Influence of collateral ligament laxity on patient satisfaction after total knee arthroplasty: a comparative bilateral study

Introduction Correct ligamentous balancing is an important determinant of the clinical outcome in total knee arthroplasty (TKA). Many surgeons prefer a tight rather than a lax knee during implantation of a TKA. The hypothesis in this study was that patients with a slightly laxer knee joint might perform better than patients with a tight knee joint after implantation of a TKA.Patients and methods Twenty-two patients with bilateral knee arthroplasties were clinically and radiologically evaluated at a mean follow-up of 4.5 years, ranging from 2 to 7 years. There were 12 women and 10 men with an average age of 68.9 years (range 32–82 years) at the time of surgery. A modified HSS score (excluding laxity), varus and valgus stress X-rays in 30° of knee flexion, and the subjective outcome of both knees were compared. A knee was considered tight when it opened less than 4° and lax if it opened 4° or more on stress X-ray.Results There was a trend towards improved range of motion and HSS score for the laxer knee joints. However, the difference did not achieve statistical significance. Eleven of the 22 patients considered one side subjectively better than the other side. In 10 out of these 11 TKA, the slacker knee joint was the preferred side (p<0.05).Conclusions As the present study compared bilateral knee joints after TKA, the same patient could act as a control group, and subtle subjective differences were revealed which are not quantifiable. The results showed that patients with a preferred side felt significantly more comfortable on the laxer side, indicating that during intraoperative ligamentous tensioning, some varus and valgus laxity at 20–30° of flexion might be preferable to an over-tight knee joint. Further biomechanical and prospective investigations will be necessary to establish the correct soft-tissue tensioning.     

Effect of body mass index on functional outcome in primary total knee arthroplasty——a single institution analysis of 2180 primary total knee replacements

AIM To evaluate the effect of body mass index(BMI) on short-term functional outcome and complications in primary total knee arthroplasty. METHODS All patients undergoing primary total knee arthroplasty at a single institution between 2007 and 2013 were identified from a prospective arthroplasty database. 2180 patients were included in the study. Age, gender, BMI, pre- and post-operative functional scores [Western Ontario and Mc Master University Arthritis Index(WOMAC) and SF-36], complications and revision rate were recorded. Patients were grouped according to the WHO BMI classification. The functional outcome of the normal weight cohort(BMI 25) was compared to the overweight and obese(BMI ≥ 25) cohort. A separate sub-group analysis was performed comparing all five WHO BMI groups; Normal weight, overweight, class 1 obese, class 2 obese and class 3 obese.RESULTS With a mean age of 67.89(28-92), 2180 primary total knee replacements were included. 64.36%(1403) were female. The mean BMI was 31.86(18-52). Ninty-three percent of patients were either overweight or obese. Mean follow-up 19.33 mo(6-60 mo). There was no significant difference in pre or post-operative WOMAC score in the normal weight(BMI 25) cohort compared to patients with a BMI ≥ 25(P 0.05). Sub-group analysis revealed significantly worse WOMAC scores in class 2 obese 30.80 compared to overweight 25.80(P 0.01) and class 1 obese 25.50(P 0.01). Similarly, there were significantly worse SF-36 scores in class 2 obese 58.16 compared to overweight 63.93(P 0.01) and class 1 obese 63.65(P 0.01) There were 32(1.47%) superficial infections, 9(0.41%) deep infections and 19(0.87%) revisions overall with no complications or revisions in the normal weight cohort(BMI 25).CONCLUSION Post-operative functional outcome was not influenced by BMI comparing normal weight individuals with BMI 25. Patients should not be denied total knee arthroplasty based solely on weight alone.     

Simultaneous bilateral total knee arthroplasty

Total knee arthroplasty (TKA) was performed simultaneously on both knees by two teams in a single procedure. The study population consisted of 74 patients (148 knee joints) with osteoarthritis (OA) or rheumatoid arthritis (RA). The peri- and postoperative results were compared with those in a group of 22 OA and RA patients (44 knee joints) who underwent staged operation during one hospital stay. Comparisons were made of functional score and range of motion (ROM) before and after operation, mean total blood loss, operative time, duration of hospital stay, and operative and postoperative complications. The simultaneous performance of bilateral procedures did not influence the functional score, ROM after operation, or mean intra- and postoperative blood loss. Nor was incidence of operative and postoperative complications increased compared with that in the staged operation group. The operative time in the simultaneous TKA group was significantly shorter than the time that would have been required had separate procedures been performed on both knees. Simultaneous bilateral TKA is beneficial for the patient.     

