onset, existence of medical comorbidities, and other pain problems, may have contributed to these differences, whereas baseline psychologic factors and functionality levels did not seem to exert an influence. Heightened acute post-surgical pain experience among TKA patients could also be related to distinct outcomes for persistent post-surgical pain. Future prospective studies should therefore collect TKA and THA samples wherein patients are homogeneous for demographic and presurgical clinical issues. Overall, these findings contribute to a small but growing body of literature documenting persistent post-surgical pain after major arthroplasty, conducted in different countries and across different health care settings. PMID:24072977
Chughtai, Morad; Sodhi, Nipun; Jawad, Michael; Newman, Jared M; Khlopas, Anton; Bhave, Anil; Mont, Michael A
Cryotherapy is widely utilized to enhance recovery after knee surgeries. However, the outcome parameters often vary between studies. Therefore, the purpose of this review is to compare (1) no cryotherapy vs cryotherapy; (2) cold pack cryotherapy vs continuous flow device cryotherapy; (3) various protocols of application of these cryotherapy methods; and (4) cost-benefit analysis in patients who had unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). A search for "knee" and "cryotherapy" using PubMed, EBSCO Host, and SCOPUS was performed, yielding 187 initial reports. After selecting for RCTs relevant to our study, 16 studies were included. Of the 8 studies that compared the immediate postoperative outcomes between patients who did and did not receive cryotherapy, 5 studies favored cryotherapy (2 cold packs and 3 continuous cold flow devices). Of the 6 studies comparing the use of cold packs and continuous cold flow devices in patients who underwent UKA or TKA, 3 favor the use of continuous flow devices. There was no difference in pain, postoperative opioid consumption, or drain output between 2 different temperature settings of continuous cold flow device. The optimal device to use may be one that offers continuous circulating cold flow, as there were more studies demonstrating better outcomes. In addition, the pain relieving effects of cryotherapy may help minimize pain medication use, such as with opioids, which are associated with numerous potential side effects as well as dependence and addiction. Meta-analysis on the most recent RCTs should be performed next. Copyright © 2017 Elsevier Inc. All rights reserved.
Eom, Sang Hwa; Bamne, Ankur B.; Chowdhry, Madhav; Chae, Ihn Seok
Purpose We aimed to determine the quantity and quality of research output of selected Asian countries in the field of total knee arthroplasty (TKA) in the last 10 years. Materials and Methods Top 15 Asian countries were selected according to their gross domestic product. The Science Citation Index Expanded database was used to search for the literature published between 2004 and 2013 using "Total Knee Arthroplasty". The numbers of articles, journals and citations and the contribution of each country were analyzed. The articles were classified according to the type of study and the relative proportion of each type was analyzed. Results Asian surgeons have increasingly contributed to orthopedic literature on TKA for the past 10 years, but the dominant contribution came from only a few countries. The total number of articles published by Asian countries increased by 261%, with Japan producing most of the studies and China showing the maximum growth rate. The majority of studies were published in low impact factor journals. Korea published the highest proportion of articles in high impact factor journals. Clinical papers were most frequent. Conclusions Our identification of research productivity pertaining to TKA among Asian countries gives a unique insight into the level of academic research in the field of TKA in these countries. There is a need to improve the quality of research to enhance the publishing power in high impact journals as well as the need for more basic research and epidemiological studies considering the unique differences among Asian patients undergoing TKA. PMID:26389067
Hepperger, Caroline; Gföller, Peter; Abermann, E; Hoser, Christian; Ulmer, Hanno; Herbst, Elmar; Fink, Christian
The purpose of this study was to investigate sports activities and functional abilities in patients following total knee arthroplasty (TKA). It was hypothesized that patients who had undergone TKA would return to a higher activity level as that experienced preoperatively. Two hundred patients were included in this prospective single-cohort study. All the patients completed subjective questionnaires (Tegner Activity Level, Oxford Knee Score, Visual Analog Scale for pain) prior to surgery as well as at 6, 12, and 24 months postoperatively. Additionally, sports behaviour was evaluated. Sports frequency was divided into four categories: more than 5 times a week, 2-3 times a week, occasionally, and no sports activities. Additionally, the patients were asked to state their three favourite summer and winter sports. All patient-reported outcome scores improved significantly over time (p ≤ 0.005). The Tegner Activity Level increased significantly from the preoperative state to 24 months postsurgery (p = 0.005). Six months after surgery, 43% of the patients returned to the same and 35% to a higher Tegner Activity Level than prior to surgery. Gender-related differences were observed for the Tegner Activity Level showing a higher activity level for the male than for the female patients. Overall, 24 months postsurgery 83% of the patients practiced sports in comparison with 79% prior to surgery. Following TKA, the patients were able to increase sports performance, while pain was reduced. Therefore, patients who want to continue their desired sports may safely consider TKA. II.
Zhao, Zhongyuan; Wang, Weiguang; Wang, Shijun; Jiang, Limin; Zhang, Shudong; Zhao, Yuchi
Besides the long-leg standing X-ray film focusing on static standing mechanical alignment of the lower extremity, dynamic alignment from full extension to 90° flexion after total knee arthroplasty (TKA) is rarely mentioned. Computer-assisted surgical technology enables surgeons to measure and assess knee behaviour during surgery. This study was designed to analyse the influences of femoral rotation on dynamic alignment of the lower extremity in TKA. Seventy-six consecutive patients with end-stage knee osteoarthritis were enrolled. External rotation osteotomy of the distal femur during TKA was completed according to the pre-operative external rotation angle (ERA), intra-operative transepicondylar axis (TEA) and anteroposterior (AP) line. Passive dynamic alignment of the lower extremity during knee flexion was recorded. The variation trend of hip-knee-ankle (HKA) alignment and the influences of femoral external rotation osteotomy were analysed. Postoperative deviation of HKA alignment from 0° to 90° flexion was associated with the rotational alignment of the femoral component (r = -0.769, p < 0.001). Variation trend of HKA alignment during knee flexion tended to be varus, valgus and neutral according to the selected angle of external rotation osteotomy of the distal femur. External rotation osteotomy of the distal femur played a crucial role in determining dynamic HKA alignment in TKA.
COTTINO, UMBERTO; DELEDDA, DAVIDE; ROSSO, FEDERICA; BLONNA, DAVIDE; BONASIA, DAVIDE EDOARDO; ROSSI, ROBERTO
Knee extensor mechanism rupture is a serious complication of total knee arthroplasty (TKA). Its prevalence ranges from 1 to 10% and it is commonly observed as a chronic multifactorial pathology with the patellar tendon as the most common site of rupture. Knee extensor mechanism reconstruction can be performed using allogenic or synthetic grafts. In the literature it is still not clear whether one of these techniques is superior to the other and the choice is usually tailored to the patient case by case. Allografts allow better restoration of the anatomical landmarks, whereas the mesh technique is more reproducible and the graft does not elongate over time. Allografts carry an increased risk of infection compared with synthetic reconstructions, while the mesh technique is cheaper and more readily available. In this paper, we review the etiology, diagnosis and treatment of this pathology, drawing on the most recent literature. PMID:27900308
Vaishya, Raju; Agarwal, Amit Kumar; Vijay, Vipul
Extensor mechanism disruption following total knee arthroplasty (TKA) is a rare but devastating complication. These patients may require revision of the implants, but even then, it may not be possible to restore the normal function of the knee after the disruption. The patterns of extensor mechanism disruption can broadly be classified into three types: suprapatellar (quadriceps tendon rupture), transpatellar (patellar fracture), or infrapatellar (patellar tendon rupture). Infrapatellar tendon ruptures are the worst injuries, as they carry maximum morbidity and are challenging to manage. The disruption of the extensor mechanism may occur either intra-operatively or in the immediate postoperative period due to an injury. The treatment of extensor mechanism complications after TKA may include either nonsurgical management or surgical intervention in the form of primary repair or reconstruction with autogenous, allogeneic, or synthetic substitutes. We have provided an algorithm for the management of extensor mechanism disruption after TKA.
Junqueira, Jader Joel Machado; Helito, Camilo Partezani; Bonadio, Marcelo Batista; Pécora, Jose Ricardo; Demange, Marco Kawamura
Chronic lateral dislocation of the patella is a rare condition and acquired causes are usually secondary to knee trauma. The neglected chronic dislocation leads to progressive genu valgum and external tibial torsion deformities with subsequent gonarthrosis, which becomes painful and debilitating. There is no consensus regarding treatment of these patients, but total knee arthroplasty (TKA) is a useful therapy in cases of painful symptomatic gonarthrosis. Few reports have shown that subvastus approach and lateral release may be a valid option for TKA, since it allows the correction of valgus deformity and patellar tracking without interrupting vascular blood supply of patella. This article reports a case of TKA and extensor mechanism realignment without patellar resurfacing in a patient with genu valgum and chronic post-traumatic patellar dislocation with satisfactory results after two years of follow-up.
Jakobs, Oliver; Schoof, Benjamin; Klatte, Till Orla; Schmidl, Stefan; Fensky, Florian; Guenther, Daniel; Frommelt, Lars; Gehrke, Thorsten; Gebauer, Matthias
Fungal periprosthetic joint infection (PJI) is a rare but devastating complication following total knee arthroplasty (TKA). A standardized procedure regarding an accurate treatment of this serious complication of knee arthroplasty is lacking. In this systematic review, we collected data from 36 studies with a total of 45 reported cases of a TKA complicated by a fungal PJI. Subsequently, an analysis focusing on diagnostic, medicaments and surgical procedures in the pre-, intra- and postoperative period was performed. Candida spp. accounts for about 80% (36 out of 45 cases) of fungal PJIs and is therefore the most frequently reported pathogen. A systemic antifungal therapy was administered in all but one patient whereas a local antifungal therapy, e.g. the use of an impregnated spacer, is of inferior relevance. Resection arthroplasty with delayed re-implantation (two-stage revision) was the surgical treatment of choice. However, in 50% of all reported cases the surgical therapy was heterogeneous. The outcome under a combined therapy was moderate with recurrent fungal PJI in 11 patients and subsequent bacterial PJI as a main complication in 5 patients. In summary, this systematic review integrates data from up to date 45 reported cases of a fungal PJI of a TKA. On the basis of the current literature strategies for the treatment of this devastating complication after TKA are discussed.
Park, Man Jun; Jung, Chul-Young; Ko, Young-Chul; Kim, Young-June; Kim, Chang-kyu; Kang, Eun-Jin
Streptococcus dysgalactiae subspecies dysgalactiae (SDSD), Lancefield group C streptococcus, is an animal pathogen which often causes pyogenic infection in domestic animals. Human infection by SDSD has been reported as a cellulitis on the upper arm, but a prosthetic joint infection caused by SDSD after total knee arthroplasty (TKA) has not yet been reported in the literature demonstrating that its clinical manifestation and management have not been well established. In this case report, we aimed to present a case of SDSD prosthetic joint infection after TKA, which was successfully treated by two-stage re-implantation with an application of antibiotic-impregnated cement spacer. PMID:22708114
Gan, Yudong; Ding, Jing; Xu, Yongqing; Hou, Chunlin
This study develops and validates a novel patient-specific navigational template for total knee arthroplasty (TKA). A total of 70 patients who underwent TKA were randomized and divided into conventional method group and navigational template group. In the navigational template group, the patient-specific navigational templates were designed and used intraoperatively to assist 35 patients with knee arthroplasty. Information on operation time and blood loss was recorded. After surgery, the positions of the prosthesis were evaluated using CT scan and X-rays. Analysis showed significant differences in errors between the two techniques. In addition, mean operation time and mean blood loss were statistically and significantly lower in the navigational template group than in the conventional group. Overall, the navigational template method showed a high degree of accuracy and efficacy. PMID:26550129
Fedorka, Catherine J; Chen, Antonia F; McGarry, William M; Parvizi, Javad; Klatt, Brian A
Prosthetic joint infection is an uncommon but serious complication of total knee arthroplasty (TKA). Control of infection after TKA is not always possible, and the resolution of infection may require an above-knee amputation (AKA). The purpose of this study was to determine the etiology of AKA and the functional outcomes of AKA after infected TKA. We retrospectively reviewed 35 patients who underwent AKA after an infected TKA. The amputations were performed an average of 6 years (range, 21 days to 24 years) after primary TKA. There were 19 females and 16 males with a mean age of 62 years (range, 26-88 years). Patient demographic information, comorbidities, surgical treatments, cultures, and culture sensitivities were recorded. Complications and functional status, including SF-12 and activities of daily living questionnaires, after AKA were also studied. The minimum followup was 7 months (mean, 39 months; range, 7-96 months). Two patients died secondary to cardiac arrest and 13 more died during the followup period of unrelated causes. Nine patients required irrigation and débridement for nonhealing wounds after AKA and two patients had repeat AKA for bony overgrowth. Of the 14 patients fitted for prostheses, eight were functionally independent outside of the home. Patients fitted with a prosthesis had higher mean activities of daily living scores (58 versus 38) and also tended to be younger with fewer comorbidities than those who were not fitted with a prosthesis. We found low functional status in living patients with an AKA after infection with only half of the patients walking after AKA. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Heyse, Thomas J; Chong, Le Roy; Davis, Jack; Haas, Steven B; Figgie, Mark P; Potter, Hollis G
Patellar Clunk Syndrome is a painful condition associated with a mechanical catching or clunking during active extension following total knee arthroplasty (TKA). The syndrome is caused by growth of interposing soft tissue usually at the superior pole of the patella. This interposed soft tissue cannot be visualized on plain radiographs. The aim was to ascertain if magnetic resonance imaging (MRI) would prove helpful in confirming the clinical diagnosis of patellar clunk by visualizing the interposed soft tissues adjacent to the patella and that the recognition of this tissue would be highly reproducible. MRI scans of 12 patients with clinical suspicion or related symptoms of a patellar clunk syndrome following primary TKA were retrospectively evaluated. Size of soft tissue masses proximal to the patella were determined in sagittal and axial MRI views. Largest diameters were recorded in two dimensions by two independent observers, and interobserver reliability was determined by intra-class correlation coefficients (ICC). Nine patients (75%) showed obvious MRI findings consistent with a patellar clunk lesion with high interobserver reliability (ICC values >0.75). In eight patients, this lead to operative treatment with arthroscopic debridement. MRI helps confirm the clinical diagnosis of patellar clunk. The data indicate that MRI is effective in defining the soft tissue lesion that is implicated in clinically evident patellar clunk syndrome after TKA.
Banerjee, Samik; Issa, Kimona; Kapadia, Bhaveen H; Khanuja, Harpal S; Harwin, Steven F; McInerney, Vincent K; Mont, Michael A
Substantial amounts of perioperative blood loss occur during total knee arthroplasty (TKA) that may require allogeneic transfusion in more than 30% of patients. Increased blood loss leads to poor physical functioning, increases infection risks, and prolongs hospitalization, which may eventually affect the overall clinical outcomes of TKA. In addition, allogeneic blood transfusions are associated with increased risks of transfusion reactions, immunosuppression, and a variety of immunological reactions. These concerns have led surgeons and anesthesiologists to develop various strategies to conserve blood, reduce costs, and decrease complications related to blood transfusions. Multiple nonpharmacologic intraoperative blood-saving measures have been used including acute normovolemic hemodilution, hypotensive anesthesia, tourniquets, bipolar sealants, intraoperative blood salvage systems, intramedullary femoral plugs, computer-assisted surgery, and the use of patient-specific instrumentation. However, no clear protocol exists currently to help surgeons choose the appropriate method for blood preservation. The aim of this article was to review the various nonpharmacologic intraoperative blood management strategies that have been used in TKA and to analyze their effectiveness and potential complications according to current evidence.
Fritz, Jan; Lurie, Brett
Primary total knee arthroplasty is a highly effective treatment that relieves pain and improves joint function in a large percentage of patients. Despite an initially satisfactory surgical outcome, pain, dysfunction, and implant failure can occur over time. Identifying the etiology of complications is vital for appropriate management and proper timing of revision. Due to the increasing number of knee arthroplasties performed and decreasing patient age at implantation, there is a demand for accurate diagnosis to determine appropriate treatment of symptomatic joints following knee arthroplasty, and for monitoring of patients at risk. Magnetic resonance (MR) imaging allows for comprehensive imaging evaluation of the tissues surrounding knee arthroplasty implants with metallic components, including the polyethylene components. Optimized conventional and advanced pulse sequences can result in substantial metallic artifact reduction and afford improved visualization of bone, implant-tissue interfaces, and periprosthetic soft tissue for the diagnosis of arthroplasty-related complications. In this review article, we discuss strategies for MR imaging around knee arthroplasty implants and illustrate the imaging appearances of common modes of failure, including aseptic loosening, polyethylene wear–induced synovitis and osteolysis, periprosthetic joint infections, fracture, patellar clunk syndrome, recurrent hemarthrosis, arthrofibrosis, component malalignment, extensor mechanism injury, and instability. A systematic approach is provided for evaluation of MR imaging of knee implants. MR imaging with optimized conventional pulse sequences and advanced metal artifact reduction techniques can contribute important information for diagnosis, prognosis, risk stratification, and surgical planning. ©RSNA, 2015 PMID:26295591
Okamoto, Nobukazu; Nakamura, Eiichi; Nishioka, Hiroaki; Karasugi, Tatsuki; Okada, Tatsuya; Mizuta, Hiroshi
Mobile-bearing total knee arthroplasty (TKA) expects high conformity and low contact stress. It is designed to correct the rotational mismatch between femoral and tibial components. We examined the difference in weight-bearing knee kinematics in patients with mobile-bearing and fixed-bearing TKA performing step-up activities. We randomly assigned 40 knees (37 patients) to mobile-bearing TKA (n=20) or fixed-bearing TKA (n=20). Using fluoroscopic imaging we evaluated knee kinematics during step-up activity one year after surgery. The total extent of rotation was not different for the two TKAs. Due to the axial rotation of the polyethylene insert, patients with mobile-bearing TKA had a wider range of absolute axial rotation. The position of the medial and the lateral condyles was significantly more posterior in the fixed-bearing TKA. There were only minor kinematic differences between the two TKAs. The polyethylene insert in the mobile-bearing TKA moved as designed especially with respect to the self-alignment feature.
Banerjee, Samik; Kapadia, Bhaveen H; Issa, Kimona; McElroy, Mark J; Khanuja, Harpal S; Harwin, Steven F; Mont, Michael A
Blood loss is a serious concern during lower extremity total joint arthroplasty with the estimated reduction in hemoglobin concentration known to vary between 2 and 4 g/dL after total knee arthroplasty (TKA). Allogeneic transfusions are commonly used to treat the acute blood loss and postoperative anemia to diminish the potential cardiovascular risks in up to 50% of such cases with a high volume of blood loss. However, these transfusions are associated with the risks of immunologic reactions, immunosuppression, and infection transmission. Multiple blood-saving strategies have been developed to minimize blood loss, to reduce transfusion rates, to decrease complications, and to improve outcomes in the postoperative period. Currently, there are no clear guidelines on the blood management strategies adopted to lessen the blood loss associated with TKA. The aim of this study was to review the literature and provide a broad summary of the efficacy and complications associated with several blood-saving measures that are currently used in the postoperative period. Evidence suggests that simple techniques such as limb elevation, cryotherapy, compression dressings, and drain clamping may reduce external drainage, however, whether these techniques lead to less allogeneic transfusions is currently debatable. Further research on using a combination of these strategies and their cost-effectiveness are needed.
Williams, Daniel H; Greidanus, Nelson V; Masri, Bassam A; Duncan, Clive P; Garbuz, Donald S
While the primary objective of joint arthroplasty is to improve patient quality of life, pain, and function, younger active patients often demand a return to higher function that includes sporting activity. Knowledge of rates and predictors of return to sports will help inform expectations in patients anticipating return to sports after joint arthroplasty. We measured the rate of sports participation at 1 year using the UCLA activity score and explored 11 variables, including choice of procedure/prosthesis, that might predict return to a high level of sporting activity, when controlling for potential confounding variables. We retrospectively evaluated 736 patients who underwent primary metal-on-polyethylene THA, metal-on-metal THA, hip resurfacing arthroplasty, revision THA, primary TKA, unicompartmental knee arthroplasty, and revision TKA between May 2005 and June 2007. We obtained UCLA activity scores on all patients; we defined high activity as a UCLA score of 7 or more. We evaluated patient demographics (age, sex, BMI, comorbidity), quality of life (WOMAC score, Oxford Hip Score, SF-12 score), and surgeon- and procedural/implant-specific variables to identify factors associated with postoperative activity score. Minimum followup was 11 months (mean, 12.1 months; range, 11-13 months). Preoperative UCLA activity score, age, male sex, and BMI predicted high activity scores. The type of operation and implant characteristics did not predict return to high activity sports. Our data suggest patient-specific factors predict postoperative activity rather than factors specific to type of surgery, implant, or surgeon factors. Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Thienpont, E; Zorman, D
To compare the postoperative subjective outcome for fixed- and mobile-bearing total knee arthroplasty (TKA) by using the forgotten joint score (FJS-12), a new patient-reported outcome score of 12 questions evaluating the potential of a patient to forget about his operated joint. The hypothesis of this study was that a mobile-bearing TKA would have a higher level of forgotten joint than a fixed-bearing model of the same design. A retrospective cohort study was conducted in 100 patients who underwent TKA at least 1 year [mean (SD) 18 (5) months] before with either a fixed-bearing (N = 50) or a mobile-bearing (N = 50) TKA from the same implant family. Clinical outcome was evaluated with the knee society score and patient-reported outcome with the forgotten joint score. No difference was observed for demographics in between both study groups. The mean (SD) postoperative FJS-12 for the fixed-bearing TKA was 71 (28) compared to a mean (SD) of 56.5 (30) for the mobile-bearing TKA. The clinical relevance of the present retrospective study is that it shows for the first time a significant difference between fixed- and mobile-bearing TKA by using a new patient-reported outcome score. The hypothesis that mobile-bearing TKA would have a higher degree of forgotten joint than a fixed-bearing TKA could not be confirmed. A level I prospective study should be set up to objectivise these findings. IV.
Bhende, Harish; Laud, Nanadkishore; Deore, Sandeep; Shashidhar, V
In Klippel–Trenaunay syndrome, vascular malformations are not only in skin and superficial soft tissues but also in deep tissues like muscles bones and joints. It is well documemted that these recurrent intraarticular bleeds can cause early arthritis and joint pain. Performing arthroplasty in such patients is difficult and fraught with complications. We describe such a case where navigated total knee arthroplasty was performed with success to avoid the problems of intra medullary alignment used in the presence of intra medullary vascular malformations. We also suggest certain measures when knee arthroplasty is considered in such patients. PMID:26538765
Tilbury, C; Leichtenberg, C S; Tordoir, R L; Holtslag, M J; Verdegaal, S H M; Kroon, H M; Nelissen, R G H H; Vliet Vlieland, T P M
The aim of this study was to measure return to work and duration until return to work in patients undergoing total hip or knee arthroplasty (THA or TKA). This prospective study included patients under 65 years of age, undergoing THA or TKA, who provided information on their work status preoperatively (paid work yes/no and working hours) and 1 year thereafter (paid work yes/no, working hours and time until return to work). Seventy-one THA and 64 TKA patients had a paid job preoperatively. The employment rates 1 year postoperatively were 64/71 (90 %) after THA and 53/64 (83 %) after TKA. Of those who returned to work, 9/64 (14 %) of THA patients and 10/53 (19 %) of TKA patients worked less hours than preoperatively [mean decrease of 16 (SD 11.5) and 14 (SD 13.0) hours, respectively]. The mean time to return to work was 12.5 (SD 7.6) and 12.9 (SD 8.0) weeks in THA and TKA, respectively. The majority of working patients who underwent THA or TKA returned to work, after approximately 12 weeks. A considerable proportion of the patients returning to work worked less hours than preoperatively. More research into patients who do not return or decrease their working hours is needed.
Papalia, Rocco; Vasta, Sebastiano; D'Adamio, Stefano; Albo, Erika; Maffulli, Nicola; Denaro, Vincenzo
To overview the complications involving extensor apparatus of the knee following total knee arthroplasty (TKA) and to summarize which are the lines of treatment available and their reported outcomes in literature. A comprehensive search of several databases was performed using as basic keywords "complications after TKA", "extensor mechanism disruption", "periprosthetic patellar fracture", "quadriceps tendon rupture", "quadriceps tendon rupture" isolated or combined with other terms by using Boolean operators. The methodological quality of each article was also evaluated using the Coleman methodology score (CMS). Twenty-nine studies were evaluated. The mean CMS of the studies selected was 33.1/100. Patellar fractures, requiring surgical treatment when there is rupture of the extensor mechanism or loosening of the patellar component, were treated surgically in 28.1 % of patients. The patellar and quadriceps tendon ruptures were surgically treated with reconstruction or augmented repair, respectively, in 98.6 and 76.5 %. Complications involving the extensor apparatus of the knee following a TKA need early and appropriate management to avoid their devastating influence on joint functionality. Management has to be evaluated very carefully based on the site of the lesion, integrity of the prosthetic components and surrounding tissue to restore, and the patients' individual characteristics. The surgical approach for comminuted periprosthetic fractures and reconstruction of torn tendons of the extensor apparatus are needed to restore function and decrease pain, but, given the poor methodological quality of the studies published so far, it is not clear which surgical technique or graft leads to better outcomes. Therefore, there is an absolute need for better designed comparative trials producing clearer and stronger evidence on this critical matter. IV.
Dreyer, Hans C.; Strycker, Lisa A.; Senesac, Hilary A.; Hocker, Austin D.; Smolkowski, Keith; Shah, Steven N.; Jewett, Brian A.
Background. By the year 2030, 3.48 million older U.S. adults are projected to undergo total knee arthroplasty (TKA). Following this surgery, considerable muscle atrophy occurs, resulting in decreased strength and impaired functional mobility. Essential amino acids (EAAs) have been shown to attenuate muscle loss during periods of reduced activity and may be beneficial for TKA patients. Methods. We used a double-blind, placebo-controlled, randomized clinical trial with 28 older adults undergoing TKA. Patients were randomized to ingest either 20 g of EAAs (n = 16) or placebo (n = 12) twice daily between meals for 1 week before and 2 weeks after TKA. At baseline, 2 weeks, and 6 weeks after TKA, an MRI was performed to determine mid-thigh muscle and adipose tissue volume. Muscle strength and functional mobility were also measured at these times. Results. TKA patients receiving placebo exhibited greater quadriceps muscle atrophy, with a –14.3 ± 3.6% change from baseline to 2 weeks after surgery compared with –3.4 ± 3.1% for the EAA group (F = 5.16, P = 0.036) and a –18.4 ± 2.3% change from baseline to 6 weeks after surgery for placebo versus –6.2 ± 2.2% for the EAA group (F = 14.14, P = 0.001). EAAs also attenuated atrophy in the nonoperated quadriceps and in the hamstring and adductor muscles of both extremities. The EAA group performed better at 2 and 6 weeks after surgery on functional mobility tests (all P < 0.05). Change in quadriceps muscle atrophy was significantly associated with change in functional mobility (F = 5.78, P = 0.021). Conclusion. EAA treatment attenuated muscle atrophy and accelerated the return of functional mobility in older adults following TKA. Trial registration. Clinicaltrials.gov NCT00760383. Funding. Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Office of the Director (OD), and the National Institutes of Health Office of Dietary Supplements (ODS), NIH grant K01HD057332, and the Medical
Spence, Sean A; Doren, Erin L; Dayicioglu, Deniz; Bernasek, Thomas
We report the case of a 56-year-old patient who had posttraumatic bilateral knee arthritis and underwent sequential bilateral total knee arthroplasty (TKA). The left knee joint required 2-stage reconstruction: a free flap for enhanced soft-tissue coverage and then left knee TKA. Uniquely, at age 16 years this patient sustained a left tibia grade IIIB high-energy crush injury in a car crash and underwent reconstruction with multiple pedicle tube flaps and transfer of soft tissues. Most of that reconstruction was done between the ages of 16 and 19. At age 56 years, staged TKA was performed. To our knowledge, this is the first report of a knee reconstructed with pedicle tube flaps for a grade IIIB tibial fracture, followed years later by free-flap coverage before TKA. This report offers insights and treatment recommendations through long-term follow-up of a unique case and a historical perspective on how reconstructive options have evolved.
Lee, Kyung-Jae; Cho, Chul-Hyun; Son, Eun-Seok; Jung, Jae-Won
Purpose To evaluate the radiological stability according to the number of modular augments after revision of infected total knee arthroplasty (TKA). Materials and Methods Between February 2006 and September 2013, 37 patients (39 knees) followed ≥2 years after revision of infected TKA using modular metal augments for bone defects were reviewed retrospectively. We divided the patients into 3 groups according to the number of augments into group A (≤2 augments, 14 knees), group B (3–4 augments, 18 knees), and group C (5≥ augments, 7 knees) and evaluated the width of radiolucent zones around the implant at the last follow-up. Results There were 3 Anderson Orthopedic Research Institute type I, 33 type II, and 3 type III bone defects. The mean number of radiolucent zones of group A was 3 and the sum of width averaged 4.4 mm. In group B, the values were 4.8 and 6.2 mm, respectively. In group C, the values were 8.1 and 12.9 mm, respectively. The differences between the three groups were statistically significant. Conclusions In revision TKA with modular metal augmentation caused by infected TKA, increased modularity can result in radiological instability. PMID:26955613
Koh, In Jun; Kim, Min Woo; Kim, Ju Hwan; Han, Sang Yup; In, Yong
We analyzed the records of 29,895 high tibial osteotomies (HTOs), 12,589 unicompartmental knee arthroplasties (UKAs) and 363,386 total knee arthroplasties (TKAs) performed from 2009 to 2013 in Korea. They were compared with the latest nationwide registry reports of seven Western countries. Over the last 5 years, in Korea, the number of HTO, UKA and TKA increased by 210%, 138%, and 18%, respectively. The largest increase was observed in 55-64 year olds in HTO and UKA, while the largest increase in TKA was in ≥75 year olds. Females commonly had a three- to seven-fold higher rate in all procedures. Worldwide, the use of HTO and UKA decreased or remained stable, whereas that of TKA increased steadily, even in younger patients.
