Total knee arthroplasties from the origin to navigation: history, rationale, indications

Does the clinical and radiologic outcomes following total knee arthroplasty using a new design cobalt-chrome tibial plate or predecessor different?

BACKGROUND

This study aimed to compare clinical and radiographic outcomes for a new tibial component (Attune S +) and the previous design (Attune S) in total knee arthroplasty (TKA) patients using ATTUNE® posterior stabilized (PS) prosthesis and also assessed related factors for the development of tibial radiolucent line(RLL).

METHODS

This retrospective study included 362 knees (179 Attune S, 183 Attune S +) with an average 4 years (range, 2-8) follow-up. Clinical outcomes, radiologic parameters and the incidence of RLL around the tibial component were compared through the serial assessment. For the subgroup analysis, radiologic parameters were compared between patients with and without RLL.

RESULTS

There was no significant difference in terms of clinical outcomes and radiologic parameters between two designs. The incidence of RLL was not different through the serial follow-up (P > 0.05). In the subgroup analysis, the preoperative medial proximal tibial angle (83.7° versus 85.0°, P = 0.01) was smaller and preoperative hip-knee-ankle angle (169.1° versus 171.8°, P = 0.01) has more varus in the group with RLL than those without.

CONCLUSIONS

The clinical and radiologic outcomes including the incidence of tibial RLL between new design and predecessor were not significantly different at average 4 years follow-up. The development of tibial RLL was associated with preoperative varus deformity of tibia and lower limb alignment.

Economic burden of knee joint replacement in Iran

BACKGROUND

The knee is the most commonly afflicted weight-bearing joint. Osteoarthritis of the knee is regarded as one of the most commonly diagnosed causes of disability in the elderly. Knee joint replacement can be regarded as a final solution for Osteoarthritis of the knee in which the joint is worn out, accompanied by clinical symptoms such as pain, deformity, and limited movement.

AIM

this study sought to estimate the economic burden of knee joint replacement procedures carried out in Iran.

METHOD

This cross-sectional descriptive study utilized the Incidence-based approach to assess the economic burden of knee joint replacement surgeries conducted in Iran during 2022, estimating the costs of the disease from a societal perspective. The sampling method employed was random sampling, and the sample size consisted of 300 patients. Direct costs were calculated employing the top-down approach, while indirect costs were estimated using the human capital approach. Microsoft Excel was employed for data analysis.

RESULT

The average direct medical costs of the knee replacement procedure per patient were $10,076.87 and $13,099.93 in the public and private sectors, respectively. The average direct non-medical costs of knee joint replacement surgery are $1123.64, with companion costs constituting most of the direct non-medical costs. Finally, the economic burden of the knee joint replacement surgery was estimated at $67340417.28.

CONCLUSION

Despite insurance coverage, knee joint replacement surgery in Iran incurs substantial costs. With the anticipated rise in the elderly population, the frequency of these procedures is expected to increase, amplifying the economic burden on the Iranian public.

No Benefit of Robotic-Assisted over Computer-Assisted Surgery for Achieving Neutral Coronal Alignment in Total Knee Arthroplasty

The use of robotic-assisted surgery (RAS) in total knee arthroplasty (TKA) is becoming increasingly popular due to better precision, potentially superior outcomes and the ability to achieve alternative alignment strategies. The most commonly used alignment strategy with RAS is a modification of mechanical alignment (MA), labeled adjusted MA (aMA). This strategy allows slight joint line obliquity of the tibial component to achieve superior balancing. In the present study, we compared coronal alignment after TKA using RAS with aMA and computer-assisted surgery (CAS) with MA that has been the standard in the center for more than 10 years. We analyzed a prospectively collected database of patients undergoing TKA in a single center. Lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were compared for both techniques. In 140 patients, 68 CASs and 72 RASs, we observed no difference in postoperative measurements (median 90 degrees for all, LDFA p = 0.676, MPTA p = 0.947) and no difference in outliers <2 degrees (LDFA p = 0.540, MPTA p = 0.250). The present study demonstrates no benefit in eliminating outliers or achieving neutral alignment of both the femoral and the tibial components in robotic-assisted versus computer-assisted TKA if MA is the target. To utilize the precision of RAS, it is recommended to aim for more personalized alignment strategies. The level of evidence is level III retrospective study.

