Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BackgroundThe management of the patella during total knee arthroplasty (TKA) remains controversial. The aim of this study is to evaluate the evidence regarding the use of patellar resurfacing in TKA.MethodsA meta-analysis of randomized controlled trials (RCTs) was performed to compare outcomes between knees receiving patellar resurfacing vs those not receiving resurfacing during primary TKA. Outcomes of interest were the Knee Society Scores, reoperation rates, anterior knee pain, patient satisfaction, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score subscores, and range of motion.ResultsTwenty RCTs met all eligibility criteria and were included in the analysis. There were statistically significant differences favoring the resurfaced group in the knee component and functional component of Knee Society Scores that were not clinically significant. There was an increased risk of reoperation among knees that did not receive resurfacing with number needed to treat to prevent one case of reoperation of 25 knees (for reoperation for any reason) and 33 knees (for reoperation for anterior knee pain). There were no statistically significant differences in any other outcomes.ConclusionThe only clear relationship is that knees that do not receive patellar resurfacing are more likely to receive reoperation, most often for secondary resurfacing. However, the disease burden of differing complication profiles associated with resurfacing and nonresurfacing groups remains unclear. Continuing to collect data from large, well-designed RCTs would be beneficial in guiding management of the patella during TKA.     

Local Infiltration Analgesia With Liposomal Bupivacaine Improves Pain Scores and Reduces Opioid Use After Total Knee Arthroplasty: Results of a Randomized Controlled Trial

Background

Local infiltration analgesia (LIA) with liposomal bupivacaine (LB) in patients undergoing total knee arthroplasty (TKA) has yielded mixed results. The PILLAR study, which was designed to minimize limitations associated with previous studies, compared the effects of LIA with or without LB on pain scores, opioid consumption, including proportion of opioid-free patients, time to first opioid rescue, and safety after primary unilateral TKA.

Does Barbed Suture Lower Cost and Improve Outcome in Total Knee Arthroplasty? A Randomized Controlled Trial

Background

Wound closure is key to prevent infection, facilitate immediate rehabilitation, and improve efficiency of total knee arthroplasty (TKA). Continuous knotless suturing with barbed suture can potentially save time and distribute tension more evenly. However, its role in TKA in terms of cost-effectiveness and wound complications is not clear. This study aims at comparing barbed and traditional sutures' wound closure time and cost in primary TKA.

Is a Titanium Implant for Total Knee Arthroplasty Better? A Randomized Controlled Study

BackgroundLighter weight and lower modulus are potential advantages of titanium (Ti) implants over cobalt chrome (CoCr) implants in total knee arthroplasty (TKA). This study was conducted to determine whether Ti implants in TKA resulted in better clinical outcomes and radiologic results.MethodsOne hundred and eight patients (216 knees) with knee arthritis warranting bilateral primary TKA were randomly allocated to undergo Ti rotating-platform TKA in one knee and CoCr rotating-platform TKA in the contralateral knee. The mean follow-up period was 5.3 years (range, 1-7 years). The weight of Ti implants was one-third lighter than that of CoCr implants (133.9 g vs 390.1 g, P < .01). Clinical outcomes were evaluated using clinical scores, patient preferences (lightness, comfort, naturalness, and satisfaction), gait analysis (kinetic and kinematic data), range of motion, and degree of pain. Radiologic results were evaluated based on the radiolucent line (RLL), degree of medial tibial bone loss, and loosening as seen on X-ray.ResultsNo significant differences were observed in clinical scores or patient preference. Regarding implant weight, approximately 70% of patients did not perceive the Ti implant as lighter. No significant differences were observed in gait analysis, range of motion, or degree of pain. The RLL was seen in 9% of the Ti implant group and 19% of the CoCr implant group.ConclusionThe lighter Ti implant did not show any clinical benefit over CoCr implants. The lightness of the Ti implant is not sufficient to matter or be noticeable. However, the Ti implant showed lower rate of RLL than the CoCr implant.Level of Evidencelevel I, randomized controlled trial.     

Does a Program Based on Cognitive Behavioral Therapy Affect Kinesiophobia in Patients Following Total Knee Arthroplasty? A Randomized,Controlled Trial With a 6-Month Follow-Up

Background

To evaluate the effects of a cognitive behavioral therapy (CBT) program on kinesiophobia, knee function, pain and pain catastrophizing in patients following total knee arthroplasty (TKA).

Patella Denervation in Primary Total Knee Arthroplasty – A Randomized Controlled Trial with 2 Years of Follow-Up

We randomized 126 consecutive patients undergoing primary total knee arthroplasty into group 1: patella denervation (n = 63) and group 2: no patella denervation (n = 63). Assessment was performed preoperatively and at 3, 12 and 24 months post-operatively. Average follow-up of patients was 26.5 months for denervation group and 26.3 months for no denervation group (P = 0.84). Pain scores for anterior knee pain were significantly better in the denervation group at 3 months but not at 12 and 24 months. Patient satisfaction was higher in the denervation group. Flexion range was higher in the denervation group at 3, 12 and 24 months review (P < 0.01). There were, however, no statistically significant differences with other validated knee scores.     

