Patient Satisfaction After Total Knee Replacement: A Systematic Review

Predictors of chronic pain and level of physical function in total knee arthroplasty: a protocol for a systematic review and meta-analysis

INTRODUCTION

One in five patients undergoing total knee arthroplasty (TKA) experience unchanged or worse pain and physical function 1 year after surgery. Identifying risk factors for unfavourable outcomes is necessary to develop tailored interventions to minimise risk. There is a need to review more current literature with updated methodology that addresses the limitations of earlier systematic reviews and meta-analyses. We present a Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols compliant protocol for a systematic review and meta-analysis of predictors of chronic pain and impaired function after TKA.

METHODS AND ANALYSIS

This review will include prospective longitudinal observational studies, or randomised trials (including cluster and crossover designs) that report arm-wise predictors of chronic postsurgical pain or impaired physical function at 3 months, 6 months or 12 months. A comprehensive literature search of studies published between 2000 and 2019 will be performed in Medline, Embase, CINAHL, Cochrane Library and PEDro. Blinded assessment with consensus agreement will be applied for inclusion of studies, data extraction and assessment of bias risk (Quality in Prognosis Studies tool). The co-primary outcomes, pain and impaired function, at 12 months after TKA will be analysed separately. Estimates of association between each outcome and any preoperative or intraoperative factor that may predict chronic pain or impaired physical function will be extracted from the included studies, where possible. For randomised studies, results will only be extracted from TKA arms (or the first period of crossover trials). Estimates of association from the primary evidence will be synthesised narratively, and quantitatively using multivariate meta-analysis to provide 'pooled' estimates of association. Subgroup and sensitivity analyses will be performed. Certainty of evidence for each predictor will be derived from the Grading of Recommendations Assessment, Development and Evaluation framework.

ETHICS AND DISSEMINATION

No ethical issues are associated with this project. The results from this review will be published in peer-reviewed journals and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42018079069.

Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty?

BACKGROUND

Up to 15% of patients express dissatisfaction after total hip arthroplasty (THA). Preoperative patient-report outcome measures (PROMs) scores can potentially mitigate this by predicting postoperative satisfaction, identifying patients that will benefit most from surgery. The aim of this study was to (1) calculate the minimal clinically important difference (MCID) thresholds for Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) mental component summary (MCS) and physical component summary (PCS) scores and (2) identify the threshold values of these PROMs that could be used to predict patient satisfaction and expectation fulfilment.

METHODS

Prospectively collected registry data of 1334 primary THA patients who returned for 2-year follow-up from 1998 to 2016 were reviewed. All patients were assessed preoperatively and postoperatively at 2 years using the OHS, WOMAC, and SF-36 PCS/MCS scores. The MCID for each PROMs was calculated, and the proportion of patients that attained MCID was recorded. The relationship between satisfaction, expectation fulfilment, and MCID attainment was analyzed using Spearman rank correlation. Optimal threshold scores for each PROM that predicted MCID attainment and satisfaction/expectation fulfilment at 2 years were calculated using receiver operating curve analysis.

RESULTS

The calculated MCID for OHS, WOMAC, SF-36 PCS, and SF-36 MCS were 5.2, 10.8, 6.7, and 6.2, respectively. A threshold value of 24.5 for the preoperative OHS was predictive of achieving WOMAC MCID at 2 years after THA (area under the curve 0.80, P < .001). 93.1% of patients were satisfied, and 95.5% had expectations fulfilled at 2 years. None of the PROMs were able to predict satisfaction.

CONCLUSION

OHS and WOMAC scores can be used to determine clinical meaningful improvement but are limited in their ability to predict patient satisfaction after THA.

Posterior clearance increases the knee extension angle in cruciate retaining type total knee arthroplasty: Intraoperative evaluation using a navigation system

BACKGROUND

Posterior osteophyte of the femur can impinge on the tibia insert in total knee arthroplasty (TKA). Although osteophyte removal [posterior clearance (PC)] improves the flexion angle, its influence on the gaps and extension angle are unclear. This study investigated the effect of PC on the gaps and range of motion (ROM) using a navigation system, as well as PC's relationship with osteophyte size.

METHODS

Twenty-seven knees that underwent cruciate-retaining (CR)-type TKA were examined. Before and after PC, the ROM, hip-knee-ankle (HKA) angle, and flexion and extension gaps were recorded using a navigation system. Osteophyte size was measured in the lateral view in radiographs, and in the sagittal and axial planes of computed tomography (CT) images. The effects of PC on the gaps and ROM were analysed statistically.

RESULTS

PC caused the extension gap to increase by 0.7 ± 0.9 mm in the medial (p < 0.001), and 0.9 ± 1.5 mm in the lateral compartment (p = 0.006). The extension angle increased by 4.9 ± 1.6°, flexion angle increased by 6.5 ± 5.0°, and HKA decreased by 0.3°. The increase in extension angle by PC was significantly correlated with the preoperative HKA angle (r = 0.594) and with the osteophyte area in radiographs and CT (r = 0.626 to 0.681).

CONCLUSIONS

The extension and flexion gaps increased less than 1 mm in the medial and lateral compartments. PC achieving an additional 5° extension angle could promote full extension in severely deformed knees with a large posterior osteophyte. The extension angle increase by PC was correlated with the preoperative HKA angle and osteophyte size.

Analgesic efficacy of infiltration between the popliteal artery and capsule of the knee (iPACK) block added to local infiltration analgesia and continuous adductor canal block after total knee arthroplasty: a randomized clinical trial

Background

A combination of motor-sparing analgesia with local infiltration analgesia (LIA) and continuous adductor canal block (CACB) may improve postoperative pain and functional recovery for total knee arthroplasty (TKA). We hypothesized that the addition of a novel technique for posterior knee block, known as the infiltration between the popliteal artery and capsule of the knee (iPACK) block, to LIA with CACB would reduce opioid requirements.

Methods

In this double-blinded randomized controlled trial, 72 patients were assigned to receive either LIA with CACB (LIA+CACB group) or iPACK block with LIA and CACB (iPACK+LIA+CACB group). The primary outcome was cumulative postoperative intravenous morphine consumption within 24 hours. The secondary outcomes included numerical rating scale pain scores, incidence of posterior knee pain, performance test results, patient satisfaction, length of stay, and adverse events.

Results

Morphine consumption within 24 hours postoperatively showed no significant intergroup difference (LIA+CACB; 1.31±1.85 mg vs iPACK+LIA+CACB; 0.61±1.25 mg, p=0.08). There were no clinically significant differences in the overall pain scores between the groups. The lower Timed Up and Go test scores on postoperative days 1 and 2, along with a shorter duration of hospitalization, were found in the iPACK+LIA+CACB group (p<0.05).

Conclusion

The addition of an iPACK block to the LIA and CACB does not reduce the postoperative opioid consumption nor improve analgesia. However, it may improve immediate functional performance and reduce the length of hospitalization after TKA.

Trial registration number

TCTR20180702001.

What Influences Patient Satisfaction after TKA? A Qualitative Investigation

BACKGROUND

Patient satisfaction is a common measure of the success of an orthopaedic intervention. However, there is poor understanding of what satisfaction means to patients or what influences it.

QUESTIONS/PURPOSES

Using qualitative study methodology in patients undergoing TKA, we asked: (1) What does it mean to be satisfied after TKA? (2) What factors influence satisfaction levels after TKA?

