Patient Satisfaction After Total Knee Replacement: A Systematic Review

Background:

The quality and state of satisfaction reporting after total knee replacement (TKR) is variable.

Questions/Purposes:

The purposes of this systematic review were (1) to examine the available literature on patient satisfaction after TKR, (2) to evaluate the quality of available evidence, and (3) to identify predictors of patient satisfaction after TKR.

Methods:

A systematic review of the MEDLINE database was performed. The initial search yielded 1219 studies. The inclusion criteria were English language, clinical outcome study with primary outcome related to TKR for osteoarthritis, and patient-reported satisfaction included as an outcome measure. Studies were assessed for demographics, methodology for reporting satisfaction, and factors influencing satisfaction.

Results:

Two hundred eight studies, including 95,560 patients who had undergone TKR, met all inclusion and exclusion criteria; 112 (53.8%) of these studies were published in the past 3 years. Satisfaction was most commonly measured using an ordinal scale. Twenty-seven studies (13%) used a validated satisfaction survey. Eighty-three percent of studies reported more than 80% satisfaction. The most commonly reported predictor of satisfaction was post-operative patient-reported functional outcome. Pre-operative anxiety/depression was the most common pre-operative predictor of dissatisfaction.

Conclusion:

There are numerous studies reporting patient satisfaction after TKR, and publication on the topic has been increasing over the past decade. However, the majority of studies represent lower levels of evidence and use heterogeneous methods for measuring satisfaction, and few studies use validated satisfaction instruments. In general, the majority of studies report satisfaction rates ranging from 80 to 100%, with post-operative functional outcome and relief of pain being paramount determinants for achieving satisfaction.

     

Risk Factors for Peroneal Nerve Injury and Recovery in Knee Dislocation

Background  

Acute knee dislocation is rare but has a high rate of associated neurovascular injuries and potentially limb-threatening complications. These include the substantial morbidity associated with peroneal nerve injury: neuropathic pain, decreased mobility, and considerably reduced function, which not only impairs patient function but complicates treatment.     

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BackgroundRecent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.MethodsPubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.ResultsTwenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.ConclusionED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.     

Risk Factors for Mid-Flexion Instability After Total Knee Arthroplasty: A Systematic Review

BackgroundMid-flexion instability after total knee arthroplasty (TKA) is a clinical entity that is not well studied and one that has been associated with patient dissatisfaction and inferior outcomes. We sought to provide a comprehensive review of risk factors associated with mid-flexion instability.MethodsA comprehensive literature search of PUBMED, EMBASE, Google Scholar, and Cochrane Library was performed using keywords “mid flexion,” “instability,” and “knee arthroplasty” in all possible combinations. All studies published from 2010 to 2020 in English were considered for inclusion. Research design, question studied, and outcomes were recorded for each study. Quantitative and qualitative analysis was performed.ResultsEighteen articles meeting inclusion criteria were identified and reviewed. There were 5 computational studies, 5 cadaveric studies, and 8 clinical studies. There were 14 different risk factors investigated in relation to mid-flexion instability after TKA: 6 implant-related, 6 technique-related, and 2 patient-related factors. Of these risk factors, 5 had contradictory results published to date, resulting in an inconclusive association with mid-flexion instability. The results of this review suggest that the effects of joint line elevation and radius-of-curvature of the femoral component on mid-flexion instability are inconclusive while articular surface conformity and preoperative joint laxity may play a bigger role than previously thought.ConclusionMid-flexion instability after TKA is a clinical entity distinct from other established forms of instability. There are patient-related, implant-related, and technique-related factors associated with mid-flexion instability. The majority of the evidence on this topic is derived from computational and cadaveric studies, underscoring the need for further clinical studies.     

Treatment of Extensor Tendon Disruption After Total Knee Arthroplasty: A Systematic Review

BackgroundPatellar or quadriceps tendon ruptures after total knee arthroplasty constitute a devastating complication with historically poor outcomes. With advances in soft tissue reconstruction and repair techniques, treatment has become more nuanced. Numerous graft options for reconstruction and suture techniques for repair have been described but there is no consensus regarding optimal treatment.MethodsA search of PubMed, MEDLINE, Embase, and Scopus was conducted. Articles meeting inclusion criteria were reviewed. Type of intervention performed, type of injury studied, outcome measures, and complications were recorded. Quantitative and qualitative analyses were performed.ResultsTwenty-eight articles met inclusion criteria. The complication rate after repair of patellar tendon (63.16%) was higher than the complication rate after repair of quadriceps tendon (25.37%). However, the complication rate for patellar and quadriceps tendon tears after autograft, allograft, or mesh reconstruction was similar (18.8% vs 19.2%, respectively). The most common complication after extensor mechanism repair or reconstruction was extension lag of 30° or greater (45.33%). This was followed by re-rupture and infection (25.33% and 22.67%, respectively). Early ruptures had a higher overall complication rate than late injuries.ConclusionExtensor mechanism disruption after total knee arthroplasty is a complication with high morbidity. Reconstruction of patellar tendon rupture has a much lower complication rate than repair. Our findings support the recommendation of patellar tendon reconstruction in both the early and late presentation stages. Quadriceps rupture can be treated with repair in early ruptures or with reconstruction in the late rupture or in the case of revision surgery.     

Efficacy and Degree of Bias in Knee Injury Prevention Studies: A Systematic Review of RCTs

Background

Knee injury prevention programs have been developed to address the epidemic of knee injuries in young athletes. These programs include exercises that focus on balance, proprioception, and neuromuscular control. Some studies have suggested such specialized exercise programs may reduce the risk of knee injury.

