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Akhtar M, Razick D, Seibel A, Asad S, Shekhar A, Shelton T. Outcomes of Early Versus Delayed Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2024:S0883-5403(24)00531-X. [PMID: 38797451 DOI: 10.1016/j.arth.2024.05.059] [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: 01/15/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Stiffness following total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA). However, there is debate regarding the timing of MUA, with many recommending against MUA beyond 3 months after TKA. Therefore, the purpose of this systematic review was to evaluate the functional and clinical outcomes of early versus delayed MUA for stiffness following TKA. METHODS A search following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was performed in the PubMed, Embase, Scopus, and Cochrane databases in November 2023. Data regarding study characteristics, demographics, knee flexion and extension, patient-reported outcomes, complications, and revisions were collected. A quality assessment was performed using the Methodological Index for Non-randomized Studies. Included were 14 studies analyzing 13,445 knees, 72.1% of which underwent early MUA and 27.8% of which underwent delayed MUA. Of the 14 studies, 10 defined early MUA as being performed within 3 months of the index TKA. RESULTS Pre-MUA and post-MUA knee flexion for the early/delayed groups was 71.3°/77.9° and 103.0°/96.1°, respectively. Upon meta-analysis, pre-MUA knee flexion was significantly higher in the delayed group (P = .003), whereas post-MUA flexion was similar in both groups (P = .36). The mean gain in knee flexion for the early and delayed groups was 32.0°/19.2°. The surgical complication and revision TKA rates for the early and delayed groups were 4.9%/10.3% and 5%/9%, respectively. A meta-analysis found the risk of surgical or medical complications and revision TKA to be significantly higher in the delayed MUA group (P < .00001 and = .002, respectively). CONCLUSIONS Although post-MUA knee flexion was similar in patients undergoing early and delayed MUA following TKA, the mean gain in flexion for early patients was nearly double that of delayed patients. Delayed patients also had significantly higher risks of surgical or medical complications and revision TKA following MUA.
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Affiliation(s)
- Muzammil Akhtar
- College of Medicine, California Northstate University, Elk Grove, California
| | - Daniel Razick
- College of Medicine, California Northstate University, Elk Grove, California
| | - Amalia Seibel
- College of Medicine, California Northstate University, Elk Grove, California
| | - Shaheryar Asad
- College of Medicine, California Northstate University, Elk Grove, California
| | - Adithya Shekhar
- Department of Orthopedic Surgery, Samaritan Health System, Corvallis, Oregon
| | - Trevor Shelton
- Utah Valley Orthopedics and Sports Medicine, Intermountain Health, Provo, Utah
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Rana P, Brennan J, Johnson A, Turcotte J, MacDonald JH, King P. The association between losartan potassium prescription and postoperative outcomes following total knee arthroplasty: A TriNetX analysis. Orthop Traumatol Surg Res 2024:103851. [PMID: 38428487 DOI: 10.1016/j.otsr.2024.103851] [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: 09/27/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common surgical procedure performed to alleviate pain and improve functional outcomes in patients with knee osteoarthritis and rheumatoid arthritis who have failed conservative treatments. Arthrofibrosis has been extensively studied due to its negative impact on TKA outcomes. Losartan, an angiotensin receptor blocker (ARB), has the potential to improve TKA outcomes by inhibiting TGF-β and decreasing fibrosis. This study aims to analyze a large-scale, real-world healthcare database to investigate the association between losartan potassium prescription and postoperative outcomes such as readmissions, ED visits, and the need for MUA or revision TKA. HYPOTHESIS Based on previous literature and the nature of ARBs, it is expected that the addition of losartan will aid in better outcomes for patients following a primary TKA. PATIENTS AND METHODS In this retrospective observational study, the TriNetX Research Network (TriNetX) database was queried as of June 21, 2023. All patients who underwent a primary total knee arthroplasty (TKA) prior to June 21, 2022 were included. Patients were then divided into two cohorts by whether they had an active losartan potassium prescription within the year prior to their surgery to within 90days postoperatively. Patients were then propensity-matched to eliminate differences in demographics and comorbidities. RESULTS Losartan TKA patients were 1.18 [OR: 0.85 (95% CI: 0.79-0.90), p<0.001] times less likely to be readmitted within 90days and were 1.15 (OR: 0.87 (95% CI: 0.79-0.96); p=0.009) times less likely to undergo a manipulation under anesthesia (MUA) within the 1-year postoperative period. There were no statistically significant differences in rates of emergency department (ED) visits at 90days postoperatively or revision TKAs at 1year postoperatively. DISCUSSION In conclusion, patients with an active losartan prescription prior to TKA had a significantly lower likelihood of readmission within 90days and a lower likelihood of undergoing MUA within the 1-year postoperative period compared to patients not taking losartan. This presents an opportunity for further clinical investigation to explore the value of losartan in TKA. LEVEL OF EVIDENCE III; an observational cohort study.
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Affiliation(s)
- Parimal Rana
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Jane Brennan
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Andrea Johnson
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Justin Turcotte
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States.
| | - James H MacDonald
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Paul King
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
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Zhang L, Fan S, Cai B. Intervention of Refractory Arthrofibrosis After Anterior Cruciate Ligament Reconstruction: A Case Report. J Sport Rehabil 2023:1-6. [PMID: 37156539 DOI: 10.1123/jsr.2022-0429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/06/2023] [Accepted: 03/02/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES Although nonsurgical and surgical management of knee arthrofibrosis has been reported in the literature, there is little information on the effect of procedural treatment modalities of refractory arthrofibrosis on clinical outcomes. The purpose of this case report is to describe the intervention of refractory knee arthrofibrosis after anterior cruciate ligament reconstruction and investigate long-term clinical outcomes after procedural intervention. METHODS A 27-year-old male presented with decreased range of motion (ROM), patellar mobility, strength, and knee joint function following anterior cruciate ligament reconstruction of his left knee. After failed conservative management, the patient underwent manipulation under anesthesia (MUA) to release scar tissue. Following MUA, the emphasis of comprehensive physiotherapy was on decreasing inflammation, relieving pain, and maintaining patellar mobility while increasing knee joint ROM and strength. Knee ROM, patellofemoral motion, gait, and quadriceps recruitment were measured 3, 6, 12, and 24 months after MUA. RESULTS At 2-year follow-up after MUA, the patient continued to present with decreased ROM and quadriceps strength compared to the contralateral knee, but had returned to a running program and reported knee joint dysfunction no longer interfered with his daily activities. CONCLUSIONS This case report demonstrates signs and symptoms that could indicate knee arthrofibrosis and introduces procedural intervention for refractory arthrofibrosis after anterior cruciate ligament reconstruction.
