Patient-Reported Outcomes, Quality of Life, and Satisfaction Rates in Young Patients Aged 50 Years or Younger After Total Knee Arthroplasty

Is Younger Age a Risk Factor for Failure Following Aseptic Revision Total Knee Arthroplasty?

BACKGROUND

Revision total knee arthroplasties (rTKAs) are being performed more frequently in the United States in younger patients. Few large studies have evaluated the effect of age following rTKA. The study sought to evaluate the effect of age on rTKA outcomes.

METHODS

The American Joint Replacement Registry was used to identify aseptic rTKAs in younger (18 to 64 years, n = 32,631) and older (> 65 years, n = 43,992) patients from January 2012 to September 2020, allowing for a minimum 2-year follow-up. The mean age was 56 years in the younger cohort and 73 years in the older cohort. The mean follow-up was 5.4 years. Sex and body mass index were similar between groups. Kaplan-Meier survivorship analysis was performed with rerevision as the primary endpoint. Secondarily, multivariate analyses were performed to adjust for demographics and comorbidities.

RESULTS

The proportion with rerevision was higher in the younger cohort compared to the older (8.1 versus 5.4%, P < 0.001). The 10-year survivorship free of all-cause rerevision was 90.2% (95% confidence interval [CI]: 89.7 to 90.7) in the younger cohort versus 93.7% (95% CI: 93.4 to 94.1) in the older cohort (P < 0.0001). Younger age was significantly associated with a higher adjusted hazard ratio (HR) for all-cause rerevision (HR: 1.4, 95% CI: 1.3 to 1.6), as were men (HR: 1.4, 95% CI: 1.2 to 1.5) and initial revision for instability (HR: 1.3, 95% CI: 1.1 to 1.5). In a subgroup analysis of patients aged < 65 years, a 5-year decrease in age was associated with a 10.0% increase in risk of rerevision. Indications for rerevisions differed among the younger and older cohorts (P < 0.01): infection (30.2 versus 34.9%), aseptic loosening (19.0 versus 15.8%), and instability (12.2 versus 12.7%).

CONCLUSIONS

Younger age, men, and initial revision performed for instability were associated with significantly increased risk for all-cause rerevision following aseptic rTKA. Notably, age may have a continuous effect on rerevision rates, as each 5-year decrease in age was associated with a 10% increase in risk of rerevision. Future research may further elucidate these increased risks in this younger patient population.

Medicaid Insurance Is Associated With Increased Readmissions and Mortality After Surgery for Periprosthetic Joint Infection

BACKGROUND

Patients with Medicaid insurance are at an increased risk of postoperative complications following total knee arthroplasty and total hip arthroplasty (TJA); however, their outcomes following revision TJA for periprosthetic joint infection (PJI) requires further study.

METHODS

A retrospective query was conducted for adult patients undergoing implant explantation and antibiotic spacer placement for TJA PJI from the Premier Healthcare Database between December 1, 2016, and December 31, 2021. Patients were then grouped by Medicaid or non-Medicaid insurance status and were age matched through exact caliper matching. Multivariable regression models addressed potential confounding. Adjusted risks of 90-day postoperative complications were reported.

RESULTS

Of the 40,346 patients identified, 2,711 Medicaid patients were matched to 10,844 non-Medicaid patients on age (56.1 vs. 56.1 years, P = 1.000). Patients with Medicaid experienced higher risk of sepsis (adjusted odds ratio [aOR] = 1.20, P = 0.010), readmission (aOR = 1.12, P = 0.022), being discharged to a skilled nursing facility (aOR = 1.13, P = 0.031), and had longer length of stay (9.48 vs. 6.67 days, P < 0.001), compared with patients with non-Medicaid. Medicaid patients had a higher rate of inpatient mortality (0.81% vs. 0.48%, P = 0.038); however, the risk was similar after accounting for differences in comorbidities.

CONCLUSION

Following revision TJA for PJI, patients with Medicaid were at an increased risk for postoperative complication, including sepsis and readmission. They experienced a higher rate of inpatient mortality that may be driven by differences in comorbidities. Insurers and policy makers should consider this information to develop risk stratification-based payment strategies that take into account the healthcare burden of this high-risk patient population.

LEVEL OF EVIDENCE

IV.

Robotic-Assisted Primary Total Knee Arthroplasty Requires Fewer Soft-Tissue Releases and Is Associated With a Larger Reduction in Early Postoperative Pain

BACKGROUND

Robotic-assisted total knee arthroplasty (RATKA) has been shown to improve the accuracy of component alignment and to potentially reduce the need for soft-tissue releases. To date, however, the potential benefits of expedited recovery, improved functional outcomes, and improved longevity of RATKA remain unproven. The purpose of this study was to compare functional outcomes and rates of soft-tissue releases between RATKA, conventional instrumentation (CONV), and accelerometer-based navigation (ABN) in primary total knee arthroplasties (TKAs).

METHODS

A retrospective study of 2,338 consecutive TKAs performed by two surgeons was performed. There were 1,216 TKAs performed with CONV and the goal of neutral mechanical alignment. There were 724 TKAs performed with ABN and restricted kinematic alignment goals. There were 398 RATKAs performed with a functional alignment philosophy. Radiographs were reviewed for all knees. We compared Patient-Reported Outcomes Measurement Information System scores (2 weeks, 6 weeks, and 1 year) and rates of soft-tissue releases between ABN and RATKA cohorts. Chi-square tests were used to compare rates of releases between cohorts. Generalized estimating equations were used to evaluate outcomes over time.

RESULTS

Overall, the rate of soft-tissue releases was 47.9% in CONV, 74.4% in the ABN group, and 29.9% in the RATKA group. The RATKAs required significantly fewer medial releases in varus knees than CONV (19.9 versus 46.3%, P < 0.001) and ABN TKAs (19.9 versus 68.8%, P < 0.001). In valgus knees, RATKAs required significantly fewer lateral releases than CONV (33.7 versus 61.6%, P < 0.001) and ABN TKAs (33.7 versus 46.6%, P < 0.001). The RATKA had a greater reduction in pain scores (mean 4.5 more points) than the ABN cohort from preoperative to 6 weeks (P = 0.038) with no difference in pain scores beyond 6 weeks. There were no differences in Patient-Reported Outcomes Measurement Information System scores at 1-year follow-up.

CONCLUSIONS

In this series, RATKA with a functional alignment goal performed by adjusting component placement and bony cuts to balance the knee resulted in fewer soft-tissue releases when compared to conventional instrumented TKA and navigated TKA. The RATKAs also demonstrated a larger reduction in short-term pain scores when compared to ABN TKAs, but no differences in patient-reported outcome scores at 1 year.

Fitting the Knee to the Patient, Not the Other Way Around: A Three-Dimensional Analysis of Total Knee Arthroplasty Implant Fit

BACKGROUND

Despite the growing interest in alternative alignment strategies, advancement in surgical technique, and implant design, several studies have demonstrated that a large number of patients continue to be dissatisfied following total knee arthroplasty (TKA). The purpose of this study was to outline differences in three-dimensional (3D) knee morphology associated with sex and deformity of the arthritic knee and compare these to available off-the-shelf (OTS) and patient-specific implants.

METHODS

A total of 85,604 preoperative computed tomography scans of patients undergoing TKA were analyzed. Distal femoral geometry was quantified via 11 measurements taken from 3D models and landmarks. These values were then compared to the geometries of 12 common TKA implants from the American Joint Replacement Registry.

RESULTS

The average overall alignment of the studied population was found to be 3.3° varus with the average hip-knee-ankle angle being smaller in men than women. Femoral distal offset was found to play an important role in driving both varus and valgus deformities. Nearly 40% of knees in the cohort had a distal condylar offset and 25.6% had a posterior condylar offset that would require beyond the traditionally acceptable 3° varus or valgus or require internal rotation when using the most common OTS implants on the market. The range of adequate coverage across the evaluated implant systems ranged from 20 to 63%. On average, less than half (41%) of the patient population fell within the bounds considered to be a proper fit for the 12 OTS implant systems evaluated.

CONCLUSIONS

To our knowledge, this study is the largest 3D analysis of osteoarthritic knees to date and identified crucial differences in knee morphology among patients undergoing TKA. These data demonstrate a consistent asymmetry of femoral geometry, despite most OTS femoral implants being symmetric. In addition, there was a larger posterior condylar offset and smaller distal condylar offset, questioning the utility of a single-radius femoral design in all patients.

Total knee arthroplasty survivorship and outcomes in young patients: a review of the literature and 40-year update to a longitudinal study

INTRODUCTION

Growing numbers of younger patients are electing to undergo total knee arthroplasty (TKA) for end-stage osteoarthritis. The purpose of this study was to compare established literature regarding TKA outcomes in patients under age 55, to data from an ongoing longitudinal young patient cohort curated by our study group. Further, we aimed to provide a novel update on survivorship at 40 years post-TKA from our longitudinal cohort.

METHODS

A literature search was conducted using the electronic databases PubMed, Embase, and Cochrane Library, using terms related to TKA, patients under age 55, and osteoarthritis. Demographic and outcome data were extracted from all studies that met the inclusion criteria. Data were divided into the "longitudinal study (LS) group," and the "literature review (LR) group" based on the patient population of the study from which it came.

RESULTS

After screening, 10 studies met the inclusion criteria; 6 studies comprised the LR group, and 4 studies comprised the LS group. 2613 TKAs were performed among the LR group, and 114 TKAs were longitudinally followed in the LS group. The mean patient ages of the LR and LS groups were 46.1 and 51, respectively. Mean follow-up was 10.1 years for the LR group. Mean postoperative range of motion was 113.6° and 114.5° for the LR and LS groups, respectively. All-cause survivorship reported at 10 years or less ranged from 90.6% to 99.0%. The LS cohort studies reported survivorship ranges of 70.1-70.6% and 52.1-65.3% at 30 and 40 years, respectively.

CONCLUSIONS

Young TKA patients demonstrated improved functionality at each follow-up time point assessed. Survivorship decreased with increasing lengths of follow-up, ultimately ranging from 52.1-65.3% at 40 years post-TKA. The paucity of literature on long-term TKA outcomes in this patient population reinforces the necessity of further research on this topic.

Evaluating the accuracy of a new robotically assisted system in cadaveric total knee arthroplasty procedures

BACKGROUND

Robot-assisted total knee arthroplasty (TKA) has been shown to facilitate high-precision bone resection, which is an important goal in TKA. The aim of this cadaveric study was to analyze the accuracy of the target angle and bone resection thickness of a recently introduced robotic TKA system.

