Bone quality of the calcaneus 5years after total knee arthroplasty

Patient-Centered Discharge and Postoperative Length of Hospital Stay in Primary Total Knee Arthroplasty

Background This study aimed to identify factors affecting the length of hospital stay (LOS) after total knee arthroplasty (TKA) in patients classified as American Society of Anesthesiologists (ASA) physical status I or II, with a focus on patient-dependent determination of discharge. The goal was to explore strategies to shorten LOS. Methods A retrospective cohort study was conducted on 398 patients (494 knees) who underwent primary TKA. Factors associated with LOS were analyzed, including age, body mass index, operative time, clinical scores, anemia, albumin levels, age group, sex, and ASA physical status. Data are presented as medians (interquartile range). Results The median LOS for all patients was 35 days (range: 29-42 days). Patients aged 80 and over had a significantly longer LOS (39 days; range: 31-45) compared to younger age groups (vs. less than 60s: 32 days (range: 26-37 days), p=0.016; vs. 60s: 33 days (range: 30-38 days), p<0.001; vs. 70s: 35 days (range: 29-43 days), p=0.033). Females also had a significantly longer LOS (36 days [range: 30-43 days]) compared to males (31 days [range: 24-40 days]; p<0.001). Multivariate analysis confirmed that being aged 80 or over (p<0.001) and being female (p<0.001) were significantly associated with longer LOS. Conclusion Postoperative interventions tailored for patients aged 80 years or older and females may be effective in shortening LOS after TKA. A patient-centered approach suggests a maximum LOS of approximately five weeks. Balancing provider-driven early discharge with patient-centered extended stays is crucial for optimizing postoperative care.

Association of bone health by calcaneal quantitative ultrasound with quadriceps strength and function one year after unilateral total knee arthroplasty

Introduction

Although total knee arthroplasty (TKA) effectively improves knee pain and functional decline due to knee osteoarthritis, hip fractures are more likely to occur in the first year after surgery. Bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) decreases in the first year after TKA, but it is not clear whether BMD measured by quantitative ultrasound (QUS) also shows a decrease. This study aimed to evaluate the change in QUS parameters before and 1 year after TKA and to investigate the association of QUS parameters with quadriceps strength and function 1 year after TKA.

Methods

This prospective cohort study included 30 patients scheduled for their unilateral TKA. We assessed BMD using QUS before and 1 year after surgery. Quadriceps strength was assessed using a hand-held dynamometer, and function was assessed using a self-reported questionnaire. A linear mixed model estimated the mean difference in QUS parameters before and 1 year after TKA. A general linear model was also used to examine the association of QUS parameters with quadriceps strength and self-reported function at 1 year after surgery.

Results

We found no significant decrease in the QUS parameters on either the surgical or non-surgical side at 1 year postoperatively compared to preoperatively. The QUS parameters were not associated with quadriceps strength or self-reported function on either the surgical or non-surgical side at 1 year postoperatively.

Conclusions

QUS alone may not be sufficient to detect changes in BMD from before surgery to 1 year after TKA. Clinicians should evaluate BMD preoperatively to identify patients at high risk for hip fractures and develop a program to prevent postoperative hip fractures.

Level of evidence

Level 3, Cohort study.

Long-Term Nonoperative Management is Associated With Lower Mean 9-Year Follow-Up Survival Compared to Total Knee Arthroplasty in Knee Osteoarthritis Patients-Survival Analysis of a Nationwide South Korean Cohort

BACKGROUND

Total knee arthroplasty (TKA) and medications are both considered as a treatment for knee osteoarthritis. However, the impact of the TKA on long-term survival remains controversial. This study aimed to compare 9-year follow-up survival between a TKA group with a nonoperative medication group.

METHODS

From 2007 to 2009, knee osteoarthritis patients were divided into TKA (N = 2,228) and nonoperative medication (N = 76,430) groups, and followed for up to 9 years. The hazard ratio (HR) and subdistribution HR (SHR) were derived from Cox proportional hazards regressions and Fine and Gray analyses, respectively.