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Affiliation(s)
- Ling Zhang
- School of Exercise and Health, Shanghai University of Sport, Shanghai,China
| | - Shuai Fan
- Department of Rehabilitation Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai,China
| | - Bin Cai
- School of Exercise and Health, Shanghai University of Sport, Shanghai,China
- Department of Rehabilitation Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai,China
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DeFrance MJ, Cheesman QT, Hameed D, DiCiurcio WT, Harrer MF. Manipulation Under Anesthesia Is Associated With an Increased Rate of Early Total Knee Arthroplasty Revision. Orthopedics 2022; 45:270-275. [PMID: 35700432 DOI: 10.3928/01477447-20220608-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) frequently has been used as a first-line treatment to restore functional range of motion after unsuccessful physical therapy. Although there are studies reporting that MUA assisted in restoring range of motion, there is a paucity of literature on the influence of MUA on the risk of revision TKA. The goal of our study was to determine whether MUA was associated with an increase in the rate of revision TKA within 2 years of MUA. A total of 49,310 patients within a single institution who underwent primary TKA were identified from 1999 to 2019. Data were matched at a 1:3 ratio (TKA with and without MUA, respectively) based on age, sex, and body mass index. A matched comparison cohort was conducted, with the MUA cohort having 575 patients and the no MUA cohort having 1725 patients. A statistically significant increase in the rate of noninfectious etiology revision TKA was found in the MUA cohort (7.3%) compared with the no MUA cohort (4.9%; P=.034). The most common reason for revision TKA after MUA was persistent stiffness, including arthrofibrosis and ankylosis; however, aseptic loosening, ligamentous instability, and periprosthetic fracture were found to be responsible for 21.4% of revision TKA procedures. Although MUA is a commonly performed procedure for treating stiffness after primary TKA, the orthopedic surgeon should counsel patients on the association of increased rate of revision TKA after MUA, most commonly, persistent stiffness. [Orthopedics. 2022;45(5):270-275.].
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SALA J, JAROMA A, SUND R, HUOPIO J, KRÖGER H, SIROLA J. Manipulation under anesthesia after total knee arthroplasty: a retrospective study of 145 patients. Acta Orthop 2022; 93:583-587. [PMID: 35727106 PMCID: PMC9214639 DOI: 10.2340/17453674.2022.3167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Manipulation under anesthesia (MUA) is considered to be effective in treating stiffness after total knee arthroplasty (TKA). However, not all patients achieve a satisfactory range of motion (ROM) after MUA. This retrospective study determined the outcome of MUA and identified the factors affecting it. PATIENTS AND METHODS The final sample consisted of 150 MUAs performed on 145 patients. The parameters of interest were ROM and Knee Society Score (KSS) or Oxford Knee Score (OKS). The associations of preoperative, perioperative, and postoperative risk factors with gain in flexion and flexion at post-MUA follow-up (an average of 2 months after MUA) were analyzed using multivariable regression model. RESULTS The mean of 26° (95% CI 23-29) gain in flexion and the mean of 3° (CI 2-4) gain in extension were noticed at post-MUA follow-up when compared with the ROM preceding MUA. The mean post-MUA-FU flexion was 99° (CI 97-102) and the mean post-MUA-FU extension deficit was 4° (CI 2-5). KSS (121 vs. 129) and OKS (29 vs. 28) were similar before and after MUA. The early timing of MUA was associated with better gain in flexion -0.04 (CI -0.08 to -0.01), while we found no association between the timing of MUA and flexion after MUA -0.004 (CI -0.03 to 0.03). High BMI was associated with better gain in flexion 0.8 (CI 0.2-1.5). INTERPRETATION We found that ROM improved substantially after MUA. The gain in flexion decreased as the time between TKA and MUA increased.
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Affiliation(s)
- Julius SALA
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio,Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Antti JAROMA
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio,Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Reijo SUND
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio
| | - Jukka HUOPIO
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio,Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Heikki KRÖGER
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio,Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Joonas SIROLA
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio,Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
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Severino FR, de Oliveira VM, de Paula Leite Cury R, Severino NR, de Moraes Barros Fucs PM. Causes of knee pain evaluated by arthroscopy after knee arthroplasty: a case series. INTERNATIONAL ORTHOPAEDICS 2022; 46:697-703. [DOI: 10.1007/s00264-021-05048-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 12/27/2022]
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Crawford DA, Adams JB, Morris MJ, Berend KR, Lombardi AV. Manipulation under Anesthesia after Knee Arthroplasty Is Associated with Worse Long-Term Clinical Outcomes and Survivorship. J Knee Surg 2021; 34:739-744. [PMID: 31645072 DOI: 10.1055/s-0039-1700569] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The literature is mixed on the long-term fate of knees that undergo manipulation under anesthesia (MUA). The purpose of this study is to evaluate the long-term outcomes and survivorship of patients who required a MUA after primary total knee arthroplasty (TKA) compared with a cohort of patients who did not undergo a MUA. Between 2003 and 2007, 2,193 patients (2,783 knees) underwent primary TKA with 2-year minimum follow-up; 182 knees (6.5%) had a MUA. Patients who had a manipulation were younger (p < 0.001) and had worse preoperative range of motion (ROM) (p < 0.001). Postoperative ROM, Knee Society clinical (KSC), functional, and pain (KSP) scores, revisions, and survivorship were compared between MUA and no MUA. Mean follow-up was 9.7 years. MUA patients had lower postoperative ROM (p < 0.001), change in ROM (p < 0.001), KSC (p < 0.001), KSP (p < 0.001), and change in KSP scores (0.013). Revisions occurred in 18 knees (9.9%) in the MUA group compared with 77 knees (3%) without a MUA (p < 0.001). Most common reason for revision after MUA was continued stiffness (50%). Relative risk for revision after one MUA was 2.01 (95% confidence interval [CI], 1.1-3.8, p < 0.001) and after three or more MUAs were 27.02 (95% CI, 16.5-44.1, p < 0.001). Ten-year survival after MUA was 89.4% (95% CI, 87.1-91.7%) compared with 97.2% (95% CI, 96.9-97.5%) without a MUA (p < 0.001). Patients who undergo a MUA after primary TKA may have a knee at risk with higher revision rates, worse long-term clinical scores, ROM and survivorship.
