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Saeed AZ, Khaleeq T, Ahmed U, Ajula R, Boutefnouchet T, D'Alessandro P, Malik SS. No clinical advantage with customized individually made implants over conventional off-the-shelf implants in total knee arthroplasty: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:1311-1330. [PMID: 37979098 DOI: 10.1007/s00402-023-05090-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 09/25/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) can be performed with either conventional off-the-shelf (OTS) or customized individually-made (CIM) implants. The evidence for CIM implants is limited and variable, and the aim of this review was to compare clinical and radiological outcomes between CIM and OTS implants. METHODS A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Studies reporting on clinical, radiological, or alignment outcomes for CIM and OTS implants were selected. The studies were appraised using the Methodical index for non-randomized studies tool. RESULTS Twenty-three studies fulfilled the inclusion criteria. The studies comprised 2856 CIM and 1877 OTS TKAs. Revision rate was higher with CIM (5.9%) compared to OTS (3.7%) implants [OR 1.23(95% CI 0.69-2.18)]. Manipulation under anesthesia (MUA) was higher in CIM (2.2%) compared to OTS (1.1%) group [OR 2.95(95% CI 0.95-9.13)] and complications rate was higher in CIM (5%) vs. OTS (4.5%) [OR 1.45(95% CI 0.53-3.96)] but neither reached statistical significance. Length of stay was significantly shorter in CIM group 2.9 days vs. 3.5 days [MD - 0.51(95% CI - 0.82 to - 0.20)]. Knee Society Score showed no difference between CIM and OTS groups for Knee 90.5 vs. 90.6 [MD - 0.27(95% CI - 4.27 to 3.73)] and Function 86.1 vs. 83.1 [MD 1.51(95% CI - 3.69 to 6.70)]. CONCLUSION CIM implants in TKA have theoretical benefits over OTS prostheses. However, in this present review, CIM implants were associated with higher revisions, MUA, and overall complication rates. There was no difference in outcome score and CIM implants did not improve overall target alignment; however, more CIM TKAs were found to be in the HKA target zone compared to OTS TKAs. The findings of this review do not support the general utilization of CIM over OTS implants in TKA.
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Affiliation(s)
- Abu Z Saeed
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK.
| | - Tahir Khaleeq
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - Usman Ahmed
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Randeep Ajula
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia, Medical School, Discipline of Surgery, University of Western Australia, Perth, Australia
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Kirschner N, Anil U, Shah A, Teo G, Schwarzkopf R, Long WJ. Role of non-ASA VTE prophylaxis in risk for manipulation following primary total knee arthroplasty. Arch Orthop Trauma Surg 2023; 143:2135-2140. [PMID: 35674820 DOI: 10.1007/s00402-022-04488-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Stiffness and decreased range of motion frequently lead to hindrance of activities of daily living and dissatisfaction follow total knee arthroplasty (TKA). This study aims to evaluate the effect of non-aspirin (ASA) chemoprophylaxis and determine patient-related risk factors for stiffness and need for manipulation under anesthesia (MUA) following primary TKA. MATERIALS AND METHODS A review of all patients undergoing primary TKA from 2013 to 2019 at a single academic orthopedic hospital was conducted. The primary outcome measure was MUA performed post-operatively. Chi-square analysis and Mann-Whitney U test were used to determine statistically significant relationships between risk factors and outcomes. Significance was set at p < 0.05. Univariate logistic regression was performed to control for identified independent risk factors for MUA. RESULTS A total of 11,550 patients undergoing primary TKA from January 2013 to September 2019 at an academic medical center were included in the study. Increasing age and Charlson Comorbidity Index were associated with statistically significant decreased odds of MUA (0.93, 95% CI: 0.92-0.94, p < 0.001, OR 0.71, 95% CI 0.63-0.79, p < 0.001). Active smokers had a 2.01 increased odds of MUA (OR 2.01, 95% CI 1.28, 3.02, p < 0.001). There was no significant difference in rates of MUA between ASA and non-ASA VTE prophylaxis (p 0.108). CONCLUSIONS Younger age, lower CCI, and history of smoking are associated with a higher rate, while different chemical VTE prophylaxis does not influence rate of MUA after TKA. Arthroplasty surgeons should consider these risk factors when counseling patient preoperatively. Understanding each patients' risk for MUA allows surgeons to appropriately set preoperative expectations and reasonable outcome goals.
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Affiliation(s)
- Noah Kirschner
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA.
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA
| | - Akash Shah
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA
| | - Greg Teo
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA
| | - William J Long
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, 10021, USA
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High Complication Rate Associated With Arthroscopic Lysis of Adhesions Versus Manipulation Under Anesthesia for Arthrofibrosis After Total Knee Arthroplasty. J Am Acad Orthop Surg 2023; 31:e216-e225. [PMID: 36728979 DOI: 10.5435/jaaos-d-22-00430] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/09/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Arthrofibrosis after total knee arthroplasty (TKA) is often treated by arthroscopic lysis of adhesions (ALAs) or manipulation under anesthesia (MUA). This study compared the 2-year complication rates of ALA and MUA and range-of-motion (ROM) outcomes for ALA, early MUA (<3 months after TKA), and delayed MUA (>3 months after TKA). METHODS This retrospective cohort study included 425 patients undergoing ALA or MUA after primary TKA from 2001 to 2018. Demographics, clinical variables, and complication rates were collected from clinical records and compared using Student t -tests and Kaplan-Meier log-rank tests. Multivariable logistic regressions were used for adjusted analysis. ROM data were analyzed using fixed and mixed-effects models. RESULTS ALA patients were younger (55.2 versus 58.9 years, P < 0.001) and underwent surgery later from the index TKA (12 versus 1.9 months, P < 0.001). The Charlson Comorbidity Index was higher in the MUA group. Preoperative ROM was significantly worse in the MUA cohort, but did not differ between groups after the procedure (117°, P = 0.27) or at 2 years. Demographics and ROM outcomes were equivalent between early MUA and delayed MUA ( P = 0.75). The incidence of repeat arthrofibrosis (7.1%) and revision arthroplasty (2.4%) was similar between ALA and MUA cohorts while ALA patients had significantly more surgical site infections (3.8%) compared with MUA patients (0.47%, P = 0.017). DISCUSSION Equivalent ROM outcomes were seen between ALA, early MUA, and delayed MUA for the treatment of arthrofibrosis after TKA. However, this study demonstrated a markedly higher complication rate, particularly surgical site infection, after ALA, suggesting that MUA may be the preferred option for treating arthrofibrosis at both early and late time points.