Werner, Brian C; Evans, Cody L; Carothers, Joshua T; Browne, James A
This study utilized a national database to evaluate 90 day postoperative complication rates after total knee arthroplasty (TKA) in super obese (BMI > 50 kg/m(2)) patients (n = 7666) compared to non-obese patients (n = 1,212,793), obese patients (n = 291,914), morbidly obese patients (n = 169,308) and revision TKA patients (n = 28,812). Super obese patients had significantly higher rates of local and systemic complications compared to all other BMI groups as well as those undergoing revision TKA with higher rates of venous thromboembolism (VTE), infection, and medical complications. Super obesity is associated with dramatically increased rates of postoperative complications after TKA compared to non-obese, obese, and morbidly obese patients as well as those undergoing revision TKA.
Werner, Brian C; Carr, James B; Wiggins, John C; Gwathmey, F Winston; Browne, James A
A national database was used to evaluate the risk for manipulation under anesthesia (MUA) after total knee arthroplasty (TKA), the association of demographics and comorbidities with needing MUA, and the risk of revision TKA after MUA. Of the 141,016 patients who underwent TKA, 4.3% required MUA within 6 months. Age under 50 years (OR: 2.79, P<0.0001), age 50-65 years (OR: 2.03, P<0.0001), and female gender (OR: 1.12, P<0.0001) were all associated with increased rates of MUA. In patients under age 65 years, smoking (OR: 1.47, P<0.0001) was associated with an increased rate of MUA. Patients who require MUA within 6 months after TKA have a significantly increased risk of early revision TKA (OR: 2.43, P<0.0001).
Cline, Joseph T.; Alentorn-Geli, Eduard; Choi, J. H. James; Stuart, Joseph J.; Kruger, Terry; Moorman III, Claude T.
Posterolateral rotatory instability is a relatively uncommon cause of unstable total knee arthroplasty (TKA). In most cases, surgical treatment requires revision TKA into a more constrained design or thicker polyethylene liner. We present a case of a patient with unstable TKA who remained unstable after increasing thickness of the polyethylene liner and undergoing more constrained TKA. After several revision surgeries, the patient was still unstable. Posterolateral corner reconstruction with a fibular-based technique using a tibialis anterior allograft was performed. At 1-year follow-up, the patient was stable and asymptomatic and with excellent function. A soft-tissue procedure only (fibular-based posterolateral corner reconstruction) can be effective at restoring posterolateral rotatory stability in a patient with persistent instability after revision TKA. PMID:26881160
Argenson, Jean-Noël A; Scuderi, Giles R; Komistek, Richard D; Scott, W Norman; Kelly, Michael A; Aubaniac, Jean-Manuel
In designing a posterior-stabilized total knee arthroplasty (TKA) it is preferable that when the cam engages the tibial spine the contact point of the cam move down the tibial spine. This provides greater stability in flexion by creating a greater jump distance and reduces the stress on the tibial spine. In order to eliminate edge loading of the femoral component on the posterior tibial articular surface, the posterior femoral condyles need to be extended. This provides an ideal femoral contact with the tibial articular surface during high flexion angles. To reduce extensor mechanism impingement in deep flexion, the anterior margin of the tibial articular component should be recessed. This provides clearance for the patella and patella tendon. An in vivo kinematic analysis that determined three dimensional motions of the femorotibial joint was performed during a deep knee bend using fluoroscopy for 20 subjects having a TKA designed for deep flexion. The average weight-bearing range-of-motion was 125 degrees . On average, TKA subjects experienced 4.9 degrees of normal axial rotation and all subjects experienced at least -4.4 mm of posterior femoral rollback. It is assumed that femorotibial kinematics can play a major role in patellofemoral kinematics. In this study, subjects implanted with a high-flexion TKA design experienced kinematic patterns that were similar to the normal knee. It can be hypothesized that forces acting on the patella were not substantially increased for TKA subjects compared with the normal subjects.
Hwang, Jin-Young; Oh, Sohee; Kim, Chong-Soo; Chang, Jee-Eun; Min, Seong-Won
Abstract The number of elderly patients undergoing total knee arthroplasty (TKA) has steadily increased. Elderly patients undergoing TKA usually have underlying diseases, and some of them take antithrombotic agents for the prevention or treatment of these co-morbidities, including cardiovascular, cerebrovascular, or thromboembolic diseases. When these patients are scheduled to undergo TKA, preoperative cessation of antithrombotic agents is considered on the basis of its risks and benefits. This study was aimed to evaluate the impact of discontinuing antithrombotic agents for primary total knee arthroplasty (TKA) on perioperative complications. Patients who underwent primary TKA between 2008 and 2012 were identified, and classified into two groups: group A, in whom antithrombotic agents were ceased preoperatively, and group B, in which patients did not receive antithrombotic therapy. Patient characteristics, history of antithrombotic therapy, intraoperative blood loss, perioperative blood transfusion, postoperative 30-day complications, and postoperative hospital stay were recorded. Of 885 patients undergoing primary TKA, 218 (24.6%) patients were included in group A, and 667 (75.4%) in group B. Group A received transfusion more frequently than group B (P < 0.001). However, there was no difference between the two groups in terms of intraoperative blood loss, postoperative 30-day complications, and postoperative hospital stay. Patients who discontinued antithrombotic drugs before primary TKA do not have a higher incidence of postoperative 30-day complications, including cardiovascular, cerebrovascular, or thromboembolic events. Moreover, the estimated intraoperative blood loss was not different compared with patients not receiving antithrombotic agents preoperatively. Larger prospective studies of this issue are required. PMID:27902607
Duivenvoorden, T; Vissers, M M; Verhaar, J A N; Busschbach, J J V; Gosens, T; Bloem, R M; Bierma-Zeinstra, S M A; Reijman, M
A subset of patients with total hip arthroplasty (THA) or total knee arthroplasty (TKA) has suboptimal postoperative results in terms of Patient Reported Outcomes (PROs), and psychological factors could contribute to these suboptimal results. To examine the prevalence of anxiety and depressive symptoms in patients undergoing primary THA or TKA preoperatively and postoperatively, and the relationship between preoperative anxiety and depressive symptoms on PROs of THA and TKA. In this prospective study patients were measured preoperatively, and 3 and 12 months postoperatively. Patients filled in the Hospital Anxiety and Depression Scale, Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS) and a satisfaction questionnaire. Data were obtained from 149 hip and 133 knee patients. The prevalence of anxiety symptoms decreased significantly from 27.9% to 10.8% 12 months postoperatively in hip patients, and from 20.3% to 14.8% in knee patients. Depressive symptoms decreased significantly from 33.6% to 12.1% 12 months postoperatively in hip patients, and from 22.7% to 11.7% in knee patients. In hip and knee patients, preoperative depressive symptoms predicted smaller changes in different HOOS or KOOS subscales and patients were less satisfied 12 months postoperatively. Preoperatively, the prevalence of anxiety and depressive symptoms was high. At 3 and 12 months postoperatively, the prevalence of anxiety and depressive symptoms was decreased in both hip and knee patients. However, patients with preoperative anxiety and depressive symptoms had worse PROs 3 and 12 months after THA and TKA and were less satisfied than patients without anxiety or depressive symptoms. Copyright © 2013 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Saito, Hidetomo; Aizawa, Toshiaki; Miyakoshi, Naohisa; Shimada, Yoichi
One component of conventional total knee arthroplasty is removal of the anterior cruciate ligament, and the knee after total knee arthroplasty has been said to be a knee with anterior cruciate ligament dysfunction. Bicruciate stabilized total knee arthroplasty is believed to reproduce anterior cruciate ligament function in the implant and provide anterior stability. Conventional total knee arthroplasty was performed on the right knee and bicruciate stabilized total knee arthroplasty was performed on the left knee in the same patient, and a triaxial accelerometer was fitted to both knees after surgery. Gait analysis was then performed and is reported here. The subject was a 78-year-old woman who underwent conventional total knee arthroplasty on her right knee and bicruciate stabilized total knee arthroplasty on her left knee. On the femoral side with bicruciate stabilized total knee arthroplasty, compared to conventional total knee arthroplasty, there was little acceleration in the x-axis direction (anteroposterior direction) in the early swing phase. Bicruciate stabilized total knee arthroplasty may be able to replace anterior cruciate ligament function due to the structure of the implant and proper anteroposterior positioning. PMID:27648328
Love, Gavin J; Kinninmonth, Andrew W G
Computer navigation aims to improve the surgical accuracy of total knee replacement by more reliably placing the cutting blocks in the optimum location in order to create a neutral mechanical axis. Aside from the obvious clinical benefit to the patient, we believe computer navigation has a valuable role as a training tool. The aim of this study is to demonstrate the effectiveness of computer navigation as a training tool in total knee arthroplasty. We performed a training exercise using Sawbone plastic models to simulate four common sources of error in the saw technique; 1. cutting guide movement due to inadequate fixation, 2. the effect of using slotted or open cutting guides, 3. the effect of bending the saw blade, and 4. the effect of recutting on the accuracy of the intended resection. We found that bony resection errors resulted from; use of less than three pins to fix the cutting guide, use of open cutting guides, deliberate and inadvertent "hanging" or "lifting" of the saw on the cutting guide and recutting after moving the cutting guide. The immediate feedback provided by computer navigated TKA allows surgeons and trainee surgeons the opportunity to improve the accuracy of their technique and increase awareness of their individual sources of error in TKA. Used as a teaching tool, computer navigation can immediately identify errors in surgical technique and target subsequent training to minimise these errors. Training can be conducted whilst ensuring there is no detriment to patient safety. Copyright © 2012 Elsevier B.V. All rights reserved.
Bottros, John; Gad, Bishoy; Krebs, Viktor; Barsoum, Wael K
It is well known that the success of total knee arthroplasty is collectively dependent on the proper recreation of the joint line, appropriate soft tissue balancing, and respectful management of the extensor mechanism. One of the most decisive factors within the surgeon's control is the reestablishment of proper knee kinematics through both medial-lateral and flexion-extension ligamentous balancing. This can be accomplished only by a comprehensive intraoperative evaluation in full flexion, mid flexion, and full extension to minimize potential gap mismatches. Most of the discussion will focus on this aspect of soft tissue balancing, but this does not undermine the importance of the other aforementioned principles of successful knee arthroplasty.
Dunbar, Michael; Newman, Jared M; Khlopas, Anton; Chughtai, Morad; Martinez, Nick; Bhowmik-Stoker, Manoshi; Mont, Michael A
This study surveyed a group of US and international orthopaedic surgeons to prioritize areas of improvement in primary total knee arthroplasty (TKA). Specifically, we assessed surgeon responses regarding the top five areas of TKA needing improvement; which were stratified by: a) US surgeons, b) international surgeons, c) US surgeons' implant-brand-loyalty, and d) surgeons' years of experience and case volume. Four hundred and eighteen surgeons who were board-certified, in practice for at least two years, spent 60% of their time in clinical practice, and performed a minimum of 25 lower extremity joint arthroplasties per year were surveyed. They chose the top five areas (among 17) needing improvement for TKA. Results were stratified by surgeons' location (US and international), implant-brand-loyalty, years of experience, and case volume. Functional outcomes was the top identified area for improvement (US 63% and international 71%), followed by brand loyalty (Company I 68%, other brand 59%, and multi-brand/no loyalty 66%), years of experience (early-career 64%, mid-career 63%, and late-career 75%) and case volume (low-volume 69%, mid-volume 60%, and high-volume 71%). Following this was costs for US surgeons (47%) and implant survivorship for international surgeons (57%). While costs were the next highest area for specific Company-loyal surgeons (57%), implant survivorship was the next highest area for the other two cohorts. Implant survivorship was the second most important area of improvement regardless of years of experience and for low- and mid-volume surgeons. Surgeons identified functional outcomes as the most important area needing improvement. Cost of implants was more important for American as compared to international surgeons.
Houdek, Matthew T; Scorianz, Maurizio; Wyles, Cody C; Trousdale, Robert T; Sim, Franklin H; Taunton, Michael J
Pigmented villonodular synovitis (PVNS) is a rare, benign proliferation of the synovium, commonly affecting the knee. Arthroplasty can successfully manage arthrosis in this population; however, outcome data is limited. The purpose of this study was to investigate the oncologic and functional outcome of patients undergoing total knee arthroplasty (TKA) in the setting of PVNS. 48 patients were identified at our institution with histologically confirmed PVNS that subsequently received TKA. The cohort consisted of 28 females and 20 males with a mean age and body mass index of 61years and 29.2kg/m(2). 37patients had "active" disease, defined as diffuse in 40 patients and focal in eight. Mean follow-up was 14years. The 10-year disease free-survival was 88%. Recurrence occurred in 6 patients and was treated with synovectomy and revision arthroplasty (n=4), local excision (n=1) and transfemoral amputation (n=1). 25 patients sustained at least 1 complication, most commonly decreased knee range of motion. Complications resulted in revision TKA in 10 patients (21%). There was no difference (P=0.74) between mean pre- and postoperative ROM; however, there was a significant reduction in the number of patients with a flexion contracture >15° (P=0.03). The mean Knee Society score and functional score significantly improved following surgery (P<0.001). This study indicates arthroplasty in the setting of PVNS improves patient function and reduces the presence of flexion contractures. Patients with a history of PVNS should be cautioned when undergoing arthroplasty on the elevated risk of subsequent procedures. Level III. Copyright © 2017 Elsevier B.V. All rights reserved.
Liebs, Thoralf R; Herzberg, Wolfgang; Rüther, Wolfgang; Haasters, Jörg; Russlies, Martin; Hassenpflug, Joachim
To evaluate if the timing of aquatic therapy influences clinical outcomes after total knee arthroplasty (TKA) or total hip arthroplasty (THA). Multicenter randomized controlled trial with 3-, 6-, 12-, and 24-month follow-up. Two university hospitals, 1 municipal hospital, and 1 rural hospital. Patients (N=465) undergoing primary THA (n=280) or TKA (n=185): 156 men, 309 women. Patients were randomly assigned to receive aquatic therapy (pool exercises aimed at training of proprioception, coordination, and strengthening) after 6 versus 14 days after THA or TKA. Primary outcome was self-reported physical function as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 3-, 6-, 12-, and 24-months postoperatively. Results were compared with published thresholds for minimal clinically important improvements. Secondary outcomes included the Medical Outcomes Study 36-Item Short-Form Health Survey, Lequesne-Hip/Knee-Score, WOMAC-pain and stiffness scores, and patient satisfaction. Baseline characteristics of the 2 groups were similar. Analyzing the total study population did not result in statistically significant differences at all follow-ups. However, when performing subanalysis for THA and TKA, opposite effects of early aquatic therapy were seen between TKA and THA. After TKA all WOMAC subscales were superior in the early aquatic therapy group, with effect sizes of WOMAC physical function ranging from .22 to .39. After THA, however, all outcomes were superior in the late aquatic therapy group, with WOMAC effect sizes ranging from .01 to .19. However, the differences between treatment groups of these subanalyses were not statistically significant. Early start of aquatic therapy had contrary effects after TKA when compared with THA and it influenced clinical outcomes after TKA. Although the treatment differences did not achieve statistically significance, the effect size for early aquatic therapy after TKA had the same magnitude as the
Mikashima, Yoshinori; Takagi, Tadashi; Tomatsu, Taisuke; Horikoshi, Mariko; Ikari, Katsunori; Momohara, Shigeki
The purpose of this study was to determine whether acupuncture is effective in reducing pain and swelling around the knee and improving range of motion (ROM) during the post-acute phase of rehabilitation after total knee arthroplasty (TKA). Following TKA, 80 knees in 80 patients were randomly assigned to either an acupuncture treatment group (Group A) or a control group (Group C). In Group A, the complementary treatment of acupuncture was performed three times/week from postoperative day 7 until postoperative day 21. Outcome measures were: i) pain as assessed by a visual analog scale; ii) reduction of swelling around the knee as indicated by its circumference at the center of the patella; and iii) ROM of the affected knee. Group A patients had significantly reduced pain and swelling around the knees and earlier recovery of ROM than did those in Group C. Acupuncture provides effective treatment during the post-acute phase of rehabilitation after TKA with respect to pain relief, reduction of swelling around the knee, and early recovery of ROM.
Nam, Denis; Barrack, Toby; Nunley, Ryan M; Barrack, Robert L
Prior investigations have recognized the presence of patient-perceived noise generation after total knee arthroplasty (TKA). However, questions remain regarding its overall frequency after both TKA and unicompartmental knee arthroplasty (UKA) as well as with respect to its association with demographic and prosthesis-related factors and its association with patient-reported outcomes. The purposes of this study were (1) to determine the frequency with which patients report noise coming from the knee after TKA or UKA; (2) to identify patient and prosthesis-related factors associated with noise generation; and (3) to ascertain whether noise coming from the knee is associated with residual symptoms after knee arthroplasty. A five-center survey study was designed to identify patient-perceived noise and to quantify the degree of residual symptoms and functional deficits in patients after TKA or UKA. Data were collected by an independent, third-party survey center, which administered questions about residual symptoms, function, and pre- and postoperative activity levels. Patients meeting prespecified inclusion criteria were specifically questioned regarding perceived noises from their knee within the last 30 days; those who reported hearing noises sometimes, often, or extremely often were categorized as positive. We retrospectively identified 2671 patients who underwent TKA and 744 patients who underwent UKA and who met inclusion criteria; the final survey population included 1580 patients who underwent TKA and 476 patients who underwent UKA (68% response rate). TKA implant types included cruciate-retaining (59%), posterior-stabilized (16%), rotating-platform (13%), gender-specific (7%), and high-flex (5%). Differences in baseline demographic variables were accounted for using multiple logistic regression statistical analyses. Chi square analyses were used to compare the frequency of residual symptoms in those patients with and without noise generation. Overall, 27% (557
MARRA, FRANCESCO; ROSSO, FEDERICA; BRUZZONE, MATTEO; BONASIA, DAVIDE EDOARDO; DETTONI, FEDERICO; ROSSI, ROBERTO
Purpose different strategies have been developed to reduce blood loss in total knee arthroplasty (TKA). The efficacy of both systemic and local tranexamic acid (TXA) administration is demonstrated in the literature. The aim of the present study was to compare the efficacy of systemic, local and combined (systemic + local) administration of TXA in reducing blood loss after TKA. Methods we enrolled all patients submitted to a primary TKA in our department between November 2014 and August 2015. They were divided into three groups corresponding to the method of TXA administration used: intravenous (IV), intra-articular (IA), and a combination of the two. Demographic data, as well as preoperative hemoglobin and platelet levels, were collected. The primary outcome was the maximum hemoglobin loss, while the secondary outcomes were the amount of blood in the drain (cc/hour) and the rate of transfusions; postoperative pain was also assessed. Student’s t-test or a χ2 test was used to evaluate between-group differences, using p<0.05 as the cut-off for statistically significant differences. Results the sample comprised 34 patients: IV, 10 cases; IA, 15 cases, and combined (IV + IA), 9 cases. The average age of the patients was 71.1±6.4 years. No significant differences in the outcome measures were found between the groups, with the exception of a significantly lower maximum hemoglobin loss in the combined versus the IV group (p=0.02). There were no differences between the groups in the amount of blood in the drain or the rate of transfusions. Conclusions the data from this preliminary study, as well as data from the literature, confirm that TXA administration is safe and effective in reducing total blood loss in TKA, and no administration protocol seems to be superior to the others. Level of evidence Level II, prospective comparative study. PMID:28217656
Jeon, Young-Tae; Kim, Byung-Gun; Park, Young Ho; Sohn, Hye-Min; Kim, Jungeun; Kim, Seung Chan; An, Seong Soo; Kim, SangYun
Abstract Background: The type of postoperative cognitive decline after surgery under spinal anesthesia is unknown. We investigated the type of postoperative cognitive decline after total knee arthroplasty (TKA). Neuropsychological testing was conducted and the changes in cerebrospinal fluid (CSF) biomarkers after surgery were evaluated. Methods: Fifteen patients who required bilateral TKA at a 1-week interval under spinal anesthesia were included. Neuropsychological tests were performed twice, once the day before the first operation and just before the second operation (usually 1 week after the first test) to determine cognitive decline. Validated neuropsychological tests were used to examine 4 types of cognitive decline: memory, frontal-executive, language-semantic, and others. Concentrations of CSF amyloid peptide, tau protein, and S100B were measured twice during spinal anesthesia at a 1-week interval. The patients showed poor performance in frontal-executive function (forward digit span, semantic fluency, letter-phonemic fluency, and Stroop color reading) at the second compared to the first neuropsychological assessment. Results: S100B concentration decreased significantly 1 week after the operation compared to the basal value (638 ± 178 vs 509 ± 167 pg/mL) (P = 0.019). Amyloid protein β1–42, total tau, and phosphorylated tau concentrations tended to decrease but the changes were not significant. Conclusion: Our results suggest that frontal-executive function declined 1 week after TKA under spinal anesthesia. The CSF biomarker analysis indicated that TKA under regional anesthesia might not cause neuronal damage. PMID:28033253
Guan, Shanyuanye; Gray, Hans A; Schache, Anthony G; Feller, Julian; de Steiger, Richard; Pandy, Marcus G
No data are available to describe six-degree-of-freedom (6-DOF) knee-joint kinematics for one complete cycle of overground walking following total knee arthroplasty (TKA). The aims of this study were firstly, to measure 6-DOF knee-joint kinematics and condylar motion for overground walking following TKA; and secondly, to determine whether such data differed between overground and treadmill gait when participants walked at the same speed during both tasks. A unique mobile biplane X-ray imaging system enabled accurate measurement of 6-DOF TKA knee kinematics during overground walking by simultaneously tracking and imaging the joint. The largest rotations occurred for flexion-extension and internal-external rotation whereas the largest translations were associated with joint distraction and anterior-posterior drawer. Strong associations were found between flexion-extension and adduction-abduction (R(2) = 0.92), joint distraction (R(2) = 1.00), and anterior-posterior translation (R(2) = 0.77), providing evidence of kinematic coupling in the TKA knee. Although the measured kinematic profiles for overground walking were grossly similar to those for treadmill walking, several statistically significant differences were observed between the two conditions with respect to temporo-spatial parameters, 6-DOF knee-joint kinematics, and condylar contact locations and sliding. Thus, caution is advised when making recommendations regarding knee implant performance based on treadmill-measured knee-joint kinematic data. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1634-1643, 2017. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Hsu, Andrew R; Kim, Jeffrey D; Bhatia, Sanjeev; Levine, Brett R
The use of digital radiography and templating software continues to become more prevalent in orthopedics as the number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures increases every year. The purpose of this study was to evaluate the effect of training level on the accuracy of digital templating for primary THA and TKA. Digital radiographs of 97 patients undergoing primary THA (49 cases) and TKA (48 cases) were retrospectively templated using OrthoView digital planning software (OrthoView LLC, Jacksonville, Florida). Anteroposterior hip and lateral knee radiographs were digitally templated and compared with the actual size of the implants used intraoperatively. An implant sales representative, physician assistant, medical student (J.D.K.), resident (A.R.H.), and fellowship-trained arthroplasty surgeon (B.R.L.) templated all cases independently after a standardized orientation and were blinded to the actual component sizes used for surgery. The medical student, resident, and arthroplasty surgeon retemplated the same 97 cases 1 month later to determine intraobserver reliability. Digital templating was accurate in predicting the correct implant size in 33% of THAs and 54% of TKAs. In 73% of THAs and 92% of TKAs, digital templating was within 1 size of the actual implant used, and in 88% of THAs and 99% of TKAs, templating was within 2 sizes of the final components. In no cases did the templated implant size vary by >3 sizes from the final components. Interobserver reliability for templating THAs and TKAs showed good reliability as measured by intraclass correlation coefficient (ICC) (ICC(THA)=.70; ICC(TKA)=.86). Intraobserver reliability for templating THAs had excellent reliability for the resident and arthroplasty surgeon, with a kappa coefficient (κ) of 0.92, and good reliability for the medical student (κ=0.78). Intraobserver reliability for templating TKAs showed excellent reliability among all examiners (κ=0.90).
Tosun, Hacı Bayram; Uludağ, Abuzer; Serbest, Sancar; Gümüştaş, Seyitali; Erdoğdu, İbrahim Halil
INTRODUCTION Nonpigmented villonodular synovitis (non-PVNS) is a benign proliferative disease involving the synovium. It is a rare condition that is little recognized. Non-PVNS has been reported as a cause of total knee replacement failure. PRESENTATION OF CASE We report a case of extensive diffuse non-PVNS in a patient with tibial component loosening after total knee replacement and review the related literature. DISCUSSION It is reported that pigmented villonodular synovitis (PVNS) occurs less frequently than non-PVNS after knee replacement. However, there are many more case reports of PVNS than non-PVNS after knee arthroplasty in the English-language literature. CONCLUSION Previously, there were no reported cases of extensive diffuse non-PVNS after total knee arthroplasty (TKA). This case study highlights an unusual case of non-PVNS as a cause of TKA failure. We propose that non-PVNS should be considered as a differential diagnosis in patients after TKA who present with recurrent pain and effusion/hemarthrosis of the knee, and that it is one of the causes of implant loosening after TKA. PMID:24892248
Tosun, Hacı Bayram; Uludağ, Abuzer; Serbest, Sancar; Gümüştaş, Seyitali; Erdoğdu, Ibrahim Halil
Nonpigmented villonodular synovitis (non-PVNS) is a benign proliferative disease involving the synovium. It is a rare condition that is little recognized. Non-PVNS has been reported as a cause of total knee replacement failure. We report a case of extensive diffuse non-PVNS in a patient with tibial component loosening after total knee replacement and review the related literature. It is reported that pigmented villonodular synovitis (PVNS) occurs less frequently than non-PVNS after knee replacement. However, there are many more case reports of PVNS than non-PVNS after knee arthroplasty in the English-language literature. Previously, there were no reported cases of extensive diffuse non-PVNS after total knee arthroplasty (TKA). This case study highlights an unusual case of non-PVNS as a cause of TKA failure. We propose that non-PVNS should be considered as a differential diagnosis in patients after TKA who present with recurrent pain and effusion/hemarthrosis of the knee, and that it is one of the causes of implant loosening after TKA. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
Singh, Jasvinder A.; Kwoh, C. Kent; Richardson, Diane; Chen, Wei; Ibrahim, Said A.
Objective Total knee arthroplasty (TKA) is a widely utilized and an effective treatment option for end-stage knee OA. Knee OA is more prevalent among women compared to men, but there are limited data on gender differences in surgical outcomes after total knee arthroplasty. Methods Our sample consisted of all primary TKA’s performed in the State of Pennsylvania during the fiscal year 2002. We used ICD-9 codes to identify major complications and surgical revision. We used mixed effects logistic regression models to examine the associations between gender and all-cause mortality, readmissions, and major surgical complications. We used proportional hazards model to assess the risk of surgical revision after index arthroplasty. We adjusted for race, age, hospital teaching status, hospital procedure volume, insurance status and risk of mortality. Results In 17,994 primary TKA’s, there were 46 deaths at 30-days and 220 at one-year. Compared to women, men had higher adjusted odds of one-year mortality (Odds Ratio (OR)=1.48; 95% CI=1.13–1.94) after primary TKA. The overall odds of most major 30-day complications did not differ by gender, except surgical wound infections, which were higher in men compared to women (OR= 1.31; 95% CI=1.08–1.60); 30-day readmission was higher in men (OR=1.25; 95% CI=1.10–1.43). Men had significantly higher rates of index knee arthroplasty revision at 5-years (hazard ratio= 1.20; 95% CI=1.05–1.36) compared to women. Conclusion Higher rates of mortality, hospital readmissions, revision surgery and wound infections in men undergoing elective TKA, compared to women, indicates gender disparity in these outcomes. PMID:23335560
Medalla, Greg Anthony; Moonot, Pradeep; Peel, Tamlyn; Kalairajah, Yegappan; Field, Richard E
The American Knee Society score (AKSS) and the Oxford Knee score (OKS) are validated outcome measures for evaluation of total knee arthroplasties (TKAs). We investigated whether patient self-assessment using the OKS offers a viable alternative to clinical review using the AKSS. Preoperative, 2-year, 5-year, and 10-year postoperative OKS and AKSS were reviewed from TKA patients. The scores were analyzed using the Pearson correlation. There was good correlation of OKS and AKSS at 2 years. This implies that patient self-assessment is a viable screening tool to identify which patients require clinical review, at 2 years, after TKA. However, the moderate correlation at 5 and 10 years indicates that clinical evaluation remains necessary at these time points.
Rossi, Mark D; Brown, Lee E; Whitehurst, Michael
The purpose of this study was to document the early history of knee extensor torque production before and after total knee arthroplasty (TKA), explore the relationship between strength assessments, and describe an 8-week resistive-training protocol. Thirty-eight individuals (19 men, 19 women) with unilateral TKA volunteered to participate in this repeated-measures study. For this group, the mean age was 72.23 +/- 5.34 years; height was 168.00 +/- 8.57 cm; and weight was 79.42 +/- 14.57 kg. Torque production of the knee extensors was assessed isokinetically at 60 and 180 degrees .s(-1) before surgery, 30 days after unilateral TKA (+30), and 60 days after unilateral TKA (+60). Torque production was significantly different between limbs at both 60 and 180 degrees .s(-1) (p < 0.0125) before surgery. Torque production was lower at +30 compared with before surgery at both 60 and 180 degrees .s(-1) (p < 0.002). By +60, torque production was greater than at +30 at both 60 and 180 degrees .s(-1) (p < 0.002).
Pang, Hee-Nee; Bin Abd Razak, Hamid Rahmatullah; Petis, Stephen; Naudie, Douglas D. R.; MacDonald, Steven J.
