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
Sanders, Thomas L; Maradit Kremers, Hilal; Schleck, Cathy D; Larson, Dirk R; Berry, Daniel J
Despite the large increase in total hip arthroplasties and total knee arthroplasties, the incidence and prevalence of additional contralateral or ipsilateral joint arthroplasty are poorly understood. The purpose of this study was to determine the rate of additional joint arthroplasty after a primary total hip arthroplasty or total knee arthroplasty. This historical cohort study identified population-based cohorts of patients who underwent primary total hip arthroplasty (n = 1,933) or total knee arthroplasty (n = 2,139) between 1969 and 2008. Patients underwent passive follow-up through their medical records beginning with the primary total hip arthroplasty or total knee arthroplasty. We assessed the likelihood of undergoing a subsequent total joint arthroplasty, including simultaneous and staged bilateral procedures. Age, sex, and calendar year were evaluated as potential predictors of subsequent arthroplasty. During a mean follow-up of 12 years after an initial total hip arthroplasty, we observed 422 contralateral total hip arthroplasties (29% at 20 years), 76 contralateral total knee arthroplasties (6% at 10 years), and 32 ipsilateral total knee arthroplasties (2% at 20 years). Younger age was a significant predictor of contralateral total hip arthroplasty (p < 0.0001), but not a predictor of the subsequent risk of total knee arthroplasty. During a mean follow-up of 11 years after an initial total knee arthroplasty, we observed 809 contralateral total knee arthroplasties (45% at 20 years), 31 contralateral total hip arthroplasties (3% at 20 years), and 29 ipsilateral total hip arthroplasties (2% at 20 years). Older age was a significant predictor of ipsilateral or contralateral total hip arthroplasty (p < 0.001). Patients undergoing total hip arthroplasty or total knee arthroplasty can be informed of a 30% to 45% chance of a surgical procedure in a contralateral cognate joint and about a 5% chance of a surgical procedure in noncognate joints within 20 years of
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.
Thienpont, Emmanuel; Opsomer, Gaetan; Koninckx, Angelique; Houssiau, Frederic
The purpose of this study was to validate the 'Forgotten Joint' score (FJS-12), a 12-item questionnaire designed to analyze the patient's ability to forget the joint in everyday life, in French and to compare the results of this Patient Reported Outcome (PRO) score in patients who had other than total joint arthroplasties. The score was compared in 122 patients that had either medial unicompartmental (N=51), patellofemoral (N=21) or total knee arthroplasty (N=50). After having validated the FJS-12 in French, a similar PRO was observed in unicompartmental and postero-stabilized total knee arthroplasty. Patellofemoral resurfacing had a significantly lower score than the two other types of arthroplasty, which can be explained by a significantly younger and smaller patient group. Copyright © 2014 Elsevier Inc. All rights reserved.
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.
The aim was to study the influence of different designs of the joint area on tibial component fixation, kinematics and clinical outcome after a cemented total knee arthroplasty (TKA). The HSS score and a special questionnaire were used at the clinical examination. Conventional radiography was done to record the positioning of the implants and development of radiolucencies. The migration and inducible displacement were evaluated using radiostereometry (RSA). The kinematics of the knee during active extension was studied using dynamic RSA. In randomised and prospective studies 87 knees in 83 patients (28 male, 55 female, age 69, range 50-83) received an AMK (DePuy, Johnson & Johnson) TKA. The patients were divided into two groups. In group 1 the patients had varus/valgus deformities of < or = 5 degrees and the PCL was retained. The PCL was resected in group 2 where the patients had deformities exceeding 5 degrees and/or fixed flexion deformities of more than 10 degrees. In group 1 a flat (F, n = 20) or a concave (C, n = 20) design was implanted (study 3). In group 2 (study 4) the patients received a concave (n = 25) or a posterior-stabilised (PS, n = 22) tibial plateau. The migration of the tibial component, positioning of the prosthesis, development of radiolucencies and the clinical outcome was evaluated after 1 and 2 years. Twenty-two patients (11 F, 11 C) in group 1 (study 1) and 22 knees in 20 patients in group 2 (study 2, 11 C, 11 PS) were examined 1 year post-operatively to evaluate the kinematics of the knee. Eleven normals served as controls. During active extension of the knee the inducible displacements of the tibial component were recorded in 16 knees (15 patients). Based on successful RSA examinations 5 knees (4 F, 1 C) from group 1 and 11 knees (5 C, 6 PS) from group 2 were selected (study 5). Abnormal kinematics and especially increased AP translations compared to normals (p < 0.0005) were recorded in all designs. The concave design showed the widest
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.
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.
Myles, Christine M; Rowe, Philip J; Walker, Colin R C; Nutton, Richard W
The functional ranges of movement of the knee were investigated in a group of patients with knee osteoarthritis (n = 42, mean age 70 years) before, 4 months and at 18-24 months after total knee arthroplasty and then compared with age matched normal subjects (n = 20, mean age 67 years). Flexible electrogoniometry was used to record the maximum flexion-extension angle, the minimum flexion-extension angle and flexion-extension excursions of both knees during eleven functional activities along with the active and passive knee joint range of motion measured using a manual goniometer. Over the eleven functional activities the patients pre-operatively exhibited 28% less knee joint excursion than normal age matched subjects. By 18-24 months following total knee arthroplasty only 2% of this deficit was recovered. Statistically this recovery was only significant in level walking, slope ascent and slope descent. A greater range of movement was measured in a non-weight bearing position than was used in weight bearing functional activity. It is concluded that total knee arthroplasty gives rise to little improvement in knee motion during functional activities and that functional range of movement of the knee remains limited when compared to normal knee function for a minimum of 18 months following operation.
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.
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.
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.
Yulou, Si; Yanqin, Xue; Yongjun, Xing
To discuss the method and effect of total knee arthroplasty osteotomy and soft tissue release for serious knee joint space narrowing. Clinical data of 80 patients from October 2013 to December 2014 was selected with a retrospective method. All patients have undergone total knee arthroplasty. Then the X-rays plain film in weight loading was measured before and after operation and osteotomy was performed accurately according to the knee joint scores and the conditions of lower limb alignments. The average angle of tibial plateau osteotomy of postoperative patients was 4.3°, and the corrective angle of soft tissue balancing was 10.7°; the postoperative patients' indicies including range of joint motion, knee joint HSS score, angle between articular surfaces, tibial angle, femoral-tibial angle and flexion contracture were distinctly better than the preoperative indicies (p<0.05) and the differences were statistically significant; the postoperative patients' flexion contracture and range of joint motion were distinctly better than the preoperative indicies (p<0.05) and the differences were statistically significant. The effective release of the soft tissue of the posterior joint capsule under direct vision can avoid excess osteotomy and get satisfactory knee replacement space without influencing the patients' joint recovery.
Yulou, Si; Yanqin, Xue; Yongjun, Xing
To discuss the method and effect of total knee arthroplasty osteotomy and soft tissue release for serious knee joint space narrowing. Clinical data of 80 patients from October 2013 to December 2014 was selected with a retrospective method. All patients have undergone total knee arthroplasty. Then the X-rays plain film in weight loading was measured before and after operation and osteotomy was performed accurately according to the knee joint scores and the conditions of lower limb alignments. The average angle of tibial plateau osteotomy of postoperative patients was 4.3°, and the corrective angle of soft tissue balancing was 10.7°; the postoperative patients’ indicies including range of joint motion, knee joint HSS score, angle between articular surfaces, tibial angle, femoral-tibial angle and flexion contracture were distinctly better than the preoperative indicies (p<0.05) and the differences were statistically significant; the postoperative patients’ flexion contracture and range of joint motion were distinctly better than the preoperative indicies (p<0.05) and the differences were statistically significant. The effective release of the soft tissue of the posterior joint capsule under direct vision can avoid excess osteotomy and get satisfactory knee replacement space without influencing the patients’ joint recovery. PMID:28352736
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.
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.
Nagai, Kanto; Muratsu, Hirotsugu; Matsumoto, Tomoyuki; Miya, Hidetoshi; Kuroda, Ryosuke; Kurosaka, Masahiro
The influence of joint distraction force on intraoperative soft tissue balance was evaluated using Offset Repo-Tensor® for 78 knees that underwent primary posterior-stabilized total knee arthroplasty. The joint center gap and varus ligament balance were measured between osteotomized surfaces using 20, 40 and 60 lbs of joint distraction force. These values were significantly increased at extension and flexion as the distraction force increased. Furthermore, lateral compartment stiffness was significantly lower than medial compartment stiffness. Thus, larger joint distraction forces led to larger varus ligament balance and joint center gap, because of the difference in soft tissue stiffness between lateral and medial compartments. These findings indicate the importance of the strength of joint distraction force in the assessment of soft tissue balance, especially when using gap-balancing technique.
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
Coles, L G; Gheduzzi, S; Miles, A W
The patellofemoral joint is a common site of pain and failure following total knee arthroplasty. A contributory factor may be adverse patellofemoral biomechanics. Cadaveric investigations are commonly used to assess the biomechanics of the joint, but are associated with high inter-specimen variability and often cannot be carried out at physiological levels of loading. This study aimed to evaluate the suitability of a novel knee simulator for investigating patellofemoral joint biomechanics. This simulator specifically facilitated the extended assessment of patellofemoral joint biomechanics under physiological levels of loading. The simulator allowed the knee to move in 6 degrees of freedom under quadriceps actuation and included a simulation of the action of the hamstrings. Prostheses were implanted on synthetic bones and key soft tissues were modelled with a synthetic analogue. In order to evaluate the physiological relevance and repeatability of the simulator, measurements were made of the quadriceps force and the force, contact area and pressure within the patellofemoral joint using load cells, pressure-sensitive film, and a flexible pressure sensor. The results were in agreement with those previously reported in the literature, confirming that the simulator is able to provide a realistic physiological loading situation. Under physiological loading, average standard deviations of force and area measurements were substantially lower and comparable to those reported in previous cadaveric studies, respectively. The simulator replicates the physiological environment and has been demonstrated to allow the initial investigation of factors affecting patellofemoral biomechanics following total knee arthroplasty. © IMechE 2014.
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.
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.
Dargel, Jens; Michael, Joern W P; Feiser, Janna; Ivo, Roland; Koebke, Juergen
This study investigates differences in the anatomy of male and female knee joints to contribute to the current debate on sex-specific total knee implants. Morphometric data were obtained from 60 human cadaver knees, and sex differences were calculated. All data were corrected for height, and male and female specimens presenting with an identical length of the femur were analyzed as matched pairs. Male linear knee joint dimensions were significantly larger when compared with females. When corrected for differences in height, medial-lateral dimensions of male knees were significantly larger than female; however, matched paired analysis did not prove these differences to be consistent. Although implant design should focus interindividual variations in knee joint anatomy, our data do not support the concept of a female-specific implant design.
Nguyen, Manny; Sukeik, Mohamed; Zahar, Akos; Nizam, Ikram; Haddad, Fares Sami
Background: Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. In an aging population of the developed world, the increasing numbers of hip and knee replacements will inevitably lead to increasing incidence of PJI, carrying with (it) significant patient morbidity and cost to the health care system. Two-stage exchange arthroplasty is currently the gold standard but it is associated with multiple operations, prolonged hospitalization and impaired functionality. One-stage exchange arthroplasty is similar to the two-stage procedure but the interval between removal of the prosthesis and reimplantation of a new one is only a few minutes. It has the theoretical benefits of a single anesthetic, shorter hospitalization, less cost and improved function. Methods: We reviewed the current literature regarding the outcomes of one-stage exchange arthroplasties focusing on re-infection rates and functional outcomes. Results: Current themes around the one-stage exchange procedure include the indications for the procedure, definition of re-infection, surgical techniques used to provide fixation and differences in approach for hip and knee replacements. Conclusion: The current literature on one-stage exchange procedure is promising, with comparable results to two-stage revisions for hips and knees in selected patients. However, there is a great need for a large multi-centred randomized control trial, focusing on re-infection rates and functional scores postoperatively, to provide concrete guidelines in managing this complex condition. PMID:28144374
Sadaka, Chantal; Kabalan, Ziad; Hoyek, Fadi; Abi Fares, Georges; Lahoud, Jean-Claude
During revision total knee arthroplasty, the joint line is frequently malpositioned, due to the disappearance of the anatomical landmarks following previous interventions. This leads to decreased clinical outcome and increased risk of re-intervention. Many methods have been proposed to restore the joint line, but none of them has shown itself to be reliable. We describe an accurate and precise method to localize the exact position of the joint line which guarantees a better clinical knee score. The adductor tubercle (AT) is recognized to be the most reliable landmark used to localize the knee joint line (JL). The distance from the AT to the JL on antero-posterior radiographs (ATJL) and the femoral diameter (FD) on true lateral views were measured on 200 randomly selected normal knees. These measurements were tested for intra- and inter-observer differences. Then, the relationship between these two measurements was studied. A significant correlation and linear regression between FD and ATJL was found (p < 0.001), making the adductor tubercle a valid landmark to accurately position the prosthetic joint within 4 mm from the normal position. No significant difference was noted in the intra and inter-observer measurements (F test not significant). Sex was found to be an intervening variable (p ˂ 0.001). The correlation and regression between ATJL and FD had to be adjusted accordingly. Once the ATJL was determined preoperatively, the JL level is found during surgery by using a caliper that is held on the easily palpable AT. Knowing the femoral diameter, we can easily locate the joint line level surgically, using the adductor tubercle as a landmark. This method leads to better clinical outcomes and a reduced risk of re-intervention following revision total knee arthroplasty.
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.
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.
Aslani, Hamidreza; Nourbakhsh, Seyed Taghi; Lahiji, Farivar A.; Heydarian, Keykavoos; Jabalameli, Mahmood; Ghazavi, Mohammad Taghi; Tahmasebi, Mohammad Naghi; Fayyaz, Mahmoud Reza; Sazegari, Mohammad Ali; Mohaddes, Maziar; Rajabpour, Mojtaba; Emami, Mohammad; Jazayeri, Seyyed Mohammad; Madadi, Firooz; Farahini, Hossein; Mirzatoloee, Fardin; Gharahdaghi, Mohammad; Ebrahimzadeh, Mohammad Hossein; Ebrahimian, Mohammadreza; Mirvakili, Hossein; Bashti, Kaveh; Almasizadeh, Mohtasham; Abolghasemian, Mansour; Taheriazam, Afshin; Motififard, Mehdi; Yazdi, Hamidreza; Mobarakeh, Mahmood Karimi; Shayestehazar, Masoud; Moghtadae, Mehdi; Siavashi, Babak; Sajjadi, Mohammadreza M.; Rasi, Alireza Manafi; Chabok, Seyyed Kazem; Zafarani, Zohreh; Salehi, Shahin; Ahmadi, Monireh; Mohammadi, Amin; Shahsavand, Mohammad Ebrahim
Periodic evaluation and monitoring the health and economic outcome of joint replacement surgery is a common and popular process under the territory of joint registries in many countries. In this article we introduce the methodology used for the foundation of the National Iranian Joint Registry (IJR) with a joint collaboration of the Social Security Organization (SSO) and academic research departments considering the requirements of the Iran’s Ministry of Health and Education. PMID:27200403
Aslani, Hamidreza; Nourbakhsh, Seyed Taghi; Lahiji, Farivar A; Heydarian, Keykavoos; Jabalameli, Mahmood; Ghazavi, Mohammad Taghi; Tahmasebi, Mohammad Naghi; Fayyaz, Mahmoud Reza; Sazegari, Mohammad Ali; Mohaddes, Maziar; Rajabpour, Mojtaba; Emami, Mohammad; Jazayeri, Seyyed Mohammad; Madadi, Firooz; Farahini, Hossein; Mirzatoloee, Fardin; Gharahdaghi, Mohammad; Ebrahimzadeh, Mohammad Hossein; Ebrahimian, Mohammadreza; Mirvakili, Hossein; Bashti, Kaveh; Almasizadeh, Mohtasham; Abolghasemian, Mansour; Taheriazam, Afshin; Motififard, Mehdi; Yazdi, Hamidreza; Mobarakeh, Mahmood Karimi; Shayestehazar, Masoud; Moghtadae, Mehdi; Siavashi, Babak; Sajjadi, Mohammadreza M; Rasi, Alireza Manafi; Chabok, Seyyed Kazem; Zafarani, Zohreh; Salehi, Shahin; Ahmadi, Monireh; Mohammadi, Amin; Shahsavand, Mohammad Ebrahim
Periodic evaluation and monitoring the health and economic outcome of joint replacement surgery is a common and popular process under the territory of joint registries in many countries. In this article we introduce the methodology used for the foundation of the National Iranian Joint Registry (IJR) with a joint collaboration of the Social Security Organization (SSO) and academic research departments considering the requirements of the Iran's Ministry of Health and Education.
Ewell, Melvin; Griffin, Christopher; Hull, Jason
The purpose of this study was to review and synthesize available evidence on the effect of focal knee joint cryotherapy on quadriceps arthrogenic muscle inhibition and to discuss the implications of the findings regarding the use of this modality for patients after a total knee arthroplasty. An electronic literature search that targeted peer reviewed journals was completed by using the PubMed, CINAHL, ScienceDirect, and OvidSP databases. An article was included when it was determined that the article was relevant to the topic of focal knee joint cryotherapy and its effect on quadriceps muscle function. There were 6 studies that met the inclusion criteria. Of the reviewed studies, effect sizes for quadriceps activation ranged from very small to large. Five of the 6 studies observed medium to large effects. Effect sizes for quadriceps torque and force production ranged from no effect to a large effect. Two of the 5 studies with outcome measurements related to quadriceps torque or force production observed medium and large effects. Analysis of this evidence suggests that focal joint cooling of the knee shows the potential to improve quadriceps activation as well as quadriceps torque and force production in patients with arthrogenic muscle inhibition. Arthrogenic muscle inhibition of the quadriceps is an impairment commonly observed in patients after a total knee arthroplasty. Analysis of the evidence uncovered in this review suggests that this patient population may be positively impacted by the use of this modality to improve quadriceps activation as well as quadriceps torque and force production.
Reed, M R; Farhan, M J; Chaudhuri, C
A case of patellar stress fracture after total knee arthroplasty in a man with gout and previous osteonecrosis of the tali is reported. The combination of fat pad excision and lateral release causing disruption to the patellar blood supply during primary total knee arthroplasty resulted in the development of a patellar fracture. Avascular necrosis, caused by gout, may form part of the pathogenesis.
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
Picetti, G D; McGann, W A; Welch, R B
One hundred total knee replacements with a total condylar prosthesis and without patellar resurfacing were followed for a minimum of two years. Eighty-four per cent of the knees were affected by osteoarthrosis. Graded according to the knee-rating system of the Hospital for Special Surgery, there were eighteen excellent, fifty-three good, eighteen fair, and eleven poor results. At the most recent follow-up, twenty-nine knees (29 per cent), nine of which were affected by rheumatoid arthritis, were still painful in the patellofemoral area. The height and weight of the patient definitely influenced the amount of patellofemoral pain postoperatively. Small patients who had osteoarthrosis were exceptionally free of pain, regardless of sex, age, or level of activity. It seems that the best approach to patellofemoral replacement includes resurfacing of the patella in all patients who have rheumatoid arthritis and in patients who have osteoarthrosis if they have preoperative patellofemoral pain, are more than 160 centimeters tall, weigh more than sixty kilograms, and have advanced changes in the patella at the time of the operation.
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.
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
Sabatini, L.; Schirò, M.; Atzori, F.; Ferrero, G.; Massè, A.
INTRODUCTION Isolated patellofemoral (PF) arthritis is rare, and there is no complete agreement about the best surgical treatment. The operative treatments are total knee arthroplasty and patellofemoral replacement (PFR). The incidence of many early complications of PF arthroplasty has decreased with the introduction of newer designs. Nowadays, the main cause of revision surgery is the progression of tibiofemoral osteoarthritis. In the past, PF arthroplasty was contraindicated in patients with evidence of osteoarthritis or pain in medial or lateral tibiofemoral compartments. The improvement in implant designs and surgical techniques has allowed the addition of a monocompartmental arthroplasty for the medial or lateral tibiofemoral compartment. In this work, we evaluate our first experience with PF arthroplasty and its combination with unicompartmental knee arthroplasty. MATERIALS AND METHODS From May 2014 to March 2016, we treated 14 patients. An isolated PF arthroplasty was performed in six knees (five patients), and a combined PF and unicompartmental knee arthroplasty was performed in nine cases. We observed a significant improvement in the clinical and functional Knee Society Scores (KSSs) after surgery in our patients. RESULTS We obtained good results in our cases both for clinical and functional KSSs. Patellar clunk was recorded in one case. DISCUSSION AND CONCLUSION We are going toward a new attitude in which partial osteoarthritic changes could be treated with partial resurfacing prosthetic solutions such as unicompartmental, bi–unicompartmental or PFR alone, or unicompartmental combined, which respects the cruciates and achieves maximal bone preservation, which is vital, particularly, for young patients. PMID:27891054
Schindler, Oliver S
Patellar and femoral component in total knee arthroplasty are inextricably linked as a functional unit. The configuration of this unit has been a matter of ongoing debate, and the myriad of different patellar and femoral components currently available reflect the lack of consensus with respect to the ideal design. One of the major challenges is to overcome the biomechanical disadvantages of a small contact area through which high contact pressures are transferred, making this mechanical construct the weakest part of the prosthetic knee. Contact areas are highly dependent on the congruency of the patellofemoral joint articulation, and are significantly smaller for dome shaped patellar components compared to those of more anatomic designs. However, when exposed to 3-dimensional movements, the contact areas of the dome shaped patella are significantly greater, indicating enhanced forgiveness regarding patellar malpositioning. Although contact stresses, a function of implant design and surface conformity, can reach levels far beyond the yield strength of UHMWPE, catastrophic failure of resurfaced patellar components, commonly seen in metal backed patellae, fashionable in the 1980s, has rarely been observed since. Although plastic deformation and wear of UHMWPE continue to represent a problem, in the absence of suitable alternatives polyethylene remains the bearing surface of choice. The appreciation of the consequences of the mechanical environment on the behaviour of the patellofemoral joint is of particular importance in the endeavour to develop knee replacement systems which provide satisfactory function together with clinical long-term success.
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.
Xu, B Y; Ji, B C; Guo, W T; Mu, W B; Cao, L
Objective: To evaluate the influence of patellofemoral joint degeneration and pre-operative pain location on the outcome of medial Oxford unicompartmental knee arthroplasty (UKA). Methods: A total of 58 patients (58 knees) with medial Oxford UKA had been performed for medial osteoarthritis from March 2013 to July 2014 in Department of Orthopaedic Surgery at First Teaching Hospital of Xinjiang Medical University were retrospective reviewed. There were 24 males and 34 females, the age from 43 to 87 years with the mean age was 68.5 years. The mean body mass index was 25.2 kg/m(2) ranging from 19.7 to 31.5 kg/m(2). Patients were divided into anterior-medial pain group (35 knees), anterior knee pain group (17 knees) and general knee pain group (6 knees) according to pre-operative pain location. Pre-operative radiological statuses of the patellefemoral joint were defined by Ahlback system and divided into patellofemoral joint degeneration group (16 knees) and normal group (42 knees). Patients were also divided into medial patellofemoral degeneration group (20 knees), lateral patellofemoral degeneration group (12 knees) and normal group (26 knees) according to Altman scoring system. Outerbridge system was used intraoperatively and the patients were divided into patellofemoral joint degeneration group (21 knees) and normal group (37 knees). Pre- and post-operative outcomes were evaluated with Oxford Knee Score (OKS), Western Ontario and MacMaster (WOMAC) and patellofemoral score system of Lonner. T test and ANOVA were used to analyze the data. Results: The average duration of follow-up was 33 months (from 26 to 42 months). There were no patients had complications of infection, deep vein thrombosis, dislocation or loosing at the last follow-up. Compared to pre-operation, OKS (18.9±3.5 vs. 38.9±4.7, 19.3±4.2 vs. 39.6±4.6, 18.1±3.2 vs. 38.1±3.7)(t=5.64 to 7.08, all P<0.01) and WOMAC (10.9±2.3 vs.53.2±4.5, 10.4±2.1 vs.54.6±3.4, 11.7±1.8 vs.52.8±3.7)(t=14.50 to 19
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.
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.
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.
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.
Belvedere, C; Ensini, A; Leardini, A; Dedda, V; Feliciangeli, A; Cenni, F; Timoncini, A; Barbadoro, P; Giannini, S
In total knee arthroplasty, surgical navigation systems provide tibio-femoral joint (TFJ) tracking for relevant bone preparation, disregarding the patello-femoral joint (PFJ). Therefore, the important intra-operative assessment of the effect of component positioning, including the patella, on the kinematics of these two joints is not available. The objective of this study is to explore in vivo whether accurate tracking of the patella can result in a more physiological TFJ and PFJ kinematics during surgery. Ten patients underwent navigated knee replacement with patellar resurfacing. A secondary system was used to track patellar motion and PFJ kinematics using a special tracker. Patellar resection plane position and orientation were recorded using an instrumented probe. During all surgical steps, PFJ kinematics was measured in addition to TFJ kinematics. Abnormal PFJ motion patterns were observed pre-operatively at the impaired knee. Patellar resection plane orientation on sagittal and transverse planes of 3.9° ± 9.0° and 0.4° ± 4.1° was found. A good restoration of both TFJ and PFJ kinematics was observed in all replaced knees after resurfacing, in particular the rotations in the three anatomical planes and medio-lateral patellar translation. Patella tracking results in nearly physiological TFJ and PFJ kinematics in navigated knee arthroplasty with resurfacing. The intra-operative availability also of PFJ kinematics can support the positioning not only of the patellar component in case of resurfacing, but also of femoral and tibial components.
Takayama, Koji; Matsumoto, Tomoyuki; Muratsu, Hirotsugu; Ishida, Kazunari; Araki, Daisuke; Matsushita, Takehiko; Kuroda, Ryosuke; Kurosaka, Masahiro
The effect of posterior slope on joint gap in unicompartmental knee arthroplasty (UKA) has yet to be quantified. The purpose of this study was to quantify the effect of the tibial slope on the joint component gap and postoperative range of motion in UKA. Forty consecutive patients were prospectively enrolled. The correlation between the tibial slope changes and the component gap, the component gap difference between flexion angles, the postoperative extension or flexion angles was examined. The correlation of joint looseness with tibial slope changes and postoperative extension angle was also examined. Increased tibial slope positively correlated with the differences between the component gap at 90° and 10°, 120° and 10°, or 135° and 10° knee flexion angle. Although tibial slope change did not affect postoperative flexion angle, increased tibial slope reduced postoperative extension angle. Moreover, increased tibial slope resulted in decreased joint looseness during 10° of knee flexion and decreased joint looseness during 10° of knee flexion resulted in reduced postoperative extension angle. Increased tibial slope resulted in tight component gap at knee extension compared with that at knee flexion. Furthermore, tight component gap at extension lead to decreased postoperative extension angle. These results indicate that an individual anatomical tibial slope should be considered when tibial sagittal osteotomy was performed and increasing tibial slope should be avoided to achieve full extension angle after UKA. II. Copyright © 2016. Published by Elsevier B.V.
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
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
Singh, Jas; Politis, Angelos; Loucks, Lynda; Hedden, David R.; Bohm, Eric R.
Background National joint replacement registries outside North America have been effective in reducing revision risk. However, there is little information on the role of smaller regional registries similar to those found in Canada or the United States. We sought to understand trends in total hip (THA) and knee (TKA) arthroplasty revision patterns after implementation of a regional registry. Methods We reviewed our regional joint replacement registry containing all 30 252 cases of primary and revision THA and TKA performed between Jan. 1, 2005, and Dec. 31, 2013. Each revision case was stratified into early (< 2 yr), mid (2–10 yr) or late (> 10 yr), and we determined the primary reason for revision. Results The early revision rate for TKA dropped from 3.0% in 2005 to 1.3% in 2011 (R2 = 0.84, p = 0.003). Similarly, the early revision rate for THA dropped from 4.2% to 2.1% (R2 = 0.78, p = 0.008). Despite primary TKA and THA volumes increasing by 35.5% and 39.5%, respectively, there was no concomitant rise in revision volumes. The leading reasons for TKA revision were infection, instability, aseptic loosening and stiffness. The leading reasons for THA revision were infection, instability, aseptic loosening and periprosthetic fracture. There were no discernible trends over time in reasons for early, mid-term or late revision for either TKA or THA. Conclusion After implementation of a regional joint replacement registry we observed a significant reduction in early revision rates. Further work investigating the mechanism by which registry reporting reduces early revision risk is warranted. PMID:27438053
Sen, T.; Cankaya, D.; Kendir, S.; Basarır, K.; Tabak, Y.
Objectives The purpose of this study was to develop an accurate, reliable and easily applicable method for determining the anatomical location of the joint line during revision knee arthroplasty. Methods The transepicondylar width (TEW), the perpendicular distance between the medial and lateral epicondyles and the distal articular surfaces (DMAD, DLAD) and the distance between the medial and lateral epicondyles and the posterior articular surfaces (PMAD, DLAD) were measured in 40 knees from 20 formalin-fixed adult cadavers (11 male and nine female; mean age at death 56.9 years, sd 9.4; 34 to 69). The ratios of the DMAD, PMAD, DLAD and PLAD to TEW were calculated. Results The mean TEW, DMAD, PMAD, DLAD and PLAD were 82.76 mm (standard deviation (sd) 7.74), 28.95 mm (sd 3.3), 28.57 mm (sd 3), 23.97 mm (sd 3.27) and 24.42 mm (sd 3.14), respectively. The ratios between the TEW and the articular distances (DMAD/TEW, DLAD/TEW, PMAD/TEW and PLAD/TEW) were calculated and their means were 0.35 (sd 0.02), 0.34 (sd 0.02), 0.28 (sd 0.03) and 0.29 (sd 0.03), respectively. Conclusion This method provides a simple, reproducible and reliable technique enabling accurate anatomical joint line restoration during revision total knee arthroplasty. Cite this article: B. Ozkurt, T. Sen, D. Cankaya, S. Kendir, K. Basarır, Y. Tabak. The medial and lateral epicondyle as a reliable landmark for intra-operative joint line determination in revision knee arthroplasty. Bone Joint Res 2016;5:280–286. DOI: 10.1302/2046-3758.57.BJR-2016-0002.R1. PMID:27388715
Luo, Jiang-Ming; Guo, Lin; Chen, Hao; Yang, Peng-Fei; Xiong, Ran; Peng, Yang; Yang, Liu
To evaluate, by way of intraoperative tissue culture and pathological study, the pre-operative presence of micro-organisms in knee joints of patients with rheumatoid arthritis (RA) who need total knee arthroplasty (TKA). From November 2012 to January 2014, 47 patients with RA (53 knees) who needed TKA were included in this study. Patients received routine pre-operative examination and joint fluid routine and culture. Each RA patient was match-paired with one osteoarthritis (OA) patient. During arthrotomy, synovial tissue was reserved and portioned for culture, frozen section, and routine pathologic examination. Pre-operative infection in all knees was ruled out. There were 12 RA patients (13 knees) with positive culture results: two Escherichia coli, two Staphylococcus epidermidis, two Staphylococcus aureus, one Proteus mirabilis, one Staphylococcus warneri, one Enterococcus faecalis, one Acinetobacter baumannii, one Candida albicans, one Ochrobactrum anthropi, and one Candida glabrata. Except for microabscess found in one RA patient, all pathological sections showed mild chronic inflammation but no infection. All patients with positive culture results were administered sensitive antibiotics for six weeks after surgery. Two patients had deep infection: one had a fused knee after a failed debridement, and the second was previously treated with an amphotericin injection. Pre-operative presence of micro-organism in knee joints of RA patients is common (24.5%). This finding of a high incidence of pre-operative presence of micro-organism in joints of RA patients before arthroplasty may suggest a role of micro-organism in the pathogenesis of prosthetic joint infection (PJI). Intraoperative synovial tissue culture is valuable for diagnosis of this condition and in instruction of antibacterial treatment. Copyright © 2016 Elsevier B.V. All rights reserved.
Marshall, Deborah; Christiansen, Tanya; Smith, Christopher; Howden, Jane Squire; Werle, Jason; Fyie, Ken; Frank, Cy
Despite various health system improvements across Alberta, the wait times benchmark was not being met for all patients requiring hip or knee arthroplasty. Alberta Health Services Bone and Joint Clinical Network working groups, in collaboration with other provincial organizations, gained consensus on the development and implementation of a set of provincial Wait Times Rules. These rules standardize the definition and measurement of data elements specific to joint replacement and distinguish between voluntary (patient-related) versus involuntary (healthcare system-related) wait times. Collectively, this information will help identify trends in wait times and more accurately show where wait times can be reduced.
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.
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
Song, Moo-Ho; Kim, Bu-Hwan; Ahn, Seong-Jun; Yoo, Seong-Ho; Kang, Suk-Woong; Oh, Kwan-Taek
The purpose of this study is to investigate the likelihood of unicompartmental knee arthroplasty (UKA) in patients with chondrosis in the patellofemoral joint. We evaluated the pain and functional changes in the patellofemoral joint of 62 patients who underwent medial UKA for medial compartmental osteoarthritis with symptoms in the patellofemoral joint. They were analyzed by the patellofemoral score of Lonner at postoperative 3months, 6months, 1year, and 2years prospectively. Preoperatively, the grade by total score was poor in all 62 cases, but it was improved to 36 excellent (58%), 16 good (26%), and 10 fair (16%), and there were no poor cases at 2years. The last follow-up showed satisfactory results in pain score, function score, and total score (p<0.05). Regarding this result, we believe chondrosis in the patellofemoral joint is not a contraindication to UKA, even in patients with patellofemoral joint symptoms.
Liow, Ming Han Lincoln; Xia, Zhan; Wong, Merng Koon; Tay, Keng Jin; Yeo, Seng Jin; Chin, Pak Lin
Robot-assisted Total Knee Arthroplasty (TKA) improves the accuracy and precision of component implantation and mechanical axis (MA) alignment. Joint-line restoration in robot-assisted TKA is not widely described and joint-line deviation of>5mm results in mid-flexion instability and poor outcomes. We prospectively randomised 60 patients into two groups: 31 patients (robot-assisted), 29 patients (conventional). No MA outliers (>±3° from neutral) or notching was noted in the robot-assisted group as compared with 19.4% (P=0.049) and 10.3% (P=0.238) respectively in the conventional group. The robot-assisted group had 3.23% joint-line outliers (>5mm) as compared to 20.6% in the conventional group (P=0.049). Robot-assisted TKA produces similar short-term clinical outcomes when compared to conventional methods with reduction of MA alignment and joint-line deviation outliers.
Niinimäki, Tuukka T; Murray, David W; Partanen, Juha; Pajala, Ari; Leppilahti, Juhana I
The indications and contraindications for unicompartmental knee arthroplasty (UKA) are controversial. The aim of the study was to determine the risk factors for re-operation in our practice. A series of 113 medial UKAs with mean follow-up of 63 months were reviewed retrospectively. Pre-operatively all knees had radiographic or arthroscopic evidence of severe cartilage damage. The re-operation rate was not related to age, gender, arthroscopic finding or body mass index. It was related to the joint space on pre-operative standing weight bearing radiographs taken in extension. The re-operation rate was 6 (95% CI 2.1-17, P<0.001) times higher when the thickness of the pre-operative medial joint space was >2 mm rather than ≤2 mm. It was 8 (95% CI 2.8-22.5, P<0.001) times higher when the thickness of the pre-operative medial space was >40% of the thickness of the lateral space. The ratio of pre-operative joint spaces has a greater influence on revision rate than the absolute measurement and is independent of radiographic magnification or the patient's normal cartilage thickness. We therefore recommend that, in medial knee osteoarthritis, UKA should only be used if the pre-operative medial joint space on standing radiographs is ≤40% of the lateral joint space, even if severe cartilage damage is seen arthroscopically.
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
Meehan, John P; Danielsen, Beate; Kim, Sunny H; Jamali, Amir A; White, Richard H
Although early aseptic mechanical failure after total knee arthroplasty has been reported in younger patients, it is unknown whether early revision due to periprosthetic joint infection is more or less frequent in this patient subgroup. The purpose of this study was to determine whether the incidence of early periprosthetic joint infection requiring revision knee surgery is significantly different in patients younger than fifty years of age compared with older patients following primary unilateral total knee arthroplasty. A large population-based study was conducted with use of the California Patient Discharge Database, which allows serial linkage of all discharge data from nonfederal hospitals in the state over time. Patients undergoing primary unilateral total knee arthroplasty during 2005 to 2009 were identified. Principal outcomes were partial or complete revision arthroplasty due to periprosthetic joint infection or due to aseptic mechanical failure within one year. Multivariate analysis included risk adjustment for important demographic and clinical variables. The effect of hospital total knee arthroplasty volume on the outcomes of infection and mechanical failure was analyzed with use of hierarchical modeling. At one year, 983 (0.82%) of 120,538 primary total knee arthroplasties had undergone revision due to periprosthetic joint infection and 1385 (1.15%) had undergone revision due to aseptic mechanical failure. The cumulative incidence in patients younger than fifty years of age was 1.36% for revision due to periprosthetic joint infection and 3.49% for revision due to aseptic mechanical failure. In risk-adjusted models, the risk of periprosthetic joint infection was 1.8 times higher in patients younger than fifty years of age (odds ratio = 1.81, 95% confidence interval = 1.33 to 2.47) compared with patients sixty-five years of age or older, and the risk of aseptic mechanical failure was 4.7 times higher (odds ratio = 4.66, 95% confidence interval = 3.77 to
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.
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.
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.
Roberts, Dustyn; Khan, Humera; Kim, Joo H; Slover, James; Walker, Peter S
There is no universally accepted definition of human joint stability, particularly in nonperiodic general activities of daily living. Instability has proven to be a difficult parameter to define and quantify, since both spatial and temporal measures need to be considered to fully characterize joint stability. In this preliminary study, acceleration-based parameters were proposed to characterize the joint stability. Several time-statistical parameters of acceleration and jerk were defined as potential stability measures, since anomalous acceleration or jerk could be a symptom of poor control or stability. An inertial measurement unit attached at the level of the tibial tubercle of controls and patients following total knee arthroplasty was used to determine linear acceleration of the knee joint during several activities of daily living. The resulting accelerations and jerks were compared with patient-reported instability as determined through a standard questionnaire. Several parameters based on accelerations and jerks in the anterior/posterior direction during the step-up/step-down activity were significantly different between patients and controls and correlated with patient reports of instability in that activity. The range of the positive to negative peak acceleration and infinity norm of acceleration, in the anterior/posterior direction during the step-up/step-down activity, proved to be the best indicators of instability. As time derivatives of displacement, these acceleration-based parameters represent spatial and temporal information and are an important step forward in developing a definition and objective quantification of human joint stability that can complement the subjective patient report.
No associations between self-reported knee joint instability and radiographic features in knee osteoarthritis patients prior to Total Knee Arthroplasty: A cross-sectional analysis of the Longitudinal Leiden Orthopaedics Outcomes of Osteo-Arthritis study (LOAS) data.
