Manipulation Under Anesthesia is Safe After Cementless Total Knee Arthroplasty: A Multicenter Study

BackgroundCementless total knee arthroplasty (TKA) is thought to facilitate durable, biological fixation between the bone and implant. However, the 4-12 weeks required for osseointegration coincides with the optimal timeframe to perform a manipulation under anesthesia (MUA) if a patient develops postoperative stiffness. This study aims to determine the impact of early MUA on cementless fixation by comparing functional outcomes and survivorship of cementless and cemented TKAs.MethodsA consecutive series of patients who underwent MUA for postoperative stiffness within 90 days of primary, unilateral TKA at 2 academic institutions between 2014 and 2018 were identified. Cases involving extensive hardware removal were excluded. Cementless TKAs undergoing MUA (n = 100) were propensity matched 1:1 to cemented TKAs undergoing MUA (n = 100) using age, gender, body mass index, and year of surgery. Both groups had comparable baseline Knee Injury and Osteoarthritis Outcome Scores (KOOS), Short Form (SF)-12 Physical, and SF-12 Mental scores. MUA-related complications as well as postoperative KOOS and SF-12 scores were compared.ResultsMUA-related complications were equivalently low in both groups (P = .324), with only 1 patella component dissociation in the cementless group. No tibial or femoral components acutely loosened in the perioperative period. Postoperative KOOS (P = .101) and SF-12 Mental scores (P = .380) were similar between groups. Six-year survivorship free from any revision after MUA was 98.0% in both groups (P = 1.000).ConclusionEarly postoperative MUA after cementless TKA was not associated with increased MUA-related complications or worse patient-reported outcomes compared to cemented TKA. Short-term survivorship was also comparable, suggesting high durability of the bone-implant interface.     

Cementless and cemented total knee arthroplasty in patients younger than fifty five years. Which is better?

Purpose

The purpose of this prospective, randomised study was to evaluate long-term clinical results, radiographic findings, complications and revision and survivorship rates in patients <55 years at a minimum of 16 years after undergoing bilateral, sequential, simultaneous, cemented and cementless total knee arthroplasties (TKAs) in the same patients.

Methods

Bilateral, sequential, simultaneous TKAs were performed in 80 patients (160 knees). There were 63 women and 17 men with a mean age of 54.3 years (range 49–55), who received a cementless prosthesis in one knee and a cemented prosthesis in the other. The mean follow-up was 16.6 years (range 16–17).

Results

At final review, the mean Knee Society (KS) knee scores (95.8 versus 96.9), Western Ontario and McMaster Universities (WOMAC) osteoarthritis (OA) index (25.4 versus 25.9), range of motion (ROM) (125°versus 128°), patient satisfaction (8.1 versus 8.3) and radiological results were similar in both groups. Femoral component survival rate was 100 % in both groups at 17 years; at 17 years, the cemented tibial component survival rate was 100 % and the cementless tibial component 98.7 %. No osteolysis was identified in either group.

Conclusion

Long-term results of both cementless and cemented TKAs were encouraging in patients with OA who were <55 years. However, we found no evidence to prove the superiority of cementless over cemented TKAs.     

The 22 to 25-Year Survival of Cemented and Cementless Total Knee Arthroplasty in Young Patients

BackgroundDespite cementless total knee arthroplasties (TKAs) have potential advantages over cemented TKAs, there are conflicting results. The purpose of the present study is to determine the long-term clinical and radiographic results, the survival rate, and the prevalence of osteolysis of cemented vs cementless TKAs.MethodsA total of 261 patients (522 knees) who underwent bilateral simultaneous TKAs were included in the present study (mean age, 62.5 ± 5.5 years). Patients were evaluated clinically, radiographically, and also using computed tomography scans. A mean follow-up period was 23.8 years (range, 22-25 years).ResultsThere were no significant differences between the Knee Society total score, change in total score, knee function score, and Western Ontario and McMaster Universities Osteoarthritis Index score in the 2 groups. In total, 8 knees (3%) were revised in the cementless group and 5 knees (2%) in the cemented group. Radiographs and computed tomography scans showed no femoral, tibial, or patellar osteolysis in either group. The rate of survival at 25 years was 97% (95% confidence interval [CI], 92%-100%) in the cementless group and 98% (95% CI, 94%-100%) in the cemented group, with reoperation for any reason as the end point. The rate of survival at 25 years was 98% (95% CI, 94%-100%), with reoperation for aseptic loosening as the end point in both groups.ConclusionsAt this length of follow-up, cementless TKA has comparable outcomes and survivorship to cemented TKA.     

