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Leal J, Wellman SS, Jiranek WA, Seyler TM, Bolognesi MP, Ryan SP. Continuation of Oral Antidiabetic Medications Was Associated With Better Early Postoperative Blood Glucose Control Compared to Sliding Scale Insulin After Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00189-X. [PMID: 38428690 DOI: 10.1016/j.arth.2024.02.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND This study evaluated blood glucose (BG), creatinine levels, metabolic issues, length of stay (LOS), and early postoperative complications in diabetic primary total knee arthroplasty (TKA) patients. It examined those who continued home oral antidiabetic medications and those who switched to insulin postoperatively. The hypothesis was that continuing home medications would lead to lower BG levels without metabolic abnormalities. METHODS Patients who had diabetes who underwent primary TKA from 2013 to 2022 were evaluated retrospectively. Diabetic patients who were not on home oral antidiabetic medications or who were not managed as an inpatient postoperatively were excluded. Patient demographics and laboratory tests collected preoperatively and postoperatively as well as 90-day emergency department visits and 90-day readmissions, were pulled from electronic records. Patients were grouped based on inpatient diabetes management: continuation of home medications versus new insulin coverage. Acute postoperative BG control, creatinine levels, metabolic abnormalities, LOS, and early postoperative complications were compared between groups. Multivariable regression analyses were performed to measure associations. RESULTS A total of 867 primary TKAs were assessed; 703 (81.1%) patients continued their home oral antidiabetic medications. Continuing home antidiabetic medications demonstrated lower median maximum inpatient BG (180.0 mg/dL versus 250.0 mg/dL; P < .001) and median average inpatient BG (136.7 mg/dL versus 173.7 mg/dL; P < .001). Logistic regression analyses supported the presence of an association (odds ratio = 17.88 [8.66, 43.43]; P < .001). Proportions of acute kidney injury (13.5 versus 26.7%; P < .001) were also lower. There was no difference in relative proportions of metabolic acidosis (4.4 versus 3.7%; P = .831), LOS (2.0 versus 2.0 days; P = .259), or early postoperative complications. CONCLUSIONS Continuing home oral antidiabetic medications after primary TKA was associated with lower BG levels without an associated worsening creatinine or increase in metabolic acidosis. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Justin Leal
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Takahashi T, Hatayama K, Nishino M, Hai H, Yamada Y, Suzuki K, Takeshita K. Comparison of postoperative clinical outcome in medial-pivotal and gradually reducing radius design cruciate-retaining total knee arthroplasty-A multicenter analysis of propensity-matched cohorts. J Exp Orthop 2024; 11:e12002. [PMID: 38455450 PMCID: PMC10903436 DOI: 10.1002/jeo2.12002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 12/24/2023] [Indexed: 03/09/2024] Open
Abstract
Purpose To clarify differences in surgery duration, postoperative knee range of motion (ROM), anterior and posterior (AP) laxity, and Forgotten Joint Score (FJS) in patients undergoing medial-pivot (MP) and GRADIUS cruciate-retaining (CR) total knee arthroplasty (TKA) surgeries. Methods We examined patients who underwent either MP or CR TKA at six different Japanese centres. Patients were propensity score matched for age, sex, and preoperative hip-knee angle (HKA). We compared the groups' average surgery duration, postoperative knee ROM, AP laxity, and FJS 1 year after surgery. Results There were 86 study patients: 43 MP and 43 CR TKA matched for age, sex, and preoperative HKA. The MP group enjoyed a significantly shorter surgery duration (89.1 ± 10.9 mins vs. 95.7 ± 12.0 mins, p = 0.0091) and significantly better postoperative knee flexion than the CR group (123.7 ± 9.1° vs. 115.3 ± 12.4°, p < 0.001). The MP had significantly smaller postoperative AP laxity with 30° of knee flexion than the CR group (3.4 ± 1.3 vs. 5.6 ± 2.2 mm, p < 0.001). Conversely, postoperative AP laxity with 90° of knee flexion was significantly larger for the MP group (3.6 ± 1.3 vs. 2.7 ± 1.9 mm, p = 0.0098). There were no between-group differences in postoperative FJS. Conclusions The MP group showed better postoperative knee flexion, midrange AP knee stability, and shorter surgery duration. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Tsuneari Takahashi
- Department of Orthopedic SurgeryIshibashi General HospitalShimotsukeJapan
| | - Kazuhisa Hatayama
- Department of Orthopedic SurgeryJapan Community Health Care Organization Gunma Central HospitalMaebashiJapan
| | - Masahiro Nishino
- Department of Orthopedic SurgeryHokusuikai Memorial HospitalMitoJapan
| | - Hironari Hai
- Department of Orthopedic SurgeryToyokawa City HospitalToyokawaJapan
| | - Yuichiro Yamada
- Department of Orthopedic SurgeryNagoya Kyoritsu HospitalNagoyaJapan
| | - Kosuke Suzuki
- Department of Orthopedic SurgerySeirei Hamamatsu HospitalHamamatsuJapan