OBTAIN A: Outcome Benefits of Tranexamic Acid in Hip Arthroplasty. A Randomized Double-Blinded Controlled Trial

Background

We examined whether the blood conserving effect of tranexamic acid (TXA) in total hip arthroplasty using the direct anterior approach, translates to an effect on functional outcomes in the perioperative period.

Tranexamic Acid in Knee Surgery Study—A Multicentered,Randomized, Controlled Trial

Background

Postoperative anemia following elective arthroplasty can lead to prolonged hospital stay and delays in rehabilitation and is often poorly tolerated in patients with cardiovascular disease. Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in total knee arthroplasty (TKA). However, questions over its optimal route of administration remain.

Electromagnetic Navigated Versus Conventional Total Knee Arthroplasty—A Five-Year Follow-Up of a Single-Blind Randomized Control Trial

BackgroundThe objective of this study is to provide the 5-year follow-up results of a randomized study comparing conventional versus electromagnetic computer navigated total knee arthroplasty.MethodsAnalysis of 127 patients (66 navigated and 61 conventional surgeries) was performed from a prospective, single-blinded, randomized controlled trial. Patient-reported outcome measures were collected at 5 years after surgery and compared with previously published 1-year clinical outcomes. Five-year surgical revision rates were collated and compared between intervention groups.ResultsOverall, there have been continued improvements in the clinical scores of patients in both groups when compared with clinical data at 1 year; however, at 5 years, there is no statistical difference in any of the patient-reported outcome measures between conventional and navigated surgery. Interestingly, improved implant survivorship was observed in the navigated (0% revision rate) compared with the conventional group (4.9% all-cause revision rate).ConclusionElectromagnetic computer navigated technology produces similar clinical outcomes compared with traditional surgery. Further work is required to monitor implant survivorship, and clinical outcomes with long-term follow-up, to determine the cost effectiveness of this technology.     

Do Changes in Patellofemoral Joint Offset Lead to Adverse Outcomes in Total Knee Arthroplasty With Patellar Resurfacing? A Radiographic Review

Background

Patellofemoral joint biomechanics contribute to anterior knee pain, instability, and dysfunction following total knee arthroplasty (TKA). Information about specific factors leading to anterior knee pain and dysfunction is currently limited. Changes in patellofemoral joint offset (PFO) refers to a mismatch between the preoperative and postoperative anteroposterior geometry of the patellofemoral joint. It remains unclear whether these changes lead to adverse outcomes in TKA.

Does Nefopam Provide Analgesic Effect and Reduce Morphine Consumption After Primary Total Knee Arthroplasty? A Prospective,Double-Blind,Randomized Controlled Trial

BackgroundOne of the most undesirable results after total knee arthroplasty (TKA) is severe immediate postoperative pain, resulting in patient dissatisfaction. We aimed to evaluate nefopam’s analgesic efficacy after primary TKA along with related outcomes, including morphine consumption and adverse events.MethodsWe conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 24 hours of 80 mg of continuous intravenous nefopam to placebo infusion. A 100-mm Visual Analog Scale (VAS) for pain-at-rest and in-motion ≤48 hours was the primary outcome measure. Secondary outcomes were morphine and antiemetic consumption, adverse events, and functional outcomes: time-to-walk, timed up-and-go test, postoperative knee range of motion at 24 and 48 hours, time-to-discharge, and patient satisfaction scores.ResultsPatients in the nefopam group had significantly lower VAS at rest 6 hours postop (20.3 ± 27.3 vs 35 ± 24.3, P = .01). Other timepoints and in-motion VAS did not significantly differ. Total morphine consumption (0-48 hours) was 37% less, significantly lower, in the nefopam group (5.3 ± 4.5 vs 8.4 ± 7.5 mg, P = .03). Antiemetic consumption was also 61% lower in the nefopam group but not statistically significant (0.8 ± 2.3 vs 2.0 ± 3.8 mg, P = .08). There were no variations in adverse events, functional outcomes, and satisfaction scores between groups.ConclusionContinuous nefopam administration as part of multimodal analgesia for 24 hours post-TKA produced a significant analgesic effect but only within the first 6 hours. However, there was a notable reduction in morphine use 48 hours postop. Nefopam is a useful agent for contemporary pain control after TKA.Level of EvidenceTherapeutic Level I.     

Patellar Management in Revision Total Knee Arthroplasty : Is Patellar Resurfacing a Better Option?

The management of the patella during revision total knee arthroplasty (TKA) depends on the indication for revision, the type and stability of the patellar component in place, and availability of bone stock. We prospectively compared the clinical outcome and satisfaction rates in revision TKA patients managed with patellar resurfacing (n = 13, group I) to retention of the patellar component (n = 22, group II) or patelloplasty (n = 11, group III) at a minimum follow-up of 2 years. There were no differences in the improvement of Knee Society Scores, Short-Form 36 Scores, and satisfaction rates between the groups. There were no revision surgeries for patellar component failure or patellar fractures. Satisfactory results can be achieved using a variety of methods of patellar management in revision TKA by individualizing the treatment modality depending on the clinical scenario.     