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Li TJ, Sun JY, Du YQ, Shen JM, Zhang BH, Zhou YG. Early patellar tendon rupture after total knee arthroplasty: A direct repair method. World J Clin Cases 2022; 10:11349-11357. [PMID: 36387798 PMCID: PMC9649570 DOI: 10.12998/wjcc.v10.i31.11349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/28/2022] [Accepted: 09/27/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patellar tendon rupture after total knee arthroplasty (TKA) is a catastrophic complication. Although the occurrence of this injury is rare, it can lead to significant dysfunction for the patient and is very tricky to deal with. There has been no standard treatment for early patella tendon rupture after TKA, and long-term follow-up data are lacking.
AIM To introduce a direct repair method for early patella tendon rupture following TKA and determine the clinical outcomes and complications of this method.
METHODS During the period of 2008 to 2021, 3265 consecutive TKAs were retrospectively reviewed. Twelve patients developed early patellar tendon rupture postoperatively and were treated by a direct repair method. Mean follow-up was 5.7 years. Demographic, operative, and clinical data were collected. The clinical outcomes were assessed using the Western Ontario and McMaster Universities (WOMAC) score, the Hospital for Special Surgery (HSS) score, knee range of motion, extensor lag, and surgical complications. Descriptive statistics and paired t test were employed to analyze the data.
RESULTS For all 12 patients who underwent direct repair for early patellar tendon rupture, 3 patients failed: One (8.3%) for infection and two (17.6%) for re-fracture. The two patients with re-fracture both underwent reoperation to reconstruct the extensor mechanism and the patient with infection underwent revision surgery. The range of motion was 109.2° ± 10.6° preoperatively to 87.9° ± 11° postoperatively, mean extensor lag was 21° at follow-up, and mean WOMAC and HSS scores were 65.8 ± 30.9 and 60.3 ± 21.7 points, respectively.
CONCLUSION This direct repair method of early patellar tendon rupture is not an ideal therapy. It is actually ineffective for the recovery of knee joint function in patients, and is still associated with severe knee extension lag and high complication rates. Compared with the outcomes of other repair methods mentioned in the literature, this direct repair method shows poor clinical outcomes.
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Affiliation(s)
- Tie-Jian Li
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing 100048, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing 100853, China
| | - Jing-Yang Sun
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing 100048, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing 100853, China
| | - Yin-Qiao Du
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing 100048, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing 100853, China
| | - Jun-Min Shen
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing 100048, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing 100853, China
| | - Bo-Han Zhang
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing 100048, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing 100853, China
| | - Yong-Gang Zhou
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing 100048, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing 100853, China
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De Franco C, de Matteo V, Lenzi M, Marano E, Festa E, Bernasconi A, Smeraglia F, Balato G. The active knee extension after extensor mechanism reconstruction using allograft is not influenced by "early mobilization": a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:153. [PMID: 35264223 PMCID: PMC8905813 DOI: 10.1186/s13018-022-03049-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative rehabilitation after extensor mechanism reconstruction (EMR) with allograft following total knee arthroplasty (TKA) is not standardized. This meta-analysis aimed to evaluate the effectiveness of early and late knee mobilization after EMR. The range of motion (ROM) and extensor lag in both groups were also assessed as the secondary endpoint. METHODS Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed, including studies dealing with the use of allograft for EMR following TKA. Failure was defined as the persistence of extensor lag > 20°. Coleman Methodology Score and Methodological Index for Non-Randomized Studies (MINORS) score were used to assess the quality of studies included. The failure rate was set as the primary outcome in early (4 weeks) and late (8 weeks) mobilization groups after EMR with allograft. Secondary outcomes were postoperative extensor lag and ROM. RESULTS Twelve articles (129 knees) were finally selected for this meta-analysis. Late and early knee mobilization was described in five and seven studies, respectively. No difference was noted between both groups' failure rates (11/84 vs. 4/38, respectively; p = 0.69). The mean extensor lag at last follow-up was 9.1° ± 8.6 in the early mobilization group, and 6.5° ± 6.1 in the late mobilization group is not significantly different (p > 0.05). The mean postoperative knee flexion was 107.6° ± 6.5 and 104.8° ± 7 in the early and late mobilization group, respectively. CONCLUSION While immobilization after EMR in TKA is mandatory to allow tissue healing, early knee mobilization after four weeks can be recommended with no additional risk of failure and increased extensor lag compared to a late mobilization protocol. LEVEL OF EVIDENCE IV, therapeutic study. Registration PROSPERO (International Prospective Register of Systematic Reviews): CRD42019141574.
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Affiliation(s)
- Cristiano De Franco
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy
| | - Vincenzo de Matteo
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy
| | - Marco Lenzi
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy
| | - Ernesto Marano
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy
| | - Enrico Festa
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy
| | - Alessio Bernasconi
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy
| | - Francesco Smeraglia
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy
| | - Giovanni Balato
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5 80130, Naples, Italy.
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Li J, Zhang J, Zhao K, Zhu Y, Meng H, Jin Z, Ye D, Chen W, Zhang Y. Incidence and risk factors for decreased range of motion of the knee joint after surgery for closed tibial plateau fracture in adults. J Orthop Surg Res 2021; 16:549. [PMID: 34488833 PMCID: PMC8422622 DOI: 10.1186/s13018-021-02700-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/30/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose The aim of this study was to quantify the incidence of and identify independent risk factors for decreased range of motion (ROM) of the knee joint after surgery for closed tibial plateau fractures in adults. Methods This retrospective study was performed at the trauma centre in our hospital from January 2018 to December 2019. Data from adult patients with tibial plateau fractures treated by surgery were extracted from the electronic medical records. A total of 220 tibial plateau fracture patients were enrolled. We extracted the patients’ demographic characteristics, fracture characteristics, and surgery-related variables. Univariate and multivariate logistic regression models were used to investigate the potential independent risk factors. Results Fifty-seven patients developed decreased ROM of the knee joint at the 1-year follow-up in this study. The overall incidence was 25.9%. The independent predictors of decreased ROM after surgery, as identified in the multivariate analysis, were orthopedic polytrauma (odds ratio = 3.23; 95% CI = 1.68–6.20; p = 0.000), fracture type (Schatzker V-VI) (odds ratio = 2.52; 95% CI = 1.16–5.47; p = 0.019), and an open reduction and internal fixation approach (odds ratio = 2.10; 95% CI = 1.07–4.12; p = 0.031). Conclusions The study confirmed that patients with orthopaedic polytrauma, more complex fractures and those treated with open reduction and internal fixation (ORIF) surgery were more likely to suffer decreased ROM of the knee joint 1 year after surgery.
