Clinical Outcomes of Revision Total Knee Arthroplasty after High Tibial Osteotomy and Unicompartmental Knee Arthroplasty: A Systematic Review and Meta‐Analysis

As more high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are performed, orthopaedic surgeons realize that more HTO and UKA failures will require revision to total knee arthroplasty (TKA) in the future. To systematically evaluate the clinical outcomes of TKA after HTO and TKA after UKA, the Embase, PubMed, Ovid, Web of Science, and Cochrane Library databases were searched for studies investigating revision TKA after HTO and UKA published up to June 2021. RevMan version 5.3 was used to perform the meta‐analysis. The revision TKA after HTO and revision TKA after UKA groups were compared in terms of operative time, range of motion (ROM), knee score, postoperative complications, postoperative infection, revision, and revision implants used. Nine studies were ultimately included in the meta‐analysis. Results revealed that the knee score for the revision TKA after HTO group was better than that of the revision TKA after UKA group (MD 4.50 [95% CI 0.80–8.20]; p = 0.02). The revision TKA after HTO group had a lower revision rate (OR 0.65 [95% CI 0.55–0.78]; p < 0.00001) and fewer revision implants used (OR 0.11 [95% CI 0.05–0.23]; p < 0.00001). There were no statistical differences in operation time (MD ‐2.00 [95% CI −11.22 to 7.21]; p = 0.67), ROM (MD ‐0.04 [95% CI ‐3.69–3.61]; p = 0.98), postoperative complications (OR 1.41 [95% CI 0.77–2.60]; p = 0.27), or postoperative infections (OR 0.89 [95% CI 0.61–1.29]; p = 0.53). To conclude, the revision rate of revision TKA after UKA was greater, and more revision implants were required. It is important for orthopaedic surgeons to preserve bone during primary UKA.     

Results of Revision Surgery and Causes of Unstable Total Knee Arthroplasty

Background

The aim of this study was to evaluate causes of unstable total knee arthroplasty and results of revision surgery.

Methods

We retrospectively reviewed 24 knees that underwent a revision arthroplasty for unstable total knee arthroplasty. The average follow-up period was 33.8 months. We classified the instability and analyzed the treatment results according to its cause. Stress radiographs, postoperative component position, and joint level were measured. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) score and range of motion.

Results

Causes of instability included coronal instability with posteromedial polyethylene wear and lateral laxity in 13 knees, coronal instability with posteromedial polyethylene wear in 6 knees and coronal and sagittal instability in 3 knees including post breakage in 1 knee, global instability in 1 knee and flexion instability in 1 knee. Mean preoperative/postoperative varus and valgus angles were 5.8°/3.2° (p = 0.713) and 22.5°/5.6° (p = 0.032). Mean postoperative α, β, γ, δ angle were 5.34°, 89.65°, 2.74°, 6.77°. Mean changes of joint levels were from 14.1 mm to 13.6 mm from fibular head (p = 0.82). The mean HSS score improved from 53.4 to 89.2 (p = 0.04). The average range of motion was changed from 123° to 122° (p = 0.82).

Conclusions

Revision total knee arthroplasty with or without a more constrained prosthesis will be a definite solution for an unstable total knee arthroplasty. The solution according to cause is very important and seems to be helpful to avoid unnecessary over-constrained implant selection in revision surgery for total knee instability.     

Total knee arthroplasty using subvastus approach in stiff knee: A retrospective analysis of 110 cases

Background:

Subvastus approach used in total knee arthroplasty (TKA) is known to produce an earlier recovery but is not commonly utilized for TKA when the preoperative range of motion (ROM) of the knee is limited. Subvastus approach is known for its ability to give earlier recovery due to less postoperative pain and early mobilization (due to rapid quadriceps recovery). Subvastus approach is considered as a relative contraindication for TKA in knees with limited ROM due to difficulty in exposure which can increase risk of complications such as patellar tendon avulsion or medial collateral injury. Short stature and obesity are also relative contraindications. Tarabichi successfully used subvastus approach in knees with limited preoperative ROM. However, there are no large series in literature with the experience of the subvatus approach in knees with limited preoperative ROM. We are presenting our experience of the subvastus approach for TKA in knees with limited ROM.

