Outcome of subvastus approach in elderly nonobese patients undergoing bilateral simultaneous total knee arthroplasty: A randomized controlled study

Background:

Subvastus approach in total knee arthroplasty (TKA) spares the quadriceps and may assist in faster rehabilitation. The present randomised controlled study was conducted to determine if the subvastus approach results in early recovery, faster mobilization, shorter hospital stay, and improved function.

Materials and Methods:

100 patients undergoing simultaneous bilateral TKA were randomized into two groups: subvastus group and medial parapatellar group. The patients were assessed clinically using VAS, time to straight leg raise, ability to stand with walker, ability to use a commode chair, ability to climb stairs, flexion at discharge, and day of discharge. Perioperative blood loss and duration of surgery were also compared. The patient were kept on same pain management and physiotherapy protocol. The evaluation was done at day 0,1,3 and at discharge. Statistical analyses tested the null hypotheses of no differences in patients treated with either group at 95% significance level (P < 0.05).

Results:

The VAS score was significantly lower in subvastus group on day 1 and day 3. Also mean hospital stay was 2.04 days less in subvastus group. Patients with subvastus approach were able to perform straight leg raising 0.44 days earlier. Though time to stand with walker was same for both groups, the ability to use commode chair, and climb stairs was significantly early (P < 0.05) in the subvastus group. The average flexion at the time of discharge in subvastus and parapatellar group were 100.8 and 96.8°, respectively. The mean perioperative blood loss in subvastus group and parapatellar group were 343 ml and 372 ml, respectively. Average surgical time required for subvastus approach and parapatellar approach were 108.5 and 94.3 min, respectively.

Conclusions:

Subvastus approach produce appreciably less pain and faster mobilization due to lesser insult to quadriceps, thus assisting in early rehabilitation, shorter hospital stay, less expenditure, and more patient satisfaction.     

Total knee arthroplasty in valgus knees using minimally invasive medial-subvastus approach

Background:

An ideal approach for valgus knees must provide adequate exposure with minimal complications due to approach per se. Median parapatellar approach is most commonly used approach in TKA including valgus knees. A medial subvastus approach is seldom used for valgus knees and has definite advantages of maintaining extensor mechanism integrity and minimal effect on patellar tracking. The present study was conducted to evaluate outcomes of total knee arthroplasty (TKA) and efficacy of subvastus approach in valgus knees in terms of early functional recovery, limb alignment and complications.

Materials and Methods:

We retrospectively reviewed 112 knees with valgus deformity between January 2006 and December 2011. All patients were assessed postoperatively for pain using Visual Analog Scale (VAS) and quadriceps recovery in form of time to active straight leg raising (SLR) and staircase competency and clinical outcomes using American Knee Society (AKS) score and radiographic evaluation with average followup of 40 months (range 24–84 months).

Results:

The mean VAS on postoperative day (POD) 1 and POD2 at rest was 2.73 and 2.39, respectively and after mobilization was 3.28 and 3.08, respectively (P < 0.001). The quadriceps recovery was very early and 92 (86.7%) patients were able to do active SLR by POD1 with mean time of 21.98 h while reciprocal gait and staircase competency was possible at 43.05 h. The AKS and function score showed significant improvement from preoperative mean score of 39 and 36 to 91 and 79 (P < 0.001), respectively, and the mean range of motion increased from 102° preoperatively to 119° at recent followup (P < 0.001). The mean tibiofemoral valgus was corrected from preoperative 16° (range 10°–35°) to 5° (range 3°–9°) valgus (P < 0.001).

Conclusions:

Mini-subvastus quadriceps approach provides adequate exposure and excellent early recovery for TKA in valgus knees, without increase in incidence of complications.     

Total knee arthroplasty in patients with stiff knees

The purpose of this study was to evaluate the clinical outcome of total knee arthroplasty and analyze the prognostic factors in patients with stiff knees. Thirty-two patients (39 knees) with severe knee arthritis and an arc of motion of 50° or less were treated by total knee arthroplasty. The mean follow-up period was 58 months (range, 24-123 months). The mean arc of motion improved from 35° before the operation to 94° at the time of the latest follow-up (P<.05). Improvement in knee motion after postoperative 3 months was insignificant. The most important factor related to the final arc of knee motion was preoperative arc of knee motion. The V-Y quadricepsplasty was associated with an inferior clinical outcome. Total knee arthroplasty in patients with stiff knees has substantially improved in the clinical outcome and the arc of motion.     