Leichtenberg, Claudia S; Meesters, Jorit J L; Kroon, Herman M; Verdegaal, Suzan H M; Tilbury, Claire; Dekker, Joost; Nelissen, Rob G H H; Vliet Vlieland, Thea P M; van der Esch, Martin
To describe the prevalence of self-reported knee joint instability in patients with pre-surgery knee osteoarthritis (OA) and to explore the associations between self-reported knee joint instability and radiological features. A cross-sectional study including patients scheduled for primary Total Knee Arthroplasty (TKA). Self-reported knee instability was examined by questionnaire. Radiological features consisted of osteophyte formation and joint space narrowing (JSN), both scored on a 0 to three scale. Scores >1 are defined as substantial JSN or osteophyte formation. Regression analyses were provided to identify associations of radiological features with self-reported knee joint instability. Two hundred and sixty-five patients (mean age 69years and 170 females) were included. Knee instability was reported by 192 patients (72%). Substantial osteophyte formation was present in 78 patients (41%) reporting and 33 patients (46%) not reporting knee joint instability. Substantial JSN was present in 137 (71%) and 53 patients (73%), respectively. Self-reported knee instability was not associated with JSN (relative to score 0, odds ratios (95% CI) of score 1, 2 and 3 were 0.87 (0.30-2.54), 0.98 (0.38-2.52), 0.68 (0.25-1.86), respectively) or osteophyte formation (relative to score 0, odds ratios (95% CI) of score 1, 2 and 3 were 0.77 (0.36-1.64), 0.69 (0.23-1.45), 0.89 (0.16-4.93), respectively). Stratified analysis for pain, age and BMI showed no associations between self-reported knee joint instability and radiological features. Self-reported knee joint instability is not associated with JSN or osteophyte formation. Copyright © 2017 Elsevier B.V. All rights reserved.
Steinbrück, A; Milz, S; Woiczinski, M; Schröder, C; Utzschneider, S; Jansson, V; Fottner, A
The patellofemoral joint constitutes a complex anatomical and functional entity. The tensile force of the quadriceps femoris muscle is transmitted through the patella and patellar ligament onto the tibial tuberosity. This particular three-dimensional arrangement increases the torsional moment acting on the knee joint. Dynamic alignment of the patella is determined by trochlear geometry and is supported by active muscular and passive connective tissue stabilizers. In addition to the retinaculum of the patella, the medial patellofemoral ligament is attracting increasing clinical attention. Multidirectional motion of the patella is closely connected to retropatellar pressure distribution which can be modulated by moving the patellar ligament insertion. Implantation of a knee endoprosthesis changes the joint surface geometry and consequently patella kinematics and retropatellar pressure distribution. Finite element analysis provides the possibility to assess retropatellar pressure distribution before and after implantation of prostheses.
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.
Background Poor pain and function outcomes are undesirable after an elective surgery such as total hip or knee arthroplasty (THA/TKA). Recent studies have indicated that the presence of contralateral joint influences outcomes of THA/TKA, however the impact of ipsilateral knee/hip involvement on THA/TKA outcomes has not been explored. The objective of this study was to assess the association of ipsilateral knee/hip joint involvement on short-term and medium-term pain and function outcomes after THA/TKA. Methods In this retrospective study of prospectively collected data, we used the data from the Mayo Clinic Total Joint Registry to assess the association of ipsilateral knee or hip joint involvement with moderate to severe pain and moderate to severe activity limitation at 2-year and 5-year follow-up after primary and revision THA and TKA using multivariable-adjusted logistic regression analyses. Results At 2 years, 3,823 primary THA, 4,701 primary TKA, 1,218 revision THA and 725 revision TKA procedures were studied. After adjusting for multiple covariates, ipsilateral knee pain was significantly associated with outcomes after primary THA (all P values <0.01): (1) moderate to severe pain: at 2 years, odds ratio (OR), 2.3 (95% confidence interval (CI) 1.5 to 3.6); at 5 years, OR 1.8 (95% CI 1.1 to 2.7); (2) moderate to severe activity limitation: at 2 years, OR 3.1 (95% CI 2.3 to 4.3); at 5 years, OR 3.6 (95% CI 2.6 to 5.0). Ipsilateral hip pain was significantly associated with outcomes after primary TKA (all P values <0.01): (1) moderate to severe pain: at 2 years, OR 3.3 (95% CI 2.3 to 4.7); at 5 years, OR 1.8 (95% CI 1.1 to 2.7); (2) moderate to severe activity limitation: at 2 years, OR 3.6 (95% CI 2.6 to 4.9); at 5 years, OR 2.2 (95% CI 1.6 to 3.2). Similar associations were noted for revision THA and TKA patients. Conclusions To the best of our knowledge, this is the first study showing that the presence of ipsilateral joint involvement after THA or TKA is
van der Woude, J. A. D.; Nair, S. C.; Custers, R. J. H.; van Laar, J. M.; Kuchuck, N. O.; Lafeber, F. P. J. G.; Welsing, P. M. J.
Objective In end-stage knee osteoarthritis the treatment of choice is total knee arthroplasty (TKA). An alternative treatment is knee joint distraction (KJD), suggested to postpone TKA. Several studies reported significant and prolonged clinical improvement of KJD. To make an appropriate decision regarding the position of this treatment, a cost-effectiveness and cost-utility analysis from healthcare perspective for different age and gender categories was performed. Methods A treatment strategy starting with TKA and a strategy starting with KJD for patients of different age and gender was simulated. To extrapolate outcomes to long-term health and economic outcomes a Markov (Health state) model was used. The number of surgeries, QALYs, and treatment costs per strategy were calculated. Costs-effectiveness is expressed using the cost-effectiveness plane and cost-effectiveness acceptability curves. Results Starting with KJD the number of knee replacing procedures could be reduced, most clearly in the younger age categories; especially revision surgery. This resulted in the KJD strategy being dominant (more effective with cost-savings) in about 80% of simulations (with only inferiority in about 1%) in these age categories when compared to TKA. At a willingness to pay of 20.000 Euro per QALY gained, the probability of starting with KJD to be cost-effective compared to starting with a TKA was already found to be over 75% for all age categories and over 90–95% for the younger age categories. Conclusion A treatment strategy starting with knee joint distraction for knee osteoarthritis has a large potential for being a cost-effective intervention, especially for the relatively young patient. PMID:27171268
Maradit Kremers, Hilal; Lewallen, Laura W; Mabry, Tad M; Berry, Daniel J; Berbari, Elie F; Osmon, Douglas R
Diabetes mellitus is an established risk factor for infections but evidence is conflicting to what extent perioperative hyperglycemia, glycemic control and treatment around the time of surgery modify the risk of prosthetic joint infections (PJIs). In a cohort of 20,171 total hip and knee arthroplasty procedures, we observed a significantly higher risk of PJIs among patients with a diagnosis of diabetes mellitus (hazard ratio [HR] 1.55, 95% CI 1.11, 2.16), patients using diabetes medications (HR 1.56, 95% CI 1.08, 2.25) and patients with perioperative hyperglycemia (HR 1.59, 95% CI 1.07, 2.35), but the effects were attenuated after adjusting for body mass index, type of surgery, ASA score and operative time. Although data were limited, there was no association between hemoglobin A1c values and PJIs.
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
Okamoto, Nobukazu; Breslauer, Leigh; Hedley, Anthony K; Mizuta, Hiroshi; Banks, Scott A
Many younger and highly active patients desire to achieve high flexion after total knee arthroplasty. This study's purpose was to determine if a contemporary total knee arthroplasty design improved functional knee flexion compared with a traditional total knee arthroplasty in patients living a Western lifestyle. Ten patients with bilateral total knee arthroplasty of 2 types were studied during weight-bearing lunge, kneeling, and stair activities using fluoroscopic imaging. There were no differences in maximum knee flexion during lunging or kneeling. Statistically significant differences in tibial rotation and condylar translation were observed during the 3 activities. Although several joint kinematic differences were observed, no important functional differences were observed in clinically excellent, high performing subjects with bilateral total knee arthroplasty of 2 types.
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.
Thomsen, Morten G; Latifi, Roshan; Kallemose, Thomas; Barfod, Kristoffer W; Husted, Henrik; Troelsen, Anders
Background and purpose When evaluating the outcome after total knee arthroplasty (TKA), increasing emphasis has been put on patient satisfaction and ability to perform activities of daily living. To address this, the forgotten joint score (FJS) for assessment of knee awareness has been developed. We investigated the validity and reliability of the FJS. Patients and methods A Danish version of the FJS questionnaire was created according to internationally accepted standards. 360 participants who underwent primary TKA were invited to participate in the study. Of these, 315 were included in a validity study and 150 in a reliability study. Correlation between the Oxford knee score (OKS) and the FJS was examined and test-retest evaluation was performed. A ceiling effect was defined as participants reaching a score within 15% of the maximum achievable score. Results The validity study revealed a strong correlation between the FJS and the OKS (intraclass correlation coefficient (ICC) = 0.81, 95% CI: 0.77–0.85; p < 0.001). The test-retest evaluation showed almost perfect reliability for the FJS total score (ICC = 0.91, 95% CI: 0.88–0.94) and substantial reliability or better for individual items of the FJS (ICC? 0.79). We found a high level of internal consistency (Cronbach’s? = 0.96). The ceiling effect for the FJS was 16%, as compared to 37% for the OKS. Interpretation The FJS showed good construct validity and test-retest reliability. It had a lower ceiling effect than the OKS. The FJS appears to be a promising tool for evaluation of small differences in knee performance in groups of patients with good clinical results after TKA. PMID:26937689
Thomsen, Morten G; Latifi, Roshan; Kallemose, Thomas; Barfod, Kristoffer W; Husted, Henrik; Troelsen, Anders
Background and purpose - When evaluating the outcome after total knee arthroplasty (TKA), increasing emphasis has been put on patient satisfaction and ability to perform activities of daily living. To address this, the forgotten joint score (FJS) for assessment of knee awareness has been developed. We investigated the validity and reliability of the FJS. Patients and methods - A Danish version of the FJS questionnaire was created according to internationally accepted standards. 360 participants who underwent primary TKA were invited to participate in the study. Of these, 315 were included in a validity study and 150 in a reliability study. Correlation between the Oxford knee score (OKS) and the FJS was examined and test-retest evaluation was performed. A ceiling effect was defined as participants reaching a score within 15% of the maximum achievable score. Results - The validity study revealed a strong correlation between the FJS and the OKS (intraclass correlation coefficient (ICC) = 0.81, 95% CI: 0.77-0.85; p < 0.001). The test-retest evaluation showed almost perfect reliability for the FJS total score (ICC = 0.91, 95% CI: 0.88-0.94) and substantial reliability or better for individual items of the FJS (ICC? 0.79). We found a high level of internal consistency (Cronbach's? = 0.96). The ceiling effect for the FJS was 16%, as compared to 37% for the OKS. Interpretation - The FJS showed good construct validity and test-retest reliability. It had a lower ceiling effect than the OKS. The FJS appears to be a promising tool for evaluation of small differences in knee performance in groups of patients with good clinical results after TKA.
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.
Aoki, Yasuchika; Murakami, Masazumi
Achieving correct soft tissue balance and preparing equal and rectangular extension and flexion joint gaps are crucial goals of TKA. Intraoperative gap balances would change postoperatively; however, changes in joint gap balances between pre- and postoperation remain unclear. To explore these changes associated with TKA, we prospectively investigated 21 posterior cruciate ligament retaining TKAs for varus knees. Intraoperative extension gap balance (iEGB) was 2.6 ± 2.0° varus versus postoperative extension gap balance (pEGB) of 0.77 ± 1.8° valgus (P < 0.01), while no significant difference between intraoperative flexion gap balance (iFGB) and postoperative flexion gap balance (pFGB) was observed. We also explored correlations between intraoperative and postoperative gap balances but found no significant correlations. These observations indicate that (i) surgeons should avoid excessive release of the medial soft tissue during TKA for varus knees and (ii) intraoperative gap balance may not be necessarily reflected on postoperative gap balance. PMID:24669320
Nakajima, Arata; Aoki, Yasuchika; Murakami, Masazumi; Nakagawa, Koichi
Achieving correct soft tissue balance and preparing equal and rectangular extension and flexion joint gaps are crucial goals of TKA. Intraoperative gap balances would change postoperatively; however, changes in joint gap balances between pre- and postoperation remain unclear. To explore these changes associated with TKA, we prospectively investigated 21 posterior cruciate ligament retaining TKAs for varus knees. Intraoperative extension gap balance (iEGB) was 2.6 ± 2.0° varus versus postoperative extension gap balance (pEGB) of 0.77 ± 1.8° valgus (P < 0.01), while no significant difference between intraoperative flexion gap balance (iFGB) and postoperative flexion gap balance (pFGB) was observed. We also explored correlations between intraoperative and postoperative gap balances but found no significant correlations. These observations indicate that (i) surgeons should avoid excessive release of the medial soft tissue during TKA for varus knees and (ii) intraoperative gap balance may not be necessarily reflected on postoperative gap balance.
Patel, Ripal; Alijanipour, Pouya; Parvizi, Javad
Periprosthetic joint infection (PJI) is a complication of total joint arthroplasty that is challenging to diagnose. Currently, there is no “gold standard” for definite diagnosis of PJI. A multi-criteria definition has been described for PJI based on microbiology cultures, serum markers, such as erythrocyte sedimentation rate and C-reactive protein (CRP), synovial fluid biomarkers, such as leukocyte esterase and histopathology assessment of the periprosthetic tissue. The conventional serum markers are generally nonspecific and can be elevated in inflammatory conditions. Therefore, they cannot be relied on for definite diagnosis of PJI. Hence, with the use of proteomics, synovial fluid biomarkers such as α-defensin, IL-6, and CRP have been proposed as more accurate biomarkers for PJI. Current methods to culture micro-organisms have several limitations, and can be false-negative and false-positive in a considerable number of cases. In an attempt to improve culture sensitivity, diagnostic methods to target biofilms have recently been studied. The understanding of the concept of biofilms has also allowed for the development of novel techniques for PJI diagnosis, such as visualizing biofilms with fluorescent in-situ hybridization and detection of bacteria via DNA microarray. Lastly, the use of amplification-based molecular techniques has provided methods to identify specific species of bacteria that cause culture-negative PJI. While diagnosing PJI is difficult, these advances could be valuable tools for clinicians. PMID:28144375
Montero-Quijano, M; Ceja-Barriga, A; Núñez-Robles, J; Barrios-Benítez, U; Núñez-Barragán, J L; Antonio-Romero, E
The appearance of patellofemoral pain after a knee arthroplasty, particularly in rheumatic diseases, resulted in the incorporation of the substitution of the patellar component in all designs. The replacement of the patella became a standard part of knee arthroplasty, but the controversy over whether to restore it or not continues among orthopedists that perform knee arthroplasties. To analyze the incidence of anterior knee pain in patients who underwent primary knee arthroplasty with or without replacement of the patellar component. Observational, retrospective, descriptive and transversal study from January 2011 to December 2013. A total of 54 patients were included, 12 men (with an average age of 63 years) and 42 women (with an average age of 71 years), totaling 64 knees that were surgically intervened. This study found no significant difference in anterior knee pain and in the function of the patellofemoral joint and the knee in the groups of patients who were tested with the different scales.
Goh, Graham Seow-Hng; Bin Abd Razak, Hamid Rahmatullah; Tan, Joshua Yuan-Wang; Yeo, Seng-Jin
The adverse effects of joint line (JL) changes on kinematics and outcomes of total knee arthroplasty (TKA) have been studied. Some authors have quantified JL changes using intraoperative data from computer navigation, despite no studies validating these measurements to date. We designed a prospective study to determine whether intraoperative measurements of JL changes using computer navigation correlate with measurements obtained on weight-bearing radiographs postoperatively. A total of 195 consecutive patients (195 knees) underwent computer-navigated cruciate-retaining TKA by the senior author. Twenty-four patients had missing radiographic data and were excluded from the study. The final JL change was calculated intraoperatively from the verified bony cuts and planned JL change as determined by the computer. JL position was also measured on preoperative and postoperative radiographs using an anteroposterior method. One hundred seventy-one knees were evaluated. Using computer-navigated and radiographic measurements, the mean JL change was 1.95 ± 1.5 mm (0-8.0 mm) and 4.05 ± 2.9 mm (0-17.3 mm), respectively. One hundred fourteen (67%) vs 129 (75%) had JL elevation, 44 (26%) vs 30 (18%) had JL depression, and 13 (7%) vs 12 (7%) had no JL change, respectively. Inter-rater and intrarater reliability of radiographic measurements was excellent. We found a poor correlation between computer-navigated and radiographic measurements (r = 0.303). There is a poor correlation between computer-aided and radiographic measurements of JL changes post-TKA. Elevation/depression of the JL needs to be considered in patients who remain symptomatic despite TKA, although the optimal method of assessment remains uncertain. Copyright © 2016 Elsevier Inc. All rights reserved.
Merican, A M; Ghosh, K M; Iranpour, F; Deehan, D J; Amis, Andrew A
Complications after total knee arthroplasty (TKA) often involve the patellofemoral joint, and problems with patellar maltracking or lateral instability have sometimes been addressed by external rotation of the femoral component. This work sought to measure the changes of knee kinematics caused by TKA and then to optimise the restoration of both the patellofemoral and tibiofemoral joint kinematics, by variation of femoral component internal-external rotation. The kinematics of the patella and tibia were measured in eight cadaveric knees during active extension motion. This was repeated with the knee intact, with a Genesis II TKA in the standard position (3° of external rotation) and with the femoral component at ±5° rotation from there. Both patellar and tibial motions were significantly different from normal with the standard TKA rotation, with 3° tibial abduction at 90° flexion and reversal of the screw-home from 5° external rotation to 6° internal rotation. The patella was shifted medially 6 mm in flexion and tilted 7° more laterally near extension. Femoral rotation to address one abnormality caused increased abnormality in other degrees of freedom. Internal and then external rotation of 5° caused tibial abduction and then adduction of 5° at 90° flexion. These femoral rotations also caused increased patellar lateral tilt of 4° with femoral external rotation and decreased tilt by 4° with internal rotation. Thus, correction of tibial abduction in flexion, by external rotation of the femoral component, worsened the patellar lateral tilt near extension. It was concluded that femoral rotation alone could not restore all aspects of both patellar and tibial kinematics to normal with this specific implant. The clinical relevance of this is that it appears to be inadvisable to reposition the femoral component, in an attempt to improve patellar tracking, if that repositioning may then cause abnormal tibiofemoral kinematics. Further, the pattern of patellar
Surgical Wound; Revision Total Knee Arthroplasty; Wounds and Injuries; Joint Disease; Musculoskeletal Disease; Prosthesis-Related Infections; Infection; Postoperative Complications; Pathologic Processes
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
Gesell, Mark W; Tria, Alfred J
Unicondylar arthroplasty of the knee has seen a resurgence of interest in the United States. The principles of unicondylar arthroplasty of the knee are different from those for total knee arthroplasty, allowing replacement of only the affected joint compartment with less bone loss. Minimally invasive surgery allows for less soft tissue dissection with the potential for less morbidity. The key question is: will the changes associated with the minimally invasive surgery procedure improve the clinical results of the standard unicondylar arthroplasty of the knee or will the changes make the procedure too difficult and lead to an increasing failure rate? This study reviews the surgical technique and presents the 2 to 4 year results of the minimally invasive unicondylar arthroplasty of the knee 47 knees in 41 patients. The average range of motion increased from 121 degrees -132 degrees . The Knee Society pain score improved from 45-80 and the function score improved from 47-78. Only one knee has been revised. With proper patient selection, minimally invasive unicondylar arthroplasty of the knee allows for results that are at least equal to those of the standard open procedure at 2 to 4 years after the surgery.
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
Beswick, Andrew D.; Peters, Tim J.; Gooberman-Hill, Rachael; Whitehouse, Michael R.; Blom, Ashley W.
Background Hip and knee arthroplasty are common interventions for the treatment of joint conditions, most notably osteoarthritis. Although many patients benefit from surgery, approximately 1% of patients develop infection afterwards known as deep prosthetic joint infection (PJI), which often requires further major surgery. Objective To assess support needs of patients undergoing treatment for PJI following hip or knee arthroplasty and to identify and evaluate what interventions are routinely offered to support such patients. Design Systematic review Data sources MEDLINE, EMBASE, Web of Science, PsycINFO, Cinahl, Social Science Citation Index, The Cochrane Library, and reference lists of relevant studies from January 01, 1980 to October 05, 2016. Selection criteria Observational (prospective or retrospective cohort, nested case-control or case-control) studies, qualitative studies, or clinical trials conducted in patients treated for PJI and/or other major adverse occurrences following hip or knee arthroplasty. Review methods Data were extracted by two independent investigators and consensus was reached with involvement of a third. Given the heterogeneous nature of study designs, methods, and limited number of studies, a narrative synthesis is presented. Results Of 4,213 potentially relevant citations, we identified one case-control, one prospective cohort and two qualitative studies for inclusion in the synthesis. Patients report that PJI and treatment had a profoundly negative impact affecting physical, emotional, social and economic aspects of their lives. No study evaluated support interventions. Conclusion The findings demonstrate that patients undergoing treatment for PJI have extensive physical, psychological, social and economic support needs. The interpretation of study results is limited by variation in study design, outcome measures and the small number of relevant eligible studies. However, our review highlights a lack of evidence about support
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.
Hamilton, D F; Loth, F L; Giesinger, J M; Giesinger, K; MacDonald, D J; Patton, J T; Simpson, A H R W; Howie, C R
To validate the English language Forgotten Joint Score-12 (FJS-12) as a tool to evaluate the outcome of hip and knee arthroplasty in a United Kingdom population. All patients undergoing surgery between January and August 2014 were eligible for inclusion. Prospective data were collected from 205 patients undergoing total hip arthroplasty (THA) and 231 patients undergoing total knee arthroplasty (TKA). Outcomes were assessed with the FJS-12 and the Oxford Hip and Knee Scores (OHS, OKS) pre-operatively, then at six and 12 months post-operatively. Internal consistency, convergent validity, effect size, relative validity and ceiling effects were determined. Data for the TKA and THA patients showed high internal consistency for the FJS-12 (Cronbach α = 0.97 in TKAs, 0.98 in THAs). Convergent validity with the Oxford Scores was high (r = 0.85 in TKAs, r = 0.79 for THAs). From six to 12 months, the change was higher for the FJS-12 than for the OHS in THA patients (effect size d = 0.21 versus -0.03). Ceiling effects at one-year follow-up were low for the FJS-12 with just 3.9% (TKA) and 8.8% (THA) of patients achieving the best possible score. The FJS-12 has strong measurement properties in terms of validity, internal consistency and sensitivity to change in TKA and THA patients. Low ceiling effects and good relative validity allow the monitoring of longer term outcomes, particularly in well-performing groups after total joint arthroplasty. Cite this article: Bone Joint J 2017;99-B:218-24. ©2017 Hamilton et al.
Keren, Amit; Berkovich, Yaron; Berkovitch, Yaron; Soudry, Michael
Joint arthroplasty is one of the commonest surgical procedures in orthopedic surgery. In recent years there was an increase in the number of procedures, patient satisfaction and implant survival. Originally, these operations were designed for old patients in order to relieve pain and to enable ambulation. Over the past few years, these operations have become common in younger patients which desire to return to activity, including sports activities. The importance of physical activity is a well known fact. In recent years it became clear that with the proper physical activity the outcomes of the operations are better. There are several types of arthroplasty. Many factors influence the outcome of the operation apart from the post-surgery physical activity. These factors include patient factors, surgical technique and type of arthroplasty. This review summarizes the recommendations for sports activities after hip and knee arthroplasties. These activities are evaluated according to surgeons' recommendations, stress applied on the implant and long term outcomes. The recommended sports activities after joint arthroplasties are walking, swimming and cycling. Soccer, basketball and jogging are not advised. Tennis, downhill skiing and horse riding are recommended with previous experience. There are many more sports activities that patients can participate in, and it is important that the patient discuss the different options prior to the operation. Since these operations are so common, many non-orthopedic physicians encounter these patients in their practice. They should be acquainted with the recommendations for sports activities and encourage them.
Zumbrunn, Thomas; Varadarajan, Kartik Mangudi; Rubash, Harry E; Malchau, Henrik; Li, Guoan; Muratoglu, Orhun K
Lack of ACL and non-anatomic articular surfaces in contemporary total knee implants result in kinematic abnormalities. We hypothesized that such abnormalities may be addressed with a biomimetic bi-cruciate retaining (BCR) design having anatomical articular surfaces. We used dynamic computer simulations to compare kinematics among the biomimetic BCR, a contemporary BCR and cruciate-retaining implant for activities of daily living. During simulated deep knee bend, chair-sit and walking, the biomimetic BCR implant showed activity dependent kinematics similar to healthy knees in vivo. Restoring native knee geometry together with ACL preservation provided these kinematic improvements over contemporary ACL-preserving and ACL-sacrificing implants. Further clinical studies are required to determine if such biomimetic implants can result in more normal feeling knees and improve quality of life for active patients.
Thienpont, Emmanuel; Price, Andrew
Studies have shown that after total knee arthroplasty neither normal biomechanics nor function is obtained. Selective resurfacing of diseased compartments could be a solution. A narrative review of the available literature on bicompartmental arthroplasty is presented. A literature review of all peer reviewed published articles on bicompartmental arthroplasty of the knee was performed. Bicompartmental arthroplasty is by definition the replacement of the tibiofemoral and the patellofemoral joint. It can be performed with a modular unlinked or a monolithic femoral component. Bicompartmental arthroplasty performed with modular components obtains good to excellent results at ± 10 years follow-up. Function and biomechanics are superior to total knee arthroplasty. Modern monolithic femoral components are reported to give early failure and high revision rates and should be avoided. Modular bicompartmental arthroplasty is an excellent alternative to treat bicompartmental arthritis of the knee leading to good functional results and superior biomechanics in well-selected patients. Caution is needed since only a few peer reviewed articles with small series and old implant designs are available on this type of arthritis treatment. Survivorship in these studies is inferior to total knee arthroplasty.
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.
Chronic pain in the knee joint is frequently a sign of arthrosis in adults. This must be clearly differentiated from other knee problems. Patellofemoral stress syndrome (occurs mostly in young people) and arthritis with effusion in the knee joint after long and mostly unusual stress also allow only a reduced function of the knee joint. However, even when the knee joint is still fully functional, chronic problems could already exist: For example, for joggers, iliotibial band friction syndrome (runner's knee) or after high unphysiological stress, patellar tendinopathy (jumper's knee). These must be differentiated from pes anserinus syndrome and a plica mediopatellaris.
Schüttler, Karl Friedrich; Efe, Turgay; Heyse, Thomas J; Haas, Steven B
Polyethylene wear in total knee arthroplasty is a still unsolved problem resulting in osteolysis and long-term failure of knee joint replacement. To address the problem of polyethylene wear, research aimed for an optimal implant design and for an optimal combination of bearing surfaces. Oxidized zirconium was introduced to minimize surface wear and thus potentially increase long-term implant survival. This review comprises the current literature related to in vitro and in vivo studies evaluating performance of oxidized zirconium total knee arthroplasty and results from retrieval analyses.
von Knoch, F; Munzinger, U
Unicondylar knee arthroplasty (UKA) is an established therapeutic option for advanced medial or lateral gonarthrosis. The cornerstones of a successful UKA, careful patient selection, preoperative planning and precise operation technique, are discussed in this overview article. In contrast to total knee arthroplasty, UKA allows preservation of the contralateral and patellofemoral compartments as well as the cruciate ligaments and is often associated with rapid postoperative recovery, improved knee kinematics and knee function. However, UKA is technically very demanding. High revision rates have been reported in particular with widespread application, according to national joint replacement registries. Successful UKA relies on meticulous patient selection, preoperative planning and surgical technique. It is justified to broaden classic UKA indications. In medial and lateral UKA three types of mechanical varus-valgus deformity can be encountered: type 1 (isolated intraarticular deformity), type 2 (pronounced deformity due to extraarticular varus deformity in medial UKA or valgus deformity in lateral UKA), type 3 (reduced deformity due to extraarticular valgus deformity in medial UKA or varus deformity in lateral UKA). We believe these deformities should be addressed accordingly with surgical technique.
D’Lima, Darryl D.; Fregly, Benjamin J.; Patil, Shantanu; Steklov, Nikolai; Colwell, Clifford W.
Knee forces are highly significant in osteoarthritis and in the survival and function of knee arthroplasty. A large number of studies have attempted to estimate forces around the knee during various activities. Several approaches have been used to relate knee kinematics and external forces to internal joint contact forces, the most popular being inverse dynamics, forward dynamics, and static body analyses. Knee forces have also been measured in vivo after knee arthroplasty, which serves as valuable validation of computational predictions. This review summarizes the results of published studies that measured knee forces for various activities. The efficacy of various methods to alter knee force distribution, such as gait modification, orthotics, walking aids, and custom treadmills are analyzed. Current gaps in our knowledge are identified and directions for future research in this area are outlined. PMID:22468461
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.
Ueng, Steve W N; Hsieh, Pang-Hsin; Shih, Hsin-Nung; Chan, Yi-Shan; Lee, Mel S; Chang, Yuhan
The objective of this study was to evaluate the antibacterial activities of joint fluids of patients undergoing total-knee arthroplasty (TKA). Thirty patients who were scheduled for primary cemented TKA were enrolled in the study. The patients were grouped on the basis of whether the cement was without antibiotic loading (control group) or loaded with oxacillin (oxacillin group) or vancomycin (vancomycin group). Cefazolin was administered to every patient as the perioperative prophylactic antibiotic. Samples of joint fluids were collected from the knee joints at 8, 16, 24, 32, 40, and 48 h after prosthesis implantation. We assessed the bioactivities of the joint fluids against methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA). The antibiotic contents of the joint fluid samples were further evaluated by using high-performance liquid chromatography. Against MSSA, all joint fluid samples exhibited at least 24 h of bacterial inhibition activity. The oxacillin (43.2 h ± 2 h) and vancomycin (40.8 h ± 1.8 h) groups exhibited significantly longer durations of antibacterial activities than the control group (28 h ± 1.3 h; P < 0.05). However, antibacterial activity against MRSA was observed only in the vancomycin group. In conclusion, cefazolin, which was administered as a prophylactic antibiotic in TKA, exhibited good ability for knee joint penetration and was sufficient to inhibit MSSA during its administration. The use of antibiotic-loaded cement can prolong the antibacterial activity of joint fluid in TKA. Further, vancomycin-loaded cement had antibacterial activity against MRSA superior to that of cement loaded with oxacillin or without antibiotic loading.
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
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
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.
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
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.
Konopka, Joseph F; Hansen, Viktor J; Rubash, Harry E; Freiberg, Andrew A
This article reviews recently proposed clinical tools for predicting risks and outcomes in total hip arthroplasty and total knee arthroplasty patients. Additionally, we share the Massachusetts General Hospital experience with using the Risk Assessment and Prediction Tool to predict the need for an extended care facility after total joint arthroplasty.
Koh, Chuan Kong; Zeng, Irene; Ravi, Saiprassad; Zhu, Mark; Vince, Kelly G; Young, Simon W
Although large series from national joint registries may accurately reflect indications for revision TKAs, they may lack the granularity to detect the true incidence and relative importance of such indications, especially periprosthetic joint infections (PJI). Using a combination of individual chart review supplemented with New Zealand Joint Registry data, we asked: (1) What is the cumulative incidence of revision TKA? (2) What are the common indications for revising a contemporary primary TKA? (3) Do revision TKA indications differ at various followup times after primary TKA? We identified 11,134 primary TKAs performed between 2000 and 2015 in three tertiary referral hospitals. The New Zealand Joint Registry and individual patient chart review were used to identify 357 patients undergoing subsequent revision surgery or any reoperation for PJI. All clinical records, radiographs, and laboratory results were reviewed to identify the primary revision reason. The cumulative incidence of each revision reason was calculated using a competing risk estimator. The cumulative incidence for revision TKA at 15 years followup was 6.1% (95% CI, 5.1%-7.1%). The two most-common revision reasons at 15 years followup were PJI followed by aseptic loosening. The risk of revision or reoperation for PJI was 2.0% (95% CI, 1.7%-2.3%) and aseptic loosening was 1.2% (95% CI, 0.7%-1.6%). Approximately half of the revision TKAs secondary to PJI occurred within 2 years of the index TKA (95% CI, 0.8%-1.2%), whereas half of the revision TKAs secondary to aseptic loosening occurred 8 years after the index TKA (95% CI, 0.4%-0.7%). In this large cohort of patients with comprehensive followup of revision procedures, PJI was the dominant reason for failure during the first 15 years after primary TKA. Aseptic loosening became more important with longer followup. Efforts to improve outcome after primary TKA should focus on these areas, particularly prevention of PJI. Level III, therapeutic study.
Nagai, Kanto; Muratsu, Hirotsugu; Takeoka, Yoshiki; Tsubosaka, Masanori; Kuroda, Ryosuke; Matsumoto, Tomoyuki
During modified gap-balancing technique, there is no consensus on the best method for obtaining appropriate soft-tissue balance and determining the femoral component rotation. Sixty-five varus osteoarthritic patients underwent primary posterior-stabilized total knee arthroplasty using modified gap-balancing technique. The influence of joint distraction force on the soft-tissue balance measurement during the modified gap-balancing technique was evaluated with Offset Repo-Tensor between the osteotomized surfaces at extension, and between femoral posterior condyles and tibial osteotomized surface at flexion of the knee before the resection of femoral posterior condyles. The joint center gap (millimeters) and varus ligament balance (°) were measured under 20, 40, and 60 pounds of joint distraction forces, and the differences in these values at extension and flexion (the value at flexion minus the value at extension) were also calculated. The differences in joint center gap (-6.7, -6.8, and -6.9 mm for 20, 40, and 60 pounds, respectively) and varus ligament balance (3.5°, 3.8°, and 3.8°) at extension and flexion were not significantly different among different joint distraction forces, although the joint center gap and varus ligament balance significantly increased stepwise at extension and flexion as the joint distraction force increased. The difference in joint center gap and varus ligament balance at extension and flexion were consistent even among the different joint distraction forces. This novel index would be useful for the determination of femoral component rotation during the modified gap-balancing technique. Copyright © 2017 Elsevier Inc. All rights reserved.
Ni, Sheng-Hui; Jiang, Wen-Tong; Guo, Lei; Jin, Yu-Heng; Jiang, Tian-Long; Zhao, Yuyan; Zhao, Jie
The effectiveness of cryotherapy on joint arthroplasty recovery remains controversial. This systematic review was conducted to assess the effectiveness of cryotherapy in patients after joint arthroplasty. Comprehensive literature searches of several databases including Cochrane Library (2013), MEDLINE (1950-2013), and Embase (1980-2013) were performed. We sought randomised controlled trials that compared the experimental group received any form of cryotherapy with any control group after joint arthroplasty. The main outcomes were postoperative blood loss, adverse events, and pain. Analyses were performed with Revman 5.0. Results were shown as mean differences (MD) and standard deviations or as risk difference and 95 % confidence intervals (CIs). Ten trials comprised 660 total knee arthroplastys and three trials comprised 122 total hip arthroplastys (THAs) met the inclusion criteria. Blood loss was significantly decreased by cryotherapy (MD = -109.68; 95 % CI -210.92 to -8.44; P = 0.03). Cryotherapy did not increase the risk of adverse effect (n.s.). Cryotherapy decreased pain at the second day of postoperative (MD = -1.32; 95 % CI -2.37 to -0.27; P = 0.0003), but did not decreased pain at the first and third day of postoperative (n.s.). Cryotherapy appears effective in these selected patients after joint arthroplasty. The benefits of cryotherapy on blood loss after joint arthroplasty were obvious. However, the subgroup analysis indicated that cryotherapy did not decreased blood loss after THA. Cryotherapy did not increase the risk of adverse effect. Cryotherapy decreased pain at the second day of postoperative, but did not decreased pain at the first and third day of postoperative. II.
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
Siston, Robert A; Maack, Thomas L; Hutter, Erin E; Beal, Matthew D; Chaudhari, Ajit M W
The success of total knee arthroplasty depends, in part, on the ability of the surgeon to properly manage the soft tissues surrounding the joint, but an objective definition as to what constitutes acceptable postoperative joint stability does not exist. Such a definition may not exist due to lack of suitable instrumentation, as joint stability is currently assessed by visual inspection while the surgeon manipulates the joint. Having the ability to accurately and precisely measure knee stability at the time of surgery represents a key requirement in the process of objectively defining acceptable joint stability. Therefore, we created a novel sterilizable device to allow surgeons to measure varus-valgus, internal-external, or anterior-posterior stability of the knee during a total knee arthroplasty. The device can be quickly adjusted between 0 deg and 90 deg of knee flexion. The device interfaces with a custom surgical navigation system, which records the resultant rotations or translations of the knee while the surgeon applies known loads to a patient's limb with a handle instrumented with a load cell. We validated the performance of the device by having volunteers use it to apply loads to a mechanical linkage that simulated a knee joint; we then compared the joint moments calculated by our stability device against those recorded by a load cell in the simulated knee joint. Validation of the device showed low mean errors (less than 0.21 ± 1.38 Nm and 0.98 ± 3.93 N) and low RMS errors (less than 1.5 Nm and 5 N). Preliminary studies from total knee arthroplasties performed on ten cadaveric specimens also demonstrate the utility of our new device. Eventually, the use of this device may help determine how intra-operative knee stability relates to postoperative function and could lead to an objective definition of knee stability and more efficacious surgical techniques.
Platzer, Patrick; Schuster, Rupert; Aldrian, Silke; Prosquill, Stella; Krumboeck, Anna; Zehetgruber, Isabella; Kovar, Florian; Schwameis, Katrin; Vécsei, Vilmos
The incidence of periprosthetic fractures after total knee arthroplasty is continuously rising because of an increasing number of knee joint replacements and an enhanced survivorship of the elderly population after knee arthroplasty. The purpose of this study was to analyze the practicability and effectiveness of the various treatment methods for management of periprosthetic fractures after total knee arthroplasty, and to determine the clinical and radiographic long-term results of patients following surgical and nonoperative treatment of these injuries. We reviewed the clinical and radiographic records of 41 patients (31 women and 10 men; average age, 78.6 years) with periprosthetic fractures after total knee arthroplasty between 1992 and 2008. Thirty-seven patients showed a periprosthetic fracture of the distal femur, and four patients had a periprosthetic proximal tibial fracture. Thirty-six patients underwent operative stabilization by plate fixation (n = 18), intramedullary nailing (n = 15) or revision arthroplasty (n = 3), and five patients were treated nonoperatively by long-term cast immobilization. Twenty-eight patients returned to their preinjury activity level and were satisfied with their clinical outcome. In 10 patients, we saw a relevant decrease of knee function and severe limitations in gait and activities of daily living. Three patients died related to surgery. Successful fracture healing within 6 months was achieved in 33 (87%) of 38 patients. Failures of reduction or fixation occurred in 8 (21%) of 38 patients. Reoperation due to technical failures was necessary in three patients. Compared with current data in literature, we had a satisfactory outcome in following individualized treatment of periprosthetic fractures after knee joint replacement. Referring to the wide field of treatment options and high rates of complications, periprosthetic femoral fractures around the knee commonly constitute a challenging problem for the treating surgeons and
Kilicarslan, Kasim; Yalcin, Nadir; Cicek, Hakan; Cila, Erdal; Yildirim, Hasan
We prospectively evaluated 30 hips of 22 patients who had normal knees with a mean age of 53.4 years (range, 38-72 years). In the early postoperative period, genu valgum deformity was observed in all knees. Of 22 patients, 17 complained of severe pain owing to strain in the medial collateral ligament and iliotibial tract. Postoperatively, the ipsilateral extremities of the patients were extended by a mean of 16.5 mm (8-25 mm). Q angles of the patients increased by a mean of 4.4° ± 2.5° (P < .001). Although the Harris hip scores were improved (40.7-87.8 points), postoperative Lysholm-Gillquist knee scores were significantly reduced (92-76 points, P < .001). Reduction of displaced hips into the anatomical hip center and lengthening the extremity despite shortening procedure may lead to strain at the knee joint iatrogenically, particularly with the mechanical effect of tensor fascia lata, which results with changes in the knee biomechanics.