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Affiliation(s)
- Junyong Li
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China.,The First Hospital of Shijiazhuang City, Shijiazhuang, 050000, Hebei, P. R. China
| | - Junzhe Zhang
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China
| | - Kuo Zhao
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China
| | - Yanbin Zhu
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China
| | - Hongyu Meng
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China
| | - Zhucheng Jin
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China
| | - Dandan Ye
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China
| | - Wei Chen
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China.,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China
| | - Yingze Zhang
- Department of Orthopaedic surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China. .,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China. .,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China. .,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, Hebei, P. R. China. .,Hebei Orthopedic Clinical Research Center, Shijiazhuang, 050051, Hebei, P. R. China.
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Sunil Kumar KH, Mamarelis G, Pettit M, Khanduja V. Management of Stiffness following Total Knee Arthroplasty: International Survey on Surgeon Preferences. SICOT J 2021; 7:30. [PMID: 33929314 PMCID: PMC8086424 DOI: 10.1051/sicotj/2021008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/10/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction: Stiffness following total knee arthroplasty (TKA) is a challenging complication and can result in a poor functional outcome. There is considerable debate concerning the definition, work-up, and optimal management of this complication. The aim of this study was to record the definition of stiffness, management practices, and expectations of outcome among surgeons from an international community using a peer-reviewed questionnaire. Methods: A 23-item peer-reviewed online questionnaire was sent to all members of SICOT to gauge and record the management practices and expectations of outcome in the management of patients with stiffness following TKA. Results: A total of 315 surgeons completed this peer-reviewed questionnaire. Manipulation under anaesthesia (MUA) was the preferred treatment option for stiffness post-TKA, with a majority of the surgeons opting to carry out this procedure between 6 and 12 weeks following the index TKA. Physiotherapy and a continuous passive motion device were also used by the majority of surgeons following MUA, as additional treatment measures. Discussion: MUA is perceived to be a safe and effective primary treatment option for stiffness following TKA. It is best performed between weeks 6 and 12 with expected gains in range of motion from 10 to 20 degrees in 75% of patients.
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Affiliation(s)
- Karadi Hari Sunil Kumar
- Specialty Registrar in Trauma & Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Georgios Mamarelis
- Specialty Registrar in Trauma & Orthopaedics, Royal London Hospital, Whitechapel, London E1 1BB, UK
| | | | - Vikas Khanduja
- Consultant Orthopaedic Surgeon, Addenbrooke's Cambridge University Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Manipulation Under Anesthetic After Primary Knee Arthroplasty Is Associated With a Higher Rate of Subsequent Revision Surgery. J Arthroplasty 2020; 35:2640-2645.e2. [PMID: 32475786 DOI: 10.1016/j.arth.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/18/2020] [Accepted: 04/06/2020] [Indexed: 02/02/2023] Open
Abstract
AIM To determine the association between manipulation under anesthetic (MUA) after primary knee arthroplasty and subsequent revision surgery. METHODS Patients undergoing primary knee arthroplasty from April 2011 to April 2016 with minimum 1-year follow-up to April 2017 were identified from the national hospital episode statistics for England. The first arthroplasty per patient, per side, was included; cases with a record of subsequent infection or periprosthetic fracture were excluded. Patients undergoing MUA within 1 year to the same knee were identified, defining the populations for the MUA and non-MUA cohorts. Mortality-adjusted Kaplan-Meier survival analysis (revision arthroplasty) was performed to a maximum of 6 years. A Cox proportional hazards model was used to determine the hazard for revision, adjusting for type of primary arthroplasty, gender, age group, year, comorbidity index, obesity, regional deprivation, rurality, and ethnicity. RESULTS A total of 309,650 primary arthroplasty cases (309,650 patients) were included. MUA within 1 year was recorded in 6882 patients (2.22%; 95% confidence interval [95% CI], 2.17-2.28) defining the MUA cohort; all others were included in the parallel non-MUA cohort. At 6 years, the mortality-adjusted estimated implant survival rate in the MUA cohort was 91.2% (95% CI, 90.0-92.2) in comparison to 98.1% (95% CI, 98.0-98.2) in the non-MUA cohort. In the fully adjusted model, this corresponded to an adjusted hazard for revision of 5.03 (hazard ratio; 95% CI, 4.55-5.57). CONCLUSION Patients who underwent MUA within 1 year of primary arthroplasty were at a 5-fold increased risk of subsequent revision even after excluding cases of infection or fracture. Further investigation of the etiology of stiffness after primary knee arthroplasty and the optimal treatment options to improve outcomes is justified.
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Postoperative Serum Cytokine Levels Are Associated With Early Stiffness After Total Knee Arthroplasty: A Prospective Cohort Study. J Arthroplasty 2020; 35:S336-S347. [PMID: 32269006 PMCID: PMC8279012 DOI: 10.1016/j.arth.2020.02.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/03/2020] [Accepted: 02/21/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Inflammatory cytokines have been implicated in organ fibrosis; however, their role in the development of arthrofibrosis after total knee arthroplasty (TKA) has not been well explored. The purpose of this study is to assess whether perioperative synovial fluid or blood plasma cytokine levels are associated with reduced early post-TKA range of motion. METHODS A total of 179 patients with end-stage idiopathic osteoarthritis undergoing TKA were enrolled in this prospective cohort study. Synovial fluid and blood plasma were collected prearthrotomy and plasma was collected longitudinally in the postacute care unit and on postoperative days (PODs) 1 and 2. Stiffness was defined as ≤95° range of motion measured with a goniometer at 6 weeks (±2 weeks). RESULTS Thirty-two of 162 (19.8%) patients analyzed were stiff at 6 weeks postoperatively. Postoperative plasma levels of 9 cytokines (Eotaxin3, IL-5, IL12_23p40, IP10, VEGF, IL-7, IL-12p70, IL-16, IL-17a) were significantly different between stiff and nonstiff patients on POD1 and/or POD2. An association between preoperative plasma and synovial fluid cytokine levels and the development of postoperative stiffness was not detected. CONCLUSION The results of this study suggest that there is a distinct acute postoperative cytokine response profile in patients who develop stiffness 6 weeks after TKA. This profile was characterized by significant differences in levels of 9 cytokines over the first 2 postoperative days. These results identify cytokines that are potential biomarkers for risk of early stiffness after TKA and may play a role in the pathophysiology of this outcome.
