Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature

Common Design, Data Elements and Core Outcome Measures Reported on Clinical Trials of Genicular Artery Embolization for Knee Osteoarthritis: An Interactive Systematic Review

RATIONALE AND OBJECTIVES

Genicular artery embolization (GAE) is an emerging, potentially effective treatment option in patients with knee osteoarthritis (OA). This study aimed to describe the current state of common design data elements (CDDEs) and core outcome measures (COMs) in recent trials of GAE for knee OA.

MATERIALS AND METHODS

A comprehensive search of seven online databases were searched within the Nested Knowledge AutoLit living review platform, followed by categorization of primary and secondary outcomes. Studies were tagged with the relevant outcomes of interest in each article. Results were synthesized and examined for the CDDEs.

RESULTS

Pain is the most frequent reported outcome, present in 23 of the 24 studies (95.8%). However, there is considerable variability in the description of in the study designs, procedural techniques, embolic materials, time points, and MRI parameters. Greater consistency is observed in eligibility criteria, and adverse events reporting. Although findings thus far have been favorable, current data is still constrained by the heterogeneity of the study design, embolization area nomenclature, limited follow-up, and in many cases, the absence of control group.

CONCLUSION

To enhance the potential for future meta-analyses and robust, evidence-based evaluations of GAE as a treatment for knee OA, further research is required to address the identified shortcomings. By establishing more standardized protocols, the efficacy and safety of GAE can be more accurately assessed and understood.

Total hip and knee arthroplasty in HIV- and HCV-positive hemophilia patients: short term follow-up of 14 patients

BACKGROUND

Haemophilic arthropathy (HA) is a common comorbidity of haemophilia. Some people with haemophilia (PWH) were human immunodeficiency virus (HIV)-positive. Arthroplasty is an effective treatment for end-stage HA. This study was carried out to report the effectiveness and satisfaction following total hip arthroplasty (THA) or total knee arthroplasty (TKA) in PWH with HIV.

PATIENTS AND METHODS

All patients with haemophilia and HIV undergoing THA or TKA in our centre from January 2015 to June 2020 were reviewed. All patients were followed for at least twenty-four months. The improvements in postoperative indicators were evaluated at the latest follow-up, including the Visual Analogue Scale (VAS) score, range of motion (ROM), and validated joint scores such as Knee Society Score (KSS; clinical and functional) and Harris Hip Score (HHS). The complications and satisfaction were analysed likewise. Those were utilized to weigh the risks and benefits of the procedure in the population.

RESULTS

Fourteen patients (7 hips and 14 knees) were included in the study. The follow-up of the THA cohort was 53.3 months (range, 27-82) and the TKA cohort was 50.1 months (range, 25-85), respectively. The average VAS score was ameliorated from 7.3 to 3.0 and 6.6 to 2.8 in the two groups (P < .001, respectively). Similarly, two cohorts (THA and TKA) showed statistically significant changes in the extension and flexion ROM between the preoperative and the latest follow-up (P < .05, P < .001, respectively). Besides, statistically significant differences between the preoperative and final follow-up values of HHS (from 41.6 to 82.3), clinical KSS (from 34.8 to 72.8), and functional KSS (from 42.9 to 73.2) were observed (P < .001, respectively). Notably, there were 4 complications noted among 21 arthroplasties performed, giving a 19.0% complication rate. Based on the satisfaction score, the majority of patients were optimistic about the arthroplasty.

CONCLUSION

Given these findings, THA or TKA of the PWH with HIV is a worthwhile procedure and can be performed by an experienced and collaborative multidisciplinary team in a tertiary centre with a good haemophilia care system.

Minimally invasive medial femoral approach to total knee arthroplasty improves short-term outcomes compared to the standard medial parapatellar approach: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to conduct a comprehensive evaluation of the effectiveness of the medial parapatellar approach via the vastus medialis obliquus muscle in comparison with the standard medial parapatellar approach for total knee arthroplasty, using a systematic approach.