全膝关节置换术后早期功能康复

目的　探讨全膝关节置换术后进行早期功能康复的方法和时机。方法　２３ 例（３４ 膝） 骨水泥全膝关节置换术后患者按照预定的康复计划进行早期功能锻炼。术后６ ｈ 内即开始进行膝关节ＣＰＭ 锻炼,２４ ｈ 下地站立。术后引流血予以回输。结果　术后２ 周平均关节活动度达９０°,ＨＳＳ评分平均７１ 分。３ 例出现切口局部皮缘灶性坏死延期愈合,无其它并发症。结论　术后早期功能锻炼安全可行,可使关节功能早期恢复,并可有效预防并发症。     

全膝关节置换术围手术期镇痛

目的探讨全膝关节置换术(TKA)围手术期镇痛效果,获得最佳的镇痛方案。方法2005年1月至2006年4月的82例单侧TKA手术患者随机分成两组,采用不同的镇痛方案进行围手术期镇痛治疗。对术后疼痛进行评分分析并观察并发症。结果两种镇痛方法均具有明显的镇痛效果,患者满意率及功能康复效果取得明显改善,并发症发生率较低。结论TKA围手术期采用积极的综合镇痛措施,具有重要意义。     

全膝关节置换术后镇痛治疗的研究进展

背景 术后镇痛治疗是全膝关节置换术(total knee arthroplasty,TKA)后的基本辅助措施,直接关系到手术效果和术后膝关节功能的恢复.目的 综述国内外关于TKA镇痛治疗的研究进展.内容 TKA的镇痛疗法各有优缺点,新型镇痛药物及技术的应用使镇痛方案选择更加多元化,镇痛方式及药物的选择也更加注重利于患者术后膝关节功能的康复及个体化感受.趋向 以局部浸润镇痛(local infiltration analgesia,LIA)治疗为代表的多模式镇痛(multimodal analgesia,MMA)是近年来国内外提出并研究较多的新的镇痛治疗方式,通过已有的研究已经证实MMA的积极治疗作用,但如何制定个体化的MMA方案仍然是临床面临的重要问题之一.     

Surgical factors for total knee arthroplasty in younger patients

With improvements in implant modularity and polyethylene, it is important to assess the contemporary performance of cement vs. cementless fixation in total knee arthroplasty (TKA). Aseptic loosening is the most common indication for revision. Registry data indicates that the type of fixation (cemented, cementless, or hybrid) makes little difference in revision rates for younger patients (<55 years old). Regardless of the type of fixation, there is an opportunity for improvement. Attention to surgical factors, such as coronal alignment and cementing technique, can improve the survivorship of TKA.     

盐熨法促进全膝关节置换患者术后功能康复

目的 促进全膝关节置换术后患者膝关节功能康复。方法 将66例膝骨性关节炎患者随机分为两组各33例;对照组术后行常规护理,观察组在常规护理的基础上增加盐熨法,连续干预8周后评价效果。结果 观察组术后疼痛评分、肿胀程度显著低于对照组,术后中文版美国膝关节协会评分显著高于对照组(均P<0.05);术后3 d及1周C-反应蛋白值显著低于对照组(均P<0.01);干预期间观察组未发生水疱、皮肤破损等烫伤情况。结论 对膝关节置换术后患者在常规护理模式下增加盐熨法,有利于患肢减痛消肿,促进膝关节功能恢复。     

