Psychometrical properties of the Turkish translation of the New Knee Society Scoring System

ObjectiveTo translate the New Knee Society Scoring System (KSS) into Turkish and to evaluate the psychometric properties of the translated questionnaire.MethodsThis study was conducted on 66 knees of 43 pre-op patients who were scheduled for total knee arthroplasty (TKA) and 50 knees of 26 knee arthroplasty patients at least 6 months postoperatively. KSS was translated and culturally adapted according to the guidelines of Guillemin and Beaton. Demographic and clinical characteristics of the patients were recorded. Patients completed WOMAC, KOOS and SF-36 surveys along with the Turkish version of the new KSS. After the initial evaluation, patients were asked to refill the new KSS 1 week later. Internal consistency and reliability were tested using Cronbach's alpha coefficient and intraclass correlation coefficient (ICC). Validity was assessed by calculating the Spearman's correlation coefficient between the new KSS and WOMAC, KOOS and SF-36 scores.ResultsThe mean ages of the pre and post-operative groups were 67.16 ± 7.85 years and 71.65 ± 6.95 years respectively. The Cronbach's alpha coefficients of the new KSS calculated for symptoms (0.814), patient satisfaction (0.947), patient expectations (pre-op = 1.000, post-op = 0.997) and functional activities (0.864) were high. The ICC scores ranged between 0.790 and 0.951. The pain subscore of the new KSS and the pain subscores of the WOMAC (r = −0.720; p < 0.01), KOOS (r = 0.550; p < 0.01) and SF-36 (r = −0.434; p < 0.01) were highly correlated. Emotional role functioning (RH), mental health (MH) and social role functioning (SF) subscores of SF-36 showed no correlation with the all subscores of the new KSS (p > 0.05). No floor or ceiling effects in the new KSS scores were detected.ConclusionIt is concluded that the new KSS is a valid and reliable questionnaire which can be used in evaluating the pre and post-operative Turkish speaking TKA patients.Level of evidenceLevel III Diagnostic Study.     

One-Stage Sequential Bilateral Total Knee Arthroplasty: An Effective Treatment for Advanced Bilateral Knee Osteoarthritis Providing High Patient Satisfaction

BackgroundThe mortality and risks of bilateral total knee arthroplasty (BTKA) have been reported to be far greater than in unilateral total knee arthroplasty (UTKA). This study aimed to determine whether this remains the case using contemporary anesthetic and surgical techniques for one-stage single anesthetic sequential BTKA.MethodsTwo cohorts of 394 patients were created by propensity matching for gender, age, body mass index, American Society of Anesthesiologists grade, and Veterans Rand-12 health survey scores. Primary outcome was morbidity and mortality, with satisfaction measures using patient-reported outcome measures.ResultsThe mortality rate was low with one case after BTKA. Major complications were also low; however, a pulmonary embolism rate of 2% in BTKA patients was significantly higher than 0.3% after UTKA (P < .05), and associated with an American Society of Anesthesiologists grade ≥3. The rate of minor complications between the 2 cohorts was comparable (P = .95). Blood transfusions were uncommon and not significantly different between cohorts (2.5% vs 1.3%, P = .3). BTKA patients stayed in hospital a mean 1.3 days longer with greater rehabilitation requirements. At final follow-up, patient satisfaction was high with all patient-reported outcome measures significantly improved and comparable between cohorts.ConclusionBTKA is safe and effective in the majority of patients. Transfusion rates were far lower than historically reported and major complications were rare after both UTKA and BTKA. A significant increase in the rate of pulmonary embolism after BTKA was observed, especially in high risk patients. At minimum 1-year postoperatively, cohorts had the same significant clinical improvement and high level of satisfaction.     

Staged Versus Simultaneous Bilateral Knee Arthroplasty: Does Minimal Cost Difference Justify Risks?