| | - Katsushi Takeshita
- Department of Orthopedic Surgery, School of MedicineJichi Medical UniversityShimotsukeJapan
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Porter MA, Johnston MG, Kogan C, Gray CG, Eppich KE, Scott DF. The Joint Awareness Score: A Shortened, Simplified, Improved Alternative to the Forgotten Joint Score. Arthroplast Today 2023; 24:101239. [PMID: 37964917 PMCID: PMC10641080 DOI: 10.1016/j.artd.2023.101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/12/2023] [Indexed: 11/16/2023] Open
Abstract
Background The Forgotten Joint Score (FJS) is a 12-question patient-reported outcomes measure created to measure a patient's awareness of their artificial joint. The FJS has attained wide usage, though it is not without weaknesses. Our patients report that the semantics of the English translation are flawed and that the 5 answer options for each question are poorly differentiated. Additionally, the FJS will result in no score if 3 or more questions are unanswered. This prompted the development of an alternative patient-reported outcomes measure, the Joint Awareness Score (JAS), that builds upon the core concept of joint awareness underlying the FJS, but that is easier to understand and shorter to complete. We completed an exploratory, pilot study to evaluate this outcomes instrument. Our hypothesis is that the JAS will correlate strongly with the FJS and could be used as a substitute. Methods Knee arthroplasty patients in a prospective registry were administered the FJS and the JAS. Internal consistency and correlation were calculated with Cronbach's alpha and Pearson's correlation coefficient, respectively. Results This study included 174 patients. Cronbach's alpha for FJS was 0.97 for 6 months and 0.97 for 12 months, whereas JAS was 0.89 at 6 months and 0.85 at 12 months. Pearson correlation comparing FJS and JAS at 6 months was 0.88 (95% confidence interval: 0.83, 0.92) and 0.86 (95% confidence interval: 0.78, 0.92) at 12 months. Conclusions The Joint Awareness Score is a new patient-reported outcomes measure that is a substitute for the FJS, with half the number of questions, improved semantics, and simplified answers.
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Affiliation(s)
- Matthew A. Porter
- Washington State University Elson S. Floyd College of Medicine, Spokane, WA, USA
| | - Michael G. Johnston
- Washington State University Elson S. Floyd College of Medicine, Spokane, WA, USA
| | | | | | - Kade E. Eppich
- Washington State University Elson S. Floyd College of Medicine, Spokane, WA, USA
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Jones BK, Carlson BJ, Scott DF. Better flexion and early recovery with medial-stabilized vs single-radius total knee arthroplasty with kinematic alignment: Two-year clinical results. Knee 2023; 43:217-223. [PMID: 37467702 DOI: 10.1016/j.knee.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/27/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND There are few studies comparing outcomes in patients with posterior cruciate ligament-sacrificing single-radius (SR) versus medial-stabilized (MS) knee devices. Both types of implants are designed to maximize deep-flexion and to maintain stability throughout the knee flexion arc. The aim of this study was to determine whether two-year outcomes differ between these two implant groups. METHODS Two-hundred and ten patients took part in this retrospective cohort single center study. The SR patients (n = 109) were enrolled in one randomized trial, and the MS knees (n = 101) in another. Patient consent and Investigative Review Board approval was obtained. Radiographs and clinical outcomes were gathered preoperatively and at six weeks, six months, one year and two years. RESULTS There were no statistically significant differences between treatment groups in terms of preoperative demographic characteristics. The MS group had significantly better knee flexion starting at six months postoperative through two years postoperatively (p < 0.05 - p< 0.001). The Knee Society Pain/Motion score was better in the MS group at one year (95.41 vs 90.86, p < 0.002). The Knee Society Pain score was also better in the MS group starting at six weeks through one year (six weeks: 35.3 vs 30, p = 0.007; one year: 46.4 vs 42.4, p = 0.005, respectively). CONCLUSION The MS group had better clinical outcomes than the SR group, with significantly greater knee flexion from six months through two years, better Knee Society Pain scores at six weeks through one year, and higher Knee Society Pain/Motion scores at six weeks and one year postoperatively. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Brett K Jones
- Elson S. Floyd College of Medicine Washington State University, 412 E Spokane Falls Blvd, Spokane, WA 99202, USA.
| | - Brian J Carlson
- Elson S. Floyd College of Medicine Washington State University, 412 E Spokane Falls Blvd, Spokane, WA 99202, USA.
| | - David F Scott
- Elson S. Floyd College of Medicine Washington State University, 412 E Spokane Falls Blvd, Spokane, WA 99202, USA; Spokane Joint Replacement Center, Inc., Spokane, WA, USA.