Increased Survivorship of Cementless versus Cemented TKA in the Morbidly Obese. A Minimum 5-Year Follow-Up

Background

Total knee arthroplasty (TKA) in the morbidly obese patients can be challenging with an increased risk of complications. Studies have shown increased aseptic failures with well-aligned cemented TKAs in the obese patient. The purpose of this study is to determine if TKA in the morbidly obese (body mass index [BMI] ≥ 40) using cementless implants would demonstrate improved results and survivorship compared to cemented TKA at a minimum 5-year follow-up.

Perioperative and Early Postoperative Comparison of a Modern Cemented and Cementless Total Knee Arthroplasty of the Same Design

Background

Cementless total knee arthroplasty (TKA) designs that incorporate a highly porous, titanium surface have the potential to achieve biologic fixation and improve component survivorship. This study's purpose was to compare perioperative and early postoperative outcomes of a cemented vs cementless TKA of the same design.

Results of Cemented vs Cementless Primary Total Knee Arthroplasty Using the Same Implant Design

Background

Although cemented total knee arthroplasty (TKA) continues to be the gold standard, there are patient populations with higher failure rates with cemented TKAs such as the obese, morbidly obese, and younger active males. Cementless TKA usage continues to increase because of the potential benefits of long-term biologic fixation similar to the rise in cementless total hip arthroplasty. The purpose of this study was to evaluate the clinical and radiographic results of cementless TKA using a novel highly porous cementless tibial baseplate.

Influence of operation duration on perioperative morbidity in revision total hip arthroplasty

This retrospective study investigated the impact of patient and procedure-related parameters on the complication rate following revision total hip arthroplasty. Complications included vessel and nerve damage, periprosthetic femoral fracture, wound infection, wound bleeding, prosthesis dislocations, thromboembolism, cardiac and pulmonary complications, and death. The influence of operation duration, gender, revision status, ASA classification, and type of fixation of the primary implant on the perioperative morbidity was investigated in a sample of 60 revision procedures (cemented stems, cemented or cementless cups). Odds ratio [OR] and 95% confidence interval [CI] were estimated with multiple regression models. Perioperative morbidity was significantly correlated to operation duration (OR = 1.03; CI: 1.00-1.05), but not to age (OR = 1.01; CI: 0.93-1.09), gender (OR = 2.66; CI: 0.50-14.05), revision status (OR = 2.34; CI: 0.54-10.05), ASA classification (OR = 1.24; CI: 0.30-5.18), or type of fixation of the primary implant (OR = 2.49; CI: 0.47-13.17) Duration of the revision operation appeared as a predictive parameter for perioperative morbidity in revision total hip arthroplasty in our study group.     

Subgaleal suction drain leading to fatal sagittal sinus haemorrhage

The use of wound drains in surgical practice, very often falls into the realm of habit, rather than science. The utility of a prophylactic drain in surgical wounds may be questionable, but this practice is not uncommon, despite complications. We report a case of fatal haemorrhage from the superior sagittal sinus, due to a closed negative suction drain of the craniotomy wound in an infant operated upon for a growing fracture skull.     

Drainage versus nondrainage in simultaneous bilateral total hip arthroplasties

A prospective study of 48 patients (96 hips) who had undergone primary simultaneous bilateral total hip arthroplasty was conducted to assess the effect of postoperative suction drainage on wound healing and infection. A suction drain was placed by randomization of the drained versus undrained side. The same surgical technique was used in all total hip arthroplasty wounds. Statistical analysis of the results showed significant differences with respect to drainage from the wound, soaked dressings requiring reinforcements, ecchymosis, and erythema about the wound in the group without drainage. There was no specific correlation between the incidence of wound complications and infection after total hip arthroplasty and the use or nonuse of closed-suction drainage. The hip score and range of motion of the hip were unaffected by the use or nonuse of the drains. The cost of 1 set of hemovac drains is $135 and the cost for 4–5 dressings and bed sheet changes is about $50. Although the hemovac is more expensive, the authors recommend the routine use of suction drains for wounds after primary total hip arthroplasty to reduce drainage, soaked dressings requiring reinforcement, ecchymosis and erythema around the wound, and psychological impact on the patient's fear of bleeding.     

