Patient Acceptable Symptom State for the Forgotten Joint Score in Primary Total Knee Arthroplasty

The Negative Impacts of Sarcopenia on Primary Total Knee Arthroplasty under the Enhanced Recovery after Surgery Protocol

OBJECTIVE

Sarcopenia, as an emerging public health concern, has been associated with postoperative adverse outcomes in various surgical procedures. However, the evidence regarding the impacts of sarcopenia on total knee arthroplasty (TKA) remained limited. This study aimed to assess the impacts of sarcopenia on primary TKA based on the enhanced recovery after surgery (ERAS) protocol.

METHODS

This retrospective study included 291 patients who received unilateral TKA from October 2017 to May 2018 in our institution. Sarcopenia was diagnosed based on the algorithm of Asian Working Group for Sarcopenia 2019. The handgrip strength was measured using a handheld dynamometer and the muscle mass was estimated by a previously validated anthropometric equation. Patients were classified into sarcopenia group and non-sarcopenia group. The outcomes included complications, postoperative length of stay (LOS), total hospitalization cost, operative time, total estimated blood loss, blood transfusion rate, and the 12-item forgotten joint score (FJS-12) at the follow-up. The propensity score matching (PSM) was used to adjust confounding factors. We compared continuous variables using Student's t-test and the Wilcoxon Mann-Whitney U test for normal and non-normal distributions, respectively, and categorical variables with chi-square tests.

RESULTS

Of the 291 patients, 58 (19.9%) patients were identified as having sarcopenia. After PSM, each group matched 42 patients. All matched patients were followed-up at least 5 years. Patients with sarcopenia had higher rates of surgical complications compared to the non-sarcopenia group (p = 0.019), and no significant difference was observed in 30-day readmission, and periprosthetic joint infection. The sarcopenia group had significantly longer LOS (p = 0.038), higher total hospitalization (p = 0.015) than the non-sarcopenia group. For the FJS-12 scores at follow-up, patients with sarcopenia had significantly higher scores than the non-sarcopenia group (p = 0.024).

CONCLUSION

Our findings indicated sarcopenia may be a risk factor for postoperative complications, prolonged LOS, increased hospitalization cost and reduced patient satisfaction.

Short-term functional outcomes of robotic-assisted TKA are better with functional alignment compared to adjusted mechanical alignment

INTRODUCTION

Ligament balancing is essential to the functional outcome of total knee arthroplasty (TKA). The optimal method of alignment remains a controversial issue. The primary objective was to compare the clinical outcomes of TKA between functional and adjusted mechanical alignment techniques. The secondary objectives were to compare bone resection, robotic alignment, and radiological assessment.

MATERIALS AND METHODS

This was a retrospective case-control series comparing TKA performed with functional alignment (FA) and adjusted mechanical alignment (aMA). Sixty-four FA subjects were matched with 64 aMA controls. These two groups were matched for age, gender, body mass index (BMI), surgeon, and type of frontal deformity. Both surgical procedures were performed using the MAKO® haptic robotic system. Functional scores (Forgotten Joint Score (FJS), Knee Society Score (KSS), and Oxford Knee Score (OKS)) were measured at the final postoperative follow-up. A radiographic evaluation was performed at the same time.

RESULTS

Mean FJS were respectively 63.4 ± 25.1 [0-100] and 51.2 ± 31.8 [0-100] in FA versus aMA group (p = 0.034). Mean OKS were respectively 40.8 ± 6.3 [21-48] and 34.9 ± 11.8 [3-48] in FA versus aMA group (p = 0.027). Mean KSS were respectively 184.9 ± 17.0 [126-200] and 175.6 ± 23.1 [102-200] in FA versus aMA group (p = 0.02). The main residual symptom was "none" for 73.0% versus 57.8%, "instability" for 6.4% versus 21.9%, "Pain" for 19.1% versus 12.5%, and "effusion" for 1.6% and 7.8% respectively for FA and aMA group (p = 0.016). There were 4 complications in the FA group versus 5 in the aMA group (p > 0.999). Mean postoperative hip-knee-ankle (HKA) robotic assessment were respectively 177.3° ± 2.0 [172-180] and 178.2° ± 2.0 [173-180] for FA and aMA group (p = 0.018). The median difference between HKA robotic and HKA radiological was -3.0° (IQR = 3.0; p < 0.001).