Materials and Methods:

We conducted retrospective analysis of patients with limited preoperative ROM (flexion ≤90°) of the knee who underwent TKA using subvastus approach and presenting the 2 years results. There were a total 84 patients (110 knees) with mean age 64 (range 49–79 years) years. The mean preoperative flexion was 72° (range 40°–90°) with a total ROM of 64° (range 36°–90°).

Results:

Postoperatively knee flexion improved by mean 38° (P < 0.05) which was significant as assed by Student''s t- test. The mean knee society score improved from 36 (range 20–60) to 80 (range 70–90) postoperatively (P < 0.05). There was one case of partial avulsion of patellar tendon from the tibial tubercle.

Conclusions:

We concluded that satisfactory results of TKA can be obtained in knees with limited preoperative ROM using subvastus approach maintaining the advantages of early mobilization.     

Comparison of Single‐Radius with Multiple‐Radius Femur in Total Knee Arthroplasty: A Meta‐Analysis of Prospective Randomized Controlled Trials

BackgroundWhether there was clinical superiority for the single‐radius prosthesis over the multi‐radius prothesis in total knee arthroplasty (TKA) still remains to be clarified. We updated a meta‐analysis including prospective randomized controlled trials (RCTs) to compare the clinical prognosis of patients receiving single‐radius TKA (SR‐TKA) or multi‐radius TKA (MR‐TKA).MethodsWe searched the databases of PubMed, Web of Science, EMBASE, Cochrane Library, MEDLINE for eligible RCTs. Two reviewers evaluated the study quality according to the Risk of Bias tool of the Cochrane Library and extracted the data in studies individually. The extracted data included the baseline data and clinical outcome. The baseline data include the author''s name, country, and year of included studies, the name of knee prosthesis used in studies, sample size, follow‐up time, and BMI of patients. The clinical data comprised primary indicators including postoperative knee range of motion (ROM), sit‐to‐stand rest, severe postoperative scorings, such as visual analog scale (VAS), American Knee Society knee score (AKS), Oxford knee scoring (OKS), and SF‐36 Quality of Life Scale, as well as various secondary indicators of complications including anterior knee pain, postoperative infection, aseptic prosthesis loosening, and prosthesis revision. The data analysis was performed using Review Manager 5.3 software and STATA 12.0. The sensitivity analysis was performed using STATA 12.0.ResultsA total of 13 RCTs, along with 1720 patients and 1726 knees, were finally included in our present meta‐analysis. We found that patients in SR‐TKA group performed better in the sit‐to‐stand test (OR = 1.89, 95% CI: 1.05–3.41, p = 0.03) and satisfaction evaluation (OR = 3.27, 95% CI: 1.42–7.53, p = 0.005), which were only evaluated in two included RCTs. While no significant difference was found between SR‐TKA and MR‐TKA groups in terms of postoperative ROM, VAS scoring, AKS scoring, SF‐36 scoring, OKS scoring, and various complications including anterior knee pain, postoperative infection, aseptic prosthesis loosening, and prosthesis revision.ConclusionIn conclusion, our present meta‐analysis indicated that SR implants were noninferior to MR implants in TKA, and SR implants could be an alternative choice over MR implants, since patients after SR‐TKA felt more satisfied and performed better in the sit‐to‐stand test, with no significant difference in complications between SR‐TKA and MR‐TKA groups. While more relevant clinical trials with long‐term follow‐up time and specific tests evaluating the function of knee extension mechanism should be carried out to further investigate the clinical performance of SR implants.     

Total Knee Replacement Arthroplasty with Buechel and Pappas Knee: Minimum 2-Year Follow-up

BackgroundClinical and radiologic evaluation and analyses of the surgeries using Buechel and Pappas (B-P) knee implants.MethodsThe study was conducted on 60 patients who underwent 94 total knee replacement arthroplasty with B-P knee implants from May 2009 to December 2010. The results were compared to the results of 41 patients who underwent 60 knee joint surgeries using NexGen-LPS implants from January 2008 to August 2009.ResultsThe American Knee Society score of the B-P knee group increased from an average of 66.9 (clinical score) and 65.5 (functional score) to 93.4 and 90.3, respectively; while those for the NexGen-LPS group increased from an average of 68.8 (clinical score) and 62.4 (functional score) to 86.3 and 76, respectively. The average ranges of motion of the B-P knee group and the NexGen-LPS group were 119.1° and 114.8°, respectively, before surgery and improved to 121.0° and 123.0° at final follow-up after the surgery. The visual analogue scale scores for the B-P knee group and the NexGen-LPS group improved from 4.7 and 4.6 to 1.4 and 1.8, respectively. The flexion contracture also improved from 5.1° and 6.3° to 0.64° and 1.72°. The tibio-femoral angle for the B-P knee group and the NexGen-LPS group also improved greatly after the surgery, from varus 0.34° and 0.73° each to valgus 6.7° and 6.9°, respectively.ConclusionsThe evaluation of more than 2 years of total knee replacement arthroplasty using B-P knee implants showed good results. B-P knee implants showed a relatively higher degree of satisfaction in clinical knee score and less intraoperative bone mass removal than NexGen-LPS implants.     

