Does Unicompartmental Knee Replacement Offer Improved Clinical Advantages Over Total Knee Replacement in the Treatment of Isolated Lateral Osteoarthritis? A Matched Cohort Analysis From an Independent Center

BackgroundThe purpose of this study is to compare the functional and radiographic results, perioperative complications, satisfaction rate, and mid-term survivorship after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) for the treatment of lateral compartmental knee osteoarthritis (LCKO).MethodsBetween March 2007 and September 2017, we identified 35 patients with primary TKAs and 121 patients with lateral UKAs (LUKAs) for LCKO with a minimum follow-up of 2 years (mean 5.3 years, range 2-12.4). The matched variables were age, gender, operation side, body mass index, American Society of Anesthesiologist grade, initial diagnosis, osteoarthritis grade in lateral compartment, and follow-up time. All patients were assessed using the Oxford Knee Score, Hospital for Special Surgery score, range of motion, length of hospital stay, satisfaction, and complications. Survivorship of UKA and TKA implants was also compared.ResultsAt last follow-up, LUKA had a significantly better postoperative Oxford Knee Score, Hospital for Special Surgery score, range of motion, shorter length of hospital time, and higher satisfaction rate than matched TKA group. There were significant differences regarding patellar tendon injury (P = .043), superficial wound infection (P = .028), patellar snapping or impingement (P = .047), and stiffness (P < .001). Five-year survivorships free from revision were similar in both groups (99.2% vs 97.1%, P = .347).ConclusionLUKA for LCKO demonstrated more favorable 5-year results in comparison with TKA. Furthermore, LUKA achieved comparable mid-term survivorship and was less likely to suffer from wound infection and knee stiffness, although not overall surgical complications.     

Staging Bilateral Total Knee Arthroplasties Reduces Alignment Outliers

BackgroundPatients frequently present with bilateral symptomatic knee osteoarthritis and request simultaneous total knee arthroplasties (TKAs). Technical differences between simultaneous and staged TKAs could affect clinical and radiographic outcomes. We hypothesized that staged TKAs would have fewer mechanical alignment outliers than simultaneous TKAs.MethodsWe reviewed 87 simultaneous and 72 staged TKAs with at least 2 years of follow-up. Radiographic assessment was done using standing long leg and lateral radiographs of the knee. Coronal and sagittal measurements were performed by 4 blinded observers on 2 separate occasions with an intraobserver agreement of 0.95 and interobserver of 0.92.ResultsThe first simultaneous knee had no difference in the probability of establishing the mechanical axis outside 3° of neutral (45%) compared to the first staged knee (54%, P = .337). However, the second simultaneous knee (49%) was more likely to establish the axis outside mechanical neutral compared to the second staged knee (28%; odds ratio 2.54, confidence interval 1.31-4.94, P = .006). There was an increased risk of deep venous thrombosis with staged TKA (odds ratio 2.96, confidence interval 1.28-6.84, P = .011), but other perioperative complication rates were not significantly different. There were no clinically significant differences in range of motion or Knee Society Score.ConclusionThere is a significantly increased risk of establishing the second knee outside mechanical neutral during a simultaneous TKA compared to staged bilateral TKAs, possibly related to a number of surgeon-related and system-related factors. The impact on clinical outcomes and radiographic loosening may become significant in long-term follow-up.     

Long-Term Functional Outcomes and Quality of Life at Minimum 10-Year Follow-Up After Fixed-Bearing Unicompartmental Knee Arthroplasty and Total Knee Arthroplasty for Isolated Medial Compartment Osteoarthritis