BackgroundSimultaneous bilateral total knee arthroplasty (BTKA) is associated with a higher risk but can be perceived to afford faster improvement and mitigated costs versus staged BTKA. We aimed to explore (1) health care utilization, (2) surgical supply costs of simultaneous BTKA; and (3) 1-year improvement in patient-reported pain, function, and quality of life (QOL) versus staged BTKA.MethodsA prospective cohort of 198 simultaneous and 625 staged BTKAs was obtained (2016-2020). Simultaneous BTKA cohort was propensity score-matched (1:2) to a similar group of staged patients (simultaneous = 198 versus staged = 396). Outcomes included length of stay, discharge disposition, 90-day readmission, 1-year reoperation, surgical episode supply cost, Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain, KOOS-Physical Function Short Form, and KOOS-QOL. Rates of attaining minimal clinically important difference and Patient Acceptable Symptomatic State were calculated.ResultsCompared to both staged BTKA surgeries combined, simultaneous BTKA demonstrated shorter median net length of stay (2.00 [2.00, 3.00] days versus 2.00 [2.00, 4.00] days; P < .001) but higher rates of nonhome discharge (n = 56 [28.3%] versus n = 32 [4.04%]; P < .001), 90-day readmission (n = 20 [10.1%] versus n = 48 [6.06%]; P = .047) and similar reoperation rates (P = .44). Simultaneous BTKA afforded slight reduction in net surgical cost compared to that of both staged BTKAs combined ($643; P = .028). There was no significant difference in 1-year improvement and minimal clinically important difference attainment rates with simultaneous versus staged BTKA for KOOS-pain (P = .137 and P = .99), KOOS-QOL (P = .095 and P = .81), or KOOS-Physical Function Short Form (P = .75 and P = .49, respectively) or Patient Acceptable Symptomatic State (P = .12).ConclusionStaged BTKA is associated with similar 1-year pain, function, and QOL at a better safety profile and minimal surgical supply cost increase compared to simultaneous BTKA.     

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).     

固定平台与旋转平台假体用于外翻膝的早期疗效观察

目的:比较外翻膝人工全膝关节置换术应用旋转平台和固定平台两型假体的早期临床疗效。方法:选取2011年1月至2013年12月吉林大学第一医院骨关节外科由同一医师进行初次人工膝关节置换的17例(23膝)进行回顾性随访研究,其中男2例,女15例;年龄48～75岁,平均61.5岁。术前诊断为骨性关节炎14例(19膝),类风湿性关节炎3例(4膝),所有膝关节有外翻畸形。其中9例(12膝)使用固定平台型假体(PFC Sigma),8例(11膝)使用旋转平台型假体(PFC Sigma RP).术前和术后随访行KSS、HSS、WOMAC评分,测量关节活动度、胫股角等指标,进行统计学分析。结果:所有患者获随访,时间6～36个月,平均25个月。两组患者膝外翻畸形均得到矫正,术后末次随访的KSS、HSS、WOMAC评分及膝关节活动度、胫股角较术前明显改善(P<0.01).其中固定平台组和旋转平台组在术后KSS、HSS、WOMAC评分以及胫骨角、膝关节活范围改善度方面比较,差异无统计学意义(P>0.05);而术后末次随访膝关活动范围固定平台组(101.8±8.8)°与旋转平台组(108.4±7.2)°差异有统计学意义(P<0.05).旋转平台组没有发现垫片脱位,两组术后均无感染、腓总神经麻痹、脱位、膝关节不稳等并发症发生,X线检查未见假体骨溶解及松动发生。结论:外翻膝人工全膝关节置换术使用旋转平台和固定平台型假体均能获得满意的早期临床效果,两者的近期临床疗效比较无明显差异。     

A Mid-term Comparison of the Functional Outcomes of Medial Pivot and Rotating Platform Mobile-Bearing Total Knee Arthroplasty in the Indian Population

BackgroundBoth medial pivot (MP) and rotating platform (RP) mobile-bearing (MB) total knee arthroplasty (TKA) have been developed to better mimic the natural knee kinematics and femoral roll back in flexion. The purpose of this retrospective study was to compare the mid-term functional outcomes and range of motion (ROM) of MP and RP types of total knee arthroplasty.Methods116 patients (mean age of 66.3 years) undergoing TKA (52 Medial pivot design and 64 Rotating Platform design) were evaluated retrospectively with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) knee score, knee society score (KSS) with its subgroups namely, Knee Score (KSKS) and Functional Score (KSFS) and forgotten joint score (FJS) at a mean follow-up of 7.1 years. Range of motion (ROM) and tibiofemoral anatomic angle on the radiographs were also compared.ResultsMean ROM, WOMAC and KSKS improved significantly from pre-operative to postoperative knees in both the groups. There was, however, no significant difference between the two groups at the final follow-up. In contrast, mean KSFS score improved to 89.5 ± 8.1 in MP group and 86.3 ± 7.1 in RP Group (p = 0.025), while mean FJS was 85.6 ± 4.1 and 80.9 ± 5.4 in the MP and RP groups, respectively (p = < 0.0001).ConclusionSatisfactory clinical and functional outcomes can be obtained using either a MP or RP knee joint in tricompartmental osteoarthritis of knee. The MP design scores better on the KSFS score and FJS than the RP-TKA.     