METHODS

This study used 4 frozen cadaveric specimens (8 knees), 2 different implant designs, navigation, and a robotic system. The 4 surgeons who participated in this study were trained and familiar with the basic principles and operating procedures of this system. The angle of the bone cuts performed using the robotic system was compared with the target angles from the intraoperative plan. For each bone cut, the resection thickness was recorded and compared with the planned resection thickness.

RESULTS

The mean angular difference for all specimens was less than 1°, and the standard deviation was less than 2°. The mean difference between the planned and measured angles was close to 0 and not significantly different from 0 except for the difference in the frontal tibial component angle, which was 0.88°. The mean difference in the hip-knee-ankle axis angle was - 0.21°± 1.06°. The mean bone resection difference for all specimens was less than 1 mm, and the standard deviation was less than 0.5 mm.

CONCLUSIONS

The results of the cadaveric experimental study showed that the new TKA system can realize highly accurate bone cuts and achieve planned angles and resection thicknesses. Despite the limitations of small sample sizes and large differences between cadaveric and clinical patients, the accuracy of cadaveric experiments provides strong support for subsequent clinical trials.

A Lack of Generalizability-Total Knee Demographics in the Active Duty Population

INTRODUCTION

Age and sex are known demographic risk factors for requiring revision surgery following primary total knee arthroplasty (TKA). Military service members are a unique population with barriers to long-term follow up after surgery. This study aims to compare demographic data between active duty military personnel and a nationwide sample to identify differences that may impact clinical and economic outcomes.

METHODS

A retrospective observational analysis was performed using the Military Health System Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP). Databases were queried for patients undergoing primary TKA between January 1, 2015 and December 31, 2020. The MDR was queried for demographic data including age, sex, duty status, facility type, geographic region, history of prior military deployment, history of deployment-related health condition, branch of military service, and military rank. National Surgical Quality Improvement Program was queried for age and sex. Median age between populations was compared with the Mann-Whitney U test, and gender was compared with a chi-squared test.

RESULTS

During the study period, 2,094 primary TKA patients were identified from the MDR, and 357,865 TKA patients were identified from the NSQIP database. Military TKA patients were 79.4% male with a median age of 49.0, and NSQIP TKA patients were 38.9% were male, with a median age of 67. Military TKA patients were significantly more likely to be male (P < .001) and younger (P < .001).

CONCLUSION

Patients undergoing TKA in the military are younger and more likely to be male compared to national trends. Current evidence suggests these factors may place them at a significant revision risk in the future. The application of quality metrics based on nationwide demographics may not be applicable to military members within the Military Health System.

Safety and Effectiveness of Robotic-Arm Assisted Total Knee Arthroplasty

OBJECTIVE

We investigated the advantages of robotic arm-assisted total knee arthroplasty (raTKA) over conventional manual TKA (cmTKA) by comprehensively comparing patients who received raTKA and cmTKA in terms of postoperative pain, function, imaging assessment, and trauma to the body. This study investigated the efficacy and safety of raTKA in patients using the YUANHUA-TKA system.

METHODS

In a prospective, randomized single-blind trial, 60 patients undergoing primary unilateral TKA from October 2020 to December 2020 were randomly assigned to either raTKA or cmTKA. Clinical evaluation, including the time of osteotomy and prosthesis model testing, the total operation time, the visual analogue scale at rest, VAS in motion, opioid consumption, white blood cell count, neutrophil ratio, erythrocyte sedimentation rate, C-reactive protein (CRP), passive and active range of motion (pROM, aROM), Western Ontario and McMaster Universities Arthritis Index (WOMAC [stiffness, pain, and function]) score, gait analysis, keen society score (KSS), adverse events, and blood loss were collected by the project nurse, as well as the imaging evaluation, including the lateral tibia component angle (LTC), frontal femoral component angle, frontal tibia component angle (FTC), lateral femoral component angl, and hip-knee-ankle angle (HKA). The student t-test (or the Wilcoxon signed-rank test) and the χ2-test (or the Fisher exact test) were used to determine differences in categorical variables.

RESULTS

No significant difference was found between the two groups in pain throughout the whole follow-up period. On the third day postoperatively, the erythrocyte sedimentation rate in the cmTKA group was significantly higher (p = 0.02), as well as the CRP (p = 0.04). No significant difference was found in the WOMAC stiffnes score or pROM. However, the aROM and the flexion range when walking (FRW) were significantly better in the raTKA group throughout the trial (p < 0.05). The KSS at the 1-month follow-up and the WOMAC function score at the 1-year follow-up were both significantly better in the raTKA group (p < 0.05). The HKA and the LTC in the raTKA group closer to the ideal angle, and the difference between the groups was significant (p < 0.05). The total operation time of the raTKA group was significantly longer (p = 0.001). The intraoperative blood loss had no significant difference in the two groups.

CONCLUSION

Compared with cmTKA, raTKA with the YUANHUA robot not only avoids extra pain and trauma in patients but promises better functional recovery and improves the accuracy of the prosthesis position and axial alignment reconstruction.

Factors Correlated with the Quality of Life after Total Knee Arthroplasties: A Literature Review

Introduction

Total Knee Arthroplasty (TKA) has been widely reported to improve outcomes and quality of life (QoL) in patients with knee osteoarthritis (KOA), but there are still 15 - 20% of patients still experience pain, physical limitations, and other complications after TKA. Therefore, it is necessary to identify various factors that correlate with QoL from current evidence. The objective is to review the literature on factors that correlate with QoL in patients who underwent TKA.

Materials and methods

A literature search was conducted on five databases, i.e. ProQuest, CINAHL, Medline, Embase, and Scopus, using the following keywords: total knee arthroplasty (TKA), post-operative, quality of life (QoL), and outcome. There were no restrictions on the research design.

Results

This review found 14 articles (7 prospective studies and 7 retrospective studies) involving 15,972 patients who underwent TKA, with an age range of 32 - 94 years. All articles reported improvement in QoL after TKA. The review revealed 30 factors, of which 15 factors were significantly correlated with QoL after TKA. The factors were grouped into four types: demographic, socioeconomic, clinical, and psychosocial factors.

Conclusion

Information regarding factors that correlate with QoL after TKA can be used for directing treatment and discharge planning according to the patient's factors.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Why and What Happens to Patients Younger Than 60 Years Who Need Revision Total Knee Arthroplasty?

BACKGROUND

With the increasing number of young patients undergoing primary total knee arthroplasty (TKA), there will be an increase in the number of patients who require revision. While the results of TKA in younger patients are well known, there is little information regarding to the outcomes of revision TKA in this population. The purpose of this study was to evaluate the clinical outcomes in patients <60 years of age undergoing aseptic revision TKA.

METHODS

We retrospectively reviewed 433 patients undergoing aseptic revision TKA between 2008 and 2019. There were 189 patients <60 years compared to a group of 244 patients >60 years undergoing revision TKA for aseptic failures in terms of implant survivorships, complications, and clinical outcomes. Patients were followed for a mean of 48 months (range, 24 to 149).

RESULTS

A total of 28 (14.8%) patients less than 60 years of age required repeat revision compared to 25 (10.2%) 60 years or older (odds ratio (OR) 1.94, 95% confidence interval (CI) 0.73-5.22, P = .187). There were no differences regarding postprocedural Patient-Reported Outcomes Measurement Information System (PROMIS) physical health scores (72.3 ± 13.7 versus 72.0 ± 12.0, P = .66) and PROMIS mental health scores (66.6 ± 17.4 versus 65.8. ± 14.7, P = .72), at an average of 32.9 and 30.7 months, respectively. Postoperative infection occurred in 3 (1.6%) patients <60 years of age, while 12 (4.9%) postoperative infections occurred in patients 60 years or older (OR 0.75, 95% CI 0.06-10.2, P = .83).

CONCLUSION

There were no statistically significant differences in clinical outcomes between patients <60 versus > 60 years of age undergoing aseptic revision TKA.

Characteristics of Preoperative Arteriosclerosis Evaluated by Cardio-Ankle Vascular Index in Patients with Osteoarthritis before Total Knee Arthroplasty

PURPOSE

Cardiovascular disease (CVD) is a major risk factor for mortality in patients with osteoarthritis, and comorbidities increase postoperative complications after total knee arthroplasty (TKA). Arteriosclerosis plays a main role in hemodynamic dysfunction and CVD; however, arteriosclerosis has not been preoperatively evaluated before TKA using the cardio-ankle vascular index (CAVI). In this study, we evaluated the degree of preoperative arteriosclerosis using the CAVI in patients undergoing TKA, as well as its correlations with several preoperative patient factors.

METHODS

Arteriosclerosis was evaluated in 209 consecutive patients (251 knees) with osteoarthritis who underwent TKA at our institution between May 2011 and June 2022. The CAVI was measured in the supine position 1 day before TKA, and the correlations between the CAVI and several clinical factors were analyzed.

RESULTS

The CAVI was normal in 62 knees (25%), borderline in 71 knees (28%), and abnormal in 118 knees (47%). Univariate analysis revealed a moderate positive correlation between preoperative CAVI and age (r = 0.451, p < 0.001) and a weak negative correlation between preoperative CAVI and body weight (r = -0.306, p < 0.001) and body mass index (BMI) (r = -0.319, p < 0.001). Multivariate analysis showed that age (β = 0.349, p < 0.001) and BMI (β = -0.235, p < 0.001) were significantly correlated with preoperative CAVI.

CONCLUSION

Arteriosclerosis should be carefully managed intraoperatively and postoperatively in patients with osteoarthritis undergoing TKA, particularly in older patients and patients with a low BMI.

Clinical evaluation of the first semi-active total knee arthroplasty assisting robot made in China: a retrospective propensity score-matched cohort study

OBJECTIVE

The precision of overall alignment and knee morphotype after robot-assisted total knee arthroplasty has been fully confirmed. This study aims to conduct a clinical evaluation of the first China-made semi-active total knee arthroplasty assisting robot.

METHODS

After a 1 : 2 propensity score matching, that is, a matched cohort study, patients were matched to the robot group (52 cases) and the conventional group (104 cases). The robot group received osteotomy according to preoperative planning, while the conventional group adopted preoperative planning based on the full-length radiograph and received conventional osteotomy. Perioperative clinical indicators, such as operation time, tourniquet time, hospitalization days, intraoperative bleeding, and hemoglobin level of the two groups were recorded; radiological indicators of postoperative prosthesis position, including hip-knee-ankle angle, frontal femoral component angle, frontal tibial component angle, lateral femoral component angle, and lateral tibial component angle were also recorded; deviations and outliers of the radiological indicators were calculated.

