Total knee arthroplasty for post-traumatic arthrosis

Pre-existing knee osteoarthritis and severe joint depression are associated with the need for total knee arthroplasty after tibial plateau fracture in patients aged over 60 years

Aims

This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.

Methods

This is a retrospective cohort study of 182 displaced TPFs in 180 patients aged ≥ 60 years, over a 12-year period with a minimum follow-up of one year. The mean age was 70.7 years (SD 7.7; 60 to 89), and 139/180 patients (77.2%) were female. Radiological assessment consisted of fracture classification; pre-existing knee osteoarthritis (OA); reduction quality; loss of reduction; and post-traumatic OA. Fracture depression was measured on CT, and the volume of defect estimated as half an oblate spheroid. Operative management, complications, reoperations, and mortality were recorded.

Results

Nearly half of the fractures were Schatzker II AO B3.1 fractures (n = 85; 47%). Radiological knee OA was present at fracture in 59/182 TPFs (32.6%). Primary management was fixation in 174 (95.6%) and acute TKA in eight (4.4%). A total of 13 patients underwent late TKA (7.5%), most often within two years. By five years, 21/182 12% (95% confidence interval (CI) 6.0 to 16.7) had required TKA. Larger volume defects of greater depth on CT (median 15.9 mm vs 9.4 mm; p < 0.001) were significantly associated with TKA requirement. CT-measured joint depression of > 12.8 mm was associated with TKA requirement (area under the curve (AUC) 0.766; p = 0.001). Severe joint depression of > 15.5 mm (hazard ratio (HR) 6.15 (95% CI 2.60 to 14.55); p < 0.001) and pre-existing knee OA (HR 2.70 (95% CI 1.14 to 6.37); p = 0.024) were independently associated with TKA requirement. Where patients with severe joint depression of > 15.5 mm were managed with fixation, 11/25 ultimately required TKA.

Conclusion

Overall, 12% of patients aged ≥ 60 years underwent TKA within five years of TPF. Severe joint depression and pre-existing knee arthritis were independent risk factors for both post-traumatic OA and TKA. These features should be investigated as potential indications for acute TKA in older adults with TPFs.

Acute Total Knee Arthroplasty for Unicondylar Tibial Plateau Fracture Using Metaphyseal Cones

Tibial plateau fractures (TPFs) in older adults are increasing in incidence and now account for 8% of all fractures in patients over 60 years of age. Although primary fixation remains standard, the risk of fixation failure, loss of reduction, and the development of posttraumatic osteoarthritis are all markedly increased in this age group with higher rates of conversion to total knee arthroplasty (TKA) of 12%. When joint depression is severe with significant subchondral bone loss, up to half ultimately require TKA. TPFs with unicondylar depression can be managed primarily using tibial cones in acute TKA. In this study, we report the surgical technique for performing acute TKA using tibial cones for the primary management of TPFs in older adults and illustrate this technique with case examples.

Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty With Prior Hardware

BACKGROUND

End-stage knee osteoarthritis with retained periarticular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention versus removal of hardware during TKA is controversial.

METHODS

Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. The mean follow-up was 60 months (range, 24-223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes.

RESULTS

The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (odds ratio: 20.7, P < .05), implant failures (odds ratio: 13.9, P < .05), and lower the Veterans Rand 12 Mental Score (VR-12 MS) (-14.8, P < .05). Hardware removal versus retention and use of single versus multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, P < .05) VR-12 MS compared to retention of all hardware.

CONCLUSIONS

TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes.

LEVEL OF EVIDENCE

IV, cohort without control.

Total knee arthroplasty in post-traumatic osteoarthritis is more challenging, but results in similar patient satisfaction - An analysis of 1646 cases

BACKGROUND

Patients with post-traumatic osteoarthritis (PTOA) present a variety of technical challenges to surgeons. Surgical parameters, complication rates and patient-reported outcomes (PROs) have been reported as detrimental in total knee arthroplasty (TKA) for PTOA. The purpose of this study was to compare these variables and satisfaction with the results of TKA in patients with post-traumatic osteoarthritis with a matched-pair cohort of primary osteoarthritis (POA).

METHODS

A registry-embedded prospective case-control study was performed. Of a total of 1646 TKAs, 155 were performed due to PTOA between 2012 and 2019. One-hundred and thirty-six could be one-to-one propensity score-matched to patients with POA undergoing primary TKA based on similar patient demographic variables. Outcomes investigated included operation time, estimated blood loss, types of implants, postoperative complications and PROs pre- and 1 year postoperatively as well as satisfaction with the results of surgery. Sub-cohort analysis was performed for patients with prior fracture and soft tissue trauma, respectively.

RESULTS

Surgical parameters were significantly different in disadvantages of PTOA: operation time (P < 0.001), estimated blood loss (P < 0.001), blood transfusions (P = 0.039), type of implants (P < 0.001). Manipulation under anaesthesia (MUA) was necessary more often in the PTOA fracture group (odds ratio 5.01, (95% confidence interval 1.04; 24.07). PRO demonstrated no substantial differences after 1 year. Satisfaction with the results of TKA was as equally high in all cohorts.

CONCLUSIONS

This study demonstrated that TKAs in patients with PTOA require higher surgical effort but can result in similar PROs and satisfaction compared to POA, regardless of the underlying trauma.

Outcomes of Total Knee Arthroplasty in Patients with Prior Hardware: A Case-Control Study Using Handheld Navigation

Presence of hardware in juxta-articular location poses challenge during total knee arthroplasty (TKA). When present in distal femur, it precludes the use of an intramedullary femoral jig during TKA often necessitating removal of hardware leading to prolonged surgery, higher risk of complications, and inferior results. We conducted a case-control study to assess the outcome of TKA among patients with post-traumatic arthritis using a handheld navigation system to perform bone cuts allowing retention of hardware in situ. In 15 patients with post-traumatic arthritis and hardware around the knee (Group A), none or part(s) of hardware were removed while performing TKA. These patients were matched to 15 patients who underwent TKA with handheld navigation for primary OA knee (Group B). The perioperative outcomes assessed were operative time, intraoperative blood loss, length of hospital stay, complications, and 30 days reoperation rate. Clinical outcomes were assessed by using Knee Society Score (KSS) and radiological outcomes using mechanical axis and coronal and sagittal component angles. Mean age of patients at surgery were 65.67 years (Group A) and 66.73 years (Group B). Mean operative time and blood loss were significantly higher in Group A as compared with Group B. At the mean follow-up of 34 months, KSS significantly improved in both the groups. However, there was no statistically significant difference in the clinical and radiological outcomes between the two groups. One patient in Group A developed wound dehiscence and had to undergo debridement and flap coverage within 30 days. The use of navigation helps surgeons in gaining proper limb alignment and implant positioning without complete removal of hardware.

