Knee arthroplasty today

Research advance of 3D printing for articular cartilage regeneration

Articular cartilage lesion frequently leads to dysfunction and the development of degenerative diseases, posing a significant public health challenge due to the limited self-healing capacity of cartilage tissue. Current surgical treatments, including marrow stimulation techniques and osteochondral autografts/allografts, have limited efficacy or have significant drawbacks, highlighting the urgent need for alternative strategies. Advances in 3D printing for cartilage regeneration have shown promising potential in creating cartilage-mimicking constructs, thereby opening new possibilities for cartilage repair. In this review, we summarize current surgical treatment methods and their limitations for addressing articular cartilage lesion, various 3D printing strategies and their features in cartilage tissue engineering, seed cells from different sources, and different types of biomaterials. We also explore the benefits, current challenges, and future research directions for 3D printing in the treatment of articular cartilage lesion within the field of cartilage tissue engineering.

A pilot study on preferences from surgeons to deal with an innovative customized and connected knee prosthesis - A discret choice experiment

Background

To address the increasing global demand for Total Knee Arthroplasty and reduce the need for revisions, several technologies combining 3D planning and artificial intelligence have emerged. These innovations aim to enhance customization, improve component positioning accuracy and precision. The integration of these advancements paves the way for the development of personalized and connected knee implant.

Questions/purposes

These groundbreaking advancements may necessitate changes in surgical practices. Hence, it is important to comprehend surgeons' intentions in integrating these technologies into their routine procedures. Our study aims to assess how surgeons' preferences will affect the acceptability of using this new implant and associated technologies within the entire care chain.

Methods

We employed a Discrete Choice Experiment, a predictive technique mirroring real-world healthcare decisions, to assess surgeons' trade-off evaluations and preferences.

Results

A total of 90 experienced surgeons, performing a significant number of procedures annually (mostly over 51) answered. Analysis indicates an affinity for technology but limited interest in integrating digital advancements like preoperative software and robotics. However, they are receptive to practice improvements and considering the adoption of future sensors.

Conclusions

In conclusion, surgeons prefer customized prostheses via augmented reality, accepting extra cost. Embedded sensor technology is deemed premature by them.

Total knee arthroplasty in France: Male-driven rise in procedures in 2009-2019 and projections for 2050

BACKGROUND

The number of Total Knee Arthroplasty (TKA) procedures has been rising steadily for several decades in Europe and the USA. The increase varies in pace across countries, with a gradual climb in northern and central Europe, a slowing in the USA, and an exponential surge in the UK. In France, a 32.2% rise in the number of TKA and unicompartmental knee arthroplasty procedures was documented between 2012 and 2018. However, no study has focussed specifically on changes in both TKA procedures and the features of TKA patients. The objective of this study was to use the French national healthcare database to evaluate (1) increases in TKA procedures according to sex and age, (2) whether TKA is being performed at increasingly younger ages, (3) whether the comorbidity profile at TKA is changing, and (4) whether the TKA incidence rate will stabilise in the future, with a projection for 2050.

HYPOTHESIS

In France, the number of TKA procedures is rising in both males and females but the pace of the increases differs between sexes.

MATERIAL AND METHOD

This study used data collected in France in 2009-2019, separately for different age groups and for males and females, in the French national healthcare database (Système national des données de santé, SNDS) that collects information on all surgical procedures performed nationwide. Based on information about the TKA procedures, we determined (1) the TKA incidence rates with their time trends and (2) indirectly, the comorbidity profiles of the patients at TKA. Linear, Poisson, and logistic models were built to predict incidence rates in 2030, 2040, and 2050.