The use of modular total knee arthroplasty (TKA) implants allows surgeons to perform isolated tibial polyethylene insert exchange (IPE) while retaining well-fixed and stable components. The purported advantages of IPE include preservation of bone stock, shorter operating time, less blood loss, faster rehabilitation and lower cost. However, the indications for IPE are limited. IPE for wear and osteolysis has moderate success in the medium term but should be avoided in cases of accelerated wear. In selected cases, debridement and IPE for early infection can result in low morbidity with high success rates in the short term. IPE for arthrofibrosis has poor results. IPE should be undertaken with caution and an institutional algorithm should be followed. Cite this article: EFORT Open Rev 2017;2:66–71 DOI: 10.1302/2058-5241.2.160049 PMID:28507777
Boureau, F; Putman, S; Arnould, A; Dereudre, G; Migaud, H; Pasquier, G
Management of bone loss is a major challenge in revision total knee arthroplasty (TKA). The development of preformed porous tantalum cones offers new possibilities, because they seem to have biological and mechanical qualities that facilitate osseointegration. Compared to the original procedure, when metaphyseal bone defects are too severe, a single tantalum cone may not be enough and we have developed a technique that could extend the indications for this cone in these cases. We used 2 cones to fill femoral bone defects in 7 patients. There were no complications due to wear of the tantalum cones. Radiological follow-up did show any migration or loosening. The short-term results confirm the interest of porous tantalum cones and suggest that they can be an alternative to allografts or megaprostheses in case of massive bone defects. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Dolfin, Marco; Saccia, Francesco
The mobile bearing (MB) concept in total knee arthroplasty (TKA) was developed as an alternative to fixed bearing (FB) implants in order to reduce wear and improve range of motion (ROM), especially focused on younger patients. Unfortunately, its theoretical advantages are still controversial. In this paper we exhibit a review of the more recent literature available comparing FB and MB designs in biomechanical and clinical aspects, including observational studies, clinical trials, national and international registries analyses, randomized controlled trials, meta-analyses and Cochrane reviews. Except for some minor aspects, none of the studies published so far has reported a significant improvement related to MBs regarding patient satisfaction, clinical, functional and radiological outcome or medium and long-term survivorship. Thus the presumed superiority of MBs over FBs appears largely inconsistent. The routine use of MB is not currently supported by adequate evidences; implant choice should be therefore made on the basis of other factors, including cost and surgeon experience. PMID:27162777
Capella, Marcello; Dolfin, Marco; Saccia, Francesco
The mobile bearing (MB) concept in total knee arthroplasty (TKA) was developed as an alternative to fixed bearing (FB) implants in order to reduce wear and improve range of motion (ROM), especially focused on younger patients. Unfortunately, its theoretical advantages are still controversial. In this paper we exhibit a review of the more recent literature available comparing FB and MB designs in biomechanical and clinical aspects, including observational studies, clinical trials, national and international registries analyses, randomized controlled trials, meta-analyses and Cochrane reviews. Except for some minor aspects, none of the studies published so far has reported a significant improvement related to MBs regarding patient satisfaction, clinical, functional and radiological outcome or medium and long-term survivorship. Thus the presumed superiority of MBs over FBs appears largely inconsistent. The routine use of MB is not currently supported by adequate evidences; implant choice should be therefore made on the basis of other factors, including cost and surgeon experience.
Pang, Hee-Nee; Bin Abd Razak, Hamid Rahmatullah; Petis, Stephen; Naudie, Douglas D R; MacDonald, Steven J
The use of modular total knee arthroplasty (TKA) implants allows surgeons to perform isolated tibial polyethylene insert exchange (IPE) while retaining well-fixed and stable components.The purported advantages of IPE include preservation of bone stock, shorter operating time, less blood loss, faster rehabilitation and lower cost. However, the indications for IPE are limited.IPE for wear and osteolysis has moderate success in the medium term but should be avoided in cases of accelerated wear. In selected cases, debridement and IPE for early infection can result in low morbidity with high success rates in the short term. IPE for arthrofibrosis has poor results.IPE should be undertaken with caution and an institutional algorithm should be followed. Cite this article: EFORT Open Rev 2017;2:66-71 DOI: 10.1302/2058-5241.2.160049.
Ding, Liangjia; Liu, Xiaomin; Liu, Changlu; Liu, Yingli
[Purpose] The reasons for femorotibial rotational malalignment after total knee arthroplasty (TKA) were analyzed to provide evidence for clinical knee joint surgery and to reduce complications. [Subjects and Methods] Ninety knees of 60 patients were selected and randomly divided into two groups (n=30). For one group, rotational alignment of the femoral component was determined by the transepicondylar axis and TKA was performed. For the other group, rotational alignment of the femoral component was conducted through 3° external rotation of the posterior femoral condyles. Knee joint specimens were operated with TKA and various biomechanical indices were measured. [Results] The femoral epicondylar axis was a constant, reliable reference for femoral component rotational alignment. When the femoral component was rotated by 0° versus the epicondylar axis, the peak contact pressure on the patellofemoral joint was optimal. When the femoral component was arranged in parallel with Whiteside’s line, the peak contact pressure on the patellofemoral joint varied largely. The patellofemoral contact areas of the two groups were similar. [Conclusion] Axial rotational alignment of the femoral component influenced the contact pressure of patellofemoral joints in TKA more significantly than external rotation of the femoral condyles. It is more reliable to use the femoral epicondylar axis as the reference for the rotational alignment of the femoral component. PMID:26311929
Hrnack, Scott A; Skeen, Nick; Xu, Tom; Rosenstein, Alexander D
Almost one-third of Americans older than 20 years are considered obese. Excessive weight has been linked to faster destruction of weight-bearing joints, which may then need to be replaced. Joint replacement surgeons disagree about an association between obesity and increased blood loss during hip or knee joint replacement. In this retrospective study, we examined the effect of body mass index (BMI), operative time (length of procedure), and anesthesia time on total blood loss during primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA). Intraoperative data from 94 primary TKAs and 78 primary THAs were reviewed, and divided into obese and nonobese groups on the basis of calculated BMI. Regression analysis was used to compare intraoperative blood loss amounts to patient characteristics. TKA and THA groups were analyzed separately. Obesity did not correlate with increased intraoperative blood loss in the TKA or THA group. However, operative time correlated with increased intraoperative blood loss. A 1-minute increase in anesthesia time resulted in total blood loss increases of 3.167 mL during TKA and 1.552 mL during THA.
Dasa, Vinod; Lensing, Gabriel; Parsons, Miles; Harris, Justin; Volaufova, Julia; Bliss, Ryan
Total knee arthroplasty (TKA) is a common procedure resulting in significant post-operative pain. Percutaneous cryoneurolysis targeting the infrapatellar branch of the saphenous nerve and anterior femoral cutaneous nerve could relieve post-operative knee pain by temporarily blocking sensory nerve conduction. A retrospective chart review of 100 patients who underwent TKA was conducted to assess the value of adding perioperative cryoneurolysis to a multimodal pain management program. The treatment group consisted of the first 50 patients consecutively treated after the practice introduced perioperative (five days prior to surgery) cryoneurolysis as part of its standard pain management protocol. The control group consisted of the 50 patients treated before cryoneurolysis was introduced. Outcomes included hospital length of stay (LOS), post-operative opioid requirements, and patient-reported outcomes of pain and function. A significantly lower proportion of patients in the treatment group had a LOS of ≥2days compared with the control group (6% vs. 67%, p<0.0001) and required 45% less opioids during the first 12weeks after surgery. The treatment group reported a statistically significant reduction in symptoms at the six- and 12-week follow-up compared with the control group and within-group significant reductions in pain intensity and pain interference at two- and six-week follow-up, respectively. Perioperative cryoneurolysis in combination with multimodal pain management may significantly improve outcomes in patients undergoing TKA. Promising results from this preliminary retrospective study warrant further investigation of this novel treatment in prospective, randomized trials. III. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.
Saevarsson, Stefan K; Romeo, Carolina I; Anglin, Carolyn
Knee kinematics provide information about how the femoral, tibial and patellar bones or prosthetic components move relative to each other. Accurate knowledge of kinematics is valuable for implant design, comparisons between designs or surgical techniques, and to identify differences between patients with good and poor outcomes. Both static and dynamic imaging techniques have been used to evaluate kinematics. In general, static imaging is used to capture better quality images or to capture views that cannot be acquired by dynamic imaging, whereas dynamic imaging is used to capture real-life movements. How well static kinematics represent dynamic kinematics is subject to frequent debate and has not been adequately addressed, especially after total knee arthroplasty (TKA). We compared the static and dynamic weightbearing kinematics of 10 female subjects after TKA. Using the same clinical scanner for both methods, static images were taken using our standard protocol, sequential-biplane radiographs at multiple flexion angles, as well as with dynamic video fluoroscopy during a step up activity. The static method can reliably measure all 12 degrees of freedom (DOF) after TKA, however only seven were compared due to the poorer out-of-plane reliability in the single-plane dynamic imaging. No differences were found between the static and dynamic kinematics for nine out of ten subjects. For one subject, however, a difference of 5-8° in internal/external tibial rotation was found. The research question, study purpose and the advantages and disadvantages of each method need to be considered when determining which imaging method to use.
Kim, Abraham D; Shah, Vivek M; Scott, Richard D
We evaluated the intraoperative effect of patellar thickness on intraoperative passive knee flexion and patellar tracking during total knee arthroplasty (TKA) in patients with preoperative arthrofibrosis and compared them to patients with normal preoperative range of motion (ROM) documented in a prior study. Routine posterior cruciate ligament-retaining TKA was performed in a total of 34 knees, 23 with normal ROM and 11 with arthrofibrosis, defined as ≤100° of passive knee flexion against gravity under anesthesia. Once clinical balance and congruent patellar tracking were established, custom trial patellar components thicker than the standard trial by 2-mm increments (2-8 mm) were sequentially placed and trialed. Passive flexion against gravity was recorded using digital photograph goniometry. Gross mechanics of patellofemoral tracking were visually assessed. On average, passive knee flexion decreased 2° for every 2-mm increment of patellar thickness (P < .0001), which was similar to patients with normal preoperative ROM. In addition, increased patellar thickness had no gross effect on patellar subluxation and tilt in patients with arthrofibrosis as well as those with normal ROM. Patellar thickness had a modest effect on intraoperative passive flexion and no effect on patellar tracking in patients with arthrofibrosis undergoing TKA. There was no marked difference in intraoperative flexion and patellar tracking between patients with arthrofibrosis and patients with normal preoperative ROM. Copyright © 2016 Elsevier Inc. All rights reserved.
Tai, Ta-Wei; Lin, Tzu-Chieh; Ho, Chia-Jung; Kao Yang, Yea-Huei; Yang, Chyun-Yu
Oral bacteremia has been presumed to be an important risk factor for total knee arthroplasty (TKA) infection. We aimed to investigate whether dental scaling could reduce the risk of TKA infection. A nested case-control study was conducted to compare 1,291 TKA patients who underwent resection arthroplasty for infected TKA and 5,004 matched controls without infection in the TKA cohort of Taiwan's National Health Insurance Research Database (NHIRD). The frequency of dental scaling was analyzed. Multiple conditional logistic regression was used to assess the frequency of dental scaling and the risk of TKA infection. The percentage of patients who received dental scaling was higher in the control group than in the TKA infection group. The risk for TKA infection was 20% lower for patients who received dental scaling at least once within a 3-year period than for patients who never received dental scaling. Moreover, the risk of TKA infection was reduced by 31% among patients who underwent more frequent dental scaling (5-6 times within 3 years). Frequent and regular dental scaling is associated with a reduced risk of TKA infection.
Tai, Ta-Wei; Lin, Tzu-Chieh; Ho, Chia-Jung; Kao Yang, Yea-Huei; Yang, Chyun-Yu
Oral bacteremia has been presumed to be an important risk factor for total knee arthroplasty (TKA) infection. We aimed to investigate whether dental scaling could reduce the risk of TKA infection. A nested case-control study was conducted to compare 1,291 TKA patients who underwent resection arthroplasty for infected TKA and 5,004 matched controls without infection in the TKA cohort of Taiwan’s National Health Insurance Research Database (NHIRD). The frequency of dental scaling was analyzed. Multiple conditional logistic regression was used to assess the frequency of dental scaling and the risk of TKA infection. The percentage of patients who received dental scaling was higher in the control group than in the TKA infection group. The risk for TKA infection was 20% lower for patients who received dental scaling at least once within a 3-year period than for patients who never received dental scaling. Moreover, the risk of TKA infection was reduced by 31% among patients who underwent more frequent dental scaling (5–6 times within 3 years). Frequent and regular dental scaling is associated with a reduced risk of TKA infection. PMID:27336912
Davies, Gareth Sion; van Duren, Ben; Shorthose, Matthew; Garfjeld Roberts, Patrick; Morley, John R; Monk, Andrew P; Murray, David W; Pandit, Hemant G
Post-operative shortening of the patellar tendon resulting in an abnormally low-lying patella has been described previously, but the degree of change in patella tendon length over time and extent of its progression after different types of knee arthroplasties remains unknown. This study assesses the incidence of patella tendon length change following lateral unicompartmental knee arthroplasty (UKA), medial UKA, and total knee arthroplasty (TKA), and its impact on patient-reported outcome at 5 years post-surgery. Immediate post-operative, 1- and 5-year radiographs were reviewed for 50 patients undergoing each operation (n = 150), with the Insall-Salvati ratio used as a measure of patella tendon length. Clinical outcome was assessed using the Oxford Knee Score (OKS). At 5-year follow-up, no significant change in patella tendon length was found following medial UKA (1.07-1.05), whilst a significant shortening was found after TKA (1.02-0.96), and a significant lengthening found after lateral UKA (1.02-1.05). For the UKA groups, no further change in tendon length was observed after the first year post-surgery, whereas the TKA group continued to shorten between years one and five. OKS was significantly better in the UKA groups as compared to TKA group. Change in patella tendon length within individual groups did not correlate with OKS at 5 years. Patella tendon length shortening is more prevalent in TKAs, whilst lengthening is more prevalent in lateral UKAs. Despite the vertical incision through the patella tendon, lateral UKAs do not cause increased tendon shortening at 5 years post-surgery. However, in the medium term, changes in patella tendon length do not affect patient-reported outcome. Retrospective, comparative study, Level III.
Jenny, Jean-Yves; Louis, Pascal; Diesinger, Yann
The tested hypothesis was following: the High Activity Arthroplasty Score has a significant lower ceiling effect than American Knee Society Score and Oxford Knee Score after total knee arthroplasty. One hundred patients operated on for total knee arthroplasty with more than one-year follow-up have been included. The ceiling effect was 53% for the American Knee Society Score, 33% for the Oxford Knee Score, and 0% for the High Activity Arthroplasty Score. High Activity Arthroplasty Score had a significantly lower ceiling effect than American Knee Society Score and Oxford Knee Score. High Activity Arthroplasty Score has the potential to detect more subtle differences in level of function than standard scoring systems among a non-selected total knee arthroplasty population. © 2014.
Saleh, Hesham; Yu, Stephen; Vigdorchik, Jonathan; Schwarzkopf, Ran
AIM To review and report functional outcomes, complications, and survivorship associated with total knee arthroplasty (TKA) in the treatment of post-traumatic arthritis (PTA). METHODS We conducted a systematic review according to the PRISMA guidelines. We searched PubMed, Cochrane Library, and SCOPUS in December 2015 for English-language clinical research studies, both prospective and retrospective, examining the use of TKA for the treatment of PTA. All relevant articles were accessed in full. The manual search included references of retrieved articles. We extracted data on patients’ demographics and clinical outcomes, including preoperative diagnosis and pre- and post-operative functional scores. We summarized the data and reported the results in tables and text. RESULTS Sixteen studies, four prospective and ten retrospective, examined patients who underwent TKA for PTA due to fractures of the proximal tibia, patella, and/or distal femur. Eleven studies utilized the Knee Society Scores criteria to assess functional outcomes. All studies utilizing these criteria reported an improvement in functional and knee scores of patients following TKA. Further, studies reported an increased range of motion (ROM) and reduction of pain following surgery. The most commonly reported complications with TKA included infection, stiffness, wound complications, intraoperative rupture of tendons, and osteolysis/polyethylene wear. The overwhelming majority of these complications occurred within the first two years following surgery. Six studies examined the survivorship of TKA with subsequent revision for any reason as an endpoint. Compared to patients with osteoarthritis, patients with PTA required more revisions, the majority for polyethylene wear. CONCLUSION Although associated with higher complication rates, TKA is an effective treatment for PTA, as it improves ROM, pain and functional outcomes. PMID:27672572
Asada, Shigeki; Mori, Shigeshi; Inoue, Shinji; Tsukamoto, Ichiroh; Akagi, Masao
The purpose of this study was to investigate the ankle center position as determined from the malleoli for total knee arthroplasty (TKA). We retrospectively analyzed computed tomography data from 102 patients with osteoarthritic knees. The tibial anteroposterior (AP) axis and transmalleolar axis (TMA) were used as rotational reference axes of the knee and ankle joint, respectively. With these axes, we regarded the offset distance from the intermalleolar midpoint as the position of the ankle center and investigated any angular osteotomy errors on the proximal tibia when the ankle center was assumed to the intermalleolar midpoint. The mean offset distances relative to the tibial AP axis were 1.8±0.9mm medial and 4.2±1.2mm anterior, and the distances relative to the TMA were 3.0±0.9 and 3.6±1.1mm in the coronal and sagittal planes, respectively. Mean angular osteotomy errors were 0.3±0.2° in the coronal plane and 0.8±0.2° in the sagittal plane. The ankle center was located around the intermalleolar midpoint. The position of the ankle center observed along the knee reference axis further approached the intermalleolar midpoint than when observed along the ankle reference axis in the coronal plane, but not in the sagittal plane. And the coronal angular osteotomy error was smaller than the sagittal error. Therefore, the intermalleolar midpoint in the coronal plane is a reliable landmark for the ankle center during TKA. However, surgeons should be cognizant of this sagittal angular error. Copyright © 2016 Elsevier B.V. All rights reserved.
Giesinger, K.; Hamilton, D.F.; Jost, B.; Holzner, B.; Giesinger, J.M.
Summary Objective The aim of this study was to compare the responsiveness of various patient-reported outcome measures (PROMs) and clinician-reported outcomes following total knee arthroplasty (TKA) over a 2-year period. Methods Data were collected in a prospective cohort study of primary TKA. Patients who had completed Forgotten Joint Score-12 (FJS-12), Western Ontario and McMaster Universities (WOMAC) osteoarthritis (OA) index, EQ-5D, Knee Society Score and range of movement (ROM) assessment were included. Five time points were assessed: pre-operative, 2 months, 6 months, 1 year and 2 years post-operative. Results Data from 98 TKAs were available for analysis. Largest effect sizes (ES) for change from pre-operative to 2-month follow-up were observed for the Knee Society Score (KSS) Knee score (1.70) and WOMAC Total (−1.50). For the period from 6 months to 1 year the largest ES for change were shown by the FJS-12 (0.99) and the KSS Function Score (0.88). The EQ-5D showed the strongest ceiling effect at 1-year follow-up with 84.4% of patients scoring the maximum score. ES for the time from 1- to 2-year follow-up were largest for the FJS-12 (0.50). All other outcome measures showed ES equal or below 0.30. Conclusion Outcome measures differ considerably in responsiveness, especially beyond one year post-operatively. Joint-specific outcome measures are more responsive than clinician-reported or generic health outcome tools. The FJS-12 was the most responsive of the tools assessed; suggesting that joint awareness may be a more discerning measure of patient outcome than traditional PROMs. PMID:24262431
Seo, Jai-Gon; Moon, Young-Wan; Kim, Sang-Min; Park, Sang-Hoon; Lee, Byung-Hoon; Chang, Moon-Jong; Jo, Byung-Chul
Pseudo-patella baja (PPB) is a surgical complication that can arise from total knee arthroplasty and occurs when the patella tendon is not shortened but the level of the femorotibial joint line is elevated. The goal of this study was to assess the performance of a technique specifically designed to prevent the occurrence of PPB and its radiological results. Ninety-nine patients undergoing total knee arthroplasty were included. Patients were divided into a non-correction group and a correction group. The correction group were applied an additional metal block in order to reduce the excess resection of the distal femur. To evaluate PPB, the change in the pre- and postoperative joint line was measured using the modified Blackburne-Peel Index (BPI). In the non-correction group, 68 of 74 cases showed an occurrence of PPB (92 %), in the correction group, 6 of 57 cases showed an occurrence of PPB (11 %). The preoperative-modified BPI of the non-correction group was not significantly different from that of the correction group (0.6 ± 0.1 vs. 0.6 ± 0.2). The modified BPI decreased significantly in the non-correction group after TKA (0.6 ± 0.1 vs. 0.2 ± 0.1, p < 0.05). However, the modified BPI did not change significantly in the correction group after TKA (0.6 ± 0.2 vs. 0.6 ± 0.2). The comparison of preoperative and postoperative radiological results showed that our intervention maintained the joint line without elevation. We proposed an effective method to prevent various complications due to the joint line elevation that occur in PPB. III.
Bakırhan, Serkan; Angın, Salih; Karatosun, Vasfi; Ünver, Bayram; Günal, Izge
The aim of this study was to compare quadriceps femoris muscle performance parameters of patients who underwent unilateral and bilateral total knee arthroplasty (TKA). The study included 80 patients. Thirty-five underwent unilateral primary TKA (35 females; mean age: 67.11 ± 3.97 years) and 45 underwent bilateral primary TKA (2 males, 43 females; mean age: 67.12 ± 7.32 years). Patients were evaluated in terms of performance parameters including stand-up time, rising index, standing postural sway velocity, and symmetries of body weight distribution on the extremities while standing up using a Balance Master® balance and performance instrument in the postoperative 6th and 12th month. No significant difference was determined in body weight symmetry ratios between the operated and non-operated extremity in unilateral TKA patients in the 6th and 12th month sit-to-stand test (p>0.05) whereas there was a significant difference in bilateral TKA patients (p<0.05). There was no significant difference between unilateral and bilateral TKA patients in terms of time needed for standing up, rising index and gravity sway velocity at the postoperative 6th month and 12th month (p>0.05). Bilateral TKA patients stood up in a shorter time than unilateral TKA patients (p<0.05) although the degree of body sway was higher after standing up (p<0.05). Bilateral TKA patients should be encouraged to focus on exercises with non-dominant limbs and to use them more while physiotherapy and rehabilitation programs including physical performance activities are planned.
Niki, Yasuo; Takeda, Yuki; Harato, Kengo; Suda, Yasunori
Achievement of very deep knee flexion after total knee arthroplasty (TKA) can play a critical role in the satisfaction of patients who demand a floor-sitting lifestyle and engage in high-flexion daily activities (e.g., seiza-sitting). Seiza-sitting is characterized by the knees flexed >145º and feet turned sole upwards underneath the buttocks with the tibia internally rotated. The present study investigated factors affecting the achievement of seiza-sitting after TKA using posterior-stabilized total knee prosthesis with high-flex knee design. Subjects comprised 32 patients who underwent TKA with high-flex knee prosthesis and achieved seiza-sitting (knee flexion >145º) postoperatively. Another 32 patients served as controls who were capable of knee flexion >145º preoperatively, but failed to achieve seiza-sitting postoperatively. Accuracy of femoral and tibial component positions was assessed in terms of deviation from the ideal position using a two-dimensional to three-dimensional matching technique. Accuracies of the component position, posterior condylar offset ratio and intraoperative gap length were compared between the two groups. The proportion of patients with >3º internally rotated tibial component was significantly higher in patients who failed at seiza-sitting (41 %) than among patients who achieved it (13 %, p = 0.021). Comparison of intraoperative gap length between patient groups revealed that gap length at 135º flexion was significantly larger in patients who achieved seiza-sitting (4.2 ± 0.4 mm) than in patients who failed at it (2.7 ± 0.4 mm, p = 0.007). Conversely, no significant differences in gap inclination were seen between the groups. From the perspective of surgical factors, accurate implant positioning, particularly rotational alignment of the tibial component, and maintenance of a sufficient joint gap at 135º flexion appear to represent critical factors for achieving >145º of deep knee flexion after TKA.
Nam, Denis; Nunley, Ryan M; Johnson, Staci R; Keeney, James A; Barrack, Robert L
Recently, Levy et al questioned the effectiveness of mobile compression devices (MCDs) as the sole method of thromboprophylaxis following simultaneous bilateral total knee arthroplasty (TKA). This study's purpose was to assess if the addition of aspirin to MCDs improves venous thromboembolism (VTE) prevention following simultaneous bilateral TKA. Ninety-six patients (192 TKAs) were retrospectively reviewed: 47 patients received MCDs for 10 days and aspirin for 6 weeks postoperatively based on a risk stratification protocol, while 49 patients received warfarin for 4 weeks postoperatively. One symptomatic VTE was noted in the warfarin cohort, while one patient in the MCD/aspirin cohort and three patients in the warfarin cohort were readmitted within 3 months of surgery. In appropriately selected patients, MCDs with aspirin shows promise in VTE prevention following simultaneous bilateral TKA.
Barretto, João Maurício; Loures, Fabrício Bolpato; Albuquerque, Rodrigo Sattamini Pires E; Bezerra, Filipe das Neves; Faro, Rafael Vinagre; Cavanellas, Naasson Trindade
To evaluate the behavior of C-reactive protein (CRP) levels in the first three weeks after total knee arthroplasty (TKA) and define the factors related to its variation. We evaluated the CRP values in 103 patients undergoing primary TKA. Serum CRP was measured on the day before surgery, and on the third and twenty-first days after the procedure. PCR showed sudden increase on the third day after surgery, reaching the mean value of 111.9 mg/L, median 75.9 mg/L. Only one-third of the patients returned to normal levels in the third week. In the immediate postoperative period, CRP was not correlated with body mass index (BMI), age, gender, blood transfusion, or complications. Serum CRP remains high in the third week after TKA in most patients, and this change is primarily related to surgical trauma.
Lewis, Cynthia; Gunta, Kathleen; Mitchell, Kimberly; Bobay, Kathleen
Numerous methods for postoperative pain management after total knee arthroplasty (TKA) are reported. Multimodal pain management approaches, including peripheral nerve blocks and systemic analgesia, have been shown to decrease patient pain, increase patient satisfaction with pain control, decrease length of stay (LOS), and improve patient outcomes. To compare patient outcomes (pain scores, LOS, postoperative nausea and vomiting, and movement) between 66 TKA patients of a single orthopaedic surgeon in 2010 who received a multimodal approach to 45 historical (control) patients in 2009 who did not receive a multimodal pain management protocol. Patients who were treated with the multimodal pain protocol had significantly lower pain scores in the immediate postoperative period, less postoperative nausea and vomiting day of surgery, and a decrease in LOS by half a day despite increased buckling and increased level of assistance with ambulation. The multimodal pain approach improved patient outcomes in TKA patients.
Charters, Michael A; Frisch, Nicholas B; Wessell, Nolan M; Dobson, Christopher; Les, Clifford M; Silverton, Craig D
The oral Factor Xa inhibitor rivaroxaban (Xarelto) has been the pharmacologic agent used for venous thromboembolism (VTE) prophylaxis after primary hip and knee arthroplasty (THA/TKA) at our institution since February 2012. The purpose of our study was to compare rates of VTE and major bleeding between rivaroxaban and our previous protocol of enoxaparin after THA/TKA. A retrospective cohort study was performed including 2406 consecutive patients at our institution between 1/1/11 and 9/30/13. Patients who did not have unilateral primary THA/TKA or who received other anticoagulants were excluded. Of the 1762 patients included, 1113 patients (63.2%) received enoxaparin and 649 patients (36.8%) received rivaroxaban. This study found no demonstrable differences between these two anticoagulants in rates of VTE, infection, reoperation, transfusion, or major bleeding. Therapeutic, Retrospective comparative study, Level III. Copyright © 2015 Elsevier Inc. All rights reserved.
Talmo, Carl T; Cooper, Andrew J; Wuerz, Tom; Lang, Jason E; Bono, James V
The best operative technique for achieving appropriate postoperative alignment following total knee arthroplasty (TKA) remains controversial, with proponents of extramedullary, intramedullary and computer-assisted techniques. One hundred ninety-two consecutive patients undergoing TKA were prospectively evaluated with full-length lower extremity radiographs. Patients underwent cemented TKA using femoral and tibial intramedullary instrumentation. Digital radiographs were analyzed using PACS (AGFA Healthcare, Ridgefield Park, NJ) software. Tibial component alignment was measured in the coronal and sagittal planes. Tibial component slope averaged 3.89° + 1.96 for the cruciate-retaining components and averaged 1.7° + 1.92 for PS components. The average coronal tibial component alignment was 90.00°, and 99% were within 3° of neutral mechanical alignment with only 2 (1%) outliers. Intramedullary instrumentation resulted in excellent postoperative tibial component and lower extremity alignment.
Park, Cheol-Hee; Lee, Seung-Hyuk; Kang, Dong-Geun; Cho, Kye-Youl; Lee, Sang-Hak; Kim, Kang-Il
Compartment syndrome after total knee arthroplasty (TKA) is a rare complication. Because of its rarity, it may be overlooked and misdiagnosed as peroneal nerve palsy or deep vein thrombosis. This misdiagnosis could have a profound impact on the patient's outcome. We report a case of a 77-year-old female who developed unilateral compartment syndrome in the calf after staged bilateral TKA at an outside clinic. The patient presented with medical complications related to compartment syndrome: rhabdomyolysis and myoglobinuria, which caused acute renal failure. Thus, we performed late fasciotomy one week after symptom onset to debride necrotic tissue and salvage the compartment. In the discussion section, we will discuss risk factors for compartment syndrome after TKA, results of late fasciotomy and other indications for surgical treatment of compartment syndrome.
Mathew, Anoop; Abraham, Biju Jacob; Fischer, Louie; Punnoose, Eapen
Acute popliteal artery thrombosis is a rare complication following total knee arthroplasty (TKA), with sequelae including critical limb ischaemia and amputation. We report the case of a 54-year-old woman who developed acute popliteal artery thrombosis following TKA, presenting 2 weeks after the initial symptoms. While such cases have been traditionally managed with surgical thrombectomy or bypass grafting, percutaneous aspiration thrombectomy is an emerging alternative management strategy in the early postoperative period. However, in patients in whom intervention is delayed, the efficacy of percutaneous aspiration thrombectomy is not known. Our patient had complete resolution of thrombus following percutaneous thrombus aspiration, angioplasty and tirofiban administration. Prompt diagnosis and early percutaneous intervention may avert critical limb ischaemia in patients presenting with popliteal artery thrombosis following TKA. PMID:25414222
Bagsby, Deren T; Ireland, Phillip H; Meneghini, R Michael
The purpose of this study was to compare a novel liposomal bupivacaine to traditional peri-articular injection (PAI) in a multi-modal pain protocol for total knee arthroplasty (TKA). A retrospective cohort study compared 85 consecutive patients undergoing TKA with a traditional PAI of ropivacaine, epinephrine and morphine to 65 patients with a liposomal bupivacaine PAI. After the initial 24h, inpatient self-reported pain scores were higher in the liposomal bupivacaine group compared to the traditional PAI group (P = 0.04) and a smaller percentage (16.9%) of patients in the liposomal bupivacaine group rated their pain as "mild" compared to the traditional group (47.6%). Liposomal bupivacaine PAI provided inferior pain control compared to the less expensive traditional PAI in a multi-modal pain control program in patients undergoing TKA.