Conversion Total Knee Arthroplasty After Tibial Plateau Fixation Is Associated With Lower Reimbursement, Greater Complication Rates, and Similar Opioid Use

Objective

Total knee replacement after previous open reduction and internal fixation for tibial plateau fracture (conversion total knee) increases the complexity of the procedure and the complication rate. However, very little research exists to report on opioid use and cost associated with total knee arthroplasty (TKA) following tibial plateau fracture fixation as compared to primary TKA patients with no history of tibial plateau fracture. The aim of this study is to compare the differences in opioid use, reimbursements, and complication rates between patients with and without a history of tibial plateau fracture undergoing TKA.

Methods and materials

This is a retrospective large database review study. The study included patients across the country and in various clinical settings including, but not limited to, institutions, primary and tertiary care centers, and private practice. The PearlDiver database was reviewed for patients undergoing TKA between 2010 and 2019. Patients who underwent TKA following surgical repair of a tibial plateau fracture were identified using Common Procedural Terminology (CPT) codes and the appropriate International Classification of Diseases Ninth and Tenth Revision (ICD-9, ICD-10) codes. This group was then matched by age, gender, Charleston Comorbidity Index (CCI) score, Elixhauser Comorbidity Index (ECI) score, obesity, tobacco use, and diabetes to a group of similar patients who underwent TKA with no history of tibial plateau fracture. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day reimbursed cost were compared between groups using an unequal variance t-test. Complication rates at 30 days, 90 days, and one year postoperatively, and revision rates at one and two years postoperatively were compared using the odd’s ratio (OR) with 95% confidence intervals (95%CI).

Results

The episode of care cost for TKA was significantly lower for patients with a history of tibial plateau fracture ($11,615 ± $15,704) than it was for patients without a history of tibial plateau fracture ($16,088 ± $18,573) (p = 3.56E-14). At 30 days after knee arthroplasty, patients with a history of tibial plateau fracture had significantly more episodes of dehiscence (OR 2.665 [95% CI 1.327-5.351]; p = 0.006) and surgical site infection (SSI) (OR 1.698 [95% CI 1.058-2.724]; p = 0.028), which was significant at 90 days postop for both dehiscence (OR 1.358 [95% CI 0.723-2.551]; p = 0.001) and SSI (OR 1.634 [95% CI 1.100-1.802]; p = 0.015), as well as mechanical complications of the implant device (OR 2.420 [95% CI 1.154-5.076]; p = 0.019). There was no significant difference in the number of opioids prescribed postoperatively to patients with a history of tibial plateau fracture (2218 ± 3255 MME) compared to those without prior tibial plateau fracture (2400 ± 4843 MME) (p = 0.258). However, there was a small but statistically significant increase in the number of days postoperatively patients with a history of tibial plateau fracture were prescribed opioids (11.99 ± 7.73 days) compared to non-tibial plateau fracture patients (11.15 ± 7.18 days) (p = 0.004).

Conclusion

Patients with a history of tibial plateau fracture who then underwent conversion TKA have a lower reimbursed cost of TKA but a higher postoperative risk for dehiscence, mechanical complications, and surgical site infections. There is no significant difference in postoperative opioid use between the two groups.

Measuring appropriate need for unicompartmental knee arthroplasty: results of the MANUKA study

PURPOSE

Indications for unicompartmental knee arthroplasty (UKA) are controversial. Studies based solely on radiographic criteria suggest up to 49% of patients with knee osteoarthritis (OA) are suitable for UKA. In contrast, the 'Appropriate use criteria' (AUC), developed by the AAOS, apply clinical and radiographic criteria to guide surgical treatment of knee OA. The aim of this study was to analyze patient suitability for TKA, UKA and osteotomy using both radiographic criteria and AUC in a cohort of 300 consecutive knee OA patients.

METHODS

Included were consecutive patients with clinical and radiographic signs of knee OA referred to a specialist clinic. Collected were demographic data, radiographic wear patterns and clinical findings that were analyzed using the AUC. A comparison of the radiographic wear patterns with the treatment suggested by the AUC as well as the Surgeon Treatment Decision was performed.

RESULTS

There were 397 knees in 300 patients available for analysis. Median age was 68 [IQR 15], BMI 30 [6] with 55% females. Excellent consistency for both the radiographic criteria and the AUC criteria was found. Based on radiological criteria, 41% of knees were suitable for UKA. However, when using the AUC criteria, UKA was the appropriate treatment in only 13.3% of knees. In 19.1% of knees, no surgical treatment was appropriate at the visit, based on the collected data.

CONCLUSION

Application of isolated radiologic criteria in patients with knee OA results in a UKA candidacy is misleadingly high. AUC that are based on both radiological and clinical criteria suggest UKA is appropriate in less than 15% of patients.

LEVEL OF EVIDENCE

III retrospective study.

Increased Revisions in Conversion Total Knee Arthroplasty After Periarticular Open Reduction Internal Fixation Compared With Primary Total Knee Arthroplasty: A Matched Cohort Analysis

BACKGROUND

Prior studies on conversion total knee arthroplasty (cTKA) have reported increased technical challenges and risk of complications compared with primary knee arthroplasty. The purpose of this study was to compare two-year postoperative complication/revision rates between patients undergoing cTKA after prior periarticular open reduction and internal fixation (ORIF) and those undergoing primary TKA.

METHODS

Patients who underwent cTKA after prior periarticular ORIF of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2018. This ORIF-cTKA cohort was propensity matched to participants undergoing primary TKA based on age, gender, Charlson comorbidity index, and obesity status. Univariate analysis was performed to analyze differences in two-year complication and revision rates.

RESULTS

After propensity matching, 823 patients were included in the ORIF-cTKA cohort and 1640 patients in the primary TKA cohort. No differences in demographics or comorbidities existed between cohorts. Relative to the primary TKA cohort, the ORIF-cTKA cohort had significantly higher incidences of all-cause revision (5.47% vs 2.47%, P = .001), periprosthetic joint infection (PJI; 4.74% vs 1.34%, P < .001), and intraoperative or postoperative periprosthetic fracture (1.58% vs 0.55%, P = .01) at two years postoperatively. There was also a nonsignificant trend toward increased rates of aseptic loosening (1.82% vs 0.91%, P = .052) in the ORIF-cTKA.