RESULTS

Compared with the conventional group, the operation time and tourniquet time of the robot group were longer, and the postoperative hemoglobin level decreased less, the differences were statistically significant; the lateral tibial component angle of the conventional group was 80.9°±3.6°, which was smaller than 86.7 °±2.3° of the robot group, the difference was statistically significant ( P <0.001); except for lateral femoral component angle, the absolute deviations of the radiological indicators in the robot group were significantly smaller than that in the conventional group ( P ≤0.001); the outliers of the radiological indicators in the robot group were significantly smaller than that in the conventional group with a statistical difference ( P <0.05).

CONCLUSION

Compared with the conventional group, the operation time of the robot group was relatively longer, but the perioperation blood loss was less. The robot group could better control the posterior inclination of the tibial prosthesis, and the absolute deviations and outliers of the prosthesis position were relatively smaller. There was no difference in short-term clinical score between the two groups.

Correlation Between Patient-Reported "Happiness" With Knee Range of Motion and Objective Measurements in Primary Knee Arthroplasty

BACKGROUND

The purpose of this study was to evaluate the correlation between objective knee range of motion (ROM) and patient "happiness" with knee ROM after total knee arthroplasty.

METHODS

This was a retrospective review of all primary total knee arthroplasties from June through December 2019, yielding 902 patients (1,009 knees). Records were reviewed for knee ROM preoperatively and postoperatively at 6-week follow-up as well as whether patients self-reported being "Happy with their ROM" (HWROM). Clinical records were reviewed for documents ROM as well as manipulation under anesthesia (MUA).

RESULTS

The mean preoperative ROM was 110 ± 16 degrees, and 40% of patients were happy with their ROM. Postoperatively, the mean ROM was 106 ± 13 degrees (P < .001), and 76% of patients were HWROM (P < .001). The mean change in knee ROM was (-) 5 ± 17 degrees. The mean postoperative ROM and change in ROM of patients who were HWROM after surgery were 109 ± 12 degrees and (-)2 ± 16 degrees. In patients not HWROM postoperatively, the mean ROM and change in ROM were 98 ± 14 degrees and (-)12 ± 18 degrees (P < .001). Patients with a lower preoperative ROM were statistically significantly more likely to have a positive change in their HWROM (f ratio = 41, P < .001). MUAs were performed in 7.2% of knees, and 28% of patients who underwent an MUA were HWROM before MUA.

CONCLUSION

Early postoperative knee ROM was correlated with patient HWROM. However, further longer term follow-up and more detailed analysis of patient happiness with ROM are needed.

What Are the All-Cause Survivorship Rates and Functional Outcomes in Patients Younger Than 55 Years Undergoing Primary Knee Arthroplasty? A Systematic Review

BACKGROUND

Approximately one-fourth of TKAs will be performed in patients 55 years or younger within the next decade. Postoperative outcomes for younger patients who had a knee arthroplasty were systematically reviewed in 2011; however, numerous studies evaluating young patients who had both a TKA and unicompartmental knee arthroplasty (UKA) have been reported in the past decade. Therefore, to better counsel this growing population of young patients undergoing knee arthroplasty, an updated understanding of their expected postoperative outcomes is warranted.

QUESTIONS/PURPOSES

In this systematic review, we evaluated (1) all-cause survivorship, (2) reasons for revision, (3) patient-reported outcomes, and (4) return to physical activity and sport in patients 55 years or younger undergoing primary TKA or UKA.

METHODS

A comprehensive search of PubMed, Medline, SportDiscus, and CINAHL was performed to identify all original studies evaluating outcomes after primary knee arthroplasty for young patients (55 years of age or younger) from inception until March 2021. The following keywords were used: knee, arthroplasty, replacement, pain, function, revision, survivorship, sport, physical activity, and return to play. Only original research studies that were related to knee arthroplasty and reported postoperative outcomes with a minimum 1-year follow-up for patients 55 years or younger were included. Unpublished materials, publications not available in English, and studies with a primary diagnosis of rheumatoid arthritis were excluded. The Methodological Index for Non-Randomized Studies (MINORS) score was used to evaluate the study quality of case series and comparative studies, while the Cochrane Risk of Bias tool and the Jadad scale were used for randomized studies. The primary outcomes of interest for this study were all-cause survivorship rate, reasons for all-cause revision, Knee Society and Knee Society Function scores (minimum clinically important difference [MCID] 7.2 and 9.7, respectively), WOMAC scores (MCID 10), Tegner scores (no reported MCID for knee arthroplasty), and return to physical activity or sport. Knee Society and Knee Society Function scores range from 0 to 100, with scores from 85 to 100 considered excellent and below 60 representing poor outcomes. All-cause survivorship rate and reasons for revision were both reported in 17 total studies. Knee Society scores were presented in 19 and Knee Society Function scores were reported in 18 included studies. WOMAC scores and Tegner scores were each found in four included studies, and return to physical activity and return to sport analyses were performed in seven studies. Overall, 21 TKA studies and five UKA studies were included in this analysis, featuring 3095 TKA knees and 482 UKA knees.

RESULTS

Kaplan-Meier estimates of all-cause survivorship ranged from 90% to 98% at 5 to 10 years of follow-up after TKA and from 84% to 99% (95% CI 93% to 98%) at 10 years to 20 years post-TKA. All-cause UKA survivorship was 90% at 10 years and 75% at 19 years in the largest Kaplan-Meier estimate of survivorship for patients younger than 55 who underwent UKA. Common reasons for revision in TKA patients were polyethylene wear/loosening, aseptic tibial loosening, and infection, and in UKA patients the common reasons for revision were knee pain, aseptic loosening, progression of knee osteoarthritis, and polyethylene wear/loosening. Knee Society scores ranged from 85 to 98 for 5-year to 10-year follow-up and ranged from 86 to 97 at 10-year to 20-year follow-up in TKA patients. Knee Society Function scores ranged from 70 to 95 for 5-year to 10-year follow-up and ranged from 79 to 86 at 10-year to 20-year follow-up. Return to physical activity and sport was reported variably; however, most patients younger than 55 have improved physical activity levels after knee arthroplasty relative to preoperative levels.

CONCLUSION

Although all-cause survivorship rates were frequently above 90% and patient-reported outcome scores were generally in the good to excellent range, several studies reported long-term survivorship rates from 70% to 85% and fair patient-reported outcome scores, which must be factored into any preoperative counseling with patients. We could not control for surgeon volume in this report, and prior research suggests that increasing volume is associated with less frequent complications; in addition, the studies we included were variably affected by selection bias, transfer bias, and assessment bias, which makes it likely that the findings of our review represent best-case estimates. To limit the frequency of revision in patients younger than 55 years undergoing TKA, clinicians should be cautious of polyethylene wear/loosening, aseptic tibial loosening, and infection, while knee pain and progression of knee osteoarthritis are also common reasons for revision in patients younger than 55 undergoing UKA. Further research should isolate younger knee arthroplasty patients and evaluate postoperative activity levels while accounting for preoperative physical activity and sport participation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression

BACKGROUND

Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA.

METHODS

The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression.

RESULTS

In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively.

CONCLUSION

Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.

Outcomes of Total Knee Arthroplasty in Patients With Rheumatoid Arthritis

The purpose of this study was to examine current literature regarding the efficacy of total knee arthroplasty for patients with rheumatoid arthritis. Studies that assessed total knee arthroplasty outcomes in patients with rheumatoid arthritis were identified on MEDLINE from January 2009 to November 2018. All 4 studies that assessed knee pain and 9 of 11 studies that assessed knee function noted significant improvement in average knee score. However, between 10% and 47% of patients had significant knee pain at final follow-up. Total knee arthroplasty provides significant improvement in knee pain and function for patients with rheumatoid arthritis. However, the rates of postoperative pain vary widely. [Orthopedics. 2021;44(5):e626-e632.].

[A prospective randomized controlled trial on the short-term effectiveness of domestic robot-assisted total knee arthroplasty]

Objective

To explore the short-term effectiveness of domestic robot-assisted total knee arthroplasty (RATKA) conducted by a prospective randomized controlled trial.

Methods

Patients who were scheduled for primary unilateral TKA between October 2020 and December 2020 were eligible in this randomized controlled trial. According to the random number table method, they were allocated to the traditional TKA group and the RATKA group [application of the Yuanhua robotic-assisted TKA (YUANHUA-TKA) system during operation]. A total of 63 patients met the selection criteria were enrolled in the study, of which 3 cases voluntarily withdrew from the trial. And finally 60 cases were enrolled for analysis; of which 28 cases were in the RATKA group and 32 cases were in the traditional TKA group. There was no significant difference in gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, duration of osteoarthritis, surgical side, and preoperative knee visual analogue scale (VAS) resting and motion scores, joint range of motion (ROM), Knee Society Score (KSS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain, stiffness, and function scores, hip-knee-ankle angle (HKA) deviation ( P>0.05). The operation time and intraoperative blood loss of the two groups were recorded. Knee joint VAS resting and motion scores, ROM, KSS scores, and WOMAC pain, stiffness, and function scores were used to evaluate the knee joint function and pain. Gait analysis (flexion and extension angle) was conducted at 3 months after operation. The full length X-ray films of lower limbs and anteroposterior and lateral X-ray films of knee joint were taken. The HKA deviation, lateral tibia component (LTC), frontal femoral component (FFC), frontal tibia component (FTC), and lateral femoral component (LFC) measured on the X-ray films were used to evaluat the lower limb alignment and prosthesis position.

Results

The operations of the two groups completed successfully; the incisions healed by first intention after operation, and no complications related to the operation occurred. The operation time of the RATKA group was significantly longer than that of the traditional TKA group ( t=12.253, P=0.001), and there was no significant difference in intraoperative blood loss between the two groups ( t=3.382, P=0.071). All patients were followed up 3 months. At 3 months after operation, the knee joint VAS resting and motion scores, ROM, KSS scores, and WOMAC pain, stiffness, and function scores improved significantly when compared with preoperatively in the two groups ( P<0.05); there was no significant difference of pre- and post-operative indicators between the two groups ( P>0.05). The gait analysis showed that the flexion and extension angle in the RATKA group was significantly bigger than that in the traditional TKA group ( t=9.469, P=0.003). X-ray films reexamination at 3 months after operation showed that the prostheses in the two groups were in good positions, and there was no adverse events such as prosthesis loosening or sinking. There were significant differences in the HKA deviation between pre- and post-operation in the two groups ( P<0.05), but the difference of pre- and post-operative HKA deviation between the two groups was not significant ( t=1.254, P=0.267). There was no significant difference in FFC, FTC, and LFC between the two groups ( P>0.05); the LTC was significantly smaller in the RATKA group than in the traditional TKA group ( t=17.819, P=0.000), which was closer to the ideal value.

