Epidemiology of Revision Total Knee Arthroplasty: A Single Center's Experience

Appearance and evolution of radiolucent lines below the tibial implant in primary total knee arthroplasty

BACKGROUND

The aim of this study was to evaluate total knee arthroplasty (TKA) radiographically to detect the occurrence of radiolucent lines (RLL) under the tibial base plate and to determine what type of RLL may have a correlation with aseptic loosening (AL). The study had two hypotheses: (1) RLLs may have different radiological aspects and evolutions in time depending of different factors (2) Signs of micro- and/or macro-mobility of the implant are necessary before diagnosing aseptic loosening of the tibial component.

METHODS

Retrospective cohort study of 774 patients operated with a Vanguard TKA (Zimmer Biomet, Warsaw, IN, US) from 2007 to 2015. RLLs were recorded in a database and described according to their radiological aspect, localization, time of apparition, progression and eventual evolution to AL. Other collected parameters were pre- and post-operative HKA angles, amount of post-operative HKA correction, surgical, clinical and demographic data.

RESULTS

178/774 TKAs (23%) showed RLLs under the tibial base plate including 9 (1.2%) tibial implants needing revision for AL. Three different types and two aspects of RLLs were observed. Important deformity corrections or undercorrected implants were recognized as a mechanical risk factor for loosening. Elderly women with osteoporosis and young men with important pre-operative deformities were identified as clinical risk factors for RLLs.

CONCLUSIONS

RLLs are frequently present at the epiphyseal bone/implant interface after total knee arthroplasty, but do not mean the implant is loose. They can be considered a sign of reduced epiphyseal surface fixation due to micro mobility of the tibial implant. Aseptic loosening can be observed radiologically when signs of macro-mobility of the implant are present at the metaphyseal level.

LEVEL OF EVIDENCE

III.

Prediction of suitable outpatient candidates following revision total knee arthroplasty using machine learning

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

Methods

Data were obtained from the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) database from the years 2018 to 2020. Patients with elective, unilateral rTKA procedures and a total hospital length of stay between zero and four days were included. Demographic, preoperative, and intraoperative variables were analyzed. A multivariable logistic regression (MLR) model and various machine learning techniques were compared using area under the curve (AUC), calibration, and decision curve analysis. Important and significant variables were identified from the models.

Results

Of the 5,600 patients included in this study, 342 (6.1%) underwent SDD. The random forest (RF) model performed the best overall, with an internally validated AUC of 0.810. The ten crucial factors favoring SDD in the RF model include operating time, anaesthesia type, age, BMI, American Society of Anesthesiologists grade, race, history of diabetes, rTKA type, sex, and smoking status. Eight of these variables were also found to be significant in the MLR model.

Conclusion

The RF model displayed excellent accuracy and identified clinically important variables for determining candidates for SDD following rTKA. Machine learning techniques such as RF will allow clinicians to accurately risk-stratify their patients preoperatively, in order to optimize resources and improve patient outcomes.

Postoperative scores for robot-assisted and conventional total knee arthroplasty: A meta-analysis

Background

Knee osteoarthritis is the most common joint disease globally. As obesity and age rates continue to rise in the U.S., the demand for total knee arthroplasty (TKA) is expected to grow significantly by 2030. Advanced techniques such as robotic-assisted (RA-TKA) aim to address this growing concern and improve patient quality-of-life. Since utilization of RA-TKA increased from 2010 to 2018, it is important to compare RA-TKA to conventional TKA (C-TKA) performance. This study compares RA-TKA to C-TKA in patient-reported WOMAC scores and objective range of motion (ROM) scores in eligible short-term (one-year or less) and long-term (one-year to fifteen-years) postoperative follow-up studies.

Methods

A systematic review using the PubMed database was performed to identify articles including RA-TKA, CA-TKA, C-TKA, WOMAC scores, and ROM scores.

Results

Between RA-TKA and C-TKA, weighted analysis found significant effects in short-term (15.45, 95% CI: 4.96-25.94) and long-term (2.62, 95% CI: 0.62-4.61) WOMAC scores.