BackgroundThe aim of this study is to compare the long-term functional outcome and quality of life between total knee arthroplasty (TKA) and fixed-bearing unicompartmental knee arthroplasty (UKA) for the treatment of isolated medial compartment osteoarthritis.MethodsBetween 2000 and 2008, a total of 218 patients underwent primary UKA at our tertiary hospital. A TKA group was matched through 1:1 propensity score matching and adjusted for age, gender, body mass index, preoperative knee flexion, and function scores. All patients had medial compartment osteoarthritis. The patients were assessed with the range of motion, Knee Society Knee Score and Knee Society Function Score, Oxford Knee Score, Short Form-36 physical component score (PCS) and mental component score preoperatively, at 6 months, 2 years, and 10 years. Patients’ satisfaction, expectation fulfillment, and minimal clinically important difference were analyzed.ResultsThere were no differences in baseline characteristics between groups after propensity score matching (P > .05). UKA had greater knee flexion at all time points. Although the Knee Society Function Score was superior in UKA by 5.5, 3, and 4.3 points at 6 months, 2 years, and 10 years, respectively (P < .001), these differences did not exceed the minimal clinically important difference (Knee Society Knee Score 6.1). There were no significant differences in the Oxford Knee Score and Short Form-36 physical component score/mental component score. At 10 years, similar proportions of UKA and TKA were satisfied (90.8% vs 89.9%, P = .44) and had expectation fulfillment (89.4% vs 88.5%, P = .46). Between 2 and 10 years, all function scores deteriorated significantly for both groups (P < .01).ConclusionUKA and TKA are excellent treatment modalities for isolated medial compartment osteoarthritis, with similar functional outcomes, quality of life, and satisfaction at 10 years.     

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BackgroundFor patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes.MethodsOur total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12).ResultsFor CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients.ConclusionComplications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.     

Comparison of Anterior-Stabilized and Posterior-Stabilized Total Knee Arthroplasty in the Same Patients: A Prospective Randomized Study

BackgroundA highly conforming, anterior-stabilized (AS) insert is designed to provide anteroposterior (AP) stability of the posterior-stabilized (PS) insert without a post. The purpose of this study was to compare the static and dynamic stability and function of AS and PS total knee arthroplasty (TKA) in the same patients.MethodsA prospective, randomized controlled trial was performed in 45 patients scheduled to undergo same-day bilateral TKA. One knee was randomly assigned to receive an AS TKA, and the other knee was scheduled for a PS TKA from the same knee system. At 2 years postoperatively, the static AP stability was compared using anterior and posterior drawer stress radiographs at 90° knee flexion. Dynamic AP stability was evaluated using one-leg standing lateral fluoroscopic images throughout the range of motion. Knee function was compared using the Knee Society Score and Western Ontario and McMaster Universities Osteoarthritis Index score.ResultsAt 2 years postoperatively, there was a significant difference in knee AP laxity at 90° of flexion between the two groups (7.6 ± 3.9 mm in the AS group vs 2.2 ± 2.3 in the PS group, P < .001). However, there were no differences in dynamic AP stability under one-leg standing fluoroscopic lateral images at 30°, 60°, and 90° knee flexion (P = .732, P = .764, and P = .679, respectively). The Knee Society Score and Western Ontario and McMaster Universities Osteoarthritis Index scores were not significantly different between the two groups (P = .641 and P = .582, respectively).ConclusionDespite the fact that the AS TKA group showed significantly more static posterior displacement than the PS TKA group at 90° of knee flexion, both the AS and PS TKA groups showed similar dynamic stability under weight-bearing conditions and knee function at 2 years postoperatively.     

Clinical Outcomes of a Modern Total Knee Arthroplasty Prosthesis Compared to Its Predecessor at 5-Year Follow-Up: Matched Pair Analysis

BackgroundResidual pain is an important cause of patient dissatisfaction after total knee arthroplasty (TKA). A recent study at our institution found that a modern prosthesis was associated with less residual and anterior knee pain at 2-year follow-up when compared to its predecessor. The aim of this study is to evaluate these implants at 5-year follow-up.MethodsFrom July 2012 to December 2013, 100 consecutive modern TKAs were identified from our prospective Institutional Review Board approved database. All patients with 5-year clinical follow-up (n = 77) were matched in a one-to-one fashion based on age, gender, body mass index, and follow-up with a predecessor TKA. Clinical outcomes were assessed with a patient-administered questionnaire for specifically anterior knee pain, painless noise, painful crepitation, and satisfaction. Overall function was assessed using Knee Society Scores and Western Ontario and McMaster University Osteoarthritis Index.ResultsAt 5-year follow-up, there were no significant differences between the modern TKA and a predecessor TKA in the Knee Society pain or function scores (P = .24 and P = .54, respectively). The overall prevalence of residual pain was less with the modern TKA compared to its predecessor (19.5% vs 36.3%; P = .02), but the prevalence of isolated anterior knee pain was similar in both cohorts (11.7% vs 22.1%; P = .09). There was no difference in painless noise (19.5% vs 13.3%; P = .28) or satisfaction scores (7.9 ± 2.4 vs 7.6 ± 2.6; P = .25) between the modern and predecessor cohorts.ConclusionAt 5-year follow-up, we found that both the modern and predecessor prostheses provided excellent clinical outcomes. The modern TKA was associated with less residual pain compared to its predecessor, but we were unable to detect differences in the prevalence of isolated anterior knee pain, painless noise, Knee Society Scores, or radiographic evaluation.     