CONCLUSION

Relative to primary TKA, cTKA after periarticular ORIF is associated with significantly increased rates of all-cause revision, PJI, and periprosthetic fracture at two years postoperatively. Surgeons should counsel these patients about the increased risks of these postoperative complications and consider treating them as high risk for PJI in the perioperative period.

Conversion Total Knee Arthroplasty

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Conversion total knee arthroplasty (TKA) represents a heterogeneous group of procedures and most commonly includes TKA performed after ligamentous reconstruction, periarticular open reduction and internal fixation (ORIF), high tibial osteotomy (HTO), and unicompartmental knee arthroplasty (UKA).

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Relative to patients undergoing primary TKA, patients undergoing conversion TKA often have longer operative times and higher surgical complexity, which may translate into higher postoperative complication rates.

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There is mixed evidence on implant survivorship and patient-reported outcome measures when comparing conversion TKA and primary TKA, with some studies noting no differences between the procedures and others finding decreased survivorship and outcome scores for conversion TKA.

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By gaining an improved understanding of the unique challenges facing patients undergoing conversion TKA, clinicians may better set patient expectations, make intraoperative adjustments, and guide postoperative care.

Incidence and risk factors for poor ankle functional recovery, and the development and progression of posttraumatic ankle osteoarthritis after significant ankle ligament injury (SALI): the SALI cohort study protocol

Background

Ankle sprains are one of the most common musculoskeletal injuries, accounting for up to 5% of all Emergency Department visits in the United Kingdom. Ankle injury may be associated with future ankle osteoarthritis. Up to 70% of ankle osteoarthritis cases may be associated with previous ankle injury. There is limited research regarding the association between ankle sprain and ankle osteoarthritis development. The current study aims to phenotype those who suffer significant ankle ligament injuries, identify potential risk factors for ankle injuries and subsequent poor recovery, examine why individuals may develop osteoarthritis, and what factors influence this chance.

Methods

In this multicentre cohort study participants were recruited from nine Emergency Departments and two Urgent Care Centres in the United Kingdom. Participants (aged 18–70 years old) were defined as those who had suffered an isolated acute ankle sprain, which was Ottawa Ankle Rules positive, but negative for a significant ankle fracture on x-ray. Age and sex matched controls were also recruited. The controls were individuals who had not suffered a significant ankle injury, including ankle pain, function affected for more than 7 days, or the ankle caused them to report to an Emergency Department. Data is collected through a series of seven questionnaires (at baseline, 3 months, 1 year, 3 years, 5 years, 10 years, and 15 years later). The questionnaires include four sections (demographic questions; index injury, and injury history questions; functional assessment questions; and quality of life questions) and are designed to collect detailed information about the individual, their injury, potential risk factors for ankle sprains and ankle osteoarthritis, plus their medical history and any medication consumed.

Discussion

The Significant Ankle Ligament Injury (SALI) study aims to add to the limited knowledge regarding which factors can predict ankle sprains, complaints, and osteoarthritis. This is important because despite ankle sprains being regarded as a benign injury that resolves quickly, residual symptoms are not uncommon months and years after the injury.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04230-8.

TKR after posttraumatic and primary knee osteoarthritis: a comparative study

Background

A few literatures reported that the outcomes of total knee replacement (TKR) in posttraumatic osteoarthritis (PTOA) were lower compared to TKR in primary osteoarthritis (primary OA). The study’s purpose was to compare the comorbidity and outcome of TKR among fracture PTOA, ligamentous PTOA, and primary OA. The secondary aim was to identify the effect of postoperatively lower limb mechanical axis on an 8-year survivorship after TKR between PTOA and primary OA.

Methods

Seven hundred sixteen patients with primary OA, 32 patients with PTOA (knee fracture subgroup), and 104 PTOA (knee ligamentous injury subgroup) were recruited. Demography, comorbidities, Charlson Comorbidity Index (CCI), operative parameters, mechanical axis, functional outcome assessed by WOMAC, and complications were compared among the three groups.

Results

PTOA group was significantly younger (p<0.0001) with a higher proportion of men (p=0.001) while the primary OA group had higher comorbidities than the PTOA group, including anticoagulant usage (p=0.0002), ASA class ≥3 (p<0.0001), number of diseases ≥ 4 (p<0.0001), and CCI (p<0.0001). Both the fracture PTOA group (p<0.0001) and ligamentous PTOA group (p = 0.009) had a significantly longer operative time than the primary OA group. The fracture PTOA group had significantly lower pain components and stiffness components than the primary OA group. There was no significant difference in the rate of an aligned group, outlier group, and an 8-year survivorship in both groups.

Conclusion

The outcome following TKR in the fracture PTOA was poorer compared to primary knee OA in the midterm follow-up. However, no difference was detected between the ligamentous PTOA and primary knee OA. The mechanical axis alignment within the neutral axis did not affect the 8-year survivorship after TKR in both groups.

Level of evidence

Level III; retrospective cohort study

Patient-reported outcomes of 7133 distal femoral, patellar, and proximal tibial fracture patients: A national cross-sectional study with one-, three-, and five-year follow-up

BACKGROUND

Few studies have described patient-reported outcome measures (PROMs) in knee fracture patients. We reported knee-specific and generic median PROM scores after knee fracture and identified risk factors for poor outcome defined by low median PROM scores.

METHODS

In a Danish cross-sectional study of 7133 distal femoral, patellar, and proximal tibial fracture patients during 2011-2017, OKS, FJS-12, EQ5D-5L Index, and EQ5D-5L Visual Analogue Scale (VAS), were collected electronically (response rate 53%; median age 60; 63% female). Poor outcome was defined as score lower than median PROM score. Poor outcome risk factors were estimated as odds ratios from binary logistic regression models.

RESULTS

At 0 to one year after knee fracture, median PROM scores were 31 (OKS), 27 (FJS-12), 0.50 (EQ5D-5L Index), and 74 (EQ5D-5L VAS). At >5 years after knee fracture, median OKS score was 40, median FJS-12 score was 54, median EQ5D-5L Index was 0.76, and median EQ5D-5L VAS score was 80. Age > 40 years had higher odds for poor OKS and FJS-12 scores at short- and long-term follow-up after knee fracture. Comorbidity burden, distal femoral fracture, and treatment with external fixation and knee arthroplasty were risk factors for poor outcome at long-term follow-up, for all four PROMs.