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Affiliation(s)
| | | | - Michael J Morris
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Aspinall SK, Bamber ZA, Hignett SM, Godsiff SP, Wheeler PC, Fong DT. Medical stretching devices are effective in the treatment of knee arthrofibrosis: A systematic review. J Orthop Translat 2021; 27:119-131. [PMID: 33659182 PMCID: PMC7878963 DOI: 10.1016/j.jot.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/07/2020] [Accepted: 11/08/2020] [Indexed: 12/04/2022] Open
Abstract
AIMS This systematic review examines the available evidence on the use of medical stretching devices to treat knee arthrofibrosis, it suggests a focus for future studies addressing limitations in current research and identifies gaps in the published literature to facilitate future works. MATERIALS AND METHODS Articles were identified using the Cochrane Library, MEDLINE, PubMed and SCOPUS databases. Articles from peer reviewed journals investigating the effectiveness of medical stretching devices to increase range of movement when treating arthrofibrosis of the knee were included. RESULTS A total of 13 studies (558 participants) met the inclusion criteria with the devices falling into the following categories; CPM, load control or displacement control stretching devices. A statistically significant increase in range of movement was demonstrated in CPM, load-control and displacement-control studies (p < 0.001). The results show that the stretch doses applied using the CPM, load-control devices were performed over a considerably longer treatment time and involved significantly more additional physiotherapy compared to the displacement-control and patient actuated serial stretching devices. CONCLUSION The systematic review indicates that load-control and displacement-control devices are effective in increasing range of movement in the treatment of knee arthrofibrosis. Displacement-control devices involving patient actuated serial stretching techniques, may be more effective in increasing knee flexion than those utilising static progressive stretch.The paucity of research in this field indicates that more randomised controlled trials are required to investigate the superiority of the different types of displacement-control stretching devices and which of these would be most effective for use in clinical practice and to compare these with standard physiotherapy treatment.
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Affiliation(s)
- Sara K. Aspinall
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Zoe A. Bamber
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Division of Orthopaedics, Trauma and Sports Medicine, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sue M. Hignett
- Loughborough Design School, Loughborough University, Loughborough, UK
| | - Steven P. Godsiff
- Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Patrick C. Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel T.P. Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Aspinall SK, Wheeler PC, Godsiff SP, Hignett SM, Fong DTP. The STAK tool: evaluation of a new device to treat arthrofibrosis and poor range of movement following total knee arthroplasty and major knee surgery. Bone Jt Open 2020; 1:465-473. [PMID: 33215140 PMCID: PMC7667223 DOI: 10.1302/2633-1462.18.bjo-2020-0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims This study aims to evaluate a new home medical stretching device called the Self Treatment Assisted Knee (STAK) tool to treat knee arthrofibrosis. Methods 35 patients post-major knee surgery with arthrofibrosis and mean range of movement (ROM) of 68° were recruited. Both the STAK intervention and control group received standard physiotherapy for eight weeks, with the intervention group additionally using the STAK at home. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at all timepoints. An acceptability and home exercise questionnaire capturing adherence was recorded after each of the interventions. Results Compared to the control group, the STAK intervention group made significant gains in mean ROM (30° versus 8°, p < 0.0005), WOMAC (19 points versus 3, p < 0.0005), and OKS (8 points versus 3, p < 0.0005). The improvements in the STAK group were maintained at long-term follow-up. No patients suffered any complications relating to the STAK, and 96% of patients found the STAK tool ‘perfectly acceptable’. Conclusion The STAK tool is effective in increasing ROM and reducing pain and stiffness. Patients find it acceptable and adherence to treatment was high. This study indicates that the STAK tool would be of benefit in clinical practice and may offer a new, cost-effective treatment for arthrofibrosis. Cite this article: Bone Joint Open 2020;1-8:465–473.
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Affiliation(s)
- Sara K Aspinall
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Patrick C Wheeler
- Department of Sport and Exercise Medicine, University Hospitals of Leicester, Leicester, UK
| | - Steven P Godsiff
- Department of Orthopaedic Surgery, University Hospitals of Leicester, Leicester, UK
| | - Sue M Hignett
- Loughborough Design School, Loughborough University, Loughborough, UK
| | - Daniel T P Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Vaish A, Vaishya R, Bhasin VB. Etiopathology and Management of Stiff Knees: A Current Concept Review. Indian J Orthop 2020; 55:276-284. [PMID: 33927806 PMCID: PMC8046887 DOI: 10.1007/s43465-020-00287-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Knee stiffness after trauma, fracture fixation, arthroscopic surgery, infection, and knee arthroplasty is a known complication, which is challenging to manage and causes significant disability to the patients. METHODS We did a comprehensive search on the stiff knees, in the last week of May 2020, from the search engines of PubMed, SCOPUS, Google Scholar, and Research Gates using the appropriate keywords. RESULTS We found two types of articles related to knees stiffness: (a) following trauma, internal and external fixation of fractures and arthroscopic surgery, and (b) following total knee arthroplasty. Arthroscopic surgery was found to be a favored mode of management of stiff knees in both of the above groups. The Manipulation under Anesthesia (MUA) was also found effective if done carefully and in the early course of the stiffness. CONCLUSION Knee stiffness due to any cause is a trouble proposition to both patients and treating surgeons. Various methods of management have been described to deal with knee stiffness. Amongst the operative treatment, MUA and arthroscopic surgery were found to be the most effective. Arthroscopic surgery offers a good option of release stiff knees in the majority of cases, and it is most valuable and effective if done earlier in the course of the stiffness (preferably between 3 and 6 months).
