Inferior outcomes of total knee replacement in early radiological stages of osteoarthritis

Patients Who Have Kellgren-Lawrence Grade 3 and 4 Osteoarthritis Benefit Equally From Total Knee Arthroplasty

BACKGROUND

Recently, some payers have limited access to total knee arthroplasty (TKA) to patients who have Kellgren-Lawrence (KL) grade 4 osteoarthritis only. This study compared the outcomes of patients who have KL grade 3 and 4 osteoarthritis after TKA to determine if this new policy is justified.

METHODS

This was a secondary analysis of a series originally established to collect outcomes for a single, cemented implant design. A total of 152 patients underwent primary, unilateral TKA at two centers from 2014 to 2016. Only patients who had KL grade 3 (n = 69) or 4 (n = 83) osteoarthritis were included. There was no difference in age, sex, American Society of Anesthesiologists score, or preoperative Knee Society Score (KSS) between the groups. Patients who had KL grade 4 disease had a higher body mass index. KSS and Forgotten Joint Score (FJS) were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Generalized linear models were used to compare outcomes.

RESULTS

Controlling for demographics, improvements in KSS were comparable between the groups at all time points. There was no difference in KSS, FJS, and the proportion that achieved the patient acceptable symptom state for FJS at 2 years.

CONCLUSION

Patients who had KL grade 3 and 4 osteoarthritis experienced similar improvement at all time points up to 2 years after primary TKA. There is no justification for payers to deny access to surgical treatment for patients who have KL grade 3 osteoarthritis and have otherwise failed nonoperative treatment.

Less improvement in knee function and higher rates of dissatisfaction in the short-term following total knee arthroplasty in people with mild radiographic arthritis

INTRODUCTION

The purpose of this study was to assess if severity of radiographic changes of knee arthritis was associated with patient improvement after total knee arthroplasty (TKA). We hypothesised that patients with mild arthritis were more likely to report lower satisfaction, improvement in knee function and Oxford knee score (OKS) compared to patients with moderate or severe arthritis.

MATERIALS AND METHODS

Secondary analysis of prospectively collected data from TKA patients of two arthroplasty centres with knee radiographs available for assessment of disease severity. Patients completed the Oxford knee score (OKS) and were asked to rate the global improvement in knee condition and their satisfaction at 6 months post-TKA. Bivariable analysis and multivariable regression models were used to test the association between disease severity and each outcome.

RESULTS

2226 patients underwent primary TKA and 3.6% had mild arthritis. Mean OKS improved from 17.0 (SD 18.0) to 38.0 (SD 8.1) 6 months after TKA. Two hundred and twenty-two patients (10%) reported 'Poor' or 'Fair' satisfaction, and 173 (8%) reported knee function was 'Much worse', 'A little worse' or 'About the same' 6 months post-TKA. Patients with mild arthritis showed improvement in OKS [mean improvement in OKS = 19 (SD 15)], but were significantly more likely to report dissatisfaction (OR = 3.10, 95% CI 1.62 to 5.91, p = 0.006), lack of improvement (OR = 4.49, 95% CI 2.38 to 8.47, p < 0.001) and lower OKS scores (- 3 points, 95% CI - 5.39 to - 0.85, p = 0.008) compared to patients with moderate to severe arthritis.

CONCLUSIONS

While patients with mild radiographic arthritic changes improve after TKA, they were significantly more likely to report higher rates of dissatisfaction, less improvement in knee function and OKS compared to patients with moderate-severe grades of arthritis.

Mild radiographic osteoarthritis is associated with increased pain and dissatisfaction following total knee arthroplasty when compared with severe osteoarthritis: a systematic review and meta-analysis

PURPOSE

The association between severity of radiographic osteoarthritis with patient pain, function, and satisfaction following total knee arthroplasty has been disputed. The discrepancies in current literature prompt us to further examine this association in a systematic review and meta-analysis.

METHODS

The OVID-Medline, Embase, and Web of Science databases were searched from their inception up to Mar 2020. The main independent variable was osteoarthritis severity as defined by preoperative radiographs. The outcomes measured were pain, function and satisfaction following total knee arthroplasty. A minimum of three studies assessing the same patient-reported outcome measures were included in the meta-analysis, as well as those separating patients by chronic pain or dissatisfaction.