METHODS

People in a hospital registry who had completed 12-month follow-up questionnaires and were not more than 18 months post-TKA at the time of sampling were eligible (n = 121). To recruit a sample that provided insight into a range of TKA experiences, we divided eligible candidates on the registry into quadrants based on their responder status and satisfaction level. A responder was an individual who experienced a clinically meaningful change in pain and/or function on the WOMAC according to the Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria. Individuals were considered satisfied unless they indicated somewhat dissatisfied or very dissatisfied for one or more of the four items on the Self-Administered Patient Satisfaction Scale. From the resulting quadrants: responder satisfied, nonresponder satisfied, nonresponder dissatisfied, responder dissatisfied, we identified men and women with a range of ages and invited them to participate (n = 85). The final sample (n = 40), consisted of 10 responder satisfied, nine nonresponder satisfied, eight nonresponder dissatisfied, and 13 responder dissatisfied; 71% were women, with a mean age of 71 ± 7 years and a mean time since TKA surgery of 17 ± 2 months (range 13 to 25 months). Interview transcripts were analyzed by looking for factors in the participants' narrative that appeared to underscore their level of satisfaction and attaching inductive (data-derived, rather than a priori derived) codes to relevant sections of text. Coded data from participants who reported high and low levels of satisfaction were compared/contrasted and emerging patterns were mapped into a conceptual model. Recruitment continued until no new information was uncovered in data analysis of subsequent interviews, signalling to the researchers that further interviews would not change the key themes identified and data collection could cease.

RESULTS

In those with high satisfaction levels, satisfaction was conceptualized as an improvement in pain and function. In those with low satisfaction levels, rather than an improvement, satisfaction was conceptualized as completely resolving all symptoms and functional limitations. In addition, we identified three pathways through which participants reached different levels of low and high satisfaction: (1) The full-glass pathway, characterized by no or minimal ongoing symptoms and functional deficits, which consistently led to high levels of satisfaction; (2) the glass-half-full pathway, characterized by ongoing symptoms and functional limitations, which led to high satisfaction; and (3) the glass-half-empty pathway, also characterized by ongoing symptoms and functional limitations, which led to low satisfaction levels. The latter two pathways were mediated by three core mechanisms (recalibration, reframing valued activities, and reconceptualization) influenced either positively or negatively by (1) a persons' thoughts and feelings such as optimism, self-efficacy, pain catastrophizing, external locus of control; and (2) social and contextual factors such as fulfilment of social roles, therapeutic alliance, lack of family/social support.

CONCLUSIONS

This qualitative study suggests that for preoperative patients in whom unrealistically high hopes for complete symptom resolution and restoration of functional capacity persists, it may be appropriate to direct them away from TKA due to the risk of low satisfaction. For postoperative patients troubled by ongoing symptoms or functional limitations, clinicians may improve levels of satisfaction by targeting the three core mechanisms (recalibration, reframing valued activities, and reconceptualization) through addressing modifiable negative thoughts and feelings in interventions such as psychology or psychotherapy; and negative social and contextual factors by promoting a strong therapeutic alliance and engagement in community activities. Given that these factors may be identifiable preoperatively, future research is needed to explore if and how addressing them preoperatively may improve satisfaction post-TKA.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

How to choose kinematic or mechanical alignment individually according to preoperative characteristics of patients?

Background

Making decisions in alignment techniques in total knee arthroplasty (TKA) remains controversial. This study aims to identify the potential patients who were suitable for the kinematic (KA) or mechanical alignment (MA).

Methods

We reviewed 296 consecutive patients (296 TKAs, including 114 KA-TKAs and 182 MA-TKAs) who underwent unilateral TKA using a computer-assisted navigation from 2016 to 2018 in our prospectively maintained database. The minimum followup was 1 year. Clinical outcomes including the range of motion (ROM) and knee society score (KSS) were compared between KA-TKAs and MA-TKAs. Multiple regression models were used to evaluate the relationship between alignment techniques and KSS at the 1-year followup. Interaction and stratified analyses were conducted according to gender, age, body mass index (BMI), preoperative hip-knee-ankle (HKA) angle, ROM and KSS.

Results

ROM and KSS at the 1-year followup didn’t differ between MA-TKAs and KA-TKAs (all p > 0.05). Alignment techniques did not associate with postoperative ROM (Adjusted β = 0.4, 95% confidence interval [CI]: − 0.3, 1.6; p = 0.752) or 1-year KSS (Adjusted β = 2.2, 95%CI: − 0.7, 5.6; p = 0.107). Patients with a BMI more than 30 kg/m^2 achieved better 1-year KSS when using MA than KA (p for interaction< 0.05). Additionally, patients with preoperative HKA angle more than 10 degrees varus benefited more from KA than MA (p for interaction< 0.05).

Conclusions

Patients with severe varus deformity may be suitable for the KA technique, whereas MA should be used in obese patients.

Preoperative pain catastrophisation may predict worse patient-reported outcomes after primary hip arthroplasty: A pilot study

AIM

to investigate the relationship between pain catastrophising and patient-reported clinical outcomes following primary total hip arthroplasty.

MATERIALS AND METHODS

prospective consecutive study of 103 patients who completed preoperative Pain Catastrophisation Score (PCS), preoperative and 12-month postoperative Oxford Hip Score (OHS). Correlation analysis was carried out between the improvement in OHS (mean difference between pre- and postoperative scores) and the mean preoperative PCS score using the Pearson's r rank test. Multiple linear regression was then performed using the postoperative OHS as the outcome variable against a number of predictor variables.

RESULTS

there were 37 males and 66 females with average age of 60.5 years (range 22-84). Mean preoperative PCS score was 16.3 (±13.6; range 0-49). Mean preoperative OHS was 16.5 (±3.5) which had improved at 12-months postoperatively to a mean 38.1 (±11.1). The difference was statistically significant (P < 0.0001). Preoperative PCS scores were correlated with the OHS improvement at 12-months which revealed a weak negative correlation Pearson's correlation coefficient r = - 0.248 (P = 0.0114). Preoperative PCS score, predictor variable, had statistically significant relationship with the postoperative OHS (P = 0.0207). The regression coefficient for the PCS was -0.25, therefore for each unit increase in the preoperative PCS score there was a 0.25 unit decrease in the postoperative OHS score.

CONCLUSION

pain catastrophising appear to predict poorer postoperative patient-reported outcome measures. Further research is needed to evaluate the value of early identification of high-risk patients and the role of preoperative involvement of pain specialists and its effects on postoperative outcomes.

Comparison of infection in cemented, cementless and hybrid primary total knee arthroplasty: a network meta-analysis and systematic review of randomized clinical trials

BACKGROUND

Prosthetic joint infection (PJI) is a serious complication of joint replacement surgeries. Surgeons often take extra measures to reduce the risk of PJI. Whilst many studies have compared between cemented, cementless and hybrid fixation (femoral cementless, tibial cemented), most focus on survivorship, clinical and function outcome scores as primary endpoints. This meta-analysis aims to study the association between fixation methods and risk of PJI in primary total knee arthroplasty (TKA).

METHODS

A systematic review and network meta-analysis of randomized controlled trials (RCT) were performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Data from studies assessing prevalence of PJI in each fixation type were extracted and analysed.

RESULTS

Twelve RCT comprising a total of 1573 knees were included. Six RCT compared between cemented (n = 486 knees) and cementless (n = 440 knees) fixation, while six RCT compared between hybrid (n = 324 knees) and cementless (n = 323 knees) fixation. Network meta-analysis did not reveal any fixation type that significantly increased the infection rate in TKA. Rate of all infection was lowest in cemented TKA as compared to cementless (odds ratio (OR) 0.90, 95% confidence interval (CI) 0.35-2.28) and hybrid (OR 0.63, 95%CI 0.13-2.99) TKA. Rate of PJI requiring revision surgery was lowest in cementless TKA as compared to cemented (OR 0.89, 95%CI 0.30-2.41) and hybrid (OR 0.57, 95%CI 0.09-2.71) TKA. Rate of PJI not requiring revision surgery was lowest in cemented TKA as compared to hybrid (OR 0.56, 95%CI 0.06-6.10) and cementless (OR 0.55, 95% 0.14-5.63).

CONCLUSION

Unlike total hip arthroplasties, fixation method is not a predisposing risk factor for infections in TKA. However, this meta-analysis may not have sufficient statistical power to show a significant difference between fixation types. It is recommended that prophylactic precautions against other known risk factors for infection should still be clinically practiced.