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Knapp P, Weishuhn L, Pizzimenti N, Markel DC. Risk factors for manipulation under anaesthesia after total knee arthroplasty. Bone Joint J 2020; 102-B:66-72. [DOI: 10.1302/0301-620x.102b6.bjj-2019-1580.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims Postoperative range of movement (ROM) is an important measure of successful and satisfying total knee arthroplasty (TKA). Reduced postoperative ROM may be evident in up to 20% of all TKAs and negatively affects satisfaction. To improve ROM, manipulation under anaesthesia (MUA) may be performed. Historically, a limited ROM preoperatively was used as the key harbinger of the postoperative ROM. However, comorbidities may also be useful in predicting postoperative stiffness. The goal was to assess preoperative comorbidities in patients undergoing TKA relative to incidence of postoperative MUA. The hope is to forecast those who may be at increased risk and determine if MUA is an effective form of treatment. Methods Prospectively collected data of TKAs performed at our institution’s two hospitals from August 2014 to August 2018 were evaluated for incidence of MUA. Comorbid conditions, risk factors, implant component design and fixation method (cemented vs cementless), and discharge disposition were analyzed. Overall, 3,556 TKAs met the inclusion criteria. Of those, 164 underwent MUA. Results Patients with increased age and body mass index (BMI) had decreased likelihood of MUA. For every one-year increase in age, the likelihood of MUA decreased by 4%. Similarly, for every one-unit increase in BMI the likelihood of MUA decreased by 6%. There were no differences in incidence of MUA between component type/design or fixation method. Current or former smokers were more likely to have no MUA. Surprisingly, patients discharged to home health service or skilled nursing facility were approximately 40% and 70% less likely than those discharged home with outpatient therapy to be in the MUA group. MUA was effective, with a mean increased ROM of 32.81° (SD 19.85°; -15° to 90°). Conclusion Younger, thinner patients had highest incidence of MUA. Effect of discharge disposition on rate of MUA was an important finding and may influence surgeons’ decisions. Interestingly, use of cement and component design (constraint) did not impact incidence of MUA. Level of Evidence II: Prospective cohort study. Cite this article: Bone Joint J 2020;102-B(6 Supple A):66–72.
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Affiliation(s)
- Paul Knapp
- Ascension Providence Hospital Orthopaedic Residency, Novi, Michigan, USA
| | - Luke Weishuhn
- Beaumont Hospital Orthopedic Residency, Farmington Hills, Michigan, USA
| | | | - David C. Markel
- Ascension Providence Hospital Orthopaedic Residency, Novi, Michigan, USA
- The Core Institute, Novi, Michigan, USA
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A dynamic knee extension device improves flexion contracture before total knee arthroplasty: a randomized controlled trial. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kornuijt A, Das D, Sijbesma T, de Vries L, van der Weegen W. Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature. Musculoskelet Surg 2018; 102:223-230. [PMID: 29546693 DOI: 10.1007/s12306-018-0537-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 03/08/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery. METHODS A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA. RESULTS Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA. CONCLUSION Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.
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Affiliation(s)
- A Kornuijt
- Department of Physiotherapy, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - D Das
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - T Sijbesma
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - L de Vries
- Department of Orthopedic Surgery, Westfriesgasthuis Hospital, Maelsonstraat 3, 1624 NP, Hoorn, The Netherlands
| | - W van der Weegen
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands.
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e Silva DCCM, de Andrade Alexandre DJ, Silva JG. Immediate effect of myofascial release on range of motion, pain and biceps and rectus femoris muscle activity after total knee replacement. J Bodyw Mov Ther 2018; 22:930-936. [DOI: 10.1016/j.jbmt.2017.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/06/2017] [Accepted: 12/04/2017] [Indexed: 12/11/2022]
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Abstract
OBJECTIVE To determine the risk factors for knee stiffness surgery after tibial plateau fixation. DESIGN Retrospective observational cohort study. SETTING Academic Level I trauma center. PATIENTS/PARTICIPANTS A study group of 110 patients who underwent knee stiffness surgery (manipulation while under anesthesia, arthroscopic lysis of adhesion, or quadricepsplasty) at a time remote from open reduction and internal fixation of tibial plateau fractures and a control group of 319 patients with tibial plateau fractures treated with open reduction and internal fixation who did not undergo knee stiffness surgery and who had either a minimum of 1 year of follow-up or clearly documented range of motion ≥110 degrees with a minimum of 90 days of follow-up. INTERVENTION Each case was assessed from the time of index admission through study event, end of minimum follow-up, or achievement of ≥110 degrees range of motion. MAIN OUTCOME MEASUREMENTS Knee stiffness surgery. RESULTS Total number of weeks in an external fixator (odds ratio, 1.5 per week; 95% confidence interval, 1.3-1.7; P < 0.001) and the presence of bilateral tibial plateau fractures (odds ratio, 3.3; 95% confidence interval, 1.2-9.1; P = 0.02) were significant predictors of knee stiffness intervention. CONCLUSION Clinicians should be aware that the time spent in external fixation and the presence of bilateral tibial plateau injuries are strong risk factors for requiring subsequent surgery to treat knee stiffness. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Dailey K, McMorris M, Gross MT. Tibiofemoral joint mobilizations following total knee arthroplasty and manipulation under anesthesia. Physiother Theory Pract 2018; 36:863-870. [PMID: 30130416 DOI: 10.1080/09593985.2018.1510452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
STUDY DESIGN Case report. BACKGROUND The purpose of this case report is to describe the use of tibiofemoral joint mobilizations to improve knee flexion in a patient with arthrofibrosis following total knee arthroplasty (TKA) and failed manipulation under anesthesia (MUA). CASE DESCRIPTION A 62-year-old female presented to physical therapy 15 days after TKA with full knee extension, 45 deg of active knee flexion, 48 deg of passive knee flexion, pain, and a Lower Extremity Functional Scale (LEFS) score of 28. INTERVENTIONS/OUTCOMES A multimodal intervention strategy was used initially with minimal improvement in knee flexion. The patient was diagnosed with fibrosis and MUA was performed. Passive knee flexion was 80 deg before MUA and 75 deg after MUA. Focused grade III and IV tibiofemoral joint mobilizations were used after MUA. At discharge, the patient had 90 deg of active and 116 deg of passive knee flexion, no pain, and an LEFS score of 80. DISCUSSION A conventional multimodal intervention approach was ineffective for a patient who developed arthrofibrosis following TKA. A focused intervention approach of grade III and IV tibiofemoral joint mobilizations improved knee flexion, pain, and function following TKA and failed MUA.