RESULTS

29 studies were included in this study. Significant heterogeneity was seen between radiographic evaluation and reported outcomes. Patients with only mild radiographic osteoarthritis were more likely to suffer from chronic pain (odds ratio = 2.45, 95% CI = 1.80-3.34, p < 0.001) and dissatisfaction (odds ratio = 2.43, 95% CI = 1.79-3.31, p < 0.001) compared to patients with severe osteoarthritis. A significant association was found between mild radiographic severity and lower total Western Ontario and McMaster Universities Osteoarthritis scores (95% CI = - 0.37-0.06, p = 0.006) as well as Knee Society Scores (CI: - 0.54-0.16, p < 0.001).

CONCLUSION

Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis. They are also at risk for chronic pain and dissatisfaction and should be consulted about this risk prior to surgery.

LEVEL OF EVIDENCE

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.

Severity of valgus knee osteoarthritis has no effect on clinical outcomes after total knee arthroplasty

INTRODUCTION

Advanced valgus osteoarthritis (OA) is one of the most challenging indications for total knee arthroplasty (TKA). There is no information in the literature about the optimal timing of surgery. The current study investigates the impact of the preoperative deformity and degree of arthritis on postoperative outcome after TKA.

MATERIAL AND METHODS

The study evaluated 133 knees in 107 patients with valgus OA that failed nonoperative treatment with a minimum 2-year follow-up. Mechanical alignment, Kellgren and Lawrence (K/L) score, and minimal joint space width (minJSW) were measured on AP- and hip-to-ankle radiographs. All knees had advanced OA (i.e., K/L grades 3 or 4 and less than 50% minJSW). Pre- and postoperative WOMAC, VR-12, UCLA, VAS, ROM were recorded.

RESULTS

There was no difference in clinical outcome (WOMAC, UCLA, VR-12, VAS or ROM) between patients with different degrees of valgus deformities (< 5.0 deg., 5.0-9.9 deg., 10.0-14.9 deg., ≥ 15.0 deg.). There was also no correlation between K/L score or minimal joint space width and any of the outcome parameters.

CONCLUSIONS

The degree of valgus deformity and the grade of osteoarthritis do not predict the outcome of TKA in patients with valgus OA. Since the risk of complication and the need for implant constraint increases with increasing deformity and instability of the knee, surgery appears to be justified in patients with advanced OA that failed nonoperative treatment, regardless of the degree of deformity.

Personalised high tibial osteotomy has mechanical safety equivalent to generic device in a case-control in silico clinical trial

Background

Despite favourable outcomes relatively few surgeons offer high tibial osteotomy (HTO) as a treatment option for early knee osteoarthritis, mainly due to the difficulty of achieving planned correction and reported soft tissue irritation around the plate used to stablise the osteotomy. To compare the mechanical safety of a new personalised 3D printed high tibial osteotomy (HTO) device, created to overcome these issues, with an existing generic device, a case-control in silico virtual clinical trial was conducted.

Methods

Twenty-eight knee osteoarthritis patients underwent computed tomography (CT) scanning to create a virtual cohort; the cohort was duplicated to form two arms, Generic and Personalised, on which virtual HTO was performed. Finite element analysis was performed to calculate the stresses in the plates arising from simulated physiological activities at three healing stages. The odds ratio indicative of the relative risk of fatigue failure of the HTO plates between the personalised and generic arms was obtained from a multi-level logistic model.

Results

Here we show, at 12 weeks post-surgery, the odds ratio indicative of the relative risk of fatigue failure was 0.14 (95%CI 0.01 to 2.73, p = 0.20).

Conclusions

This novel (to the best of our knowledge) in silico trial, comparing the mechanical safety of a new personalised 3D printed high tibial osteotomy device with an existing generic device, shows that there is no increased risk of failure for the new personalised design compared to the existing generic commonly used device. Personalised high tibial osteotomy can overcome the main technical barriers for this type of surgery, our findings support the case for using this technology for treating early knee osteoarthritis.

Treatment of Rotator Cuff Tears with platelet rich plasma: a prospective study with 2 year follow-up

BACKGROUND

Surgical treatment of full-thickness rotator cuff (RC) tears is associated with generally good results. There is no consensus regarding treatment of partial thickness tears that fail conservative treatment. The purpose of this study was to look at the efficacy and confirm the safety of dual injection PRP into the shoulder of patients with rotator cuff pathology who have failed conservative treatment with followup to two years.