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Christensen JC, Blackburn BE, Anderson LA, Gililland JM, Peters CL, Archibeck MJ, Pelt CE. Recovery Curve for Patient Reported Outcomes and Objective Physical Activity After Primary Total Knee Arthroplasty - A Multicenter Study Using Wearable Technology. J Arthroplasty 2023; 38:S94-S102. [PMID: 36996947 DOI: 10.1016/j.arth.2023.03.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND This study aimed to describe the trajectory of recovery based on patient reported outcomes (PROs) and objective metrics of physical activity measures over the first 12 months post-total knee arthroplasty (TKA). METHODS In total, 1,005 participants who underwent a primary unilateral TKA surgery between November 2018 and September 2021 from a multi-site prospective study were analyzed. Generalized estimating equations were used to evaluate PROs and objective physical activity measures over time. RESULTS All Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), EuroQol-5D (EQ-5D) and steps per day scores were greater than pre-operative scores (P<0.05). The flights of stairs per day, gait speed and walking asymmetry all declined at 1-month (all, P<0.001). However, all subsequent scores improved by 6 months (all, P<0.01). The greatest clinically important differences from previous visit in KOOS JR (β=18.1; 95% Confidence Interval (CI)=17.2, 19.0), EQ-5D (β=0.11; 95% CI=0.10, 0.12), steps per day (β=1169.3; 95% CI=1012.7, 1325.9), gait speed (β=-0.05; 95% CI=-0.06, -0.03), and walking asymmetry (β=0.00; 95% CI=-0.03, 0.03) were observed at 3 months. CONCLUSION The KOOS JR, EQ-5D, and steps per day measures showed earlier improvements than other physical activity metrics, with the greatest magnitude of improvement within the first 3 months post-TKA. The greatest magnitude of improvement in walking asymmetry was not observed until 6 months, while gait speed and flights of stairs per day were not observed until 12 months. This data may further help provide expectation setting information to patients prior to surgery, and may aid in identifying outliers to the normal recovery curve who may benefit from targeted interventions.
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Affiliation(s)
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | | | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah.
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Indelli PF, Giuntoli M, Zepeda K, Ghirardelli S, Valtanen RS, Iannotti F. Native knee kinematics is not reproduced after sensor guided cruciates substituting total knee arthroplasty. J Exp Orthop 2023; 10:17. [PMID: 36786878 PMCID: PMC9929011 DOI: 10.1186/s40634-023-00567-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/11/2023] [Indexed: 02/15/2023] Open
Abstract
PURPOSE Gait analysis was used to evaluate knee kinematics in patients who underwent successful primary total knee arthroplasty (TKA) using two modern bi-cruciate substituting designs. The knee joint was balanced intraoperatively using real-time sensor technology, developed to provide dynamic feedback regarding stability and tibiofemoral load. The authors hypothesized that major differences exist in gait parameters between healthy controls and post-TKA patients. METHODS Ten patients who underwent successful TKA using bi-cruciate substituting designs were evaluated at a minimum of 9 months postoperatively using three-dimensional knee kinematic analysis; a multi-camera optoelectronic system and a force platform were used. Sensor-extracted kinematic data included knee flexion angle at heel-strike (KFH), peak midstance knee flexion angle (MSKFA), maximum and minimum knee adduction angle (KAA) and knee rotational angle at heel-strike. Multiple gait analysis data from the study group were compared to a group of ten healthy controls who were matched by age, sex and BMI. Clinical outcome in the TKA group was also measured using the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS Clinically, at final follow-up, a statistically significant difference in pain, general symptoms, and activities of daily living was seen between the groups. From a gait analysis standpoint, TKA patients had significantly less rotation at heel strike (p = 0.04), lower late stance peak extension moments (p = 0.02), and less Knee Adduction Angle excursion during swing phase (p = 0.04) compared to the control group. No statistically significant difference was observed for knee flexion angle at heel strike, knee adduction moment, or peak knee flexion moment between the groups. CONCLUSIONS Modern bi-cruciate substituting TKA designs failed to reproduce normal knee kinematics. The lack of full knee extension during the stance phase, absence of the "screw-home mechanism" typical of an ACL functioning knee, and the reduced fluctuation in knee adduction angle during the swing phase still represent major proprioceptive and muscular recruitment differences between normal and replaced knees.
