There are two techniques widely used to determine the rotational
alignment of the components in total knee arthroplasty (TKA); gap
balancing (GB) and measured resection (MR). Which technique is the
best remains controversial. We aimed to investigate this in a systematic
review and meta-analysis. In accordance with the methods of Cochrane, databases were searched
for all randomised controlled trials in the literature between January
1986 and June 2015 comparing radiographic and clinical outcomes
between the use of these two tecniques. Meta-analysis involved the
use of the Revman5.3 software provided by Cochrane collaboration.Aims
Materials and Methods
Worldwide rates of primary and revision total
knee arthroplasty (TKA) are rising due to increased longevity of
the population and the burden of osteoarthritis. Revision TKA is a technically demanding procedure generating
outcomes which are reported to be inferior to those of primary knee
arthroplasty, and with a higher risk of complication. Overall, the
rate of revision after primary arthroplasty is low, but the number
of patients currently living with a TKA suggests a large potential
revision healthcare burden. Many patients are now outliving their prosthesis, and consideration
must be given to how we are to provide the necessary capacity to
meet the rising demand for revision surgery and how to maximise
patient outcomes. The purpose of this review was to examine the epidemiology of,
and risk factors for, revision knee arthroplasty, and to discuss
factors that may enhance patient outcomes. Cite this article:
The purpose of this article was to review the current literature
pertaining to the use of mobile compression devices (MCDs) for venous
thromboembolism (VTE) following total joint arthroplasty (TJA),
and to discuss the results of data from our institution. Previous studies have illustrated higher rates of post-operative
wound complications, re-operation and re-admission with the use
of more aggressive anticoagulation regimens, such as warfarin and
factor Xa inhibitors. This highlights the importance of the safety,
as well as efficacy, of the chemoprophylactic regimen.Aims
Patients and Methods
The role of high tibial osteotomy (HTO) is being questioned by
the use of unicompartmental knee arthroplasty (UKA) in the treatment
of medial compartment femorotibial osteoarthritis. Our aim was to
compare the outcomes of revision HTO or UKA to a total knee arthroplasty
(TKA) using computer-assisted surgery in matched groups of patients. We conducted a retrospective study to compare the clinical and
radiological outcome of patients who underwent revision of a HTO
to a TKA (group 1) with those who underwent revision of a medial
UKA to a TKA (group 2). All revision procedures were performed using
computer-assisted surgery. We extracted these groups of patients
from our database. They were matched by age, gender, body mass index,
follow-up and pre-operative functional score. The outcomes included
the Knee Society Scores (KSS), radiological outcomes and the rate
of further revision.Aims
Patients and Methods
The patient with a painful arthritic knee awaiting
total knee arthroplasty (TKA) requires a multidisciplinary approach.
Optimal control of acute post-operative pain and the prevention
of chronic persistent pain remains a challenge. The aim of this
paper is to evaluate whether stratification of patients can help
identify those who are at particular risk for severe acute or chronic
pain. Intense acute post-operative pain, which is itself a risk factor
for chronic pain, is more common in younger, obese female patients
and those suffering from central pain sensitisation. Pre-operative
pain, in the knee or elsewhere in the body, predisposes to central
sensitisation. Pain due to osteoarthritis of the knee may also trigger
neuropathic pain and may be associated with chronic medication like
opioids, leading to a state of nociceptive sensitisation called
‘opioid-induced hyperalgesia’. Finally, genetic and personality
related risk factors may also put patients at a higher risk for
the development of chronic pain. Those identified as at risk for chronic pain would benefit from
specific peri-operative management including reduction in opioid
intake pre-operatively, the peri-operative use of antihyperalgesic
drugs such as ketamine and gabapentinoids, and a close post-operative
follow-up in a dedicated chronic pain clinic. Cite this article:
In the absence of patellar resurfacing, we have
previously shown that the use of electrocautery around the margin of
the patella improved the one-year clinical outcome of total knee
replacement (TKR). In this prospective randomised study we compared
the mean 3.7 year (1.1 to 4.2) clinical outcomes of 300 TKRs performed
with and without electrocautery of the patellar rim: this is an
update of a previous report. The overall prevalence of anterior knee
pain was 32% (95% confidence intervals [CI] 26 to 39), and 26% (95%
CI 18 to 35) in the intervention group compared with 38% (95% CI
29 to 48) in the control group (chi-squared test; p = 0.06). The
overall prevalence of anterior knee pain remained unchanged between
the one-year and 3.7 year follow-up (chi-squared test; p = 0.12). The
mean total Western Ontario McMasters Universities Osteoarthritis
Indices and the American Knee Society knee and function scores at
3.7 years’ follow-up were similar in the intervention and control
groups (repeated measures analysis of variance p = 0.43, p = 0.09
and p = 0.59, respectively). There were no complications. A total
of ten patients (intervention group three, control group seven)
required secondary patellar resurfacing after the first year. Our study suggests that the improved clinical outcome with electrocautery
denervation compared with no electrocautery is not maintained at
a mean of 3.7 years’ follow-up. Cite this article:
Fractures around total knee arthroplasties pose
a significant surgical challenge. Most can be managed with osteosynthesis
and salvage of the replacement. The techniques of fixation of these
fractures and revision surgery have evolved and so has the assessment
of outcome. This specialty update summarises the current evidence
for the classification, methods of fixation, revision surgery and
outcomes of the management of periprosthetic fractures associated
with total knee arthroplasty. Cite this article:
We present detailed information about early morbidity
after aseptic revision knee replacement from a nationwide study.
