Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: how much knee motion is sufficient for normal daily life?

Clinical Relevance of Posterior Osteophyte Formation in Ultra-congruent Total Knee Arthroplasty: Midterm Radiographic Rollback and Impingement Analysis

Background

Posterior femoral condylar osteophytes were frequently observed in patients with the ultra-congruent (UC) deep-dish design prosthesis. Therefore, the purpose of the present study was to verify the clinical relevance of osteophyte formation in the UC design.

Methods

From March 2014 to February 2018, a comparative study was conducted on 96 knees using the UC design. They were divided into 2 groups (group 1: osteophyte +, group 2: osteophyte -). Intraoperative findings, indirect femoral rollback assessment using 30° flexion and active full flexion lateral radiographs, serial change of the osteophyte, and outcomes were compared.

Results

The mean follow-up period was 49.35 ± 3.47 months in group 1 and 47.52 ± 3.37 months in group 2. Posterior component coverage was significantly different between the groups: group 1 exhibited more underhang and group 2 exhibited more overhang (p = 0.022). On the indirect assessment of the femoral rollback, there was a statistically significant difference in deep flexion and change in distance (p < 0.001 and p < 0.001, respectively). There was no statistical difference between the 2 groups in the American Knee Society knee and function score, and group 2 showed significant improvement in pain compared to group 1 in Western Ontario and McMaster University Arthritis Index pain score (p = 0.029).

Conclusions

Posterior condylar osteophyte formation was related to posterior impingement. It was more frequently observed in the underhang of the femoral component and insufficient femoral rollback. In addition, it changed with time and caused negative effects, including a gradual decrease in flexion and more pain.

Telerehabilitation following fast-track total knee arthroplasty is effective and safe: a randomized controlled trial with the ReHub® platform

PURPOSE

After a total knee arthroplasty (TKA), ensuring rehabilitation is continued at home is essential for a successful recovery. The aim of this randomized clinical trial (NCT04155957) was to demonstrate the safety and efficacy of an interactive telerehabilitation system (ReHub®) to guide and provide feedback during exercise in the postoperative period of a fast-track TKA program.

METHODS

Fifty-two patients who underwent TKA were randomized to intervention (N = 26) or control (N = 26). Upon discharge, they followed a 4-week plan of 5 daily exercises and up to 10 physiotherapy home visits. The intervention group performed exercises with ReHub® autonomously, control did not use any auxiliary device. Data were collected 1) on the day of discharge, 2) after 2 weeks and 3) after 4 weeks.

RESULTS

Telerehabilitation patients showed higher adherence to exercise (p = 0.002) and greater quadriceps strength (p = 0.028). No significant differences between groups were found in other outcomes. Only 1 adverse event was linked to ReHub®. Patients gave the platform high System Usability Scale scores (83/100).

CONCLUSION

Interactive telerehabilitation with ReHub® during a post-TKA exercise program is effective, safe, and well-received by patients. It provides real-time performance feedback and ensures communication. Quadriceps strength and adherence to the exercise plan are improved with ReHub®.

Optimal Duration of Physical Therapy Following Total Knee Arthroplasty

Aims & Objectives

The purpose of this study was to identify patient characteristics associated with engagement and completion of physical therapy (PT) following total knee arthroplasty (TKA) and examine the relationship between number of PT sessions attended and outcomes during the first 12 weeks after surgery.

Methods

Patients underwent unilateral primary TKA by a single surgeon and were advised to complete 17 PT sessions over 6 weeks at a hospital-affiliated facility. Analyses examined predictors of PT engagement (attendance of ≥2 sessions) and completion (attendance of 17 ± 1 sessions) within 6 weeks and associations between number of PT sessions attended and changes in range of motion (ROM) and Knee Injury and Osteoarthritis Outcome Score (KOOS) values.

Results

Patients living <40 km were more likely to be engaged in PT than those living ≥40 km from the clinic (P < .0001). Among patients who completed PT within 6 weeks, 95.0%, 85.1%, and 56.4% achieved flexion of, respectively, ≥90°, ≥100°, and ≥110°. Among engaged patients, the active flexion thresholds of ≥90°, ≥100°, and ≥110° were achieved by, respectively, 94.4%, 82.5%, and 58.1% by 6 weeks and by 96.7%, 92.1%, and 84.2% by 12 weeks. Improvement in KOOS Symptoms (P = .029), Function in daily living (P = .030) and quality of life (P = .031) linearly decreased as number of PT sessions increased.

Conclusions

These results raise the question of whether patients who meet satisfactory outcomes before completing 6 weeks of prescribed PT and those who attend more PT sessions than prescribed may be over-utilizing healthcare resources without additional benefit.

The Vega advanced third generation posterior stabilized total knee arthroplasty system enables the restoration of range of motion for high demanding daily activities - A 5-years follow-up study

BACKGROUND

The Vega System® PS (Aesculap AG, Tuttlingen, Germany) is an advanced, third generation fixed implant that aims to mimic natural knee kinematics by optimizing pivotal motion while reducing surface stress. This study evaluated mid-term survival and clinical outcomes, including range of motion (ROM) of the modern posterior stabilized implant in order to analyse whether this biomechanically successful implant reaches good results in situ.

METHODS

The first 100 patients to receive the Vega PS System for total knee arthroplasty were invited to take part in this single centre, single surgeon study. Of these, 84 patients were clinically assessed 5-6 years postoperatively. Data which was obtained during this follow-up examination included revision data, range of motion and clinical scores.

RESULTS

The 5-year survival rate for exchange of any component was 97.6%, whereby two patients required replacement of the polyethylene gliding surface. Secondary patella resurfacing was performed in 7 patients. Significantly improved results in comparison to the preoperative state could be obtained at the follow-up: KOOS improved from 39.4 to 78.8, SF-12 PCS improved from 32.1 to 42 SF-12 MCS improved from 46 to 53.8 and patella pain improved from 2.7 to 0.3. The mean ROM of the 84 patients after 5 years was 133.1° and mean total KSS was 189.9.

DISCUSSION & CONCLUSIONS

This study demonstrates a high survival rate of the Vega PS System® and significant improvements in clinical outcomes 5 years after implantation. The obtained mean ROM indicates that this implant provides good flexibility of the knee joint, allowing a high number of activities. However, due to the rate of secondary patella implantation, routine resurfacing of the patella for all PS TKA cases is highly recommended.

CLINICAL TRIALS REGISTRATION

The study was registered at clinicaltrials.gov (NCT02802085).

Calipered kinematic alignment restored the arithmetic hip-knee-ankle angle, achieved high satisfaction and improved clinical outcomes

PURPOSE

The purpose of this study was to determine whether unrestricted calipered kinematic alignment (KA), coupled with a medial-stabilised (MS) implant system, can reproduce the patient's constitutional alignment as per the arithmetic hip-knee-ankle (aHKA) and improve clinical outcomes.

METHODS

One-hundred and ninety-three patients received total knee arthroplasty by the senior author. To determine whether the constitutional alignment was achieved, the postoperative hip-knee-ankle (HKA) alignment was compared against the aHKA. Range of motion (ROM) was determined preoperative and postoperatively at 6 months and 2 years by measuring the active flexion and extension. Patient-Reported Outcomes Measures (PROMs) including Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS), Forgotten Joint Score (FJS) and Visual Analogue Scale for Satisfaction were also completed. The Sports and Recreation component of KOOS was used to assess the patient's ability to return to sports and daily activities.

RESULTS

There was a strong correlation between postoperative HKA and aHKA (r = 0.7, p < 0.05). There was a significant improvement in both extension and flexion seen from as early as 6 months postoperatively, with a mean flexion of 123° ± 11° and extension of 1° ± 3° at 2 years. PROMs had significant improvements with a mean score of 42.8 ± 6.0 for the OKS and all KOOS subscales consisting of Symptoms (88.0 ± 11.7), Pain (91.4 ± 11.6), Activities of Daily Living (91.1 ± 12.4), Sports (76.8 ± 22.1) and Quality of Life (83.0 ± 19.1). The FJS had significant improvements from 6 months to 2 years of 19.9 (p < 0.05), with a mean score of 69.2 ± 26.6 at 2 years. Ninety-three percent (180 patients) were classified as 'satisfied' at the 2-year timepoint. The KOOS Sports component was completed by 64% (124 patients), whereby the mean age was younger than the noncompliant patients (67.7 ± 9.4 vs. 71.7 ± 8.2 years).

CONCLUSION

Unrestricted calipered KA can result in an alignment that closely resembles the patient's constitutional alignment, as per the aHKA. This resulted in improved knee ROM and patient satisfaction, as well as assisting younger patients to return to sports and daily activities.

LEVEL OF EVIDENCE

Level IV.

Numerical study of osteophyte effects on preoperative knee functionality in patients undergoing total knee arthroplasty

Osteophytes are routinely removed during total knee arthroplasty, yet the preoperative planning currently relies on preoperative computed tomography (CT) scans of the patient's osteoarthritic knee, typically including osteophytic features. This complicates the surgeon's ability to anticipate the exact biomechanical effects of osteophytes and the consequences of their removal before the operation. The aim of this study was to investigate the effect of osteophytes on ligament strains and kinematics, and ascertain whether the osteophyte volume and location determine the extent of this effect. We segmented preoperative CT scans of 21 patients, featuring different osteophyte severity, using image-based active appearance models trained to identify the osteophytic and preosteophytic bone geometries and estimate the cartilage thickness in the segmented surfaces. The patients' morphologies were used to scale a template musculoskeletal knee model. Osteophytes induced clinically relevant changes to the knee's functional behavior, but these were variable and patient-specific. Generally, severe osteophytic knees significantly strained the oblique popliteal ligament (OPL) and posterior capsule (PC) relative to the preosteophytic state. Furthermore, there was a marked effect on the lateral collateral ligament and anterolateral ligament (ALL) strains compared to mild and moderate osteophytic knees, and concurrent alterations in the tibial lateral-medial translation and external-internal rotation. We found a strong correlation between the OPL, PC, and ALL strains and posterolateral condylar and tibial osteophytes, respectively. Our findings may have implications for the preoperative planning in total knee arthroplasty, toward reproducing the physiological knee biomechanics as close as feasibly possible.