Impact of Tibial Tubercle Osteotomy on Final Outcome in Revision Total Knee Arthroplasty: Our Experience and Technique in Pakistan

BackgroudDue to extensive fibrosis during revision surgery, adequate exposure is essential and it can be achieved with several extensile approach options, such as tibial tubercle osteotomy. Information regarding surgical exposure during revision arthroplasty is limited in developing countries, such as Pakistan, due to the lack of adequate data collection and follow-up. Therefore, the purpose of this study was to evaluate the impact of tibial tubercle osteotomy on final outcome of revision total knee arthroplasty (TKA).MethodsA total of 231 revision TKAs were performed between January 2008 and December 2017. Twenty-nine patients underwent tibial tubercle osteotomy for adequate exposure during revision surgery. Of these, 27 patients with complete follow-up were included in our study. Factors examined include age at the time of revision surgery, gender, comorbidities, arthroplasty site (right or left), body mass index (BMI), and primary indications for the tibial tubercle osteotomy during revision TKA. Functional outcome was measured by using Knee Society score (KSS) at 3 months and the final follow-up. All statistical analysis was done using SPSS version 20.0 with a p-value < 0.05 considered significant.ResultsOut of 27 patients, 6 patients (22.2%) were men and 21 patients (77.7%) were women. Right knee revision arthroplasty was performed in 15 patients (55.5%), left knee revision arthroplasty was performed in 12 patients (44.4%), and bilateral revision surgery was performed in only 1 patient (3.7%). The mean BMI was 29.2 kg/m². We used a constrained condylar knee in 20 patients (74%), a rotating hinge knee in 5 patients (18.5%), and mobile bearing tray plus metaphyseal sleeves in 2 patients (7.4%). The KSS was 52.21 ± 4.05 preoperatively, and 79.42 ± 2.2 and 80.12 ± 1.33 at 3 months and 12 months, respectively. Radiological union was achieved in all patients at 3 months. Of 27 patients, only 1 patient (3.7%) had proximal migration of the osteotomy site at 6 months: the patient was asymptomatic and union was also achieved and, therefore, no surgical intervention was performed.ConclusionsTibial tubercle osteotomy during revision TKA can be a safe and reliable technique with superior outcomes and minimal complication rates.     

Reconstruction for Massive Proximal Tibial Bone Defects Using Patient‐Customized Three‐Dimensional‐Printed Metaphyseal Cones in Revision Total Knee Arthroplasty

ObjectiveTo review the clinical outcomes of revision total knee arthroplasty (RTKA) with massive proximal tibial bone defects using patient‐customized three‐dimensional (3D) printed highly porous metaphyseal cones.MethodsA retrospective study of all patients at our institution who underwent RTKA with the Anderson Orthopaedic Research Institute type III tibial defects using patient‐customized 3D‐printed highly porous metaphyseal cones was performed from 2016 to 2018. Seven patients were enrolled in this study. General results (age, sex, and body mass index); intraoperative results (interface compatibility and stability, and operating time); and perioperative complications (total blood loss, blood transfusion rate, and deep venous thrombosis) were recorded and analyzed. Clinical improvement and functional evaluation (survivorship of implant, improvement of Hospital for Special Surgery Score and McMaster Universities Osteoarthritis Index, and improvement of range of motion [ROM]), and radiographic improvement and implant evaluation (progressive radiolucent lines or radiographic loosening, and mechanical alignment) were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and then annually, postoperatively.ResultsThe mean age at diagnosis was 68 (61–77) years. The mean follow‐up was 25.3 (19–36) months. At the latest follow‐up, no aseptic loosening, prosthetic joint infection, or other complications were noted. The mean Hospital for Special Surgery Score increased from 49 (39–63) to 78 (70–83) (P < 0.01), whereas the mean Western Ontario and McMaster Universities Osteoarthritis Index increased from 59 (46–73) to 26 (12–38) (P < 0.01). All patients achieved improved postoperative ROM with the mean flexion angle increasing from 66° (30°–80°) to 93° (80°–100°), and improved mechanical alignment with all hip–knee–ankle (HKA) angles within ±3°.ConclusionsThe patient‐customized 3D‐printed metaphyseal cone is useful technique for reconstructing massive proximal tibial bone defects, with encouraging clinical and radiological outcomes in RTKA.     

