Five-year follow-up of minimally invasive computer assisted total knee arthroplasty (MICATKA) versus conventional computer assisted total knee arthroplasty (CATKA) - A population matched study

How Does Tibial Pin Placement in Navigated Total Knee Arthroplasty Affect the Torsional Strength of the Tibia?

INTRODUCTION

Surgical navigation technology has recently become more prevalent for total knee arthroplasty. Surgical navigation typically requires pin placement in the proximal tibia diaphysis to stabilize the bone-tracking hardware, and there have been several recent reports of fractures through these residual navigation pin holes. The objective of this biomechanical study was to determine whether a difference exists in the torsional bone strength of a 5-mm navigation pin hole drilled at a single location in three different orientations: unicortical, bicortical, and transcortical.

METHODS

Biomechanical composite sawbone tibias were used to test four conditions: the intact condition with no holes, a unicortical hole, a bicortical hole, and a transcortical hole through the proximal diaphysis. Seven specimens from each group were tested in external rotation to failure at 1 deg/sec. Torque-to-failure, absorbed energy-to-failure, and rotational angle-to-failure were statistically compared across the four groups.

RESULTS

All specimens failed proximally by spiral oblique fractures. No statistical differences were found between unicortical and bicortical groups in torque-to-failure, energy-to-failure, and angle-to-failure. However, both unicortical and bicortical groups were markedly lower in all measures than the intact group. The transcortical group was markedly lower in all measures than the intact group and both unicortical and bicortical groups.

DISCUSSION

An appropriately placed navigation residual pin hole, either unicortical or bicortical, markedly decreases the torque-to-failure, energy-to-failure, and angle-to-failure of the tibia compared with the intact condition in a synthetic sawbones model. No notable difference was detected between the unicortical and bicortical holes; however, an errant transcortical residual navigation pin hole markedly decreases all measures compared with an appropriately placed unicortical or bicortical hole.

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.

Factors Affecting Hospital Length of Stay following Total Knee Replacement: A Retrospective Analysis in a Regional Hospital

In an effort to reduce hospital length of stay (LoS) following total knee arthroplasty (TKA), patient management strategies have evolved over time. The aims of this study were threefold: first, to quantify the reduction in LoS for TKA in a regional hospital; second, to identify the patient, surgical and management factors associated with hospital LoS; and lastly, to assess the change in complications incidence and hospital readmission as a function of LoS. A retrospective chart review was conducted on a consecutive series of primary and revision TKAs from January 2012 to March 2018. Factors describing patient demographics, as well as preoperative, intraoperative, surgical, and postoperative management, were extracted from paper and electronic medical records by a team of reviewers. Multivariate linear regression was performed to assess the association between these factors and LoS. In total, 362 procedures were included, which were reduced to 329 admissions once simultaneous bilateral procedures were taken into account. Median LoS reduced significantly (p = 0.001) from 6 to 2 days over the period of review. A stepwise regression analysis identified patient characteristics (age, gender, comorbidities, discharge barriers), perioperative management (anesthesia type), surgical characteristics (approach, alignment method), and postoperative management (mobilization timing, postoperative narcotic use, complication prior to discharge) as factors explaining 58.3% of the variance in LoS. Representation to emergency (6%) and hospital readmission (3%) remained low for the reviewed period. Efforts to reduce hospital LoS following TKA within a regional hospital setting can be achieved over time without significant increases in the rate or severity of complications or representation to acute care and subsequent readmission. The findings establish the role of patient, surgical and management factors in the context of agreed discharge criteria between care providers.

Education, engagement and provision of empathy by trained counselor enhances the patient satisfaction after Total Knee Arthroplasty

BACKGROUND

One of the major concerns following Total Knee Arthroplasty (TKA) surgery is patient satisfaction. Hence, this study sought to assess the effect of patient education, engagement and provision of empathy delivered by trained counselor on patient satisfaction.

METHODS

All the patients included in the study were randomly allocated to two groups: Patients who received counseling from trained personnel during pre-, peri- and post-TKA phase constituted group-A (n = 100) whereas patients who were advised by the surgeon before the procedure constituted group-B (n = 100). All the patients who were counseled by trained personnel continued to receive counseling up to six months following TKA surgery. Patients belonging to group-A were provided counseling pertaining to education related to TKA procedure, the modalities of pain management and post-TKA ambulation regimen. Patient satisfaction was measured with Forgotten Joint Score-12 (FJS-12) and consumer gap (defined as the difference between patient perception and expectation) was recorded by an independent observer after 52-week of the TKA procedure.

