Total knee replacement in acute and chronic traumatic events

Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement

OBJECTIVES

Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA.

MATERIALS AND METHODS

Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT).

RESULTS

A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing.

CONCLUSIONS

This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.

Primary Total Knee Arthroplasty for Fractures Around the Knee

Primary arthroplasty for fractures of the femoral neck is a very common procedure and even the gold standard for the geriatric patient. In contrast, primary arthroplasty for perigenicular fractures is a rare event. On the other hand, it can be a therapeutic option, especially for geriatric patients with prior osteoarthritis or complex fractures and severe osteoporosis.The operative procedure can be complex and requires experience in primary and revision arthroplasty as well as suitable implants and good preoperative planning.There are case series reporting primary arthroplasty in a total of approximately 200 cases of both distal femoral and proximal tibial fractures. Complication rates are between 0 and 90% and mostly concern wound healing problems and infections. From a functional point of view, predominantly good results and a range of motion of 100° can be achieved.Primary arthroplasty can be a therapeutic option for selected cases of perigenicular fractures and gives good functional results. The most frequent complications are wound healing problems and infections.

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.

Multiple trauma-induced, secondary osteoarthritis, knee Arthroplasty and technology: Conventional approach to an unconventional scenario

A 49-year-old man was involved in a high-energy motor vehicle accident. Haemodynamic instability with multiple long bone fractures of lower limbs was the hallmarks of the injury. Closed fragmented fracture of left femur shaft and open displaced supracondylar fracture of the contralateral femur. Closed comminuted high-grade fracture of the Tibia plateau (Schatzker VI) was diagnosed bilaterally. 'Orthopaedic damage control' was initiated with bilateral 'cross knee' external fixation, followed by conversion to open reduction internal fixation of all fracture sits at 8 days later. The patient underwent nine subsequent hospitalisations, of which eight involved operative treatment. The interval from admission to last documented surgery was 7 years. The endpoint was total knee arthroplasty (TKA) with mega prosthesis of the left knee and a primary-type TKA in the right knee. Both arthroplasties were non-assisted, conventional procedures. Postoperative Western Onterio and McMaster Universities Arthritis Index (WOMAC) score was 85 at 9-year follow-up from the injury incurred.

Primary total knee arthroplasty in tibial plateau fractures: Literature review and our institutional experience

BACKGROUND

Displaced proximal tibia fractures in the elderly may be very difficult to manage. If osteosynthesis represents the standard of care in the younger patients, in the aged population this solution is controversial because a significant failure rate has been reported after internal fixation. Moreover, osteoarthritis progression following tibial plateau fractures is common, often requiring a subsequent total knee arthroplasty (TKA). In recent years, in order to overcome the fracture healing problems and to allow immediate full weight bearing, primary TKA after tibial plateau fractures in elderly patients has gained popularity.

MATERIAL AND METHODS

from 2015 to 2019, 11 tibial plateau fractures in elderly patients with pre-existing osteoarthritis were treated with a primary TKA. Age, gender, mechanism of trauma, pre-operative autonomy level, fractures classification, degree of osteoarthritis and intraoperative data (ligamentous stability and type of implant) were collected. After a mean follow-up of 28 months, Knee Society Score (KSS), post-operative autonomy level and Forgotten Joint Score (FJS) were evaluated. The radiological assessment (signs of loosening, limb axis and patellar height indices) and complications were also recorded.

RESULTS

according to fracture type and ligamentous competence, 6 cases of posterior-stabilized (PS) design and 5 cases of semi-constrained TKA were implanted. At the final follow up, mean KSS knee score was 83±16 and mean KSS functional score was 74±15. Mean pre-operative autonomy level assessed with the Parker scale, was significantly higher than the post-operative one (7.5±1.4 vs 5.6 ± 1.3). Mean FJS was 66 ± 14. No lines of radiolucency or limb malalignment were found at the final radiological follow-up. One major complication was recorded: one acute periprosthetic infection. One patient reported a periprosthetic femoral fracture after 26 months.

