全膝关节置换术治疗膝外翻畸形疗效观察

目的探讨膝外翻畸形患者施行全膝关节置换的手术方法和临床疗效。方法 2001年7月至2008年6月收治膝外翻畸形患者25例29膝,男5例,女20例;年龄55-75岁,平均64.3岁。手术采用髌旁内侧入路,模具引导下截骨,按Whiteside方法进行外侧软组织松解,采用后方稳定型假体。对比手术前、后股胫角变化,采用KSS评分评价手术疗效。结果 1例患者住院期间发生深静脉血栓,经溶栓治疗后症状消失。全部患者获12-48个月随访,无感染、腓总神经损伤、髌骨脱位、膝关节不稳等并发症。术后12个月平均股胫角（7.42±1.80）°,KSS临床评分（82.47±5.38）分,功能评分（86.47±4.83）分,与术前比较有统计学意义（P〈0.05）。结论膝外翻畸形施行全膝关节置换手术,术中正确截骨,合理软组织松解,保持髌骨良好运行轨迹,防止腓总神经损伤,可以获得满意疗效。     

Prior Knee Arthroscopy Does Not Influence Long-Term Total Knee Arthroplasty Outcomes and Survivorship

Background

Arthroscopic knee surgery frequently precedes total knee arthroplasty (TKA). There have been mixed data on the effect of prior arthroscopic surgery on results of TKA. The purpose of this study was to compare the 10-year Knee Society Score (KSS), survivorship, and complications of TKA in a cohort of patients who had a previous knee arthroscopy to a control cohort.

Quality of Life Outcomes in Revision Versus Primary Total Knee Arthroplasty

The purpose of this study was to evaluate and compare the quality of life and satisfaction outcomes of patients undergoing primary and revision total knee arthroplasty (TKA). Sixty revision and 199 primary TKA patients were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford-12 Knee Score, Short Form-12, and patient-reported satisfaction. Baseline preoperative scores demonstrate that revision TKA patients have inferior quality of life across all measures (WOMAC, Oxford-12, and Short Form-12) in comparison with primary TKA patients (P < .05). At follow-up revision, TKA patients continue to have inferior outcomes (P < .05) in comparison with primary TKA patients. When adjusting for confounding factors in regression analyses, revisions are inferior to primary TKA by 8.6 (95% confidence interval, 2.7-14.6) normalized WOMAC units.     

Prior Knee Arthroscopy Is Associated With Increased Risk of Revision After Total Knee Arthroplasty

BackgroundKnee arthroscopy (KA) is frequently performed to provide improved joint function and pain relief. However, outcomes following total knee arthroplasty (TKA) after prior KA are not fully understood. The purpose of this study is to determine the relationship between prior KA within 2 years of TKA on revision rates after TKA.MethodsData were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2006 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes to identify primary TKA. Patients were stratified into 2 groups based upon a history of prior KA. Univariate and multivariate analyses were conducted to determine association between KA and outcomes at 2-year postoperative period.ResultsIn total, 138,019 patients were included in this study, with 3357 (2.4%) patients receiving a KA before TKA and 134,662 (97.6%) patients who did not. The most common reason for KA was osteoarthritis (40.0%), followed by medial tear of the meniscus (26.0%) and chondromalacia (21%.0). After adjustment, prior KA was associated with increased revision rate (odds ratio [OR], 1.392; P = .003), postoperative stiffness (OR, 1.251; P = .012), periprosthetic joint infection (OR, 1.326; P < .001), and aseptic loosening (OR, 1.401; P = .048).ConclusionPrior KA is significantly associated with increased 2-year TKA revision rate. The most common etiology for arthroscopy was osteoarthritis. The results of the study, showing that arthroscopy before TKA substantially increases the rates of revision, PJI, aseptic loosening, and stiffness, lend further credence to the idea that patients may be better served by nonsurgical management of their degenerative pathology until they become candidates for TKA. Subjecting this population to arthroscopy appears to offer limited benefit at the cost of poorer outcomes when they require arthroplasty in the future.Level of EvidenceLevel III therapeutic study.     