LEVEL OF EVIDENCE

Level I, meta-analysis of randomized controlled trials.

Development and Validation of the Hospital for Special Surgery Anterior Cruciate Ligament Postoperative Satisfaction Survey

PURPOSE

To develop and validate a standardized patient satisfaction measurement tool for adult patients undergoing primary anterior cruciate ligament reconstruction (ACLR).

METHODS

A 4-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation was used. To develop and validate the Hospital for Special Surgery ACL Satisfaction Survey (HSS ACL-SS), 70 patients were included in the survey development phase and 77 patients were included in the validation phase. The HSS ACL-SS was compared with other currently used ACLR outcome measures including the International Knee Documentation Committee score, Tegner-Lysholm score, Short Form 12 (SF-12) Mental Component Score, and SF-12 Physical Component Score. Test-retest reliability, internal consistency, convergent and discriminant validity, and floor and ceiling effects were assessed.

RESULTS

The HSS ACL-SS consists of 10 items identified by patients as being important for satisfaction after ACLR. In the validation phase, the mean score on the HSS ACL-SS (of 50) among all patients was 37.9 ± 9.9 (range, 10-50). Statistically significant positive correlations were seen between the HSS ACL-SS score and the International Knee Documentation Committee score (r = 0.351, P = .002) and Tegner-Lysholm score (r = 0.333, P = .003). No statistically significant correlation was found between the satisfaction score and the SF-12 Mental or Physical Component Score. The lowest possible score (10 of 50 points) was achieved in 1 patient (1.3%) and the highest possible score (50 of 50 points) was achieved in 7 patients (9.1%), indicating no significant floor or ceiling effects of the instrument. Internal consistency for all 10 items was strong (Cronbach α, 0.995). The mean intraclass correlation coefficient between test and retest responses was 0.701, indicating moderate agreement.

CONCLUSIONS

The HSS ACL-SS is a validated and reliable patient-derived satisfaction measure with excellent psychometric properties for active adults undergoing ACLR. The results of this study show that the HSS ACL-SS may be a useful tool to measure postoperative patient satisfaction.

LEVEL OF EVIDENCE

Level II, development of diagnostic or monitoring criteria in consecutive patients.

Assessment of a Satisfaction Measure for Use After Primary Total Joint Arthroplasty

BACKGROUND

Patient satisfaction after total hip (THA) and total knee arthroplasty (TKA) is a core outcome selected by the Outcomes Measurement in Rheumatology. Up to 20% of THA/TKA patients are dissatisfied. Improving patient satisfaction is hindered by the lack of a validated measurement tool that can accurately measure change.

METHODS

The psychometric properties of a proposed satisfaction instrument, consisting of 4 questions rated on a Likert scale, scored 1-100, were tested for validity, reliability, and sensitivity to change using data collected between 2007 and 2011 in an arthroplasty registry.

RESULTS

We demonstrated construct validity by confirming our hypothesis; satisfaction correlated with similar constructs. Satisfaction correlated moderately with pain relief (TKA ρ = 0.61, THA ρ = 0.47) and function (TKA ρ = 0.65, THA ρ = 0.51) at 2 years; there was no correlation with baseline/preoperative pain/function values, as expected. Overall Cronbach's alpha >0.88 confirmed internal consistency. Test-retest reliability with weighted kappa ranged 0.60-0.75 for TKA and 0.36-0.56 for THA. Hip disability and Osteoarthritis Outcome Score/Knee injury and Osteoarthritis Outcome Scores quality of life improvement (>30 points) corresponds to a mean satisfaction score of 93.2 (standard deviation, 11.5) after THA and 90.4 (standard deviation, 13.8) after TKA, and increasing relief of pain and functional improvement increased the strength of their association with satisfaction. The satisfaction measure has no copyright and is available free of cost and represents minimal responder burden.

CONCLUSION

Patient satisfaction with THA/TKA can be measured with a validated 4-item questionnaire. This satisfaction measure can be included in a total joint arthroplasty core measurement set for total joint arthroplasty trials.

Efficacy and Safety of Lower Limb Progressive Resistance Exercise for Patients With Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the efficacy and safety of progressive resistance exercise (PRE) for patients with total knee arthroplasty (TKA) in a meta-analysis.

DATA SOURCES

PubMed, MEDLINE, Cochrane's Library, and EMBASE databases.

STUDY SELECTION

Randomized controlled trials evaluating the effect of PRE on mobility and function in patients with TKA.

DATA EXTRACTION

A random-effects model was applied if significant heterogeneity was detected; otherwise, a fixed-effects model was applied.

DATA SYNTHESIS

Seven randomized controlled trials. Compared with a rehabilitation program without PRE, physiotherapy including PRE was associated with improvements in the 6-minute walking test (weighed mean difference [WMD], 19.22m; P=.04) with a wide confidence interval (CI, 0.48∼37.95). However, sensitivity analysis by omitting 1 study with preoperative rehabilitation revealed nonsignificant results (WMD, 15.15m; P=.16). Moreover, PRE did not significantly improve the maximal walking speed (WMD, 0.05m/s, 95% CI, 0.00∼0.11; P=.05). However, PRE was associated with improved knee strength of extension (standardized mean difference [SMD], 0.72; 95% CI, 0.47∼0.96; P<.001) and flexion (SMD, 0.47; 95% CI, 0.19∼0.74; P<.001) but not self-reported physical function (SMD, -0.17; 95% CI, -0.37∼0.03; P=.10) or changes in pain score (SMD, 0.11; 95% CI, -0.15∼0.37; P=.40). PRE did not increase the risk of adverse events (risk ratio, 1.19; 95% CI, 0.52∼2.71; P=.68).

CONCLUSIONS

PRE may lead to improvements in physical function among patients receiving a TKA. PRE leads to higher ultimate strength in the surgical knee and is safe to perform.

In vivo kinematics of deep lunges and sit-to-stand activities in patients with bicruciate-retaining total knee arthroplasty

AIMS

The removal of the cruciate ligaments in total knee arthroplasty (TKA) has been suggested as a potential contributing factor to patient dissatisfaction, due to alteration of the in vivo biomechanics of the knee. Bicruciate retaining (BCR) TKA allows the preservation of the cruciate ligaments, thus offering the potential to reproduce healthy kinematics. The aim of this study was to compare in vivo kinematics between the operated and contralateral knee in patients who have undergone TKA with a contemporary BCR design.

METHODS

A total of 29 patients who underwent unilateral BCR TKA were evaluated during single-leg deep lunges and sit-to-stand tests using a validated computer tomography and fluoroscopic imaging system. In vivo six-degrees of freedom (6DOF) kinematics were compared between the BCR TKA and the contralateral knee.

RESULTS

During single-leg deep lunge, BCR TKAs showed significantly less mean posterior femoral translation (13 mm; standard deviation (SD) 4) during terminal flexion, compared with the contralateral knee (16.6 mm, SD 3.7; p = 0.001). Similarly, BCR TKAs showed significantly less mean femoral rollback (11.6 mm (SD 4.5) vs 14.4 mm (SD 4.6); p < 0.043) during sit-to-stand. BCR TKAs showed significantly reduced internal rotation during many parts of the strenuous flexion activities particularly during high-flexion lunge (4° (SD 5.6°) vs 6.5° (SD 6.1°); p = 0.051) and during sit-to-stand (4.5° (SD 6°) vs 6.9° (SD 6.3°); p = 0.048).

CONCLUSION

The contemporary design of BCR TKA showed asymmetrical flexion-extension and internal-external rotation, suggesting that the kinematics are not entirely reproduced during strenuous activities. Future studies are required to establish the importance of patient factors, component orientation and design, in optimizing kinematics in patients who undergo BCR TKA. Cite this article: Bone Joint J 2020;102-B(6 Supple A):59-65.