Duloxetine for rehabilitation after total knee arthroplasty: a systematic review and meta-analysis

OBJECTIVE

The aim was to evaluate the efficacy and safety of duloxetine for postoperative recovery after total knee arthroplasty.

METHODS

The following electronic databases were searched for eligible trials: PubMed, EMBASE, Web of Science, Cochrane Library, VIP, Wanfang Data, and China National Knowledge Infrastructure (CNKI). The search was performed from the inception dates to 10 August 2022. Data extraction and quality assessment were performed by two independent reviewers. Standard mean differences or mean differences with 95% CIs for pooled data were calculated. The primary outcomes were pain, physical function, and analgesic consumption. Secondary outcomes included range of motion (ROM) of the knee, depression, and mental health.

RESULTS

This meta-analysis included 11 studies, reporting on a total of 1019 patients. Results of analyses indicated that duloxetine showed a statistically significant reduction in pain at rest at 3 days, 1 week, 2, and 6 weeks and pain on movement at 5 days, 1 week, 2, 4, 6, and 8 weeks. However, there was no statistical significance in pain at rest and on movement at 24 h, 12 weeks, 6 months, and 12 months. Additionally, duloxetine had a significant improvement in physical function, ROM of the knee at 6 weeks, and emotional function (depression and mental health). Moreover, the cumulative opioid consumption at 24 h in the duloxetine groups was lower than in the control groups. But there was no statistical significance for the cumulative opioid consumption over 7 days between the duloxetine groups and controls.

CONCLUSIONS

In conclusion, duloxetine might reduce pain mainly over a time span of 3 days-8 weeks and lower cumulative opioid consumption within 24 h. In addition, it improved physical function, ROM of the knee with a time span of 1-6 weeks and emotional function (depression and mental health).

No Difference in Clinical Outcomes and Survivorship for Robotic, Navigational, and Conventional Primary Total Knee Arthroplasty with a Minimum Follow-up of 10 Years

Background

Computer-assisted surgery, including robotic and navigational total knee arthroplasty (TKA), has been proposed as a technique used to improve alignment of implants. The purpose of this study was to compare the clinical and radiological outcomes during a minimum follow-up period of 10 years among robotic, navigational, and conventional TKA.

Methods

A total of 855 knees (robotic group, 194; conventional group, 270; and navigational group, 391) were available for physical and radiological examinations over a mean follow-up period of 10 years. The survival rate was analyzed using the Kaplan-Meier method based on the survival endpoint. The Hospital for Special Surgery score, Western Ontario and McMaster Universities Osteoarthritis Index, Knee Society Score, and range of motion were used for clinical evaluation. The hip-knee-ankle (HKA) axis angle, the coronal inclination of femoral and tibial components, and the presence of radiolucent lines were also assessed at the final follow-up.

Results

All clinical assessments at the final follow-up revealed improvements in the three groups without any significant difference among the groups (p > 0.05). The cumulative 10-year survival rate was 97.4% in the robotic group, 96.6% in the conventional group, and 98.2% in the navigational group, with no significant difference (p = 0.447). The rates of complication-associated surgery were not significantly different among the groups (p = 0.907). Only the proportion of outliers in the HKA axis angle showed a significant difference (p = 0.001), but other radiological outcomes were not significantly different among the three groups.

Conclusions

Our study demonstrated satisfactory survival rates for robotic, navigational, and conventional TKAs and similar clinical outcomes during the long-term follow-up. Larger studies with continuous serial data are needed to confirm these findings.