METHODS

Seventy-one shoulders with MRI confirmed, rotator cuff pathology who failed conservative treatment, had dual PRP injection into the rotator cuff. Global improvement, Quick DASH and VAS scores were collected at 6, 12, and 24 months after treatment and comparison of means was used to analyze changes.

RESULTS

No adverse events were seen in any patient. Based on global rating scores positive results were seen in 77.9 % of patients at 6 months, 71.6 % at 1 year, and 68.8 % of patients at 2 years. Mean VAS scores improved from 50.2 [CI 44.4-56.0] pre-injection to 26.2 [CI 19.5-32.9] at 6 months, 22.4[CI 16.1-28.7] at 1 year and 18.2 [CI 12.3-24.1] at 2 years (p < 0.0001 for all). The mean Q- DASH scores (0-100, 100 worse) improved from 39.2 [CI 34.3-44.1] for all patients before treatment to 20.7[CI 15.0-26.4] at 6 months, 18.0[CI 12.9-23.1] at 1 year, and 13.8 [CI 8.4-18.8] at 2 years (p < 0.0001 for all). No patient with partial tear had clinical evidence of progression to full thickness tear. When separated into subgroups based on rotator cuff status, all subgroups showed improvement. Patients in the > 50 % partial tear group had the best overall improvement based on Global Rating scores while those in the tendinitis group had the poorest outcomes.

CONCLUSIONS

PRP injection is a safe and effective treatment for RC cuff injury in patients who have failed conservative treatment of activity modification and physical therapy without deterioration of results two years after treatment. Better results are obtained with greater structural tendon damage than in shoulders with inflammation without structural damage.

TRIAL REGISTRATION

This is not a clinical trial.

Association Between Preoperative Radiographic Severity of Osteoarthritis and Patient-Reported Outcomes of Total Knee Replacement

The goal of this study was to investigate the association between preoperative radiographic severity of knee osteoarthritis (OA) and patient-reported outcomes following total knee replacement.

Correlations between radiological classification systems and confirmed cartilage loss in severe knee osteoarthritis

AIMS

Although knee osteoarthritis (OA) is diagnosed and monitored radiologically, actual full-thickness cartilage loss (FTCL) has rarely been correlated with radiological classification. This study aims to analyze which classification system correlates best with FTCL and to assess their reliability.

METHODS

A prospective study of 300 consecutive patients undergoing unilateral total knee arthroplasty (TKA) for OA (mean age 69 years (44 to 91; standard deviation (SD) 9.5), 178 (59%) female). Two blinded examiners independently graded preoperative radiographs using five common systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlbäck. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). Intraoperatively, anterior cruciate ligament (ACL) status and the presence of FTCL in 16 regions of interest were recorded. Radiological classification and FTCL were correlated using the Spearman correlation coefficient.

RESULTS

Knees had a mean of 6.8 regions of FTCL (SD 3.1), most common medially. The commonest patterns of FTCL were medial ± patellofemoral (143/300, 48%) and tricompartmental (89/300, 30%). ACL status was associated with pattern of FTCL (p = 0.023). All radiological classification systems demonstrated moderate ICC, but this was highest for the IKDC: whole knee 0.68 (95% confidence interval (CI) 0.60 to 0.74); medial compartment 0.84 (95% CI 0.80 to 0.87); and lateral compartment 0.79 (95% CI 0.73 to 0.83). Correlation with actual FTCL was strongest for Ahlbäck (Spearman rho 0.27 to 0.39) and KL (0.30 to 0.33) systems, although all systems demonstrated medium correlation. The Ahlbäck score was the most discriminating in severe knee OA. Osteophyte presence in the medial compartment had high positive predictive value (PPV) for FTCL, but not in the lateral compartment.

CONCLUSION

The Ahlbäck and KL systems had the highest correlation with confirmed cartilage loss at TKA. However, the IKDC system displayed the best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, although it was less discriminating in more severe disease. Cite this article: Bone Joint J 2020;102-B(3):301-309.

