Functional disabilities and satisfaction after total knee arthroplasty in female Asian patients

Strategies to Manage Poorer Outcomes After Hip or Knee Arthroplasty: A Narrative Review of Current Understanding, Unanswered Questions, and Future Directions

PURPOSE

Although hip or knee arthroplasty is generally a successful intervention, it is documented that 15%-30% of patients undergoing arthroplasty report suboptimal outcomes. This narrative review aims to provide an overview of the key findings concerning the management of poorer outcomes after hip or knee arthroplasty.

METHOD

A comprehensive search of articles was conducted up to November 2023 across three electronic databases. Only studies written in English were included, with no limitations applied regarding study design and time.

RESULT

Efficiently addressing poorer outcomes after arthroplasty necessitates a thorough exploration of appropriate methods for assessing recovery following hip or knee arthroplasty, ensuring accurate identification of patients at risk or experiencing poorer recovery. When selecting appropriate outcome measure tools, various factors should be taken into consideration, including understanding patients' priorities throughout the recovery process, assessing psychometric properties of outcome measure tools at different time points after arthroplasty, understanding how to combine/reconcile provider-assessed and patient-reported outcome measures, and determining the appropriate methods to interpret outcome measure scores. However, further research in these areas is warranted. In addition, the identification of key modifiable factors affecting outcomes and the development of interventions to manage these factors are needed.

CONCLUSION

There is growing attention paid to delivering interventions for patients at risk or not optimally recovering following hip or knee arthroplasty. To achieve this, it is essential to identify the most appropriate outcome measure tools, factors associated with poorer recovery and management of these factors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The pre-anesthetic period is the best time to evaluate the knee flexion angle for predicting the flexion angle after total knee arthroplasty: A prospective cohort study

INTRODUCTION

Knee flexion angle (KFA) is one of the most critical factors for evaluating patient functional outcomes after total knee arthroplasty (TKA). Preoperative KFA and intraoperative drop leg test are both accepted as predictors of postoperative KFA after TKA. Preoperative testing performed after anesthesia helps overcome pain-related limitations; however, the KFA measurement timepoint that best predicts KFA at 6 months after TKA has not yet been established.

METHODS

This prospective cohort study recruited patients who underwent unilateral primary TKA at Siriraj Hospital (Bangkok, Thailand) during August 2012 to August 2017. We recorded KFA at the pre-anesthetic phase, post-anesthetic phase, intraoperation using drop leg test, and at 6-months post-operation. Pearson's correlation coefficient was used to evaluate correlation between different measurement timepoints and 6 months after surgery. Those same relationships were evaluated for overall patients, and for patients with KFA <90° (poor KFA), 90-120° (average KFA), and >120° (high KFA).

RESULTS

A total of 165 patients with a mean age of 68.7 years were recruited. Pre-anesthetic KFA measurement had the highest positive correlation with the 6-month KFA (r = 0.771, p<0.05). Post-anesthetic measurement and intraoperative drop leg KFA measurement had moderate positive correlation (r = 0.561, p<0.05) and low positive correlation (r = 0.368, p<0.05) with the 6-month KFA, respectively. The average KFA group had the highest positive correlation between pre-anesthetic KFA measurement and the 6-month KFA (r = 0.711, p<0.05). Predicted 6-month KFA (degrees) adjusted for pre-anesthetic KFA is 45.378 + [0.596 x pre-anesthetic KFA (degrees)] (r = 0.67, p <0.05).

CONCLUSIONS

Pre-anesthetic KFA demonstrated the highest correlation with the final KFA at six months after unilateral primary TKA, especially in the patients who had a preoperative KFA within 90-120°.

Different expectations of patients and surgeons with regard to rotator cuff repair

BACKGROUND

Rotator cuff lesions are a common shoulder pathology mainly affecting patients aged >50 years. This condition is accompanied by not only pain and loss of function but also impaired quality of life and psychological stress. A frequently employed treatment option is arthroscopic repair. But expectations regarding the outcome after surgery might differ between patients and surgeons and therefore lead to dissatisfaction on both sides. The aim of this study was to document patient expectations of a planned arthroscopic rotator cuff repair and compare the results with the assessment of shoulder surgeons.

MATERIALS AND METHODS

A total of 303 patients and 25 surgeons were involved in this study. Patients with partial- or full-thickness tear of the rotator cuff scheduled for arthroscopic repair were included in this study. Preoperatively, they were asked to fill out questionnaires inquiring sociodemographic data, scores of the underlying pathology, as well as expectations regarding the operation with regard to pain relief, gain of range of motion and strength, as well as the effect on activities of daily life, work, and sports. Furthermore, 25 surgeons were surveyed on what they think their patients expected using the same standardized questions.

RESULTS

Among the patients, 43.9% considered gain of range of motion to be the most important goal after rotator cuff repair, followed by pain relief (30.6%) and gain of force (13.7%). Among the surgeons, 72% believed pain relief to be the most important for their patient followed by movement (20%) and strength (8%). When asked which parameter was the most important to achieve after operation, for patients, movement was on first place, pain second, and strength third. For shoulder specialists, the ranking was pain, movement, and strength. Surgeons significantly overrated pain relief when ranking against movement compared with their patients.

CONCLUSION

The expectations of patients regarding their operation differ from the surgeon's assessment. Whereas gaining range of motion was more important for patients, surgeons clearly voted for pain relief. Different expectations should therefore be discussed within the pretreatment interview and taken into account when planning the right therapy. This might lead to better satisfaction on both sides.

No Effect of Oral Mecobalamin on Skin Numbness at 3 Months After Total Knee Arthroplasty

An area of skin numbness (AON) around an incision commonly occurs following total knee arthroplasty (TKA). Mecobalamin has been shown to facilitate peripheral nerve recovery in various conditions; accordingly, the present study aimed to investigate the ameliorative effect of mecobalamin on AON following TKA, as compared with a placebo.

A high degree of knee flexion after TKA promotes the ability to perform high-flexion activities and patient satisfaction in Asian population

Background

This study investigated whether achieving a higher degree of knee flexion after TKA promoted the ability to perform high-flexion activities, as well as patient satisfaction and quality of life.

Methods

Clinical data on 912 consecutive primary TKA cases involving a single high-flexion posterior stabilized fixed-bearing prosthesis were retrospectively analyzed. Demographic and clinical data were collected, including knee flexion angle, the ability to perform high-flexion activities, and patient satisfaction and quality of life.

Results

Of the cases, 619 (68%) achieved > 130° of knee flexion after TKA (high flexion group). Knee flexion angle and clinical scores showed significant annual changes, with the maximum improvement seen at 5 years and slight deterioration observed at 10 years postoperatively. In the high flexion group, more than 50% of the patients could not kneel or squat, and 35% could not stand up from on the floor. Multivariate analysis revealed that > 130° of knee flexion, the ability to perform high-flexion activities (sitting cross-legged and standing up from the floor), male gender, and bilateral TKA were significantly associated with patient satisfaction after TKA, while the ability to perform high-flexion activities (sitting cross-legged and standing up from the floor), male gender, and bilateral TKA were significantly associated with patient quality of life after TKA.

Conclusions

High knee flexion angle (> 130°) after TKA increased the ease of high-flexion activities and patient satisfaction. The ease of high-flexion activities also increased quality of life after TKA in our Asian patients, who frequently engage in these activities in daily life.

Joint line elevation is not associated with mid-flexion laxity in patients with varus osteoarthritis after total knee arthroplasty

PURPOSE

Previous cadaver studies showed that the additional bone cuts in the distal and posterior femur and joint line elevation resulted in laxity at mid-flexion after total knee arthroplasty (TKA). However, these results are not always applicable to TKA candidates because the related studies used cadaver knees with no osteoarthritis. It was hypothesized that the joint line elevation results in mid-flexion laxity after TKA in patients with knee osteoarthritis. The purpose of this study was to analyze the relationship between joint line elevation and mid-flexion laxity in patients with knee osteoarthritis.

METHODS

30 knees with varus osteoarthritis undergoing TKA were evaluated. Two femoral trial component models were prepared: (1) normal model with a thickness of the distal and posterior femoral components of 9 mm, and (2) 2-mm joint line elevation model with a thickness of the distal and posterior femoral components of 9 - 2 = 7 mm. This 2-mm joint line elevation model simulated an additional bone cut in the distal and posterior femur, and joint line elevation, without an additional bone cut. The femoral trial component models were set before implantation and measured the joint gap kinematics using a tensor device through the full knee range of motion.

RESULTS

The differences in joint gap change from 30° to 90° were not statistically significant between the two models. However, the joint line elevation model decreased the joint gap laxity at 120° (p = 0.02) and at 145° (p = 0.01).

CONCLUSIONS

This study showed that a 2-mm joint line elevation was not associated with mid-flexion laxity in patients with varus osteoarthritis in the knee. The results of this study differed from the results in previous cadaver studies.

LEVEL OF EVIDENCE

Therapeutic study, level II, prospective comparative study.

[A Structural Equation Model of Health-Related Quality of Life among Older Women Following Bilateral Total Knee Replacement]

PURPOSE

This study aimed to develop and test a structural equation model of health-related quality of life among older women following bilateral total knee replacement based on a literature review and Wilson and Cleary's model of health-related quality of life.

METHODS

One hundred ninety three women who were diagnosed with osteoarthritis, were older than 65 years, and were between 13 weeks and 12 months of having a bilateral total knee replacement were recruited from an outpatient clinic. Data were collected from July 2017 to April 2018 using a structured questionnaire and medical records. Data were analyzed using SPSS/WIN 22.0, AMOS 22.0, and Smart PLS 3.2.4.

RESULTS

The fitness of the hypothetical model was good, with coefficients of determination (R²) ranging between .28 and .75 and predictive relevance (Q²) between .26 and .73. The standardized root mean square residual of the model fit indices for the hypothetical model was .04; which explained 64.2% of physical and 62.5% of mental health-related quality of life. Self-efficacy, symptom status, functional status, and general health perceptions had a significant direct effect on physical health-related quality of life, while social support, symptom status, and general health perceptions had a significant direct effect on participants' mental-health-related quality of life.

CONCLUSION

To improve the physical and mental quality of life of older women who receive bilateral knee replacement, nursing-based intervention strategies that reduce symptoms, improve functional status, and increase health perceptions, self-efficacy, and social support are needed. The most important factor is the symptom status.

A High Proportion of Patients Have Unfulfilled Sexual Expectations After TKA: A Prospective Study

BACKGROUND

Most patients have high expectations about restoration of the knee function after TKA, expecting a more active life after retirement. However, 20% to 30% of patients report that their expectations are not met postoperatively. Among those unmet expectations may be the anticipation to engage in sexual activity after surgery, but few studies have evaluated sexual activity after arthroplasty.

QUESTIONS/PURPOSES

In this study, our purposes were (1) to evaluate the anticipation and the fulfillment of sexual activity after TKA in men and women, and (2) to identify prognostic factors for the fulfillment of anticipated postoperative sexual activity.

METHODS

This was a prospective, multicenter study of all 1371 patients scheduled for TKA between June 2012 and July 2015. The study was part of the Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS). After screening according to LOAS inclusion criteria, 1213 respondents remained. Our primary study endpoint was whether sexual expectations were met 1 year after TKA; we used the sexual-activity-expectation question from the Hospital for Special Surgery (HSS) Knee Replacement Expectations Survey, which allows the patient to score the result on a 5-point scale. To assess postoperative fulfillment of sexual activity 1 year after TKA, we asked the patient to score the current status of sexual activity on the same 5-point scale: 1 (back to normal), 2 (large improvement), 3 (moderate improvement), 4 (slight improvement), and 5 (does not apply). Patients with incomplete data on the preoperative expectation- and postoperative fulfillment-question of sexual activity were excluded, leaving 71% (866 of 1213) patients for analysis. The difference between the pre- and postoperative scores determined whether expectations of sexual activity were unfulfilled (lower than expected) or fulfilled/exceeded (neutral or higher than expected). Pre- and postoperatively, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Short Form-12 Mental and Physical Component Summary scores (SF-12 MCS and SF-12 PCS), the EuroQoL-5 Dimensions (EQ-5D), and the EQ-5D VAS scale were used. Multivariate regression models were used for analysis.

RESULTS

Preoperatively, 54% patients (467 of 866) anticipated postoperative sexual activity after recovery from surgery. Both genders showed that the proportion who anticipated "back to normal" sexual activity decreased with higher age. Likewise, postoperative fulfillment of anticipated sexual activity was found in 58% (111 of 191 for men; 159 of 276 for women). Younger women (younger than 65 years of age) experienced fulfillment more often compared with younger men. A positive postoperative change in functional and health status was associated with fulfilled/exceeded scores of patients anticipating postoperative sexual activity. A better preoperative health status, the EQ-5D VAS score (odds ratio [OR] 1.02 [95% CI 1.01 to 1.03]; p = 0.006), was associated with a higher likelihood of fulfillment of anticipated postoperative sexual activity.

CONCLUSION

In both men and women, two of five patients who anticipated postoperative sexual activity indicated that their expectation of sexual activity was not met 1 year after TKA. These patients had worse functional recovery scores compared with patients who achieved the anticipated level of sexual activity. The latter is associated with functional recovery. Surgeons should be aware that many patients anticipate restoration of normal sexual activity, and that this may be the expectation for patients of all ages and for women and men alike. The results underscore the need for more qualitative research to understand this topic in greater depth.

LEVEL OF EVIDENCE

Level II, therapeutic study.

High pre- and postoperative symptom burden in non-responders to total knee arthroplasty

OBJECTIVES

One in five patients does not improve in pain with walking (non-responders) 12 months after total knee arthroplasty (TKA). This longitudinal study investigated a broad range of symptoms before and after TKA and evaluated possible differences in symptom distress between responders and non-responders with regards to pain with walking after TKA.

METHODS

Prior to TKA surgery, 182 patients completed a demographic questionnaire and the Memorial Symptom Assessment Scale-Short Form (MSAS-SF). The MSAS-SF was repeated 12 months following TKA. Clinical data were extracted from medical records. Patients were categorized as responders or non-responders based on their trajectories of pain with walking assessed prior to surgery, on postoperative day 4, at 6 weeks, and at 3 and 12 months.

RESULTS

Overall, the most distressful preoperative symptoms were pain, lack of energy, difficulty sleeping, feeling drowsy, worrying, feeling bloated, and problems with sexual interest or activity. However, compared with patients classified as responders to TKA, non-responders had higher total symptom distress scores both preoperatively and 12 months postoperatively. Preoperatively, non-responders scored higher than responders on five of the seven most distressing symptoms (i.e., all except difficulty sleeping and feeling bloated), and 12 months postoperatively, non-responders scored higher than responders on six of the seven most distressing symptoms (i.e., all but feeling bloated). In a multivariate analysis, higher preoperative distress scores for pain and problems with sexual interest or activity were significant predictors of non-response to TKA, controlling for other relevant factors.

CONCLUSIONS

Patients' preoperative symptom burden may be a useful indicator of their risk for non-improvement following TKA surgery. Future studies need to evaluate the effect of reducing patients' preoperative symptom burden on TKA outcomes.

Comparison of Posterior Cruciate-Retaining and High-Flexion Cruciate-Retaining Total Knee Arthroplasty Design

BACKGROUND

High-flexion prostheses have been developed to achieve deep flexion after total knee arthroplasty. The purpose of this study is to compare standard NexGen (CR, cruciate-retaining) and high-flexion NexGen (CR-flex) total knee prostheses in terms of range of motion, clinical and radiologic outcomes, rates of complications, and survivorship in long-term follow-up.

METHODS

From January 2000 to December 2008, 423 consecutive knees underwent total knee arthroplasty using standard CR or CR-flex prostheses. Fifty-three patients were lost to follow-up or declined to participate and 54 died, leaving 290 knees. The minimum duration of follow-up was 8 years (mean 10.1 years). Physical examination and knee scoring of patients were assessed preoperatively, at 6 months and 1 year after surgery, and annually thereafter. Supine anteroposterior and lateral radiographs and standing anteroposterior hip-to-ankle radiographs were obtained preoperatively and at each follow-up.

RESULTS

Mean postoperative range of motions in the standard CR group and the CR-flex group were similar, showing no significant difference between the 2 groups (P = .853). At the time of the final follow-up, mean total Hospital for Special Surgery scores were similar between the 2 groups (P = .118). Mean Knee Society pain (P = .325) and function scores (P = .659) were also comparable between the 2 groups. Western Ontario and McMaster Universities Osteoarthritis Index score showed no intergroup difference either (P = .586). The mean hip-knee-ankle angle at the final follow-up was approximately the same (P = .940). Mean coronal angles of femoral and tibial component at final follow-up were also similar (P = .211 and P = .764, respectively). The prevalence of the radiolucent line was 0.6% in the standard CR group and 0.9% in the CR-flex group. Estimated survival rate according to Kaplan-Meier survival analysis was 97.2% in the standard CR group and 95.6% in the CR-flex group at mean follow-up of 10.1 years.

CONCLUSION

This study suggests that excellent clinical and radiographic outcomes could be achieved with both standard and high-flexion CR total knee designs. High-flexion CR prosthesis did not show any advantages over the standard design.

Kneeling ability after total knee replacement

Kneeling ability is consistently the poorest patient-rated outcome after total knee replacement (TKR), with 60-80% of patients reporting difficulty kneeling or an inability to kneel.Difficulty kneeling impacts on many activities and areas of life, including activities of daily living, self-care, leisure and social activities, religious activities, employment and getting up after a fall. Given the wide range of activities that involve kneeling, and the expectation that this will be improved with surgery, problems kneeling after TKR are a source of dissatisfaction and disappointment for many patients.Research has found that there is no association between range of motion and self-reported kneeling ability. More research is needed to understand if and how surgical factors contribute to difficulty kneeling after TKR.Discrepancies between patients' self-reported ability to kneel and observed ability suggests that patients can kneel but elect not to. Reasons for this are multifactorial, including knee pain/discomfort, numbness, fear of harming the prosthesis, co-morbidities and recommendations from health professionals. There is currently no evidence that there is any clinical reason why patients should not kneel on their replaced knee, and reasons for not kneeling could be addressed through education and rehabilitation.There has been little research to evaluate the provision of healthcare services and interventions for patients who find kneeling problematic after TKR. Increased clinical awareness of this poor outcome and research to inform the provision of services is needed to improve patient care and allow patients to return to this important activity. Cite this article: EFORT Open Rev 2019;4:460-467. DOI: 10.1302/2058-5241.4.180085.

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.

Current Status and Changes in Pain and Activities of Daily Living in Elderly Patients with Osteoarthritis Before and After Unilateral Total Knee Replacement Surgery

Knee osteoarthritis (OA) is a very common disease in the elderly, and total knee replacement (TKR) surgery is currently considered the most effective treatment. A prospective, observational, repeated measures study was performed to explore the current status and changes in pain and activities of daily living (ADL) in 58 OA elderly patients undergoing unilateral TKR. The Wong–Baker Faces Pain Rating Scale (WBS) for pain and the self-reported Barthel Index for ADL were measured on the day before surgery, 48 hours after surgery, and the day before discharge. Moderate pain was reported before surgery. Pain significantly improved after surgery and before discharge. At all three time points, pain scores were significantly higher in patients who used assistive devices compared to those who did not. Partial independence in ADL was reported before surgery. The ADL scores reported were highest before surgery, and those reported after surgery were lowest. However, ADL scores gradually increased before discharge. ADL scores were higher in the subjects who lived in a detached, single-family homes compared to those who lived in bungalows at all three time points. The results could be used to screen for knee OA elderly patients at high-risk for pain or low ADL and to provide timely intervention strategies as soon as possible.

Pre-operative pressure pain thresholds do not meaningfully explain satisfaction or improvement in pain after knee replacement: a cohort study

OBJECTIVES

Pain sensitization could be a risk factor for poor outcomes after knee replacement surgery (KR) for knee osteoarthritis (KOA). We aimed to evaluate the association between pre-operative central and peripheral pain sensitization measured using a digital pressure algometer and KR outcomes.

METHODS

Consecutive patients with severe KOA listed for KR were recruited. Sociodemographic and symptoms data were collected prior to surgery. Pre-operative pressure pain thresholds (PPTs) were measured using a digital pressure algometer at the index knee and forearm. Patient satisfaction at 6 and 12 months after KR was assessed using a 4-point Likert scale, and dichotomized to satisfied and dissatisfied to KR. Western Ontario and McMaster Universities Index (WOMAC) Pain and function was assessed. The associations between pre-operative PPTs with KR outcomes at 6 and 12 months were evaluated.

RESULTS

Of the 243 patients recruited, response rate at 6 and 12 months were 95.5% and 96.7%. The dissatisfaction rates were 8.2% and 5.1% at 6 and 12 months. There was no statistically significant association between pre-operative index knee or forearm PPTs and patient satisfaction. PPTs measured at the knee, but not the forearm, were weakly associated with change in the WOMAC pain score at 12 months, after adjustment for confounding factors.

CONCLUSION

Pre-operative central sensitization, measured by handheld digital algometry, was not statistically significantly associated with satisfaction or change in pain after KR. Pre-operative peripheral sensitization was associated with change in pain symptoms after KR; however, this association was weak and unlikely to be a meaningful predictor of KR outcome in clinical practice.

Acceptable Functional Outcomes and Patient Satisfaction Following Total Knee Arthroplasty in Asians with Severe Knee Stiffness: A Matched Analysis

Background

This study evaluated outcomes following total knee arthroplasty for severely stiff knees in Asians.

Methods

Registry data of patients undergoing primary total knee arthroplasty between 2004 and 2013 were collected and retrospectively reviewed. Sociodemographic and anthropometric data together with the Oxford Knee Score and the Knee Society Score (Knee Society Knee Score and the Knee Society Function Score) were collected both preoperatively and postoperatively for up to 2 years. Case subjects consisted of patients with a preoperative flexion range of ≤ 20°. Control subjects consisted of patients with a preoperative flexion range of > 90°. Patients were matched for age, sex, and all preoperative scores in a 2:1 fashion. Two-year outcomes and 5-year revision rates were then compared between cases and controls.

Results

There were 28 cases and 56 controls. Cases had a significantly lower body mass index than the controls (p = 0.003) and had a longer hospital stay (p < 0.0001). At 2 years, cases had a significantly lower flexion range (p < 0.001) and a lower Knee Society Function Score (p = 0.020) than the controls. Cases had a significantly greater improvement in the flexion range (p < 0.001) postoperatively than controls. The mean change in functional outcomes at 2 years was comparable between the two groups. Seventy-one percent of the cases and 88% of controls were satisfied. There was a significant difference in the 5-year revision rate (10% vs 0%, p = 0.013). More cases were discharged to a rehabilitation facility compared to controls (p = 0.011). There were no differences in inpatient complication rates.

Conclusions

Functional outcomes and patient satisfaction were acceptable following total knee arthroplasty in Asian patients with severe knee stiffness.

Joint Gap in Mid-Flexion Is Not a Predictor of Postoperative Flexion Angle After Total Knee Arthroplasty

BACKGROUND

Postoperative knee flexion angle is one of the most important outcomes of total knee arthroplasty (TKA). Intraoperative ligament balancing may affect the postoperative range of motion of the knee. However, the relationship between intraoperative ligament balancing and postoperative flexion angle was still controversial. The purpose of this study was to determine whether intraoperative joint gap affects postoperative knee flexion angle or not.

METHODS

Prospective multicenter study of 246 knees with varus osteoarthritis undergoing a posterior-stabilized, mobile-bearing TKA was performed. The joint gap before implantation and after implantation was measured. The joint gap after implantation was measured using a specially designed tensor device with the same shape of a total knee prosthesis at 0°, 30°, 60°, 90°, 120°, and 145° of flexion with the reduction of the patellofemoral joint. Stepwise multiple regression analysis was conducted to determine the predictors of the flexion angle of the knee after the operation.

RESULTS

Predictors were identified in the following 3 categories: (1) preoperative flexion angle, (2) intraoperative flexion angle, and (3) joint gap looseness at 120° of flexion (joint gap after implantation at 120° of flexion - joint gap after implantation at 0° of flexion) (R = 0.472, P < .01).

CONCLUSION

Flexion angle after TKA was not affected by the flexion joint gap looseness before implantation and the joint gap looseness after implantation from 30° to 90° of flexion. Surgeons should notice that joint gap looseness in mid-flexion range did not increase the postoperative knee flexion angle.

Cultural Factors Influencing Osteoarthritis Care in Asian Communities: A Review of the Evidence

With the prevalence of osteoarthritis (OA) increasing internationally, there is a need to study the impact of this disease on culturally diverse populations. Individuals of Asian descent make up more than 60% of the world population, yet comprehensive information on the cultural factors that impact OA care is not available. Scoping review methodology using directed content analysis was employed to identify and analyze existing research on OA care for Asians. A categorization matrix was developed using the six care areas from the OA clinical practice guidelines along with an additional three non-clinical areas (cross-cultural adaptation of clinical tools; psychological well-being; family systems and informal care) identified in an initial scan resulting in a total of nine OA care areas to guide initial coding. A full scoping review was conducted across five databases resulting in 656 abstracts screened. All text was coded using the categorization matrix and resulting subthemes were identified. A total of 74 articles were analyzed with 23 subthemes identified across the nine categories. Four new perspectives emerged to support OA care for Asian populations: (1) the importance of family and peer assistance, (2) the importance of culturally specific activities, (3) distrust in western medicine, and (4) impact of positive coping mechanisms on health appraisals. While Asians are more susceptible to knee and hand OA because of their cultural lifestyle factors (e.g. squatting for chores, hygiene and religious activities), and traditional beliefs on OA management (e.g. traditional diet, topical oils, physical therapy), many do not present themselves for conventional treatments (e.g. surgery) until all traditional treatments are exhausted. The results suggest that cultural factors influence the uptake of OA management practices among Asians. Greater awareness of these cultural factors may improve diagnosis, treatment, and management of OA among Asian patients.

Quality of life after total knee arthroplasty

Total knee arthroplasty (TKA) results in a high degree of patient satisfaction, as it provides patients with considerable medium- and long-term benefits in terms of quality of life, pain relief and function. Nevertheless, the literature reports that up to 30% of patients are dissatisfied. This dissatisfaction is directly related to the patients' quality of life, which they deem insufficient. Their quality of life depends on many physical, behavioural, social and psychological factors that are not taken into account by functional outcome scores. After describing the principles of quality of life evaluation after TKA, we will assess the effects of patient-related factors, the surgical technique and postoperative program through an exhaustive review of the literature. Patient expectations after TKA will then be outlined, particularly return to work and return to sports.

Morphological evaluation of the sagittal plane femoral load-bearing surface in computer-simulated virtual total knee arthroplasty implantation at different flexion angles

PURPOSE

To examine the effect of implantation of the femoral component of a total knee arthroplasty (TKA) system in 0°, 3°, and 6° of flexion on the sagittal plane morphology of the femoral load-bearing surfaces. It was hypothesized that increasing the flexion angle would result in undersizing of the anterior surface without changing the flexion gap.

METHODS

Computer simulation of a TKA using three-dimensional models of 10 healthy knees, matched to three different sized femoral components. Size discrepancy in the sagittal plane anterior, distal, and posterior joint surfaces between the native and prosthetic knees was calculated at 0°, 3°, and 6° of flexion.

RESULTS

The required component size varied with the angle of implantation: 0°, size 3/size 4 (N = 7/3), 3°, size 3 (N = 10); and 6°, size 2/size 3 (N = 4/6). Component undersizing ranged between 4.4-6.3 mm at the anterior lateral surface, with a significant difference between 0° and 6° (p < 0.05), and 1.2-3.5 mm at the anterior medial surface. Component oversizing of the distal surface of the lateral condyle (2.9 mm) and undersizing of the medial surface of the posterior condyle (1.6-2.3 mm) were comparable at all three flexion angles of component implantation.

CONCLUSIONS

Increasing the flexion angle of implantation increased the incidence of using a smaller size of femoral component without significant interference with the flexion gap. However, the effect of a smaller femoral component on undersizing of the anterior surface of the condyle and the impact on the extensor mechanism need to be considered.

The effect of numbness on outcome from total knee replacement

INTRODUCTION Some patients report continuing pain and functional limitations after total knee replacement (TKR). While numbness around the TKR scar is common, the impact of numbness is less clear. One particular activity that could be influenced by numbness is kneeling. The aim of this study was to explore the impact of numbness around TKR scars on health related quality of life and kneeling ability. METHODS Fifty-six patients were recruited one year after primary TKR. Sensation around the knee was assessed through patient self-reporting, monofilament testing and vibration, and patients' distress was measured on a visual analogue scale. Patient reported outcome measures (PROMs) including the Western Ontario and McMaster Universities (WOMAC^®) index, the Knee injury and Osteoarthritis Outcome Score (KOOS), the painDETECT^® (Pfizer, Berlin, Germany) questionnaire and the EQ-5D™ (EuroQol, Rotterdam, Netherlands) questionnaire were used. Participants were also asked about kneeling ability. RESULTS While 68% of patients reported numbness around their TKR scar, there was no statistically significant correlation between numbness and distress at numbness (self-report: 0.23, p=0.08; monofilament: 0.15, p=0.27). Furthermore, numbness did not correlate significantly with joint specific PROMs (WOMAC^®: 0.21, p=0.13; KOOS: 0.18, p=0.19). However, difficulty with kneeling did correlate with both self-reported numbness (0.36, p=0.020) and worse PROM scores (WOMAC^® pain subscale: 0.62, p<0.001; KOOS: 0.64, p<0.001). CONCLUSIONS Numbness after knee replacement is common but is not associated with worse patient reported outcomes.

Improvements in Sexual Activity After Total Knee Arthroplasty

BACKGROUND

Sexual limitations in the setting of total knee arthroplasty (TKA) are poorly understood.

METHODS

Surveys were designed to assess preoperative and postoperative sexual function, and limitations were retrospectively administered to 91 sexually active TKA patients at an average of 2.1 years (range, 0.5-4.0) after surgery. Preoperative and postoperative responses were compared using 1-tailed and 2-proportion z tests, with P < .05 as the threshold for significance.

RESULTS

Before TKA, sexual quality and/or frequency was limited in 45% of patients because of their knee. Patients experienced an average 17.1 months (range, 0-60) of sexual limitations before surgery, resulting largely from pain (87%) and diminished range of motion or flexibility (44%). Fifty-five percent of patients reported the need to change their sexual positions to accommodate their knee, with 97% of these patients indicating the need to avoid kneeling during sex. Postoperatively, fewer patients had to adjust their sexual positions to accommodate their knee (55% vs 28%, P = .0005), and avoid bearing weight on the afflicted knee during sex (97% vs 79%, P = .0213). Patients resumed sexual activity after an average of 2.4 months (range, 0-18). Despite these general improvements, 25% of individuals had less sex in the first year after surgery. After 1 year of recovery, however, 60% indicated that they more easily engaged in sexual activity than in the previous year, with 84% of these patients experiencing less pain, and 30% experiencing greater mobility or range of motion.

CONCLUSION

TKA does not eliminate sexual limitations, but it significantly decreases kneeling dysfunction and gives patients more liberty in selecting their sexual positions.

Distinctions of introarticular force distribution between genesis-II posterior stabilized and cruciate retaining total knee arthroplasty: An intraoperative comparative study of 45 patients

BACKGROUND

Although both the posterior stabilized and cruciate retaining total knee arthroplasty have been proven to effectively relieve pain and restore basic functions, the joint gap width during flexion was reported to be different due to the presence or absence of posterior cruciate ligament, which may lead to different intra-articular force distribution. In this study, we investigated the distinctions in intra-articular force distribution between the two types of TKA designs in patients with varus knee osteoarthritis.

METHODS

Forty five patients (50 knees) with varus knee osteoarthritis were prospectively included, with each 25 knees receiving cruciate retaining and posterior stabilized total knee arthroplasty, respectively. With an intra-articular force measurement system, the intra-articular force distribution with knee flexion at 0°, 30°, 45°, 60°, 90°, and 120° were recorded in all patients.

FINDINGS

The total force was similar for posterior stabilized and cruciate retaining knees at all flexion degrees. However, force in the medial compartment accounted for 59.8%-84.0% of total force in posterior stabilized knees, while 27.4%-65.7% in cruciate retaining knees. In cruciate retaining knees, no significant difference was found between forces in the two compartments at 30° flexion (P=0.444), but force was significantly concentrated in the lateral side during 45°-120° flexion (P=0.000-0.028).

INTERPRETATION

Although the entire intra-articular forces were similar between CR and PS knees at different flexion angles, medial part had higher force than lateral part when PS knee was used. The posterior cruciate ligament do a role in soft balance, and make the force more evenly distributed.

Development and validation of a questionnaire assessing discrepancy between patients' pre-surgery expectations and abilities and post-surgical outcomes following knee replacement surgery

PURPOSE

The discrepancy between patient-desired outcomes and achievable functional outcomes is a source of patient dissatisfaction. This paper reports development and validation of a questionnaire to assess this discrepancy in patients undergoing knee replacement surgery.

METHODS

The initial questionnaire (Knee Surgery Perception Questionnaire, KSPQ) comprised two parts. Part A, assessed patients' perception of their current level of function and pain, and Part B, assessed patients' desired outcomes of the surgery. Validation was carried out for Part A and then applied to Part B using a one-factor congeneric model and was tested in 185 patients preceding surgery. A discrepancy score between patients' expectations and desired outcome (Part B) and their perception of current function (Part A) was also calculated. Pearson correlations were used between the KSPQ total score and subscales and other knee-specific questionnaires to determine construct validity.

RESULTS

The final best set of models included four items for each subscale with a Chi-square value of 7.3 (n.s). The subscales and the total KSPQ showed significant strong to moderate correlations with knee-specific questionnaires. The discrepancy score in each subscale and the overall score showed relatively large discrepancy between patients' expectations and their perception of current function; with higher discrepancy score reported for pain and walking.

CONCLUSION

The KSPQ is a valid questionnaire to assess patients' expected and desired outcomes of knee replacement surgery and their perception of their current abilities and function, and discrepancy between these. The KSPQ now requires further investigation at different stages of recovery following surgery.

LEVEL OF EVIDENCE

III.

Differential knee skin temperature following total knee arthroplasty and its relationship with serum indices and outcome: A prospective study

Objectives To monitor knee skin temperature changes for 12 months following total knee arthroplasty (TKA) and identify potential reasons for any differences in skin temperature and to investigate if there is a relationship between the differential temperature and clinical outcome. Methods Patients who attended for a unilateral TKA due to primary osteoarthritis between August 2012 and August 2014 were eligible for this prospective study. The skin temperature of both knees was monitored preoperatively and postoperatively using an infrared thermometer. Serum indices and Hospital for Special Surgery (HSS) knee scores were assessed. Results Thirty-nine patients were involved in the study. The skin temperature of both knees as well as the differential temperature increased following TKA. Serum haemoglobin, haematocrit and days from surgery showed inverse correlations with the differential temperature, while body mass index and American Society of Anesthesiologists scores showed positive correlations. There was a strong inverse correlation between the differential temperature and HSS. score. Conclusions Differential knee skin temperature elevation 12 months post-TKA may be a normal surgical response.

Active Flexion in Weight Bearing Better Correlates with Functional Outcomes of Total Knee Arthroplasty than Passive Flexion

PURPOSE

Correlations between maximum flexion and functional outcomes in total knee arthroplasty (TKA) patients are reportedly weak. We investigated whether there are differences between passive maximum flexion in nonweight bearing and other types of maximum flexion and whether the type of maximum flexion correlates with functional outcomes.

MATERIALS AND METHODS

A total of 210 patients (359 knees) underwent preoperative evaluation and postoperative follow-up evaluations (6, 12, and 24 months) for the assessment of clinical outcomes including maximum knee flexion. Maximum flexion was measured under five conditions: passive nonweight bearing, passive weight bearing, active nonweight bearing, and active weight bearing with or without arm support. Data were analyzed for relationships between passive maximum flexion in nonweight bearing by Pearson correlation analyses, and a variance comparison between measurement techniques via paired t test.

RESULTS

We observed substantial differences between passive maximum flexion in nonweight bearing and the other four maximum flexion types. At all time points, passive maximum flexion in nonweight bearing correlated poorly with active maximum flexion in weight bearing with or without arm support. Active maximum flexion in weight bearing better correlated with functional outcomes than the other maximum flexion types.

CONCLUSIONS

Our study suggests active maximum flexion in weight bearing should be reported together with passive maximum flexion in nonweight bearing in research on the knee motion arc after TKA.

Three-year follow-up study of health related QOL and lifestyle indicators for Japanese patients after total hip arthroplasty

BACKGROUND

In non-Western countries including Japan, activities requiring deep flexion of the hip joint, such as seiza (kneeling with calves tucked under the thighs and buttocks resting on the heels) and using squat toilets are commonly practiced. The purpose of this study was to assess longitudinal changes in traditional health-related quality of life measures and measures of physical functions associated with lifestyle for Japanese patients pre-surgery and after total hip arthroplasty.

METHODS

Consecutive primary total hip arthroplasty patients between July 2003 and November 2006 were eligible. Patients were measured preoperatively and at 6 weeks, 1 year and 3 years postoperatively. Patients completed the EuroQol 5D, the Western Ontario and McMaster Universities Osteoarthritis Index and items related to Japanese lifestyle activities such as squatting. Changes in these scale scores across the four time points were tested, and we examined predictive factors of EuroQol 5D score at 3-year follow-up using multiple linear regression.

RESULTS

Of 1103 eligible patients, 576 completed questionnaires at all four time points. By 6 weeks post-surgery, reductions in pain and improvements in physical function and stiffness became highly significant, and improvements continued to 3 years postoperative. In contrast, improvements were far more limited for items related to Japanese lifestyle functions such as seiza and use of a Japanese squat toilet, even 3 years after surgery. Predictive factors of EQ5D at 3-year post THA were WOMAC pain and physical function, seiza, age and comorbidity measured at 3-year post THA.

CONCLUSION

The rate of improvement in QOL requiring deep flexion of the hip joint was much slower than that in QOL related to Western lifestyle. Our study suggests a need for lifestyle modification for THA patients in the other countries where kneeling and squatting are commonly performed.

Patient satisfaction after total knee arthroplasty: an Asian perspective

INTRODUCTION

Total knee arthroplasty (TKA) is an effective method for alleviating pain and restoring knee function in patients with severe osteoarthritis. However, despite the improvements in surgical technique and postoperative care, it has been reported that up to 19% of patients are dissatisfied after their operations. The aim of this study was to evaluate patient satisfaction levels after TKA in an Asian cohort, as well as assess the correlation between patient satisfaction levels and the results of traditional physician-based scoring systems.

METHODS

The medical data of 103 Asian patients who underwent 110 TKAs between December 2008 and June 2009 were obtained from our hospital's Joint Replacement Registry. The minimum follow-up period was one year and patient expectations were assessed before TKA. Patient satisfaction was assessed postoperatively using a 5-point Likert scale. Reasons for patient dissatisfaction were recorded. Standardised instruments (e.g. the Knee Society Score, the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and the generic Short Form-36 health survey) were used to assess the patient's functional status and the severity of symptoms pre- and postoperatively.

RESULTS

Among the 110 TKAs performed, 92.8% resulted in patient satisfaction. Patient satisfaction correlated with postoperative WOMAC function scores (p = 0.028), postoperative WOMAC final scores (p = 0.040) and expectations being met (p = 0.033).

CONCLUSION

Although there was a high level of patient satisfaction following TKA in our cohort of Asian patients, a significant minority was dissatisfied. Patient satisfaction is an important outcome measure and should be assessed in addition to traditional outcome scores.

Are the Current Outcome Measurement Tools Appropriate for the Evaluation of the Knee Status in Deep Flexion Range?

We determined whether current outcome measurement tools are appropriate for the evaluation of the knee status in deep flexion range after TKA. Patients (n = 604) with more than 120° of knee flexion were evaluated by Knee Society score, WOMAC, and high flexion knee score (HFKS). The appropriateness of measurement tools was analyzed by correlation analyses and group comparisons (group 1: 120°-129°, group 2: 130°-139°, group 3: 140°-150°). HFKS showed stronger correlation with knee flexion compared with other scores. While other scores only differentiated between groups 2 and 3, HFKS could differentiate among groups 1, 2 and 3. These findings suggest that employment of proper outcome measurement tool is needed to evaluate and differentiate the knee status in deep flexion range after TKA.

The effect of end-of-range grade A+ knee mobilisation following acute primary total knee arthroplasty: A randomised controlled trial

Background/Aims:

Although the number of total knee arthroplasty procedures being performed is increasing worldwide, the rehabilitation protocols following surgery are poorly studied in the literature. Research suggests that exercise therapy and joint mobilisation are recommended in the later stages of osteoarthritis. However, best practice for rehabilitation in the immediate postoperative period is yet to be determined. This prospective randomised controlled trial examined whether adding grade A+ joint mobilisation to the standard in-hospital rehabilitative approach would increase pain (based on recordings of pain intensity on the visual analogue scale) and improve range of motion in the knee.

Methods:

Participants (n=32; mean±SD age: 71.1± 8.9 years) undergoing primary total knee arthroplasty at a university hospital were randomly assigned to two equal groups. Measurements were recorded before surgery and on the first, third and seventh days following total knee arthroplasty. All participants received standard care postoperatively, with participants in the experimental group receiving additional grade A+ joint mobilisation for knee flexion and extension twice a day for 20 minutes using the JAS Knee system (Joint Active Systems®, Effingham, Illinois).

Results:

There were no statistically significant differences in visual analogue scale scores or range of motion in all measurements (p > 0.05). Increased range of motion at a faster pace was observed in the obese subgroup of patients (p = 0.016). Other factors such as age, body mass index, type of anaesthesia and implant model did not influence the final outcome.

Conclusions:

Early grade A+ joint mobilisation combined with the standard in-hospital rehabilitative approach is safe to be used during the post-acute phase of rehabilitation after total knee arthroplasty. Despite increasing trends in the obese subgroup of patients, adding grade A+ joint mobilisation to the standard protocol did not significantly improve overall range of motion. The results of this study and heterogeneities in the literature identify the need for further research and development in this area.

Mobile-bearing prosthesis and intraoperative gap balancing are not predictors of superior knee flexion: a prospective randomized study

PURPOSE

Range of motion is a crucial measure of the outcome of total knee arthroplasty. Gap balancing technique and mobile-bearing prosthesis can improve postoperative range of motion. The purpose of this study was to determine the factors that are predictive of the postoperative range of motion.

METHODS

A total of 94 knees with varus osteoarthritis were prospectively randomized to receive either a posterior-stabilized mobile-bearing or a posterior-stabilized fixed-bearing prosthesis. All preoperative and postoperative protocols and operative techniques were identical in the two groups. Extension and flexion joint gaps were measured using a tensor device during the operation. Multiple regression analysis was conducted to determine the best predictors of the knee flexion angle 2 years after the operation. The independent variables were type of prosthesis (mobile-bearing or fixed-bearing), difference between flexion and extension joint gaps (mm), age, gender, body mass index (BMI), preoperative and intraoperative knee flexion angles, change in posterior condylar offset, and posterior tilt of the tibial plateau.

RESULTS

The mean difference between flexion and extension joint gaps was 0.8 ± 1.3 (mean ± SD) mm for mobile-bearing and 0.8 ± 1.9 mm for fixed-bearing prosthesis. The mean flexion angle for mobile-bearing and fixed-bearing groups was 120 ± 16° and 116 ± 20° preoperatively (n.s.), 142 ± 9° and 141 ± 12° intraoperatively (n.s.), and 129 ± 10° and 128 ± 13° at 2 years postoperatively (p = 0.773), respectively. Predictors were identified in the following three categories: (1) preoperative flexion angle, (2) intraoperative radiographic flexion angle, and (3) BMI (R = 0.603, p < 0.001).

CONCLUSIONS

Mobile-bearing prosthesis and optimal gap balancing did not result in superior postoperative flexion angle. Better preoperative and intraoperative flexion angles and lower BMI were the significant predictors for better postoperative flexion angle.

LEVEL OF EVIDENCE

Therapeutic study, Level I.

Patients still wish for key improvements after total knee arthroplasty

Purpose

Our goals were to rigorously document and explore the interrelationships of various parameters in the aftermath of total knee arthroplasty (TKA), including patient characteristics, clinical scores, satisfaction levels, and patient-perceived improvements.

Materials and Methods

A questionnaire addressing sociodemographic factors, levels of satisfaction, and "wished-for" improvements was administered to 180 patients at least 1 year post primary TKA. Both satisfaction levels and wished-for improvements were assessed through nine paired parameters. Patients responded using an 11-point visual analogue scale (VAS) and the results were summarized as mean VAS score. Correlations between clinical scores and satisfaction levels and between satisfaction levels and desired improvements were analyzed.

Results

Patient satisfaction levels were only modest (mean score, 4-7) for eight of the nine parameters, including pain relief and restoration of daily living activities, the top two ranked parameters in wished-for improvement while high-flexion activity constituted the top source of discontent. Wished-for improvement was high in seven parameters, the top three being restoration of daily living activities, pain relief, and high-flexion activity. The effects of sociodemographic factors on satisfaction levels and wished-for improvement varied. Satisfaction levels correlated positively with functional outcomes, and satisfaction in pain relief and restoration of daily living activities correlated more often and most strongly with clinical scores.

Conclusions

Following TKA, patient satisfaction is not high for a number of issues, with improvements clearly needed in restoring daily living activities and relieving pain. Continued efforts to achieve better surgical outcomes should address patient-perceived shortcomings.

The impact of total joint arthroplasty on sexual function in young, active patients

There is limited information regarding sexual function following total hip (THA) and knee arthroplasty (TKA). A multicenter study of 806 THA, 542 TKA, and 181 control patients less than 60 years of age was conducted using an independent survey center to question subjects about their sexual function. Only 1.3% of THA and 1.6% of TKA patients stated they were not sexually active due to their operation. No significant differences were noted in sexual function based on the bearing surface, femoral head size, or use of surface replacement arthroplasty in the hip cohort. Multivariate analysis revealed no difference in the percentage of patients sexually active following a THA or TKA (OR 1.19, P=0.38). Most young active patients return to sexual activity after hip and knee arthroplasty.

Chinese patients' satisfaction with total hip arthroplasty: what is important and dissatisfactory?

Through validated self-administered questionnaires, we conducted a retrospective investigation in 818 patients (1009 hips) who underwent primary THA, to collect data on overall satisfaction plus satisfaction and importance rating for 16 specific functions and issues. Overall, 8.1% patients were dissatisfied with the surgery. The top 3 important items are pain relief, squatting, and walking. The top 3 dissatisfactory items are jogging, squatting, and rising after squatting. The strongest risk factors for dissatisfaction with walking were pain (6.1×), muscle weakness(3.7×), and LLD (3.3×). The strongest risk factors for dissatisfaction with squatting were low postoperative HHS ROM (3.7×) and muscle weakness (2.6×). For Chinese patients, ROM, muscle strength and LLD are very important.

Differences in anatomy and kinematics in Asian and Caucasian TKA patients: influence on implant positioning and subsequent loading conditions in mobile bearing knees

The objective of our study was to determine the mechanical stress conditions under tibiofemoral loading with an overlay of knee kinematics in deep flexion on two different mobile bearing designs in comparison to in vivo failure modes. This study investigates the seldom but severe complication of fatigue failure of polyethylene components at mobile bearing total knee arthroplasty designs. Assuming a combination of a floor-based lifestyle and tibial malrotation as a possible reason for a higher failure rate in Asian countries we developed a simplified finite element model considering a tibiofemoral roll-back angle of 22° and the range of rotational motion of a clinically established floating platform design (e.motion FP) at a knee flexion angle of 120° in order to compare our results to failure modes found in retrieved implants. Compared to the failure mode observed in the clinical retrievals the locations of the occurring stress maxima as well as the tensile stress distribution show analogies. From our observations, we conclude that the newly introduced finite element model with an overlay of deep knee flexion (lateral roll-back) and considerable internally rotated tibia implant positioning is an appropriate analysis for knee design optimizations and a suitable method to predict clinical failure modes.

Quality of life after total knee arthroplasty: systematic review

Objective

To review the literature on quality of life among patients who underwent total knee arthroplasty (TKA) and assess the impact of various associated factors.

Methods

this was a systematic review of the literature in the Medline, Embase, Lilacs and SciELO databases, using the terms: TKA (total knee arthroplasty); TKR (total knee replacement); quality of life; and outcomes. There were no restrictions regarding study design.

Results

31 articles addressing this topic using various quality-of-life evaluation protocols were selected. SF-36/SF-12, WOMAC and Oxford were the ones most frequently used. The studies made it possible to define that TKA is capable of making an overall improvement in patients’ quality of life. Pain and function are among the most important predictors of improvement in quality of life, even when function remains inferior to that of healthy patients.

Conclusion

The factors associated negatively were obesity, advanced age, comorbidities, persistence of pain after the procedure and a lengthy wait for surgery.

Patient satisfaction after posterior-stabilized total knee arthroplasty: a functional specific analysis

BACKGROUND

Despite the success of total knee arthroplasty (TKA) in treating end-stage knee arthritis, 11% to 19% of patients are dissatisfied with the outcome of their surgery. In this study we investigated how satisfied overall patients are with the outcome of posterior stabilized TKA and what particular functional deficits or residual symptoms cause the most dissatisfaction for patients after surgery.

METHODS

Using patient-completed validated questionnaires, we retrospectively analyzed data for 1013 posterior-stabilized TKAs performed in 748 Chinese patients regarding the overall satisfaction with surgery and the importance ranking of each of 15 specific functions and residual symptoms.

RESULTS

Our data demonstrate an overall satisfaction rate of 87.4%. Satisfaction percentages ranged from 45.0% to 89.0%. The top 6 dissatisfactory items were sitting with legs crossed (dissatisfaction rate of 55.0%), squatting (51.7%), walking fast or jogging (45.4%), knee clunking (34.5%), abnormal feeling in knee (31.2%), and climbing stairs (28.2%). The top 6 important functions or issues were pain relief, walking on flat ground, climbing stairs, ability to return to household work, decreased limping, and squatting.

CONCLUSIONS

Approximately 1 in 8 patients was dissatisfied with overall outcome. Patients were most dissatisfied with climbing stairs and squatting, functions that they considered most important.

[Satisfaction after total knee arthroplasty. Comparison of 1990-1999 with 2000-2012]

Total knee arthroplasty (TKA) is one of the most common operations in orthopedic surgery worldwide but despite being mainly successful only 81 % of patients are satisfied with the final result. The following systematic review compared patient satisfaction and analyzed the causal connections and influencing factors after TKA between 1990-1999 and 2000-2012. From 1990 to 1999 a total of 81.2 % of patients were satisfied after TKA and in the period 2000-2012 patient satisfaction increased to 85 %. Influencing factors on postoperative satisfaction derived from the 25 publications included in the study were consistently body-mass index, patient expectations, pain, joint function and mental factors. A lack of satisfaction scores and different designs resulted in difficulties in comparing the studies and were subsequently limitations of this study.

Comparison of stress on knee cartilage during kneeling and standing using finite element models

Kneeling is a common activity required for both occupational and cultural reasons and has been shown to be associated with an increased risk of knee disorders. While excessive contact pressure is considered to be a possible aggressor, it is not clear whether and to what extent stress on the cartilage during kneeling is different from that while standing. In this study, finite element models of the knee joint for both kneeling and standing positions were constructed. The results indicated differences in high-stress regions between kneeling and standing. And both the peak von-Mises stress and contact pressure on the cartilage were larger in kneeling. During kneeling, the contact pressure reached 4.25 MPa under a 300 N compressive load. It then increased to 4.66 MPa at 600 N and 5.15 MPa at 1000 N. Changing the Poisson's ratio of the cartilage, which represents changes in compressibility caused by different loading rates, was found to have an influence on the magnitude of stress.

Fixation of high-flexion total knee prostheses: five-year follow-up results of a four-arm randomized controlled clinical and roentgen stereophotogrammetric analysis study

BACKGROUND

High-flexion total knee arthroplasty was introduced to meet the demands of daily activity requiring increased knee flexion. However, concerns have been raised regarding the fixation of high-flexion total knee arthroplasty components and increased rates of loosening have been reported. To date, migration, and thus fixation, of high-flexion total knee arthroplasty components has not been analyzed and the preferential bearing type (mobile or fixed) is unknown.

METHODS

Of eighty-six consecutive eligible patients, seventy-four patients (seventy-eight knees) scheduled for total knee arthroplasty were randomized to one of four Legacy Posterior Stabilized (LPS) total knee prosthesis designs: (1) LPS-Flex mobile, (2) LPS-Flex fixed, (3) LPS mobile, and (4) LPS fixed. The primary outcome was component migration measured with use of Roentgen stereophotogrammetric analysis, and secondary outcomes were postoperative knee flexion and extension and Knee Society Score. Patients were evaluated postoperatively at six, twelve, twenty-six, and fifty-two weeks and annually thereafter. At the five-year follow-up, eight patients had died and two patients were lost to follow-up. Seventy-seven tibial and forty-two femoral components were suitable for migration measurements.

RESULTS

The overall five-year migration of the seventy-seven tibial components was not significantly different among the four total knee prosthesis designs (compared with the LPS fixed design, the range of overall mean differences for the other three designs was 0.02 to 0.25 mm) and migration was comparable at the two and five-year follow-up. Migration stabilized in all but three components (two LPS-Flex mobile and one LPS fixed); one of these components has already been revised and was aseptically loose. The overall five-year migration of the forty-two femoral components was comparable among the four designs (compared with the LPS fixed design, the range of overall mean differences for the other three designs was 0.01 to 0.18 mm) and was similar at two and five years postoperatively. One femoral component (LPS-Flex mobile) migrated excessively. In patients who had a mean postoperative flexion of ≥ 125° or a maximum flexion of ≥ 135° during the one to five-year follow-up period, migration of high-flexion components was comparable with that of conventional components and indicative of appropriate fixation. Postoperative flexion, extension, Knee Society Score, and Knee Society Score function were comparable during the five-year follow-up period and at the two and five-year follow-up.

CONCLUSIONS

The LPS-Flex total knee prosthesis with either a mobile or a fixed bearing had migration comparable that of with its conventional counterpart and is expected to have similar (excellent) long-term survival in these patients.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Is greater than 145{degrees} of deep knee flexion under weight-bearing conditions safe after total knee arthroplasty?: a fluoroscopic analysis of Japanese-style deep knee flexion

We investigated the characteristics of patients who achieved Japanese-style deep flexion (seiza-sitting) after total knee replacement (TKR) and measured three-dimensional positioning and the contact positions of the femoral and tibial components. Seiza-sitting was achieved after surgery by 23 patients (29 knees) of a series of 463 TKRs in 341 patients. Pre-operatively most of these patients were capable of seiza-sitting, had a lower body mass index and a favourable attitude towards the Japanese lifestyle (27 of 29 knees). According to two-/three-dimensional image registration analysis in the seiza-sitting position, flexion, varus and internal rotation angles of the tibial component relative to the femoral component had means of 148° (SD 8.0), 1.9° (SD 3.2) and 13.4° (SD 5.9), respectively. Femoral surface contact positions tended to be close to the posterior edge of the tibial polyethylene insert, particularly in the lateral compartment, but only 8.3% (two of 24) of knees showed femoral subluxation over the posterior edge. The mean contact positions of the femoral cam on the tibial post were located 7.8 mm (sd 1.5) proximal to the lowest point of the polyethylene surface and 5.5 mm (SD 0.9) medial to the centre of the post, indicating that the post-cam contact position translated medially during seiza-sitting, but not proximally. Collectively, the seiza-sitting position seems safe against component dislocation, but the risks of posterior edge loading and breakage of the tibial polyethylene post remain.

No better flexion or function of high-flexion designs in Asian patients with TKA

BACKGROUND

Recently, high-flexion PCL-retaining (CR) and -substituting (PS) knee prostheses were designed to allow greater and safer flexion after TKA. However, the advantages of high-flexion TKA over standard design have been debated in terms of early maximal flexion. A recent study reported a high incidence of early loosening of the femoral component related to the deep flexion provided by high-flexion PS TKA.

QUESTIONS/PURPOSES

We determined whether high-flexion fixed bearing CR and PS prostheses would provide (1) a better flexion, (2) a better function, and (3) a higher incidence of radiographic loosening than TKA performed using standard fixed bearing CR prostheses in Asian patients.

METHODS

From a total of 182 patients with primary unilateral TKA, we retrospectively reviewed 137 TKAs: 47 with high-flexion CR, 42 with high-flexion PS, and 48 with standard CR designs. ROM, Knee Society scores, and WOMAC scores were evaluated and compared among the three groups. Radiographically, we assessed radiolucent zones and component loosening. Minimum followup was 5 years (mean, 6.2 years; range, 5-8 years).

RESULTS

We found no differences among the three groups in mean maximal flexion (high-flexion CR: 135°; high-flexion PS: 134°; standard CR: 136°), Knee Society scores, and WOMAC scores at last followup. Also, there were no differences among the three groups in terms of radiolucent lines around the prosthesis. No patient in any group had loosening of the femoral component.

CONCLUSIONS

The high-flexion CR or PS design had no advantages over the standard CR design with respect to ROM, clinical scores, and radiolucent lines around the femoral or tibial component after 5 years' followup.

High-flexion prosthesis improves function of TKA in Asian patients without decreasing early survivorship

BACKGROUND

Two previous studies recently raised the possibility of a high risk of early femoral components loosening with high-flexion (HF) prostheses in Asian populations and suggested that the high failure rate of HF TKAs was associated with HF ability. However, these findings are controversial given other studies reporting a low incidence of aseptic failures in HF prostheses.

QUESTIONS/PURPOSES

We therefore determined (1) the rate of achieving postoperative HF after HF TKA; (2) whether the aseptic loosening rate of HF prostheses is high; and (3) whether the survivorship was worsened in patients who achieved postoperative deep knee flexion in our cohort of Korean patients.

METHODS

We retrospectively reviewed 488 patients who had 698 primary TKAs using the NexGen(®) Legacy Posterior-Stabilized Flex system implanted from 2003 to 2010. There were 40 men and 448 women with a mean age of 68 years. We obtained Hospital for Special Surgery scores, maximal flexion, and radiographs. The minimum followup for functional and radiographic evaluations was 2 years (median, 4.8 years; range, 2-8.7 years). We performed a survival analysis on all patients for aseptic loosening.

RESULTS

Three hundred sixty knees (52%) could achieve ≥ 135° maximum flexion. Six of the 698 knees (0.9%) developed aseptic loosening (three femoral and three tibial). The survival at 5 years for aseptic loosening was 99.1%. The overall survival for aseptic failure did not differ between knees that achieved HF and those that did not.

CONCLUSIONS

We observed a low incidence of early aseptic loosening of HF designs in this series. Our findings suggest HF TKAs have high survival in Asian patients at 5 years although half of the patients attained maximum flexion more than 135° postoperatively.

The Effect of Electrocautery around the Patellar Rim in Patellar Non-Resurfacing Total Knee Arthroplasty

Purpose

The purpose of this study was to evaluate the clinical effect of electrocautery on the reduction of pain in patellar non-resurfacing bilateral total knee arthroplasty.

Materials and Methods

A total of 50 patients were enrolled into this study; all patients had undergone bilateral patellar non-resurfacing total knee arthoplasty at our hospital, between January 2007 to December 2008. The minimum follow-up period was 1 year. The electrocautery of the patellar rim was performed randomly on one side only. The clinical results were evaluated between the electrocautery group and the non-electrocautery group based on measures of anterior knee pain, range of motion, American Knee Society clinical rating score, Feller knee score, Western Ontario and McMaster Universities score, and radiographic analysis.

Results

There were statistically significant differences between preoperative and postoperative status for all parameters. There were no statistically significant differences noted between the electrocautery group and the non electrocautery group for all parameters.

Conclusions

Electrocautery of patellar rim is thought to be less effective in reducing anterior knee pain.