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Affiliation(s)
- Kathryn Dailey
- Department of Allied Health Sciences: Physical Therapy, University of North Carolina , Chapel Hill, NC, USA
| | - Michael McMorris
- Department of Allied Health Sciences: Physical Therapy, University of North Carolina , Chapel Hill, NC, USA
| | - Michael T Gross
- Department of Allied Health Sciences: Physical Therapy, University of North Carolina , Chapel Hill, NC, USA
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Zachwieja E, Perez J, Hardaker WM, Levine B, Sheth N. Manipulation Under Anesthesia and Stiffness After Total Knee Arthroplasty. JBJS Rev 2018; 6:e2. [DOI: 10.2106/jbjs.rvw.17.00113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kahlenberg CA, Trivellas M, Lee YY, Padgett DE. Preoperative Valgus Alignment Does Not Predict Inferior Outcome of Total Knee Arthroplasty. HSS J 2018; 14:50-54. [PMID: 29398995 PMCID: PMC5786588 DOI: 10.1007/s11420-017-9576-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 08/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preoperative valgus deformity is present in an estimated 10-20% of patients undergoing total knee replacement (TKR). QUESTIONS/PURPOSES The objective of this study was to compare the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after TKR in a matched cohort of patients with preoperative valgus and varus deformities. METHODS This is a matched cohort study of 162 patients with varus native knees and 162 patients with valgus native knees who underwent TKR and were prospectively followed in our institutional registry. Patients matched were based on age, BMI, sex, and severity of preoperative knee deformity, which was classified as mild, moderate, severe varus or valgus, or no deformity. Outcomes were evaluated using the WOMAC preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. RESULTS No significant difference was found between the matched varus and valgus cohorts in all WOMAC subdomain scores except for a marginally worse stiffness at 1 year in patients with valgus deformity (WOMAC stiffness, 75.1 varus vs. 70.1 valgus; P = 0.049). This is below the minimal clinically important difference for WOMAC scores. There was no significant difference in postoperative varus/valgus alignment between the two groups (P = 0.092). CONCLUSION We found no clinically significant difference in any of the WOMAC domains in patients with preoperative varus deformity versus valgus deformity within the first year after TKR. These findings may allow surgeons to more appropriately counsel patients with osteoarthritis with valgus deformity that they can expect similar outcomes compared to patients with varus deformity.
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Affiliation(s)
- Cynthia A. Kahlenberg
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Myra Trivellas
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Yuo-yu Lee
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Douglas E. Padgett
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Bodendorfer BM, Kotler JA, Zelenty WD, Termanini K, Sanchez R, Argintar EH. Outcomes and Predictors of Success for Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty. Orthopedics 2017; 40:e1062-e1068. [PMID: 29058757 DOI: 10.3928/01477447-20171012-06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 09/08/2017] [Indexed: 02/03/2023]
Abstract
A stiff total knee arthroplasty (TKA) can manifest as pain and decreased range of motion (ROM). When conservative management including physical therapy and manipulation under anesthesia fails, arthroscopic lysis of adhesions (LOA) is frequently pursued. The authors examined the efficacy of LOA for the stiff TKA. They retrospectively reviewed the records of 18 patients who underwent LOA for stiff TKA between April 2013 and June 2016 and who failed to meet 90° ROM at 6 weeks postoperatively. They recorded patient demographics, ROM prior to TKA, and incidence of manipulation under anesthesia between initial TKA and LOA as well as pre- and postoperative outcomes of ROM, pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The mean time from TKA to LOA was 117 days, with a mean follow-up of 449 days. Mean improvements in ROM flexion contracture, flexion, and arc were 6.11° (P<.05), 29.45° (P<.001), and 35.56° (P<.001), respectively. Range of motion improved for 17 of 18 patients. The WOMAC was completed by 15 of 18 patients, with a mean improvement in scores of 32.23% (P<.001); all 15 patients with available WOMAC scores improved. Pain score improved by a mean of 2.17 (P<.001), with 14 of 18 patients reporting decreased pain. Improvements in flexion contracture, flexion, ROM arc, WOMAC scores, and pain were all statistically significant (P<.05). Age, weight, body mass index, and time to LOA were found to be statistically significant predictors of outcome. Finally, pre-TKA and pre-LOA ROM parameters were found to be statistically significant predictors of post-LOA ROM outcomes. [Orthopedics. 2017; 40(6):e1062-e1068.].
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Donaldson JR, Tudor F, Gollish J. Revision surgery for the stiff total knee arthroplasty. Bone Joint J 2017; 98-B:622-7. [PMID: 27143732 DOI: 10.1302/0301-620x.98b5.35969] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 01/14/2016] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to examine the results of revision total knee arthroplasty (TKA) undertaken for stiffness in the absence of sepsis or loosening. PATIENTS AND METHODS We present the results of revision surgery for stiff TKA in 48 cases (35 (72.9%) women and 13 (27.1%) men). The mean age at revision surgery was 65.5 years (42 to 83). All surgeries were performed by a single surgeon. Stiffness was defined as an arc of flexion of < 70° or a flexion contracture of > 15°. The changes in the range of movement (ROM) and the Western Ontario and McMasters Osteoarthritis index scores (WOMAC) were recorded. RESULTS At a mean follow up of 59.9 months (12 to 272) there was a mean improvement in arc of movement of 45.0°. Mean flexion improved from 54.4° (5° to 100°) to 90° (10° to 125°) (p < 0.05) and the mean flexion contracture decreased from 12.0° (0° to 45°) to 3.5° (0° to 25°) (p < 0.05). The mean WOMAC scores improved for pain, stiffness and function. In patients with extreme stiffness we describe a novel technique, which we have called the 'sloppy' revision. This entails downsizing the polyethylene insert by 4 mm and using a more constrained liner to retain stability. CONCLUSION To our knowledge, this is the largest series of revision surgeries for stiffness reported in the literature where infection and loosening have been excluded. TAKE HOME MESSAGE Whilst revision surgery is technically demanding, improvements in ROM and outcome can be achieved, particularly when the revision is within two years of the primary surgery. Cite this article: Bone Joint J 2016;98-B:622-7.