Bone scans after total knee arthroplasty in asymptomatic patients. Cemented versus cementless

The natural history of bone scans after total knee arthroplasty (TKA) was studied in 26 patients with 28 cemented TKAs and 29 patients with 31 cementless TKAs. The bone scans were examined at specified postoperative intervals. Radionuclide activity of the femoral, tibial, and patellar regions was measured. Six patients who developed pain postoperatively were excluded. Bone scans immediately postoperative and at three months demonstrated increased uptake, which gradually decreased to baseline levels at ten to 12 months. Radioisotope uptake was comparable in the cemented and cementless groups, but was highly variable in individual patients and in each of the follow-up periods. A single postoperative bone scan cannot differentiate component loosening from early bone remodeling. Sequential bone scans, as a supplement to the clinical examination and conventional radiography, may prove useful in the diagnosis of TKA failure.     

Transfusion of autologous blood from reinfusion systems in total knee arthroplasty

After total knee arthroplasty (TKA) the technique of wound management is not standardised. In this prospective study the efficacy of autologous blood reinfusion from the wound was investigated. One hundred patients (100 TKAs) were enrolled in this sequential cohort study. In one-half of the operations, a reinfusion system with suction and in the other half one wound drain without suction were used. Blood loss, transfusion requirements, range of motion, Insall scores and the incidence of complications were studied. The use of a reinfusion system did not decrease the homologous transfusion requirements. The blood loss in the group with a suction drainage system was significantly higher. Our experiences since May 2002 with one drain without suction in 787 consecutive TKAs confirm all findings of the current study.     

The Use of Cementless Components Does Not Significantly Increase Procedural Costs in Total Knee Arthroplasty

BackgroundModern cementless total knee arthroplasty (TKA) designs have shown promising early clinical success; however, concerns exist regarding the higher cost of the cementless implants. The purpose of this study is to evaluate the total facility cost of cementless vs traditional cemented TKA along with the effect of cementless fixation on short-term outcomes.MethodsWe reviewed a consecutive series of patients between 2015 and 2017 who underwent either cementless or cemented primary TKA. Itemized facility costs were calculated for every procedure using a time-driven activity-based costing algorithm. Controlling for demographic variables and medical comorbidities, we performed a multivariate analysis to identify independent risk factors for facility costs following TKA. Short-term outcome metrics including complications, readmissions, and patient-reported outcomes were compared between groups.ResultsAmong the 2426 primary TKA patients in this study, 119 (4.91%) were performed using cementless implants. When compared to cemented TKA, cementless TKA patients had higher implant costs ($3047.80 vs $2808.73, P < .0001), but lower supply costs ($639.49 vs $815.57, P < .0001) and lower operating room personnel costs ($982.01 vs $1238.26, P < .0001). When controlling for confounding variables, cementless fixation did not have a significant effect on total facility cost or outcomes.ConclusionIn conclusion, the use of cementless TKA implants did not significantly increase total procedural costs when compared to traditional cemented TKA components at our institution. Our data suggest that the increased cost of a cementless implant is recouped through savings in cost of cement and supplies, as well as shorter operative times. The authors encourage investigators at other institutions to use the authors' methodology to evaluate (preferably in a prospective manner) whether the findings from this study can be corroborated.     

Chemoprophylaxis without intra-articular wound drainage can replace autotransfusion in primary TKA

We compared outcomes in 2 groups undergoing total knee arthroplasty (TKA) with different blood-saving strategies (ie, chemoprophylaxis vs reinfusion). We hypothesized that chemoprophylaxis would lead to reduced blood loss and fewer transfusions, with no increase in associated complications. Group A was a prospective series of 91 consecutive cemented TKAs undertaken with chemoprophylaxis to reduce bleeding and blood allogeneic exposure. Group B consisted of 44 historical TKAs undertaken with postoperative reinfusion. With the exception of mean patient age (group A, 74.3 years; group B, 70.9 years; P=.006), there were no statistically significant differences between the 2 study groups.Mean total blood loss throughout the 7-day perioperative period was 1490 mL in group A and 1828 mL in group B. The rate of blood transfusion in group A was almost zero. In group B, 41 of 44 patients were administered blood intravenously. Despite the absence of autotransfusion, postoperative hemoglobin levels were significantly higher in group A than in group B. No major bleeding complications emerged in the immediate postoperative period in either group.Chemoprophylaxis proved superior to reinfusion at decreasing blood transfusion requirements in the routine daily setting of unilateral cemented primary TKA.     