Conclusion

As approximately 7-20% of C-TKA surgeries result in poor subjective outcomes, and with revision rates and the demand for TKA set to rise, our analysis suggests that patient quality-of-life and cost effectiveness may be significantly improved by RA-TKA over C-TKA.

Evaluation of the safety and efficacy of the fully automated active robotic system in robotic assisted total knee arthroplasty

Background

Use of semi-active and active robotic system for performing Total Knee Arthroplasty (TKA) is increasing. The novel fully automated active robotic system performs milling of the bone surfaces with a high speed burr. The aim of the current study was to assess the safety and efficacy of the system in robotic assisted TKA (RA-TKA).

Materials and methods

A single center clinical trial was conducted following 30 knees undergoing active RA-TKA for 6 months. Inclusion criteria were patients undergoing RA-TKA for end stage arthritis. Patients undergoing conventional TKA and revision TKA were excluded from the study. Sample size was estimated to be 28 patients with α error of 0.05 and β error of 0.2 with power of study being 80. A pre-defined list of RA-TKA adverse events was employed to study the safety of the system. Efficacy was judged by comparing the planned versus achieved Implant size, alignment and limb alignment on post-operative radiographs. The post-operative clinical evaluation was done by an independent observer who was not part of the operating team. The primary safety and efficacy hypothesis was tested using a one sided Exact binomial test. The p value < 0.05 was considered significant.

Results

Pre-defined adverse events did not occur in any of the 30 RA-TKA (statistically significant p value < 0.001). The implant size accuracy was 100% (30 out of 30 knees) for femoral component and 96.67% (29 out of 30 knees) for tibial component (statistically significant, Chi-squared test, p value 0.0105 and 0.0461 respectively). The implant position and limb alignment was accurate in 100% of patients (p value < 0.001).

Conclusion

Early experience of the use of fully automated active robotic system in TKA shows that it is safe and also is effective in achieving accurate implant size and implant/limb alignment.

Effect of Proprioception and Balance Training Combined with Continuous Nursing on BBS Score and HSS Score of Patients Undergoing Total Knee Arthroplasty

Background

Total knee arthroplasty is one of the most effective methods for the treatment of end-stage knee osteoarthritis, but 10% of patients still show insufficient function, strength, and mobility. Continuous nursing service plays an important role in the rehabilitation of patients undergoing total knee arthroplasty. For discharged and convalescent patients, the traditional follow-up model cannot solve the nursing problems of discharged patients. How to meet the health needs of discharged patients under the limited nursing resources has become an existing problem.

Objective

To explore the effect of proprioception and balance training combined with continuous nursing on Berg balance scale (BBS) score and Hospital for Special Surgery (HSS) score of patients undergoing total knee arthroplasty (TKA) is the objective of this study.

Methods

Sixty patients undergoing TKA in our hospital from December 2019 to April 2021 were enrolled. The patients were randomly assigned into the control group and the study group. The control group received continuous nursing, and the study group received proprioception and balance training combined with continuous nursing.

Results

The nursing satisfaction of the study group was higher than that of the control group (P < 0.05). The HSS scores at discharge, 1 month, 3 months, and 6 months after discharge in the study group were higher than those in the control group (P < 0.05). It was higher in the study group than in the control group at 1 month, 3 months, and 6 months after discharge (P < 0.05). The pain catastrophizing score of the study group at discharge was lower than that of the control group at 1 month, 3 months, and 6 months after discharge (P < 0.05). The BBS scores at discharge, 1 month, 3 months, and 6 months after discharge in the study group were higher than those in the control group (P < 0.05). The Lindmark balance scores at discharge, 1 month, 3 months, and 6 months after discharge in the study group were lower than those in the control group (P < 0.05).

Conclusion

Proprioception and balance training combined with continuous nursing can effectively promote the recovery of knee joint function of patients after TKA, enhance patients' pain catastrophizing grade, enhance patients' quality of life, effectively promote patients' knee joint function and BBS score, and promote the improvement of disease.