对侧膝关节疼痛对全膝关节置换手术患者的临床影响

目的:评估对侧膝关节疼痛程度对骨性关节炎患者全膝关节置换术(total knee arthroplasty,TKA)后1年手术侧关节功能障碍及治疗满意度的影响。方法:2019年3月至2021年1月行TKA的635例患者,男296例,女339例;年龄(69.33±9.38)岁,病程(1.15±0.44)年。根据术后对侧膝关节疼痛视觉模拟评分(visual analogue scale,VAS)分为轻度或无疼痛(VAS 0～3分)423例,中度疼痛(VAS 4～6分)105例,重度疼痛(VAS 7～10分)107例。分析比较对侧膝关节不同疼痛程度对术后12个月膝关节功能及满意度评分的影响。结果:对侧膝关节疼痛VAS在TKA术后明显降低,年龄大、身体质量指数高、术后手术侧膝关节WOMAC评分高、对侧膝关节中、重度疼痛是患者不满意的危险因素(P<0.05),OR分别为1.285、1.665、2.319、1.863。手术侧膝关节疼痛度高、居家环境为步梯房是患者出院1年后WOMAC评分高的危险因素(P<0.05);出院后坚持锻炼、功能性训练是患者出院1年后WOMAC评分高的保护因素(P...     

The painful total knee arthroplasty: Keys to diagnosis

As the prevalance of patients living with total knee replacements continues to rise we continue to see a significant portion of patients living with pain following their primary total knee arthroplasty. For some patients, the etiology of their pain following knee replacement is obvious, yet in many cases the cause of pain remains elusive and thus creates a significant burden for the patient and treating physician. In this review article we focus on common sources of pain following knee replacement and discuss keys to diagnosis. We also propose a unique clinical pathway algorithm to guide diagnostic work up and treatment options.     

Cemented total knee arthroplasty remains the “gold standard”

Despite its availability for several decades, current literature does not provide sufficient evidence to demonstrate superiority of cementless total knee arthroplasty (TKA) when compared to cemented TKA. This review aims to highlight the current disadvantages and shortcomings of cementless fixation for TKA.     

膝关节置换时股骨髓内定位对假体排列的影响

目的 :探讨膝关节置换时股骨髓内定位杆进针点的位置对下肢力线造成的误差及其相关的影响殷素。方法 :选取行TACK膝关节置换的骨关节病患者 40例。术中股骨截骨髓内定位杆的进针点为股骨滑车中心。术前术后于 14英寸× 17英寸X线片测量膝关节的股胫角 (FTA)、股骨外侧角。并根据数学模型计算TACK置换后可能造成的最大误差。结果 :股骨解剖轴线一般与股骨内侧髁相交 ,距滑车中心平均 7mm ( 0～ 11mm) ,膝外翻者股骨解剖轴线偏离滑车中心更多。术后测量股骨假体外侧角为 80～ 90° ,内外翻误差 2°以内者占 70 % ,理论计算如果进针点位于滑车中心 ,会导致外翻误差增加。结论 :真正的髓内定位杆进针点应位于股骨解剖轴线上 ,进针点外移会导致股骨假体过度外翻。术前应在全长或 14英寸× 17英寸站立正位X线画出股骨解剖轴线 ,根据股骨轴线与股骨髁交点的实际位置进行髓内定位 ,可减小误差     

Wound healing after total knee arthroplasty

Wound healing complications in the early postoperative period can be severely detrimental to clinical outcomes after total knee arthroplasty. Thorough knowledge of preoperative risk factors, meticulous surgical technique and wound closure, along with careful postoperative wound monitoring can prevent wound complications or lead to their resolution without subsequent morbidity. If complications arise in the postoperative period, the wound must be evaluated and treated promptly to avoid periprosthetic infection.     