Conclusion

YUANHUA-TKA system can improve the accuracy of osteotomy and the prosthesis placement as well as the lower limb alignment. Its short-term effectiveness can be promised, but long-term effectiveness needs to be further studied.

Improvement in Health-Related Quality of Life After Total Ankle Arthroplasty Compares Well With Other Successful Orthopaedic and Nonorthopaedic Procedures

Background. Ankle arthritis is a major cause of disability. Orthopaedic literature suggests improvement in health-related quality of life (HRQOL) after total ankle arthroplasty (TAA). This has not been compared with improvements observed in successful orthopaedic and nonorthopaedic procedures, including anterior cervical discectomy/fusion (ACDF), total knee arthroplasty (TKA), coronary artery bypass grafting (CABG), and orthotopic liver transplant (OLT). We hypothesize that the effects after TAA are comparable to several successful surgical procedures. Methods. 500 consecutive TAA patients were included and grouped with 2 other large series. Short Form-36 (SF36) were collected at standardized intervals. A systematic literature review identified studies comparing preoperative and postoperative SF36 physical (PCS) and mental component summary (MCS) scores. Using meta-analyses, we pooled the data for each procedure to compare with the TAA group. Results. Patients in all cohorts had preoperative SF36 MCS and PCS scores that were significantly lower than that in the general population. Improvements in HRQOL after TAA were not statistically different from improvements reported in PCS and MCS after ACDF, TKA, and OLT. However, improvement in PCS after TAA was better than that observed after CABG. Conclusions. Disability with ankle arthritis is severe. Disability associated with cervical disc disease, knee arthrosis, coronary artery disease, and liver failure is also severe, with surgical intervention providing major improvements in HRQOL postoperatively. The improvement in HRQOL after TAA did not differ statistically from ACDF, TKA, CABG, and OLT. Our investigation suggests that the HRQOL benefits of TAA meet benchmarks set by some of modern medicine's best.Levels of Evidence: Level III: Systematic review.

Improvements in functional outcome and quality of life are not sustainable for patients ≥ 68 years old 10 years after total knee arthroplasty

PURPOSE

The aims of this study are to evaluate whether improvements in functional outcome and quality of life are sustainable 10 years after total knee arthroplasty (TKA), and the age cut-off for clinical deterioration in outcomes METHODS: Prospectively collected registry data of 120 consecutive patients who underwent TKA at a tertiary hospital in 2006 was analysed. All patients were assessed at 6 months, 2 years and 10 years using the Knee Society Function Score, Knee Society Knee Score, Oxford Knee Score, Short-Form 36 Physical/Mental Component Scores and postoperative satisfaction. One-way ANOVA was used to compare continuous variables, while Chi-squared test to compare categorical variables. Multivariate logistic regression and receiver operating curve analysis was performed to evaluate the predictive factors associated with deterioration of scores postoperatively.

RESULTS

Significant improvements were noted in all functional outcome and quality of life scores at 6 months after TKA. Between 6 months and 2 years, the KSFS and OKS continued to improve but the KSKS, PCS and MCS plateaued. Between 2 and 10 years, there was a deterioration in the KSFS and OKS, whilst KSKS, PCS and MCS were maintained. Increasing age was noted to be a significant risk factor for deterioration of KSFS at 10 years with age ≥ 68 as the cut-off value. 91.7% of patients with KSFS Minimally Clinically Important Difference(MCID) (≥ 7 points) continued to be satisfied after 10 years compared to 100.0% who did not experience KSFS MCID deterioration (p = 0.02).

CONCLUSION

Patients ≥ 68 years experience deterioration in functional outcomes and quality of life from 2 to 10 years after TKA.

LEVEL OF EVIDENCE

Retrospective study, Level III.

Mild knee osteoarthritis predicts dissatisfaction after total knee arthroplasty: a prospective study of 186 patients aged 65 years or less with 2-year follow-up

Background and aims

The incidence of total knee arthroplasty (TKA) is increasing, especially among younger working-age patients. However, dissatisfaction rates in this population are higher than among older patients. The aim of this study was to assess the rates of dissatisfaction and persistent pain after TKA and to evaluate those factors that predict these outcomes.

Material and methods

In total, 186 patients undergoing unilateral TKA aged 65 years or less were enrolled into this prospective observational study with 2-year follow-up. To assess the outcome, the visual analogue scales regarding satisfaction and persistent pain at rest and during exercise were used. In addition, the association between patients´ demographics, radiographic severity of knee osteoarthritis (OA), patient-reported outcome measures (PROMs) and dissatisfaction and persistent pain were tested by univariate logistic regression analysis. Mild OA was defined as Kellgren-Lawrence (KL) grade 2 and severe OA as KL grade 3–4. Furthermore, multiple logistic regression analysis was also conducted to test statistically significant relations.

Results

After 2 years, 12 % (n = 23) of patients were dissatisfied with the outcome of TKA, 27 % (n = 50) reported persistent pain during exercise and 10 % (n = 18) at rest. Patients with mild knee OA were significantly more dissatisfied (28.6 %) than patients with more severe OA (8.7 %) (p = 0.003). Younger patients had an increased risk for both dissatisfaction and persistent pain. Apart from KOOS Quality of Life, poor preoperative KOOS subscores were also predictive for these outcomes.

Conclusion

Mild radiographic knee OA was the main predicting factor for dissatisfaction after TKA. Thus, performing TKA for such patients should be carefully considered. Furthermore, these patients should be informed about the increased risk for dissatisfaction and the same seems to apply to younger patients. Interestingly, when TKA is performed for patients with more severe knee OA, the satisfaction rates seem to be somewhat higher than those previously reported.

Trial registration

The study was retrospectively registered with ClinicalTrials.gov (registration number NCT03233620) on 28 July 2017.

Influence of Psychological Distress in Patients with Hypoallergenic Total Knee Arthroplasty. Treatment Algorithm for Patients with Metal Allergy and Knee Osteoarthritis

The outcome in total knee arthroplasty (TKA) depends on multiples factors, among them is the psychological condition. In addition, up 15 to 30% of the patients that undergo TKA show little or no improvement after surgery, which implies the diagnosis of a painful TKA is a challenge for the orthopedic surgeon, who must rule out a possible metal allergy (MA). It is considered an exclusion diagnosis. Due to the complex relationship between psychological condition and MA, and according to the worse results in patients treated with a hypoallergenic TKA, we asked: (1). What degree of psychological distress (PD) is present in patients who have a hypoallergenic TKA, and how does it influence the results of quality of life (QoL) and functional capacity. (2). Can we develop a new algorithm for patients with a possible MA that improves the outcomes? A pragmatic clinical study was carried out that included patients who underwent hypoallergenic TKA during three consecutive years. Quality of life and functional capacity were measured with (Western Ontario McMaster Universities Osteoarthritis Index) WOMAC index, the Short Form 12 questionnaire (SF-12) questionnaire, and the The EQ-5D-5L questionnaire essentially consists of two pages: the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS) (Euro-QoL-5D L-VAS (EQ5D)), in all patients. To assess PD, a Psychological Distress Score was developed. SPSS software was performed to statistical analysis, and Student´s test for independent variables with a p < 0.005 as statistically significant. A total of 72 anallergic TKAs in 64 patients were treated during this period; 31.3% of these patients showed features of PD before the surgery. According with the severity of the PD, 60% were classified as severe, 10% as moderate and 30% as mild. Patients with PD had statistically significant worse results on the final WOMAC, SF-12, and EQ5D questionnaires. The final scores of the physical subscale of the SF-12 and EQ5D showed better results in patients diagnosed by psychiatrist. Up to one third of the patients with hypoallergenic TKAs have PD, and their results are clearly inferior to those patients with MA without PD. When PD was diagnosed according with Psychological Distress Score, patients should be carefully assessed in order to determine if a specialist referral is recommended. According with our results, PD should be assessed either by the PCP or by us. If the PD is confirmed, a psychiatry referral is then requested for better preoperative management and treatment. We believe that this approach would lead to better TKA outcomes.

[A cadaveric experimental study on domestic robot-assisted total knee arthroplasty]

OBJECTIVE

To simulate and validate the performance, accuracy, and safety of the Yuanhua robotic-assisted total knee arthroplasty system (YUANHUA-TKA) through cadaver-based experiment, thus optimizing the robotic system for the future human clinical application.

METHODS

Six unilateral adult cadaver specimens of the lower limbs were scanned by three-dimensional CT before the experiment, and then the three-dimensional models of femur and tibia were obtained by using the preoperative software of YUANHUA-TKA system, so as to plan the type of prosthesis implant, the osteotomy volume and osteotomy angles [hip-knee-ankle angle (HKA), coronal frontal femoral component (FFC) and frontal tibial component (FTC)], the ideal value of HKA was set to 180°, and of FFC and FTC were set to 90°, respectively. The operator could further confirm the osteotomy plan according to the intraoperative situation before osteotomy, and then install the prosthesis after completing the osteotomy in each plane with the assistance of YUANHUA-TKA system. At last, the X-ray films of hip joint, knee joint, and ankle joint were taken and stitched into the full length X-ray film of the lower limb, and HKA, coronal FFC and FTC were measured.

RESULTS

During the experiment, YUANHUA-TKA system ran stably. All sections of femur and tibia were smooth and no ligament injury was found. After operation, the HKA was 177.1°-179.7°, FFC was 87.9°-91.4°, and FTC was 87.3°-91.4°, which were within ±3° from the ideal values of preoperative planning.

CONCLUSION

The YUANHUA-TKA system can assist the surgeon to carry out precise osteotomy according to the preoperative planned value, which has a good auxiliary effect for total knee arthroplasty. It is expected to assist joint surgeons to improve the surgical accuracy in clinical application.

The KOOS-12 shortform shows no ceiling effect, good responsiveness and construct validity compared to standard outcome measures after total knee arthroplasty

PURPOSE

To investigate the validity, responsiveness and ceiling effect of the recently introduced KOOS-12 and compare its performance to the KOOS, OKS, WOMAC and UCLA activity scales.

METHODS

Patients from an independent multicentre study examining a medially stabilized knee system prospectively completed the KOOS, OKS, WOMAC and UCLA preoperatively and at 1 year postoperatively. KOOS-12 scores were calculated from the full length KOOS data. Construct validity was assessed using Spearman's correlation analysis. The ceiling effect was evaluated by calculating the percentage of patients with a maximum score. If the percentage exceeded 15%, a ceiling effect was considered to be present. Responsiveness was evaluated by performing paired t tests on the changes in measures and calculation of Cohen's d.

