Early patient outcomes after primary and revision total knee arthroplasty. A prospective study

There has been speculation as to how the outcome of revision total knee arthroplasty (TKA) compares with that of primary TKA. We have collected data prospectively from patients operated on by one surgeon using one prosthesis in each group. One hundred patients underwent primary TKA and 60 revision TKA. They completed SF-12 and WOMAC questionnaires before and at six and 12 months after operation. The improvements in the SF-12 physical scores and WOMAC pain, stiffness and function scores in both primary and revision TKA patients were highly statistically significant at six months. There was no statistically significant difference in the size of the improvement in the SF-12 physical and WOMAC pain, stiffness and function scores between the primary and revision patients at six months after surgery. The SF-12 mental scores of patients in both groups showed no statistically significant difference after surgery at the six- and 12-month assessments. Our findings show that primary and revision TKA lead to a comparable improvement in patient-perceived outcomes of physical variables in both generic and disease-specific health measures at follow-up at one year.     

Computer Navigation Results in Less Severe Flexion Contracture Following Total Knee Arthroplasty

We compared postoperative flexion contracture in navigated total knee arthroplasty (TKA) versus conventional TKA. Two groups (Group 1: conventional, Group 2: navigated) of 235 consecutive patients matched for age and gender were retrospectively compared. Range of motion, mechanical axes, Knee Society Scores, Oxford Knee Scores and Short Form-36® (SF-36) scores were collected prospectively and compared preoperatively and at 2 years following TKA. At 2 years, patients who underwent navigated TKA averaged significantly lesser flexion contracture of 1 degree compared to 6 degrees in patients who underwent conventional TKA. There were a significantly larger proportion of outliers in the conventional group. Computer navigation results in less severe flexion contracture and less frequent flexion contracture of more than 5 degrees as compared to conventional techniques.     

Functional outcome of total knee arthroplasty after high tibial osteotomy.

OBJECTIVE: To evaluate the functional outcome for patients who undergo total knee arthroplasty (TKA) after high tibial osteotomy (HTO). DESIGN: Retrospective matched cohort study. SETTING: University of Toronto affiliated hospital. PATIENTS: Twenty patients who underwent TKA after HTO and 20 matched patients who received a primary TKA. INTERVENTION: TKA. OUTCOME MEASURES: The Medical Outcomes Study Short Form (SF-36) health survey score and the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index. Univariate analyses were used to compare the case and control groups with respect to baseline variables using the t-test, chi2 test or Fisher's exact test. Functional outcomes were assessed by multivariate analyses. RESULTS: Operative problems were more frequently encountered in the study group, which had longer operative times (p < 0.0001), more difficulties with patellar eversion (p = 0.021) and an increased number of lateral releases performed (p = 0.0089). There were trends toward a significant difference in the pain (p = 0.07), function (p = 0.18) and stiffness (p = 0.14) categories of the WOMAC Osteoarthritis Index between the 2 groups, suggesting poorer functional outcomes of TKA after HTO, but the results did not reach statistical significance. A previous HTO does not affect the general health of patients after TKA, as there was no difference between the 2 groups in SF-36 scores. CONCLUSIONS: TKA after HTO is a technically more challenging procedure than primary TKA. The functional outcomes at a mean follow-up of 5 years after TKA in patients with a previous HTO tended to be inferior but the differences were not significant (p > or = 0.05).     

Total knee arthroplasty for treatment of post-traumatic arthritis: Systematic review

AIM To review and report functional outcomes, complications,and survivorship associated with total knee arthroplasty(TKA) in the treatment of post-traumatic arthritis(PTA).METHODS We conducted a systematic review according to the PRISMA guidelines. We searched PubMed, Cochrane Library, and SCOPUS in December 2015 for Englishlanguage clinical research studies, both prospective and retrospective, examining the use of TKA for the treatment of PTA. All relevant articles were accessed in full. The manual search included references of retrieved articles.We extracted data on patients' demographics and clinical outcomes, including preoperative diagnosis and pre- and post-operative functional scores. We summarized the data and reported the results in tables and text.RESULTS Sixteen studies, four prospective and ten retrospective,examined patients who underwent TKA for PTA due to fractures of the proximal tibia, patella, and/or distal femur. Eleven studies utilized the Knee Society Scores criteria to assess functional outcomes. All studies utilizing these criteria reported an improvement in functional and knee scores of patients following TKA. Further, studies reported an increased range of motion(ROM) and reduction of pain following surgery. The most commonly reported complications with TKA included infection, stiffness, wound complications, intraoperative rupture of tendons, and osteolysis/polyethylene wear. The overwhelming majority of these complications occurred within the first two years following surgery. Six studies examined the survivorship of TKA with subsequent revision for any reason as an endpoint. Compared to patients with osteoarthritis, patients with PTA required more revisions, the majority for polyethylene wear.CONCLUSION Although associated with higher complication rates,TKA is an effective treatment for PTA, as it improves ROM, pain and functional outcomes.     