CONCLUSIONS

Although knee fracture patients have relatively high knee function and quality of life, their ability to forget about the knee joint after knee fracture is compromised. We identified several important risk factors for poor outcome measured by PROMs at different follow-up periods following knee fracture, which will help direct future quality-improvement initiatives.

Total knee arthroplasty following intramedullary tibial nailing

Introduction/purpose

Total knee arthroplasty (TKA) in the setting of previous periarticular hardware increases resource utilization, readmissions, complications, and revision rates. Despite the frequency of intramedullary nail (IMN) fixation for tibial fractures, little guidance exists on the management of these patients and no series have reported on outcomes of patients undergoing TKA in the setting of a retained or removed IMN.

Methods

This is a retrospective case series of patients who underwent TKA after IMN fixation of tibial fractures. Patient and case data, including need for hardware removal, staged vs non-staged procedures, operative time, and need for revision implants, were recorded. Postoperative data, including complications and revision, were recorded. Oxford Knee Score (OKS) was performed at follow-up.

Results

Nine patients were identified consisting of eight women and one man. Follow-up ranged from 0.8–13 years. Non-staged removal of the intramedullary hardware occurred in three cases that had increased operative lengths recorded. There were no complications related to wound healing or infection. No patients required revision. Two of the three patients who underwent non-staged TKA developed arthrofibrosis requiring manipulation. OKS scores in patients who underwent non-staged surgery were consistently low.

Conclusions

Conversion TKA after tibial IMN fixation can result in satisfying outcomes in many patients. However, intramedullary hardware presents challenges to TKA similar to more extensively studied conversion TKA scenarios. Removing hardware in either a staged or non-staged fashion results in increased resource utilization and imparts perioperative challenges with only theoretical benefits of one approach compared to the other. Increased stiffness may be associated with a non-staged approach to hardware removal and TKA. Several technical factors may permit component positioning without removal of hardware. Despite limitations, this is the first series to discuss this challenging clinical scenario and provides surgeons with technical guidance and data on operative outcomes.

Outcomes of lateral unicompartmental knee arthroplasty in post-traumatic osteoarthritis, a retrospective comparative study

PURPOSE

We asked whether the clinical and radiographic outcomes and survivorship after unicompartmental knee arthroplasty (UKA) for osteoarthritis (OA) consequent to lateral tibial plateau fracture were comparable with those obtained after lateral UKA for primary OA.

METHODS

A total of 13 patients receiving lateral UKA for OA secondary to tibial plateau fracture (post-traumatic UKA, P-UKA) were compared with 13 patients who underwent lateral UKA for primary OA (OA-UKA). Patients were matched for age at surgery, gender, body mass index, and follow-up length. Pre- and post-operative clinical and radiographic assessments included clinical (KSS-c) and functional (KSS-f) Knee Society Score, Hip-Knee-Ankle (HKA) angle, and signs of osteolysis.

RESULTS

Mean follow-up was similar in both groups: 9.9 ± 4.6 years for P-UKA and 9.3 ± 2.4 years for OA-UKA. The two way ANOVA procedure followed by the Bonferroni multiple comparisons test highlighted a baseline difference in KSS-c with P-UKA having greater scores than OA-UKA (+ 12; p < 0.05) and both groups showed large improvements in KSS-c (p < 0.001), KSS-f (p < 0.001), and HKA angle (p < 0.001) at follow-up. The nine year prosthesis survival rate, tested by the Kaplan-Meier methods, was 92% in both groups.

CONCLUSION

Lateral UKA for OA secondary to tibial plateau fracture was efficient in restoring joint function, improving clinical results, and correcting lower limb alignment. Clinical outcomes and nine year survivorship did not differ from lateral UKA for primary OA. Consequently, lateral UKA should be considered a valid option in treating lateral posttraumatic OA in carefully selected patients.

TRIAL REGISTRATION NUMBER

( clinicaltrials.gov ) NCT04198389.

Lingering risk: A meta-analysis of outcomes following primary total knee arthroplasty for patients with post-traumatic arthritis

BACKGROUND

Currently, no meta-analysis exists to elucidate the outcomes of primary total knee arthroplasty (TKA) in patients with post-traumatic arthritis (PTA). The primary aim of this meta-analysis was to compare revision and complication rates for patients with PTA versus osteoarthritis (OA).

METHODS

The following databases were used for searching existing literature (from their inception to October 2019): PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science. The primary outcomes were the incidences of revision and complications, Secondary outcomes included operative time and patient-reported outcomes (PRO) scores.

RESULTS

Nine studies with a total of 6,783,990 patients were included. This study found that there was a statistically significant difference in the rates of superficial wound infection, periprosthetic infection, stiffness, wound complications, and revision, with these outcomes occurring more frequently in patients with PTA. However, PTA did not increase the risks for periprosthetic fracture, aseptic loosening or instability, and VTE. Moreover, PTA was associated with increased operative time, worse postoperative PRO scores, and similar changes in PRO scores.

CONCLUSIONS

This meta-analysis highlight the complexity of PTA and demonstrates increased risks of infection, wound complications, stiffness, and revision. Surgeons can use this information to help aid in counseling patients preoperatively.

Total Knee Arthroplasty in Patients with Prior Femoral and Tibial Fractures: Outcomes and Risk Factors for Surgical Site Complications and Reoperations

Objective

To investigate the outcomes of total knee arthroplasty (TKA) in patients with a prior femoral or tibial fracture, and identify the risk factors for surgical site complications and reoperations.

Methods

Seventy‐one TKAs performed in 71 patients with a prior tibial or femoral fracture between January 2005 and December 2016 were reviewed retrospectively. Forty males (40 knees) and 31 females (31 knees) were included. The mean age at the time of TKA was 59.2 (range, 29–83) years. Outcomes were assessed using the Knee Society score before surgery and at the final follow‐up visit. The patients' satisfaction rates were evaluated. Complications and reoperations were recorded by clinical and radiographic assessment. Logistic regression analysis was used to identify the risk factors for surgical site complications and reoperations.