Appropriateness of clinical criteria for the use of SYmptomatic Slow-Acting Drug for OsteoArthritis (SYSADOA). A Delphi Method Consensus initiative among experts in Italy

BACKGROUND

Osteoarthritis (OA) is a theme currently representing an emerging topic for its increasing incidence. It is well known that it is a chronic disease that could lead to important long-lasting disability; this generates increasing costs for the health care system. OA treatment options vary: localization, etiology, grading and symptomatology should be considered before choosing the most adequate therapy. Currently, a modern approach to managing OA involves SYmptomatic Slow-Acting Drug for OsteoArthritis (SYSADOAs). However, while all preparations may claim to deliver a therapeutic level of glucosamine or chondroitin, not all of them are supported by clinical evidence. Recently the European Society for Clinical and Economic aspects of Osteoporosis, Osteoarthritis and musculoskeletal diseases (ESCEO), produced an evidenced based document providing practitioners with the latest clinical and economic information, thereby allowing them to optimize the management of knee OA. According to this report, only crystalline glucosamine sulphate and the pharmaceutical-grade chondroitin sulphate are considered as effective in the first line approach to treating knee OA as an alternative drug to acetaminophen. However, some OA guidelines do not agree are not concordant in recommending the use of SYSADOA, perhaps because they are generally considered as a class and distinctions among formulations are not made.

AIM

Aim of this study was to identify the main aspects involved in patient selection, the choice of therapeutic agents and the safety profile in using SYSADOA.

DESIGN

Delphi method Consenus Statement.

POPULATION

Italian Physicians having expertise in Osteoarthritis management.

METHODS

A committee of 11 experts from Italian universities, public hospitals, territorial services, research institutes and patient associations was set up. Sixty-three clinicians from a large number of Italian medical centers specialized in osteoarthritis management took part in a Delphi process which was aimed at obtaining consensus statements among the participants.

RESULTS

Large consensus was obtained for statements grouped under the following main themes: treatment indications; drug/medical devices choice; treatment efficacy.

CONCLUSIONS

Results from the Italian consensus on appropriateness of OA therapies in osteoarthritis seems to be in line with the stepwise approach proposed by the ESCEO algorithm, where crystalline glucosamine sulphate shows greater clinical efficacy than other glucosamine-based formulations, according to several independent meta-analyses.

CLINICAL REHABILITATION IMPACT

This study may be used as a practical reference tool to help Italian physicians treat osteoarthritis patients using SYSADOA.

The Knee Osteoarthritis Grading System for Arthroplasty

BACKGROUND

The aim of this study is to validate the Knee Osteoarthritis Grading System (KOGS) of progressive osteoarthritic degeneration for the tri-compartmental knee. This system defines the site and severity of osteoarthritis to determine a specific knee arthroplasty.

METHODS

The radiographic sequence for KOGS includes standing coronal (anteroposterior), lateral, 30° skyline patella, 15° and 45° Rosenberg and stress views in 20° of flexion. Cohen's kappa and related agreement statistical methods were used to assess the level of concordance of the 7 evaluators between A and B cohorts for each evaluator and also against the actual arthroplasty used. Sensitivity and specificity was also assessed for the KOGS in identifying true partial knee arthroplasties (PKAs) and total knee arthroplasties (TKAs) as decided from the cohort A evaluations.

RESULTS

From a cohort of 330 patients who were included in the study, 71 (22.5%) underwent a TKA procedure, 258 (78.2%) a PKA, and 1 (0.3%) was neither a TKA nor PKA. KOGS was able to identify true PKAs (sensitivity) in the range of 92.2%-98.5% across all the different evaluators. The KOGS method was able to identify a PKA or a TKA with an accuracy ranging from 92% to 98.8% across all different evaluators. The surgical results after 20 months are at least comparable with the expected average in the academic literature.

CONCLUSION

The KOGS classification provides a reliable and accurate tool to assess suitability of an individual patient for undergoing PKA or TKA.

The incidence and impact of arthroscopy in the year prior to total knee arthroplasty

BACKGROUND

Prior knee surgery and arthroscopy is known to increase complications and re-operations in subsequent total knee arthroplasty (TKA). We set out to examine the time dependant effect of arthroscopy on Patient Reported Outcome Measures following subsequent TKA.