骨水泥与非骨水泥固定在初次全膝关节置换术中的应用:系统评价和meta分析

背景:全膝关节置换术(TKA)治疗终末期膝关节疾病的效果已被公认。目前TKA中假体-骨的固定形式主要有骨水泥固定和非骨水泥固定两种;前者应用广泛,但理想的假体固定方法仍存在争议。目的:通过meta分析评价骨水泥或非骨水泥固定在初次TKA中的优缺点,探讨其不同的适应证并提出TKA的最佳固定方式。方法:通过检索策略检索PubMed、The Cochrane Library、EMbase、CNKI、VIP、CBM和万方数据库,收集所有TKA术中骨水泥和非骨水泥固定的报道,采用RevMan 5.1软件进行meta分析。结果:最终纳入17项研究,并对其报道的结局指标进行合并分析。其中9项研究报道了TKA术后5年内的膝关节假体生存率,发现骨水泥固定组与非骨水泥固定组间生存率有显著统计学差异(RR=1.02,95%CI:1.00~1.05,P=0.02),但5年后的膝关节假体生存率无统计学差异(RR=1.01,95%CI:0.97~1.04,P=0.75)。术后假体相关并发症,骨水泥与非骨水泥固定组间无显著统计学差异(RR=0.97,95%CI:0.75~1.27,P=0.84)。影像学指标:术后两组间胫骨组件位置在冠状位及矢状位上偏移度数存在统计学差异,其他指标无统计学意义。结论:非骨水泥固定TKA植入组件发生偏转的概率相对较高,但非骨水泥固定TKA在假体中期生存率和临床疗效方面与骨水泥固定结果相似。为了更全面、准确地评价骨水泥固定与非骨水泥固定的长期生存率、安全性、临床及放射学指标,还需进一步研究。     

Closed suction drainage for hip and knee arthroplasty. A meta-analysis

BACKGROUND: The use of closed-suction drainage systems after total joint replacement is a common practice. The theoretical advantages for the use of drains is a reduction in the occurrence of wound hematomas and infection. The aim of this meta-analysis was to determine, on the basis of the evidence from randomized controlled trials, the advantages and adverse effects of surgical drains. METHODS: All randomized trials, as far as we know, that compared patients managed with closed-suction drainage systems and those managed without a drain following elective hip and knee arthroplasty were considered. The trials were identified with use of searches of the Cochrane Collaboration with no restriction on languages or source. Two authors independently extracted the data, and the methods of all identified trials were assessed. RESULTS: Eighteen studies involving 3495 patients with 3689 wounds were included in the analysis. The pooled results indicated that there was no significant difference between the wounds treated with a drain and those treated without a drain with respect to the occurrence of wound infection (relative risk, 0.73; 95% confidence interval, 0.47 to 1.14), wound hematoma (relative risk, 1.73; 95% confidence interval, 0.74 to 4.07), or reoperations for wound complications (relative risk, 0.52; 95% confidence interval, 0.13 to 1.99). A drained wound was associated with a significantly greater need for transfusion (relative risk, 1.43; 95% confidence interval, 1.19 to 1.72). Reinforcement of wound dressings was required more frequently in the group managed without drains. No difference between the groups was seen with respect to limb-swelling, venous thrombosis, or hospital stay. CONCLUSIONS: Studies to date have indicated that closed suction drainage increases the transfusion requirements after elective hip and knee arthroplasty and has no major benefits. Further randomized trials with use of larger numbers of patients with full reporting of outcomes are indicated before the absence of any benefit, particularly for the outcome of wound infection, can be proved.     

Mechanical alignment of tibial stems in revision total knee arthroplasty

This multicenter, retrospective study evaluates the radiographic results of achieving optimal tibial alignment in revision total knee arthroplasty (TKA) using a single modular CoCr cemented or cementless stemmed implant design. Stem size and length also were evaluated. The hundred ninety-nine Revision TKAs were performed between January 1993 and January 1996 by 13 experienced revision knee surgeons. The cases were subdivided into 5 comparative groups: (1) cemented stems, (2) 140-mm length canal-filling stems, (3) 140-mm length non—canal-filling stems, (4) 95-mm length canal-filling stems, and (5) 95-mm length non—canal-filling stems. The anteroposterior (AP) tibial alignment angle was measured. The canal-filling ratio (CFR) was determined by dividing the stem diameter by the endosteal diameter at the stem tip. Overall, the ability to achieve tibial alignment in the AP plane was more predictable when canal-filling (CFR ≥ 0.85) cementless stems were used. This was further enhanced when long canal-filling cementless stems were selected. The least-predictable results and the highest probability of varus malalignment were achieved with cemented stems.     