CONCLUSION

With greater residual deformity and without release, functional alignment showed a statistically significantly better short-term clinical outcome than adjusted mechanical alignment. This difference may not be clinically significant.

Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) in patients who have undergone total knee arthroplasty: a systematic review

BACKGROUND

The present systematic review investigated the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) of several frequent and established PROMs used to assess patients who have undergone TKA. This study was conducted according to the 2020 PRISMA statement.

METHODS

In September 2023, PubMed, Web of Science, and Embase were accessed with no time constraint All clinical studies investigating tools to assess the clinical relevance of PROMs used to evaluate patients having received TKA were accessed. Only studies which evaluated the MCID, PASS, or SCB were eligible. The PROMs of interest were the Forgotten Joint Score-12 (FJS-12), the Oxford Knee Score (OKS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and its related subscales activity of daily living (ADL), pain, quality of life (QoL), sports and recreational activities, and symptoms, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, the Knee Society Score (KSS) and related function score, and the Short Form-12 (SF-12) and Short Form-36 (SF-36).

RESULTS

Data from 29,737 patients were collected. The overall risk of bias was low to moderate. The great variability of thresholds for MCID, SCB and PASS between questionnaires but also between investigated aspects was noted, whereby MCIDs for the SF-36 appear lower than for knee-specific questionnaires.

CONCLUSION

Despite its critical role from a patient's perspective, the dimension of SCB is still neglected in the literature. Moreover, thresholds for the different concepts need to be condition-specific. We encourage authors to specifically report such data in future studies and to adhere to previously reported definitions to allow future comparison. Level of evidence Level IV, systematic review and meta-analysis.

Cruciate-substituting and posterior-stabilised total knee arthroplasties had similar gait patterns in the short term

PURPOSE

Surgeons want to achieve native kinematics in primary total knee arthroplasty (TKA). Cruciate-substituting (CS) implants could restore the knee kinematics more efficiently than posterior-stabilised (PS) TKA. This study aimed to compare gait patterns in patients with CS or PS TKA at 6 months. The hypothesis was that CS implants would demonstrate comparable gait parameters to PS implants at 6 months.

METHODS

In this prospective case-control study, 38 primary TKA without coronal laxity were divided into 2 groups: 19 cruciate-substituting (CS) and 19 posterior-stabilised (PS) implants. The type of prosthesis was determined according to the surgical period. Exclusion criteria were TKA revision, associated procedures and inability to walk on a treadmill. Gait analysis was conducted on a treadmill 6 months postoperatively for each patient with a knee assessment device (KneeKG®). Gait characteristics included analysis in three spatial dimensions (flexion-extension, abduction-adduction, internal-external rotation, anterior-posterior translation). Clinical outcomes (Knee Society Score and Forgotten Joint Score) were compared between both groups at 6 months postoperatively.

RESULTS

At 6 months, the gait analysis did not demonstrate any significant difference between CS and PS implants. The range and the maximum anteroposterior translation were similar in both groups (9.2 ± 6.5 mm in CS group vs. 8.1 ± 3 mm in PS group (n.s.); and - 5.2 ± 5 mm in CS group vs. - 6.3 ± 5.9 mm in PS group (n.s.), respectively). The internal/external rotation, the flexion, and the varus angle were similar between CS and PS implants. The KSS Knee score was higher at 6 months in the CS group than in the PS group (92.1 ± 5.6 vs. 84.8 ± 8.9 (p < 0.01)).

