Comparing Outcomes of Medial Parapatellar and Subvastus Approaches in Total Knee Arthroplasty : A Randomized Controlled Trial

The medial parapatellar (MP) approach in total knee arthroplasty is more common, but the subvastus (SV) approach is less insulting to the quadriceps. Whether the SV approach affords better outcomes was investigated using 90 participants with knee osteoarthritis, randomized to receive either SV or MP approaches and followed for 18 months. The primary outcome was the American Knee Society Score (AKSS); secondary outcomes included pain, knee range, quadriceps lag, Oxford Knee Score, 3-m timed “Up and Go” test, days to straight leg raise, surgeon perceived difficulty, operation duration, and length of stay. Analysis (n = 76) revealed no significant difference in AKSS (P = .076) or other outcomes, except the following: AKSS Functional scores at 12 and 18 months, favoring the MP (P = .032 and P = .028 respectively); surgeon's perceived difficulty, favoring the MP (P = .001); and days to straight leg raise, favoring the SV (P = .044). This study found that the SV approach offers no clinical benefit over the MP approach.     

Postoperative Pain and Contracture Following Total Knee Arthroplasty Comparing Parapatellar and Subvastus Approaches

The purpose of this study was to see if subvastus approach would decrease incidence of postoperative contracture and pain following TKA compared to standard parapatellar approach. Retrospective review of 546 patients in Group A undergoing TKA using parapatellar approach were compared to 255 patients in Group B undergoing subvastus approach. No statistically significant differences regarding OR time, blood loss, BMI, or LOS. Total of 23 (4%) manipulations under anesthesia for contracture in Group A compared to 6 (2%) in Group B (p > 0.05). Postoperative pain scores at 6 weeks was greater in Group A, p < 0.05. We feel that a subvastus approach minimizes trauma to the extensor mechanism, and therefore decreases the incidence of postoperative pain following TKA.     

Surgical Approaches in Total Knee Arthroplasty: A Meta-Analysis Comparing the Midvastus and Subvastus to the Medial Peripatellar Approach

Subvastus, midvastus and medial parapatellar approaches are the most popular approaches in total knee arthroplasty (TKA). However, the superior approach in TKA still remains controversial. We therefore conducted a meta-analysis to quantitatively compare the midvastus and subvastus approaches to the medial parapatellar approach in TKA. A total of 32 randomized controlled trials (RCTs) with 2451 TKAs in 2129 patients were included in this study. The meta-analysis suggested that, when compared with the medial parapatellar approach, the midvastus approach showed better outcomes in pain and knee range of motion at postoperative 1–2 weeks but also was associated with longer operative time; the subvastus approach showed better outcomes in knee range of motion at postoperative 1 week, straight leg raise and lateral retinacular release.     

Comparison of Quadriceps-Sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

Background

The quadriceps-sparing (QS) technique for total knee arthroplasty (TKA) was introduced to improve outcomes associated with the medial parapatellar (MP) approach. There is no clear consensus on what advantages, if any, QS provides.

Cryotherapy Treatment After Unicompartmental and Total Knee Arthroplasty: A Review

Background

Cryotherapy is widely utilized to enhance recovery after knee surgeries. However, the outcome parameters often vary between studies. Therefore, the purpose of this review is to compare (1) no cryotherapy vs cryotherapy; (2) cold pack cryotherapy vs continuous flow device cryotherapy; (3) various protocols of application of these cryotherapy methods; and (4) cost-benefit analysis in patients who had unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA).

Intraoperative Practice Variability in Total Knee Arthroplasty

BackgroundConsiderable practice variability exists among orthopedic surgeons performing total knee arthroplasty (TKA). The purpose of this study is to understand what TKA surgical and perioperative techniques are standard among high-volume academic knee arthroplasty surgeons.MethodsA written survey with 59 questions regarding management preferences in TKA was distributed by the 2018 John N. Insall Traveling Fellows to all arthroplasty-trained attending physicians at 13 medical centers, with 45 responses recorded.ResultsSurveyed surgeons performed unicompartmental knee arthroplasty (88%) and bilateral TKA (87%). Most surveyed surgeons rarely or never performed outpatient primary TKA (71%). Conventional alignment guides and cemented implants were used by 80% of respondents. Most surgeons used posterior-stabilized implants (67%), followed by cruciate-retaining (20%), ultracongruent (20%), and medial congruent or medial pivot designs (17.8%). Surveyed surgeons frequently or always resurfaced the patella (73%), used a tourniquet for the entire case (73%), and used tranexamic acid for all TKAs (91%). The most common locations for intra-articular anesthetic injection were the arthrotomy (91%), the periosteum (84%), and the medial posterior capsule (82%). Saline (62%) and dilute iodine (47%) were the most common irrigation fluids. The arthrotomy was most commonly closed with running barbed suture (60%) followed by interrupted vicryl (40%). Skin closure was predominantly with running monocryl (60%) followed by staples (29%). Anticoagulation for TKA was primarily aspirin 81 mg BID (60%).ConclusionThere was considerable variability among surgeons polled although a strong preference for more conventional and less developmental techniques prevailed.     