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Affiliation(s)
- Pier Francesco Indelli
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, USA. .,Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway, Redwood City, CA, 94063, USA.
| | - Michele Giuntoli
- grid.5395.a0000 0004 1757 3729Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Karlos Zepeda
- grid.430773.40000 0000 8530 6973Touro College of Osteopathic Medicine, New York, USA
| | | | - Rosa Susanna Valtanen
- grid.168010.e0000000419368956Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, USA
| | - Ferdinando Iannotti
- Department of Orthopaedic and Trauma Surgery, San Paolo Hospital, Civitavecchia, Italy
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7
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Gousopoulos L, Dobbelaere A, Ratano S, Bondoux L, Tibesku CO, Aït-Si-Selmi T, Bonnin MP. Custom total knee arthroplasty combined with personalised alignment grants 94% patient satisfaction at minimum follow-up of 2 years. Knee Surg Sports Traumatol Arthrosc 2023; 31:1276-1283. [PMID: 36656348 DOI: 10.1007/s00167-023-07318-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE The purpose was to report detailed patient-reported outcome measures (PROMs) and satisfaction rates for computed tomography (CT)-based custom TKA at minimum follow-up of 2 years. The hypothesis was that custom TKA combined with 'personalised alignment' would yield equivalent or better PROMs compared to values reported in systematic reviews and meta-analyses on off-the-shelf (OTS) TKA. METHODS Of an initial cohort of 150 custom TKAs, four died (unrelated to surgery), one required a revision, and five refused participation, leaving 140 patients for analysis. Patients completed pre- and post-operative PROMs (Oxford Knee Score (OKS), Forgotten Joint Score (FJS), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster osteoarthritis index (WOMAC)) as well as overall level of satisfaction. Proportions that attained a patient acceptable symptom state (PASS) were calculated for OKS and FJS. Clinical findings were compared to the average scores reported for PROMs in recent systematic reviews and/or meta-analyses on OTS TKA. Descriptive statistics were used to summarise the clinical findings as means, standard deviations (SD) and ranges, or numbers and percentages. RESULTS At mean follow-up 33.5 ± 4.5 months, 94% (135/143) were either satisfied or very satisfied. Proportions that achieved PASS were 89% for OKS (120/135), and 85% for FJS (118/139). Median OKS, WOMAC and KOOS Symptoms and Pain scores were all within the 4th quartile of medians reported in systematic reviews and/or meta-analyses. CONCLUSIONS At a minimum follow-up of two years following custom TKA combined with 'personalised alignment', 94% of patients were either satisfied or very satisfied, and the PASS criteria were achieved in 89% for OKS and 85% for FJS, all of which compare favourably to published outcomes of OTS TKA. Direct comparisons to the literature may not be appropriate, however, considering the heterogeneity of patient demographics and alignment techniques. Randomised controlled trials with sufficient statistical power are needed to corroborate these findings and generalise them to unselected TKA patients. LEVEL OF EVIDENCE IV, retrospective cohort study.
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Affiliation(s)
- Lampros Gousopoulos
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Andreas Dobbelaere
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Salvatore Ratano
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Louka Bondoux
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | | | - Tarik Aït-Si-Selmi
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Michel P Bonnin
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
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Massé V, Cholewa J, Shahin M. Personalized alignment™ for total knee arthroplasty using the ROSA ® Knee and Persona ® knee systems: Surgical technique. Front Surg 2023; 9:1098504. [PMID: 36733674 PMCID: PMC9888495 DOI: 10.3389/fsurg.2022.1098504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023] Open
Abstract
Total knee arthroplasty (TKA) procedures are expected to increase up to 565% in the United States over the next 3 decades. TKAs were traditionally performed with neutral mechanical alignments that provided equal medial and lateral gaps in extension and flexion to reduce implant wear but were less successful at restoring native knee function and associated with high patient dissatisfaction. Kinematic alignment (KA) restores native anatomy and minimizes soft tissue release; however, KAs that recreate severe deformities and/or biomechanically inferior alignments result in significant increases in implant stress and risk of aseptic loosening. Restricted kinematic alignment (rKA) recreates pre-arthritic anatomy within a range of acceptable alignment boundaries, and improved patient clinical scores and faster recoveries have been reported with rKA techniques. Personalized Alignment™ is an evolution of rKA that relies heavily upon robotic assistance to reliably recreate patient anatomy, native soft tissue laxity, and accurate component placement to improve patients' clinical outcomes. The purpose of this surgical technique report is to describe the Personalized Alignment TKA method using the ROSA® Knee System and Persona® The Personalized Knee® implants. Herein we provide specific procedures for pre-operative planning, anatomical landmarking and evaluation, intra-operative planning and adjustment of resections and cuts, cut validation and soft tissue evaluation with robotic-assisted personalized TKA.