Results

The median follow‐up period was 4.7 (range, 3.2–7.1) years. The median knee range of motion increased from 90° preoperatively to 110° at the latest follow‐up. The Knee Society knee score and function score improved from 35 (30, 40) and 40 (30, 50) to 90 (82, 93) and 90 (65, 100), respectively. The degree of overall satisfaction after TKA surgery was very satisfied in 41 patients, satisfied in 20 patients, neutral in four patients, dissatisfied in four patients, and very dissatisfied in two patients. The overall satisfaction (very satisfied and satisfied) rate was 85.9% (61 knees). Twelve knees (16.9%) had 19 surgical site complications. Six knees (8.3%) underwent reoperations, including one revision due to periprosthetic joint infection, one debridement and implant retention for superficial infection, two debridements for delayed wound healing, one open reduction and internal fixation for supracondylar fracture, and one re‐fixation and bone grafting for hardware failure after a combined femoral shaft osteotomy and TKA. Preoperative patella baja was diagnosed in 12 knees, and was identified as a risk factor for surgical site complications and reoperations.

Conclusions

TKA for post‐fracture osteoarthritis significantly relieved pain and improved function, but the incidence of surgical site complications and reoperations was high. Preoperative patella baja was a risk factor for surgical site complications and reoperations.

Managing of post-traumatic knee arthritis by total knee arthroplasty: case series of 15 patients and literature review

Purpose

Post-traumatic arthritis is one of the leading causes of joint disability. This study aims at outlining outcomes of total knee arthroplasty in post-traumatic arthritis and technical difficulty and reviewing literature regarding this issue

Patients and methods

We analyzed the outcome of total knee arthroplasty following post-traumatic arthritis in 15 patients with unilateral involvement. Ten had stable arthritic knees treated with posterior stabilized (PS) prosthesis, while five with unstable arthritic knees treated as follows: three with ligamentous instability managed by constrained condylar prosthesis and two with osseous deficiency, metal augmentation used together with stemmed constrained condylar prosthesis (CCK). Average follow-up 6 years, mean age 49.8 years at time of arthroplasty. Patient outcomes were evaluated on the basis of Knee Society score.

Results

Mean clinical knee society scores (CKSS) at latest follow-up improved from 43.6 ± 11.66 points to 77.3± points postoperatively while mean functional knee society score (FKSS) improved from 40. ± 6.3 to 76.6 ± 84 postoperatively. Patients with stable knees had a higher mean values, both clinical and functional KSS, while unstable knees were poorer. Complications occurred in three cases, one with wound dehiscence with prolonged drainage treated by antibiotics and daily dressings until the wound closed completely, one was complicated by infection and improved by serial debridement, and the third case had aseptic loosening which required revision surgery.

Conclusion

Total knee arthroplasty for post-traumatic arthritis decreases pain and improves knee function. However; the procedure is not as simple as primary arthroplasty as it is technically demanding and requires adequate planning.

Patient-Reported Outcome Measures of Total Knee Arthroplasties for Post-Traumatic Arthritis versus Osteoarthritis: A Short-Term (5- to 10-year) Retrospective Matched Cohort Study

BACKGROUND

The objective of the study was to compare the patient-reported outcome measures (PROM) of patients with post-traumatic arthritis (PTA) versus patients with osteoarthritis (OA) undergoing total knee arthroplasty (TKA) and compare the rates of revision among these two groups.

METHODS

Using a prospectively held institutional registry, we retrospectively reviewed patients ≥60 years of age who underwent unilateral TKA between May 2007 and February 2012. Patients with previous or concomitant diagnosis of inflammatory arthropathy or an initial open fracture were excluded. PTA patients were matched 1:5 with OA patients undergoing TKA. Validated PROMs were recorded at baseline before index TKA and the last follow-up. Reason and time to revision surgery was reported, and survivorship was compared using Kaplan-Meier curves.

RESULTS

Seventy-five PTA patients were matched to 375 OA patients. There was no difference between these groups with respect to age (67.7 ± 5.6 vs 67.8 ± 5.5 years; P = .876), body mass index (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m²; P = .948), sex (65.3% vs 65.3% females; P = .999), Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P = .999), and time to follow-up (93.0 ± 13.4 vs 88.2 ± 13.7 months; P = .999). No statistically significant difference was found in PROMs at baseline and the last follow-up (P > .05), the rate or time to revision surgery between the two groups (P-value = .635; log-rank test).

CONCLUSION

Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared to TKA for OA. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA.

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

BACKGROUND

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

MATERIALS/METHODS

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

RESULTS

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

CONCLUSION

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

Primary and Secondary Total Knee Arthroplasty for Tibial Plateau Fractures

The surgical management of tibial plateau fractures can be technically demanding. In younger patients, the mainstay is fixation with cartilage preservation. In older patients with osteoporotic bone, this method has higher rates of fixation failure; in addition, it requires prolonged bed rest or protected weight bearing, which are major challenges in this group. In contrast, total knee arthroplasty performed acutely for primary treatment of tibial plateau fractures has potential advantages for elderly patients, such as immediate stability, early mobilization, and positive functional outcomes with decreased rates of reoperation. Additionally, arthroplasty can be technically challenging in younger patients with previous tibial plateau fractures in whom debilitating posttraumatic arthritis develops. In these patients, old wounds, retained metalwork, bony deficiency, and instability can lead to poorer outcomes and higher complication rates than in routine knee arthroplasty. In both cases, we recommend surgery be performed by experienced arthroplasty surgeons with ample access to a range of implants with varying constraints and the option of stems and augments.

Primary total knee arthroplasty using constrained condylar knee design for severe deformity and stiffness of knee secondary to post-traumatic arthritis

Background

Key to a successful outcome of total knee arthroplasty (TKA) is to attain optimum alignment, adequate balance, and deformity correction. In primary TKA, this can be achieved efficiently by posterior stabilized (PS) design with or without the sub-periosteal release. However, certain circumstances such as post-traumatic arthritis are often associated with severe deformities with a significant bone defect, stiffness, and instability. Such deformities are extremely difficult to balance with soft tissue release only and require additionally constrained prostheses even in primary TKA. In such situation, constrained condylar knee (CCK) design is the ultimate choice. This study primarily aimed to report on clinical outcome, regain of function, and complication of patients who underwent primary CCK-TKA for severe deformity of the knee secondary to post-traumatic arthritis. The secondary aim was to find out the mid-term prostheses survival.

Methods

Between February 2007 and November 2013, 38 consecutive patients with post-traumatic arthritis of the knee received cemented primary CCK-TKA. Thirty-four patients (21 men and 13 women) who had a minimum of 3 years follow-up were included in this retrospective study. We used Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, and roentgenographic evaluation form to assess the patients. Prostheses survival was assessed using Kaplan-Meier’s survival analysis.

