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Connolly P, Coombs S, Schwarzkopf R. Mechanical complications after total knee arthroplasty. Expert Rev Med Devices 2023; 20:1105-1117. [PMID: 37950354 DOI: 10.1080/17434440.2023.2282744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/08/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION With the increasing demand for total knee arthroplasty (TKA) and the burden of revision TKA on the healthcare system, as well as the quality of life implications for patients, it is extremely important for surgeons to be able to anticipate and prevent TKA mechanical complications. Surgeons must be familiar with the different causes and mechanisms of TKA complications so that they can properly treat patients with failed TKAs and better avoid these complications. AREAS COVERED This review addresses TKA mechanical complications and provides context for the topic. A detailed review of surgical factors, implant factors, and patient factors that contribute to mechanical complications after TKA is provided. All of the literature cited in this review was gathered from the PubMed online database using different keywords based on the section of the manuscript. EXPERT OPINION As surgeons and engineers solve certain issues in TKA, new challenges will inevitably arise. We must continue to push forward and innovate from both a surgical technique and implant design perspective.
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Affiliation(s)
- Patrick Connolly
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Stefan Coombs
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Annapareddy A, Mulpur P, Jayakumar T, Kikkuri RR, Suhas Masilamani AB, V R, Vaishya R, Reddy AVG. Patella non-resurfacing in primary total knee arthroplasty provides good functional results-a retrospective review of nine thousand three hundred forty six knees. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05819-5. [PMID: 37186286 DOI: 10.1007/s00264-023-05819-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Patellar resurfacing has long been a contentious subject in TKA with no consensus and the literature yielding disparate results. The aim of this study was to evaluate the long-term functional outcomes and complications of patients undergoing primary TKA without patellar resurfacing (non-resurfacing). METHODS This study retrospectively analysed 9346 patients who underwent primary manual jig-based TKA without patellar resurfacing at a single high-volume arthroplasty centre between 2010 and 2018. Patients with a minimum three year follow-up irrespective of disease etiology and implant manufacturer were included in the study. Primary outcome was measured using Oxford knee score and patellofemoral Feller score. Secondary outcomes included determining the incidence of patellofemoral complications and re-operation rates following TKA. RESULTS A total of 8695 knees were eligible for final evaluation having a mean follow-up of 6.6 years. Mean age of the patients was 62.6 (SD-7.5) years with female predominance of (N-6619, 70.8%). The majority of the patients had primary OA (N-8792, 94.1%) with varus deformity (N-8642, 92.46%). Depuy was the most used manufacturer (n = 2592, 26.4%) with the posterior stabilised (N-4127, 44.2%) design being the most predominant. The mean Feller score of the study population was 24.5 (SD = 3) with a majority of patients having good to excellent outcomes (86.95%, N-8424) and mean Oxford knee score was 36.9 (SD-6.9) with a majority of the patients having an OKS greater than 30 (87.1%, N-8133) with anterior knee pain (AKP) reported in only 4.8% patients (N-418). Most common complications included patellar clunk (N-56, 0.7%), traumatic patellar fractures (N-62, 0.8%), quadriceps tendon tear (N-54, 0.7%) and patellar dislocation (N-4, 0.05%) CONCLUSION: Patellar non-resurfacing has no detrimental impact on functional outcomes and incidence of AKP. We conclude that it is a safe, cost-effective and satisfactory approach in primary TKA with no significant complications.
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Affiliation(s)
- Adarsh Annapareddy
- Sunshine Bone and Joint Institute, KIMS-Sunshine Hospitals, Hyderabad, India
| | - Praharsha Mulpur
- Sunshine Bone and Joint Institute, KIMS-Sunshine Hospitals, Hyderabad, India
| | - Tarun Jayakumar
- Sunshine Bone and Joint Institute, KIMS-Sunshine Hospitals, Hyderabad, India.