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Affiliation(s)
| | - F Tudor
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - J Gollish
- Sunnybrook Health Sciences Centre, Toronto, Canada
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20
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Heesterbeek PJC, Goosen JHM, Schimmel JJP, Defoort KC, van Hellemondt GG, Wymenga AB. Moderate clinical improvement after revision arthroplasty of the severely stiff knee. Knee Surg Sports Traumatol Arthrosc 2016. [PMID: 26215774 DOI: 10.1007/s00167-015-3712-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Revision of the severe stiff total knee arthroplasty (TKA) is challenging, and clinical outcome is inferior to other indications for revision. The purpose of the present study was to determine clinical outcome of TKA revision in patients with severe stiffness (range of motion (ROM) ≤ 70°) and evaluate a possible influence of accompanying findings, such as component malposition, aseptic loosening or instability. METHODS A prospective cohort of 40 patients with a preoperative ROM ≤ 70° and a minimum of 2-year follow-up after total system revision (Genesis or Legion stemmed condylar implant) was evaluated. ROM, Knee Society Scoring System (KSS) and visual analogue scale (VAS) pain scores were obtained preoperatively and at 2 years. Patient satisfaction and complication rate were assessed. Component malposition was most frequently reported as accompanying finding (n = 27). Comparisons between pre- and postoperative outcome (p < 0.05) and between different subgroups (component malposition, aseptic loosening, and instability) based on accompanying findings were made (no statistical comparison). RESULTS ROM, KSS and VAS pain scores improved significantly (p < 0.001): median ROM at two years 85° (range 10-125) and median gain 25° (range -10 to +85). Median VAS satisfaction was 53.5 points (range 15-98). Seventeen patients reported at least one complication, including one re-revision. Six patients underwent manipulation under anaesthesia, and five were referred to the pain clinic. No clear differences between subgroups were observed. CONCLUSIONS TKA revision in patients with severe stiffness resulted in a moderate but significant improved clinical outcome after 2 years. Accompanying abnormalities such as component malposition, aseptic loosening or instability did not influence clinical outcome. Realistic patient counselling on the moderate outcome and possible remaining limitations in daily life might help to improve patient satisfaction. LEVEL OF EVIDENCE Therapeutic studies-case series with no comparison group, Level IV.
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Affiliation(s)
| | - J H M Goosen
- Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, Netherlands
| | - J J P Schimmel
- Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, Netherlands
| | - K C Defoort
- Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, Netherlands
| | | | - A B Wymenga
- Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, Netherlands
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Newman JM, de Paz Nieves A, Cáceres Sánchez L, Lee YY, Gonzalez Della Valle A. Women and Minorities Are at Risk of Developing Unexpected Reduction of Preoperative Flexion After Total Knee Arthroplasty. J Arthroplasty 2016; 31:781-5. [PMID: 26654488 DOI: 10.1016/j.arth.2015.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/22/2015] [Accepted: 10/23/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Reduced flexion after total knee arthroplasty (TKA) compared to the preoperative values can affect patient's activities of daily living and lead to patient dissatisfaction. The aim of this study was to determine preoperative risk factors for developing a decrease in knee flexion after a primary TKA. METHODS We identified 37 knees diagnosed with osteoarthritis with a preoperative knee flexion ≥120° but a 12-month postoperative range of motion (ROM) ≤110°. A random sample of 111 patients (1:3) from the same database, whose knees had a preoperative and 12-month postoperative ROM ≥120°, based on a diagnosis of primary osteoarthritis and no previous open knee surgery, were selected as the controls. RESULTS We found female gender, black ethnicity, and the low preoperative knee-specific Knee Society Score to be significant risk factors for developing a reduction of knee flexion after TKA with odds ratios of 3.48, 5.11, and 0.95, respectively. CONCLUSION In the absence of the well-recognized preoperative risk factors for a limited postoperative ROM, female patients, minorities, and those with lower knee-specific Knee Society Scores are at an increased risk of developing a decrease in flexion after an elective primary TKA.
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Affiliation(s)
- Jared M Newman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Ana de Paz Nieves
- Department of Orthopaedic Surgery, University Hospital of Móstoles, Móstoles, Madrid, Spain
| | - Libertad Cáceres Sánchez
- Department of Orthopaedic Surgery, Hospital San Juan de Dios del Aljarafe, Bormujos, Seville, Spain
| | - Yuo-Yu Lee
- Department of Biostatistics and Epidemiology, Hospital for Special Surgery, New York, New York
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Mamarelis G, Sunil-Kumar KH, Khanduja V. Timing of manipulation under anaesthesia for stiffness after total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:316. [PMID: 26697476 DOI: 10.3978/j.issn.2305-5839.2015.10.09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Stiffness following total knee arthroplasty (TKA) is a debilitating condition for the patient with limitation of functional outcome. There are various causes of stiffness, which can be classified as pre-operative, per-operative and post-operative. Arthrofibrosis is one of the causes, which can be managed in different ways, and manipulation under anaesthesia (MUA) is routinely performed as the first line of management. The timing of MUA is often debated. We review the paper by Issa et al., which looks at the effect of timing of manipulation on a stiff TKA. They conclude that early manipulation within 12 weeks of performing the TKA had a higher mean flexion gain (36.5°), higher final range of motion (ROM) (119°) and higher knee society score (89 points) compared to those performed after 12 weeks which were 17°, 95° and 84 points respectively. Other studies have also reinforced the idea that early manipulation within 12 weeks has a better outcome than those performed after 12 weeks. There may still be a benefit of manipulation until 26 weeks after which open arthrolysis may be needed to improve ROM.