Results

Patients were followed up for an average duration of 6.47 years. KSS knee score improved from 44 points (23–68) pre-operatively to 91 points (76–100) post-operatively [P < 0.001]. The average KSS functional score improved from 49 points (20–75) pre-operatively to 91 points (65–100) post-operatively [P < 0.001]. The average HSS score improved from 51 points (27–83) pre-operatively to 91 points (75–100) post-operatively [P < 0.001]. Similarly, the average ROM improved from 68.09° ± 35.99° (0°–120°) to 113.68° ± 8.90° (100°–130°) post-operatively [P < 0.001]. The average hip-knee-ankle (HKA) angle was 176.88° ± 14.48° (135°–199°) pre-operatively and 180.24° ± 1.77° (175°–184°) post-operatively. Radiolucencies were evident in 13 knees, mostly on the tibial side. Prostheses survival was 94.7% at a mean follow-up of 6.47 years.

Conclusion

Despite severe deformity, instability, and stiffness at a relatively young age, mid-term follow-up of primary CCK-TKA in post-traumatic arthritis provides satisfactory clinical and functional outcomes with 94.7% prostheses survival. However, it is not without complication.

Preoperative Diagnosis Can Predict Conversion Total Knee Arthroplasty Outcomes

BACKGROUND

Compared to total knee arthroplasty (TKA) for primary osteoarthritis, conversion TKAs in the post-traumatic setting are associated with increased operative times, infection rates, and readmissions. We aim at determining how post-traumatic osteoarthritis and previous knee surgery influence postoperative outcomes in conversion TKA.

METHODS

Seventy-two conversion TKA procedures with prior knee trauma at a single institution between April 2012 and 2016 were examined. Twenty-seven (37.5%) cases had a preoperative site-specific diagnosis such as fracture of the proximal tibia, distal femur, or patella whereas 45 (62.5%) cases had a preoperative diagnosis of significant soft-tissue trauma. These 2 groups were compared in terms of total implant cost, length of stay, complications, and readmission and reoperation rates. A subanalysis was conducted to evaluate the effects of previous knee surgery on surgical outcomes.

RESULTS

The postfracture TKA cohort suffered significantly higher early surgical site complications (22% vs 4.4%, P = .02) and 90-day readmissions (14.8% vs 2.2%, P = .042) compared to the soft-tissue trauma cohort. Operative time, total implant costs, length of stay, medical complications, 30-day readmissions, and 90-day reoperation rates did not significantly differ. It was also found that patients with multiple prior knee surgeries compared to one prior knee surgery are younger (53.0 vs 63.1, P = .003), healthier, and receive significantly more expensive implants (1.72 vs 1.07, P = .026). In addition, patients with previous open reduction internal fixations experience more surgical site complications than patients with previous arthroscopies (31% vs 3.3%, P = .042).

CONCLUSION

Patients with previous site-specific fracture are more likely to experience surgical site complications and 90-day readmissions after conversion TKA than patients with previous soft-tissue knee trauma. Multiple previous knee surgeries appear to serve as an independent factor in the selection of costlier implants irrespective of preoperative diagnosis.

Associations between cartilage proteoglycan density and patient outcomes 12months following anterior cruciate ligament reconstruction

BACKGROUND

Lower proteoglycan density (PGD) of the articular cartilage may be an early marker of osteoarthritis following anterior cruciate ligament (ACL) reconstruction (ACL-R). The purpose this study was to determine associations between the Knee Injury and Osteoarthritis Outcomes Score (KOOS) and PGD of the articular cartilage in the femur and tibia 12-months following ACL-R.

METHODS

We evaluated KOOS pain, symptoms, function in activities of daily living (ADL), function in sport and recreation (Sport), and quality of life (QOL), as well as PGD using T1rho magnetic resonance imaging in 18 individuals 12.50±0.70months (these are all mean±standard deviation) following unilateral ACL-R (10 females, eight males; 22.39±4.19years; Marx Score=10.93±3.33). Medial and lateral load-bearing portions of the femoral and tibial condyles were sectioned into three (anterior, central and posterior) regions of interest (ROIs). T1rho relaxation times in the ACL-R knee were normalized to the same regions of interest in the non-surgical knees. Alpha levels were set at P≤0.05.

RESULTS

Worse KOOS outcomes were significantly associated with greater T1rho relaxation time ratios in the posterior-lateral femoral condyle [pain (r=-0.54), ADL (r=-0.56), Sport (r=-0.62) and QOL (r=-0.59)] central-lateral femoral condyle [Sport (r=-0.48) and QOL (r=-0.42)], and the anterior-medial femoral condyle [Sport (r=-0.46) and QOL (r=-0.40)]. There were no significant associations between the KOOS and T1rho outcomes for tibial ROI.

CONCLUSIONS

Lower PGD of the femoral cartilage in the ACL-R knees was associated with worse patient-reported outcomes.

Biochemical markers of cartilage metabolism are associated with walking biomechanics 6-months following anterior cruciate ligament reconstruction

The purpose of our study was to determine the association between biomechanical outcomes of walking gait (peak vertical ground reaction force [vGRF], vGRF loading rate [vGRF-LR], and knee adduction moment [KAM]) 6 months following anterior cruciate ligament reconstruction (ACLR) and biochemical markers of serum type-II collagen turnover (collagen type-II cleavage product to collagen type-II C-propeptide [C2C:CPII]), plasma degenerative enzymes (matrix metalloproteinase-3 [MMP-3]), and a pro-inflammatory cytokine (interleukin-6 [IL-6]). Biochemical markers were evaluated within the first 2 weeks (6.5 ± 3.8 days) following ACL injury and again 6 months following ACLR in eighteen participants. All peak biomechanical outcomes were extracted from the first 50% of the stance phase of walking gait during a 6-month follow-up exam. Limb symmetry indices (LSI) were used to normalize the biomechanical outcomes in the ACLR limb to that of the contralateral limb (ACLR/contralateral). Bivariate correlations were used to assess associations between biomechanical and biochemical outcomes. Greater plasma MMP-3 concentrations after ACL injury and at the 6-month follow-up exam were associated with lesser KAM LSI. Lesser KAM was associated with greater plasma IL-6 at the 6-month follow-up exam. Similarly, lesser vGRF-LR LSI was associated with greater plasma MMP-3 concentrations at the 6-month follow-up exam. Lesser peak vGRF LSI was associated with higher C2C:CPII after ACL injury, yet this association was not significant after accounting for walking speed. Therefore, lesser biomechanical loading in the ACLR limb, compared to the contralateral limb, 6 months following ACLR may be related to deleterious joint tissue metabolism that could influence future cartilage breakdown. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2288-2297, 2017.