CONCLUSION

Based on our and results and those reported on literature, primary TKA is a suitable option in case of tibial plateau fractures in elderly patients with pre-existing osteoarthritis and poor bone quality, in which osteosynthesis outcome may be poor. Unlike ORIF, primary TKA may allow immediate weightbearing and a faster recovery. Nevertheless, it is a demanding surgery with a significant complications rate and should be reserved for selected patients and experienced surgeons.

Evaluation of efficacy and safety of a novel lipogel containing diclofenac: A randomized, placebo controlled, double-blind clinical trial in patients with signs and symptoms of osteoarthritis

Background

Effectiveness and safety of pharmaceuticals is the prime concern of every osteoarthritis (OA) treatment. Chronic administration of NSAIDs, especially in case of geriatrics, through oral route tend to compromise the patient's safety, whereas topical treatments are not found to be effective owing their poor ability to deliver drug molecules.Thus, the present study deals with a randomized, double-blind, controlled trial conducted on patients with knee osteoarthritis (OA) for comparing the performance of a novel topical gel (liposomal gel) of diclofenac with a placebo and a marketed gel.

Methods

The patients were treated and evaluated for 6 weeks as per the Western Ontario McMaster Universities (WOMAC) Index for OA. Patients were also observed for any adverse events. All the results were analyzed statistically using Kruskal-Wallis test, followed by Student's t-test at p ≤ 0.05.

Results

Patients treated with liposomal gel showed statistically significantly improvements in treatment in comparison to the other tested formulations. All the treatments were found to be well tolerated with no report of adverse event. The results unequivocally demonstrated the superiority of the diclofenac liposomal gel, in the relieving the symptoms of OA of the knee, in comparison to placebo and marketed gel.

Conclusion

From above results it was revealed that the drug in liposome have higher therapeutic potential. Thus, this can be a safe and effective option for the management of chronic OA especially for geriatric patients.

Knee arthroplasty with hardware removal: complication cascade. Is it preventable?

An elderly woman underwent hardware removal and total joint replacement (TJR) of her right knee. Ipsilateral total tip replacement was performed 7 years earlier, and 12 months later, a supracondylar fracture of the index femur was successfully treated by open reduction internal fixation (ORIF) of the distal femur with a locking compression plate condylar plate. Hardware removal attempt, prior to the arthroplasty, resulted in fracture of the distal femur. Total knee replacement (TKR) was commenced with temporary reduction and final stabilisation of the femur fracture with a condylar plate. Postoperatively, non-union of the femur fracture developed twice with fatigue failure of the plate fixation device in both instances. Refixation of the femur was performed on both occasions and additional bone healing augmentation measures were performed for each subsequent surgery. Femur union was achieved fourteen months after the last surgery.

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.

Total knee arthroplasty for distal femoral fractures in osteoporotic bone: a systematic literature review

PURPOSE

Distal femoral fractures in the elderly are associated with high morbidity and mortality and their incidence is increasing with an ageing population. Management of these fractures has evolved over recent decades and there is now an accepted recognition of the important role that acute arthroplasty may have in treatment of these fractures. Our purpose was to systematically review the evidence available in the literature for arthroplasty as a treatment option for distal femoral fractures.

METHODS

This systematic review was conducted in accordance with the PRISMA reporting guidelines. We searched CENTRAL, MEDLINE, EMBASE, and Science Citation Index Expanded (until October 2018) for studies and case series. Furthermore, clinical trial registries were searched for ongoing studies. We included all studies or case series that described total knee arthroplasty for distal femoral fractures irrespective of language, publication status, sample size, or follow-up period due to limited studies available in the literature. Exclusion criteria included single patient case reports, isolated tibia fractures, and periprosthetic fractures. Two authors independently identified trials for inclusion and independently extracted the data. Outcome measures included mortality, peri-operative complications (excluding mortality), anaesthetic time, blood loss, time to mobilisation, length of hospital stay, functional scores, radiological loosening, and revision rate.