Does Recession of the Posterior Cruciate Ligament Influence Outcome in Total Knee Arthroplasty?

BackgroundFor a PCL-retaining (posterior cruciate ligament) total knee arthroplasty (TKA) to function suitably, proper soft tissue balancing, including PCL recession, is required. Yet, when the recession of the PCL is needed, there is still a debate as to whether a cruciate-retaining (CR) TKA should be converted to a posterior-stabilized TKA due to the concern of instability and poorer clinical outcomes. The purpose of this study is to determine whether recession of the PCL adversely affects clinical outcomes in patients who undergo CR TKA.MethodsCR TKAs of the same design performed by the senior author (J.M.) were identified between December 2006 and July 2015. Clinical outcome measurements were collected and included the Western Ontario and McMaster Universities Osteoarthritis Index score, the Knee Society Clinical Rating System, Short Form-12 Physical Composite Score/Mental Health Composite Score, and revision rates.ResultsThere were no significant differences in clinical outcome when the PCL was retained, partially recessed, or completely released during PCL-retaining TKA (Western Ontario and McMaster Universities Osteoarthritis Index: P = .54, Knee Society Clinical Rating System: P = .42, Short Form-12 Mental Health Composite Score: P = .89, Short Form-12 Physical Composite Score: P = .527).ConclusionThis study presents evidence of similar clinical outcomes when the PCL is retained or released during PCL-retaining TKA, provided attention is paid to appropriate soft tissue balancing. CR TKA undergoing partial or complete release of the PCL should not routinely be converted to a posterior-stabilized knee design.Level of EvidenceLevel II, Prognostic study.     

Isolated Versus Full Component Revision in Total Knee Arthroplasty for Aseptic Loosening

BackgroundRevision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost; however, implant survivorship and clinical outcomes of these different operations are unclear.MethodsBetween January 2009 and December 2019, a consecutive cohort of revision TKA was reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles, Knee Society functional, knee osteoarthritis and outcome score for joint replacement, Veterans RAND 12 (VR-12) physical, and VR-12 mental).ResultsA total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, P = .343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [Hazard ratio 10.11, P < .001] and iliotibial band release was associated with more complications (Odds ratio 9.87, P = .027). Preoperative symptoms of instability were associated with the worst improvement in University of California Los Angeles score. Higher American Society of Anesthesiologists status and higher Charlson Comorbidity Index were related with worse VR-12 physical (?30.5, P = .008) and knee osteoarthritis and outcome score for joint replacement (?4.2, P = .050) scores, respectively.ConclusionIsolated and full component revision TKA for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor American Society of Anesthesiologists status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement.Level of evidenceIII, cohort with control.     

Comparison of Modular Conventional and High-Flexion Posterior-Stabilized Total Knee Arthroplasties in the Same Patients at a Mean Follow-Up of 15 Years