Neuro-orthopaedic check-up and walking in people with multiple sclerosis: toward a more specific assessment to improve rehabilitation results

The rehabilitation process of people with multiple sclerosis (PwMS) is a challenge, and decision-making requires a thorough assessment to increase the chances of success in rehabilitation planning. The aim of this study was to investigate the importance of the neuroorthopaedic check-Up (NOChU) for gait prognosis. Participated in the study 105 PwMS with different levels of impairment. The NOChU includes measurements of passive range of motion (ROM), muscle strength, and spasticity. Additionally, was carried out the spatial-temporal analysis of the walking, Timed Up and Go test, and 6-min walk test. ROM remained relatively preserved to perform daily life activities except for ankle dorsiflexion. Muscle strength was also relatively preserved. Spasticity affected especially the ankle muscles, clearly the sural triceps. Among the NOChU measurements the catch seemed to have the most impact on walking on its different phases and on other activities. Accurate NOChU measurements play a crucial role in clinical settings, guiding informed decisions in rehabilitation planning. Future research endeavours could focus on exploring the correlations between NOChU deficiencies and the decline in walking capabilities among PwMS, with the goal of proposing personalized treatment strategies that address their specific requirements.

Evaluation of time to reimplantation as a risk factor in two-stage revision with static spacers for periprosthetic knee joint infection

INTRODUCTION

We investigated the time to reimplantation (TTR) during two-stage revision using static spacers with regard to treatment success and function in patients with chronic periprosthetic joint infection (PJI) of the knee.

METHODS

163 patients (median age 72 years, 72 women) who underwent two-stage exchange for chronic knee PJI between 2012 and 2020 were retrospectively analyzed (based on the 2011 Musculoskeletal Infection Society criteria). A cutoff TTR for increased risk of reinfection was identified using the maximally selected log-rank statistic. Infection control, aseptic revisions and overall survival were analyzed using Kaplan-Meier survival estimates. Adjustment for confounding factors-the Charlson Comorbidity Index (CCI) and C-reactive protein (CRP)-was done with a Cox proportional hazards model.

RESULTS

When TTR exceeded 94 days, the adjusted hazard of reinfection was increased 2.8-fold (95% CI 1.4-5.7; p = 0.0036). The reinfection-free rate was 67% (95% CI 52-79%) after 2 years and 33% (95% CI 11-57%) after 5 years for a longer TTR compared to 89% (95% CI 81-94%) and 80% (95% CI 69-87%) at 2 and 5 years, respectively, for a shorter TTR. Adjusted overall survival and number of aseptic revisions did not differ between the longer TTR and shorter TTR groups. Maximum knee flexion was 90° (IQR 84-100) for a longer TTR and 95° (IQR 90-100) for a shorter TTR (p = 0.0431), with no difference between the groups in Oxford Knee Score. Baseline characteristics were similar (body mass index, age, previous surgeries, microorganisms) for the two groups, except that there was a higher CCI (median 4 vs. 3) and higher CRP (median 3.7 vs 2.6 mg/dl) in the longer TTR group.

CONCLUSION

A long TTR is sometimes unavoidable in clinical practice, but surgeons should be aware of a potentially higher risk of reinfection.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Effects of an Early Exercise Program with Cryotherapy on Range of Motion, Pain, Swelling, and Gait in Patients with Total Knee Arthroplasty: A Randomized Controlled Trial

Background: This study aimed to investigate the effects of cryotherapy on range of motion, pain, swelling, and gait in patients who underwent total knee arthroplasty. Methods: Forty-three patients who underwent TKA (total knee arthroplasty) and met the inclusion criteria were randomly divided into two groups. The experimental (n = 21) and control (n = 22) groups underwent cryotherapy and non-cryotherapy treatments, respectively, six times a week for two weeks, and once each before and after exercise for 3 min. Both groups followed a similar initial rehabilitation exercise program using a continuous passive motion device. Results: The results showed a significant difference in knee flexion range of motion, pain, edema, and 10 MWT comparisons from pre- to post-test (p < 0.001). The above values were also significantly different in the comparison between the two groups (p < 0.05). Conclusions: Therefore, this study confirmed that an initial rehabilitation exercise program accompanied by cryotherapy could be an effective intervention method for range of motion, pain, edema, and walking in patients undergoing total knee arthroplasty.

Minimal clinically important change of knee flexion in people with knee osteoarthritis after non-surgical interventions using a meta-analytical approach

BACKGROUND

Minimal clinically important change (MCIC) represents the minimum patient-perceived improvement in an outcome after treatment, in an individual or within a group over time. This study aimed to determine MCIC of knee flexion in people with knee OA after non-surgical interventions using a meta-analytical approach.

METHODS

Four databases (MEDLINE, Cochrane, Web of Science and CINAHL) were searched for studies of randomised clinical trials of non-surgical interventions with intervention duration of ≤ 3 months that reported change in (Δ) (mean change between baseline and immediately after the intervention) knee flexion with Δ pain or Δ function measured using tools that have established MCIC values. The risk of bias in the included studies was assessed using version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). Bayesian meta-analytic models were used to determine relationships between Δ flexion with Δ pain and Δ function after non-surgical interventions and MCIC of knee flexion.

RESULTS

Seventy-two studies (k = 72, n = 5174) were eligible. Meta-analyses included 140 intervention arms (k = 61, n = 4516) that reported Δ flexion with Δ pain using the visual analog scale (pain-VAS) and Δ function using the Western Ontario and McMaster Universities Osteoarthritis Index function subscale (function-WOMAC). Linear relationships between Δ pain at rest-VAS (0-100 mm) with Δ flexion were - 0.29 (- 0.44; - 0.15) (β: posterior median (CrI: credible interval)). Relationships between Δ pain during activity VAS and Δ flexion were - 0.29 (- 0.41, - 0.18), and Δ pain-general VAS and Δ flexion were - 0.33 (- 0.42, - 0.23). The relationship between Δ function-WOMAC (out of 100) and Δ flexion was - 0.15 (- 0.25, - 0.07). Increased Δ flexion was associated with decreased Δ pain-VAS and increased Δ function-WOMAC. The point estimates for MCIC of knee flexion ranged from 3.8 to 6.4°.

CONCLUSIONS

The estimated knee flexion MCIC values from this study are the first to be reported using a novel meta-analytical method. The novel meta-analytical method may be useful to estimate MCIC for other measures where anchor questions are problematic.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022323927.

Manipulation Under Anesthesia is Safe and Effective for Management of Early Postoperative Knee Arthrofibrosis in Adolescent Patients

BACKGROUND

Management of postoperative knee arthrofibrosis can be challenging and the preferred time for intervention remains controversial. The purpose of this study is to evaluate the safety and efficacy of early (<3 mo postoperatively) manipulation under anesthesia (MUA) for the treatment of knee arthrofibrosis in adolescent patients. We hypothesized that early MUA could restore normal knee motion with a low complication rate and without the need for more invasive intervention.

METHODS

In a retrospective review, 57 patients who underwent MUA for postoperative knee arthrofibrosis were identified. The time between the index surgery and MUA as well as changes in range of motion (ROM) before and after MUA were analyzed. Descriptive statistics with median and interquartile range were used to analyze this non-parametric study cohort. Repeated measures ANOVA was performed to assess improvement in ROM over time. A P value <0.05 denoted statistical significance.

RESULTS

The median age of the cohort at time of MUA was 14.5 years [interquartile range (IQR) 12.9 to 17.6)]. 54.4% were male. Median time to MUA was 64 days (IQR 52 to 79) after index surgery. ROM before MUA was 90.0 degrees (IQR 75 to 100), which improved to 130 degrees (120 to 135) after MUA. At final median follow-up of 8.9 months (IQR 5.1 to 16.1), mean ROM was 133 degrees (130 to 140). There were no iatrogenic fractures or physeal separations associated with MUA. 12.3% (n=7/57) failed MUA either due to the need for subsequent repeat MUA (n=2), need for lysis of adhesions (n=3) or need for surgery after MUA (n=2). Those who failed early MUA and required subsequent procedures had ROM >120 degrees at final follow-up.

CONCLUSIONS

Postoperative knee arthrofibrosis can be safely and effectively treated with early (<3 mo postoperative) MUA. There were no iatrogenic fractures or physeal separations during MUA. Patients who had recurrence of motion deficits after early MUA and required further intervention, regained satisfactory knee motion at final follow-up. Although further research is warranted to better characterize risk factors for knee arthrofibrosis in adolescent patients, early recognition and MUA is a safe and effective treatment for arthrofibrosis to help patients regain full ROM without invasive intervention.

LEVEL OF EVIDENCE

Therapeutic Study - Level IV.

Gait kinematics and knee stability 10-years following posterior-stabilised total knee arthroplasty comparable to healthy adults >55

PURPOSE

The purpose of this study was to compare the long-term objective biomechanical and functional parameters of a high-flexion total knee arthroplasty (TKA) design against healthy older adults to determine whether knee biomechanics are comparable in both populations.

METHODS

One cohort of patients with a primary TKA, and a cohort of healthy adults over 55 years old with no musculoskeletal deficits or arthritis participated. Bilateral knee range of motion (RoM) was assessed with a goniometer, and gait patterns were analysed with a three-dimensional-motion capture system. An arthrometer quantified the anterior-posterior laxity of each knee. Statistical analyses were performed in SPSS software (α = 0.05).