RESULTS

A ceiling effect was present for the KOOS Pain, ADL and QoL subscales and the KOOS-JR at 1 year postoperatively. No ceiling effect was observed for the KOOS-12. Correlation of the KOOS-12 was low (0.3 < r < 0.5) with the UCLA, moderate (0.5 < r < 0.7) with the KOOS symptoms, sports and WOMAC stiffness subscales and high (r > 0.7) with all other scores and subscales. Effect size of the UCLA activity scale was moderate (Cohen's d 0.2-0.8) whereas effect sizes of all other outcome measures were large (d > 0.8).

CONCLUSION

The KOOS-12 does not exhibit a ceiling effect, has good convergent construct validity and is responsive to changes in pain, function, QoL and knee impact between preoperatively and 1 year postoperatively.

LEVEL OF EVIDENCE

Diagnostic level III.

The Relationship Between Psychological Aspects and Trajectories of Symptoms in Total Knee Arthroplasty and Total Hip Arthroplasty

BACKGROUND

This study aimed to examine different trajectories of physical symptoms in hip and knee arthroplasty patients from presurgery to 1 year postsurgery and relate this to preoperative anxiety and depressive symptoms.

METHODS

Patients (N = 345) completed the Hip injury and Osteoarthritis Outcome Score or the Knee injury and Osteoarthritis Outcome Score to examine their preoperative and postoperative pain, stiffness, and function, presurgery, and 3, 6, and 12 months postsurgery. Presurgery anxiety and depressive symptoms were assessed using the 7-item Generalized Anxiety Disorder Scale and the 9-item Patient Health Questionnaire. Latent trajectory analysis was used to identify different subgroups in trajectories. The step-3 method was used to assess subgroup characteristics.

RESULTS

The effect of time on pain, function, and stiffness was different between subgroups of patients. Knee patients belonged mainly to classes with least improvement. Least improvement in pain was characterized by a combination of high levels of both anxiety and depressive symptoms. Anxiety and depressive symptoms were independently related to less reduction in stiffness while little improvement in function was characterized by higher depressive symptoms.

CONCLUSION

The results of this study indicate that anxiety and depressive symptoms were significantly, but differently, related to the distinct physical symptoms examined.

Early post-operative oxford knee score and knee society score predict patient satisfaction 2 years after total knee arthroplasty

BACKGROUND

There is poor correlation between functional outcomes and patient satisfaction following total knee arthroplasty (TKA). We asked if early post-operative scores at 6 months or the pre- to post-operative change in scores are predictive of patient satisfaction 2 years after TKA.

METHODS

We conducted a retrospective review of prospectively collected registry data of 4359 TKAs performed at a single institution. At 6 months and 2 years, the Knee Society Score (KSS), Oxford Knee Score (OKS), and Short-Form 36 scores were assessed. A satisfaction questionnaire was also completed. Logistic regression was used to generate receiver-operating characteristic (ROC) curves to assess the ability of each scoring system in predicting satisfaction at 2 years.

RESULTS

At 2 years, 91.1% of patients were satisfied. For the absolute post-operative OKS at 6 months, an AUC of 0.762 (95% CI 0.736-0.788) and a threshold of ≤ 21.5 points (or ≥ 38.5 points on the new scale) were obtained. For the KSS knee score, an AUC of 0.704 (95% CI 0.674-0.734) and a threshold of ≥ 80.5 points were identified. The OKS performed significantly better than the KSS knee score (p = 0.03) and the other post-operative scores (p < 0.001). When analysing the change in scores pre-operatively to 6 months, the AUC was < 0.7 for all scales.

CONCLUSIONS

Early post-operative scores, specifically the OKS and KSS knee score, can predict patient satisfaction at 2 years after TKA with good accuracy. The threshold values offer surgeons an additional tool to identify patients at risk of dissatisfaction at 2 years, enabling them to intervene earlier to ensure good patient satisfaction.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Clinical value of CT-based patient-specific 3D preoperative design combined with conventional instruments in primary total knee arthroplasty: a propensity score-matched analysis

Purpose

To evaluate the operation and early clinical effect in primary total knee arthroplasty (TKA) about the novel combination of CT-based patient-specific three-dimensional (3D) preoperative design and conventional osteotomy instruments, compared with the conventional method.

Methods

After a 1:1 propensity score-matching (PSM), patients were matched to the novel technique group and the conventional group, 109 cases in each group. The conventional group adopted a preoperative design based on a full-length radiograph (FLX) and received TKA with conventional osteotomy instruments. The novel technique group used a CT-based patient-specific 3D preoperative design combined with conventional osteotomy instruments; during the surgery, the femoral entry point, femoral valgus osteotomy angle, the fix point of tibial plateau extramedullary guide pin, and the position of tibial extramedullary positioning rod were accurately selected according to the preoperative 3D design to ensure accurate intraoperative implementation. The lower limb alignment, component position, operation time, tourniquet time, hospital stay, blood loss volume, incidence of postoperative complications, visual analog scale (Vas) score, and New Knee Society Score System (NEW-KSS) at 1 day before operation and 1, 6, and 12 months after operation were recorded and compared.

Results

The novel technique group was significantly better than the conventional group in controlling lateral tibial component angle (LTC) (P < 0.001), and the novel technique group had lower percentages of hip-knee-ankle angle (HKA) outliers (P < 0.001) and overcorrection (P = 0.003). The operation time, tourniquet time, and hospital stay of the novel technique group was shorter (P < 0.05). In 1 month after the operation, the novel technique group achieved a significantly better VAS score (P < 0.05), but a similar NEW-KSS score (P > 0.05) when compared with the conventional group. But in 6 and 12 months after surgery, no statistical differences were seen in the above two scores (P > 0.05).

Conclusion

The novel technique of CT-based patient-specific 3D preoperative design combined with conventional instruments can improve the accuracy of osteotomy in primary total knee arthroplasty, with benefits of significantly reducing pain and rapid recovery during the early postoperative period, but having no obvious effect on outcome after a 1-year follow-up.

[An animal experimental study on domestic robot-assisted total knee arthroplasty]

OBJECTIVE

To evaluate the performance, safety, and precision of the Yuanhua robotic-assisted total knee arthroplasty system (YUANHUA-TKA) through animal experiments, which will provide reference data for human clinical trials.

METHODS

Six 18-month-old goats, weighing 30-35 kg, were used in this study. The experimental study was divided into two parts: the preoperative planning and intraoperative bone resection. CT scans of the goats' lower extremities were firstly performed before the experiments. Then the CT scans were segmented to generate the femoral and tibial three-dimensional (3D) models in the YUANHUA-TKA system. The volumes and angles of each resection plane on the femur and tibia were planned. The bone resection was finally implemented under the assistance of the YUANHUA-TKA system. After completing all bone resections, the lower extremities of each goat were taken to have CT scans. By comparing the femoral and tibial 3D models before and after the experiments, the actual bone resection volumes and angles were calculated and compared with the preoperative values.

RESULTS

During the experiments, no abnormal bleeding was found; the YUANHUA-TKA system ran smoothly and stably and was able to stop moving and keep the osteotomy in the safe zone all the time. After the experiment, the resection planes were observed immediately and found to be quite flat. There was no significant difference between the planned and actual osteotomy thickness and osteotomy angle ( P>0.05); the error of the osteotomy thickness was less than 1 mm, and the error of the osteotomy angle was less than 2°.

CONCLUSION

The YUANHUA-TKA system can assist the surgeons to perform osteotomy following the planned thickness and angle values. It is expected to assist surgeons to implement more accurate and efficient osteotomy in the future clinical applications.

Quality of life, chronic pain, insomnia, and jaw malfunction in patients after alloplastic temporomandibular joint replacement: a questionnaire-based pilot study

Studies of patients undergoing alloplastic total temporomandibular joint replacement seldom report on quality of life (QoL) and sleep. The aim of this pilot study was to assess these factors in such a patient cohort using validated psychometric questionnaires. Data were collected via online surveys comprising the following six questionnaires: Short Form-12 Health Survey (SF-12), Patient Health Questionnaire-15, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, Insomnia Severity Index, Graded Chronic Pain Scale, and Jaw Disability List. Pain intensity, limitation in nutrition, and treatment satisfaction were assessed using numerical rating scales. Mouth opening was measured at follow-up. The SF-12 Physical Composite Score was markedly lower than that of the age-matched general population, whereas the Mental Composite Score did not differ significantly. Participants indicated a low somatization level and low level of disability due to pain, but reduced QoL. Clinically relevant insomnia was reported by 36% of participants. In conclusion, the results of this pilot study indicate that QoL and sleep in patients with a total temporomandibular joint replacement differ from those in the general population, indicating the need for a comprehensive outcome assessment utilizing validated psychometric tools in accordance with the current biopsychosocial model of chronic disorders.

Decrease of Quality of Life, Functional Assessment and Associated Psychological Distress in Patients with Hypoallergenic Total Knee Arthroplasty

Total knee arthroplasty (TKA) is the final treatment for knee osteoarthritis, and 15-30% of patients show little or no improvement. This high percentage is related to aspects of the surgical technique, the selected implant, and specific patient characteristics. The aim of this study was to analyze whether there are differences in quality of life (QoL) and functional capacity among patients undergoing TKA with conventional implants compared to those treated with hypoallergenic oxinium implants. A pragmatic clinical study was carried out that included patients who underwent TKA between January 2013 and December 2015. During this period, 245 knees in 228 patients were treated. Eleven patients were excluded, leaving a sample of 161 conventionally treated knees, 72 knees treated with hypoallergenic implants, and one patient who received both implant types. In all patients, QoL and functional capacity were measured with the WOMAC index, the SF-12 questionnaire, and the Euro-Qol-5D L-VAS. We also assessed the psychological distress of each patient and related the findings to the functional results. The differences in QoL were tested using ANCOVA and propensity score matching (PSM) models adjusted for sex, age, weight, psychiatric history and associated complications. Patients who underwent TKA using conventional prostheses had significantly better scores on the total WOMAC index and in the pain domain (p < 0.05) than those who received hypoallergenic prostheses, but no significant differences were observed for the other domains in the ANCOVA. In contrast, with the PSM, we also found statistically significant differences in the difficulty domain of the WOMAC. Significant differences were found for the SF-12 mental health questionnaire results (p = 0.038), but the same did not occur for the physical health domain in the ANCOVA and PSM. We also found statistically significant differences in the Euro-Qol-5D index results (p = 0.041), but not in the VAS scale scores for the same questionnaire in the ANCOVA, and we did not find significant differences in either with the PSM. Patients with metal allergies and those who present psychological distress had WOMAC, SF-12, and Euro-Qol-5D results that were statistically significantly worse than those of patients who received conventional implants. Patients who underwent hypoallergic TKA had lower scores on the QoL and functional capacity scales than patients who received conventional Cr-Co implants. Additionally, patients with psychological distress had worse results on the questionnaires, and those with a metal allergy had even lower scores; the differences were statistically significant.