BackgroundAs previous studies are limited to short-term clinical data on conventional and high-flexion total knee arthroplasties (TKAs), long-term clinical data on these TKAs remain unclear. Therefore, we evaluated long-term functional outcome, range of knee motion, revision rate, implant survival, and the prevalence of osteolysis after conventional and high-flexion TKAs in the same patients.MethodsThe authors evaluated a cohort of 1206 patients with a mean age of 65.3 ± 7 years (range: 22-70) who underwent bilateral simultaneous sequential TKAs. One knee received a conventional TKA and the other received a high-flexion TKA. The mean duration of follow-up was 15.6 years (range: 14-17).ResultsNo significant differences were found between the 2 groups at the latest follow-up with respect to Knee Society score (93 vs 92 points, P = .765), pain score (45 vs 44 points, P = .641), range of knee motion (125° vs 126°, P = .712), and radiographic and computed tomography scan results. Furthermore, no significant revision rate differences were found between the 2 groups (1.3% for conventional TKA vs 1.6% for high-flexion TKA; P = .137). There was no osteolysis recorded in either group. The rate of survivorship free of implant revision or aseptic loosening was 98.7% (95% CI = 91-100) for conventional TKA and 98.4% (95% CI = 91-100) for high-flexion TKA at 17 years.ConclusionAt the latest follow-up, we were not able to demonstrate any significant difference between conventional and high-flexion TKAs with respect to functional outcome scores, range of knee motion, revision rate, implant survival, and prevalence of osteolysis.     

Higher Activity Level Following Total Knee Arthroplasty Is Not Deleterious to Mid-Term Implant Survivorship

BackgroundThe impact of a patient’s activity level following total knee arthroplasty (TKA) remains controversial, with some surgeons concerned about increased polyethylene wear, aseptic loosening, and revisions. The purpose of this study is to report on implant survivorship and outcomes of high activity patients compared to low activity patients after TKA.MethodsA retrospective review identified 1611 patients (2038 knees) that underwent TKA with 5-year minimum follow-up. Patients were divided in 2 groups based on their University of California Los Angeles (UCLA) activity level: low activity (LA) (UCLA ≤5) and high activity (HA) (UCLA ≥6). Outcomes included range of motion, Knee Society scores, complications, and reoperations. Parametric survival analysis was performed to evaluate the significance of activity level on survivorship while controlling for age, gender, preoperative pain, Knee Society clinical scores, Knee Society functional scores, and body mass index (BMI).ResultsMean follow-up was 11.4 years (range 5.1-15.9). The LA group had significantly more female patients, were older, had higher BMI, and had lower functional scores preoperatively (all with P < .001). The HA group had significantly higher improvements in Knee Society scores (P < .001) and pain postoperatively (P < .001). Revisions were performed in 4% of the LA group and 1.7% knees of the HA group (P = .003). After controlling for age, gender, preoperative pain, Knee Society clinical scores, Knee Society functional scores, and BMI, a higher postoperative activity level remained a significant factor for improved survivorship with an odds ratio of 2.4 (95% confidence interval 1.2-4.7, P = .011). The all-cause 12-year survivorship was 98% for the HA group and 95.3% for the LA group (P = .003). The aseptic 12-year survivorship was 98.4% for the HA group and 96.3% for the LA group (P = .02).ConclusionHighly active patients had increased survivorship at 5-year minimum follow-up compared to lower activity patients after TKA. Patient activity level after TKA may not need to be limited with modern implants.     

Anatomic Patellar Design Has No Clinical Superiority Over Dome Patellar Design in Total Knee Arthroplasty: A Randomized Clinical Trial

BackgroundVarious patellar designs are used in total knee arthroplasty (TKA) for optimal management of patellofemoral pain. The aim of this study was to compare postoperative 2-year clinical outcomes of 3 patellar designs: medialized anatomic (MA), medialized dome (MD), and Gaussian dome (GD).MethodsIn this randomized controlled trial, 153 patients undergoing primary TKA from 2015 to 2019 were enrolled. Patients were allocated to 3 groups (MA, MD, and GD). Demographic characteristics, clinical variables including knee flexion angle and patient-reported outcome measures (Kujala score, Knee Society Scores, the Hospital for Special Surgery score, and The Western Ontario and McMaster Universities Arthritis Index), and complications were collected. Radiologic parameters including Blackburne-Peel ratio and patellar tilt angle (PTA) were measured. A total of 139 patients who completed postoperative follow-up for 2 years were analyzed.ResultsKnee flexion angle and patient-reported outcome measures did not statistically differ among the 3 groups (MA, MD, and GD). There were no extensor mechanism-related complications at any group. Group MA showed significantly higher mean values of postoperative PTA than group GD (0.1 ± 3.2 versus −1.8 ± 3.4, P = .011). Group GD (20.8%) had a tendency to have more outliers (over 5 degrees) in PTA than groups MA (10.6%) and MD (4.5%), although the differences were not statistically significant (P = .092).ConclusionAnatomic patellar design was not clinically superior over dome design in TKA, showing comparable results in terms of clinical scores, complications, and radiographic indices.     