Primary total knee arthroplasty in patients with fibromyalgia

No data on the results of total knee arthroplasty (TKA) in patients with fibromyalgia have been published. The purposes of this study were to review a cohort of patients with fibromyalgia undergoing TKA to determine the level of postoperative pain and satisfaction with the surgery, the incidence of postoperative surgical complications, and revision rates and their relationship to TKA design. One hundred ten patients with fibromyalgia (141 knees) who underwent primary TKA between 1990 and 2001 were studied. The average age was 64 years (range, 39-86 years), and the average follow-up was 7 years (range, 2-16 years). Forty-five knees were cruciate retaining, and 96 had a posterior stabilized design. Clinical outcome was assessed using the Knee Society Knee Score and satisfaction regarding the results of the procedure. Postoperative surgical complications and reoperations were obtained from the registry. Sixty-two patients (44%) continued with some pain after TKA. Eighty-five patients (82%) were satisfied with the results. The most common complications were arthrofibrosis and symptomatic instability. The revision rate was 6% (8 knees). Survivorship free from revision at 7 years was 89% for cruciate retaining knees and 98% for posterior stabilized knees. Patients with fibromyalgia undergoing primary TKA have a high prevalence of complications and pain. Despite continued pain, the majority of patients were satisfied with the results and reported improvements after TKA. This data should be used to counsel patients with fibromyalgia preoperatively regarding limited goals with respect to pain relief and suggests that a multimodal individualized treatment program may be necessary to achieve optimal outcomes in patients with fibromyalgia.     

Quality-of-life outcomes with laparoscopic vs open cholecystectomy

BACKGROUND: Few studies have assessed the health outcomes of patients who underwent cholecystectomy. The goal of this study was to evaluate the health-related quality-of-life (HRQoL) improvement of patients undergoing laparoscopic versus open cholecystectomy. METHODS: A prospective observational study was performed of consecutive patients on waiting lists to undergo cholecystectomy for nonmalignant disease in six hospitals. Patients were asked to complete two questionnaires that measure (HRQoL)-the SF-36 and the Gastrointestinal Quality of Life Index (GIQLI)-before the intervention and 3 months later. RESULTS: Improvement after surgery, measured by the SF-36 and GIQLI, was similar for both surgical techniques. The SF-health transition item showed a perception of worse health, compared to 1 year previously, for those who underwent open surgery and complications were also higher. CONCLUSIONS: HRQoL improvement at 3 months was relevant and similar for both surgical techniques, although the health transition perception was worse for those who underwent open surgery.     

Patterns of Weight Change and Their Effects on Clinical Outcomes Following Total Knee Arthroplasty in an Asian Population

BackgroundThis prospective cohort study was designed to evaluate weight change patterns and their effects on clinical outcomes following total knee arthroplasty (TKA) in the Asian population. We hypothesized that Asian patients will have a different pattern of weight change following TKA compared to Western patients and that weight loss following TKA will be associated with better clinical outcomes.MethodsA cohort of consecutive patients who underwent TKA from 2004 to 2015 was included. All patients received a conventional posterior-stabilized TKA implant and underwent a standard perioperative care pathway. Assessments were done preoperatively, at 6 months, and 2 years after surgery. The range of motion, Knee Society Score, Oxford Knee Score, and the Short-Form 36 questionnaire were used to assess outcomes. Height and weight of patients were recorded for body mass index (BMI) calculation. Patterns of weight loss following TKA in this cohort were charted. Clinical outcomes were then analyzed against the change in BMI.ResultsA total of 602 patients (602 knees) were reviewed. Mean age was 66.39 ± 7.27 years. Mean BMI was 27.75 ± 4.51 kg/m². Overall, 63.12% of all our patients gained weight following TKA. Moreover, weight loss did not influence patients’ odds for better clinical outcomes. Furthermore, patients who were in the preoperative BMI category of obese class I were more likely to gain weight as compared to those in the normal category (odds ratio 0.35, 95% confidence interval 0.2-0.61, P < .001). Moreover, older people were more likely to gain more weight compared to younger people. We also showed that the mean 2-year Knee Society Knee Score was significantly higher in the patients who gained weight while the patients who lost weight had the highest mean 2-year Oxford Knee Score and the lowest mean 2-year Knee Society Function Score.ConclusionAsians tend to gain weight following TKA. However, this weight change following TKA does not affect clinical outcomes, which remain good across all BMI groups.Level of EvidenceTherapeutic Level III.     