Comparable results between crosslinked polyethylene and conventional ultra-high molecular weight polyethylene implanted in total knee arthroplasty: systematic review and meta-analysis of randomised clinical trials

PURPOSE

Total knee arthroplasty (TKA) has experienced exponential growth over the last decade, including increasingly younger patients with high functional demands. Highly crosslinked polyethylene (HXLPE) has been proven effective in reducing osteolysis and loosening revisions while improving long-term survival and performance in total hip arthroplasty; nevertheless, this superiority is not demonstrated in TKA. The aim of this systematic review and meta-analysis was to examine whether HXLPE improved overall survival and postoperative functional and radiological outcomes compared to conventional polyethylene (CPE) in TKA.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, a literature search of five databases (PubMed, Medline, Scopus, Science Direct and Embase) was made. A PICOS model was performed. The initial screening identified 2541 studies. Each eligible clinical article was analysed according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (LoE). Only randomised clinical trials (RCTs) of LoE 1 and 2 were included. The methodological quality of the articles was assessed using the Risk of Bias 2 (RoB 2) tool.

RESULTS

Six clinical studies were included in the final study. This systematic review and meta-analysis were registered on the International Prospective Register of Systematic Reviews (PROSPERO). A total of 2285 knees were included. Eight outcomes (total reoperations, reoperations for prosthesis loosening and infections, radiolucent lines, osteolysis, mechanical failure, postoperative KSS knee score and function score) were analysed. For none of them, a statistically significant difference was found about the superiority of HXLPE over CPE (p > 0.05).

CONCLUSIONS

There were no statistically significant differences between HXLPE and CPE for TKA concerning clinical, radiological, and functional outcomes; nevertheless, HXLPE did not show higher failure rates or complications and can be safely used for TKA.

LEVEL OF EVIDENCE

II.

Titanium Nanoparticles Enhance Production and Suppress Stabilin-1-Mediated Clearance of GDF-15 in Human Primary Macrophages

Macrophages are key innate immune cells that mediate implant acceptance or rejection. Titanium implants degrade over time inside the body, which results in the release of implant wear-off particles. Titanium nanoparticles (TiNPs) favor pro-inflammatory macrophage polarization (M1) and lower tolerogenic activation (M2). GDF-15 regulates immune tolerance and fibrosis and is endocytosed by stabilin-1. How TiNPs affect the healing activities of macrophages and their release of circulating cytokines is an open question in regenerative medicine. In this study for the first time, we identified the transcriptional program induced and suppressed by TiNPs in human pro-inflammatory and healing macrophages. Microarray analysis revealed that TiNPs altered the expression of 5098 genes in M1 (IFN-γ-stimulated) and 4380 genes in M2 (IL-4–stimulated) macrophages. 1980 genes were differentially regulated in both M1 and M2. Affymetrix analysis, confirmed by RT-PCR, demonstrated that TiNPs upregulate expression of GDF-15 and suppress stabilin-1, scavenger receptor of GDF-15. TiNPs also significantly stimulated GDF-15 protein secretion in inflammatory and healing macrophages. Flow cytometry demonstrated, that scavenging activity of stabilin-1 was significantly suppressed by TiNPs. Confocal microscopy analysis showed that TiNPs impair internalization of stabilin-1 ligand acLDL and its transport to the endocytic pathway. Our data demonstrate that TiNPs have a dual effect on the GDF-15/stabilin-1 interaction in macrophage system, by increasing the production of GDF-15 and suppressing stabilin-1-mediated clearance function. In summary, this process can result in a significant increase of GDF-15 in the extracellular space and in circulation leading to unbalanced pro-fibrotic reactions and implant complications.