Combination Effect of High-Dose Preoperative and Periarticular Steroid Injection in Total Knee Arthroplasty. A Randomized Controlled Study

BackgroundPostoperative pain remains a major barrier to a patient’s recovery after total knee arthroplasty (TKA). Periarticular corticosteroids in local infiltration analgesics (LIA) and high-dose intravenous corticosteroids have individually shown to improve pain control after TKA. However, potential interactions between them have not been investigated.This study aims to evaluate any combination effect of both routes of corticosteroids in TKA.MethodsThis is a double-blinded, paired, randomized controlled trial involving 1-stage bilateral TKAs. All received 16 mg of dexamethasone intravenously. One knee was randomized to receive LIA with 40 mg of triamcinolone, while the other knee receives LIA without corticosteroids.For each patient, one knee was affected by intravenous steroids only, while the other was under the combined effect of intravenous and periarticular steroids (IVPAS).Knee pain, Southampton wound scores, and functional knee scores (Knee Society Knee Score and Oxford Knee Scores) were compared between knees of the same patient.ResultsForty-six patients (92 TKAs) were included. IVPAS knees showed significantly lower visual analog scale scores from day 1 to 6 weeks (P < .05) and a larger range of movement from day 2 to 4 (P < .05). IVPAS knees achieved active straight leg raise earlier than intravenous steroids (1.6 vs 2.3 days, P < .05).No differences in Southampton wound scores and functional knee scores for up to 1 year.ConclusionCombining intravenous and periarticular corticosteroids improved pain control and recovery after TKA with no increase in wound complications up to 1 year.     

Patients With Parkinson’s Disease Have Poorer Function and More Flexion Contractures After Total Knee Arthroplasty

BackgroundParkinson’s disease (PD) may negatively influence the rehabilitative course after total knee arthroplasty (TKA). However, functional outcomes in this select group remain poorly defined. We compared complication, mortality and revision rates, as well as patient-reported outcomes, and satisfaction between patients with PD and controls after TKA.MethodsPatients with PD who underwent primary unilateral TKA were identified and matched 1:1 with a control group using propensity scores adjusting for age, sex, body mass index, Charlson Comorbidity Index, baseline range of motion, Knee Society Knee Score, Knee Society Function Score, Oxford Knee Score, and 36-item Short-Form Health Survey Mental and Physical Component Summary. Functional outcomes and patient satisfaction were assessed at 6 months and 2 years. Complications, survivorship, and all-cause mortality were analyzed.ResultsIn total, 114 patients were included. Majority of PD patients had Hoehn and Yahr stage 1 or 2 disease. Overall complication rate was 26.3% in the PD group and 10.5% in the control group (P = .030). There was no difference in transfusions, length of stay, and discharge to rehabilitation or readmissions. Patients with PD had more flexion contractures, poorer Knee Society Function Score and Oxford Knee Score at 2 years, and poorer 36-item Short-Form Health Survey Physical Component Summary at 6 months. 80.4% of patients with PD were satisfied compared with 85.5% of controls (P = .476). At follow-up of 8.5 ± 2.7 years, one TKA was revised in each group. All-cause mortality was higher in the PD group (15.8% vs 5.3%, P = .067).ConclusionAlthough patients with PD had relatively poorer knee function and quality of life, these patients still experienced significant functional gains compared with their preoperative status, and high satisfaction was achieved.Level of EvidenceIII.     

The Combination of Inlay Patellofemoral Arthroplasty and Medial Unicompartmental Knee Arthroplasty Versus Total Knee Arthroplasty for Mediopatellofemoral Osteoarthritis: A Comparison of Mid-Term Outcomes

