Clinical outcomes and patient satisfaction following revision of failed unicompartmental knee arthroplasty to total knee arthroplasty are as good as a primary total knee arthroplasty

BackgroundWith unicompartmental knee arthroplasty (UKA) being increasingly performed for medial compartment osteoarthritis (OA) of the knee, revision total knee arthroplasty (TKA) for failed UKA is expected to increase. Our primary aim is to evaluate patients in our tertiary institution who underwent revision of failed UKA to TKA to compare their pre-operative clinical scores (patient-reported outcome measures, PROMs) to those of primary TKA.MethodsRetrospective review of our institutional arthroplasty registry between 2001 and 2014 was performed. We identified 70 patients who underwent revision of UKA to TKA. The revision UKA to TKA patients was matched with 140 patients who underwent primary TKA for OA in terms of preoperative demographics, gender, age at time of surgery, body mass index (BMI), primary surgeon, and PROMs. Intra-operative data and postoperative complications or re-revision surgeries performed were reviewed.ResultsIn the revision UKA to TKA group, more stems, augments or constrained implants were used compared to primary TKA. A greater proportion of patients with metal-backed UKA revision to TKA required stems, augments or constrained implants as compared to all-polyethylene UKA revision to TKA, but not a significant proportion (P = 0.250). At two years postoperatively, there were no significant differences observed between the groups in terms of patient satisfaction and PROMs.ConclusionsThis study showed similar outcomes following revision of failed UKA to TKA and primary TKA. There were significant improvements in PROMs for revision UKA to TKA, which is comparable to that of primary TKA.     

Psychosocial predictors of outcomes up to one year following total knee arthroplasty

BackgroundTotal knee arthroplasty (TKA) aims to relieve pain and improve physical functioning of the knee, however, some patients continue to experience pain and impaired function following TKA which cannot be explained by surgical and implant factors. Psychological factors may influence the outcomes of TKA. The aim of this prospective study was to examine the psychosocial factors that predicted pain, stiffness and physical functioning up to one year following TKA.MethodsOne hundred and two patients completed pre-operative and one-year questionnaires which assessed a wide range of psychosocial and sociodemographic factors prior to surgery. The Oxford Knee Score (OKS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain, Stiffness and Physical Functioning subscales were used as outcome measures. Pearson correlation analysis and multiple linear regression were conducted to examine relationships between predictor and outcome variables.ResultsRegression analysis showed that regarding variance in WOMAC outcome measures post TKA, our model predicted 31% for physical functioning, 25% for pain and 29% for stiffness at one year. Regarding variance in OKS post TKA, the model predicted 36% at one year. Greater levels of depressive symptoms and neuroticism and worse pre-operative scores significantly predicted poorer outcomes.ConclusionsThe findings indicate that pre-operative psychosocial factors are important in understanding outcomes of TKA. Psychosocial factors could be considered during pre-operative assessment. Further research conducted on psychological interventions is needed within this population to determine whether early and one-year outcomes can be improved.     

膝关节置换者的自我管理模式

背景：自我管理模式是一种新型的疾病干预模式,可显著改善患者的健康行为及健康状况,同时减少住院天数和次数,降低医疗费用,已日渐成为人工膝关节置换后康复的研究热点,但其研究多集中在西方国家,国内报道较少。 目的：探讨自我管理模式在膝关节置换患者康复中的应用价值。 方法：选择膝关节置换住院患者84例,随机分为对照组和实验组,实验组采取自我管理模式,对照组采取常规教育模式,利用自我管理调查表、膝关节评分、住院时间和膝关节屈曲达90°所需时间来评价干预效果,比较两组干预前后相关参数的变化。 结果与结论：两组患者自我管理得分和膝关节评分均有提高,实验组显著优于对照组(P < 0.05);住院天数和膝关节屈曲90°所需时间均有缩短,实验组显著低于对照组(P < 0.05)。 结果显示自我管理模式可有效提高膝关节置换患者自我管理能力,改善膝关节功能,提高生活质量。     

Convincing long-term results independent from the postoperative leg alignment following cementless total knee arthroplasty

BackgroundCementless primary total knee arthroplasty shows numerous advantages compared with cemented implants (e.g., shorter operation time, preservation of the bone stock). Up to now an increasing number of clinical long-term studies exist. Despite this fact, there is no evidence about the influence of the postoperative leg alignment on the results of cementless knee arthroplasty. There is no work on the clinical outcome of the specific implant, which was used in this study (VANGUARD®, ZimmerBiomet). The purpose of this study was to assess the clinical and radiological long-term results after cementless knee arthroplasty in relation to the postoperative mechanical leg alignment.MethodsClinical and radiological results were retrospectively assessed in 83 patients at 10.3 years (ranging from 9.6 to 11.8 years) after implantation. Hip-knee-ankle angle (HKA) was measured, and the patients were separated into a corrected (HKA between three degrees of varus and three degrees of valgus, n = 60) and a varus/valgus (HKA > 3° of varus and valgus, n = 23) group.ResultsUp to the time of the clinical follow-up, three out of 83 patients already underwent a revision surgery due to a deep infection (3.6%). Tegner–Lysholm Knee scale was 89.1 in the corrected group and 88.8 in the varus/valgus group (p = .94). The mean Knee Injury and Osteoarthritis Outcome score (KOOS) was 81.2 in the corrected group and 82.4 in the varus/valgus group (p = .63).ConclusionsResults of this study showed convincing clinical and radiological results after primary cementless knee arthroplasty. Under- or overcorrected postoperative mechanical leg alignments did not influence the long-term clinical results.     

The predictors of outcome in total knee arthroplasty for post-traumatic arthritis

BackgroundThe outcomes of total knee arthroplasty (TKA) for post-traumatic arthritis are less reliable than for idiopathic osteoarthritis. These patients tend to be younger, present with varying degrees of deformity, and often have a history of prior surgery, resulting in a wide spectrum of pathology. We hypothesized that preoperative variables, in particular the location of deformity, would predict pain and functional outcomes.MethodsThe outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 47 knees treated at our institution. All patients were administered the Knee Society Score (KSS) preoperatively and at follow-up (mean 52 months, range 16 to 124). We classified the defects into four categories: intra-articular, metaphyseal, diaphyseal, and combined femoral and tibial deformities.ResultsThere was a significant improvement in KSS scores for pain (p < 0.0001) and a trend toward higher function (p = 0.06) comparing preoperative scores to final follow-up. The largest improvements in pain and functional scores were in patients with isolated articular deformities, while patients with combined tibial and femoral deformities did not have significant improvements in pain or function. Soft-tissue defects requiring flap coverage were associated with worsening in the pain score (p = 0.027).ConclusionsThe location of post-traumatic deformity and compromise of the soft-tissue envelope influence the pain and functional outcomes of total knee arthroplasty for post-traumatic arthritis. Specifically, isolated articular deformities have the largest improvement in pain and function while patients with combined tibial and femoral deformities as well as patients with soft-tissue compromise experience poor outcomes.Level of evidenceIV—Retrospective Case Series.     

Five types of inflammatory arthritis following total knee arthroplasty

Joint effusion after total knee arthroplasty (TKA) is considered as a manifestation of certain inflammatory reactions within prosthetic joints. This study investigated causes of joint effusion following TKA and analyzed phenotypic characteristics of synovial fluid leukocytes for each cause. Forty-six TKAs for rheumatoid arthritis (RA) and 49 TKAs for osteoarthritis (OA) displaying joint effusion were investigated. Causes of joint effusion were clinically identified and frequencies of each cause were compared between RA and OA. Synovial fluid cell phenotypes were analyzed using a fluorescence-activated cell sorter. Clinical diagnoses for joint effusion were classified into five different groups: deep infection (DI); increased activity of RA (IRA); particle-induced synovitis (PS); metal sensitivity (MS); and nonspecific synovitis (NS). The most frequent cause of post-TKA effusion was IRA in RA, and NS in OA. Biomaterial-related arthritis such as PS and MS were more frequent with OA than with RA. Analysis of synovial fluid cell phenotypes revealed that the characteristic cells for each diagnosis were CD16(+)CD14(-) neutrophils in IRA and DI, CD14(+) macrophages in PS, and CD3(+)CD45RO(+) T cells in MS. Post-TKA joint effusion is clinically caused by five different types of arthritis. Phenotypic characteristics of synovial fluid leukocytes reflect joint pathology and contribute to diagnosis and exclusion of biomaterial-related arthritis.     

Effect of postoperative use of nasal oxygen catheter supplementation in wound healing following total knee arthroplasty

OBJECTIVES:

Healing is an event that is fundamental to the success of total knee arthroplasty. The aims of the present study were to compare the rates of complications related to wound healing between two groups of volunteers submitted to total knee arthroplasty and to evaluate the effects of postoperative oxygen supplementation by means of a nasal catheter.

METHOD:

A total of 109 patients who underwent total knee arthroplasty were randomized into two groups, namely, groups that did and did not receive postoperative oxygen supplementation via a nasal catheter. The surgical wound was monitored every day during the hospital stay and on the 7^th, 14^th, 21^st, 30^th and 42^nd postoperative days. Characteristics related to healing were observed, including hyperemia, dehiscence, necrosis, phlyctenules and deep and superficial infection.

RESULTS:

There were no cases of deep infection. Hyperemia was statistically correlated with the total number of complications in the groups, with oxygen demonstrated to be a protective factor against hyperemia. Approximately 30% of the patients who exhibited hyperemia had other complications, independent of oxygen supplementation.

CONCLUSION:

Oxygen supplementation following total knee arthroplasty was shown to be effective in diminishing hyperemia around the operative wound. The development of hyperemia was a precursor to other complications, irrespective of whether oxygen supplementation was used.     

Reconstruction of soft tissue defects following total knee arthroplasty

Soft tissue defects following total knee arthroplasty can represent serious problems for the patient and the surgeon. Perioperative soft tissue complications can result in loss of the prosthesis or limb. In this study, we present 17 cases with complex wounds following total knee arthroplasty who had surgery between May-1994 and July-2001. Patient-related factors, wound factors, surgical operation, secondary procedures, and duration of follow-up have been analysed for each patient. After local wound care and debridement, soft tissue defects have been covered with either a fasciocutaneous or gastrocnemius myocutaneous flap. All the knees (100%) have been salvaged although in 1 patient (6%) replacement of the prosthesis was necessary. In 5 patients (30%) secondary surgical procedures have been performed. Even though there is no consensus in the management of soft tissue defects following total knee arthroplasty, adequate wound care, including identification of infection, debridement, and early appropriate defect coverage should be the main points to consider.     

Early quadriceps tendon rupture after primary total knee arthroplasty

Background

Extensor mechanism disruption following total knee arthroplasty (TKA) is a rare complication and results in significant morbidity and severe functional limitations. Quadriceps tendon rupture in the early postoperative period after TKA is one limitation about which there is a significant paucity of available information.

Recurrent posterior dislocation following primary posterior-stabilized total knee arthroplasty

In our series of 136 patients with primary total knee arthroplasty using posterior-stabilized prosthesis, a female patient with Parkinson disease developed posterior dislocation of the knee 9 months after surgery. Eventually, the dislocation became recurrent, occurring several times a day. The patient made the reposition always by herself. Two months after the first dislocation, we performed the revision of the polyethylene tibial insert and found wearing of the tibial insert's cam as an hitherto unreported cause of the mechanical instability of the total knee prosthesis.     

Preoperative quadriceps weakness preferentially predicts postoperative aberrant movement patterns during high-demand mobility following total knee arthroplasty

Background

Nearly all patients with total knee arthroplasty show aberrant movement patterns during tasks requiring greater joint demand compared to matched peers. Greater movement compensation leads to increased loading onto other joints, decreased functional capacity and limited reserve for independence later in life. Understanding how preoperative predictors contribute to postoperative aberrant movement patterns is needed to make better decisions for patients considering total knee arthroplasty.

A comparison of patient based outcome following knee arthrodesis for failed total knee arthroplasty and revision knee arthroplasty

Arthrodesis of the knee is an infrequently performed operation perceived by both patient and surgeon to have a poor outcome. This study compares functional outcome of knee arthrodesis following failed primary arthroplasty with that of revision knee arthroplasty in a matched patient group. Outcome was measured using the SF12 and Oxford Knee Score. Twelve patients underwent arthrodesis, of which eight were available for functional review at a mean of 53 months. No significant difference was found between the outcome scores of the two groups, although it is recognised that the numbers involved were low. Arthrodesis of the knee may be considered as a surgical option following failed arthroplasty when factors are present that may mitigate against an optimal result following revision knee arthroplasty.     