RESULTS

Twenty-three knees were replaced in 20 patients. At 9.8 ± 3.1 years postoperatively, patients' knees had a statistically significantly poorer RoM than healthy controls' knees (n = 23) due to limited flexion; p < 0.0001. Patients also failed to achieve the same degree of knee flexion as controls during downhill gait. No kinematic differences were observed during mid-flexion in level nor downhill gait; a state that has been associated with instability (p = 0.614; not significant [n.s]). There were no differences between groups in knee laxity (n.s).

CONCLUSION

Patients in this study had similar gait patterns to healthy older adults during mid-flexion and were no more likely than the healthy controls to exhibit anterior-posterior translation of the knee > 7 mm; a known risk factor of instability. However, the knee flexion range was poorer. This likely led to bilateral pathological knee flexion patterns during downhill gait.

LEVEL OF EVIDENCE

Level III.

Virtual versus in-person physiotherapy following total knee arthroplasty: a comparative analysis

PURPOSE

At our centre, we developed and implemented a video-based post-operative physiotherapy program for patients undergoing total knee arthroplasty (TKA). Our aims were to analyse and compare the outcomes of this program to in-person physiotherapy.

METHODS

We reviewed the outcomes of 112 patients and captured range-of-motion (ROM) measurements and pain scores (P4 questionnaire). We compared the outcomes to a cohort of 175 patients undergoing in-person therapy. Comparative analysis was performed using a two-tailed Student's t-test.

RESULTS

There was no significant difference between the two groups in age, sex, or initial post-operative knee ROM. On discharge from virtual physiotherapy, mean flexion was 122.6° (SD 7.6). There was no significant difference in improvement in knee flexion between the virtual and in-person groups (mean 30.6° vs 34.0°, p = 0.07). There was no significant difference in the proportion of patients achieving ≥ 120° of flexion (85.0% virtual vs 91.3% in-person, p = 0.11) or those achieving an extension deficit of ≤ 5° (96.0% vs 98.3%, p = 0.25). There was no difference in the number of PT visits to discharge (10.5 vs 11.1, p = 0.14) or final pain scores (12.4 vs 11.9, p = 0.61).

CONCLUSION

Improvements in knee ROM measures are comparable between virtual and in-person physiotherapy with both groups achieving a good functional range. These findings have implications for the virtual delivery of healthcare, especially among remote populations and patients with mobility limitations.

Total knee arthroplasty for neuropathic arthropathy in a patient with leprosy

Patients with leprosy are known to tend to develop neuropathic arthropathy, known as Charcot joint. There are no case reports of total knee arthroplasty (TKA) in patients with leprosy with polyarticular neuropathic arthropathy, and the results are unknown. In this study, we report a case of TKA in a patient with leprosy with polyarticular neuropathic arthropathy and discuss its outcomes and indications. Right TKA using the NexGen Legacy Constrained Condylar Knee implant was performed in a 62-year-old man with neuropathic arthropathy in multiple joints with clinical symptoms, particularly in the right knee. Seven years post-operation, the American Knee Society Score-knee and -function, which represent knee function and activities of daily living on a scale of 100 points, were significantly improved compared with preoperative values, from 30 to 99 points and 0 to 60 points, respectively. Indications for arthroplasty for neuropathic arthropathy should be carefully considered in each individual case. In this case, the patient had neuropathic arthropathy in multiple joints; however, TKA was performed because recovery of function in the right knee was expected to significantly improve the patient's activities of daily living, and a good mid-term clinical outcome was achieved. Therefore, indications for arthroplasty should be considered in patients with systemic neuropathic arthropathy such as leprosy, and with accurate assessment and appropriate implant selection, good long-term outcomes may be expected.

Comparison of the clinical outcomes following total knee arthroplasty in osseous ankylosed and non-ankylosed knees using propensity-score matching

OBJECTIVES

Few studies have compared the clinical outcomes and complications of total knee arthroplasty (TKA) in patients with and without osseous ankylosed knees. Thus, we investigated the clinical outcomes and complications of TKA in patients with osseous ankylosed knees using a propensity-score matching method.

METHODS

Thirteen knees in the osseous ankylosed-knees group and 13 knees in the non-ankylosed-knees group were included after excluding those with less than 2 years of follow-up or a lack of data and after propensity-score matching. The American Knee Society Score-knee (AKSS-knee), AKSS-function, knee-flexion angle, knee-extension angle, knee range of motion (ROM) before and after TKA, and the number of knees with postoperative complications were evaluated as primary outcomes.

RESULTS

The AKSS-knee, AKSS-function, knee-flexion angle, and knee ROM in the osseous ankylosed-knees group after TKA were significantly lower than those in the non-ankylosed-knees group. The knee-extension angle after TKA and number of knees with postoperative complications within 2 years were not significantly different between the two groups.

CONCLUSIONS

The clinical results of TKA in patients with osseous ankylosed knees were inferior to those in patients with non-ankylosed knees.

Home-based tele-rehabilitation versus hospital-based outpatient rehabilitation for pain and function after initial total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aims to compare the effectiveness of home-based tele-rehabilitation programs with hospital-based rehabilitation programs in improving pain and function at various time points (≤6 weeks, ≤14 weeks, and ≤ 52 weeks) following the initial total knee arthroplasty.

METHODS

This study used PRISMA and AMSTAR reporting guidelines. We systematically searched 5 databases (PubMed, Embase, Web of Science, Cochrane Library, and Medline) to identify randomized controlled trials published from January 1, 2019, to January 1, 2023. The primary outcomes were pain, knee injury and osteoarthritis outcome score, and mobility (knee range of motion).

RESULTS

We included 9 studies involving 1944 patients. Low-quality evidence showed hospital-based rehabilitation was better than home-based tele-rehabilitation in knee injury and osteoarthritis outcome score (mean difference [MD], -2.62; 95% confidence interval [CI], -4.65 to -0.58; P = .01) at ≤ 14 weeks after total knee arthroplasty. Based on low-quality evidence, home-based tele-rehabilitation was better than hospital-based rehabilitation in knee range of motion (MD, 2.00; 95% CI, 0.60 to 3.40; P = .005). There was no significant difference between hospital-based rehabilitation and home-based tele-rehabilitation in knee pain at ≤ 6 weeks (MD, 0.18; 95% CI, -0.07 to 0.42; P = .16), 14 weeks (MD, 0.12; 95% CI, -0.26 to 0.49; P = .54), and ≤ 52 weeks (MD, 0.16; 95% CI, -0.11 to 0.43; P = .24).

CONCLUSION

Home-based tele-rehabilitation and hospital-based rehabilitation programs showed comparable long-term outcomes in pain, mobility, physical function, and patient-reported health status after primary total knee arthroplasty. Considering the economic costs, home-based tele-rehabilitation programs are recommended as a viable alternative to hospital-based rehabilitation programs.

Cemented total knee arthroplasty provides greater knee range of motion at 2 years than cementless technique

INTRODUCTION

Optimal fixation method between cemented, cementless, and hybrid techniques for total knee arthroplasty (TKA) is still debated. The purpose of this study is to evaluate the clinical outcomes of patients undergoing cemented versus cementless TKA.

METHODS

We reviewed 168 patients who underwent a primary TKA at a single academic institution between January 2015 and June 2017. Patients were categorized into cemented (n = 80) or cementless (n = 88) groups. Only patients with greater than or equal to 2-year follow-up were included in the study. Multivariate regressions were performed to analyze the relationship between the surgical fixation technique and the clinical outcomes.

RESULTS

There were no differences in demographics or baseline operative characteristics between the two groups. The cemented group had fewer manipulations under anesthesia (MUA) (4 vs. 15, p = 0.01), longer intraoperative tourniquet times (101.30 vs. 93.55 min, p = 0.02), and increased knee range of motion (ROM) at final follow-up (111.48 vs. 103.75°, p = 0.02) compared to the cementless group.

DISCUSSION AND CONCLUSION

Both cemented and cementless component fixation are viable options for (TKA). This study found that patients who underwent a cemented TKA required fewer MUA's and had greater final ROM compared to patients undergoing cementless TKA. Additional research is required regarding cementless and cemented fixation. We believe that the choice of which fixation technique to use ultimately comes down to patient characteristics and surgeon preference.

The Early Clinical Outcomes Following Unrestricted Caliper Verified Kinematic Alignment Using a Medial Stabilized Design Total Knee Arthroplasty With a Cruciate Retaining Insert

Background

Although various total knee arthroplasty (TKA) implant designs are widely used, the ideal TKA design is yet to be agreed upon. Although the benefits of cruciate-retaining (CR) TKA and medial stabilized (MS) TKA have been reported in literature, the early clinical outcomes of an MS TKA with CR inserts have not been reported. This study aims to report on the patient-reported clinical and radiological outcomes of MS-TKA combined with a CR insert.

Methods

A prospective single-surgeon series evaluated the clinical- and patient-reported outcomes of 115 patients implanted with GMK Sphere CR. Patient outcomes were assessed with the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Forgotten Joint Score, and Visual Analogue Scale for Satisfaction. Radiological assessment for alignment along with active flexion and extension were also assessed.

Results

Improvement in all scores was observed between the preoperative and 1-year follow-up timepoints, with statistical significance seen for Oxford Knee Score as well as KOOS Symptoms, Pain, Sport, quality of life, and activities of daily living subscales. The mean active flexion between the preoperative and both postoperative timepoints at 6 months and 1 year was also statistically significant (P = .021 and P = .001).

Conclusions

MS-TKA with a CR insert can facilitate symptom relief and improve overall function of the knee after surgery. Both the patient and clinical outcomes were comparable to 1-year outcomes utilizing other MS-TKA designs and were superior to those at 1-year follow-up following implantation of CR-TKA. Most notability, the KOOS symptoms and sports score were higher for the MS-TKA with a CR insert than for an MS-TKA design.