| | | | | | - Ratnakar V
- Sunshine Bone and Joint Institute, KIMS-Sunshine Hospitals, Hyderabad, India
| | | | - A V Gurava Reddy
- Sunshine Bone and Joint Institute, KIMS-Sunshine Hospitals, Hyderabad, India
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Limberg AK, Tibbo ME, Ollivier M, Tammachote N, Abdel MP, Berry DJ. Factors Affecting the Risk of Aseptic Patellar Complications in Primary TKA Performed with Cemented All-Polyethylene Patellar Resurfacing. J Bone Joint Surg Am 2022; 104:451-458. [PMID: 34932523 DOI: 10.2106/jbjs.21.00356] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patellar complications are a consequential cause of failure of primary total knee arthroplasty (TKA). The purpose of this study was to evaluate the association of demographic and patient factors with the long-term risk of patellar complications as a function of time in a very large cohort of primary TKAs performed with patellar resurfacing. METHODS We identified 27,192 primary TKAs utilizing cemented all-polyethylene patellar components that were performed at a single institution from 1977 through 2015. We evaluated the risk of any aseptic patellar complication and any aseptic patellar reoperation or revision, subanalyzed risks of reoperation or revision for loosening, maltracking/instability, and wear, and evaluated the risk of clinical diagnosis of patellar fracture and clunk/crepitus. The mean age at TKA was 68 years (range, 18 to 99 years); 57% of the patients were female. The mean body mass index (BMI) was 32 kg/m2. The primary diagnosis was osteoarthritis in 83%, and 70% of the TKAs were posterior-stabilized. Median follow-up was 7 years (range, 2 to 40 years). Risk factors for each outcome were evaluated with Cox regression models. RESULTS Nine hundred and seventy-seven knees with all-polyethylene patellae developed patellar complications. Survivorship free from any aseptic patellar complication was 93.3% at 20 years. Twenty-year survivorship free from any aseptic patellar reoperation was 97.3% and free from any aseptic patellar revision was 97.4%. Fifteen-year survivorship for the same end points for procedures performed from 2000 to 2015 was 95.7%, 99.2% and 99.3% respectively, representing substantial improvements compared with implants placed before 2000. Univariate analysis demonstrated that male sex (hazard ratio [HR], 1.4), an age of <65 years (HR, 1.3), and a BMI of ≥30 kg/m2 (HR, 1.2) were associated with increased risk of patellar complications (all p ≤0.01). Posterior-stabilized designs were associated with fewer patellar reoperations and revisions overall (HR, 0.4 and 0.4; p < 0.001) but higher risk of patellar clunk/crepitus (HR, 14.1; p < 0.001). CONCLUSIONS The 20-year survivorship free from any aseptic patellar complication in this series of cemented all-polyethylene patellae was 93%. Important risk factors for any aseptic patellar complication were male sex, an age of <65 years, a BMI of ≥30 kg/m2, and a patella implanted before 2000. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Afton K Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Meagan E Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthieu Ollivier
- Department of Orthopedic Surgery, Aix-Marseille Université, Marseille, France
| | | | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Thiengwittayaporn S, Sumranwanich N, Hongku N, Sansawat P. Onlay Patellar Resurfacing in a Posterior-Stabilized Total Knee Arthroplasty Increases Patellar Crepitus Complication: A Randomized, Controlled Trial. J Arthroplasty 2021; 36:3443-3450. [PMID: 34116913 DOI: 10.1016/j.arth.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patellar crepitus (PC) is a potentially problematic complication after total knee arthroplasty (TKA) more commonly occurring with a posterior-stabilized (PS) prosthesis. Patellar resurfacing has been reported to reduce PC complications; however, no study has compared the PC complication rates between 2 different resurfacing techniques, namely inlay and onlay. METHODS A prospective, randomized controlled trial was conducted to compare the PC complication between inlay and onlay patellar resurfacing techniques. A total of 222 patients who underwent unilateral TKA using a Legion PS Total Knee System were randomized into 2 groups. PC incidence, time of PC presentation, radiographic parameters associated with PC development, and clinical outcomes were evaluated at 3, 6, 9, 12, 18, and 24 months postoperatively. RESULTS PC occurred significantly more in the onlay group (17.9% vs 6.5%, P = .009). Time of PC presentation in both groups was not different. Anterior knee pain was found in 11.5% of PC patients, and none required any surgical procedure. Postoperative radiographic parameters, range of motion, Knee Society score, Oxford score, patellar score, incidence and intensity of anterior knee pain, and visual analog scale of overall knee pain were not significantly different between the 2 groups during the follow-up period. CONCLUSION To reduce the chance of PC development, we suggest an inlay patellar resurfacing technique during PS-TKA with this knee system.