Questions/purposes

We conducted a systematic review of randomized controlled trials (RCTs) of knee injury prevention programs and evaluated the risks of bias in these studies.

Methods

We performed a systematic search using MEDLINE (from 1966), CINAHL (from 1982), Cochrane (CENTRAL), and EMBASE (from 1974) in April 2011. The searches were limited to RCTs. Two reviewers independently assessed the internal validity of the included studies using the van Tulder critical appraisal tool for RCTs. Authors were contacted when internal validity was unclear in the methodology. Ten Level I studies (RCTs) met the inclusion criteria. The average risk of bias score for these studies was 7 of 11 (range, 5–10).

Results

Two of the 10 studies reported a reduction in knee injuries. Of the three studies that provided ACL injuries as an outcome measure, none showed a reduction in overall ACL injury.

Conclusions

Current evidence suggests most (eight of 10) well-designed RCTs show no difference of treatment benefit. Perhaps refinements of interventions may lead to a reduction in knee and ACL injuries in future trials. Limitations in the number and heterogeneity of currently published RCTs of injury prevention programs place restraints on quantifying intervention efficacy with a meta-analytic approach. Future research articles should more clearly describe the different elements of their methodology, consistent with the standards set forth by the CONSORT statement.     

External Fixation vs Intramedullary Nailing for Knee Arthrodesis After Failed Infected Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

The aim of this study is to compare intramedullary nailing with external fixation for knee arthrodesis after failed infected total knee arthroplasty (TKA). Primary outcome is radiographic union. Secondary outcomes include recurrent deep infection, revision arthrodesis, and amputation.

A Systematic Review of Clinical Outcomes and Survivorship After Total Knee Arthroplasty With a Contemporary Modular Knee System

A systematic review appraising the clinical performance and safety of the primary SIGMA modular knee system (DePuy-Synthes, Warsaw, Ind.) found 5 registry reports and 53 journal publications reporting survivorship or postoperative increase in Knee Society scores on 241 632 primary SIGMA knee arthroplasties. Pooled data from national joint registries and clinical studies on primary SIGMA knee survivorship were comparable. Both were higher than for all other knees in 5 national joint registries up to 5 years. Compared with pooled data from 2 independent systematic reviews of primary non-SIGMA knees, the SIGMA system provided comparable postoperative changes in Knee Society knee score and a nonsignificant trend of higher postoperative changes in Knee Society function score. This finding suggests that this knee system provides excellent durable results.     

膝关节完全脱位合并腘部血管损伤的处理（附11例报告）

膝关节完全脱位合并腘部血管损伤11例,经治疗10例成功。本文着重提出早期诊断的要点,认为只有及时诊断,早期手术探查,对不同类型的血管损伤,采取血管端端吻合,血管修补,大隐静脉移植术等方法,重建血循环和修复关节稳定结构,获得较为满意效果。     

The Role of Cryotherapy After Total Knee Arthroplasty: A Systematic Review

BackgroundPrevious research shows conflicting evidence regarding the postoperative role of cryotherapy after total knee arthroplasty (TKA). This systematic review aims to further investigate the effect of various methods of cryotherapy on the following: (1) pain; (2) swelling; (3) postoperative opioid use; and (4) range of motion (ROM).MethodsA strategic keyword search of Medline, Cochrane, Embase, and CINAHL retrieved randomized controlled trials examining cryotherapy following TKA published between February 1, 2017, and February 24, 2022. The studied outcomes included pain ratings, knee/limb swelling, opioid use, and ROM. Six studies were selected for inclusion in this review.ResultsOpioid use was significantly decreased in cryotherapy groups compared to noncryotherapy groups within the first postoperative week only (P < .05). This effect may be augmented by the use of computer-assisted (temperature regulated) cryotherapy devices, compared to other modalities including ice packs. Pain ratings also decrease, but this decrease may not be clinically relevant. Cryotherapy appears to confer no consistent benefit to ROM and swelling at any time point. Computer-assisted cryotherapy may be associated with decreased opioid consumption after TKA compared to traditional ice packs.ConclusionCryotherapy’s role after TKA appears to be in decreasing opioid consumption primarily in the first postoperative week. Pain ratings also decrease consistently with cryotherapy use, but this decrease may not be clinically relevant. Study heterogeneity requires further research focusing on optimizing cryotherapy modalities within the first postoperative week, and analyzing cost associated with modern outpatient postoperative TKA protocols.     

Editorial Commentary: External Fixation and/or Vascular Injury Is Associated With Postoperative Arthrofibrosis After Multiple-Ligament Knee Injury Reconstruction

Patients with a body mass index over 30 do not have a significant increase in postoperative arthrofibrosis after multiple-ligament knee injury (MLKI) reconstruction compared with patients with a body mass index under 30. However, although this may be associated with the severity of injury, recent research has shown that patients who undergo external fixation at index surgery and/or who have vascular injury are at increased risk of requiring manipulation under anesthesia. This finding is clinically significant in that it is reassuring that stiffness requiring manipulation is no more likely to develop in obese patients than in non-obese patients after MLKI reconstruction. I have often believed that controlled arthrofibrosis can be somewhat beneficial in the management of MLKI and have advised patients over the years that a required manipulation in this case is not really a complication but more of a continuation of care. Stiffness after an MLKI surgical procedure is preferable to recurrent instability.