Miller, Adam G; Swank, Michael L
The goals of wound closure are a low infection rate and timely healing. Total joint arthroplasty (TJA) requires mobile recovery, and, therefore, a high-tension wound care environment. We conducted a study to compare the efficacy of high-viscosity Dermabond (Ethicon, Somerville, New Jersey) and the efficacy of surgical staples in healing high-tension, mobile surgical sites of TJA. Of 236 total knee arthroplasties and 223 total hip arthroplasties (459 surgeries total), 250 were performed with Dermabond and 209 with staples. According to χ2 analysis, case and control infection rates were equivalent. Signs of acute inflammation (redness, drainage, dehiscence) also were statistically equivalent. Absence of staples accounted for a significant decrease in tape blisters and skin abscesses. Dermabond is superior to staples in high-tension wound care.
Appropriate history taking and examination can ensure accurate diagnosis of common knee problems, and rapid and effective interventions or referral to orthopaedic specialists. This article describes the anatomy of the knee joint and discusses relevant history taking, the examination process, special tests and radiology, as well as common knee injuries and their management.
Kloth, J K; Tanner, M; Stiller, W; Burkholder, I; Kauczor, H U; Ewerbeck, V; Weber, M A
To reduce radiation exposure of frequently performed radiographs of the knee in follow-up of total-knee arthroplasty ensuring accurate assessment by using objective quality control criteria. In this prospective randomized study 278 radiographs of the knee in follow-up of total-knee arthroplasty were performed with standard and 37% reduced radiation dose. The evaluation of the plain-radiographs was conducted using the following criteria: bone-implant interface, implant-surface character, implant-implant discrimination and periarticular heterotopic ossification. Two radiologists evaluated these criteria using a score ranging from 1 (definitely assessable) to 4 (not assessable). If a single criterion had been evaluated with a score ≥ 3 or more than 2 criteria with ≥ 2 points, the radiograph was score das "not assessable". The study was designed as non-inferiority-trial. 100% of examined radiographs were scored as assessable, hence no statistical inferiority between the examinations with standard and reduced dose could be observed. Singular assessment of the defined criteria was likewise dose-independent. Plain-radiography of the knee following total-knee arthroplasty can be performed with 63% of standard dose without loss of diagnostic validity. Due to the non-inferiority of digital radiographs of the knee joint after total-knee arthroplasty done with 37% reduced image receiver dose we recommend the tested speed class of SC 800 as a new reference value for digital radiographs with this indication. © Georg Thieme Verlag KG Stuttgart · New York.
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
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
Baumann, Florian; Ernstberger, Toni; Loibl, Markus; Zeman, Florian; Nerlich, Michael; Tibesku, Carsten
Evaluation of further improvement in treatment of patients with osteoarthritis of the knee requires measurement tools with a high discriminatory power. In this context, joint awareness in everyday life is seen as crucial criterion. Purpose of this study was to adapt and validate a German version of the "Forgotten Joint Score" (FJS) according to the COSMIN checklist. We evaluated a German translation of the FJS for reliability, validity and responsiveness according to the COSMIN checklist. Therefore, patients with an artificial knee joint completed the G-FJS questionnaire twice at intervals of at least 2 weeks. In addition, the Knee Society Score, the Oxford Knee Score, the Tegner Activity Scale, a Visual Analogue Scale, the EuroQol-5D (EQ 5-D), and a subjective assessment of the limitations were recorded. Between June and December 2014, one hundred and five patients (average age 65.2 years) completed both questionnaires and were available for data analysis. Test-retest reliability of the FJS was high with an ICC = 0.80 (95 % CI 0.69, 0.90) and with a Cronbach's alpha of 0.95 (95 % CI 0.92, 0.99). The German translation of the FJS is a viable tool for the postoperative monitoring after arthroplasty of the knee. This is the first study providing data on test-retest reliability of the FJS. The FJS is a reliable and valid measurement tool for evaluation of patient rated outcome in patients with an artificial knee joint. Validating cohort study, Level 1b.
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
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.
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.
MacLean, Ian S; Day, Shandra R; Moore, Christopher C; Browne, James A
Blastomycosis is a rare fungal disease that can cause intraarticular infection and joint destruction requiring surgical reconstruction. We describe a patient who presented with destruction of the knee joint of unknown etiology. The patient was initially treated with debridement and spacer placement followed by antifungal therapy after cultures grew blastomycosis. Following adequate treatment of the infection, the patient was taken back to the operating room for reconstruction with a total knee arthroplasty. The patient had a successful outcome with no evidence of infection at two years following surgery. To our knowledge, this case report represents the first documented case in which a blastomycotic infection of a native knee was successfully treated with a two-stage total knee arthroplasty. Copyright © 2015 Elsevier B.V. All rights reserved.
Shih, H N; Hsu, K Y; Tan, C F; Hsueh, S; Hsu, R W
Geodes (subchondral cysts) are a well-known manifestation of rheumatoid arthritis. Solitary cysts or cysts larger than 2 cm are not generally found in the knee joint of patients with rheumatoid arthritis (RA). We report a case of RA involving both knees with a giant geode over the right proximal tibia. Surgical treatment was performed including synovectomy, cyst enucleation and packing of autogenous bone chips followed by primary total knee arthroplasty. The postsurgical result was excellent with the knee restored to good function and complete healing of the cystic lesion.
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.
Sánchez Mayo, B; Rodríguez-Mansilla, J; González Sánchez, B
The purpose of this study was to know the effects of continuous passive mobilization in patients who underwent total knee arthroplasty. A search strategy was developed to retrieve all clinical trials, written in English and/or Spanish, published in the electronic search databases PubMed, Cochrane Library Plus, Dialnet, CSIC and PEDro. The inclusion criteria were: clinical trials published from January 2000 until November 2014 in English or Spanish. Out of 537 clinical trials that were potentially relevant, a total of 12 were included in this review. The evaluation of 1,153 patients shows that there is no significant difference in improving the range of the joint, pain, balance, motion, healing and hospital stay using continuous passive mobilization against the regular physiotherapy treatment for total knee arthroplasty. The application of continuous passive mobilization in the long-term does not provide any benefit in terms of the breadth of the range of the joint, pain and improvement of standing and motion in comparison with conventional postoperative physiotherapy treatment in total knee arthroplasty. In the short term an improvement is obtained in the range of joint motion in knee flexion.
Tali, Maie; Maaroos, Jaak
The aim of the study was to evaluate gait characteristics, lower limbs joint function, and pain relationships associated with knee osteoarthritis of female patients before and 3 months after total knee arthroplasty at an outpatient clinic rehabilitation department. Gait parameters were registered, the active range of lower extremity joints was…
Tali, Maie; Maaroos, Jaak
The aim of the study was to evaluate gait characteristics, lower limbs joint function, and pain relationships associated with knee osteoarthritis of female patients before and 3 months after total knee arthroplasty at an outpatient clinic rehabilitation department. Gait parameters were registered, the active range of lower extremity joints was…
Matziolis, G; Röhner, E
23 % of all persons older than 65 years suffer from osteoarthritis of the medial compartment of the knee joint, a very common situation in orthopaedic practice 1. As a result of the demographic trend the number of patients is expected to increase in the future. Based on specific joint biomechanics and kinematics the medial knee joint compartment is more frequently affected than the lateral. Only an understanding of the functional anatomy and underlying pathology allows a critical evaluation of different available conservative and operative treatment options. This article gives an overview of diagnostic and therapeutic strategies of osteoarthritis of the medial knee joint. Frequently performed surgeries, e.g. high tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) will be presented in a comparative manner. The actual scientific evidence will be given with the goal of an evidence based therapy that is adopted to stage and pathology of osteoarthritis of the medial compartment of the knee joint. Georg Thieme Verlag KG Stuttgart · New York.
Vogel, Laura A; Carotenuto, Giuseppe; Basti, John J; Levine, William N
Total joint arthroplasty (TJA) is a common surgical option to treat painful degenerative joint disease. However, there is currently no consensus on the appropriate intensity of physical activity after TJA or how physical activity level affects the rate of revision surgery. A systematic review of the literature regarding physical or athletic activity after TJA was performed to determine current clinical opinion and recommendations regarding appropriate activity levels after TJA, as well as variables affecting successful surgery and improved outcomes. Many studies in the literature regarding athletic activity after TJA focus on total hip arthroplasty and total knee arthroplasty. The literature reports contradictory results regarding rates of physical activity after TJA as well as the relationship between physical activity and rates of revision surgery. The current trend in expert opinion shows more liberal recommendations for patients to engage in athletic activity after TJA. Individual characteristics, lifestyle, and patient preferences must be taken into account when one considers appropriate recommendations for athletic activity after TJA. Current trends in clinical opinion favor a higher level of athletic activity after TJA, but clinicians should caution patients not to participate in contact sports or sports that create high joint loads in the replaced joint.
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.
... presentations/100088.htm Knee joint replacement - series—Normal anatomy To use the sharing features on this page, ... Bethesda, MD 20894 U.S. Department of Health and Human Services National Institutes of Health Page last updated: ...
... now use different materials, including metal on metal, ceramic on ceramic, or ceramic on plastic. Why the Procedure is Performed The ... people DO NOT need help walking after they fully recover. Most artificial knee joints last 10 to ...
Gomez, Eric; Cazanave, Charles; Cunningham, Scott A.; Greenwood-Quaintance, Kerryl E.; Steckelberg, James M.; Uhl, James R.; Hanssen, Arlen D.; Karau, Melissa J.; Schmidt, Suzannah M.; Osmon, Douglas R.; Berbari, Elie F.; Mandrekar, Jayawant
Periprosthetic tissue and/or synovial fluid PCR has been previously studied for prosthetic joint infection (PJI) diagnosis; however, few studies have assessed the utility of PCR on biofilms dislodged from the surface of explanted arthroplasties using vortexing and sonication (i.e., sonicate fluid PCR). We compared sonicate fluid 16S rRNA gene real-time PCR and sequencing to culture of synovial fluid, tissue, and sonicate fluid for the microbiologic diagnosis of PJI. PCR sequences generating mixed chromatograms were decatenated using RipSeq Mixed. We studied sonicate fluids from 135 and 231 subjects with PJI and aseptic failure, respectively. Synovial fluid, tissue, and sonicate fluid culture and sonicate fluid PCR had similar sensitivities (64.7, 70.4, 72.6, and 70.4%, respectively; P > 0.05) and specificities (96.9, 98.7, 98.3, and 97.8%, respectively; P > 0.05). Combining sonicate fluid culture and PCR, the sensitivity was higher (78.5%, P < 0.05) than those of individual tests, with similar specificity (97.0%). Thirteen subjects had positive sonicate fluid culture but negative PCR, and 11 had negative sonicate fluid culture but positive PCR (among which 7 had prior use of antimicrobials). Broad-range PCR and culture of sonicate fluid have equivalent performance for PJI diagnosis. PMID:22895042
Finn, Daphna M; Agarwal, Rishi R; Ilfeld, Brian M; Madison, Sarah J; Ball, Scott T; Ferguson, Eliza J; Morgan, Anya C; Morris, Beverly A
Combined scientific advances in pharmaceutical agents, perineural blocks, and pump delivery capabilities such as those used with continuous peripheral nerve blocks have demonstrated advantages in pain management for patients undergoing joint arthroplasty. This report documents the incidence of falls increased after the implementation of a continuous peripheral nerve block program for patients undergoing knee and hip arthroplasty in an academic medical center.
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
Lavernia, Carlos; D'Apuzzo, Michele; Rossi, Mark D; Lee, David
Measurement of knee joint range of motion (ROM) is important to assess after total knee arthroplasty. Our objective was to determine level of agreement and accuracy between observers with different knowledge on total ROM after total knee arthroplasty. Forty-one patients underwent x-ray of active and passive knee ROM (gold standard). Five different raters evaluated observed and measured ROM: orthopedic surgeon, clinical fellow, physician assistant, research fellow, and a physical therapist. A 1-way analysis of variance was used to determine differences in ROM between raters over both conditions. Limit of agreement for each rater for both active and passive total ROM under both conditions was calculated. Analysis of variance indicated a difference between raters for all conditions (range, P = .004 to P < or =.0001). The trend for all raters was to overestimate ROM at higher ranges. Assessment of ROM through direct observation without a goniometer provides inaccurate findings.
Measurement of knee joint gaps without bone resection: "physiologic" extension and flexion gaps in total knee arthroplasty are asymmetric and unequal and anterior and posterior cruciate ligament resections produce different gap changes.
Nowakowski, Andrej Maria; Majewski, Martin; Müller-Gerbl, Magdalena; Valderrabano, Victor
General agreement is that flexion and extension gaps should be equal and symmetrical in total knee arthroplasty (TKA) procedures. However, comparisons using a standard TKA approach to normal knee joints that have not undergone bone resection are currently unavailable. Since bony preparation can influence capsule and ligament tension, our purpose was to perform measurements without this influence. Ten normal cadaveric knees were assessed using a standard medial parapatellar TKA approach with patellar subluxation. Gap measurements were carried out twice each alternating 100 and 200 N per compartment using a prototypical force-determining ligament balancer without the need for bony resection. Initial measurements were performed in extension, followed by 908 of flexion. The ACL was then resected, and finally the PCL was resected, and measurements were carried out in an analogous fashion. In general, the lateral compartment could be stretched further than the medial compartment, and the corresponding flexion gap values were significantly larger. ACL resection predominantly increased extension gaps, while PCL resection increased flexion gaps. Distraction force of 100 N per compartment appeared adequate; increasing to 200 N did not improve the results.
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.].
MacIntyre, Norma J; Johnson, Jenna; MacDonald, Nicole; Pontarini, Lauren; Ross, Kaitlyn; Zubic, Gorana; Majumdar, Sampa Samanta
Objectif : Identifier les caractéristiques des personnes souffrant d'arthrose du genou ou de la hanche qui se rendent à un centre de triage régional pour une première consultation et sont considérées comme n'étant pas prêtes pour une arthroplastie totale des articulations (ATA). Méthodes : Des notes de première consultation (n=482) ont été examinées de manière rétrospective. Des variables prédictives ont d'abord été tirées de la recension des écrits à ce sujet, puis 14 de ces variables se sont avérées convenables pour une inclusion dans des analyses de régression logistique multiple par étapes. Résultats : Sur les 222 personnes admissibles, 131 (59 %) ont été considérées comme n'étant pas prêtes pour une ATA. Cinq variables ont été entrées dans le modèle ([Formula: see text]=133,19, p<0,001) pour un taux global de réussite de 81,1 %. Les personnes considérées comme n'étant pas prêtes pour une ATA étaient plus susceptibles de souffrir d'arthrose du genou (hanche et genou; rapport de cotes [RC]=0,352, p=0,018), de souffrir d'arthrose moins grave (RC=0,246 pour chaque augmentation de catégorie de gravité, p<0,001), de n'utiliser aucune aide à la marche (canne et aucune aide à la marche; RC=0,390, p=0,033) et d'avoir des résultats plus élevés à l'échelle fonctionnelle des membres inférieurs (RC=1,050 pour chaque augmentation d'un point, p=0,003) et des articulations en meilleur état selon le score des échelles de hanche Harris et de la Knee Society (RC=3,946 pour chaque augmentation de catégorie, p=0,007). Conclusion : Le fait de tenir compte des caractéristiques énumérées ci-dessus aidera les cliniciens à identifier les personnes qui pourraient avoir besoin d'une intervention autre que l'ATA.
Dornacher, D; Kappe, T; Reichel, H
The incidence of total knee arthroplasty in young patients continues to rise in certain countries despite evidence of decreased patient satisfaction and increased likelihood for revision in patients 55 years of age or less. As long as sufficient pain relief and functional improvement can be obtained by alternative means, total knee arthroplasty should be avoided whenever possible. In young patients with unicompartmental osteoarthritis, and a partially conserved joint space, correctional osteotomy around the knee accompanied by cartilage surgery should be preferred in the presence of the respective deformity. In cases of advanced unicompartmental arthritis, unicompartmental arthroplasty should be considered even in younger patients. Only if advanced arthritic changes in more than one compartment or accompanying tibiofemoral instability are present in younger patients, is total knee arthroplasty indicated in selected cases. The strongest predictor of satisfaction even in younger patients is, however, a realistic expectation about the outcome of surgery.
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.
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.
Heyse, Thomas J; El-Zayat, Bilal F; De Corte, Ronny; Scheys, Lennart; Chevalier, Yan; Fuchs-Winkelmann, Susanne; Labey, Luc
Modular bicompartmental knee arthroplasty (BKA) for treatment of medio-patellofemoral osteoarthritis (OA) should allow for close to normal kinematics in comparison with unicondylar knee arthroplasty (UKA) and the native knee. There is so far no data to support this. Six fresh frozen full leg cadaver specimens were prepared and mounted in a kinematic rig with six degrees of freedom for the knee joint. Three motion patterns were applied with the native knee and after sequential implantation of medial UKA and patellofemoral joint replacement (PFJ): passive flexion-extension, open chain extension, and squatting. During the loaded motions, quadriceps and hamstrings muscle forces were applied. Infrared cameras continuously recorded the trajectories of marker frames rigidly attached to femur, tibia and patella. Prior computer tomography allowed identification of coordinate frames of the bones. Strains in the collateral ligaments were calculated from insertion site distances. UKA led to a less adducted and internally rotated tibia and a more strained medial collateral ligament (MCL). Addition of a patellofemoral replacement led to a more posterior position of both femoral condyles, a more dorsally located tibiofemoral contact point and higher MCL strain with squatting. In comparison to UKA modular BKA leads to a more dorsal tibial contact point, a medial femoral condyle being located more posteriorly, and more MCL strain. Mainly the changes to the trochlear anatomy as introduced by PFJ may account for these differences. © 2014 Elsevier B.V. All rights reserved.
The GSB Knee joint is a nonconstrained hinge joint, which combines the advantages of the so-called condylar or surface prosthesis with those of the constrained hinge joints. This report is of observations on the results and complications in 150 arthroplasties performed over a 5 year period.
Ji, Song-Jie; Zhou, Yi-Xin; Jiang, Xu; Cheng, Zhi-Yuan; Wang, Guang-Zhi; Ding, Hui; Yang, Ming-Lei; Zhu, Zhong-Lin
Joint line (JL) is a very important factor for total knee arthroplasty (TKA) to restore. The objective of this study was to evaluate the early clinical and kinematic results of TKAs with posterior-stabilized (PS) or cruciate retaining (CR) implants in which the JL was elevated postoperatively. Data were collected from patients who underwent TKA in our department between April 2011 and April 2014. The patients were divided into two groups based on the prosthesis they received (PS or CR). At 1-year postoperatively, clinical outcomes were evaluated by the American Knee Society (AKS) knee score, AKS function score, and patella score. In vivo kinematic analysis after TKA was performed on all patients and a previously validated three-dimensional to two-dimensional image registration technique was used to obtain the kinematic data. Anteroposterior (AP) translation of the medial and lateral femoral condyles, and axial rotation relative to the tibial plateau, were analyzed. The data were assessed using the Mann-Whitney test. At time of follow-up, there were differences in the AKS knee scores (P = 0.005), AKS function scores (P = 0.025), patella scores (P = 0.015), and postoperative range of motions (P = 0.004) between the PS group and the CR group. In the PS group, the magnitude of AP translation for the medial and lateral condyle was 4.9 ± 3.0 mm and 12.8 ± 3.3 mm, respectively. Axial rotation of the tibial component relative to the femoral component was 12.9 ± 4.5°. In the CR group, the magnitude of AP translation for the medial and lateral condyle was 4.3 ± 3.5 mm and 7.9 ± 4.2 mm, respectively. The axial rotation was 6.7 ± 5.9°. There were statistically different between PS group and CR group in kinematics postoperatively. Our results demonstrate that postoperative JL elevation had more adverse effects on the clinical and kinematic outcomes of CR TKAs than PS TKAs.
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.
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.
Nikolopoulos, Dimitrios; Michos, Ioannis; Safos, George; Safos, Petros
The majority of orthopaedic surgeons even currently agree that primary total arthroplasty in valgus knees with a deformity of more than ten degrees may prove challenging. The unique sets of bone and soft tissue abnormalities that must be addressed at the time of the operation make accurate axis restoration, component orientation and joint stability attainment a difficult task. Understanding the specific pathologic anatomic changes associated with the valgus knee is a prerequisite so as to select the proper surgical method, to optimize component position and restore soft-tissue balance. The purpose of this article is to review the valgus knee anatomical variations, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. It will also be underlying the up-to-date main approaches and surgical techniques be proposed in the English literature both for bone cuts and soft tissue management of valgus knees. PMID:26191494
Manson, Theodore T; Khanuja, Harpal S; Jacobs, Michael A; Hungerford, Marc W
Postoperative stiffness or instability may result from a total knee arthroplasty imbalanced in the sagittal plane. Total knee arthroplasty instrumentation systems differ in the basic strategies used to assure this balance. In an anterior referencing system, changes in femoral size affect flexion gap tightness, and femoral size selection is paramount to assure sagittal plane balance. Conversely, in posterior referencing systems, femoral size changes do not affect the flexion gap but, rather, influence femoral component-patella articulation. Flexion/extension gap systems use calibrated spacer blocks to ensure gap balance but do not guarantee midrange stability; if used incorrectly, they may cause component malposition and joint line elevation. The authors reviewed the strengths and weaknesses of system types and provided system-specific troubleshooting guidelines for clinicians addressing intraoperative sagittal plane imbalance.
Clements, Warren J; Miller, Lisa; Whitehouse, Sarah L; Graves, Stephen E; Ryan, Philip
Background Patella resurfacing in total knee arthroplasty is a contentious issue. The literature suggests that resurfacing of the patella is based on surgeon preference, and little is known about the role and timing of resurfacing and how this affects outcomes. Methods We analyzed 134,799 total knee arthroplasties using data from the Australian Orthopaedic Association National Joint Replacement Registry. Hazards ratios (HRs) were used to compare rates of early revision between patella resurfacing at the primary procedure (the resurfacing group, R) and primary arthroplasty without resurfacing (no-resurfacing group, NR). We also analyzed the outcomes of NR that were revised for isolated patella addition. Results At 5 years, the R group showed a lower revision rate than the NR group: cumulative per cent revision (CPR) 3.1% and 4.0%, respectively (HR = 0.75, p < 0.001). Revisions for patellofemoral pain were more common in the NR group (17%) than in the R group (1%), and “patella only” revisions were more common in the NR group (29%) than in the R group (6%). Non-resurfaced knees revised for isolated patella addition had a higher revision rate than patella resurfacing at the primary procedure, with a 4-year CPR of 15% and 2.8%, respectively (HR = 4.1, p < 0.001). Interpretation Rates of early revision of primary total knees were higher when the patella was not resurfaced, and suggest that surgeons may be inclined to resurface later if there is patellofemoral pain. However, 15% of non-resurfaced knees revised for patella addition are re-revised by 4 years. Our results suggest an early beneficial outcome for patella resurfacing at primary arthroplasty based on revision rates up to 5 years. PMID:19968604
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
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
Middleton, Addie; Lin, Yu-Li; Graham, James E; Ottenbacher, Kenneth J
In an effort to improve quality and reduce costs, payments are being increasingly tied to value through alternative payment models, such as episode-based payments. The objective of this study was to better understand the pattern and variation in outcomes among Medicare beneficiaries receiving lower extremity joint arthroplasty over 90-day episodes of care. Observed rates of mortality, complications, and readmissions were calculated over 90-day episodes of care among Medicare fee-for-service beneficiaries who received elective knee arthroplasty and elective or nonelective hip arthroplasty procedures in 2013-2014 (N = 640,021). Post-acute care utilization of skilled nursing and inpatient rehabilitation facilities was collected from Medicare files. Mortality rates over 90 days were 0.4% (knee arthroplasty), 0.5% (elective hip arthroplasty), and 13.4% (nonelective hip arthroplasty). Complication rates were 2.1% (knee arthroplasty), 3.0% (elective hip arthroplasty), and 8.5% (nonelective hip arthroplasty). Inpatient rehabilitation facility utilization rates were 6.0% (knee arthroplasty), 6.7% (elective hip arthroplasty), and 23.5% (nonelective hip arthroplasty). Skilled nursing facility utilization rates were 33.9% (knee arthroplasty), 33.4% (elective hip arthroplasty), and 72.1% (nonelective hip arthroplasty). Readmission rates were 6.3% (knee arthroplasty), 7.0% (elective hip arthroplasty), and 19.2% (nonelective hip arthroplasty). Patients' age and clinical characteristics yielded consistent patterns across all outcomes. Outcomes in our national cohort of Medicare beneficiaries receiving lower extremity joint arthroplasties varied across procedure types and patient characteristics. Future research examining trends in access to care, resource use, and care quality over bundled episodes will be important for addressing the challenges of value-based payment reform. Copyright © 2017 Elsevier Inc. All rights reserved.
Yoon, Jung-Ro; Oh, Kwang-Jun; Wang, Joon Ho; Yang, Jae-Hyuk
In vivo comparative gap measurements were performed in three different patella positions (reduced, subluxated and everted) using offset-type-force-controlled-spreader-system. Prospectively, 50 knees were operated by total knee arthroplasty using a navigation-assisted gap-balancing technique. The offset-type-force-controlled-spreader-system was used for gap measurements. This commercially available instrument allows controllable tension in patella-reduced position. The mediolateral gaps of knee extension (0°) and flexion (90°) angle were recorded in three different patella positions; reduced, subluxated and everted. Any gap differences of more than 3 mm were considered as a meaningful difference. Correlation between the difference with the demographic data, preoperative radiologic alignment and intraoperative data was analysed. For statistical analysis, ANOVA and Pearson's correlation test were used. The gaps in patella eversion demonstrated smaller gaps both in knee extension and flexion position compared to the gaps of patella reduction position. The amount of decreased gaps was more definite in knee flexion position. Statistically significant difference was observed for the lateral gap of patella eversion compared to gap of patella reduction in knee flexion position (p < 0.05). There were notable cases of variability in knee flexion position. Significant portion of 12 (24 %) knees of patella subluxation and 33 (66 %) knees of patella evertion demonstrated either increased or decreased gaps in knee flexion position compared to the gaps of patella reduction position. The gaps in patella eversion demonstrated smaller gaps both in knee extension and flexion position compared to the gaps of patella reduction position. The amount of decreased gaps was more definite in knee flexion position. Therefore, the intraoperative patellar positioning has influence on the measurement of the joint gap. Keeping the patella in reduced position is important during gap balancing. I.
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.
McGrory, B J; Stuart, M J; Sim, F H
To summarize previously published findings and to present the opinions of a group of reconstructive orthopedic surgeons from a single institution on participation in sports after hip or knee arthroplasty. We reviewed the literature pertaining to participation in sports after hip or knee arthroplasty and surveyed a group of orthopedic surgeons about their recommendations for resumption of various sports activities by patients who had undergone total hip or knee arthroplasty. A computerized literature search was performed, and salient issues about participation in sports after joint replacement procedures were synthesized. At the Mayo Clinic, 28 orthopedic surgeons (13 consultants and 15 fellows or residents) completed a single-page questionnaire that requested a recommendation ("yes," "no," or "depends") about patients resuming participation in 28 common sports after recovery from total hip or knee arthroplasty. Staff surgeon responses were compared with responses from fellows and residents by using the Mann-Whitney U test. Sports in which 75% of surgeons would not allow participation were identified as "not recommended," whereas sports in which 75% of surgeons would allow participation were labeled as "recommended." Fellows and residents were less likely than staff surgeons to allow return to cross-country skiing after total knee arthroplasty. Otherwise, responses from consultant surgeons and from fellows and residents did not differ significantly. Recommended sports included sailing, swimming laps, scuba diving, cycling, golfing, and bowling after hip and knee replacement procedures and also cross-country skiing after knee arthroplasty. Sports not recommended after hip or knee arthroplasty were running, waterskiing, football, baseball, basketball, hockey, handball, karate, soccer, and racquetball. After hip or knee arthroplasty, participation in no-impact or low-impact sports can be encouraged, but participation in high-impact sports should be prohibited.
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.
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.
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.
Yau, Wai-Pan; Wong, Jimmy W K; Chiu, Kwong-Yuen; Ng, Tze-Pui; Tang, Wai-Man
Two hundred thirty-six posterior stabilized total knee arthroplasties (TKAs) were performed consecutively. Twenty-seven patellar clunk syndromes were identified in 25 patients. Insall-Salvati ratio, position of joint line, postoperative patellar height, and anterior-posterior position of tibial tray were measured. It was found that postoperative low-lying patella (P<.001) and anterior placement of tibial tray (P=.011) was associated with patellar clunk syndrome. Thirteen patients had bilateral TKAs of the same prosthesis (5 bilateral AMK knees and 8 bilateral Insall Burstein knees) but unilateral patellar clunk syndrome. The nonclunk sides were used as control for comparison with the clunk sides. The congruency and tilting of the patellar button in the skyline view were documented. It was observed that the congruency of the patellar button was less satisfactory in the clunk side (P=.019).
Bender, T T A; Marinova, M; Radbruch, L; Conrad, R; Jobst, D; Mücke, M
Chronic pain in the knee joint is most commonly caused by osteoarthritis, especially in elderly patients but can be due to other causes, such as rheumatoid arthritis. The diagnostics include an exact patient medical history and a clinical examination, which often already provide clear indications of the cause of the knee pain. Subsequently, further diagnostics can then be considered, such as radiological procedures and laboratory diagnostics. The treatment is determined by the cause and the individual patient and aims to reduce pain and to preserve the mobility of the joint. Generally, therapy consists of pain management and physiotherapy as well as alternative therapeutic procedures, mostly in combination. Proximal tibial opening wedge osteotomy can be useful; however, partial or total knee arthroplasty should only be considered when conservative treatment options have been exhausted.
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
Forsythe, Michael E.; Englund, Roy E.; Leighton, Ross K.
Objective To compare the results of cementless unicondylar knee arthroplasty (UKA) with those already reported in a similar study on cemented UKA. Design A case-series cross-sectional study. Setting The Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax. Patients Fifty-one patients who underwent a total of 57 UKAs between May 1989 and May 1997. Inclusion criteria were osteoarthritis involving the predominantly the medial compartment of the knee, relative sparing of the other compartments, less than 15° of varus, minimal knee instability, and attendance at the postoperative clinical visit. Intervention Cementless UKA. Main outcome measures Clinical parameters that included pain, range of motion and the Knee Society Clinical Knee Score. Roentgenographic parameters that included α, β, γ and σ angles and the presence of periprosthetic radiolucency or loose beads. Results Age, weight, gender and follow-up interval did not significantly affect the clinical results in terms of pain, range of motion or knee score. Knees with more than 1 mm of radiolucency had significantly lower knee scores than those with no radiolucency. Knees that radiologically had loose beads also had significantly lower knee scores. The clinical outcomes of cementless UKA were comparable to those already reported on cemented UKA. Cementless femurs had less radiolucency than the cemented femurs, whereas cementless tibias had more radiolucency than their cemented counterparts. Conclusions Cementless UKA seems to be as efficacious as cemented UKA. However, there is some concern about the amount of radiolucency in the cementless tibial components. A randomized clinical trial comparing both cementless and cemented tibial components with a cementless femur (hybrid knee) is needed to further assess this controversial issue in UKA. PMID:11129829
Wilson, Sean; Marx, Robert G; Pan, Ting-Jung; Lyman, Stephen
for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons and hospitals. This should help patients, surgeons, hospitals, and policymakers to make decisions with regard to the optimal delivery of total knee arthroplasty. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.
Ferrel, Jason R; Davis, Richard L; Agha, Obiajulu A J C; Politi, Joel R
Poor range of motion may decrease a patient's ability to participate in activities of daily living after total knee arthroplasty. Manipulation under anesthesia has been shown to improve range of motion; however, some patients have persistent stiffness even after manipulation. The goal of this study was to evaluate the outcomes and complications of patients who underwent a second manipulation under anesthesia for persistent stiffness after total knee arthroplasty. The review of surgical records of two joint arthroplasty surgeons identified 226 knees in 210 patients who underwent a manipulation under anesthesia for poor range of motion after total knee arthroplasty. Of these patients, 16 patients underwent a second manipulation under anesthesia. For patients undergoing two manipulations under anesthesia procedures, at latest follow up (mean 539 days), mean extension improved from 10.50° to 2.50° (p=0.001) and mean flexion improved from 87.50° to 112.69° (p=0.001) respectively. SF-12 scores were available for 12 of 16 knees with a mean score of 34.42. Two of 16 patients (12.5%) experienced a complication. Three of 16 (18.8%) patients who underwent a second manipulation required a revision arthroplasty procedure. In conclusion, a second manipulation under anesthesia can achieve functional range of motion that is sustained after total knee arthroplasty.
Mai, Kenny T; Verioti, Christopher A; Hardwick, Mary E; Ezzet, Kace A; Copp, Steven N; Colwell, Clifford W
Postoperative flexion is an important factor in the outcome of total knee arthroplasty. Although normal activities of daily living require a minimum of 105° to 110° of flexion, patients from non-Western cultures often engage in activities such as kneeling and squatting that require higher flexion. The desire to achieve greater flexion serves as the driving force for prosthetic modifications, including high-flexion designs. Techniques used to measure knee flexion and knee position during measurement are not often described or are different depending on the examiner. The purpose of this study was to compare active (self) and passive (assisted) flexion after successful total knee arthroplasty for 5 prostheses (2 standard and 3 high-flexion) using clinical (goniometer) and radiographic (true lateral radiograph) measurement techniques by different independent examiners.At a mean follow-up of 2.7 years (range, 1-5.6 years), a total of 108 patients (144 total knee arthroplasties) had completed the study. Mean postoperative active flexion was 111° clinically and 109° radiographically for the standard designs and 114° clinically and 117° radiographically for the high-flexion designs. Adding passive flexion increased flexion to 115° clinically and 117° radiographically for the standard designs and 119° clinically and 124° radiographically for the high-flexion designs. Flexion differences between the 2 measurement techniques (active vs passive and clinically vs radiographically) were statistically significant (P<.05). These findings demonstrate the importance of describing how flexion is measured in studies and understanding how the method of measurement can affect the findings.
Leylabadlo, Hamed Ebrahimzadeh; Zeinalzadeh, Elham; Akbari, Najibeh Asl Rahnemaii; Kafil, Hossein Samadi
Infection is a serious complication after implantation of total knee-prostheses. However, fungal infection is rarely found in periprosthetic joints, and in most reports, the infecting organism is a Candida species. This is a case report of infection after left knee total arthroplasty caused by Malassezia species. The patient is still undergoing antifungal therapy with voriconazole and is still being followed-up. To the authors’ knowledge, the present case is the first report of Malassezia species in a patient after total knee arthroplasty. PMID:27730027
Sharareh, Behnam; Phan, Duy L; Goreal, Wamda; Schwarzkopf, Ran
Metallosis occurs when periprosthetic soft tissues, synovium, and/or bone is infiltrated by metallic debris secondary to metal-on-metal wear. This debris can cause a chronic inflammatory reaction leading to joint instability, pain, and swelling, and may cause osteolysis, implant looseningand ultimately implant failure. An 81 year old female, with a history of primary left total knee arthroplasty, presented with a 6 month history of left knee pain, swelling, and limited range of motion following a fall. Radiographs and joint aspiration were performed, with results that showed no evidence of periprosthetic trauma or infection but were suspicious for chronic metallosis. The patient underwent revision total knee replacement of the left knee which revealed extensive necrotic black metal debris throughout the joint space. Histopathology confirmed the diagnosis of a foreign body reaction consistent with metallosis. This case is a rare example of chronic metallosis presenting 26 years following total knee replacement. Treatment with revision total knee replacement is the consensus management choice to avoid further destruction of the bone and joint capsule that can occur with metal-induced inflammation.
Ellsworth, Bridget; Kamath, Atul F.
Malnutrition is prevalent in patients undergoing elective total joint arthroplasty (TJA). Malnutrition has been shown to be an independent risk factor for multiple postsurgical complications following TJA in addition to increasing postoperative mortality. In the current healthcare environment, it is important to recognize and correct modifiable risk factors preoperatively to minimize perioperative complications and improve patient outcomes. Recently, multiple studies have been published focusing on the association between malnutrition and perioperative complications following TJA. The findings of these studies are summarized in this review. Further research is required to determine if optimization of nutritional status preoperatively influence surgical outcomes in the elective TJA patient. PMID:27376151
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
Since its introduction, unicompartmental knee arthroplasty has been controversial because of poor early clinical outcomes due to implant design, bony fixation, surgical instrumentation, and technique. Improvements in surgical technique and implant design have resulted in improved results and greater survivorship. The ability to obtain accurate implant placement includes avoiding surgeon decisions leading to potential errors. These errors include alignment in the sagittal, coronal, and axial planes on each prepared condyle as well as the preservation of the joint line and the resulting overall limb alignment as something critical to obtaining a successful outcome. Copyright © 2014 Elsevier Inc. All rights reserved.
Romness, D W; Morrey, B F
Sixteen total knee arthroplasties performed between 1977 and 1985 in 13 patients with prior ipsilateral hip arthrodesis or ankylosis were studied to determine the preferred sequence and long-term follow-up of procedures in this clinical setting. Twelve of 16 underwent fusion takedown and total hip arthroplasty prior to knee replacement. The average age at total knee arthroplasty was 52.7 years and the average time from hip fusion to total knee arthroplasty was 36.3 years. Mean follow-up after total knee arthroplasty was 5.5 years (range, 2.3 to 10 years). The Hospital for Special Surgery knee score increased from a mean of 31.8 preoperatively to 72.2 after surgery. In patients who had conversion of the hip fusion prior to knee replacement, knee scores were 28 before and 72.5 after both procedures. Patients who retained their hip fusion had mean scores of 43.5 and 72.1, respectively. None of the knees has been removed and 14 of 16 had no pain at last follow-up. One had mild pain and one had moderate pain attributed to pes anserine bursitis. Although the numbers are small, this experience reveals that takedown of the fusion with total hip arthroplasty is an effective technique before performing the knee replacement. Though successful in some instances, the experience is too small to show that if hip fusion is in good position, knee replacement without fusion takedown is acceptable.
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.
Bal, B S; Garino, J; Ries, M; Rahaman, M N
Bearings made of ceramics have ultra-low wear properties that make them suitable for total hip arthroplasty (THA) and total knee arthroplasty (TKA). When compared to cobalt chrome (CoCr)-on-polyethylene (PE) articulations, ceramics offer drastic reductions in bearing wear rates. Lower wear rates result in fewer wear particles produced by the articulating surfaces. In theory, this should reduce the risk of periprosthetic osteolysis and premature implant loosening, thereby contributing to the longevity of total joints. In addition to ceramics, other alternative bearing couples, such as highly cross-linked PE (XLPE) and metal-on-metal also offer less wear than CoCr-on-PE articulations in total joint arthroplasty. Alumina and zirconia ceramics are familiar to orthopaedic surgeons since both materials have been used in total joints for several decades. While not new in Europe, alumina-on-alumina ceramic total hips have only recently become available for widespread use in the United States from various orthopaedic implant manufacturers. As the search for the ideal total joint bearing material continues, composite materials of existing ceramics, metal-on-ceramic articulations, and new ceramic technologies will offer more choices to the arthroplasty surgeon. The objective of this paper is to present an overview of material properties, clinical applications, evolution, and limitations of ceramic materials that are of interest to the arthroplasty surgeon.
