Bilateral staged total knee arthroplasty in obese patients

Introduction The purpose of this study was to compare the clinical and functional results and complications associated with staged bilateral total knee arthroplasty (TKA) performed 4–11 days apart during a single hospitalization in patients who were obese and patients who were not obese. Methods We retrospectively evaluated 48 (96 knees) patients who were obese and divided into two groups based on their body mass indices (BMI). Morbidly obese patients (group A1, BMI ≥ 40 kg/m²) consisted of 21 patients (42 knees), and obese patients (group A2, BMI ≥ 30 kg/m²) consisted of 27 patients (54 knees). The control group (group B, BMI < 30 kg/m²) consisted of 20 non-obese patients (40 knees), who were undergoing staged bilateral procedure within the same time frame. All patients had cemented TKAs with use of posterior cruciate sparing prosthesis without patellar resurfacing. If medically stable after the first arthroplasty the patients then underwent the second arthroplasty 4–11 days later. The data on major complications and minor complications were evaluated. Results Although, there was no statistically significant difference in overall complication rates in any of the groups, the non-obese group had fewer wound complications than the other groups (P > 0.05). No significant differences in preoperative or postoperative Knee Society score, and functional score could be demonstrated between the three groups (P > 0.05). Both obese and nonobese patients showed improvements in pain and function from pre-surgery to a minimum 2 years follow-up. Conclusion Results of bilateral staged TKAs in obese patients have low complication and high success rates and increased BMI has no negative effect on the early outcome. Bilateral staged TKA might be a good treatment alternative for the improvement of the patient’s quality of life and functional and clinical outcomes.     

同期和分期双膝关节置换安全性的Meta分析

[目的]比较双膝关节置换的同期和分期治疗的主要并发症差异,系统评价两种不同手术方式的安全性.[方法]检索Medline、Embase、Cochrane library、中国CBM,收集双膝关节置换的同期和分期治疗的对照试验,提取数据进行分析,采用统计软件RevMan5.0.18进行Meta分析.[结果]纳入18个临床对照试验,共101 084例手术,其中SB-TKA 26 536例,Staged B-TKA 74 548例.Meta分析的结果显示,前者术后1个月内死亡率(OR=2.92)、3个月内的死亡率(OR=2.11)和肺栓塞发生率(OR=2.46)均高于后者,两组比较有统计学差异.[结论]目前证据表明,双膝关节置换手术组的术后1个月内死亡率、3个月内的死亡率和肺栓塞率高于分期治疗手术组.围手术期主要死因是心肺并发症.但还需要开展更多高质量的临床随机对照试验以增加证据的强度.     

Simultaneous bilateral total knee arthroplasty

Total knee arthroplasty (TKA) was performed simultaneously on both knees by two teams in a single procedure. The study population consisted of 74 patients (148 knee joints) with osteoarthritis (OA) or rheumatoid arthritis (RA). The peri- and postoperative results were compared with those in a group of 22 OA and RA patients (44 knee joints) who underwent staged operation during one hospital stay. Comparisons were made of functional score and range of motion (ROM) before and after operation, mean total blood loss, operative time, duration of hospital stay, and operative and postoperative complications. The simultaneous performance of bilateral procedures did not influence the functional score, ROM after operation, or mean intra- and postoperative blood loss. Nor was incidence of operative and postoperative complications increased compared with that in the staged operation group. The operative time in the simultaneous TKA group was significantly shorter than the time that would have been required had separate procedures been performed on both knees. Simultaneous bilateral TKA is beneficial for the patient.     

单髁置换术与全膝关节置换术治疗膝单间室骨性关节炎近中期疗效的对比研究

目的探讨膝单髁置换术(UKA)和全膝关节置换术(TKA)治疗膝单间室重度骨性关节炎(KOA)的近中期临床疗效。方法随访本研究中因患膝单间室重度KOA接受单髁置换术的患者23例(23膝),同时期同术者施行的全膝关节置换术50例(56膝)。UKA组23位患者22名获得到了较为完整的临床随访,1例死亡。平均时间为28.6个月(4个月～7年),TKA组50位患者均获得随访,平均时间为32.9个月(2个月～7年)。对手术前后HSS评分,疼痛缓解,术中出血量及术后3d血红蛋白下降量,关节屈曲大于90°时间及屈曲大于120°膝关节数进行比较。结果UKA组与TKA组均获得满意疗效,两组患者均无假体松动,无关节翻修等严重并发症,HSS评分UKA组术前(64±5.75)分,术后末次随访(86±7.85)分(t=11.53,P0.001);TKA组术前(61±6.53)分,术后末次随访(84±7.92)分(t=18.64,P0.001)。与TKA组比较,UKA组术中出血(t=12.47,P0.001)及术后3d天血红蛋白下降少(t=13.61,P0.001),疼痛缓解相似(2=0.007,P0.05),术后膝关节屈曲到90°时间短(t=3.97,P0.05),术后能屈曲到120°的比率高。结论在严格掌握适应证的前提下,对于膝单间室重度KOA患者的手术治疗,UKA的近中期疗效可与TKA相媲美,而且UKA具有创伤小,出血少,患者耐受性好,术后恢复快的优点。     

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.     