Definitions of poor outcome after total knee arthroplasty: an inventory review

Background

A significant proportion of patients experiences poor response (i.e. no or little improvement) after total knee arthroplasty (TKA) because of osteoarthritis. It is difficult to quantify the proportion of patients who experiences poor response to TKA, as different definitions of, and perspectives (clinician’s and patient’s) on poor response are being used. The aim of this study was therefore to review the literature and summarize definitions of poor response to TKA.

Methods

A systematic search was performed to identify and review studies that included dichotomous definitions of poor outcome after primary TKA. The type, amount and combination of domains (e.g. functioning), outcome measures, type of thresholds (absolute/relative, change/cut-off), values and moments of follow-up used in definitions were summarized.

Results

A total of 47 different dichotomous definitions of poor response to TKA were extracted from 2163 initially identified studies. Thirty-six definitions incorporated one domain, seven definitions comprised two domains and four definitions comprised three domains. Eight different domains were used in identified definitions: pain, function, physical functioning, quality of life (QoL), patient satisfaction, anxiety, depression and patient global assessment. The absolute cut-off value was the most common type of threshold, with large variety in value and timing of follow-up.

Conclusions

Our inventory review shows that definitions of poor response to TKA are heterogeneous. Our findings stresses the need for an unambiguous definition of poor response to draw conclusions about the prevalence of poor-responders to TKA across hospitals and countries, and to identify patients at risk.

Two-dimensional/three-dimensional EOS™ imaging is reliable and comparable to traditional X-ray imaging assessment of knee osteoarthritis aiding surgical management

BACKGROUND

X-ray imaging is the gold standard for assessing lower limb conditions and preoperative planning. A novel low-radiation-dose EOS™ imaging system enables full-length weight-bearing imaging in one session and three-dimensional (3D) reconstruction. Thus, it can improve assessment of limb deformities, preoperative planning and follow-up with lower radiation exposure. The objective of this study was to measure lower limbs from EOS™ images to determine its accuracy and reproducibility in comparison with long-leg X-ray images.

METHODS

Over a one-year period, twenty patients (forty lower limbs) with knee osteoarthritis were recruited from clinic. Thirty-five (five excluded due to knee prosthesis) two-dimensional- (2D) EOS™, 3D EOS™ and X-ray images were measured independently by four observers, measuring lower limb angles and lengths. On average, twelve weeks later, observers repeated measurements on 2D EOS™ and X-ray images.

RESULTS

A t-test comparing 2D EOS™ with X-ray images showed no significant difference in all angle and length measurements (P > 0.05). When analysing observers separately, all measurements showed no significant difference, apart from the femoral anatomic-mechanical angle (fAMA) from observer 2 (2D EOS™ fAMA 6.21° vs. X-ray fAMA 7.10°, P = 0.02). Intra-observer intraclass correlation coefficient (ICC) for 2D EOS™ and X-ray was 1.00 and 1.00, respectively, and inter-observer ICC was 1.00 and 0.99, respectively. A t-test comparing 2D- with 3D EOS™ images showed no significant difference in all measurements. A t-test comparing 3D EOS™ with X-ray images showed no significant difference in all measurements.

CONCLUSION

This study showed the EOS™ imaging system to be a valid alternative method of imaging lower limbs for alignment, measurements and preoperative arthroplasty planning.

Role of Gender and Race in Patient-Reported Outcomes and Satisfaction

The role of gender, race, and socioeconomic status in outcomes and satisfaction are reflected in patient-reported outcomes using measurement tools representing outcome domains. These domains include pain relief, physical and emotional functioning, adverse events, participant disposition, and patient satisfaction. Measurement tools exist for each of the outcomes in both acute and chronic pain. Patients with lower economic status have greater difficulty accessing care, are involved less in shared decision-making process, and are less satisfied with their care. Blacks, Hispanics, and Asians also have increased difficulty in accessing good quality care. Women have inferior outcomes after medical and surgical interventions.

The Psychology of Total Joint Arthroplasty

Patient dissatisfaction after total joint arthroplasty can be as high as 20%. There are many factors that lead to dissatisfaction including unmet expectations, persistent pain, and technical errors. There is increasing evidence that psychological factors play a role in a patient's ability to manage with the surgical stress of total joint arthroplasty. These factors play an important role in dissatisfaction after surgery. In addition, there are several studies that demonstrate certain psychological factors such as resiliency can affect patient outcomes. This symposium explores the impact of these psychological factors on total joint arthroplasty with a specific focus on identification and modification of these factors.

Cementless Oxford Medial Unicompartmental Knee Replacement-Clinical and Radiological Results of 228 Knees with a Minimum 2-Year Follow-Up

(1) Background: Studies show several advantages of unicompartmental knee replacement (UKR) over total knee replacements (TKR), whereas registry based revision rates of UKR are significantly higher than for TKA. Registry data report lower revision rates for cementless UKR compared to cemented UKR. The aim of this study was to assess clinical and radiological results of cementless Oxford UKR (OUKR) in an independent cohort. (2) Methods: This retrospective cohort study examines a consecutive series of 228 cementless OUKR. Clinical outcome was measured using functional scores (Oxford Knee Score (OKS), American Knee Society Score (AKSS), Hannover Functional Ability Questionnaire for Osteoarthritis (FFbH-OA), range of motion (ROM)), pain and satisfaction. Radiographs were analyzed regarding the incidence of radiolucent lines (RL), implant positioning, and their possible impact on clinical outcome. (3) Results: At a mean follow-up of 37.1 months, the two and three year revision free survival-rates were 97.5% and 96.9%. Reasons for revision surgery were progression of osteoarthritis, inlay dislocation and pain. All clinical outcome scores showed a significant improvement from pre- to postoperative. The incidence of RL around the implant was highest within the first year postoperatively (36%), and decreased (5%) within the second year. Their presence was not correlated with inferior clinical outcome. Implant positioning showed no influence on clinical outcome. (4) Conclusion: Cementless OUKR showed excellent clinical outcome and survival rates, with reliable osteointegration. Neither the incidence of radiolucent lines nor implant positioning were associated with inferior clinical outcome.

Risk of Periprosthetic Infection Following Intra-Articular Corticosteroid Injections After Total Knee Arthroplasty

BACKGROUND

Recent literature has advocated for the effectiveness of postoperative steroid injections following total knee arthroplasty (TKA) for improving pain and range of motion when other correctible causes of these symptoms have been eliminated. The safety of such injections has not been thoroughly evaluated. The aim of this study was to determine the risk of acute infection following intra-articular corticosteroid injection into a preexisting TKA.

METHODS

The Humana dataset was used to identify patients who underwent TKA from 2007 to 2017. Patients with ipsilateral knee corticosteroid injections in the postoperative period were then identified and compared to a 2:1 matched control cohort. A diagnosis of infection within 6 months and 1 year following the injection and an ipsilateral procedure for infection at any time postoperatively were then assessed and compared to controls using a multivariate binomial logistic regression analysis.

RESULTS

Of the 166,946 TKA performed during the study period, 5628 patients had a postoperative corticosteroid injection (3.4%). Patients with injections had a significantly higher rate of periprosthetic infection compared to noninjection matched controls at all studied time points.

CONCLUSION

In a large national database, about 3% of patients who undergo TKA have a postoperative steroid injection into their postoperative knee. While there is some existing literature demonstrating improvement in pain and stiffness symptoms after TKA with postoperative injections, the present study demonstrates a significant correlation between postoperative intra-articular corticosteroid injections in patients with preexisting TKA and periprosthetic joint infection compared to matched controls who did not receive an injection.

How should we evaluate robotics in the operating theatre?