RESULTS

Between 2009 and 2019, the TKA incidence rate showed a steeper increase in males than in females (from 71.2 to 122.9 [+73%] vs. 124.2 to 181.0 [+46%], respectively). Although this increase was replicated in all age groups, it was sharper in patients younger than 65 years, in both males and females (from 20.9 to 37.9 [+82%] and 33.6 to 51.3 [+53%], respectively). During the study period, the number and proportion of patients increased in the group with mild comorbidities (from 40 093 to 67 430 TKAs, i.e., from 53.1% to 65.7% of all TKAs) but not in the other comorbidity groups. All projection models were validated. Nonetheless, the most likely scenario, provided by the logistic model, is a 33% rise by 2050 in both males and females (i.e., to 151 575 TKA procedures) with a plateau starting around 2030.

CONCLUSION

Although the increase in TKA procedures is more marked in males than in females, the trends are similar in both sexes, with a sharper rise in the group younger than 65 years and a shift toward patients with milder comorbidities. In the longer term, incidence rate trends follow logistic dynamics, with a plateau starting around 2030. To meet the increasing demand, a corresponding development in relevant healthcare resources must be planned.

LEVEL OF EVIDENCE

IV, descriptive epidemiological study.

Robotic-assisted total knee arthroplasty in clinical practice: protocol for a randomised controlled trial

Between 2 and 20% of patients who undergo total knee arthroplasty (TKA) report restricted motion and anterior knee pain. Non-optimal alignment of the implant components is a common cause of such complaints. Robotic-assisted TKA has been advocated to improve the accuracy of component positioning to match patients' anatomy and biomechanics. However, the advantages of robotic surgery over conventional freehand TKA are still unclear. The present study is a protocol for a single-blind clinical trial in which patients will be randomly allocated to undergo either robotic-assisted TKA or conventional freehand TKA. A restricted kinematic alignment with medial para-stellar approach shall be made in all patients. The present study follows the SPIRIT guidelines. The primary outcome of interest is to compare robotic TKA versus traditional freehand TKA in terms of patient-reported outcome measures (PROMs), length of hospitalisation, blood values, blood transfusion units, and range of motion. The second outcome of interest is to evaluate the accuracy of component positioning of robotic-assisted TKA compared to the conventional freehand TKA.Level of evidence Level I, randomised controlled trial.Registration German Registry of Clinical Trials (ID: DRKS00030614).

Negative Association of Subclinical Hypothyroidism on Improvement in Patient-Reported Outcomes After Total Knee Arthroplasty

BACKGROUND

The purpose of this study is to analyze the potential influence of subclinical hypothyroidism (SCH) on improvement in patient-reported outcome measures following primary total knee arthroplasty.

METHODS

A prospective, comparative cohort study between 92 SCH and 90 euthyroid patients was performed. Patients were followed up to 5 postoperative years. Patient-reported outcome measure was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. The Knee Society Scores were used for functional evaluation, and 5-point Likert scale for patient satisfaction. The Hospital Anxiety and Depression scale was also used.

RESULTS

All outcome scores significantly improved from preoperative to final follow-up in both groups (P = .001). There were no significant differences between groups in Knee Society Scores (P = .057) at the final follow-up, but Western Ontario and McMaster Universities Osteoarthritis Index scores were significantly lower in the SCH group (P = .015). Likewise, the patient satisfaction rate was significant lower in the SCH group (0.010).

CONCLUSION

SCH patients have a slower functional recovery than euthyroid patients, and trended toward lower improvements in patient-reported scores. Depression was the most important negative factor. The findings of this study can provide the surgeon with an important information for better counseling the SCH patients.

Medial femoral epicondyle upsliding osteotomy with posterior stabilized arthroplasty provided good clinical outcomes such as constrained arthroplasty in primary total knee arthroplasty with severe valgus deformity

PURPOSE

A modified technique referred to as a medial femoral epicondyle upsliding osteotomy was proposed to address severe valgus deformity with unconstrained posterior stabilized (PS) arthroplasty. The study compared the effectiveness of the technique and PS arthroplasty with constrained arthroplasty during primary total knee arthroplasty (TKA).