Biomechanical and Finite-Element Analysis of Femoral Pin-Site Fractures Following Navigation-Assisted Total Knee Arthroplasty

BACKGROUND

Femoral pin-site fracture is one of the most serious complications of navigation-assisted total knee arthroplasty (TKA). Its occurrence is associated with the loss of biomechanical strength caused by intraoperative femoral drilling. This study aimed to investigate the drilling location as a risk factor for pin-site fracture.

METHODS

A biomechanical analysis using rabbit femora was performed to determine the effects of drilling eccentricity and height. Torsional, 3-point bending, and axial compression tests were performed to evaluate biomechanical parameters, including failure strength, failure displacement, and stiffness. Fracture type and the presence of comminution were noted and analyzed. Finite-element analysis (FEA) was utilized to assess the stress distribution and deformation. The cumulative sum (CUSUM) method was applied to define the safe range for drilling eccentricity.

RESULTS

Drilling operations were accurately implemented. Biomechanical tests confirmed that severely eccentric drilling significantly reduced the biomechanical strength of the femur, especially in torsion. FEA results provided evidence of threatening stress concentration in severely eccentric drilling. The overall safe range of eccentricity relative to the center of the femur was found to be between 50% of the radius in the anterolateral direction and 70% of the radius in the posteromedial direction.

CONCLUSIONS

Severely eccentric drilling significantly increased the risk of femoral pin-site fracture, especially under torsional stress. Femoral drilling should be performed in the safe zone that was identified.

Status and future of modern technologies in arthroplasty : Results of a survey of the German Society for Orthopedics and Trauma Surgery (DGOU)

BACKGROUND

The orthopedic community is divided on the question of whether modern technologies in arthroplasty improve outcomes. Therefore, the aim of this initiative of the working group on intraoperative imaging and technology integration (Arbeitsgemeinschaft intraoperative Bildgebung und Technologieintegration, AGiTEC) is to initiate the collection of additional data for the scientific evaluation of modern technologies.

QUESTION

To what extent are modern technologies currently used and which implementations are planned? Do the members of the German Society for Orthopedics and Trauma Surgery (DGOU) consider the acquisition of additional data for scientific assessment necessary?

METHODS

Members of the DGOU were asked via an e‑mail survey about the distribution and projected introduction of modern technologies in arthroplasty. They were also asked whether sufficient data were collected for scientific evaluation and whether acquisition of additional data in studies or arthroplasty registries were considered necessary.

RESULTS

Of the 7923 probands surveyed, 428 completed the questionnaire in full (5.4%). It was found that individual implants and navigation are currently the most frequently used (31% and 29%, respectively). The largest increases in the next 2 years are projected for virtual reality and robotics (+30% and +23%, respectively), 85% of respondents indicated that insufficient data were collected for scientific evaluation, and 89% each requested initiation of multicenter studies and inclusion of technologies in the arthroplasty registry.

CONCLUSION

The results of this study should motivate the scientific community, industry, and those responsible for the arthroplasty registries to collect and analyze data for the scientific assessment of modern technologies.

Recent trends in revision knee arthroplasty in Germany

We aimed to answer the following questions: (1) How did numbers of revision knee arthroplasty procedures develop in Germany over the last decade compared to primary TKA? (2) How high was the percentage of septic interventions in knee prosthesis revisions? (3) Which treatment strategy was chosen for surgical treatment of knee PJI? Revision arthroplasty rates as a function of age, gender, infection and type of prosthesis were quantified based on Operation and Procedure Classification System codes using revision knee arthroplasty data from 2008 to 2018, provided by the Federal Statistical Office of Germany (Destatis). In 2018, a total number 23,812 revision knee arthroplasties were performed in Germany, yielding an overall increase of 20.76% between 2008 and 2018. In comparison, primary TKA procedures increased by 23.8% from 152,551 performed procedures in 2008 to 188,866 procedures in 2018. Hence, 12.6% of knee arthroplasties required a revision in 2018. Septic interventions increased by 51.7% for all revisions. A trend towards higher numbers in younger patients was observed. Compared to 2008, 17.41% less DAIR procedures were performed, whereby single-stage and two- or multi-stage change increased by 38.76% and 42.76% in 2018, respectively. The increasing number of revision knee arthroplasty in Germany, especially in younger patients and due to infection, underlines the need for future efforts to improve treatment strategies to delay primary arthroplasty and avoid periprosthetic joint infection.