METHODS

A computer search was conducted on PubMed, EMBASE, Medline, Cochrane libraries, and Web of Science databases to comprehensively collect randomized controlled studies on minimally invasive (MMV) approaches for knee arthroplasty, specifically the vastus and medial parapatellar (MP) approaches. Two authors independently screened the literature based on inclusion and exclusion criteria, evaluated the quality of the included studies using the Cochrane systematic review method, and performed a meta-analysis using RevMan 5.3 software.

RESULTS

A total of twelve randomized controlled studies were ultimately included, comprising 788 knees. The small incision medial femoral muscle approach (MMV) group consisted of 398 cases, while the traditional parapatellar approach (MP) group consisted of 390 cases. Data analysis showed that in the comparison of KSS, VAS, and ROM score at 3 months after surgery, MMV approach was superior to MP approach [MD = 2.89, 95%CI (0.33, 5.46), P = 0.03], [MD = - 0.22, 95%CI (- 0.36, - 0.09), P = 0.001], and [MD = 1.08, 95%CI (0.04, 2.12), P = 0.04]. However, there was no significant difference in the postoperative KSS, VAS, and ROM score between the MMV and MP approaches at 6 and 12 months after surgery. The operation time of the MMV group was longer than that of the MP group [MD = 8.98, 95%CI (4.64, 13.32), P < 0.0001], and the number of days of straight leg raising after surgery was shorter in the MMV group than in the MP group [MD = - 1.91, 95%CI (- 3.45, - 0.37), P = 0.01], with statistically significant differences. There was no significant difference in the lateral support band release rate [OR = 0.72, 95%CI (0.23, 2.28), P = 0.58], length of hospital stay [MD = 0.07, 95%CI (- 0.18, 0.31), P = 0.58], postoperative complications [MD = 0.62, 95%CI (0.33, 1.18), P = 0.15], and intraoperative blood loss [MD = 70.50, 95%CI (- 57.51, 198.72), P = 0.28].

CONCLUSION

Most of the approaches have similar length of stay and incidence of complications compared to standard approaches. However, the minimally invasive midvastus approach has shown potential to improve short-term outcomes.

STUDY REGISTRATION

PROSPERO registration number CRD42023410583.

Trunk control, motion and alignment after total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Trunk control improves mobility, balance and quality of life early after total knee arthroplasty (TKA) and is therefore considered an important parameter during the recovery process. However, little is known about trunk control, motion and alignment after TKA. Increasing our understanding aids in optimizing treatment strategies to enhance functional mobility after TKA.

RESEARCH QUESTION

Does trunk control, motion and alignment return to normal after TKA and is this related to functional mobility?

METHODS

Five scientific databases were searched until July 2021. Eligibility criteria consisted of outcomes assessing trunk control and alignment in a population of adults undergoing TKA. Two reviewers independently screened studies and risk of bias was assessed by Mixed Methods Appraisal Tool (MMAT). Meta-analysis was performed for subgroups gait and alignment.

RESULTS

Of the 362 studies retrieved, 24 were included. Study designs were cohorts with mixed methods (pre-post treatment, case-control and case-case) and three randomized controlled trials. The mean MMAT score was 75%, corresponding to low bias. In total 1178 patients and 197 controls were included. Results showed that pre-operative trunk motion was characterized by increased amplitudes in all three planes and altered alignment which did not all return to normal after TKA. Frontal plane motion and alignment recovered faster than the sagittal and transversal plane. Although pelvic tilt improved after surgery, sagittal imbalance (anteriorly shifted trunk position) was still present.

SIGNIFICANCE

Recovery of trunk motion after TKA is time-, speed- and technique-dependent. The observed differences in trunk motion with the healthy controls persisted after TKA. This indicates that incorporating a full biomechanical chain approach, including trunk motion and gait-retraining exercises with a strong focus on postural alignment could improve functional mobility after TKA. Limited studies are available assessing trunk control and trunk motion during functional tasks besides walking which warrant further investigation.