METHODS

Fifty-three patients presenting with valgus knees with a mean valgus angle (VA) greater than 30° were prospectively randomized and divided into two groups, and both groups received primary TKA. Upsliding osteotomy with PS arthroplasty was performed on the knees of 27 patients (group A), while the remaining 26 patients (group B) received a constrained arthroplasty. The Knee Society function score (KSF), Hospital for Special Surgery knee score (HSS), range of motion (ROM), mediolateral stability and hospitalization expenses were recorded. The hip-knee-ankle angle (HKA), femorotibial angle (FTA) and VA were analysed. Complications were also recorded.

RESULTS

The patients received follow-up care for more than 50 months. The postoperative KSF, HSS and ROM showed marked improvement in both groups (p < 0.05). Radiological assessments showed that HKA, FTA and VA for group A were restored to (179.9 ± 3.0)°, (173.0 ± 2.4)° and (7.0 ± 2.4)°, respectively. For group B, the HKA, FTA and VA were restored to (181.5 ± 2.3)°, (172.5 ± 2.3)° and (7.5 ± 2.3)°, respectively. Only two patients from group A demonstrated mild medial laxity in their knees, and the remaining patients from both groups were stable medially and laterally. However, the total hospitalization expenses and material expenses of group A were less than those of group B because of the more expensive constrained prosthesis and stems. No late-onset loosening or recurrent valgus deformity was displayed.

CONCLUSIONS

Both medial femoral epicondyle upsliding osteotomy with PS arthroplasty and constrained arthroplasty showed good outcomes for the restoration of neutral limb alignment and soft tissue balance, which are demonstrated to be safe and effective techniques for correcting severely valgus knees. Therefore, the clinically important finding of this study is that medial femoral epicondyle upsliding osteotomy with PS arthroplasty can be an alternative method for correcting severe valgus knees.

LEVEL OF EVIDENCE

II.

Total knee arthroplasty in Italy: reflections from the last fifteen years and projections for the next thirty

PURPOSE

Annual rates of knee arthroplasty are increasing in all developed countries, imposing a significant economic and organizational burden; it is crucial to forecast the future need for knee arthroplasty, to assist stakeholders in planning strategies and investments, especially in a country like Italy, with the largest proportion of elderly citizens in Europe. Few epidemiological studies have been performed worldwide to estimate the demand for future knee replacement, and a variety of methods have been proposed.

METHODS

We investigated the epidemiology of knee arthroplasty performed in Italy in the last 15 years and projected incidence rates up to the year 2050, utilizing, comparing, and adapting the available methodologies.

RESULTS

From 2001 to 2016, 812,639 primary TKA were performed in Italy on patients over 40. The total number of surgeries increased by 262% with an average annual growth rate of 6.6%.

CONCLUSIONS

Adopting the best fitting projection method, an increase of 45% in incidence rate is expected for 2050.

Better results with patelloplasty compared to traditional total knee arthroplasty

PURPOSE

The aim of this study was to compare the results of primary total knee arthroplasty with or without patelloplasty.

METHODS

We retrospectively reviewed 89 patients who had received total knee arthroplasty. In patelloplasty, the patellar cartilage was resected using a tangential saw cut, and in the traditional treatment, only the surrounding osteophytes were removed. The outcome was measured using radiographs, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, Knee Society Score, Knee Society Function Score and Knee Society Pain Score.

RESULTS

Patelloplasty patients had a better outcome according to the Oxford Knee Score (P = 0.012), Knee Injury and Osteoarthritis Outcome Score (P = 0.003) and all of the Knee Injury and Osteoarthritis Outcome Score subscales (P < 0.05). The patella was significantly thinner (P = 0.001) post-operatively in the patelloplasty patients, but there was no statistically significant correlation between Oxford Knee Score or Knee Injury and Osteoarthritis Outcome Score and post-operative patellar thickness in the patelloplasty group.

CONCLUSIONS

In this follow-up, patelloplasty was better than traditional treatment in relieving pain and improving function and quality of life.