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Affiliation(s)
- Vincent Massé
- Hôpital Maisonneuve-Rosemont, Surgery Department, Université de Montréal, Montreal, Quebec, Canada,Personalized Arthroplasty Society, Atlanta, GA, United States,Duval Orthopaedic Clinic, Laval, Québec, Canada,Correspondence: Vincent Massé
| | | | - Maged Shahin
- Personalized Arthroplasty Society, Atlanta, GA, United States,Duval Orthopaedic Clinic, Laval, Québec, Canada
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Scott DF, Hellie AA. Mid-Flexion, Anteroposterior Stability of Total Knee Replacement Implanted with Kinematic Alignment: A Randomized, Quantitative Radiographic Laxity Study with Posterior-Stabilized and Medial-Stabilized Implants. J Bone Joint Surg Am 2023; 105:9-19. [PMID: 36574642 DOI: 10.2106/jbjs.22.00549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
UPDATE This article was updated on January 4, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 16, in Figure 5, the x-axis that had read "P<0.0086" now reads "KSS Pain (p=0.02)," and the value for the MS group that had read "48.9" now reads "48.8."This article was updated on January 6, 2022, because of a previous error. On page 13, in the section entitled "Results," the sentence that had read "However, when only the subset of female subjects was considered, the MS group demonstrated significantly less anteroposterior laxity in 90° of flexion than the MS group (2.3 versus 5.4 mm; p = 0.008)." now reads "However, when only the subset of female subjects was considered, the MS group demonstrated significantly less anteroposterior laxity in 90° of flexion than the PS group (2.3 versus 5.4 mm; p = 0.008)." BACKGROUND Stability in mid-flexion is important for satisfactory clinical outcomes following total knee arthroplasty (TKA). The purpose of the present study was to compare the anteroposterior stability of knees that had been treated with a posterior-stabilized (PS) device or a medial-stabilized (MS) device. We hypothesized that mid-flexion laxity would be greater in the PS group and that clinical outcome scores would be better for the group with lower laxity. METHODS Sixty-three patients who had been randomly selected from a larger randomized, prospective, blinded clinical trial underwent primary TKA with either a PS implant (n = 30) or an MS implant (n = 33). Range of motion, the Knee Society Score (KSS), and the Forgotten Joint Score (FJS) were collected, and anteroposterior laxity with the knee in 45° and 90° of flexion was evaluated with stress radiographs. RESULTS In 45° of flexion, the MS group demonstrated significantly less total anteroposterior displacement than the PS group (mean, 3.6 versus 16.5 mm; p ≤ 0.0001). In 90° of flexion, the total anteroposterior displacement was not significantly different for the 2 groups when both male and female patients were included (mean, 3.9 versus 5.9; p = 0.07). However, when only the subset of female subjects was considered, the MS group demonstrated significantly less anteroposterior laxity in 90° of flexion than the PS group (2.3 versus 5.4 mm; p = 0.008). The groups did not differ significantly in terms of preoperative age, body mass index, sex distribution, FJS, KSS, or range of motion, and they also did not differ in terms of postoperative FJS or range of motion. However, all 33 patients in the MS group returned to sports as indicated in question 12 of the FJS, compared with 19 subjects in the PS group (p = 0.0001). The postoperative KSS Pain, Pain/Motion, and Function scores were all significantly higher in the MS group than the PS; specifically, the mean KSS Pain score was 48.8 in the MS group, compared with 44.8 in the PS group (p = 0.02); the mean KSS Pain/Motion score was 98.4 in the MS group, compared with 89.5 in the PS group (p < 0.0001); and the mean KSS Function score was 95.5 in the MS group, compared with 85.7 in the PS group (p = 0.003). CONCLUSIONS Mid-flexion laxity was greater in patients with PS implants than in those with MS implants, and laxity in 90° was greater in the subset of female patients in the PS group. The decreased laxity observed in the MS group correlated with higher KSS Pain, Pain/Motion, and Function scores as well as with a higher rate of return to sports activities. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David F Scott
- Spokane Joint Replacement Center, Inc., Spokane, Washington.,Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington
| | - Amy A Hellie
- Spokane Joint Replacement Center, Inc., Spokane, Washington