Increased risk of early and medium-term revision after post-fracture total knee arthroplasty

Background and purpose - Total knee arthroplasty (TKA) due to posttraumatic fracture osteoarthritis (PTFA) may be associated with inferior prosthesis survival. This study is the first registry-based study solely addressing this issue. Both indications and predictors for revision were identified. Patients and methods - 52,518 primary TKAs performed between 1997 and 2013 were retrieved from the Danish Knee Arthroplasty Register (DKR). 1,421 TKAs were inserted due to PTFA and 51,097 due to primary osteoarthritis (OA). Short-term (< 1 year), medium-term (1-5 years), and long-term (> 5 years) implant survival were analyzed using Kaplan-Meier analysis and Cox regression after age stratification (< 50, 50-70, and >70 years). In addition, indications for revision and characteristics of TKA patients with subsequent revision were determined. Results - During the first 5 years, TKAs inserted due to PTFA had a higher risk of revision than OA (with adjusted hazard ratio ranging from 1.5 to 2.4 between age categories). After 5 years, no significant differences in the risk of revision were seen between the groups. Infection and aseptic loosening were the most common causes of revision in both groups, but TKA instability was a more frequent indication for revision in the PTFA group. In both groups, the revision rates were higher with younger age and extended duration of primary surgery. Interpretation - We found an increased risk of early and medium-term revision of TKAs inserted due to previous fractures in the distal femur and/or proximal tibia. Predictors of revision such as age <50 years and extended duration of primary surgery were identified, and revision due to instability occurred more frequently in TKAs performed due to previous fractures.

Knee replacement in chronic post-traumatic cases

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

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

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

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

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

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

History of previous knee surgery does not affect the clinical outcomes of primary total knee arthroplasty in an Asian population

BACKGROUND

Patients with a history of previous knee surgeries, such as anterior cruciate ligament reconstruction (ACLR) and high tibial osteotomy (HTO), often have a higher likelihood of requiring a subsequent total knee arthroplasty (TKA). However, there is relatively limited data, especially in the Asian population, on how previous knee surgery could affect the clinical outcomes of TKA. Therefore, this study aims to evaluate the impact of previous knee surgeries on the clinical outcomes of future TKA.

METHODS

We reviewed the prospectively-collected data of 303 patients who underwent TKA by a single surgeon from a total joint registry of a tertiary hospital over a period of 5 years. Those with a history of previous knee surgery were identified. The SF-36 Health Survey, Oxford Knee Score (OKS) and Knee Society Score (KSS) were used to evaluate clinical outcomes pre-operatively, at 6 months and 2 years.

RESULTS

Previous knee surgery did not have a significant impact on the patients' pre-operative baseline clinical scores and body mass index (BMI). Patients with a history of knee surgery undergo TKA at a significantly younger age (mean of 6.6 years younger). On follow-up, patients with a history of knee surgery have similar post-operative outcome scores as those without previous knee surgery. Also, a high proportion of these patients are satisfied with their post-operative results and feel that their expectations have been met.

CONCLUSIONS

Patients with previous knee surgery had TKA at a significantly younger age than those without. But these patients have similar clinical and quality of life outcomes after TKA. In addition, a high proportion of these patients are satisfied with the results of surgery and feel that their expectations of TKA are met. This is important for clinicians when counselling patients pre-operatively.

[Posttraumatic deformities of the knee joint : Intra-articular osteotomy after malreduction of tibial head fractures]

Malreduction of tibial head fractures often leads to malalignment of the lower extremity, pain, limited range of motion and instability. The extent of the complaints and the degree of deformity requires an exact analysis and a standardized approach. True ligamentous instability should be distinguished from pseudoinstability of the joint. Also extra- and intra-articular deformities have to be differentiated. In intra-articular deformities the extent of articular surface displacement, defects and clefts must be accurately evaluated. A specific surgical approach is necessary, which allows adequate visualization, correct osteotomy and refixation of the fractured area of the tibial head. In the long-term course good clinical results are described for intra-articular osteotomies. If the joint is damaged to such an extent that it cannot be reconstructed or in cases of advanced posttraumatic osteoarthritis, total knee arthroplasty may be necessary; however, whenever possible and reasonable, anatomical reconstruction and preservation of the joint should be attempted.

Distal Femoral Replacement for Acute Distal Femoral Fractures in Elderly Patients

OBJECTIVES

To evaluate outcomes and complications using cemented modular distal femoral replacement in elderly patients with distal femoral fractures.

DESIGN

Retrospective chart review, case series.

SETTING

A Level 1 and Level 2 trauma center, both tertiary referral hospitals.

PATIENTS/PARTICIPANTS

Eighteen patients older than 60 years (average age 77 years) who had cemented distal femoral replacement for distal femoral fractures (comminuted, intraarticular, osteoporotic, arthritic) between 2005 and 2013. Patients with previous knee surgery were excluded.

INTERVENTION

Cemented modular distal femoral replacement.

MAIN OUTCOME MEASURES

Implant status, complications, Knee Society Score, Musculoskeletal Tumor Society score, and Western Ontario and McMaster Osteoarthritis Index.

RESULTS

All patients were extremely or very satisfied with their outcomes. For patients with functional outcome data, Knee Society Score averaged 85.7 with a functional score of 35, Musculoskeletal Tumor Society score averaged 19.2, and Western Ontario and McMaster Osteoarthritis Index score averaged 23.1 at an average follow-up of 2.3 years. Range of motion was 1-99 degrees. Implant-related complications occurred in 2 patients (11%); one required revision to total femoral replacement because of periprosthetic fracture and the other had a deep infection that required exchange of the components. No patient had aseptic loosening or patellar maltracking. There were no perioperative deaths or late amputations.

CONCLUSIONS

Cemented modular distal femoral replacement is a viable treatment option in elderly patients that permits immediate full weight-bearing, with most patients returning to preoperative functional status.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification?

BACKGROUND

Total knee arthroplasty (TKA) is often the best answer for end-stage, posttraumatic osteoarthritis after intra-articular and periarticular fractures about the knee. Although TKA in this setting is often considered more technically demanding, outcomes are typically worse for patients. This study examines the intraoperative differences and 30-day outcomes in posttraumatic vs primary TKA cohorts.

METHODS

Patients undergoing TKA were selected from the National Surgical Quality Improvement Program database from 2010 to 2013. Patients were stratified on the basis of concurrent procedures and administrative codes indicating posttraumatic diagnoses. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether posttraumatic arthritis was a risk factor for poor outcomes.

