Patellar Tracking in Revision Total Knee Arthroplasty: Does Retaining a Patella From a Different Implant System Matter?

BackgroundPatellar maltracking is a potential surgical complication following total knee arthroplasty (TKA) and can result in anterior knee pain, recurrent patellar dislocation, and damage to the medial patellar soft tissue stabilizers. Data remain unclear as to whether the patellar button should be revised during a revision TKA (rTKA) if changing the component implant system. Our study examines whether retaining the original patellar button during an rTKA using a different implant system affects patellar tracking.MethodsA retrospective cohort study of rTKA patients between August 2011 and June 2019 was performed at an urban, tertiary referral center. Patients were divided into 2 cohorts depending on whether their retained patella from their primary TKA was of the same (SIM) or different implant manufacturer (DIM) as the revision system used. Radiographic measurements were performed on preoperative and postoperative knee radiographs and differences were compared between the 2 groups. Baseline demographic data were also collected.ResultsOf the 293 consecutive, aseptic rTKA cases identified, 122 underwent revision in the SIM cohort and 171 in the DIM cohort. There were no demographic differences between the groups. No statistical significance was calculated for differences in preoperative and postoperative patellar tilt or Insall-Salvati ratio between the groups. The DIM group was found to have more lateral patellar translation (?0.01 ± 6.09 vs 2.68 ± 7.61 mm, P = .001). However, when calculating differences in the magnitude of the translation (thereby removing differences due to laterality), no difference was observed (0.06 ± 3.69 vs 0.52 ± 4.95 mm, P = .394).ConclusionNo clinically significant differences in patellar tracking were observed when the original patellar component was retained and a different revision implant system was used. Given the inherent risks of bone loss and fracture with patellar component revision, surgeons performing rTKA may retain the primary patella if it is well fixed and can still expect appropriate patellar tracking regardless of the revision implant system used.Level of EvidenceIII, Retrospective cohort study.     

Primary Total Knee Arthroplasty: How Does Residual Patellar Thickness Affect Patient-Oriented Outcomes?

Background

Maintenance of the native patellar thickness has been deemed important for proper clinical outcomes after total knee arthroplasty (TKA). Our objective was to study the effects of the change in patellar thickness on patient-perceived outcomes (PPOs) after TKA. We hypothesized that reestablishing native patellar thickness after TKA results in better PPOs.

Does Minimally Invasive Surgery Improve Short-term Recovery in Total Knee Arthroplasty?

Background  

Concerns have been raised regarding minimally invasive surgery (MIS) and its possible effect on postoperative functional recovery, complications, and survival rate after TKA.     

Is Selectively Not Resurfacing the Patella an Acceptable Practice in Primary Total Knee Arthroplasty?

Background

To resurface or not to resurface the patella remains a controversy in total knee arthroplasty (TKA). The purpose of this study was to assess the long-term outcomes associated with selectively not resurfacing the patella.

Does Tranexamic Acid Save Blood in Minimally Invasive Total Knee Arthroplasty?

Background  

Tranexamic acid (TEA) reportedly reduces perioperative blood loss in TKA. However, whether it does so in minimally invasive TKA is not clear.     

Does Total Knee Arthroplasty Change Frontal Plane Knee Biomechanics During Gait?

Background  

Dynamic knee varus angle and adduction moments have been reported to be reduced after TKA. However, it is unclear whether this reduction is maintained long term.     

Patella Resurfacing during Total Knee Arthroplasty: Have We Got the Issue Covered?

Background

Management of the patella during total knee arthroplasty (TKA) is controversial. Multiple studies have examined mechanical and clinical results of TKA with native and resurfaced patellae with no clear consensus.

Methods

We surveyed a large cohort of consultant surgeons in a questionnaire based study in order to assess the indications for patella resurfacing and to correlate practice with degree of specialization, experience and volume of procedures performed.

Results

Six hundred and nineteen surgeons were included. The main indication for patella resurfacing was patellofemoral arthritis. The ratio of those who always:sometimes:never resurfaced was 1:2:1 irrespective of experience or volume performed. There was no difference between knee specialists and non-specialists (p = 0.977) or between high and lower volume surgeons (p = 0.826). Senior and high volume surgeons tended to always resurface.

Conclusions

The majority of surgeons only sometimes resurfaced the patella. The number who always and never resurfaced were similar. There was a tendency for more experienced and high volume surgeons to always resurface.     