A Mid‐term Follow‐up Study on the Reimplantation of Autoclaved Femoral and Tibial Components as Spacers for Treating Infected Total Knee Arthroplasty

ObjectiveInfection after total knee arthroplasty (TKA) is a rare but devastating complication. Different types of spaces have been used in two‐stage revision. The study aimed to evaluate the effect of autoclaved femoral and tibial components as spacers for treating periprosthetic infections after TKA.MethodsA retrospective study was performed for 13 patients (five males, eight females) with a mean age of 69 ± 6 (range, 57–80) years and suffering from periprosthetic infection after TKA. They were treated with unconventional two‐stage revision from May 2008 to June 2017. In the first‐stage surgery, the autoclaved femoral and tibial components were reimplanted with a new liner as a spacer after a thorough debridement. After 4–6 months, the second‐stage surgery was performed according to the patients'' requirements. The knee society score (KSS) and knee range of motion (ROM) were assessed before and after surgery. The reinfection rate was calculated.ResultsThe mean duration of follow‐up was 5.7 ± 2.1 (range, 3.1–8.8) years. Culture‐positive infections comprised 69% of the cohort. All patients were able to walk 24 h after the first stage surgery, and the knee ROM could reach 90° in 1 week. Two patients (15.4%) experienced an infection recurrence. One patient was reinfected 1 year after the first stage surgery. Another patient developed reinfection 3 years after surgery but did not choose re‐revision and died of pneumonia. Only one patient underwent the second stage revision. The remaining 10 patients refused to receive a new prosthesis. At the time of the final follow‐up, six patients had slight pain in the knee while walking, and one patient required crutches to walk. There were no signs of prosthesis dislocation, rupture, deep vein thrombosis, pulmonary embolism, or delayed wound healing. No radiolucent lines or osteolysis were found. The mean KSS improved from 51 ± 10 (range, 35–63) points preoperatively to 79 ± 5 (range, 60–85) points at the final follow‐up. The average ROM before and after the first stage surgery were 62° ± 29° (range, 10°–100°) and 104° ± 9° (range, 90°–120°) (t = 4.659, P < 0.01) respectively. The infection control rate was 84.6%.ConclusionReimplantation of the autoclaved original femoral and tibial components as an articulating spacer during the first stage surgery is a valuable addition for treating an infected TKA.     

PROMs in total knee replacement: analysis of negative outcomes

IntroductionNHS England uses the Oxford Knee Score (OKS) as part of patient-reported outcome measures (PROMs) to evaluate ‘health gains’ following total knee replacement. Policy makers use this to guide healthcare funding and resource allocation. Our study aims to undertake a qualitative and quantitative analysis of OKS among patients who experienced a negative outcome after a total knee replacement at our centre.Materials and methodsBetween April 2017-March 2018, 19 of 189 (10%) patients had a worsened OKS at our centre. We retrospectively and prospectively reviewed 14 of these patients. Structured telephone interviews with a repeat OKS were carried out in September 2019 (18–29 months post-operation).ResultsEight patients were female and the total age range was 57–95, mean average 75.6 (SD 9.9 years). Of 48 (higher scores meaning better outcomes), the average preoperative OKS was 24.2 and the average postoperative OKS at 6 months was 19.4 (decrease of 20%). The average postoperative OKS at 18–29 months was 35.6 (an increase of 83.5% from 6 months).DiscussionThe OKS was developed and validated over 20 years ago in Oxford. In our study, four patients asked for clarification of questions 4, 6 and 10 owing to ambiguous language. All 14 patients who had negative OKS outcomes had positive outcomes when retested after 18 months, depicting ‘health gains’ not conveyed in PROMs analysis.ConclusionThe OKS needs to be revalidated on current patient groups for accurate and reliable data. Further prospective studies should be undertaken on larger cohorts to understand the recovery course and whether PROMs should be carried out later.     