Different microbial and resistance patterns in primary total knee arthroplasty infections - a report on 283 patients from Lithuania and Sweden

Background

The microbiology and the susceptibility patterns of infected total knee arthroplasties (TKAs) vary depending on demographic, local antimicrobial stewardship, and surgical factors. We wanted to compare the recent microbial profile and antimicrobial resistance pattern in revisions due to infections after primary TKAs in Sweden and Lithuania. Our hypothesis was that there is a difference in bacteriology and resistance pattern based on patient related, societal and local hospital factors as almost similar praxis have been applied for TKA surgery, short term systemic prophylaxis and routine use of local gentamicin containing bone cement.

Methods

Primary TKAs revised for the first time due to verified or suspected infection were collected nationwide in Sweden during 2018, and in Lithuania between 2011 and 2020 from a single major TKA revision centre in Kaunas. We identified 202 TKAs in Sweden from the Swedish Knee Arthroplasty Register and 84 from Kaunas revised due to infection. We collected available culture reports and evaluated the type of microorganisms with antimicrobial resistance pattern at revision.

Results

The majority of the infected cases in Sweden were early-type prosthetic joint infection (PJI) (44%), whereas late-type PJI (52%) were more common in the Kaunas cases. Gram-positive bacteria prevailed in both Sweden (55%) and Lithuania (80%). Staphylococcus aureus was the most frequent organism identified in both countries (33% in Sweden and 34% in Lithuania). More polymicrobial infections were observed in Sweden than in Lithuania (16 and 6% respectively). Methicillin resistance in Staphylococcus aureus and coagulase-negative staphylococci were higher in Lithuania (4/28 and 19/29) than in Sweden (1/42 and 9/41).

Conclusions

The type of infections, microbial profile, and drug resistance pattern differed between Sweden and Lithuania. Societal and local hospitals factors with emerging resistance in Lithuania are the most plausible explanation for the difference. Lack of complete data on a national level in Lithuania underlines the importance of adding microbiology of PJIs in implant registers for national aggregation and allow cross country comparisons.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04689-5.

Cost of Revision Total Knee Replacement: A Protocol for Systematic Review and Meta-Analysis

BACKGROUND

A major limitation of total knee replacement (TKR), as with other joint replacements, is the risk of revision. Revision TKR is associated with high risk and economic burden to patients, healthcare providers, and societies. It will be worthwhile to assess the economic burden of revision TKR across countries or different study settings. This study aims to review the literature on the cost of revision TKR to assess costs across countries and studies, estimate a pooled cost estimate for homogenous data, and identify major cost components that contribute to the cost burden.

METHODS

We will conduct a search of the MEDLINE (OvidSp), EMBASE, Web of Science, Cochrane Library, EconLit, and Google Scholar databases to identify relevant studies, and will use an optimally designed search approach to search for relevant studies. EndNote library will be used to manage the searched studies. Selection will be undertaken in two phases-screening and eligibility. Study selection, data extraction, and assessment of the risk of bias will be performed in duplicate, after which the data will be analysed narratively and a meta-analysis performed for homogenous studies, if possible.

DISCUSSION

This protocol provides a proposed stepwise plan for conducting a systematic review and meta-analysis of the cost of revision TKR. Findings from this systematic review will provide information about the cost across settings and identify the major cost drivers of revision TKR, which will, in turn, stimulate efforts to minimize the cost.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020171988.

Estrogen-related receptors: novel potential regulators of osteoarthritis pathogenesis

Osteoarthritis (OA) is a chronic inflammatory disease that is associated with articular cartilage destruction, subchondral bone alterations, synovitis, and even joint deformity and the loss of joint function. Although current basic research on the pathogenesis of OA has made remarkable progress, our understanding of this disease still needs to be further improved. Recent studies have shown that the estrogen-related receptor (ERR) family members ERRα and ERRγ may play significant roles in the pathogenesis of OA. In this review, we refer to the latest research on ERRs and the pathogenesis of OA, elucidate the structure and physiopathological functions of the ERR orphan nuclear receptor family, and systematically examine the relationship between ERRs and OA at the molecular level. Moreover, we also discuss and predict the capacity of ERRs as potential targets in the clinical treatment of OA.