No Difference in Range of Motion, Components, or Complications Following Conversion of Robotic-Assisted Total Knee Arthroplasty Compared to Manual TKA After Undergoing Manual or Robotic-Assisted Unicompartmental Knee Arthroplasty

Background

Conversion surgery from unicondylar knee arthroplasty (UKA) to total knee arthroplasty (TKA) remains a challenge due to scarring, implant/cement removal, and loss of bony landmarks. Robotic-assisted (RA) TKA may assist in challenges seen in manual conversion TKA. The aim of this study is to identify if there are differences in components and functional outcomes dependent on manual/RA primary UKA and conversion TKA.

Methods

A retrospective chart review was performed on patients undergoing conversion from UKA to TKA over a 10-year period at a single institution. Data extracted included surgical technique, reason for UKA failure, range of motion at 1 year, need for augments, and utilization of revision components.

Results

Forty-nine patients (50 knees) with a UKA converted to a TKA were divided into 4 groups based on primary and conversion surgery: manual-to-manual (n = 11), manual-to-robot (n = 11), robot-to-manual (n = 11), and robot-to-robot (n = 17). There was no difference in need for augments (P = .376), size of poly (P = .23), postoperative flexion (P = .52), or extension (P = .76) at 1 year between the 4 groups. However, patients with primary manual UKA did require significantly more augments during revision (P = .032).

Conclusions

Our study did not show any statistically significant differences of primary RA or manual UKA to RA or manual TKA in terms of range of motion at 1 year, complications, or differences in components. RA conversion from UKA to TKA is a new but equivalent technique to manual conversion. Primary surgery may impact the requirement for augments during conversion surgery.

A new tibial insert design with ball-in-socket medial conformity and posterior cruciate ligament retention closely restores native knee tibial rotation after unrestricted kinematic alignment

PURPOSE

In total knee arthroplasty (TKA) with posterior cruciate ligament (PCL) retention, the medial and lateral insert conformity that restores in vivo native (i.e., healthy) knee tibial rotation and high function without causing stiffness is unknown. The purpose was to determine whether a ball-in-socket (B-in-S) medially conforming (MC) and flat lateral insert implanted with unrestricted kinematic alignment (KA) TKA and PCL retention restores tibial rotation to native.

METHODS

One group of 25 patients underwent unrestricted KA TKA with manual instruments. Another group of 25 patients had native knees. Single-plane fluoroscopy imaged each knee while patients performed step-up and chair rise activities. Following 3D model-to-2D image registration, anterior-posterior (A-P) positions of the femoral condyles were determined. Changes in A-P positions with flexion were used to determine tibial rotation.

RESULTS

At maximum flexion, mean tibial rotations of KA TKA knees were comparable to native knees (Step up: 12.3° ± 4.4° vs. 13.1° ± 12.0°, p = 0.783; Chair Rise: 12.7° ± 6.2° vs. 12.6° ± 9.5º, p = 0.941). However, paths of rotation differed in that screw home motion was less evident in KA TKA knees. At 8 months follow-up, the median Forgotten Joint Score was 69 points (range 65 to 85), the median Oxford Knee Score was 43 points (range 40 to 46), and mean knee flexion was 127º ± 8°.

CONCLUSIONS

The ball-in-socket medial, flat lateral insert and PCL retention implanted with unrestricted KA TKA restored in vivo native knee tibial rotation at maximum flexion for each activity and high function without stiffness. Providing high A-P stability, this implant design might benefit patients desiring to return to demanding work and recreational activities.

LEVEL OF EVIDENCE

Therapeutic - Level II.

Lipedema Reduction Surgery Improves Pain, Mobility, Physical Function, and Quality of Life: Case Series Report

Background

Lipedema is a chronic inflammatory subcutaneous adipose-rich connective tissue disease affecting millions of women worldwide. Disproportionate fat accumulation on the extremities characterized by heaviness, tenderness, and swelling can affect function, mobility, and quality of life. Treatments include conservative measures and lipedema reduction surgery (LRS). Here, we report lipedema comorbidities and surgical techniques, outcomes measures, and complications after LRS.

Methods

This is a single outpatient clinic retrospective chart review case series of comorbidities and complications in 189 women with lipedema. Bioelectrical impedance analyses, knee kinematics, gait, physical examinations, Patient-Reported Outcomes Measurement Information System, and RAND Short Form-36 questionnaires collected before and after LRS were analyzed for 66 of the 189 women. Hemoglobin levels were measured by transdermal hemoglobin monitor (Masimo noninvasive hemoglobin monitoring; Irvine, Calif.).

Results

Common comorbidities in 189 women were hypermobile joints (50.5%), spider/varicose veins (48.6/24.5%), arthritis (29.1%), and hypothyroidism (25.9%). The most common complication in 5.5% of these women after LRS was lightheadedness with a 2-g reduction or more in hemoglobin. After conservative measures and LRS in 66 women, significant improvements (P ≤ 0.0009) were found for: (1) knee flexion (10 degrees); (2) gait; (3) Patient-Reported Outcomes Measurement Information System T-score (16%); (4) mobility questions: gait velocity, rising from a chair, stair ascent; (5) RAND Short Form-36 scores: physical functioning, energy/fatigue, emotional well-being, social function, general health; (6) and Bioelectrical impedance analyses total and segmental body fat mass.

Conclusion

LRS provided significant improvements to women with lipedema using direct physical measurements and validated outcome measures, comparable to those seen after total knee replacement.

The biomechanical and functional outcomes of autologous chondrocyte implantation for articular cartilage defects of the knee: A systematic review

PURPOSE

Autologous chondrocyte implantation (ACI) is primarily performed in active, young patients to treat knee pain and functional limitations resulting from articular cartilage injury. Nevertheless, the functional outcomes of ACI remain poorly understood. This systematic review aimed to evaluate the biomechanical and functional outcomes of ACI.

METHODS

Ovid MEDLINE, Embase, and Web of Science were systematically searched using the terms 'Knee OR Knee joint AND Autologous chondrocyte implantation OR ACI'. Inclusion and exclusion criteria were used to screen publications by title, abstract, and full text. Study quality and bias were assessed by two reviewers. Means and standard deviations of all collected variables were calculated and presented in the review.

PROSPERO ID

CRD42021238768.

RESULTS

Nineteen articles including 20 ACI cohorts were included. In general, the average range of motion (ROM) improved with clinical (>5°) and statistical significance (p < 0.05) postoperatively: 130.5 ± 14.8° to 136.1 ± 10.2°. Knee strength significantly improved within the first two postoperative years but remained poorer than control groups at final follow-up. No statistical differences were found between ACI and control groups in their ability to perform functional activities like the 6-minute walk test.

CONCLUSION

Knee range of motion generally improved following ACI. Although, some studies reported that knee strengths remained significantly poorer than healthy controls, particularly >2-years postoperatively, implying that longer-term strength training may benefit patients.However, the volume of research and current level of evidence remain low, thus further research is required to better understand the impact of ACI on knee function and guide future rehabilitative protocols.

Lower-limb sagittal joint angles during gait can be predicted based on foot acceleration and angular velocity

Background and purpose

Continuous monitoring of lower-limb movement may help in the early detection and control/reduction of diseases (such as the progression of orthopedic diseases) by applying suitable interventions. Therefore, it is invaluable to calculate the lower-limb movement (sagittal joint angles) while walking daily for continuous evaluation of such risks. Although cameras in a motion capture system are necessary for calculating lower-limb sagittal joint angles during gait, the method is unrealistic considering the setting is difficult to achieve in daily life. Therefore, the estimation of lower-limb sagittal joint angles during walking based on variables, which can be measured using wearable sensors (e.g., foot acceleration and angular velocity), is important. This study estimates the lower-limb sagittal joint angles during gait from the norms of foot acceleration and angular velocity using machine learning and validates the accuracy of the estimated joint angles with those obtained using a motion capture system.

Methods

Healthy adults (n = 200) were asked to walk at a comfortable speed (10 trials), and their lower-limb sagittal joint angles, foot accelerations, and angular velocities were obtained. Using these variables, we established a feedforward neural network and estimated the lower-limb sagittal joint angles.

Results

The average root mean squared errors of the lower-limb sagittal joint angles during gait ranged between 2.5°-7.0° (hip: 7.0°; knee: 4.0°; and ankle: 2.5°).

Conclusion

These results show that we can estimate the lower-limb sagittal joint angles during gait using only the norms of foot acceleration and angular velocity, which can help calculate the lower-limb sagittal joint angles during daily walking.

Cryotherapy following total knee replacement

BACKGROUND

Total knee replacement (TKR) is a common intervention for people with end-stage symptomatic knee osteoarthritis, resulting in significant improvements in pain, function and quality of life within three to six months. It is, however, acutely associated with pain, local oedema and blood loss. Post-operative management may include cryotherapy. This is the application of low temperatures to the skin surrounding the surgical site, through ice or cooled water, often delivered using specialised devices. This is an update of a review published in 2012.

OBJECTIVES

To evaluate the effect of cryotherapy in the acute phase after TKR (within 48 hours after surgery) on blood loss, pain, transfusion rate, range of motion, knee function, adverse events and withdrawals due to adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers, as well as reference lists, related links and conference proceedings on 27 May 2022.

SELECTION CRITERIA

We included randomised controlled trials or controlled clinical trials comparing cryotherapy with or without other treatments (such as compression, regional nerve block or continuous passive motion) to no treatment, or the other treatment alone, following TKR for osteoarthritis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We discussed any disagreements and consulted another review author to resolve them, if required. Major outcomes were blood loss, pain, transfusion rate, knee range of motion, knee function, total adverse events and withdrawals from adverse events. Minor outcomes were analgesia use, knee swelling, length of stay, quality of life, activity level and participant-reported global assessment of success.