BackgroundTo the best of our knowledge, there have been no studies in the literature related to the use of second-generation inlay patellofemoral arthroplasty and unicompartmental knee arthroplasty combination (inlay PFA/UKA) in the treatment of mediopatellofemoral osteoarthritis (MPFOA). The aim of this study is to evaluate the efficacy of inlay PFA/UKA in MPFOA.MethodsThe study included 49 patients applied with inlay PFA/UKA because of MPFOA and 49 patients applied with TKA, matched one-to-one according to age, gender, body mass index, follow-up period, preoperative Knee Society Score, and range of motion. All the patients were evaluated clinically using the Knee Society Score, Knee Injury Osteoarthritis Outcome Score, and range of motion, and were also evaluated radiologically. Complication rates and length of hospital stay were compared.ResultsThe mean follow-up period was 54 ± 4 and 54.4 ± 3.9 months in inlay PFA/UKA and TKA groups, respectively. (P = .841). No statistically significant difference was determined between the 2 groups in respect of the mean clinical scores at the final follow-up examination (P ≥ .129). Total complications were fewer and length of hospital stay was shorter in the inlay PFA/UKA group than in the TKA group (P = .037 and P = .002). There was no radiographic evidence of progression of lateral compartment osteoarthritis according to Kellgren-Lawrence in any patient in the inlay PFA/UKA group.ConclusionIn selected patient groups, inlay PFA/UKA is an alternative to TKA, with lower complication rates, shorter length of hospital stay, and clinical and functional results similar to those of TKA without osteoarthritis progression in the unresurfaced lateral compartment in the mid-term.Level of EvidenceIII.     

Comparison of Intravenous and Topical Dexamethasone for Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Study of Effects on Dexamethasone Administration Route and Enhanced Recovery

BackgroundThe optimal route for dexamethasone (DEX) administration regimen for patients undergoing primary TKA has not been investigated. This study aims to determine whether intravenous and topical DEX provide different clinical effects in patients with TKA.MethodsIn this double-blinded, placebo-controlled trial, 90 patients undergoing primary TKA were randomized to intravenous DEX group (n = 45) or topical DEX group (n = 45, DEX applied in anesthetic cocktail for periarticular injection). The primary outcome was postoperative VAS pain score and morphine consumption. Secondary outcomes were included knee swelling, knee flexion, and extension angle, Knee Society Score (KSS), and postoperative hospital stays. Tertiary outcomes assessed the blood-related metrics, including inflammatory biomarkers and fibrinolysis parameters. Finally, nausea and vomiting and other adverse events were compared.ResultsThe topical administration of DEX provide lower pain score at 2h, 8h, 12h at rest (P < .05) and 12h, 24h with activity (P < .05), and less knee swelling in the first postoperative day (P < .05), while intravenous DEX was more effective in decreasing blood inflammatory biomarkers, including C-reactive protein (CRP) at postoperative 24h (P < .05) and interleukin-6 (IL-6) at postoperative 24h, 48h (P < .05), and reducing postoperative nausea (P < .05) for patients receiving TKA. However, there was no significant difference in knee flexion and extension angle, KSS, postoperative hospital stays, and complications occurrence (P > .05) between intravenous and topical DEX after TKA.ConclusionTopical administration of DEX provided better clinical outcomes on postoperative pain management and knee swelling early after TKA, while intravenous DEX was more effective in decreasing blood inflammatory biomarkers and preventing postoperative nausea.     

Conversion Total Knee Arthroplasty: Prior Fracture or Osteotomy Around the Knee Leads to Increased Resource Utilization

BackgroundPrior knee surgery before total knee arthroplasty (TKA) puts patients at higher risk of inferior outcomes and increased care cost. This study compares intraoperative and postoperative variables including procedure duration, components, length of stay, readmission, complications, and reoperations among patients undergoing conversion TKA.MethodsPrimary TKA from a single-surgeon database identified 130 patients with prior knee surgery to form a “conversion” cohort. One-to-one matching identified 130 patients of similar age, American Society of Anesthesiologists score, body mass index, and gender without prior knee surgery for comparison. Perioperative and 90-day postoperative variables were compared between patients with and without prior surgery, within the conversion group based on the type of prior surgery, and whether the prior surgery was bony or soft tissue.ResultsThe conversion group had longer mean operative time (96.1 vs 90.0 minutes, P = .01), higher revision component utilization (8.5% vs 0.8%, P = .005), and higher calculated blood loss (1440 vs 1249 mL, P = .004). Thirty-eight patients with prior fracture or osteotomy were compared to the remaining 92 patients in the conversion group and showed longer operative time (107.1 vs 91.3 minutes, P < .001), higher 90-day readmissions (18.4% vs 3.3%, P = .003), more complications (23.7% vs 8.7%, P = .021), and greater utilization of revision components (26.3% vs 1.1%, P < .001).ConclusionPatients undergoing conversion TKA required increased resource utilization, particularly patients with a prior osteotomy or fracture. Policymakers should consider these variables, as they did in conversion THA, in adding a code to account for increased case complexity and resource utilization.     