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
Siston, Robert A; Giori, Nicholas J; Goodman, Stuart B; Delp, Scott L
Total knee arthroplasty is a successful procedure to treat pain and functional disability due to osteoarthritis. However, precisely how a total knee arthroplasty changes the kinematics of an osteoarthritic knee is unknown. We used a surgical navigation system to measure normal passive kinematics from 7 embalmed cadaver lower extremities and in vivo intraoperative passive kinematics on 17 patients undergoing primary total knee arthroplasty to address two questions: How do the kinematics of knees with advanced osteoarthritis differ from normal knees?; and, Does posterior substituting total knee arthroplasty restore kinematics towards normal? Osteoarthritic knees displayed a decreased screw-home motion and abnormal varus/valgus rotations between 10 degrees and 90 degrees of knee flexion when compared to normal knees. The anterior-posterior motion of the femur in osteoarthritic knees was not different than in normal knees. Following total knee arthroplasty, we found abnormal varus/valgus rotations in early flexion, a reduced screw-home motion when compared to the osteoarthritic knees, and an abnormal anterior translation of the femur during the first 60 degrees of flexion. Posterior substituting total knee arthroplasty does not appear to restore normal passive varus/valgus rotations or the screw motion and introduces an abnormal anterior translation of the femur during intraoperative evaluation.
Maslow, Jed; Zuckerman, Joseph D; Immerman, Igor
Post-patellectomy patients represent a specific subgroup of patients that may develop arthritis and persistent knee pain and potentially require treatment with total knee arthroplasty. This article reviews the treatment and functional outcomes following total knee arthroplasty in patients with prior patellectomy. A case report is presented as an example of the clinical management of a post-patellectomy patient with significant knee pain and disability treated with total knee arthroplasty. Emphasis will be placed in decision- making, specifically with the use of a posterior stabilized implant. In addition, postoperative strengthening of the quadriceps is essential to compensate for the lack of the patella and increase the success of total knee arthroplasty in this subgroup of patients.
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
Cushner, Fred D; Foley, Iris; Kessler, Debra; Scuderi, Giles; Scott, W Norman
Much attention has been focused on blood management issues in orthopaedic surgery in recent years, but blood management in patients having revision total knee arthroplasty is not well-established. Hematologic values and transfusion records of 100 patients (52 women, 48 men; mean age, 65 years) who had aseptic revision total knee arthroplasty at the authors' institution were evaluated retrospectively. Two- or three-component revisions comprised 66% of the procedures, and 58 patients participated in a preoperative autologous donation program. The mean preoperative hemoglobin level was 12.1 g/dL in the women and 14.1 g/dL in the men, but the men experienced a greater decrease in hemoglobin level (mean largest decrease, 4.2 g/dL versus 3.1 g/dL), possibly caused by the higher allogeneic transfusion rate in women (19.2%) versus men (4.2%). Patient age did not influence hemoglobin level or transfusion rates. Patients who participated in a preoperative autologous donation program had significantly higher hemoglobin levels before donation (14.4 g/dL versus 13.3 g/dL for patients who did not participate in a program) but comparable hemoglobin levels after predonation (12.9 g/dL). Patients with preoperative hemoglobin levels less than 13 g/dL were significantly more likely to have a transfusion. Symptom-based transfusion strategies and blood management approaches such as epoetin alfa that elevate preoperative hemoglobin level therefore may be beneficial in patients having revision total knee arthroplasty.
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.
Navacchia, Alessandro; Rullkoetter, Paul J.; Schütz, Pascal; List, Renate B.; Fitzpatrick, Clare K.; Shelburne, Kevin B.
Understanding the mechanical loading environment and resulting joint mechanics for activities of daily living in total knee arthroplasty is essential to continuous improvement in implant design. Although survivorship of these devices is good, a substantial number of patients report dissatisfaction with the outcome of their procedure. Knowledge of in vivo kinematics and joint loading will enable improvement in preclinical assessment and refinement of implant geometry. The purpose of this investigation was to describe the mechanics of total knee arthroplasty during a variety of activities of daily living (gait, walking down stairs, and chair rise/sit). Estimates of muscle forces, tibial contact load, location, and pressure distribution was performed through a combination of mobile fluoroscopy data collection, musculoskeletal modeling, and finite element simulation. For the activities evaluated, joint compressive load was greatest during walking down stairs; however, the highest contact pressure occurred during chair rise/sit. The joint contact moment in the frontal plane was mainly varus for gait and walking down stairs, while it was valgus during chair rise/sit. Excursion of the center of pressure on the tibial component was similar during each activity and between the medial and lateral sides. The main determinants of center of pressure location were internal–external rotation, joint load, and tibial insert conformity. PMID:26792665
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.
Wannaphan, Patsiri; Chanthasopeephan, Teeranoot
Knee rehabilitation after total knee replacement arthroplasty is essential for patients during their post-surgery recovery period. This study is about designing one degree of freedom knee rehabilitation equipment to assist patients for their post-surgery exercise. The equipment is designed to be used in sitting position with flexion/extension of knee in sagittal plane. The range of knee joint motion is starting from 0 to 90 degrees angle for knee rehabilitation motion. The feature includes adjustable link for different human proportions and the torque feedback control at knee joint during rehabilitation and the control of flexion/extension speed. The motion of the rehabilitation equipment was set to move at low speed (18 degrees/sec) for knee rehabilitation. The rehabilitation link without additional load took one second to move from vertical hanging up to 90° while the corresponding torque increased from 0 Nm to 2 Nm at 90°. When extra load is added, the link took 1.5 seconds to move to 90° The torque is then increased from 0 Nm to 4 Nm. After a period of time, the speed of the motion can be varied. User can adjust the motion to 40 degrees/sec during recovery activity of the knee and users can increase the level of exercise or motion up to 60 degrees/sec to strengthen the muscles during throughout their rehabilitation program depends on each patient. Torque control is included to prevent injury. Patients can use the equipment for home exercise to help reduce the number of hospital visit while the patients can receive an appropriate therapy for their knee recovery program.
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.].
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
Chatellard, R; Sauleau, V; Colmar, M; Robert, H; Raynaud, G; Brilhault, J
In several recent studies, unicompartmental knee arthroplasty (UKA) produced better functional outcomes than did total knee arthroplasty with 10-year prosthesis survival rates greater than 95%. Nevertheless, UKA is still widely viewed as producing inconsistent results. Tibial component loosening is the leading cause of failure. We consequently sought to identify tibial component position criteria associated with outcomes of medial UKA. We conducted a retrospective multicentre study of 559 medial UKAs performed between 1988 and 2010 in 421 patients (262 females and 159 males) with a mean age of 69.51±8.72 years at surgery. We recorded the following radiographic parameters: joint space height, obliquity and slope of the tibial implant, whether the tibial component was perpendicular to the femoral component, and lower limb malalignment. The International Knee Society (IKS) score was used to assess clinical outcomes. Mean follow-up at re-evaluation was 5.17±4.33 years. The mean 10-year prosthesis survival rate was 83.7±3.5%. Factors associated with decreased prosthesis survival were a greater than 2-mm change in joint space height, a greater than 3° change in tibial component obliquity, a slope value greater than 5° or a change in slope greater than 2°, and more than 6° of divergence between the tibial and femoral components. Residual mechanical varus of 5° or more was also associated with mechanical failure. The only factor associated with worse functional score values was joint space elevation by more than 2mm. The high level of accuracy required for optimal positioning of the tibial component during medial UKA indicates a need for considerable technical expertise and emphasises the conservative nature of the procedure. Optimal positioning is crucial to restore normal knee kinematics and to prevent implant wear and lesions to adjacent compartments. IV, retrospective study. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
Marcellin-Little, Denis J; Doyle, Nancy D; Pyke, Joanna Freeman
Patients who have total joint arthroplasty have varying needs related to rehabilitation. In the short term, rehabilitation should be used in all dogs to identify high-risk patients and to minimize the likelihood of postoperative complications. Many patients undergoing total hip replacement recover uneventfully without needing long-term physiotherapy. All patients undergoing total knee replacement and total elbow replacement need rehabilitation to restore limb use and maximize their functional recovery. This article presents rehabilitation considerations for companion animals undergoing total hip replacement, total knee replacement, and total elbow replacement; postoperative complications and how to mitigate risks; and anticipated patient outcomes.
Halawi, Mohamad J
Fracture blisters are tense vesicles that arise on markedly swollen skin overlying traumatized soft tissue. While this relatively uncommon complication has been well described in the trauma literature, this article reports for the first time a case of fracture blisters after primary total knee arthroplasty. The fracture blisters developed within 36 hours of surgery and were associated with profound swelling and erythema. There was no evidence of vascular injury, compartment syndrome, iatrogenic fracture, or deep venous thrombosis. The patient was treated with leg elevation, loosely applied nonadhesive dressings, and a short course of oral antibiotics after skin desquamation. Blood-filled blisters required longer time to reepithelialization than fluid-filled blisters. Knee stiffness developed because of pain and fear of participation with physical therapy, but the patient was able to resume intensive rehabilitation after resolution of the blisters. Patient factors, surgical factors, and review of the literature are discussed.
Oh, Kwang-Jun; Yoon, Seok-Tae; Ko, Young-Bong
Total limb rotation, an important anatomical feature of the lower limb, is defined as any rotation of the lower limb on its longitudinal axis. The aim of the present study was to evaluate the discrepancies of rotational profiles of total limb between nonoperated and operated limb following unilateral total knee arthroplasty. We conducted an analysis of the computed tomography (CT) data from 32 patients undergoing primary unilateral total knee arthroplasty. Using these CT scan, rotational profiles of total limb, such as femoral neck anteversion angle expressed as femoral torsion angle (FTA), tibial torsion angle (TTA), knee joint rotation angle (KJRA), and total limb rotation (TLR) were measured. There were significant discrepancies of FTA and KJRA between operated and nonoperated limb following unilateral total knee arthroplasty. The mean difference of operated and nonoperated side for FTA and KJRA were -6.51 ± 11.88 degrees (p = 0.0041) and -6.83 ± 5.04 degrees (p < 0.001), respectively. However, there were no significant discrepancies of TLR, TTA. These results are due to the compensation effect of KJRA. However, excessive external rotation of the femoral component beyond the compensation effect of prosthetic knee joint can lead to a total limb rotational discrepancy in patient undergoing unilateral total knee arthroplasty.
Clarke, H. Harrison, Ed.
This report by the President's Council on Physical Fitness and Sports examines the effects of various forms of physical exercise on the knee joint which, because of its vulnerability, is especially subject to injury. Discussion centers around the physical characteristics of the joint, commonly used measurements for determining knee stability,…
Background A number of factors have been identified as influencing total knee arthroplasty outcomes, including patient factors such as gender and medical comorbidity, technical factors such as alignment of the prosthesis, and provider factors such as hospital and surgeon procedure volumes. Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of total joint arthroplasty to higher volume centers, and adoption of volume standards. To contribute to the discussions concerning the optimization of provider factors and proposals to regionalize total knee arthroplasty practices, we undertook a systematic review to investigate the association between surgeon volume and primary total knee arthroplasty outcomes. Methods We performed a systematic review examining the association between surgeon volume and primary knee arthroplasty outcomes. To be included in the review, the study population had to include patients undergoing primary total knee arthroplasty. Studies had to report on the association between surgeon volume and primary total knee arthroplasty outcomes, including perioperative mortality and morbidity, patient-reported outcomes, or total knee arthroplasty implant survivorship. There were no restrictions placed on study design or language. Results Studies were variable in defining surgeon volume (‘low’: <3 to <52 total knee arthroplasty per year; ‘high’: >5 to >70 total knee arthroplasty per year). Mortality rate, survivorship and thromboembolic events were not found to be associated with surgeon volume. We found a significant association between low surgeon volume and higher rate of infection (0.26% - 2.8% higher), procedure time (165 min versus 135 min), longer length of stay (0.4 - 2.13 days longer), transfusion rate (13% versus 4%), and worse patient reported outcomes. Conclusions Findings suggest a trend towards better outcomes for higher volume surgeons, but results must be interpreted with caution. PMID
Comas, Mercè; Román, Rubén; Quintana, José Maria
Background There is a high volume of unmet needs for knee arthroplasty in the population despite the increase in surgery rates. Given the long waiting times to have a knee arthroplasty, some governments have proposed prioritization systems for patients on waiting lists based on their level of need. Questions/Purposes We therefore estimated the needs and demand of knee arthroplasty in four regions of Spain during a 5-year period. Methods We developed a discrete event simulation model to reproduce the process of knee arthroplasty. The prioritization system was compared with the usual waiting list management strategy (by waiting time only). Results Under the prioritization system, patients saved an average of 4.5 months (95% confidence interval, 4.4–4.6 months) adjusted by level of need. The proportion of patients who experienced excessive waiting times was small and was associated with low levels of priority. The 5-year projection of the volume of unmet needs for knee arthroplasty remained stable; however, although the volume of need for the first knee arthroplasty decreased by 12%, the volume of need for an arthroplasty in the contralateral knee increased by 50%. Conclusions The data suggested the prioritization system was more beneficial than assigning surgery by waiting time only. The 5-year projection of the volume of unmet needs for knee arthroplasty remained stable, despite the increase in the need for contralateral knee arthroplasty. Level of Evidence Level II, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence. PMID:19911242
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.
Patel, A; Pavlou, G; Mújica-Mota, R E; Toms, A D
Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are recognised and proven interventions for patients with advanced arthritis. Studies to date have demonstrated a steady increase in the requirement for primary and revision procedures. Projected estimates made for the United States show that by 2030 the demand for primary TKA will grow by 673% and for revision TKA by 601% from the level in 2005. For THA the projected estimates are 174% and 137% for primary and revision surgery, respectively. The purpose of this study was to see if those predictions were similar for England and Wales using data from the National Joint Registry and the Office of National Statistics. Analysis of data for England and Wales suggest that by 2030, the volume of primary and revision TKAs will have increased by 117% and 332%, respectively between 2012 and 2030. The data for the United States translates to a 306% cumulative rate of increase between 2012 and 2030 for revision surgery, which is similar to our predictions for England and Wales. The predictions from the United States for primary TKA were similar to our upper limit projections. For THA, we predicted an increase of 134% and 31% for primary and revision hip surgery, respectively. Our model has limitations, however, it highlights the economic burden of arthroplasty in the future in England and Wales as a real and unaddressed problem. This will have significant implications for the provision of health care and the management of orthopaedic services in the future.
Traer, Emily A; Williams, Mark R; Keenan, Jon N
A 76-year-old man with a medical history of rheumatoid arthritis, lupus intersititial nephritis, and steroid therapy was found at first-stage revision total knee arthroplasty to have Erysipelothrix rhusiopathiae (a zoonotic pathogen normally associated with pigs and fish) infection of the arthroplasty. He had a history of potential occupational exposure to the organism. On literature review, we found only 3 other case reports of E rhusiopathiae linked to septic arthritis in humans. This unique case of an infected joint arthroplasty further illustrates the pathogenicity of E rhusiopathiae in humans.
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
Ma, Tong; Tu, Yihui; Xue, Huaming; Wen, Tao; Mei, Jiong
Unicompartmental knee arthroplasty (UKA) is an effective treatment option for medial compartment osteoarthritis (OA) of the knee. Whether spontaneous osteonecrosis of the knee (SPONK) can be successfully treated with UKA remains controversial. This study evaluated the clinical and radiological results of patients with SPONK who were treated by UKA using Oxford phase III prostheses. We compared a prospective series of 23 UKA cases operated for SPONK with 235 UKA cases operated for OA. All patients underwent Magnetic Resonance Imaging (MRI) to confirm the diagnosis and exclude any major lesion in the lateral compartment. The stage, condylar ratio, and volume of the necrotic lesion were evaluated. The pre and postoperative Oxford knee scores (OKSs) were compared. The mean follow-up was 60 months. No statistical differences in complication rates between the groups were found. The mean OKS improved from 39.48 ± 5.69 to 18.83 ± 3.82 ( p < 0.05). There were no significant differences in the pre and postoperative OKS between the different groups. SPONK can be successfully treated with UKA, with a favorable short- to mid-term follow-up.
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.
Smith, James R A; Robinson, James R; Porteous, Andrew J; Murray, James R D; Hassaballa, Mohammad A; Artz, Neil; Newman, John H
Isolated unicompartmental knee arthritis is less common laterally than medially. Lateral unicompartmental knee arthroplasty (UKA) constitutes only 1% of all knee arthroplasty performed. Use of medial UKA is supported by several published series showing good long-term survivorship and patient satisfaction, in large patient cohorts. Results of lateral UKA however have been mixed. We present the short and mid-term survivorship and 5-year clinical outcome of 101 lateral UKAs using a single prosthesis. Over a 9 year period, 100 patients who satisfied inclusion criteria underwent a lateral fixed-bearing unicompartmental arthroplasty. American Knee Society (AKSS), Oxford Knee (OKS) and modified Western Ontario McMaster Universities Arthritis Index (WOMAC) scores were completed preoperatively and at 1, 2 and 5 years postoperatively. Kaplan-Meier survival analysis was used to determine the 2-year and 5-year survivorship, using revision for any cause as end point. Survivorship was 98.7% and 95.5% at 2 and 5 years respectively. 1 knee was revised for subsidence of the tibial component and 1 knee for progression of medial compartment osteoarthritis. Of a possible 35 knees in situ at 5 year follow-up, 33 knees were fully scored. Median AKSS, OKS and modified WOMAC scores were 182, 41, and 16 respectively. The mid-term survivorship and outcome scores at 5-years suggest that lateral unicompartmental knee arthroplasty provides a valuable alternative to total joint replacement in selected patients with isolated lateral tibio-femoral arthritis at mid-term follow-up. Level II evidence. Copyright © 2014 Elsevier B.V. All rights reserved.
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
Pearle, Andrew D; O'Loughlin, Padhraig F; Kendoff, Daniel O
The outcomes of unicompartmental knee arthroplasties (UKAs) have demonstrated inconsistent long-term survival. We report the first clinical series of UKA using a semiactive robotic system for the implantation of an inlay unicondylar knee arthroplasty. Ten patients were selected for this study. Preoperative mechanical leg alignment values ranged from 0.3 degrees varus to 9.8 degrees varus. A haptic guidance system was used; a detailed description is given in the manuscript. The setup time for the robot was 41 minutes; intraoperative registration process, 7.5 minutes (6-13 minutes); skin incision, 8 cm; robot-assisted burring, 34.8 minutes (18-50 minutes); mean tourniquet time, 87.4 minutes (68-113 minutes); and overall operation time, 132 minutes (118-152 minutes). The planned and intraoperative tibiofemoral angle was within 1 degrees. The postoperative long leg axis radiographs were within 1.6 degrees. Haptic guidance in combination with a navigation module allows for precise planning and execution of both inlay components in UKA. 2010 Elsevier Inc. All rights reserved.
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.
Petersen, Wolf; Rembitzki, Ingo Volker; Brüggemann, Gerd-Peter; Ellermann, Andree; Best, Raymond; Koppenburg, Andreas Gösele-; Liebau, Christian
Anterior knee pain is one of the most common causes of persistent problems after implantation of a total knee replacement. It can occur in patients with or without patellar resurfacing. As a result of the surgical procedure itself many changes can occur which may affect the delicate interplay of the joint partners in the patello-femoral joint. Functional causes of anterior knee pain can be distinguished from mechanical causes. The functional causes concern disorders of inter- and intramuscular coordination, which can be attributed to preoperative osteoarthritis. Research about anterior knee pain has shown that not only the thigh muscles but also the hip and trunk stabilising muscles may be responsible for the development of a dynamic valgus malalignment. Dynamic valgus may be a causative factor for patellar maltracking. The mechanical causes of patello-femoral problems after knee replacement can be distinguished according to whether they increase instability in the joint, increase joint pressure or whether they affect the muscular lever arms. These causes include offset errors, oversizing, rotational errors of femoral or tibial component, instability, maltracking and chondrolysis, patella baja and aseptic loosening. In these cases, reoperation or revision is often necessary.
Abbas, Ammar M I; Morgan-Jones, Rhidian L
Periprosthetic knee fractures and their complications are expected to increase as the numbers of knee arthroplasties continue to rise. We report our experience with revision knee arthroplasty for failure of primary fracture treatment. Five periprosthetic knee non-unions and 1 mal-union in 6 patients, with ages ranging from 65 to 83years (average 74.6years) were treated with revision total knee arthroplasty, and were followed up for 3 to 10years (average 4.5years). Union occurred in 8 to 18weeks (average 12.5weeks). All patients were ambulatory at the latest follow-up, with a range of motion averaging 84.2° (P = 0.03), and an Oxford Knee Score averaging 35 (P = 0.03). We conclude that union complications of periprosthetic knee fractures can be satisfactorily addressed with revision arthroplasty.
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.
Roth, A; Ghanem, M; Fakler, J
Periprosthetic patella fractures occur both with and without retropatellar joint replacement. A non-operative treatment yields satisfactory results with low morbidity. It can be applied in minimally displaced fractures that have an intact retropatellar component and an intact extensor mechanism, combined with an initial immobilization. The surgical treatment is associated with relatively poor results and with high complication rates. There was only minor improvement of functional results, no matter which surgical technique was used. Surgical intervention is still required in fractures with a loosening of the patellar component, considerable dislocations of fragments, and damage to or rupture of the extensor mechanism. In particular, type II fractures require repair of the extensor mechanism and the fracture or patellectomy. Type III fractures require a revision or resection of the patella, a patelloplasty or total patellectomy. In addition, early or late reconstruction using allograft to restore the extensor mechanism can be taken in consideration.
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
Foote, J A J; Smith, H K; Jonas, S C; Greenwood, R; Weale, A E
A retrospective study of a consecutive cohort of 109 patients, under the age of 60, who had either a Patellofemoral replacement (PFR), Unicompartmental replacement (UKR) or a Total knee replacement (TKR). They were operated on by two senior surgeons between 2002 and 2006 at the Avon Orthopaedic Centre in Bristol. The aim of this study was to look at the effect of knee replacement on the employment status of this group of patients. Data were collected from patient's hospital records and a questionnaire regarding occupational status was sent postoperatively to the patients. Statistical analysis showed that our groups were similar which meant that further comparison between them was valid. Eighty-two percent of the patients who were working prior to surgery and who had either a TKR or UKR were able to return to work postoperatively. Only 54% of those who had a PFR were able to return to work and this was statistically significant when compared with patients in the other two groups p=0.047. The median time for return to work postoperatively for the study population was 12 weeks. Those in the PFR group took significantly longer to do so (20 weeks) compared to those who had either a UKR (11 weeks) or TKR (12 weeks) p=0.01. Patient's subjective opinion as to their ability to work following knee arthroplasty was worse in the PFR group p=0.049. This is the first study to compare employment status following Patellofemoral, Unicompartmental knee and Total Knee Replacement. TKR and UKR are effective in returning patients under 60 years old to active employment and this is typically 3 months following surgery. Patients who had a PFR did not experience the same benefits in terms of numbers returning to work, time to do so and their subjective opinion as to their ability to cope with normal duties.
Finger, Eric; Willis, F Buck
Total Knee Arthroplasty operations are increasing in frequency, and knee flexion contracture is a common pathology, both pre-existing and post-operative. A 61-year-old male presented with knee flexion contracture following a total knee arthroplasty. Physical therapy alone did not fully reduce the contracture and dynamic splinting was then prescribed for daily low-load, prolonged-duration stretch. After 28 physical therapy sessions, the active range of motion improved from -20 degrees to -12 degrees (stiff knee still lacking full extension), and after eight additional weeks with nightly wear of dynamic splint, the patient regained full knee extension, (active extension improved from -12 degrees to 0 degrees ).
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
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
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
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.
Streit, Marcus R; Streit, Julia; Walker, Tilman; Bruckner, Thomas; Philippe Kretzer, J; Ewerbeck, Volker; Merle, Christian; Aldinger, Peter R; Gotterbarm, Tobias
Advanced knee arthritis in young patients is a challenging problem that may necessitate surgical treatment. There are few published studies of mobile-bearing unicompartmental knee arthroplasty (UKA) in young patients, while indications have expanded to its use in this demanding patient group. The clinical and radiographic results of the first 118 consecutive Oxford medial UKAs (OUKA) using a minimally invasive technique (phase 3) in 101 patients 60 years of age or younger at the time of surgery were evaluated. Median age at surgery was 57 (25-60) years. Kaplan-Meier survivorship analysis was used to estimate implant survival. Mean time of follow-up evaluation was five (SD 1.6) years. At final follow-up, three patients (three knees) had died, and two patients (three knees) were lost to follow-up. Five knees were revised: three for unexplained pain, one for early infection and one for bearing fracture. There was one impending revision for progression of osteoarthritis in the lateral compartment. The radiographic review demonstrated that 5 % of the knees had progressive arthritis in the lateral knee compartment, of those 2 % with full joint space loss and pain. The Kaplan-Meier survival analysis, using revision for any reason as the endpoint, estimated the five-year survival rate at 97 % (95 % CI 91-99). Ninety-six per cent of the non-revised patients were satisfied with the outcome, and 4 % were dissatisfied. The mean Oxford knee score was 41 (SD 7), with 6 % of the knees having a poor result. The mean AKSS was 89 (SD 14), mean flexion was 129° (SD 13) and the mean UCLA score was 6.8 (SD 1.5). Minimally invasive Oxford medial UKA was reliable and effective in this young and active patient cohort providing high patient satisfaction at mid-term follow-up. Progressive arthritis in the lateral knee compartment was a relevant failure mode in this age group. Most revisions were performed for unexplained pain, while we did not find loosening or wear in any patient
Emodi, George J; Callaghan, John J; Pedersen, Douglas R; Brown, Thomas D
One of the most commonly cited reasons for retaining the posterior cruciate ligament (PCL) during total knee arthroplasty is to preserve femoral rollback and theoretically improve extensor mechanism efficiency (lengthening the moment arm). This study was undertaken to assess PCL function in this regard and to delineate the effects of joint line elevation that can be manipulated intraoperatively by the surgeon. The anterior movement of tibiofemoral contact following PCL resection at flexion angles 60 degrees demonstrated the beneficial effect of the PCL on extensor function. This anterior translation and the concomitant increases in quadriceps tendon load and patellofemoral contact pressures were consistently observed. This study demonstrated that small changes of the joint line position significantly influenced PCL strain and knee kinematics. In order to preserve the desired functions that would be lost with an overly lax PCL and to avoid the potential adverse effects of an overly tight PCL (posterior edge loading and increased tibiofemoral contact), the surgeon should make every effort to restore the preoperative joint line. If this is not possible, consideration should be given to posterior cruciate recession or use of a posterior cruciate substituting design. PMID:10847521
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.
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.
Smith, E J; Maru, M; Siegmeth, A
Hip and knee arthroplasties are very common operations in the UK with over 150,000 hip and knee arthroplasties taking place in England and Wales in 2011. Fortunately mortality following these operations is rare. This study aimed to evaluate the incidence and causes of death within 30 days after undergoing hip or knee arthroplasty in our unit and to highlight possible risk factors. We looked at 30-day mortality in all patients undergoing hip or knee arthroplasty in our institution between 2005 and 2011. Data on post-operative deaths was requested from the Information Services Division (ISD) and correlated with procedural and demographic data from our hospital Patient Administration System (PAS). The notes of all patients who died within 30 days were reviewed to collect data on co-morbid conditions, pre-operative investigations, post-operative thromboprophylaxis and cause of death. All primary and revision knee and hip arthroplasties including bilateral procedures were included. Arthroplasty for trauma was excluded. 12,243 patients underwent hip or knee arthroplasty within the study period. The male:female ratio was 2:3. The mean age was 68 with a range of 21-91. Ten patients died giving a 30-day mortality rate of 0.08%. The most common cause of death was myocardial infarction (7/10 patients). Our finding of a mortality rate of 0.08% is similar or lower to those found in previous studies. To our knowledge this is the first series of this size looking at mortality from hip and knee arthroplasty within a single centre in the UK. Copyright © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Rodriguez-Merchan, E. Carlos
The aim of this review article is to analyze the results of high tibial osteotomy compared to unicompartmental knee arthroplasty in patients with unicompartmental knee osteoarthritis. The search engine used was PubMed. The keywords were: “high tibial osteotomy versus unicompartmental knee arthroplasty”. Twenty-one articles were found on 28 February 2015, but only eighteen were selected and reviewed because they strictly focused on the topic. In a meta-analysis the ratio for an excellent outcome was higher in unicompartmental knee arthroplasty than high tibial osteotomy and the risks of revision and complications were lower in the former. A prospective comparative study showed that unicompartmental knee arthroplasty offers better long-term success (77% for unicompartmental knee arthroplasty and 60% for high tibial osteotomy at 7-10 years). However, a review of the literature showed no evidence of superior results of one treatment over the other. A multicenter study stated that unicompartmental knee osteoarthritis without constitutional deformity should be treated with unicompartmental knee arthroplasty while in cases with constitutional deformity high tibial osteotomy should be indicated. A case control study stated that unicompartmental knee arthroplasty offers a viable alternative to high tibial osteotomy if proper patient selection is done. The literature is still controversial regarding the best surgical treatment for unicompartmental knee osteoarthritis (high tibial osteotomy or unicompartmental knee arthroplasty). However, unicompartmental knee arthroplasty utilization is increasing, while high tibial osteotomy utilization is decreasing, and a meta-analysis has shown better outcomes and less risk of revision and complications in the former. A systematic review has found that with correct patient selection, both procedures show effective and reliable results. However, prospective randomized studies are needed in order to answer the question of this article
Pandher, Dilbans Singh; Boparai, Randhir Singh; Kapila, Rajesh
The case report highlights an unusual case of posterolateral knee pain after total knee arthroplasty. Tendinitis of the patellar tendon or pes anserinus is a common complication after total knee arthroplasty; however, there is no report in the literature regarding the biceps femoris tendinitis causing acute pain in the early postoperative period. In this case, the biceps tendinitis was diagnosed and treated by ultrasound-guided injection into the tendon sheath.
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
Colwell, Clifford W; Froimson, Mark I; Anseth, Scott D; Giori, Nicholas J; Hamilton, William G; Barrack, Robert L; Buehler, Knute C; Mont, Michael A; Padgett, Douglas E; Pulido, Pamela A; Barnes, C Lowery
Venous thromboembolic events, either deep venous thrombosis or pulmonary embolism, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.) with or without aspirin compared with current pharmacological protocols for prophylaxis against venous thromboembolism in patients undergoing elective primary unilateral arthroplasty of a lower-extremity joint. A multicenter registry was established to capture the rate of symptomatic venous thromboembolic events following primary knee arthroplasty (1551 patients) or hip arthroplasty (1509 patients) from ten sites. All patients were eighteen years of age or older with no known history of venous thromboembolism, coagulation disorder, or solid tumor. Use of the compression device began perioperatively and continued for a minimum of ten days. Patients with symptoms of deep venous thrombosis or pulmonary embolism underwent duplex ultrasonography and/or spiral computed tomography. All patients were evaluated at three months postoperatively to document any evidence of deep venous thrombosis or pulmonary embolism. Of 3060 patients, twenty-eight (0.92%) had venous thromboembolism (twenty distal deep venous thrombi, three proximal deep venous thrombi, and five pulmonary emboli). One death occurred, with no autopsy performed. Symptomatic venous thromboembolic rates observed in patients who had an arthroplasty of a lower-extremity joint using the mobile compression device were noninferior (not worse than), at a margin of 1.0%, to the rates reported for pharmacological prophylaxis, including warfarin, enoxaparin, rivaroxaban, and dabigatran, except in the knee arthroplasty group, in which the mobile compression device fell short of the rate reported for rivaroxaban by 0.06%. Use of the mobile compression device with or without aspirin for patients undergoing arthroplasty of a lower-extremity joint provides a
Frank, Rachel M; Della Valle, Craig J; Plummer, Darren R; Chalmers, Peter N; Cole, Brian J
This study compared patients who failed a cartilage restoration procedure and underwent ipsilateral knee arthroplasty with matched control subjects undergoing knee arthroplasty without prior cartilage restoration. Although patients with a failed cartilage procedure derived benefit from knee arthroplasty, their magnitude of improvement and final outcomes scores were lower than the matched control subjects. In this cohort, the cartilage patients also experienced little to no benefit from cartilage restoration, suggesting that unmeasured shared patient characteristics may play a role. This information can be used to counsel this difficult patient population on expected outcomes following arthroplasty procedures. Further research identifying characteristics of responders to treatment remains critical to refine clinical decision-making for this difficult patient group. Copyright © 2017 Elsevier Inc. All rights reserved.
Stickles, B; Phillips, L; Brox, W T; Owens, B; Lanzer, W L
The purpose of this study was to examine the relationship between obesity and patient-administered outcome measures after total joint arthroplasty. A voluntary questionnaire-based registry contained 592 primary total hip arthroplasty patients and 1011 primary total knee arthroplasty patients with preoperative and 1-year data. Using logistic regression, the relationships between body mass index and the several outcome measures, including Short Form-36 and Western Ontario and McMaster Universities Osteoarthritis Index, were examined. There was no difference between obese and non-obese patients regarding satisfaction, decision to repeat surgery, and Delta physical component summary, Delta mental component summary, and Delta Western Ontario and McMaster Universities Osteoarthritis Index scores (p > 0.05 for all). Body mass index was associated with an increased risk of having difficulty descending or ascending stairs at 1 year (odds ratio, 1.2 to 1.3). Obese patients enjoy as much improvement and satisfaction as other patients from total joint arthroplasty.
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.
Pinson, Michelle L; Coop, Christopher A; Webb, Charles N
To review the clinical manifestations, testing methods, and treatment options for hypersensitivity reactions to total joint arthroplasty procedures. Studies were identified using MEDLINE and reference lists of key articles. Randomized controlled trials were selected when available. Systematic reviews and meta-analyses of peer-reviewed literature were included, as were case series and observational studies of clinical interest. Total joint arthroplasty procedures are increasing, as are the hypersensitivity reactions to these implants. Evidence is not conclusive as to whether metal joint implants increase metal sensitivity or whether metal sensitivity leads to prosthesis failure. Currently, patch testing is still the most widely used method for determining metal hypersensitivity; however, there are no standardized commercial panels specific for total joint replacements available currently. In vitro testing has shown comparable results in some studies, but its use in the clinical setting may be limited by the cost and need for specialized laboratories. Hypersensitivity testing is generally recommended before surgery for patients with a reported history of metal sensitivity. In cases of metal hypersensitivity-related joint failure, surgical revision ultimately may be required. Knowledge about joint replacement hypersensitivity reactions becomes vital because the approach to the evaluation depends on appropriate testing to guide recommendations for future arthroplasty procedures. Evaluation of hypersensitivity reactions after total joint arthroplasty requires a systematic approach, including a careful history, targeted evaluation with skin testing, and in vitro studies. Copyright © 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
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
Hitt, Kirby; Bhowmik-Stoker, Manoshi; Howard, Michael; Mittal, Yogesh; Heekin, R David; Jacofsky, David
We investigated a new revision total knee arthroplasty device and associated instrumentation to determine if it could reduce intraoperative complexity and restore the joint line through the arc of motion. In a prospective multicenter study, a total of 95 consecutive patients undergoing a revision knee arthroplasty were evaluated. Medical history, functional health scores, and intraoperative data were collected. The joint line was restored to 28 mm ± 5 mm in full extension and 90-degree flexion. Significant improvements were noted in all functional and general health scores. The anatomic boss position may allow for a reduction in instrumentation, as the need for femoral offset adapters was limited. Joint line restoration with proper posterior condylar offset correlated with positive functional outcomes.
Breugem, Stefan J; van den Bekerom, Michel PJ; Tuinebreijer, Willem E; van Geenen, Rutger C I
Background and purpose Poor outcomes have been linked to errors in rotational alignment of total knee arthroplasty components. The aims of this study were to determine the correlation between rotational alignment and outcome, to review the success of revision for malrotated total knee arthroplasty, and to determine whether evidence-based guidelines for malrotated total knee arthroplasty can be proposed. Patients and methods We conducted a systematic review including all studies reporting on both rotational alignment and functional outcome. Comparable studies were used in a correlation analysis and results of revision were analyzed separately. Results 846 studies were identified, 25 of which met the inclusion criteria. From this selection, 11 studies could be included in the correlation analysis. A medium positive correlation (ρ = 0.44, 95% CI: 0.27–0.59) and a large positive correlation (ρ = 0.68, 95% CI: 0.64–0.73) were found between external rotation of the tibial component and the femoral component, respectively, and the Knee Society score. Revision for malrotation gave positive results in all 6 studies in this field. Interpretation Medium and large positive correlations were found between tibial and femoral component rotational alignment on the one hand and better functional outcome on the other. Revision of malrotated total knee arthroplasty may be successful. However, a clear cutoff point for revision for malrotated total knee arthroplasty components could not be identified. PMID:25708694
Komistek, Richard D; Mahfouz, Mohamed R; Bertin, Kim; Rosenberg, Aaron; Kennedy, William
The objective of this study was to determine if consistent posterior femoral rollback of an asymmetrical posterior cruciate retaining (PCR) total knee arthroplasty was mostly influenced by the implant design, surgical technique, or presence of a well-functioning posterior cruciate ligament (PCL). Three-dimensional femorotibial kinematics was determined for 80 subjects implanted by 3 surgeons, and each subject was evaluated under fluoroscopic surveillance during a deep knee bend. All subjects in this present study having an intact PCL had a well-functioning PCR knee and experienced normal kinematic patterns, although less in magnitude than the normal knee. In addition, a surprising finding was that, on average, subjects without a PCL still achieved posterior femoral rollback from full extension to maximum knee flexion. The findings in this study revealed that implant design did contribute to the normal kinematics demonstrated by subjects having this asymmetrical PCR total knee arthroplasty.
Background Periprosthetic joint infections (PJI) are often treated by two stage exchange with the use of an antibiotic impregnated spacer. Most of the two-stage exchange algorithms recommend the implantation of an antibiotic-impregnated spacer during the first stage for a period of 2–24 weeks before reimplantation of the new prosthesis. For the spacer to have a therapeutic effect, the local antibiotic concentration must be greater than the minimal inhibition concentration (MIC) against the pathogens causing the PJI. It must remain so for the entire spacer period, otherwise recurrence of infection or resistances might occur. The question as to whether a sufficient concentration of antibiotics in vivo is reached for the entire spacer period has not been answered satisfactorily. Case presentation We here present a case of a histologically confirmed chronic PJI 20 month after primary arthroplasty. The primary knee arthroplasty was performed due to osteoarthritis of the joint. Initial assessment did not detect a causative pathogen, and two stage exchange with a vancomycin-gentamycin impregnated spacer was performed. At the time of reimplantation, sonication of the explanted spacer revealed a multi-resistant strain of staphylococcus epidermidis on the device and in the joint. Adaption of the therapy and prolonged treatment successfully eradicated the infection. Conclusion According to the authors’ knowledge, the case presented here confirms for the first time the surface contamination (proven through sonication) of a vancomycin-/gentamicin- impregnated Vancogenx®-spacer with a MRSE after ten weeks of implantation. This case study demonstrates the difficulties still associated with the diagnostics of PJI and the published different two stage treatment regimes with the use of antibiotic impregnated spacers. PMID:24641471
Schunck, J; Jerosch, J
After the introduction of mobile-bearing knee arthroplasty in the late 1970s, he benefits were discussed in comparison to the well-established modular fixed-bearing systems. The hypothetical advantages of mobile-bearing designs are the ability of axial rotation and a greater articular conformity, which reduces significantly fatigue failure of the polyethylene. Biomechanical analyses showed for each system characteristic features, which are not concordant with the aim of restoring normal knee kinematics. In both groups the long-term clinical results were excellent with 10-year survival rates of 95-98%. Ligamentous stability and a perfect operative technique are key factors in mobile-bearing knee arthroplasty. Prospective randomized clinical trials are necessary to find answers concerning backside and volumetric polyethylene wear and the detrimental effects of wear particle size. Before this is accomplished, the indication for a mobile-bearing knee arthroplasty, especially in young patients, should be carefully considered in each case.