MAIN RESULTS

We included 22 trials (20 randomised trials and two controlled clinical trials), with 1839 total participants. The mean ages reflected the TKR population, ranging from 64 to 74 years. Cryotherapy with compression was compared to no treatment in four studies, and to compression alone in nine studies. Cryotherapy without compression was compared to no treatment in eight studies. One study compared cryotherapy without compression to control with compression alone. We combined all control interventions in the primary analysis. Certainty of evidence was low for blood loss (downgraded for bias and inconsistency), pain (downgraded twice for bias) and range of motion (downgraded for bias and indirectness). It was very low for transfusion rate (downgraded for bias, inconsistency and imprecision), function (downgraded twice for bias and once for inconsistency), total adverse events (downgraded for bias, indirectness and imprecision) and withdrawals from adverse events (downgraded for bias, indirectness and imprecision). The nature of cryotherapy made blinding difficult and most studies had a high risk of performance and detection bias. Low-certainty evidence from 12 trials (956 participants) shows that cryotherapy may reduce blood loss at one to 13 days after surgery. Blood loss was 825 mL with no cryotherapy and 561 mL with cryotherapy: mean difference (MD) 264 mL less (95% confidence interval (CI) 7 mL less to 516 mL less). Low-certainty evidence from six trials (530 participants) shows that cryotherapy may slightly improve pain at 48 hours on a 0- to 10-point visual analogue scale (lower scores indicate less pain). Pain was 4.8 points with no cryotherapy and 3.16 points with cryotherapy: MD 1.6 points lower (95% CI 2.3 lower to 1.0 lower). We are uncertain whether cryotherapy improves transfusion rate at zero to 13 days after surgery. The transfusion rate was 37% with no cryotherapy and 79% with cryotherapy (risk ratio (RR) 2.13, 95% CI 0.04 to 109.63; 2 trials, 91 participants; very low-certainty evidence). Low-certainty evidence from three trials (174 participants) indicates cryotherapy may improve range of motion at discharge: it was 62.9 degrees with no cryotherapy and 71.2 degrees with cryotherapy: MD 8.3 degrees greater (95% CI 3.6 degrees more to 13.1 degrees more). We are uncertain whether cryotherapy improves function two weeks after surgery. Function was 75.4 points on the 0- to 100-point Dutch Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale (lower score indicates worse function) in the control group and 88.6 points with cryotherapy (MD 13.2 points better, 95% CI 0.5 worse to 27.1 improved; 4 trials, 296 participants; very low-certainty evidence). We are uncertain whether cryotherapy reduces total adverse events: the risk ratio was 1.30 (95% CI 0.53 to 3.20; 16 trials, 1199 participants; very low-certainty evidence). Adverse events included discomfort, local skin reactions, superficial infections, cold-induced injuries and thrombolytic events. We are uncertain whether cryotherapy reduces withdrawals from adverse events (RR 2.71, 95% CI 0.42 to 17.38; 19 trials, 1347 participants; very low-certainty evidence). No significant benefit was found for secondary outcomes of analgesia use, length of stay, activity level or quality of life. Evidence from seven studies (403 participants) showed improved mid-patella swelling between two and six days after surgery (MD 7.32 mm less, 95% CI 11.79 to 2.84 lower), though not at six weeks and three months after surgery. The included studies did not assess participant-reported global assessment of success.

AUTHORS' CONCLUSIONS

The certainty of evidence was low for blood loss, pain and range of motion, and very low for transfusion rate, function, total adverse events and withdrawals from adverse events. We are uncertain whether cryotherapy improves transfusion rate, function, total adverse events or withdrawals from adverse events. We downgraded evidence for bias, indirectness, imprecision and inconsistency. Hence, the potential benefits of cryotherapy on blood loss, pain and range of motion may be too small to justify its use. More well-designed randomised controlled trials focusing especially on clinically meaningful outcomes, such as blood transfusion, and patient-reported outcomes, such as knee function, quality of life, activity level and participant-reported global assessment of success, are required.

Extensor Mechanism Disruption Remains a Challenging Problem

BACKGROUND

Extensor mechanism disruption (EMD) following total knee arthroplasty (TKA) is a devastating problem commonly treated with allograft or synthetic reconstruction. Understanding of reconstruction success rates and patient recorded outcomes is lacking.

METHODS

Patients who have an EMD after TKA undergoing mesh or whole-extensor allograft reconstruction between 2011 and 2019, with minimum 2-year follow-up were reviewed at two tertiary care centers. Functional failure was defined as extensor lag >30 degrees, amputation, or fusion, as well as revision extensor mechanism reconstruction (EMR). Survivorship was assessed using Kaplan-Meier curves, and factors for success were determined with logistic regressions.

RESULTS

Of fifty-six EMRs (49 patients), 50.0% (28/56) were functionally successful at 3.2 years of mean follow-up (range, 0.2 to 7.4). In situ survivorship of the reconstructions at 36 months was 75.0% (42 of 58). There were 50.0% (14 of 28) of functionally failed EMRs that retained their reconstruction at last follow-up. Mean extensor lag among successes and failures was 5.4 and 71.0° (P = .01), respectively. Mean Knee Injury and Osteoarthritis Outcome Score, Joint Replacement scores were 67.1 and 48.8 among successes and failures (P = .01). There were 64.0% (16 of 25) of successes and 1 of 19 failures that obtained a Knee Injury and Osteoarthritis Outcome Score, Joint Replacement score above the minimum patient-acceptable symptom state for TKA. Survivorship and success rates were similar between reconstruction methods (P = .86; P = .76). All-cause mortality was 8.2% (4 of 49), each with EMR failure prior to death. All-cause reoperation rate was 42.9% (24 of 56), with a 14.3% (8 of 56) rate of revision EMR and 10.7% (6 of 56) rate of above-knee-amputation or modular fusion.

CONCLUSIONS

This multicenter investigation of mesh or allograft EMR demonstrated modest functional success at 3.2 years. Complication and reoperation rates were high, regardless of EMR technique. Therefore, EMD after TKA remains problematic.

The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes

PURPOSE

Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes.

METHODS

We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement.

RESULTS

Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively.

CONCLUSION

Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.

The Effect of a Multidimensional Home Rehabilitation Program for Post-Total Knee Arthroplasty Elderly Patients

Patients with total knee arthroplasty (TKA) experience pain, decreased muscle strength, and decreased knee function, resulting in increases in depression and decreased subjective well-being. A multidimensional home program may prevent these adverse events. The aim of this study was to test the effect of a home rehabilitation program that included education, exercise, aroma massage, and phone counseling for post-TKA patients. We used a randomized control group pretest/posttest design. Fifty-nine patients participated, with 29 in the experimental group and 30 in the control group. Pain, knee joint range of motion (ROM), quadriceps strength, depression, and subjective well-being were measured as outcome variables. Data were analyzed using repeated-measures analysis of variance and generalized estimating equations. The experimental group showed significant improvement in knee pain, active ROM, muscle strength, depression, and subjective well-being with no significant between-groups difference in passive ROM. The multidimensional home rehabilitation program can be an effective nursing intervention for physical and emotional recovery of patients with TKA.

A systematic review of outcomes of high tibial osteotomy for the valgus knee

PURPOSE

Osteoarthritis is a prolific condition in an increasingly ageing and obese population. Research into treatments of this condition and their efficacy are vital. Outcomes of high tibial osteotomy (HTO) for the varus knee is widely reported. There is less evidence for HTO in the valgus knee. This systematic review aimed to compile all literature reporting the outcomes of HTO to correct the valgus knee, focusing on post-operative clinical outcomes.

METHODS

Ovid MEDLINE, Embase and Web of Science were searched using key terms: Osteoarthritis [All Fields] AND High tibial osteotomy [All Fields] AND Lateral OR Valgus [All Fields]. Papers were screened for eligibility based on an inclusion and exclusion criteria. Full text screening was completed by two reviewers and data was extracted from the agreed included papers by one reviewer. Quality assessments of the papers were also conducted.

PROSPERO ID

CRD42021239045.

RESULTS

Across 17 papers reporting 517 knees, the average pre-operative femorotibial and hip-knee-ankle angles were corrected from 13.6 ± 7.0° and 4.9 ± 1.9° valgus to 2.8 ± 2.9° and 1.2 ± 1.7° varus. Studies show that the procedure is successful at offloading the lateral knee compartment and some evidence it can delay the need for a total knee replacement. However, its impact on overall quality of life remains poorly understood.

CONCLUSIONS

High tibial osteotomy may be a viable treatment option for valgus knee deformities caused by lateral compartment osteoarthritis. Nevertheless, research into the procedure remains limited. Importantly, our understanding of the relationship between the achieved alignment and outcome remains largely unknown.

LEVEL OF EVIDENCE

IV.

Lumbar Spine Sagittal Mismatch Deformity Negatively Affects Total Knee Arthroplasty Outcomes

There is currently a paucity of data regarding the potential relationships between preexisting spinal deformity and clinical outcomes following total knee arthroplasty (TKA). We sought to expand upon this deficit. We hypothesize that lumbar sagittal mismatch deformity (MD) will correlate with a decrease in functional outcomes after TKA. This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure sagittal parameters of interest: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, and deformity mismatch. Ninety-four TKAs were subsequently available for inclusion and divided into two groups: those with MD as defined by |PI-LL| > 10 degrees and those without MD. The following clinical outcomes were compared between the groups: total postoperative arc of motion (AOM), incidence of flexion contracture, and need for manipulation under anesthesia (MUA). In total, 53 TKAs met the MD criteria, while 41 did not have MD. There were no significant differences in demographics, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with MD were more likely to have MUA (p = 0.026), ROM <0 to 120 (p < 0.001), a decreased AOM by 16 degrees (p < 0.001), and a flexion contracture postoperatively (p = 0.01). Preexisting MD may adversely affect clinical results following TKA. Statistically and clinically significant decreases in postoperative ROM/AOM, increased likelihood of flexion contracture, and increased need for MUA were all noted in those with MD. This is a Level 3 study.

Restoration of the Joint Line Configuration Reproduces Native Mid-Flexion Biomechanics after Total Knee Arthroplasty: A Matched-Pair Cadaveric Study

Background: Recent evidence supports that restoration of the pre-arthritic condition via total knee arthroplasty (TKA) is associated with improved post-TKA performance and patient satisfaction. However, whether the restored pre-arthritic joint line simulates the native mid-flexion biomechanics remains unclear. Objective: We performed a matched-pair cadaveric study to explore whether restoration of the joint line via kinematically aligned (KA) TKA reproduced native knee biomechanics more accurately than the altered joint line associated with mechanically aligned (MA) TKA. Methods: Sixteen fresh-frozen cadaveric knees (eight pairs) were affixed onto a customized knee-squatting simulator for measurement of femoral rollback and medial collateral ligament (MCL) strain during mid-flexion. One knee from each cadaver was randomly designated to the KA TKA group (with the joint line restored to the pre-arthritic condition) and the other to the MA TKA group (with the joint line perpendicular to the mechanical axis). Optical markers were attached to all knees and rollback was analyzed using motion capture cameras. A video extensometer measured real-time variations in MCL strain. The kinematics and MCL strain prior to and following TKA were measured for all specimens. Results: KA TKA was better for restoring the knee kinematics to the native condition than MA TKA. The mid-flexion femoral rollback and axial rotation after KA TKA were consistently comparable to those of the native knee. Meanwhile, those of MA TKA were similar only at ≤40° of flexion. Furthermore, KA TKA better restored the mid-flexion MCL strain to that of the native knee than MA TKA. Over the entire mid-flexion range, the MCL strain of KA TKA and native knees were similar, while the strains of MA TKA knees were more than twice those of native knees at >20° of flexion. Conclusions: The restored joint line after KA TKA effectively reproduced the native mid-flexion rollback and MCL strain, whereas the altered joint line after MA TKA did not. Our findings may explain why patients who undergo KA TKA experience superior outcomes and more natural knee sensations during daily activities than those treated via MA TKA.

Early Knee Range of Motion Following Operative Treatment for Tibial Tubercle Avulsion Fractures Is Safe

BACKGROUND

Tibial tubercle avulsion fractures (TTAF) often require surgical reduction and stabilization. Traditional teachings recommend postoperative knee immobilization for 4 to 6 weeks; however, the necessity of these restrictions is unclear and the actual practice varies. This study's purpose was to: (1) retrospectively review operatively managed TTAFs at a single center to examine the spectrum of postoperative rehabilitation guidelines, and (2) compare the outcomes of patients based on the timing of initiation of postoperative knee range of motion (ROM).

METHODS

Operatively managed TTAFs treated at a single center from 2011-2020 were identified. Patients with polytrauma, associated lower extremity compartment syndrome, or treatment other than screw fixation were excluded. Patient demographics, mechanism of injury, Ogden Classification, associated injuries, operative technique, postoperative ROM progression, and time to release to unrestricted activities were collected. Patients were grouped based on the initiation of postoperative ROM as Early (<4 wk, EROM) or Late (≥4 wk, LROM). Bivariate analysis was used to compare characteristics between these 2 groups.

RESULTS

Study criteria identified 134 patients, 93.3% (n=125) of whom were male. The mean age of the cohort was 14.77 years [95% confidence interval (CI: 14.5 to 15.0]. Forty-nine patients were designated EROM; 85 patients were categorized as LROM. The groups did not differ significantly with regards to age, race, injury characteristics, or surgical technique. Both groups progressed similarly with regards to postoperative range of motion. Ultimate activity clearance was achieved at ~20 weeks postoperatively without differences between groups ( P >0.05). Four instances of postoperative complication were identified, all of which occurred in the LROM group.

CONCLUSION

A broad range of postoperative immobilization protocols exists following the screw fixation of TTAFs. Across otherwise similar cohorts of patients undergoing operative treatment, initiation of knee range of motion before 4 weeks was without complication and provided equivalent outcomes to traditional immobilization practices. Given the clear benefits to patients and caregivers provided by the permission of early knee motion and the avoidance of casting, providers should consider more progressive postoperative rehab protocols following operatively treated TTAFs.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort.

Machine Learning Algorithm to Predict Worsening of Flexion Range of Motion After Total Knee Arthroplasty

Background

Methods

Results

Conclusions

Journey-Deuce bicompartmental knee arthroplasty with the addition of computer navigation achieves good clinical outcomes and implant survival at 10 years

PURPOSE

To report 10-year outcomes and survivorship in patients undergoing bicompartmental knee arthroplasty (BCKA) using the Journey-Deuce prosthesis in a consecutive prospective case series.

METHODS

Between November 2006 and November 2009, 41 patients with a mean age of 69.6 years (range 51-86) underwent 51 bicompartmental knee arthroplasties with the Journey-Deuce knee prosthesis. All patients presented with symptomatic medial and patellofemoral compartment osteoarthritis, with intact cruciate ligaments and a preserved lateral compartment on plain radiographs and Magnetic Resonance Imaging. Clinical assessment was undertaken pre-surgery and at 1, 2, 5 and 10 years post-surgery using the Oxford Knee Score (OKS), EuroQol Group 5-Dimension self-reported questionnaire (EQ-5D) and maximal active range of motion (ROM).

RESULTS

30 patients (37 knees) were followed-up at a mean time of 11.4 years (SD 1.1; range 10.5-14.0). Eight patients (ten knees) were deceased and three could not be contacted at final review. No major component revision was performed. Pre-operative OKS 25.4 (SD 5.2; range 15-40), knee flexion 116.4° (SD 10.3°; range 100°-140°) and EQ-5D 70.5 (SD 19.9; range 25-95). 10-year OKS 43.5 (SD 4.1; range 32-48), knee flexion 127.3° (SD 11.1°; range 105°-144°) and EQ-5D 77.4 (SD 9.3; range 60-100). The OKS (p < 0.0001), EQ-5D (p = 0.024) and active knee flexion ROM (p < 0.0001) all significantly improved from pre-surgery to 1-year post-surgery, with no further significant changes in these scores between any post-operative time period up until 10 years. 32% (7/22) of tibial and 45% (10/22) of femoral components showed progressive radiolucencies between 2 and 5-year and 10-year follow-up.

CONCLUSIONS

This is the largest cohort of patients having undergone BCKA (with the Journey-Deuce prosthesis) with longest follow-up described in the literature. At 10 years, patients presented with significantly improved clinical outcomes, comparable to other surgical arthroplasty options. No major component revision was performed. Progressive radiolucencies were noted in 32% of tibial and 45% of femoral components without corresponding clinical signs of loosening.

LEVEL OF EVIDENCE

Level III.

Cryoneurolysis Is a Safe, Effective Modality to Improve Rehabilitation after Total Knee Arthroplasty

Although long term pain and mobility outcomes in total knee arthroplasties (TKA) are successful, many patients experience significant amount of debilitating pain during the immediate post-operative period that necessitates narcotic use. Percutaneous cryoneurolysis to the infrapatellar saphenous and anterior femoral cutaneous nerves may help to better restore function and rehabilitation after surgery while limiting narcotic consumption. A retrospective chart review of primary TKA patients receiving pre-operative cryoneurolysis from 2019 to 2020 was performed to assess total opioid morphine milligram equivalents (MME) consumed inpatient and at interval follow-up. Demographics and medical comorbidities were compared between cryoneurolysis and age-matched control patients to assess baseline characteristics. Functional rehabilitation outcomes, including knee range of motion (ROM), ambulation distance, and Boston AM-PAC scores, as well as patient reported outcomes using the KOOS JR and SF-12 scores were analyzed using STATA 17 Software. The analysis included 29 cryoneurolysis and 28 age-matched control TKA patients. Baseline demographics and operative technique were not significant between groups. Although not statistically significant, cryoneurolysis patients had a shorter length of stay (2.5 vs. 3.5 days) and overall less inpatient and outpatient MME requirements. Cryoneurolysis patients had statistically significant improved 6-week ROM and 1-year follow-up KOOS JR and SF-12 mental scores compared to the control. There were no differences in complication rates. Cryoneurolysis is a safe, effective treatment modality to improve active functional recovery and patient satisfaction after TKA by reducing MME requirements. Patients who underwent cryoneurolysis had on average fewer MME prescribed during the perioperative period, improved active ROM, and improved patient-reported outcomes with no associated increased risk of infections, deep vein thrombosis, or neurologic complications.

Distal femoral replacement or internal fixation for management of periprosthetic distal femur fractures: A systematic review

BACKGROUND

The number of periprosthetic fractures above a total knee arthroplasty continues to increase. These fractures are associated with a high risk of morbidity and mortality. Techniques for addressing these fractures include open reduction internal fixation (ORIF) and revision arthroplasty, including distal femoral replacement (DFR). The primary aim of this review is to compare mortality and reoperation rates between ORIF and DFR when used to treat periprosthetic distal femur fractures.

METHODS

A systematic review including MEDLINE, Embase and Cochrane Library databases was completed from inception to April 10, 2021. Studies including a comparator cohort were meta-analyzed.

RESULTS

Fourteen studies were identified for inclusion, of which, five had sufficient homogeneity for inclusion in a meta-analysis. 30-day and 2-year mortality was 4.1% and 14.6% in the DFR group. There was no statistically significant difference between ORIF and DFR (log Odds-Ratio (OR) = -0.14, 95 %CI: -0.77 to 0.50). The reoperation rate in the DFR group was 9.3% versus 14.8% for ORIF, with no difference between groups (log OR = 0.10, 95 %CI: -0.59 to 0.79). There was no difference in rates of deep infection (log OR = 0.22, 95 %CI: -0.83 to 1.28). Direct comparison of functional outcomes was not possible, though did not appear significant.

CONCLUSION

DFR in the setting of periprosthetic distal femur fractures is equivalent to ORIF with respect to mortality and reoperation rate and thus a safe and reliable treatment strategy. DFR may be more reliable in complex fracture patterns where the ability to obtain adequate fixation is difficult.