RESULTS

The TKA group had a significantly lower adjusted mortality rate (adjusted HR , 0.78, 95% confidence interval [CI], 0.68-0.9) than the nonoperative medication group. Dose-response relationship between medication possession ratio and mortalities for overall (adjusted HR , 1.02; 95% CI, 1.01-1.04) and cardiovascular (CV) death (adjusted SHR, 1.03; 95% CI, 1.01-1.05) was also found. Also, there were significant interactions that indicate stronger protective survival effects of the TKA in several covariates: age >75 years (P = .04 for overall; P = .009 for CV), hypertension (P = .006 for overall), and ischemic heart disease (P = .009 for CV).

CONCLUSIONS

This study suggests that TKA patients had better mean 9-year follow-up survival than the nonoperative medication group after adjusting for baseline differences. For overall death, including CV death, adjusted mortality rates were higher in the medication group and showed a dose-response relationship. Specifically, the protective effect of the TKA for overall or CV deaths was found to be higher for age >75, hypertension, or ischemic heart disease patients.

LEVEL OF EVIDENCE

III.

Positive effect of total knee arthroplasty on progression of arteriosclerosis evaluated by cardio-ankle vascular index

INTRODUCTION

Physical function is expected to improve with an increase in physical activity owing to improvement in knee joint pain after total knee arthroplasty (TKA). This study was performed to evaluate the impact of TKA on arteriosclerosis by measuring the cardio-ankle vascular index (CAVI) before and after surgery.

MATERIALS AND METHODS

In total, 206 consecutive patients undergoing unilateral TKA were investigated. The CAVI, an index of the overall stiffness of the artery from the origin of the aorta to the ankle, was used to evaluate the degree of arteriosclerosis. The CAVI of the TKA side and non-TKA side was compared before and 1 year after TKA.

RESULTS

There were no differences in the CAVI before and after TKA on the TKA side and non-TKA side, although these values should have worsened at 1 year compared with preoperative values. The CAVI, which did not differ between the two sides preoperatively, differed significantly between the two sides postoperatively (p = 0.013). A generalized linear model showed no interaction between each time point and the measured sides in terms of the CAVI. The relationship between the preoperative CAVI and the difference between the preoperative and postoperative CAVI were examined, showing that R =  - 0.428 (p < 0.001) for the TKA side and R =  - 0.416 (p < 0.001) for the non-TKA side (significant negative correlation).

CONCLUSIONS

The lack of significant age-related deterioration over time on both sides suggests that TKA may slow the progression of arteriosclerosis, especially on the operated side. The effect of TKA was found to be greater with a higher CAVI (i.e., more advanced arteriosclerosis).

Reference Values and Correlations for Multiple Physical Performance Measures: A Cross-Sectional Study among Independently Mobile Older Men in Japan

Purpose: Japan is one of few countries with a male life expectancy over 80 years. The gap between the healthy life span and the total life expectancy is large, highlighting the importance of maintaining physical performance. The present study aims to establish reference values for multiple physical performance measures among high-functioning oldest-old Japanese men and to investigate the correlations among these measurements to understand how these variables are related. Methods: This study was conducted with 120 Japanese males aged 80 years or older who were able to walk independently. Seven measures of physical performance were assessed: handgrip strength, quadriceps strength, static balance ability (one-legged stance), dynamic balance ability (Functional Reach Test; FRT), walking ability (5-m walking time test), combined movement ability (Timed Up & Go test), and bone quality. Cognitive function was also measured (Mini-Mental State Examination; MMSE). Results: Specific reference values are reported for each physical performance measurement explored in this study. Only six participants were classified as cognitively impaired, and 16 had mild cognitive impairment. There were significant correlations of varying levels among all of the measures of physical performance. Age was significantly correlated with all performance measures except FRT, and there was no correlation between age and MMSE. MMSE was weakly correlated with FRT and unrelated to the other performance measures. Conclusions: The reference ranges can be used by older men who have not yet reached 80 years and their health care providers as physical performance targets to facilitate the maintenance of independent mobility in later life.