小切口经股内侧肌入路行全膝关节置换术

目的 探讨小切口经股内侧肌入路行全膝关节置换术的早期临床疗效和特点.方法 小切口经股内侧肌入路行全膝置换28例(30膝).分别对术后切口长度、疼痛度、镇痛剂使用量、手术前后Hb减少量、输血量、引流量、直腿抬高时间、术后住院时间、假体力线对位,术后6、12周、1年的活动度(ROM)及术后1年膝关节HSS评分等观察指标进行疗效分析.结果 28例患者均获得随访,时间1年～1年6个月.切口长度8.5～14(11.3±0.8) cm,VAS评分1.2～4(2.76±0.76)分,术后2例患者肌注75 mg杜冷丁,5例口服塞来昔布(西乐葆)0.4 g,余患者均未给予镇痛剂,引流量25～300(96.8±55.9)ml、Hb减少10～55(25.5±10.5)g/L,距能直腿抬高时间1～8(3.8±1.57)d,术后住院6～14(8.6±2.0)d,术后6、12周、1年的平均ROM分别为107°±6.3°、117°±5.5°、121°±6°,1年HSS评分平均95分±1.7分;除有1例胫骨假体对位不良外,其余均获得正确的力线对位.结论 小切口经股内侧肌入路行全膝关节置换,术后膝关节功能恢复快,早期疗效满意.     

Total knee arthroplasty for the stiff knee

The underlying cause of stiffness must be carefully evaluated when considering total knee arthrolasty for the stiff knee. Any previous skin incision must be recorded as well as the state of the extensor mechanism. The choice of prosthesis constraint should be decided on the state of the soft-tissues often released extensively to gain flexion. A quadriceps release or plasty and a tibial tubercle osteotomy are the current options for exposure, soft-tissue release and bone cuts. Postoperatively, the motion should be started early combined to pain control in order to obtain an average of 65° of flexion at follow-up. The complication rate remains high including recurrent stiffness, delayed wound healing and deep infection.     

Factors affecting range of motion in total knee arthroplasty using high flexion prosthesis: A prospective study

Background:

High flexion implants have been reported to provide better range of motion (ROM). The few studies analyzing the factors affecting the ROM are scarce. This study aims to find the factors that affect ROM when using a high flex knee design (INDUS knee).

Materials and Methods:

Two hundred and fifty three consecutive patients of total knee arthroplasty (TKA) done by using INDUS knee prosthesis between Sept 2008 and Sept 2009 were included in the study. The cases with osteoarthritis (OA) and Rheumatoid arthritis (RA) were included in study. 5 patients were lost to followup and 248 patients (267 knees, 19 bilateral, 221 OA, and 46 RA) were analyzed for the following factors – sex, age, body mass index (BMI), preoperative ROM, flexion deformity, preoperative total knee score and functional score, time of tourniquet release and patella resurfacing. Subgroup classification using above factors was performed and statistical analysis of effect of all the above factors on final knee ROM was done. Assessment was done preoperatively and at 3 months, 6 months and 1 year postoperatively. The final outcome evaluation was done at one year followup.

Results:

The mean age was 68.2 years (range 40-89 years) with 79 males and 189 females. The mean knee range improved from 97.62 ± 11° to 132 ± 8°. Factors that positively affect ROM of INDUS knee prosthesis at the end of 1 year were preoperative ROM, total knee score and functional score, and diagnosis of osteoarthritis, whereas BMI, preoperative flexion deformity has a negative influence on final flexion at the end of 1 year. Age and gender of the patients, patella resurfacing, and use of two different tourniquet protocols did not affect the final outcome.

Conclusion:

Preoperative ROM and preoperative functional status are the most important factors affecting final range. Patients should be counseled accordingly and made to understand these factors.     

Total knee arthroplasty component templating: a predictive model

Preoperative planning is essential to total knee arthroplasty (TKA); however, TKA templating is historically inaccurate. To improve on templating accuracy and streamline preoperative planning, we set out to predict component sizes based on patient characteristics without radiographs. A total of 123 consecutive patients undergoing unilateral TKA were identified and included in the model study. Input variables consisted of age, gender (as a binary number), height, weight, and body mass index. A linear regression model was created. The models predicted component size exactly in 74% of femurs and 85% of tibias. All model predictions were within a ±1 size of the actual components implanted. Our models were more accurate than any previous model for TKA reported.     