Using the articularis genu to test peri-articular muscle health during knee osteoarthritis

Knee osteoarthritis (OA) involves peri-articular sarcopenia. The infrapatellar articularis genu (AG) links to the quadriceps femoris (QF) and can be sampled from discarded tissue during arthroplasty. We predict disuse-mediated changes in AG myofiber type ratio and atrophy similar to reports on the QF during OA. OA AGs (n = 40) were preserved and grouped by poor (≤ 85°; n = 11), fair (90°-110°; n = 19), and good (≥ 115°; n = 10) range of motion (ROM). Immunolabeling of slow and fast myosin heavy chains in AG sections allowed comparing distribution and cross-sectional area (CSA) of type-I (T1) and type-II (T2) myofibers between groups and associating to ROM. T1/T2 ratios in fair and poor ROM groups was consistent with those published in OA QF. Increasing mean ± SD T2 percentages from good (43.31 ± 11.76), to fair (50.96 ± 5.85), and poor (60.02 ± 8.29) ROM groups was significant between poor versus fair (p = 0.018) and good (p < 0.0001) in association with ROM deficits (r = - 0.729; p < 0.0001). T1 and T2 CSA decreased with worsening ROM, which associates with lower symptom scores (r = 0.3198; p = 0.0472). In-depth evaluation of the OA AG as a surrogate for the OA QF relative to serum and/or synovial fluid biomarkers of sarcopenia could refine diagnostics of peri-articular muscle health to guide individualized strength rehabilitation after surgery.

Movement characteristics during customized exergames after total knee replacement in older adults

Introduction

There is limited understanding of how older adults can reach kinematic goals in rehabilitation while performing exergames and conventional exercises, and how similar or different the kinematics during exergaming are when compared with conventional therapeutic exercise with similar movement. The aim of this study was to describe the movement characteristics performed during exercise in custom-designed exergames and conventional therapeutic exercises among patients who have undergone unilateral total knee replacement (TKR). In addition, the secondary aim was to assess the relation of these exercise methods, and to assess participants' perceived exertion and knee pain during exergaming and exercising.

Materials and methods

Patients up to 4 months after the TKR surgery were invited in a single-visit exercise laboratory session. A 2D motion analysis and force plates were employed to evaluate movement characteristics as the volume, range, and intensity of movement performed during custom-designed knee extension-flexion and weight shifting exergames and conventional therapeutic exercises post TKR. The perceived exertion and knee pain were assessed using the Borg Rating of Perceived Exertion and Visual Analog Scale, respectively.

Results

Evaluation of seven patients with TKR [age median (IQR), 65 (10) years] revealed that the volume and intensity of movement were mostly higher during exergames. Individual goniometer-measured knee range of motion were achieved either with exergames and conventional therapeutic exercises, especially in knee extension exercises. The perceived exertion and knee pain were similar after exergames and conventional therapeutic exercises.

Conclusions

During custom-designed exergaming the patients with TKR achieve the movement characteristics appropriate for post-TKR rehabilitation without increasing the stress and pain experienced even though the movement characteristics might be partly different from conventional therapeutic exercises by the volume and intensity of movement. Physical therapists could consider implementing such exergames in rehabilitation practice for patients with TKR once effectiveness have been approved and they are widely available.

Efficacy of non-operative treatment of patients with knee arthrofibrosis using high-intensity home mechanical therapy: a retrospective review of 11,000+ patients

Background

Recovery from knee surgery or injury can be hindered by knee arthrofibrosis, which can lead to motion limitations, pain and delayed recovery. Surgery or prolonged physical therapy are often treatment options for arthrofibrosis, but they can result in increased costs and decreased quality of life. A treatment option that can regain lost motion without surgery would help minimize risks and costs for the patient. The purpose of this study was to determine treatment efficacy of high-intensity home mechanical stretch therapy in patients with knee arthrofibrosis.

Methods

Records were reviewed for 11,000+ patients who were prescribed a high-intensity stretch device to regain knee flexion. Initial and last recorded knee flexion and days between measurements were available for 9842 patients (Dataset 1). Dataset 2 was a subset of 966 patients from Dataset 1. These 966 patients had separate more rigorous measurements available from physical therapy notes (Dataset 3) in addition to data from the internal database (Dataset 2). Within and between dataset statistics were calculated using t tests for comparison of means and Cohen’s d for determination of effect size.

Results

All dataset showed significant gains in flexion (p < 0.01). Mean initial flexion, last recorded flexion and flexion gain were 79.5°, 108.4°, and 29.9°, respectively in Dataset 1. Differences between Datasets 2 and 3 had small effect sizes (Cohen’s d < 0.17). The were no significant differences when comparing workers’ compensation and non-workers’ compensation patients. The average last recorded flexion for all datasets was above the level required to perform activities of daily living. Motion gains were recorded in under 60 days from device delivery.

Conclusions

High-intensity home mechanical stretch therapy was effective in restoring knee flexion, generally in 2 months or less, and in avoiding additional surgery in severe motion loss patients regardless of sex, age, or workers’ compensation status. We believe high-intensity stretching should be considered in any patient who is at risk for a secondary motion loss surgery, because in over 90% of these patients, the complications and costs associated with surgery can be avoided.

Exploring human activity recognition using feature level fusion of inertial and electromyography data

Wearables are objective tools for human activity recognition (HAR). Advances in wearables enable synchronized multi-sensing within a single device. This has resulted in studies investigating the use of single or multiple wearable sensor modalities for HAR. Some studies use inertial data, others use surface electromyography (sEMG) from multiple muscles and different post-processing approaches. Yet, questions remain about accuracies relating to e.g., multi-modal approaches, and sEMG post-processing. Here, we explored how inertial and sEMG could be efficiently combined with machine learning and used with post-processing methods for better HAR. This study aims recognition of four basic daily life activities; walking, standing, stair ascent and descent. Firstly, we created a new feature vector based on the domain knowledge gained from previous mobility studies. Then, a feature level data fusion approach was used to combine inertial and sEMG data. Finally, two supervised learning classifiers (Support Vector Machine, SVM, and the k-Nearest Neighbors, kNN) were tested with 5-fold cross-validation. Results show the use of inertial data with sEMG increased overall accuracy by 3.5% (SVM) and 6.3% (kNN). Extracting features from linear envelopes instead of bandpass filtered sEMG improves overall HAR accuracy in both classifiers. Clinical Relevance- Post-processing on sEMG signals can improve the performance of multimodal HAR.

Smart Wearable Device for Quantification of Risk of Fall: Exploring Role of Gait Phases and Knee Bending Angle for Parkinson's Patients

Gait disturbances with falls are common among patients with Parkinson's disease. Falls commonly occur from slips while walking on pathways with turns. Gait phases namely Loading Response and Terminal Stance are linked with forward and backward slips. Also, postural deformities (connected with knee joint angles) are debilitating symptoms of Parkinson's patients and are related with falls. Here, we have focused on exploring the contribution of Loading Response and Terminal Stance to risk of fall along with the relevance of postural deformity (e.g., knee bending) while an individual walked overground on pathways (with 0° and 180° turn) under dual task condition. For this, we have used a wearable device consisting of a pair of Sensored shoes and Knee Bending Angle Recorder Units. The device was used to compute Coefficient of Variation of knee bending angle during different gait phases as an indicator of one's risk of fall that corroborated with clinical measure. Clinical Relevance- A study with age and gender matched healthy and Parkinson's individuals indicated the importance of Loading Response and pathway turn while assessing risk of fall. This can serve as important pre-clinical input while designing intervention paradigms.

The Role of Virtual Clinics in Postoperative Total Knee Replacement Surgery Follow-Up during COVID-19 Pandemic

Background

The purpose of this study was to evaluate the feasibility of the virtual clinic for outpatient follow-up care after TKR surgery.

Methods

A total of 546 TKR surgeries were performed from January 2017 to December 2019. 30 patients were not able to go the hospital for routine follow-up. The data collections were taken for age, gender, year of surgery, functional score (Oxford Knee Score (OKS)), and active range of motion (ROM). The virtual clinic was conducted with the physician assistant and the operating surgeon via WhatsApp video call (WhatsApp Inc., Mountain View, California, USA) or Zoom (Zoom Video Communications, Inc., San Jose, California, USA).

Result

The average follow-up period was 39.1 months. The earliest follow-up was 20 months, while the longest follow-up was 97 months. The average OKS score was 45. The average consultation time for the virtual clinic is 9 minutes 21 seconds. Most of the patients were satisfied with the online consultation, with only two patients having a satisfaction score below 80%.

Conclusion

The virtual clinic for TKR surgery showed a high satisfaction rate during the COVID-19 pandemic, which has the potential to extend to the postpandemic era.

Outcomes after ORIF of Bicondylar Schatzker VI (AO type C) Tibial Plateau Fractures in an Elderly Population

BACKGROUND

The surgical management of bicondylar tibial plateau (BTP) fractures in elderly patients aims to restore knee stability while minimizing soft tissue complications. The purpose of this study was to compare injury characteristics and surgical outcomes after ORIF of BTP fractures (AO/OTA 41-C (Schatzker VI)) in young (< 50 years) versus elderly (> 65 years) patients.

METHODS

A retrospective cohort study was conducted using data from two American College of Surgeons (ACS) level I trauma centers. Inclusion criteria were: (1) age 18 years or older, (2) bicondylar tibial plateau fracture (AO/OTA 41-C or Schatzker VI), (3) treatment with ORIF, and (4) minimum of 6 months follow-up. Patients between 50 and 65 years of age were excluded. Data collection was performed by reviewing electronic medical records, operative reports, and radiology reports.