Arterial Injury in Total Knee Arthroplasty

Arterial complications associated with knee arthroplasty are relatively rare, although probably underreported, complications of knee arthroplasty that carry a risk of significant morbidity. Thorough preoperative assessment and close liaison with a vascular surgeon, combined with an appreciation of common anatomical variants or distorted anatomy, may help prevent both thromboembolic and direct injuries from occurring. Clinical features of arterial complications following knee arthroplasty may vary significantly from acute hemorrhage or ischemia in the immediate postoperative period to chronic pain and swelling presenting even months following the procedure. There is potential for diagnostic confusion and delay that may adversely affect outcome. Early diagnosis along with vascular surgical review and intervention is key to successful management.     

Prior Knee Arthroscopy Increases the Failure Rate of Subsequent Unicompartmental Knee Arthroplasty

BackgroundIn selected patients, knee arthroscopy is performed prior to unicompartmental knee arthroplasty (UKA) to treat symptomatic mechanical pathology, delay arthroplasty, and assess the knee compartments. The purpose of this study was to determine if knee arthroscopy prior to UKA is associated with increased rates of UKA failure or conversion to total knee arthroplasty (TKA).MethodsData was collected from the Humana insurance database from 2007-2017. Patients who underwent knee arthroscopy within two years prior to UKA were identified and matched with controls based on age, gender, Charlson Comorbidity Index, smoking status, and obesity. Rates of conversion to TKA and failure for various causes were compared between cohorts.ResultsPrior to propensity matching, 8353 UKA patients met inclusion criteria. Of these, 1079 patients (12.9%) underwent knee arthroscopy within two years of UKA and were matched to 1079 patients (controls) who did not undergo knee arthroscopy in the two years preceding UKA. No differences in demographics/comorbidities existed among cohorts. Compared to controls, the knee arthroscopy cohort was more likely to experience failure for aseptic loosening (2.4% vs 1.1%; OR 2.166; P = .044) and significantly more likely to require conversion to TKA (10.4% vs 4.9%; OR 2.113; P < .001) within two years of UKA.ConclusionKnee arthroscopy within two years of UKA is associated with an increased rate of UKA conversion to TKA and a higher rate of UKA failure from aseptic loosening. Although clinicians should be mindful of this association when performing knee arthroscopy in patients who may be indicated for future UKA, further research is needed to better characterize these findings.     

Outcomes of Primary Total Knee Arthroplasty in Patients With Ehlers-Danlos Syndromes

Background

Ehlers-Danlos syndromes (EDS) are connective tissue disorders that cause defects in collagen synthesis or processing, resulting in joint hypermobility. Following total knee arthroplasty (TKA), concern exists that hypermobility will affect the outcome as prosthesis relies on soft tissues for stability. The purpose of this study is to investigate the outcome of TKA in the setting of EDS compared to patients undergoing TKA for osteoarthritis (OA).

Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty

BackgroundTo determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient.MethodsRetrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed.ResultsThe cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2).ConclusionThe LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient’s first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge.Level of EvidenceLevel 3-retrospective cohort study.     

Overlapping Surgery Increases Operating Room Efficiency Without Adversely Affecting Outcomes in Total Hip and Knee Arthroplasty