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
Vaish, Abhishek; Vaishya, Raju; Agarwal, Amit Kumar; Vijay, Vipul
We report a rare case of proximal fibular fatigue fracture developing 14 years after total knee arthroplasty in a known case of rheumatoid arthritis. A valgus deformity of the knee can put abnormal stress on the upper fibula leading to its failure. We believe that, as the fibula acts as an important lateral strut, its disruption due to a fracture led to rapid progress of the valgus deformity of the knee in this patient.
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.
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.
Ritter, Merrill A; Davis, Kenneth E; Davis, Peter; Farris, Alex; Malinzak, Robert A; Berend, Michael E; Meding, John B
Implant survival after total knee arthroplasty has historically been dependent on postoperative knee alignment, although failure may occur when alignment is correct. Preoperative knee alignment has not been thoroughly evaluated as a possible risk factor for implant failure after arthroplasty. The purpose of this study was to analyze the effect of preoperative knee alignment on implant survival after total knee arthroplasty. We performed a retrospective review of 5342 total knee arthroplasties performed with use of cemented Anatomic Graduated Component implants from 1983 to 2006. Each knee was independently measured preoperatively and postoperatively for overall coronal alignment. Neutral ranges for preoperative and postoperative alignment were defined by means of Cox proportional hazards regression. The overall failure rate was 1.0% (fifty-four of 5342 prostheses); failure was defined as aseptic loosening of the femoral and/or tibial component. The average preoperative anatomical alignment (and standard deviation) was 0.1° ± 7.7° of varus (range, 25° of varus to 35° of valgus), and the average postoperative anatomical alignment (and standard deviation) was 4.7° ± 2.5° of valgus (range, 12° of varus to 20° of valgus). The failure rate in knees in >8° of varus preoperatively (2.2%; p = 0.0005) or >11° of valgus preoperatively (2.4%; p = 0.0081) was elevated when compared with knees in neutral preoperatively (0.71%). Knees with preoperative deformities corrected to postoperative neutral alignment (2.5° through 7.4°) had a lower failure rate (1.9%) than undercorrected or overcorrected knees (3.0%) (p = 0.0103). Knees with postoperative neutral alignment, regardless of preoperative alignment, had a lower failure rate (0.74%) than knees with postoperative alignment of <2.5° or >7.4° of anatomic valgus (1.7%) (p < 0.0001). Patients with excessive preoperative alignment (>8° of varus or >11° of valgus) have a greater risk of failure (2.3%). Neutral
Nam, Denis; Abdel, Matthew P; Cross, Michael B; LaMont, Lauren E; Reinhardt, Keith R; McArthur, Benjamin A; Mayman, David J; Hanssen, Arlen D; Sculco, Thomas P
Complications involving the knee extensor mechanism and patellofemoral joint occur in 1% to 12% of patients following total knee arthroplasty and have major negative effects on patient outcomes and satisfaction. The surgeon must be aware of intraoperative, postoperative, and patient-related factors that can increase the rate of these problems. This review focuses on six of the most commonly encountered problems: patellar tendon disruption, quadriceps tendon rupture, patellar crepitus and soft-tissue impingement, periprosthetic patellar fracture, patellofemoral instability, and osteonecrosis of the patella. The goals of this report are to (1) review the relevant anatomy of the knee extensor mechanism, (2) present risk factors that may lead to extensor mechanism complications, (3) provide a diagnostic and treatment algorithm for each of the aforementioned problems, and (4) review the specific surgical techniques of Achilles tendon allograft reconstruction and synthetic mesh augmentation. Extensor mechanism disorders following total knee arthroplasty remain difficult to manage effectively. Although various surgical techniques have been used, the results in patients with a prior total knee arthroplasty are inferior to the results in the young adult without such a prior procedure. Surgical attempts at restoration of the knee extensor mechanism are usually warranted; however, the outcomes of treatment of these complications are often poor, and management of patient expectations is important.
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.
Zhang, YiChao; Zhang, Hong; Clarke, Henry D; Hattrup, Steven J
All charges for patients undergoing unilateral and bilateral hip or knee arthroplasties at 1 hospital in Beijing, China, were identified and assigned to 1 of 11 charge categories: hospital room, nursing, radiology, laboratory, anesthesia, surgery, prosthesis, pharmacy, blood transfusion, materials, and miscellaneous. The prosthesis and pharmacy charges at this institution accounted for approximately 80% of the total charges; compared with published data from institutions in North America and Taiwan, these 2 charges accounted for a greater percentage of total charges. In distinction, labor costs in China accounted for a lower percentage of total charges. Importantly, because the percentage of costs covered by medical insurance was relatively low, a substantial financial burden was imposed on patients that may limit access to joint arthroplasty in China. Copyright © 2012 Elsevier Inc. All rights reserved.
Harris, Ian A; Harris, Anita M; Naylor, Justine M; Adie, Sam; Mittal, Rajat; Dao, Alan T
We surveyed 331 patients undergoing total hip or knee arthroplasty pre-operatively, and patients and surgeons were both surveyed 6 and 12 months post-operatively. We identified variables (demographic factors, operative factors and patient expectations) as possible predictors for discordance in patient-surgeon satisfaction. At 12 months, 94.5% of surgeons and 90.3% of patients recorded satisfaction with the outcome. The discordance between patient and surgeon satisfaction was mainly due to patient dissatisfaction-surgeon satisfaction. In an adjusted analysis, the strongest predictors of discordance in patient-surgeon satisfaction were unmet patient expectations and the presence of complications. Advice to potential joint arthroplasty candidates regarding the decision to proceed with surgery should be informed by patient reported outcomes, rather than the surgeon's opinion of the likelihood of success. Copyright © 2013 Elsevier Inc. All rights reserved.
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.
Vykukal, H. C. (Inventor)
Pressure suit mobility joints are for use in interconnecting adjacent segments of an hermetically sealed spacesuit in which low torques, low leakage and a high degree of reliability are required. Each of the joints is a special purpose joint characterized by substantially constant volume and low torque characteristics and includes linkages which restrain the joint from longitudinal distension and includes a flexible, substantially impermeable diaphragm of tubular configuration spanning the distance between pivotally supported annuli. The diaphragms of selected joints include rolling convolutions for balancing the joints, while various joints include wedge-shaped sections which enhance the range of motion for the joints.
Although cementless knee arthroplasty is a commonly performed procedure, to date very little was known about the process of osseointegration of knee arthroplasty components. Using a knee prosthesis that was specially designed for the sheep stifle joint, this process of osseointegration could be studied in vivo, together with its effects on clinical and functional performance, its influence on mechanical fixation, and its influence on component stability or migration over time. Additionally, the osseointegration capacity of a newly developed cast mesh porous coating could be examined. The rationale for this newly developed coating was to provide a surface texture with theoretically superior osseointegration capacity, by offering a larger and better controlled pore size, with higher ingrowth area compared to conventional bead type coatings. In summary, the conclusions that are drawn from this work are the following: 1. The degree of osseointegration of knee arthroplasty components is not correlated with clinical and functional performance. Knee arthroplasty components with fibrous integration can function as well as osseointegrated components at least during the first years after implantation. This explains the occasional reports in the literature of post mortem retrieved, well functioning knee arthroplasty components, with purely fibrous integration on histomorphometric analysis. 2. Fibrous integration of tibial knee arthroplasty components, however, leads to less mechanical fixation strength of these components. Osseointegrated components are much more strongly fixed to the underlying bone. This difference in mechanical fixation strength is detectable under physiologic loads. 3. Fibrous integration of tibial knee arthroplasty components leads to increased migration, becoming apparent after 1 year with radiostereometric analysis (RSA). Osseointegrated components are significantly more stable over time. 4. Fibrous integration is less desirable, since it leads to
Pereira, Gavin C; von Kaeppler, Ericka; Alaia, Michael J; Montini, Kenneth; Lopez, Matthew J; Di Cesare, Paul E; Amanatullah, Derek F
Restoration of the joint line of the knee during primary and revision total knee arthroplasty is a step that directly influences patient outcomes. In revision total knee arthroplasty, necessary bony landmarks may be missing or obscured, so there remains a lack of consensus on how to accurately identify and restore the joint line of the knee. In this study, 50 magnetic resonance images of normal knees were analyzed to determine a quantitative relationship between the joint line of the knee and 6 bony landmarks: medial and lateral femoral epicondyles, medial and lateral femoral metaphyseal flares, tibial tubercle, and proximal tibio-fibular joint. Wide variability was found in the absolute distance from each landmark to the joint line of the knee, including significant differences between the sexes. Normalization of the absolute distances to femoral or tibial diameters revealed reliable spatial relationships to the joint line of the knee. The joint line was found to be equidistant from the lateral femoral epicondyle and the proximal tibio-fibular joint, representing a reproducible point of reference for joint line restoration. The authors propose a simple 3-step algorithm that can be used with magnetic resonance imaging, computed tomography, or radiography to reliably determine the anatomical location of the joint line of the knee relative to the surrounding bony anatomy. [Orthopedics. 2016; 39(6):381-386.].
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.
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
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
Camanho, Gilberto Luiz
OBJECTIVE To present nine patients with ankylosis in their knees that were submitted to a total arthroplasty to lessen their pain and improve their functional limitation. For these patients, arthrodesis remained a possibility in the event of arthroplasty failure. INTRODUCTION Ankylosis of the knee is a severe functional limitation that becomes worse when pain is present. Arthrodesis of the knee is a classical indication for such patients, since it resolves the pain; however, the severe functional limitation remains. METHODS In the present study, we evaluated the clinical course of nine patients who underwent total arthroplasty of the knee, and were followed up for at least five years. RESULTS The results demonstrate that all of the patients experienced a significant reduction in pain and some improvement in the degree of knee flexion and extension. CONCLUSION Based on the latest follow-up, there has been no need to perform arthrodesis for any of our patients, showing that a total arthroplasty could be a option for treatment in knee ankylosis. PMID:19330242
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
Rittmeister, M; König, D P; Eysel, P; Kerschbaumer, F
The manuscript features the different minimally invasive approaches to the hip for joint replacement. These include medial, anterior, anterolateral, and posterior approaches. The concept of minimally invasive hip arthroplasty makes sense if it is an integral part of a larger concept to lower postoperative morbidity. Besides minimal soft tissue trauma, this concept involves preoperative patient education, preemptive analgesia, and postoperative physiotherapy. It is our belief that minimal incision techniques for the hip are not suited for all patients and all surgeons. The different minimally invasive approaches to the knee joint for implantation of a knee arthroplasty are described and discussed. There have been no studies published yet that fulfill EBM criteria. The data so far show that minimally invasive approaches and implantation techniques for total knee replacements lead to quicker rehabilitation of patients.
Schneider, R.; Soudry, M.
Various radiographic and scintigraphic methods are used to supplement clinical findings in the evaluation of total knee arthroplasty and its complications. Serial roentgenograms offer reliable information for diagnosing mechanical loosening. Wide and extensive radiolucency at the cement-bone interface and shift in position and alignment of prosthetic components can be seen in almost all cases by the time revision is necessary. Radiographic abnormalities are usually not present in acute infection, but are often present in chronic infection. Bone scanning has a high sensitivity for diagnosis of infection or loosening, but is nonspecific because increased uptake is often present around asymptomatic total knee arthroplasties with normal radiographs. Differential bone and Gallium scanning and scanning with Indium 111-labeled leukocytes have a greater specificity for diagnosis of infection than does bone or Gallium scanning alone. Routine radiographic and scintigraphic studies have shown a high incidence of deep vein thrombosis in the calf after total knee arthroplasty. Clinically significant pulmonary embolization is infrequent.
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.
Hurst, Jason M; Berend, Keith R
With the recent increase in medial unicompartmental arthroplasty, this article reviews the design history, indications, results, and modern technique for the implantation of the Oxford mobile-bearing unicompartmental arthroplasty. The article also discusses how the indications for the Oxford differ from the historical indications for medial unicompartmental arthroplasty and supports this paradigm shift with review of the recent data. A detailed series of surgical pearls is also presented to help surgeons with the surgical nuances of the Oxford partial knee. Copyright © 2014 Elsevier Inc. All rights reserved.
Hurst, Jason M; Berend, Keith R
With the recent increase in medial unicompartmental arthroplasty, this article reviews the design history, indications, results, and modern technique for the implantation of the Oxford mobile-bearing unicompartmental arthroplasty. The article also discusses how the indications for the Oxford differ from the historical indications for medial unicompartmental arthroplasty and supports this paradigm shift with review of the recent data. A detailed series of surgical pearls is also presented to help surgeons with the surgical nuances of the Oxford partial knee. Copyright © 2015 Elsevier Inc. All rights reserved.
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.
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
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.
Hooper, N; Snell, D; Hooper, G; Maxwell, R; Frampton, C
This study reports on the first 150 consecutive Oxford cementless unicompartmental knee arthroplasties (UKA) performed in an independent centre (126 patients). All eligible patients had functional scores (Oxford knee score and high activity arthroplasty score) recorded pre-operatively and at two- and five-years of follow-up. Fluoroscopically aligned radiographs were taken at five years and analysed for any evidence of radiolucent lines (RLLs), subsidence or loosening. The mean age of the cohort was 63.6 years (39 to 86) with 81 (53.1%) males. Excellent functional scores were maintained at five years and there were no progressive RLLs demonstrated on radiographs. Two patients underwent revision to a total knee arthroplasty giving a revision rate of 0.23/100 (95% confidence interval 0.03 to 0.84) component years with overall component survivorship of 98.7% at five years. There were a further four patients who underwent further surgery on the same knee, two underwent bearing exchanges for dislocation and two underwent lateral UKAs for disease progression. This was a marked improvement from other UKAs reported in New Zealand Joint Registry data and supports the designing centre's early results. ©2015 The British Editorial Society of Bone & Joint Surgery.
Kapadia, Bhaveen H; Pivec, Robert; Johnson, Aaron J; Issa, Kimona; Naziri, Qais; Daley, Jacqueline A; Mont, Michael A
Despite advances in our understanding of surgical site infections following total joint arthroplasty, this serious surgical complication continues to represent a substantial economic burden for the patient, the treating institution and the healthcare system. After increasing for the past decade, infection rates have stabilized at 1.6%; however, the total cost is projected to increase with the total number of revision procedures performed. A systematic review of the literature was performed to identify studies that assess the efficacy of pre-, peri- and post-operative infection prevention strategies in the setting of total hip or knee arthroplasty. Preference was given to randomized-controlled trials, data from national registries and meta-analyses within the past 5 years; however, all relevant articles were included in this analysis. The results of the literature search returned 549 articles that addressed infection in total joint arthroplasty, of which 71 specifically addressed infection prevention. Topics that were addressed included the CDC recommendations, skin preparation techniques, hair removal techniques, surgical draping techniques, operative dress, operating room ventilation, operating room traffic and antibiotic utilization. Newer infection prevention techniques, such as preoperative antiseptic scrubbing, are affected and may help reduce the infection rate, while traditionally accepted methods of prophylaxis such as laminar-flow operating rooms and body exhaust suits may raise the infection rate.
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.
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
Abolghasemian, Mansour; Samiezadeh, Saeid; Sternheim, Amir; Bougherara, Habiba; Barnes, C Lowry; Backstein, David J
A biomechanical computer-based model was developed to simulate the influence of patellar thickness on passive knee flexion after arthroplasty. Using the computer model of a single-radius, PCL-sacrificing knee prosthesis, a range of patella-implant composite thicknesses was simulated. The biomechanical model was then replicated using two cadaveric knees. A patellar-thickness range of 15 mm was applied to each of the knees. Knee flexion was found to decrease exponentially with increased patellar thickness in both the biomechanical and experimental studies. Importantly, this flexion loss followed an exponential pattern with higher patellar thicknesses in both studies. In order to avoid adverse biomechanical and functional consequences, it is recommended to restore patellar thickness to that of the native knee during total knee arthroplasty.
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.
Larson, A Noelle; Razonable, Raymund R; Hanssen, Arlen D
We report the case of a 59-year-old man with Waldenstrom's macroglobulinemia and active alcohol use who presented with bilateral knee pain 5 years after a bilateral staged TKA. Cultures of synovial fluid and periprosthetic tissue specimens from both knees yielded, after prolonged anaerobic incubation, a catalase- and oxidase-positive gram-negative bacillus, which was identified as Capnocytophaga canimorsus by 16S ribosomal RNA PCR analysis. C. canimorsus, an organism that is commonly found in dog and cat saliva, is a rare cause of various infections in immunocompromised and healthy individuals. However, a review of the medical literature indicates C. canimorsus has not been reported previously to cause infection after joint arthroplasty. The patient was immunocompromised by cytotoxic chemotherapy, corticosteroids, and alcohol use. The patient was managed successfully with bilateral two-stage exchange and 6 weeks of intravenous ertapenem therapy. Because of its fastidious and slow-growing characteristics, C. canimorsus may be an unrecognized cause of culture-negative joint arthroplasty infections, especially in cases when dog and cat exposure is evident in the clinical history.
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.
Słupik, Anna; Kowalski, Marcin; Białoszewski, Dariusz
The aim of the study was to compare the authors' own modification of the Staffelstein-Score against the HSS Knee Score in the assessment of early results of knee arthroplasty. A total of 67 patients qualified for knee arthroplasty (average age 68.5 years) were examined. 62 patients underwent a surgical procedure. A control group comprised 74 healthy patients (average age 67.5 years). Muscle strength and knee range of motion were measured and HSS Knee Score (HSS) and modified Staffelstein-Score (MSS) assessments were performed. The experimental group was assessed at baseline (Test 1) and at 8 (Test 2) and 100 (Test 3) days postoperatively. The control group was examined once. The Staffelstein-Scores on successive examinations were 67, 59 and 100 pts in the experimental group and 119 pts in the control group. Statistically significant differences were noted between the results within the experimental group and between the groups. The respective HSS Knee Score results were 46, 44 and 73 pts in the experimental group and 96 pts in the control group. Statistically significant differences were observed as regards the results, except the baseline assessment vs. Test 2. 1. The sensitivity of the HSS Knee Score is insufficient if tests are carried out at short intervals. It does not provide a balanced assessment of the functional capability and clinical performance of the joint. 2. The modified Staffelstein-Score has a high sensitivity to clinical changes, even those occurring a few days following an arthroplasty procedure. 3. The MSS is also useful as a balanced assessment of pain, joint functional capability and clinical examination results.
Bottomley, N.; Jones, L. D.; Rout, R.; Alvand, A.; Rombach, I.; Evans, T.; Jackson, W. F. M.; Beard, D. J.; Price, A. J.
Aims The aim of this to study was to compare the previously unreported long-term survival outcome of the Oxford medial unicompartmental knee arthroplasty (UKA) performed by trainee surgeons and consultants. Patients and Methods We therefore identified a previously unreported cohort of 1084 knees in 947 patients who had a UKA inserted for anteromedial knee arthritis by consultants and surgeons in training, at a tertiary arthroplasty centre and performed survival analysis on the group with revision as the endpoint. Results The ten-year cumulative survival rate for revision or exchange of any part of the prosthetic components was 93.2% (95% confidence interval (CI) 86.1 to 100, number at risk 45). Consultant surgeons had a nine-year cumulative survival rate of 93.9% (95% CI 90.2 to 97.6, number at risk 16). Trainee surgeons had a cumulative nine-year survival rate of 93.0% (95% CI 90.3 to 95.7, number at risk 35). Although there was no differences in implant survival between consultants and trainees (p = 0.30), there was a difference in failure pattern whereby all re-operations performed for bearing dislocation (n = 7), occurred in the trainee group. This accounted for 0.6% of the entire cohort and 15% of the re-operations. Conclusion This is the largest single series of the Oxford UKA ever reported and demonstrates that good results can be achieved by a heterogeneous group of surgeons, including trainees, if performed within a high-volume centre with considerable experience with the procedure. Cite this article: Bone Joint J 2016;(10 Suppl B):22–7. PMID:27694512
Koutras, George; Heep, Hansjoerg; Koutras, Christos
Objectives Long-term follow-up care after total joint arthroplasty is essential to evaluate hip and knee arthroplasty outcomes, to provide information to physicians and improve arthroplasty performance, and to improve patients' health condition. In this paper, we aim to improve the communication between arthroplasty patients and physicians and to reduce the cost of follow-up controls based on mobile application technologies and cloud computing. Methods We propose a mobile-based healthcare system that provides cost-effective follow-up controls for primary arthroplasty patients through questions about symptoms in the replaced joint, questionnaires (WOMAC and SF-36v2) and the radiological examination of knee or hip joint. We also perform a cost analysis for a set of 423 patients that were treated in the University Clinic for Orthopedics in Essen-Werden. Results The estimation of healthcare costs shows significant cost savings (a reduction of 63.67% for readmission rate 5%) in both the University Clinic for Orthopedics in Essen-Werden and the state of North Rhine-Westphalia when the mobile-based healthcare system is applied. Conclusions We propose a mHealth system to reduce the cost of follow-up assessments of arthroplasty patients through evaluation of diagnosis, self-monitoring, and regular review of their health status. PMID:28261533
GEORGEANU, Vlad; ATASIEI, Tudor; GRUIONU, Lucian
Introduction: The clinical studies have shown that the displacement of the prosthesis components, especially of the tibial one is higher during the first year, after which it reaches an equilibrum position compatible with a good long term functioning. This displacement takes place due to bone remodelling close to the implant secondary to different loading concentrations over different areas of bone. Material and Method: Our study implies a simulation on a computational model using the finite element analysis. The simulation started taking into account arbitrary points because of non-linear conditions of bone-prosthesis interface and it was iterative.. A hundred consecutive situations corresponding to intermediate bone remodelling phases have been calculated according to given loadings. Bone remodelling was appreciated as a function of time and bone density for each constitutive element of the computational model created by finite element method. For each constitutive element a medium value of stress during the walking cycle was applied. Results: Analyse of proximal epiphysis-prosthesis complex slices showed that bone density increase is maintained all over the stem in the immediately post-operative period. At 10 months, the moment considered to be the end of bone remodelling, areas with increased bone density are fewer and smaller. Meanwhile, their distribution with a concentration toward the internal compartment in the distal metaphysis is preserved. Conclusions: After the total knee arthroplasty the tibial bone suffered a process of remodelling adapted to the new stress conditions. This bone remodelling can influence, sometimes negatively, especially in the cases with tibial component varus malposition, the fixation, respectively the survival of the prosthesis. This process has been demonstrated both by clinical trials and by simulation, using the finite elements method of periprosthetic bone remodelling. PMID:25553127
Karachalios, Th; Varitimidis, S; Bargiotas, K; Hantes, M; Roidis, N; Malizos, K N
The Advance Medial-Pivot total knee arthroplasty (TKA) was designed to reflect contemporary data regarding the kinematics of the knee. We wished to examine the long-term results obtained with this prosthesis by extending a previous evaluation. We retrospectively evaluated prospectively collected data from 225 consecutive patients (41 men and 184 women; mean age at surgery 71 years, 52 to 84) who underwent 284 TKAs with a mean follow-up of 13.4 years (11 to 15). Implant failure, complication rate, clinical (both subjective and objective) and radiological outcome were assessed. Pre- and post-operative clinical and radiographic data were available at regular intervals for all patients. A total of ten patients (4.4%; ten TKAs) were lost to follow-up. Survival analysis at 15 years showed a cumulative success rate of 97.3% (95% confidence interval (CI) 96.7 to 97.9) for revision for any reason, of 96.4% (95% CI 95.2 to 97.6) for all operations, and 98.8% (95% CI 98.2 to 99.4) for aseptic loosening as an end point. Three TKAs (1.06%) were revised due to aseptic loosening, two (0.7%) due to infection, one (0.35%) due to instability and one (0.35%) due to a traumatic dislocation. All patients showed a statistically significant improvement on the Knee Society Score (p = 0.001), Western Ontario and McMaster University Osteoarthritis Index (p = 0.001), Short Form-12 (p = 0.01), and Oxford Knee Score (p = 0.01). A total of 207 patients (92%) were able to perform age appropriate activities with a mean flexion of the knee of 117° (85° to 135°) at final follow-up. This study demonstrates satisfactory functional and radiographic long-term results for this implant. Cite this article: Bone Joint J 2016;98-B:1050-5. ©2016 The British Editorial Society of Bone & Joint Surgery.
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.
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.
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.
Martínez-Vélez, David; González-Fernández, Enrique; Esteban, Jaime; Cordero-Ampuero, José
The risk of knee arthroplasty infection and appropriateness of antibiotic treatment are not clearly established in patients with preoperative asymptomatic bacteriuria. It has been the purpose to analyze the prevalence of preoperative asymptomatic bacteriuria in knee arthroplasty patients, as well as the incidence of prosthetic joint infection in those with asymptomatic bacteriuria treated and not with specific antibiotics. This prospective study included 215 consecutive knee arthroplasty patients (73 ± 6 years, 168 females) with neither urinary symptoms nor perioperative urethral catheterization. A "clean-catch" urinalysis was obtained from all patients before surgery and an urine culture if urinalysis was abnormal. Asymptomatic bacteriuria was diagnosed if >100,000 colony-forming units/ml were cultured. Patients were treated (Group A) or not (Group B) with additional specific antibiotics for urine bacteria according to surgeon criteria. Minimum follow-up reached 48 months. No patient was lost to follow-up. Asymptomatic bacteriuria was diagnosed in 11/215 patients (5.1 %) (11/11 females), and four of these 11 were treated with specific antibiotics (Group A). Only one patient in Group A suffered a prosthesis infection along the first 3 months (1/125, 0.5 %), but bacteria cultured from the wound were absolutely different to those in urine culture. No patient in Group B suffered a prosthesis infection. Asymptomatic bacteriuria presents a low prevalence. We have not found any case of arthroplasty infection from urinary focus in patients with asymptomatic bacteriuria whether they received or not specific antibiotics.
Arliani, Gustavo Gonçalves; Júnior, João Alberto Yazigi; Angelini, Felipe Bertelli; Ferlin, Fernando; Hernandes, Andrea Canizares; Astur, Diego da Costa; Cohen, Moises
Objective: The aim of this study was to evaluate the approaches and procedures used by Brazilian orthopedic surgeons for treating osteoarthrosis by means of unicompartmental knee arthroplasty and high tibial osteotomy of the knee. Methods: A questionnaire with 14 closed questions was developed and applied to Brazilian knee surgeons during the three days of the 43rd Brazilian Congress of Orthopedics and Traumatology. Results: A total of 113 surgeons filled out the questionnaire completely and became part of the sample analyzed. In this study, the majority of the surgeons performed fewer than five unicompartmental knee arthroplasty procedures/year (61.1%) and between 5 and 15 high tibial osteotomy procedures/year (37.2%). Use of computerized navigation systems during surgery remains uncommon in our environment, since only 0.9% of the specialists were using it. 65.5% of the surgeons reported that they had chosen to use total knee arthroplasty rather than partial arthroplasty due to lack of familiarity with the surgical technique. When asked about the possibility that the number of unicompartmental prostheses used in Brazil would grow as surgeons in this country become increasingly familiar with the technique, 80.5% of the respondents believed in this hypothesis. In this sample, we found that the greater the surgeon's experience was, the greater the numbers of unicompartmental prostheses and tibial osteotomies performed annually were (r = 0.550 and r = 0.465, respectively; p < 0.05). Conclusions: There is a clear evolutional trend towards treatment of unicompartmental osteoarthritis using partial knee arthroplasty in Brazil. However, further prospective controlled studies are needed in order to evaluate the clinical and scientific benefits of these trends. PMID:27047891
Pour, Aidin Eslam; Bradbury, Thomas L; Horst, Patrick; Harrast, John J; Erens, Greg A; Roberson, James R
A certified list of all operative cases performed within a six month period is required of surgeons by the American Board of Orthopaedic Surgery (ABOS) as a prerequisite to taking the Part II Oral Examination. Using the data on these cases collected and maintained by ABOS, this study assessed the influence of prior fellowship training in adult reconstruction on the volume and surgeon-reported complication rate of knee joint arthroplasty cases over time. All data were self reported to a secure Internet database (SCRIBE) by candidates who applied to take Part II of the ABOS Examination for the first time. This database was searched for all procedures done between 2003 and 2013 with CPT codes for total and revision knee arthroplasty and removal of knee implant (static or dynamic spacer) to determine procedural volumes and early complication rates among Board-eligible orthopaedic surgeons with and without adult reconstructive fellowship training. More than 43,000 knee arthroplasty surgeries were identified. Surgeons who had completed adult reconstruction fellowship training after residency performed 55 % of total knee arthroplasties, averaging 33.5 knee arthroplasties during the six month case-collection period compared to 7.4 procedures by non-fellowship-trained surgeons (p < 0.001). Adult reconstruction fellowship-trained surgeons performed significantly more revisions for infection (average 6.6 versus 2.2 revisions) (p < 0.001). Adult reconstruction fellowship training did not significantly affect complication rates for primary arthroplasty but was associated with an increased complication rate for revisions. Those surgeons who performed more than 100 arthroplasties a year reported significantly fewer complications in primary arthroplasties (12.7 % versus 16.9 %) (p < 0.001). Over time, an increasing percentage of arthroplasties were done by surgeons with adult reconstruction fellowship training. Adult reconstruction fellowship-trained surgeons
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
Antuña, S A; Méndez, J G; Castellanos, J L; Jimenez, J P
The authors report a case of Pasteurella multocida infection in a total knee arthroplasty as a result of a dog bite. The patient was treated with one-stage reimplantation of a new prosthesis and with intravenous antibiotics, resulting in complete relief of symptoms with no evidence of recurrence of infection after 24 months.
Jeong, Min; Shin, Sung Jin; Kang, Byoung Youl
Insufficiency fracture of the calcaneus is a rare entity. In the absence of trauma, evaluating a painful ankle in an elderly patient can be difficult and also it might be overlook the insufficiency fracture. We experienced a case of insufficiency calcaneus fracture that occurred after ipsilateral total knee arthroplasty. Here, we report our case with a review of literatures. PMID:26981521
König, A; Kirschner, S
The number of total knee arthroplasties performed per year has increased steadily. This increase will probably continue since the principal risk factors obesity and advanced age will increase as well. The results of total knee arthroplasty are influenced by many physical, psychological, and social factors, which are presented. These factors have not been taken into account sufficiently by most of the investigations performed so far. Therefore, very few long-term data on the quality of life and functional gain are available. Survival analyses of single centers exhibit serious methodological flaws and a simplified data presentation, which reduces the generalizability of these results considerably. A critical analysis of these results was performed. Total knee arthroplasty has positive effects on the patient's pain level, ability to walk, and quality of life. There are a number of reliable uni- and tricompartmental designs. The revision rate is influenced by age, sex, disease, fixation mode, and prosthetic design. Tricompartmental prostheses have a revision rate of about 7% after 10 years. The revision rate has continuously improved over the last decades. Studies on total knee arthroplasty can be improved considerably according to international standards in terms of methodology and presentation of the results. The results from the patient's perspective need to be taken more into account.
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.
Heyse, Thomas J; Slane, Joshua; Peersman, Geert; Dworschak, Philipp; Fuchs-Winkelmann, Susanne; Scheys, Lennart
Balancing mobile-bearing (MB) unicondylar knee arthroplasty (UKA) is challenging. If performed improperly, potential complications include pain, implant loosening, or progression of osteoarthritis in the preserved compartment. The purpose of this study was to document effects of improper balancing on knee kinematics and joint contact stress. It was hypothesized that over-stuffing would lead to more valgus and higher lateral contact force. Seven fresh-frozen cadaver legs were mounted in a kinematic rig that applied three motion patterns to the specimens: passive flexion-extension, open chain extension, and squatting. During testing, an infrared camera system recorded the trajectories of markers rigidly attached to femur and tibia, while a pressure sensor measured contact pressure in the lateral compartment. Prior computer tomography scans allowed identification of coordinate frames of the bones and calculations of anatomical rotations and translations. Collateral ligament strains were calculated, and quadriceps forces recorded. Following testing on the native knee, a medial MB UKA was implanted in each specimen and all motion trials were repeated. Three inlay thicknesses were tested to simulate optimal balancing as well as under- (1 mm thinner) and over-stuffing (1 mm thicker) of the medial compartment relative to the optimal thickness. Under-stuffing of the medial compartment leads to kinematics closest to the native knee. Subjectively balanced and over-stuffed MB UKA knees were in more valgus. Lateral peak contact stress was higher from mid- to deep flexion following UKA in all three tested states; however, these results were not significant. Peak strain in the superficial medial collateral ligament (sMCL) was significantly higher in MB UKA, regardless of the inlay thickness mainly in mid-flexion. Inlay thickness had no significant impact on measured quadriceps force during squatting. The results underline the importance of optimal balancing. Over
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.
Feldscher, Sheri B
Although protocols provide therapists with the scaffolding with which to build a treatment program, it is the judgment, knowledge, and skills of the therapist, and how the one uses such information that allows for modification of a protocol when deemed necessary. This therapist outlines how she modified a postsurgical protocol by using anatomy, biomechanics, the literature, and clinical judgment. This article describes the methodical approach used to successfully modify a standard postsurgical protocol after a PIP joint 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.
Wang, Shangzeng; Cheng, Shao; Wang, Yisheng
To evaluate the effectiveness of Oxford mobile-bearing bipolar prosthesis unicompartmental knee arthroplasty (UKA) in the treatment of single compartmental knee osteoarthritis. Between June 2011 and July 2013, 22 cases of single compartmental knee osteoarthritis were treated by Oxford mobile-bearing bipolar prosthesis UKA. Of 22 cases, 8 were male and 14 were female with an average age of 65 years (range, 45-80 years); the left knee was involved in 12 cases, and the right knee in 10 cases, with a mean disease duration of 32.5 months (range, 8-90 months). The mean weight was 55.2 kg (range, 50-65 kg), and the mean body mass index was 20.8 kg/m2 (range, 17-25 kg/m2). Osteoarthritis involved in the single knee medial compartment in all patients. Knee society score (KSS) and range of motion (ROM) were measured to evaluate the knee joint function. Primary healing of incision was obtained in all patients, and there was no complication of infection, bedsore, or deep venous thrombosis. Postoperative follow-up was 2-4 years (mean, 3.2 years). The X-ray films showed good position of prosthesis, no prosthesis dislocation, or periprosthetic infection during follow-up. Knee ROM, KSS function score, and KSS clinical score were significantly improved at 1 week after operation and at last follow-up when compared with preoperative ones (P < 0.05), but no significant difference was shown between at 1 week and at last follow-up (P > 0.05). Oxford mobile-bearing bipolar prosthesis UKA is an effective method to treat single compartmental knee osteoarthritis, with the advantages of less trauma, earlier rehabilitation exercise, near physiological state in joint function, and less risk of complications.
Goh, Graham Seow-Hng; Liow, Ming Han Lincoln; Lim, Winston Shang-Rong; Tay, Darren Keng-Jin; Yeo, Seng Jin; Tan, Mann Hong
The Zimmer iASSIST system is a novel accelerometer-based navigation system for TKA. 76 patients (76 knees) were prospectively matched for age, BMI, gender, diagnosis, and pre-operative scores, and underwent TKA using the iASSIST (n=38) or optical CAS (n=38). There were no significant differences in clinical outcomes or satisfaction rates at six months post-operatively (P>0.05). Mechanical axis was 1.8±1.3° in the iASSIST cohort versus 2.1±1.6° in the CAS cohort (P=0.543). There were no significant differences in number of outliers for mechanical axis (P=1.000), coronal femoral-component angle (P=0.693), coronal tibial-component angle (P=0.204) or joint line deviation (P=1.000). The duration of surgery was significantly longer in the CAS group (P<0.001), while the added cost of accelerometer-based navigation was approximately $1000 per operation.
Davies, B L; Rodriguez y Baena, F M; Barrett, A R W; Gomes, M P S F; Harris, S J; Jakopec, M; Cobb, J P
A brief history of robotic systems in knee arthroplasty is provided. The place of autonomous robots is then discussed and compared to more recent 'hands-on' robotic systems that can be more cost effective. The case is made for robotic systems to have a clear justification, with improved benefits compared to those from cheaper navigation systems. A number of more recent, smaller, robot systems for knee arthroplasty are also described. A specific example is given of an active constraint medical robot, the ACROBOT system, used in a prospective randomized controlled trial of unicondylar robotic knee arthroplasty in which the robot was compared to conventional surgery. The results of the trial are presented together with a discussion of the need for measures of accuracy to be introduced so that the efficacy of the robotic surgery can be immediately identified, rather than have to wait for a number of years before long-term clinical improvements can be demonstrated.
Kamara, Eli; Berliner, Zachary P; Hepinstall, Matthew S; Cooper, H John
There has been a great increase in the use of navigation technology in joint arthroplasty. In most types of navigation-assisted surgery, several temporary navigation pins are placed in the patient. Goals of this study are (1) to identify complications and (2) risk factors associated with placement of these pins. This is a retrospective cohort study of all navigation-assisted hip and knee arthroplasty performed a single institution over a 3-year period. Records were reviewed and outcome measures were tabulated in a database. Complications included in the database were pin site infection, deep prosthetic joint infection, neurologic injury, vascular injury, and fracture through a pin site. A total of 3136 pin sites in 839 patients were included in the study. Five pin site complications were reported with a complication rate of 0.16% per pin site and 0.60% per patient. The complications-per-procedure were slightly higher for unicondylar knee arthroplasty (0.64%) compared with patellofemoral arthroplasty (0%) and total hip arthroplasty (0.46%), but not statistically significant. There were three infections, one neuropraxia, and one suture abscess. No periprosthetic fractures through a pin site were reported. All complications were resolved with nonoperative treatment. The infections required oral antibiotics, and were associated with transcortical drilling in two cases and juxtacortical drilling in the third. Pins required for navigation-assisted arthroplasty have a low complication rate. Transcortical or juxtacortical drilling may be a risk factor for pin site infection; future studies should be directed at quantifying this effect. Copyright © 2017 Elsevier Inc. All rights reserved.
Watanabe, Toshifumi; Abbasi, Ali Z; Conditt, Michael A; Christopher, Jennifer; Kreuzer, Stefan; Otto, Jason K; Banks, Scott A
There is great interest in providing reliable and durable treatments for one- and two-compartment arthritic degeneration of the cruciate-ligament intact knee. One approach is to resurface only the diseased compartments with discrete unicompartmental components, retaining the undamaged compartment(s). However, placing multiple small implants into the knee presents a greater surgical challenge than total knee arthroplasty, so it is not certain that the natural knee mechanics can be maintained or restored. The goal of this study was to determine whether near-normal knee kinematics can be obtained with a robot-assisted multi-compartmental knee arthroplasty. Thirteen patients with 15 multi-compartmental knee arthroplasties using haptic robotic-assisted bone preparation were involved in this study. Nine subjects received a medial unicompartmental knee arthroplasty (UKA), three subjects received a medial UKA and patellofemoral (PF) arthroplasty, and three subjects received medial and lateral bi-unicondylar arthroplasty. Knee motions were recorded using video-fluoroscopy an average of 13 months (6-29 months) after surgery during stair and kneeling activities. The three-dimensional position and orientation of the implant components were determined using model-image registration techniques. Knee kinematics during maximum flexion kneeling showed femoral external rotation and posterior lateral condylar translation. All knees showed femoral external rotation and posterior condylar translation with flexion during the step activity. Knees with medial UKA and PF arthroplasty showed the most femoral external rotation and posterior translation, and knees with bicondylar UKA showed the least. Knees with accurately placed uni- or bi-compartmental arthroplasty exhibited stable knee kinematics consistent with intact and functioning cruciate ligaments. The patterns of tibiofemoral motion were more similar to natural knees than commonly has been observed in knees with total knee
Ivie, Conrad B; Probst, Patrick J; Bal, Amrit K; Stannard, James T; Crist, Brett D; Sonny Bal, B
Patient-specific guides can improve limb alignment and implant positioning in total knee arthroplasty, although not all studies have supported this benefit. We compared the radiographs of 100 consecutively-performed patient-specific total knees to a similar group that was implanted with conventional instruments instead. The patient-specific group showed more accurate reproduction of the theoretically ideal mechanical axis, with fewer outliers, but implant positioning was comparable between groups. Our odds ratio comparison showed that the patient-specific group was 1.8 times more likely to be within the desired +3° from the neutral mechanical axis when compared to the standard control group. Our data suggest that reliable reproduction of the limb mechanical axis may accrue from patient-specific guides in total knee arthroplasty when compared to standard, intramedullary instrumentation.