Total knee arthroplasty using the total condylar III knee prosthesis

Twenty-seven total knee arthroplasties (TKAs) were performed in 24 patients using the total condylar III knee prosthesis (TCP III) and were evaluated clinically and radiographically with a mean follow-up period of 4 years. Eighteen were revision TKAs, and nine were primary knee arthroplasties. Evaluations were made using the Hospital for Special Surgery (HSS) knee scale as well as the Knee Society radiographic evaluation method. Clinical results for all knees were 11% (3 of 27) excellent, 70% (19 of 27) good, 15% (4 of 27) fair, and 4% (1 of 27) poor. The one poor rating resulted from an intraoperative vascular injury. The results showed no statistical difference between revision and primary TKA. After operation, pain relief, range of motion, walking, function, and activity level improved in both the primary and revision patients. Radiolucencies 2 mm or greater in width were found in 6 of the 27 tibial components, in none of the 27 femoral components, and in 1 of the 19 patellar components. Only two tibial implants showed progressive radiolucencies. No correlation was found between the radiographic position of the implants and the clinical results. The authors conclude that the TCP III is a satisfactory choice for TKA in selected knees in which there is significant instability and in which intramedullary fixation is required.     

Total knee arthroplasty of the stiff knee: three hundred and four cases

Purpose

The purpose of this study was to analyse the results of total knee arthroplasty (TKA) in stiff knees (flexion ≤90° and/or flexion contracture ≥20°). Our hypothesis was that despite having poorer results than those obtained in a “standard” population and a high rate of complications, TKA was a satisfactory treatment in patients with osteoarthritis of the knee associated with significant stiffness.

Methods

Three hundred and four consecutive primary HLS TKAs (Tornier), whose data were prospectively collected between October 1987 and October 2012, were retrospectively analysed at a mean of 60 months (range, 12–239) postoperatively. Two groups, those with a “flexion contracture” and those with a “flexion deficit”, were assessed for postoperative range of motion (as integrated to the Knee Society score [KSS]), physical activity level and patient satisfaction.

Results

At the latest follow-up, range of motion was significantly improved, as was the KSS. Ninety-four percent of patients were satisfied or very satisfied, and activity levels were increased after surgery. The complication rate, however, was high in patients with a preoperative flexion deficit (17 %). Pain and residual stiffness were the most common complications.

Conclusion

TKA provides satisfactory results in patients with knee osteoarthritis associated with significant pre-operative stiffness. The surgical plan should be adapted to anticipate complications, which are particularly frequent in the presence of a flexion deficit.     

膝关节伸直位僵硬的人工关节置换治疗

目的 探讨膝关节伸直位僵硬的人工关节置换的手术方法及近期临床疗效.方法 对9例膝关节伸直位僵硬患者(12膝)行人工关节置换术,术中采用二次截骨加软组织松解的方法,分别记录手术前后膝关节HSS评分及关节活动度,并进行统计分析.结果 经过 12～56(36.2±9.61)个月的随访,膝关节HSS评分由术前13～45(28.6±7.12)分提高到术后56～89(65.45±6.25)分(P<0.01).关节活动度由术前0°提高到术后70°～110°(85.5°±10.18°)(P<0.01).结论 膝关节伸直位僵硬可以进行人工膝关节置换,手术效果满意.掌握熟练的手术技巧及正确术后康复至关重要.     

Early results of subvastus versus medial parapatellar approach in primary total knee arthroplasty

Introduction To evaluate the clinical and radiographic results immediately after total knee arthroplasty, we compared the parapatellar and subvastus approach.Materials and methods Fifty-two patients with osteoarthritis were randomly assigned to two groups. The measurement was based on clinical and radiographic features.Results There was a significant difference in passive range of motion. Patients in the subvastus approach group revealed a full knee extension and flexion of 90° significantly earlier than those in the parapatellar group. However, on the day of discharge, both groups were comparable. Radiological assessment revealed analogous results in both groups. Correction of varus or valgus deformity was required in 48 patients.Conclusion Regardless of the surgical approach, the anteroposterior tibial femoral angle improved significantly in both groups. Concerning pain, operation time, blood loss, blood substitution and complications, no major differences could be seen.     

Assessing short-term functional outcomes and knee alignment of computer-assisted navigated total knee arthroplasty

This retrospective study examined the relationship between the mechanical axis of the knee throughout its functional arc and functional outcomes in patients with computer-assisted navigation total knee arthroplasty. Data on final intraoperative functional arc alignment were obtained on 76 patients who had computer-assisted navigation total knee arthroplasty over a 2-year period and correlated with scores from postoperative Short Form 12 and Western Ontario and McMaster Universities functional outcome surveys. No correlation was found between functional arc alignment and outcomes from Western Ontario and McMaster Universities or Short Form 12 surveys; however, subgroup analysis of patients with more than 3° average final intraoperative alignment throughout the functional arc of motion demonstrated increased difficulty with daily activities (P = .05). The results indicate that patients with more than 3° average alignment throughout the functional arc of motion perform more poorly with daily activities postoperatively.     