Can Octogenarians Undergoing Total Knee Arthroplasty Experience Similar Functional Outcomes,Quality of Life,and Satisfaction Rates as Their Younger Counterparts? A Propensity Score Matched Analysis of 1188 Patients

BackgroundCurrent literature lacks consensus regarding the impact of advanced age on the clinical outcomes of total knee arthroplasty (TKA). Moreover, there is paucity of literature on the subjective benefit reported by elderly patients. We compared the functional outcomes, quality of life, and satisfaction rates between octogenarians and age-appropriate controls undergoing primary TKA with a minimum follow-up of 2 years.MethodsProspectively collected registry data of 594 patients aged ≥80 years (n = 594) and a propensity score matched cohort of 594 patients aged 65-74 years who underwent primary TKA at a single institution were reviewed. The range of motion, clinical outcome scores, and satisfaction rates were assessed at 6 months and 2 years. Revision rates were also recorded.ResultsOctogenarians had a significantly lower Knee Society Function Score, Oxford Knee Score, and SF-36 Physical Component Summary at 6 months and 2 years (P < .05 for each). Furthermore, a lower proportion of octogenarians achieved the minimal clinically important difference for each score (P < .05 for each). Although the rates were similar at 6 months (P = .853), octogenarians were less satisfied at 2 years compared to age-appropriate controls (89.3% vs 93.3%, P = .042), and there was a trend toward poorer expectation fulfillment (88.4% vs 92.1%, P = .062).ConclusionOctogenarians undergoing TKA had a relatively lower rate of satisfaction and clinically meaningful improvement compared to younger controls. Nevertheless, elderly patients still experienced a successful outcome after surgery. The clinical trajectory outlined may help clinicians provide valuable prognostic information to elderly patients and guide preoperative counseling.     

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

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

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundTourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes.MethodsPatients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected.ResultsVisual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent.ConclusionThis study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.     

Improvements in Objectively Measured Activity Behaviors Do Not Correlate With Improvements in Patient-Reported Outcome Measures Following Total Knee Arthroplasty

BackgroundActivity monitors have added a new dimension to our ability to objectively measure physical activity in patients undergoing total knee arthroplasty (TKA). The aim of the study is to assess whether changes in the time spent sitting, standing, and stepping were associated with changes in patient-reported outcome measures (PROMs) before and after TKA.MethodsValid activPAL data (>3 days) and PROMs were obtained from 49 men and women (mean [SD] age, 62.8 [8.6] years; body mass index, 33.8 [7.1] kg/m²) who underwent primary TKA, before and at 6 weeks or 6 months after surgery. Patient-reported symptoms of pain, stiffness, and knee function were obtained using the Knee injury and Osteoarthritis Outcome Score and Oxford Knee Score questionnaires.ResultsMean (SD) Knee injury and Osteoarthritis Outcome Score (80.1 [16.3] to 41.6 [6.5], P < .001) and Oxford Knee Score (12.0 [9.8] to 17.7 [22.8], P < .001) scores improved 6 months after TKA. Walking time (mean [95% confidence interval]; min/d) increased from before (79 [67-91]) to 6 months after TKA (101 [88-114], P = .006). Standing time (318 [276-360] to 321 [291-352], P = .782) and sitting time (545 [491-599] to 509.0 [459.7-558.3], P = .285) did not change from before to 6 months after TKA. Participants took more steps (2559 [2128-2991] to 3515 [2983-4048] steps/day, P = .001) and accumulated more steps (31 [30-34] to 34 [33-35] steps/min, P < .001) after TKA compared to before. There were no associations between changes in activity behaviors and changes in PROMs (P > .05).ConclusionDespite improvements in self-reported knee pain and functional ability, these changes do not correlate with improvements in objectively measured light-intensity and sedentary activity behaviors.