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Affiliation(s)
- Abhishek Vaish
- grid.414612.40000 0004 1804 700XDepartment of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076 India
| | - Raju Vaishya
- grid.414612.40000 0004 1804 700XDepartment of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076 India
| | - Vishwa Bandhu Bhasin
- grid.415985.40000 0004 1767 8547Department of Orthopaedics, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 1100060 India
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Manipulation under anesthesia as a therapy option for postoperative knee stiffness: a retrospective matched-pair analysis. Arch Orthop Trauma Surg 2020; 140:785-791. [PMID: 32112161 DOI: 10.1007/s00402-020-03381-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Due to demographic changes, total knee arthroplasty (TKA) is one of the most frequently performed orthopedic surgeries. Therapies for associated postoperative complications, such as postoperative knee stiffness (PKS), are becoming increasingly important. The aim of this retrospective matched-pair analysis was to evaluate mid-term-results following manipulation under anesthesia (MUA). MATERIALS AND METHODS Fifty-one patients with PKS were evaluated and 51 matched-pair patients without PKS after primary TKA were chosen for the control group. In addition to the range of motion, the functionality was recorded by Knee Society Score (KSS), Western Ontario and Mc Masters Universities Osteoarthritis Index (WOMAC), and Short-Form-12 Questionnaire (SF-12). Experience of pain was mapped using a 10-point Numeric Rating Scale (NRS), and the analgesic requirement was mapped using the WHO step scheme. A final follow-up examination was conducted approximately three years after TKA. To evaluate potential risk factors for the development of PKS, TKA alignment was measured via postoperative X-ray images. RESULTS Improvement of the average knee flexion of 35.7° and total flexion of 107.4° was detected in PKS patients after MUA. The flexion of the control group was 112.4°; no significant between-group difference was present regarding prosthesis type, sex, age and BMI. Regarding KSS, WOMAC, and SF-12, the MUA cohort achieved statistically-relevant lower overall scores than the control group, p = 0.006, p = 0.005, p = 0.001, respectively. Significantly higher experiences of pain and a higher need for analgesics in MUA patients were reported (p = 0.001 and p < 0.001, respectively). Radiological evaluation of the prosthesis alignment did not show any differences between the two groups. CONCLUSIONS MUA can improve mobility after PKS, whereby MUA seemed to be a functional therapy option for PKS. Compared to the control group, the MUA group showed lower functional values and an increased experience of pain. A correlation between prosthesis malalignment and MUA could not be detected radiologically. Further studies are necessary to investigate the reasons for PKS.
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Kim GB, Seo MS, Park WT, Lee GW. Bone Marrow Aspirate Concentrate: Its Uses in Osteoarthritis. Int J Mol Sci 2020; 21:E3224. [PMID: 32370163 PMCID: PMC7247342 DOI: 10.3390/ijms21093224] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 11/16/2022] Open
Abstract
Human bone marrow (BM) is a kind of source of mesenchymal stem cells (MSCs) as well as growth factors and cytokines that may aid anti-inflammation and regeneration for various tissues, including cartilage and bone. However, since MSCs in BM usually occupy only a small fraction (0.001%) of nucleated cells, bone marrow aspirate concentrate (BMAC) for cartilage pathologies, such as cartilage degeneration, defect, and osteoarthritis, have gained considerable recognition in the last few years due to its potential benefits including disease modifying and regenerative capacity. Although further research with well-designed, randomized, controlled clinical trials is needed to elucidate the exact mechanism of BMAC, this may have the most noteworthy effect in patients with osteoarthritis. The purpose of this article is to review the general characteristics of BMAC, including its constituent, action mechanisms, and related issues. Moreover, this article aims to summarize the clinical outcomes of BMAC reported to date.
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Affiliation(s)
- Gi Beom Kim
- Department of Orthopedic Surgery, Yeungnam University College of Medicine, Yeungnam University Medical Center, 170 Hyonchung-ro, Namgu, Daegu 42415, Korea; (G.B.K.); (W.T.P.)
| | - Min-Soo Seo
- Laboratory Animal Center, Daegu-Gyeongbuk Medical Innovation Foundation (DGMIF), Daegu 41061, Korea;
| | - Wook Tae Park
- Department of Orthopedic Surgery, Yeungnam University College of Medicine, Yeungnam University Medical Center, 170 Hyonchung-ro, Namgu, Daegu 42415, Korea; (G.B.K.); (W.T.P.)
| | - Gun Woo Lee
- Department of Orthopedic Surgery, Yeungnam University College of Medicine, Yeungnam University Medical Center, 170 Hyonchung-ro, Namgu, Daegu 42415, Korea; (G.B.K.); (W.T.P.)
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Poultsides LA, Triantafyllopoulos GK, Wanivenhaus F, Pumberger M, Memtsoudis SG, Sculco TP. Same-Day Surgery Does Not Increase the Manipulation Under Anesthesia and Reoperation Rates for Stiffness Following Bilateral Total Knee Arthroplasty. J Arthroplasty 2019; 34:2646-2651. [PMID: 31272825 DOI: 10.1016/j.arth.2019.06.017] [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: 02/05/2019] [Revised: 06/03/2019] [Accepted: 06/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is a paucity of data on the incidence of stiffness and need for subsequent manipulation under anesthesia (MUA) and reoperation following same-day bilateral total knee arthroplasty (BTKA). We compared the rates of at least 1 MUA, bilateral knee involvement, single and multiple MUA rates, and stiffness-related reoperation rates between patients undergoing same-day, same-admission staged, and staged within 1 year BTKA in a tertiary institution. METHODS We analyzed institutional data for 3175 same-day (group A), 153 same-admission staged (group B), and 1226 staged within 1 year BTKA patients (group C) from 1998 to 2009. Several variables, including patient demographics, comorbidity profile, Charlson-Deyo index, and range of motion at different time points, were tabulated. Follow-up was minimum 1 year after first MUA. Univariate analyses were performed using the Wilcoxon rank-sum or Kruskal-Wallis test, and Fisher exact or the chi-square test for continuous and categorical variables, respectively. The Cochran-Armitage trend test was used to check the bilateral knee involvement rate across groups. RESULTS Overall, 2.2% (98/4554) of BTKA patients required MUA. The rate of at least 1 MUA was similar across groups but the percentage of bilateral knee involvement was higher in group A. The single MUA rate was comparable among groups. Both no revision and revision reoperation rates were similar among the manipulated groups. CONCLUSION Same-day BTKA was not associated with increased incidence of single or multiple MUA and stiffness-related reoperation rates. These findings may facilitate preoperative counseling in patients with symptomatic bilateral knee disease, eligible for same-day BTKA.