Comparisons of the Efficacy and Safety of Total Knee Arthroplasty by Different Surgical Approaches: A Systematic Review and Network Meta-analysis

The purpose of this network meta‐analysis was to investigate the efficacy and safety of total knee arthroplasty (TKA) considering seven different surgical approaches. Four databases (PubMed, Cochrane Library, EMBASE, Web of Science) were searched for clinical randomized controlled trials (RCTs) involving TKA with different surgical approaches. STATA 14.0 was used to construct network maps and publication bias graphs and conduct inconsistency tests, network meta‐analyses, and surface under the cumulative ranking (SUCRA) calculations. A total of 51 RCTs involving 4061 patients and 4179 knees from 18 countries were included. Among the seven surgical approaches, the midvastus approach (MV) was the top choice to reduce tourniquet use time, the subvastus approach (SV) had the shortest operation time, the mini‐midvastus approach (Mini‐SV) was associated with the least amount of time to achieve straight leg raise (SLR) after surgery, the mini‐medial parapatellar approach (Mini‐MP) reduced postoperative pain effects, and the medial parapatellar approach (MP) was the best approach to improve range of motion (ROM). Excluding the quadriceps‐sparing approach (QS), which was not compared, the use of the mini‐midvastus (Mini‐MV) may shorten the hospital stay. There were no significant differences in blood loss, postoperative complications, American Knee Society Score (AKSS) objective, or AKSS functional between the seven surgical approaches (P > 0.05).

Implementation of robotic-assisted total knee arthroplasty in the public health system: a comparative cost analysis

PURPOSE

Robotic-assisted total knee arthroplasty (TKA) may improve the precision of bone preparation and component alignment when compared to the conventional surgical approach; however, the detailed cost analysis of robotic-assisted TKA is lacking. This study aims to compare in-hospital costs between robotic-assisted and computer-navigated TKA.

METHODS

Patients undergoing primary TKA at a public hospital in Sydney between October 2018 and June 2019 were included. Patient demographics, surgical outcomes and in-hospital cost variables including, staff, critical care, emergency department, diagnostic, prosthesis, operating room, ward and other related costs until the discharge to the community were collected. Differences across in-hospital costs between robotic-assisted and computer-navigated TKA were compared using independent Student's t-tests.

RESULTS

Of the 258 primary TKAs, 181 (70.2%) were computer-navigated and 77 (29.8%) robotic-assisted. Surgical time (p < 0.001) and operating time (p < 0.001) were both significantly shorter in computer-navigated TKA, while robotic-assisted TKA cases were more likely to be discharged directly home without extended in-patient rehabilitation (p = 0.014). When removing the capital costs of surgical equipment and maintenance, there was no difference in total in-hospital cost between computer-navigated ($19,512.3) and robotic-assisted TKA ($18,347.1; p = 0.179). When these capital costs were included, the mean in-hospital cost of robotic-assisted surgery was $21,507.6 compared to $19,659.7 for computer-navigated TKA (p = 0.034).

CONCLUSIONS

The total in-hospital cost, during the implementation period of robotic-assisted TKA, is comparable with computer-navigated TKA. Robotic-assisted TKA was significantly more expensive when the upfront cost of the robotic system and maintenance costs were included. Longer term cost benefit of robotic-assisted TKA should be investigated in future studies.

Patellar retraction versus eversion on functional outcomes in total knee replacement: a randomized controlled study protocol

Background

Patellar mobilization technique during total knee replacement (TKR) has been debated, with some suggesting that lateral retraction, rather than eversion, of the patella may be beneficial. This randomized controlled trial was to investigate the effects of patellar eversion on functional outcomes in TKR.