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Medial Pivot Designs Versus Conventional Bearing Types in Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202212000-00006. [PMID: 36732308 PMCID: PMC9726426 DOI: 10.5435/jaaosglobal-d-22-00170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/09/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Medial pivot (MP) designs are growing in popularity. They provide increased sagittal plane stability and theoretically replicate some aspects of native joint kinematics, which may improve total knee arthroplasty outcomes. METHODS A systematic review was performed of randomized controlled trials (RCTs) that compared MP designs with cruciate-retaining, posterior-stabilized (PS), ultracongruent, or mobile-bearings in primary total knee arthroplasty, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome measures were all clinical function scores, patient-reported outcome measures, and range of motion. The secondary outcome was complications. Two authors independently selected studies, performed data extraction, and risk-of-bias assessment. Studies at high risk of bias were excluded from meta-analysis. Treatment effects were assessed using random-effects meta-analysis and quantified using pooled mean differences or incidence rate differences as appropriate. RESULTS Eight RCTs met inclusion criteria. Five compared MP with PS, two with ultracongruent, and one with cruciate-retaining and mobile-bearing. In total, 350 knees were randomized to MP and 375 to conventional bearings. One RCT was excluded from meta-analysis because of high risk of bias. Meta-analysis comparing MP with PS only was possible and found no differences at any time points for any outcome measure, including 2-year follow-up for Oxford Knee Score (MD = 0.35 favoring PS; 95% CI -0.49 to 1.20) and range of motion (MD = 1.58 favoring MP; 95% CI -0.76 to 11.92, P = 0.30) and 12 months for Western Ontario Arthritis Index (MD = 4.42 favoring MP; 95% CI -12.04 to 3.20, P = 0.09). CONCLUSIONS There is no difference in clinical outcomes, with contemporary measurement tools, at any time points, between MP and PS. There are insufficient RCTs comparing MP with other bearings.
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Custom TKA combined with personalised coronal alignment yield improvements that exceed KSS substantial clinical benefits. Knee Surg Sports Traumatol Arthrosc 2022; 30:2958-2965. [PMID: 35182169 DOI: 10.1007/s00167-022-06867-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to report Knee Society Scores (KSS) at 12-month follow-up in a series of 266 knees that received custom TKA. The hypothesis was that custom TKA combined with personalised alignment would yield improvements greater than substantial clinical benefits (SCB) of KSS Knee and Function. METHODS From a consecutive series of 905 patients (918 knees) that received primary TKAs, 261 (29%) patients (266 knees) received computed tomography (CT)-based posterior-stabilised cemented custom TKA. Knees were aligned aiming to preserve or restore constitutional alignment within predetermined limits of 85°-95° for femoral mechanical angle (FMA) and tibial mechanical angle (TMA), and 175°-183° for hip knee ankle (HKA) angle. The KSS Knee and Function were collected preoperatively and 12 months postoperatively, to determine if patients achieved SCB. Uni- and multivariable analyses were performed to determine associations between KSS scores (Knee and Function) and patient demographics as well as pre- and postoperative radiographic alignments. RESULTS Of the initial cohort of 261 patients, 4 (1.8%) were reoperated for patellar resurfacing, 1 (0.4%) for lavage to treat infection, and 1 (0.4%) had arthroscopy to treat a stiff knee with < 90° range of motion. Complete clinical records were available for 227 patients (232 knees, 87%) that comprised 102 men (5 bilateral) and 125 women. At 12-month follow-up, mean improvements in KSS Knee and Function scores were, respectively, 61.0 ± 13.0 and 42.7 ± 16.7, which exceeded the SCB of KSS. Comparison of knees inside versus outside the target zone revealed no differences in KSS Knee (94.1 ± 9.1 versus 94.3 ± 9.0, n.s.) and Function (96.1 ± 9.2 versus 96.3 ± 8.9, n.s.). Multivariable analysis revealed worse KSS Knee in knees with preoperative FMA > 95° (β = - 6.21; p = 0.023), but no association between KSS Function and patient demographics or pre- and postoperative radiographic alignments. CONCLUSIONS Custom TKA combined with personalised alignment yielded improvements that exceeded substantial clinical benefits of KSS Knee and Function scores. These findings demonstrate the feasibility of custom TKA with 'personalised alignment' and encourage further investigations using comparative studies at longer follow-up. LEVEL OF EVIDENCE IV, case series.