Recent Trends, Technical Concepts and Components of Computer-Assisted Orthopedic Surgery Systems: A Comprehensive Review

Computer-assisted orthopedic surgery (CAOS) systems have become one of the most important and challenging types of system in clinical orthopedics, as they enable precise treatment of musculoskeletal diseases, employing modern clinical navigation systems and surgical tools. This paper brings a comprehensive review of recent trends and possibilities of CAOS systems. There are three types of the surgical planning systems, including: systems based on the volumetric images (computer tomography (CT), magnetic resonance imaging (MRI) or ultrasound images), further systems utilize either 2D or 3D fluoroscopic images, and the last one utilizes the kinetic information about the joints and morphological information about the target bones. This complex review is focused on three fundamental aspects of CAOS systems: their essential components, types of CAOS systems, and mechanical tools used in CAOS systems. In this review, we also outline the possibilities for using ultrasound computer-assisted orthopedic surgery (UCAOS) systems as an alternative to conventionally used CAOS systems.

[Digitalization and artificial intelligence in orthopedics and traumatology]

In the course of digitalization it is becoming increasingly rare for medical documents to be handwritten. As a result, digitalization has already become an integral part of routine patient care but in contrast to other specialist disciplines, such as radiology or laboratory medicine, orthopedics and trauma surgery are still at the beginning of new technologies. Artificial intelligence is not only used in the form of surgical robots in joint surgery or in the design of individualized implants but also provides valuable decision-making aids through appropriate algorithms for diagnosis and treatment. It can be assumed that these technologies will be further developed and used increasingly more in the coming years. Typical examples are intuitively operable and autonomously working programs and systems that support the networking and work of medical personnel and make processes inside and outside inpatient care more precise and less vulnerable to disturbances.

Conventional versus computer-assisted surgery in total knee arthroplasty: comparison at ten years follow-up

PURPOSE

Computer-assisted systems (CAS) for total knee arthroplasty (TKA) were expected to result in more accurate prosthesis implantation, better patient outcomes, and longer implant survival when compared to conventional instrumentation (CI). The aim of this study was to compare two groups of patients operated using CAS or CI at ten years follow-up.

METHODS

One hundred twenty TKA patients, 60 using CAS and 60 using CI, were contacted after a decade for follow-up. Eligible patients received radiological examination to assess the lower-limb mechanical axis. They were also clinically assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Knee Society Score for Knee (KSS-K) and Function (KSS-F) Scoring. Kaplan-Meier survival analysis was performed to assess revisions, not for post-traumatic reasons.

RESULTS

In CAS and CI groups, the lower-limb mechanical axis was 1.7° ± 2.4° and 1.5° ± 2.8°, respectively; corresponding KOOS values were 82.3 ± 14.3 and 78.6 ± 14.4; KSS-K values were 85.9 ± 11.1 and 85.0 ± 9.7; KSS-F values were 82.2 ± 19.3 and 83.8 ± 18. For these assessments, the differences between the two groups were not statistically significant (p > 0.05). Two CAS (3.8%) and three CI patients (5.7%) were revised. The Kaplan-Meier analysis showed no significant differences between the two groups.

CONCLUSIONS

No significant differences were found at long-term follow-up in terms of radiographical-clinical outcomes and of implant survival between TKA operated using CAS or CI.