Is Pseudo-Patella Baja Really a Serious Complication of Total Knee Arthroplasty?

BackgroundThe available evidence on pseudo-patella baja (PPB) is limited. The purpose of this study is to investigate prospectively the occurrence of PPB after primary total knee arthroplasty and its clinical consequences in a large series of patients with a minimum follow-up of 2 years. PPB was defined as a patella distally displaced in relationship to the femoral trochlea with absence of patellar tendon shortening (Grelsamer RP. J Arthroplasty 2002;17:66-69) due to elevation of the joint line.MethodsThis study is a prospective case series of 354 patients with a mean age of 71.7 (range 52-87) years. Clinical evaluation was performed by the Knee Society Scores (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short-Form 12-item (SF12), and range of motion. Patellar height was assessed by the Insall-Salvati and Blackburne-Peel ratios.ResultsThe mean follow-up was 3.6 (range 2.0-6.6) years. Postoperatively, 286 (80.7%) patients had a normal patellar height, 17 (4.8%) had true patella baja (TPB), and 51 (14.4%) had PPB. There were no significant differences between the 3 groups in mean KSS-function (P = .107), range of motion (P = .408), WOMAC-pain (P = .095), WOMAC-stiffness (P = .279), or SF12-mental (P = .363). Between normal and PPB groups, there were no significant differences in mean KSS-knee (P = .903), WOMAC-function (P = .294), or SF12-physical (P = .940). However, the TPB group had significantly lower mean KSS-knee (P = .031), WOMAC-function (P = .018), and SF12-physical (P = .005) as compared with either 2 other groups.ConclusionPPB was a relatively common finding, but no significant differences in terms of clinical outcomes were found as compared to patients with postoperative normal patellar height. TPB was infrequent, but these patients had significantly worse clinical outcomes than those with PPB or normal patellar height.     

Patellar Tracking in Revision Total Knee Arthroplasty: Does Retaining a Patella From a Different Implant System Matter?

BackgroundPatellar maltracking is a potential surgical complication following total knee arthroplasty (TKA) and can result in anterior knee pain, recurrent patellar dislocation, and damage to the medial patellar soft tissue stabilizers. Data remain unclear as to whether the patellar button should be revised during a revision TKA (rTKA) if changing the component implant system. Our study examines whether retaining the original patellar button during an rTKA using a different implant system affects patellar tracking.MethodsA retrospective cohort study of rTKA patients between August 2011 and June 2019 was performed at an urban, tertiary referral center. Patients were divided into 2 cohorts depending on whether their retained patella from their primary TKA was of the same (SIM) or different implant manufacturer (DIM) as the revision system used. Radiographic measurements were performed on preoperative and postoperative knee radiographs and differences were compared between the 2 groups. Baseline demographic data were also collected.ResultsOf the 293 consecutive, aseptic rTKA cases identified, 122 underwent revision in the SIM cohort and 171 in the DIM cohort. There were no demographic differences between the groups. No statistical significance was calculated for differences in preoperative and postoperative patellar tilt or Insall-Salvati ratio between the groups. The DIM group was found to have more lateral patellar translation (?0.01 ± 6.09 vs 2.68 ± 7.61 mm, P = .001). However, when calculating differences in the magnitude of the translation (thereby removing differences due to laterality), no difference was observed (0.06 ± 3.69 vs 0.52 ± 4.95 mm, P = .394).ConclusionNo clinically significant differences in patellar tracking were observed when the original patellar component was retained and a different revision implant system was used. Given the inherent risks of bone loss and fracture with patellar component revision, surgeons performing rTKA may retain the primary patella if it is well fixed and can still expect appropriate patellar tracking regardless of the revision implant system used.Level of EvidenceIII, Retrospective cohort study.     

Overview of Randomized Controlled Trials in Total Knee Arthroplasty (47,675 Patients): What Have We Learnt?

BackgroundThe aim of this study is to provide an overview of randomized controlled trials (RCTs) in primary total knee arthroplasty summarizing the available high-quality evidence.MethodsFollowing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2019, Issue 3), Ovid MEDLINE, and Embase. We excluded nonrandomized trials, trials on unicompartmental knee arthroplasty or revision surgery, systematic reviews, and meta-analyses. Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to the intervention groups (surgical approach, tourniquet use, design, etc.).ResultsFour hundred and three RCTs met the inclusion criteria and were included. The total number of patients in those 403 RCTs was 47,675. Only 33 RCTs (8.2%) reported significant differences between the intervention and the control groups. The trials were grouped into surgical approach 34, tourniquet 31, minimally invasive surgery 13, patient specific instrumentation 30, knee design 37, fixation 27, mobile bearing 47, navigation 50, polyethylene 19, technique 27, patella resurfacing 26, drain 19, closure 16, and others 27 RCTs.ConclusionFor the vast majority of patients, a standard conventional total knee arthroplasty with a surgical approach familiar to the surgeon using standard well-established components, with or without tourniquet, without surgical drain leads to satisfactory long-term clinical outcomes.