METHODS

A retrospective review of theatre and clinical records identified 186 patients who underwent TKA within a year of arthroscopy (2009-2013). Oxford knee score (OKS) data was compared with a published cohort from the same department (1708 patients).

RESULTS

One hundred and eighty six patients were identified who underwent TKA within a year of arthroscopy; 112 females, 74 males; mean age 64 (SD 10); mean BMI 31.4 (SD 4.6). There was no significant difference between groups with respect to sex, age, BMI, or pre-operative OKS. One hundred and three patients underwent TKA within six months of arthroscopy. This group had a significant reduction in OKS compared to the previously published cohort (32.8 vs 36.3, p<0.005). There was no significant difference in OKS when TKA was performed more than six months after arthroscopy (35.3). The re-operation rate was 14% in the arthroscopy group, with a revision rate of 3.8% vs 1.6% in a previously published large cohort from the same institution.

CONCLUSIONS

There appears to be a negative impact of arthroscopy in relation to subsequent TKA which seems to be time dependent. TKA should not routinely be performed within six months of arthroscopy. This should inform guidelines on the management knee osteoarthritis.

Predicting dissatisfaction following total knee arthroplasty in patients under 55 years of age

AIMS

Risk of revision following total knee arthroplasty (TKA) is higher in patients under 55 years, but little data are reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction in these patients.

PATIENTS AND METHODS

We prospectively assessed 177 TKAs (157 consecutive patients, 99 women, mean age 50 years; 17 to 54) from 2008 to 2013. Age, gender, implant, indication, body mass index (BMI), social deprivation, range of movement, Kellgren-Lawrence (KL) grade of osteoarthritis (OA) and prior knee surgery were recorded. Pre- and post-operative Oxford Knee Score (OKS) as well as Short Form-12 physical (PCS) and mental component scores were obtained. Post-operative range of movement, complications and satisfaction were measured at one year.

RESULTS

Overall, 44 patients with 44 TKAs (24.9%) under 55 years of age were unsure or dissatisfied with their knee. Significant predictors of dissatisfaction on univariate analysis included: KL grade 1/2 OA (59% dissatisfied), poor pre-operative OKS, complications, poor improvements in PCS and OKS and indication (primary OA 19% dissatisfied, previous meniscectomy 41%, multiply operated 42%, other surgery 29%, BMI > 40 kg/m² 31%, post-traumatic OA 45%, and inflammatory arthropathy 5%). Poor pre-operative OKS, poor improvement in OKS and post-operative stiffness independently predicted dissatisfaction on multivariate analysis.

CONCLUSION

Patients receiving TKA younger than 55 years old should be informed about the increased risks of dissatisfaction. Offering TKA in KL 1/2 is questionable, with a dissatisfaction rate of 59%. Cite this article: Bone Joint J 2016;98-B:1625-34.

Patients with isolated lateral osteoarthritis: Unicompartmental or total knee arthroplasty?

BACKGROUND

Lateral unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are both reliable treatment options for patients with isolated lateral osteoarthritis (OA). However, studies comparing both procedures are scarce. Aims of this study were to (I) compare short-term functional outcomes following lateral UKA and TKA and (II) assess the role of patient characteristics on outcomes as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

METHODS

In this retrospective cohort study, 82 patients (48 undergoing lateral UKA and 34 undergoing TKA) were identified that presented with lateral OA and completed the WOMAC. Independent t-tests were used to compare outcomes following lateral UKA and TKA.

RESULTS

Mean follow-up was 2.8 years (range: 2.0 - 5.0 years). Preoperatively, no differences between lateral UKA and TKA were seen (50.1±13.5 and 53.3±17.1, respectively, p=0.551). Postoperatively, lateral UKA patients reported better overall outcomes than TKA (90.5±11.7 vs. 81.8±17.9, p=0.017). Subgroup analysis showed better outcomes following lateral UKA than TKA in patients younger than 75 years (92.1±9.9 vs. 81.3±19.6, p=0.014) and in females (91.6±9.9 vs. 81.0±18.2, p=0.014).

CONCLUSION

These findings indicate that lateral UKA has superior short-term functional outcomes compared to TKA in patients with isolated lateral OA. Better outcomes were especially seen in younger patients and females. These findings may help orthopedic surgeons choose treatment for patients presenting with lateral OA and optimize treatment for individual patients.