CONCLUSION

Cruciate-substituting and posterior-stabilised TKA had similar gait patterns at 6 months postoperatively, despite a non-equivalent posterior stabilisation system. CS prostheses were an interesting option for primary TKA for knee kinematics restoration without requiring a femoral box.

LEVEL OF EVIDENCE

Prospective, case-control study; Level II.

Clinical and Radiographic Outcomes of Inversed Restricted Kinematic Alignment Total Knee Arthroplasty by Asia Specific (Huang’s) Phenotypes, a Prospective Pilot Study

Inverse restricted kinematic alignment (irKA) was modified from restricted kinematic alignment for total knee arthroplasty (TKA). This prospective single-center study aimed to evaluate the outcomes of irKA-TKA on all knee subtypes classified by Asia specific (Huang’s) phenotypes. A total of 96 knees that underwent irKA-TKA at one hospital between January 2018 and June 2020 were included, with 15 knees classified in Type 1, nine in Type 2, 15 in Type 3, 47 in Type 4, and 10 in Type 5 by Huang’s phenotypes. Outcomes were knee alignment measures and patient-reported satisfaction evaluated by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and traditional Chinese version of the Forgotten Joint Score-12 (FJS-12). Follow-up was one year. Type 4 knee was most significantly corrected in all angles by irKA-TKA, followed by Type 2 and 3 knees. Type 5 and 1 knee were only significantly corrected in some angles. The correlation between FJS-12 and WOMAC was good at 6 months (Pearson correlation coefficient (r) = 0.74) and moderate at 6 weeks, 3 months, and 12 months during follow-up (r = 0.37~0.47). FJS-12 and WOMAC displayed comparable hip–knee–ankle angle cut-off value (4.71° vs. 6.20°), sensitivity (70.49% vs. 67.19%), specificity (84.00% vs. 85.71%), and Youden index (54.49% vs. 52.90%) in prediction of good prognosis. In conclusion, irKA-TKA corrects knee alignment in all knee types with increasing satisfaction for one-year follow-up. Knees with presurgical varus deformity are most recommended for irKA-TKA. Both presurgical scores of the traditional Chinese version of FJS-12 and WOMAC predict the prognosis of irKA-TKA.

The distal metatarsal screw is not always necessary in third-generation MICA: a case-control study

INTRODUCTION

To evaluate the clinical and radiological results after fixation of the first metatarsal head (MTH) with one or two screws as part of the third-generation minimally invasive Chevron-Akin osteotomy (MICA) for hallux valgus deformities.

MATERIALS AND METHODS

Between August 2020 and November 2021, 55 MICA procedures (50 patients, male:female = 7:43), 22 with two (MICA2), 33 with one screw (MICA1) were performed for mild to severe hallux valgus deformities. Exclusion criteria were a concomitant pes adductus (Sgarlato angle > 20°) or hindfoot/midfoot deformities requiring treatment. In 27 cases, additional procedures on the forefoot (small toe corrections or metatarsal osteotomies II-V) were necessary. Pre- and post-operatively, hallux valgus angle (HVA) and intermetatarsal I/II angle (IMA) were measured. Clinically, subjective satisfaction, range of motion (ROM) of the first metatarsophalangeal joint (MTPJ), and pain level (NRS score) were evaluated. The minimum follow-up was 12 months.

RESULTS

Displacement of MTH was 70-90% on average, all osteotomies showed full consolidation at latest follow-up. In one case of either group, a slight subsidence of MTH was documented. The radiological and clinical parameters showed no differences between the groups. The pain level improved by an average of three points. The mobility of the MTPJ showed a slight reduction in nine cases after three months (4 MICA2, 5 MICA1) which persisted in three cases. Fifty-two of 55 patients (95%) would opt again for the operation.

CONCLUSIONS

Fixation of the first MTH with a single bicortical screw in MICA with moderate lateralization of MTH shows stable anchoring and good clinical results. The routine use of a second metatarsal screw can be omitted.