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Affiliation(s)
- Lazaros A Poultsides
- Department of Orthopaedic Surgery, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, New York, NY
| | - Georgios K Triantafyllopoulos
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Florian Wanivenhaus
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Matthias Pumberger
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Thomas P Sculco
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
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Abstract
It is clear that the stiff total knee arthroplasty (TKA) is a multifactorial entity associated with preoperative, intraoperative and postoperative factors. Management of the stiff TKA is best achieved by preventing its occurrence using strategies to control preoperative factors, avoid intraoperative technical errors and perform aggressive, painless postoperative physical medicine and rehabilitation; adequate pain control is paramount in non-invasive management. Careful attention to surgical exposure, restoring gap balance, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, pain control and adequate physical medicine and rehabilitation (physiotherapy, Astym therapy) all serve to reduce its incidence. For established stiff TKA, there are multiple treatment options available including mobilization under anaesthesia (MUA), arthroscopic arthrolysis, revision TKA, and combined procedures.
Cite this article: EFORT Open Rev 2019;4:602-610. DOI: 10.1302/2058-5241.4.180105
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Ten-Year Minimum Outcomes and Survivorship With a High Flexion Knee System. J Arthroplasty 2019; 34:1975-1979. [PMID: 31104836 DOI: 10.1016/j.arth.2019.04.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/10/2019] [Accepted: 04/18/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The purpose of this study is to report the long-term outcomes and survivorship of a high flexion knee system. METHODS We identified 1312 patients (1664 knees) who underwent primary total knee arthroplasty with the Vanguard Complete Knee System with 10-year minimum follow-up. Preoperative and postoperative range of motion, Knee Society scores, complications, and reoperations were evaluated. RESULTS At an average of 11.9 years of follow-up, 88 knees were revised (5.3%). The deep infection rate was 1.4%. There was an average range of motion improvement of 3.9°, pain level decreased by 35.8, Knee Society clinical scores improved by 48, and Knee Society functional scores improved by 15.1 (all P < .001). Survival was 96.4% at 10 years for aseptic causes and 95.5% for all causes. CONCLUSION At a 10-year minimum follow-up, this high flexion knee system demonstrates excellent survivorship.
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Tibbo ME, Limberg AK, Salib CG, Ahmed AT, van Wijnen AJ, Berry DJ, Abdel MP. Acquired Idiopathic Stiffness After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2019; 101:1320-1330. [PMID: 31318813 PMCID: PMC6641113 DOI: 10.2106/jbjs.18.01217] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stiffness is a common reason for suboptimal clinical outcomes after primary total knee arthroplasty (pTKA). There is a lack of consensus regarding its definition, which is often conflated with its histopathologic subcategory-i.e., arthrofibrosis. There is value in refining the definition of acquired idiopathic stiffness in an effort to select for patients with arthrofibrosis. We conducted a systematic review and meta-analysis to establish a consensus definition of acquired idiopathic stiffness, determine its prevalence after pTKA, and identify potential risk factors for its development. METHODS MEDLINE, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Scopus databases were searched from 2002 to 2017. Studies that included patients with stiffness after pTKA were screened with strict inclusion and exclusion criteria to isolate the subset of patients with acquired idiopathic stiffness unrelated to known extrinsic or surgical causes. Three authors independently assessed study eligibility and risk of bias and collected data. Outcomes of interest were then analyzed according to age, sex, and body mass index (BMI). RESULTS In the 35 included studies (48,873 pTKAs), the mean patient age was 66 years. In 63% of the studies, stiffness was defined as a range of motion of <90° or a flexion contracture of >5° at 6 to 12 weeks postoperatively. The prevalence of acquired idiopathic stiffness after pTKA was 4%, and this did not differ according to age (4%, I = 95%, among patients <65 years old and 5%, I = 96%, among those ≥65 years old; p = 0.238). The prevalence of acquired idiopathic stiffness was significantly lower in males (1%, I = 85%) than females (3%, I = 95%) (p < 0.0001) as well as in patients with a BMI of <30 kg/m (2%, I = 94%) compared with those with a BMI of ≥30 kg/m (5%, I = 97%) (p = 0.027). CONCLUSIONS Contemporary literature supports the following definition for acquired idiopathic stiffness: a range of motion of <90° persisting for >12 weeks after pTKA in patients in the absence of complicating factors including preexisting stiffness. The mean prevalence of acquired idiopathic stiffness after pTKA was 4%; females and obese patients were at increased risk. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Meagan E. Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Afton K. Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Ahmed T. Ahmed
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Li Z, Lan F, Shen Y, An S, Xu N, Yin C, Yu W, Ye W, Cao G, Wang T. Prediction of the need for manipulation under anesthesia for flexion contracture after total knee arthroplasty in patients of advanced age. J Int Med Res 2019; 47:3061-3069. [PMID: 31144553 PMCID: PMC6683935 DOI: 10.1177/0300060519851328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective This study was performed to develop a prediction model for requiring manipulation under anesthesia (MUA) for flexion contracture after total knee arthroplasty (TKA) in patients of advanced age. Methods We retrospectively reviewed 269 patients of advanced age undergoing primary TKA in one center with a minimum 1-year follow-up. Patients who underwent postoperative MUA had flexion contracture of >10° after 4 weeks of postoperative rehabilitation, and their demographic data and preoperative clinical conditions [knee diagnosis, diabetes mellitus, hypertension, lumbar spinal disorders, hip disorders, ankle disorders, knee deformity (varus/valgus), preoperative flexion contracture (PFC), range of motion (ROM), and Hospital for Special Surgery (HSS) knee score] were compared with those of patients without MUA. All preoperative factors were collected to develop the predictive model. Results Thirty patients underwent MUA. Patients who underwent MUA after surgery had significant differences in PFC, higher HSS knee scores before surgery (59.10 ± 7.22 vs. 55.70 ± 13.09), and lower preoperative ROM (81.57 ± 30.86 vs. 95.47 ± 24.36) than those who did not undergo MUA. Conclusion A prediction model for MUA in advanced-age patients with flexion contracture was developed and mainly consisted of preoperative risk factors including PFC, HSS scores, and ROM.