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Scott DF, Gray CG. Outcomes are Better With a Medial-Stabilized vs a Posterior-Stabilized Total Knee Implanted With Kinematic Alignment. J Arthroplasty 2022; 37:S852-S858. [PMID: 35189286 DOI: 10.1016/j.arth.2022.02.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is no consensus whether a posterior-stabilized (PS) total knee device is superior to a more congruent, cruciate-substituting, medial-stabilized device (MS). This study compared the clinical outcomes of these devices. The primary hypothesis was that the clinical outcomes would be better in the MS group implanted with kinematic alignment. METHODS This prospective, randomized, single-center Level 1 study compared the outcomes of 99 patients who received a PS device and 101 patients who received an MS device implanted with kinematic alignment. Institutional Review Board approval and informed consent were obtained. Clinical and radiographic assessments were performed preoperatively, 6 weeks, 6 months, and annually. RESULTS All subjects reached the minimum follow-up of 2 years. There were no statistically significant differences in demographic characteristics, preoperative scores, or alignment (preoperative or postoperative). Tourniquet time was 7.24% longer for the PS group (40.28 min vs 37.56 min, P < .0086). There were significant differences between groups for the 1-year and 2-year Knee Society scores, Forgotten Joint Score, and ROM; in every case favoring the MS group. The FJS was 68.3 in the MS group at 2 years and 58.3 in the PS group (P = .02). The maximum flexion at 2 years was 132° in the MS group and 124° in the PS group (P < .0001). CONCLUSION The clinical outcomes of the MS group at 1 and 2 years were better. At the minimum 2-year follow-up, the results demonstrate the superiority of the medial-stabilized device in terms of multiple clinical outcomes. LEVEL OF EVIDENCE I.
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Affiliation(s)
- David F Scott
- Spokane Joint Replacement Center Inc., Spokane, Washington; Washington State University, Elson S. Floyd College of Medicine, Spokane, Washington
| | - Celeste G Gray
- Spokane Joint Replacement Center Inc., Spokane, Washington
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13
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Press-Fit Dual-Pivot Total Knee Arthroplasty: Early Results With a Minimum 2-Year Follow-Up. J Arthroplasty 2022; 37:S238-S244. [PMID: 35197199 DOI: 10.1016/j.arth.2022.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/24/2021] [Accepted: 01/15/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Ultracongruent (UC) tibial bearings are being used with increasing frequency in the United States. Evidence suggests that the use of certain UC bearings may lead to improved patient satisfaction when compared with using conventional inserts. However, little is known as to what effect the use of UC tibial inserts has on bone ingrowth in uncemented total knee arthroplasty (TKA). The purpose of this study was to determine the early clinical and radiographic results of TKA using a press-fit dual-pivot design. METHODS Between 2017 and 2019, a consecutive series of 232 TKAs were implanted using a press-fit tibial and femoral component and a UC dual-pivot tibial insert. Sixty-two percent of patients were male. The average age was 56 years. Patients were followed for a minimum of 2 years (range, 24-42 months) using KOOS-JR and Knee Society clinical and radiographic evaluation. RESULTS No patient had more than mild knee stiffness at the final follow-up. Two patients reported moderate knee pain with stair climbing. All other patients reported either mild or no pain with activity. Knee Society pain scores averaged 42 points. Flexion averaged 118 degrees. Three knees (1.3%) were revised (one each for flexion instability, tibial plateau fracture, and suspected femoral component loosening). No other cases of femoral or tibial loosening were identified. CONCLUSION Although the success of uncemented TKA is determined by a variety of factors, the use of this dual-pivot knee design did not appear to influence tibial or femoral component fixation at early follow-up, yielding acceptable clinical and radiographic outcomes.
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Christensson A, Tveit M, Kesteris U, Flivik G. Similar migration for medial congruent and cruciate-retaining tibial components in an anatomic TKA system: a randomized controlled trial of 60 patients followed with RSA for 2 years. Acta Orthop 2022; 93:68-74. [PMID: 34633885 PMCID: PMC8815372 DOI: 10.1080/17453674.2021.1983709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - There is an ongoing debate regarding the appropriate level of constraint in primary TKA. To provide increased stability and better kinematics, more resembling a natural knee, a medial congruent (MC) tibial insert has been introduced. To investigate potential impact on implant migration, we evaluated the cemented Persona TKA, randomizing between MC and cruciate-retaining (CR) tibial designs. Patients and methods - 60 patients with primary osteoarthritis were randomized to either the CR or MC tibial component. Radiostereometric analysis (RSA) examinations, evaluating translational and rotational migration as well as maximal total point motion (MTPM), were performed on the first postoperative day, at 3 months, and 1 and 2 years after surgery. Preoperative, and 1- and 2-year patientreported outcome measures (PROMs) data (KOOS and FJS) were collected. Results - The mean tibial MTPM at 3 months were 0.48 mm (95% CI 0.37-0.58) and 0.56 mm (0.45-0.67) for the CR and MC respectively. 2 years postoperatively the respective values were 0.62 mm (0.50-0.73) and 0.73 mm (0.49-0.96). There was no statistically significant difference in migration between groups, for either the femoral or the tibial component, regarding x-, y-, and z-translations or rotations. Both CR and MC groups improved as expected in PROM scores pre- to postoperatively, but without a statistically significant difference between groups. There were no revisions or other serious adverse events related to surgery. Interpretation - The results are promising, indicating good fixation for both designs, and this is in line with other well-performing TKAs on the market. The increased medial congruity of the MC inlay does not seem to affect the migration or the PROMs up to 2 years.