Unicompartmental Knee Arthroplasty vs Total Knee Arthroplasty for Medial Compartment Arthritis in Patients Older Than 75 Years: Comparable Reoperation,Revision, and Complication Rates

Background

Prior studies comparing unicompartmental knee arthroplasty (UKA) with total knee arthroplasty (TKA) in the elderly are limited by heterogeneity in arthritic disease patterns and patient selection. We report the results of UKA and TKA in patients 75 years and older with isolated medial compartmental arthritis, with special emphasis on immediate postoperative recovery, complications, reoperation rates, and implant survivorship at midterm follow-up.

Intraoperative Medial Pivot Affects Deep Knee Flexion Angle and Patient-Reported Outcomes After Total Knee Arthroplasty

The aim of this study was to evaluate the relationship between clinical results including patient-reported outcomes and intraoperative knee kinematic patterns after total knee arthroplasty (TKA). A cross-sectional survey of forty consecutive medial osteoarthritis patients who had a primary TKA using a CT-based navigation system was conducted. Subjects were divided into two groups based on intraoperative kinematic patterns: a medial pivot group (n = 20) and a non-medial pivot group (n = 20). Subjective outcomes with the new Knee Society Score and clinical outcomes were evaluated. The functional activities, patient satisfaction and the knee flexion angle of the medial pivot group were significantly better than those of the non-medial pivot group. An intraoperative medial pivot pattern positively influences deep knee flexion and patient-reported outcomes.     

A Retrospective Comparison of a Medial Pivot and Posterior-Stabilized Total Knee Arthroplasty With Respect to Patient-Reported and Radiographic Outcomes

Background

Medial pivot (MP) type total knee arthroplasty (TKA) implants are designed with a highly congruent medial tibiofemoral articulation. Compared with the cam-and-post design of the posterior-stabilized (PS) TKA, the MP-TKA design has been hypothesized to better replicate the natural kinematics of the knee. We compared the MP-TKA and PS-TKA designs, with our primary outcome measures being range of motion (ROM) and patient-reported satisfaction.

Comparison of Intraoperative Soft Tissue Balance Between Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty Performed by a Newly Developed Medial Preserving Gap Technique

Background

Medial stability of the knee is considered to be associated with good clinical results after total knee arthroplasty (TKA). This study aimed to compare intraoperative soft tissue balance between cruciate-retaining (CR) and posterior-stabilized (PS) TKA performed by a newly developed medial preserving gap technique, which aimed at preserving medial stability throughout the range of motion.

Medial Unicompartmental Knee Arthroplasty After Failed Open-Wedge High Tibial Osteotomy

BackgroundControversy exists whether or not a previous high tibial osteotomy (HTO) influences the outcome and survival of a unicompartmental knee arthroplasty (UKA). The aim of this retrospective study was to evaluate clinical, radiological, and functional outcomes of UKA after failed open-wedge HTO compared with UKA with no previous HTO.MethodsBetween 2001 and 2017, 24 post-HTO UKAs (group A) with an average follow-up of 8.1 years (range: 5 to 13) were compared with a control group of 30 patients undergoing simple UKA (group B) with an average follow-up of 9.5 years (range: 2 to 16). All patients were evaluated preoperatively and postoperatively using Knee Society Score, University of California at Los Angeles Activity Score, Western Ontario and McMaster University Osteoarthritis Index, and through objective evaluation. Mechanical coronal alignment and Caton-Deschamps index were measured both preoperatively and postoperatively.ResultsIn both groups, Knee Society Score, University of California at Los Angeles Activity Score, and Western Ontario and McMaster University Osteoarthritis Index scores significantly improved at follow-up (P < .001). In addition, statistically significant greater improvements in clinical and functional scores were reported in group B compared with group A (P < .001). No statistically significant differences concerning postoperative mechanical axis were observed between groups (2.7° and 3.2°, respectively, P = .27) and with regard to Caton-Deschamps index (1.0° and 1.1°, respectively, P = .44).ConclusionThis study demonstrated improvements in clinical and functional outcomes compared with preoperatory status in both groups irrespective of a previous HTO. A prior HTO was a determinant for having reduced postoperative clinical and functional outcomes after UKA.     

Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases

Below knee amputation protects the ipsilateral knee from osteoarthritis and overloads the contralateral knee predisposing it to symptomatic osteoarthritis. We retrospectively reviewed 13 primary total knee arthroplasty (TKAs) in 12 patients with a prior lower extremity amputation. Twelve TKAs were performed on the contralateral side of the amputated limb while only one TKA was performed on the ipsilateral side. The average clinical follow-up was 6.8 ± 4.8 years. Knee Society Scores improved from 30.4 ± 11.8 to 88.5 ± 4.2 after TKA with a prior contralateral amputation. Three (23.1%) patients with TKA after contralateral amputation had aseptic loosening of the tibial component. Patients experience clinically significant improvement with TKA after lower extremity amputation. Augmentation of tibial fixation with a stem may be advisable during TKA after contralateral amputation.     