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Affiliation(s)
- Zheng Li
- 1 Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fei Lan
- 2 Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanyan Shen
- 2 Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuai An
- 1 Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Na Xu
- 2 Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Cheng Yin
- 2 Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Yu
- 2 Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiguang Ye
- 2 Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guanglei Cao
- 1 Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- 2 Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Kornuijt A, Das D, Sijbesma T, de Vries L, van der Weegen W. Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature. Musculoskelet Surg 2018; 102:223-230. [PMID: 29546693 DOI: 10.1007/s12306-018-0537-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 03/08/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery. METHODS A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA. RESULTS Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA. CONCLUSION Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.
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Affiliation(s)
- A Kornuijt
- Department of Physiotherapy, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - D Das
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - T Sijbesma
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - L de Vries
- Department of Orthopedic Surgery, Westfriesgasthuis Hospital, Maelsonstraat 3, 1624 NP, Hoorn, The Netherlands
| | - W van der Weegen
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands.
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Arshi A, Leong NL, D'Oro A, Wang C, Buser Z, Wang JC, Jones KJ, Petrigliano FA, SooHoo NF. Outpatient Total Knee Arthroplasty Is Associated with Higher Risk of Perioperative Complications. J Bone Joint Surg Am 2017; 99:1978-1986. [PMID: 29206787 DOI: 10.2106/jbjs.16.01332] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As concerns regarding health-care expenditure in the U.S. remain at the national forefront, outpatient arthroplasty is an appealing option for carefully selected patient populations. The purpose of this study was to determine the nationwide trends and complication rates associated with outpatient total knee arthroplasty (TKA) in comparison with standard inpatient TKA. METHODS We performed a retrospective review of the Humana subset of the PearlDiver Patient Record Database to identify patients who had undergone TKA (Current Procedural Terminology [CPT] code 27447) as either outpatients or inpatients from 2007 to 2015. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision (ICD-9) and CPT codes. Multivariate logistic regression analysis adjusted for age, sex, and Charlson Comorbidity Index (CCI) was used to calculate odds ratios (ORs) of complications among outpatients relative to inpatients treated with TKA. RESULTS Cohorts of 4,391 patients who underwent outpatient TKA and 128,951 patients who underwent inpatient TKA were identified. The median age was in the 70 to 74-year age group in both cohorts. The incidence of outpatient TKA increased across the study period (R = 0.60, p = 0.015). After adjustment for age, sex, and CCI, outpatient TKAs were found to more likely be followed by tibial and/or femoral component revision due to a noninfectious cause (OR = 1.22, 95% confidence interval [CI] = 1.01 to 1.47; p = 0.039), explantation of the prosthesis (OR = 1.35, CI = 1.07 to 1.72; p = 0.013), irrigation and debridement (OR = 1.50, CI = 1.28 to 1.77; p < 0.001), and stiffness requiring manipulation under anesthesia (OR = 1.28, CI = 1.17 to 1.40; p < 0.001) within 1 year. Outpatient TKA was also more frequently associated with postoperative deep vein thrombosis (OR = 1.42, CI = 1.25 to 1.63; p < 0.001) and acute renal failure (OR = 1.13, CI = 1.01 to 1.25; p = 0.026). CONCLUSIONS With the potential to minimize arthroplasty costs among healthy patients, outpatient TKA is an increasingly popular option. Nationwide data from a private insurance database demonstrated a higher risk of perioperative surgical and medical complications including component failure, surgical site infection, knee stiffness, and deep vein thrombosis. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Natalie L Leong
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Anthony D'Oro
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Christopher Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Kristofer J Jones
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Frank A Petrigliano
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Nelson F SooHoo
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
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Rogatko CP, Warnock JJ, Bobe G, Verpaalen VD. Comparison of iatrogenic articular cartilage injury in canine stifle arthroscopy versus medial parapatellar mini-arthrotomy in a cadaveric model. Vet Surg 2017; 47:O6-O14. [DOI: 10.1111/vsu.12736] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 06/13/2017] [Accepted: 07/06/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Cleo P. Rogatko
- Department of Clinical Sciences, College of Veterinary Medicine; Oregon State University; Corvallis Oregon
| | - Jennifer J. Warnock
- Department of Clinical Sciences, College of Veterinary Medicine; Oregon State University; Corvallis Oregon
| | - Gerd Bobe
- Department of Rangeland Sciences and The Linus Pauling Institute; Oregon State University; Corvallis Oregon
| | - Valentine D. Verpaalen
- Department of Clinical Sciences, College of Veterinary Medicine; Oregon State University; Corvallis Oregon
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Arthrofibrosis Associated With Total Knee Arthroplasty. J Arthroplasty 2017; 32:2604-2611. [PMID: 28285897 DOI: 10.1016/j.arth.2017.02.005] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 01/03/2017] [Accepted: 02/05/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. METHODS In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. RESULTS Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. CONCLUSION Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.
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Wanivenhaus F, Tscholl PM, Aguirre JA, Giger R, Fucentese SF. Novel Protocol for Knee Mobilization Under Femoral and Sciatic Nerve Blocks for Postoperative Knee Stiffness. Orthopedics 2016; 39:e708-14. [PMID: 27111083 DOI: 10.3928/01477447-20160419-07] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/08/2016] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate the effectiveness of intermittent femoral and sciatic nerve blocks combined with an in-house physiotherapy protocol for treating postoperative knee stiffness. Sixty-eight patients with postoperative knee stiffness were evaluated for passive knee flexion and extension at different time points, beginning preoperatively and continuing throughout a median 10-month follow-up after mobilization intervention. Sciatic and femoral nerve catheters were activated 1 hour prior to each physiotherapy session, which was performed twice per day and supported by a continuous passive range of motion machine. Median time from admission to catheter removal was 4 days (range, 1-8 days). Mean hospital length of stay was 7 days (range, 2-19 days). Overall mean flexion increased significantly from pretreatment (74°) to discharge (109°; P<.01). There was no significant difference in mean flexion at 6-week follow-up compared with that at discharge (108°; P=.764), but there was a significant increase in flexion at final follow-up (120°; P=.002). Overall mean knee extension lag decreased significantly from pretreatment (5°) to discharge (0.4°; P=.001). There was no significant increase in mean extension lag from discharge to final follow-up (1°; P=.2). Overall, 11 patients underwent revision surgery for persistent stiffness. This novel protocol for continuous knee mobilization under perineural blocks is a valuable alternative to knee manipulation under anesthesia for this select group of procedures. The 2 techniques produced a similar early range of motion gain, but the reported protocol resulted in less range of motion loss at follow-up and fewer possible complications. [Orthopedics. 2016; 39(4):e708-e714.].