The application of robotics in the operating theatre for knee arthroplasty remains controversial. As with all new technology, the introduction of new systems might be associated with a learning curve. However, guidelines on how to assess the introduction of robotics in the operating theatre are lacking. This systematic review aims to evaluate the current evidence on the learning curve of robot-assisted knee arthroplasty. An extensive literature search of PubMed, Medline, Embase, Web of Science, and Cochrane Library was conducted. Randomized controlled trials, comparative studies, and cohort studies were included. Outcomes assessed included: time required for surgery, stress levels of the surgical team, complications in regard to surgical experience level or time needed for surgery, size prediction of preoperative templating, and alignment according to the number of knee arthroplasties performed. A total of 11 studies met the inclusion criteria. Most were of medium to low quality. The operating time of robot-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is associated with a learning curve of between six to 20 cases and six to 36 cases respectively. Surgical team stress levels show a learning curve of seven cases in TKA and six cases for UKA. Experience with the robotic systems did not influence implant positioning, preoperative planning, and postoperative complications. Robot-assisted TKA and UKA is associated with a learning curve regarding operating time and surgical team stress levels. Future evaluation of robotics in the operating theatre should include detailed measurement of the various aspects of the total operating time, including total robotic time and time needed for preoperative planning. The prior experience of the surgical team should also be evaluated and reported.

Cite this article: Bone Joint J 2020;102-B(4):407–413.

Comparable outcomes in mini-midvastus versus mini-medial parapatellar approach in total knee arthroplasty: a meta-analysis and systematic review

BACKGROUND

Minimally invasive surgery (MIS) techniques in total knee arthroplasties (TKA) have gained popularity over conventional techniques due to benefits of hastened recovery and reduced complications. There are a variety of MIS techniques available and two most common techniques currently employed are the mini-midvastus (mMV) and mini-medial parapatellar (mMPP) approaches. This meta-analysis aims to compare the clinical outcomes and peri-operative parameters between mMV and mMPP in TKA in order to determine the presence of a superior technique.

METHODS

A multi-database search was performed according to PRISMA guidelines. Data from studies comparing clinical outcomes and peri-operative parameters between mMV and mMPP approaches in TKA were extracted and analysed.

RESULTS

A total of five randomized controlled trials were included for analysis, consisting of 190 mMV and 189 mMPP knees. Clinically unimportant differences were noted in blood loss and surgical time between the groups (5 mL less blood loss and 7 min less surgical time in mMV, P < 0.001). There was no statistically significant difference between both groups for Knee Society Score at 1 and 2 years, range of motion at 1 and 2 years, incision length or incidence of lateral retinacular release (all non-significant, P > 0.05).

CONCLUSION

The mMV and mMPP MIS TKA approaches have equivalent clinical outcomes. Despite a statistically significant longer operative time and higher mean blood loss in mMV than mMPP approach, clinically significant difference was not demonstrated. Both mMV and mMPP MIS techniques are reliable and safe to perform in TKA.

Preoperative Expectations Associated With Postoperative Dissatisfaction After Total Knee Arthroplasty: A Cohort Study

INTRODUCTION

Unfulfilled expectations, assessed postoperatively, have been consistently associated with dissatisfaction after total knee arthroplasty (TKA). However, identifying these expectations preoperatively has been a challenge. We aimed at identifying specific expectations that are most likely to affect postoperative dissatisfaction.

METHODS

We included all patients in our institutional registry with a body mass index of <40 kg/m who underwent primary unilateral TKA and had a minimum 2-year follow-up. Preoperatively, patients completed the 19-item Hospital for Special Surgery Expectations Survey, Short Form-12, Knee Injury and Osteoarthritis Outcomes Score and EuroQol 5-D. Two years postoperatively, patients reported their dissatisfaction on five domains. We estimated logistic regression models to identify the expectation items associated with each domain.

RESULTS

A total of 2,279 TKA patients (mean age: 65.3 ± 9.2 years; mean body mass index: 30.2 ± 5.9 kg/m) met our inclusion/exclusion criteria. The association between expectations and dissatisfaction was domain specific, that is, subsets of 4 to 5 items were markedly associated with each dissatisfaction domain, and these expectations differed depending on the dissatisfaction domain examined. Of those, expectations predicting dissatisfaction on multiple domains included kneeling ability and leg straightening and participation in recreation and sports.

DISCUSSION

We identified a subset of expectations most likely to affect dissatisfaction after TKA. Our findings should inform preoperative patient education approaches on those expectations to realistically orient patient expectations and increase satisfaction.

LEVEL OF EVIDENCE

Level II.

Effect of Medial Osteophyte Removal on Correction of Varus Deformity in Total Knee Arthroplasty

BACKGROUND

To restore neutral limb alignment in total knee arthroplasty (TKA), the procedure usually starts with removing osteophytes in varus osteoarthritic knees. However, the exact effect on alignment correction is unknown. The purpose of this study was to determine the effect of osteophyte removal alone during TKA for varus knees on correction of limb alignment on the coronal plane.

METHODS

Fifteen knees with medial osteoarthritis and varus malalignment scheduled for TKA were studied. After registration in a navigation system, each knee was tested at maximum extension, and at 30, 40, and 60 degrees of flexion, before and after osteophyte removal. External loads of 10 N·m valgus torque at each angle and in both states were applied. Later, the widths of the resected osteophytes were measured.

RESULTS

The average preoperative hip-knee-ankle angle was -14.2 degrees. The average width of osteophytes was 7.6 mm in the femur and 5.3 mm in the tibia. Angle corrections after osteophyte removal were 3.4 degrees at maximum extension, 3.4 degrees at 30 degrees flexion, and 3.6 degrees at 60 degrees flexion; the difference was significant for all angles. There was a positive correlation between osteophyte width and the degree of angle correction at 30 degrees.

CONCLUSION

At 30 degrees of knee flexion, osteophyte width was correlated with the degree of angle correction on the coronal plane in TKA. The degree of angle correction per 1 mm of width of removed osteophytes was 0.4 degrees.

Does the medial pivot knee improve the clinical and radiographic outcome of total knee arthroplasty? A single centre study on two hundred and ninety seven patients

PURPOSE

Total knee arthroplasty (TKA) is a cost-effective surgery with a survival rate higher than 90% after 15 years. Nevertheless, patients are unsatisfied in more than 15% of cases. Medial pivot (MP) prosthetic designs were introduced in late 90's with the aim to reproduce natural knee kinematics. The purpose of this study is to evaluate the survivorship and clinical outcomes of a novel design of MP knee with a minimum follow-up of five years.

METHODS

This is a retrospective review of all patients who underwent primary TKA using the K-Mod dynamic congruence implant (Gruppo Bioimpianti, Peschiera Borromeo, Milan, Italy) between 2012 and 2013 at a single institution. A total of 339 patients (351 knees) were included with a mean age of 74 years (range 41-89). The Knee Society score, the global range of movement, the Western Ontario and McMaster Universities Osteoarthritis score, Forgotten Joint score, and the short-term form 12 health survey were collected. FJS and SF-12 were collected only post-operatively. Radiographic outcomes were evaluated according to the Knee Society's roentgenographic evaluation system. Kaplan-Meyer (KM) curves were performed to evaluate implant survivorship. A two-tailed paired t test was performed to evaluate the differences between pre-operative and post-operative score.

RESULTS

A total 297 patients (315 knees) were available for clinical and radiographic analysis, and the mean follow-up was 66.4 months. A total of 17 patients (17 knees 5.4%) experienced a post-operative complication, and a reoperation was performed in five patients (5 knees 1.6%). Four patients had a periprosthetic joint infection, and two patients had a post-traumatic periprosthetic femoral fracture. The KM survivorship at five years was 98.2% (95% CI 0.96 to 0.99) for revision for any reason. There was a statistically significant improvement (p < 0.05) in all the objective and subjective outcomes measured.

CONCLUSION

The K-Mod dynamic congruence design has shown an excellent clinical, radiographic, and patient-reported outcome in primary TKAs.

When Has a Knee or Hip Replacement Failed? A Patient Perspective

OBJECTIVE

To define the patient perspective of what constitutes a failure of total joint replacement (TJR) in a qualitative study.