Current Trends and Projected Burden of Primary and Revision Total Knee Arthroplasty in Korea Between 2010 and 2030

BACKGROUND

This study aimed to (1) document the total knee arthroplasty (TKA) use in Korea from 2010 to 2018, (2) evaluate whether rapid increase in TKA use has been maintained, and (3) estimate the projected TKA burden to 2030 based on the current use.

METHODS

Using the Health Insurance Review and Assessment Korean database, procedural rate, growth rate, and revision burden of primary and revision TKAs in Korea between 2010 and 2018 were analyzed. TKA procedural numbers were also stratified by age and gender. Then, the projected TKA burden to 2030 including procedural number and medical costs were estimated using linear and quasi-Poisson regression models, respectively.

RESULTS

Between 2010 and 2018, procedural rate of primary and revision TKAs has increased by 35% and 68%, respectively. More than 85% of primary and revision TKAs were performed on female patients, and the subgroup of patients aged ≥80 years showed a marked increase in primary and revision TKA use. According to the projection model, the number of primary and revision TKAs is predicted to increase between 53% and 91%, and between 75% and 155%, respectively, by 2030.

CONCLUSION

Between 2010 and 2018, the procedural rates of primary and revision TKAs in Korea increased gradually by 35% and 68%, respectively, and previously observed striking growth rate has markedly slowed. Nevertheless, compared to 2018, the burdens of primary and revision TKAs are projected to increase up to 91% and 155%, respectively, by 2030.

LEVEL OF EVIDENCE

Therapeutic Level III.

Comparison between Dexmedetomidine and Clonidine as an Adjuvant to Ropivacaine in Ultrasound-Guided Adductor Canal Block for Postoperative Analgesia in Total Knee Replacement: A Randomized Controlled Trial

Background

Total knee replacement (TKR) surgeries are associated with significant postoperative pain. Ultrasound-guided adductor canal block is associated with better pain scores. The addition of Clonidine and Dexmedetomidine as additives to local anesthetics was the recent focus of interest. However, there are minimal studies comparing the duration of analgesia as additives to Ropivacaine in ultrasound-guided adductor canal block for TKRs.

Materials and Methods

Prospective, randomized, double-blind design was followed. One hundred and two American Society of Anesthesiologists I to III patients undergoing unilateral TKR surgeries were included in the study and randomized into two groups. Group C received Clonidine 150 mcg and Group D received Dexmedetomidine 100 mcg as an add on to 30 mL of 0.2% ropivacaine for adductor canal block. Postoperatively, duration of analgesia, sedation score, rescue analgesic requirement, hemodynamics, and any other adverse effects were monitored.

Results

The total duration of analgesia in Group D (16.01 h [standard deviation [S. D]-0.5]) was significantly higher as compared to Group C (13.02 h [S. D-0.5]) (P < 0.0001). The numerical rating score (NRS) was significantly lower in Group D compared to Group C (P < 0.05) at multiple postoperative timelines. Group D (2.25(S. D-0.44)) had better sedation scores as compared to Group C (2 [S. D-0]) (P = 0.001).

Conclusion

Dexmedetomidine has longer duration, lower pain, and better sedation scores as compared to clonidine in adductor canal blocks for postoperative pain relief in TKR surgeries.

Unintended consequences of COVID-19 safety measures on patients with chronic knee pain forced to defer joint replacement surgery

COVID-19 crisis deferred elective arthroplasty leading to potential surgical backlog. Prolonged surgical waiting times may worsen physical and mental health of patients in chronic pain.