混合型单髁与全膝关节置换治疗膝内侧间室骨关节炎的疗效比较

目的：探讨Oxford第3代混合型单髁置换（unicompartmental knee arthroplasty,UKA）与全膝关节置换（total knee arthroplasty,TKA）治疗膝关节内侧间室骨关节炎的疗效。方法：回顾性分析2017年10月至2019年10月行膝关节置换术的156例患者,男44例,女112例,年龄50~75（58.76±4.97）岁。根据不同治疗方式分为单侧TKA组和单侧Oxford第3代混合型UKA组。单侧TKA 81例（81膝）,男23例,女58例,年龄51~75（58.60±5.01）岁;单侧Oxford第3代混合型UKA 75例（75膝）,男21例,女54例,年龄50~72（58.92±4.95）岁。比较两组临床评估指标,包括手术一般情况、相关并发症、美国膝关节协会评分（American Knee Society score,AKSS）临床评分和功能评分;影像评估指标包括髋膝踝角（hip-knee-ankle angle,HKA）、股骨假体内外翻角（femoral component valgus/varus angle,FCVA）、股骨假体后倾角（femoral component posterior slope angle,FCPSA）、胫骨假体内外翻角（tibial component valgus/varus angle,TCVA）、胫骨假体后倾角（tibial component posterior slope angle,TCPSA）,是否发生膝关节外侧间室进展、衬垫脱位、假体下沉、松动。结果：UKA组术中出血量、手术时间、住院天数均显著优于TKA组（P<0.05）,两组术后均未出现并发症。两组患者均获随访,时间24~54（38.01±8.90）个月。末次随访两组AKSS临床评分、功能评分、HKA均优于术前（P<0.05）。末次随访UKA组AKSS临床评分、功能评分均优于TKA组（P<0.05）,TKA组HKA优于UKA组（P<0.05）。末次随访两组TCVA、FCVA差异无统计学意义（P>0.05）,UKA组TCPSA、FCPSA大于TKA组（P<0.05）,UKA组未出现外侧室进展。结论：Oxford第3代混合型UKA治疗膝关节内侧间室骨关节炎,较TKA具有手术创伤小、失血量少、手术时间短、住院时间短、术后快速康复、膝关节功能恢复更好等优势,疗效满意。     

Effect of total knee arthroplasty on recreational and sporting activity

BACKGROUND: Common concerns of patients undergoing total knee arthroplasty (TKA) are whether they can continue with certain recreational and sporting activities or even commence new ones after the procedure. The present study was designed to determine preoperative and postoperative activities, the numbers participating and the time to resume these activities. METHODS: Between 1 and 2 years after TKA, patients who had undergone 144 arthroplasties, were surveyed by postal questionnaire to ascertain how the arthroplasty had affected their recreational and sporting ability. Their preoperative and postoperative activity along with the time to resume was recorded. The Oxford knee score and estimate of physical activity was also collected. RESULTS: Out of the 144 TKA performed, 122 participated in sport and recreational activity preoperatively and 108 participated postoperatively. Patients stated that the surgery had a beneficial effect on their performance of sporting and recreational activities although the number of sporting events decreased. By multiplying individuals by the number of activities they participated in, there were 254 occurrences of sport and recreational activities preoperatively giving a mean for the group of 1.76 sports/patient. Postoperatively this had reduced to 204, giving a mean of 1.41. Three activities showed a significant change for individual patients from pre- to postoperation. Those which showed an increase were exercise walking, where 19 patients (13.2%) who did not walk before surgery took up walking afterwards (P < 0.006) and aqua aerobics, where five took up aqua aerobics postoperatively for the first time (P < 0.025). Golf was the only sport which had a significant fall in participation from pre- to postoperation, with 10 out of 19 golfers giving up (P < 0.025). CONCLUSION: The present study has shown that patients are adopting lower impact activities to participate in after TKA. The total number of patients performing a sport decreases postoperatively and the total amount of sport played decreases. These data will help to counsel patients.     

Anterior knee pain following primary total knee arthroplasty

Despite improvements in technique and technology for total knee arthroplasty (TKA), anterior knee pain impacts patient outcomes and satisfaction. Addressing the prosthetic and surgical technique related causes of pain after TKA, specifically as it relates to anterior knee pain, can aid surgeons in addressing these issues with their patients. Design features of the femoral and patellar components which have been reported as pain generators include: Improper femoral as well as patellar component sizing or designs that result in patellofemoral stuffing; a shortened trochlear groove distance from the flange to the intercondylar box; and then surgical technique related issues resulting in: Lateral patellar facet syndrome; overstuffed patella/flange combination; asymmetric patellar resurfacing, improper transverse plane component rotation resulting in patellar subluxation/tilt. Any design consideration that allows impingement of extensor mechanism anatomical elements has the possibility of impacting outcome by becoming a pain generator. As the number of TKA procedures continues to increase, it is increasingly critical to develop improved, evidence based prostheses that maximize function and patient satisfaction while minimizing pain and other complications.     