Total knee arthroplasty in patients 40 years and younger

Total knee arthroplasty (TKA) is a procedure with excellent clinical results in older patients with a primary diagnosis of osteoarthritis. Many younger patients undergo unicompartmental or high tibial osteotomy rather than TKA, but are not always good candidates for these joint-preserving procedures. The purpose of this study was to review the outcomes of patients 40 years of age and under who underwent TKA. We identified 33 patients (38 knees) who were 40 years of age or less at the time of surgery. These patients had a mean age of 36 years (range, 23 to 40 years), and were followed for a mean of 49 months (range, 16 to 101 months). The survival rate in the study cohort was 97%. For the young patient who is not a candidate for other types of joint preserving procedures, in the senior authors' experience total knee arthroplasties have performed well.     

Treatment of cervical myelopathy in patients with the fibromyalgia syndrome: outcomes and implications

Some patients with fibromyalgia also exhibit the neurological signs of cervical myelopathy. We sought to determine if treatment of cervical myelopathy in patients with fibromyalgia improves the symptoms of fibromyalgia and the patients’ quality of life. A non-randomized, prospective, case control study comparing the outcome of surgical (n = 40) versus non-surgical (n = 31) treatment of cervical myelopathy in patients with fibromyalgia was conducted. Outcomes were compared using SF-36, screening test for somatization, HADS, MMPI-2 scale 1 (Hypochondriasis), and self reported severity of symptoms 1 year after treatment. There was no significant difference in initial clinical presentation or demographic characteristics between the patients treated by surgical decompression and those treated by non-surgical means. There was a striking and statistically significant improvement in all symptoms attributed to the fibromyalgia syndrome in the surgical patients but not in the non-surgical patients at 1 year following the treatment of cervical myelopathy (P ≤ 0.018–0.001, Chi-square or Fisher’s exact test). At the 1 year follow-up, there was a statistically significant improvement in both physical and mental quality of life as measured by the SF-36 score for the surgical group as compared to the non-surgical group (Repeated Measures ANOVA P < 0.01). There was a statistically significant improvement in the scores from Scale 1 of the MMPI-2 and the screening test for somatization disorder, and the anxiety and depression scores exclusively in the surgical patients (Wilcoxon signed rank, P < 0.001). The surgical treatment of cervical myelopathy due to spinal cord or caudal brainstem compression in patients carrying the diagnosis of fibromyalgia can result in a significant improvement in a wide array of symptoms usually attributed to fibromyalgia with attendant measurable improvements in the quality of life. We recommend detailed neurological and neuroradiological evaluation of patients with fibromyalgia in order to exclude compressive cervical myelopathy, a potentially treatable condition.     

Functional Outcomes are Comparable Between Posterior Stabilized and Cruciate-Substituting Total Knee Arthroplasty Designs at Short-Term Follow-up

BackgroundPosterior stabilized (PS) polyethylene inserts have been shown to have excellent long-term functional results following total knee arthroplasty (TKA). A cruciate-substituting (CS) design has been introduced to minimize bony resection and eliminate concerns regarding wear on the PS post. The purpose of this study is to compare the outcomes of patients who underwent TKA using either a PS or CS insert.MethodsWe reviewed a consecutive series of 5970 patients who underwent a cruciate-sacrificing TKA and received either a PS (3,314) or CS (2,656) polyethylene liner. We compared demographics, Knee Injury and Osteoarthritis Outcome Score Jr (KOOS Jr), Short-Form 12 (SF-12) scores, and revision rates between the groups at a minimum 2 years followup. A multivariate regression was performed to identify the independent effect of design on functional outcomes.ResultsRevision rates between the groups were comparably low (0.35% for PS vs 0.51% for CS, P = .466) at an overall mean follow-up of 43 months. Patients in the PS cohort had statistically higher KOOS Jr scores at 2 years (69.8 vs 72.9, P < .001). Multivariate regression analysis found CS patients to have lower postoperative KOOS Jr scores (estimate ?2.26, P = .003), and less overall improvement in KOOS Jr scores (estimate ?2.42, P = .024) than PS patients, but neither was a clinically significant difference.ConclusionPatients who undergo TKA with a CS polyethylene insert have comparable functional outcomes and revision rates to those with a PS design at short-term follow-up. Longer follow-up is needed to determine whether CS can match the outstanding track record of PS TKA.     