The Role of Patient Characteristics on the Choice of Unicompartmental versus Total Knee Arthroplasty in Patients With Medial Osteoarthritis

Background

Medial unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are both viable treatment options for medial osteoarthritis (OA). However, it remains unclear when to choose for which arthroplasty treatment. Goals of this study were therefore to (1) compare outcomes after both treatments and (2) assess which treatment has superior outcomes in different patient subgroups.

Incidence of Leg-Length Discrepancy After Index Hinge Total Knee Arthroplasty

BackgroundLeg-length discrepancies are not commonly associated with total knee arthroplasty (TKA); however, hinge TKA is a complex form of knee reconstruction where functionality of all knee ligaments is replaced by the TKA construct. The purpose of this study is to evaluate the incidence of leg-length discrepancies after unilateral index hinge TKA and association with patient outcomes.MethodsA retrospective review was performed of all patients who underwent unilateral index hinge TKA at a single academic institution from 1999 to 2019. Among 671 patients who underwent index hinge TKA, 188 (28%) had full-length standing anteroposterior hip-to-ankle radiographs available for review both preoperatively and postoperatively. All patients with a leg-length change ≥2 cm were also contacted with a standardized questionnaire to assess for complications. The mean age was 65 years, the mean body mass index was 33 kg/m², and 52% were female. The mean number of prior surgeries was 2 (range, 0-12).ResultsThe absolute mean and median change in leg lengths was 20 mm and 13 mm, respectively (range, 0-130 mm). Lengthening occurred in 119 (63%) patients compared with shortening in 69 (37%) patients. An absolute change in leg lengths ≥1 cm was observed in 109 (58%) patients, ≥2 cm in 63 (34%) patients, and ≥5 cm in 15 (8%) patients.ConclusionLarge changes in the leg length are common after hinge TKA, likely secondary to altered soft-tissue constraints. Surgeons should be cognizant of potential changes in the leg length in the setting of hinge TKA and incorporate this into preoperative planning and patient counseling.Level of EvidenceLevel IV, therapeutic.     

Braking Time Following Total Knee Arthroplasty: A Systematic Review

Background

Currently, no guidelines exist to assist surgeons in providing recommendations to patients undergoing total knee arthroplasty (TKA) on when it is safe to return to driving. The purpose of this systematic review is to analyze the best available literature to assist surgeons in providing evidence-based recommendations on when it is safe to return to driving after TKA.

Total Knee Arthroplasty Combined With Medial Patellofemoral Ligament Reconstruction for Osteoarthritic Knee With Preoperative Valgus Deformity and Chronic Patellar Dislocation

We report a challenging case of a 44-year-old woman who had osteoarthritis in the lateral compartment of her right knee with severe valgus deformity and chronic lateral patellar dislocation. Total knee arthroplasty was performed for the knee. However, persistent patellar dislocation remained during the surgery; and therefore, medial patellofemoral ligament (MPFL) reconstruction was additionally performed at the time of the surgery. Stable patellar tracking was obtained after the MFPL reconstruction; and during the 2-year follow-up, her knee functioned well, and no recurrent patellar dislocation was observed. This clinical case indicates the usefulness of MPFL reconstruction for obtaining stable patellar tracking during total knee arthroplasty when a tendency for lateral patellar dislocation remains.     

15-Year Follow-Up of Mobile Bearing Medial Unicompartmental Knee Arthroplasty

IntroductionMedial unicompartmental knee arthroplasty (UKA) is a successful treatment for antero-medial osteoarthritis. However, there are few published studies on the long-term survival of this procedure. The purpose of this study was to review the 15-year minimum outcomes and survival of a mobile-bearing medial UKA.MethodsA retrospective review was performed between July 2004 and December 2006 of all patients who underwent a medial UKA eligible for a minimum of 15-year follow-up. The initial query revealed 299 patients (349 knees). One hundred-seventeen patients died or were lost to follow-up, leaving 182 patients (219 knees) for analyses. Clinical outcomes and survivorship were analyzed.ResultsThere were 59 implant-related reoperations which occurred at a mean of 10 years (range, 0 to 16 years). The most common reasons for reoperation were arthritic progression (9.1%) and aseptic loosening (9.1%). The 10-year survival with revision to TKA was 89% (95% confidence interval: 86% to 92.4%), and the 15-year survival was 84.1% (95% confidence interval: 80.3% to 88%). There were no statistically significant differences in survival between sex, body mass index, and age. Patients who were not revised had statistically significant improvements in knee range of motion and Knee Society scores.ConclusionsThis study found similar long-term survival of a medial mobile-bearing UKA to published total knee arthroplasty outcomes. The implant evaluated in this study has undergone subsequent improvements in instrumentation and design. Further analyses should be performed on the long-term outcomes of the current implant platform.