METHODS

We used the nominal group technique (NGT) with participants who had undergone elective total hip replacements (THR) and/or total knee replacements (TKR) to answer the question, "When would you consider a knee or hip replacement to be a failure?"

RESULTS

We performed 8 nominal groups with 42 participants, all of whom had undergone THR and/or TKR between 2016 and 2018. Of these, 48% were male, 17% were Black, 79% had college education or above, and 76% had had osteoarthritis as the underlying diagnosis. The nominated responses/themes that were ranked the highest by the participants were as follows: (1) refractory index joint pain (80 votes); (2) occurrence of postoperative adverse events (54 votes); (3) unable to resume normal activities or go back to work (38 votes); (4) little or no improvement in quality of life (35 votes); (5) early revision surgery (35 votes); (6) death (7 votes); and (7) other, including nurse or physician negligence (2 votes) and expectation-outcome mismatch (1 vote).

CONCLUSION

Lack of relief of pain or restoration of function or quality of life, or the occurrence of surgical complications after TJR were defined as TJR failure by participants. Functional TJR failure seems as important or more important than surgical failure. This patient perspective emphasizing pain, function, satisfaction, adverse events, and revision as critical domain components of TJR failure independently validated their inclusion in the TJR core domain set for clinical trials in people undergoing knee or hip TJR.

Dual-pivot bearings improve ambulation and promote increased activity levels in Total knee arthroplasty: A match-controlled retrospective study

BACKGROUND

Modern understanding of native knee kinematics reveals more complex pattern of lateral-pivot in early flexion activities, and medial-pivot in deeper flexion (i.e. dual-pivot). The purpose of this study was to compare patient outcomes with a contemporary dual-pivot TKA, designed to replicate anterior-cruciate substitution and stability, with a traditional TKA.

METHODS

One hundred and eighty-three dual-pivot TKAs were matched with 183 traditional non-conforming TKAs. All TKAs were cemented and performed with identical perioperative protocols. Patients were matched on age, sex, BMI, and ASA score. Patient-reported outcome measures were prospectively obtained and compared at minimum one-year follow-up.

RESULTS

Study cohorts were identical with 72% female, average age of 68 years, and BMI of 33 kg/m². There were no differences in prevalence of fibromyalgia, depression, preoperative narcotic use, or femoral component alignment (p ≥ 0.105). Dual-pivot TKA patients had a greater prevalence of lumbar spine disease (p = 0.012) and more reported their knee never feels normal preoperatively (p = 0.012). Dual-pivot TKA patients reported less walking pain at latest follow-up (p = 0.022). Trends for greater level of participation in very active activities or impact sports (p = 0.067) and more reporting their knee feels normal (p = 0.091) were observed in dual-pivot TKAs.

CONCLUSION

Patients with dual-pivot knees reported less walking pain despite greater lumbar spine disease, supporting the potential benefit of lateral-pivot motion in early flexion activities. However, the groups were similar in overall satisfaction suggesting the nuances and potential ceiling-effect of patient satisfaction warrants further study.

Prospective, observational study to evaluate the relation between patient-reported outcomes and component rotation in total knee replacement: protocol for the CRACK study

INTRODUCTION

Total knee replacement (TKR) for osteoarthritis results in a satisfactory outcome in the majority of patients, although up to one in five patients may be dissatisfied with the outcome. Persistent pain is a main contributor to patient dissatisfaction, and femoral and tibial component malrotation have been identified as a potential cause for both persistent pain and patellofemoral problems. Based on the assumption that component malrotation is the causative factor for persistent pain, early revision for patients with symptomatic malrotated components has been advocated in the literature. However, convincing evidence that component malrotation indeed results in less than optimal outcomes is lacking. This study aims to assess the relation between knee prosthesis component rotation and patient-reported outcomes in a large group of patients and to determine the range of femoral, tibial and combined rotation that results in the best clinical outcomes.

METHODS AND ANALYSIS

In this single-centre, prospective observational cohort study, a total of 500 patients will undergo TKR. All patients will have a 3D-CT assessment of femoral and tibial component rotation within 8 weeks after surgery. Outcome measures will include the Oxford Knee Score, the Knee Injury and Osteoarthritis Outcome Score, EQ-5D, visual analogue scale for pain, the American Knee Society Score and the knee joint range of motion. We will assess the relation between femoral, tibial and combined component rotation and patient-reported outcome measures at 8 weeks and 1 year of follow-up, and we will determine the range of femoral, tibial and combined rotation that results in the best clinical outcomes.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the Isala Hospital ethics committee. The results will be published in a peer-reviewed journal and presented at relevant meetings.

TRIAL REGISTRATION NUMBER

NL7635.

The Effect of an App for Day-to-Day Postoperative Care Education on Patients With Total Knee Replacement: Randomized Controlled Trial

Background

Patients who undergo primary Total Knee Replacement surgery (TKR) are often discharged within 1-3 days after surgery. With this relatively short length of hospital stay, a patient’s self-management is a crucial factor in optimizing the outcome of their treatment. In the case of TKR, self-management primarily involves adequate pain management, followed by physiotherapy exercises and daily self-care activities. Patients are educated on all these topics by hospital staff upon discharge from the hospital but often struggle to comprehend this information due to its quantity, complexity, and the passive mode of communication used to convey it.

Objective

This study primarily aims to determine whether actively educating TKR patients with timely, day-to-day postoperative care information through an app could lead to a decrease in their level of pain compared to those who only receive standard information about their recovery through the app. In addition, physical functioning, quality of life, ability to perform physiotherapy exercises and daily self-care activities, satisfaction with information, perceived involvement by the hospital, and health care consumption were also assessed.

Methods

A multicenter randomized controlled trial was performed in five Dutch hospitals. In total, 213 patients who had undergone elective, primary, unilateral TKR participated. All patients had access to an app for their smartphone and tablet to guide them after discharge. The intervention group could unlock day-to-day information by entering a personal code. The control group only received weekly, basic information. Primary (level of pain) and secondary outcomes (physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption) were measured using self-reported online questionnaires. All outcomes were measured weekly in the four weeks after discharge, except for physical functioning and quality of life, which were measured at baseline and at four weeks after discharge. Data was analyzed using Student t tests, chi-square tests, and linear mixed models for repeated measures.

Results

In total, 114 patients were enrolled in the intervention group (IG) and 99 in the control group (CG). Four weeks after discharge, patients in the IG performed significantly better than patients in the CG on all dimensions of pain: pain at rest (mean 3.45 vs mean 4.59; P=.001), pain during activity (mean 3.99 vs mean 5.08; P&lt;.001) and pain at night (mean 4.18 vs mean 5.21; P=.003). Additionally, significant differences were demonstrated in favor of the intervention group for all secondary outcomes.

Conclusions

In the four weeks following TKR, the active and day-to-day education of patients via the app significantly decreased their level of pain and improved their physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption compared to standard patient education. Given the rising number of TKR patients and the increased emphasis on self-management, we suggest using an app with timely postoperative care education as a standard part of care.

Trial Registration

Netherlands Trial Register NTR7182; https://www.trialregister.nl/trial/6992

The effects of preoperative balance training on balance and functional outcome after total knee replacement: a randomized controlled trial

Objective:

To assess the effects of preoperative balance training on the early postoperative balance and functional outcomes after total knee replacement surgery and to test whether an outpatient intervention may be as effective as a domiciliary intervention.

Design:

This is a three-arm randomized controlled trial.

Setting:

University hospital.

Subjects:

Eighty-six individuals were recruited. Seventy-seven were analysed, aged 72.1 (SD 7.6) years, of which 68% were women.