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.
Anglin, Carolyn; Brimacombe, Jill M; Wilson, David R; Masri, Bassam A; Greidanus, Nelson V; Tonetti, Jérôme; Hodgson, Antony J
The optimal amount of patellar component medialization in knee arthroplasty is unknown. We measured the impact, on patellofemoral kinematics and contact force distribution, of 0.0-, 2.5-, and 5.0-mm patellar component medialization in 7 cadaveric specimens implanted with knee arthroplasty components. The knees were flexed dynamically in a weight-bearing rig. Medialization led to lateral shift of the patellar bone, slight medial shift of the patellar component in the femoral groove, lateral tilt of the patella, reduced patellofemoral contact force in later flexion, and lateral shift of the center of pressure in early flexion. Effects on shift and tilt were proportional to the amount of medialization. As a result of this investigation, we recommend medializing the patellar component slightly-on the order of 2.5 mm. Copyright (c) 2010 Elsevier Inc. All rights reserved.
Ritterman, Scott; Rubin, Lee E
Total hip and knee replacement are two of the most common and successful elective surgeries preformed in the United States each year. Preoperative medical preparation and postoperative rehabilitation are equally important to a successful outcome. Physical deconditioning, tobacco use, obesity and medical co-morbidities can adversely affect outcomes and should be addressed before any elective procedure. Formal postoperative therapy is geared towards the specific surgery and is aimed at returning the patient to independent activity.
Chi, Zihui; Zhao, Yuan; Huang, Lin; Zheng, Zhu; Jiang, Huabei
Knee joint is one of the largest and most complex joints of the body. Knee joint diseases are common, and current clinical imaging technologies such as x-ray computed tomography, magnetic resonance imaging, and ultrasound imaging have limitations in the diagnosis of knee joint diseases. Emerging imaging technologies such as diffuse optical tomography and photoacoustic imaging (PAI) have been applied to the detection of osteoarthritis (OA). However, they are limited to small joints such as the finger and difficult to be used for large joints such as the knee. Thermoacoustic imaging (TAI), also an emerging modality, provides high contrast and deep tissue penetration. Here, the authors apply TAI to the knee joint and demonstrate the potential of TAI for imaging large joints. Adult New Zealand male rabbits (average weight = 2 kg) were chosen for this study. In a TAI experiment, a rabbit was placed in a holder to keep in a genuflex position after being injected with pentobarbital through its ear margin intravenous (30 mg/kg). The holder and the rabbit were then positioned under the horn antenna of the TAI system for signal acquisition and image reconstruction. After the experiment, the imaged knee joint was dissected and photographed. Identical procedures were performed for several rabbits (n = 4). Finally, detailed comparative analyses between TAI images and anatomical pictures of the knee joint were conducted. There were high similarities between the reconstructed TAI images and anatomical pictures of the knee joint, in terms of the shape and size of various knee joint tissues. TAI could clearly image ligament, fat pad, and other joint tissues. The differences in appearance of TAI images due to motion effect of the knee joint were also discussed. TAI could reveal details of rabbit knee joint in high resolution. As the recovered TAI images represent the dielectric property distributions of joint tissues, TAI may offer a new tool for noninvasive detection of joint
a seven-fold increase in total knee arthroplasty (TKA) within the past 40 years . More importantly perhaps is that the incidence over the past...that a higher level of physical activity places individuals at greater risk for developing osteoarthritis (OA) [8–10]. Military service members in...Medical Evaluation Board (MEB), the military disability system equivalent, is OA. After a hip or knee arthroplasty, patients are advised to make
Zhang, Wei; Lyman, Stephen; Boutin-Foster, Carla; Parks, Michael L; Pan, Ting-Jung; Lan, Alexis; Ma, Yan
Previous studies of racial disparities in total joint replacement, particularly total knee arthroplasty, in the U.S. have predominantly focused on disparities between blacks and whites and were limited to Medicare patients or veterans, populations that are not representative of the entire U.S. We sought to study racial disparities in the utilization of total knee arthroplasty, the use of high-volume hospitals, and total knee arthroplasty outcomes, including mortality and complications, using all-payer databases. We analyzed data from 8 years and 8 racially diverse states in the State Inpatient Databases (SID). Patient race was categorized according to the SID as white, black, Hispanic, Asian, Native American, and mixed race. Both crude and adjusted racial and/or ethnic disparities were evaluated. In comparison with whites (4.65 per 1000 population per year), black (3.90), Hispanic (3.71), Asian (3.89), Native American (4.40), and mixed-race (3.69) populations had lower rates of total knee arthroplasty utilization (p < 0.0001). After risk adjustment, the rate of total knee arthroplasty utilization was significantly lower for blacks (odds ratio [OR] = 0.87 [95% confidence interval (CI), 0.85 to 0.89]; p < 0.0001), Hispanics (OR = 0.76 [95% CI, 0.68 to 0.83]; p < 0.0001), Asians (OR = 0.83 [95% CI, 0.78 to 0.89]; p < 0.0001), Native Americans (OR = 0.87 [95% CI, 0.81 to 0.93]; p < 0.0001), and mixed race (OR = 0.84 [95% CI, 0.79 to 0.90]; p < 0.0001) compared with the rate for whites. Lower rates of total knee arthroplasty utilization for blacks, Hispanics, and mixed-race groups became worse over the years. Patients from minority groups were less likely to undergo total knee arthroplasty in high-volume hospitals than were whites. Moreover, the rates of mortality were significantly higher for blacks (OR = 1.52 [95% CI, 1.17 to 1.97]; p = 0.0017), Native Americans (OR = 6.52 [95% CI, 4.63 to 9.17]; p < 0.0001), and mixed-race patients (OR = 4.35 [95% CI, 3.24 to 5
Purpose total joint replacement is one of the most successful procedures in medicine and cost reimbursements to hospitals for the joint arthroplasty diagnosis-related group are among the largest payments made by a Regional Health Service. Despite the popularity of these procedures, there are few high-quality cost-effectiveness studies on this topic. This study evaluates the cost of total joint arthroplasty performed in a district hospital. Methods direct and indirect costs have been measured and patient procedure pathway was analyzed subdivided into three stages: surgical procedure, inpatient care and outpatient clinic. Results the cost of the surgical procedure stage was calculated as 3,798 euros, while that of the inpatient stage was 2,924 euros. The mean hospital costs per procedure amounted to 6,952 euros. Conclusions although the Health Service tariffs fully reimburse the cost of providing a joint replacement, our data contribute to point out the role of hospital staff’s organization to support sustainable improvements on health care for joint replacement surgery. Level of evidence Level VI, single economic evaluation. PMID:26904524
total joint replacement is one of the most successful procedures in medicine and cost reimbursements to hospitals for the joint arthroplasty diagnosis-related group are among the largest payments made by a Regional Health Service. Despite the popularity of these procedures, there are few high-quality cost-effectiveness studies on this topic. This study evaluates the cost of total joint arthroplasty performed in a district hospital. direct and indirect costs have been measured and patient procedure pathway was analyzed subdivided into three stages: surgical procedure, inpatient care and outpatient clinic. the cost of the surgical procedure stage was calculated as 3,798 euros, while that of the inpatient stage was 2,924 euros. The mean hospital costs per procedure amounted to 6,952 euros. although the Health Service tariffs fully reimburse the cost of providing a joint replacement, our data contribute to point out the role of hospital staff's organization to support sustainable improvements on health care for joint replacement surgery. Level VI, single economic evaluation.
Voronov, Michael L; Pinzur, Michael S; Havey, Robert M; Carandang, Gerard; Gil, Joseph A; Hopkinson, William J
Surgeons have questioned whether foot deformity applies abnormal loading on a knee implant. A total of 24 patients with mild knee deformity underwent a static recording of foot loading prior to and at 3 months following knee replacement. Of these patients, 13 had a preoperative varus deformity. The recorded postoperative to preoperative loading in all 6 geographic sites was decreased by an average of 10%. The largest changes were observed in the hallux and lesser toe masks, whereas the postoperative to preoperative foot pressure ratio in the metatarsal head (lateral and medial), heel, and midfoot masks was 0.94. This preliminary investigation reveals a minimal change in geographic foot loading following total knee arthroplasty in patients with mild knee deformity.
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
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.
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
Eaton, M. J.; Nutton, R. W.; Wade, F. A.; Evans, S. L.; Pankaj, P.
Objectives Up to 40% of unicompartmental knee arthroplasty (UKA) revisions are performed for unexplained pain which may be caused by elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on bone strain in a cemented fixed-bearing medial UKA using a finite element model (FEM) validated experimentally by digital image correlation (DIC) and acoustic emission (AE). Materials and Methods A total of ten composite tibias implanted with all-polyethylene (AP) and metal-backed (MB) tibial components were loaded to 2500 N. Cortical strain was measured using DIC and cancellous microdamage using AE. FEMs were created and validated and polyethylene thickness varied from 6 mm to 10 mm. The volume of cancellous bone exposed to < -3000 µε (pathological loading) and < -7000 µε (yield point) minimum principal (compressive) microstrain and > 3000 µε and > 7000 µε maximum principal (tensile) microstrain was computed. Results Experimental AE data and the FEM volume of cancellous bone with compressive strain < -3000 µε correlated strongly: R = 0.947, R2 = 0.847, percentage error 12.5% (p < 0.001). DIC and FEM data correlated: R = 0.838, R2 = 0.702, percentage error 4.5% (p < 0.001). FEM strain patterns included MB lateral edge concentrations; AP concentrations at keel, peg and at the region of load application. Cancellous strains were higher in AP implants at all loads: 2.2- (10 mm) to 3.2-times (6 mm) the volume of cancellous bone compressively strained < -7000 µε. Conclusion AP tibial components display greater volumes of pathologically overstrained cancellous bone than MB implants of the same geometry. Increasing AP thickness does not overcome these pathological forces and comes at the cost of greater bone resection. Cite this article: C. E. H. Scott, M. J. Eaton, R. W. Nutton, F. A. Wade, S. L. Evans, P. Pankaj. Metal-backed versus all-polyethylene unicompartmental knee arthroplasty: Proximal
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.
Koenen, Paola; Bäthis, Holger; Schneider, Marco M; Fröhlich, Matthias; Bouillon, Bertil; Shafizadeh, Sven
Patients' expectations have become increasingly important over the last decade, as the fulfilment of preoperative expectations has been shown to be associated with postoperative satisfaction. Understanding the pattern of patients' expectations is necessary to provide a better basis for recommendations to patients opting for arthroplasty. The aim of this study was to show patients' expectations of joint replacement surgery in Germany and to elucidate factors, which might have an influence. A retrospective analysis of anonymously collected data was performed on people participating in a patient information event for joint replacement surgery. They were asked to complete a survey, which consisted of five questions requesting demographic data and three questions regarding preoperative expectations. The latter were taken from the New Knee Society Score. An expectation score (0-12 points) was generated by adding the single point values of the three questions. 180 attendees were included in this study. The distribution of patients' expectations was remarkably skewed towards high expectations, the mean expectation score was 10.17. 87.2 % of participants had high and very high expectations and only 12.8 % had low and moderate expectations. Patients' expectations were independent of age and previous participation in a patient information event. Female gender and a history of arthroplasty led to a slightly higher expectation score. Patients with isolated knee pain had significantly lower expectations than patients suffering from isolated hip pain. This study shows that the majority of patients have high expectations regarding joint replacement surgery. To improve postoperative patients' satisfaction a straightforward physician-patient communication is necessary to prevent patients from potentially unrealistic expectations and therefore dissatisfaction with surgery.
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
Takano, Y; Ueno, M; Kiguchi, K; Ito, J; Mawatari, M; Hotokebuchi, T
A purpose of this study is to examine the effect that quadriceps femoris force gives to rotation angle and joint reaction force of total knee prosthesis during deep knee flexion such as a unique sitting style called 'seiza' in Japanese. For the evaluation, we developed the knee motion simulator which could bend to 180 degrees continually simulating the passive flexion performed by clinicians. A total knee prosthesis, which is a specially-devised posterior stabilized type and capable of flexion up to 180 degrees, was inserted into bone model. And this prosthesis pulled by three kinds of quadriceps femoris forces to perform parameter study. The results obtained in this study were showed the same tendency with those in the past cadaveric experiment. It is suggested that the rotation angle and joint reaction force of total knee prosthesis are affected by shape of prosthesis, a vector of quadriceps femoris force, and bony aliments during deep knee flexion.
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.
Halawi, Mohamad J; Vovos, Tyler J; Green, Cindy L; Wellman, Samuel S; Attarian, David E; Bolognesi, Michael P
The purpose of this study was to identify preoperative predictors of discharge destination after total joint arthroplasty. A retrospective study of three hundred and seventy-two consecutive patients who underwent primary total hip and knee arthroplasty was performed. The mean length of stay was 2.9 days and 29.0% of patients were discharged to extended care facilities. Age, caregiver support at home, and patient expectation of discharge destination were the only significant multivariable predictors regardless of the type of surgery (total knee versus total hip arthroplasty). Among those variables, patient expectation was the most important predictor (P < 0.001; OR 169.53). The study was adequately powered to analyze the variables in the multivariable logistic regression model, which had a high concordance index of 0.969.
Correia, João; Kendoff, Daniel; Klatte, Till Orla; Gehrke, Thorsten; Citak, Mustafa
Total joint replacements provide many benefits to patients but expose them to a variety of possible complications. Revision surgery is demanding and associated to a greater number of risks and possible complications than primary joint replacement. We describe the unsuccessful technique of percutaneous cementing in a loosened revision total knee arthroplasty. We report on a 66-year old male patient, admitted to our clinic with a painful left knee, four months after percutaneous cementation without implant exchange of the loosened rotating hinge implant was performed. Although less demanding, for the surgeon and the patient, it resulted in a delayed revision surgery. This attempt at avoiding revision surgery could have led to even further complications. This case emphasizes the need to avoid novel techniques on patients, with no previous studies and to refer these patients to specialized joint replacement centers for revision surgery.
Hamilton, T. W.; Pandit, H. G.; Lombardi, A. V.; Adams, J. B.; Oosthuizen, C. R.; Clavé, A.; Dodd, C. A. F.; Berend, K. R.; Murray, D. W.
Aims An evidence-based radiographic Decision Aid for meniscal-bearing unicompartmental knee arthroplasty (UKA) has been developed and this study investigates its performance at an independent centre. Patients and Methods Pre-operative radiographs, including stress views, from a consecutive cohort of 550 knees undergoing arthroplasty (UKA or total knee arthroplasty; TKA) by a single-surgeon were assessed. Suitability for UKA was determined using the Decision Aid, with the assessor blinded to treatment received, and compared with actual treatment received, which was determined by an experienced UKA surgeon based on history, examination, radiographic assessment including stress radiographs, and intra-operative assessment in line with the recommended indications as described in the literature. Results The sensitivity and specificity of the Decision Aid was 92% and 88%, respectively. Excluding knees where a clear pre-operative plan was made to perform TKA, i.e. patient request, the sensitivity was 93% and specificity 96%. The false-positive rate was low (2.4%) with all affected patients readily identifiable during joint inspection at surgery. In patients meeting Decision Aid criteria and receiving UKA, the five-year survival was 99% (95% confidence intervals (CI) 97 to 100). The false negatives (3.5%), who received UKA but did not meet the criteria, had significantly worse functional outcomes (flexion p < 0.001, American Knee Society Score - Functional p < 0.001, University of California Los Angeles score p = 0.04), and lower implant survival of 93.1% (95% CI 77.6 to 100). Conclusion The radiographic Decision Aid safely and reliably identifies appropriate patients for meniscal-bearing UKA and achieves good results in this population. The widespread use of the Decision Aid should improve the results of UKA. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):3–10. PMID:27694509
Otero, Jesse E; Gholson, J Joseph; Pugely, Andrew J; Gao, Yubo; Bedard, Nicholas A; Callaghan, John J
Length of hospital stay is a quality metric in joint arthroplasty. Rapid recovery protocols have safely reduced the average length of hospitalization, but it is unclear whether there is a difference in complication and readmission rates between patients discharged the day of surgery or on postoperative day 1 (POD 1). We calculated 30-day complication and readmission after total knee arthroplasty (TKA), total hip arthroplasty (THA), and unicompartmental knee arthroplasty (UKA) based on day of discharge. We then analyzed the rapid recovery group by comparing those discharged the day of surgery and those discharged on POD 1. Patients undergoing joint arthroplasty between 2011 and 2013 were selected from the American College of Surgeons (ACS) National Surgical Quality Improvement Program. Demographics, comorbidities, and 30-day complication and readmission were determined based on discharge date. Propensity-matched comparisons were performed between patients discharged POD 0 vs POD 1. We used multivariate logistic regression to determine independent risk factors for 30-day complication and readmission. There was no difference in complication or readmission after TKA or UKA between POD 0 or POD 1 discharge. In the propensity-matched cohort in THA, however, there was an increased rate of any complication in the POD 0 compared with the POD 1 discharge cohort. Risk factors for complication and readmission among THA, TKA, and UKA include age >80 years and smoking, and discharge after day 3. Increased length of stay is associated with increased complication and readmission after joint arthroplasty for patients with a hospital stay of 3 or more days. However, in THA, there was an increased complication rate in patients discharged POD 0 as compared to POD 1. Efforts to improve patient selection are expected to reduce short-term complications after outpatient joint arthroplasty. Further research is needed to determine which patients can be discharged POD 0 without increased
Dennis, Douglas A; Komistek, Richard D; Mahfouz, Mohamed R; Walker, Scott A; Tucker, Abby
A multicenter analysis was done to determine in vivo femorotibial axial rotation magnitudes and patterns in 1,027 knees (normal knees, nonimplanted ACL-deficient knees, and multiple designs of total knee arthroplasty). All knees were analyzed using fluoroscopy and a three-dimensional computer model-fitting technique during a deep knee bend and/or gait. Normal knees showed 16.5 degrees and 5.7 degrees of internal tibial rotation during a deep knee bend and gait, respectively. Rotation magnitudes and the percent having normal axial rotation patterns decreased in all total knee arthroplasty groups during a deep knee bend. During gait, all knee arthroplasty groups had similar rotational patterns (limited magnitudes). Average axial rotational magnitudes in gait and a deep knee bend were similar among major implant categories (ie, fixed-bearing versus mobile-bearing, etc). Average values in normal knees and ACL-retaining total knee arthroplasty patients (16.5 degrees and 8.1 degrees , respectively) were higher than in groups in which the ACL was absent (< 4.0 degrees ). All total knee arthroplasty groups had at least 19% of patients have a reverse axial rotational pattern during a deep knee bend and at least 31% during gait. Normal axial rotation patterns are essential for good patellar tracking, reduction of patellofemoral shear forces, and maximization of knee flexion.
Manninen, P; Riihimaki, H; Heliovaara, M; Suomalainen, O
Objective: To examine the effect of weight changes between 20 and 50 years of age on the risk of severe knee osteoarthritis (OA) requiring arthroplasty. Subjects and methods: Cases were 55–75 year old men and women (n = 220) having had knee arthroplasty for primary osteoarthritis at the Kuopio University Hospital in 1992–93. Controls (n = 415) were randomly selected from the population of Kuopio Province. Weight at the age of 20, 30, 40, and 50 years was collected retrospectively with a postal questionnaire. Results: After adjustment for age, sex, history of physical workload, recreational physical activity, and previous knee injury, weight gain resulting to a shift from normal body mass index (BMI ⩽25 kg/m2) to overweight (BMI >25 kg/m2) was associated with a higher relative risk of knee OA requiring arthroplasty than persistent overweight from 20–50 years of age, compared with those with normal relative weight during the corresponding age period. The odds ratios (OR) were 3.07 (95% confidence interval 1.87 to 5.05) for those with normal weight at the age of 20 years and overweight at two or three of the ages 30, 40 or 50 years, 3.15 (1.85 to 5.36) for those with overweight from the age of 30 years, and 2.37 (1.21 to 4.62) for those with overweight from the age of 20 years, respectively. Conclusion: In adult life, a shift from normal to overweight may carry a higher risk for knee OA requiring arthroplasty than does constant overweight. PMID:15479892
Mine, Takatomo; Ihara, Koichiro; Kawamura, Hiroyuki; Kuriyama, Ryutaro; Date, Ryo
Elderly onset Rheumatoid arthritis (EORA) has important clinical distinctions when compared with younger onset RA (YORA). In knee arthritis of elderly patients, infection, crystal-induced arthritis or EORA should be suspected if elevation of CRP in the preoperative examination and turbid joint effusion in their knee joint are found. Furthermore, if joint swelling and effusion remain after performing total knee arthroplasty (TKA), the infection after TKA, implant debris-related arthritis and EORA should be considered. However, it is difficult to diagnose patients as EORA if Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) are negative. The differential diagnosis is very important. PMID:28217205
Hudáková, Zuzana; Zięba, Halina Romualda; Lizis, Paweł; Dvořáková, Vlasta; Cetlová, Lada; Friediger, Teresa; Kobza, Wojciech
[Purpose] Osteoarthritis is a chronic and degenerative joint disease and is considered to be one of the most common musculoskeletal disorders. This study evaluated the differences in the quality of life of females treated with supervised physiotherapy and a standardized home program after unilateral total knee arthroplasty. [Subjects and Methods] From January 2012 to May 2015, a total of 40 females were examined at the Central Military Hospital in Ruzomberk, Slovakia. Quality of life was assessed with the Short Form-36. Quality of life and intensity of pain after normal daily activity, according to the visual analog scale, were assessed before total knee arthroplasty, immediately after physiotherapy, 3 months after total knee arthroplasty, and 6 months after total knee arthroplasty. [Results] We found statistically significant improvement of the quality of life results and a decreased intensity of pain at each time point compared with before total knee arthroplasty. [Conclusions] The results of this study provide further evidence indicating that patients who undergo total knee arthroplasty for primary osteoarthritis of the knee can achieve a significant improvement in the quality of life by using supervised physiotherapy compared with a standardized home program. PMID:27313341
Hudáková, Zuzana; Zięba, Halina Romualda; Lizis, Paweł; Dvořáková, Vlasta; Cetlová, Lada; Friediger, Teresa; Kobza, Wojciech
[Purpose] Osteoarthritis is a chronic and degenerative joint disease and is considered to be one of the most common musculoskeletal disorders. This study evaluated the differences in the quality of life of females treated with supervised physiotherapy and a standardized home program after unilateral total knee arthroplasty. [Subjects and Methods] From January 2012 to May 2015, a total of 40 females were examined at the Central Military Hospital in Ruzomberk, Slovakia. Quality of life was assessed with the Short Form-36. Quality of life and intensity of pain after normal daily activity, according to the visual analog scale, were assessed before total knee arthroplasty, immediately after physiotherapy, 3 months after total knee arthroplasty, and 6 months after total knee arthroplasty. [Results] We found statistically significant improvement of the quality of life results and a decreased intensity of pain at each time point compared with before total knee arthroplasty. [Conclusions] The results of this study provide further evidence indicating that patients who undergo total knee arthroplasty for primary osteoarthritis of the knee can achieve a significant improvement in the quality of life by using supervised physiotherapy compared with a standardized home program.
Bistolfi, Alessandro; Rosso, Federica; Crova, Maurizio; Massazza, Giuseppe
The goal of this study was to analyze the clinical and radiographic results and the survival rate of a series of rotating-hinge implants used for revision total knee arthroplasties in mild and severe instability. Between December 1991 and June 2004, fifty-three revision total knee arthroplasties were performed using the Endo-Modell (Waldemar LINK GmbH and Co, Hamburg, Germany) rotating-hinge prosthesis; 7 (13.2%) patients underwent partial revision of a previous Endo-Modell. All patients were evaluated preoperatively, 3 and 6 months postoperatively, and annually thereafter using the Hospital for Special Surgery (HSS) knee score and the Knee Society Roentgenographic Evaluation System (KS-RES). Mean follow-up was 155.2±40.1 months (range, 78-240 months), with 32 patients examined at the final follow-up. All HSS knee scores increased from preoperatively to last follow-up. No statistically significance differences were found in the HSS knee scores between septic and aseptic revisions and between total or partial revisions. Progressive radiolucent lines were detected in 8 (25%) patients. Implant failure occurred in 11 (20.7%) patients; the cumulative survival of the implants was 80.4% at 150 months for the final 32 patients. The authors recommend use of this implant for revision total knee arthroplasty, especially in patients with severe instability and bone loss.
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
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.
Hube, R; Pfitzner, T; von Roth, P; Mayr, H O
Surgical technique for primary and revision total knee arthroplasty to reconstruct bone defects with metal augments and reproducible positioning of the implant at the right joint line. Primary and revision total knee arthroplasty with bone defects. Complete destruction of the metaphysis. Implantation of revision components performed in three consecutive steps: first, positioning of the tibia component at correct height and rotation; second, determination of the posterior joint line in flexion through the size and correct rotation of the femoral implant; third, determination of the distal joint line by use of positioning of the femoral component. These steps are performed independently from bone defects, which are subsequently reconstructed with metal augments. Mobilization with weight bearing and range of motion as tolerated, depending on osseous and soft tissue condition at primary or revision surgery. In a prospective study, 132 consecutive knee revisions in 76 women and 56 men with an average age of 72.4 years (range 49-93 years) were followed up clinically and radiologically preoperatively and at a mean follow-up of 74 months (range 38-105 months). Clinical results were based on the American Knee Society score. The score was 46.3 (range 31-65) preoperatively and 82.5 (range 61-96) at follow-up. Radiologically 12.1 % of the knees showed lysis around the augment with no clinical signs of loosening. No revisions were performed due to aseptic loosening. The joint line was correctly reconstructed in 84.8 %.
Piscitelli, Prisco; Iolascon, Giovanni; Innocenti, Massimo; Civinini, Roberto; Rubinacci, Alessandro; Muratore, Maurizio; D’Arienzo, Michele; Leali, Paolo Tranquilli; Carossino, Anna Maria; Brandi, Maria Luisa
Summary Background Symptomatic severe osteoarthritis and hip osteoporotic fractures are the main conditions requiring total hip arthroplasty (THA), whereas total knee arthroplasty (TKA) is mainly performed for pain, disability or deformity due to osteoarthritis. After surgery, some patients suffer from “painful prosthesis”, which currently represents a clinical problem. Methods A systematic review of scientific literature has been performed. A panel of experts has examined the issue of persistent pain following total hip or knee arthroplasty, in order to characterize etiopathological mechanisms and define how to cope with this condition. Results Four major categories (non infective, septic, other and idiopathic causes) have been identified as possible origin of persistent pain after total joint arthroplasty (TJA). Time to surgery, pain level and function impairment before surgical intervention, mechanical stress following prosthesis implant, osseointegration deficiency, and post-traumatic or allergic inflammatory response are all factors playing an important role in causing persistent pain after joint arthroplasty. Diagnosis of persistent pain should be made in case of post-operative pain (self-reported as VAS ≥3) persisting for at least 4 months after surgery, or new onset of pain (VAS ≥3) after the first 4 months, lasting ≥2 months. Acute pain reported as VAS score ≥7 in patients who underwent TJA should be always immediately investigated. Conclusions The cause of pain needs always to be indentified and removed whenever possible. Implant revision is indicated only when septic or aseptic loosening is diagnosed. Current evidence has shown that peri-and/or post-operative administration of bisphosphonates may have a role in pain management and periprosthetic bone loss prevention. PMID:24133526
Boldt, Jens G; Munzinger, Urs K; Zanetti, Marco; Hodler, Juerg
The objective of this study was to determine gray-scale and power Doppler sonographic findings in patients with arthrofibrosis associated with total knee arthroplasty. SUBJECTS AND METHODS. From a consecutive cohort of more than 3000 mobilebearing total knee arthroplasties, 44 cases (1.5%) with arthrofibrosis were identified, of which 38 were recruited for a clinical and sonographic investigation. A control group of 38 patients with a well-functioning total knee arthroplasty was matched. Synovial hypertrophy, presence of neovascularity, patellar tendon thickness, and extent of effusion were assessed. Synovial membrane thickness was significantly (p < 0.001) increased in the arthrofibrosis group (medial, 3.4 mm; lateral, 3.0 mm; suprapatellar, 3.1 mm) when compared with the control group (medial, 2.0 mm; lateral, 2.0 mm; suprapatellar, 1.9 mm). When a cutoff of 3.0 mm was used, sonography had a sensitivity of 84% and a specificity of 82% for detecting arthrofibrosis. Neovascularity (rated as grades 0-3) of the synovial membrane and Hoffa's fat pad was significantly (p
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.
Papalia, Rocco; Del Buono, Angelo; Zampogna, Biagio; Maffulli, Nicola; Denaro, Vincenzo
Although the clinical and functional outcomes of patients undergoing knee arthroplasty have widely been investigated, there is little information on the postoperative sport activity status. We performed a comprehensive search of CINAHL, Embase, Medline and the Cochrane Central Registry of Controlled Trials, from inception of the database to 25 February 2011, using various combinations of the keyword terms 'Knee arthroplasty', 'Knee replacement', 'Total Knee replacement', 'Unicondylar Knee replacement', 'Knee Prosthesis', 'Sport Activity', 'Return To Sport Activity Level' and 'Recreational Sporting Level'. Twenty-two articles published in peer-reviewed journals were included in this review. Patients report improved outcomes, in terms of pain, symptoms, activities of daily living, sport activity and quality of life, compared with preoperative status. Only low-impact physical activities are recommended. The Coleman Methodology Score showed great heterogeneity in the study design, patients' characteristics, management methods and outcome assessment, and generally low methodological quality. Data are too heterogeneous to allow for definitive conclusions on long-term outcomes of total knee arthroplasty. It is not possible to compare the post-operative sport activity status of the patients. Validated and standardized measures should be used to report outcomes of patients undergoing knee arthroplasty. Function surveys that better depict sport activities, and include actual physical function testing, should be used. There is a need to perform appropriately powered randomized clinical trials using standard diagnostic assessment, and a common and validated scoring system comparing reported outcomes and the duration of follow-up >2 years.
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.
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.
Godoy, Gustavo; Sumarriva, Gonzalo; Ochsner, J. Lockwood; Chimento, George; Schmucker, Dana; Dasa, Vinod; Meyer, Mark
Background: C-reactive protein (CRP) has been suggested as an independent risk factor for cardiovascular pathology in the nonsurgical setting. While postoperative CRP and erythrocyte sedimentation rate (ESR) have an established role in aiding the diagnosis of periprosthetic joint infections, some authors suggest a link between preoperative CRP and postoperative complications in patients undergoing total joint arthroplasty. Methods: We conducted a retrospective cohort study of 351 patients who underwent unilateral primary total knee arthroplasty by a single surgeon during a 28-month period (January 2013 through April 2015). Patient medical records were reviewed for the following complications occurring within 90 days postoperatively: myocardial infarction, arrhythmia, pulmonary embolism, wound infection, acute renal failure, and reoperation. Results: We found no statistically significant link between postoperative complications and preoperative CRP levels (P=0.5005) or ESR levels (P=0.1610). Conclusion: The results of this study do not support the routine inclusion of CRP and ESR analysis as part of the preoperative evaluation for elective total knee arthroplasty. PMID:27999506
Molloy, Ilda B; Martin, Brook I; Moschetti, Wayne E; Jevsevar, David S
Utilization of total knee and hip arthroplasty has greatly increased in the past decade in the United States; these are among the most expensive procedures in patients with Medicare. Advances in surgical techniques, anesthesia, and care pathways decrease hospital length of stay. We examined how trends in hospital cost were altered by decreases in length of stay. Procedure, demographic, and economic data were collected on 6.4 million admissions for total knee arthroplasty and 2.8 million admissions for total hip arthroplasty from 2002 to 2013 using the National (Nationwide) Inpatient Sample, a component of the Healthcare Cost and Utilization Project. Trends in mean hospital costs and their association with length of stay were estimated using inflation-adjusted, survey-weighted generalized linear regression models, controlling for patient demographic characteristics and comorbidity. From 2002 to 2013, the length of stay decreased from a mean time of 4.06 to 2.97 days for total knee arthroplasty and from 4.06 to 2.75 days for total hip arthroplasty. During the same time period, the mean hospital cost for total knee arthroplasty increased from $14,988 (95% confidence interval [CI], $14,927 to $15,049) in 2002 to $22,837 (95% CI, $22,765 to $22,910) in 2013 (an overall increase of $7,849 or 52.4%). The mean hospital cost for total hip arthroplasty increased from $15,792 (95% CI, $15,706 to $15,878) in 2002 to $23,650 (95% CI, $23,544 to $23,755) in 2013 (an increase of $7,858 or 49.8%). If length of stay were set at the 2002 mean, the growth in cost for total knee arthroplasty would have been 70.8% instead of 52.4% as observed, and the growth in cost for total hip arthroplasty would have been 67.4% instead of 49.8% as observed. Hospital costs for joint replacement increased from 2002 to 2013, but were attenuated by reducing inpatient length of stay. With demographic characteristics showing an upward trend in the utilization of joint arthroplasty, including a shift
Geannette, Christian; Miller, Theodore; Saboeiro, Gregory; Parks, Michael
Patellar clunk syndrome is a painful mechanical phenomenon that may develop following total knee arthroplasty. The diagnosis is usually made clinically, but cross-sectional imaging may be needed to confirm the clinical suspicion. Sonographic confirmation of patellar clunk syndrome can be obtained by directly visualizing the soft tissue proliferation deep to the distal quadriceps tendon and by dynamically demonstrating the clunking tissue during flexion and extension of the knee. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:105-107, 2017. © 2016 Wiley Periodicals, Inc.
Lee, Song; Lee, Jae Il; Kim, Jin Woo
Purpose To analyze the causes and types of complications after unicompartmental knee arthroplasty (UKA) and determine proper prevention and treatment methods. Materials and Methods A total of 1,576 UKAs were performed for osteoarthritis of the knee from January 2002 to December 2014 at one institution. We analyzed complications after UKA retrospectively and investigated proper methods of treatment. Results A total of 89 complications (5.6%) occurred after UKA. Regarding the type of complications after UKA, there were 42 cases of dislocation of the mobile bearing, 23 cases of loosening of the prosthesis, 6 cases of periprosthetic fracture, 3 cases of polyethylene wear, 3 cases of progression of arthritis in the contralateral compartment, 2 cases of medial collateral ligament injury, 2 cases of impingement, 5 cases of infection, 1 case of arthrofibrosis, and 2 cases of failure due to unexplained pain. The most common complication after UKA was mobile bearing dislocation in the mobile-bearing knees and loosening of the prosthesis in the fixed-bearing knees, but polyethylene wear and progression of arthritis were relatively rare. The complications were treated with conversion to total knee arthroplasty in 58 cases and simple bearing change in 21 cases. Conclusions The most common complication after UKA was dislocation of the mobile bearing. When a complication occurs after UKA, appropriate treatment should be performed after accurate analysis of the cause of complication. PMID:26952551
Rosenberg, Aaron G
Uncontrolled pain associated with total knee arthroplasty can have significant untoward effects on patient outcomes, leading to delayed recovery, inability to participate in rehabilitation, prolonged hospitalization, and increased use of health care resources. In this article, I review the methodologies and outcomes of several studies and protocols involving preemptive, perioperative, and postoperative use of various anesthetic and analgesic agents. Used together with minimally invasive techniques, appropriate pain control should result in significant improvements in patient outcomes.
Weddendorf, Bruce (Inventor)
This invention is an apparatus for controlling the pivotal movement of a knee brace comprising a tang-and-clevis joint that has been uniquely modified. Both the tang and the clevis have a set of teeth that, when engaged, can lock the tang and the clevis together. In addition, the tang is biased away from the clevis. Consequently, when there is no axial force (i.e., body weight) on the tang, the tang is free to pivot within the clevis. However, when an axial force is exerted on the tang, the tang is pushed into the clevis, both sets of teeth engage, and the tang and the clevis lock together.
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).
Proposed orthotic knee joint locks and unlocks automatically, at any position within range of bend angles, without manual intervention by wearer. Includes tang and clevis, locks whenever wearer transfers weight to knee and unlocks when weight removed. Locking occurs at any angle between 45 degrees knee bend and full extension.
Kawaguchi, Kohei; Michishita, Kazuhiko; Manabe, Takeshi; Akasaka, Yoshiyuki; Kaminaga, Naoto
Introduction: It has been reported that the unicompartmental knee arthroplasty has good long-term outcomes for Western and Japanese patients. Alternatively, several reports have described reoperations after unicompartmental knee arthroplasty because of post-operative knee pain and sometimes it is difficult to diagnose the cause of pain. Case Report: We treated a patient with anteromedial knee pain caused by intra-articular scar tissue that contained residual cement fragments on the anterior surface of a femoral implant following Oxford unicompartmental knee arthroplasty. After arthroscopic resection of the scar tissue and removal of the 3 mm residual cement covered with the scar tissue, the patient’s post-operative symptoms were considerably alleviated. Conclusion: This is the first report describing a case of painful intra-articular scar tissue following unicompartmental knee arthroplasty. PMID:28164064
Kawaguchi, Kohei; Michishita, Kazuhiko; Manabe, Takeshi; Akasaka, Yoshiyuki; Kaminaga, Naoto
It has been reported that the unicompartmental knee arthroplasty has good long-term outcomes for Western and Japanese patients. Alternatively, several reports have described reoperations after unicompartmental knee arthroplasty because of post-operative knee pain and sometimes it is difficult to diagnose the cause of pain. We treated a patient with anteromedial knee pain caused by intra-articular scar tissue that contained residual cement fragments on the anterior surface of a femoral implant following Oxford unicompartmental knee arthroplasty. After arthroscopic resection of the scar tissue and removal of the 3 mm residual cement covered with the scar tissue, the patient's post-operative symptoms were considerably alleviated. This is the first report describing a case of painful intra-articular scar tissue following unicompartmental knee arthroplasty.
Duivenvoorden, T; Verburg, H; Verhaar, J A N; Bierma-Zeinstra, S M A; Reijman, M
Approximately 5-10% of patients is dissatisfied after a total knee arthroplasty. Several studies suggest that unrealistic expectations contribute to this; however, a systematic overview of the literature is missing. Systematic literature review METHOD: Using a systematic search strategy, prospective and retrospective studies with a follow-up of a minimum of six months, were obtained from PubMed publisher, MEDLINE, Embase, Cochrane, PsycINFO, CINAHL, and Web-of-Science. The search terms included 'total knee arthroplasty', 'preoperative expectations' and 'patient satisfaction'. Two reviewers independently selected the studies. Two reviewers independently conducted the quality assessment. Finally, a best evidence synthesis was performed. The search yielded 6802 studies, of which eight met the inclusion criteria. Limited evidence was found that there is no significant relation between expectations and satisfaction regarding limitations in recreation, walking distance, use of a walking aid and expected time to full recovery. Conflicting evidence was found that high expectations regarding general improvement, pain reduction and limitations in activities of daily living are associated with more dissatisfaction. Moderate evidence was found that patients with unfulfilled expectations were more often dissatisfied. Limited prospective research has been published on the relationship between expectations and patient satisfaction concerning total knee arthroplasty. The outcomes are very heterogenous and conclusions from these outcomes should be treated carefully. Future research needs to be more standardised and should utilise validated questionnaires.