BackgroundSeveral recent studies have demonstrated that overlapping surgeries in total hip (THA) and knee (TKA) arthroplasty do not increase the rates of complications, but whether this practice is cost-effective has yet to be addressed in the literature. The purpose of this study is to determine the effect of overlapping surgery on procedural costs and surgical productivity during THA and TKA.MethodsWe identified all patients undergoing primary THA or TKA from 2015 to 2018 by 18 surgeons at a single orthopedic specialty hospital. Procedural and personnel costs were calculated for each case using a time-driven activity-based costing algorithm. Overlap of surgical time by at least 30 minutes was used to define an overlapping procedure. We compared costs and outcomes between overlapping and nonoverlapping procedures, standardizing all costs to 8-hour time blocks. A multivariate regression analysis was performed to determine independent effect of overlapping procedures on costs and outcomes.ResultsOf the 4786 consecutive procedures, 968 (20.2%) overlapped by at least 30 minutes. Although overlapping rooms increased mean operative time by 8.3 minutes (P < .0001) and operating room personnel costs by $80 per case (<.0001), overlapping surgeons could perform significantly more procedures per 8 hours (7.6 vs 6.4; P < .0001), increasing total 8-hour profit margin by $1215 per procedure. There was no difference in 90-day readmission rate, length of stay, or rates of discharge home between the groups.ConclusionOverlapping noncritical portions of procedures in primary THA and TKA appear to be both a safe practice and an effective strategy.     

Rotating Hinge Implants for Complex Primary and Revision Total Knee Arthroplasty

Background

Contemporary rotating hinge knee (RHK) prosthesis has shown improved survival rates over earlier generations. However, reports of high complication and mechanical failure rates highlight the need for more clinical outcome data in the complex primary and revision setting. The purpose of this study is to report our results of using a contemporary rotating hinge for complex primary and revision total knee arthroplasty.

The Risk of Direct Peroneal Nerve Injury Using the Ranawat “Inside-Out” Lateral Release Technique in Valgus Total Knee Arthroplasty

The purposes of our study are to define a “danger zone” and a “safe zone” to avoid common peroneal nerve direct injury performing the “inside-out” release technique of posterior-lateral corner during total knee arthroplasty and to identify anatomic landmarks to localize the nerve before the soft-tissues release. Twenty cadaver dissections were used for testing. The distance from the nerve to the posterior-lateral corner of the tibia and to the posterior border of the iliotibial band averaged, respectively, 13.5 and 35.8 mm. The nerve is at risk during the release of the posterior-lateral capsule, in the triangle defined by the popliteus tendon, the tibial cut surface, and the most posterior fibers of iliotibial band (danger zone), but not during pie-crusting of the iliotibial band (safe zone).     

Osteopetrosis is Associated With an Increased Risk for Intraoperative Periprosthetic Fracture in Total Hip Arthroplasty but not in Total Knee Arthroplasty

BackgroundOsteopetrosis is a rare, inherited disorder in which bone remodels to become pathologically dense. There has been a paucity of data evaluating medical and surgical complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in this patient population. The objective of this study was to evaluate osteopetrosis as a potential risk factor for medical and surgical complications following THA and TKA.MethodsPatients who had a diagnosis of osteopetrosis and underwent THA or TKA from 2010 to 2020 were identified in a national database. A total of 534 THA and 972 TKA patients who had osteopetrosis were identified and compared with matched cohorts of 2,670 and 4,860 patients, respectively. The rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were calculated. In addition, reimbursements and lengths of stay were determined. Osteopetrosis patients were then compared to a 5:1 matched cohort without osteopetrosis using logistic regression analyses to control for additional confounding factors.ResultsThe osteopetrosis THA group had a substantially higher incidence of intraoperative periprosthetic fracture compared to the matched cohort (1.12% versus 0.19%, Odds Ratio 5.88, P = .005). Patients who had a history of osteopetrosis were not found to be at a significantly increased risk for other investigated medical or surgical complications compared to matched controls following THA or TKA.ConclusionPatients who had a history of osteopetrosis undergoing elective primary THA are associated with a significantly increased risk for intraoperative periprosthetic fracture. Patients with a history of osteopetrosis undergoing elective primary TKA were not found to be at an increased risk for any of the investigated complications.     

Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty

Background

Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA.