Weight change 1 year following total knee or hip arthroplasty

BACKGROUND: Pain secondary to osteoarthritis (OA) of the hip or knee is often used as a reason to not lose weight prior to total knee or hip arthroplasty (TKA, THA). This study followed the weight change of patients who subjectively increased their activity levels 1 year following TKA or THA. METHODS: We reviewed the records and prospectively followed the weight of 84 patients 1 year following surgery. The pre and postoperative weight were compared, including separate 10 kg categories (e.g. 60.1-70.0 kg). RESULTS: All patients had improved mobility as evaluated by either the clinical notes or a patient-based questionnaire. At 1 year, there was no significant change in weight; only an insignificant small increase in weight was seen. CONCLUSIONS: This study suggests that lower preoperative activity levels are not the cause for the inability to lose weight or that the gain in mobility achieved by joint replacement, of its own, does not result in weight loss.     

Simultaneous bilateral total knee arthroplasty is safe and effective for patients in different ages

BackgroundSimultaneous bilateral total knee arthroplasty is considered beneficial for patients with bilateral end-stage knee osteoarthritis, even though there could be potential postoperative complications. Presently, there is a paucity of evidence of the efficacy and safety of SB-TKA for elderly patients. This study aimed to compare the clinical outcomes of simultaneous bilateral total knee arthroplasty by different age groups.MethodsA total of 216 knees of 108 patients, who underwent simultaneous bilateral total knee arthroplasty for osteoarthritis at our hospital between April 2015 and September 2018, were divided into three groups based on age: 60s (44 knees), 70s (106 knees), and 80s (66 knees). Perioperative data and postoperative clinical outcomes 1 year after surgery were compared between the age groups.ResultsThe patients in the Group 60s were characterized by a higher body mass index (BMI) (P < 0.01), a lower pre-operative knee function score (P < 0.01), longer operation time (P < 0.01), greater intra-operative (P < 0.01), and postoperative bleeding (P = 0.026). No significant difference was found in terms of occurrence of various postoperative complications, although deep vein thrombosis and delirium occurred slightly more frequently in the Group 70s and the Group 80s than in the Group 60s group. The Knee Society Knee Score, a function score, and patient satisfaction scores were significantly improved in all groups 1 year after surgery. Moreover, these indexes of clinical outcomes were similar among the three groups.ConclusionPerforming simultaneous bilateral total knee arthroplasty in 80s patients was found to be as safe and effective as in the 60s and 70s patients.Level of evidence3 (A retrospective cohort study).     

混合型单髁与全膝关节置换治疗膝内侧间室骨关节炎的疗效比较

目的：探讨Oxford第3代混合型单髁置换（unicompartmental knee arthroplasty,UKA）与全膝关节置换（total knee arthroplasty,TKA）治疗膝关节内侧间室骨关节炎的疗效。方法：回顾性分析2017年10月至2019年10月行膝关节置换术的156例患者,男44例,女112例,年龄50~75（58.76±4.97）岁。根据不同治疗方式分为单侧TKA组和单侧Oxford第3代混合型UKA组。单侧TKA 81例（81膝）,男23例,女58例,年龄51~75（58.60±5.01）岁;单侧Oxford第3代混合型UKA 75例（75膝）,男21例,女54例,年龄50~72（58.92±4.95）岁。比较两组临床评估指标,包括手术一般情况、相关并发症、美国膝关节协会评分（American Knee Society score,AKSS）临床评分和功能评分;影像评估指标包括髋膝踝角（hip-knee-ankle angle,HKA）、股骨假体内外翻角（femoral component valgus/varus angle,FCVA）、股骨假体后倾角（femoral component posterior slope angle,FCPSA）、胫骨假体内外翻角（tibial component valgus/varus angle,TCVA）、胫骨假体后倾角（tibial component posterior slope angle,TCPSA）,是否发生膝关节外侧间室进展、衬垫脱位、假体下沉、松动。结果：UKA组术中出血量、手术时间、住院天数均显著优于TKA组（P<0.05）,两组术后均未出现并发症。两组患者均获随访,时间24~54（38.01±8.90）个月。末次随访两组AKSS临床评分、功能评分、HKA均优于术前（P<0.05）。末次随访UKA组AKSS临床评分、功能评分均优于TKA组（P<0.05）,TKA组HKA优于UKA组（P<0.05）。末次随访两组TCVA、FCVA差异无统计学意义（P>0.05）,UKA组TCPSA、FCPSA大于TKA组（P<0.05）,UKA组未出现外侧室进展。结论：Oxford第3代混合型UKA治疗膝关节内侧间室骨关节炎,较TKA具有手术创伤小、失血量少、手术时间短、住院时间短、术后快速康复、膝关节功能恢复更好等优势,疗效满意。     