Urish, Kenneth L; DeMuth, Peter W; Craft, David W; Haider, Hani; Davis, Charles M
In acute periprosthetic infection, irrigation and debridement with component retention has a high failure rate in some studies. We hypothesize that pulse lavage irrigation is ineffective at removing biofilm from total knee arthroplasty (TKA) components. Staphylococcus aureus biofilm mass and location was directly visualized on arthroplasty materials with a photon collection camera and laser scanning confocal microscopy. There was a substantial reduction in biofilm signal intensity, but the reduction was less than a ten-fold decrease. This suggests that irrigation needs to be further improved for the removal of biofilm mass below the necessary bioburden level to prevent recurrence of acute infection in total knee arthroplasty. Copyright © 2014 Elsevier Inc. All rights reserved.
Watanabe, Toshifumi; Muneta, Takeshi; Sekiya, Ichiro; Banks, Scott A
Adjusting joint gaps and establishing mediolateral (ML) soft tissue balance are considered essential interventions for better outcomes in total knee arthroplasty (TKA). However, the relationship between intraoperative laxity measurements and weightbearing knee kinematics has not been well explored. This study aimed to quantify the effect of intraoperative joint gaps and ML soft tissue balance on postoperative knee kinematics in posterior-stabilized (PS)-TKA. We investigated 44 knees in 34 patients who underwent primary PS-TKA by a single surgeon. The central joint gaps and ML tilting angles at 0°, 10°, 30°, 60°, 90°, 120° and 135° flexion were measured during surgery. At a minimum of two year follow-up, we analyzed in vivo kinematics of these knees and examined the influence of intraoperative measurements on postoperative kinematics. Gap difference of knee flexion at 135° minus 0° was correlated with the total posterior translation of lateral femoral condyle (r=0.336, p=0.042) and femoral external rotation (r=0.488, p=0.002) during squatting, anteroposterior position of lateral femoral condyle (r=-0.510, p=0.001) and maximum knee flexion (r=0.355, p=0.031) in kneeling. Similar correlations were observed between deep flexion gap differences with respect to the 90° reference and postoperative knee kinematics. Well-balanced knees showed less anterior translation of medial femoral condyle in mid- to deep flexion, consistent femoral external rotation, and the most neutral valgus/varus rotation compared with unbalanced knees. These findings indicate the importance of adequate intraoperative joint gaps in deep flexion and ML soft tissue balance throughout the range of motion. Copyright © 2015 Elsevier B.V. All rights reserved.
Zhu, Chen; Wang, Jiaxing; Cheng, Mengqi; Peng, Xiaochun; Wang, Qi; Zhang, Xianlong
Background and purpose There is no consensus regarding the clinical relevance of gender-speciﬁc prostheses in total knee arthroplasty (TKA). We summarize the current best evidence in a comparison of clinical and radiographic outcomes between gender-speciﬁc prostheses and standard unisex prostheses in female patients. Methods We used the PubMed, Embase, Cochrane, Science Citation Index, and Scopus databases. We included randomized controlled trials published up to January 2013 that compared gender-speciﬁc prostheses with standard unisex prostheses in female patients who underwent primary TKAs. Results 6 trials involving 423 patients with 846 knee joints met the inclusion criteria. No statistically significant differences were observed between the 2 designs regarding pain, range of motion (ROM), knee scores, satisfaction, preference, complications, and radiographic results. The gender-specific design (Gender Solutions; Zimmer Inc, Warsaw, Indiana) reduced the prevalence of overhang. However, it had less overall coverage of the femoral condyles compared to the unisex group. In fact, the femoral prosthesis in the standard unisex group matched better than that in the gender-speciﬁc group. Interpretation Gender-speciﬁc prostheses do not appear to confer any beneﬁt in terms of clinician- and patient-reported outcomes for the female knee. PMID:24954488
Nishizawa, Yuichiro; Matsumoto, Tomoyuki; Kubo, Seiji; Muratsu, Hirotsugu; Matsushita, Takehiko; Oka, Shinya; Ishida, Kazunari; Matsuzaki, Tokio; Nishida, Kotaro; Akisue, Toshihiro; Kuroda, Ryosuke; Kurosaka, Masahiro
Although the patella reduced or everted position has recently been recognised as an important factor influencing soft tissue balance during assessment in total knee arthroplasty (TKA), the influence of patella height on soft tissue balance has not been well addressed. Therefore, the relationship between soft tissue balance and patella height was investigated and differences between cruciate-retaining (CR) and posterior-stabilised (PS) TKA were compared. Forty consecutive patients blinded to the type of implant received, were randomised prospectively. Using lateral radiographs, pre-operative patella height was measured. Using an offset-type tensor designed to measure the soft tissue balance with a reduced patellofemoral (PF) joint and femoral component in place, soft tissue balance was intra-operatively assessed in CR TKA (n = 20) and PS TKA (n = 20) in osteoarthritic patients. The joint component gap and varus ligament balance at zero, ten, 45, 90 and 135° of knee flexion with the patella reduced were measured. In PS TKA, the joint component gap positively correlated with patella height at 90 and 135° of knee flexion. However, there was no correlation between joint component gap and patella height at other flexion angles in PS TKA and any flexion angle in CR TKA. Varus ligament balance showed no significant correlation with patella height in either CR or PS TKA. Analysis of soft tissue balance and patella height only showed a positive correlation in joint component gap at a high flexion angle (90 and 135°) in PS TKA but not in other parameters examined. Pre-operative measurement of patella height may be an important factor for predicting an intra-operative flexion gap in PS TKA.
Gregory, Patricia C; Rogic, Roselyn; Eddington, Carolyn
There are a number of complications associated with total knee-joint arthroplasty. These include deep venous thromboses, peroneal palsy, infection, anemia, and Ogilvie's syndrome. An uncommon but potentially limb-threatening complication is acute arterial occlusion. Approximately 35 cases have been reported in the orthopedic literature. Prompt recognition and treatment intervention are the keys to successful outcome. We describe the case of one patient who had mild peroneal palsy and developed acute arterial occlusion 9 days postoperatively while on the inpatient rehabilitation service. Prompt aggressive management restored arterial circulation to the lower limb. Careful management of patients after total knee arthroplasty requires an understanding that arterial occlusion is a rare limb-threatening complication of surgery, but that it is treatable with prompt, deliberate management. Physiatrists should be aware that this condition exists in postoperative knee-joint arthroplasty patients. They should pay careful attention to any patient with a history of peripheral vascular disease or postoperative peroneal palsy.
Barnett, Steven L; Mayer, Ryan R; Gondusky, Joseph S; Choi, Leera; Patel, Jay J; Gorab, Robert S
Stepped porous titanium metaphyseal sleeves may provide an option for enhanced fixation in managing challenging tibial defects in revision total knee arthroplasty (TKA). We retrospectively reviewed data on 51 patients who underwent revision TKA utilizing a metaphyseal sleeve for Anderson Orthopaedic Research Institute (AORI) Type II and III tibial defects between June 2007 and July 2011. Of these 51 patients, 36 patients had complete clinical and radiographic data. At final follow-up (mean: 38 months) significant improvements in knee range of motion and Knee Society scores were observed postoperatively (P < 0.001). Four revision procedures were necessary, but none for aseptic implant fixation failure. Radiographic review at final follow-up revealed stable, osteointegrated components without component migration or clinically significant osteolysis. Metaphyseal sleeve use in the management of moderate to severe tibial defects in revision TKA resulted in satisfactory clinical outcomes and is a versatile option for achieving stable fixation.
Mather, Richard C; Hug, Kevin T; Orlando, Lori A; Watters, Tyler Steven; Koenig, Lane; Nunley, Ryan M; Bolognesi, Michael P
The projected demand for total knee arthroplasty is staggering. At its root, the solution involves increasing supply or decreasing demand. Other developed nations have used rationing and wait times to distribute this service. However, economic impact and cost-effectiveness of waiting for TKA is unknown. A Markov decision model was constructed for a cost-utility analysis of three treatment strategies for end-stage knee osteoarthritis: 1) TKA without delay, 2) a waiting period with no non-operative treatment and 3) a non-operative treatment bridge during that waiting period in a cohort of 60 year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective with national average Medicare reimbursement. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, effectiveness, and quality-adjusted life years; and net health benefits. In the base case, a 2-year wait-time both with and without a non-operative treatment bridge resulted in a lower number of average QALYs gained (11.57 (no bridge) and 11.95 (bridge) vs. 12.14 (no delay). The average cost was $1,660 higher for TKA without delay than wait-time with no bridge, but $1,810 less than wait-time with non-operative bridge. The incremental cost-effectiveness ratio comparing wait-time with no bridge to TKA without delay was $2,901/QALY. When comparing TKA without delay to waiting with non-operative bridge, TKA without delay produced greater utility at a lower cost to society. TKA without delay is the preferred cost-effective treatment strategy when compared to a waiting for TKA without non-operative bridge. TKA without delay is cost saving when a non-operative bridge is used during the waiting period. As it is unlikely that patients waiting for TKA would not receive non-operative treatment, TKA without delay may be an overall cost-saving health care delivery strategy
Smith, Jessica W.; Marcus, Robin L.; Tracy, Brian L.; Foreman, K. Bo; Christensen, Jesse C.; LaStayo, Paul C.
The main objectives of this pilot study were to: 1) investigate stance time variability (STV) during stair stepping in older adults with osteoarthritis (OA) before and after total knee arthroplasty (TKA), and compare to an age- and sex-matched group of healthy controls with native knees and 2) evaluate the relationship between quadriceps strength and STV during stair stepping before and after TKA. A prospective, observational, pilot study was carried out on 13 individuals (15% male, mean age 62.71 ± 6.84 years) before and after TKA using an instrumented stairway, patient-reported outcomes, timed stair stepping test, and quadriceps strength measures. At 6-months post-operatively, STV during stair descent was significantly greater in the TKA-GROUP compared to the CONTROL-GROUP, but was not significantly different at 12-months compared to controls. There were no significant differences in STV for stair ascent between the pre- and post-operative visits, or compared to controls. There was a trend toward significance for the relationship between quadriceps strength and STV during stair ascent (P=0.059) and descent (P=0.073). Variability during stair stepping may provide an important, short-term rehabilitation target for individuals following TKA and may represent another parameter to predict declines in functional mobility. PMID:26590484
Gunaratne, Rajitha; Pratt, Dylan N; Banda, Joseph; Fick, Daniel P; Khan, Riaz J K; Robertson, Brett W
Dissatisfaction following total knee arthroplasty (TKA) is common. Approximately 20% of patients report dissatisfaction following primary TKA. This systematic literature review explores key factors affecting patient dissatisfaction following TKA. Six literature databases published between 2005 and 1 January 2016 were searched using 3 key search phrases. Papers were included if the study investigated patient dissatisfaction in primary unilateral or bilateral TKA. Information from each article was categorized to the domains of socioeconomic, preoperative, intraoperative, and postoperative factors affecting patient dissatisfaction. This review found that patient dissatisfaction pertains to several key factors. Patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic and surgical domains. Identifying who may be dissatisfied after their TKA is mystifying; however, we note several strategies that target factors whereby an association exists. Further research is needed to better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully appreciated and strategies employed to target them. Copyright © 2017 Elsevier Inc. All rights reserved.
Tsunoda, Kenji; Sonohata, Motoki; Kugisaki, Hajime; Someya, Shinsuke; Honke, Hidefumi; Komine, Mitsunori; Izumi, Masataka; Ide, Shuya; Mawatari, Masaaki
Background: Air tourniquet-induced skeletal muscle injury increases the concentrations of some cytokines such as interleukin-6 (IL-6) in plasma. However, the effect of an air tourniquet on the IL-6 concentrations after total knee arthroplasty (TKA) is unclear. We therefore investigated the impact of tourniquet-induced ischemia and reperfusion injury in TKA using the IL-6 level as an index. Methods: Ten patients with primary knee osteoarthrosis who underwent unilateral TKA without an air tourniquet were recruited (Non-tourniquet group). We also selected 10 age- and sex-matched control patients who underwent unilateral TKA with an air tourniquet (Tourniquet group). Venous blood samples were obtained at 3 points; before surgery, 24 h after surgery, and 7 days after surgery. The following factors were compared between the two groups; IL-6, C-reactive protein (CRP), creatine phosphokinase (CPK), the mean white blood cell (WBC) counts, and the maximum daily body temperatures. Results: The IL-6 level at 24 h after surgery was significantly higher than that at any other point (p<0.01). No significant differences were observed in the WBC count, the body temperature, or the CRP, CPK, or IL-6 levels of the two groups at any of the time points. Conclusion: The effect of ischemia and reperfusion due to the use of an air tourniquet on increasing the IL-6 level was much smaller than that induced by surgical stress in TKA. PMID:28217217
Jones, G. G.; Kotti, M.; Wiik, A. V.; Collins, R.; Brevadt, M. J.; Strachan, R. K.; Cobb, J. P.
Aims To compare the gait of unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) patients with healthy controls, using a machine-learning approach. Patients and Methods 145 participants (121 healthy controls, 12 patients with cruciate-retaining TKA, and 12 with mobile-bearing medial UKA) were recruited. The TKA and UKA patients were a minimum of 12 months post-operative, and matched for pattern and severity of arthrosis, age, and body mass index. Participants walked on an instrumented treadmill until their maximum walking speed was reached. Temporospatial gait parameters, and vertical ground reaction force data, were captured at each speed. Oxford knee scores (OKS) were also collected. An ensemble of trees algorithm was used to analyse the data: 27 gait variables were used to train classification trees for each speed, with a binary output prediction of whether these variables were derived from a UKA or TKA patient. Healthy control gait data was then tested by the decision trees at each speed and a final classification (UKA or TKA) reached for each subject in a majority voting manner over all gait cycles and speeds. Top walking speed was also recorded. Results 92% of the healthy controls were classified by the decision tree as a UKA, 5% as a TKA, and 3% were unclassified. There was no significant difference in OKS between the UKA and TKA patients (p = 0.077). Top walking speed in TKA patients (1.6 m/s; 1.3 to 2.1) was significantly lower than that of both the UKA group (2.2 m/s; 1.8 to 2.7) and healthy controls (2.2 m/s; 1.5 to 2.7; p < 0.001). Conclusion UKA results in a more physiological gait compared with TKA, and a higher top walking speed. This difference in function was not detected by the OKS. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):16–21. PMID:27694511
Jones, G G; Kotti, M; Wiik, A V; Collins, R; Brevadt, M J; Strachan, R K; Cobb, J P
To compare the gait of unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) patients with healthy controls, using a machine-learning approach. 145 participants (121 healthy controls, 12 patients with cruciate-retaining TKA, and 12 with mobile-bearing medial UKA) were recruited. The TKA and UKA patients were a minimum of 12 months post-operative, and matched for pattern and severity of arthrosis, age, and body mass index. Participants walked on an instrumented treadmill until their maximum walking speed was reached. Temporospatial gait parameters, and vertical ground reaction force data, were captured at each speed. Oxford knee scores (OKS) were also collected. An ensemble of trees algorithm was used to analyse the data: 27 gait variables were used to train classification trees for each speed, with a binary output prediction of whether these variables were derived from a UKA or TKA patient. Healthy control gait data was then tested by the decision trees at each speed and a final classification (UKA or TKA) reached for each subject in a majority voting manner over all gait cycles and speeds. Top walking speed was also recorded. 92% of the healthy controls were classified by the decision tree as a UKA, 5% as a TKA, and 3% were unclassified. There was no significant difference in OKS between the UKA and TKA patients (p = 0.077). Top walking speed in TKA patients (1.6 m/s; 1.3 to 2.1) was significantly lower than that of both the UKA group (2.2 m/s; 1.8 to 2.7) and healthy controls (2.2 m/s; 1.5 to 2.7; p < 0.001). UKA results in a more physiological gait compared with TKA, and a higher top walking speed. This difference in function was not detected by the OKS. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):16-21. ©2016 Jones et al.
Bandholm, Thomas; Thorborg, Kristian; Lunn, Troels Haxholdt; Kehlet, Henrik; Jakobsen, Thomas Linding
Background Loading and contraction failure (muscular exhaustion) are strength training variables known to influence neural activation of the exercising muscle in healthy subjects, which may help reduce neural inhibition of the quadriceps muscle following total knee arthroplasty (TKA). It is unknown how these exercise variables influence knee pain after TKA. Objective To investigate the effect of loading and contraction failure on knee pain during strength training, shortly following TKA. Design Cross-sectional study. Setting Consecutive sample of patients from the Copenhagen area, Denmark, receiving a TKA, between November 2012 and April 2013. Participants Seventeen patients, no more than 3 weeks after their TKA. Main outcome measures: In a randomized order, the patients performed 1 set of 4 standardized knee extensions, using relative loads of 8, 14, and 20 repetition maximum (RM), and ended with 1 single set to contraction failure (14 RM load). The individual loadings (kilograms) were determined during a familiarization session >72 hours prior. The patients rated their knee pain during each repetition, using a numerical rating scale (0–10). Results Two patients were lost to follow up. Knee pain increased with increasing load (20 RM: 3.1±2.0 points, 14 RM: 3.5±1.8 points, 8 RM: 4.3±2.5 points, P = 0.006), and repetitions to contraction failure (10% failure: 3.2±1.9 points, 100% failure: 5.4±1.6 points, P<0.001). Resting knee pain 60 seconds after the final repetition (2.7±2.4 points) was not different from that recorded before strength training (2.7±1.8 points, P = 0.88). Conclusion Both loading and repetitions performed to contraction failure during knee- extension strength-training, increased post-operative knee pain during strength training implemented shortly following TKA. However, only the increase in pain during repetitions to contraction failure exceeded that defined as clinically relevant, and was very short-lived. Trial Registration
Rahman, Jeeshan; Tang, Quen; Monda, Maureen; Miles, Jonathan; McCarthy, Ian
The aim of the study was to assess gait in total knee arthroplasty (TKA) patients, using a technique that can to be used on a routine basis in a busy orthopaedic clinic. A total of 103 subjects were recruited: 29 pre-op TKA patients; 17 TKA patients at 8 weeks post-op; 28 TKA patients at 52 weeks post-op; and 29 age-matched controls. Inertial measurement units (IMUs) were used to assess gait. Limb segment angles, knee angle and temporal parameters of gait were calculated. Specific gait parameters were quantified, and data analysed using MANOVA and discriminant analysis. The gait of TKA patients as a group was only slightly improved at 12 months when compared with the pre-operative group, and both groups were significantly different to controls in several variables. Knee flexion range in stance was the most important variable in discriminating between patients and controls; knee flexion range in swing was the only variable that showed a significant difference between pre- and post-operative patients. When considered individually, only 1/29 patient was within the normal range for this variable pre-operatively, but 9/28 patients were within the normal range 12 months post-operatively. Even after 12 months after surgery, many TKA patients have not improved their gait relative to pre-operative patients. Routine gait assessment may be used to guide post-operative rehabilitation, and to develop strategies to improve mobility of these patients.
Moulder, Elizabeth; Marsh, Clayton
Melorheostosis is a rare condition which can cause soft tissue joint contractures. We present a case of melorheostosis causing disabling knee joint contracture, treated successfully by total knee arthroplasty.
Frisch, Nicholas; Wessell, Nolan M; Charters, Michael; Peterson, Ed; Cann, Brett; Greenstein, Alex; Silverton, Craig D
Perioperative blood management remains a challenge during total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to systematically examine the relationship between body mass index (BMI) and perioperative blood transfusion during THA and TKA while attempting to resolve conflicting results in previously published studies. The authors retrospectively evaluated 2399 patients, 896 of whom underwent THA and 1503 of whom underwent TKA. Various outcome variables were assessed for their relationship to BMI, which was stratified using the World Health Organization classification scheme (normal, <25 kg/m(2); overweight, 25-30 kg/m(2); obese, >30 kg/m(2)). Among patients undergoing THA, transfusion rates were 34.8%, 27.6%, and 21.9% for normal, overweight, and obese patients, respectively (P=.002). Among patients undergoing TKA, transfusion rates were 17.3%, 11.4%, and 8.3% for normal, overweight, and obese patients, respectively (P=.002). Patients with an elevated BMI have decreased rates of blood transfusion following both THA and TKA. This same cohort also loses a significantly decreased percentage of estimated blood volume. No trends were identified for a relationship between BMI and deep venous thrombosis, pulmonary embolism, myocardial infarction, discharge location, length of stay, 30-day readmission rate, and preoperative hemoglobin level. Elevated BMI was significantly associated with increased estimated blood loss in patients undergoing THA and those undergoing TKA. There was a statistically significant trend toward increased deep surgical-site infection in patients undergoing THA (P=.043). Patients with increased BMI have lower rates of blood transfusion and lose a significantly smaller percentage of estimated blood volume following THA and TKA. [Orthopedics.2016; 39(5):e844-e849.]. Copyright 2016, SLACK Incorporated.
Husted, Henrik; Jørgensen, Christoffer C; Gromov, Kirill; Kehlet, Henrik
Background and purpose - Body mass index (BMI) outside the normal range possibly affects the perioperative morbidity and mortality following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in traditional care programs. We determined perioperative morbidity and mortality in such patients who were operated with the fast-track methodology and compared the levels with those in patients with normal BMI. Patients and methods - This was a prospective observational study involving 13,730 procedures (7,194 THA and 6,536 TKA operations) performed in a standardized fast-track setting. Complete 90-day follow-up was achieved using national registries and review of medical records. Patients were grouped according to BMI as being underweight, of normal weight, overweight, obese, very obese, and morbidly obese. Results - Median length of stay (LOS) was 2 (IQR: 2-3) days in all BMI groups. 30-day re-admission rates were around 6% for both THA (6.1%) and TKA (5.9%), without any statistically significant differences between BMI groups in univariate analysis (p > 0.4), but there was a trend of a protective effect of overweight for both THA (p = 0.1) and TKA (p = 0.06). 90-day re-admission rates increased to 8.6% for THA and 8.3% for TKA, which was similar among BMI groups, but there was a trend of lower rates in overweight and obese TKA patients (p = 0.08 and p = 0.06, respectively). When we adjusted for preoperative comorbidity, high BMI in THA patients (very obese and morbidly obese patients only) was associated with a LOS of >4 days (p = 0.001), but not with re-admission. No such relationship existed for TKA. Interpretation - A fast-track setting resulted in similar length of hospital stay and re-admission rates regardless of BMI, except for very obese and morbidly obese THA patients.
Kim, Eric G; Patel, Nirav K; Chughtai, Morad; Elmallah, Randa D K; Delanois, Ronald E; Harwin, Steven F; Mont, Michael A
The best strategy to address large bony defects in revision total knee arthroplasty has yet to be determined. The relatively recent development of porous tantalum cones and their use to address massive bone loss in knee arthroplasty has shown promising short- and intermediate-term results. The purpose of this review is to present the current literature on: (1) basic science of porous tantalum, (2) classification and treatment for bone loss, (3) clinical results, and (4) evolution of newer generation cones. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
de Alencar, Paulo Gilberto Cimbalista; De Bortoli, Giovani; Ventura Vieira, Inácio Facó; Uliana, Christiano Saliba
The increasing number of total knee arthroplasties, in combination with the population's longer life expectancy, has led to a greater number of long-term complications. These add to the poor bone quality of elderly patients and often culminate in periprosthetic fractures. This complex orthopedic problem has a great diversity of clinical presentation. It may affect any of the bones in the knee and, because of the difficulty in finding solutions, may lead to disastrous outcomes. Its treatment requires that orthopedists should have broad knowledge both of arthroplasty techniques and of osteosynthesis, as well as an elaborate therapeutic arsenal including, for example, access to a bone bank. PMID:27022546
Amato, Bruno; Benassai, Giacomo; Apperti, Marco; Sellitti, Antonio; Sivero, Luigi; Furino, Ermenegildo
Abstract Aging is one of the major risk factors for varicose veins. The same is for Knee and Hip Osteoarthritis. Most of the patients undergoing to Hip (THA) or Knee (TKA) arthroplasty are over sixteen. Varicose veins, excluding thrombophilia, are the most significant risk factors for VTE after THA and TKA. This study investigates on the usefulness of prophylactic treatment of GSV insufficiency in elderly patients undergoing to orthopedic surgery. A retrospective study enrolling 44 over-sixty five patients, undergoing to TKA or THA. 24 patients underwent to traditional surgery and 20 to EVLA. The presence of evident varicosities and/or a saphenic reflux lasting > 500 ms has been considered as operability criterion. Both in surgery and EVLA group has been performed the ablation of visible varicosities and only saphenic refluxing traits. Results: 1 case of symptomatic DVT was recorded after arthroplasty. A statistically significant difference (p = 0.006) of recovery time between surgery and EVLA groups has been detected. There is not a statistically significant difference in long-term recurrence rate between surgery and EVLA. Conclusions: It is useful to program GSV surgery, before treat hip or knee. This study showed a 50% decrease in the incidence of postoperative DVT. PMID:28352838
Robin, Brett N; Ellington, Matthew D; Jupiter, Daniel C; Allen, Bryce C
The plateau-patella angle (PPA) has been proposed as a new and simpler method to describe patellar height. This method has not been used or validated in knees following total knee arthroplasty (TKA). A modified PPA (mPPA) was developed for use in this population. The method was validated by determining the interobserver and intraobserver reliability of the technique in 50 consecutive patients compared to three well-described methods of describing patellar height after TKA. Three observers then evaluated the mPPA of 297 post-operative radiographs to describe a normal range after TKA for a given technique and implant. The interobserver reliability was the highest for the mPPA compared to the other methods. The mean mPPA for the entire cohort was 21.06, 20.49, and 19.94 for the three observers. The modified plateau-patella angle is a reliable way to evaluate patellar height in patients who have undergone total knee arthroplasty. Copyright © 2014 Elsevier Inc. All rights reserved.
Kim, Tae Woo; Lee, Sang Min; Seong, Sang Cheol; Lee, Sahnghoon; Jang, Jak; Lee, Myung Chul
There remains no consensus as to whether mobile total knee arthroplasty (TKA) should use a posterior cruciate ligament-sacrificing ultracongruent (UC) or a posterior cruciate ligament-substituting posterior stabilized (PS) prosthesis. The purpose of this study was to assess intraoperative kinematics and clinical outcomes of UC and PS rotating platform mobile-bearing TKA. In this randomized controlled study, mobile UC TKA prostheses (n = 45) were compared with mobile PS TKA prostheses (n = 45) with regard to intraoperative kinematics and clinical outcomes. The passive kinematic study using intraoperative navigation system included anterior/posterior translation, varus/valgus alignment and rotation of femur during flexion. The patients were clinically and radiographically evaluated over a 3-year follow-up. Paradoxical anterior translation of the femur was 10.8 ± 5.2 mm in the UC knee from 0° to 82° of knee flexion and 8.7 ± 3.0 mm in the PS knee from 0° to 70° of knee flexion (p = 0.027). Paradoxical internal rotation of the femur was 5.8° in the UC knees and 9.9° in the PS knees (p = 0.003). But, there was no significant difference between the groups in regard to the coronal alignment. There was no significant difference in the range of motion, KS knee scores, KS function scores, and WOMAC index scores. Despite different intraoperative kinematics between mobile UC and mobile PS TKA, neither design reproduced physiologic knee kinematics and there was no difference in clinical outcomes between the two groups. The clinical relevance of the study is that despite different intraoperative kinematics, UC design can be a considerable alternative to PS design in mobile-bearing TKA in respect of clinical outcomes. II.
van Houten, Albert H; Heesterbeek, Petra J C; Wymenga, Ate B
Incidence of anterior knee pain after total knee arthroplasty (TKA) is reported to be between 4 and 49 %. The incidence of AKP at long-term follow-up and possible determinants after cruciate cruciate-retaining TKA were investigated. A 10-year follow-up of a cohort of 55 patients (63 TKAs), who received the balanSys™ cruciate-retaining total knee system (Mathys Ltd, Bettlach, Switzerland) between 1999 and 2002, was performed. Patients had undergone the balanced gap technique, with either a fixed bearing or an AP-glide bearing. Standardised diagnostic questions regarding AKP were collected and categorised into two groups: those with and without AKP. The lateral patellar tilt, patellar displacement measurement and modified Insall-Salvati ratio were used for patella position evaluation on skyline radiographs. The Knee Society Score (KSS), the Knee Osteoarthritis Outcome Score (KOOS) and Numerical Rating Scales (NRS) for pain and satisfaction were obtained at follow-up. Sixteen patients in the study population experienced AKP. Incidence of AKP (fixed bearing 13/44; AP-glide bearing baring 3/17) was not dependent on type of insert (n.s.). There were no statistical differences in patella position and tibiofemoral contact point between the AKP group and the no AKP group (n.s.). KSS, KOOS, NRS-pain and NRS-satisfaction were significantly lower for the patients with AKP (all p < 0.05). Twenty-six percentage of the patients experienced AKP 10 years after balanced gap TKA. Postoperative patella positioning was not found to be a determinant for anterior knee pain after TKA. However, patellar displacement does not seem completely favourable. Moreover, type of bearing was not found a determinant for AKP at long-term follow-up. Lower quality prospective cohort study (<80 % follow-up, patients enrolled at different time points in disease), Level II.
Metal allergy in total knee arthroplasty (TKA) is still a controversial topic. Oxinium, ceramic or titanium niobium nitride (TiNbN) coated implants are available for some knee systems. The hypothesis of this study was that the use of TiNbN-coated components would not lead to inferior results compared to conventional implants and that none of the allergic patients receiving TiNbN-coated implants would require revision for metal allergy. This study was a retrospective, 2 to 1 matched pairs study with 40 titanium niobium nitride-coated TKA compared with 80 conventional cobalt chrome implants. No demographic differences between these groups were observed. The mean follow-up for this study was 2 years. No differences in clinical, radiological, or patient-reported outcome measurements were observed between the two groups. No patients have been revised at this short- to medium-term outcome evaluation. Metal allergy leading to contact or systemic dermatitis is especially linked to chrome and cobalt allergy. Nickel allergy because of knee implants rarely gives cutaneous symptoms, but could potentially lead to peri-prosthetic osteolysis and loosening. The use of titanium niobium nitride implants in case of a positive history of metal allergy could avoid this devastating complication. The use of titanium niobium nitride-coated implants for primary knee osteoarthritis shows similar clinical and radiological outcomes as conventional TKA without revision for loosening at short- to medium-term follow-up. Level of evidence Level IV study.