Cementless Porous‐Coated Metaphyseal Sleeves Used for Bone Defects in Revision Total Knee Arthroplasty: Short‐ to Mid‐Term Outcomes

ObjectivesWhile many studies have presented excellent short‐term outcomes of the metaphyseal sleeves used in revision total knee arthroplasty (TKA), currently published mid‐term results remain limited and some controversial issues remain unresolved. The purpose of this study was to investigate clinical and radiographic mid‐term outcomes of the sleeves for the management of metaphyseal bone defects in revision TKAs.MethodsFrom 2015 to 2019, 44 patients (45 knees) who were operated with cementless porous‐coated metaphyseal sleeve in revision TKA were included in this study. Bone defects were assessed according to Anderson Orthopaedic Research Institute Classification. On the tibial side, there were 37 type II and six type III, and with regards to the femur, 15 were type II, and four were type III. Through reviewing electronic records, data were collected, including baseline demographics, operative details, information of prothesis, and complications. Clinical and radiographic evaluations were performed, including Knee Society Scores (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion (ROM), the radiolucent line, level of joint line, and implant survival rate. Statistical analysis was performed by paired t‐test for clinical and radiographic indexes.ResultsThe mean follow‐up time was 4.4 ± 1.4 years. During surgery, sleeve‐related fractures were encountered in four (8.9%) knees, including incomplete tibial fracture of lateral cortex in one knee and of medial cortex in two knees, and longitudinal femoral metaphyseal fracture in one knee. Unions were achieved in all cases at the final follow‐up. Significant improvements in KSS and WOMAC scores were found at the final follow‐up, respectively, from 83.8 ± 29.1 to 152.9 ± 31.0 (t = −12.146, p < 0.001) and from 148.4 ± 42.3 to 88.1 ± 52.5 (t = 6.025, p < 0.001). The mean ROM improved from 88.7 ± 31.9° to 113.7 ± 13.7° (t = −5.370, p < 0.001). A 75 mm length of cementless stem was used in all patients and only one patient was identified as tibial end‐of‐stem pain. No sleeve‐related revision occurred, and one patient was diagnosed with early postoperative infection and was treated with irrigation and debridement, polyethylene liner exchange, and appropriate antibiotic treatment. The overall implant survival was 97.8% with the endpoint reoperation and 100% with the endpoint revision. Osseointegration at the bone‐sleeve interface was found in all patients and no loosening happened. Satisfactory alignment between 3° varus and 3° valgus was achieved in all but not in three patients.ConclusionThe use of metaphyseal sleeves in the treatment of bone defects in rTKAs can provide stable fixation and significantly improve the clinical scores at the midterm follow‐up. In addition, the rare occurrence of end‐of‐stem pain suggests routine use of cementless stems. Although there are chances of intraoperative fractures, it has no negative effect on outcome when managed properly.     

Two-Stage Revision for Infected Total Knee Arthroplasty: Based on Autoclaving the Recycled Femoral Component and Intraoperative Molding Using Antibiotic-Impregnated Cement on the Tibial Side

Background

The purpose of this study was to determine the degree of infection control and postoperative function for new articulating metal-on-cement spacer.

Methods

A retrospective study of 19 patients (20 cases), who underwent a two-stage revision arthroplasty using mobile cement prosthesis, were followed for a minimum of 2 years. This series consisted of 16 women and 3 men, having an overall mean age of 71 years. During the first stage of revision, the femoral implant and all the adherent cement was removed, after which it was autoclaved before replacement. The tibial component was removed and a doughy state, antibiotic-impregnated cement was inserted on the tibial side. To achieve joint congruency, intraoperative molding was performed by flexing and extending the knee joint. Each patient was evaluated clinically and radiologically. The clinical assessments included range of motion, and the patients were scored as per the Hospital for Special Surgery (HSS) and Knee Society (KS) criteria.

Results

The mean range of knee joint motion was 70° prior to the first stage operation and 72° prior to the second stage revision arthroplasty; following revision arthroplasty, it was 113° at the final follow-up. The mean HSS score and KS knee and function scores were 86, 82, and 54, respectively, at the final follow-up. The success rate in terms of infection eradication was 95% (19/20 knees). No patient experienced soft tissue contracture requiring a quadriceps snip.

Conclusions

This novel technique provides excellent radiological and clinical outcomes. It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.     

Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty

Background

Revision knee arthroplasty with a rotating-hinge design could be an option for the treatment of instability following total knee arthroplasty (TKA) in elderly patients.

Purpose

To evaluate the clinical and radiographic results of revision arthroplasties in TKAs with instability using a rotating-hinge design in elderly patients.

Methods

We retrospectively reviewed 96 rotating-hinge arthroplasties. The average age of the patients was 79 years (range, 75–86 years); the minimum follow-up was 5 years (mean, 7.3 years; range, 5–10 years). Patients were evaluated clinically (Knee Society score) and radiographically (position of prosthetic components, signs of loosening, bone loss).

Results

At a minimum followup of 5 years (mean, 7.3 years; range, 5–10 years), Knee Society pain scores improved from 37 preoperatively to 79 postoperatively, and function scores improved from 34 to 53. ROM improved on average from −15° of extension and 80° of flexion before surgery to −5° of extension and 120° of flexion at the last followup (p = 0.03). No loosening of implants was observed. Nonprogressive radiolucent lines were identified around the femoral and tibial components in 2 knees. One patient required reoperation because of a periprosthetic infection.

Conclusions

Revision arthroplasty with a rotating-hinge design provided substantial improvement in function and a reduction in pain in elderly patients with instability following TKA.

Level of evidence

Level IV, therapeutic study.     

Manipulation Under Anaesthesia for Stiffness Following Knee Arthroplasty

INTRODUCTION

Stiffness following knee arthroplasty is a frustrating complication and a significantly disabling problem. We present our experience of knee stiffness requiring manipulation under anaesthesia (MUA) as the first line of treatment following partial or total knee arthroplasty.

PATIENTS AND METHODS

All stiff knees requiring MUA over a 6-month period from March to August 2007 were retrospectively analysed from theatre records and case notes. Data were collected regarding demographics, range of knee motion before and after manipulation and at subsequent follow-up. Complications of the procedure and outcomes were also analysed.

RESULTS

Twenty-one patients (11 female, 10 male) underwent MUA. The average age was 62 years (range, 56–80 years). Sixteen primary and 3 revision total knee replacements underwent manipulation, as did one medial unicompartmental replacement and one patellofemoral arthroplasty. General anaesthesia with good muscle relaxation was used in all but one patient. The mean duration between arthroplasty and MUA was 13.2 weeks (range, 6-32 weeks). The range of knee movement improved from a mean range of 10.4–71.2° in the pre-MUA period to 2.1–94.0° post-MUA and at follow-up was 2.3–91.9°. The mean arc of motion improved from 60.2° (range, 40–80°) pre-MUA to 91.9° (range, 45–120°) post-MUA. The mean improvement in the arc of motion was 31.6° (P < 0.001). At an average follow-up of 3 months (range, 6 weeks to 8 months), the mean arc of motion was 90.4° (range, 40–120°). The mean improvement in knee movement from the pre-MUA at the follow-up was 30.2° (P < 0.001). One patient failed to gain any improvement from MUA. There were no complications noted from the procedure.

CONCLUSIONS

MUA has a role in the treatment of early stiffness with excellent immediate outcomes. We advocate that MUA should be the first line of management for stiff knee arthroplasties after failed physiotherapy.     

The Cardiff Arthroplasty Satisfaction Index (CASI). A Simple Tool for the Assessment of Outcome Following Knee Arthroplasty

Our aim was to develop a patient reported outcome measure of satisfaction following total knee arthroplasty (TKA) and assess its correlation with Oxford knee score (OKS), Quality of life (EQ5D) and Visual analogue scale for pain (VAS). 172 patients with minimum 5 year follow up post primary total knee arthroplasty completed CASI, OKS, EQ5D and VAS for pain. Receiver–operator curve analysis was performed to identify an OKS threshold of poor satisfaction defined by CASI rarely/never. The CASI showed positive correlation with the OKS, VAS for pain, and EQ5D, (Spearman's rho); 0.779; 0.711; 0.629. A threshold of 20 for the Oxford Knee score had 85% specificity and 85% sensitivity for poor satisfaction on CASI. The CASI is a useful measure of patient satisfaction following TKA.     

Outcome of Total Knee Arthroplasty After High Tibial Osteotomy: Does Malalignment Jeopardize the Results when Using a Posterior-Stabilized Arthroplasty?