RESULTS

Patients belong to group-A had higher satisfaction as compared to those in group-B as evident by statistically higher FJS-12 score (64.5 ± 16.4 vs. 59.4 ± 17.9; p = 0.0369). There was statistically significant difference observed in consumer gap between group-A (6%) and group-B (16%) (p = 0.0242).

CONCLUSIONS

The results of the study are encouraging to employ counseling by trained personnel during pre-, peri- and post-TKA phases as to improve patient satisfaction and reduce consumer gap.

Minimally Invasive Total Knee Arthroplasty: Does Surgical Technique Actually Impact the Outcome?

A surgical approach to total knee arthroplasty has been at the forefront of many conversations. Surgeons used the medial parapatellar approach for its familiarity of anatomy, reliability, and ability to convert to a more extensile approach. This article reviews the current literature and information regarding the effect of surgical approach on patients' outcomes. The results of the limited medial parapatellar, subvastus, midvastus, and quadriceps-sparing approaches were analyzed. All techniques can provide adequate exposure with successful outcomes. It is recommended that a surgeon perform the approach with which they are most comfortable, because that will likely yield the best patient outcome.

Better outcomes after mini-subvastus approach for primary total knee arthroplasty: a Bayesian network meta-analysis

Introduction

Alternatives to the classical medial parapatellar (MPP) approach for total knee arthroplasty (TKA) include the mini-medial parapatellar (MMPP), mini-subvastus (MSV), mini-midvastus (MMV) and quadriceps-sparing (QS) approaches. The best approach has been not fully clarified. The purpose of the present study was to conduct a Bayesian network meta-analysis comparing these approaches.

Materials and methods

The present analysis was carried out according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. The databases search was performed in October 2019. All clinical trials comparing two or more approaches for primary TKA were considered for inclusion. The baseline comparability was evaluated through the analysis of variance (ANOVA) test. The statistical analysis was performed through the STATA software/MP. A Bayesian hierarchical random-effects model analysis was adopted in all the comparisons.

Results

Data from 52 articles (4533 patients) were collected. The mean follow-up was 20.38 months. With regard to diagnosis, gender, age and BMI, adequate baseline comparability was detected. The MSV approach ranked better concerning clinical scores (the lowest visual analogic scale, the higher KSS and KSFS) and functional outcomes (the shortest straight leg raise, the greatest degree of flexion and range of motion). Concerning perioperative data, the MSV evidenced the shortest hospital stay, while the MPP the shortest surgical duration and lowest estimated blood loss.

Conclusion

According to the main findings of the present study, the mini-subvastus approach for total knee arthroplasty demonstrated superior overall compared to the other approaches. Orthopaedic surgeons should consider this approach in the light of the evidence and limitations of this Bayesian network meta-analysis.

Minimally invasive total knee replacement: techniques and results

In this review, we outlined the definition of minimally invasive surgery (MIS) in total knee replacement (TKR) and described the different surgical approaches reported in the literature. Afterwards, we went through the most recent studies assessing MIS TKR. Next, we searched for potential limitations of MIS knee replacement and tried to answer the following questions: Are there selective criteria and specific patient selection for MIS knee surgery? If there are, then what are they? After all, a discussion and conclusion completed this article. There is certainly room for MIS or at least less invasive surgery for appropriate selected patients. Nonetheless, there are differences between approaches. Mini-medial parapatellar is easy to master, quick to perform and potentially extendable, whereas mini-subvastus and mini-midvastus are trickier and require more caution related to risk of haematoma and vastus medialis oblique (VMO) nerve damage. Current evidence on the safety and efficacy of mini-incision surgery for TKR does not appear fully adequate for the procedure to be used without special arrangements for consent and for audit or continuing research. There is an argument that a sudden jump from standard TKR to MIS TKR, especially without computer assistance such as navigation, patient-specific instrumentation or robotic, may breach a surgeon's duty of care towards patients because it exposes patients to unnecessary risks. As a final point, more evidence is required on the long-term safety and efficacy of this procedure which will give objective shed light on real benefits of MIS TKR.