Mittag, Falk; Leichtle, Carmen Ina; Schlumberger, Michael; Leichtle, Ulf Gunther; Wünschel, Markus
Infection after total hip (THA) and knee arthroplasty (TKA) is a serious complication which typically leads to a long lasting and intensive surgical and medicamentous treatment. The aim of this study was to identify factors that influence outcome after revision surgery caused by prosthetic infection. We retrospectively analyzed 64 patients who had revision surgery between 1989 and 2009 due to periprosthetic infection. We examined a total of 69 joints (TKA: 36%, THA: 64%), follow-up 5.1 years (0.5-21 years) after the initial surgical intervention. The mean patient age at time of surgery was 67 years old (43-79 years old). Clinical data and scores including the Western Ontario and McMaster Universities (WOMAC)-Index, the Harris Hip Score (HHS) and the Hospital for Special Surgery Score (HSS) were surveyed. There was no difference in clinical scores regarding treatment between a single and a multiple stage treatment regime. Infections with multiple microorganisms and Enterococcus spp. lead to a significantly higher number of interventions. Using a modified Tsukayama system we classified 24% as type I, 34% type II and 42% type III- infections, with no differences in clinical outcome. Overweight patients had a significantly lower HHS and WOMAC-score. Immunosuppression leads to a worse WOMAC and HSS-Score. An increased number of procedures was associated to a limping gait. Thorough surgical technique leads to good clinical results independent of infection-type and treatment philosophy. Level of Evidence III, Case Control Study.
Kuster, Markus S; Stachowiak, Gwidon W
A complication of total knee arthroplasty (TKA) is fatigue-type wear, which can destroy a tibial inlay in <10 years. This deleterious wear mechanism occurs during cyclic loading if the yield stress of polyethylene is exceeded. Because increased stress on and within the polyethylene inlay is associated with increased wear, it is important to reduce the inlay stress by either activity restrictions or conformity changes of design. All stress parameters are more sensitive to conformity changes (eg, design changes) than to load changes (eg, activity restrictions). However, the reduction of stress on and within the polyethylene through increased conformity will increase the stress at the tibial fixation interfaces. An attempt was made to solve this problem with the introduction of mobile-bearing designs. Many mobile-bearing designs exist with good long-term results. One important difference among the various designs is the amount of flexion range with full conformity between the femoral component and the tibial inlay. Although a single radius design reduces polyethylene stress throughout the flexion range, it may be disadvantageous for a revision design to intraoperatively adapt to different degrees of constraint. Aseptic loosening and osteolysis due to small abrasive and adhesive wear particles have also been reported as a cause of failure. The design and material parameters affecting polyethylene wear in TKAs, as well as the potential detrimental effects of wear particle size, are the key issues in defining the life of a TKA.
Ong, Johnny C A; Chin, Pak Lin; Lin, Chin Pak; Fook-Chong, Stephanie M C; Tang, Andrew; Yang, Kuang Ying; Ying, Yang Kuang; Tay, Boon Keng; Keng, Tay Boon
To determine whether continuous infiltration of local anaesthetic can reduce the pain score and morphine use over 48 hours after total knee arthroplasty (TKA). 11 men and 43 women aged 50 to 82 years who underwent unilateral TKA for osteoarthritis were recruited. They were randomised into 3 groups. In group 1, 17 patients who acted as controls received patient-controlled analgesia (PCA) with intravenous morphine for 48 hours. In group 2, 16 patients received continuous infiltration of bupivacaine to the subcutaneous tissue and intra-articular space for 48 hours, in addition to PCA. In group 3, 21 patients received an intra-articular injection of local anaesthetic, followed by continuous infiltration of bupivacaine to the subcutaneous tissue and intraarticular space for 48 hours, in addition to PCA. For each patient, a visual analogue score (VAS) for pain was recorded postoperatively at 2, 4, 6, 12, 24, 36, and 48 hours. The total amount of morphine used was recorded at 24 and 48 hours. Over 48 hours, the VAS for pain and morphine use was significantly higher in controls than patients in groups 2 and 3. Continuous infiltration of local anaesthetic into the intra-articular space and subcutaneous tissues, in addition to PCA with intravenous morphine, provides significantly more pain relief and reduces morphine use.
Harato, Kengo; Ozaki, Masahiro; Sakurai, Aiko; Kudo, Yutaka; Otani, Toshiro
Stress fractures after total knee arthroplasty (TKA) occur mainly in patients with considerable deformity of the knee. In addition, the majority of these fractures after TKA involve the hip joint. We present two cases of stress fractures of the first metatarsal after TKA in patients with severe varus deformity. Correction of leg alignment and pain reduction obtained by TKA lead to stress fracture of the bone. Gait analysis was carried out for both cases in order to clarify the gait characteristics of the stress fracture. As a result, side-to-side differences of the distance between first metatarsal and foot center of pressure in the coronal plane were observed using gait analysis in these patients. Fortunately, conservative treatment was successful for these patients. Stress fractures should be considered when a patient who had a considerable severe deformity of the knee preoperatively complains of foot pain on the affected side. Contrary to stress fractures at the hip joint, patients with the fracture of the first metatarsal can be treated without surgery.
Kotela, Andrzej; Wilk-Frańczuk, Magdalena; Żbikowski, Piotr; Łęgosz, Paweł; Ambroziak, Paweł; Kotela, Ireneusz
Background The results of total knee arthroplasty (TKA) in patients with inherited bleeding disorders (IBDs) are poorer when compared with those in the general population, with a notably higher risk of complications and higher revision rates. Thus, revision procedures are becoming a growing concern in this group of patients. The aim of this study was to evaluate the results of revision TKA in patients with IBD. Material/Methods A retrospective cohort study with longitudinal assessment of hemophilia patients scheduled for revision TKA between January 2010 and September 2015 was performed. The clinical status of the patients was assessed based on the Knee Society Score, and the Numeric Rating Scale was used to assess knee pain severity and patient satisfaction with the surgery. Radiological examination, post-operative complications, and reinterventions were recorded and analyzed. Results Very good results were obtained in all patients treated for aseptic loosening of the implant. However, inferior results were found in cases with infection. All patients operated on for aseptic loosening required only single-stage TKA, whereas patients with infection underwent multiple interventions. Complications were observed only in cases with infection. Conclusions Our study clearly outlined the differences in results based on failure mode, with far inferior results obtained in cases with infection. Given the lack of data in this area as well as the high specificity of this population, further high-quality studies are needed. PMID:28068306
SADIGURSKY, DAVID; ANDION, DANIEL; BOUREAU, PÉRICLES; FERREIRA, MARIA CORDULINA; CARNEIRO, ROGÉRIO JAMIL FERNANDES; COLAVOLPE, PAULO OLIVEIRA
ABSTRACT Objectives: To analyze the effectiveness of intravenous (IV) tranexamic acid (TA) in reducing blood loss in total knee arthroplasty (TKA). Method: The population sample was composed of patients with a diagnosis of primary knee osteoarthritis. The patients undergoing TKA were divided in two groups. Group A: comprised patients who used IV TA and B group, formed by patients who did not use TA in the intra or post-operative period. For descriptive analysis, quantitative variables were represented by mean and standard deviations when their distribution was normal and interquartile ranges and medians for non-normal variables. Results: The mean age of patients was 68 years old, most of them were female and with involvement of the left knee. Postoperatively patients who had used IV TA showed less bleeding rate and less hemoglobin rate reduction. Conclusion: The use of IV TA in TKA reduces blood loss in peri- and postoperative periods. Regarding total blood loss reduction, hemoglobin rate and need for blood transfusions, IV TA should be used routinely during TKA since it has been shown to be safe with no increase in side effects as thromboembolic events. Level of Evidence III. Retrospective Comparative Study. PMID:27217813
Jansen, E; Brienza, S; Gierasimowicz-Fontana, A; Matos, C; Reynders-Frederix-Dobre, C; HateM, S M
Numbers of total hip and knee arthroplasties are increasing on a regular basis. Clinical pathways tend to shorten the duration of hospitalization in acute care after surgery. Therefore, the preoperative preparation of the patient and his abilities for postoperative rehabilitation should be carefully addressed. Before the surgical intervention, it is recommended that the patient receives an educational program and a physical preparation. After the surgical intervention, the patient can benefit from a home-based rehabilitation program supervised by a physiotherapist, if there were no preoperative reasons for prolonging the hospital stay and if the surgery took place without complications. Some patients may benefit from postsurgical rehabilitation in a specialized locomotor rehabilitation long-stay care unit. The indications for inpatient multidisciplinary rehabilitation are : two simultaneous arthroplasties, revision of a previous hip or knee arthroplasty, postsurgical complications, advanced age, comorbidities influencing the rehabilitation process, social difficulties, necessity for adaptation of the environment, insufficient or unadapted out-patient (para)medical care. The goals of the rehabilitation treatment depend on the patient's characteristics and environment, on the properties of the prosthesis and on the postsurgical complications. The functional prognosis of a total joint arthroplasty of the knee or hip is excellent, provided that there are no post-surgical complications and that the patient benefits from adequate rehabilitation therapy. The present paper describes the different phases of rehabilitation treatment and the general and specific complications of total hip and knee arthroplasties that may influence the rehabilitation outcome.
Malcolm, Tennison; Szubski, Caleb R.; Schiltz, Nicholas K.; Klika, Alison K.; Koroukian, Siran M.; Barsoum, Wael K.
“ Off-label use” refers to medical device utilization for purposes or subpopulations other than those approved by the United States Food and Drug Administration. The primary goal of this study was to determine the current epidemiology of off-label total hip and knee arthroplasty (THA and TKA, respectively) in the United States and to project further off-label use through 2040. Over the past decade, the prevalence of off-label THA and TKA was 30.4% and 37.0%, respectively, growing ~70% from 2000 2010. By 2040, the majority of THA (86.1%) and TKA (91.5%) could be off-label. The high prevalence of off-label arthroplasty and the dramatically shifting patient profile illustrated by these results highlight the need for continued medical device surveillance among on-and off label patients. PMID:26059502
Huang, Chuan-Ching; Jiang, Ching-Chuan; Hsieh, Chang-Hsun; Tsai, Chia-Jung; Chiang, Hongsen
Osteoporosis and osteoarthritis commonly coexist in the elderly. In patients undergoing prosthetic total knee arthroplasty (TKA), the bone quality around the knee joint may affect the safety of prosthetic implantation and consequently satisfaction with the surgical outcome. We recruited 50 postmenopausal women undergoing TKA for primary osteoarthritis; 43 completed the study protocol. The bone quality parameters of the operated knee, including bone mineral density assessed using dual-energy X-ray absorptiometry and microarchitecture variables assessed using micro-computed tomography, were determined. Surgical outcomes were assessed according to immediate (<1 week) postoperative pain quantified using the visual analog scale and knee function quantified using the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 2 and 6 months postoperatively. The influence of bone quality parameters on surgical outcomes was analyzed using simple and multiple regression analyses. Volumetric bone mineral density (R(2) = 0.187-0.234, p < 0.01), the structural model index (R(2) = 0.103-0.181, p < 0.05), and trabecular separation (R(2) = 0.289-0.424, p < 0.05) were significantly associated with postoperative pain and improvement according to the KOOS. In conclusion, local bone quality, including mineral content and microarchitecture, affects the surgical outcome of TKA. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Kuster, Markus S; Jeffcote, Benjamin O; Schirm, Andreas C; Jacob, Hilaire; Nicholls, Rochelle L
Total knee arthroplasty (TKA) relies on soft tissue to regulate joint stability after surgery. In practice, the exact balance of the gaps can be difficult to measure, and various methods including intra-operative spreaders or distraction devices have been proposed. While individual ligament strain patterns have been measured, no data exist on the isometricity of the soft tissue envelope as a whole. In this study, a novel device was developed and validated to compare isometricity in the entire soft tissue envelope for both the intact and TKA knee. A spring-loaded rod was inserted in six cadaver knee joints between the tibial shaft and the tibial plateau or tibial tray after removing a 7 mm slice of bone. The displacement of the rod during passive flexion represented variation in tissue tension around the joint. The rod position in the intact knee remained within 1 mm of its initial position between 15 degrees and 135 degrees of flexion, and within 2 mm (+/-1.2 mm) throughout the entire range of motion (0-150 degrees). After insertion of a mobile-bearing TKA, the rod was displaced a mean of 6 mm at 150 degrees (p<0.001). The results were validated using a force transducer implanted in the tibial baseplate of the TKA, which showed increased tibiofemoral force in the parts of the flexion range where the rod was most displaced. The force measurements were highly correlated with the displacement pattern of the spring-loaded rod (r=-0.338; p=0.006). A simple device has been validated to measure isometricity in the soft tissue envelope around the knee joint. Isometricity measurements may be used in the future to improve implantation techniques during TKA surgery.
Shi, Xiaojun; Shen, Bin; Kang, Pengde; Yang, Jing; Zhou, Zongke; Pei, Fuxing
To evaluate and quantify the effect of the tibial slope on the postoperative maximal knee flexion and stability in the posterior-stabilized total knee arthroplasty (TKA). Fifty-six patients (65 knees) who had undergone TKA with the posterior-stabilized prostheses were divided into the following 3 groups according to the measured tibial slopes: Group 1: ≤4°, Group 2: 4°-7° and Group 3: >7°. The preoperative range of the motion, the change in the posterior condylar offset, the elevation of the joint line, the postoperative tibiofemoral angle and the preoperative and postoperative Hospital for Special Surgery (HSS) scores were recorded. The tibial anteroposterior translation was measured using the Kneelax 3 Arthrometer at both the 30° and the 90° flexion angles. The mean values of the postoperative maximal knee flexion were 101° (SD 5), 106° (SD 5) and 113° (SD 9) in Groups 1, 2 and 3, respectively. A significant difference was found in the postoperative maximal flexion between the 3 groups (P < 0.001). However, no significant differences were found between the 3 groups in the postoperative HSS scores, the changes in the posterior condylar offset, the elevation of the joint line or the tibial anteroposterior translation at either the 30° or the 90° flexion angles. A 1° increase in the tibial slope resulted in a 1.8° flexion increment (r = 1.8, R (2) = 0.463, P < 0.001). An increase in the posterior tibial slope can significantly increase the postoperative maximal knee flexion. The tibial slope with an appropriate flexion and extension gap balance during the operation does not affect the joint stability.
Heym, B; Jouve, F; Lemoal, M; Veil-Picard, A; Lortat-Jacob, A; Nicolas-Chanoine, M H
The patient we report here underwent a total knee arthroplasty (TKA) which got infected with P. multocida after her dog had licked a small wound at the third toe of the same foot. Despite a correct treatment comprising synovectomy and cleansing, and an active antibiotic treatment for 3 months, the patient was readmitted for persistent infection of the same knee 2 weeks after the end of the antibiotic treatment. Sampling during surgery allowed for the growth of a P. multocida isolate proven by a molecular method to be identical to the previously isolated strain. This recurrent P. multocida infection was treated by a two-step change of the TKA comprising a 2-month period of antibiotic treatment between the two surgical interventions.
Denjean, S; Chatain, F; Tayot, O
Same-stage tibial osteotomy may deserve consideration in candidates to total knee arthroplasty (TKA) who have severe bone deformities, particularly at extra-articular sites. This strategy obviates the need for either a major and technically difficult ligament release procedure, which may compromise ligament balancing, or the use of a semi-constrained prosthesis. This technical note describes a one-stage, computer-assisted technique consisting in TKA followed by corrective tibial osteotomy to obtain an overall mechanical axis close to 180° without extensive ligament balancing. This technique provided satisfactory outcomes in 8 patients followed-up for at least 3 years, with no specific complications or ligament instability and with a hip-knee-ankle angle close to 180°. After planning, intra-operative computer assistance ensures accurate determination of both implant position and the degree of correction achieved by the osteotomy.
Nodzo, Scott R; Rachala, Sridhar R
Polypropylene mesh has previously been shown to be an effective treatment for failed patellar tendon repairs after total knee arthroplasty (TKA), but there have been few reports of this synthetic mesh used in complete quadriceps rupture after TKA. We retrospectively reviewed seven consecutive cases in six patients with complete quadriceps tears after TKA who had their quadriceps tendon repaired with suture and polypropylene mesh augmentation. All but two patients had previously failed primary suture repair. Patient outcomes were evaluated using the Knee Society Score. Standardized anterior-posterior (AP), lateral and merchant radiographs were evaluated preoperatively and at final follow-up. Seven knees in six patients were evaluated with a mean follow-up of 34±10 (range 24 to 49months) months. There were only four clinical successes defined as an extensor lag less than 30°. Of the functioning knees at final follow-up (n=5) the overall extensor lag in this group did significantly improve from 50±13° to 20±15° (range 5 to 40°) (p=.01). Mean postoperative flexion at final follow-up was 115±8°. Mean Knee Society Score for function improved from 20±30 to 45±54 (p=.03) as did the mean Knee Society Score for pain (44±18 vs. 74±78, p=.02). Polypropylene mesh offered limited postoperative functional results when used as an augment to the multiply operated knee that sustains a complete quadriceps rupture after TKA, but did allow for significant improvement in postoperative pain outcomes. IV. Copyright © 2015 Elsevier B.V. All rights reserved.
He, Rui; Yang, Liu
Acute arterial occlusion is a rare complication following total knee arthroplasty (TKA). The incidence as reported previously is from 0.03% to 0.17%; however, the sequelae can be disastrous because of its potential threat to limb loss.We report a case of acute arterial occlusion in the midpiece of femoral artery following TKA occurred 40 min postoperatively. The occlusion site existed at the midpiece of femoral artery is uncommon. Arterial circulation of the lower limb could not be restored by the thrombolysis and thrombectomy treatments performed within 11 h after TKA. In the end, amputation had to be carried out. In the treatment of acute arterial occlusion following TKA with a tourniquet, it is important to fully consider that arteriosclerosis may induce atheromatous plaque disruption, which might be the reason for acute arterial occlusion.
Okazaki, Ken; Tashiro, Yasutaka; Mizu-uchi, Hideki; Hamai, Satoshi; Doi, Toshio; Iwamoto, Yukihide
Adjusting the joint gap length to be equal in both extension and flexion is an important issue in total knee arthroplasty (TKA). It is generally acknowledged that posterior tibial slope affects the flexion gap; however, the extent to which changes in the tibial slope angle directly affect the flexion gap remains unclear. This study aimed to clarify the influence of tibial slope changes on the flexion gap in cruciate-retaining (CR) or posterior-stabilizing (PS) TKA. The flexion gap was measured using a tensor device with the femoral trial component in 20 cases each of CR- and PS-TKA. A wedge plate with a 5° inclination was placed on the tibial cut surface by switching its front-back direction to increase or decrease the tibial slope by 5°. The flexion gap after changing the tibial slope was compared to that of the neutral slope measured with a flat plate that had the same thickness as that of the wedge plate center. When the tibial slope decreased or increased by 5°, the flexion gap decreased or increased by 1.9 ± 0.6mm or 1.8 ± 0.4mm, respectively, with CR-TKA and 1.2 ± 0.4mm or 1.1 ± 0.3mm, respectively, with PS-TKA. The influence of changing the tibial slope by 5° on the flexion gap was approximately 2mm with CR-TKA and 1mm with PS-TKA. This information is useful when considering the effect of manipulating the tibial slope on the flexion gap when performing CR- or PS-TKA. Copyright © 2014 Elsevier B.V. All rights reserved.
Gollwitzer, H; Burgkart, R; Diehl, P; Gradinger, R; Bühren, V
Arthrofibrosis is one of the most common complications after total knee arthroplasty with an overall incidence of approximately 10%. Nevertheless, published data are rare and clinical trials mostly include small and heterogeneous patient series resulting in controversial conclusions. Clinically, arthrofibrosis after knee arthroplasty is defined as (painful) stiffness with scarring and soft tissue proliferation. Differentiation between local (peripatellar) and generalized fibrosis is therapeutically relevant. Histopathology typically shows subsynovial fibrosis with synovial hyperplasia, chronic inflammatory infiltration, and excessive and unregulated proliferation of collagen and fibroblasts. Diagnostic strategies are based on the exclusion of differential causes for painful knee stiffness, and especially the exclusion of low-grade infections represents a diagnostic challenge. Early and intensive physiotherapy combined with sufficient analgesia should be initiated as a basic therapy. The next therapeutic steps for persisting arthrofibrosis include closed manipulation and open arthrolysis. Arthroscopic interventions should be limited to local fibrosis. Revision arthroplasty represents a rescue surgery, often associated with recurrence of fibrosis. Prevention of arthrofibrosis by sufficient analgesia and early physiotherapy remains the best treatment option for painful stiffness after knee arthroplasty.
Sasanuma, Hideyuki; Sekiya, Hitoshi; Takatoku, Kenzou; Takada, Hisashi; Sugimoto, Naoya; Hoshino, Yuichi
The objective of the present study was to compare the intraoperative use of tranexamic acid (TNA) plus intra-articular diluted-epinephrine (DEP) with preoperative autologous blood donations and transfusions in reducing an allogeneic blood transfusion (ABT) in primary unilateral total knee arthroplasty (TKA). Patients (n=133) treated with unilateral primary TKA were divided into three groups retrospectively: patients administered autologous blood transfusions were assigned to group A (n=51); patients administered preoperative injections of TNA and postoperative intra-articular injections of DEP were assigned to group B (n=42); and patients treated with the drain-clamp method in addition to injections of TNA and DEP were assigned to group C (n=40). The rate of avoidance of ABTs, postoperative blood loss, and complications (DVT/PE, skin problems) were examined. The differences among the three groups were not significant in terms of the proportion of patients requiring no ABTs (94% in group A, 93% in group B and 95% in group C, n.s.). The total blood loss calculated was 1,140±451 ml, 852±343 ml, and 850±296 ml, respectively (group B>A, group C>A, P=0.0009). The significant complications were not observed in three groups. The results of the study showed that the TNA plus DEP combination exerted a comparable effect with preoperative autologous blood transfusion in avoiding ABTs in unilateral primary TKA. Considering several problems of preoperative autologous blood donation, the use of TNA plus DEP is recommended. In addition, it is highly possible that allogeneic blood transfusions can be avoided for patients with preoperative Hb values≥10.5 using the method described in this study, and the need for preoperative autologous blood donations can be decreased.
Wetterslev, Mik; Hansen, Signe Elisa; Hansen, Morten Sejer; Mathiesen, Ole; Dahl, Jørgen B.
Introduction The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA). Methods This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L’Abbe Plots and trial sequential analysis. Results The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low. Conclusion A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA. PMID:28273133
Fu, Xin; Tian, Peng; Xu, Gui-Jun; Sun, Xiao-Lei; Ma, Xin-Long
The present meta-analysis pooled the results from randomized controlled trials (RCTs) to identify and assess the efficacy and safety of thrombin-based hemostatic agent in primary total knee arthroplasty (TKA). Potential academic articles were identified from the Cochrane Library, Medline (1966-2015.5), PubMed (1966-2015.5), Embase (1980-2015.5), and ScienceDirect (1966-2015.5). Relevant journals and the recommendations of expert panels were also searched by using Google search engine. RCTs assessing the efficacy and safety of thrombin-based hemostatic agent in primary TKA were included. Pooling of data was analyzed by RevMan 5.1 (The Cochrane Collaboration, Oxford, UK). A total of four RCTs met the inclusion criteria. The meta-analysis revealed significant differences in postoperative hemoglobin decline (p < 0.00001), total blood loss (p < 0.00001), drainage volume (p = 0.01), and allogenic blood transfusion (p = 0.01) between the treatment group and the control group. No significant differences were found regarding incidence of infection (p = 0.45) and deep vein thrombosis (DVT; p = 0.80) between the groups. Meta-analysis indicated that the application of thrombin-based hemostatic agent before wound closure decreased postoperative hemoglobin decline, drainage volume, total blood loss, and transfusion rate and did not increase the risk of infection, DVT, or other complications. Therefore, the reviewers believe that thrombin-based hemostatic agent is effective and safe in primary TKA. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Li, Katherine; Ackland, David C; McClelland, Jodie A; Webster, Kate E; Feller, Julian A; de Steiger, Richard; Pandy, Marcus G
Patients with total knee arthroplasty (TKA) frequently exhibit changes in gait biomechanics post-surgery, including decreased ranges of joint motion and changes in joint loading; however, the actions of the lower-limb muscles in generating joint moments and accelerating the center of mass (COM) during walking are yet to be described. The aim of the present study was to evaluate differences in lower-limb joint kinematics, muscle-generated joint moments, and muscle contributions to COM accelerations in TKA patients and healthy age-matched controls when both groups walk at the same speed. Each TKA patient was fitted with a posterior-stabilized total knee replacement and underwent patellar resurfacing. Three-dimensional gait analysis and subject-specific musculoskeletal modeling were used to determine lower-limb and trunk muscle forces and muscle contributions to COM accelerations during the stance phase of gait. The TKA patients exhibited a 'quadriceps avoidance' gait pattern, with the vasti contributing significantly less to the extension moment developed about the knee during early stance (p=0.036). There was a significant decrease in the contribution of the vasti to the vertical acceleration (support) (p=0.022) and forward deceleration of the COM (braking) (p=0.049) during early stance; however, the TKA patients compensated for this deficiency by leaning their trunks forward. This significantly increased the contribution of the contralateral back extensor muscle (erector spinae) to support (p=0.030), and that of the contralateral back rotators (internal and external obliques) to braking (p=0.004). These findings provide insight into the biomechanical causes of post-operative gait adaptations such as 'quadriceps avoidance' observed in TKA patients.
Background Despite good results of primary total knee arthroplasty (TKA), the number of revision total knee arthroplasties (rTKAs) is rising. Proper implant position is essential, since malposition leads to worse clinical outcome. In rTKA most anatomical landmarks have disappeared because of extensive bone loss, making it more difficult to adequately implant the knee prosthesis. In primary TKA, computer-assisted surgery (CAS) leads to better prosthetic alignment than mechanical navigation guides. Literature about the use of CAS in rTKA is scarce though, and the effect on rotational prosthetic alignment has not been investigated yet. Hence the primary objective of this study is to compare rotational prosthetic alignment when using CAS in rTKA compared to a mechanical navigation guide. Secondary objectives are to compare prosthetic alignment in the coronal and sagittal planes. It is hypothesized that CAS leads to better rotational, coronal and sagittal prosthetic alignment when used during rTKA. Methods/Design A prospective clinical intervention study with use of a historical control group will be conducted. Forty-four patients with a minimum age of 18 to be admitted for CAS-rTKA between September 2012 and September 2015 will be included in the intervention group. Forty-four patients with a minimum age of 18 who underwent rTKA with the use of a mechanical navigation guide between January 2002 and April 2012 will form the historical control group. Both groups will be matched according to gender and type of revision prosthesis. Rotational prosthesis alignment will be evaluated using a CT-scan of the knee joint. Discussion Proper implant position is essential, since malposition leads to worse clinical outcome. Several studies show a significantly positive influence of CAS on prosthetic alignment in primary TKA, but literature about the use of CAS in rTKA is limited. The purpose of this study is thus to investigate the influence of CAS during rTKA on postoperative
Scott, C E H; Davidson, E; MacDonald, D J; White, T O; Keating, J F
Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer. The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis. Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score. Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437). Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable. Cite this article: Bone Joint J 2015;97-B:532-8.
Ebraheim, Nabil A; Ray, Joseph R; Wandtke, Meghan E; Buchanan, Grant S; Sanford, Chris G; Liu, Jiayong
AIM: To investigate the known incidences, treatment options, and related outcomes of periprosthetic tibia fractures after total knee arthroplasty (TKA). METHODS: A literature search was done to identify studies that fit the inclusion criteria. The database search yielded 185 results, which were further reduced by the exclusion criteria to 13 papers, totaling 157 patients that met these criteria. Incidence rates of the different types of periprosthetic tibia fractures were determined and their treatments were subsequently analyzed based on the fracture’s subclass, with patient outcomes being overall favorable. RESULTS: Of the 144 documented patients, 54 (37.5%) had a subclass C fracture, which are frequently seen in revision arthroplasties or when using cement intraoperatively. The fractures of subclasses A and B occur postoperatively. There were 90 subclass A and B fractures with incidences of 18.75% and 43.75% respectively. When broken down by type, 62 (55.36%) were type 1, 24 (21.4%) were type 2, 24 (21.4%) were type 3, and 2 (1.8%) were type 4. Furthermore, from the studies that included origin of injury, the types were further classified as having non-traumatic or traumatic origins. Type 1 had 78% (40/51) non-traumatic origin and 22% (11/51) traumatic origin. Fifteen fractures were type 2, but 5 were falls and 1 through a motor vehicle accident, giving a trauma causation of 40% (6/15). Of the 24 type 3 fractures, 12 were falls and 2 vehicular accidents, leading to a trauma causation of 58% (14/24). CONCLUSION: Type 1 fractures were the most common. Subclass A was treated with locking plates, B required a revision TKA, and C was treated intraoperatively or nonoperatively. PMID:26396942
Luyet, Anais; Fischer, Jean-François; Jolles, Brigitte M; Lunebourg, Alexandre
Unicompartimental knee arthroplasty is a successful procedure for the treatment of localized osteoarthritis to one compartment of the knee with good long-term results. However, several modes of failure of unicompartimental knee arthroplasty have been described, namely aseptic or septic loosening, progression of disease, wear, and instability. Metallosis after unicompartimental knee arthroplasty is rarely reported and is most often related with polyethylene wear or break. We report on a case of rapid failure of unicompartimental knee arthroplasty in oxidized zirconium associated with metallosis secondary to the dislocation of the polyethylene.