Postoperative numbness of the knee following total knee arthroplasty

Introduction

The infrapatellar branch of the saphenous nerve is often injured during total knee arthroplasty (TKA), leading to numbness in its distribution distal to the incision. This is illustrated in a patient who suffered full-thickness burns to the lateral aspect of the knee from a hot water bottle. However, the proportion of patients who are informed of this phenomenon (as well as the effect of informing the patient of numbness) has not previously been studied according to the authors’ knowledge. The aim of this study was to establish the proportion of patients with whom postoperative numbness was discussed during the consent procedure and whether this discussion was documented.

Methods

A total of 73 patients (103 TKAs) agreed to take part in this study between 16 May and 9 July 2011. Patients were asked about their recollection of numbness being mentioned prior to the procedure as well as whether they experienced postoperative numbness. Statistical analysis was performed using SPSS®.

Results

Subjective numbness was noted in 27% of the patients in this study. The prevalence of numbness decreased with time. Patients whose consent process included a discussion of numbness were 3.3 times more likely to report numbness after TKA (p=0.003).

Conclusions

Patient education regarding postoperative numbness increases the patient’s awareness of any insensate skin that may develop. Numbness after TKA does improve with time but does not resolve completely. It is therefore recommended by the authors that numbness is discussed preoperatively with the patient and that this discussion is documented.     

Total knee arthroplasty for the stiff knee

The underlying cause of stiffness must be carefully evaluated when considering total knee arthrolasty for the stiff knee. Any previous skin incision must be recorded as well as the state of the extensor mechanism. The choice of prosthesis constraint should be decided on the state of the soft-tissues often released extensively to gain flexion. A quadriceps release or plasty and a tibial tubercle osteotomy are the current options for exposure, soft-tissue release and bone cuts. Postoperatively, the motion should be started early combined to pain control in order to obtain an average of 65° of flexion at follow-up. The complication rate remains high including recurrent stiffness, delayed wound healing and deep infection.     

The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty

Purpose

The aim of this study was to explore the influence of a half-course tourniquet strategy on the peri-operative blood loss and early functional recovery in primary total knee arthroplasty.

Methods

A prospective clinical randomised controlled study was carried out in which 64 patients were equally divided into two groups: half-course group and whole-course group. A series of indicators were observed and recorded. These included operation time, peri-operative blood loss, visual analogue scale (VAS) score of the thigh or knee, limb swelling index, rehabilitation progress and occurrence of deep venous thrombosis cases.

Results

There was no significant difference in operation time between the two groups. The intra-operative blood loss was slightly more in the half-course group, while the difference was not significant. The post-operative blood loss and calculated blood loss were less in the half-course group and the difference was significant. The thigh VAS score, limb swelling and time intervals required for patients to achieve straight leg raises and 90° of knee flexion in the half-course group were better than in the whole-course group. No case of symptomatic deep venous thrombosis happened in this study, while occult incidence of deep venous thrombosis happened in both groups, but no significant difference between the groups was confirmed.

Conclusions

The half-course tourniquet strategy could decrease the total peri-operative blood loss in primary total knee arthroplasty. It was beneficial in helping patients to achieve earlier functional recovery by improving the pain experience and limb swelling early in the post-operative period.     

Intraoperative cutting errors in total knee arthroplasty

Introduction Precise reconstruction of leg alignment offers the best opportunity for achieving good long-term results in total knee arthroplasty (TKA). It was the aim of this study to evaluate the bone-cutting process as a potential source of inaccuracy in TKA.Materials and methods In a consecutive series of 50 computer-assisted TKAs, cutting errors, which were defined as a difference between the cutting block position before sawing and the achieved resection plane afterwards, were measured for the distal femur and proximal tibia resection. Measurements were performed using a CT-based navigation system.Results For the distal femoral cut, there was a mean varus/valgus deviation of 0.6° (SD±0.5°) and a mean flexion/extension deviation of 1.4° (SD±1.3°). For the proximal tibia, varus/valgus alignment showed a mean deviation of 0.5° (SD±0.5°). The mean sagittal variability was 1.0° (SD±0.9°). Differences between the frontal and the sagittal plane were significant.Conclusion To minimize cutting errors, techniques and instruments are needed which enable a more stable fixation of the cutting blocks or even more appropriate preparation instruments. Using a computer-assisted technique, the surgeon is aware of cutting errors occurring at each point of the operation and will therefore be able to correct these errors during surgery, while he is not aware of those errors with the conventional TKA technique.