Background

The controversy regarding the outcome of total knee arthroplasties after high tibial osteotomy may relate to malalignment secondary to overcorrection after high tibial osteotomy (HTO) [1, 2] and to the type of arthroplasty itself (posterior-stabilized arthroplasty or posterior cruciate ligament-retaining prosthesis).

Questions/Purpose

We asked two questions: (1) Would a posterior-stabilized arthroplasty provide sufficient constrain and improve pain and function in patients with severe malalignment due to a previous HTO? (2) Will malalignment of the previous HTO jeopardize the long-term results of a total knee reconstruction with a posterior-stabilized implant?

Patients and Methods

We retrospectively reviewed 25 posterior-stabilized TKAs in 25 patients with severe valgus deformity after HTO (ranging from 10° to 20° of valgus) and compared the results with a series of matched 25 posterior-stabilized TKAs in 25 patients with normocorrection after HTO ranging from 5° of valgus to 5° of varus. Clinical, operative, and radiographic data were reviewed. Minimum follow-up was 10 years after the arthroplasty (average, 15 years; range, 10–20 years).

Results

All the knees had standard posterior-stabilized total knee arthroplasty implants. Patients with an overcorrected HTO were more likely to require a soft tissue release to balance the knee. However, Average Knee Society and Function Score improved, respectively, from 48 to 85 and from 50 to 90 points in the severely overcorrected group, versus, respectively, 50 to 89 and 52 to 97 in the normocorrected group, but the range of mobility was superior for patients with normal alignment. Fifteen-year survivorship after the arthroplasty comparison showed no significant difference between the two groups (one revision in each group).

Conclusions

Patients with an overcorrected HTO are more likely to require a soft tissue release to balance the knee. However, both groups show improvements in function and pain. With a posterior-stabilized arthroplasty, the degree of deformity has no impact on the longevity of the TKA.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9344-x) contains supplementary material, which is available to authorized users.     

Fungal prosthetic joint infection after total knee arthroplasty

Fungal prosthetic joint infection after total knee arthroplasty (TKA) is a rare complication. Lacunae exist in the management of this complication. 62 year old lady presented with pain and swelling in left knee and was diagnosed as Candida tropicalis fungal infection after TKA. She underwent debridement, resection arthroplasty and antifungal plus antibiotic loaded cement spacer insertion, antifungal therapy with fluconazole followed by delayed revision TKA and further fluconazole therapy. Total duration of fluconazole therapy was 30 weeks. At 2 year followup, she has pain less range of motion of 10^°-90^° and there is no evidence of recurrence of infection.     

The Future is Non-cemented Total Knee Arthroplasty: Volume Trends at the Hospital for Special Surgery

IntroductionThe optimal fixation method for total knee arthroplasty (TKA) is still a debate. Cemented fixation has excellent long-term results and is the gold standard. However, longevity in the younger, heavier, and more active population is suboptimal. Cementless TKA offers the opportunity to gain biological fixation and overcome these shortcomings.MethodsThis is a retrospective review of all consecutive cementless TKA procedures performed at a single academic institution from 2016 until 2020. Demographics, aseptic revisions, and septic revisions were pulled from the electronic medical record. The number of yearly implanted cementless TKA prosthesis was determined to analyze utilization trends.ResultsEight-hundred and two patients were identified with a mean age of 61.57 ± 7.78 years, and a mean of BMI 32.12 ± 5.98 kg/m². The mean time to revision was 12.31 ± 13.91 months. There were four septic failures and nine aseptic failures during the study period. Of these nine aseptic failures only five were due to mechanical loosening. There was a yearly linear increase in the use of cementless fixation.ConclusionCementless fixation is here to stay, and its use will continue to increase. Early and mid-term outcomes have been excellent thus far. Changing clinical practice takes time but we have already seen this transition take place in total hip arthroplasty. As technology and design continue to evolve, we believe it is a possibility.     