Hodrick, Jeffrey T.; Severson, Erik P.; McAlister, Deborah S.; Dahl, Brian
Highly cross-linked polyethylene (XLPE) has been used with good initial success in hip arthroplasty to reduce wear. However, the process of crosslinking reduces fracture toughness, raising concerns as to whether it can be safely used in total knee arthroplasty (TKA). We therefore asked whether XLPE can be used safely in TKA. We performed a retrospective review of 100 subjects receiving XLPE and compared them to 100 subjects who received standard polyethylene in the setting of TKA. The standard polyethylene group had a mean age of 70 with a minimum follow up of 82 months. The highly cross-linked polyethylene group had a mean age of 67 and a minimum follow up of 69 months (mean, 75 months; range, 69–82 months). On radiographic review, the standard group demonstrated 20 TKAs with radiolucencies; 4 of these had evidence of a loose tibial component. The standard group required three revisions related to loose tibial components. The XLPE group had 2 subjects that demonstrated radiolucencies on radiograph and no subjects with evidence of tibial loosening. There were no reoperations related to osteolysis. The data suggest XLPE in TKA can be used safely at least short- to midterm. Our study provides an impetus for further long-term investigation. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:18781371
Koh, In Jun; Kim, Min Woo; Kim, Man Soo; Jang, Sung Won; Park, Dong Chul; In, Yong
This simultaneous bilateral randomized study investigated whether patients would perceive the difference between the subvastus approach (SVA) and the medial parapatellar approach (MPA) after total knee arthroplasty (TKA). In 50 patients scheduled to undergo same-day bilateral TKA, one knee was randomly assigned to SVA and the other to MPA. Patient-reported measures (pain, Western Ontario McMaster University Osteoarthritis Index score, and side preference) and physician-assessed measures (isokinetic muscle strength, range of motion, and Knee Society score) were compared. No differences were observed in the patient-reported measures and physician-assessed measures, with the exception of greater quadriceps strength at postoperative 1 week in knees that underwent SVA. Patients receiving contemporary perioperative management after same-day bilateral TKA do not perceive any difference between knees that underwent SVA or MPA.
Lippe, Craig N; Crossett, Lawrence S
Revision total knee arthroplasty (TKA) should offer the same benefits to patients as primary TKA. As in primary TKA, a main objective of revision TKA is to reduce pain and restore functional range of motion. There are several potential causes of total knee failure, but the principles of repairing each of them is similar. The long-term success of the low contact stress knee system in primary TKA is well established, and clinical evidence for revision TKA with the low contact stress knee is promising.
Background Total knee arthroplasty (TKA) is a common form of treatment to relieve pain and improve function in cases of rheumatoid arthritis (RA). Good clinical outcomes have been reported with a variety of TKA prostheses. The cementless Hi-Tech Knee II cruciate-retaining (CR)-type prosthesis, which has 6 fins at the anterior of the femoral component, posterior cruciate ligament (PCL) retention, flat-on-flat surface component geometry, all-polyethylene patella, strong initial fixation by the center screw of the tibial base plate, 10 layers of titanium alloy fiber mesh, and direct compression molded ultra high molecular weight polyethylene (UHMWPE), is appropriate for TKA in the Japanese knee. The present study was performed to evaluate the clinical results of primary TKA in RA using the cementless Hi-Tech Knee II CR-type prosthesis. Materials and methods We performed 32 consecutive primary TKAs using cementless Hi-Tech Knee II CR-type prosthesis in 31 RA patients. The average follow-up period was 8 years 3 months. Clinical evaluations were performed according to the American Knee Society (KS) system, knee score, function score, radiographic evaluation, and complications. Results The mean postoperative maximum flexion angle was 115.6°, and the KS knee score and function score improved to 88 and 70 after surgery, respectively. Complications, such as infection, occurred in 1 patient and revision surgery was performed. There were no cases of loosening in this cohort, and prosthesis survival rate was 96.9% at 12 years postoperatively. Conclusion These results suggest that TKA using the cementless Hi-Tech Knee II CR-type prosthesis is a very effective form of treatment in RA patients at 5 to 12 years postoperatively. Further long-term follow-up studies are required to determine the ultimate utility of this type of prosthesis. PMID:22356935
Ebert, Jay R; Joss, Brendan; Jardine, Berit; Wood, David J
To investigate the efficacy of manual lymphatic drainage (MLD) in the early postoperative period after total knee arthroplasty (TKA) to reduce edema and pain and improve knee range of motion. Prospective randomized controlled trial. Private hospital and functional rehabilitation clinic. Consecutive sample of patients (N=43; 53 knees) scheduled for TKA. MLD (vs no MLD) on days 2, 3, and 4 postoperatively. Both groups underwent conventional, concomitant physical therapy. Clinical assessment was undertaken pre- and postoperatively prior to and after the designated postoperative MLD sessions (days 2, 3, and 4) and at 6 weeks postsurgery. This included active knee flexion and extension range of motion, lower limb girths (ankle, midpatella, thigh, and calf), and knee pain using a numeric rating scale and the Knee Injury and Osteoarthritis Outcome Score. A significant group effect was observed for active knee flexion, with post hoc tests demonstrating a significantly greater active knee flexion in the MLD group when compared with the control (no MLD) group at the final measure prior to hospital discharge (day 4 postsurgery) and at 6 weeks postsurgery. There were no further group effects observed for the remaining patient-reported and functional outcomes. MLD in the early postoperative stages after TKA appears to improve active knee flexion up to 6 weeks postsurgery, in addition to conventional care. Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Huang, Yilun; Lee, Merrill; Chong, Hwei Chi; Ning, Yilin; Lo, Ngai Nung; Yeo, Seng Jin
Up to 20% of patients who underwent total knee arthroplasty (TKA) reported dissatisfaction with surgical outcome. Despite the multiple studies looking into the factors contributing to patients' dissatisfaction, little research has been done to examine the subjective reasons and complaints patients have post-arthroplasty. This study aimed to look at an Asian patient population which underwent TKA and examine the factors contributing to patient dissatisfaction and the reasons they were dissatisfied with their surgery. A total of 3069 TKAs were performed between January 2011 to April 2013 in a single institution. Preoperative and postoperative variables were prospectively captured, such as standardised knee scores, knee range of motion and patient satisfaction scores. These variables were then analysed with a multiple logistic regression model to determine the statistically significant factors that contribute to patients' satisfaction. Dissatisfied patients were individually interviewed to find the reasons for their unhappiness. Preoperative variables were then analysed to identify the statistically significant factors associated with these subjective complaints. Minimum duration of follow-up was 2 years, with an overall patient satisfaction rate of 91.3%. Preoperative variables contributing to patient dissatisfaction included female gender and better knee flexion. Postoperative variables included lesser improvement in knee flexion at 6 months postoperatively, as well as poorer scores in various validated knee scores at both 6 months and 2 years postoperatively. The top reason for dissatisfaction was pain. Weakness, another reason for patient dissatisfaction, had statistically significant preoperative predictors of increased age and poorer Short-Form 36 Physical Component Score. Although TKA has an impressive patient satisfaction rate in this Asian population, factors contributing to postoperative dissatisfaction suggest a targeted group of patients would benefit from
Civinini, Roberto; Carulli, Christian; Matassi, Fabrizio; Lepri, Andrea Cozzi; Sirleo, Luigi; Innocenti, Massimo
Polyethylene (PE) wear is a major contributor to implant loosening following total knee arthroplasty (TKA), and advanced bearings in TKA are being investigated with hopes of reducing or eliminate wear-related loosening. Currently, information on knee tribology is available from national joint registries and may be the best tools to evaluate the efficacy and safety of design innovations in joint arthroplasty. We performed a review of national joint registries trying to answer the following questions: "Which is the main factor directly related to revisions rate in TKA?" and "Are there new bearing options better than conventional ones?" A review was performed of all published annual reports of National Joint Registers, as well as of the literature. The search was carried out using and comparing the National Joint Registers. Current data from registries for total knee arthroplasty indicates that age is the major factor affecting the outcome of primary total knee replacement. The 10-year cumulative revision rate for non-cross-linked PE was 5.8% and for XLPE it was 3.5%. The effect of cross-linked polyethylene was more evident in the younger patients. The survival of the oxidized zirconium (OxZr) femoral component appears better when compared to a similar age group of patients with conventional group of prostheses. Our review suggests that the revision rates are half for the OxZr components compared to conventional CoCr femoral components. Age is the most relevant single factor related to revision rate. Cross-linked PE has a statistical lower revision rate at 10 years compared to conventional PE and, in the OxZr group, the revision rate is 2 times lower than Co-Cr in the same group of age.
Ishii, Yoshinori; Noguchi, Hideo; Sato, Junko; Todoroki, Koji; Ezawa, Nobukazu; Toyabe, Shin-ichi
Background: Preoperative periarticular bone quality is affected by joint loading. The purpose of this study was to determine the periarticular bone mineral density of the knee joint of patients undergoing total knee arthroplasty, and whether the location of the load-bearing axis correlates with the measured bone mineral density. Materials and Methods: The bone mineral densities of the medial and lateral femoral condyles and the medial and lateral tibial condyles were analyzed in consecutive 116 osteoarthritic patients (130 knees) by dual energy x-ray absorptiometry. Results: The median bone mineral density values in the condyles were 1.138 in femoral medial, 0.767 in femoral lateral, 1.056 in tibial medial, and 0.714 in tibial lateral. The medial condyles showed significantly higher bone mineral densities than the lateral condyles in both the femur and tibia. In addition, the femoral medial showed significantly higher bone mineral density levels than the tibial medial, and the femoral lateral condyle had higher bone mineral density levels than the tibial lateral. The bone mineral density Medial/Lateral ratio was significantly negatively correlated with the location (tibial medial edge 0%, lateral edge 100%) of the load-bearing axis in the femur and tibia. Conclusion: Preoperative bone mineral density values may provide against the changes in bone mineral density after total knee arthroplasty by reflecting the correlation with joint loading axis. These results help explain why total knee arthroplasty has such good long-term clinical outcomes with a low frequency of component loosening and periarticular fractures despite a high degree of postoperative bone loss. PMID:27583058
Witjes, Suzanne; Gouttebarge, Vincent; Kuijer, P Paul F M; van Geenen, Rutger C I; Poolman, Rudolf W; Kerkhoffs, Gino M M J
People today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse. Our aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes. PRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) 'arthroplasty', 'sports' and 'recovery of function', the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators. Out of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89% after TKA and from 75 to >100% after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1-4.6 after UKA and 0.2-1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA
Manzotti, Alfonso; Chemello, Cesare; Pullen, Chris; Cerveri, Pietro; Confalonieri, Norberto
This study presents a consecutive series of patients who underwent total knee arthroplasty (TKA) after prior distal femoral fracture without hardware removal. The purpose of this study was to determine the effectiveness of computer-assisted TKA in patients with posttraumatic arthritis, specifically those with retained hardware after prior distal femoral fracture. The study group included a consecutive series of 16 patients who had developed posttraumatic knee arthritis after a distal femoral fracture with retention of hardware (group A). Patients in the study group were matched with patients who had undergone a computer-assisted TKA using the same implant and software (group B). The indication for TKA in all group B patients was atraumatic arthritis, and surgery was performed during the same period as that in the study group. Patients were matched for age, sex, preoperative range of motion, preoperative severity of arthritis, type and grade of deformity, and implant features. No statistically significant differences existed between the 2 study groups in terms of operative time, duration of hospital stay, or intra- and postoperative complications. At last follow-up, no statistically significant differences existed in Knee Society Scores and Western Ontario and McMaster Universities Arthritis Index scores. Implant alignment and radiological parameters were similar in both groups. This study demonstrated that posttraumatic knee arthritis after prior distal femoral fracture can be safely managed using a computer-assisted TKA without hardware removal. Comparison between the study group and a matched group with atraumatic arthritis showed similar postoperative results and complication rates. Copyright 2012, SLACK Incorporated.
Inacio, M C S; Paxton, E W; Graves, S E; Namba, R S; Nemes, S
The purpose of our study was to estimate the future incidence rate (IR) and volume of primary total knee arthroplasty (TKA) in the United States from 2015 to 2050 using a conservative projection model that assumes a maximum IR of procedures. Furthermore, our study compared these projections to a model assuming exponential growth, as done in previous studies, for illustrative purposes. A population based epidemiological study was conducted using data from US National Inpatient Sample (NIS) and Census Bureau. Primary TKA procedures performed between 1993 and 2012 were identified. The IR, 95% confidence intervals (CI), or prediction intervals (PI) of TKA per 100,000 US citizens over the age of 40 years were calculated. The estimated IR was used as the outcome of a regression modelling with a logistic regression (i.e., conservative model) and Poisson regression equation (i.e., exponential growth model). Logistic regression modelling suggests the IR of TKA is expected to increase 69% by 2050 compared to 2012, from 429 (95%CI 374-453) procedures/100,000 in 2012 to 725 (95%PI 121-1041) in 2050. This translates into a 143% projected increase in TKA volume. Using the Poisson model, the IR in 2050 was projected to increase 565%, to 2854 (95%CI 2278-4004) procedures/100,000 IR, which is an 855% projected increase in volume compared to 2012. Even after using a conservative projection approach, the number of TKAs in the US, which already has the highest IR of knee arthroplasty in the world, is expected to increase 143% by 2050. Copyright © 2017 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Comparison of periprosthetic tissues in knee and hip joints: differential expression of CCL3 and DC-STAMP in total knee and hip arthroplasty and similar cytokine profiles in primary knee and hip osteoarthritis.
Tomankova, T; Kriegova, E; Fillerova, R; Luzna, P; Ehrmann, J; Gallo, J
To identify expression profiles (EP) associated with aseptic loosening of total knee arthroplasty (TKA) and to compare them with EP observed in total hip arthroplasty (THA), and primary knee and hip osteoarthritis (OA). Gene EP of TNF, IL-6, IL-8, CHIT1, BMP4, CCL3, CCL18, MMP9, RANKL, OPG, DC-STAMP and SOCS3 were assessed using quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) on tissues retrieved from patients with aseptically failed TKA (n = 21), THA (n = 41) and primary knee (n = 20) and hip (n = 17) OA. Immunohistochemistry was applied to localize the proteins. When compared to knee OA, the pseudosynovial tissue in TKA exhibit (1) elevation of alternative macrophage activation marker (CHIT1), chemokine (IL-8), and a proteolytic enzyme (MMP9); (2) downregulation of pro-inflammatory cytokine (TNF), osteoclastic regulator (OPG) and a stimulator of bone formation (BMP4); (3) no difference in IL-6, CCL3, CCL18, RANKL, DC-STAMP and SOCS3. The EP in TKA differed from EP in aseptically failed THA by lower CCL3 and DC-STAMP mRNA and protein expression. EP of all studied inflammatory and osteoclastogenic molecules were similar in knee and hip OA. Comparing to OA, aseptic loosening of TKA is associated with upregulated expression of CHIT1, IL-8 and MMP9, dysregulated RANKL:OPG ratio and low levels of inflammatory cytokines. Similar cytokine profiles were associated with primary knee and hip OA. Further research is required to explain the differences in CCL3 and DC-STAMP expression between failed TKA and THA. Copyright © 2014 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Background and purpose Activated platelets release a cocktail of growth factors, some of which are thought to stimulate repair. We investigated whether the use of autologous platelet gel (PG) in total knee arthroplasty (TKA) would improve wound healing and knee function, and reduce blood loss and the use of analgesics. Patients and methods 102 patients undergoing TKA were randomly assigned to a PG group (n = 50) or to a control (C) group (n = 52). The primary analysis was based on 73 participants (PG: 32; C: 41) with comparison of postoperative wound scores, VAS, WOMAC, knee function, use of analgesics, and the pre- and postoperative hemoglobin values after a follow-up of 3 months. 29 participants were excluded due to insufficient data. Results The characteristics of the protocol-compliant patients were similar to those of the patients who were excluded. Analysis was per protocol and focused on the remaining 73 patients. At baseline and after 3 months of follow-up, there were no statistically significant differences between both groups regarding age, height, weight, sex, side of operation, platelet count, hemoglobin values, severity of complaints (WOMAC), and level of pain. Interpretation In our patients undergoing TKA, application of PG to the wound site did not promote wound healing. Also, we found that PG had no effect on pain, knee function, or hemoglobin values. PMID:19916689
Koeck, Franz Xaver; Schmitt, Miriam; Baier, Clemens; Stangl, Hubert; Beckmann, Johannes; Grifka, Joachim; Straub, Rainer H
So far, there exists no golden standard for the treatment of arthrofibrosis (AF) following total knee arthroplasty (TKA). Although pain is a hallmark of AF, nociceptive nerve fibers have never been investigated in affected joint tissue. A total of 24 patients with osteoarthritis (OA) of the knee (n = 12) and post-TKA AF of the knee (n = 12) were included. Along evaluation of typical clinical signs and symptoms by using the Knee Society Clinical Rating System (KSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC index), the innervation of joint tissue was studied by semiquantitative immunofluorescence of nerve fibers. Patients with AF compared to OA had a lower KSS and lower KOOS. In all compartments (anterior, medial, and lateral recesses), the density of synovial sympathetic nerve fibers was significantly higher in OA compared to AF, which was also true for the density of sensory nerve fibers in the medial and lateral recesses. In synovial tissue of the anterior recess of patients with AF compared to OA, the density of nociceptive sensory nerve fibers was significantly higher relative to sympathetic nerve fibers. This was similarly observed in the neighboring infrapatellar fat pad of the knee. Similar as in many painful musculoskeletal diseases, this study indicates that patients with arthrofibrosis of the knee after TKA demonstrate a preponderance of profibrotic sensory nerve fibers over antifibrotic sympathetic nerve fibers. This could serve as a starting point for AF therapy with specific antifibrotic pain medication or regional anesthetic techniques.
Steinbrück, Arnd; Schröder, Christian; Woiczinski, Matthias; Müller, Tatjana; Müller, Peter E; Jansson, Volkmar; Fottner, Andreas
Although continuous improvements have been made, there is still a considerable amount of unsatisfied patients after total knee arthroplasty (TKA). A main reason for this high percentage is anterior knee pain, which is supposed to be provoked by post-operative increased retropatellar peak pressure. Since rotational malalignment of the implant is believed to contribute to post-operative pain, the aim of this study was to examine the influence of tibial component rotation on knee kinematics and retropatellar pressure. Eight fresh-frozen knee specimens were tested in a weight-bearing knee rig after fixed-bearing TKA under a loaded squat from 20° to 120° of flexion. To examine tibial components with different rotations, special inlays with 3° internal rotation and 3° external rotation were produced and retropatellar pressure distribution was measured with a pressure-sensitive film. The kinematics of the patella and the femorotibial joint were recorded with an ultrasonic-based motion analysis system. Retropatellar peak pressure decreased significantly from 3° internal rotation to neutral position and 3° external rotation of the tibial component (8.5 ± 2.3 vs. 8.2 ± 2.4 vs. 7.8 ± 2.5 MPa). Regarding knee kinematics femorotibial rotation and anterior-posterior translation, patella rotation and tilt were altered significantly, but relative changes remained minimal. Changing tibial rotation revealed a high in vitro influence on retropatellar peak pressure. We recommend the rotational alignment of the tibial component to the medial third of the tibial tuberosity or even more externally beyond that point to avoid anterior knee pain after TKA.
El-Zayat, Bilal Farouk; Heyse, Thomas J; Fanciullacci, Nelson; Labey, Luc; Fuchs-Winkelmann, Susanne; Innocenti, Bernardo
No evidence-based guidelines are available to determine the appropriate stem length, and whether or not to cement stems in revision total knee arthroplasty (TKA). Therefore, the objective of this study was to compare stresses and relative movement of cemented and uncemented stems of different lengths using a finite element analysis. A finite element model was created for a synthetic tibia. Two stem lengths (95 and 160 mm) and two types of fixation (cemented or press fit) of a hinged TKA were examined. The average compressive stress distribution in different regions of interest, as well as implant micromotions, was determined and compared during lunge and squat motor tasks. Both long and short stems in revision TKA lead to high stresses, primarily in the region around the stem tip. The presence of cement reduces the stresses in the bone in every region along the stem. Short stem configurations are less affected by the presence of cement than the long stem configuration. Press-fit stems showed higher micromotions compared to cemented stems. Lowest stresses and micromotion were found for long cemented stems. Cementless stems showed more micromotion and increased stress levels especially at the level of the stem tip, which may explain the clinical phenomenon of stem-end pain following revision knee arthroplasty. These findings will help the surgeon with optimal individual implant choice.
Yoo, Moon-Jib; Ryu, Jee-Won; Kim, Jeong-Sang
Purpose Although allogeneic blood transfusion is the most common method of transfusion in total knee arthroplasty (TKA), there are reports showing significant decrease in the amount of allogeneic transfusion and incidence of side effects after combined use of autologous transfusion. The purpose of this study is to investigate the efficacy of using an autologous transfusion device in TKA. Materials and Methods Patients who underwent TKA at our institution from January 2003 to January 2014 were divided into two groups: group A (n=127) who received allogeneic transfusion only in TKA and group B (n=118) who received autologous transfusion via an autologous transfusion device and allogeneic transfusion. In both groups, the patients were transfused when the hemoglobin level was below 9 g/dL. In group B, blood collected by the autologous transfusion device was transfused only once after surgery. The total blood loss volume, total transfusion volume, and the presence of side effects were assessed based on medical records. Results Group A received 294.6 mL more allogeneic transfusion than group B (p<0.001). There were no significant differences with regard to the development of side effects between groups. Conclusions Application of an autologous transfusion device during TKA can be effective in reducing the allogeneic transfusion volume. Moreover, allogeneic transfusion was not necessary after autologous transfusion in some patients. PMID:26389070
McCartney, Colin J L; Nelligan, Kathleen
Total knee arthroplasty (TKA) is a common surgical procedure in the elderly and is associated with severe pain after surgery and a high incidence of chronic pain. Several factors are associated with severe acute pain after surgery, including psychological factors and severe preoperative pain. Good acute pain control can be provided with multimodal analgesia, including regional anesthesia techniques. Studies have demonstrated that poor acute pain control after TKA is strongly associated with development of chronic pain, and this emphasizes the importance of attention to good acute pain control after TKA. Pain after discharge from hospital after TKA is currently poorly managed, and this is an area where increased resources need to be focused to improve early pain control. This is particularly as patients are often discharged home within 4-5 days after surgery. Chronic pain after TKA in the elderly can be managed with both pharmacological and non-pharmacological techniques. After excluding treatable causes of pain, the simplest approach is with the use of acetaminophen combined with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). Careful titration of opioid analgesics can also be helpful with other adjuvants such as the antidepressants or antiepileptic medications used especially for patients with neuropathic pain. Topical agents may provide benefit and are associated with fewer systemic side effects than oral administration. Complementary or psychological therapies may be beneficial for those patients who have failed other options or have depression associated with chronic pain.
Hernandez-Vaquero, D; Noriega-Fernandez, A; Suarez-Vazquez, A; Roncero-Gonzalez, S; Sierra-Pereira, A A; Gil-Martinez, L; Fernandez-Carreira, J M
To establish the concordance between angulation of the femoro-tibial mechanical axis measured with x-rays and surgical navigation in both the pre and postoperative period after a total knee arthroplasty (TKA) was implanted. Pre and postoperative measurements were analyzed in 88 TKA of the same model and all performed with the same surgical navigation system. The mechanical frontal angle (MFA) and femoro-tibial anatomic angle were measured before and after the TKA. The angulation was digitally measured with a teleradiography. In the navigation, the femoro-tibial angle at rest, forced varus and valgus were registered and the average of these three measurements was calculated. The mean preoperative MFA measured on the radiograph was 4.55°. The mean of the same angle measured on the postoperative radiograph was 1.72°, (p=0.05). The mean of the MFA measured with navigation before TKA was 3.12° and after the implant with navigation was 0.53 (P=.013). The concordance coefficient between the MFA in teleradiography and in navigation was 0.869 (P<.001) preoperatively and 0.709 postoperatively (P=.017). We found a strong concordance between radiographic and surgical navigation measurements of the MFA. This may imply that teleradiography is not necessary when using surgical navigation in TKA. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.
Seol, Young-Jun; Seon, Jong-Keun; Lee, Seung-Hun; Jin, Cheng; Prakash, Jatin; Park, Yong-Jin
Purpose Total knee arthroplasty (TKA) accompanies the risk of bleeding and need for transfusion. There are several methods to reduce postoperative blood loss and blood transfusion. One such method is using tranexamic acid during TKA. The purpose of this study was to confirm whether tranexamic acid reduces postoperative blood loss and blood transfusion after TKA. Materials and Methods A total of 100 TKA patients were included in the study. The tranexamic acid group consisted of 50 patients who received an intravenous injection of tranexamic acid. The control included 50 patients who received a placebo injection. The amounts of drainage, postoperative hemoglobin, and transfusion were compared between the groups. Results The mean amount of drainage was lower in the tranexamic acid group (580.6±355.0 mL) than the control group (886.0±375.5 mL). There was a reduction in the transfusion rate in the tranexamic acid group (48%) compared with the control group (64%). The hemoglobin level was higher in the tranexamic acid group than in the control group at 24 hours postoperatively. The mean units of transfusion were smaller in the tranexamic acid group (0.76 units) than in the control group (1.28 units). Conclusions Our data suggest that intravenous injection of tranexamic acid decreases the total blood loss and transfusion after TKA. PMID:27595071
Neuprez, Audrey; Crielaard, Jean-Michel; Bruyère, Olivier; Reginster, Jean-Yves
Introduction The objective of this study was to assess the number and magnitude of preoperative expectations and to correlate them with the degree of satisfaction expressed one year after Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA), in patients with severe and painful osteoarthritis (OA). Materials and Methods Preoperative expectations (within 20 days prior to surgery) and postoperative satisfaction (one year after the intervention) were measured using the previously validated French version of the Hospital for Special Surgery Hip or Knee Replacement Expectations Survey. Postoperative satisfaction was measured using a specific scale, following the same methodology as that used for the assessment of expectations. Prediction of the satisfaction of the patients was performed using multivariate linear regression modelling. Results A total of 138 patients (80 THA and 58 TKA) completed the two parts of the study. The expectations score (mean ± SD) (range 0–100) was 72.58 ± 12.63 before THA and 69.10 ± 13.72 before TKA (p = 0.13). The number of expectations expressed was 14.34 ± 1.32 (out of a potential maximum of 18) before THA and 14.70 ± 2.29 (out of a potential maximum of 19) before TKA. After 1 year, THA generated a significantly higher degree of satisfaction compared to TKA (69.70 ± 14.46 v 60.44 ± 17.54, p<0.001) (range 0–100). The pre-operative expectations score was the single best positive predictor of the post-surgery satisfaction assessment both for TKA and THA. Conclusion Patients undergoing total joint arthroplasty for end-stage OA have a high level of expectations, before both THA and TKA. While both types of interventions significantly improve essential and non-essential activities, the rate of satisfaction is significantly greater post THA. Preoperative expectations are a major contributor to the final degree of satisfaction, one year after surgery. These results re-emphasize the need for an optimal preoperative interaction
Neuprez, Audrey; Delcour, Jean-Pierre; Fatemi, Firouzeh; Gillet, Philippe; Crielaard, Jean-Michel; Bruyère, Olivier; Reginster, Jean-Yves
The objective of this study was to assess the number and magnitude of preoperative expectations and to correlate them with the degree of satisfaction expressed one year after Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA), in patients with severe and painful osteoarthritis (OA). Preoperative expectations (within 20 days prior to surgery) and postoperative satisfaction (one year after the intervention) were measured using the previously validated French version of the Hospital for Special Surgery Hip or Knee Replacement Expectations Survey. Postoperative satisfaction was measured using a specific scale, following the same methodology as that used for the assessment of expectations. Prediction of the satisfaction of the patients was performed using multivariate linear regression modelling. A total of 138 patients (80 THA and 58 TKA) completed the two parts of the study. The expectations score (mean ± SD) (range 0-100) was 72.58 ± 12.63 before THA and 69.10 ± 13.72 before TKA (p = 0.13). The number of expectations expressed was 14.34 ± 1.32 (out of a potential maximum of 18) before THA and 14.70 ± 2.29 (out of a potential maximum of 19) before TKA. After 1 year, THA generated a significantly higher degree of satisfaction compared to TKA (69.70 ± 14.46 v 60.44 ± 17.54, p<0.001) (range 0-100). The pre-operative expectations score was the single best positive predictor of the post-surgery satisfaction assessment both for TKA and THA. Patients undergoing total joint arthroplasty for end-stage OA have a high level of expectations, before both THA and TKA. While both types of interventions significantly improve essential and non-essential activities, the rate of satisfaction is significantly greater post THA. Preoperative expectations are a major contributor to the final degree of satisfaction, one year after surgery. These results re-emphasize the need for an optimal preoperative interaction between health care providers and patients, to allow
Estour, Gilles; Nemer, Charbel; Colle, Pierre-Emmanuel
The purpose of this study was twofold: to evaluate the radiological and clinical results of 33 total knee arthroplasties (TKA) implanted between January 1993 and March 2005, to replace failed medial unicompartmental knee arthroplasty (UKA), and to develop a strategy to deal with bone defects in the tibial plateau. Failure was due to: tibial loosening (15 cases), femoral loosening (five cases), femoral and tibial loosening (two cases), polyethylene wear (five cases), lateral compartment osteoarthritis (two cases), patellofemoral osteoarthritis (two cases), laxity and PE dislocation (one case), and sepsis in one case. In 12 cases the tibial bone defect was filled with a metallic wedge, in seven we used an allograft (femoral head), and in one we used both. We report the results of 27 cases (five patients died and one was lost to follow-up). The mean follow-up was 73±41.7 months (range, 8–153) and the global IKS score was 166.72±21.3 points (range, 128–200). X-rays of the eight allografts showed osteointegration in all cases and no radiolucency was noted. PMID:18563411
Kang, K-T; Koh, Y-G; Son, J; Kwon, O-R; Baek, C; Jung, S H; Park, K K
Malrotation of the femoral component can result in post-operative complications in total knee arthroplasty (TKA), including patellar maltracking. Therefore, we used computational simulation to investigate the influence of femoral malrotation on contact stresses on the polyethylene (PE) insert and on the patellar button as well as on the forces on the collateral ligaments. Validated finite element (FE) models, for internal and external malrotations from 0° to 10° with regard to the neutral position, were developed to evaluate the effect of malrotation on the femoral component in TKA. Femoral malrotation in TKA on the knee joint was simulated in walking stance-phase gait and squat loading conditions. Contact stress on the medial side of the PE insert increased with internal femoral malrotation and decreased with external femoral malrotation in both stance-phase gait and squat loading conditions. There was an opposite trend in the lateral side of the PE insert case. Contact stress on the patellar button increased with internal femoral malrotation and decreased with external femoral malrotation in both stance-phase gait and squat loading conditions. In particular, contact stress on the patellar button increased by 98% with internal malrotation of 10° in the squat loading condition. The force on the medial collateral ligament (MCL) and the lateral collateral ligament (LCL) increased with internal and external femoral malrotations, respectively. These findings provide support for orthopaedic surgeons to determine a more accurate femoral component alignment in order to reduce post-operative PE problems.Cite this article: K-T. Kang, Y-G. Koh, J. Son, O-R. Kwon, C. Baek, S. H. Jung, K. K. Park. Measuring the effect of femoral malrotation on knee joint biomechanics for total knee arthroplasty using computational simulation. Bone Joint Res 2016;5:552-559. DOI: 10.1302/2046-3758.511.BJR-2016-0107.R1. © 2016 Kang et al.