In recent months, with the emergence of the COVID-19 pandemic, the American College of Surgeons and the U.S. Centers for Disease Control and Prevention officially recommended the delay of nonemergency procedures until the public health crisis is resolved. Deferring elective joint replacement surgeries for an unknown period is likely to decrease the incidence of infection with SARS-CoV-2 but is likely to have detrimental effects in individuals suffering from chronic knee pain. These detrimental effects extend beyond the discomfort of osteoarthritis (OA) and the inconvenience of rescheduling surgery. Disabling pain is a driving factor for individuals to seek medical intervention, including pharmacological palliative treatment and surgical procedures. The need for surgical intervention due to chronic pain as for knee and hip replacement is now put on hold indefinitely because access to surgical care has been limited. Although a moderate delay in surgical intervention may not produce a significant progression of OA within the knee, it could lead to muscle wasting due to immobility and exacerbate comorbidities, making rehabilitation more challenging. Importantly, it will have an impact on comorbidities driven by OA severity, notably decreased quality of life and depression. These patients with unremitting pain become increasingly susceptible to substance use disorders including opioids, alcohol, as well as prescription and illegal drugs. Appreciation of this downstream crisis created by delayed surgical correction requires aggressive consideration of nonsurgical, nonopiate supported interventions to reduce the morbidity associated with these delays brought upon by the currently restricted access to joint repair.

Epidemiology of Revision Total Hip Arthroplasty: An Indian Experience

BACKGROUND

With increasing numbers of primary total hip replacement (THR), there has been a substantial increase in revision total hip replacement (RTHR) surgeries. RTHR are complex joint reconstruction surgeries involving significant cost, expertise and infrastructure. With its significant socioeconomic impact, we need to keep a close watch on the epidemiological trends of these procedures.

METHODS

We prospectively studied the first-time RTHR performed at our institution for a 7-year period (2011-2017). We looked at patient demographics, the workload of RTHR and its etiology. We reviewed the microbiological profiles of septic revisions.

RESULTS

Of the 1244 THR procedures performed, 260 (21%) were first-time revisions. The predominant cause of revisions was a prosthetic infection (38%) followed by aseptic loosening (33%), instability (15%), peri-prosthetic fracture (11%) and implant breakage (3%). In the aseptic loosening group, 55% of cases had primary cemented implant, 44% had only stem loosening, 31% had cup loosening and 25% had both cup and stem loosening. In the early, midterm, and late-failure groups, prosthetic infection remained the main cause of failure. In 60% of the septic revisions, the offending organisms could not be identified and of those identified most (77%) were gram negative.

CONCLUSION

In our study, the RTHR burden was 21%, which is similar to historic revision data from the west (1998-2001) and twice as compared to recent trends from the west (9-11%). Unlike western data, which show aseptic loosening (30-60%) as the predominant cause of hip revisions, in our study infection was the number one cause (38%).

Loosening of total knee arthroplasty - always aseptic?

PURPOSE

When revision surgery is needed in total knee arthroplasty (TKA) the most frequent reasons are aseptic loosening (AL) and periprosthetic joint infection (PJI). However preoperative distinction between AL and PJI remains challenging. Aim of this study is to determine the incidence of PJI in patients with suspected AL after TKA and to evaluate a diagnostic algorithm for reliable differential diagnosis.

METHODS

In this study a total of 149 symptomatic patients with radiographic signs of prosthetic loosening and suspected AL were included. Preoperatively all patients underwent a standardized diagnostic algorithm. For each patient demographics, as well as the results of laboratory and microbiological testing were collected from the medical records.

RESULTS

Of the included patients 117 (78.5%) were diagnosed with AL and 32 (21.5%) with PJI. The latency period from primary arthroplasty to the presentation with symptomatic implant loosening was significantly shorter for PJI compared to AL (p < 0.05). The initial CRP values were significantly higher in patients with PJI compared to patients with AL (p < 0.05). Elevated count of white blood cells or percentage of neutrophils within the synovial fluid support the diagnosis of PJI. The sensitivity of synovial cell count (CC) count for PJI in patients with radiographic signs of loosening was 0.84 (CI 0.81-0.87) with a specificity of 0.96 (CI 0.92-0.98). The single best measure for the diagnosis of PJI was synovial fluid cultures with a specificity of 1, however this measure provides poor sensitivity.

CONCLUSION

Patients with radiographic signs of loosening in TKA need thorough diagnostics. Information about primary TKA, serological testing, and results of joint aspiration can rule out a PJI in most cases.