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Affiliation(s)
- Albin Christensson
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Magnus Tveit
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Uldis Kesteris
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Gunnar Flivik
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
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Conforming Polyethylene Inserts in Total Knee Arthroplasty: Beyond the Posterior-Stabilized and Cruciate-Retaining Debate. J Am Acad Orthop Surg 2021; 29:e1097-e1104. [PMID: 34478416 DOI: 10.5435/jaaos-d-20-01232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 07/24/2021] [Indexed: 02/01/2023] Open
Abstract
Total knee arthroplasty continues to be one of the most commonly performed surgical procedures worldwide. However, considerable controversy exists regarding the optimal implant design. Total knee implants with both posterior-stabilized and cruciate-retaining designs have excellent long-term outcomes with inadequate data demonstrating superiority of either design. Recently, the popularity of total knee designs with more conforming polyethylene liners has increased. These polyethylene inserts prevent paradoxical anterior translation of the femur, without relying on a cam and post mechanism, and promote more physiologic native knee kinematics. This review summarizes the design rationale of several commercially available implants, discusses the kinematic data of several designs, and reviews the available clinical data.
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Webb JI, Stoner RS, Afzal I, Evans CR, Scott G, Field RE. The Medial Rotation Knee replacement: Clinical and radiological results of a multi-centre surveillance study at five years. Knee 2021; 28:247-255. [PMID: 33453513 DOI: 10.1016/j.knee.2020.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 09/20/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Medial Rotation Knee (MRK) has one of the lowest revision rates of total knee replacement designs in the National Joint Registry. While survival is one metric of performance of implants, patient-reported outcomes, combined with clinical and radiological evaluation, allow more complete analysis. We report the five-year results of a prospective, multi-centre surveillance study of the MRK. METHODS A 16-surgeon, three-centre series of 520 total knee replacements were performed in 486 patients, comprising 182 males and 304 females. The mean age was 70.3 years (46-96) and BMI 29.5 kg/m2 (18-57). Study subjects were given questionnaires pre-operatively, at six months, and annually thereafter. Clinical and radiological reviews were scheduled pre-operatively, at six months, three and five years. RESULTS At five years, 395 of the original 486 patients (427 of 520 knees) remained under active review. Twenty-six patients (27 knees) had withdrawn, 44 patients/knees had died and one was excluded. Thirteen patients (14 knees) were lost to follow-up, but were not revised. Seven knees were revised, equating to a survival probability of 98.6% at five years. There were significant improvements in mean Oxford Knee Score (21.23-35.79), EQ-5D (0.440-0.694) and Knee Society Score (Knee 43.00-83.97; Function 49.45-71.39). Of the radiographs available for evaluation, radiolucency was identified in 25 knees (14.6%) with one case of osteolysis of the tibial component. CONCLUSION In addition to excellent survivorship, mid-term patient-reported, clinical and radiological results at five years are satisfactory, and consistent with other medial pivot designs.
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Affiliation(s)
- Jeremy I Webb
- South West London Elective Orthopaedic Centre, Dorking Road, Epsom, Surrey KT18 7EG, United Kingdom.
| | - Rebecca S Stoner
- South West London Elective Orthopaedic Centre, Dorking Road, Epsom, Surrey KT18 7EG, United Kingdom
| | - Irrum Afzal
- South West London Elective Orthopaedic Centre, Dorking Road, Epsom, Surrey KT18 7EG, United Kingdom
| | - Chris R Evans
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry SY10 7AG, United Kingdom
| | - Gareth Scott
- The Royal London Hospital, Whitechapel, London E1 1BB, United Kingdom
| | - Richard E Field
- South West London Elective Orthopaedic Centre, Dorking Road, Epsom, Surrey KT18 7EG, United Kingdom
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