Kang, K-T.; Koh, Y-G.; Son, J.; Kwon, O-R.; Baek, C.; Jung, S. H.
Objectives Malrotation of the femoral component can result in post-operative complications in total knee arthroplasty (TKA), including patellar maltracking. Therefore, we used computational simulation to investigate the influence of femoral malrotation on contact stresses on the polyethylene (PE) insert and on the patellar button as well as on the forces on the collateral ligaments. Materials and Methods Validated finite element (FE) models, for internal and external malrotations from 0° to 10° with regard to the neutral position, were developed to evaluate the effect of malrotation on the femoral component in TKA. Femoral malrotation in TKA on the knee joint was simulated in walking stance-phase gait and squat loading conditions. Results Contact stress on the medial side of the PE insert increased with internal femoral malrotation and decreased with external femoral malrotation in both stance-phase gait and squat loading conditions. There was an opposite trend in the lateral side of the PE insert case. Contact stress on the patellar button increased with internal femoral malrotation and decreased with external femoral malrotation in both stance-phase gait and squat loading conditions. In particular, contact stress on the patellar button increased by 98% with internal malrotation of 10° in the squat loading condition. The force on the medial collateral ligament (MCL) and the lateral collateral ligament (LCL) increased with internal and external femoral malrotations, respectively. Conclusions These findings provide support for orthopaedic surgeons to determine a more accurate femoral component alignment in order to reduce post-operative PE problems. Cite this article: K-T. Kang, Y-G. Koh, J. Son, O-R. Kwon, C. Baek, S. H. Jung, K. K. Park. Measuring the effect of femoral malrotation on knee joint biomechanics for total knee arthroplasty using computational simulation. Bone Joint Res 2016;5:552–559. DOI: 10.1302/2046-3758.511.BJR-2016-0107.R1. PMID:28094763
Manning, Blaine T; Lewis, Natasha; Tzeng, Tony H; Saleh, Jamal K; Potty, Anish G R; Dennis, Douglas A; Mihalko, William M; Goodman, Stuart B; Saleh, Khaled J
Postoperative pain, which has been attributed to poor outcomes after total knee arthroplasty (TKA), remains problematic for many patients. Although the source of TKA pain can often be delineated, establishing a precise diagnosis can be challenging. It is often classified as intra-articular or extra-articular pain, depending on etiology. After intra-articular causes, such as instability, aseptic loosening, infection, or osteolysis, have been ruled out, extra-articular sources of pain should be considered. Physical examination of the other joints may reveal sources of localized knee pain, including diseases of the spine, hip, foot, and ankle. Additional extra-articular pathologies that have potential to instigate pain after TKA include vascular pathologies, tendinitis, bursitis, and iliotibial band friction syndrome. Patients with medical comorbidities, such as metabolic bone disease and psychological illness, may also experience prolonged postoperative pain. By better understanding the diagnosis and treatment options for extra-articular causes of pain after TKA, orthopaedic surgeons may better treat patients with this potentially debilitating complication.
Giurea, A.; Fraberger, G.; Kolbitsch, P.; Lass, R.; Schneider, E.; Kubista, B.; Windhager, R.
Ten to twenty percent of patients with total knee arthroplasty (TKA) are dissatisfied with their clinical outcome. Aim of this study was to investigate the impact of personality traits on the subjective outcome of TKA. We investigated 80 patients with 86 computer navigated TKAs. We asked for patients satisfaction and divided patients into two groups (satisfied or dissatisfied). 12 personality traits were tested by the Freiburg Personality Inventory (FPI-R). Postoperative examination included Knee Society Score (KSS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the Visual Analogue Scale (VAS). Radiologic investigation was done in all patients. 84% of our patients were satisfied, while 16% were not satisfied. The FPI-R showed statistical significant influence of four personality traits on patient satisfaction: life satisfaction (p = 0.006), performance orientation (p = 0.015), somatic distress (p = 0.001), and emotional stability (p = 0.002). All clinical scores (VAS, WOMAC, and KSS) showed significantly better results in the satisfied patient. Radiological examination showed optimal alignment of all TKAs. There were no complications requiring revision surgery. The results of our study show that personality traits may influence patients satisfaction and clinical outcome after TKA. Therefore patients personality traits may be a useful predictive factor for postoperative satisfaction after TKA. PMID:26989686
Pozzi, F; Snyder-Mackler, L; Zeni, J
Total knee arthroplasty (TKA) is the gold standard treatment for end-stage knee osteoarthritis. Most patients report successful long-term outcomes and reduced pain after TKA, but recovery is variable and the majority of patients continue to demonstrate lower extremity muscle weakness and functional deficits compared to age-matched control subjects. Given the potential positive influence of postoperative rehabilitation and the lack of established standards for prescribing exercise paradigms after TKA, the purpose of this study was to systematically review randomized, controlled studies to determine the effectiveness of postoperative outpatient care on short- and long-term functional recovery. Nineteen studies were identified as highly relevant for the review and four categories of postoperative intervention were discussed: 1) strengthening exercises; 2) aquatic therapy; 3) balance training; and 4) clinical environment. Optimal outpatient physical therapy protocols should include: strengthening and intensive functional exercises given through land-based or aquatic programs, the intensity of which is increased based on patient progress. Due to the highly individualized characteristics of these types of exercises, outpatient physical therapy performed in a clinic under the supervision of a trained physical therapist may provide the best long-term outcomes after the surgery. Supervised or remotely supervised therapy may be effective at reducing some of the impairments following TKA, but several studies without direct oversight produced poor results. Most studies did not accurately describe the "usual care" or control groups and information about the dose, frequency, intensity and duration of the rehabilitation protocols were lacking from several studies.
Guo, Chong-Jun; Lv, Jin-Han; Niu, Dong-Sheng; Ma, Tao; Sun, Shou-Xuan; Li, Li-Xin; Zhao, Xin; Wu, Long; Jin, Qun-Hua
Rheumatoid arthritis (RA) is the most common chronic inflammatory joint disorder and anti-cyclic citrullinated peptide antibody (anti-CCP Ab) is regarded as a serological marker for diagnosing early and late RA. In the present study, we aimed to determine the levels of anti-CCP Ab in serum, synovial tissue (ST) and synovial fluid (SF) in RA patients undergoing total knee arthroplasty (TKA). 23 patients were included. Rheumatoid factor (RF) and anti-CCP Ab in serum were detected prior to surgery and then at 1, 3, 6 and 12 months after TKA. Synovial samples were obtained by knee arthroscopy and used for anti-CCP detection. One month after TKA, anti-CCP levels were significantly reduced (P < 0.01) in RA patients. However, their levels were not significantly different between pre-surgery and 1 year post-surgery (P > 0.05). Furthermore, anti-CCP levels in ST were much higher than in serum. These findings suggest that RA patients should continue antirheumatic therapy after TKA. ST is the preferred place for the synthesis of anti-CCP Ab.
Giurea, A; Fraberger, G; Kolbitsch, P; Lass, R; Schneider, E; Kubista, B; Windhager, R
Ten to twenty percent of patients with total knee arthroplasty (TKA) are dissatisfied with their clinical outcome. Aim of this study was to investigate the impact of personality traits on the subjective outcome of TKA. We investigated 80 patients with 86 computer navigated TKAs. We asked for patients satisfaction and divided patients into two groups (satisfied or dissatisfied). 12 personality traits were tested by the Freiburg Personality Inventory (FPI-R). Postoperative examination included Knee Society Score (KSS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the Visual Analogue Scale (VAS). Radiologic investigation was done in all patients. 84% of our patients were satisfied, while 16% were not satisfied. The FPI-R showed statistical significant influence of four personality traits on patient satisfaction: life satisfaction (p = 0.006), performance orientation (p = 0.015), somatic distress (p = 0.001), and emotional stability (p = 0.002). All clinical scores (VAS, WOMAC, and KSS) showed significantly better results in the satisfied patient. Radiological examination showed optimal alignment of all TKAs. There were no complications requiring revision surgery. The results of our study show that personality traits may influence patients satisfaction and clinical outcome after TKA. Therefore patients personality traits may be a useful predictive factor for postoperative satisfaction after TKA.
Paterson, K L; Sosdian, L; Hinman, R S; Wrigley, T V; Kasza, J; Dowsey, M; Choong, P; Bennell, K L
Sex and body mass may influence knee biomechanics associated with poor total knee arthroplasty (TKA) outcomes for knee osteoarthritis (OA). This study aimed to determine if gait differed between men and women, and overweight and class I obese patients with severe knee OA awaiting TKA. 34 patients with severe knee OA (average age 70.0 (SD 7.2) years, body mass index 30.3 (4.1kg/m(2))) were recruited from a TKA waiting list. Three-dimensional gait analysis was performed at self-selected walking speed. Comparisons were made between men and women, and overweight (body mass index (BMI) 25.0-29.9kg/m(2)) and class I obese (BMI 30.0-34.9kg/m(2)) participants. Biomechanical outcomes included absolute and body size-adjusted peak knee adduction moment (KAM), KAM impulse, peak knee flexion moment, as well as peak knee flexion and varus-valgus angles, peak varus-valgus thrust, and peak vertical ground reaction force (GRF). Men had a higher absolute peak KAM, KAM impulse and peak GRF compared to women, and this sex-difference in frontal plane moments remained after adjusting for body size. However, when additionally adjusting for static knee alignment, differences disappeared. Knee biomechanics were similar between obesity groups after adjusting for the greater body weight of those with class I obesity. Men had greater KAM and KAM impulse even after adjustment for body size; however adjustment for their more varus knees removed this difference. Obesity group did not influence knee joint kinematics or moments. This suggests sex- and obesity-differences in these variables may not be associated with TKA outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.
Tria, Alfred J; Scuderi, Giles R
Minimally invasive surgery (MIS) for arthroplasty of the knee began with surgery for unicondylar knee arthroplasty (UKA). Partial knee replacements were designed in the 1970s and were amenable to a more limited exposure. In the 1990s Repicci popularized the MIS for UKA. Surgeons began to apply his concepts to total knee arthroplasty. Four MIS surgical techniques were developed: quadriceps sparing, mini-mid vastus, mini-subvastus, and mini-medial parapatellar. The quadriceps sparing technique is the most limited one and is also the most difficult. However, it is the least invasive and allows rapid recovery. The mini-midvastus is the most common technique because it affords slightly better exposure and can be extended. The mini-subvastus technique entirely avoids incising the quadriceps extensor mechanism but is time consuming and difficult in the obese and in the muscular male patient. The mini-parapatellar technique is most familiar to surgeons and represents a good starting point for surgeons who are learning the techniques. The surgeries are easier with smaller instruments but can be performed with standard ones. The techniques are accurate and do lead to a more rapid recovery, with less pain, less blood loss, and greater motion if they are appropriately performed. PMID:26601062
Kumar, Nishikant; Yadav, Chandrashekhar; Kumar, Ashok
Complications involving the extensor mechanism after TKA are potentially disastrous. We are reporting a case of patellar tendon rupture from tibial tuberosity following total knee arthroplasty. We managed it by direct repair with fiberwire using Krackow suture technique without augmentation. Our long term result has been very encouraging. Our method is a safe and better method of management of patellar tendon avulsion following TKA when it happens without any tissue loss. PMID:25632362
Worni, Mathias; Pietrobon, Ricardo; Zammar, Guilherme Roberto; Shah, Jatin; Yoo, Bryan; Maldonato, Mauro; Takemoto, Steven; Vail, Thomas P.
Background The Hospital Acquired Condition Strategy (HACS) denies payment for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The intention is to reduce complications and associated costs, while improving the quality of care by mandating VTE prophylaxis. We applied a system dynamics model to estimate the impact of HACS on VTE rates, and potential unintended consequences such as increased rates of bleeding and infection and decreased access for patients who might benefit from TKA. Methods and Findings The system dynamics model uses a series of patient stocks including the number needing TKA, deemed ineligible, receiving TKA, and harmed due to surgical complication. The flow of patients between stocks is determined by a series of causal elements such as rates of exclusion, surgery and complications. The number of patients harmed due to VTE, bleeding or exclusion were modeled by year by comparing patient stocks that results in scenarios with and without HACS. The percentage of TKA patients experiencing VTE decreased approximately 3-fold with HACS. This decrease in VTE was offset by an increased rate of bleeding and infection. Moreover, results from the model suggest HACS could exclude 1.5% or half a million patients who might benefit from knee replacement through 2020. Conclusion System dynamics modeling indicates HACS will have the intended consequence of reducing VTE rates. However, an unintended consequence of the policy might be increased potential harm resulting from over administration of prophylaxis, as well as exclusion of a large population of patients who might benefit from TKA. PMID:22536313
Worni, Mathias; Pietrobon, Ricardo; Zammar, Guilherme Roberto; Shah, Jatin; Yoo, Bryan; Maldonato, Mauro; Takemoto, Steven; Vail, Thomas P
The Hospital Acquired Condition Strategy (HACS) denies payment for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The intention is to reduce complications and associated costs, while improving the quality of care by mandating VTE prophylaxis. We applied a system dynamics model to estimate the impact of HACS on VTE rates, and potential unintended consequences such as increased rates of bleeding and infection and decreased access for patients who might benefit from TKA. The system dynamics model uses a series of patient stocks including the number needing TKA, deemed ineligible, receiving TKA, and harmed due to surgical complication. The flow of patients between stocks is determined by a series of causal elements such as rates of exclusion, surgery and complications. The number of patients harmed due to VTE, bleeding or exclusion were modeled by year by comparing patient stocks that results in scenarios with and without HACS. The percentage of TKA patients experiencing VTE decreased approximately 3-fold with HACS. This decrease in VTE was offset by an increased rate of bleeding and infection. Moreover, results from the model suggest HACS could exclude 1.5% or half a million patients who might benefit from knee replacement through 2020. System dynamics modeling indicates HACS will have the intended consequence of reducing VTE rates. However, an unintended consequence of the policy might be increased potential harm resulting from over administration of prophylaxis, as well as exclusion of a large population of patients who might benefit from TKA.
Moon, Young-Wan; Kim, Hyun-Jung; Ahn, Hyeong-Sik; Lee, Dae-Hee
This meta-analysis was performed to analyze serial changes in thigh muscles, including quadriceps and hamstring muscles, from before to one year after total knee arthroplasty (TKA). All studies sequentially comparing isokinetic quadriceps and hamstring muscle strengths between the TKA side and the contralateral uninjured limb were included in this meta-analysis. Five studies with 7 cohorts were included in this meta-analysis. The mean differences in the strengths of quadriceps and hamstring muscles between the TKA and uninjured sides were greatest three months after surgery (26.8 N∙m, 12.8 N∙m, P<0.001), but were similar to preoperative level at six months (18.4 N∙m, 7.4 N∙m P<0.001) and were maintained for up to one year (15.9 N∙m, 4.1 N∙m P<0.001). The pooled mean differences in changes in quadriceps and hamstring strengths relative to preoperative levels were 9.2 N∙m and 4.9 N∙m, respectively, three months postoperatively (P = 0.041), but were no longer significant after six months and one year. During the year after TKA, quadriceps and hamstring muscle strengths were lowest after 3 months, recovering to preoperative level after six months, but not reaching the muscle strength on the contralateral side. Relative to preoperative levels, the difference in muscle strength between the TKA and contralateral knees was only significant at three months. Because decrease of strength of the quadriceps was significantly greater than decrease in hamstring muscle strength at postoperative three months, early rehabilitation after TKA should focus on recovery of quadriceps muscle strength.
Zahn, Robert Karl; Fussi, Jasmin; von Roth, Philipp; Perka, Carsten F; Hommel, Hagen
Standing long-leg radiographs allow assessment of the mechanical axis in the frontal plane before and after total knee arthroplasty (TKA). An alteration in loading, and hence in the forces acting on the knee joint, occurs postoperatively. We therefore postulated that the mechanical axis measured in the long-leg standing radiograph would change within the first year after TKA. Standing long-leg radiographs of 156 patients were performed 7 days, 3 months, and 12 months after TKA with determination of mechanical axis of the lower limb. Seven days after surgery, the mechanical axis amounted 0.8° ± 1.7° valgus. Three months after the operation, at 1.3° ± 1.3° varus, it was significantly different (P < .001) from the primary measurement. No further alteration in the mechanical axis occurred during the first year after TKA. This difference was even more pronounced (P < .001) in patients with a postoperative lack of complete extension. Seven days after surgery, they had a valgus axis deviation of 1.6° ± 1.6°; after 3 months, the measurement amounted 1.2° ± 1.3° varus. Measured by a standing long-leg radiograph, the frontal mechanical axis after TKA changes over time. The predictive power of a standing long-leg radiograph in the first week after surgery is limited because limb loading is altered because of pain and is therefore nonphysiological. The actual mechanical axis resulting after TKA can only be assessed in a standing long-leg radiograph at physiological loading. Copyright © 2016 Elsevier Inc. All rights reserved.
Loyd, Brian J; Jennings, Jason M; Falvey, Jason R; Kim, Raymond H; Dennis, Douglas A; Stevens-Lapsley, Jennifer E
Malalignment of the lower extremity is commonly seen in patients with severe osteoarthritis undergoing total knee arthroplasty (TKA) and is believed to play a role in quadriceps strength loss. Deformity correction is typically achieved through surgical techniques to provide appropriate ligamentous balancing. Therefore, this study examined the influence of change in lower extremity alignment on quadriceps strength outcomes after TKA. Seventy-three participants (36 male; mean age, 62 years; and mean body mass index, 29.7 kg/m(2)) undergoing primary unilateral TKA were used in this investigation. Before surgery and at 1 and 6 months after surgery, measures of isometric knee extensor strength, quadriceps activation, and long-standing plain films were collected. Using the films, measures of mechanical axis, distal femoral angle (DFA), proximal tibial angle, and patellofemoral angle were performed. Hierarchical linear regression was used to evaluate how change in alignment from baseline to 1 and 6 months influenced the change in quadriceps strength. DFA was found to significantly contribute to changes in quadriceps strength at 1 and 6 months after TKA above those contributed by associated covariates. None of the other measures of lower extremity alignment were found to contribute to quadriceps strength in this sample. Reductions in quadriceps strength experienced after TKA are likely to be influenced by changes in lower extremity alignment. Specifically, measures of DFA were found to significantly contribute to these changes. Future work is needed to prospectively examine measures of lower extremity alignment change and recovery after TKA. Copyright © 2017 Elsevier Inc. All rights reserved.
Lange, Toni; Schmitt, Jochen; Kopkow, Christian; Rataj, Elisabeth; Günther, Klaus-Peter; Lützner, Jörg
Although total knee arthroplasty (TKA) is among the most frequent orthopedic procedures for end-stage knee osteoarthritis (OA), systematically developed patient treatment goals for this elective intervention are missing. This constitutes a relevant barrier toward patient-centered healthcare. A Delphi consensus study was conducted. Patients who were candidates for TKA were recruited through 11 outpatient orthopedic surgeons, 4 physiotherapists, and a patient organization in Germany. The initial questionnaire included 20 potential treatment goals derived from a systematic review on outcomes assessed in TKA trials. Patients were asked to rate these potential treatment goals as "main goal," "secondary goal," or "no goal." It was specified that a main goal must be met to consider TKA as successful. Patients could add further goals which were included in the next questionnaire together with a feedback on their own and the group's previous rating. Patients could then confirm or revise their responses to find group consensus, which was defined as ≥70% of participants rating a treatment goal as main goal. From initial 108 participants, 93 (86%) completed the study. Consensus was achieved that symptom reduction ("pain reduction," "improvement of stability"), functional improvements (improvement of "physical function," "range of motion," "walking distance," "walking stairs," "physical activity"), "improvement of quality of life," and prevention and safety concerns ("prevention from secondary impairments," "long implant survival") are the main treatment goals of patients who are candidates for TKA. Physicians should consider patient treatment goals in routine clinical decision making to meet the requirements of patient-centered healthcare. Researchers should consider those treatment goals in effectiveness studies on TKA. Copyright © 2017 Elsevier Inc. All rights reserved.
Belvedere, C; Catani, F; Ensini, A; Moctezuma de la Barrera, J L; Leardini, A
Abnormal patellar tracking results in patello-femoral (PF) joint disorders and frequently in failure of total knee arthroplasty (TKA). It is fundamental to assess this tracking intra-operatively, i.e. since the implantation of the femoral and tibial components. The aim of this study was to assess the feasibility of three-dimensional anatomical-based patellar tracking intra-operatively in standard TKA. A surgical navigation system was utilized to test the new technique in-vitro. An original tracking device and a reference frame were designed and an articular convention for the description of PF joint kinematics was adopted. Six fresh-frozen amputated legs were analyzed with the new technique. Landmark digitations were used to define anatomical reference frames for the femur, tibia, and patella. Five trials of passive flexion were performed with 100 N force on the quadriceps, before and after standard knee arthroplasty. Patellar flexion, tilt, rotation and shift were calculated in addition to standard tibio-femoral (TF) joint kinematics. An intra-specimen repeatable path of motion over repetitions and a coupled path of motion throughout the flexion-extension cycle were observed in all intact knees, both at the TF and PF joints. Replication of the original PF motion in the intact knee was not fully accomplished in the replaced knee. These results revealed the feasibility and the necessity of patellar tracking during TKA. By monitoring intra-operatively also the PF kinematics, the surgeon has a more complete prediction of the performance of the final implant and therefore a valuable support for the most critical surgical decisions.
Turner, N S; Pagnano, M W; Sim, F H
A retrospective review was done of the total joint registry at the Mayo Clinic, Rochester, Minnesota, which contains the computerized records of 19,808 consecutive total knee arthroplasties (TKAs) including primary and revision that were performed from 1970 to 1997. From that database, 9 patients were found to have had a TKA after an ipsilateral peripheral arterial reconstruction. One patient had had bilateral peripheral arterial reconstruction followed by bilateral TKA, and 10 TKAs were reviewed. The medical records were reviewed retrospectively with particular attention given to the type of peripheral bypass surgery performed, the bypass graft source, the timing of the bypass surgery relative to TKA, the use of a tourniquet at the time of TKA, and the occurrence of complications after TKA. Of the 10 TKAs, 2 patients had acute arterial occlusion. One patient had a tourniquet, and the other patient did not. There was not a statistical correlation between graft type, tourniquet use, timing of surgery, postoperative anticoagulation, and occurrence of arterial occlusion. There is a marked risk of acute thrombosis of an ipsilateral arterial bypass graft after TKA that cannot be eliminated by performing the TKA without a tourniquet. Careful monitoring of the vascular status of the limb is required in the early postoperative period to detect arterial compromise. Should limb ischemia be suspected, an emergent vascular surgery consultation is required, and arterial flow to the lower extremity must be re-established.
Moo, Ing H; Chen, Jerry Y Q; Pagkaliwaga, Eric H; Tan, See W; Poon, Kein B
Total knee arthroplasty (TKA) is associated with major blood loss and blood transfusion is often required. This study aimed to evaluate the efficacy of bone wax in reducing blood loss and transfusion rates after TKA. A prospective randomized controlled study that included 100 patients undergoing primary unilateral TKA with cement was conducted in a tertiary center between March 2014 and June 2014. The bone wax group received 2.5 g of bone wax, applied onto the uncovered bone around the prostheses and the nail holes before the tourniquet was released, whereas the control group had hemostasis achieved using electrocautery only. Total blood loss was calculated using the hemoglobin balance method. There were no demographic differences between the 2 groups. The preoperative serum hemoglobin levels were comparable between the 2 groups. The drop in serum hemoglobin levels at 24 h post-TKA was 1.6 ± 0.9 and 2.1 ± 1.1 g/dL in the bone wax and control groups respectively (P = .021), while the drop in serum hemoglobin levels at 72 h post-TKA was 2.7 ± 1.1 and 3.6 ± 1.2 g/dL respectively (P = .013). Total blood loss at 72 h post-TKA was 987.9 and 1183.5 mL for the bone wax and control groups respectively (P = .017). There was no adverse event associated with the use of bone wax at the 3-month follow-up. The application of bone wax in TKA was safe and effective for reducing total blood loss and maintaining higher hemoglobin levels. Copyright © 2016 Elsevier Inc. All rights reserved.
Lindberg, Maren Falch; Miaskowski, Christine; RustøEn, Tone; Rosseland, Leiv Arne; Cooper, Bruce A; Lerdal, Anners
Background and purpose - Functional limitations after total knee arthroplasty (TKA) are common. In this longitudinal study, we wanted to identify subgroups of patients with distinct trajectories of pain-related interference with walking during the first year after TKA and to determine which demographic, clinical, symptom-related, and psychological characteristics were associated with being part of this subgroup. Patients and methods - Patients scheduled for primary TKA for osteoarthritis (n = 202) completed questionnaires that evaluated perception of pain, fatigue, anxiety, depression, and illness on the day before surgery. Clinical characteristics were obtained from the medical records. Interference of pain with walking was assessed preoperatively, on postoperative day 4, and at 6 weeks, 3 months, and 12 months after TKA. Results - Using growth mixture modeling, 2 subgroups of patients were identified with distinct trajectories of pain-related interference with walking over time. Patients in the Continuous Improvement class (n = 157, 78%) had lower preoperative interference scores and reported a gradual decline in pain-related interference with walking over the first 12 months after TKA. Patients in the Recurrent Interference class (n = 45, 22%) reported a high degree of preoperative pain-related interference with walking, initial improvement during the first 3 months after TKA, and then a gradual increase-returning to preoperative levels at 12 months. Patients in the Recurrent Interference class had higher preoperative pain, fatigue, and depression scores, and poorer perception of illness than the Continuous Improvement class. Interpretation - 1 in 5 patients did not improve in pain-related interference with walking at 12 months after TKA. Future studies should test the efficacy of interventions designed to modify preoperative characteristics.
Gholson, J Joseph; Duchman, Kyle R; Otero, Jesse E; Pugely, Andrew J; Gao, Yubo; Callaghan, John J
When new technologies are introduced, it is important to evaluate the rate of adoption and outcomes compared with preexisting technology. The purpose of this study was to determine the adoption rate of computer-assisted navigation in total knee arthroplasty (TKA), to determine if the short-term complication rate changed over time with navigation, and to compare short-term complication rates of navigated and traditional TKA. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 108,277 patients undergoing primary TKA between 2010 and 2014, of which 3573 cases (3.30%) were navigated. Rates of adoption of navigated TKA were determined. Differences in short-term complications by year were compared using propensity score matching. Navigation utilization decreased from 4.96% in 2010 to 3.06% in 2014. Blood transfusion rates for the entire cohort decreased from 19% in 2011 to 6% in 2014, and was not decreased with navigation compared with traditional TKA in 2014 (P = .1309). Operative time was not increased by navigation, and average 94.2 minutes. There were no significant differences in all-cause complications, reoperation rate, unplanned readmission, or length of stay for any year. There was a 38.3% decrease in TKA navigation utilization from 2010-2014. Blood transfusion rates decreased 68% over the 5-year study, and were not decreased with navigation in 2014. Navigation was not found to increase operative time. There were no significant differences in short-term complications, readmission rate, or length of stay between navigated and traditional TKA. Copyright © 2017 Elsevier Inc. All rights reserved.
Lindberg, Maren Falch; Miaskowski, Christine; RustøEn, Tone; Rosseland, Leiv Arne; Cooper, Bruce A; Lerdal, Anners
Background and purpose — Functional limitations after total knee arthroplasty (TKA) are common. In this longitudinal study, we wanted to identify subgroups of patients with distinct trajectories of pain-related interference with walking during the first year after TKA and to determine which demographic, clinical, symptom-related, and psychological characteristics were associated with being part of this subgroup. Patients and methods — Patients scheduled for primary TKA for osteoarthritis (n = 202) completed questionnaires that evaluated perception of pain, fatigue, anxiety, depression, and illness on the day before surgery. Clinical characteristics were obtained from the medical records. Interference of pain with walking was assessed preoperatively, on postoperative day 4, and at 6 weeks, 3 months, and 12 months after TKA. Results — Using growth mixture modeling, 2 subgroups of patients were identified with distinct trajectories of pain-related interference with walking over time. Patients in the Continuous Improvement class (n = 157, 78%) had lower preoperative interference scores and reported a gradual decline in pain-related interference with walking over the first 12 months after TKA. Patients in the Recurrent Interference class (n = 45, 22%) reported a high degree of preoperative pain-related interference with walking, initial improvement during the first 3 months after TKA, and then a gradual increase—returning to preoperative levels at 12 months. Patients in the Recurrent Interference class had higher preoperative pain, fatigue, and depression scores, and poorer perception of illness than the Continuous Improvement class. Interpretation — 1 in 5 patients did not improve in pain-related interference with walking at 12 months after TKA. Future studies should test the efficacy of interventions designed to modify preoperative characteristics. PMID:27658970
Słupik, Anna; Kowalski, Marcin; Białoszewski, Dariusz
The study aimed to assess the impact of joint degeneration due to advanced gonarthrosis and the effect of arthroplasty on proprioception and sensorimotor system performance of the knee. The arthroplasty group comprised 62 persons, aged 68.8 years on average, who underwent knee replacement due to gonarthrosis. The control group consisted of 74 healthy persons, with an average age of 67.5 years. The participants performed a test of Joint Position Sense (JPS) at 45° flexion and a Sensorimotor Control Test (SCT) designed by the authors to evaluate sensorimotor system performance (on a scale of 0-5). The arthroplasty group was assessed three times: before the knee replacement surgery, and then at 8 and 100 days after the surgery. The control group was assessed once. The control group scored a mean of 4.9 in the SCT test and 3.9° in the JPS test. The mean scores upon consecutive measurements in the arthroplasty group were 3.1, 2.9 and 4.5 for the SCT test and 10.5°, 9.5° and 3.9° (compared to 8.1° for the healthy limb) for the JPS test. 1. Considerable proprioceptive and sensorimotor system performance deficits, as recorded in the arthroplasty group, may contribute to faster progression of degenerative disease and increase the risk of a fall. 2. The Sensorimotor Control Test designed by the authors seems to represent an objective and comprehensive method for assessing the sensorimotor system performance of the knee in gonarthrosis patients. 3. The Sensorimotor Control Test provides a qualitative assessment and may be employed in the clinical therapeutic setting.