Knee joint laxity is restored in a bi-cruciate retaining TKA-design

PURPOSE

The goal is to evaluate the passive stability of a bicruciate retaining, cruciate retaining and bicruciate substituting TKA design in relation to the native knee stability in terms of the laxity envelope. A bicruciate retaining knee prosthesis was hypothesized to offer a closer to normal knee stability in vitro.

METHODS

Fourteen cadaveric knee specimens have been tested under passive conditions with and without external loads, involving a varus/valgus and an external/internal rotational torque, distraction/compression force and an anteroposterior shear force. Subsequently, the native knee, bicruciate retaining, cruciate retaining and finally a bicruciate substituting total knee arthroplasty were tested.

RESULTS

Through the range of motion, the width of the varus/valgus and internal/external laxity envelope for the native knee and the bicruciate retaining knee were almost equivalent, whereas the cruciate retaining and the bicruciate substituting knee displayed less laxity and more joint distraction. In all prosthetic knees, an equal anteroposterior laxity was seen for the lateral and medial side whereas in the native knee, a difference in laxity was seen between the stable medial side and the more mobile lateral side.

CONCLUSION

Bicruciate retaining knee prostheses can restore normal laxity and thus have the potential to offer more normal knee function. Restoration of natural peri-articular soft-tissue tension is clinically important because of its obvious effects on joint stability and range of motion. Furthermore, the results of this study could help to establish the ideal ligament tension and laxity in more conventional implants by approaching the normal values for passive knee evaluation as presented here.

Multiple-dose tranexamic acid for perioperative blood loss in total knee arthroplasty in patients with rheumatoid arthritis：a single-blinded, randomised, parallel-controlled study protocol in China

INTRODUCTION

This clinical trial is designed to evaluate the effect of multiple-dose tranexamic acid (TXA) on perioperative blood loss in patients with rheumatoid arthritis (RA).

METHODS AND ANALYSIS

A randomised, single-blinded, parallel-controlled study will be designed. Patients with RA (age 50-75 years) undergoing unilateral primary end-stage total knee arthroplasty will be randomly divided into group A or group B. Group A will be treated with one dose of TXA (1 g; intravenous injection 3 hours postsurgery) and group B with three doses (1 g; intravenous injection at 3, 6 and 12 hours postsurgery) after surgery. The primary outcomes will be evaluated with blood loss, maximum haemoglobin drop and transfusion rate. The secondary outcomes will be evaluated with knee function and complications.

ETHICS AND DISSEMINATION

The Shanghai Guanghua Hospital of Integrated Traditional Chinese Medicine and Western Medicine Ethics Committee approved in this study in July 2019. Informed consent will be obtained from all participants. Results of the trial will be published in the Dryad and repository in a peer-reviewed journal. Additionally, deidentified data collected and analysed for this study will be available for review from the corresponding author on reasonable request.

TRIAL REGISTRATION NUMBER

ChiCTR1900025013.

Patient-reported outcome measures (PROMs): can they be used to guide patient-centered care and optimize outcomes in total knee replacement?

PURPOSE

As patient-reported outcome measures (PROMs) are increasingly integrated into clinical practice, there is a need to translate collected data into valuable information to guide and improve the quality and value of patient care. The purpose of this study was to investigate health-related quality-of-life (QoL) trajectories in the 5 years following total knee replacement (TKR) and the patient characteristics associated with these trajectories. The feasibility of translating QoL trajectories into valuable information for guiding patient-centered care was also explored.

METHODS

Data on patients who underwent TKR between 2006 and 2011 from a single-institution registry were extracted including patient-reported QoL (captured using the Short Form Survey (SF-12) instrument) up to 5 years post-surgery. QoL trajectories were modelled using latent class growth analysis. Quality-adjusted life-years (QALYs) were calculated to illustrate longer term health benefit. Multinomial logistic regression analyses were performed to examine the association between trajectory groups and baseline patient characteristics.

RESULTS

After exclusions, 1553 patients out of 1892 were included in the analysis. Six unique QoL trajectories were identified; with differing levels at baseline and improvement patterns post-surgery. Only 18.4% of patients were identified to be in the most positive QoL trajectory (low baseline, large sustainable improvement after surgery) associated with the greatest gain in QALY. These patients were likely to be younger, have no co-morbidities and report greater pain at pre-surgery than most in other QoL trajectories.

CONCLUSIONS

Our findings demonstrate the importance of underlying heterogeneity in QoL trajectories, resulting in variable QALY gains. There is scope in translating routinely collected PROMs to improve shared decision-making allowing for more patient engagement. However, further research is required to identify suitable approaches of its implementation into practice to guide clinical care and maximize patient outcomes.

Should patients aged 75 years or older undergo medial unicompartmental knee arthroplasty? A propensity score-matched study

INTRODUCTION

With increasing life expectancies worldwide, more elderly patients with isolated medial compartment osteoarthritis may become suitable UKA candidates. However, there is a paucity of literature comparing outcomes between older patients (≥ 75 years) and younger patients undergoing UKA. The aim of this study was to determine if there were differences in functional and HRQoL measures between older patients (≥ 75 years) and younger controls (< 75 years) undergoing primary UKA.

MATERIALS AND METHODS

Prospectively collected registry data of 1041 patients who underwent primary, cemented, fixed-bearing medial UKA at a single institution from 2002-2013 were reviewed. Propensity scores generated using logistic regression was used to match older patients (≥ 75 years, n = 94) to controls (< 75 years, n = 188) in a 1:2 ratio. Knee Society Scores, Oxford Knee Score, Short Form-36, satisfaction/expectation scores, proportion of patients attaining OKS/SF-36 PCS MCID and survivorship were analysed.

RESULTS

Patients ≥ 75 years had significantly lower KSFS (67.1 ± 17.9 vs 79.4 ± 18.2, p < 0.001) and SF-36 PCS (47.3 ± 10.1 vs 50.4 ± 9.1, p = 0.01) as compared to the control group. In addition, a significantly lower proportion of patients ≥ 75 years attained MCID for SF-36 PCS when compared to the controls (50.0% vs 63.8%, p = 0.04). Survival rates at mean 8.3 ± 3.0 years were 98.9% (95% CI, 96.7-100) in the older group versus 92.8% (95% CI, 86.8-98.8) in the younger group (p = 0.31).

CONCLUSIONS

Our findings highlight the need to counsel older patients regarding potentially reduced improvements in functional outcomes, despite advantages of lower revision. However, UKA in older patients continues to be a viable option for isolated medial compartment osteoarthritis LEVEL OF EVIDENCE: Level III Propensity score matched study.

Changes in Expectation Fulfillment Following Total Knee Arthroplasty: A 10-Year Follow-Up Study

BACKGROUND

This study aims to investigate how expectation fulfillment changes up to 10 years following total knee arthroplasty (TKA).

METHODS

Preoperative data were collected for 323 patients undergoing TKA (Hospital for Special Surgery Knee Replacement Expectations survey, Oxford Knee Score [OKS], and Short Form [SF]-12). Expectation fulfillment, OKS, SF-12, and patient satisfaction were assessed at 1 year and 9-10 years postoperatively. Relative risk (RR) of dissatisfaction at late follow-up was calculated for each specific expectation question. Linear regression analysis was used to identify factors independently associated with early (1 year) and late (mean 9 years) expectation fulfillment scores.

RESULTS

Mean expectation fulfillment scores declined from early to late follow-up (25.9-23.9, P = .025). Multivariate analysis identified younger age and better 1-year OKS as factors independently associated with long-term expectation fulfillment. Twelve percent of patients reported dissatisfaction at late follow-up. The risk of long-term dissatisfaction was greatest in patients with high preoperative expectations of kneeling (RR 2.2, 95% confidence interval [CI] 0.9-5.5), walking without aids (RR 2.4, 95% CI 0.7-7.6), and improved psychological well-being (RR 3.9, 95% CI 0.9-5.0). Night pain relief, kneeling ability, participating in outside activities, and sports were the most poorly fulfilled expectations at both early and late time points. Fulfillment improved the least from early to late for kneeling ability (17%) and ability to participate in outside activities (17%).

CONCLUSION

Expectation fulfillment following TKA changes with time. Expectations of kneeling ability and the ability to perform outside activities demonstrated persistently low levels of fulfillment. This information can be used to manage the longer term expectations of patients undergoing TKA.

Patient-Reported Outcomes and Perioperative Complications of Total Hip Arthroplasty Following Joint Preservation Surgery for Hip Dysplasia

BACKGROUND

There is growing recognition of the importance of patient-reported outcome measures and assessment of patient satisfaction in the evaluation of outcomes following surgical interventions. This study aimed to evaluate patient-reported outcomes and complication rates after total hip arthroplasty following joint preservation surgery for hip dysplasia.

METHODS

Patient-reported outcomes and complication rates of 85 hips with previous joint preservation surgery (salvage group) were compared with those of 1279 hips without joint preservation surgery (primary arthroplasty group). As a patient-reported outcome measure, the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire was used to evaluate the hip condition both preoperatively and 12 months postoperatively. Operative data and postoperative (within 12 months) complications were investigated.

RESULTS

The salvage group had a longer operative time (56.8 vs 44.9 minutes, P < .001) and a higher total complication rate (5.9% vs 1.1%, P < .001). Additionally, the salvage group exhibited a lower degree of improvement in the visual analog scale value for satisfaction (75.1 vs 83.1 mm, P = .011), the pain and movement category scores, and the total score of the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire (14.2 vs 16.2, P = .031; 13.7 vs 16.0, P = .005; and 42.3 vs 47.9, P = .007, respectively) compared with the primary arthroplasty group.

CONCLUSION

This study demonstrated a lower rate of improvement in patient satisfaction and worse self-reported outcomes in the salvage group. Furthermore, these patients had a longer operative time and a higher risk of operative complications.