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Affiliation(s)
- Satit Thiengwittayaporn
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nattapol Sumranwanich
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Natthapong Hongku
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pichai Sansawat
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Duan G, Cai S, Lin W, Pan Y. Risk Factors for Patellar Clunk or Crepitation after Primary Total Knee Arthroplasty: A Systematic Review and Meta-analysis. J Knee Surg 2021; 34:1098-1109. [PMID: 32131098 DOI: 10.1055/s-0040-1701515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patellar clunk and crepitation (PCC) have been reported as a consequence of primary total knee arthroplasty (TKA). The incidence and contributing factors have not been fully defined. We performed this systematic review to evaluate factors associated with PCC following primary TKA. We identified studies on PCC following TKA from an electronic search of articles in Medline, Embase and the Cochrane databases (dated up to May 2018). Eighteen studies altogether, including 600 cases of PCC within 8,131 TKAs, were included in the meta-analysis. Several factors including demographic, intraoperative, clinical variables, and radiographic measurements were pooled for meta-analysis. Among intraoperative and clinical variables, patients involved with patellar retention (odds ratio [OR] = 9.420; confidence interval [CI]: 5.770-13.070), lateral reticular release (OR = 2.818; CI: 1.114-7.125), and previous surgery (OR = 2.724; CI: 1.549-4.790) were more likely to having PCCs. Among radiographic measurements, increased anterior tibial offset (weighted mean difference [WMD] = 0.387; CI: 0.139-0.634), increased joint line changes (WMD = 1.325; CI: 0.595-2.055), and increased knee flexion angle (WMD = 3.592; CI: 1.811-5.374) were considered risk factors associated with PCC. Demographic factors (age, gender, body mass index [BMI], and diagnosis) and other reported radiographic measurements were not associated with PCCs. This study identified intraoperative variables (patellar retention and lateral reticular release), clinical variables (previous surgery), and radiographic measurements (increased anterior tibial offset, increased joint line changes, and increased postoperative knee flexion angle) that contribute to an increased risk for PCC. Modifiable factors (patellar retention and lateral reticular release) should be considered and addressed to limit the risk for PCC following TKA. Patients with conditions that may not be modifiable may benefit from counseling about their increased risks for PCC to limit potential dissatisfaction with their procedure.
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Affiliation(s)
- Guman Duan
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Sijia Cai
- Department of Endocrinology, Beijing Hepingli Hospital, Beijing, People's Republic of China
| | - Weiwei Lin
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Yongwei Pan
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
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Sequeira SB, Scott J, Novicoff W, Cui Q. Systematic review of the etiology behind patellar clunk syndrome. World J Orthop 2020; 11:184-196. [PMID: 32280608 PMCID: PMC7138860 DOI: 10.5312/wjo.v11.i3.184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/24/2019] [Accepted: 01/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Total knee arthroplasty is one of the most successful operations performed worldwide today. Patellar clunk syndrome (PCS) is a postoperative complication that arises due to the development of a fibrous nodule along the undersurface of the quadriceps tendon. The current literature on PCS has not yet come to a consensus regarding its etiology. To date, this is the first study that analyzes the existing literature on PCS in order to generate a conclusion regarding its etiology. It is hypothesized that prosthesis design is the main component behind the development of PCS.
AIM To determine the etiology of PCS and its association with pre and post-operative characteristics of the prosthesis and native knee.
METHODS We conducted a systematic review according to the PRISMA guidelines by searching through PubMed, Cochrane, and Google Scholar from May-July 2018 for cases of PCS using search MeSH terms “patella OR patellar” AND “clunk” OR “catch” OR “crepitus”. The search included case series and clinical trials and excluded review articles, yielding 30 articles from the original search and 3 additional articles from reference lists. We extracted data upon the outcomes in patients afflicted with PCS to determine the etiology of PCS. We performed additional bias assessments to validate our search algorithm and results.
RESULTS Prosthesis design was the metric most frequently implicated in the incidence of PCS, though several other metrics were contributory toward its pathogenesis. Later prosthetic designs incorporate a reduced intercondylar box ratio and box width to reduce contact between the proximal patellar pole and the intercondylar box, thereby reducing incidence of PCS.
CONCLUSION The etiology of PCS is multifactorial, owing to the growing metrics that have associations with its incidence. This conclusion is validated by the significance of prosthesis design as the most likely parameter involved in developing PCS since different prosthesis designs are often the result of different parameters. Future studies should be directed at isolating individual prosthetic parameters of prosthesis designs in order to determine what permutation of parameters is most closely associated with the development of PCS.