Outpatient Total Knee Arthroplasty: Are We There Yet? (Part 2)

The method by which surgeons conduct outpatient total knee procedures has yet to be fully elucidated. Literature demonstrates different experiences from various care protocols in place across the nation. This article reviews current recommendations for implementing successful total knee arthroplasty (TKA) and unicompartmental knee arthroplasty outpatient protocols. Specifically, information regarding anesthesia and analgesia modalities, perioperative care, operative technique, and postoperative care within outpatient TKA pathways is discussed.

Minimally invasive surgery (MIS) for total knee replacement; medium term results with minimum five year follow-up

BACKGROUND

MIS TKA has been shown to offer a reduced in-patient stay, but no clinical difference at two years. Whilst there may be a benefit from earlier discharge, we need to ensure that there are no detrimental effects in the medium and long-term following MIS-TKA. To report the mid-term result from a prospective randomised controlled trial (RCT) comparing MIS-TKA with standard approach for TKA.

METHODS

Using knee score questionnaires, we collected patient reported outcome measures (PROMs) regarding pain and function. Sixty-six patients (from an eligible cohort of 83 patients) completed the mid-term postal follow-up.

RESULTS

There was no significant difference between groups for change in score from pre-operative to final follow-up in all three PROMs. Mean MIS and standard group improvement was: AKSS 53 and 51 (p=0.7644), OKS 15 and 16 (p=0.2341) or WOMAC 15 and 15 (p=0.9900) respectively. Both groups showed improvement in pain and function with no significant difference between groups. There was no difference between groups for revision due to malalignment at a mean six year follow-up.

CONCLUSIONS

In addition to the early benefits regarding hospital stay and complications, we have found that at a mean of six years there was no increase in malalignment, pain or function with MIS techniques.

Handheld Navigation Device and Patient-Specific Cutting Guides Result in Similar Coronal Alignment for Primary Total Knee Arthroplasty: a Retrospective Matched Cohort Study

BACKGROUND

Proper alignment of total knee arthroplasty (TKA) is essential for TKA function and may reduce the risk of aseptic failure. Technologies that prevent malalignment may reduce the risk of revision surgery.

QUESTIONS/PURPOSES

The purpose of this study was to compare two competing TKA systems that purport improved alignment: patient-specific instrumentation (PSI), and a handheld portable navigation device (NAV).

METHODS

After IRB approval, 49 consecutive PSI TKAs (40 patients) were matched based on preoperative characteristics to 49 NAV TKAs (40 patients) performed by a single surgeon. A blinded observer measured alignment on digital radiographs. Operating room records were reviewed for procedure times. Two-tailed paired sample t tests and McNemar's test were used as appropriate. Alpha level was 0.05 for all tests.

RESULTS

Preoperative cohort characteristics were not different. Mean postoperative long-leg mechanical alignment was within ±1° of neutral for both groups, although statistically different (p = 0.026). There were no other significant differences in coronal alignment. PSI exhibited significantly greater posterior tibial slope (4.4°) compared to NAV (2.7°) (p = 0.004); PSI resulted in significantly more outliers (>6°; p = 0.004). Procedure time for unilateral TKAs was lower for PSI (74.4 min) compared to that for NAV (80.6 min; p = 0.023).

CONCLUSION

NAV and PSI technologies provided excellent coronal plane alignment. NAV was better for sagittal tibial slope, while PSI procedure times were shorter for unilateral TKA. The impact of these technologies on patient-reported outcomes and TKA survivorship is controversial and should be the focus of future research.

Improving outcomes in total knee arthroplasty-do navigation or customized implants have a role?