RESULTS

Fourteen papers were included for subsequent quantitative and qualitative synthesis incorporating a total of 181 patients. The highest level of evidence identified was a single cohort study (level III), the remaining 13 papers consisted of multi- or single-centre case series (level IV). The mean mortality rate was 3.34% (range 0-10) at 30 days and 18.4% (range 0-42) at 1 year. The mean revision rate was 3.43% (range 0-25) at 1 year. The mean time to mobilisation was 3.90 days (range 2.5-6) with a mean time to discharge from the acute ward being 16.6 days (range 8-33).

CONCLUSIONS

Although there is limited evidence in the literature available, our review suggests that there is a role for acute knee arthroplasty in distal femoral fractures. This mode of treatment has satisfactory mortality and revision rates, and may result in faster time to mobilisation and discharge. There is a need for a higher level of evidence to delineate this issue further.

Midlevel Constraint Without Stem Extensions in Primary Total Knee Arthroplasty Provides Stability Without Compromising Fixation

BACKGROUND

Many total knee arthroplasty (TKA) systems allow for so-called midlevel constraint (MLC) articular bearings that can be used with primary implants. The purpose of this study is to report the early outcomes with MLC bearings in primary TKA.

MATERIALS/METHODS

From December 2005 to June 2015, minimum 2-year follow-up was available on 96 patients (103 TKA) who underwent primary TKA with an MLC bearing using the Vanguard Total Knee System. Outcomes included pain, Knee Society clinical and functional score, range of motion, and need for revision.

RESULTS

Mean follow-up was 5 years (range, 2-11 years). Range of motion improved from 103 to 113. Knee Society clinical and function scores improved from 28 and 43 to 88 and 62, respectively. There were 10 manipulations (9.9%). There were no failures for aseptic loosening of any components; however, 10% of patients were lost to follow-up. There were 3 revisions (3%): 1 patellar tendon rupture, 1 open lysis of adhesions for stiffness, and 1 2-stage treatment of infection.

CONCLUSION

In cases of intraoperative medial collateral ligament incompetence, severe deformity, or valgus deformity requiring release of the lateral collateral ligament, the use of MLC showed good survivorship with no cases of aseptic loosening or instability.

Modulation of cartilage's response to injury: Can chondrocyte apoptosis be reversed?

Osteoarthritis is characterized by a chronic, progressive and irreversible degradation of the articular cartilage associated with joint inflammation and a reparative bone response. More than 100 million people are affected by this condition worldwide with significant health and welfare costs. Our available treatment options in osteoarthritis are extremely limited. Chondral or osteochondral grafts have shown some promising results but joint replacement surgery is by far the most common therapeutic approach. The difficulty lies on the limited regeneration capacity of the articular cartilage, poor blood supply and the paucity of resident progenitor stem cells. In addition, our poor understanding of the molecular signalling pathways involved in the senescence and apoptosis of chondrocytes is a major factor restricting further progress in the area. This review focuses on molecules and approaches that can be implemented to delay or even rescue chondrocyte apoptosis. Ways of modulating the physiologic response to trauma preventing chondrocyte death are proposed. The use of several cytokines, growth factors and advances made in altering several of the degenerative genetic pathways involved in chondrocyte apoptosis and degradation are also presented. The suggested approaches can help clinicians to improve cartilage tissue regeneration.

Knee replacement in chronic post-traumatic cases

Post-traumatic knee arthritis is a challenging condition. Prosthetic surgery is demanding and the risk of complications is relatively high.

Planning is an essential element of this surgery; correct diagnosis (to exclude latent infection) and adequate considerations regarding approach, axis, bone loss, choice of implant and level of constraint are indispensable.

There are two main categories of post-traumatic arthritis: extra-articular deformities and articular deformities.

Use of an algorithms can support the surgeon’s choice of implant.

Correct implant positioning and limb alignment restoration is associated with very good results, similar to those achieved with standard total knee arthroplasty.

Cite this article: Benazzo F, Rossi SMP, Combi A, Meena S, Ghiara M. Knee replacement in chronic post-traumatic cases. EFORT Open Rev 2016:1:211-218. DOI: 10.1302/2058-5241.1.000025.

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.