双膝关节同次置换术后的早期康复锻炼

目的：探讨双膝关节置换术前和术后功能锻炼的原则和方法。方法：自2005年1月至2008年6月共完成双膝关节置换72例144膝,男33例,女39例;年龄46～78岁,平均69岁。其中骨性关节炎54例,类风湿性关节炎17例,创伤性关节炎1例。屈曲挛缩大于30°者7例9膝,固定内翻畸形大于30°者10例15膝,固定外翻畸形大于15°者6例8膝。按照术前、术后早期和术后远期的分期为患者制定合理的锻炼计划,在多模式镇痛的前提下术后及早开始功能锻炼,通过增加关节活动度（ROM）和股四头肌及腘绳肌肌力的强化训练提高手术效果。使用WOMAC评分、ROM和6min行走距离以及VAS疼痛评分分别对术前、术后膝关节功能及疼痛程度进行评价,术后下肢血管超声判断血栓的形成,根据临床表现和D-二聚体水平诊断肺栓塞。结果：分别以术前2d、术后2d及术后1、2、8、24周作为观察点。失访3例6膝。术后WOMAC评分、VAS疼痛评分低于术前,术后ROM和6min持续行走距离高于术前。128膝可在术后2周内完全伸直,屈曲大于90°,135膝术后8周屈曲可达110°。发生单侧下肢静脉血栓2例2膝,双侧下肢血栓1例2膝,未见肺栓塞发生。结论：双侧膝关节同时置换应制定术前、术后早期和术后远期功能锻炼计划,并在多模式镇痛的前提下术后早期行功能锻炼,以提高膝关节功能并降低疼痛和肿胀。     

Bilateral vs Unilateral Total Knee Arthroplasty: Racial Variation in Utilization and In-Hospital Major Complication Rates

BackgroundWe sought to examine bilateral total knee arthroplasty (BTKA) vs unilateral TKA (UTKA) utilization and in-hospital complications comparing African Americans (AAs) and Whites.MethodsIn this retrospective analysis of patients ≥50 years who underwent elective primary TKA, the (2007-2016) database of the Healthcare Cost and Utilization Project (National Inpatient Sample) was used. We computed differences in temporal trends in utilization and major in-hospital complication rates of BTKA vs UTKA comparing AAs and Whites. We performed multivariable logistic regression models to assess racial differences in trends adjusting for individual-, hospital- and community-level variables. Discharge weights were used to enable nationwide estimates. We used multiple imputation procedures to impute values for 12% missing race information.ResultsAn estimated 276,194 BTKA and 5,528,429 UTKA were performed in the US. The proportion of BTKA among all TKAs declined, and AAs were significantly less likely to undergo BTKA compared to Whites throughout the study period (trend P = .01). In-hospital complication rates for UTKA were higher in AAs compared to Whites throughout the study period (trend P < .0001). However, for BTKA, the in-hospital complication rates varied between Whites and AAs throughout the study period (trend P = .09).ConclusionIn this nationwide sample of patients who underwent total knee arthroplasty from 2007 to 2016, the utilization of BTKA was higher in Whites compared to AAs. On the other hand, while AAs have consistently higher in-hospital complication rates in UTKA over the time period, this pattern was not consistent for BTKA.     

Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty?

BackgroundDiabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA.MethodsWe reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM).ResultsCompared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (?1.22 points, P-value = .025) and knee ROM (?1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866).ConclusionPatients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.     