Clinical Outcomes Following the Use of Constrained Condylar Knees in Primary Total Knee Arthroplasty

Background

Certain clinical or adverse intraoperative situations require the use of increased constraint in primary total knee arthroplasty (TKA). These include significant angular deformities causing incompetent collateral ligaments, or inadvertent intraoperative injury to collateral structures as well as the inability to achieve a balanced flexion and extension gap. Clinical success has been described with the use of constrained condylar knee arthroplasty in the primary setting in these situations. Traditionally, increasing constraint has been in conjunction with intramedullary stems, referred to as stemmed constrained condylar knees (SCCK); however, some devices provide an intermediary option by increasing constraint without the use of stems, herein referred to as nonstemmed constrained condylar knees (NSCCK). The aim of this study was to compare the clinical outcomes of both these devices in primary TKA in terms of revision rates and change in outcome measures over the follow-up period.

Implementation of Preoperative Screening Criteria Lowers Infection and Complication Rates Following Elective Total Hip Arthroplasty and Total Knee Arthroplasty in a Veteran Population

Background

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures with a risk of complications. Attempting to minimize complications, our institution implemented preoperative screening criteria for patients undergoing elective total joint replacement. Our study aimed to determine if screening criteria lowered total complications and/or surgical site infections (SSI).

Chronic Thrombocytopenia and In-Hospital Outcomes After Primary Total Hip and Knee Arthroplasty

BackgroundThere is a lack of data on the influence of chronic thrombocytopenia (cTCP) on clinical outcomes following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Limited studies mainly focused on postoperative heparin-induced TCP from single centers with small sample sizes. This study aims to describe the characteristics, trend, and outcomes of cTCP in patients undergoing THA and TKA from a nationally reprehensive perspective.MethodsWe identified THA and TKA patients with and without cTCP from the 2005 to 2015 Nationwide Inpatient Sample. Annual percent changes were calculated to reflect cTCP trends. Multivariable regression and propensity score analyses were conducted to investigate the association of cTCP and mortality, preoperative complications, cost as well as length of stay.ResultsIn total, 578,278 and 1,237,331 patients underwent primary THA and TKA, respectively. Proportion of cTCP annually increased by 6.95% in THA and 6.66% in TKA. Patients with cTCP were associated with higher risk of medical (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.89-2.11) and surgical complications (OR 2.72, 95% CI 2.55-2.90) in THA, and higher risk of mortality (OR 1.68, 95% CI 1.22-2.31), medical (OR 1.94, 95% CI 1.85-2.03) and surgical complications (OR 2.55, 95% CI 2.38-2.73) in TKA. Additionally, higher cost and longer length of stay were observed in patients with cTCP for both surgical procedures.ConclusionPatients with cTCP had higher risk of mortality for TKA, more perioperative complications for both TKA and THA. Further studies are warranted to improve the preoperative management and to prevent worse outcomes associated with cTCP.     

Stiffness After Revision Total Knee Arthroplasty

Stiffness after a revision total knee arthroplasty (TKA) is a disabling complication that has largely been overlooked in the literature. This study attempts to define the prevalence of stiffness after revision TKA and to determine the risk factors that may lead to its development. Thirty-two knees (4.0%) presented with stiffness that we defined as a range of motion less than 90°. Risk factors were found to be poor preoperative range of motion, stiffness as primary indication for revision, younger age, shorter interval between index primary and revision TKA, presence of well-fixed components at the time of revision, postoperative wound drainage, and lower Charlson index. Because of the challenges of treating stiffness, efforts should be invested in preventing this complication.     

New 5-Factor Modified Frailty Index Predicts Morbidity and Mortality in Primary Hip and Knee Arthroplasty

Background

While the 11-factor modified frailty index (mFI) has been shown to predict adverse outcomes in patients undergoing total joint arthroplasty, the 5-factor index has not been evaluated in this patient population. The goal of this study was to evaluate the utility of the mFI-5 as a predictor of morbidity and mortality in patients undergoing primary total hip and knee arthroplasty.

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.