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Affiliation(s)
- Sean Bertram Sequeira
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
| | - James Scott
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
| | - Wendy Novicoff
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
| | - Quanjun Cui
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
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Thiengwittayaporn S, Srungboonmee K, Chiamtrakool B. Resurfacing in a Posterior-Stabilized Total Knee Arthroplasty Reduces Patellar Crepitus Complication: A Randomized, Controlled Trial. J Arthroplasty 2019; 34:1969-1974. [PMID: 31126775 DOI: 10.1016/j.arth.2019.04.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patellar crepitus (PC) is a common complication after total knee arthroplasty (TKA) using a posterior-stabilized (PS) prosthesis. While numerous factors have been associated with PC development after PS-TKA, patellar resurfacing (PR) which directly impacts the patellofemoral joint kinematics has been underinvestigated. A prospective, randomized, controlled trial was conducted to (1) compare the PC incidence in PR and non-PR PS-TKA, (2) determine the time of PC presentation in PS-TKA, (3) identify radiographic parameters associated with PC, and (4) compare clinical outcomes of patients with and without PR. METHODS A total of 84 patients who underwent unilateral TKA using the Legion PS Total Knee System were randomized into PR group or non-PR group. PC incidence, time of PC presentation, radiographic parameters associated with PC development, and clinical outcomes were evaluated at 3 months, 6 months, 9 months, and 1 year postoperatively. RESULTS PC occurred significantly more in the non-PR group (23.1% vs 7.3%, P = .048). Time of PC presentation in both groups was not different. Anterior knee pain was found in 16.7% of crepitus patients, and none required any surgical procedure. The non-PR knees had significant decreases in patellar shift index, patellar displacement, Insall-Salvati ratio, and patellar component height and increase in change in posterior femoral offset. Oxford and patellar scores were significantly better in the PR group at 9 months and 1 year. CONCLUSION Given higher PC incidence and several worse clinical outcomes in the non-PR, we recommend resurfacing during PS-TKA with this knee system to avoid PC development.
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Affiliation(s)
- Satit Thiengwittayaporn
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand
| | - Kakanand Srungboonmee
- Center of Data Mining and Biomedical Informatics, Faculty of Medical Technology, Mahidol University, Salaya, Nakornpathom, Thailand
| | - Bhakawat Chiamtrakool
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand
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Pierce TP, Jauregui JJ, Cherian JJ, Elmallah RK, Harwin SF, Mont MA. Is There an Ideal Patellar Thickness Following Total Knee Arthroplasty? Orthopedics 2016; 39:e187-92. [PMID: 26726982 DOI: 10.3928/01477447-20151222-03] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/22/2014] [Indexed: 02/03/2023]
Abstract
Orthopedic surgeons resurface the patella during total knee arthroplasty to avoid complications such as pain, patello-femoral arthritis, and patellar maltracking and to reduce the risk for reoperation. However, many complications, such as decreased range of motion, increased fractures, and polyethylene wear, have been described with this procedure. One determinant when resurfacing a patella is the thickness of its cuts. This review aims to investigate the relationship between patellar thickness and outcome parameters such as range of motion, patient-reported outcomes, periprosthetic fractures, and reoperations.
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Costanzo JA, Aynardi MC, Peters JD, Kopolovich DM, Purtill JJ. Patellar clunk syndrome after total knee arthroplasty; risk factors and functional outcomes of arthroscopic treatment. J Arthroplasty 2014; 29:201-4. [PMID: 25034884 DOI: 10.1016/j.arth.2014.03.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 02/25/2014] [Accepted: 03/03/2014] [Indexed: 02/01/2023] Open
Abstract
This study reports the incidence, risk factors, and functional outcomes of the largest reported series of patients treated arthroscopically for patella clunk syndrome (PCS). All patients treated arthroscopically for PCS were identified. Patients were matched with controls by sex and date of surgery. Follow-up was conducted using SF-12 and WOMAC questionnaires. Operative notes and preoperative and postoperative radiographs were reviewed. Seventy-five knees in 68 patients were treated arthroscopically for PCS. Average follow-up was 4.2 years. Functional scores demonstrated no statistical difference. PCS patients had a significantly more valgus preoperative alignment, greater change in posterior femoral offset and smaller patellar component size. PCS is a relatively common complication following TKA. Arthroscopy yields functional results comparable to controls. Radiographic and technical factors are associated with PCS.