Díaz-Heredia, J; Loza, E; Cebreiro, I; Ruiz Iban, M Á
To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis. A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected. A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (≥4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events. The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain. Copyright © 2014 SECOT. Published by Elsevier Espana. All rights reserved.
Moslavac, Aleksandra; Moslavac, Sasa; Cop, Renata
Alkaptonuria is a rare hereditary metabolic disorder characterised by absence of the enzyme homogentisic acid oxidase. As a result of this defect homogentisic acid accumulates and is excreted in the urine. The term ochronosis is used to describe bluish-black pigmentation of connective tissue. Ochronotic arthropathy results from the pigmented deposits in the joints of the appendicular and axial skeleton. Findings simulate those of uncomplicated degenerative joint disease, with effusion, articular space narrowing, and bony sclerosis. Our patient is a 70-year old male with ochronotic arthropathy. He has typical ears and sclera discoloration, and had arthroplasty of knees 7 and 4 years ago, respectively. In year 2002, he had undergone total right hip arthroplasty and has been admitted for rehabilitation 14th postoperative day. Individually designed rehabilitation regimen included kinesitherapy, hydrokinesitherapy, and ambulation training with gradual increase in weight bearing exercises and electro-analgesia of associated low back pain. In course of rehabilitation our patient improved his endurance with satisfying range of motion of right hip (flexion 90 degrees, abduction 40 degrees) and strength of hip and thigh musculature. The patient was able to walk with crutches without limitation. We conclude that joint destruction followed by painful locomotion due to ochronotic arthropathy is best treated by total joint arthroplasty, as described in our patient.
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
Marczak, Dariusz; Kowalczewski, Jacek; Czubak, Jarosław; Okoń, Tomasz; Synder, Marek; Sibiński, Marcin
The original knee megaprostheses with fixed or rotating hinge articulation were custom made and only used for reconstruction of the knee following distal femoral or proximal tibial tumor resections. The aim of the study was to analyze the short- and mid-term results of revision total knee arthroplasty with Global Modular Replacement System (GMRS) used in difficult situations not amenable to reconstruction with standard total knee replacement implants. Nine patients (9 knees) were treated with this comprehensive modular implant system, with a mean age of 73.7 years (range 56-83 years) and a mean followup of 5 years (range 3-8 years). Two patients were treated for distal femoral nonunion, five for distal femur periprosthetic fracture and two for periprosthetic joint infection. The mean Knee Society Score: Knee and functional scores were 77.9 and 40 points, respectively. All demonstrated full extension and flexion was at least 90°. Recurrence of infection was present in one patient. No signs of loosening, dislocation, or implant failure were observed. Based on our small series of patients that represent severe cases, GMRS provides relatively good mid-term functional results, pain relief, and good implant survivorship with a low complication rate. This salvage procedure allows elderly, infirm patients to regain early ambulatory ability.
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.
Electricwala, Ali J.; Amanatullah, Derek F.; Narkbunnam, Rapeepat I.; Huddleston, James I.; Maloney, William J.; Goodman, Stuart B.
Background: Adequate preoperative planning is the first and most crucial step in the successful completion of a revision total joint arthroplasty. The purpose of this study was to evaluate the availability, adequacy and accuracy of operative notes of primary surgeries in patients requiring subsequent revision and to construct comprehensive templates of minimum necessary information required in the operative notes to further simplify re-operations, if they should become necessary. Methods: The operative notes of 144 patients (80 revision THA’s and 64 revision TKA’s) who underwent revision total joint arthroplasty at Stanford Hospital and Clinics in the year 2013 were reviewed. We assessed the availability of operative notes and implant stickers prior to revision total joint arthroplasty. The availability of implant details within the operative notes was assessed against the available surgical stickers for adequacy and accuracy. Statistical comparisons were made using the Fischer-exact test and a P-value of less than 0.05 was considered statistically significant. Results: The primary operative note was available in 68 of 144 revisions (47%), 39 of 80 revision THAs (49%) and 29 of 66 revision TKAs (44%, p = 0.619). Primary implant stickers were available in 46 of 144 revisions (32%), 26 of 80 revision THAs (32%) and 20 of 66 revision TKAs (30%, p = 0.859). Utilizing the operative notes and implant stickers combined identified accurate primary implant details in only 40 of the 80 revision THAs (50%) and 34 of all 66 revision TKAs (52%, p = 0.870). Conclusion: Operative notes are often unavailable or fail to provide the necessary information required which makes planning and execution of revision hip and knee athroplasty difficult. This emphasizes the need for enhancing the quality of operative notes and records of patient information. Based on this information, we provide comprehensive operative note templates for primary and revision total hip and knee
Lu, Xin; Hagen, Tyson P.; Vaughan-Sarrazin, Mary S.; Cram, Peter
Background: Utilization of arthroplasty is increasing, but there are little data exploring the causes of this increase. The objective of this study was to examine the relationship between new programs for arthroplasty of the lower extremity joints and the utilization of arthroplasty. Methods: We identified twenty-four markets (hospital referral regions) that experienced the entry of new physician-owned specialty hospitals, using 1991 to 2005 Medicare data. We matched each market with a new specialty hospital to two different control markets (one market with a new arthroplasty program in a general hospital and one market without a new arthroplasty program), using a propensity score that accounted for market supply and demand for orthopaedic surgery and the regulatory environment. We compared the utilization of arthroplasty of the lower extremity joints (total hip arthroplasty and total knee arthroplasty) in each group of markets over a five-year window, extending from two years before to three years after the entry of new orthopaedic surgery programs. Results: The twenty-four markets with new specialty orthopaedic hospitals had higher utilization of arthroplasty at baseline (10.9 arthroplasties per 1000 Medicare beneficiaries per year) and follow-up (12.7 per 1000 beneficiaries) compared with the twenty-four markets with new arthroplasty programs in general hospitals (9.7 and 11.4, respectively) and the twenty-four markets with no new programs (9.9 and 11.3), although the differences were not significant (p > 0.05). Growth in the utilization of arthroplasty was similar in markets with new specialty hospitals before (an increase of 0.63 procedure per 1000 beneficiaries per year) and after the entry of new specialty hospitals (an increase of 0.39) compared with markets with new surgery programs in general hospitals (an increase of 0.24 before and 0.43 after) and markets with no new programs (an increase of 0.38 before and 0.33 after the entry of new specialty
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.
Vun, Shen Hwa; Shields, David William; Sen, Aroop; Shareef, Sajan; Sinha, Satyajit; Campbell, Alexander Craig
Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we aim to determine the current practice and trend among knee surgeons throughout the United Kingdom. Postal questionnaires were sent out to 100 knee surgeons registered with British Association of Knee Surgeons, ensuring that the whole of United Kingdom was well represented. The questions included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation. We received 82 responses. 46% of respondents performed MUA routinely, 43% sometimes, and 11 never. Majority (71.23%) performed MUA within 3 months of the index procedure. 68% routinely used CPM post-manipulation while 7% of the respondents applied splints or serial cast post MUA. 41% of the surgeons routinely used Patient Controlled Analgaesia ± Regional blocks. Majority (55%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis. Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion achieved. Manipulation should be reserved for the patient with difficult and painful flexion in the early postoperative period.
Rodriguez, Jose A; Bas, Marcel A; Orishimo, Karl F; Robinson, Jonathan; Nicholas, Stephen J
Total knee arthroplasty and its relation to gait abduction or adduction moment has not been fully described. Gait analysis was performed on 25 patients (27 knees) preoperatively, 6 months and 1 year after total knee arthroplasty. Reflective markers were placed on the lower extremity, and motion data were collected at 60 Hz using 6 infrared cameras. Ground reaction forces were recorded at 960 Hz with a force plate. Stance phase was divided into braking and propulsive phases. Coronal knee angles and moments were calculated. Repeated-measures analysis of variance was used to compare frontal plane knee impulse over time and between the braking and propulsive phases of stance. In varus knees, static alignment was corrected from 2.2° varus to 3.3° valgus and in valgus knees from 15.2° valgus to 2.7° valgus (P < .010). Braking phase adduction impulse decreased from 0.145 to 0.111 at 6 months but increased to 0.126 Nm/kg s (P > .05) at 1 year. Propulsive phase impulse changed from 0.129 to 0.085 and persisted at 1 year. Impulse changed from 0.01 (abduction) to 0.11 Nm/kg s (adduction) at 6 months and persisted (P = .01). Restoration of anatomic alignment and soft tissue balancing changes the lateral loading conditions of valgus knees. Both cases, between 6 months and 1 year, increased peak moment. Copyright © 2016 Elsevier Inc. All rights reserved.
A 53-year-old patient was admitted to our hospital with a tumour at the site of the left knee joint praepatellar. The diagnostic imaging, operative findings and histology showed a chronic ossifying bursitis praepatellaris of the knee joint. Aetiology and pathogenesis of the ossifying bursitis are discussed.
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.
Handel, M; Riedt, S; Lechler, P; Schaumburger, J; Köck, F X; Sell, S
The purpose of the study was to determine possible differences in the mid-term results of total knee arthroplasty in patients treated with and without denervation of the patella. This study included 80 total knee replacements in 71 patients who were treated with total knee replacement, either with (n = 40) or without (n = 40) simultaneous denervation of the patella out of a total population with 122 knee replacements in 100 patients. Comparability of both groups was achieved by applying matching criteria. All patients were reviewed by isokinetic tests, physical and radiological examination. The mean follow-up time was 2.2 years. The mean hospital for special surgery (HSS) score revealed no statistically significant differences between both groups (with denervation 77.9 ± 11.1 and without denervation 77.8 ± 11.0, p = 0.976). The isokinetic torque measurements with low angle velocity (60°/s) indicated slightly higher values during extension (60.2 ± 32.2 Nm versus 55.8 ± 25.2 Nm, p = 0.497) and flexion (52.4 ± 28.3 Nm versus 46.1 ± 22.3 Nm, p = 0.272) movements of the affected knee joint. However, the differences did not reach statistical significance. At high angle velocity (180°/s) no differences could be found between both groups. No cases of postoperative necrosis of the patella were observed. Anterior knee pain after denervation was reported in 6 cases (15 %) compared to 10 cases (25 %) in patients who were treated without denervation (p = 0.402). No statistically significant differences could be found between patients with and without denervation of the patella for total knee arthroplasty.
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.
Issa, Kimona; Boylan, Matthew R; Naziri, Qais; Perfetti, Dean C; Maheshwari, Aditya V; Mont, Michael A
With recent advances in the treatment of infection with hepatitis C increasing lifespan and quality of life, the need for total joint arthroplasty in this patient population is expected to grow. Presently, there are limited and conflicting data on the perioperative outcomes of lower-extremity total joint arthroplasty among patients with hepatitis C. The purpose of our study was to assess the association between hepatitis C and perioperative outcomes of lower-extremity total joint arthroplasty. The Nationwide Inpatient Sample database was used to identify patients who underwent a total hip or knee arthroplasty in the United States from 1998 to 2010. Controls were matched in a three-to-one ratio to patients with hepatitis-C infection according to surgical procedure, age, race, sex, Deyo comorbidity score, and year of surgical procedure. Outcomes included perioperative complications (any, medical, surgical) and mean length of stay. There were 1,700,400 total joint arthroplasties performed and recorded in the database during the study period, among which 8044 patients (0.47%) had a documented hepatitis-C infection. The frequency of hepatitis-C infection increased from 1.9 per 1000 total joint arthroplasties in 1998 to 5.9 per 1000 total joint arthroplasties in 2010 (slope = 0.47; r(2) = 0.93). Compared with matched controls, patients with hepatitis C had a 30% increased risk of any complication (95% confidence interval, 17% to 44%; p < 0.001), a 15% increased risk of a medical complication (95% confidence interval, 2% to 30%; p = 0.025), a 78% increased risk of a surgical complication (95% confidence interval, 49% to 112%; p < 0.001), and a mean length of stay that was 14% longer (95% confidence interval, 12% to 15%; p < 0.001). Infection with hepatitis C is an infrequent but increasingly common comorbidity among patients undergoing total joint arthroplasty. Given these findings, orthopaedic surgeons should be aware of the increased risks of total joint arthroplasty in
Duany, Nyagon G; Zywiel, Michael G; McGrath, Mike S; Siddiqui, Junaed A; Jones, Lynne C; Bonutti, Peter M; Mont, Michael A
To date, reports of surgical treatment of spontaneous osteonecrosis of the knee (SPONK) refractory to non-operative treatment have primarily focused on knee arthroplasty. This report presents an overview of the characteristics of SPONK and reports our experience with joint-preserving surgical treatment of this condition. Fifteen patients who had joint-preserving surgery after failed non-operative modalities were studied. These patients were treated at a single center between January 1998 and September 2006 with a combination of arthroscopy and core decompression, or osteochondral autograft transfers. Thirteen of the 15 knees (87%) had knee joint survival with a mean Knee Society Score of 81 points (range 45–100 points) at a mean follow-up of 40 months (range 9–120 months). Five of seven knees treated with core decompression had a successful clinical outcome. One of the patients who failed core decompression later underwent osteochondral autograft transfer, and eight of nine knees treated with this modality had a successful outcome. Overall, these results demonstrate that joint-preserving surgical treatment can successfully postpone the need for knee arthroplasty in selected patients with pre-collapse SPONK.
Oliveira, R; Ribeiro, F; Oliveira, J
The effects of cryotherapy on joint position sense are not clearly established; however it is paramount to understand its impact on peripheral feedback to ascertain the safety of using ice therapy before resuming exercise on sports or rehabilitation settings. Thus, the aim of the present study was to determine the effects of cryotherapy, when applied over the quadriceps and over the knee joint, on knee position sense. This within-subjects repeated-measures study encompassed fifteen subjects. Knee position sense was measured by open kinetic chain technique and active positioning at baseline and after cryotherapy application. Knee angles were determined by computer analysis of the videotape images. Twenty-minute ice bag application was applied randomly, in two sessions 48 h apart, over the quadriceps and the knee joint. The main effect for cryotherapy application was significant (F (1.14)=7.7, p=0.015) indicating an increase in both absolute and relative angular errors after the application. There was no significant main effect for the location of cryotherapy application, indicating no differences between the application over the quadriceps and the knee joint. In conclusion, cryotherapy impairs knee joint position sense in normal knees. This deleterious effect is similar when cryotherapy is applied over the quadriceps or the knee joint. Georg Thieme Verlag KG Stuttgart.New York.
Noguchi, Hideo; Matsuda, Yoshikazu; Kiga, Hiroshi; Takeda, Mitsuhiro; Toyabe, Shin-ichi
A preoperative quantitative evaluation of soft tissues is helpful for planning total knee arthroplasty, in addition to the conventional clinical examinations involved in moving the knee manually. We evaluated preoperative coronal laxity with osteoarthritis in patients undergoing total knee arthroplasty by applying a force of 150 N with an arthrometer. We examined a consecutive series of 120 knees in 102 patients. The median laxity was 0° in abduction and 8° in adduction. The femorotibial angle on non-weight-bearing standard anteroposterior radiographs was 180° and correlated with both abduction (r = −0.244, p = 0.007) and adduction (r = 0.205, p = 0.025) laxity. The results of a regression analysis suggested that the femorotibial angle is helpful for estimating both laxities. Considering the many reports on how to obtain well-balanced soft tissues, stress radiographs might help to improve the preoperative planning for gaining the optimal laxity deemed appropriate by surgeons. PMID:17938923
Mittag, Falk; Leichtle, Carmen Ina; Schlumberger, Michael; Leichtle, Ulf Gunther; Wünschel, Markus
ABSTRACT Objective: 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. Methods: 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. Results: 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. Conclusion: Thorough surgical technique leads to good clinical results independent of infection-type and treatment philosophy. Level of Evidence III, Case Control Study. PMID:26997914
Stulberg, S David
The treatment of small bone defects in revision total knee arthroplasty should make immediate full weight bearing and full therapy possible, provide long-term stability for the implants, and restore bone stock. These objectives are achieved with bone grafts if the defects are cavitary or small (involving less than one fourth of the cortical rim) segmental defects. These objectives are achieved with porous metal augments if the defects are segmental and involve more than one fourth of the cortical rim. The treatment of bone loss on the femur must allow the re-establishment of the distal and posterior joint lines as well as provide a firm fixation base for the implants.
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.
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.
Hube, R; Mayr, H O; Pfitzner, T; von Roth, P
Flexion contracture is a common deformity of the arthritic knee. The present publication describes causes, clinical relevance and surgical technique in the presence of flexion contractures in total knee arthroplasty. Flexion contracture can be attributed to different causes. Basically it is a mismatch between flexion and extension gaps. Moderate and severe deformities have to be corrected by additional surgical interventions. In most cases soft tissue techniques with release of contracted structures, the removal of osteophytes and additional distal femoral bone resection are necessary. The goal of these interventions is to achieve full extension of the knee. During rehabilitation attention has to be paid to maintain it with intensive physical therapy. A remaining flexion contracture is associated with inferior functional outcome and persistent pain.
Servien, E; Verdonk, P C M; Lustig, S; Paillot, J L; Kara, A D; Neyret, P
We report a prospective series of 33 unicompartmental knee arthroplasties (UKAs) operated for a spontaneous osteonecrosis of the knee (SPONK) compared with 35 UKAs operated for osteoarthritis (OA). The mean follow-up was 5 years. Preoperative functional score in the SPONK group was significantly lower than that in the OA group. The results were comparable in terms of pain, knee score and function. At the last follow-up, the survival rate was 92.8% for the SPONK group and 95.4% for the OA group. We found a higher rate of radiolucencies in the SPONK group, however, without any clinical symptoms. The UKA is a good option in the treatment of SPONK.
Whiteside, L A; Roy, M E; Nayfeh, T A
Bactericidal levels of antibiotics are difficult to achieve in infected total joint arthroplasty when intravenous antibiotics or antibiotic-loaded cement spacers are used, but intra-articular (IA) delivery of antibiotics has been effective in several studies. This paper describes a protocol for IA delivery of antibiotics in infected knee arthroplasty, and summarises the results of a pharmacokinetic study and two clinical follow-up studies of especially difficult groups: methicillin-resistant Staphylococcus aureus and failed two-stage revision. In the pharmacokinetic study, the mean synovial vancomycin peak level was 9242 (3956 to 32 150; sd 7608 μg/mL) among the 11 patients studied. Serum trough level ranged from 4.2 to 25.2 μg/mL (mean, 12.3 μg/mL; average of 9.6% of the joint trough value), which exceeded minimal inhibitory concentration. The success rate exceeded 95% in the two clinical groups. IA delivery of antibiotics is shown to be safe and effective, and is now the first option for treatment of infected total joint arthroplasty in our institution.
Matziolis, Georg; Roehner, Eric; Windisch, Christoph; Wagner, Andreas
Despite its clinical relevance, particularly in septic knee surgery, the volume of the human knee joint has not been established to date. Therefore, the objective of this study was to determine knee joint volume and whether or not it is dependent on sex or body height. Sixty-one consecutive patients (joints) who were due to undergo endoprosthetic joint replacement were enrolled in this prospective study. During the operation, the joint volume was determined by injecting saline solution until a pressure of 200 mmHg was achieved in the joint. The average volume of all knee joints was 131 ± 53 (40-290) ml. The volume was not found to be dependent on sex, but it was dependent on the patients' height (R = 0.312, p = 0.014). This enabled an estimation of the joint volume according to V = 1.6 height - 135. The considerable inter-individual variance of the knee joint volume would suggest that it should be determined or at least estimated according to body height if the joint volume has consequences for the diagnostics or therapy of knee disorders.
Khoo, L P; Goh, J C; Chow, S L
This paper presents an approach for the establishment of a parametric model of knee joint prosthesis. Four different sizes of a commercial prosthesis are used as an example in the study. A reverse engineering technique was employed to reconstruct the prosthesis on CATIA, a CAD (computer aided design) system. Parametric models were established as a result of the analysis. Using the parametric model established and the knee data obtained from a clinical study on 21 pairs of cadaveric Asian knees, the development of a prototype prosthesis that suits a patient with a very small knee joint is presented. However, it was found that modification to certain parameters may be inevitable due to the uniqueness of the Asian knee. An avenue for rapid modelling and eventually economical production of a customized knee joint prosthesis for patients is proposed and discussed.
McGrory, Aidan C; Replogle, Lee; Endrizzi, Donald
Hundreds of thousands of revision surgeries for hip, knee, and shoulder joint arthroplasties are now performed worldwide annually. Partial removal of hardware during some types of revision surgeries may create significant amounts of third body metal, polymer, or bone cement debris. Retained debris may lead to a variety of negative health effects including damage to the joint replacement. We describe a novel technique for the better containment and easier removal of third body debris during partial hardware removal. We demonstrate hardware removal on a hip joint model in the presence and absence of water-soluble gel to depict the reduction in metal debris volume and area of spread.
Chung, Kyu Sung; Lee, Jin Kyu; Lee, Hee Jae; Choi, Choong Hyeok
Severe uncontained tibial bone defects occurring during total knee arthroplasty are challenging, and which treatment method is the best remains unknown. In this study, clinical and radiographic outcomes of double metal blocks augmentation were examined. Between 2004 and 2012, double metal blocks augmentation was carried out in 17 patients with severe asymmetric uncontained tibial bone defects. The first block was attached to the tibial tray with screws, and then the second block was cemented to the first block. Out of 17 patients, 13 (8 primary, 5 revision) were available for final follow-up at a median of 69 months (range 24-99). For clinical assessment, range of motion and Knee Society score were evaluated preoperatively and annually thereafter. At the final follow-up, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford knee, Short Form-36, Lower extremity functional scale, and Lower extremity activity scale scores were evaluated. Radiographic assessment for radiolucent lines at the block-cement-bone interfaces and signs of failure was performed annually using fluoroscopy and standard radiographs. Range of motion and Knee Society score were significantly improved post-operatively. Other clinical outcomes were favourable. Radiolucent lines were seen on fluoroscopy in three knees, but no sign of failure, such as loosening, collapse, or instability, was observed at the final follow-up. Double metal blocks augmentation is a favourable and useful method, which does not cause mechanical failure or protrusion of the prosthetic because of its modularity, to manage severe asymmetric uncontained proximal tibial bone defects >15 mm in total knee arthroplasty. Case series, Level IV.
Lui, Tun Hing
Painful degenerative diseases of the second metatarsophalangeal joint are frequently progressive and difficult to treat. Surgical options for the degenerated second metatarsophalangeal joint include joint debridement and synovectomy, drilling and microfracture, core decompression, dorsal closing-wedge metatarsal osteotomies, joint arthroplasty (implant or interpositional), elevation of the depressed articular fragment and bone graft, distraction arthroplasty, osteochondral plug transplantation, osteochondral distal metatarsal allograft reconstruction, and resection arthroplasty (phalangeal base or metatarsal head). This technical note describes the arthroscopic approach of interpositional arthroplasty of the second metatarsophalangeal joint using the extensor digitorum brevis tendon. It is indicated in adult patients with extensive involvement of the metatarsal head cartilage, especially when cartilage degeneration of the proximal phalanx is also present. It is contraindicated if there is significant bone loss of the metatarsal head or the extensor digitorum brevis tendon is flimsy.
Pinheiro, Ana Alexandra da Costa; Marques, Pedro Miguel Dantas Costa; Sá, Pedro Miguel Gomes; Oliveira, Carolina Fernandes; da Silva, Bruno Pombo Ferreira; de Sousa, Cristina Maria Varino
Although compartment syndrome is a rare complication of total knee arthroplasty, it is one of the most devastating complications. It is defined as a situation of increased pressure within a closed osteofascial space that impairs the circulation and the functioning of the tissues inside this space, thereby leading to ischemia and tissue dysfunction. Here, a clinical case of a patient who was followed up in orthopedic outpatient consultations due to right gonarthrosis is presented. The patient had a history of arthroscopic meniscectomy and presented knee flexion of 10° before the operation, which consisted of total arthroplasty of the right knee. The operation seemed to be free from intercurrences, but the patient evolved with compartment syndrome of the ipsilateral leg after the operation. Since compartment syndrome is a true surgical emergency, early recognition and treatment of this condition through fasciotomy is crucial in order to avoid amputation, limb dysfunction, kidney failure and death. However, it may be difficult to make the diagnosis and cases may not be recognized if the cause of compartment syndrome is unusual or if the patient is under epidural analgesia and/or peripheral nerve block, which thus camouflages the main warning sign, i.e. disproportional pain. In addition, edema of the limb that underwent the intervention is common after total knee arthroplasty operations. This study presents a review of the literature and signals that the possible rarity of cases is probably due to failure to recognize this condition in a timely manner and to placing these patients in other diagnostic groups that are less likely, such as neuropraxia caused by using a tourniquet or peripheral nerve injury.
Pinheiro, Ana Alexandra da Costa; Marques, Pedro Miguel Dantas Costa; Sá, Pedro Miguel Gomes; Oliveira, Carolina Fernandes; da Silva, Bruno Pombo Ferreira; de Sousa, Cristina Maria Varino
Although compartment syndrome is a rare complication of total knee arthroplasty, it is one of the most devastating complications. It is defined as a situation of increased pressure within a closed osteofascial space that impairs the circulation and the functioning of the tissues inside this space, thereby leading to ischemia and tissue dysfunction. Here, a clinical case of a patient who was followed up in orthopedic outpatient consultations due to right gonarthrosis is presented. The patient had a history of arthroscopic meniscectomy and presented knee flexion of 10° before the operation, which consisted of total arthroplasty of the right knee. The operation seemed to be free from intercurrences, but the patient evolved with compartment syndrome of the ipsilateral leg after the operation. Since compartment syndrome is a true surgical emergency, early recognition and treatment of this condition through fasciotomy is crucial in order to avoid amputation, limb dysfunction, kidney failure and death. However, it may be difficult to make the diagnosis and cases may not be recognized if the cause of compartment syndrome is unusual or if the patient is under epidural analgesia and/or peripheral nerve block, which thus camouflages the main warning sign, i.e. disproportional pain. In addition, edema of the limb that underwent the intervention is common after total knee arthroplasty operations. This study presents a review of the literature and signals that the possible rarity of cases is probably due to failure to recognize this condition in a timely manner and to placing these patients in other diagnostic groups that are less likely, such as neuropraxia caused by using a tourniquet or peripheral nerve injury. PMID:26401507
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.
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.
Austin, Paul N
The majority of the evidence indicates preventing inadvertent perioperative hypothermia reduces the incidence of many perioperative complications. Among the results of inadvertent perioperative hypothermia are increased bleeding, myocardial events, impaired wound healing, and diminished renal function. Most researchers agree there is an increased incidence of surgical site infections in patients who experience inadvertent perioperative hypothermia. Forced-air warming is effective in preventing inadvertent perioperative hypothermia. Paradoxically, forced-air warmers have been implicated in causing surgical site infections in patients undergoing total knee or hip arthroplasty. The results of investigations suggest these devices harbor pathogens and cause unwanted airflow disturbances. However, no significant increases in bacterial counts were found when forced-air warmers were used according to the manufacturer's directions. The results of one study suggested the incidence of surgical site infections in patients undergoing total joint arthroplasty was increased when using a forced-air warmer. However these researchers did not control for other factors affecting the incidence of surgical site infections in these patients. Current evidence does not support forced-air warmers causing surgical site infections in patients undergoing total knee or hip arthroplasty. Clinicians must use and maintain these devices as per the manufacturer's directions. They may consider using alternative warming methods. Well-conducted studies are needed to help determine the role of forced-air warmers in causing infections in these patients.
Ayala, Alfonso E; Lawson, Kevin A; Gruessner, Angelika C; Dohm, Michael P
Advantages of unicondylar knee arthroplasty (UKA) over total knee arthroplasty include rapid recovery and shorter lengths of stay following surgery. Patients requiring extended postoperative care fail to recognize these benefits. Patient-reported outcome measures have proved useful in predicting outcomes following joint arthroplasty. The purpose of this study was to identify and report preoperative patient-reported outcome measures and clinical variables that predict discharge to skilled nursing facilities following UKA. A prospective cohort of 174 patients was used to collect 36-Item Short Form scores and objective clinical data. Univariate and multivariate analysis with backward elimination were conducted to find a predictive risk model. The predictive model reported (78.7% concordance, receiver operating characteristic curve c-statistic 0.719, P = .0016) demonstrates that risk factors for discharge to skilled nursing facilities are: older age (odds ratio 4.18; 95% confidence interval [CI] 1.256-13.911, P = .019), bilateral UKA procedures (odds ratio 1.887; 95% CI 1.054-3.378, P = .0326) and lower patient-reported preoperative 36-Item Short Form physical function scores (odds ratio 0.968; CI 0.938-1, P = .0488). The information presented here regarding possible patient disposition following UKA could aid informed decision-making regarding patients' short-term needs following surgery and help streamline preoperative planning. Copyright © 2016 Elsevier Inc. All rights reserved.
Chaweewannakom, Ukrit; Turajane, Thana; Wongsarat, Teparit; Larbpaiboonpong, Viroj; Wongbunnak, Rungsee; Sumetpimolchai, Wasan
Rationale perioperative antibiotic for prevent infection in total knee arthroplasty is well established. The recommendation are preoperative antibiotic should be administered within 1 h before skin incision and prophylactic antibiotics should be administered within 1 h before skin incision, if prolong surgery more than 4-6 hours need addition doses and duration of prophylactic antibiotic administration should not exceed the 24-hour postoperative period then not need for additional antibiotic. If there is evidences of infection, intravenous antibiotic and follow by oral antibiotic is mandatory in acute infection in conjuction with scrub and debridement. Because the burden of infection in joint replacement is disaster, it seemed to increase the antibiotic uses and impact about the cost concerned after total knee arthroplasty. No data available about the pharmaco-economical study of perioperative antibiotic in total knee arthroplasty have been established. Primary outcomes is cost anaylsis of perioperative antibiotic uses in real clinical practice for total knee arthroplasty. Secondary outcome is infectioned total knee that need to reoperative for scrub and debridement. Prospective opened lable study from joint registry in Police General Hospital from June, 2010 till March, 2011. With minimum 12 months follow-up. Total Knee Arthroplasty was enrolled in the present study about 218 cases. 3 patients lossed follow-up in each groups, so the total number in the present study are 209 patients. Perioperative antibiotic consumption initial doses and followed for 48 hour is divided in 3 group: group 1 Fosmycin 4 g (2 g initially plus 2 g intraoperatively) for 70 patients group 2: Fosmycin 2 g for 68 patients. Group 3: Cefalosporin group for 71 patients. The cost of subsequence uses of intravenous and oral antibiotic were record. And also the cases that need to scrub debridement with the indication of infected total knee arthroplasty were recorded. The minimum follow-up about
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
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.
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
Barbero Allende, José M; Romanyk Cabrera, Juan; Montero Ruiz, Eduardo; Vallés Purroy, Alfonso; Melgar Molero, Virginia; Agudo López, Rosa; Gete García, Luis; López Álvarez, Joaquín
Prosthetic joint infection (PJI) is a complication with serious repercussions and its main cause is Staphylococcus aureus. The purpose of this study is to determine whether decolonization of S.aureus carriers helps to reduce the incidence of PJI by S.aureus. An S.aureus screening test was performed on nasal carriers in patients undergoing knee or hip arthroplasty between January and December 2011. Patients with a positive test were treated with intranasal mupirocin and chlorhexidine soap 5 days. The incidence of PJI was compared with patients undergoing the same surgery between January and December 2010. A total of 393 joint replacements were performed in 391 patients from the control group, with 416 joint replacements being performed in the intervention group. Colonization study was performed in 382 patients (91.8%), of which 102 were positive (26.7%) and treated. There was 2 PJI due S.aureus compared with 9 in the control group (0.5% vs 2.3%, odds ratio [OR]: 0.2, 95% confidence interval [CI]: 0.4 to 2.3, P=.04). In our study, the detection of colonization and eradication of S.aureus carriers achieved a significant decrease in PJI due to S.aureus compared to a historical group. Copyright © 2013 Elsevier España, S.L.U. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.
Severino, Fabricio Roberto; Souza, Clodoaldo José Duarte de; Severino, Nilson Roberto
Objectives: Assess the worthiness of arthroscopy in investigating and treating knee pain after arthroplasty unexplained by clinical and subsidiary examinations. Methods: Among 402 patients submitted to total or unicompartimental arthroplasty between September 2001 and April 2007 at a public university hospital, 17 presented with pain on prosthetic articulation, without clear diagnosis by clinical, X-ray, laboratory, scintiscan, or nuclear magnetic resonance tests. All patients were submitted to arthroscopy and symptoms were assessed by using the Lysholm scale, comparing pre-and post-arthroscopy periods. Peroperative findings have been recorded. Results: The procedure was effective for pain relief in 14 of 17 patients (82.35%). The median for Lysholm scale climbed from 36 points before arthroscopy to 94 points after the procedure (p < 0.001). Most of the patients (12) were arthroscopically diagnosed with fibrosis known as “cyclop”; on the remaining five patients, anterior synovitis was found. All patients were treated by resection. Conclusions: Knee arthroscopy after arthroplasty in patients presenting unclear persistent pain shows localized arthrofibrosis (“cyclops”) or synovitis, which can be treated by using the same procedure, resulting in pain relief. PMID:27022517
Newman, Jared M; Abola, Matthew V; Macpherson, Alexandra; Klika, Alison K; Barsoum, Wael K; Higuera, Carlos A
The study's purpose was to determine if there is an association between ABO blood group and the development of symptomatic venous thromboembolism (VTE) after total joint arthroplasty (TJA). A total of 28,025 patients who underwent primary TJA at a single health care system from 2000 to 2014 were retrospectively reviewed from electronic records. Patients who experienced a symptomatic VTE were identified. A multivariate regression model adjusted for known potential risk factors, including age, gender, body mass index, surgery type, previous VTE, smokers, rheumatologic diseases, malignancy, hypercoagulable state, and VTE prophylaxis, was developed to test the association of ABO blood group and postoperative VTE. Separate multivariate regressions were performed for total knee arthroplasty and total hip arthroplasty, specifically looking at pulmonary embolism. The risk of symptomatic VTE after TJA was increased in AB blood group patients (odds ratio = 1.4; P = .03). Furthermore, the risk of pulmonary embolism was increased after total knee arthroplasty in AB blood group patients (odds ratio = 2.24; P = .001) but not after total hip arthroplasty (P = .742). AB blood group increased the risk of VTE after TJA. Patient's ABO blood group should be considered in terms of risk stratification and selection of appropriate postoperative VTE prophylaxis. Copyright © 2017 Elsevier Inc. All rights reserved.
Thienpont, E; Vanden Berghe, A; Schwab, P E; Forthomme, J P; Cornu, O
To utilize the 'Forgotten Joint' Score (FJS), a 12-item questionnaire analysing the ability to forget the joint, for comparing preoperative status in osteoarthritic patients scheduled for total hip arthroplasty (THA) or total knee arthroplasty (TKA). Higher scores represent a better result with a maximum of 100. The hypothesis of this study was that a preoperative difference in favour of hip arthritis could eventually explain why THA is cited more often as a forgotten joint than TKA. A prospective cohort study was conducted in 150 patients with either tricompartmental knee (n = 75) or hip osteoarthritis (n = 75). Patients completed FJS-12 scores preoperatively and 1 year postoperatively. A similar preoperative FJS-12 was observed for hip (22 (15)) and knee osteoarthritis (24 (17)) (n.s.). The postoperative FJS-12 score was significantly higher for THA (80 (24)) than for TKA (70 (27)) (p < 0.05). High reliability after 6 weeks was observed for the preoperative FJS-12 test-retest reliability (ICC = 0.87) in TKA. A preoperative floor effect of 15 % in THA and 0 % in TKA was found as well as a postoperative ceiling effect of 33 % in THA and 9 % in TKA. The clinical relevance of utilizing the FJS-12 as an instrument to evaluate outcome is strongly proposed for knee arthroplasty. In general, one is not aware of a healthy joint during the ADL, and it can therefore be regarded as 'forgotten'. The preoperative FJS-12 Score is a powerful tool to provide patients with clearer insights into their positive evolution after surgery. The use of the FJS-12 in THA is a topic for further research, as this study found that floor and ceiling effects limit its usefulness in studies evaluating clinical outcome in this area. II.
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
Roth, Virginia R; Mitchell, Robyn; Vachon, Julie; Alexandre, Stéphanie; Amaratunga, Kanchana; Smith, Stephanie; Vearncombe, Mary; Davis, Ian; Mertz, Dominik; Henderson, Elizabeth; John, Michael; Johnston, Lynn; Lemieux, Camille; Pelude, Linda; Gravel, Denise
BACKGROUND Hip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated. OBJECTIVES To report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period. METHODS Prospective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions. RESULTS Overall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%-16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%-4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus. CONCLUSIONS PJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden. Infect Control Hosp Epidemiol 2017;38:147-153.
Ahmed, I; Salmon, L J; Waller, A; Watanabe, H; Roe, J P; Pinczewski, L A
Oxidised zirconium was introduced as a material for femoral components in total knee arthroplasty (TKA) as an attempt to reduce polyethylene wear. However, the long-term survival of this component is not known. We performed a retrospective review of a prospectively collected database to assess the ten year survival and clinical and radiological outcomes of an oxidised zirconium total knee arthroplasty with the Genesis II prosthesis. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and a patient satisfaction scale were used to assess outcome. A total of 303 consecutive TKAs were performed in 278 patients with a mean age of 68 years (45 to 89). The rate of survival ten years post-operatively as assessed using Kaplan-Meier analysis was 97% (95% confidence interval 94 to 99) with revision for any reason as the endpoint. There were no revisions for loosening, osteolysis or failure of the implant. There was a significant improvement in all components of the WOMAC score at final follow-up (p < 0.001). The mean individual components of the KOOS score for symptoms (82.4 points; 36 to 100), pain (87.5 points; 6 to 100), activities of daily life (84.9 points; 15 to 100) and quality of life (71.4 points; 6 to 100) were all at higher end of the scale. This study provides further supportive evidence that the oxidised zirconium TKA gives comparable rates of survival with other implants and excellent functional outcomes ten years post-operatively. Total knee arthroplasty with an oxidised zirconium femoral component gives comparable long-term rates of survival and functional outcomes with conventional implants. ©2016 The British Editorial Society of Bone & Joint Surgery.
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.
Gustafson, Jonathan A; Gorman, Shannon; Fitzgerald, G Kelley; Farrokhi, Shawn
Increased walking knee joint stiffness has been reported in patients with knee osteoarthritis (OA) as a compensatory strategy to improve knee joint stability. However, presence of episodic self-reported knee instability in a large subgroup of patients with knee OA may be a sign of inadequate walking knee joint stiffness. The objective of this work was to evaluate the differences in walking knee joint stiffness in patients with knee OA with and without self-reported instability and examine the relationship between walking knee joint stiffness with quadriceps strength, knee joint laxity, and varus knee malalignment. Overground biomechanical data at a self-selected gait velocity was collected for 35 individuals with knee OA without self-reported instability (stable group) and 17 individuals with knee OA and episodic self-reported instability (unstable group). Knee joint stiffness was calculated during the weight-acceptance phase of gait as the change in the external knee joint moment divided by the change in the knee flexion angle. The unstable group walked with lower knee joint stiffness (p=0.01), mainly due to smaller heel-contact knee flexion angles (p<0.01) and greater knee flexion excursions (p<0.01) compared to their knee stable counterparts. No significant relationships were observed between walking knee joint stiffness and quadriceps strength, knee joint laxity or varus knee malalignment. Reduced walking knee joint stiffness appears to be associated with episodic knee instability and independent of quadriceps muscle weakness, knee joint laxity or varus malalignment. Further investigations of the temporal relationship between self-reported knee joint instability and walking knee joint stiffness are warranted.