Outcome measures:

Overall state of balance, as measured with the Berg Balance Scale, and patient-perceived functionality, as measured with the Knee Injury and Osteoarthritis Outcome Score Function in Activities in Daily Living (KOOS-ADL) questionnaire, were the primary outcomes. Secondary assessments targeted knee function, balance and mobility, quality of life, and self-reported outcomes. The primary end-point was six weeks after surgery.

Intervention:

The hospital group implemented a four-week preoperative outpatient balance-oriented intervention. The home group implemented similar training, but this was domiciliary. The control group was instructed to keep performing their normal activities.

Results:

Home and hospital groups presented a moderate effect against the control group ( dhospital-control = 0.54; dhome-control = 0.63), both being similarly effective in improving the overall state of balance at six weeks after surgery ( P = 0.013). KOOS-ADL scores showed no between-group differences and a small effect size ( d < 0.5; P = 0.937). Secondary assessments suggested non-significant between-group differences.

Conclusion:

Preoperative balance training, conducted either as domiciliary or as an outpatient, is an effective approach to enhance early postoperative balance outcome but not the perceived functionality of individuals undergoing total knee replacement.

The Usability and Feasibility of Conjoint Analysis to Elicit Preferences for Distal Radius Fractures in Patients 55 Years and Older

PURPOSE

Eliciting patient preferences is one part of the shared decision-making process-a process of decision making focused on the values and preferences of the patient. We evaluated the usability and feasibility of a point-of-care conjoint analysis tool for preference elicitation for shared decision making in the treatment of distal radius fractures in patients over the age of 55 years.

METHODS

Twenty-seven patients 55 years of age or older with a displaced distal radius fracture were recruited from a hand and upper extremity clinic. A conjoint analysis tool was created describing the attributes of care (eg, return of grip strength) of surgical and nonsurgical treatment. This tool was administered to patients to determine their preferences for the treatment attributes when choosing between surgical and nonsurgical treatment. Patients completed a System Usability Scale (SUS) to evaluate usability, and time to complete the tool was measured to evaluate feasibility.

RESULTS

Patients considered the conjoint analysis tool to be usable (SUS, 91.4; SD, 10.9). Mean time to complete the tool was 5.1 minutes (SD, 1.4 minutes). The most important attributes driving the decision for surgical treatment were return of grip strength at 1 year and time spent in a cast or brace. The most important attributes driving the decision for nonsurgical treatment were use of anesthesia during treatment and return of grip strength at 1 year.

CONCLUSIONS

A point-of-care conjoint analysis tool for distal radius fractures in patients 55 years and older can be used to elicit patient preferences to inform the shared decision-making process. Further investigation evaluating the effect of preference elicitation on treatment choice, involvement in decision making, and patient-reported outcomes are needed.

CLINICAL RELEVANCE

A conjoint analysis tool is a simple, structured process physicians can use during shared decision making to highlight trade-offs between treatment options and elicit patient preferences to inform treatment choices.

Knee Osteoarthritis: Alternative Range of Motion Treatment

The number of total knee arthroplasty (TKA) surgeries is expected to soar, and an effective nonoperative rehabilitation program is needed. We began treating patients with knee osteoarthritis with a range-of-motion (ROM) -based rehabilitation program that was delivered systematically, starting with ROM exercises for knee extension, followed by exercises for flexion and swelling reduction, before starting a strengthening program. In a group of 396 patients, significant improvements were made in knee extension, flexion, and KOOS subjective scores for pain, symptoms, activities of daily living, sport, and quality of life. Furthermore, the program prevented 76% of patients from undergoing TKA surgery.

Incisional squamous cell carcinoma after total knee arthroplasty

With the rising number of total knee arthroplasties being performed annually, the number of complications associated with this procedure will also continue to rise. The most common reasons for revision include infection, instability, and aseptic loosening. Fortunately, wound complications are rare, and in this case report, we describe the development of a well-differentiated squamous cell carcinoma, keratoacanthomatous type, within the surgical incision of a total knee arthroplasty several months after the index procedure.

Patient satisfaction reporting for patellofemoral arthroplasty is significantly lacking: a systematic review

Background: Patellofemoral Arthroplasty (PFA) has been shown to be successful in restoring knee function and quality of life in patients with the isolated patellofemoral disease. Patient satisfaction has been suggested as an indicator of the quality of elective orthopedic operations, although there remains no standardized method to collect and evaluate satisfaction. The present study offers a systematic review of the available literature concerning patient satisfaction following PFA to assess common methodologies for reporting patient satisfaction. Methods: A query of the Medline database produced 116 articles that were reviewed for inclusion in the review. The following inclusion criteria were used to identify suitable articles: English language, clinical outcomes study related to PFA, and patient-reported satisfaction as an outcome measure. Results: Seven studies met inclusion criteria and were eligible for review. The highest level of evidence was level-III. The study publication dates ranged from 2009 to 2016, with six published in 2015 & 2016. In total, 320 PFAs were performed on 267 patients. Four articles reported the proportion of included patients who had previous knee surgeries (range: 20-60%). Three studies used ordinal scales to rate patient satisfaction. Four studies (57.1%) reported the numeric proportion of patients satisfied following PFA, which ranged from 76% to 96.5%. Two studies used Visual Analog Scale methods. For these two studies, one of them reported the mean satisfaction score as 7.5/10, and the other reported a median of 90/100. Conclusions: The available literature on patient satisfaction after PFA was found to be limited, with low-quality evidence and variable methodology.

The Efficacy and Safety of Inpatient Rehabilitation Compared With Home Discharge After Hip or Knee Arthroplasty: A Meta-Analysis and Systematic Review

BACKGROUND

Total hip and knee arthroplasties (THKAs) are successful procedures in managing end-stage arthritis when nonoperative treatments fail. The immediate postoperative period is an important time for the body to recuperate and rehabilitate. Studies have shown that early intensive rehabilitation can enhance recovery. Rehabilitation can be provided as inpatient rehabilitation (IR) or discharge with home rehabilitation. These options have been studied, but literature on the efficacy and safety of IR compared to home discharge is scarce, and evidence is not well established. This meta-analysis aims to compare the efficacy and safety of IR to home discharge with rehabilitation after THKA.

METHODS

A multidatabase search was performed according to PRISMA guidelines. Data from studies assessing the efficacy and safety of IR and home as discharge destinations after THKA were extracted and analyzed.

RESULTS

Fifteen studies were included, consisting of 37,411 IR patients and 172,219 home discharge patients. These studies had heterogeneous reporting methods, with some conflicting results. There was no clinically significant difference in clinical outcomes between the groups. Readmission was nearly 5 times (odds ratio = 4.87, 95% confidence interval = 3.24-7.33, P < .001) and periprosthetic complications nearly 3 times (odds ratio = 2.82, 95% confidence interval: 1.54-5.24, P < .001) higher in IR patients than those discharged home after THKA.

CONCLUSION

Although IR is associated with higher risks of complications and readmissions, this may be because of patient selection bias in the clinical setting. Following THKA, it is safe to discharge patients to home with rehabilitation whenever possible.

EVIDENCE LEVEL

Level II, Meta-analysis of heterogeneous studies.

Relationship between surgical balancing and outcome measures in total knees

Background

The purpose of the study was to investigate the accuracy of balancing which could be achieved at total knee surgery and its relation to functional outcomes.

Methods

During surgery, the forces on the medial and lateral plateaus were measured at 10-15 degrees flexion in 101 patients, using an instrumented tibial trial, with equal forces being targeted. Of the initial 101 cases, 71 cases completed all follow-up visits to 1 year. At each follow-up visit, the function was measured using the Knee Society Scoring System, and varus and valgus laxity angles were measured.

Results

The mean medial/(medial + lateral) compartmental force ratio was 0.52, with a standard deviation of 0.09. The total contact force was 217 Newtons, with a standard deviation of 72 Newtons. No correlations were found between the functional scores and the compartmental force ratio or total contact force. However, the mean varus and valgus laxity angles, 2.8 and 2.3 degrees, respectively, were very close to the angles of normal intact knees.