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Affiliation(s)
- James A Costanzo
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael C Aynardi
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - John D Peters
- School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - James J Purtill
- The Rothman Institute, Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Helito CP, Gobbi RG, Tirico LEP, Pecora JR, Camanho GL. Loosening of the patellar component and extra-articular and transcutaneous migration after TKA. Orthopedics 2014; 37:e211-3. [PMID: 24679211 DOI: 10.3928/01477447-20140124-28] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 09/05/2013] [Indexed: 02/03/2023]
Abstract
Replacement of the patella during total knee arthroplasty (TKA) remains controversial. Despite some attempts to establish guidelines for this procedure, there is still no consensus in the literature. When the patella is replaced, the patient is subjected to certain complications, including loosening of the component. The loosened patellar component most commonly migrates to the intra-articular region of the knee. However, there have been a few reports of migration of the component to the extra-articular region, particularly when release of the lateral retinaculum and osteonecrosis of the patella are involved. The authors report a case of patellar component loosening and extra-articular and transcutaneous migration of the component 9 years after TKA. This report is unique because, during the primary procedure, no lateral release was performed and no patellar necrosis was evident on radiographs. The component was removed in the operating room and the wound cleaned and closed. Because of the probable slow migration of the component, there was no communication between the external environment and the joint at the time of surgery. There were no further complications after the wound healed. This case emphasizes the need for periodic radiographic follow-up after TKA.
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The effects of femoral component design on the patello-femoral joint in a PS total knee arthroplasty. Arch Orthop Trauma Surg 2014; 134:59-64. [PMID: 24202406 DOI: 10.1007/s00402-013-1877-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Anterior knee pain following TKA performed utilizing the PFC Sigma system still represents a cause of failure. The purpose of this study was to evaluate whether or not a recent change in the femoral design (PFC Sigma PS) had a positive impact on the patello-femoral complication rate. MATERIALS AND METHODS A consecutive series of 100 TKA using the PFC Sigma PS system was followed prospectively for a minimum of 3 years. All patellae were replaced and a standard lateral release was never performed. Radiographic analysis following the Knee Society Score (KSS) included antero-posterior weight-bearing, lateral and bilateral axial radiographs. TKA rotational alignment was recorded at the final follow-up in 30 consecutive knees by performing a CT evaluation. RESULTS Good to excellent clinical results according to the KSS were achieved in 94% of the knees. Survival without need of reoperation for any reason was 98% at 3 years minimum follow-up; two reoperations were done for removal of fibromatous intra-articular tissue ("Clunk syndrome"). There were no revisions for septic or aseptic loosening of the components. The mean ROM improved from 104° preoperatively to 115° (97°-132°) postoperatively: postoperative flexion was 120° or more in 58 % of the knees. Severe anterior knee pain was present in 9% of patients. Radiographic evaluation showed 90 knees with a tibio-femoral anatomical axis between 8° and 2° of valgus (±3° from the intraoperative goal). CT evaluation of 30 consecutive knees showed that the femoral component positioning in relationship to the trans-epicondylar axis had only 2.80° of external rotation (±2.10°) with respect to a planned external rotation of 3°. This difference was statistically significant. CONCLUSIONS Although the PFC Sigma PS system provides good and predictable results for tricompartmental arthritis of the knee, anterior mechanism complications still represent a reason for dissatisfaction in a substantial group of patients.
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Choi WC, Ryu KJ, Lee S, Seong SC, Lee MC. Painful patellar clunk or crepitation of contemporary knee prostheses. Clin Orthop Relat Res 2013; 471:1512-22. [PMID: 23100185 PMCID: PMC3613558 DOI: 10.1007/s11999-012-2652-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Painful patellar clunk or crepitation (PCC) is a resurgent complication of contemporary posterior-stabilized TKA. The incidence, time to presentation, causes, and treatment of PCC still remain controversial. QUESTIONS/PURPOSES We therefore (1) compared the incidence of PCC with five contemporary TKA designs, (2) evaluated the time to presentation, (3) identified possible etiologies, and (4) determined recurrence rate and change in knee functional scores after treatment for PCC. METHODS We reviewed 580 patients who had 826 posterior-stabilized TKAs involving five different designs. The incidences of PCC were compared among the prostheses. The knees were divided into two groups depending on the development of PCC, and possible etiologic factors of PCC, including prosthesis design and surgical or radiographic variables, were compared between groups. We investigated the onset time of PCC and evaluated treatment results by knee outcome scores. Minimum followup was 2.0 years (mean, 3.9 years; range, 2.0-9.8 years). RESULTS The PCC incidence was higher in the Press-Fit Condylar(®) Sigma(®) Rotating Platform/Rotating Platform-Flex Knee System (11 of 113 knees, 9.7%) than in the others (seven of 713 knees, 1.0%). Increased risk of PCC was associated with using a specific prosthesis and patellar retention. PCC occurred in all cases within a year after TKA (mean, 7.4 months). Arthroscopic treatment (16 knees) and patellar replacement (two knees) improved knee scores, with no recurrence observed over an average followup of 29 months. CONCLUSIONS Prosthesis design and patellar retention were associated with PCC. Surgery resolved the PCC.