Recurrent hemarthrosis after total knee arthroplasty

Seven patients developed recurrent hemarthroses following total knee arthroplasty. The average interval between arthroplasty and the first bleed was more than 20 months (range, 1–30 months). All seven required open synovectomy an average of 21 months (6–31 months) after arthroplasty. Follow-up evaluation averaged 44 months (19–60 months) and all had an excellent result without further bleeds. A prolific synovitis was seen in all cases, with histologic features revealing a chronic synovitis with fibrosis and hemosiderin staining. Entrapment of the proliferative synovial tissue between the components is postulated to be the etiology for these recurrent bleeds which averaged four per patient prior to synovectomy.     

Dislocation following primary posterior-stabilized total knee arthroplasty

From 1981 through 1991, 3, 032 primary total knee arthroplasties were performed using the Insall-Burstein Posterior Stabilized Condylar Prosthesis (IB-I, IB-II, and IB-II modified) (Zimmer, Warsaw, IN). Fifteen posterior dislocations occurred: 4 with the IB-I system occurring 2 or more years after surgery, 10 with the IB-II system (8 occurring 6 months after surgery and 2 occurring 2–3 years after surgery), and 1 with the IB-II modified system occurring 9 months after surgery. Statistically significant differences for the rate of dislocation between both the IB-I and IB-II modified arthroplasties versus the IB-II arthroplasties were found (P < .001). In an attempt to identify a cause for these dislocations, the authors retrospectively assessed the 15 dislocated cases with respect to sex, age, weight, height, preoperative and postoperative Hospital for Special Surgery scores, preoperative and postoperative alignment, preoperative versus postoperative reconstruction dimensions, patellar thickness and height, and postoperative flexion and compared the results with those patients who did not experience dislocation. Possible etiologies and mechanisms of dislocation were sought. There were no significant differences between the control and study groups for any variable assessed, with the exception of postoperative flexion, which averaged 118° for the study group and 105° for the control group (P < .001). Conservative management was successful in 11 cases. In September 1988 the IB-II system was introduced; modification of the tibial insert was made in January 1990. The 10 IB-II dislocations occurred prior to the modification of the modular tibial polyethylene insert, and the 3 recurrent dislocations in this group were successfully treated with revision to this modified insert. Since this modification, 656 IB-II modified systems have been implanted with one dislocation (0.15%).     

Patellar clunk in total knee arthroplasty using modified Sigma posterior stabilized femoral component

Aim

The purpose of this study was to evaluate the efficacy of the enhanced PS femoral component design released in 2008 by DePuy. The patellar clunk syndrome has been reported in a significant number of patients following total knee arthroplasty. Design modifications of the implant have been made to reduce the incidence of the patellar clunk, especially in the posterior substituted designs.

Methods

130 total knee replacements performed using the enhanced PS femoral components were followed-up with clinical and radiographic evaluations.

Results

Patellar clunk was seen in 3 of the 130 knees (2%). This is much less than the incidence of patellar clunk reported until now.

Conclusions

Removal of the sharp ridge in the intercondylar groove in the newer implant seems to have been effective in reducing the incidence of the patellar clunk. It also indicates that the sharp ridge was the most probable cause of the clunk.     

Staged versus simultaneous bilateral total knee replacement

Bilateral total knee replacements were reviewed to determine whether any difference exists in the perioperative course between procedures done under one anesthetic (simultaneous) and those done under two anesthetics (staged). There were 29 staged and 18 simultaneous cases, therefore 76 separate procedures and 94 knees done. The total operative time, blood loss, and complications were similar between the two groups. However, the staged replacements had more than twice the hospital days (34.6 +/- 7.7 vs. 16.8 +/- 5.6, P less than .001) and 18% greater hospital bills. In fact, for a given patient, the hospital bill may be greater than 50% higher if a staged rather than simultaneous replacement is done. Therefore, simultaneous replacement is recommended for appropriate patients.     

A vascular complication in computer navigated total knee arthroplasty

The use of computer navigation has the potential to improve implant position in total knee arthroplasty (TKA), but pin fixation of reference arrays introduces an additional potential source of complications. We report a case of vascular injury related to the insertion of a femoral pin during navigated TKA.     

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.     

Patello-femoral complications associated with total knee arthroplasty

The patello-femoral articulation accounts for a significant number of the complications that occur after total knee replacements and which require re-operation. These include problems with stability, component wear, fracture, loosening, and osteonecrosis. With careful attention to prosthetic design and surgical technique, these complications can be minimized. Guest Lecture presented at the 26th meeting of the Japanese Society for Replacement Arthroplasty in Tokyo on February 2, 1996     

The painful total knee arthroplasty: Keys to diagnosis

As the prevalance of patients living with total knee replacements continues to rise we continue to see a significant portion of patients living with pain following their primary total knee arthroplasty. For some patients, the etiology of their pain following knee replacement is obvious, yet in many cases the cause of pain remains elusive and thus creates a significant burden for the patient and treating physician. In this review article we focus on common sources of pain following knee replacement and discuss keys to diagnosis. We also propose a unique clinical pathway algorithm to guide diagnostic work up and treatment options.     

膝关节置换术中髌骨置换与非髌骨置换比较的Meta分析

[目的]系统评价全膝关节置换术中髌骨置换与否对术后疗效的影响,为临床治疗提供参考。[方法]全面搜索国内外关于膝关节置换术中髌骨置换和非髌骨置换的随机对照研究资料,按照既定的纳入、排除标准,核定检出符合评价标准的文献,提取所需研究数据,采用RevMan 4.2软件进行Meta分析。[结果]纳入随机对照研究16篇,共计1 922例膝关节置换术。Meta分析结果显示,髌骨置换组术后5年内发生膝前痛的风险降低,加权后RR=0.53,95%CI(0.30,0.94),但5年后二者无明显统计学差异。髌骨置换组术后5年以上发生再手术的风险低,加权后RR=0.35,95%CI(0.18,0.66),但5年内二者无明显统计学差异。膝关节KSS评分不论是亚组分析还是总体分析,均无统计学差异。总体分析结果,KSS评分加权均数差值为0.44,95%CI(-1.22,2.09)。[结论]全膝关节置换术中髌骨置换与非髌骨置换相比,术后5年内膝前痛发生率低,术后5年以上再手术的风险低,关节评分无明显差别。髌骨置换与非髌骨置换的优劣仍需大规模多中心的RCT来进一步研究。     

Midterm results of cruciate retaining total knee arthroplasty in patellectomized patients

Background:

Total knee arthroplasty (TKA) in patellectomized patients gives inferior results when compared with those in which the patella is present. The literature is ambiguous about the role of cruciate retaining or sacrificing implants for these knees. In this study, we assessed the midterm results of TKA in patellectomized knees using a cruciate retaining implant.

Materials and Methods:

Thirty three patients with a prior patellectomy underwent a cruciate retaining TKA and were followed up for an average of 9.3 years (range 2-14 years). At each followup visit, they were evaluated clinically, radiologically and by the Hospital for Special Surgery Scoring System.

Results:

Twenty one knees did not have any pain or difficulty in climbing stairs, 10 knees were slightly painful on stairs but pain free on walking on flat ground and two knees experienced mild to moderate pain on walking up and down stairs as well as on flat ground. The average range of motion preoperatively was 87°, which postoperatively increased to 118°. The average Hospital for Special Surgery Knee scores increased from 52 to 89 points. None of the knees showed any progressive radiolucencies or evidence of any loosening/osteolysis or fractures in followup.

Conclusion:

Cruciate retaining TKA offers good results at midterm followup in patients with a prior patellectomy.     

Osteolysis after total knee arthroplasty

Osteolysis ranks as the most significant cause of revision surgery in both total hip arthroplasty and total knee arthroplasty (TKA). The factors leading to osteolysis in TKA are unique and sometimes preventable. Changes in polyethylene manufacturing and implant design are striving to improve overall wear. In this review, we discuss osteolysis as it relates to TKAs. The etiology, diagnosis, contributing factors, and management are presented. The final section focuses on future improvements in TKA design, which may ultimately decrease the rate of osteolysis.     

Patients prefer a bicruciate-retaining or the medial pivot total knee prosthesis

Four-hundred forty patients underwent staged bilateral total knee arthroplasty using a different prosthesis on each side. Prostheses used were anterior-posterior cruciate-retaining (ACL-PCL), posterior cruciate-retaining (PCL), Medial Pivot (MP), posterior cruciate-substituting (PS), and mobile bearing (MB). At the 2-year evaluation, we asked “Which is your better knee overall?” Responses were as follows: 89.1% preferred the ACL-PCL to the PS and 76.2% preferred the MP to the PS. The ACL-PCL and the MP were preferred equally. The MP was preferred over the PCL by 76.0%, and 61.4% preferred the MP over the MB. The PS and PCL were preferred equally. Range of motion, pain relief, alignment, and stability did not vary significantly by prosthesis used. Patients with bilateral total knee arthroplasties preferred retention of both cruciates with use of the ACL-PCL prosthesis or substituting with an MP prosthesis.