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Huh SW, Shetty AA, Ahmed S, Lee DH, Kim SJ. Autologous bone-marrow mesenchymal cell induced chondrogenesis (MCIC). J Clin Orthop Trauma 2016; 7:153-6. [PMID: 27489409 PMCID: PMC4949404 DOI: 10.1016/j.jcot.2016.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 05/10/2016] [Accepted: 05/11/2016] [Indexed: 12/18/2022] Open
Abstract
Degenerative and traumatic articular cartilage defects are common, difficult to treat, and progressive lesions that cause significant morbidity in the general population. There have been multiple approaches to treat such lesions, including arthroscopic debridement, microfracture, multiple drilling, osteochondral transplantation and autologous chondrocyte implantation (ACI) that are currently being used in clinical practice. Autologous bone-marrow mesenchymal cell induced chondrogenesis (MCIC) is a single-staged arthroscopic procedure. This method combines a modified microfracture technique with the application of a bone marrow aspirate concentrate (BMAC), hyaluronic acid and fibrin gel to treat articular cartilage defects. We reviewed the current literatures and surgical techniques for mesenchymal cell induced chondrogenesis.
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Affiliation(s)
- Sung Woo Huh
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Asode Ananthram Shetty
- Canterbury Christ Church University, Faculty of Health and Social Sciences, 30 Pembroke Court, Chatham Maritime, Kent ME4 4UF, United Kingdom
| | - Saif Ahmed
- Canterbury Christ Church University, Faculty of Health and Social Sciences, 30 Pembroke Court, Chatham Maritime, Kent ME4 4UF, United Kingdom
| | - Dong Hwan Lee
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Seok Jung Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
- Corresponding author at: Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271, Cheonbo-ro, Uijeongbu-si, Gyeonggi-do, Republic of Korea. Tel.: +82 31 820 3654; fax: +82 31 847 3671.Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea271, Cheonbo-roUijeongbu-siGyeonggi-doRepublic of Korea
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Mamarelis G, Sunil-Kumar KH, Khanduja V. Timing of manipulation under anaesthesia for stiffness after total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:316. [PMID: 26697476 DOI: 10.3978/j.issn.2305-5839.2015.10.09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Stiffness following total knee arthroplasty (TKA) is a debilitating condition for the patient with limitation of functional outcome. There are various causes of stiffness, which can be classified as pre-operative, per-operative and post-operative. Arthrofibrosis is one of the causes, which can be managed in different ways, and manipulation under anaesthesia (MUA) is routinely performed as the first line of management. The timing of MUA is often debated. We review the paper by Issa et al., which looks at the effect of timing of manipulation on a stiff TKA. They conclude that early manipulation within 12 weeks of performing the TKA had a higher mean flexion gain (36.5°), higher final range of motion (ROM) (119°) and higher knee society score (89 points) compared to those performed after 12 weeks which were 17°, 95° and 84 points respectively. Other studies have also reinforced the idea that early manipulation within 12 weeks has a better outcome than those performed after 12 weeks. There may still be a benefit of manipulation until 26 weeks after which open arthrolysis may be needed to improve ROM.
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Affiliation(s)
- Georgios Mamarelis
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Karadi Hari Sunil-Kumar
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Vikas Khanduja
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Manipulation Under Anesthesia: A Safe and Effective Treatment for Posttraumatic Arthrofibrosis of the Knee. J Orthop Trauma 2015; 29:e464-8. [PMID: 26313319 DOI: 10.1097/bot.0000000000000395] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study investigates the results of closed manipulations performed under anesthesia (MUA) to evaluate whether it is an effective means to treat posttraumatic knee arthrofibrosis. DESIGN Retrospective review. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Twenty-two patients with a mean age of 40 underwent closed MUA for posttraumatic knee arthrofibrosis. Injuries included fractures of the femur, tibia, and patella as well as ligamentous injuries and traumatic arthrotomies. The mean time from treatment to manipulation was 90 days. Mean follow-up after manipulation was 7 months. INTERVENTION Closed knee MUA. OUTCOME MEASUREMENTS Improvement of knee range of motion (ROM) arc was the primary outcome. Patient demographics were correlated with manipulation success using a 2-sample t test. A delay in manipulation of 90 days or greater was also evaluated in this fashion with regard to its role in predicting the benefit of MUA. RESULTS The mean premanipulation ROM arc was 59 ± 25 degrees. The mean intraoperative arc of motion, achieved at the time of the manipulation was 123 ± 14 degrees. No complications occurred during the MUA procedure. At the most recent follow-up, the mean ROM arc was 110 ± 19 degrees. Tobacco use, associated injuries, elevated body mass index, open fracture, and advanced age did not impact manipulation efficacy. Additionally, manipulations performed 90 days or more after surgical treatment provided a benefit equaling those performed more acutely (P = 0.12). DISCUSSION MUA is a safe and effective method to increase knee ROM in the setting of posttraumatic arthrofibrosis. Improvement in ROM was noted in all patients. A 90-day window between fracture fixation and manipulation did not impact ROM at final follow-up and may prevent fracture displacement during the MUA. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Shetty AA, Kim SJ, Shetty V, Stelzeneder D, Shetty N, Bilagi P, Lee HJ. Autologous bone-marrow mesenchymal cell induced chondrogenesis: Single-stage arthroscopic cartilage repair. Tissue Eng Regen Med 2014. [DOI: 10.1007/s13770-014-0061-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Issa K, Kapadia BH, Kester M, Khanuja HS, Delanois RE, Mont MA. Clinical, objective, and functional outcomes of manipulation under anesthesia to treat knee stiffness following total knee arthroplasty. J Arthroplasty 2014; 29:548-52. [PMID: 24011781 DOI: 10.1016/j.arth.2013.07.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 07/22/2013] [Accepted: 07/30/2013] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to determine the clinical outcomes of manipulation under anesthesia (MUA) in a cohort who had developed knee stiffness following total knee arthroplasty (TKA). One-hundred and forty-five TKAs in 134 patients who had undergone MUA were compared to the remaining 1973 TKAs in 1671 patients who did not develop this condition. At a mean follow-up of 51 months (range, 24 to 85 months), the mean gains in flexion in the MUA cohort were 33° (range, 5° to 65°). The final range-of-motion in the MUA cohort was lower than the comparison cohort (114° versus 125°) however, this would meet the required flexion for activities of daily living. There were no differences in the Knee Society objective and functional scores between the two cohorts. It is encouraging that MUA cohort outcomes were comparable to outcomes of patients who did not develop knee stiffness.