All aseptic revision knee replacements undertaken between 1st October
2009 and 30th September 2011 were analysed using the Danish National
Patient Registry with additional information from the Danish Knee
Arthroplasty Registry. The 1218 revisions involving 1165 patients
were subdivided into total revisions, large partial revisions, partial
revisions and revisions of unicondylar replacements (UKR revisions).
The mean age was 65.0 years (27 to 94) and the median length of
hospital stay was four days (interquartile range: 3 to 5), with
a 90 days re-admission rate of 9.9%,
re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges
of 51 to 55 years (p = 0.018), 76 to 80 years (p <
0.001) and ≥ 81
years (p <
0.001) were related to an increased risk of re-admission.
The age ranges of 76 to 80 years (p = 0.018) and the large partial
revision subgroup (p = 0.073) were related to an increased risk
of re-operation. The ages from 76 to 80 years (p <
0.001), age ≥ 81
years (p <
0.001) and surgical time >
120 min (p <
0.001)
were related to increased length of hospital stay, whereas the use
of a tourniquet (p = 0.008) and surgery in a low volume centre (p
= 0.013) were related to shorter length of stay. In conclusion, we found a similar incidence of early post-operative
morbidity after aseptic knee revisions as has been reported after
primary procedures. This suggests that a length of hospital stay ≤ four
days and discharge home at that time is safe following aseptic knee
revision surgery in Denmark. Cite this article:
This non-blinded randomised controlled trial compared the effect
of patient-controlled epidural analgesia (PCEA) A total of 242 patients were randomised; 20 were excluded due
to failure of spinal anaesthesia leaving 109 patients in the PCEA
group and 113 in the LIA group. Patients were reviewed at six weeks
and one year post-operatively.Aims
Patients and Methods
Fractures of the distal femur are an important cause of morbidity.
Their optimal management remains controversial. Contemporary implants
include angular-stable anatomical locking plates and locked intramedullary
nails (IMNs). We compared the long-term patient-reported functional
outcome of fixation of fractures of the distal femur using these
two methods of treatment. A total of 297 patients were retrospectively identified from
a State-wide trauma registry in Australia: 195 had been treated
with a locking plate and 102 with an IMN. Baseline characteristics
of the patients and their fractures were recorded. Health-related
quality-of-life, functional and radiographic outcomes were compared
using mixed effects regression models at six months and one year.Aims
Patients and Methods
This study investigated the influence of body mass index (BMI)
on the post-operative fall in the level of haemoglobin (Hb), length
of hospital stay (LOS), 30-day re-admission rate, functional outcome
and quality of life, two years after total knee arthroplasty (TKA). A total of 7733 patients who underwent unilateral primary TKA
between 2001 and 2010 were included. The mean age was 67 years (30
to 90). There were 1421 males and 6312 females. The patients were
categorised into three groups: BMI <
25.0 kg/m2 (normal);
BMI between 25.0 and 39.9 kg/m2 (obese); and BMI ≥ 40.0
kg/m2 (morbidly obese).Aims
Patients and Methods
The purpose of the present study was to examine the long-term
fixation of a cemented fixed-bearing polished titanium tibial baseplate
(Genesis ll). Patients enrolled in a previous two-year prospective trial (n
= 35) were recalled at ten years. Available patients (n = 15) underwent
radiostereometric analysis (RSA) imaging in a supine position using
a conventional RSA protocol. Migration of the tibial component in
all planes was compared between initial and ten-year follow-up.