Tramadol in Knee Osteoarthritis: Does Preoperative Use Affect Patient-Reported Outcomes After Total Knee Arthroplasty?

BackgroundThe 2013 American Academy of Orthopedic Surgeons evidence-based guidelines recommend against the use of preoperative narcotics in the management of symptomatic osteoarthritic knees; however, the guidelines strongly recommend tramadol in this patient population. To our knowledge, no study to date has evaluated outcomes in patients who use tramadol exclusively as compared with narcotics naive patients.MethodsThis is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty between January 2017 and March 2018. PRO scores were obtained using a novel electronic patient rehabilitation application, which pushed PRO surveys via email and mobile devices within 1 month prior to surgery and 3 months postoperatively.ResultsOne hundred and thirty-six patients were opiate naïve, while 63 had obtained narcotics before the index operation. Of those, 21 patients received tramadol. The average preoperative Knee Disability and Osteoarthritis Outcome Scores were 50.4, 49.95, and 48.01 for the naïve, tramadol, and narcotic populations, respectively, (P = .60). The tramadol cohort had the least gain in 3 months postoperative Knee Disability and Osteoarthritis Outcome Scores, improving on average 12.5 points in comparison to the 19.1 and 20.1 improvements seen in the narcotic and naïve cohorts, respectively (P = .09). This difference was statistically significant when comparing the naïve and tramadol populations alone in post hoc analysis (P = .016).ConclusionsWhen comparing patients who took tramadol preoperatively to patients who were opiate naïve, patients that used tramadol trended toward significantly less improvement in functional outcomes in the short-term postoperative period.     

Does Patient Experience After a Total Knee Arthroplasty Predict Readmission?

BackgroundTo our knowledge, the relationship between patient Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and patient outcomes in total knee arthroplasty (TKA) has not yet been analyzed. Therefore, the purpose of this study is to determine whether readmissions within the 30 or 90 days postoperative window after TKA were predicted by patient satisfaction scores, as measured by the HCAHPS survey.MethodsWe analyzed HCAHPS survey scores from all patients who underwent primary or revision TKA at our institution between January 1, 2016 and September 1, 2016. Demographic readmission information, preoperative baseline health status measures, validated patient-reported pain and joint function measures, and HCAHPS survey scores were collected. To determine whether 30-day or 90-day readmissions were independently associated with HCAHPS scores, statistical analyses were conducted using chi-squared and Student’s t-tests for categorical and continuous variables. Multivariable regression analysis adjusted for patient-level risk factors.ResultsPatients readmitted within 30 days were significantly less likely to choose the highest rating on survey questions in several dimensions of patient satisfaction when compared to patients who were not readmitted. These dimensions included physician communication (P = .045), discharge information (P = .016), and transition of care (P = .044). Similarly, patients who were readmitted within 90 days were less likely to choose the highest rating in survey questions that pertained to physician communication (P = .046), medication information (P = .040), and quietness of the hospital environment (P = .048).ConclusionOur results show that readmission is predicted by lower patient satisfaction scores in several dimensions of patient care including physician communication, hospital environment, medication information, discharge information, and transition of care.     

Does Greater Knee Flexion Increase Patient Function and Satisfaction After Total Knee Arthroplasty?

The purpose of this study was to determine whether high flexion leads to improved benefits in patient satisfaction, perception, and function after total knee arthroplasty (TKA). Data were collected on 122 primary TKAs. Patients completed a Total Knee Function Questionnaire. Knees were classified as low (≤110°), mid (111°-130°), or high flexion (>130°). Correlation between knee flexion and satisfaction was not statistically significant. Increased knee flexion had a significant positive association with achievement of expectations, restoration of a “normal” knee, and functional improvement. In conclusion, although the degree of postoperative knee flexion did not affect patient satisfaction, it did influence fulfillment of expectations, functional ability, and knee perception. This suggests that increased knee flexion, particularly more than 130°, may lead to improved outcomes after TKA.     

Does Aspirin Have a Role in Venous Thromboembolism Prophylaxis in Total Knee Arthroplasty Patients?