Miyasaka, Teruyuki; Kurosaka, Daisaburo; Saito, Mitsuru; Omori, Toshiyuki; Ikeda, Ryo; Marumo, Keishi
Achieving neutral limb alignment during total knee arthroplasty (TKA) has been identified as a potential factor in long-term prosthesis survival. This study aimed to analyze the accuracy of component orientation and postoperative alignment of the leg after computed tomography (CT)-based navigation-assisted TKA, compare these parameters with those of a conventional technique, and analyze differences in the data of outliers. We retrospectively compared the alignment of 130 TKAs performed with a CT-based navigation system with that of 67 arthroplasties done with a conventional system. The knee joints were evaluated using radiographs. Mean hip-knee-ankle (HKA) angle, frontal femoral component angle, and frontal tibial component angle were 180.7°, 88.8°, and 90.6°, respectively, for the navigation-assisted arthroplasties and 181.1°, 88.7°, and 90.2°, respectively, for the conventional arthroplasties. All preoperative leg axes of 10 outliers in the navigation group were >193°, whereas the data of 17 outliers in the conventional group were scattered. This study demonstrates significant improvements in component positioning with the CT-based navigation system. Furthermore, when analyzing cases with preoperative HKA angles ≤192°, no outliers were found in the navigation group, indicating high alignment accuracy. However, in cases with preoperative HKA angles ≥193°, outliers were found in both groups, and no significant difference between the groups was observed (P = .08). Detailed analysis of the outlier cases in the navigation group revealed that the femoral component was placed in the varus position. These findings indicate that the varus knee is an important factor influencing accurate positioning of the femoral component and the postoperative leg axis. Copyright © 2016 Elsevier Inc. All rights reserved.
Hada, Masaru; Mizu-Uchi, Hideki; Okazaki, Ken; Kaneko, Takao; Murakami, Koji; Ma, Yuan; Hamai, Satoshi; Nakashima, Yasuharu
The purpose of this study was to evaluate the relationship between posterior tibial slope and knee kinematics in bi-cruciate stabilized (BCS) total knee arthroplasty (TKA), which has not been previously reported. This computer simulation study evaluated Journey 2 BCS components (Smith & Nephew, Inc., Memphis, TN, USA) implanted in a female patient to simulate weight-bearing stair climbing. Knee kinematics, patellofemoral contact forces, and quadriceps forces during stair climbing (from 86° to 6° of flexion) were computed in the simulation. Six different posterior tibial slope angles (0°-10°) were simulated to evaluate the effect of posterior tibial slope on knee kinematics and forces. At 65° of knee flexion, no anterior sliding of the tibial component occurred if the posterior tibial slope was less than 10°. Anterior contact between the anterior aspect of the tibial post- and the femoral component was observed if the posterior tibial slope was 6° or more. An increase of 10° in posterior tibial slope (relative to 0°) led to a 4.8% decrease in maximum patellofemoral contact force and a 1.2% decrease in maximum quadriceps force. BCS TKA has a wide acceptable range of posterior tibial slope for avoiding knee instability if the posterior tibial slope is less than 10°. Surgeons should prioritize avoiding adverse effects over trying to achieve positive effects such as decreasing patellofemoral contact force and quadriceps force by increasing posterior tibial slope. Our study helps surgeons determine the optimal posterior tibial slope during surgery with BCS TKA; posterior tibial slope should not exceed 10° in routine clinical practice.
Kim, Jun-Young; Cheon, Sang-Ho; Kyung, Hee-Soo
We compared the mid-term results after total knee arthroplasty (TKA) using PFC Sigma RP-F mobile model with PFC Sigma PS fixed model. We analyzed 45 knees that underwent TKA with PFC Sigma RP-Fn (study group) and 45 knees with PFC Sigma PS (control group). The mean follow-up period was 65 months (range, 60-69 months). The evaluation system of the American knee society was used for clinical and radiological assessment. Also, the maximal knee flexion angle was assessed. The mean maximum flexion angle in the study group (135°) was greater than that in the control group (125°) at the early post-operation & final follow-up period (p=0.033). The range of motion (ROM) in the study group was recovered earlier at the postoperative 6 months, and ROM gain was improved to a greater extent at the final follow-up period (p=0.039). The knee score and function score and radiographic evaluation were no difference between the two groups (p>0.05) at the final follow-up. The two cases of radiolucency in posterior condyle and medial tibial plateau and one case of patellar elongation were seen in the study group. The PFC Sigma RP-F mobile system appears to facilitate greater maximum flexion angle and ROM gain with two cases of radiolucent line.
Bergschmidt, Philipp; Bader, Rainer; Mittelmeier, Wolfram
We present a case involving the revision of a total knee arthroplasty with a metal femoral component using a ceramic implant due to metal hypersensitivity. A 58-year-old female patient underwent total knee arthroplasty (TKA) with a standard metal bicondylar knee system. She suffered from persistent pain and strong limitations in her range of motion (ROM) associated with flexion during the early postoperative period. Arthroscopic arthrolysis of the knee joint and intensive active and passive physical treatment, in combination with a cortisone regime, temporarily increased the ROM and reduced pain. No signs of low grade infection or other causes of implant failure were evident. Histology of synovial tissue revealed lymphoplasmacellular fibrinous tissue, consistent with a type IV allergic reaction. Allergometry (skin reaction) revealed type IV hypersensitivity against nickel-II-sulfate and palladium chloride. Revision surgery of the metal components was performed with a cemented ceramic femoral component (same bicondylar design) and a cemented titanium alloy tibial component. Postoperative evaluations were performed 10days, and 3 and 12months after the revision surgery. There was an increased ROM in flexion to 90° at the 12month follow-up. No swelling or effusion was observed at all clinical examinations after the revision surgery. No pain at rest and moderate walking pain were evident. The presented case demonstrates that ceramic implants are a promising solution for patients suffering from hypersensitivity to metal ions in total knee arthroplasty.
Longo, Umile Giuseppe; Loppini, Mattia; Trovato, Ugo; Rizzello, Giacomo; Maffulli, Nicola; Denaro, Vincenzo
One-third of patients with knee osteoarthritis (OA) has involvement of only one compartment, especially the medial one. We performed a comprehensive search of studies comparing unicompartmental knee arthoplasty (UKA) and total knee arthroplasty (TKA) in the same patient on PubMed, OVID/Medline, Cochrane, CINAHL, Google scholar and Embase databases. UKA is indicated in knee with medial OA, no flexion deformity, no joint instability and no varus deformity. Although high tibial osteotomy, UKA and TKA have been proposed to address medial OA of the knee, the best management is still controversial. Studies investigating surgical management of medial OA of the knee are increasingly frequent. Large, multicentre, powered, randomized trials comparing UKA and TKA are needed to identify the best management for medial OA of the knee. Moreover, new score systems for satisfaction of the patient should be formulated. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Pabinger, C; Lothaller, H; Geissler, A
The number of knee arthroplasties and the prevalence of obesity are increasing exponentially. To date there have been no published reviews on utilization rates of knee arthroplasty in OECD countries. We analysed economic, medical and population data relating to knee arthroplasty surgeries performed in OECD countries. Gross domestic product (GDP), health expenditures, obesity prevalence, knee arthroplasty utilization rates and growth in knee arthroplasty rates per 100,000 population were assessed for total population, for patients aged 65 years and over, and patients aged 64 years and younger. Obesity prevalence and utilization of knee arthroplasty have increased significantly in the past. The mean utilization rate of knee arthroplasty was 150 (22-235) cases per 100,000 total population in 2011. The strongest annual increase (7%) occurred in patients 64 years and under. Differences between individual countries can be explained by economic and medical patterns, with countries with higher medical expenditures and obesity prevalence having significantly higher utilization rates. Countries with lower utilization rates have significantly higher growth in utilization rates. The future demand for knee prostheses will increase x-fold by 2030, with exact rates dependant upon economic, social and medical factors. We observed a 10-fold variation in the utilization of knee arthroplasty among OECD countries. A significant and strong correlation of GDP, health expenditures and obesity prevalence with utilization of knee arthroplasty was found. Patients aged 64 years and younger show a two-fold higher growth rate in knee arthroplasty compared to the older population. This trend could result in a four-fold demand for knee arthroplasty in OECD countries by 2030. Copyright © 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Squire, Matthew W
The purpose of this article is to outline the limb alignment goals for knee replacement, current surgical technologies, and evidence-based medicine principles regarding technologically advanced total knee arthroplasty (TKA). Radiologists need an understanding of the pros and cons of technologically advanced TKA. At this time, the appropriate role for TKA has not been determined.
Vecchini, Eugenio; Micheloni, Gian Mario; Perusi, Francesco; Scaglia, Marco; Maluta, Tommaso; Lavini, Franco; Bondi, Manuel; Dall'Oca, Carlo; Magnan, Bruno
Infection of total knee arthroplasty (TKA) is a challenge in orthopedic surgery. In literature TKA infection is classified according to the time after surgery: acute postoperative; late chronic; acute hematogenous; positive intraoperative microbiological growth. The purpose of this study is to present the results of the use of a preformed antibiotic-loaded spacer in TKA infections, treated by a two-stage revision procedure. A series of 19 consecutive patients (20 knees) with a diagnosis of infected TKA were treated from January 2003 to February 2012. Two-stage reimplantation protocols were completed only in 16 patients and these data were included in the study. We lost three patients at follow-up. An antibiotic-loaded preformed articulating polymethylmethacrylate spacer was applied. Patients were observed 1, 3, and 6 months postoperatively and then yearly for clinical and radiographic examination. The mean American Knee Society Score improved from 68.4 preoperatively (range, from 34 to 108) to 112.7 at final follow-up (range, from 49 to 180). The pain was evaluated as part of clinical score. It improved from an average of 19.3 preoperatively (range, from 10 to 30) to 34.3 at final follow-up (range, from 10 to 50). The average range of motion improved from 40.1 degrees (range, from 6 to 90 degrees) to 79.3 degrees (range, from 45 to 125 degrees). The use of the spacer allows obtaining a reduction of pain, an improvement of quality of life in the period of time between the two surgical stages and an easier reimplantation of TKA.
Nedopil, Alexander J; Howell, Stephen M; Hull, Maury L
Eight patients treated with kinematically-aligned (KA) total knee arthroplasty (TKA) presented with tibial component failure. We determined whether radiographic measurements and clinical characteristics are different between patients with and without tibial component failure to identify mechanisms of failure and strategies to reduce the risk. Out of 3,212 primary TKAs (2,725 TKAs with a two-year minimum follow up), of which all were performed with KA, eight patients presented with tibial component failure. Radiographic measurements, clinical characteristics (e.g. age, gender, BMI, etc.), revision surgical records, and Oxford knee scores were compared to control cohort patients matched 1:3. Tibial component failure presented at an average of 28 ± 15 months after primary TKA. Patients with tibial component failure had a 6 kg/m(2) greater body mass index (p = 0.034) and 5° greater posterior slope of the tibia component (p = 0.002) than controls. Final follow-up averaged 56 ± 19 months after the primary TKA and 28 ± 24 months after the revision TKA. The final Oxford knee score was 39 ± 4.6 for patients with tibial component failure and 44 ± 6.5 for the controls (p = 0.005). The incidence of tibial component failure after KA TKA was 0.3% and was caused by posterior subsidence or posterior edge wear and not varus subsidence. The strategy for lowering the risk of tibial component failure when performing KA is to set the tibial component parallel to the flexion-extension plane (slope) and varus-valgus plane of the native joint line.
Background Navigation was introduced into total knee arthroplasty (TKA) to improve accuracy of component position, function and survival of implants. This study was designed to assess the outcome of navigated TKA in comparison with conventional implantation with the focus on rotational component position and clinical mid-term results. Methods In a prospectively randomized single-blinded approach, 90 patients with primary gonarthrosis were assigned to three different groups. Thirty patients each were assigned to NexGen LPS without and with navigation (groups 1 and 2), and 30 patients to navigation with the Stryker Scorpio PS (group 3). The navigation system used was the imageless Stryker KneeTrac, version 1.0. Clinical outcome was assessed by a blinded observer applying the Knee Society Score (KSS) and a visual analogue scale (VAS) for pain. CT scans and radiographs were conducted prior to and 12 weeks after index surgery. Results Seventy-nine patients were available for clinical evaluation at 3 ± 0.4 years follow-up. Four implants had to be revised for early loosening or infection (4.4%). Four patients had died and three patients were not able to follow the invitation for clinical assessment. Functional results in the KSS were significantly lower after navigated TKA. Operation time and incisions with navigation were significantly longer. Significantly less radiological outliers with navigation were found for coronal alignment of the femur, only. Conclusion In this series, no beneficial effect for navigation in TKA could be shown assessing clinical data, as functional results in the presented series seemed to be lower after first generation navigated TKA. The clinical mid- to long-term value of navigation remains to be evaluated in larger patient series or meta-analyses at longer follow-up. Trial registration number DRKS 00000430 PMID:21235810
Springer, Bryan D; Mason, J Bohannon; Odum, Susan M
Intraoperative periarticular injections (PAIs) with local anesthetic are an important component of multimodal pain control in total joint arthroplasty. Liposomal bupivacaine is an extended-release formulation of bupivacaine designed to provide extended pain relief, approved for use in a single surgical site. The systemic safety profile for use in simultaneous bilateral TKA (bTKA) with a full dose in each knee has not been evaluated. The purpose of this study was to determine the safety and pharmacokinetics of bilateral full-dose PAI liposomal bupivacaine in the blood collected in patients undergoing simultaneous bTKA. In this prospective study, patients had an identical PAI consisting of 20 cc of liposomal bupivacaine (266 mg), 30 cc of 0.25% bupivacaine (75 mg) with epinephrine, and 10 cc of normal saline injected into each knee during bTKA. Blood samples were collected at predefined intervals until patient discharge. No exogenous bupivacaine was administered. Pharmacokinetic evaluations were subsequently performed and compared to bupivacaine toxicity levels. Patients were monitored for adverse events related to anesthetic toxicity (cardiac and neurologic). Fifteen patients (mean age, 60.7 years; range, 57-64 years) were enrolled in the study. The mean peak level (Cmax) was 0.8 μg/mL (range, 0.4-1.2 μg/mL). All patients were well below the reported systemic cardiac and toxicity levels reported as 2-4 μg/mL. There were no reported cardiac and neurotoxic events in any patients. The use of full-dose PAI with liposomal bupivacaine placed into each knee during simultaneous bTKA is safe with systemic bupivacaine levels well below reported cardiac and neurotoxic levels. Copyright © 2017 Elsevier Inc. All rights reserved.
Taketomi, Shuji; Yamagami, Ryota; Tahara, Keitaro; Tanaka, Sakae
Snapping pes syndrome is defined as a snapping sensation in the medial knee caused by pes anserinus and rarely occurs. Snapping pes syndrome after unicompartmental knee arthroplasty (UKA) has not been reported yet. We experienced two cases with this syndrome after UKA. Conservative treatment was effective in one case, while surgical excision of the gracilis tendon was necessary to relieve painful snapping in the other case. The main cause of the first case might be posteromedial overhang of the tibial tray that reached up to 5 mm. The probable cause of the second case was posteromedial overhang of the mobile bearing. PMID:27274476
Inui, Hiroshi; Taketomi, Shuji; Yamagami, Ryota; Tahara, Keitaro; Tanaka, Sakae
Snapping pes syndrome is defined as a snapping sensation in the medial knee caused by pes anserinus and rarely occurs. Snapping pes syndrome after unicompartmental knee arthroplasty (UKA) has not been reported yet. We experienced two cases with this syndrome after UKA. Conservative treatment was effective in one case, while surgical excision of the gracilis tendon was necessary to relieve painful snapping in the other case. The main cause of the first case might be posteromedial overhang of the tibial tray that reached up to 5 mm. The probable cause of the second case was posteromedial overhang of the mobile bearing.
Husted, Henrik; Gromov, Kirill; Malchau, Henrik; Freiberg, Andrew; Gebuhr, Peter; Troelsen, Anders
Background and purpose — Traditions are passed on from experienced surgeons to younger fellows and become “the right way to do it”. Traditions associated with arthroplasty surgery may, however, not be evidence-based and may be potentially deleterious to both patients and society, increasing morbidity and mortality, slowing early functional recovery, and increasing cost. Methods — We identified selected traditions and performed a literature search using relevant search criteria (June 2014). We present a narrative review grading the studies according to evidence, and we suggest some lines of future research. Results — We present traditions and evaluate them against the published evidence. Preoperative removal of hair, urine testing for bacteria, use of plastic adhesive drapes intraoperatively, and prewarming of the operation room should be abandoned—as should use of a tourniquet, a space suit, a urinary catheter, and closure of the knee in extension. The safety and efficacy of tranexamic acid is supported by meta-analyses. Postoperatively, there is no evidence to support postponement of showering or postponement of changing of dressings to after 48 h. There is no evidence to recommend routine dental antibiotic prophylaxis, continuous passive motion (CPM), the use of compression stockings, cooling for pain control or reduction of swelling, flexion of at least 90 degrees as a discharge criterion following TKA, or having restrictions after THA. We present evidence supporting the use of NSAIDs, early mobilization, allowing early travel, and a low hemoglobin trigger for transfusion. Interpretation — Revision of traditions and myths surrounding hip and knee arthroplasty towards more contemporary evidence-based principles can be expected to improve early functional recovery, thus reducing morbidity, mortality, and costs. PMID:25285615
Stall, Nathan M.; Kagoma, Yoan K.; Bondy, Jennifer N.; Naudie, Douglas
Background Operating rooms (ORs) are estimated to generate up to one-third of hospital waste. At the London Health Sciences Centre, prosthetics and implants represent 17% of the institution’s ecological footprint. To investigate waste production associated with total knee arthroplasties (TKAs), we performed a surgical waste audit to gauge the environmental impact of this procedure and generate strategies to improve waste management. Methods We conducted a waste audit of 5 primary TKAs performed by a single surgeon in February 2010. Waste was categorized into 6 streams: regular solid waste, recyclable plastics, biohazard waste, laundered linens, sharps and blue sterile wrap. Volume and weight of each stream was quantified. We used Canadian Joint Replacement Registry data (2008–2009) to estimate annual weight and volume totals of waste from all TKAs performed in Canada. Results The average surgical waste (excluding laundered linens) per TKA was 13.3 kg, of which 8.6 kg (64.5%) was normal solid waste, 2.5 kg (19.2%) was biohazard waste, 1.6 kg (12.1%) was blue sterile wrap, 0.3 kg (2.2%) was recyclables and 0.3 kg (2.2%) was sharps. Plastic wrappers, disposable surgical linens and personal protective equipment contributed considerably to total waste. We estimated that landfill waste from all 47 429 TKAs performed in Canada in 2008–2009 was 407 889 kg by weight and 15 272 m3 by volume. Conclusion Total knee arthroplasties produce substantial amounts of surgical waste. Environmentally friendly surgical products and waste management strategies may allow ORs to reduce the negative impacts of waste production without compromising patient care. Level of evidence Level IV, case series. PMID:23351497
Birkeland, Øystein; Espehaug, Birgitte; Havelin, Leif I; Furnes, Ove
Background and purpose — The bone cement market for total knee arthroplasty (TKA) in Norway has been dominated by a few products and distributors. Palacos with gentamicin had a market share exceeding 90% before 2005, but it was then withdrawn from the market and replaced by new slightly altered products. We have compared the survival of TKAs fixated with Palacos with gentamicin with the survival of TKAs fixated with the bone cements that took over the market. Patients and methods — Using data from the Norwegian Arthroplasty Register for the period 1997–2013, we included 26,147 primary TKAs in the study. The inclusion criteria were TKAs fixated with the 5 most used bone cements and the 5 most common total knee prostheses for that time period. 6-year Kaplan-Meier survival probabilities were established for each cement product. The Cox proportional hazards regression model was used to assess the association between bone cement product and revision risk. Separate analyses were performed with revision for any reason and revision due to deep infection within 1 year postoperatively as endpoints. Adjustments were made for age, sex, diagnosis, and prosthesis brand. Results — Survival was similar for the prostheses in the follow-up period, between the 5 bone cements included: Palacos with gentamicin, Refobacin Palacos R, Refobacin Bone Cement R (Refobacin BCR), Optipac Refobacin Bone Cement R (Optipac Refobacin BCR), and Palacos R + G. Interpretation — According to our findings, the use of the new bone cements led to a survival rate that was as good as with the old bone cement (Palacos with gentamicin). PMID:27841713
Desai, Mohan M; Wade, Roshan N; Bava, Surendar S
Orthopaedic Surgeons rarely encounter mycobacterial infections in Post Total Knee Arthroplasty (TKA) patients. We present series of two cases to create awareness among clinicians to expect the unexpected. Tuberculosis typical/ atypical is a hidden culprit in catch clinical situations when chronic infection is Suspected, but the lab investigations are negative in persistently symptomatic patients. In such situations clinicians should suspect atypical or complex mycobacterial infections and evaluate the patients accordingly. Clinical suspicion, evaluation, isolation and treatment of atypical or complex mycobacterial infections with sensitive chemotherapy, leads to complete resolution of infection and full functional rehabilitation.
Sarmah, SS; Patel, S; Reading, G; El-Husseiny, M; Douglas, S; Haddad, FS
INTRODUCTION The number of total knee arthroplasties performed continues to rise annually and it would be expected that complications, which include periprosthetic fractures, will also therefore become more commonplace. This article reviews the current literature regarding this injury and identifies the treatment principles that enable patients to regain optimal function. METHODS A comprehensive search of the Pubmed and Embase™ databases was performed to identify relevant articles. Keywords and MeSH (Medical Subject Headings) terms included in the search strategy were ‘periprosthetic fracture(s)’, ‘femur’, ‘tibia’, ‘patella(r)’, ‘complication(s)’, ‘failure(s)’, ‘risk(s)’, ‘prevalence’, ‘incidence’, ‘epidemiology’ and ‘classification(s)’. The search was limited to all articles published in English and reference lists from the original articles were reviewed to identify pertinent articles to include in this review. A total number of 43 studies were identified. RESULTS Common treatment aims have been identified when managing patients with a periprosthetic fracture around total knee arthoplasty. The main criterion that determines which option to choose is the degree of remaining bone stock and the amount of fracture displacement. CONCLUSIONS Treatment of a periprosthetic fracture around total knee arthroplasty will either be non-operative, osteosynthesis or revision arthroplasty. It is imperative that a suitable option is chosen and based on the published literature, pathways are outlined to aid the surgeon. PMID:22943223
van der List, Jelle P; Chawla, Harshvardhan; Joskowicz, Leo; Pearle, Andrew D
Recently, there is a growing interest in surgical variables that are intraoperatively controlled by orthopaedic surgeons, including lower leg alignment, component positioning and soft tissues balancing. Since more tight control over these factors is associated with improved outcomes of unicompartmental knee arthroplasty and total knee arthroplasty (TKA), several computer navigation and robotic-assisted systems have been developed. Although mechanical axis accuracy and component positioning have been shown to improve with computer navigation, no superiority in functional outcomes has yet been shown. This could be explained by the fact that many differences exist between the number and type of surgical variables these systems control. Most systems control lower leg alignment and component positioning, while some in addition control soft tissue balancing. Finally, robotic-assisted systems have the additional advantage of improving surgical precision. A systematic search in PubMed, Embase and Cochrane Library resulted in 40 comparative studies and three registries on computer navigation reporting outcomes of 474,197 patients, and 21 basic science and clinical studies on robotic-assisted knee arthroplasty. Twenty-eight of these comparative computer navigation studies reported Knee Society Total scores in 3504 patients. Stratifying by type of surgical variables, no significant differences were noted in outcomes between surgery with computer-navigated TKA controlling for alignment and component positioning versus conventional TKA (p = 0.63). However, significantly better outcomes were noted following computer-navigated TKA that also controlled for soft tissue balancing versus conventional TKA (mean difference 4.84, 95 % Confidence Interval 1.61, 8.07, p = 0.003). A literature review of robotic systems showed that these systems can, similarly to computer navigation, reliably improve lower leg alignment, component positioning and soft tissues balancing. Furthermore
Ruffilli, Alberto; Castagnini, Francesco; Traina, Francesco; Corneti, Isabella; Fenga, Domenico; Giannini, Sandro; Faldini, Cesare
Total knee arthroplasty (TKA) is a widely accepted and successful procedure for end-stage arthritis. Nevertheless, fast-track may be compromised by many factors, such as pain, edema, and blood loss. Cryotherapy has been advocated as a safe and effective strategy to improve the postoperative results, acting on pain, edema, and blood loss. This study is a prospective randomized controlled study, involving 50 patients after primary TKA. A power analysis was performed preoperatively. Twenty-four patients were addressed to a postoperative treatment with a continuous cold flow device (Hilotherm, Hilotherm GmbH, Germany). Twenty-six patients represented the control group, treated with crushed ice packs. All the patients shared the same analgesic strategy and the same rehabilitation protocol. Pain, analgesic consumption, active knee range of motion, drain output, transfusion requirement, and total blood loss were evaluated at different follow-ups (postoperative first, third, and seventh days). The two groups were homogenous for preoperative and intraoperative features. The groups showed no statistically significant differences in all the evaluated parameters. A modest reduction of knee volume was evident after 7 days from surgery (trend). No differences in blood loss were noticed. Continuous cold flow device in the acute postoperative setting after TKA did not show superiority in reducing edema, pain, and blood loss, compared with traditional icing regimen. Thus, due to the costs, it should be reserved to selected cases.
Matassi, Fabrizio; Paoli, Tommaso; Civinini, Roberto; Carulli, Christian; Innocenti, Massimo
Oxidized zirconium (OxZr) has demonstrated excellent mechanical properties in vitro when used against articular cartilage; less coefficient of friction and less chondral damage have been found when compared with cobalt-chromium (CoCr) implants. However, controversy exists as to whether implants with a zirconium femoral component articulate safely with a native patella in total knee arthroplasty (TKA). To answer this question, the clinical and radiographic results were analysed from a group of patients who underwent a TKA with patella retention; the OxZr versus CoCr femoral components were compared. The present study prospectively evaluated 83 knees of 74 patients from 2009 to 2010. Each patient was evaluated clinically (visual analogue scale, Knee Society score, patellar score) and radiographically (long leg standing radiograph, anterior-posterior and latero-lateral projections, axial view of the patella) pre-operatively and postoperatively with a mean follow-up of 4.47years. The patellar tilt and shift, and progression of patellofemoral osteoarthritis were calculated with the axial view. There were no patient reported adverse reactions and none of the evaluated prostheses failed. Both the clinical and radiographic evaluations showed no statistically significant between-group differences. No adverse events were observed clinically or radiologically. These results justify pursuing the use of oxidized zirconium as an alternative bearing surface for a femoral component associated with patellar retention in TKA. Published by Elsevier B.V.
Seo, Jai-Gon; Moon, Young-Wan; Cho, Byung-Chul; Kim, Su Cheol; Ko, Young Hoo; Jang, Seung Pil
Purpose This study directly compared clinical assessment scores and short-term systemic complications after total knee arthroplasty (TKA) between a group of patients aged 80 or older (141 patients) and another group of patients aged between 65 and 70 years (616 patients) with advanced osteoarthritis. Materials and Methods We retrospectively investigated 757 osteoarthritic patients who underwent primary TKA from January 2007 to January 2011 with a follow-up of 1 year. The surgery was performed using an extramedullary alignment guide instrument without invasion of the intramedullary canal to decrease embolic load and blood loss. Results At 1 year after surgery, the mean Knee Society knee score was improved in both groups (from 63.6 to 83.2 in octogenarians and from 68.3 to 89.0 in the younger group) and the level of satisfaction was excellent in both groups (8 in octogenarians and 8.3 in the younger group), even though there was no notable change in function score in the octogenarians (from 61.0 to 61.9 in the octogenarians and from 62.3 to 73.6 in the younger group). The total incidence of systemic complications (3.4% vs. 1.2%, p=0.400) and surgical complications (2.1% vs. 0.5%, p=0.229) showed no significant difference between groups. Conclusions TKA yielded favorable clinical outcomes with a comparatively low postoperative complication rate in octogenarians despite the negligible functional improvement. PMID:26675818
Lange, Toni; Rataj, Elisabeth; Kopkow, Christian; Lützner, Jörg; Günther, Klaus-Peter; Schmitt, Jochen
The Outcome Measures in Rheumatology (OMERACT) initiative developed a core outcome set (COS) of domains to assess effectiveness of interventions for knee osteoarthritis. These domains (pain, physical function, patient global assessment, imaging at 1 year) should be assessed in every trial to make research evidence meaningful and comparable. We systematically evaluated and critically appraised the use of measurement instruments and outcome domains in prospective studies evaluating patients with knee osteoarthritis undergoing total knee arthroplasty (TKA) and assessed their accordance with the OMERACT COS. Literature search was performed until August 26, 2014, in Medline and Embase. Clinical trials and prospective observational studies with ≥50 participants and a follow-up of ≥1 year were included. We collected general study characteristics, comprehensive information on measurement instruments, and corresponding domains used. This systematic review identified low accordance of used outcome domains with the OMERACT COS of domains published in 1997. Only 4 of 100 included studies included all recommended core domains. Pain (85% of studies) and physical function (86%) were assessed frequently, whereas patient global assessment (21%) and joint imaging (≥1 year; 27%) were rarely assessed. There was substantial heterogeneity in the use of measurement instruments (n = 111) investigating TKA. More efforts are required to implement the existing COS. In addition, a more consistent use of adequate measurement instruments is important to make research evidence on TKA more relevant, better comparable, and thus more useful for guideline developers and clinical decision makers. Copyright © 2016 Elsevier Inc. All rights reserved.
Rieder, F; Kösters, A; Wiesinger, H-P; Dorn, U; Hofstaedter, T; Fink, C; Seynnes, O R; Müller, E
This study investigated the effectiveness of recreational skiing as an intervention to i