Outcome scores including the Knee Society Score, Western Ontario
and McMaster Universities Arthritis Index, 12-item Short Form Health
Survey, Forgotten Joint Score, and University of California, Los
Angeles Activity Score were recorded.Aims
Patients and Methods
Obesity is a worldwide epidemic that has both
economic and health implications of enormous consequence. The obese
patients tend to have earlier symptoms related to osteoarthritis,
more peri-operative medical problems, higher rates of infection
and more technical difficulties intra-operatively following hip
and knee arthroplasty. Nevertheless, these patients have good long-term
clinical outcomes and implant survival rates and are often some of
the most satisfied patients after joint arthroplasty. Therefore,
obese patients should not be denied surgery based on their weight
alone. Cite this article:
Instability is a common indication for early
revision after both primary and revision total knee arthroplasty
(TKA), accounting for up to 20% in the literature. The number of
TKAs performed annually continues to climb exponentially, thus having
an effective algorithm for treatment is essential. This relies on
a thorough pre- and intra-operative assessment of the patient. The
underlying cause of the instability must be identified initially
and subsequently, the surgeon must be able to balance the flexion
and extension gaps and be comfortable using a variety of constrained
implants. This review describes the assessment of the unstable TKA, and
the authors’ preferred form of treatment for these difficult cases
where the source of instability is often multifactorial. Cite this article:
Instability in flexion after total knee replacement
(TKR) typically occurs as a result of mismatched flexion and extension
gaps. The goals of this study were to identify factors leading to
instability in flexion, the degree of correction, determined radiologically,
required at revision surgery, and the subsequent clinical outcomes.
Between 2000 and 2010, 60 TKRs in 60 patients underwent revision
for instability in flexion associated with well-fixed components.
There were 33 women (55%) and 27 men (45%); their mean age was 65
years (43 to 82). Radiological measurements and the Knee Society
score (KSS) were used to assess outcome after revision surgery.
The mean follow-up was 3.6 years (2 to 9.8). Decreased condylar
offset (p <
0.001), distalisation of the joint line (p <
0.001)
and increased posterior tibial slope (p <
0.001) contributed
to instability in flexion and required correction at revision to regain
stability. The combined mean correction of posterior condylar offset
and joint line resection was 9.5 mm, and a mean of 5° of posterior
tibial slope was removed. At the most recent follow-up, there was
a significant improvement in the mean KSS for the knee and function
(both p <
0.001), no patient reported instability and no patient
underwent further surgery for instability. The following step-wise approach is recommended: reduction of
tibial slope, correction of malalignment, and improvement of condylar
offset. Additional joint line elevation is needed if the above steps
do not equalise the flexion and extension gaps. Cite this article:
Total knee arthroplasty (TKA) is an established
and successful procedure. However, the design of prostheses continues
to be modified in an attempt to optimise the functional outcome
of the patient. The aim of this study was to determine if patient outcome after
TKA was influenced by the design of the prosthesis used. A total of 212 patients (mean age 69; 43 to 92; 131 female (62%),
81 male (32%)) were enrolled in a single centre double-blind trial
and randomised to receive either a Kinemax (group 1) or a Triathlon
(group 2) TKA. Patients were assessed pre-operatively, at six weeks, six months,
one year and three years after surgery. The outcome assessments
used were the Oxford Knee Score; range of movement; pain numerical
rating scales; lower limb power output; timed functional assessment
battery and a satisfaction survey. Data were assessed incorporating
change over all assessment time points, using repeated measures
analysis of variance longitudinal mixed models. Implant group 2
showed a significantly greater range of movement (p = 0.009), greater
lower limb power output (p = 0.026) and reduced report of ‘worst
daily pain’ (p = 0.003) over the three years of follow-up. Differences
in Oxford Knee Score (p = 0.09), report of ‘average daily pain’
(p = 0.57) and timed functional performance tasks (p = 0.23) did
not reach statistical significance. Satisfaction with outcome was
significantly better in group 2 (p = 0.001). These results suggest that patient outcome after TKA can be influenced
by the prosthesis used. Cite this article: