Total Knee Arthroplasty for Osteoarthritis Secondary to Fracture of the Tibial Plateau. A Prospective Matched Cohort Study

Staged vs concurrent hardware removal in total ankle arthroplasty

INTRODUCTION

Ankle osteoarthritis is more commonly posttraumatic. Consequently, dealing with hardware removal is quite frequent when performing a total ankle arthroplasty (TAA). The purpose of this study is to compare outcomes regarding either a staged or concurrent hardware removal when performing TAA.

MATERIALS AND METHODS

275 consecutive patients with TAA previously treated with internal fixation were retrospectively reviewed. Finally, 57 patients were enrolled based on exclusion criteria, and were differentiated into two groups considering the timing of hardware removal (staged-group A vs concurrent-group B) to compare: neurovascular and wound complications, time to recover full weight bearing, scar-tissue esthetic, and surgical time. Moreover, a subgroup comparison considering the surgical approach (single approach, minor additional approach, major additional approach) was performed between the group A and group B.

RESULTS

No statistically significant difference other that longer surgical time (p < 0.05) was observed between group A and group B. When considering surgical approach subgroups, statistically significant higher surgical wound complications and revision rate were reported in group B (concurrent) major additional approach subgroup, and a statistically significant shorter time to full weight bearing was reported in group A (staged) major additional approach subgroup.

CONCLUSIONS

When performing TAA requiring hardware removal, no clear superiority of staged over concurrent hardware removal was observed. However, when considering a subgroup of patients requiring a separate major incision, a staged approach has shown reduced surgical time, less risk of wound complications, and shorter recovery to full weight bearing.

LEVEL OF EVIDENCE

III.

Primary Versus Secondary Total Knee Arthroplasty for Tibial Plateau Fractures in Patients Aged 55 or Over-A Systematic Review and Meta-Analysis

BACKGROUND

Total knee arthroplasty allows immediate postoperative weight-bearing and is increasingly recognized as a suitable treatment option for older patients who have tibial plateau fractures (TPFs). This systematic review evaluated the clinical and functional outcomes associated with primary versus secondary TKA for the treatment of TPFs in patients aged ≥55 years.

METHODS

Various databases were searched from inception to December 2021. Studies investigating outcomes of primary TKA (pTKA) as the initial treatment for TPFs in patients of mean age ≥55 years or those investigating outcomes of secondary TKA (sTKA) following any other primary treatment for TPFs were included. Quality of included studies was assessed using a methodological scale. Of 767 potentially relevant studies, 12 studies comprising 341 patients were included: 121 patients underwent (pTKA) and 220 patients underwent sTKA. There were 3 high-quality studies. Patients in the sTKA cohort were significantly younger at the time of TKA compared with those undergoing pTKA (mean 61.3 versus 72.2 years, P < .001, 95% confidence interval (CI) 8.2 to 13.6).

RESULTS

Intraoperative and postoperative complication rates were lower with pTKA; in particular, sTKA was associated with a significantly increased rate of stiffness requiring reintervention and patella tendon rupture. Functional outcome was greater after pTKA, but this did not reach statistical significance (85.2 versus 79.9%, P = .359, 95% CI -16.7 to 6.1).

CONCLUSION

Primary TKA was associated with lower complication rates than secondary TKA after TPF. In appropriate cases of TPF in older adults, it may be preferable to proceed with TKA as primary treatment rather than delaying until after fracture union or malunion.

Radiographic Evidence of Early Posttraumatic Osteoarthritis following Tibial Plateau Fracture Is Associated with Poorer Function

To determine if radiographic evidence of posttraumatic osteoarthritis (PTOA) following tibial plateau fracture correlates with poorer clinical and functional outcomes, patients with tibial plateau fractures were followed at 3, 6, and 12 months. All patients had baseline radiographs and computed tomography scan. Radiographs obtained at each follow-up were reviewed for healing, articular incongruence, hardware positional changes, and the development of postinjury arthritic change. Cohorts were determined based on the presence (PTOA) or absence (NPTOA) of radiographic evidence of PTOA. Demographics, fracture classification, complications, additional procedures, and functional status were compared between cohorts. Sixty patients had radiographic evidence of PTOA on follow-up radiographs at a mean final follow-up of 24.2 months. The NPTOA cohort was composed of 210 patients who were matched to the PTOA cohort based on age and Charlson comorbidity index. Mean time to fracture union for the overall cohort was 4.86 months. Cohorts did not differ in Schatzker classification, time to healing, injury mechanism, or baseline Short Musculoskeletal Function Assessment (SMFA). Patients with PTOA had a greater degree of initial depression and postoperative step-off, higher incidence of initial external fixator usage, higher rates of reoperation for any reason, and higher rates of wound complications. Associated soft tissue injury and meniscal repair did not coincide with the development of PTOA. Range of motion and SMFA scores were significantly worse at all time points in patients with PTOA. Although fracture patterns are similar, patients who required an initial external fixator, had a greater degree of initial depression or residual articular incongruity, underwent more procedures, and developed an infection were found to have increased incidence of PTOA. Radiographic evidence of osteoarthritis correlated with worse functional status in patients. The goal of surgery should be restoration of articular congruity and stability to mitigate the risk of PTOA, although this alone may not prevent degenerative changes. Patients with early loss of range of motion should be aggressively treated as this may precede the development of PTOA.

Increased complications rates and inferior patient reported outcomes following total knee arthroplasty due to post-traumatic osteoarthritis with previous fracture treatment: a systematic review

PURPOSE

This study aims to present the existing literature relating to patient-reported outcome measures (PROMs) and complications in patients undergoing total knee arthroplasty (TKA) due to posttraumatic osteoarthritis (PTOA) with prior fracture treatment around the knee compared with patients who underwent TKA because of primary osteoarthritis (OA).

METHODS

A systematic review was undertaken and synthesised in accordance with the PRISMA guidelines by searching existing literature in the following databases: PubMed, Scopus, Cochrane Library and EMBASE. A search string according to the PECO was used. After analysing 2781 studies, 18 studies (5729 PTOA patients/149,843 OA patients) were included for a final review. An analysis revealed that 12 (67%) were retrospective cohort studies, four (22%) were register studies and the remaining two (11%) were prospective cohort studies. The mean Critical Appraisal Skills Programme (CASP) score was 23.6 out of 28, signifying studies of moderate quality.

RESULTS

The most frequently reported outcome measure were postoperative complications, reported in all eighteen studies. Intraoperative complications were reported in ten (4165 PTOA/124.511 OA) and patient-reported outcome measures (PROMs) in six studies (210 PTOA/2768 OA). A total of nine different PROMs were evaluated. As far as PROMs were concerned, the scores were inferior for PTOA but did not differ statistically from OA, except for one study, which favoured the OA group. Across all studies, postoperative complications were higher in the PTOA group, reporting infections as the most common complication. Furthermore, a higher revision rate was reported in the PTOA group.

CONCLUSION

PROM analysis suggests that both patient groups benefit from a TKA in terms of functional outcome and pain relief, however, patient-reported outcomes could be inferior for PTOA patients. There is consistent evidence for increased complication rates following PTOA TKA. Patients undergoing TKA due to PTOA after fracture treatment should be informed about the risk for inferior results and refrain from comparing their knee function to patients with TKA after OA. Surgeons should be aware of the challenges that PTOA TKA poses.

LEVEL OF EVIDENCE

Level III.

Treatment of periprosthetic knee infection and coexistent periprosthetic fracture: A case report and literature review

BACKGROUND

Periprosthetic joint infection (PJI) and periprosthetic fracture (PPF) are among the most serious complications following total knee arthroplasty. Herein, we present one patient with these two complications with details on the characteristics, treatment strategy, and outcome.

CASE SUMMARY

A 69-year-old female patient who suffered from PJI and PPF following total knee arthroplasty was treated by a two-stage revision surgery. After thorough foreign material removal and debridement, we used a plate that was covered with antibiotic-loaded bone cement to link with a hand-made cement spacer to occupy the joint space and fix the fracture. Although the infection was cured, the fracture did not heal and caused bone defect due to the long interval between debridement and revision. In the revision surgery, a cemented stem and cortical allogenic splints were used to reconstruct the fracture and bone defect. At the final follow-up 27 mo after revision, the patient was satisfied with postoperative knee functions with satisfactory range of motion (104º) and Hospital for Special Surgery knee score (82 points). The radiographs showed no loosening of the prosthesis and that the bone grafts healed well with the femur.

CONCLUSION

Our two-stage revision surgery has proved to be successful and may be considered in other patients with PJI and PPF.

Concurrent Hardware Removal is Associated With Increased Odds of Infection Following Conversion Total Knee Arthroplasty

BACKGROUND

The optimal timing of removal of periarticular implants prior to conversion total knee arthroplasty (TKA) remains to be determined. The purpose of this study was to compare infection rates in conversion TKA when hardware removal was performed in either a staged or concurrent manner.

METHODS

We performed a retrospective study using a national insurance claims database of patients who underwent removal of hardware on the same day or within 1 year before their TKA. A total of 16,099 patients met the criteria. After matching, both final cohorts consisted of 4,502 patients. The 90-day and 1-year rates of prosthetic joint infection were calculated.

RESULTS

The rates of infection were 1.64% and 3.00% in the staged group and 2.62% and 3.95% in the concurrent group at 90 days and 1 year postoperatively, respectively (P = .001, P = .01). Logistic regression analyses demonstrated that patients who had hardware removal greater than 3 months prior to TKA had significantly lower odds of infection at 1-year postop (Odds Ratio 0.61 95% Confidence Interval 0.45-0.84; P = .003).

CONCLUSION

Removal of hardware performed concurrently or within 3 months of a TKA is associated with increased odds of prosthetic joint infection at 1 year postoperatively. Surgeons should consider removing periarticular hardware prior to TKA when possible.

Functional outcome of total knee arthroplasty following tibial plateau fractures: a systematic review

BACKGROUND

Posttraumatic osteoarthritis (PTOA) following a tibial plateau fracture (TPF) is a debilitating disease which often affects a young and active patient population for whom good knee function is essential. Frequently, total knee arthroplasty (TKA) is the only surgical option. The aim of this systematic review was to evaluate functional outcome for TKA in PTOA patients, together with several secondary outcome parameters.

METHODS

A systematic review according to the PRISMA guidelines was conducted. Studies were included that reported on patient-reported outcome measures, range of motion or objective functional analysis after TKA because of PTOA following TPF.

RESULTS

After analyzing 105 studies, 5 were included for the final review. In total, 162 patients with a TKA for PTOA were included of whom 125 (77%) were managed operatively for their TPF. All studies reported improvements in functional outcome after TKA, with two studies showing no significant differences between PTOA patients and a matched cohort of primary OA patients. Reported complication and re-intervention rates were higher for TKA patients with PTOA.

CONCLUSION

The results of this review indicate the TKA for PTOA after a TPF provides satisfactory functional outcome, with results similar to those of matched primary OA patients. TKA should, therefore, be considered a viable treatment option to improve function, but both patients and orthopedic surgeons should be aware of the higher complication rates in this patient population.

Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty With Prior Hardware

BACKGROUND

End-stage knee osteoarthritis with retained periarticular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention versus removal of hardware during TKA is controversial.

METHODS

Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. The mean follow-up was 60 months (range, 24-223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes.

RESULTS

The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (odds ratio: 20.7, P < .05), implant failures (odds ratio: 13.9, P < .05), and lower the Veterans Rand 12 Mental Score (VR-12 MS) (-14.8, P < .05). Hardware removal versus retention and use of single versus multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, P < .05) VR-12 MS compared to retention of all hardware.

CONCLUSIONS

TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes.

LEVEL OF EVIDENCE

IV, cohort without control.

The use of a metaphyseal sleeve total knee replacement as primary treatment for Schaztker VI tibial plateau fracture

Traditional treatment of tibial plateau fractures is with open reduction and internal fixation, or external fixation in severely displaced and comminuted fractures. Total joint arthroplasty for unreconstructable hip fractures is a successful and widely accepted treatment; however, such surgery for tibial plateau fractures is not a common practice. We present two cases of highly comminuted schaztker VI tibial plateau fractures in patients over the age of 65. Both patients had a metaphyseal sleeve revision knee arthroplasty as delayed primary treatment. Both patients have had excellent clinical and radiographical results at 6 months and 5 years follow-up, respectively. We present the first description in the literature of this implants use for bone loss as a result of trauma. There is growing evidence that total joint arthroplasty is an effective treatment in tibial plateau fractures, in particular for elderly patients who may be at high risk of failure from internal fixation.

Total knee arthroplasty in post-traumatic osteoarthritis is more challenging, but results in similar patient satisfaction - An analysis of 1646 cases

BACKGROUND

Patients with post-traumatic osteoarthritis (PTOA) present a variety of technical challenges to surgeons. Surgical parameters, complication rates and patient-reported outcomes (PROs) have been reported as detrimental in total knee arthroplasty (TKA) for PTOA. The purpose of this study was to compare these variables and satisfaction with the results of TKA in patients with post-traumatic osteoarthritis with a matched-pair cohort of primary osteoarthritis (POA).

METHODS

A registry-embedded prospective case-control study was performed. Of a total of 1646 TKAs, 155 were performed due to PTOA between 2012 and 2019. One-hundred and thirty-six could be one-to-one propensity score-matched to patients with POA undergoing primary TKA based on similar patient demographic variables. Outcomes investigated included operation time, estimated blood loss, types of implants, postoperative complications and PROs pre- and 1 year postoperatively as well as satisfaction with the results of surgery. Sub-cohort analysis was performed for patients with prior fracture and soft tissue trauma, respectively.

RESULTS

Surgical parameters were significantly different in disadvantages of PTOA: operation time (P < 0.001), estimated blood loss (P < 0.001), blood transfusions (P = 0.039), type of implants (P < 0.001). Manipulation under anaesthesia (MUA) was necessary more often in the PTOA fracture group (odds ratio 5.01, (95% confidence interval 1.04; 24.07). PRO demonstrated no substantial differences after 1 year. Satisfaction with the results of TKA was as equally high in all cohorts.

CONCLUSIONS

This study demonstrated that TKAs in patients with PTOA require higher surgical effort but can result in similar PROs and satisfaction compared to POA, regardless of the underlying trauma.

Outcomes of Total Knee Arthroplasty in Patients with Prior Hardware: A Case-Control Study Using Handheld Navigation

Presence of hardware in juxta-articular location poses challenge during total knee arthroplasty (TKA). When present in distal femur, it precludes the use of an intramedullary femoral jig during TKA often necessitating removal of hardware leading to prolonged surgery, higher risk of complications, and inferior results. We conducted a case-control study to assess the outcome of TKA among patients with post-traumatic arthritis using a handheld navigation system to perform bone cuts allowing retention of hardware in situ. In 15 patients with post-traumatic arthritis and hardware around the knee (Group A), none or part(s) of hardware were removed while performing TKA. These patients were matched to 15 patients who underwent TKA with handheld navigation for primary OA knee (Group B). The perioperative outcomes assessed were operative time, intraoperative blood loss, length of hospital stay, complications, and 30 days reoperation rate. Clinical outcomes were assessed by using Knee Society Score (KSS) and radiological outcomes using mechanical axis and coronal and sagittal component angles. Mean age of patients at surgery were 65.67 years (Group A) and 66.73 years (Group B). Mean operative time and blood loss were significantly higher in Group A as compared with Group B. At the mean follow-up of 34 months, KSS significantly improved in both the groups. However, there was no statistically significant difference in the clinical and radiological outcomes between the two groups. One patient in Group A developed wound dehiscence and had to undergo debridement and flap coverage within 30 days. The use of navigation helps surgeons in gaining proper limb alignment and implant positioning without complete removal of hardware.

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

Risk Factors for Wound Complications Following Conversion TKA after Tibial Plateau Fracture

INTRODUCTION

The purpose is to investigate the incidence of wound complications for total knee arthroplasty (TKA) following tibial plateau open reduction and internal fixation (ORIF).

MATERIALS AND METHODS

A prospective arthroplasty registry was queried for patients with CPT codes for primary TKA, tibial plateau ORIF, removal of hardware (ROH), and diagnosis of post-traumatic arthritis. Patients were included if they had undergone tibial plateau ORIF and subsequent TKA. Chart review was performed to obtain demographic, clinical and post-operative information.

RESULTS

Twenty-one patients were identified, with average age of 56.23 ± 13.2 years at time of tibial plateau ORIF and 62.91 ± 10.8 years at time of TKA. Seven (33.3%) patients had a tibial plateau fracture-related infection (FRI). Eight (38.1%) patients underwent ROH prior to TKA. Seven (33.3%) patients' TKA incision incorporated the prior plateau incisions. Eight (36.4%) patients developed wound complications following TKA and 5 (23.8%) developed an acute periprosthetic joint infection (PJI) following TKA and had the plateau incision incorporated into the TKA incision. FRI history did not increase the rate of wound complications but did increase the rate of ROH prior to TKA.

CONCLUSIONS

Previous FRI involving tibial plateau repair surgery doesn't correlate with PJI after conversion TKA for post traumatic OA. Surgeon-controlled factors such as staged ROH and incision placement can help reduce the rate of wound complications following TKA performed after tibial plateau ORIF.

LEVEL OF EVIDENCE

Prognostic Level IV.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00709-1.

Preoperative Factors Affecting the Patient-Reported Outcome Measures following Total Knee Replacement: Socioeconomic Factors and Preoperative OKS Have a Clinically Meaningful Effect

The Oxford Knee Score (OKS) is a patient-reported outcome questionnaire typically used to assess function and pain in patients undergoing total knee replacement (TKR). However, research is inconclusive as to which preoperative factors are important in explaining variation in outcome following TKR. The operative records of 12,709 patients who underwent primary TKR over a 9-year period were analyzed. The following variables were collected for each patient: age, sex, body mass index (BMI), Index of Multiple Deprivation decile rank, side of operation, diagnosis, the American Society of Anaesthesiologists (ASA) grade, preoperative OKS, EQ-5D index score, EuroQol visual analog scale (EQ-VAS) score, the postoperative OKS at 1 and 2 years. Generalized linear regression models were performed at 1 and 2 years to investigate the effect of the preoperative variables on the postoperative OKS. The effect of age, sex, BMI, Index of Multiple Deprivation decile rank, diagnosis, ASA grade, preoperative OKS, EuroQoL five-dimensional (EQ-5D) index score, and EQ-VAS score were all statistically significant in explaining the variation in OKS at 1 and 2 years postoperatively, with critical level of significance of 0.05 (5%). Being male aged 60 to 69 years of normal BMI, ASA grade I (fit and healthy), living in an affluent area, not reporting preoperative anxiety/depression, were associated with an enhanced mean postoperative OKS at both 1 and 2 years. When adjusted for potential confounding, age of 60-69 years, male sex, normal BMI, lower ASA grade, higher Index of Multiple Deprivation and higher pre-operative EQ-5D, EQ-VAS and OKS were identified as factors that resulted in higher post-operative OKS after primary TKR.

Conversion Total Knee Arthroplasty After Tibial Plateau Fixation Is Associated With Lower Reimbursement, Greater Complication Rates, and Similar Opioid Use

Objective

Total knee replacement after previous open reduction and internal fixation for tibial plateau fracture (conversion total knee) increases the complexity of the procedure and the complication rate. However, very little research exists to report on opioid use and cost associated with total knee arthroplasty (TKA) following tibial plateau fracture fixation as compared to primary TKA patients with no history of tibial plateau fracture. The aim of this study is to compare the differences in opioid use, reimbursements, and complication rates between patients with and without a history of tibial plateau fracture undergoing TKA.

Methods and materials

This is a retrospective large database review study. The study included patients across the country and in various clinical settings including, but not limited to, institutions, primary and tertiary care centers, and private practice. The PearlDiver database was reviewed for patients undergoing TKA between 2010 and 2019. Patients who underwent TKA following surgical repair of a tibial plateau fracture were identified using Common Procedural Terminology (CPT) codes and the appropriate International Classification of Diseases Ninth and Tenth Revision (ICD-9, ICD-10) codes. This group was then matched by age, gender, Charleston Comorbidity Index (CCI) score, Elixhauser Comorbidity Index (ECI) score, obesity, tobacco use, and diabetes to a group of similar patients who underwent TKA with no history of tibial plateau fracture. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day reimbursed cost were compared between groups using an unequal variance t-test. Complication rates at 30 days, 90 days, and one year postoperatively, and revision rates at one and two years postoperatively were compared using the odd’s ratio (OR) with 95% confidence intervals (95%CI).

Results

The episode of care cost for TKA was significantly lower for patients with a history of tibial plateau fracture ($11,615 ± $15,704) than it was for patients without a history of tibial plateau fracture ($16,088 ± $18,573) (p = 3.56E-14). At 30 days after knee arthroplasty, patients with a history of tibial plateau fracture had significantly more episodes of dehiscence (OR 2.665 [95% CI 1.327-5.351]; p = 0.006) and surgical site infection (SSI) (OR 1.698 [95% CI 1.058-2.724]; p = 0.028), which was significant at 90 days postop for both dehiscence (OR 1.358 [95% CI 0.723-2.551]; p = 0.001) and SSI (OR 1.634 [95% CI 1.100-1.802]; p = 0.015), as well as mechanical complications of the implant device (OR 2.420 [95% CI 1.154-5.076]; p = 0.019). There was no significant difference in the number of opioids prescribed postoperatively to patients with a history of tibial plateau fracture (2218 ± 3255 MME) compared to those without prior tibial plateau fracture (2400 ± 4843 MME) (p = 0.258). However, there was a small but statistically significant increase in the number of days postoperatively patients with a history of tibial plateau fracture were prescribed opioids (11.99 ± 7.73 days) compared to non-tibial plateau fracture patients (11.15 ± 7.18 days) (p = 0.004).

Conclusion

Patients with a history of tibial plateau fracture who then underwent conversion TKA have a lower reimbursed cost of TKA but a higher postoperative risk for dehiscence, mechanical complications, and surgical site infections. There is no significant difference in postoperative opioid use between the two groups.

Lateral unicompartmental knee arthroplasty is a safe procedure for post-traumatic osteoarthritis after lateral tibial plateau fracture: a case-control study at 10-year follow-up

PURPOSE

Very few studies focus on lateral unicompartmental arthroplasty (LUKA) in the setting of post-traumatic osteoarthritis (PTOA). The hypothesis of our study is that LUKA is an effective procedure for isolated lateral PTOA with similar outcomes to non-traumatic LUKA.

METHODS

Between 1990 and 2016, eighteen LUKA performed for isolated lateral tibiofemoral osteoarthritis secondary to tibial plateau fracture were retrospectively reviewed (post-traumatic group) and matched with a control group of thirty-six LUKA performed for non-traumatic OA. Clinical (International Knee Score), radiological outcomes and revision rate were compared between the two groups with a minimum follow-up of three years.

RESULTS

With a mean follow-up of 10.1 years, postoperative IKS scores were similar between the two groups (IKS Knee: 89.1 (control) versus 85 (p = 0.03) and IKS Function: 85.9 (control) versus 77.9 (n.s.). Clinical improvement was greater for the post-traumatic group. No difference was observed with regard to revision rate (3/18 (16.7%) cases in the post-traumatic group and 7/36 (19.4%) in the control group, n.s.) or polyethylene wear per year between the two groups. The revision free-survival rate was 64.8% for the post-traumatic group and 58.8% for the control group at 22-year follow-up (n.s.).

CONCLUSION

LUKA is an effective procedure at long-term for patients suffering from isolated lateral PTOA with similar clinical and radiographic results compared to LUKA performed for non-traumatic OA and without increased risk of revision or prosthetic wear.

LEVEL OF EVIDENCE

IV.

Modified anterior midline approach to treat hyperextension bicondylar tibial plateau fractures: Surgical technique and clinical experience with 18 cases

BACKGROUND

We evaluated the modified anterior midline approach and its efficacy for hyperextension bicondylar tibial plateau (HEBTP) fractures.

METHODS

From 2015 to 2019, 18 patients with HEBTP fractures with just little posterior cortical displacement were treated using the modified anterior midline approach. The operative protocols are fully described in this article, and the following parameters: articular step-off height (ASH), posterior tibial slope angle (pTSA), and medial tibial plateau angle (mTPA) were measured perioperatively and at the final follow-up. We also recorded the Rasmussen score and range of motion (ROM) to assess knee joint function at the final follow-up.

RESULTS

No complications, such as percutaneous nerve damage, infection, skin necrosis, and internal fixation breakage or loosening occurred perioperatively. The mean time for bony union was 13.7 weeks, and the mean preoperative ASH of the anterior cortex was 4.49 mm; this was restored to its normal height after surgery. The mean preoperative pTSA and mTPA were - 5.89° and 81.69°, respectively, compared with 3.89° and 87.91°, respectively, postoperatively. Comparing the postoperative and final follow-up radiographs, there were no significant differences in ASH, pTSA, and mTPA (P < 0.05). The average Rasmussen score was 27.2 (range, 23-29) at the final follow-up. Excellent results were achieved in 14 (77.8%) patients and good in 4 (22.2%) patients. The mean ROM in flexion was 123.2° and 2.9° in extension at the final follow-up.

CONCLUSIONS

This study suggested that the modified anterior midline approach is a reasonable alternative for HEBTP fracture repair.

Increased Revisions in Conversion Total Knee Arthroplasty After Periarticular Open Reduction Internal Fixation Compared With Primary Total Knee Arthroplasty: A Matched Cohort Analysis

BACKGROUND

Prior studies on conversion total knee arthroplasty (cTKA) have reported increased technical challenges and risk of complications compared with primary knee arthroplasty. The purpose of this study was to compare two-year postoperative complication/revision rates between patients undergoing cTKA after prior periarticular open reduction and internal fixation (ORIF) and those undergoing primary TKA.

METHODS

Patients who underwent cTKA after prior periarticular ORIF of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2018. This ORIF-cTKA cohort was propensity matched to participants undergoing primary TKA based on age, gender, Charlson comorbidity index, and obesity status. Univariate analysis was performed to analyze differences in two-year complication and revision rates.

RESULTS

After propensity matching, 823 patients were included in the ORIF-cTKA cohort and 1640 patients in the primary TKA cohort. No differences in demographics or comorbidities existed between cohorts. Relative to the primary TKA cohort, the ORIF-cTKA cohort had significantly higher incidences of all-cause revision (5.47% vs 2.47%, P = .001), periprosthetic joint infection (PJI; 4.74% vs 1.34%, P < .001), and intraoperative or postoperative periprosthetic fracture (1.58% vs 0.55%, P = .01) at two years postoperatively. There was also a nonsignificant trend toward increased rates of aseptic loosening (1.82% vs 0.91%, P = .052) in the ORIF-cTKA.

CONCLUSION

Relative to primary TKA, cTKA after periarticular ORIF is associated with significantly increased rates of all-cause revision, PJI, and periprosthetic fracture at two years postoperatively. Surgeons should counsel these patients about the increased risks of these postoperative complications and consider treating them as high risk for PJI in the perioperative period.

Conversion Total Knee Arthroplasty

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Conversion total knee arthroplasty (TKA) represents a heterogeneous group of procedures and most commonly includes TKA performed after ligamentous reconstruction, periarticular open reduction and internal fixation (ORIF), high tibial osteotomy (HTO), and unicompartmental knee arthroplasty (UKA).

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Relative to patients undergoing primary TKA, patients undergoing conversion TKA often have longer operative times and higher surgical complexity, which may translate into higher postoperative complication rates.

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There is mixed evidence on implant survivorship and patient-reported outcome measures when comparing conversion TKA and primary TKA, with some studies noting no differences between the procedures and others finding decreased survivorship and outcome scores for conversion TKA.

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By gaining an improved understanding of the unique challenges facing patients undergoing conversion TKA, clinicians may better set patient expectations, make intraoperative adjustments, and guide postoperative care.

TKR after posttraumatic and primary knee osteoarthritis: a comparative study

Background

A few literatures reported that the outcomes of total knee replacement (TKR) in posttraumatic osteoarthritis (PTOA) were lower compared to TKR in primary osteoarthritis (primary OA). The study’s purpose was to compare the comorbidity and outcome of TKR among fracture PTOA, ligamentous PTOA, and primary OA. The secondary aim was to identify the effect of postoperatively lower limb mechanical axis on an 8-year survivorship after TKR between PTOA and primary OA.

Methods

Seven hundred sixteen patients with primary OA, 32 patients with PTOA (knee fracture subgroup), and 104 PTOA (knee ligamentous injury subgroup) were recruited. Demography, comorbidities, Charlson Comorbidity Index (CCI), operative parameters, mechanical axis, functional outcome assessed by WOMAC, and complications were compared among the three groups.

Results

PTOA group was significantly younger (p<0.0001) with a higher proportion of men (p=0.001) while the primary OA group had higher comorbidities than the PTOA group, including anticoagulant usage (p=0.0002), ASA class ≥3 (p<0.0001), number of diseases ≥ 4 (p<0.0001), and CCI (p<0.0001). Both the fracture PTOA group (p<0.0001) and ligamentous PTOA group (p = 0.009) had a significantly longer operative time than the primary OA group. The fracture PTOA group had significantly lower pain components and stiffness components than the primary OA group. There was no significant difference in the rate of an aligned group, outlier group, and an 8-year survivorship in both groups.

Conclusion

The outcome following TKR in the fracture PTOA was poorer compared to primary knee OA in the midterm follow-up. However, no difference was detected between the ligamentous PTOA and primary knee OA. The mechanical axis alignment within the neutral axis did not affect the 8-year survivorship after TKR in both groups.

Level of evidence

Level III; retrospective cohort study

Staged vs Concurrent Hardware Removal During Conversion Total Knee Arthroplasty

BACKGROUND

Conversion total knee arthroplasty (TKA) in the presence of periarticular hardware can be associated with increased resource utilization, complications, and revisions. However, little guidance exists on the optimal approach to hardware removal. The purpose of this study is to compare outcomes of conversion TKA with hardware removal performed in either a staged or concurrent manner.

METHODS

This is a retrospective study of 155 TKA operations performed with staged (45) or concurrent (110) removal of hardware at the time of TKA. Differences in patient data, case data, complications, reoperations, and revisions were evaluated. Subgroup comparisons of cases involving major hardware (plates, nails, rods), minor hardware (screws, buttons, wires), and tibial plates were performed.

RESULTS

There were no differences in age, sex, body mass index, or comorbidities between patients who underwent staged or concurrent hardware removal. Rates of complications, reoperations, and revisions did not differ at multiple time points (90 days, 1 year, 2 years, 4 years). Patients who underwent staged hardware removal were more likely to have had prior surgery for fracture reconstruction (68% vs 33%, P < .001), to have had major hardware removed (84% vs 59%, P = .03), and were less likely to have had hardware removal performed through a single incision with TKA (50% vs 92%, P < .001). Subgroup analysis of major and minor hardware cases demonstrated comparable outcomes.

CONCLUSION

There remains no established benefit to either a staged or concurrent approach to hardware removal at the time of TKA. This is true regardless of hardware burden. At this time, a case-by-case approach should be taken to conversion TKA in the presence of periarticular hardware.

Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern

BACKGROUND

Acetabular fractures often require surgical intervention for fracture fixation and can result in premature osteoarthritis of the hip joint. This study hypothesized that total hip arthroplasty (THA) in patients with a prior acetabular fracture who had undergone open reduction and internal fixation (ORIF) is associated with a higher rate of subsequent periprosthetic joint infection (PJI).

METHODS

About 72 patients with a history of acetabular fracture that required ORIF, undergoing conversion THA between 2000 and 2017 at our institution, were matched based on age, gender, body mass index, Charlson comorbidity index, and date of surgery in a 1:3 ratio with 215 patients receiving primary THA. The mean follow-up for the conversion THA cohort was 2.9 years (range, 1-12.15) and 3.06 years (range, 1-12.96) for the primary THA.

RESULTS

Patients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, PJI rate was significantly higher in acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups.

CONCLUSION

The present study demonstrates that conversion THA in patients with prior ORIF of acetabular fractures is associated with higher complication rate, in particular PJI, and less optimal outcome compared with patients undergoing primary THA. The latter findings compel us to seek and implement specific strategies that aim to reduce the risk of subsequent PJI in these patients.

[Intra-articular osteotomy for malunion of the tibial plateau]

OBJECTIVE

Restoration of anatomy of the joint surface of the tibial plateau in posttraumatic deformity.

INDICATIONS

Malunions of the tibial plateau with significant intra-articular depression and/or steps.

CONTRAINDICATIONS

Local or systemic infection, critical soft tissues in the area of planned incisions; advanced osteoarthritis of the knee; loss of meniscus in the involved compartment; motoric or neurophysiological impairment hindering normal knee function.

SURGICAL TECHNIQUE

Malunion after posteromedial split fracture: posterior approach in prone position, osteotomy of the former fragment following the fracture lines, anatomical reduction of the fragment in extended position of the knee using the implant as reduction tool, fixation by posterior plate. Malunion after lateral and posterolateral split/depression fracture: Lateral approach with fibula head osteotomy in lateral decubitus position, intra-articular osteotomy of depressed fragments, autologous bone graft, lateral or posterolateral plate osteosynthesis. Osteosynthesis of fibula head with small fragment lag screw or tension-band.

POSTOPERATIVE MANAGEMENT

Walking with crutches starting from day 1 after surgery. Partial weight-bearing until radiographic healing of the osteotomies, usually 4-6 weeks. No limitation of range-of-motion.

RESULTS

A series of 23 patients had lateral corrective osteotomy after lateral tibial plateau fracture. Mean follow-up was 13 years (range 2-26 years). Two patients had early poor results. In all, 17 patients (74%) scored excellent in the Lysholm/Gillquist score, 3 patients good, 1 patient average and 2 patients poor.

Total knee arthroplasty following intramedullary tibial nailing

Introduction/purpose

Total knee arthroplasty (TKA) in the setting of previous periarticular hardware increases resource utilization, readmissions, complications, and revision rates. Despite the frequency of intramedullary nail (IMN) fixation for tibial fractures, little guidance exists on the management of these patients and no series have reported on outcomes of patients undergoing TKA in the setting of a retained or removed IMN.

Methods

This is a retrospective case series of patients who underwent TKA after IMN fixation of tibial fractures. Patient and case data, including need for hardware removal, staged vs non-staged procedures, operative time, and need for revision implants, were recorded. Postoperative data, including complications and revision, were recorded. Oxford Knee Score (OKS) was performed at follow-up.

Results

Nine patients were identified consisting of eight women and one man. Follow-up ranged from 0.8–13 years. Non-staged removal of the intramedullary hardware occurred in three cases that had increased operative lengths recorded. There were no complications related to wound healing or infection. No patients required revision. Two of the three patients who underwent non-staged TKA developed arthrofibrosis requiring manipulation. OKS scores in patients who underwent non-staged surgery were consistently low.

Conclusions

Conversion TKA after tibial IMN fixation can result in satisfying outcomes in many patients. However, intramedullary hardware presents challenges to TKA similar to more extensively studied conversion TKA scenarios. Removing hardware in either a staged or non-staged fashion results in increased resource utilization and imparts perioperative challenges with only theoretical benefits of one approach compared to the other. Increased stiffness may be associated with a non-staged approach to hardware removal and TKA. Several technical factors may permit component positioning without removal of hardware. Despite limitations, this is the first series to discuss this challenging clinical scenario and provides surgeons with technical guidance and data on operative outcomes.

Outcomes of lateral unicompartmental knee arthroplasty in post-traumatic osteoarthritis, a retrospective comparative study

PURPOSE

We asked whether the clinical and radiographic outcomes and survivorship after unicompartmental knee arthroplasty (UKA) for osteoarthritis (OA) consequent to lateral tibial plateau fracture were comparable with those obtained after lateral UKA for primary OA.

METHODS

A total of 13 patients receiving lateral UKA for OA secondary to tibial plateau fracture (post-traumatic UKA, P-UKA) were compared with 13 patients who underwent lateral UKA for primary OA (OA-UKA). Patients were matched for age at surgery, gender, body mass index, and follow-up length. Pre- and post-operative clinical and radiographic assessments included clinical (KSS-c) and functional (KSS-f) Knee Society Score, Hip-Knee-Ankle (HKA) angle, and signs of osteolysis.

RESULTS

Mean follow-up was similar in both groups: 9.9 ± 4.6 years for P-UKA and 9.3 ± 2.4 years for OA-UKA. The two way ANOVA procedure followed by the Bonferroni multiple comparisons test highlighted a baseline difference in KSS-c with P-UKA having greater scores than OA-UKA (+ 12; p < 0.05) and both groups showed large improvements in KSS-c (p < 0.001), KSS-f (p < 0.001), and HKA angle (p < 0.001) at follow-up. The nine year prosthesis survival rate, tested by the Kaplan-Meier methods, was 92% in both groups.

CONCLUSION

Lateral UKA for OA secondary to tibial plateau fracture was efficient in restoring joint function, improving clinical results, and correcting lower limb alignment. Clinical outcomes and nine year survivorship did not differ from lateral UKA for primary OA. Consequently, lateral UKA should be considered a valid option in treating lateral posttraumatic OA in carefully selected patients.

TRIAL REGISTRATION NUMBER

( clinicaltrials.gov ) NCT04198389.

Understanding the role of total knee arthroplasty for primary treatment of tibial plateau fracture: a systematic review of the literature

BACKGROUND

Surgical fixation of tibial plateau fracture in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared with younger patients. Primary total knee arthroplasty (TKA) may be of benefit in elderly patients with a combination of osteoporotic bone and metaphyseal comminution. However, there continues to be conflicting evidence on the use of TKA for primary treatment of tibial plateau fracture. This systematic review was performed to quantify the outcomes and perioperative complication rates of TKA for primary treatment of tibial plateau fracture.

MATERIALS AND METHODS

A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and outcomes of primary TKA for tibial plateau fracture. Weighted means and standard deviations are presented for each outcome.

RESULTS

Seven articles (105 patients) were eligible for inclusion. All-cause mortality was 4.75 ± 4.85%. The total complication rate was 15.2 ± 17.3%. Regarding outcomes, Knee Society scores were most commonly reported. The average Knee Society Knee Score was 85.6 ± 5.5, while the average Knee Society Function Score was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5 ± 10.0°.

CONCLUSIONS

Primary TKA for select tibial plateau fractures has acceptable clinical outcomes but does not appear to be superior to ORIF. It may be appropriate to treat certain geriatric patients with TKA to allow for early mobilization and reduce the need for reoperation. Other factors may need to be considered in deciding the optimal treatment.

LEVEL OF EVIDENCE

Level III.

Lingering risk: A meta-analysis of outcomes following primary total knee arthroplasty for patients with post-traumatic arthritis

BACKGROUND

Currently, no meta-analysis exists to elucidate the outcomes of primary total knee arthroplasty (TKA) in patients with post-traumatic arthritis (PTA). The primary aim of this meta-analysis was to compare revision and complication rates for patients with PTA versus osteoarthritis (OA).

METHODS

The following databases were used for searching existing literature (from their inception to October 2019): PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science. The primary outcomes were the incidences of revision and complications, Secondary outcomes included operative time and patient-reported outcomes (PRO) scores.

RESULTS

Nine studies with a total of 6,783,990 patients were included. This study found that there was a statistically significant difference in the rates of superficial wound infection, periprosthetic infection, stiffness, wound complications, and revision, with these outcomes occurring more frequently in patients with PTA. However, PTA did not increase the risks for periprosthetic fracture, aseptic loosening or instability, and VTE. Moreover, PTA was associated with increased operative time, worse postoperative PRO scores, and similar changes in PRO scores.

CONCLUSIONS

This meta-analysis highlight the complexity of PTA and demonstrates increased risks of infection, wound complications, stiffness, and revision. Surgeons can use this information to help aid in counseling patients preoperatively.

Arthroscopy-Assisted Corrective Osteotomy, Reduction, Internal Fixation and Strut Allograft Augmentation for Tibial Plateau Malunion or Nonunion

Purpose: The purpose of this study was to present the results of arthroscopy-assisted corrective osteotomy (AACO), reduction, internal fixation, and strut allograft augmentation for tibial plateau malunion or nonunion. Methods: Fifty-eight patients, mean age 49 ± 11.9 years old, with tibial plateau malunion (n = 44) or nonunion (n = 14), were included in this study. There were 19 Schatzker type II fractures (32.7%), 2 type III fractures (3.4%), 7 type IV fractures (12%), 20 type V fractures (34.5%), and 10 type VI fractures (17.2%). The mean follow-up period was 46.2 ± 17.6 months. Clinical and radiologic outcomes were scored by the Rasmussen system. Articular depression was measured from computed tomography. Secondary osteoarthritis was diagnosed when radiographs showed a narrowed joint space in the injured knee at follow-up. Results: Mean clinical score improved from 15.4 ± 3.9 (pre-revision) to 23.2 ± 4.5 (post-revision). Mean radiologic score improved from 7.7 ± 2.5 (pre-revision) to 12.0 ± 3.9 (post-revision). Fifty-six fractures achieved successful union. The average union time was 19.6 ± 7.5 weeks. Post-revision, 81% had good or excellent clinical results and 62% had good or excellent radiological results. Secondary osteoarthritis (OA) was noted in 91% of all injured knees, where 25.8% were mild OA, 25.8 % were moderate OA, and 38% were severe OA. There were 6 cases of deep infection (10.3%) and 1 case of wound edge necrosis (1.7%). Five cases were converted to total knee replacement after the index surgery with an average period of 13.5 months (range 8–24 months). Conclusions: Arthroscopy-assisted corrective osteotomy, reduction, internal fixation, and strut allograft augmentation can restore tibial plateau malunion/nonunion with well-documented radiographic healing and good clinical outcomes.

Total Knee Arthroplasty in Patients with Prior Femoral and Tibial Fractures: Outcomes and Risk Factors for Surgical Site Complications and Reoperations

Objective

To investigate the outcomes of total knee arthroplasty (TKA) in patients with a prior femoral or tibial fracture, and identify the risk factors for surgical site complications and reoperations.

Methods

Seventy‐one TKAs performed in 71 patients with a prior tibial or femoral fracture between January 2005 and December 2016 were reviewed retrospectively. Forty males (40 knees) and 31 females (31 knees) were included. The mean age at the time of TKA was 59.2 (range, 29–83) years. Outcomes were assessed using the Knee Society score before surgery and at the final follow‐up visit. The patients' satisfaction rates were evaluated. Complications and reoperations were recorded by clinical and radiographic assessment. Logistic regression analysis was used to identify the risk factors for surgical site complications and reoperations.

Results

The median follow‐up period was 4.7 (range, 3.2–7.1) years. The median knee range of motion increased from 90° preoperatively to 110° at the latest follow‐up. The Knee Society knee score and function score improved from 35 (30, 40) and 40 (30, 50) to 90 (82, 93) and 90 (65, 100), respectively. The degree of overall satisfaction after TKA surgery was very satisfied in 41 patients, satisfied in 20 patients, neutral in four patients, dissatisfied in four patients, and very dissatisfied in two patients. The overall satisfaction (very satisfied and satisfied) rate was 85.9% (61 knees). Twelve knees (16.9%) had 19 surgical site complications. Six knees (8.3%) underwent reoperations, including one revision due to periprosthetic joint infection, one debridement and implant retention for superficial infection, two debridements for delayed wound healing, one open reduction and internal fixation for supracondylar fracture, and one re‐fixation and bone grafting for hardware failure after a combined femoral shaft osteotomy and TKA. Preoperative patella baja was diagnosed in 12 knees, and was identified as a risk factor for surgical site complications and reoperations.

Conclusions

TKA for post‐fracture osteoarthritis significantly relieved pain and improved function, but the incidence of surgical site complications and reoperations was high. Preoperative patella baja was a risk factor for surgical site complications and reoperations.

Outcomes of knee replacement in patients with posttraumatic arthritis due to previous tibial plateau fracture

INTRODUCTION

Tibial plateau fractures are routinely treated with open reduction internal fixation (ORIF); however, the long-term results of ORIF are unclear. The purpose of the current study is to evaluate outcomes in these patients, including: the rate of conversion of ORIF to total knee arthroplasty (TKA), the relationship between elevated inflammatory markers after the initial ORIF and subsequent infection in TKA, and the rationale behind performing the conversion to TKA in one step versus two steps.

METHODS

Using current procedural terminology (CPT) codes, we assembled a cohort of 891 patients (933 knees) who underwent ORIF for a tibial plateau fracture from 2007 to 2017 at the investigating institution. The patients were then reviewed for pertinent demographic information and for the outcomes of interest.

RESULTS

Of the 933 knees, a total of 20 knees (2.15%) required conversion from ORIF to TKA. Of the 20 knees that underwent conversion to TKA, three were performed as a two-stage conversion. Of the 20 knees that underwent TKA, seven experienced postoperative arthrofibrosis, four experienced postoperative infection, and four required revision.

CONCLUSION

Our retrospective study suggests that the need for conversion to TKA is uncommon following ORIF of a tibial plateau fracture. Furthermore, the conversion to TKA can be performed as a one- or two-stage procedure, and based on our study, we suggest that there may be higher rates of infection with the single stage conversion.

LEVEL OF EVIDENCE

Level III, Retrospective study.

Clinically Asymptomatic Patients Show a High Bacterial Colonization Rate of Osteosynthetic Implants Around the Knee but Not the Hip

BACKGROUND

Patients with osteosynthetic implants around the hip and knee show higher infection rates after joint arthroplasty. Our aim was to evaluate the bacterial colonization of any osteosynthetic implants around the hip and knee in patients without clinical signs of infection.

METHODS

Consecutive patients with osteosynthetic implant removal because of related soft tissue irritations or before elective total joint arthroplasty of the hip and knee were prospectively included. Patients with signs of infection were excluded. Based on sonication fluid cultures, implants were classified according to microbial growth as negative (no growth), contaminated (nonsignificant growth), or colonized (significant growth).

RESULTS

Sonication cultures were positive in 54 of 203 implants (27%), including 8 of 34 (24%) after orthopedic and 46 of 169 (27%) after traumatological surgery. Of 203 sonication cultures, 22 (11%) grew significant bacterial counts. Most common microorganisms were coagulase-negative staphylococci (46%). Implants around the knee showed a significantly higher rate of positive sonication cultures compared with those around the hip (14% vs 2%, P = .017).

CONCLUSIONS

We detected high bacterial implant colonization rates regardless of the initial type of surgery. Predominant pathogens were staphylococci, the most common causative agents of periprosthetic joint infections. Positive sonication results do not necessarily lead to postoperative surgical complications and thus do not equal infection. It remains unclear if patients with evidence of bacterial implant colonization show a higher risk of periprosthetic joint infection after adjacent subsequent total joint arthroplasty. Nevertheless, surgeons should be aware of a significantly higher colonization rate of implants around the knee and take this into consideration when total knee arthroplasty is scheduled in patients with osteosynthetic devices.

Conversion Total Knee Arthroplasty: A Distinct Surgical Procedure With Increased Resource Utilization

BACKGROUND

Current Procedural Terminology coding currently makes no distinction between primary total knee arthroplasty (TKA) and conversion TKA, in which periarticular hardware components must be removed prior to or during TKA. We hypothesize that conversion TKA will carry increased operative time, blood loss, postoperative complications, and 90-day emergency department/readmission rate compared to primary TKA.

METHODS

Patients undergoing conversion TKA from 2005 to 2017 were identified from an institutional database and matched to primary TKA patients by age, gender, American Society of Anesthesiologists score, body mass index, and procedure date (±1 year). Intraoperative data and 90-day postoperative complications were compared between groups.

RESULTS

One hundred nine conversion TKA patients with periarticular hardware were removed prior to (n = 51) or during (n = 58) TKA and 109 primary TKA control patients were included. Conversion TKA was associated with increased tourniquet time (91 vs 71 minutes, P < .001), operative time (147 vs 113 minutes, P < .001), blood loss (225 vs 176 mL, P = .010), 90-day readmissions (14.6% vs 4.2%, P = .020), wound complication (5.6% vs 0.0%, P = .025), periprosthetic joint infection (7.9% vs 0.0%, P = .005), irrigation/debridement (9.0% vs 1.1%, P = .016), and a trend toward increased mechanical complication (6.7% vs 1.1%, P = .058). Timing of hardware removal did not affect intraoperative or postoperative outcomes.

CONCLUSION

Conversion TKA is associated with higher operative time, blood loss, readmission rate, and postoperative complications compared to primary TKA. Without a proper billing code and appropriate reimbursement level to match the expected operative and postacute resource utilization by these cases, physicians may be disincentivized to perform these operations.

Managing of post-traumatic knee arthritis by total knee arthroplasty: case series of 15 patients and literature review

Purpose

Post-traumatic arthritis is one of the leading causes of joint disability. This study aims at outlining outcomes of total knee arthroplasty in post-traumatic arthritis and technical difficulty and reviewing literature regarding this issue

Patients and methods

We analyzed the outcome of total knee arthroplasty following post-traumatic arthritis in 15 patients with unilateral involvement. Ten had stable arthritic knees treated with posterior stabilized (PS) prosthesis, while five with unstable arthritic knees treated as follows: three with ligamentous instability managed by constrained condylar prosthesis and two with osseous deficiency, metal augmentation used together with stemmed constrained condylar prosthesis (CCK). Average follow-up 6 years, mean age 49.8 years at time of arthroplasty. Patient outcomes were evaluated on the basis of Knee Society score.

Results

Mean clinical knee society scores (CKSS) at latest follow-up improved from 43.6 ± 11.66 points to 77.3± points postoperatively while mean functional knee society score (FKSS) improved from 40. ± 6.3 to 76.6 ± 84 postoperatively. Patients with stable knees had a higher mean values, both clinical and functional KSS, while unstable knees were poorer. Complications occurred in three cases, one with wound dehiscence with prolonged drainage treated by antibiotics and daily dressings until the wound closed completely, one was complicated by infection and improved by serial debridement, and the third case had aseptic loosening which required revision surgery.

Conclusion

Total knee arthroplasty for post-traumatic arthritis decreases pain and improves knee function. However; the procedure is not as simple as primary arthroplasty as it is technically demanding and requires adequate planning.

Primary total knee arthroplasty using constrained condylar knee design for severe deformity and stiffness of knee secondary to post-traumatic arthritis

Background

Key to a successful outcome of total knee arthroplasty (TKA) is to attain optimum alignment, adequate balance, and deformity correction. In primary TKA, this can be achieved efficiently by posterior stabilized (PS) design with or without the sub-periosteal release. However, certain circumstances such as post-traumatic arthritis are often associated with severe deformities with a significant bone defect, stiffness, and instability. Such deformities are extremely difficult to balance with soft tissue release only and require additionally constrained prostheses even in primary TKA. In such situation, constrained condylar knee (CCK) design is the ultimate choice. This study primarily aimed to report on clinical outcome, regain of function, and complication of patients who underwent primary CCK-TKA for severe deformity of the knee secondary to post-traumatic arthritis. The secondary aim was to find out the mid-term prostheses survival.

Methods

Between February 2007 and November 2013, 38 consecutive patients with post-traumatic arthritis of the knee received cemented primary CCK-TKA. Thirty-four patients (21 men and 13 women) who had a minimum of 3 years follow-up were included in this retrospective study. We used Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, and roentgenographic evaluation form to assess the patients. Prostheses survival was assessed using Kaplan-Meier’s survival analysis.

Results

Patients were followed up for an average duration of 6.47 years. KSS knee score improved from 44 points (23–68) pre-operatively to 91 points (76–100) post-operatively [P < 0.001]. The average KSS functional score improved from 49 points (20–75) pre-operatively to 91 points (65–100) post-operatively [P < 0.001]. The average HSS score improved from 51 points (27–83) pre-operatively to 91 points (75–100) post-operatively [P < 0.001]. Similarly, the average ROM improved from 68.09° ± 35.99° (0°–120°) to 113.68° ± 8.90° (100°–130°) post-operatively [P < 0.001]. The average hip-knee-ankle (HKA) angle was 176.88° ± 14.48° (135°–199°) pre-operatively and 180.24° ± 1.77° (175°–184°) post-operatively. Radiolucencies were evident in 13 knees, mostly on the tibial side. Prostheses survival was 94.7% at a mean follow-up of 6.47 years.

Conclusion

Despite severe deformity, instability, and stiffness at a relatively young age, mid-term follow-up of primary CCK-TKA in post-traumatic arthritis provides satisfactory clinical and functional outcomes with 94.7% prostheses survival. However, it is not without complication.

Preoperative Diagnosis Can Predict Conversion Total Knee Arthroplasty Outcomes

BACKGROUND

Compared to total knee arthroplasty (TKA) for primary osteoarthritis, conversion TKAs in the post-traumatic setting are associated with increased operative times, infection rates, and readmissions. We aim at determining how post-traumatic osteoarthritis and previous knee surgery influence postoperative outcomes in conversion TKA.

METHODS

Seventy-two conversion TKA procedures with prior knee trauma at a single institution between April 2012 and 2016 were examined. Twenty-seven (37.5%) cases had a preoperative site-specific diagnosis such as fracture of the proximal tibia, distal femur, or patella whereas 45 (62.5%) cases had a preoperative diagnosis of significant soft-tissue trauma. These 2 groups were compared in terms of total implant cost, length of stay, complications, and readmission and reoperation rates. A subanalysis was conducted to evaluate the effects of previous knee surgery on surgical outcomes.

RESULTS

The postfracture TKA cohort suffered significantly higher early surgical site complications (22% vs 4.4%, P = .02) and 90-day readmissions (14.8% vs 2.2%, P = .042) compared to the soft-tissue trauma cohort. Operative time, total implant costs, length of stay, medical complications, 30-day readmissions, and 90-day reoperation rates did not significantly differ. It was also found that patients with multiple prior knee surgeries compared to one prior knee surgery are younger (53.0 vs 63.1, P = .003), healthier, and receive significantly more expensive implants (1.72 vs 1.07, P = .026). In addition, patients with previous open reduction internal fixations experience more surgical site complications than patients with previous arthroscopies (31% vs 3.3%, P = .042).

CONCLUSION

Patients with previous site-specific fracture are more likely to experience surgical site complications and 90-day readmissions after conversion TKA than patients with previous soft-tissue knee trauma. Multiple previous knee surgeries appear to serve as an independent factor in the selection of costlier implants irrespective of preoperative diagnosis.

Increased risk of early and medium-term revision after post-fracture total knee arthroplasty

Background and purpose - Total knee arthroplasty (TKA) due to posttraumatic fracture osteoarthritis (PTFA) may be associated with inferior prosthesis survival. This study is the first registry-based study solely addressing this issue. Both indications and predictors for revision were identified. Patients and methods - 52,518 primary TKAs performed between 1997 and 2013 were retrieved from the Danish Knee Arthroplasty Register (DKR). 1,421 TKAs were inserted due to PTFA and 51,097 due to primary osteoarthritis (OA). Short-term (< 1 year), medium-term (1-5 years), and long-term (> 5 years) implant survival were analyzed using Kaplan-Meier analysis and Cox regression after age stratification (< 50, 50-70, and >70 years). In addition, indications for revision and characteristics of TKA patients with subsequent revision were determined. Results - During the first 5 years, TKAs inserted due to PTFA had a higher risk of revision than OA (with adjusted hazard ratio ranging from 1.5 to 2.4 between age categories). After 5 years, no significant differences in the risk of revision were seen between the groups. Infection and aseptic loosening were the most common causes of revision in both groups, but TKA instability was a more frequent indication for revision in the PTFA group. In both groups, the revision rates were higher with younger age and extended duration of primary surgery. Interpretation - We found an increased risk of early and medium-term revision of TKAs inserted due to previous fractures in the distal femur and/or proximal tibia. Predictors of revision such as age <50 years and extended duration of primary surgery were identified, and revision due to instability occurred more frequently in TKAs performed due to previous fractures.

Total knee arthroplasty and fractures of the tibial plateau

Tibial plateau fractures are common injuries that occur in a bimodal age distribution. While there are various treatment options for displaced tibial plateau fractures, the standard of care is open reduction and internal fixation (ORIF). In physiologically young patients with higher demand and better bone quality, ORIF is the preferred method of treating these fractures. However, future total knee arthroplasty (TKA) is a consideration in these patients as post-traumatic osteoarthritis is a common long-term complication of tibial plateau fractures. In older, lower demand patients, ORIF is potentially less favorable for a variety of reasons, namely fixation failure and the need for delayed weight bearing. In some of these patients, TKA can be considered as primary mode of treatment. This paper will review the literature surrounding TKA as both primary treatment and as a salvage measure in patients with fractures of the tibial plateau. The outcomes, complications, techniques and surgical challenges are also discussed.

Knee Arthroplasty After Subchondroplasty: Early Results, Complications, and Technical Challenges

BACKGROUND

Calcium phosphate bone substitutes (CPBS) are commonly used to augment and repair bone voids and defects after fractures around the knee joint. The purpose of this study was to determine whether prior arthroscopic application of a CPBS, for repair of magnetic resonance imaging-identified subchondral fractures associated with osteoarthritis (procedure referred to as subchondroplasty) adversely affected the performance and/or outcome of subsequent knee arthroplasty.

METHODS

Twenty-two patients who had arthroscopic repair of a periarticular fracture combined with use of a CPBS who later had knee arthroplasty were identified. Average follow-up for study patients was 23.5 months (range 12-52 months). These patients were matched demographically and for follow-up duration in a 2:1 ratio to a group of control subjects undergoing arthroplasty who had not undergone prior surgery.

RESULTS

Technical challenges related to surgical performance, clinical outcomes, and complications were determined for both the groups. At most recent follow-up, study patients had an average Oxford score of 40.6 (range, 25-48) compared with control subjects with an average score of 40.1 (range, 12-48). There was no difference in complications or surgical complexity between groups, and only standard primary components were used.

CONCLUSION

The results of our study suggest that prior arthroscopic repair combined with CPBS of periarticular fractures around the knee does not compromise the early outcomes and surgical performance or increase complications related to subsequent arthroplasty. However, longer follow-up of these patients is warranted to confirm that implant durability remains uncompromised.

Total knee arthroplasty for treatment of post-traumatic arthritis: Systematic review

AIM

To review and report functional outcomes, complications, and survivorship associated with total knee arthroplasty (TKA) in the treatment of post-traumatic arthritis (PTA).

METHODS

We conducted a systematic review according to the PRISMA guidelines. We searched PubMed, Cochrane Library, and SCOPUS in December 2015 for English-language clinical research studies, both prospective and retrospective, examining the use of TKA for the treatment of PTA. All relevant articles were accessed in full. The manual search included references of retrieved articles. We extracted data on patients’ demographics and clinical outcomes, including preoperative diagnosis and pre- and post-operative functional scores. We summarized the data and reported the results in tables and text.

RESULTS

Sixteen studies, four prospective and ten retrospective, examined patients who underwent TKA for PTA due to fractures of the proximal tibia, patella, and/or distal femur. Eleven studies utilized the Knee Society Scores criteria to assess functional outcomes. All studies utilizing these criteria reported an improvement in functional and knee scores of patients following TKA. Further, studies reported an increased range of motion (ROM) and reduction of pain following surgery. The most commonly reported complications with TKA included infection, stiffness, wound complications, intraoperative rupture of tendons, and osteolysis/polyethylene wear. The overwhelming majority of these complications occurred within the first two years following surgery. Six studies examined the survivorship of TKA with subsequent revision for any reason as an endpoint. Compared to patients with osteoarthritis, patients with PTA required more revisions, the majority for polyethylene wear.

CONCLUSION

Although associated with higher complication rates, TKA is an effective treatment for PTA, as it improves ROM, pain and functional outcomes.

Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification?

BACKGROUND

Total knee arthroplasty (TKA) is often the best answer for end-stage, posttraumatic osteoarthritis after intra-articular and periarticular fractures about the knee. Although TKA in this setting is often considered more technically demanding, outcomes are typically worse for patients. This study examines the intraoperative differences and 30-day outcomes in posttraumatic vs primary TKA cohorts.

METHODS

Patients undergoing TKA were selected from the National Surgical Quality Improvement Program database from 2010 to 2013. Patients were stratified on the basis of concurrent procedures and administrative codes indicating posttraumatic diagnoses. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether posttraumatic arthritis was a risk factor for poor outcomes.

RESULTS

A total of 67,675 primary and 674 posttraumatic TKAs were identified. Posttraumatic TKA patients were on average younger and healthier than the primary TKA population. The posttraumatic TKA group had higher rates of superficial surgical site infections and bleeding requiring transfusion. History of posttraumatic knee osteoarthritis was found to be an independent risk factor for prolonged operative time, increased length of hospital stay, and 30-day hospital readmission.

CONCLUSION

We have demonstrated increased intraoperative times, heightened transfusion requirements and surgical site infections, and higher readmission rates after conversion TKA in the posttraumatic cohort. In contrast to total hip arthroplasty, current diagnosis and reimbursement schemes do not differentiate posttraumatic patients from primary osteoarthritis groups undergoing TKA. We believe that classification reform would improve medical documentation and improve patient care.

TKA for Posttraumatic Osteoarthritis Is More Complex and Needs More Surgical Resources

The purpose of this study was to evaluate the surgical effort of total knee arthroplasty (TKA) for posttraumatic osteoarthritis (PTOA) compared with primary osteoarthritis (OA). A total of 1841 TKAs were analyzed, including 170 patients with PTOA, that resulted from soft tissue trauma in 83 patients and fractures in 87 patients. Results showed that patients were significantly younger at the time of surgery in the posttraumatic group (62 vs 71 years; P<.001). Furthermore, fracture was associated with 3.7 years earlier need of TKA compared with soft tissue trauma. Operation time was significantly longer for both of the posttraumatic groups compared with OA (P<.001). Patients undergoing TKA after knee injuries are younger and surgical treatment is more challenging compared with TKA for OA. Extended operation time and implant systems with higher constraint and modular options are required. [Orthopedics. 2016; 39(3):S36-S40.].

Angular stable plates in proximal meta-epiphyseal tibial fractures: study of joint restoration and clinical and functional evaluation

BACKGROUND

The tibial plateau fractures involve one of the main weight bearing joints of the human body. The goals of surgical treatment are anatomical reduction, articular surface reconstruction and high primary stability. The aim of this study was to evaluate the clinical and functional outcomes after internal plate fixation of this kind of fractures.

MATERIALS AND METHODS

From January 2009 to December 2012, we treated 75 cases of tibial plateau fracture with angular stable plates. We used Rasmussen Score and the Knee Society Score for the clinical and functional evaluation. Twenty-five cases that underwent hardware removal had arthroscopic and CT evaluation of the joint.

RESULTS

No complications occurred. The clinical and functional evaluation, performed by the KSS and Rasmussen Score, highlighted the high percentage of good-to-excellent results (over 90 %). In every case, the range of motion was good with flexion >90°. Arthroscopy showed the presence of chondral damage in 100 % of patients. In all the cases, we found that X-ray images seem better than the CT images.

CONCLUSIONS

Angular stable plates allow to obtain a good primary stability, permitting an early joint recovery with an excellent range of motion. Avoiding to perform a knee arthrotomy at the time of fracture reduction could prove to be an advantage in terms of functional recovery. The meniscus on the injured bone should be preserved in order to maintain good function of the joint. X-ray images remain the gold standard in checking the progression of post-traumatic osteoarthritis.

The difficult primary total knee arthroplasty: a review

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella. Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes. When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.