Clinical efficacy and cost-effectiveness of postoperative radiographs after total knee arthroplasty

BackgroundPostoperative radiographs are commonly ordered after primary total knee arthroplasty (TKA), however, there is limited data on how often these films change management over the entire postoperative time course, and what should prompt imaging to maximize clinical utility.MethodsA retrospective cohort study was conducted of patients ≥ 18 years old who underwent a primary TKA at two level one trauma centers. Postoperative data were collected to determine the frequency of postoperative radiograph series, radiograph findings that did not suggest normal healing or alignment to radiologist and orthopedists, and changes in postoperative management. The total cost and radiation exposure values were calculated for all patient radiographs using estimates from previous literature.ResultsFrom the 1258 patients included, 3831 postoperative radiographs were taken (mean ± 95% confidence interval [CI]: 3.05 ± 0.11 radiographs per patient). Of these 3831 radiographs, 44 (1.1%) contained a positive radiographic finding. Only 13 (0.3% of radiographs) of these positive radiographic findings were positive orthopaedic findings, 11 of which led to changes in management. For all but 1 of these patients (10/11, 91%), these radiographs were taken during a non-routine postoperative visit. Routine postoperative radiographs that did not change management cost $1,008,480 and administered 22.92 mSV of radiation to patients within this study.ConclusionPostoperative radiography obtained after primary TKA were of low clinical utility yet resulted in considerable healthcare costs and unnecessary radiation burden. Radiographs ordered during a non-routine visit, however, were a reliable indicator of when this imaging provided clinical utility.     

Gradual change in knee extension following total knee arthroplasty using ultracongruent inserts

BackgroundTotal knee arthroplasty (TKA) using an ultracongruent (UC) insert is widely performed. Lack of the posterior cruciate ligament or post-cam mechanism is a concern in terms of range of motion. The flexion angle of UC TKA had been well investigated; however, natural history and correlation factors of the postoperative extension angle have not been well documented. This study aimed to investigate time-dependent changes in extension after TKA using UC inserts, and to evaluate factors that correlated with the postoperative extension angle.MethodsThis study reviewed 388 gap-balanced UC TKAs (331 patients) without hyperextension at navigation and performed between November 2010 and December 2014. The extension angle (a positive number indicates hyperextension) was measured on full-extension lateral radiographs. The extension angles from five days post-operation to final follow-up were investigated. Factors correlated with the postoperative extension angle were evaluated using multiple regression analysis.ResultsMean follow-up duration was 46.2 months. Until two years, the extension angle gradually increased; mean angles at five days/six months/one year/two years/and final follow-up were: ? 9.2°/? 2.6°/0.6°/1.0°/1.0°, respectively. Female sex (β = ? 0.15, P = 0.002) and pre-operative hyperextension (β = 0.31, P < 0.001) were associated with postoperative hyperextension deformity.ConclusionsFollowing UC TKA, knees became gradually more extended until two years post-operation. Sex and pre-operative extension angle were predictive factors for the postoperative extension angle following UC TKA.Level of evidenceLevel 4, Case series.     

Acute compartment syndrome of the thigh following total knee arthroplasty

A 62year old man developed a compartment syndrome of the thigh after total knee arthroplasty. Twelve years previously he had a HTO of the same knee complicated by a compartment syndrome of the calf. The clinical diagnosis was confirmed with intracompartmental pressure measurement. Following fasciotomy pressures were normalized and further course was uncomplicated. Compartment syndrome of the thigh is a rare, but potentially devastating, complication following total knee arthroplasty. A previous compartment syndrome of the calf is identified as a risk factor.     

Effects upon bone metabolism following total hip and total knee arthroplasty.

OBJECTIVE: In a prospective study we evaluated the course of markers for bone formation and bone resorption in patients undergoing elective total hip and total knee arthroplasty due to osteoarthritis. The aim was to evaluate which changes in bone metabolism take place in the immediate postoperative course following arthroplasty. METHODS: Serum and urine samples were obtained preoperatively and in the postoperative course from patients undergoing total arthroplasty over a 90- or 180-day period. The study included a total of 63 patients with cemented hip prostheses (n = 20), uncemented hip prostheses (n = 23) and cemented knee prostheses (n = 20). Different biochemical markers of bone metabolism were assessed including the serum markers bone-specific alkaline phosphatase, and carboxyterminal propeptide of type I procollagen, and the urine markers n-telopeptide (NTx) and deoxypyridinoline (DPD). RESULTS: For all four markers, there were changes over time which were statistically significant. Markers indicating bone formation were slightly elevated after a 3-month period. In contrast, the two markers indicating bone resorption were back to normal after a 6-month period. There were differences between the groups with cemented and uncemented total hip arthroplasty in the postoperative course with higher values of the markers indicating bone resorption in the cemented group. However, these differences were not statistically significant. CONCLUSIONS: Our results indicate that the two markers of bone resorption, NTx and DPD, are elevated during the first 6 months after hip and knee arthroplasty. Therefore, during this period they cannot be used as a marker for aseptic loosening. However, if these two markers are still elevated after this period, they may reflect an impaired bone metabolism. Further studies are required to assess the potential value of these markers for the diagnosis of aseptic loosening.     