Methods and analysis

This single-center, prospective, randomized controlled test will be conducted in Jingjiang People's Hospital. Primary end-stage osteoarthritis patients that prepared for unilateral TKR were randomized to one of two patellar exposure techniques during the primary total knee arthroplasty: lateral retraction or eversion. The informed consent will be acquired in each patient. The primary outcome was operation time, length of hospital stay, and straight leg raising time. Second outcomes including Insall-Salvati ratio; range of motion at 1 month, 3 months, and 1 year following TKR; visual analog scale (VAS) at 1 month, 3 months; and Knee Society Score (KSS) score at 1 year following TKR. The significance level was defaulted as P < .05.

Results

Results will be published in relevant peer-reviewed journals.

Conclusion

Our study aims to systematically assess the functional outcomes of patellar eversion for TKR patients, which will provide clinical guidance for TKR patients.

Comparison of minimally invasive approaches and standard median parapatellar approach for total knee arthroplasty: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND: Minimally invasive total knee arthroplasty (TKA) has been actively advertised by the orthopedic industry. The purpose of this network meta-analysis was to comprehensively compare the effectiveness of four minimally invasive surgery (MIS) approaches and the medial parapatellar (MPP) approach to improve the American Knee Society Score (KSS) in primary TKA. MATERIALS AND METHODS: Studies were comprehensively searched on PubMed, Embase, Cochrane Library (CENTRAL), Web of Science and Science Direct up to June 2018 with a major focus on the outcome of KSS. Risk of bias was assessed using the Cochrane risk of bias tool. Quality assessment was performed using the GRADE system. Both pair-wise and network meta-analyses are calculated to comprehensively compare the effectiveness of four MIS and TKA approaches. RESULTS: Eleven trials with 1025 knees undergoing TKA were included. Our analysis showed that both MPP and MIS approaches provided improvement in terms of short-term (four-eight weeks) total, objective and functional KSS. The network-meta analysis revealed that MIS approaches showed a trend towards superior KSS improvement over standard MPP approaches. However, statistical advantages were only observed in the mini-MPP group for functional KSS compared to the conventional MPP and quadriceps-sparing (QS) groups. CONCLUSIONS: Evidence shows that MIS TKA approaches are effective alternatives to MPP approaches. However, orthopedic surgeons should be cautiously optimistic about minimally invasive TKA in terms of KSS improvement.

First Reported Series of Outpatient Total Knee Arthroplasty in the Middle East

Background

Outpatient total knee arthroplasty (TKA) is becoming more commonplace in the United States. Alternatively, the current practice in the Middle East involves an inpatient stay of 7-10 days in the hospital after TKA. This study reports the early results of the first reported series of outpatient TKA performed on patients in the Middle East and compares the clinical and functional outcomes with those of patients who underwent inpatient TKA.

Methods

Eighty-eight patients underwent TKA (inpatient: 44 and outpatient: 44) using the modified intervastus approach in 2 hospitals in the Middle East from 2017 to 2019. Clinical and functional outcomes were assessed by recording the Knee Injury and Osteoarthritis Outcome Score, visual analog scale (VAS) for pain, and knee range of motion (ROM) preoperatively, on the day of surgery, and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months.

Results

Two patients undergoing outpatient TKA had complications: one patient suffered a periprosthetic fracture on postoperative day 10 after a fall, and the other patient had drainage on postoperative day 5. No complications occurred in the inpatient TKA cohort. There were no significant differences observed in the VAS scores or knee ROM numbers recorded for inpatient and outpatient TKA groups at any of the follow-up periods. Overall, the Knee Injury and Osteoarthritis Outcome Score, VAS, and ROM significantly improved 6 months after surgery compared with preoperative values for both inpatient and outpatient TKA groups.

Conclusions

Outpatient TKA was safely implemented when compared with inpatient TKA, with satisfactory results. A total of 2 complications were seen in this study, which we believe are unrelated to the patient’s discharge status. The concept of outpatient TKA using the modified intervastus approach was very well accepted by the patients in this study and can potentially be applied safely elsewhere in the region.