Two-year recovery courses of physical and mental impairments, activity limitations, and participation restrictions after total knee arthroplasty among working-age patients

Purpose: Total knee arthroplasty is increasingly performed on working-age individuals, but little is known about their recovery process. Therefore this study examined recovery courses of physical and mental impairments, activity limitations and participation restrictions among working-age total knee arthroplasty recipients. Associated sociodemographic and health-related factors were also evaluated.Materials and methods: A prospective study among working total knee arthroplasty patients (aged <65 years) (n = 146). Surveys were completed preoperatively and 6 weeks and 3, 6, 12, and 24 months postoperatively. Outcomes represented domains of the International Classification of Functioning, that is, physical impairments (pain, stiffness, vitality), mental impairments (mental health, depressive symptoms), activity limitations (physical functioning), and participation restrictions (social-, work functioning, working hours). Covariates included age, gender, education, home situation, body mass index, and comorbidity.Results: Largest improvements in physical and mental impairments and activity limitations were observed until 3 months postoperatively. Participation in social roles improved early after surgery, and improvements in work participation occurred from 6 to 12 months. Older age, being male and fewer comorbidities were associated with better recovery courses.Conclusion: Working-age total knee arthroplasty patients recover soon from physical and mental impairments, activity limitations, and participation in social roles, but participation at work occurs later. Younger patients, females, and those with musculoskeletal comorbidities appear at risk for suboptimal recovery after total knee arthroplasty.Implications for rehabilitationAn increasing number of working-age patients are asking for total knee arthroplasty and have high expectations of total knee arthroplasty, in particular, to participate in the workforce again;Recovery after total knee arthroplasty (TKA) does not occur in the short term and is not limited to clinical improvements for working-age TKA recipients only, as an important part of recovery, that is, participation occurs in the long term (>6 months);Closer collaboration between occupational physicians and orthopedic surgeons might result in increased and earlier ability to work full contractual hours;Rehabilitation after TKA should focus on patients with multiple comorbidities, whereby musculoskeletal diseases may even need additional preoperative treatment to optimize outcomes and prevent work disability.

A Single Surgeon Series Comparing the Outcomes of a Cruciate Retaining and Medially Stabilized Total Knee Arthroplasty Using Kinematic Alignment Principles

BACKGROUND

Total knee arthroplasty (TKA) designs are developed to optimize kinematics and improve patient satisfaction. The cruciate retaining (CR) and medially stabilized (MS) TKA designs have reported good mid-term follow-up outcomes. However, reasons for consistently high rates of patient dissatisfaction following a TKA remain poorly understood. To further investigate this, we compared the short-term functional outcomes and quality of life, using patient-reported outcome measures (PROMs) and range of motion (ROM), between a CR and MS TKA.

METHODS

A prospective comparison was made between 2 groups (44 CR-TKAs vs 46 MS-TKAs). The Knee Injury and Osteoarthritis Outcome Score (KOOS), KOOS-12, KOOS-Short form, KOOS-Joint Replacement, Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, UCLA Activity Scale, and EuroQuality of life - 5 Dimension were completed preoperatively and 1 year postoperatively. The Forgotten Joint Score (FJS) and Visual Analogue Scale-Satisfaction were completed at 1 year postoperatively. ROM was collected preoperatively and 1 year postoperatively.

RESULTS

Patients who underwent an MS-TKA scored significantly better than the CR-TKA on the FJS (MS = 79.87, CR = 63.8, P = .005), the KOOS-12 Quality of Life subscale (MS = 82.8, CR = 74.4, P = .43), and the KOOS Quality of Life subscale (MS = 82.8, CR = 74.6, P = .44). There was no difference between the groups in all assessed PROMs or ROM, preoperatively and 1 year postoperatively.

CONCLUSION

Patients who underwent the MS-TKA scored significantly better on the FJS and the quality of life subscale of the KOOS and KOOS-12 than those who underwent a CR-TKA. All other assessed PROMs and ROM were comparable between the 2 groups and demonstrated that both implants facilitated symptom relief and improved daily function at 1 year postoperatively. These findings suggest that at short-term follow-up, the MS device is more likely to allow a patient to "forget" that a joint has been replaced and restore their quality of life. Long-term assessment of MS-TKA design outcomes in larger cohorts is recommended.

Higher Activity Level Following Total Knee Arthroplasty Is Not Deleterious to Mid-Term Implant Survivorship

BACKGROUND

The impact of a patient's activity level following total knee arthroplasty (TKA) remains controversial, with some surgeons concerned about increased polyethylene wear, aseptic loosening, and revisions. The purpose of this study is to report on implant survivorship and outcomes of high activity patients compared to low activity patients after TKA.

METHODS

A retrospective review identified 1611 patients (2038 knees) that underwent TKA with 5-year minimum follow-up. Patients were divided in 2 groups based on their University of California Los Angeles (UCLA) activity level: low activity (LA) (UCLA ≤5) and high activity (HA) (UCLA ≥6). Outcomes included range of motion, Knee Society scores, complications, and reoperations. Parametric survival analysis was performed to evaluate the significance of activity level on survivorship while controlling for age, gender, preoperative pain, Knee Society clinical scores, Knee Society functional scores, and body mass index (BMI).

RESULTS

Mean follow-up was 11.4 years (range 5.1-15.9). The LA group had significantly more female patients, were older, had higher BMI, and had lower functional scores preoperatively (all with P < .001). The HA group had significantly higher improvements in Knee Society scores (P < .001) and pain postoperatively (P < .001). Revisions were performed in 4% of the LA group and 1.7% knees of the HA group (P = .003). After controlling for age, gender, preoperative pain, Knee Society clinical scores, Knee Society functional scores, and BMI, a higher postoperative activity level remained a significant factor for improved survivorship with an odds ratio of 2.4 (95% confidence interval 1.2-4.7, P = .011). The all-cause 12-year survivorship was 98% for the HA group and 95.3% for the LA group (P = .003). The aseptic 12-year survivorship was 98.4% for the HA group and 96.3% for the LA group (P = .02).

CONCLUSION

Highly active patients had increased survivorship at 5-year minimum follow-up compared to lower activity patients after TKA. Patient activity level after TKA may not need to be limited with modern implants.

Contemporary Revision Total Knee Arthroplasty in Patients Younger Than 50 Years: 1 in 3 Risk of Re-Revision by 10 Years

BACKGROUND

There is a paucity of literature on contemporary aseptic revision total knee arthroplasty in patients ≤50 years. We sought to determine risk factors for failure in this population, with specific emphasis on survivorship free of (1) all-cause re-revision and (2) re-revision for instability.

METHODS

We retrospectively reviewed 135 nononcologic revision total knee arthroplasties (TKAs) performed from 2000 to 2012 in patients ≤50 years. Mean age was 43 years, and mean body mass index was 31 kg/m². Mean follow-up was 7 years. There were 99 (73%) first-time revisions, and 36 (27%) with prior revisions. Indications for revision included instability (47%), aseptic loosening (29%), and arthrofibrosis (9%). Multivariate Cox regression analysis was used to identify risk factors.

RESULTS

Survivorship free of all-cause re-revision was 66% at 10 years, with multiply revised TKAs (hazard ratio [HR] = 2.6, P = .008) having the poorest survivorship. Forty-three (32%) TKAs underwent re-revision including 10 (7%) for periprosthetic joint infection. Survivorship free of re-revision for instability was 88% at 10 years, with revision for instability (HR = 19, P = .03), male gender (HR = 3.0, P = .05), and multiply revised TKAs (HR = 3.5, P = .03) having poorer survival. Of the 64 TKAs revised for instability, 24 (38%) underwent re-revision, including 14 (22%) for recurrent instability.

CONCLUSION

Patients ≤50 years undergoing contemporary aseptic revision TKA had a 1 in 3 risk of re-revision. Patients specifically revised for instability or had prior TKA revisions had the highest risk of re-revision at 10 years.

LEVEL OF EVIDENCE

IV.

An optimum prosthesis combination of low-risk total knee arthroplasty options in all five primary categories of design results in a 60% reduction in revision risk: a registry analysis of 482,373 prostheses

PURPOSE

Decades of innovations in total knee arthroplasty (TKA) design have led to large number of possible prosthesis combinations in regards fixation, posterior stability, bearing mobility, bearing surface, and patella resurfacing, each of which can alter the revision risk. The accumulative effect when the lowest risk combination in each design category, or "Optimum Prosthesis Combination" (OPC) is utilized remains unknown. The purpose of this analysis was to first, identify the OPC and second, to compare the revision risk of a cohort who received the OPC to a cohort who received an Alternative Prosthesis Combination (APC).

METHODS

National registry revision risk data for primary TKA for osteoarthritis were obtained from September 1999 to December 2015 for two patient cohorts, those receiving an OPC and those receiving an APC. OPC was defined as TKA with the lowest revision risk option for five primary TKA design categories; fixation, posterior stability, bearing mobility, bearing surface, and patella resurfacing, while APC had one or more higher risk options.

RESULTS

Of the 482,373 included TKA, 42,008 (8.7%) were in the OPC cohort, who received a minimally stabilized, fixed bearing TKA with cross-linked polyethylene with patella resurfacing. Both cohorts had similar demographics. At 10 years, the OPC cohort had a Cumulative Percent Revision of 2.4% (95% CI 2.1, 2.8) compared to 5.5% (95% CI 5.4, 5.6) for the APC cohort. For all patients, revision risk of the APC cohort was higher at all times [151% greater at ≥ 3 years (p < 0.001)]. Loosening/lysis was the most common cause of revision in the ACP cohort (1.1%), while it was the second most common cause in the OPC cohort (0.3%). The increased risk was apparent in all age and gender subgroups, with the highest risk increase seen in males ≥ 65 years.

CONCLUSIONS

Patients receiving the lowest risk prosthesis design combination or Optimum Prosthesis Combination TKA had a 60% lower revision risk, with similar demographics to the Alternative Prosthesis Combination TKA.

LEVEL OF EVIDENCE

III.

Is Patient Satisfaction Associated With Clinical Outcomes After Osteochondral Allograft Transplantation in the Knee?

BACKGROUND

The association between patient satisfaction and patient-reported outcomes after cartilage repair is not well understood.

PURPOSE

To investigate the association of patient satisfaction with pain, function, activity level, and quality of life after fresh osteochondral allograft (OCA) transplantation in the knee.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study comprised 371 patients (396 knees) who underwent primary OCA transplantation for osteochondral lesions in the knee between 1997 and 2015. Mean ± SD patient age was 31.8 ± 11.6 years, and 62% were male. The majority of grafts (62%) were located on the femoral condyle; the mean number of grafts per knee was 1.5 ± 0.8; and the median graft area was 6.9 cm² (range, 1.8-50 cm²). Pain, function, activity level, and quality of life were evaluated pre- and postoperatively via International Knee Documentation Committee scores and Knee injury and Osteoarthritis Outcome Scores. Patient satisfaction with the results of the OCA transplantation was assessed postoperatively. All follow-up evaluations occurring at postoperative 1 year or later were included in the analysis.