Patient satisfaction after posterior-stabilized total knee arthroplasty: A functional specific analysis

BackgroundDespite the success of total knee arthroplasty (TKA) in treating end-stage knee arthritis, 11% to 19% of patients are dissatisfied with the outcome of their surgery. In this study we investigated how satisfied overall patients are with the outcome of posterior stabilized TKA and what particular functional deficits or residual symptoms cause the most dissatisfaction for patients after surgery.MethodsUsing patient-completed validated questionnaires, we retrospectively analyzed data for 1013 posterior-stabilized TKAs performed in 748 Chinese patients regarding the overall satisfaction with surgery and the importance ranking of each of 15 specific functions and residual symptoms.ResultsOur data demonstrate an overall satisfaction rate of 87.4%. Satisfaction percentages ranged from 45.0% to 89.0%. The top 6 dissatisfactory items were sitting with legs crossed (dissatisfaction rate of 55.0%), squatting (51.7%), walking fast or jogging (45.4%), knee clunking (34.5%), abnormal feeling in knee (31.2%), and climbing stairs (28.2%). The top 6 important functions or issues were pain relief, walking on flat ground, climbing stairs, ability to return to household work, decreased limping, and squatting.ConclusionsApproximately 1 in 8 patients was dissatisfied with overall outcome. Patients were most dissatisfied with climbing stairs and squatting, functions that they considered most important.     

同时双侧全膝表面置换与单侧全膝关节置换围手术期康复的比较

背景：目前对于双膝严重骨性关节炎行两组同时双侧全膝表面置换的围手术期康复的相关研究尚不多见。 目的：比较双膝骨性关节炎两组同时双侧全膝表面置换术与单侧全膝关节置换围手术期康复训练的效果。 方法：两组医生对59例(118膝)患者双膝骨性关节炎同台同时全膝表面置换,与同期80例单膝骨性关节炎行单侧全膝关节置换患者(对照组)进行疗效比较。两组患者置换前均进行康复教育及预备康复,置换后康复方法标准一致。 结果与结论：同时双侧全膝表面置换组置换前通过压腿平均减小屈曲畸形角度11.2°(5°~22°)。置换后3~6周,股四头肌、腘绳肌肌力5级,较置换前平均增加0.8级;平均ROM≥95°(110±15) °;无痛行走500 m以上;独自无痛上下10级楼梯,无肿胀;出院时HSS评分较置换前增加。置换后3个月没有发现松动表现及不良反应,其康复疗效与对照组对比差异无显著性意义。表明,在围手术期对双膝骨性关节炎两组医生行同时双侧全膝表面置换,通过系统而量化的康复,有利于减少置换中截骨量和置换后并发症,促进患者膝关节功能恢复,与单侧全膝关节置换相比康复结果无明显差异。     

同期双侧全膝关节置换与选择性单侧全膝关节置换后的早期功能恢复

背景：同期双侧全膝关节置换与选择性单侧全膝关节置换后的早期功能恢复一直存在着争议。 目的：评价双膝骨关节炎患者同期双侧全膝关节置换与选择性单侧全膝关节置换后功能恢复情况的差异。 方法：根据置换方案将初次行全膝关节置换的双膝骨关节炎患者86例(116膝)分为两组,双膝组(n=29,58膝)行同期双侧全膝关节置换,单膝组(n =57,57膝)行单侧全膝关节置换。分别对两组患者置换前后的关节活动度、屈曲挛缩度、肌力、疼痛评分、双下肢不等长及HSS评分进行比较分析,并记录并发症的发生率。 结果与结论：置换后1年随访,两组患者置换后关节活动度和肌力差异无显著性意义(P=0.171,0.418);置换后屈曲挛缩度、疼痛评分及双下肢不等长双膝组均显著低于单膝组(P=0.006,0.0013,0.026);同时双膝组置换后HSS评分优于单膝组(P=0.003)。提示同期双侧全膝关节置换患者在屈曲挛缩度、疼痛症状评分、双下肢不等长及HSS评分方面优于单侧全膝关节置换,而两种方案在置换后关节活动度和下肢肌力方面无明显差异。