The objectives of this study were to compare the risk of venous thromboembolism (VTE), bleeding, surgical site infection, and mortality in patients receiving aspirin or guideline-approved VTE prophylactic therapies (warfarin, low-molecular-weight heparins, synthetic pentasaccharides) in total knee arthroplasty (TKA). We analyzed clinical and administrative data from 93?840 patients who underwent primary TKA at 307 US hospitals over a 24-month period. Fifty-one thousand nine hundred twenty-three (55%) patients received warfarin, 37?198 (40%) received injectable agents, and 4719 (5%) received aspirin. After adjustment for patient and hospital factors, patients who received aspirin VTE prophylaxis (VTEP) had lower odds for thromboembolism compared to warfarin patients but with similar odds compared with injectable VTEP; there were no differences in risk of bleeding, infection, or mortality after adjustment. Our results suggest that aspirin, when used in conjunction with other clinical care protocols, may be effective VTEP for certain TKA patients.     

Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BackgroundThe management of the patella during total knee arthroplasty (TKA) remains controversial. The aim of this study is to evaluate the evidence regarding the use of patellar resurfacing in TKA.MethodsA meta-analysis of randomized controlled trials (RCTs) was performed to compare outcomes between knees receiving patellar resurfacing vs those not receiving resurfacing during primary TKA. Outcomes of interest were the Knee Society Scores, reoperation rates, anterior knee pain, patient satisfaction, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score subscores, and range of motion.ResultsTwenty RCTs met all eligibility criteria and were included in the analysis. There were statistically significant differences favoring the resurfaced group in the knee component and functional component of Knee Society Scores that were not clinically significant. There was an increased risk of reoperation among knees that did not receive resurfacing with number needed to treat to prevent one case of reoperation of 25 knees (for reoperation for any reason) and 33 knees (for reoperation for anterior knee pain). There were no statistically significant differences in any other outcomes.ConclusionThe only clear relationship is that knees that do not receive patellar resurfacing are more likely to receive reoperation, most often for secondary resurfacing. However, the disease burden of differing complication profiles associated with resurfacing and nonresurfacing groups remains unclear. Continuing to collect data from large, well-designed RCTs would be beneficial in guiding management of the patella during TKA.     

Does Recession of the Posterior Cruciate Ligament Influence Outcome in Total Knee Arthroplasty?

BackgroundFor a PCL-retaining (posterior cruciate ligament) total knee arthroplasty (TKA) to function suitably, proper soft tissue balancing, including PCL recession, is required. Yet, when the recession of the PCL is needed, there is still a debate as to whether a cruciate-retaining (CR) TKA should be converted to a posterior-stabilized TKA due to the concern of instability and poorer clinical outcomes. The purpose of this study is to determine whether recession of the PCL adversely affects clinical outcomes in patients who undergo CR TKA.MethodsCR TKAs of the same design performed by the senior author (J.M.) were identified between December 2006 and July 2015. Clinical outcome measurements were collected and included the Western Ontario and McMaster Universities Osteoarthritis Index score, the Knee Society Clinical Rating System, Short Form-12 Physical Composite Score/Mental Health Composite Score, and revision rates.ResultsThere were no significant differences in clinical outcome when the PCL was retained, partially recessed, or completely released during PCL-retaining TKA (Western Ontario and McMaster Universities Osteoarthritis Index: P = .54, Knee Society Clinical Rating System: P = .42, Short Form-12 Mental Health Composite Score: P = .89, Short Form-12 Physical Composite Score: P = .527).ConclusionThis study presents evidence of similar clinical outcomes when the PCL is retained or released during PCL-retaining TKA, provided attention is paid to appropriate soft tissue balancing. CR TKA undergoing partial or complete release of the PCL should not routinely be converted to a posterior-stabilized knee design.Level of EvidenceLevel II, Prognostic study.     

Does Bilateral Total Knee Arthroplasty Affect Gait in Women?: Comparison of Gait Analyses Before and After Total Knee Arthroplasty Compared with Normal Knees

We performed gait analysis of 24 patients with bilateral knee osteoarthritis (OA) before, 1 year, and 2 years after bilateral total knee arthroplasty and compared these results to 12 normal controls. Cadence was significantly decreased in OA patients when compared with controls. Step and stride lengths were significantly different preoperatively (shorter) and postoperatively (P < .05), but postoperative results showed no significant difference when compared with normal controls (P < .05). Step and stride times were significantly different (P < .05) between the preoperative OA group and controls, but no difference was seen with the postoperative measurements when compared with controls. In the OA group, the mean vertical component of the ground reaction forces expressed as percent body weight was significantly lower when compared with controls and postoperative results. No correlation was found between the preoperative and postoperative clinical scores and objective data obtained from gait analysis. Our results demonstrate that gait analysis is not a useful tool in evaluating the success of total knee arthroplasty patient.