Clinical and Patient-Reported Outcomes of Medial Stabilized Versus Non–Medial Stabilized Prostheses in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundThe aim of this systematic review and meta-analysis was to compare the clinical and patient-reported outcome measures (PROMs) of medial stabilized total knee arthroplasty (TKA) with non–medial stabilized TKAs.MethodsA systematic search of multiple databases was conducted in October 2019. A meta-analysis was conducted for the Knee Society Score (KSS), Knee Society Functional Score (KFS), range of motion (ROM), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Forgotten Joint Score (FJS).ResultsA total of 857 articles yielded 21 studies eligible for inclusion with 13 studies used for quantitative analysis. The meta-analysis revealed that the medial stabilized group had a mean FJS that was 13.8 points higher than that of the non–medial stabilized TKA (mean difference [MD]: 13.83, P ≤ .0001, 95% confidence interval [CI]: 8.90-18.76, I² = 0%) which was less than the minimal clinically important difference of 14. The medial stabilized group also demonstrated a statistically significant difference in the postoperative ROM (MD = 2.52, P = .05, 95% CI: ?0.03 to 5.07, I² = 85%) and OKS when compared with the non–medial stabilized group (MD = 1.25, P = .02, 95% CI: 0.17-2.33, I² = 27%), but these were not clinically significant. There was no statistically or clinically significant difference in the KSS, KFS, and WOMAC scores.ConclusionMedial stabilized knee prostheses demonstrated no clinically significant differences for the ROM, OKS, WOMAC, KSS, and KFS. The FJS demonstrated the greatest MD and warrants further investigation. Future research is required using patient-reported outcome measures with a lower ceiling effect such as the FJS.     

Conversion of patellofemoral arthroplasty to total knee arthroplasty: A matched case-control study of 13 patients

Background and purpose The long-term outcome of patellofemoral arthroplasty is related to progression of femorotibial osteoarthritis with need for conversion to total knee arthroplasty. We investigated whether prior patellofemoral arthroplasty compromises the results of total knee arthroplasty.Methods 13 patients who had had 14 Richards type II patellofemoral arthroplasties converted to total knee arthroplasty because of femorotibial osteoarthritis, were individually matched to a control group of 13 patients with 14 primary total knee arthroplasties. The mean follow-up times for the patients and the control group were 5.7 (2–13) years and 5.2 (2–13) years, respectively. Clinical outcome was assessed using Knee Society score (KSS), WOMAC score, range of motion, and complications.Results KSS and WOMAC scores were similar in the two groups (KSS in patient and control groups: 82 and 86 (p = 0.6); KSS function: 76 and 88 (p = 0.5); WOMAC score: 33 and 21 (p = 0.1)). Within 6 months after conversion, 3 knees had to be manipulated under anesthesia for limited motion. No patients in the control group required manipulation under anesthesia.Interpretation Patellofemoral arthroplasty appears not to have a negative effect on the outcome of later total knee arthroplasty.     

Evaluating the “Patella-Friendly” Concept in Total Knee Arthroplasty: A Minimum 15-Year Follow-Up Outcome Study Comparing Constant Radius,Multiradius Cruciate-Retaining,and Nonanatomical Cruciate-Retaining Implants

BackgroundPatella-friendly femoral components were developed in order to reduce anterior knee pain and patellofemoral complications in total knee arthroplasty (TKA), but their effect on long-term outcome is still unclear.MethodsWe retrospectively evaluated prospectively collected data from 3 groups consisting of 100 patients (100 knees in each). In group A, the constant radius a-MP, in group B the multiradius cruciate-retaining Genesis II, and in group C the nonanatomic, multiradius, cruciate-retaining AGC TKA was implanted. Patients of all groups were matched for age, gender, side, body mass index, and length of follow-up. Preoperative and postoperative clinical outcome data in the form of Knee Society System (KSS), Short Form-12, Western Ontario and McMaster University Osteoarthritis Index, and Oxford Knee Score were available at regular intervals for groups A and B. For patients of group C, KSS score data were available at the same time intervals. In all groups, the patellofemoral compartment was assessed using the Clinical Patella Score scale. Anterior knee pain, secondary patella resurfacing, implant failure, and radiological outcome were assessed in patients of all groups.ResultsAt 10-year and 15-year follow-up, patients of group A showed statistically significant (s.s.) higher (all P = .000) KSS values as compared to those of groups B and C. At 15-year follow-up, patients of group B showed s.s. higher (P = .001) KSS values as compared to those of group C. At 10-year and 15-year follow up, patients of group A showed s.s. higher (all P = .00) Western Ontario and McMaster University Osteoarthritis Index and Oxford Knee Score values as compared to those of group B. At 15-year follow-up only, patients of group A showed s.s. higher (P = .00) Short Form-12 (physical) values as compared to those of group B. In terms of Clinical Patella Score, patients in group A had s.s. higher values (P = .05) when compared to those of groups B and C. Anterior knee pain was recorded in 4.4% of TKAs in group A, 7.5% in group B, and 17.2% in group C. One (1.1%) patient in group A, 3 (3.25%) in group B, and 7 (8%) in group C underwent secondary resurfacing.ConclusionAnatomical, patella-friendly, constant radius femoral components outperform others in reducing anterior knee pain and patella complications in TKA in which the patellae are left nonresurfaced.     