Knee Osteoarthritis Grade does not Correlate with Quadriceps Muscle Strength or Bone Properties of the Calcaneus in Men Aged 80 Years or More who Can Walk independently

Purpose: Muscle weakness and bone deterioration in the elderly are related to falls and fractures, resulting in decreased mobility. Knee osteoarthritis also may contribute to falls and fractures and thereby affect mortality rates. The Kellgren–Lawrence (KL) classification is widely used in the radiographic evaluation of knee osteoarthritis. Aims: This study aimed to evaluate the quadriceps strength and bone properties of the calcaneus for each KL grade, and to clarify the impact of knee osteoarthritis grade on quadriceps strength and bone properties. Methods: This prospective cross-sectional study included data on 108 male patients (213 knees), aged ≥80 years, who could walk independently. A handheld dynamometer was used to measure quadriceps strength. Bone properties were evaluated using broadband ultrasound attenuation with a portable bone densitometer. Weight-bearing standing knee radiographs were evaluated using KL classification. Quadriceps strength and bone properties were evaluated for each KL grade and the correlations between the grade and quadriceps strength and bone properties were assessed simultaneously. Results: The numbers of participants in KL grades I–IV were 46, 102, 45, and 20, respectively. There were no differences among grades for either quadriceps strength or bone properties. Conclusions: Participants exhibited good quadriceps strength and bone properties regardless of their KL grade. Relatively high mechanical loading of muscle and bone incurred while walking independently, likely explaining this result. Clinically, this study demonstrated the absence of correlations between KL grade and quadriceps strength and bone properties, as was previously reported in studies showing the absence of a correlation between KL grade and pain.

Life expectancy of osteoarthritic patients after primary total knee arthroplasty

BACKGROUND

Although an increased life expectancy has been previously reported in patients with osteoarthritis (OA) after undergoing total knee arthroplasty (TKA), the long-living Japanese population may provide a more accurate cohort for determining 10- and 15-year survival rates. The aims of the present study were to (1) determine the survival of patients after TKA, (2) identify the factors important for survival, and (3) compare the survival rate of the OA patients with that of the standardized general population.

METHODS

The 5-, 10-, and 15-year survival rates were assessed in 326 consecutive OA patients treated with TKA from January 1998 to December 2013. Eighty-six of the cases were staged bilateral TKAs. All patients were followed until December 31, 2014 or until the time of death. The survival rate of the patients was compared with that of the standardized general population using Kaplan-Meier survival curves.

RESULTS

Fifty-one of the patients died before the end of the follow-up. The cumulative 5-year patient survival was 93.5%, 10-year survival was 82.1%, and 15-year survival was 66.6%. The standardized mortality ratio was 0.916 (95% confidence interval: 0.682-1.204). A Cox proportional hazards model showed that increased age and unilateral TKA were factors related to higher patient mortality rates.

CONCLUSIONS

These data suggest that patients undergoing TKA can expect similar life expectancy as the general population, with 66.6% of such patients surviving for at least 15-years. Additionally, patients undergoing bilateral TKAs may have a longer life expectancy than those undergoing unilateral TKA.

Posterior Cruciate Ligament Retention or Substitution During Total Knee Arthroplasty Does Not Affect Long-Term Bone Mineral Density or Quality

BACKGROUND

Physical activity is recognized as one of the factors that influence bone mineral density (BMD) and bone quality after total knee arthroplasty (TKA). According to biomechanical analyses after posterior cruciate ligament (PCL) retaining (PCLR) and substituting (PCLS) TKA, each implant design has different kinematics and kinetics. The purposes of this study were: (1) to perform within-patient comparisons of the midterm and long-term effects of PCL retention in mobile-bearing TKA on proximal femur and tibia BMD and calcaneus bone quality measured using ultrasound and (2) to identify correlations between them.

METHODS

A prospective, quasi-randomized design was used. Thirty-seven patients (74 knees) who underwent bilateral TKA (PCLR on one side and PCLS on the other) were evaluated. Mean follow-up periods were 118 months (standard deviation 40) and 117 months (standard deviation 36) in knees with PCLR and PCLS implants, respectively. The BMDs of the total hip and proximal tibia and broadband ultrasound attenuation (BUA; dB/MHz) through the calcaneus were measured.

RESULTS

The mean BMD of PCLR and PCLS were equivalent at the proximal hip and tibia. The BUA of the calcaneus was also the same between implants. There were significant correlations between the 3 anatomic sites.

CONCLUSION

When measured approximately 10 years after TKA, PCL retention had no substantial effect on the BMD of the proximal femur and tibia, or on the bone quality of the calcaneus. The measurement of noninvasive BUA may predict BMD, although further analysis is required.