Clinical and radiographic analysis of accurate restoration of the joint line in revision total knee arthroplasty

A clinical and radiographic analysis was performed on 89 consecutive revision total knee arthroplasties. The postoperative joint line position was evaluated and correlated with the clinical outcome. The joint line position was evaluated radiographically. Average follow-up was 8.2 years (24-197 months). Clinical outcome values were correlated to joint line position. More improvement was seen with recreation of the normal joint line to within +/-4 mm of the normal unaffected knee for Knee Society Score, average total arc of motion, flexion, and extension. There was a significant difference found for all 4 variables when combined outliers were compared with goal range (-4 to 4 mm). In this study, clinical outcome was improved if the joint line was accurately reproduced.     

Mini-subvastus approach for total knee arthroplasty in obese patients

Background:

Mini-subvastus approach for Total Knee Arthropalsty allows a faster recovery. It is traditionally not utilized for obese patients because of difficulty in exposure of the knee and eversion of the patella. We hypothesized that obesity should not really cause a problem for patients undergoing a TKA with the mini-subvastus approach as the anatomy of the quadriceps in the obese and the nonobese patient population is the same. We present an analysis of the use of mini-subvastus approach in obese patients.

Materials and Methods:

97 obese patients (109 knees) 81 females + 16 males with mean age 64 years underwent total knee arthroplasty (TKA) by mini-subvastus approach between January 2006 to July 2007. 16 patients (18 kness) were morbidly obese. All patients were prospectively evaluated by pre- and postoperative Knee Society and function score. The average follow-up was 18 months (range from 1 to 3 years) with minimum 1 year follow-up.

Results:

The approach provided adequate exposure in all knees, with an average surgical time of 90 minutes. The patella could be everted easily after the tibial and femoral cuts. The average Knee Society score improved from 42 to 89 and the function score from 48 to 65. The complications included medial collateral ligament injury (one case) and patellar tendon avulsion (one case).

Conclusion:

Our results compare favorably with other reported series in obese patients. The mini-subvastus approach can be considered in obese patients.     

Results of contralateral total knee arthroplasty in patients with a history of stiff total knee arthroplasty

This study seeks to evaluate the clinical outcomes of a second primary total knee arthroplasty in patients whose initial (contralateral) primary total knee arthroplasty was complicated by stiffness. We retrospectively compared the preoperative and postoperative range of motion and Knee Society Scores from a study group of 15 patients with an age-matched control group. Statistical analysis did not reveal a significant difference in final postoperative range of motion or Knee Society Scores between the 2 groups. However, there was a statistically significant higher rate of closed manipulation in the study group. Therefore, although the study group did show a higher rate of early stiffness, eventual functional outcome was comparable with a nonstiffness control group.     

The role of flexion contracture on outcomes in primary total knee arthroplasty

This study examined the role that flexion contracture plays in postoperative outcomes after total knee arthroplasty using a retrospective database review. The relationships between preoperative and postoperative knee extension, walking ability, stair climbing ability, Knee Society scores, pain scores, and knee function scores were studied in 5,622 knees. A preoperative flexion contracture was associated with an increased incidence of a persistent postoperative flexion deformity. A postoperative flexion contracture was associated with poorer postoperative results. Furthermore, a postoperative hyperextension deformity of greater than 10 degrees was associated with an increased risk of suboptimal pain and Knee Society scores. Knee extension deformities play a substantial detrimental role in the functional outcome of primary total knee arthroplasty.     

人工全膝关节置换治疗膝关节骨关节炎

目的探讨人工全膝关节置换术(TKA)治疗终末期膝关节骨关节炎的临床疗效。方法对行TKA治疗的181例终末期膝关节骨关节炎患者(226膝)分别于手术后40、120、180、360 d进行定期随访观察,对患者HSS膝关节功能评分及膝关节最大活动度进行比较。结果患者均获得随访,时间1~2年。膝关节功能HSS评分:优209膝(92.5%),良13膝(5.8%),可3膝(1.3%),差1膝(0.4%),优良率98.2%。术后各时间段的HSS评分及膝关节最大活动度均较术前显著提高,差异均有统计学意义(P0.05)。结论 TKA是治疗终末期膝关节骨关节炎的有效方法,正确的手术操作和合理的功能锻炼是取得满意临床效果决定性因素。     