Modern total knee arthroplasty is effective at treating the pain and disability associated with osteoarthritis. The number of total knee replacements done in the USA continues to increase. Despite the great care taken during all of these procedures, some patients remain dissatisfied with their outcome. While this dissatisfaction is likely multifactorial, malalignment of the prosthetic components is a major cause of postoperative complications. A neutral mechanical axis plus or minus 3° is felt to have a positive impact on the survivorship of the prosthesis. Conventional instrumentation has been shown to have a significant number of total knee replacements that lie well outside a neutral coronal alignment. With that in mind, significant effort has been placed into the development of technology to improve the overall alignment of the prosthesis. In order to reduce the number of outliers, several companies have developed cost-effective systems to aid the surgeon in achieving a more predictably aligned prosthesis in all three planes. We will review the literature that is available regarding several of these tools to examine if navigation or custom guides improve outcomes in total knee arthroplasty. Our review supports that while both navigation and custom implants guides seem to be a cost effective way to achieve a predictable mechanical alignment of a total knee prosthesis therefore reducing the number of outliers, the cost may be increased operative times with no perceived difference in patient satisfaction with navigation custom guides.

Minimally Invasive Computer-Assisted Total Knee Arthroplasty Compared With Conventional Total Knee Arthroplasty: A Prospective 9-Year Follow-Up

BACKGROUND

Studies on minimally invasive computer-assisted total knee arthroplasty (MICA-TKA) have shown promising results, but are limited by short follow-up. The purpose of this study was to compare the midterm radiographic features and functional outcomes between patients who underwent MICA-TKA and conventional TKA.

METHODS

A total of 108 patients who were randomized to undergo MICA-TKA or conventional TKA during 2004 and 2005 were contacted for a prospective follow-up review. Patients who were lost to contact, have passed away, or declined to participate in the study were excluded. Objective functional measurements and radiographs were obtained for assessment.

RESULTS

By the time of this study, 2 patients from the conventional group had undergone revision TKA, one due to infection and one due to aseptic loosening. A total of 67 patients (62.04%) were followed up for an average period of 9.07 years (8.51-9.61 years). At follow-up, functional scores were comparable between the 2 groups. No significant intergroup differences were found in mechanical knee alignment and component placement angle in the coronal views. No statistical or clinical significance were noticed in radiographic signs of component loosening.

CONCLUSIONS

MICA-TKA provided similar clinical, functional, and radiographic outcomes compared with conventional TKA after an average of 9-year follow-up. This technique can be used to exploit its short-term advantages without compromising midterm outcomes.

Computer-assisted total knee arthroplasty using mini midvastus or medial parapatellar approach technique: A prospective, randomized, international multicentre trial

Background

Despite the growing evidence in the literature there is still a lack of consensus regarding the use of minimally invasive surgical technique (MIS) in total knee arthroplasty (TKA).

Methods

A prospective, randomized, international multicentre trial including 69 patients was performed to compare computer-assisted TKA (CAS-TKA) using either mini-midvastus (MIS group) or standard medial parapatellar approach (conventional group).

Patients from 3 centers (Maastricht, Zwickau, Adelaide) with end-stage osteoarthritis of the knee were randomized to either an MIS group with dedicated instrumentation or a conventional group to receive cruciate retaining CAS-TKA without patella resurfacing. The primary outcome was to compare post operative pain and range of motion (ROM). The secondary outcome was to measure the duration of surgery, blood loss, chair rise test, quadriceps strength, anterior knee pain, Knee Society Score (KSS),WOMAC scores, mechanical leg axis and component alignment.

Results

Patients in the MIS group (3.97 ± 2.16) had significant more pain at 2 weeks than patients in the conventional group (2.77 ± 1.43) p = 0.003. There was no significant difference in any of the other primary outcome parameters. Surgery time was significantly longer (p < 0.001) and there were significantly higher blood loss (p = 0.002) in the MIS group as compared to the conventional group. The difference of the mean mechanical leg alignment between the groups was not statistically significant (–0.43° (95 % CI –1.50 – 0.64); p = 0.43).

There was no significant difference of component alignment between the two surgical groups with respect to flexion/extension (p = 0.269), varus/valgus (p = 0.653) or rotational alignment (p = 0.485) of the femur component and varus valgus alignment (p = 0.778) or posterior slope (p = 0.164) of the tibial component.

Conclusion

There was no advantage of the MIS approach compared to a conventional approach CAS-TKA in any of the primary outcome measurements assessed, however the MIS approach was associated with longer surgical time and greater blood loss. MIS-TKA in combination with computer navigation is safe in terms of implant positioning.

Trial registration number

ClinicalTrials.gov NCT02625311 8 December 2015