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Affiliation(s)
- Georgios Mamarelis
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Karadi Hari Sunil-Kumar
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Vikas Khanduja
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Choi HR, Siliski J, Malchau H, Freiberg A, Rubash H, Kwon YM. How often is functional range of motion obtained by manipulation for stiff total knee arthroplasty? INTERNATIONAL ORTHOPAEDICS 2014; 38:1641-5. [PMID: 24993649 DOI: 10.1007/s00264-014-2421-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 06/08/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate how often manipulation under anesthesia (MUA) can achieve functional flexion ≥ 90 degrees and identify predictor for successful outcome of MUA for stiff total knee arthroplasty (TKA). METHODS Demographic data, range of motion, and surgical and anesthetic information of 143 MUAs were retrospectively analyzed from 2000 to 2011. RESULTS One-hundred thirty-six out of 143 patients (95 %) improved mean range of motion (ROM) from pre-MUA 62 ± 17° to final ROM 101 ± 21° (p < 0.001). Flexion ≥ 90 degrees was achieved in 74% (106/143) of patients. Regional anesthesia was identified as predictor of successful MUA outcome (p = 0.007, OR: 8.5, 95% CI: 1.2-66.7). CONCLUSIONS Although the proportion of patients regaining flexion ≥ 90 degrees following MUA was less than those patients with simple overall ROM increase, the functional flexion ≥ 90 degrees was achieved in the vast majority of patients with stiff TKA following MUA.
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Affiliation(s)
- Ho-Rim Choi
- Massachusetts General Hospital, Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
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Manipulation for stiffness following total knee arthroplasty: when and how often to do it? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:1291-5. [DOI: 10.1007/s00590-013-1387-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 11/28/2013] [Indexed: 10/25/2022]
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Nawghare S, Brooks S. Manipulation under anesthesia for stiffness after total knee replacement: A systematic review. JOURNAL OF ORTHOPAEDICS AND ALLIED SCIENCES 2013. [DOI: 10.4103/2319-2585.117381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kim GK, Mortazavi SMJ, Parvizi J, Purtill JJ. Revision for stiffness following TKA: a predictable procedure? Knee 2012; 19:332-4. [PMID: 21839638 DOI: 10.1016/j.knee.2011.06.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 06/05/2011] [Accepted: 06/22/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Stiffness is a known complication following total knee arthroplasty. Multiple options are available to address this problem but revision TKA has been reported to be an effective treatment especially in the presence of technical issues such as oversized or loose components. However, it is not clearly known what factors may affect the outcome of revision TKA for stiffness. The purpose of this study was to evaluate the results of TKA revision for stiffness and to determine which potential factors may predict the outcome. MATERIALS AND METHODS Between 1999 and 2006, 39 patients (24 females and 15 males) were revised for stiffness following their primary TKA. The average age was 60.8 years with an average BMI of 30.7. The mean follow up was 74.4 months. RESULTS Following revision TKA, the overall range of motion and flexion contracture improved significantly from 68 to 90 (p=0.001) and from 14 to 5 (p<0.0001), respectively. Although the KSS were significantly improved from 45.72 to 77.10 (p<0.0001), the functional score did not improve significantly. Of the 39 knees which had stiffness, 10 (25.6%) required a second revision. We could not find any demographic or operative characteristics as a predictor failure. CONCLUSION Our study shows that TKA revision is a viable option, still unpredictable, to improve the ROM in patients with prolonged stiffness after TKA. Although revision for stiffness is not always successful in terms of achieving functional range of motion, it could improve pain in presence of less than functional range of motion. LEVEL OF EVIDENCE Prognostic Level II.
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Affiliation(s)
- Gregory K Kim
- Rothman Institute of Orthopedics at Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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Lanting BA, Snider MG, Chess DG. Effect of polyethylene component thickness on range of motion and stability in primary total knee arthroplasty. Orthopedics 2012; 35:e170-4. [PMID: 22310401 DOI: 10.3928/01477447-20120123-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Total knee arthroplasty (TKA) is a common procedure with good survivorship and functional results. Optimal results are dependent on proper osseous cuts and soft tissue balancing. Soft tissue tensioning via the polyethylene spacer thickness is an important component of soft tissue balancing. Increased thickness increases soft tissue tension and, therefore, has the potential to increase stability but decrease range of motion (ROM). Decreased polyethylene thickness may decrease soft tissue tension and has the potential to increase ROM but decrease stability. Using computer-based navigation, the intraoperative effect of increasing and decreasing polyethylene thickness in 1-mm increments on ROM and coronal stability throughout the ROM of 35 patients was examined. It was found that increasing the polyethylene thickness by 1-mm increments had a statistically significant impact on the ability to achieve full extension but had no impact on flexion. Increased polyethylene thickness decreased coronal plane motion. Coronal plane laxity increased with increased flexion irrespective of polyethylene thickness. In this patient cohort, lateral laxity became >1° when the knee was flexed. However, medial structures prevented valgus angulation of >1° in all scenarios except when the polyethylene was diminished by 2 mm. Changes in polyethylene thickness had an impact on the ability to gain full extension and coronal plane motion.
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Affiliation(s)
- Brent A Lanting
- Department of Orthopaedics, St. Joseph’s Health Care, 268 Grosvenor St, D0-213, London, Ontario N6A 4L6, Canada.
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Malik A, Salas A, Ben Ari J, Ma Y, González Della Valle A. Range of motion and function are similar in patients undergoing TKA with posterior stabilised and high-flexion inserts. INTERNATIONAL ORTHOPAEDICS 2010; 34:965-72. [PMID: 19841920 PMCID: PMC2989050 DOI: 10.1007/s00264-009-0865-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 08/18/2009] [Accepted: 08/19/2009] [Indexed: 12/01/2022]
Abstract
It is debatable whether high-flexion (HF) total knee arthroplasty (TKA) designs will improve postoperative flexion and function or will diminish the need for manipulation under anaesthesia (MUA). We retrospectively analysed range of motion (ROM), flexion, Knee Society Score (KSS), and rate of MUA in a consecutive group of patients who underwent TKA with a conventional posterior stabilised (PS) insert or an HF insert using identical surgical technique, implant design, and postoperative care. Fifty TKAs with a standard PS insert were matched for patient's age, gender, preoperative ROM, and KSS with 50 TKA performed with an HF insert. The patient's ROM and KSS were evaluated at six weeks, four months, and one year postoperatively. The outcome variables (flexion, ROM, KSS, and manipulation rate) in both groups were compared using the generalised estimating equations method. A second analysis of patients with preoperative flexion ≥120° was performed. The ROM, flexion, and patient-reported KSS was similar in both groups at each time period. The rate of MUA was also similar. Patients with a preoperative ROM of at least 120° showed similar results. Our study found that one year after surgery, patients who underwent TKA with a PS or an HF insert achieved similar flexion, ROM, and function.