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.     

Quality of life following lung cancer surgery

BACKGROUND: Patients with non-small cell bronchogenic carcinoma have a limited survival. Quality of life (QoL) is therefore an issue of importance in this group of patients. The aim of the present study was to evaluate QoL in lung cancer patients after open surgery. METHODS: During a 4 year period (1997-2000) 194 patients with primary bronchogenic carcinoma of the lung underwent surgery at the Department of Thoracic and Cardiovascular Surgery in Uppsala, Sweden; 132 patients were alive on 1 April 2001. These patients received the Short Form-36 (SF-36) health questionnaire, Hospital Anxiety and Depression (HAD) scale, and special questions related to pulmonary symptoms (response rate 85%). Patients who underwent coronary bypass surgery (CABG) served as a comparison group (response rate 91%). Corresponding estimates of QoL in healthy controls were obtained from the SF-36 manual for the Swedish population. RESULTS: Lung cancer patients differed from CABG patients in only one subgroup of the SF-36 (role physical), but had poorer QoL than healthy controls. No difference in anxiety was found between the lung cancer patients and the CABG patients, but the latter were more likely to suffer from depression (5.0% v 3.0%). Current smokers scored lower in the mental health dimension assessment. CONCLUSION: Lung cancer patients who undergo open traditional surgical resection have a QoL comparable to that of CABG patients. Lung cancer patients have poorer physical function because of reduced pulmonary function, but show no sign of increased anxiety or depression. Those who continued to smoke after surgery had impaired mental health.     

Clinical Outcomes After Simultaneous Bilateral Total Knee Arthroplasty : Comparison to Unilateral Total Knee Arthroplasty and Healthy Controls

The purpose of this study was to evaluate the functional outcomes of persons who underwent simultaneous bilateral total knee arthroplasty (TKA) compared to subjects who underwent unilateral TKA and a healthy control group. Fifteen subjects who underwent primary bilateral TKA and 15 sex, age, and body mass index-matched subjects who underwent primary unilateral TKA were observed prospectively for 2 years. Subjects in both surgical groups showed significant improvement in Knee Outcome Scores, Short Form 36 physical component scores, Timed Up and Go, and stair-climbing tasks (P ≤ .004). No differences in final outcomes were found between surgical groups. In addition, most 2-year clinical measures were no different between the surgical and control groups. Subjects medically appropriate for bilateral TKA should be afforded this option.     

The Effect of Laparoscopic Roux-en-Y Gastric Bypass on Fibromyalgia

Background Fibromyalgia is a chronic debilitating disorder affecting 3–5% of the US population. Treatment of this disorder is a challenge. The incidental finding of improvement of fibromyalgia following laparoscopic Roux-en-Y gastric bypass stimulated us to study this phenomenon. Methods A retrospective chart review of patients with fibromyalgia who underwent laparoscopic Roux-en-Y gastric bypass. Results Postoperative decrease in median of BMI from 49.4 to 29.7 was significant (p value = 0.0010). This was associated with statistically significant improvement in median of pain score (p value = 0.0010) and median points of tenderness (p value = 0.0010). Conclusion Significant weight loss following laparoscopic Roux-en-Y gastric bypass is associated with resolution or improvement of fibromyalgia. Consequently, the bariatric surgeon should be a member of the multidisciplinary team approach for treating fibromyalgia.     

Quality of life after laparoscopic bilateral adrenalectomy for Cushing's disease

BACKGROUND: Bilateral adrenalectomy to control symptoms of Cushing's disease after failed transsphenoidal operation is effective. We examined surgical outcomes and quality of life after laparoscopic bilateral adrenalectomy for the treatment of Cushing's disease. METHODS: Eighteen patients underwent laparoscopic bilateral adrenalectomy from November 1994 through December 2000. Patient data were obtained from chart reviews. Patients completed a follow-up survey including the SF-36 health survey (QualityMetric Inc, Lincoln, Neb). RESULTS: Laparoscopic bilateral adrenalectomy was accomplished in all 18 patients. There was 1 intraoperative complication of a colotomy, and 2 postoperative complications including 1 pancreatic pseudocyst and 1 hemorrhage. Three patients died at 12, 19, and 50 months after operation. At a median follow-up of 29 months, patients reported improvement in all Cushing's-related symptoms. Nine of 11 patients who responded to the survey stated their heath was improved after adrenalectomy. Results of the SF-36 health survey showed significantly lower scores in all 8 measured parameters when compared with the general population. CONCLUSIONS: Results of laparoscopic bilateral adrenalectomy show this procedure is comparable with open adrenalectomy in controlling symptoms of Cushing's disease. Despite patient reported improvement in health after adrenalectomy, this patient population continues to experience poor health as measured by the SF-36 when compared with the general population.     

Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)–A prospective study

Background

The interaction between patients is rather important source of information about surgery and recovery. Patients always prefer particularly to compare themselves with others of relatively similar ability, opinion and situation. Exploration of patients' dyads, however, is rare and needs further elaboration as to the significance of fellow patients. This study was designed to determine in whether and how preoperative assignment affects TKA's results.

Complex regional pain syndrome complicating total knee arthroplasty

PURPOSE. To compare the long-term outcome of patients diagnosed with complex regional pain syndrome-type 1 (CRPS-1) after total knee arthroplasty (TKA) with those of uncomplicated TKA knees and preoperative osteoarthritic knees. METHODS. Medical records of 1280 patients who underwent TKA for osteoarthritis were retrospectively reviewed; 8 were diagnosed as having symptoms and signs consistent with CRPS after TKA. Patients with primary inflammatory arthritis, signs of component loosening, malpositioning, or of infected arthroplasty were excluded. No patient had signs of CRPS prior to operative intervention. The 8 patients were compared with 2 groups of age- and sex-matched controls: uncomplicated TKA knees and preoperative osteoarthritic knees. Patients were followed up for a mean of 54 (range, 13-111) months and their range of movement, Western Ontario and McMaster Universities Osteoarthritis Index, SF-36 questionnaire scores, and Knee Society scores were assessed and compared. RESULTS. After appropriate treatment, most CRPS complicated patients had similar scores on SF-36, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Society scores when compared with uncomplicated TKA patients. Scores for CRPS complicated patients were significantly improved when compared with preoperative osteoarthritic patients. The incidence of CRPS after TKA was 0.7%. CONCLUSION. When managed early, patients complicated with CRPS after TKA have a similar prognosis to patients with uncomplicated TKA.     

Changing Surgeons Improves Outcome of Subsequent Primary Total Joint Arthroplasty in Previously Dissatisfied Patients

We assessed whether patients who were dissatisfied with their previous primary hip (THA) or knee (TKA) arthroplasty, done by another surgeon, would have continued dissatisfaction or would have significant improvements in outcome scores following their subsequent primary THA or TKA. The majority of reasons provided for switching surgeons and/or institutions related to dissatisfaction with some aspect of their surgical experience specifically involving the surgeon–patient interaction itself. All 12 THA and TKA patients noted that their subsequent arthroplasty had decreased their pain, improved their function and that they were satisfied with their result. All patients had a statistically significant improvement in their Harris Hip Score or Knee Society Score, WOMAC and SF-36 questionnaires. This study demonstrates that previous dissatisfaction with a THA or THA does not predispose to a suboptimal outcome following subsequent primary hip or knee arthroplasty.     

Risk of Periprosthetic Infection Following Intra-Articular Corticosteroid Injections After Total Knee Arthroplasty

BackgroundRecent literature has advocated for the effectiveness of postoperative steroid injections following total knee arthroplasty (TKA) for improving pain and range of motion when other correctible causes of these symptoms have been eliminated. The safety of such injections has not been thoroughly evaluated. The aim of this study was to determine the risk of acute infection following intra-articular corticosteroid injection into a preexisting TKA.MethodsThe Humana dataset was used to identify patients who underwent TKA from 2007 to 2017. Patients with ipsilateral knee corticosteroid injections in the postoperative period were then identified and compared to a 2:1 matched control cohort. A diagnosis of infection within 6 months and 1 year following the injection and an ipsilateral procedure for infection at any time postoperatively were then assessed and compared to controls using a multivariate binomial logistic regression analysis.ResultsOf the 166,946 TKA performed during the study period, 5628 patients had a postoperative corticosteroid injection (3.4%). Patients with injections had a significantly higher rate of periprosthetic infection compared to noninjection matched controls at all studied time points.ConclusionIn a large national database, about 3% of patients who undergo TKA have a postoperative steroid injection into their postoperative knee. While there is some existing literature demonstrating improvement in pain and stiffness symptoms after TKA with postoperative injections, the present study demonstrates a significant correlation between postoperative intra-articular corticosteroid injections in patients with preexisting TKA and periprosthetic joint infection compared to matched controls who did not receive an injection.