Gustafson, Jonathan A.; Gorman, Shannon; Fitzgerald, G. Kelley; Farrokhi, Shawn
Increased walking knee joint stiffness has been reported in patients with knee osteoarthritis (OA) as a compensatory strategy to improve knee joint stability. However, presence of episodic self-reported knee instability in a large subgroup of patients with knee OA may be a sign of inadequate walking knee joint stiffness. The objective of this work was to evaluate the differences in walking knee joint stiffness in patients with knee OA with and without self-reported instability and examine the relationship between walking knee joint stiffness with quadriceps strength, knee joint laxity, and varus knee malalignment. Overground biomechanical data at a self-selected gait velocity was collected for 35 individuals with knee OA without self-reported instability (stable group) and 17 individuals with knee OA and episodic self-reported instability (unstable group). Knee joint stiffness was calculated during the weight-acceptance phase of gait as the change in the external knee joint moment divided by the change in the knee flexion angle. The unstable group walked with lower knee joint stiffness (p=0.01), mainly due to smaller heel-contact knee flexion angles (p<0.01) and greater knee flexion excursions (p<0.01) compared to their knee stable counterparts. No significant relationships were observed between walking knee joint stiffness and quadriceps strength, knee joint laxity or varus knee malalignment. Reduced walking knee joint stiffness appears to be associated with episodic knee instability and independent of quadriceps muscle weakness, knee joint laxity or varus malalignment. Further investigations of the temporal relationship between self-reported knee joint instability and walking knee joint stiffness are warranted. PMID:26481256
Phan, Duy L; Rinehart, Joseph B; Schwarzkopf, Ran
AIM: To investigate the postoperative transfusion and complication rates of anemic and nonanemic total joint arthroplasty patients given tranexamic acid (TXA). METHODS: A cross-sectional prospective study was conducted of primary hip and knee arthroplasty cases performed from 11/2012 to 6/2014. Exclusion criteria included revision arthroplasty, bilateral arthroplasty, acute arthroplasty after fracture, and contraindication to TXA. Patients were screened prior to surgery, with anemia was defined as hemoglobin of less than 12 g/dL for females and of less than 13 g/dL for males. Patients were divided into four different groups, based on the type of arthroplasty (total hip or total knee) and hemoglobin status (anemic or nonanemic). Intraoperatively, all patients received 2 g of intravenous TXA during surgery. Postoperatively, allogeneic blood transfusion (ABT) was directed by both clinical symptoms and relative hemoglobin change. Complications were recorded within the first two weeks after surgery and included thromboembolism, infection, and wound breakdown. The differences in transfusion and complication rates, as well as the relative hemoglobin change, were compared between anemic and nonanemic groups. RESULTS: A total of 232 patients undergoing primary joint arthroplasty were included in the study. For the total hip arthroplasty cohort, 21% (18/84) of patients presented with preoperative anemia. Two patients in the anemic group and two patients in the nonanemic group needed ABTs; this was not significantly different (P = 0.20). One patient in the anemic group presented with a deep venous thromboembolism while no patients in the nonanemic group had an acute complication; this was not significantly different (P = 0.21). For nonanemic patients, the average change in hemoglobin was 2.73 ± 1.17 g/dL. For anemic patients, the average change in hemoglobin was 2.28 ± 0.96 g/dL. Between the two groups, the hemoglobin difference of 0.45 g/dL was not significant (P = 0
Leopold, Seth S; Silverton, Craig D; Barden, Regina M; Rosenberg, Aaron G
Problems with the patellofemoral articulation are the most common causes of failure after total knee arthroplasty. However, there are few reports describing outcomes following isolated revision of the patellar component. Forty knees with a Miller-Galante I prosthesis underwent isolated patellar revision (with or without lateral retinacular release). The Hospital for Special Surgery knee scores were collected prospectively, and radiographs made preoperatively and at the time of the final follow-up were analyzed with respect to alignment, component position, and patellar tracking. Particular attention was given to patients who had a reoperation or repeat revision and who had clinical or radiographic evidence of failure of the patellar revision. At a mean follow-up of sixty-two months, fifteen (38%) of the forty knees that had had an isolated revision of the patellar component failed a second time. Eight of them required a total of twelve additional operations at a mean of forty-nine months after the patellar revision. Three of the failures were severe enough to require revision of two or more of the components. Of the twenty-five knees that had not failed, the average Hospital for Special Surgery knee score at the time of the final follow-up was 87 points. Of the seven knees that did not undergo reoperation but were deemed to be failures on the basis of the patients' symptoms, the average Hospital for Special Surgery knee score at the time of the final follow-up was 72 points. Isolated patellar revision, with or without concurrent lateral retinacular release, was associated with a high rate of reoperation and a relatively low rate of success. Elements of the implant design and component alignment contributed to the patellar component failure; both should be scrutinized carefully in patients who are seen with this problem, prior to proceeding with isolated revision of the patellar component of a total knee arthroplasty. Therapeutic study, Level IV (case series [no, or
D'Lima, Darryl D; Patil, Shantanu; Steklov, Nikolai; Slamin, John E; Colwell, Clifford W
An instrumented tibial prosthesis was developed to measure forces in vivo after total tibial arthroplasty. This prosthesis was implanted in a 67-kg, 80-year-old man. The prosthesis measured forces at the 4 quadrants of the tibial tray. Tibial forces were measured postoperatively during rehabilitation, rising from a chair, standing, walking, and climbing stairs. By the sixth postoperative week, the peak tibial forces during walking averaged 2.2 times body weight (BW). Stair climbing increased from 1.9 times BW on day 6 to 2.5 times BW at 6 weeks. This represents the first direct in vivo measurement of tibial forces, which should lead to refined surgical techniques and enhanced prosthetic designs. Technical design improvements will enhance function, quality of life, and longevity of total knee arthroplasty.
Jing, F; Li, H M; Yang, X D; Li, B; Ji, J; Li, Y L; Sun, C J
Objective: To determine whether suction drainage is safe and effective compared with no-drainage in total knee arthroplasty. Methods: The literature search was based on PubMed, MEDLINE, EMBASE, Highwire, the Cochrane Library, CBM, CNKI, VIP and WFSD.The data were analysed using RevMan 5.3.Fourteen randomised controlled trials involving 1 009 knees were included in our analysis. Results: Suction drainage increases the rate and volume of blood transfusion.No-drainage group increases the rate of wound problems (OR=1.92, 95%CI 1.21-3.04, P<0.05). No significant difference was observed in the incidence of periprosthetic infection (OR=0.68, 95%CI 0.20-2.30, P=0.54), VAS (OR=-0.09, 95%CI -0.32-0.14, P=0.46) and the length of stay (OR=0.41, 95%CI -0.21-1.03; P=0.19) when the drainage group was compared with the no-drainage group (P>0.05). Conclusions: No-drainage for easy total knee arthroplasty may be a better choice. However, orthopedic surgeon need to weigh the pros and cons of no-drainage in some complicated TKAs such as extra-articular deformity .
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.
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.
Lan, Roy H; Kamath, Atul F
Understanding the socioeconomic factors that influence hospitalization and post-discharge metrics after joint replacement is important for identifying key areas of improvement in the delivery of orthopaedic care. An institutional administrative data set of 2869 patients from an academic arthroplasty referral center was analyzed to quantify the relationship between socioeconomic factors and post-acute rehabilitation care received, length of stay, and cost of care. The study used International Classification of Disease, ninth edition coding in order to identify cohorts of patients who received joint arthroplasty of the knee and hip between January 2007 and May 2015. The study found that females (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.74-2.46), minorities (OR, 2.11; 95% CI, 1.78-2.51), and non-private insurance holders (OR, 1.56; 95% CI, 1.26-1.94) were more likely to be assigned to institutional care after discharge. The study also found that minorities (OR, 1.45; 95% CI, 1.24-1.70) and non-private insurance holders (OR, 1.43; 95% CI, 1.16-1.77) are more likely to exhibit longer length of stay. Mean charges were higher for males when compared to females ($80,010 vs $74,855; P < .001), as well as total costs ($19,910 vs $18,613; P = .001). Socioeconomic factors such as gender, race, and insurance status should be further explored with respect to healthcare policies seeking to influence quality of care and health outcomes.
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
Thorp, Laura E; Orozco, Diego; Block, Joel A; Sumner, Dale R; Wimmer, Markus A
This work evaluated activity levels in a group of healthy older adults to establish a target activity level for adults of similar age after total joint arthroplasty (TJA).With the decreasing age of TJA patients, it is essential to have a reference for activity level in younger patients as activity level affects quality of life and implant design. 54 asymptomatic, healthy older adults with no clinical evidence of lower extremity OA participated. The main outcome measure, average daily step count, was measured using an accelerometer-based activity monitor. On average the group took 8813 ± 3611 steps per day, approximately 4000 more steps per day than has been previously reported in patients following total joint arthroplasty. The present work provides a reference for activity after joint arthroplasty which is relevant given the projected number of people under the age of 65 who will undergo joint arthroplasty in the coming years.
Comparative analysis of clinical usefulness of the Staffelstein Score and the Hospital for Special Surgery Knee Score (HSS) for evaluation of early results of total knee arthroplasties. Preliminary report.
Słupik, Anna; Białoszewski, Dariusz
Introduced and developed in the second half of the last century, joint arthroplasty has become a method of choice in the treatment of advanced degenerative knee joint disease. The aim of study was to compare the usefulness of the Hospital for Special Surgery Knee Score and the Staffelstein Score in the assessment of early treatment outcome, including rehabilitation, in patients who underwent knee arthroplasty due to gonarthrosis. A total of 24 patients who had undergone an arthroplasty procedure for degenerative changes in knee joints were examined in the study. The analysis included forty-four sets of results from examinations performed on average 13 days (SD 7) after knee arthroplasty. Treatment results were evaluated using the Hospital for Special Surgery Knee Score (HSS) and the Staffelstein Score (ST Score). The HSS Knee Score averaged 59.5 points (SD 19.8). The mean ST score was 82.0 points (SD 22.5). There was a strong correlation (p< 0.005) between the results obtained using both scores and their subscales (activities of daily living, clinical examination, and pain evaluation). 1. The analyzed scores seem to be a reliable source of information on the functional status of patients after knee arthroplasty and may be helpful tools in clinical evaluation also at an early postoperative stage. 2. Introducing a two-dimensional pain evaluation component, modeled on the HSS Knee Score, into the Staffelstein Score might improve its reliability. 3. A lower sensitivity of the HSS score in comparison with the ST Score that was revealed in the study requires further investigations in order to develop a questionnaire in the future that will combine the advantages of both scores.
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.
Chen, Antonia F; Stewart, Melissa K; Heyl, Alma E; Klatt, Brian A
The isolated effect of physical therapy (PT) on total joint arthroplasty hospital length of stay (LOS) has not been studied. A prospective cohort study was conducted on 136 primary total joint arthroplasties (58 hips, 78 knees). The LOS was determined by the operative start time until the time of discharge. On postoperative day (POD) 0, 60 joints remained in bed, 51 moved to a chair, and 25 received PT (22 ambulated, 3 moved to a chair). Length of stay differed for patients receiving PT on POD 0 (2.8 ± 0.8 days) compared with POD 1 (3.7 ± 1.8 days) (P = .02). There was no difference in PT treatment based on nausea/vomiting, pain levels, or discharge location. Isolated PT intervention on POD 0 shortened hospital LOS, regardless of the intervention performed.
Green, William Scott; Toy, Pearl; Bozic, Kevin J
Autologous blood donation and erythropoietin (EPO) have been shown to be effective in reducing allogeneic blood transfusion, but the cost-effectiveness of these interventions remains unclear. A cost minimization analysis was performed, comparing the total costs of allogeneic blood transfusion strategy and autologous and allogeneic blood transfusion strategy for 161 primary total hip arthroplasty (THA) and 195 total knee arthroplasty (TKA) patients. An EPO cost minimization model was constructed using a previously published algorithm for blood management after total joint arthroplasty. The least costly strategy was autologous blood donation in combination with allogeneic blood for THA and TKA patients at $856 and $892 per patient, respectively. The most costly strategy was allogeneic only at $1769 and $1352 per THA and TKA patient, respectively. The EPO strategy model predicted costs similar to the autologous and allogeneic. A strategy that combines autologous blood donation with EPO for patients who cannot donate autologous blood may provide the greatest cost savings and minimize allogeneic blood transfusion.
Slover, James; Espehaug, Birgitte; Havelin, Leif Ivar; Engesaeter, Lars Birger; Furnes, Ove; Tomek, Ivan; Tosteson, Anna
Interest in unicompartmental knee arthroplasty has recently increased in the United States, making a firm understanding of the indications for this procedure important. The purpose of this study was to examine the cost-effectiveness of unicompartmental knee arthroplasty compared with total knee arthroplasty in elderly low-demand patients. A Markov decision model was used to evaluate the cost-effectiveness of unicompartmental knee arthroplasty as compared with total knee arthroplasty in the elderly population. Transition probabilities were estimated from the Norwegian Arthroplasty Register and the arthroplasty literature, and costs were based on the average Medicare reimbursement for unicompartmental, tricompartmental, and revision knee arthroplasties. Outcomes were measured in quality-adjusted life-years. Our model showed unicompartmental knee arthroplasty to be a cost-effective strategy for this population as long as the annual probability of revision is <4%. The cost of unicompartmental knee arthroplasty must be greater than $13,500 or the cost of total knee arthroplasty must be less than $8500 before total knee arthroplasty becomes more cost-effective. Our model suggests that, on the basis of currently available cost and outcomes data, unicompartmental knee arthroplasty and total knee arthroplasty have similar cost-effectiveness profiles in the elderly low-demand patient population. However, several important parameters that could alter the cost-effectiveness analysis were identified; these included implant survival rates, costs, perioperative mortality and infection rates, and utility values achieved with each procedure. The thresholds identified in this study may help decision-makers to evaluate the cost-effectiveness of each strategy as further research characterizes the variables associate with unicompartmental and total knee arthroplasties and may be helpful for designing future appropriate clinical trials.
Velyvis, John H
Bleeding after total knee arthroplasty can result in significant morbidity and increases the need for blood transfusion. The proper use of intraoperative adjunctive topical hemostatic agents can enhance hemostasis perioperatively, potentially reducing blood transfusions. In this prospective study, 157 consecutive patients undergoing primary total knee arthroplasty received FLOSEAL (FLOSEAL Hemostatic Matrix; Baxter Healthcare Corporation, Hayward, California), a gelatin thrombin hemostatic matrix, 5 mL (74 patients) or 10 mL (83 patients). All patients received warfarin as thromboprophylaxis starting the day after surgery. Data were extracted via hospital chart review from 100 consecutive patients who underwent total knee arthroplasty and immediately preceded the FLOSEAL groups and did not receive FLOSEAL (control group). Postoperative drainage was significantly lower in the FLOSEAL 5 mL (236.9 mL) and 10 mL (120.5 mL) groups compared with the control group (430.8 mL; P<.0001 for both). The FLOSEAL 10 mL group had significantly less drainage than the FLOSEAL 5 mL group (P<.0001). The predicted probability of transfusion in the FLOSEAL 5 mL group was not significantly different compared with the control group (6.0% vs 7.6%, P=.650). The predicted probability of transfusion was lower in the FLOSEAL 10 mL group compared with the control group (0.5% vs 5.5%; P=.004). Within the FLOSEAL 10 mL group, application of FLOSEAL either before or after tourniquet release had a similarly significant effect on drainage volume and predicted probability of blood transfusion. No differences in outcomes were observed by type of anesthesia used. No adverse events occurred related to FLOSEAL use.
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.
Guenther, Daniel; Schmidl, Stefan; Klatte, Till O; Widhalm, Harald K; Omar, Mohamed; Krettek, Christian; Gehrke, Thorsten; Kendoff, Daniel; Haasper, Carl
AIM: To evaluate a possible association between the various levels of obesity and peri-operative charac-teristics of the procedure in patients who underwent endoprosthetic joint replacement in hip and knee joints. METHODS: We hypothesized that obese patients were treated for later stage of osteoarthritis, that more conservative implants were used, and the intra-and perioperative complications increased for such patients. We evaluated all patients with body mass index (BMI) ≥ 25 who were treated in our institution from January 2011 to September 2013 for a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients were split up by the levels of obesity according to the classification of the World Health Organization. Average age at the time of primary arthroplasty, preoperative Harris Hip Score (HHS), Hospital for Special Surgery score (HSS), gender, type of implanted prosthesis, and intra-and postoperative complications were evaluated. RESULTS: Six thousand and seventy-eight patients with a BMI ≥ 25 were treated with a primary THA or TKA. Age decreased significantly (P < 0.001) by increasing obesity in both the THA and TKA. HHS and HSS were at significantly lower levels at the time of treatment in the super-obese population (P < 0.001). Distribution patterns of the type of endoprostheses used changed with an increasing BMI. Peri- and postoperative complications were similar in form and quantity to those of the normal population. CONCLUSION: Higher BMI leads to endoprosthetic treat-ment in younger age, which is carried out at significantly lower levels of preoperative joint function. PMID:25621218
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
Woyski, Dustin; Emerson, Jason
Fractures of the tibial shaft in patients with ipsilateral total knee arthroplasty are rare but difficult to treat. Nonoperative treatment of these fractures with casting or bracing limits weight bearing for an extended period and can result in unacceptable malalignment. Operative fixation with plate and screws also limits early weight bearing and requires healing of soft tissue that is of poor quality. The authors present a method of internal fixation that uses a standard intramedullary tibial nail and suprapatellar instrumentation. This method can easily be performed, avoids the tibial baseplate, and does not require alteration of the instrumentation or intramedullary nail.
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.
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.
Rosenberg, N; Nierenberg, G; Lenger, R; Soudry, M
Functional assessment of patients before and after prosthetic knee arthroplasty is based on clinical examination, which is usually summarized in various knee scores. The present study proposes a different and more subject orientated assessment for functional grading of these patients by measuring their maximal distance of walking ability, which is not apparent from the conventional outcome scores. Eighteen consecutive patients with knee osteoarthritis were evaluated for their knee and knee functional scores (The Knee Society clinical rating system) and for the maximal distance of their walking ability before and 6 months after knee arthroplasty. Specially designed walking ability grading was used for evaluation of walking on walkway. The pre- and post-operative knee scores and maximal walking distance and grading were statistically compared. A significant improvement in the knee and functional scores following surgery was observed. But the maximal walking ability grades and distances did not change significantly following surgery, showing a high relation between pre- and post-operative values. The limitation in post-operative walking was due to the revealed additional health disabilities, not related to the affected knee. Therefore we suggest that pre-operative evaluation of walking abilities should be taken into consideration both for patients' selection and timing of surgery and also for matching of patients' expectation from outcome of prosthetic knee arthroplasty.
Kong, Xiangrong; Jiranek, William A.
Objective There is little evidence to guide physicians when discussing future likelihood of knee arthroplasty with patients who have symptomatic knee osteoarthritis. Data from Osteoarthritis Initiative (OAI) was used to determine the incidence of and predictors for knee arthroplasty. Methods OAI data were collected on a sample of 778 persons aged 45 to 79 years with symptomatic knee osteoarthritis. An extensive set of measurements were obtained at baseline and persons were followed for 2 years to identify who underwent knee arthroplasty. Random forest analysis was used to identify optimal variables that discriminate among those who did and those who did not undergo knee arthroplasty. Results The two year incidence of knee arthroplasty in the cohort was 3.7% (95%CI, 2.6%, 5.3%). Because of the low number of knee arthroplasty procedures, the predictor analysis was preliminary in nature. The analysis identified several variables that could be used to assist in identifying patients at future risk for knee arthroplasty. Conclusion For persons at high risk of knee arthroplasty, the two year incidence of knee arthroplasty is very low. The most powerful predictors were those that accounted for disease severity and functional loss. These data could assist physicians in advising patients with knee osteoarthritis on future surgical care. PMID:19419874
Madeti, Bhaskar Kumar; Chalamalasetti, Srinivasa Rao; Bolla Pragada, S. K. Sundara siva rao
The present paper is to know how the work is carried out in the field of biomechanics of knee. Various model formulations are discussed and further classified into mathematical model, two-dimensional model and three-dimensional model. Knee geometry is a crucial part of human body movement, in which how various views of knee is shown in different planes and how the forces act on tibia and femur are studied. It leads to know the forces acting on the knee joint. Experimental studies of knee geometry and forces acting on knee shown by various researchers have been discussed, and comparisons of results are made. In addition, static and dynamic analysis of knee has been also discussed respectively to some extent.
Gaulrapp, H; Eckstein, S
Ultrasound is often applied in the course of treatment after knee arthroplasty, although sonographic normal findings have not been described so far. Characterising these and comparing them to clinical disorders was the purpose of this study. Intra- and extra-articular hematoma and the imaging of the traumatised extension apparatus of the knee joint were of special interest. During 4 weeks all consecutive patients after knee arthroplasty were examined clinically and sonographically. Furthermore, the blood parameters were controlled for signs of inflammation or coagulation disorders. These findings were then re-checked before the end of hospital rehabilitation treatment. In all of the patients, ultrasound revealed intra-articular fluid at the beginning and at the end of hospital treatment. The fluid area, differing in extension, was markedly reduced or showed less echogenicity concomitant with an organisation. The patellar tendon in all of the patients showed a loss of echogenicity at the site of operative incision, mostly at the patellar insertion, and a thickening extending throughout the middle part of the tendon even at control. Dynamic ultrasound examination displayed one case of a major defect which had to be revised. Blood parameters of inflammation were decreased, coagulation parameters were normal. After knee arthoplasty, extended intra-articular knee hematomas are not rare, only being resorbed or organised to a small degree during a rehabilitation period of three weeks, therefore not yielding relevant information for the course of treatment. The patellar ligaments show alterations comparable to acute tendopathy, thus not recommending use of maximal forces or too high stretching of the tendon tissue. Soft tissue defects with the need for interruption of the rehabilitation programme may be detected sonographically. Further studies will be necessary to explore the course of restructuring. Disorders of patellar sliding movement and signs of prosthetic loosening
Waszczykowski, Michal; Niedzielski, Kryspin; Radek, Maciej; Fabis, Jaroslaw
Arthrodesis of the knee joint is a mainly a salvage surgical procedure performed in cases of infected total knee arthroplasty, tumor, failed knee arthroplasty or posttraumatic complication.The authors report the case of 18-year-old male with posttraumatic complication of left knee because of motorbike accident 1 year before. He was treated immediately after the injury in the local Department of Orthopaedics and Traumatology. The examination in the day of admission to our department revealed deformation of the left knee, massive scar tissue adhesions to the proximal tibial bone and multidirectional instability of the knee. The plain radiographs showed complete lack of lateral compartment of the knee joint and patella. The patient complained of severe instability and pain of the knee and a consecutive loss of supporting function of his left limb. The authors decided to perform an arthroscopic-assisted fusion of the knee with Ilizarov external fixator because of massive scar tissue in the knee region and the prior knee infection.In the final follow-up after 54 months a complete bone fusion, good functional and clinical outcome were obtained.This case provides a significant contribution to the development and application of low-invasive techniques in large and extensive surgical procedures in orthopedics and traumatology. Moreover, in this case fixation of knee joint was crucial for providing good conditions for the regeneration of damaged peroneal nerve.
Kwak, Dai Soon; Tao, Quang Bang; Todo, Mitsugu; Jeon, Insu
Knee joint implants developed by western companies have been imported to Korea and used for Korean patients. However, many clinical problems occur in knee joints of Korean patients after total knee joint replacement owing to the geometric mismatch between the western implants and Korean knee joint structures. To solve these problems, a method to determine the representative dimension parameter values of Korean knee joints is introduced to aid in the design of knee joint implants appropriate for Korean patients. Measurements of the dimension parameters of 88 male Korean knee joint subjects were carried out. The distribution of the subjects versus each measured parameter value was investigated. The measured dimension parameter values of each parameter were grouped by suitable intervals called the "size group," and average values of the size groups were calculated. The knee joint subjects were grouped as the "patient group" based on "size group numbers" of each parameter. From the iterative calculations to decrease the errors between the average dimension parameter values of each "patient group" and the dimension parameter values of the subjects, the average dimension parameter values that give less than the error criterion were determined to be the representative dimension parameter values for designing knee joint implants for Korean patients.
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.
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.
Dicks, Kristen V; Baker, Arthur W; Durkin, Michael J; Anderson, Deverick J; Moehring, Rebekah W; Chen, Luke F; Sexton, Daniel J; Weber, David J; Lewis, Sarah S
To determine the association (1) between shorter operative duration and surgical site infection (SSI) and (2) between surgeon median operative duration and SSI risk among first-time hip and knee arthroplasties. Retrospective cohort study A total of 43 community hospitals located in the southeastern United States. Adults who developed SSIs according to National Healthcare Safety Network criteria within 365 days of first-time knee or hip arthroplasties performed between January 1, 2008 and December 31, 2012. Log-binomial regression models estimated the association (1) between operative duration and SSI outcome and (2) between surgeon median operative duration and SSI outcome. Hip and knee arthroplasties were evaluated in separate models. Each model was adjusted for American Society of Anesthesiology score and patient age. A total of 25,531 hip arthroplasties and 42,187 knee arthroplasties were included in the study. The risk of SSI in knee arthroplasties with an operative duration shorter than the 25th percentile was 0.40 times the risk of SSI in knee arthroplasties with an operative duration between the 25th and 75th percentile (risk ratio [RR], 0.40; 95% confidence interval [CI], 0.38-0.56; P<.01). Short operative duration did not demonstrate significant association with SSI for hip arthroplasties (RR, 1.04; 95% CI, 0.79-1.37; P=.36). Knee arthroplasty surgeons with shorter median operative durations had a lower risk of SSI than surgeons with typical median operative durations (RR, 0.52; 95% CI, 0.43-0.64; P<.01). Short operative durations were not associated with a higher SSI risk for knee or hip arthroplasty procedures in our analysis.
Dicks, Kristen V.; Baker, Arthur W.; Durkin, Michael J.; Anderson, Deverick J.; Moehring, Rebekah W.; Chen, Luke F.; Sexton, Daniel J.; Weber, David J.; Lewis, Sarah S.
OBJECTIVE To determine the association (1) between shorter operative duration and surgical site infection (SSI) and (2) between surgeon median operative duration and SSI risk among first-time hip and knee arthroplasties. DESIGN Retrospective cohort study SETTING A total of 43 community hospitals located in the southeastern United States. PATIENTS Adults who developed SSIs according to National Healthcare Safety Network criteria within 365 days of first-time knee or hip arthroplasties performed between January 1, 2008 and December 31, 2012. METHODS Log-binomial regression models estimated the association (1) between operative duration and SSI outcome and (2) between surgeon median operative duration and SSI outcome. Hip and knee arthroplasties were evaluated in separate models. Each model was adjusted for American Society of Anesthesiology score and patient age. RESULTS A total of 25,531 hip arthroplasties and 42,187 knee arthroplasties were included in the study. The risk of SSI in knee arthroplasties with an operative duration shorter than the 25th percentile was 0.40 times the risk of SSI in knee arthroplasties with an operative duration between the 25th and 75th percentile (risk ratio [RR], 0.40; 95% confidence interval [CI], 0.38–0.56; P <.01). Short operative duration did not demonstrate significant association with SSI for hip arthroplasties (RR, 1.04; 95% CI, 0.79–1.37; P =.36). Knee arthroplasty surgeons with shorter median operative durations had a lower risk of SSI than surgeons with typical median operative durations (RR, 0.52; 95% CI, 0.43–0.64; P <.01). CONCLUSIONS Short operative durations were not associated with a higher SSI risk for knee or hip arthroplasty procedures in our analysis. PMID:26391277
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.
Dunbar, Nicholas J; Roche, Martin W; Park, Brian H; Branch, Sharon H; Conditt, Michael A; Banks, Scott A
Unicompartmental knee arthroplasty (UKA) can achieve excellent clinical and functional results for patients having single-compartment osteoarthritis. However, UKA is considered to be technically challenging to perform, and malalignment of implant components significantly contributes to UKA failures. It has been shown that surgical navigation and tactile robotics could be used to provide very accurate component placement when the bones were rigidly fixed in a stereotactic frame during preparation. The purpose of this investigation was to determine the clinically realized accuracy of UKA component placement using surgical navigation and tactile robotics when the bones are free to move. A group of 20 knees receiving medial UKA with dynamically referenced tactile-robotic assistance was studied. Implant placement errors were comparable with those achieved using tactile robotics with rigid stereotactic fixation. Copyright © 2012 Elsevier Inc. All rights reserved.
Trepte, C T; Pfanzelt, K
Soft tissue balancing and correct bone cuts are an entity in correcting malalignment in total knee arthroplasty, and cannot be considered isolated. Distinct bony deformations/deviations need enlarged soft tissue management. The extent of resection of the bone stock has to be planned exactly before the operation. Exact soft tissue balancing is necessary to stabilize the corrected knee. Soft tissue balancing has to be done primarily on the side of the contracture by lengthening of the shortened and contracted structures. After balancing the ligaments should have the same tension in extension and flexion together with the same height of the extension and flexion gap. Because of the classic resection of the tibial head, the femoral resection must follow the Insall-Line, that means 3 degrees to 5 degrees outer rotation in relation to the condyles. Only in this way a symmetric flexion gap can be achieved in combination with ligamentous stability in extension and flexion.
Sadoghi, Patrick; Leithner, Andreas; Labek, Gerold
Worldwide joint arthroplasty registers are instrumental to screen for complications or implant failures. In order to achieve comparable results a similar classification dataset is essential. The authors therefore present the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) European Arthroplasty Register (EAR) minimal dataset for primary and revision joint arthroplasty. Main parameters include the following: date of operation, country, hospital ID-code, patient's name and prename, birthday, identification code of the implant, gender, diagnosis, preoperations, type of prosthesis (partial, total), side, cementation technique, use of antibiotics in the cement, surgical approach, and others specifically related to the affected joint. The authors believe that using this minimal dataset will improve the chance for a worldwide comparison of arthroplasty registers and ask future countries for implementation.
Natoli, Roman M; Nypaver, Chrissy M; Schiff, Adam P; Hopkinson, William J; Rees, Harold W
Blount disease is associated with complex deformity of the proximal tibia, and some patients will develop knee osteoarthritis. Five patients (eight knees) with Blount disease or Blount-like deformity underwent total knee arthroplasty. Mean proximal tibial metaphyseal-diaphyseal angle was 20.75°. Each patient had substantial posteromedial tibial bony defects and six knees required extensive medial releases. Two knees required increased constraint at index procedure. One patient has undergone bilateral revision surgery with rotating hinge prostheses. Mean WOMAC scores were 13.5 and Knee Society scores were 212.5 at average 75.2 month follow-up. Despite technical challenges, patients with these deformities can have successful outcomes after total knee arthroplasty. Surgeons should be prepared to address posteromedial tibial bony defects and consider constrained arthroplasty at the index procedure.
Cromie, Melinda J; Siston, Robert A; Giori, Nicholas J; Delp, Scott L
Abnormal anterior translation of the femur on the tibia has been observed in mid flexion (20-60 degrees ) following posterior stabilized total knee arthroplasty. The underlying biomechanical causes of this abnormal motion remain unknown. The purpose of this study was to isolate the effects of posterior cruciate ligament removal on knee motion after total knee arthroplasty. We posed two questions: Does removing the posterior cruciate ligament introduce abnormal anterior femoral translation? Does implanting a posterior stabilized prosthesis change the kinematics from the cruciate deficient case? Using a navigation system, we measured passive knee kinematics of ten male osteoarthritic patients during surgery after initial exposure, after removing the anterior cruciate ligament, after removing the posterior cruciate ligament, and after implanting the prosthesis. Passively flexing and extending the knee, we calculated anterior femoral translation and the flexion angle at which femoral rollback began. Removing the posterior cruciate ligament doubled anterior translation (from 5.1 +/- 4.3 mm to 10.4 +/- 5.1 mm) and increased the flexion angle at which femoral rollback began (from 31.2 +/- 9.6 degrees to 49.3 +/- 7.3 degrees). Implanting the prosthesis increased the amount of anterior translation (to 16.1 +/- 4.4 mm), and did not change the flexion angle at which femoral rollback began. Abnormal anterior translation was observed in low and mid flexion (0-60 degrees) after removing the posterior cruciate ligament, and normal motion was not restored by the posterior stabilized prosthesis.
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.
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
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.
Mitchelson, Andrew J; Wilson, Craig J; Mihalko, William M; Grupp, Thomas M; Manning, Blaine T; Dennis, Douglas A; Goodman, Stuart B; Tzeng, Tony H; Vasdev, Sonia; Saleh, Khaled J
The prospect of biomaterial hypersensitivity developing in response to joint implant materials was first presented more than 30 years ago. Many studies have established probable causation between first-generation metal-on-metal hip implants and hypersensitivity reactions. In a limited patient population, implant failure may ultimately be related to metal hypersensitivity. The examination of hypersensitivity reactions in current-generation metal-on-metal knee implants is comparatively limited. The purpose of this study is to summarize all available literature regarding biomaterial hypersensitivity after total knee arthroplasty, elucidate overall trends about this topic in the current literature, and provide a foundation for clinical approach considerations when biomaterial hypersensitivity is suspected.
Liu, Hua-Wei; Ni, Ming; Zhang, Guo-Qiang; Li, Xiang; Chen, Hui; Zhang, Qiang; Chai, Wei; Zhou, Yong-Gang; Chen, Ji-Ying; Liu, Yu-Liang; Cheng, Cheng-Kung; Wang, Yan
This study aims to retain normal knee kinematics after knee replacement surgeries by reconstructing anterior cruciate ligament during total knee arthroplasty. We use computational simulation tools to establish four dynamic knee models, including normal knee model, posterior cruciate ligament retaining knee model, posterior cruciate ligament substituting knee model, and anterior cruciate ligament reconstructing knee model. Our proposed method utilizes magnetic resonance images to reconstruct solid bones and attachments of ligaments, and assemble femoral and tibial components according representative literatures and operational specifications. Dynamic data of axial tibial rotation and femoral translation from full-extension to 135 were measured for analyzing the motion of knee models. The computational simulation results show that comparing with the posterior cruciate ligament retained knee model and the posterior cruciate ligament substituted knee model, reconstructing anterior cruciate ligament improves the posterior movement of the lateral condyle, medial condyle and tibial internal rotation through a full range of flexion. The maximum posterior translations of the lateral condyle, medial condyle and tibial internal rotation of the anterior cruciate ligament reconstructed knee are 15.3 mm, 4.6 mm and 20.6 at 135 of flexion. Reconstructing anterior cruciate ligament in total knee arthroplasty has been approved to be an more efficient way of maintaining normal knee kinematics comparing to posterior cruciate ligament retained and posterior cruciate ligament substituted total knee arthroplasty.
Liu, Hua-Wei; Ni, Ming; Zhang, Guo-Qiang; Li, Xiang; Chen, Hui; Zhang, Qiang; Chai, Wei; Zhou, Yong-Gang; Chen, Ji-Ying; Liu, Yu-Liang; Cheng, Cheng-Kung; Wang, Yan
Background: This study aims to retain normal knee kinematics after knee replacement surgeries by reconstructing anterior cruciate ligament during total knee arthroplasty. Method: We use computational simulation tools to establish four dynamic knee models, including normal knee model, posterior cruciate ligament retaining knee model, posterior cruciate ligament substituting knee model, and anterior cruciate ligament reconstructing knee model. Our proposed method utilizes magnetic resonance images to reconstruct solid bones and attachments of ligaments, and assemble femoral and tibial components according representative literatures and operational specifications. Dynamic data of axial tibial rotation and femoral translation from full-extension to 135 were measured for analyzing the motion of knee models. Findings: The computational simulation results show that comparing with the posterior cruciate ligament retained knee model and the posterior cruciate ligament substituted knee model, reconstructing anterior cruciate ligament improves the posterior movement of the lateral condyle, medial condyle and tibial internal rotation through a full range of flexion. The maximum posterior translations of the lateral condyle, medial condyle and tibial internal rotation of the anterior cruciate ligament reconstructed knee are 15.3 mm, 4.6 mm and 20.6 at 135 of flexion. Interpretation: Reconstructing anterior cruciate ligament in total knee arthroplasty has been approved to be an more efficient way of maintaining normal knee kinematics comparing to posterior cruciate ligament retained and posterior cruciate ligament substituted total knee arthroplasty. PMID:27347334
Tardy, Nicolas; Chambat, Pierre; Murphy, Colin G; Fayard, Jean-Marie
In limbs affected by poliomyelitis, total knee arthroplasty results in satisfactory pain relief. However, the risk of failure is high, especially if the preoperative quadriceps power is low. Therefore, treating osteoarthritis in the current patient represented a challenging procedure. A 66-year-old man presented with tricompartmental osteoarthritis of both knees, with valgus deformity of 14° on the left knee and 11° on the right knee. He walked with a bilateral knee recurvatum of 30° and a grade 1 quadriceps power. The authors treated both knees with cemented custom-fit hinged total knee arthroplasty with 30° of recurvatum in the tibial keel. Clinical scores showed good results 1 year postoperatively, especially on the subjective data of quality of life and function. At follow-up, radiographs showed good total knee arthroplasty positioning on the right side and a small mechanical loosening at the end of the tibial keel on the left side. Only 5 studies (Patterson and Insall; Moran; Giori and Lewallen; Jordan et al; and Tigani et al) have reported total knee arthroplasty results in patients with poliomyelitis. This study reports an original case of bilateral custom-fit hinged total knee arthroplasty in a patient with poliomyelitis. To the authors' knowledge, this is the first report of this type of procedure in the literature. The key point is the degree of recurvatum that is needed to allow walking, avoiding excessive constraints on the implants that can lead to early mechanical failure.
Lachance, Kim; Savoie, Michel; Bernard, Maryse; Rochon, Stéphanie; Fafard, Josée; Robitaille, Robert; Vendittoli, Pascal-André; Lévesque, Sylvie; de Denus, Simon
Low hemoglobin (Hb) concentrations before lower limb joint replacement are associated with the need for blood transfusions and increased mortality. To optimize preoperative Hb, blood conservation protocols often recommend oral iron supplements, even in nonanemic patients. To investigate the impact of ferrous sulfate on the change in Hb prior to hip or knee arthroplasty and evaluate the effect of oral iron on hematocrit, mean corpuscular volume (MCV), ferritin, and transferrin saturation, as well as its tolerability and treatment adherence. We conducted a prospective, observational cohort study of adults with Hb concentrations between 10 and 15 g/dL who received iron supplementation prior to hip or knee arthroplasty. Systemic inflammatory diseases, vitamin B(12) or folate deficiency, and current use of iron supplements, intravenous iron, or erythropoietin were exclusion criteria. All participants were prescribed ferrous sulfate 300 mg 3 times daily for a minimum of 3 weeks. Complete blood cell counts and iron studies were performed before therapy and surgery. Eighty-seven patients with a mean (SD) Hb of 13.47 (0.84) g/dL were included in the study. Preoperative Hb decreased after treatment with iron (-0.14 [0.53] g/dL, p = 0.015). Hematocrit also declined (-0.6% [1.8%], p = 0.002), whereas ferritin increased (25.8 [38.6] ng/mL, p < 0.001). No significant change was seen in MCV and transferrin saturation. The mos