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Affiliation(s)
- Won Chul Choi
- />Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Keun-Jung Ryu
- />Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sahnghoon Lee
- />Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehang-ro, Jongno-gu, Seoul, 110-744 Korea
| | - Sang Cheol Seong
- />Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehang-ro, Jongno-gu, Seoul, 110-744 Korea
| | - Myung Chul Lee
- />Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehang-ro, Jongno-gu, Seoul, 110-744 Korea
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Tibial tubercle osteotomy or quadriceps snip in two-stage revision for prosthetic knee infection? A randomized prospective study. Clin Orthop Relat Res 2013; 471:1305-18. [PMID: 23283675 PMCID: PMC3586036 DOI: 10.1007/s11999-012-2763-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 12/12/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although 7% to 38% of revision total knee arthroplasties (RTKAs) are attributable to prosthetic knee infections, controversy exists regarding the best surgical approach while reducing the risk of extensor mechanism complications and the reinfection rate. QUESTIONS/PURPOSES We compared The Knee Society Score(©) (KSS), incidences of complications, maximum knee flexion, residual extension lag, and reinfection rate in patients with prosthetic knee infections treated with two-stage RTKAs using either the tibial tubercle osteotomy (TTO) or the quadriceps snip (QS) for exposure at the time of reimplantation. METHODS We prospectively followed 81 patients with chronic prosthetic knee infections treated between 1997 and 2004. Patients were randomized to receive a TTO or QS for exposure at the time of reimplantation. All patients had the same rehabilitation protocol. The minimum followup was 8 years (mean, 12 years; range, 8-15 years). RESULTS Patients in the TTO group had a higher mean KSS than the QS group (88 versus 70, respectively). Mean maximum knee flexion was greater in the TTO group (113° versus 94°); with a lower incidence of extension lag (45% versus 13%). We observed no differences in reinfection rate between groups. CONCLUSIONS We found the TTO combined with an early rehabilitation protocol associated with superior KSS did not impair extensor mechanism function or increase the reinfection rate. We believe a two-stage RTKA with TTO is a reasonable approach for treating prosthetic knee infections. LEVEL OF EVIDENCE Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Indelli PF, Marcucci M, Cariello D, Poli P, Innocenti M. Contemporary femoral designs in total knee arthroplasty: effects on the patello-femoral congruence. INTERNATIONAL ORTHOPAEDICS 2011; 36:1167-73. [PMID: 22202961 DOI: 10.1007/s00264-011-1454-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 11/29/2011] [Indexed: 12/21/2022]
Abstract
PURPOSE The objective of this study was to evaluate the radiological and clinical correlations between implant design and patellar positioning in patients who underwent TKA utilizing femoral implants with modern designs. METHODS Thirty consecutive PFC PS Sigma TKAs, characterized by a new prolonged anterior flange and a "smoother" trochlea, were prospectively reviewed. All patellae were replaced. All patients were evaluated pre-operatively and prospectively at two years follow-up both clinically according to the Knee Society score as well as radiographically. This included computed tomography (CT); patellar tilt, patellar conformity angle, patellar lateralization, and femoral component external-rotation in relation to the clinical trans-epicondylar axis. RESULTS Average patellar tilt at follow-up was 3° (±7.5°) with respect to a pre-operative 18.5° (±8.5°). Average patellar congruence angle at follow-up was -3° (range, -11° to +9°) with respect to a pre-operative 10.3° (range, + 1.5° to 25.5°). Average lateralization index at follow-up was 2.7 mm (range, -3.4 mm to +7.1 mm) with respect to a pre-operative 12.2 mm (± 4.8 mm). Femoral component positioning related to the trans-epicondylar axis showed an external rotation of 2.80° (± 2.10°) at follow-up with respect to 5.7° (± 1.80°). Clinically, two (6.6%) patients reported patello-femoral complications related to imperfections in the surgical technique more than the implant's design. CONCLUSIONS This study highlighted that modern femoral designs in TKA allow for a correct reproducibility of a normal patello-femoral conformity. Strict surgical principles are paramount to avoid patello-femoral complications even when modern implants are used.
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Affiliation(s)
- Pier Francesco Indelli
- CESAT, Universita' degli Studi di Firenze, Piazza Lavagnini 1, Fucecchio, Florence, Italy.