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Affiliation(s)
- Kimona Issa
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Bhaveen H Kapadia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Mark Kester
- Stryker Orthopaedics, Inc., Mahwah, New Jersey
| | - Harpal S Khanuja
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Gomoll AH, Kamei G, Ochi M, Shetty AA, Zaslav K. Technical Enhancements and Update on Chondrocyte Implantation. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.oto.2014.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Witvrouw E, Bellemans J, Victor J. Manipulation under anaesthesia versus low stretch device in poor range of motion after TKA. Knee Surg Sports Traumatol Arthrosc 2013; 21:2751-8. [PMID: 22864680 DOI: 10.1007/s00167-012-2152-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 07/23/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of two frequently used non-operative treatment techniques for a stiff knee after total knee arthroplasty. METHODS Sixty-four patients with a stiff knee after total knee arthroplasty (TKA) were randomized into a manipulation under anaesthesia group, or a low load stretch (stretch) group. The patients were followed up for 6 weeks and were evaluated for maximum flexion and extension, range of motion (ROM), pain, stiffness and function. RESULTS Both groups showed a significant increase in knee flexion in this study. Only the stretch group showed a significant increase in extension ROM. In both groups, a significant increase in Western Ontario and McMaster Universities was observed. No significant difference was observed between both groups for the flexion or extension ROM, or for any of the pain, function or stiffness scores during this study. CONCLUSIONS The results of this study showed that the stretch technique had equal or superior results concerning ROM and function compared to manipulation under anaesthesia. The stretch technique achieved this without requiring the patient to undergo in-hospital treatment or anaesthesia, limiting the costs and the risks for complications. The results of this study showed that stretching is a valuable tool for treating joint contractures of the knee. Therefore, the use of this stretching technique may be an excellent first choice of treatment modality in patients with slow progress of knee flexion or persistent knee stiffness following TKA, prior to manipulation under anaesthesia or lysis of adhesions.
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Affiliation(s)
- E Witvrouw
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium,
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Posttraumatische Bewegungseinschränkungen am Kniegelenk. ARTHROSKOPIE 2013. [DOI: 10.1007/s00142-013-0765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effects of combined application of muscle relaxants and celecoxib administration after total knee arthroplasty (TKA) on early recovery: a randomized, double-blind, controlled study. J Arthroplasty 2013; 28:1301-5. [PMID: 23561916 DOI: 10.1016/j.arth.2012.10.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 08/30/2012] [Accepted: 10/01/2012] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to evaluate the effectiveness of application of muscle relaxants and celecoxib in early recovery after total knee arthroplasty (TKA). One hundred and fifty patients were randomized 1:1:1 to receive either both of muscle relaxants and celecoxib or muscle relaxants alone or placebo for 2 weeks (50 patients in each group). VAS pain scores as primary efficacy, active range of motion, morphine consumption, blood loss, and postoperative complications including postoperative nausea and vomiting (PONV), extremities myasthenia and deep vein thrombosis (DVT) were determined postoperatively. Group A improved better with reduced VAS pain scores compared with another two groups. These results demonstrated that application of muscle relaxants and celecoxib into patients undergoing TKA for 2 weeks postoperative consequently improved their convalescence.
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Abstract
BACKGROUND The patella provides important mechanical leverage to the knee extensor mechanism. Patellectomy does not exclude the development of tibiofemoral arthrosis. QUESTIONS/PURPOSES We asked whether (1) TKA provides improvements in clinical outcome scores in patellectomized knees and (2) the scores of TKA in patellectomized knees are comparable to those in knees with intact patellae. METHODS We evaluated 50 patients (52 primary TKAs) with patellectomized knees and a control group of 52 patients (52 primary TKAs) with intact patellae matched for age, sex, implant, and surgical year between 1984 and 2009. We compared the preoperative and latest postoperative SF-12, WOMAC, and Knee Society score (KSS). Minimum followup was 24 months (mean, 69 months; range, 24-204 months). RESULTS The mean WOMAC score in the control group improved from 41.8 (range, 7.5-72.4) preoperatively to 69.1 (range, 17.0-100.0) postoperatively, while that in the patellectomized group improved from 35.8 (range, 5.2-62.2) to 61.3 (range, 17.5-96.2). The mean KSS improved from 80.4 (range, 4.0-143.0) preoperatively to 161.4 (range, 69.0-200.0) postoperatively in the control group and from 76.9 (range, 5-134) to 136.8 (range, 7-199) in the patellectomized group. Mean postoperative WOMAC scores were comparable between the two groups, while the mean KSS was lower in the patellectomized group. The mean SF-12 scores were not different after TKA or between groups. CONCLUSIONS Despite the mechanical disadvantage to the knee extensor mechanism rendered by a previous patellectomy, TKA for tibiofemoral arthrosis in these patients relieved pain and restored function, but function was on average lower than that in patients with intact patellae. LEVEL OF EVIDENCE Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Rodriguez-Merchan EC, Gomez-Cardero P, Jimenez-Yuste V. Iatrogenic fracture of the proximal tibia as a complication of knee manipulation under anaesthesia in a haemophilia patient with an ipsilateral stiff knee secondary to a supracondylar non-union of the femur. Haemophilia 2012; 18:e354-6. [PMID: 22537651 DOI: 10.1111/j.1365-2516.2012.02814.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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