Conclusions

The likely reason for the lack of correlation of function was that the large majority of the balancing ratios were within the range 0.4-0.6 but with a wide spread of functional scores typical of total knee study groups. However, the normal varus and valgus angles achieved at follow-up indicated that equal balancing in early flexion was a reasonable surgical target. Using instrumented tibial trials enabled accurate and consistent balancing values to be achieved, as well as normal varus and valgus laxity angles, which may be important in obtaining optimal outcomes.

The discrepancy between patient expectations and actual outcome reduces at the first 6 months following total knee replacement surgery

PURPOSE

Patients undergoing total knee arthroplasty often have unfulfilled expectations from the surgery that can lead to dissatisfaction. This study aimed to examine the discrepancy between patients' expectations and actual functional abilities prior to undergoing knee replacement surgery, and at 6 and 12 months following the surgery.

METHODS

A survey was undertaken of patients before, and 6 and 12 months post-surgery. The survey included the Knee Surgery Perception Questionnaire (KSPQ) to assess patients' current perception of their level of function and pain, their desired outcomes, and the discrepancy between the two. Pain, function and quality of life were also assessed. Repeated measure ANOVAs were used to assess differences between pre- and post-surgery.

RESULTS

A total of 176 patients were surveyed. Significant differences in the KSPQ discrepancy scores (subscale and total scores) were demonstrated between the three assessment point times (p < 0.01). Paired t tests identified significant differences between the pre-surgery and 6-month KSPQ discrepancy scores, (p < 0.01) indicative of substantial improvement in physical function and slight reduction in expectations. Overall significant improvement (p < 0.01) was reported over time across all measures: physical function, pain and stiffness and quality of life.

CONCLUSION

The discrepancy between patients' current abilities and their expectation changes following surgery, especially in the first 6 months post-surgery. Patients' goals might change as their function and pain improve post-surgery. Combining education programmes and discussion with the treating orthopaedic surgeons pre-operatively is important for the development of realistic, achievable expectations.

LEVEL OF EVIDENCE

III.

Prediction of the need for manipulation under anesthesia for flexion contracture after total knee arthroplasty in patients of advanced age

Objective

This study was performed to develop a prediction model for requiring manipulation under anesthesia (MUA) for flexion contracture after total knee arthroplasty (TKA) in patients of advanced age.

Methods

We retrospectively reviewed 269 patients of advanced age undergoing primary TKA in one center with a minimum 1-year follow-up. Patients who underwent postoperative MUA had flexion contracture of >10° after 4 weeks of postoperative rehabilitation, and their demographic data and preoperative clinical conditions [knee diagnosis, diabetes mellitus, hypertension, lumbar spinal disorders, hip disorders, ankle disorders, knee deformity (varus/valgus), preoperative flexion contracture (PFC), range of motion (ROM), and Hospital for Special Surgery (HSS) knee score] were compared with those of patients without MUA. All preoperative factors were collected to develop the predictive model.

Results

Thirty patients underwent MUA. Patients who underwent MUA after surgery had significant differences in PFC, higher HSS knee scores before surgery (59.10 ± 7.22 vs. 55.70 ± 13.09), and lower preoperative ROM (81.57 ± 30.86 vs. 95.47 ± 24.36) than those who did not undergo MUA.

Conclusion

A prediction model for MUA in advanced-age patients with flexion contracture was developed and mainly consisted of preoperative risk factors including PFC, HSS scores, and ROM.

Internal Validation of a Predictive Model for Satisfaction After Primary Total Knee Arthroplasty

BACKGROUND

As the number of total knee arthroplasty (TKA) procedures continues to rise in the context of bundled payment models, patients dissatisfied postoperatively that require additional care will impose additional cost to the healthcare system. The purpose of this study is to internally validate a predictive model for postoperative patient satisfaction after TKA.

METHODS

In total, 484 consecutive primary TKA patients between January 2014 and January 2016 were included. Patients were stratified into 4 risk tiers based on scores of a retrospectively applied, 11-component novel knee survey for postoperative satisfaction: low risk (>96.5), mild risk (75-96.4), moderate risk (60-74.9), and high risk (<60). Binary logistic and multivariate linear regression models were constructed to determine whether the survey was predictive of satisfaction. A receiver operator curve was constructed to determine a threshold score below which patients were likely to experience postoperative dissatisfaction.

RESULTS

The mean (±standard deviation) age was 66.3 ± 9.2 years (range 31.7-100.1) and mean body mass index was 34.2 ± 8.2 kg/m² (range 16.2-68.4). A knee survey score of 96.5 conferred a 97.5% sensitivity and 95.7% negative predictive value for satisfaction. Patients with higher knee survey scores had greater odds (odds ratio 1.03, 95% confidence interval 1.01-1.06, P = .003) of postoperative satisfaction. Increasing risk tier was significantly associated with decreased satisfaction (low risk 95.7%, mild risk 93.8%, moderate risk 86.4%, and high risk 80.4%; P = .007). The knee survey was not significantly correlated with complications (r = -0.43, P = .32).

CONCLUSION

This novel knee survey conferred a 97.5% sensitivity and 95.7% negative predictive value in identifying at-risk patients for postoperative dissatisfaction after primary TKA.

Advances in modern osteotomies around the knee : Report on the Association of Sports Traumatology, Arthroscopy, Orthopaedic surgery, Rehabilitation (ASTAOR) Moscow International Osteotomy Congress 2017

Corrective lower limb osteotomies are innovative and efficient therapeutic procedures for restoring axial alignment and managing unicompartmental knee osteoarthritis. This review presents critical insights into the up-dated clinical knowledge on osteotomies for complex posttraumatic or congenital lower limb deformities with a focus on high tibial osteotomies, including a comprehensive overview of basic principles of osteotomy planning, biomechanical considerations of different implants for osteotomies and insights in specific bone deformity correction techniques. Emphasis is placed on complex cases of lower limb osteotomies associated with ligament and multiaxial instability including pediatric cases, computer-assisted navigation, external fixation for long bone deformity correction and return to sport after such osteotomies. Altogether, these advances in the experimental and clinical knowledge of complex lower limb osteotomies allow generating improved, adapted therapeutic regimens to treat congenital and acquired lower limb deformities.

The EKSPECT study: the influence of Expectation modification in Knee arthroplasty on Satisfaction of PatiEnts: study protocol for a randomized Controlled Trial

Background

One out of five patients is unsatisfied to some extent after total knee arthroplasty (TKA). Unmet expectations are the main driver of post-operative dissatisfaction. Improved pre-operative education on realistic expectations for long-term outcome after TKA potentially leads to higher post-operative satisfaction. The effect of expectation modification on post-operative satisfaction in TKA patients has not yet been studied. The primary objective of the presented study is to examine whether an educational module on long-term recovery after TKA will improve patient satisfaction compared to usual pre-operative education.

Methods

The EKSPECT study is a randomized controlled trial. Patients with symptomatic and radiographic knee osteoarthritis who are indicated for a primary TKA will be randomized to the usual pre-operative education (control group) or usual education plus an additional module on realistic expectations for long-term recovery (intervention group). Patients will be naïve to study objective and difference between study groups. Outcome expectations will be measured blinded for group allocation using the HSS Knee Replacement Expectations Survey at baseline (before the intervention), pre-operatively (after the intervention) and fulfillment of expectations at 12-month follow-up. Baseline physical function, quality of life and psychological factors are measured using self-reported questionnaires. The primary outcome measure is satisfaction with treatment result at the 12-month follow-up.

Discussion

The EKSPECT study should provide evidence on the effectiveness of an education module on long-term recovery after TKA to improve treatment satisfaction. If beneficial, the education module is a simple intervention with a low burden for patients, which can easily be implemented in clinical practice.

Trial registration

Dutch Trial Registry registration number: NTR5779. Registered on 17 March 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2821-2) contains supplementary material, which is available to authorized users.