The Functional Status of the ACL in Varus OA of the Knee: The Association With Varus Deformity and Coronal Tibiofemoral Subluxation

BackgroundThe present article analyzes the association of the functional anterior cruciate ligament (ACL) status and the overall varus deformity and coronal tibiofemoral subluxation (CTFS) in varus OA of the knee.MethodsOne hundred consecutive knees with varus OA in 84 patients were prospectively included. Knees were divided into two groups, in accordance with the ACL status (functionally sufficient or insufficient). All included patients were potential candidates for unicompartmental knee arthroplasty with predominantly medial compartment OA. Knees with Kellgren/Lawrence ≥ grade 3 in the lateral compartment were excluded leaving 79 knees to be included in this study. Mechanical varus deformity and CTFS were evaluated on AP radiographs and valgus stress radiographs, and compared between the two groups.ResultsKnees with a functionally insufficient ACL had significantly more varus deformity on hip-to-ankle AP standing radiographs (P = .001) and on valgus stress radiographs (P = .017). CTFS on AP standing radiographs was significantly higher (P = .045) in knees with a functionally insufficient ACL. Seventy-three percent (8/11) of the ACL-insufficient knees had a varus deformity of ≥10° and 64% (7/11) of ACL-insufficient knees had CTFS ≥ 6mm. By contrast, only one patient (2%, 1/41) with an insufficient ACL had< 10° varus deformity and a CTFS of < 6mm.ConclusionFunctional ACL insufficiency in osteoarthritic varus knees is associated with greater varus deformity and more advanced CTFS. Seventy-three percent of ACL-insufficient knees had a varus deformity of ≥10° and 64% of ACL-insufficient knees a CTFS of ≥ 6mm. In the work-up for medial unicompartmental knee arthroplasty, functional ACL insufficiency is likely in knees with varus deformity of ≥10° and CTFS of ≥ 6mm.     

The influence of joint line restoration on functional outcome after primary total knee arthroplasty: A prospective study

ObjectiveRestoration of proper joint line position after primary total knee arthroplasty (TKA) is important for improved knee function and kinematics. We reviewed the magnitude of joint line alteration and the resulting effect on post-operative knee outcomes scores at one year follow-up.Materials and methods120 patients who underwent TKA for primary osteoarthritis knee were included. Assessment of joint line position before and after surgery was performed with the help of bony landmarks (excluding osteophytes): Medial Epicondyle Joint Line distance (MEJL), Lateral Epicondyle Joint Line distance (LEJL) and Fibula Head Joint Line distance (FHJL) were calculated. Post-operative knee function was assessed using ‘The Western Ontario and McMaster Universities Arthritis Index’ (WOMAC) and ‘Knee Society Score’ (KSS) at one year follow-up.ResultsJoint line elevation was observed in 104/120 (86.7%) patients and 16/120 (13.3%) patients had no joint line elevation. The mean joint line elevation was 3.00 (±2.13) mm. The patients were sub-classified into two study groups: Group A- Joint line elevation <5 mm and Group B- Joint line elevation ≥ 5 mm. The mean post-op one-year KSS score was significantly higher in patients in Group A compared to Group B (52.82 ± 7.564 vs. 40.73 ± 7.146; p < 0.001). The mean post-op one-year WOMAC score was lower in patients in Group A compared to Group B (65.51 ± 14.762 vs.75.64 ± 8.203) and the difference was statistically significant (p = 0.002).ConclusionElevation of joint line ≥5 mm from the pre-operative value has a negative impact on post-operative functional outcome in primary TKA.     

Minimum 5-Year Outcomes of a Multicenter,Prospective, Randomized Control Trial Assessing Clinical and Radiological Outcomes of Patient-Specific Instrumentation in Total Knee Arthroplasty

BackgroundPatient-specific instrumentation (PSI) was developed to produce more accurate alignment of components and consequently improve clinical outcomes when used in total knee arthroplasty. We compare radiological accuracy and clinical outcomes at a minimum of 5-year follow-up between patients randomized to undergo total knee arthroplasty performed using PSI or traditional cutting block techniques.MethodsThis multicenter, randomized control trial included patients blinded to the technique 1used. Outcome measures were coronal alignment measured radiologically, Euroqol-5D, Oxford knee score, and International Knee Society Score measured at 1- and 5-year follow-up.ResultsAt a minimum 5-year follow-up, there were 38 knees in the PSI group and 39 in the conventional instrumentation group for analysis. Baseline demographics and clinical outcome scores were matched between groups. Overall, there was no significant difference in the coronal femoral angle (P = .59), coronal tibial angle (P = .37), tibiofemoral angle (P = .99), sagittal femoral angle (P = .34), or the posterior tibia slope (P = .12) between knees implanted using PSI and those implanted with traditional cutting blocks. On the measurement of coronal alignment, intraobserver reliability tests demonstrated substantial agreement (k = 0.64). Clinical outcomes at both 1-year and 5-year follow-up demonstrated statistically significant and clinically relevant improvement in scores from baseline in both groups, but no difference could be detected between the Euroqol-5D (P = .78), Oxford knee score (P = .24), or International Knee Society Score (P = .86) between the 2 groups.ConclusionThis study has shown no additional benefit to PSI in terms of improved alignment or functional outcomes at minimum 5-year follow-up over traditional techniques.     

Comparison of Cruciate-Sacrificing vs Posterior-Stabilized Total Knee Replacement Using a Contemporary Total Knee System

BackgroundThe use of highly conforming polyethylene tibial inserts in cruciate-retaining total knee arthroplasty (TKA) often requires posterior cruciate ligament (PCL) release/sacrifice for balancing (CS TKA). The CS TKA relies on the posterior capsule, collateral ligaments, and articular conformity without a cam or post to achieve stability. Using prospectively collected data we compared clinical outcomes of CS TKA to posterior-stabilized (PS) TKA utilizing a contemporary TKA system.MethodsSixty-nine consecutive CS TKAs were compared to 45 consecutive PS TKAs at 2-year minimum follow-up. CS knees were balanced with the PCL released. Preoperative/postoperative range of motion (ROM), Knee Society Scores (KSS), stair function, and squatting ROM were analyzed.ResultsAt minimum 2-year follow up, CS and PS TKA demonstrated significant improvement in ROM (P < .001), KSS (Pain, P < .001; Function, P < .001), and KSS stair function (P < .001), with no revisions. There was no difference in preoperative to postoperative improvements for passive knee ROM (10° (0°-20°) vs 13° (5°-25°); P = .16), KSS Pain (34 (21-42) vs 38 (24-46); P = .22), KSS Function (35 (30-50) vs 35 (18-50); P = .34), and KSS stair function (10 (10-20) vs 10 (0-20); P = .37) for CS and PS TKA, respectively. CS TKA had higher squatting ROM (P = .02) at minimum 2-year follow-up compared to PS TKA.ConclusionBoth PS and CS TKA provided significant improvement in clinical outcomes, with no differences in passive ROM, KSS, or stair function postoperatively. Our data support that with proper articular conformity and balancing, cruciate-retaining TKA in a PCL-deficient knee (CS TKA) is appropriate. This may be design specific and further prospective randomized studies are needed to corroborate these findings.     

Effects of Perioperative Selective Serotonin Reuptake Inhibitor Use in Primary Total Hip and Knee Arthroplasty

BackgroundThe aim of this study is to compare functional outcomes and perioperative complications between patients on a selective serotonin reuptake inhibitor (SSRI) and those who are not on an SSRI preoperatively at the time of total joint arthroplasty.MethodsA retrospective study was performed on 28,386 patients who received a primary total hip (THA) or knee (TKA) arthroplasty. Patients were compared based on SSRI utilization. We measured patient-reported function and health-related quality of life using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the EuroQol-5 Dimensions (EQ-5D-5L) instruments. Chi-squared test was used to compare categorical variables and t-test was used to compare the continuous variables of 2 study groups.ResultsPatients on SSRIs have lower preoperative baseline WOMAC and EQ-5D-5L scores than those not using SSRI (P < .001). Patient-reported outcomes improved significantly following surgery, but functional outcome scores remained inferior in patients using SSRI. After adjusting for baseline variables, SSRI use in TKA predicted lower EQ-5D-5L scores than non-SSRI users (P = .036) while the WOMAC scores were not different (P = .118). For the THA cohort, SSRI use predicted lower EQ-5D-5L (P = .001) and WOMAC scores than non-SSRI users (P = .008). SSRI use was associated with increased transfusion rate, length of stay, readmission rate, and medical events. About 11.3% of TKA and 13.3% of THA patients stopped using SSRI at 12 months after arthroplasty.ConclusionPatients using an SSRI show improvement comparable to patients not on an SSRI, but their 12-month functional scores continue to be inferior. SSRI utilization was associated with increased adverse events including needing a blood transfusion.     

Minimum twelve-year follow-up of fixed- vs mobile-bearing total knee arthroplasty: Double blinded randomized trial

BackgroundTotal knee arthroplasty (TKA) with fixed-bearing (FB) implants have demonstrated impressive functional results and survival rates. Meanwhile, rotating-platform (RP) constructs have biomechanically shown to reduce polyethylene wear, lower the risk of component loosening, and better replicate anatomic knee motion. There is growing question of the clinical impact these design changes have long-term.Questions/purposes: The aim of this double-blinded prospective randomized trial was to compare function and implant survival in patients who received either FB or RP press-fit condylar Sigma (PFC Sigma, DePuy, Warsaw, IN) total knee replacements at a minimum follow-up of twelve years.Patients and methodsPatient reported outcome measures used included the functional Knee Society Score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) scores, Medical Outcomes Short Form-36 (SF-36) score, and satisfaction assessment on a four-point Likert scale. The data was collected from times preoperative, two-years, and final encounter (mean 13.95 years). A total of 28 RP and 19 FB knees (58.8%) were analyzed at the final follow-up.ResultsAmong all patients, KSS and WOMAC scores statistically improved from pre-op to 2-year, while KSS statistically worsened from 2-year to final follow-up. The RP group averaged better follow-up scores in all assessments at the final follow-up with exception of overall satisfaction. There was no statistically significant difference in the functional Knee Society Score, Short Form-36, WOMAC scores, patient satisfaction or implant survival between the two groups at any measured period.ConclusionsThe use of a fixed-bearing or rotating-platform design does not convey significant superiority in terms of function or implant longevity at a minimum twelve years after total knee arthroplasty.Level of evidenceLevel I, Experimental study, randomized controlled trial (RCT).     

Postoperative Outcomes Following Total Hip and Knee Arthroplasty in Patients with Pain Catastrophizing,Anxiety, or Depression

BackgroundThe relationship among pain catastrophizing, emotional disorders, and total joint arthroplasty (TJA) outcomes is an emerging area of study. The purpose of this study is to examine the association of these factors with 1-year postoperative pain and functional outcomes.MethodsA prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Postoperative outcomes included Visual Analog Scale (VAS) pain, Oxford, Harris Hip (HHS) and Knee Society (KSS) scores. Median regression was used to assess the pattern of relationship among preoperative clinically relevant catastrophizing (CRC) pain, abnormal HADS, and 1-year postoperative outcomes.ResultsWe recruited 463 TJA patients, all of which completed 1-year follow-up. At 1 year, CRC-rumination (adjusted median difference 1; 95% confidence interval [CI] 0.31-1.69, P = .005) and abnormal HADS-A (adjusted median difference 1; 95% CI 0.36-1.64, P = .002) were predictors of VAS pain, CRC magnification a predictor of HHS/KSS (adjusted median difference 1.3; 95% CI 5.23-0.11, P = .041), and abnormal HADS-A a predictor of Oxford (adjusted median difference 3.68; 95% CI 1.38-5.99, P = .002). CRC patients demonstrated inferior VAS pain (P = .001), Oxford (P < .0001), and HHS/KSS (P = .025). Abnormal HADS patients demonstrated inferior postoperative VAS (HADS-A, P = .025; HADS-D, P = .030) and Oxford (HADS-A, P = .001; HADS-D, P = .030). However, patients with CRC experienced significant improvement in VAS, Oxford, and HHS/KSS (P < .05) from preoperative to 1 year. Similarly, patients with abnormal HADS showed significant improvement in VAS pain and HHS/KSS (P < .05).ConclusionTJA patients who are anxious, depressed, or pain catastrophizing have inferior preoperative and postoperative pain and function. However, as compared to their preoperative status, clinically significant improvement can be expected following hip/knee arthroplasty.