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Affiliation(s)
- Aamer Malik
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Abstract
Stiffness after total knee replacement (TKR) is a frustrating complication that has many possible causes. Although the definition of stiffness has changed over the years, most would agree that flexion <75° and a 15° lack of extension constitutes stiffness. The management of this potentially unsatisfying situation begins preoperatively with guidance of the patient's expectations; it is well-known that preoperative stiffness is strongly correlated with postoperative lack of motion. At the time of surgery, osteophytes must be removed and the components properly sized and aligned and rotated. Soft tissue balancing must be attained in both the flexion/extension and varus/valgus planes. One must avoid overstuffing the tibiofemoral and/or patellofemoral compartments with an inadequate bone resection. Despite these surgical measures and adequate pain control and rehabilitation, certain patients will continue to frustrate our best efforts. These patients likely have a biological predisposition for formation of scar tissue. Other potential causes for the stiff TKR include complex regional pain syndrome or joint infection. Close follow-up of a patient's progress is crucial for the success in return of range of motion. Should motion plateau early in the recovery phase, the patient should be evaluated for manipulation under anesthesia. The results of reoperations for a stiff TKR are variable due to the multiple etiologies. A clear cause of stiffness such as component malposition, malrotation, or overstuffing of the joint has a greater chance of regaining motion than arthrofibrosis without a clear cause. Although surgical treatment with open arthrolysis, isolated component, or complete revision can be used to improve TKR motion, results have been variable and additional procedures are often necessary.
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Affiliation(s)
- Edwin P Su
- Hospital for Special Surgery, New York, New York, USA.
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Abstract
Stiffness after a revision total knee arthroplasty (TKA) is a disabling complication that has largely been overlooked in the literature. This study attempts to define the prevalence of stiffness after revision TKA and to determine the risk factors that may lead to its development. Thirty-two knees (4.0%) presented with stiffness that we defined as a range of motion less than 90 degrees . Risk factors were found to be poor preoperative range of motion, stiffness as primary indication for revision, younger age, shorter interval between index primary and revision TKA, presence of well-fixed components at the time of revision, postoperative wound drainage, and lower Charlson index. Because of the challenges of treating stiffness, efforts should be invested in preventing this complication.
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Hartman CW, Ting NT, Moric M, Berger RA, Rosenberg AG, Della Valle CJ. Revision total knee arthroplasty for stiffness. J Arthroplasty 2010; 25:62-6. [PMID: 20621436 DOI: 10.1016/j.arth.2010.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 04/01/2010] [Indexed: 02/01/2023] Open
Abstract
Few studies have evaluated the results of revision of well-fixed components for stiffness, and some authors have recommended against this intervention based on poor reported results. Thirty-five consecutive patients underwent revision of both femoral and tibial components for stiffness. At a mean of 54.5 months (range, 25-134), the mean arc of motion improved by 44.5 degrees from a preoperative mean of 53.6 degrees to a postoperative mean of 98.1 degrees (P < .0001). The arc of motion improved by more than 30 degrees in 75% (24/32) of patients evaluated at a minimum of 2 years. Seventeen (49%) of the 35 patients required a further intervention for stiffness or sustained a complication. These results suggest that revision total knee arthroplasty for stiffness can be performed with a reasonable expectation of improvement, although the risk of complications and additional operative procedures is substantial.
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Affiliation(s)
- Curtis W Hartman
- Department of Orthopaedic Surgery, University of Nebraska Medical Center Omaha, Nebraska 68198, USA
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Ahmed TAE, Hincke MT. Strategies for articular cartilage lesion repair and functional restoration. TISSUE ENGINEERING PART B-REVIEWS 2010; 16:305-29. [PMID: 20025455 DOI: 10.1089/ten.teb.2009.0590] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Injury of articular cartilage due to trauma or pathological conditions is the major cause of disability worldwide, especially in North America. The increasing number of patients suffering from joint-related conditions leads to a concomitant increase in the economic burden. In this review article, we focus on strategies to repair and replace knee joint cartilage, since knee-associated disabilities are more prevalent than any other joint. Because of inadequacies associated with widely used approaches, the orthopedic community has an increasing tendency to develop biological strategies, which include transplantation of autologous (i.e., mosaicplasty) or allogeneic osteochondral grafts, autologous chondrocytes (autologous chondrocyte transplantation), or tissue-engineered cartilage substitutes. Tissue-engineered cartilage constructs represent a highly promising treatment option for knee injury as they mimic the biomechanical environment of the native cartilage and have superior integration capabilities. Currently, a wide range of tissue-engineering-based strategies are established and investigated clinically as an alternative to the routinely used techniques (i.e., knee replacement and autologous chondrocyte transplantation). Tissue-engineering-based strategies include implantation of autologous chondrocytes in combination with collagen I, collagen I/III (matrix-induced autologous chondrocyte implantation), HYAFF 11 (Hyalograft C), and fibrin glue (Tissucol) or implantation of minced cartilage in combination with copolymers of polyglycolic acid along with polycaprolactone (cartilage autograft implantation system), and fibrin glue (DeNovo NT graft). Tissue-engineered cartilage replacements show better clinical outcomes in the short term, and with advances that have been made in orthopedics they can be introduced arthroscopically in a minimally invasive fashion. Thus, the future is bright for this innovative approach to restore function.
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Affiliation(s)
- Tamer A E Ahmed
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Case reports: Tantalum debris dispersion during revision of a tibial component for TKA. Clin Orthop Relat Res 2009; 467:1107-10. [PMID: 18941849 PMCID: PMC2650048 DOI: 10.1007/s11999-008-0586-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 10/03/2008] [Indexed: 01/31/2023]
Abstract
Porous tantalum nonmodular tibial components for TKA were introduced in 1999. We revised three well-fixed tantalum tibial trays. For removal, we used osteotomes and revision oscillating saw blades. Removal of the components was laborious and resulted in generation of abundant tantalum debris that seeded the periarticular soft tissues despite meticulous protection with gauze. The retained metallic debris that is visible on postoperative radiographs has the potential for generation of third-body wear. We alert the orthopaedic community about this phenomenon and recommend minimizing the use of motorized revision instruments for removal of trabecular metal implants.
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Salvi AE, Cattaneo A, Bettinsoli R, Larcher E, Ciattoni B. Arthroscopic evaluation of a painful prosthetic knee joint. Knee Surg Sports Traumatol Arthrosc 2008; 16:720-2; author reply 723. [PMID: 18461308 DOI: 10.1007/s00167-008-0539-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 03/28/2008] [Indexed: 10/22/2022]
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