A Comparison Between Unstemmed and Stemmed Constrained Condylar Knee Prostheses in Primary Total Knee Arthroplasty: A Propensity Score‐Matched Analysis

ObjectiveTo compare and analyze the clinical outcomes between unstemmed and stemmed constrained condylar knees (CCK) in complex primary total knee arthroplasty (TKA) in terms of implant survivorship, change in outcome evaluations, and complications.MethodsWe reviewed 156 consecutive patients who received primary TKA using PFC®SIGMA®TC3 (TC3) of constrained condylar design between January 2009 and January 2017 at our institution. After removing patients who met exclusion criteria, 25 patients were identified as unstemmed TC3 cases and 81 as stemmed TC3 cases. Propensity score matching was used to select 25 stemmed cases as a control group for the unstemmed group with comparable preoperative conditions including preoperative demographics, preoperative diagnosis, preoperative range of motion, main reason to use TC3, ASA score (American Society of Anesthesiologists), and follow‐up duration. Preoperative and postoperative clinical evaluations including Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, the 12‐Item Short‐Form Health Survey (SF‐12), and the range of motion (ROM) were obtained and compared. The instability, periprosthetic fracture, radiolucent lines, polyethylene wear, and heterotrophic ossification were assessed according to the anteroposterior and lateral radiographs of the knee. The complications and implant survivorship between the two groups were also recorded and compared.Results3After the index surgery, both groups showed substantial improvement in KSS (knee and function), HSS score, SF‐12, and ROM compared with baseline. There was no significant difference in the mean KSS scores (knee and function), HSS score, SF‐12, and ROM between the unstemmed and stemmed group postoperatively. No statistically significant difference was found in the overall complication rate between the two groups. The overall Kaplan–Meier survivorship was 98.0% (95% confidence interval 94.1%–100.0%) at 7 years. No significant difference was found in the survival rate between the unstemmed group (100.0%) and the stemmed group (96.0%) at 7 years (log rank, P = 0.317). The mean duration of follow‐up was 7.0 years for unstemmed group and 7.7 years for stemmed group.ConclusionsIn patients with adequate bone stock receiving complex primary TKA, unstemmed CCK could achieve similar clinical outcomes at mid‐term follow‐up as stemmed CCK.     

Early Clinical and Radiographic Outcomes of Robot‐Assisted Versus Conventional Manual Total Knee Arthroplasty: A Randomized Controlled Study

ObjectiveRobot‐assisted surgery has been promoted worldwide in recent years. The development of a domestic orthopaedic robot and its clinical application are therefore of great significance. This study aimed to compare the early clinical and radiographic outcomes of domestic robot‐assisted total knee arthroplasty (RA‐TKA) with conventional manual total knee arthroplasty (CM‐TKA).MethodsA total of 77 patients who underwent primary single‐sided TKA from June to December 2020 were prospectively enrolled; resulting in the inclusion of 72 patients. The patients were randomly divided into the RA‐TKA group (37 cases, with TKA being assisted by the Yuanhua Orthopaedic Robotic System) and the CM‐TKA group (35 cases, with TKA being performed using conventional tools). Knee function was evaluated by the knee range of motion (ROM), the American Knee Society Score (KSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Postoperative radiographic results were evaluated by full‐length weight‐bearing X‐rays of the lower limb and anteroposterior and lateral X‐rays of the knee were obtained preoperatively and at 90 days postoperative. The operative duration, blood loss, postoperative knee function, radiographic outcomes, and incidence of complications were compared by Student''s t‐test, Mann–Whitney U test, or chi‐square test. Serum levels of inflammatory markers before the operation and 1, 3, and 30 days after the operation were recorded and compared between the two groups.ResultsThe operation was significantly longer in the RA‐TKA group than in the CM‐TKA group (154.3 vs 115.2 min, p < 0.001). There was no significant difference in blood loss (933 vs 863 ml, p = 0.519) between the two groups. The knee ROM, KSS, and WOMAC were significantly improved in both groups 90 days after the operation compared with before the operation (p < 0.05), but there were no significant differences between the two groups (p > 0.05). The incidence of postoperative deep vein thrombosis was not statistically different between the two groups. In the radiographic findings at 90 days postoperatively we found the frequency of lateral tibial component (LTC) angle outliers was significantly lower in the RA‐TKA group (3.0% vs 29.4%, p = 0.003). The neutrophil‐to‐lymphocyte ratio (NLR) was significantly lower in the RA‐TKA group than in the CM‐TKA group on day 1 after surgery (9.9 vs 12.7, p = 0.024).ConclusionsRA‐TKA requires more time than CM‐TKA, which may be related to the learning curve and intraoperative registration. The short‐term postoperative knee functional outcomes had no differences between the two groups, and RA‐TKA improved the accuracy of tibial component alignment. Further follow‐up studies are required to investigate the long‐term outcomes.