RESULTS

We identified 323 patients (61% male) with 327 BTP fractures and a median follow-up of 685 days. There were 230 young patients (71%) < 50 years and 93 elderly patients (29%) >6 5 years at time of presentation. Elderly patients were significantly more likely to have a low energy mechanism of injury (44.6 vs. 16.2%, p < 0.001), and present with diabetes (19.4 vs. 4.4%, p < 0.001) or coronary artery disease (12.9 vs. 1.3%, p < 0.001). Elderly patients were also significantly less likely to undergo staged management with initial knee-spanning external fixation followed by delayed ORIF (19.2 vs. 33.9%, p = 0.008). Elderly patients had a lower arc of motion at final follow-up (105 vs. 113°, p < 0.001) and reduced PROMIS-10 function scores (43.8 vs. 49.8, p = 0.013). No differences were observed in rates of superficial infection, deep infection, reoperation, or EQ-5D scores between age groups.

CONCLUSIONS

This is the largest study to compare injury characteristics and outcomes after ORIF of BTP fractures according to age. Elderly patients (age > 65 years) sustained BTP fractures by lower energy mechanisms than their younger counterparts with similar fracture patterns and were often managed with ORIF. The results of this study suggest that ORIF of BTP fractures in elderly patients is associated with similar complication rates and outcomes as in younger patients despite higher comorbidities and poorer bone quality in the elderly population.

Supine leg press as an alternative to standing lunge in high-speed stereo radiography

The standing lunge is an activity commonly used to quantify in-vivo knee kinematics with fluoroscopy. The ability to perform the standing lunge varies between subjects and can necessitate movement accommodations to successfully complete the desired range of motion. We proposed a supine leg press as an alternative to the standing lunge that aimed to provide a similar evaluation of knee motion while increasing the measured range of motion. Tibiofemoral kinematics of 53 non-symptomatic adults (27 men, 26 women, 50.8 ± 7.0 yrs.) were calculated from the tracked high-speed stereo radiography (HSSR) images for supine leg press and standing lunge using CT-segmented bony geometries of the right lower limb. The supine leg press proved to be a useful alternative to the standing lunge while providing 46.2° greater range of motion in knee flexion. The difference in angle-matched kinematics across a 100° flexion range between the leg press and lunge was 0.70° in varus-valgus rotation, 1.5° in internal-external rotation, 1.0 mm in medial-lateral translation, 2.3 mm in anterior-posterior translation, and 0.46 mm in superior-inferior translation for men. The angle-matched difference for women across 100° was 0.58° in varus-valgus rotation, 2.4° internal-external rotation, 0.70 mm medial-lateral translation, 2.1 mm anterior-posterior translation, and 0.78 mm superior-inferior translation. The similar kinematics, while having a greater range of motion, and control of the applied load makes the supine leg press an alternative for quantifying in-vivo knee kinematics.

The Implication of Pathway Turn and Task Condition on Gait Quantified Using SmartWalk: Changes With Age and Parkinson's Disease With Relevance to Postural Strategy and Risk of Fall

One's gait can be affected by aging, pathway with turns, task demands, etc., causing changes in gait-related indices and knee flexion (influencing posture). Walking on pathways with turns threatens stability, affecting one's gait-related indices and posture. The ability to overcome such deficits is compromised with age and neurological disorders, e.g., Parkinson's Disease (PD) leading to falls. Also, task demands imposed by single and dual-task (e.g., counting backward while walking) conditions affect the gait of individuals using different postural strategies varying with age and neurological disorder. Existing research has investigated either the effect of the pathway with turn or task condition on one's gait. However, none (to our knowledge) have explored the differentiated implications of the pathway with turn and task conditions on one's gait-related indices and knee flexion while walking. Our study had two phases with 30 participants. Phase 1 had healthy adults (young and old) and Phase 2 had age and gender-matched healthy elderly and individuals with Parkinson's disease (PD) who walked on pathways having turns under single and dual-task conditions. We analysed gait in terms of (i) gait-related indices (Phases 1 and 2) and (ii) knee flexion (Phase 2). Also, we analysed one's counting performance during dual task. One's gait-related indices and knee flexion were measured using a portable gait quantifier. The aim was to (i)understand whether both pathways with turn and task conditions are equally effective in affecting the gait of (a)individuals of varying ages and (b) gender-matched healthy older adults and individuals with PD, (ii)study variations of knee joint angles while walking on pathways having turns (under different task conditions) in terms of its clinical relevance, and (iii) explore the implication of pathway with turn on counting performance (with relevance to postural strategy) with varying age and PD. Results indicated that for the younger group, the task condition caused statistical variations in gait-related indices. For the older group, both pathways with turn and task conditions had statistical implications on gait-related indices. Additionally, individuals with PD demonstrated a higher variation in knee flexion than their healthy counterparts. Again, pathways with varying turns elicited variations in counting performance indicating different postural strategies being employed by the three groups.

Can a Patient use an App at Home to Measure Knee Range of Motion? Utilizing a Mobile App, Curovate, to Improve Access and Adherence to Knee Range of Motion Measurements

Introduction

Knee range of motion is a critical measure of progress after knee injury and knee surgery. However, many patients do not understand the importance of knee range of motion and most do not have a way to self-monitor their knee range of motion at home. The patient being able to measure their own range of motion can provide improved access to this critical health metric, and could improve adherence with their daily knee range of motion exercises. The purpose of this technical report is to determine if a mobile app, Curovate, can provide reliable measures of knee range of motion compared to standard goniometric measurements.

Procedures

There were four positions of knee flexion and four positions of knee extension each measured twice with a standard goniometer and four different mobile devices with the app Curovate. The reliability and validity of the Curovate app was tested across mobile devices and operating systems and compare to goniometric knee range of motion measurements. A total of 80 measurements were taken. All testing was completed on a healthy 23-year-old male with no knee pathology.

Results

A strong positive correlation, Pearson's r > = 0.9985, for all positions of knee flexion and extension across all four mobile devices as well as each mobile device compared to standard goniometric measurements.

Conclusions

This article presents a unique method for patients to measure their knee range of motion using the mobile app Curovate. Overall, the mobile app, Curovate, was found to have a strong positive correlation across four mobile devices with varying operating systems and compared to goniometric measurements.

Level of evidence

4.

Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures

Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy.

The functional outcome after tumor resection and endoprosthesis around the knee: a systematic review

The evidence for the functional outcome of endo- prosthetic replacement (EPR) after tumour resection has been from few cohort studies. A scoping search revealed no systematic review on patient reported outcome measures after EPR around the knee. The purpose of this study was to evaluate the functional outcome of distal femoral and proximal tibial EPR after tumour resection. A systematic review was conducted using the PRISMA guidelines. The search identified 2560 articles from MEDLINE, EMBASE, CINAHL, and Web of Science. 36 studies satisfying the selection criteria were included for data synthesis. Pooled analysis was performed for homogenous studies. Narrative synthesis was performed for all the studies due to heterogeneity in methodological and statistical analysis. Amongst the overall patient population of 2930, mean ages ranged from 18-66 years and the mean follow up periods in the studies ranged from 12 - 180 months. The weighted mean functional outcome was similar for patients who had DFEPR and PTEPR. The functional outcome scores of Rotating Hinge Knee implants (RHK) were significantly greater than that for Fixed Hinge Knee implants (FHK). The weighted mean functional outcome scores were higher after cemented fixation and after primary EPR procedures. The current evidence suggests that functional out- come after EPR in the knee is good, and RHK implants are better than FHK implants. Functional outcome after primary EPR was significantly better than following revision EPR, and this underscores the importance of minimising complications at the primary surgery.

Prolonged Application of Continuous Passive Movement Improves the Postoperative Recovery of Tibial Head Fractures: A Prospective Randomized Controlled Study

Methods

60 patients with THFs were randomly and equally divided into the CPM group and non-CPM group. Both groups immediately received CPM and conventional physical therapies during hospitalization. After discharge, the non-CPM group was treated with conventional physical therapy alone, while the CPM group received conventional physical training in combination with CPM treatment. At 6 weeks and 6 months postoperatively, the primary outcome which was knee ROM and the secondary outcome which was knee functionality and quality of life were evaluated.

Results

The CPM group had a significantly increased ROM at both follow-up time points. The Knee Society Score, UCLA activity score, and the EuroQoL as well as the pain analysis showed significantly better results of the CPM group than the non-CPM group.

Conclusions

The prolonged application of CPM therapy is an effective method to improve the postoperative rehabilitation of THFs.

Effectiveness of proximal tibial tubercle transfer in patients with patella baja after total knee arthroplasty

Purpose

Patella baja after total knee arthroplasty (TKA) is a common problem that is usually treated via proximal transfer of the tibial tubercle. As the long-term outcomes of this procedure are unclarified, this study aimed to investigate the changes in clinical function and radiographic patellar height during five years of follow-up.

Methods

Sixty patients with patella baja after TKA who underwent proximalisation of the tibial tubercle were followed up for a mean of 71 months (range 21–153 months). The pre- and postoperative range of motion (ROM) and clinical scores (Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)) were compared. The radiographic patellar height was measured with the Caton-Deschamps index (CDI), Blackburne-Peel ratio (BP), and modified Insall-Salvati index (MIS).

Results

Proximalisation of the tibial tubercle resulted in a significant improvement in the ROM from 80° to 88°. The KSS and WOMAC did not improve or even worsened after the intervention. The radiographic patellar height immediately after tibial tubercle transfer was not better than prior to the intervention (CDI 0.72 vs. 0.63, p = 0.72; BP 0.66 vs. 0.61, p = 0.72; MIS 1.59 vs. 1.55, p = 1.00) and further decreased significantly so that the mean final values were worse than the values in the native joint (CDI 0.59 vs. 0.78, p = 0.001; BP 0.58 vs. 0.74, p = 0.001; MIS 1.39 vs. 1.81, p < 0.001).

Conclusion

Proximalisation of the tibial tubercle in patients with patella baja after TKA does neither lead to significant improvements in the clinical outcome nor in the radiographic patellar height during long-term follow-up.

Level of evidence

III