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Becher C, Heyse TJ, Kron N, Ostermeier S, Hurschler C, Schofer MD, Fuchs-Winkelmann S, Tibesku CO. Posterior stabilized TKA reduce patellofemoral contact pressure compared with cruciate retaining TKA in vitro. Knee Surg Sports Traumatol Arthrosc 2009; 17:1159-65. [PMID: 19305974 DOI: 10.1007/s00167-009-0768-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 02/20/2009] [Indexed: 11/29/2022]
Abstract
Increased patellofemoral contact pressure was described after total knee arthroplasty (TKA). Aim of this in vitro study was to compare the influence of a posterior stabilized (PS) design in comparison to a cruciate retaining (CR) design on patellofemoral contact pressure. Patellofemoral area contact pressure, peak contact pressure and the centre of pressure motion were determined in eight fresh frozen human cadaveric specimens using a Tekscan sensor (K-Scan 4000). A robotic knee simulator was used simulating an isokinetic knee extension cycle from 120 degrees of flexion to full extension. All knees were tested in a first test cycle after implantation of a CR design and in a second test cycle after replacement by a PS design, both using a 11 mm PE inlay (Genesis II, Smith & Nephew, Memphis, TN, USA). The patella remained unresurfaced. A paired sampled t test to compare mean values (significance, P < or = 0.05) was used for statistical analysis. After implantation of the PS design, average patellofemoral area contact pressure was significantly lower (P < or = 0.006) compared with the CR design (PS: 3.58 +/- 1.25 MPa; CR: 4.31 +/- 1.40 MPa). Accordingly, average patellofemoral peak contact pressure decreased significantly (P < or = 0.02) with the PS design (6.12 +/- 2.37 MPa) in comparison with the CR design (7.17 +/- 2.41 MPa). On average, the centre of pressure motion was more physiological with the PS design compared to the CR design over the complete extension cycle. However, this was not significant. In conclusion, the data suggest less patellofemoral contact pressure of a posterior stabilized TKA design in comparison to a cruciate retaining design.
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Affiliation(s)
- Christoph Becher
- Orthopaedic Department, Hannover Medical School, Hannover 30625, Germany.
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Lavernia CJ, Alcerro JC, Drakeford MK, Tsao AK, Krackow KA, Hungerford DS. Resection arthroplasty for failed patellar components. INTERNATIONAL ORTHOPAEDICS 2008; 33:1591-6. [PMID: 18956182 DOI: 10.1007/s00264-008-0674-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 09/07/2008] [Indexed: 11/26/2022]
Abstract
A total of 1,401 primary total knee arthroplasties (TKA) were reviewed; 44 (3.2%) had at least the patellar component revised. Nine of these knees (eight patients) had insufficient bone stock to allow reimplantation of another patellar component. Clinical data on the nine knees were obtained with recent follow-up evaluation, review of their medical records and radiographs. Evaluation included Hospital for Special Surgery (HSS) scores. Average follow-up was 4 years and 7 months, 2-year range (2 months to 8 years and 4 months). Common factors found in these nine knees included: thin patella after primary TKR status, osteoarthritis, good range of motion and patella alta. Results were good to excellent in seven knees and fair in two. The untoward associations with patellectomy such as quadriceps lag, extension weakness and anterior knee pain were not experienced. Resection of the patellar component, without reimplantation, is an acceptable alternative in revision TKA lacking adequate remaining bone stock.
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Affiliation(s)
- Carlos J Lavernia
- Orthopaedic Institute at Mercy Hospital, 3659 South Miami Avenue Suite 4008, Miami, FL 33133, USA.