股内侧肌下入路与髌旁内侧入路在老年膝关节置换中应用的初步临床分析

目的 分析比较全膝关节置换术（total knee arthroplasty, TKA）中采用股内侧肌下入路（subvastus approach, SVA）与髌旁内侧入路（medial parapatellar approach, MPA）的早期临床疗效。方法 回顾性分析2015年1月至2016年8月在本院完成初次TKA的69例病人资料（年龄均超过60岁）,根据手术入路的不同分为SVA组和MPA组,记录并比较两组病人的手术切口长度、手术时间、总出血量、术后可直腿抬高时间、膝关节术后活动度（range of motion, ROM）。采用疼痛视觉模拟量表（visual analogue scale, VAS）评价病人疼痛情况,采用美国膝关节协会评分（knee society score, KSS）评价病人的膝关节功能。结果 SVA组病人的手术切口长度为（11.48±1.35） cm,与MPA组的（15.24±1.41） cm相比,差异有统计学意义（t=11.041,P＜0.001）;两组间手术总失血量及手术时间比较,差异均无统计学意义（t=0.209,P=0.835;t=1.003,P=0.320）;SVA组病人的术后直腿抬高时间为（1.52±0.62） d,MPA组为（2.61±0.97） d,两组比较,差异有统计学意义（t=5.462,P＜0.001）。术后第3、7天SVA组静息和活动状态下的VAS评分均优于MPA组,两组间比较,除外术后第7天静息状态下的VAS评分,其他时间及状态下的VAS评分差异均有统计学意义（P均＜0.05）。术后第3、7天,MPA组病人的膝关节ROM（89.09°±5.51°、93.03°±7.06°）均小于SVA组（96.36°±4.55°、96.36°±6.53°）,差异均有统计学意义（t=5.842,P＜0.001;t=1.991,P=0.049）。术后2周,MPA组病人的KSS评分为（72.42±4.35）分,小于SVA组病人的（78.79±3.96）分,差异有统计学意义（t=6.214,P＜0.001）。术后第1、3、6、9个月,两组间KSS评分和膝关节ROM比较,差异均无统计学意义（P均＞0.05）。结论 人工全膝关节置换采用SVA对伸膝装置影响小,可促进置换后关节功能及关节活动度的快速恢复,减少疼痛,提高术后满意度。     

Total knee arthroplasty in patients with poliomyelitis

Between 1991 and 2001, 17 primary total knee arthroplasties were performed in 15 patients with limbs affected by poliomyelitis. Eight patients had a constrained condylar knee design, 8 a posterior stabilized design, and 1 a hinged design. Mean follow-up was 41.5 months. The mean Knee Society knee score improved from 45 preoperatively to 87 postoperative. Knee stability was obtained in all patients, including 4 patients with less than antigravity quadriceps strength. Radiologic evaluation showed satisfactory alignment with no signs of loosening. Complications included 1 case of deep venous thrombosis and 2 knees that required a manipulation for stiffness. Pain relief, functional improvement, and knee stability can be achieved after constrained total knee arthroplasty in patients with poliomyelitis despite impaired quadriceps strength, and osseous and soft tissue abnormalities.     

经股内侧肌下方入路行全膝关节置换术的早期疗效

目的探讨经股内侧肌下方入路行全膝关节置换术(TKA)的早期疗效。方法通过回顾性研究方法,比较分析经股内侧肌下方入路和经典内侧髌旁入路行TKA治疗60例64膝原发性骨关节炎患者。其中经股内侧肌下方入路32例33膝,经典内侧髌旁入路28例31膝,随访时间超过3个月。比较两组患者的手术时间、切口长度、术后伤口引流量,术后2周、6周及3个月时关节活动度、疼痛程度以及膝关节功能。结果两组患者在手术时间、切口长度间的差异无统计学意义。术后经股内侧肌下方入路组伤口引流量200.2 m l,较经典内侧髌旁入路组340.6 m l明显减少。两组患者术后直腿抬高时间分别是2.8 d和5.2 d(t=-10.0208,P=0.0000),术后2周时两组患者关节活动度分别为97.2°和83.8°(t=2.5657,P=0.0128),疼痛程度经视觉模拟评分(VAS评分)分别为3.2分和4.6分(t=-0.6545,P=0.0000),组间差异有统计学意义。而术后6周、3个月时两组患者关节活动度(6周:t=0.2274,P=0.8209;3个月:t=0.6411,P=0.5239)、疼痛程度(6周:t=-0.6146,P=0.5423;3个月:t=-1.1358,P=0.2606)和关节功能(6周:t=0.3937,P=0.6955;3个月:t=1.0541,P=0.2960)差异没有统计学意义。结论与经典内侧髌旁入路相比,经股内侧肌下方入路行TKA具有术后出血少,术后早期膝关节功能恢复快等优点,其远期疗效和经典入路没有明显差异。