Cementless Hemiarthroplasty for Intracapsular Femoral Neck Fractures in the Octa- and Nonagenarians

BackgroudCurrent evidence supports the use of cemented hemiarthroplasty for treatment of intracapsular femoral neck fractures since it is associated with a lower risk of implant-related complications. However, many medical centers employ the cementless technique for the frail elderly population because it is faster and has lower cardiovascular risks and perioperative mortality. This observational study reports the outcomes of cementless bipolar hemiarthroplasty for intracapsular femoral neck fractures in patients aged 80 years and older.MethodsA total of 424 patients (female, 77.1%) with a mean age of 86.9 years were operated for intracapsular femoral neck fractures between January 2009 and December 2017. Of those, 66.7% had an American Society of Anaesthesiologists (ASA) score of 3 or more. All operations were performed with the posterolateral surgical approach and all patients received a cementless stem. Intraoperative and perioperative values and in-hospital outcomes were evaluated, and clinical and radiographical follow-up was done at 40 days, 90 days, and when possible between 5 months and 12 months postoperatively. Multivariate analysis was performed to evaluate if there were factors affecting mortality.ResultsThe mean operative time was 50 minutes. There were no deaths intraoperatively. Intraoperative periprosthetic fractures occurred in 2.1% of the cases with 66.7% of them fixed through cerclage wires intraoperatively. The median length of hospitalization was 11 days (interquartile range, 8.75–15) and 2.4% of patients died while in hospital after surgery. Approximately 91.5% of patients presented with perioperative anemia. Only 1.9% of the complications were related to the implant, 62.5% of which were dislocations. More than 90% of patients were ambulatory either autonomously or with support at each follow-up assessment. Age, male sex, and higher ASA score were related to increased mortality.ConclusionsDespite some limitations, this observational study underlines that a cementless femoral stem of modern design can give good clinical outcomes, thus being an appropriate solution especially for the frail elderly.     

The tourniquet in total knee arthroplasty. A prospective, randomised study

We assessed the influence of the use of a tourniquet in total knee arthroplasty in a prospective, randomised study. After satisfying exclusion criteria, we divided 77 patients into two groups, one to undergo surgery with a tourniquet and one without. Both groups were well matched. The mean change in knee flexion in the group that had surgery without a tourniquet was significantly better at one week (p = 0.03) than in the other group, but movement was similar at six weeks and at four months. There was no significant difference in the surgical time, postoperative pain, need for analgesia, the volume collected in the drains, postoperative swelling, and the incidence of wound complications or of deep-venous thrombosis. We conclude that the use of a tourniquet is safe and that current practice can be continued.     

No Clear Advantage to Use of Wound Drains After Unilateral Total Knee Arthroplasty : A Prospective Randomized, Controlled Trial

We conducted a prospective randomized, controlled trial in 100 patients to compare the postoperative use of wound drains with the use of no drains in patients who underwent unilateral primary total knee arthroplasty to determine differences in blood loss, range of motion, wound healing, complications (deep vein thrombosis, wound infection), and need for blood transfusions. The patients, who underwent surgery between February 2006 and February 2007, were randomly divided into 2 groups of 50 each: group A, treated without a drain, and group B, treated with a drain. The between-group difference in total blood loss was significant: 535 ± 295 mL in group A and 853 ± 331 mL in group B. Group A needed comparatively less blood transfused than group B did. Differences in wound infection, incidence of deep vein thrombosis, and range of motion were not statistically significant between groups. We found no clear advantage to the use of wound drains in unilateral total knee arthroplasty.     

Twenty-Year Survivorship of Cementless Anatomic Graduated Component Total Knee Arthroplasty

There is a renewed interest in cementless total knee arthroplasty (TKA) due to improved biomaterials, desire for decreased surgical times and the potential increased longevity. Seventy-three cementless TKAs (AGC, Biomet, Warsaw, Ind) were performed from 1984 to 1986. All components were implanted without cement and without screws and obtained minimum 10 years of follow-up. No patient was lost to follow-up. Fifteen failures occurred, including 12 failed metal-backed patellae, and survivorship for aseptic loosening of any component was 76.4% at 20 years. Two tibial components failed of aseptic loosening at 1.1 and 2.2 years. Excluding patella failures, the survivorship for the cementless tibial component was 96.8% at 20 years. There were no femoral component failures. After eliminating patella failures, this cementless monoblock tibial component without screws demonstrated excellent 20-year survivorship.