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Quality of life after TKA for patients with juvenile rheumatoid arthritis. Clin Orthop Relat Res 2008; 466:167-78. [PMID: 18196390 PMCID: PMC2505301 DOI: 10.1007/s11999-007-0010-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 10/08/2007] [Indexed: 01/31/2023]
Abstract
UNLABELLED Total knee arthroplasty frequently is required during early adulthood in patients with advanced juvenile rheumatoid arthritis. We queried patients on issues of importance to them, asked whether they were satisfied with surgical outcomes, and ascertained their postoperative status. We retrospectively reviewed 14 adult patients (22 knees) with severe juvenile rheumatoid arthritis who were treated with primary total knee arthroplasty between 1989 and 2001. All patients were evaluated by pain and stiffness visual analog scales, range of motion, the Patient-Specific Index, Hospital for Special Surgery knee score, WOMAC Osteoarthritis Index, EuroQuol in five dimensions, and SF-36 Health Survey. Preoperative scores were assessed by recall. Patients had a minimum followup of 2 years (mean, 8 years; range, 2-13 years). Quality of life improved after TKA as measured by the Patient-Specific Index. Eighteen of 22 patients rated themselves satisfied with the functional outcome of their surgery; all patients were satisfied with pain relief. Final SF-36, EuroQuol in five dimensions, and WOMAC scores were low compared with age-matched population norms. A mean postoperative flexion arc of 77 degrees (range, 30 degrees -130 degrees ) was observed. Total knee arthroplasty had a major positive impact on quality of life as reported by patients. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Berti L, Benedetti MG, Ensini A, Catani F, Giannini S. Clinical and biomechanical assessment of patella resurfacing in total knee arthroplasty. Clin Biomech (Bristol, Avon) 2006; 21:610-6. [PMID: 16516359 DOI: 10.1016/j.clinbiomech.2006.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 12/07/2005] [Accepted: 01/10/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND Currently there is a limited understanding of the factors influencing range of motion by comparing patellar resurfacing vs non-resurfacing in total knee arthroplasty during activities of daily living. A recent meta-analysis of patellar replacement confirms better outcome with patella resurfacing; however, the result can be influenced by many other factors, such as: component design, surgeon experience, and technical aspects of the surgery. This study compares the biomechanics of the knee in patients after total knee arthroplasty with and without patellar resurfacing during stair climbing. METHODS Forty-seven patients with total knee arthroplasty were assessed at the mean follow-up of 24 months. In all of them a posterior stabilised fixed bearing prosthesis (Optetrak PS, Exactech) was implanted. Twenty-six patients were treated without patellar resurfacing and 21 with patellar resurfacing. Clinical evaluations were performed using the International Knee Society and the Hospital for Special Surgery scores. Ten patients with patellar resurfacing and 10 patients without patellar resurfacing were also studied with motion analysis during stair climbing; 10 healthy subjects were studied for statistical comparison. FINDINGS Clinical passive knee flexion, International Knee Society Function and Hospital for Special Surgery scores were significantly higher in the patellar resurfacing group. During stair climbing, active knee joint range of motion during the stance phase was greater in patients with patellar resurfacing. The maximum adduction moment was significantly higher in the group without patellar resurfacing. INTERPRETATION Patients with patellar resurfacing demonstrated better clinical scores, and kinematic and kinetic data while ascending stairs.
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Affiliation(s)
- Lisa Berti
- Movement Analysis Laboratory, Department of Orthopaedic Surgery, Istituti Ortopedici Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
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Clarke HD, Fuchs R, Scuderi GR, Mills EL, Scott WN, Insall JN. The influence of femoral component design in the elimination of patellar clunk in posterior-stabilized total knee arthroplasty. J Arthroplasty 2006; 21:167-71. [PMID: 16520202 DOI: 10.1016/j.arth.2005.05.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2004] [Accepted: 05/15/2005] [Indexed: 02/01/2023] Open
Abstract
Patellar clunk occurs after posterior-stabilized total knee arthroplasty and is believed to be a design-related complication. This study was undertaken to define the incidence of patellar clunk with an optimized third-generation, posterior-stabilized prosthesis. One hundred ninety three patients with 238 knees were evaluated at a minimum of 2 years after primary total knee arthroplasty with a cemented, NexGen Legacy Posterior-Stabilized prosthesis (Zimmer, Warsaw, Ind). The mean follow-up was 48 months (range, 24-72 months). No patient manifested symptoms of patellar clunk or underwent surgery for any patello-femoral problem. These results support prior evidence that femoral component design is the primary cause of patellar clunk and that modifications incorporated into this third-generation, posterior-stabilized prosthesis has eliminated the problem.
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Affiliation(s)
- Henry D Clarke
- Department of Orthopedics, Mayo Clinic, Scottsdale, Arizona 85259, USA
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Abstract
The literature on routine patellar resurfacing documents that the rate of anterior knee pain after TKA is the same whether the patella is resurfaced or unresurfaced. The complication rate is different in these groups. In patients in whom the native patella is left, the rate of reoperation is approximately 10%. However, when correct surgical technique is used, the rate of patellar complications after routine resurfacing is negligible. Although design modifications have helped reduce patellar complications, the surgeon is the most important variable. As long as good technique is used, routine patellar resurfacing has been proven to produce the best results in TKA.
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Affiliation(s)
- W Norman Scott
- Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, Beth Israel Medical Center-Singer Division, New York, NY, USA
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