RESULTS

The mean follow-up time was 5.5 years. Overall, the satisfaction rate was 88.1%, and this rate was constant over time. Satisfaction rates varied by diagnosis, age, sex, and anatomic location of the allograft. Postoperative International Knee Documentation Committee pain, function, and total scores differed between patients who were satisfied and not satisfied (all P < .001). All Knee injury and Osteoarthritis Outcome Score subscale results differed between those who were satisfied and not satisfied (all P < .001). Having a diagnosis of osteochondritis dissecans was the only variable that predicted which patients would be satisfied with the results of the allograft, after controlling for age, sex, anatomic location of the graft, and number of grafts.

CONCLUSION

A consistently high and durable patient satisfaction rate after OCA transplantation was found. Satisfied patients reported lower pain and higher function, activity levels, and quality of life as compared with patients who were not satisfied. Patients with osteochondritis dissecans had a particularly high level of satisfaction with the OCA procedure.

Which patients are satisfied with their overall outcome but dissatisfied with their return to recreational activities after total knee arthroplasty?

BACKGROUND

The primary aim of this study was to assess whether patients dissatisfied with both recreational activities and overall outcome were different to those dissatisfied with recreational activities but satisfied with their overall outcome one year after total knee arthroplasty (TKA).

METHODS

A retrospective cohort consisting of 3324 primary TKA were identified from an established arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Short Form (SF) 12 scores were collected pre-operatively and one year post-operatively. Overall patient satisfaction and satisfaction with recreational activities were assessed at one year.

RESULTS

The rate of patient satisfaction with recreational activities (n = 2672, 80.4%) was significantly (odds ratio (OR) 0.47, 95% confidence intervals (CI) 0.41 to 0.54, p < 0.001) lower than satisfaction with the overall outcome (n = 2982, 89.7%). When adjusting for confounding variables older age (OR 1.03, p = 0.008), increasing BMI (OR 1.05, p = 0.01) and absence of hypertension (OR 0.66, p = 0.02) were independent predictors of being dissatisfied with recreational activities in isolation. The one-year components and total WOMAC scores were significant (p < 0.001) predictors of satisfaction with recreational activities and were reliable with an area under the curve of ≥0.82 CONCLUSION: Patients of older age, higher BMI and without hypertension are more likely to be dissatisfied with recreational activities despite being satisfied with their overall outcome.

Outcome of knee arthroplasty in patients aged 65 years or less: a prospective study of 232 patients with 2-year follow-up

BACKGROUND AND AIMS

Previous studies have reported lower implant survival rates, residual pain, and higher patient dissatisfaction rates following knee arthroplasty in younger knee arthroplasty patients. We aimed to assess the real-world effectiveness of knee arthroplasty in a prospective non-selected cohort of patients aged 65 years or less with 2-year follow-up.

MATERIAL AND METHODS

In total, 250 patients (272 knees) aged 65 years or less were enrolled into this prospective cohort study. Patient-reported outcome measures were used to assess the outcome.

RESULTS

The mean Oxford Knee Score and all Knee Injury and Osteoarthritis Outcome Score subscales increased significantly (p < 0.001) from preoperative situation to the 2-year follow-up. Significant increase (p < 0.001) in physical activity was detected in High-Activity Arthroplasty Score and RAND-36 Physical Component Score (PCS). Pain was also significantly (p < 0.001) relieved during the follow-up. Total disappearance of pain was rare at 2 years. Patients with milder (Kellgren-Lawrence grade 2) osteoarthritis were less satisfied and reported poorer patient-reported outcome measure than those with advanced osteoarthritis (Kellgren-Lawrence grade 3-4). There was no difference in the outcome (any patient-reported outcome measure) between patients who underwent total knee arthroplasty and those who received unicondylar knee arthroplasty.

CONCLUSION

We found that measured with a wide set of patient-reported outcome measures, both total knee arthroplasty and unicondylar knee arthroplasty resulted in significant pain relief, as well as improvement in physical performance and quality of life in patients aged 65 years or less. Real-world effectiveness of these procedures seems to be excellent. 15% of patients still had residual symptoms and were dissatisfied with the outcome at 2 years after the operation.

Patient age of less than 55 years is not an independent predictor of functional improvement or satisfaction after total knee arthroplasty

INTRODUCTION

Management of the young patient with end-stage osteoarthritis of the knee is difficult, with surgical options of osteotomy, partial or total knee arthroplasty (TKA). The primary aim of this study was to assess whether age of less than 55 years was an independent predictor of functional outcome and satisfaction after total knee arthroplasty (TKA). The secondary aims were to identify pre-operative differences in patient demographics, comorbidity and function between patients less than 55 years old compared to those 55 years old and over.

MATERIALS AND METHODS

A retrospective cohort consisting of 2589 patients undergoing a primary TKA was identified from an established arthroplasty database. Patient demographics, comorbidity, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form (SF) 12 scores were collected pre-operatively and 1 year post-operatively. In addition, patient satisfaction was assessed at 1 year. Regression analysis was used to identify independent pre-operative predictors of change in the WOMAC and SF-12 scores, and patient satisfaction.

RESULTS

Patients less than 55 years old were significantly less likely to be satisfied with the overall outcome of their TKA (OR 0.4, p = 0.001). After adjusting for confounding variables age group was not an independent predictor of overall satisfaction with overall outcome (OR 0.71, p = 0.16). Independent predictors of an increased risk of dissatisfaction with the overall outcome at 1 year were depression (OR 0.58, p = 0.008) and worse pre-operative SF-12 MCS (p = 0.04).

CONCLUSION

Age of less than 55 years is not an independent predictor of functional outcome or rate of patient satisfaction after TKA. However, depression and poor mental health are significantly more prevalent in patients less than 55 years old and were independently associated with a lower satisfaction rate.

An Analysis of the Influence of Physical Activity Level on Total Knee Arthroplasty Expectations, Satisfaction, and Outcomes: Increased Revision in Active Patients at Five to Ten Years

This article was updated on September 19, 2018, because of a previous error. On page 1546, in the section titled "Discussion," the sentence that had read "Although a significant improvement was found in the vast majority of the inactive group, surprisingly, a majority of the active group (72.7%) reported a decrease in their activity levels below their baseline at 5 to 10 years postoperatively." now reads "Although a significant improvement was found in the vast majority of the inactive group, surprisingly, a majority of the active group (72.7%) reported no change or a decrease in their activity levels below their baseline at 5 to 10 years postoperatively."

BACKGROUND

Patients undergoing total knee arthroplasty expect pain relief, functional improvement, and a return to physical activity. The objective of this study was to determine the impact of patients' baseline physical activity level on preoperative expectations, postoperative satisfaction, and clinical outcomes in patients undergoing total knee arthroplasty.

METHODS

Using an institutional registry from 2007 to 2012, we retrospectively identified patients who underwent a unilateral primary total knee arthroplasty for osteoarthritis and completed a preoperative Lower Extremity Activity Scale (LEAS), a Hospital for Special Surgery Knee Replacement Expectations Survey (HSS-KRES), and a Knee injury and Osteoarthritis Outcome Score (KOOS) evaluation in addition to 2-year KOOS and satisfaction evaluations. Active patients were defined by an LEAS level of 13 to 18. Active patients (n = 1,008) were matched to inactive patients (n = 1,008) by age, sex, body mass index, and comorbidities. The cohorts were compared with regard to the association of expectations with KOOS and satisfaction, the change in LEAS level from baseline to 2 years, complications, and revision surgical procedures. Multivariable analyses identified predictors of satisfaction, KOOS, and revision surgical procedures.

RESULTS

Significantly more active patients (68.2%) expected to be back to normal with regard to the ability to exercise and participate in sports compared with inactive patients (55.5%; p < 0.0001). Although overall satisfaction was equivalent, active patients were more commonly very satisfied with regard to the ability to do recreational activities (67.2% compared with 57.7%; p = 0.001). There were no associations between expectations and satisfaction or outcomes. Only the inactive patient group improved in activity level at 2 years. At 2 years, 69.5% of the inactive patients and 27.3% of the active patients improved upon their baseline activity levels (p < 0.0001). Complications rates were similar. The revision rate was higher for active patients (3.2%) compared with inactive patients (1.6%) at 5 to 10 years postoperatively (p = 0.019).

CONCLUSIONS

At 2 years following total knee arthroplasty, inactive patients improved from baseline activity levels and active patients did not. Active patients had an elevated revision risk. Therefore, active patients should be carefully counseled regarding total knee arthroplasty to give them an understanding of its limitations and the potential risk of future revision.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative medial joint laxity in flexion decreases patient satisfaction after total knee arthroplasty

INTRODUCTION

The relationship between postoperative tibiofemoral ligament balance and patient satisfaction in total knee arthroplasty (TKA) has been explored previously. However, the optimal intraoperative medial-lateral ligament balance during knee flexion in terms of postoperative patient satisfaction remains unknown. We evaluated the effect of intraoperative flexion instability on patient satisfaction after TKA.

MATERIALS AND METHODS

This study consisted of 46 knees with varus osteoarthritis undergoing TKA. Medial-lateral component gaps at 0° knee extension and 90° flexion were measured intraoperatively using a knee balancer. Differences in postoperative patient outcomes at 3 weeks and 1 year were compared between medially tight knees in 90° flexion with a medial component gap of < 4 mm and medially loose knees in 90° flexion with a gap of ≥ 4 mm. Outcomes were measured using the 2011 Knee Society Scoring System (2011 KS).

RESULTS

The median total 2011 KS score at 1 year postoperatively in the medially loose knees [median 97; interquartile range (IQR) 75-117] was significantly lower than that in the medially tight knees (median 128; IQR 104-139, P < 0.01), while preoperative and 3-week postoperative scores were similar. In addition, medial flexion gaps were not significantly associated with total 2011 KS scores before surgery or at 3 weeks postoperatively. However, at 1 year after surgery, medial component flexion gaps were negatively associated with the total 2011 KS score (R = - 0.42; P < 0.01) and the 2011 KS satisfaction subscale score (R = - 0.36; P = 0.01).

CONCLUSIONS

Excessive intraoperative medial joint laxity of ≥ 4 mm at 90° flexion progressively decreased patient satisfaction for 1 year. Since intraoperative medial laxity in flexion is likely to interfere with functional recovery after TKA, medial stabilization during TKA is important throughout knee flexion.

LEVEL OF EVIDENCE

Therapeutic study, Level III.