RESULTS

A total of 67,675 primary and 674 posttraumatic TKAs were identified. Posttraumatic TKA patients were on average younger and healthier than the primary TKA population. The posttraumatic TKA group had higher rates of superficial surgical site infections and bleeding requiring transfusion. History of posttraumatic knee osteoarthritis was found to be an independent risk factor for prolonged operative time, increased length of hospital stay, and 30-day hospital readmission.

CONCLUSION

We have demonstrated increased intraoperative times, heightened transfusion requirements and surgical site infections, and higher readmission rates after conversion TKA in the posttraumatic cohort. In contrast to total hip arthroplasty, current diagnosis and reimbursement schemes do not differentiate posttraumatic patients from primary osteoarthritis groups undergoing TKA. We believe that classification reform would improve medical documentation and improve patient care.

Certified Athletic Trainers' Knowledge and Perceptions of Posttraumatic Osteoarthritis After Knee Injury

CONTEXT

  Posttraumatic osteoarthritis (PTOA) is a specific phenotype of osteoarthritis (OA) that commonly develops after acute knee injury, such as anterior cruciate ligament (ACL) or meniscal injury (or both). Athletic trainers (ATs) are well positioned to educate patients and begin PTOA management during rehabilitation of the acute injury, yet it remains unknown if ATs currently prioritize long-term outcomes in patients with knee injury.

OBJECTIVE

  To investigate ATs' knowledge and perceptions of OA and its treatment after ACL injury, ACL reconstruction, or meniscal injury or surgery.

DESIGN

  Cross-sectional study.

PATIENTS OR OTHER PARTICIPANTS

  An online survey was administered to 2000 randomly sampled certified ATs. We assessed participants' perceptions of knee OA, the risk of PTOA after ACL or meniscal injury or surgery, and therapeutic management of knee OA.

RESULTS

  Of the 437 ATs who responded (21.9%), the majority (84.7%) correctly identified the definition of OA, and 60.3% indicated that they were aware of PTOA. A high percentage of ATs selected full meniscectomy (98.9%), meniscal tear (95.4%), ACL injury (90.2%), and partial meniscectomy (90.1%) as injuries that would increase the risk of developing OA. Athletic trainers rated undertaking strategies to prevent OA development in patients after ACL injury or reconstruction (73.8%) or meniscal injury or surgery (74.7%) as extremely or somewhat important. Explaining the risk of OA to patients with an ACL or meniscal injury was considered appropriate by 98.8% and 96.8% of respondents, respectively; yet a lower percentage reported that they actually explained these risks to patients after an ACL (70.8%) or meniscal injury (80.6%).

CONCLUSIONS

  Although 84.7% of ATs correctly identified the definition of OA, a lower percentage (60.3%) indicated awareness of PTOA. These results may reflect the need to guide ATs on how to educate patients regarding the long-term risks of ACL and meniscal injuries and how to implement strategies that may prevent PTOA.

TKA for Posttraumatic Osteoarthritis Is More Complex and Needs More Surgical Resources

The purpose of this study was to evaluate the surgical effort of total knee arthroplasty (TKA) for posttraumatic osteoarthritis (PTOA) compared with primary osteoarthritis (OA). A total of 1841 TKAs were analyzed, including 170 patients with PTOA, that resulted from soft tissue trauma in 83 patients and fractures in 87 patients. Results showed that patients were significantly younger at the time of surgery in the posttraumatic group (62 vs 71 years; P<.001). Furthermore, fracture was associated with 3.7 years earlier need of TKA compared with soft tissue trauma. Operation time was significantly longer for both of the posttraumatic groups compared with OA (P<.001). Patients undergoing TKA after knee injuries are younger and surgical treatment is more challenging compared with TKA for OA. Extended operation time and implant systems with higher constraint and modular options are required. [Orthopedics. 2016; 39(3):S36-S40.].

Women and Minorities Are at Risk of Developing Unexpected Reduction of Preoperative Flexion After Total Knee Arthroplasty

BACKGROUND

Reduced flexion after total knee arthroplasty (TKA) compared to the preoperative values can affect patient's activities of daily living and lead to patient dissatisfaction. The aim of this study was to determine preoperative risk factors for developing a decrease in knee flexion after a primary TKA.

METHODS

We identified 37 knees diagnosed with osteoarthritis with a preoperative knee flexion ≥120° but a 12-month postoperative range of motion (ROM) ≤110°. A random sample of 111 patients (1:3) from the same database, whose knees had a preoperative and 12-month postoperative ROM ≥120°, based on a diagnosis of primary osteoarthritis and no previous open knee surgery, were selected as the controls.

RESULTS

We found female gender, black ethnicity, and the low preoperative knee-specific Knee Society Score to be significant risk factors for developing a reduction of knee flexion after TKA with odds ratios of 3.48, 5.11, and 0.95, respectively.

CONCLUSION

In the absence of the well-recognized preoperative risk factors for a limited postoperative ROM, female patients, minorities, and those with lower knee-specific Knee Society Scores are at an increased risk of developing a decrease in flexion after an elective primary TKA.

Posttraumatic Total Knee Arthroplasty Continues to Have Worse Outcome Than Total Knee Arthroplasty for Osteoarthritis

Small studies have shown that patients who undergo TKA following a distal femur and/or tibial plateau fracture have inferior results. The purpose of this study was to evaluate the mid-term outcomes of a large group of patients undergoing TKA following periarticular knee fractures. We identified 531 patients who underwent a TKA following a periarticular fracture from 1990 to 2012; comparing outcomes to 19,641 patients undergoing primary TKA for osteoarthritis. Periarticular fracture significantly increased the risk of revision TKA, infection and complications. There was no difference in the need for revision TKA or infection based on fracture location. Patients with TKA following a periarticular fracture have worse overall revision free survival compared to with OA, with 1 in 4 patients requiring revision TKA by 15 years.

Outcomes after Total Knee Arthroplasty for post-traumatic arthritis

INTRODUCTION

Total Knee Arthroplasty (TKA) is an important treatment for posttraumatic arthritis (PTA), but evidence on outcomes is sparse. The purpose of this study was to evaluate the impact of PTA versus primary osteoarthritis (OA) on postoperative outcomes after TKA.

METHODS

We queried the entire Medicare database from 2005 to 2012. International Classification of Diseases, 9th revision and Current Procedural Terminology codes were used to identify the procedure, indication, and complications. Patients with minimum two-years follow-up were selected. Odds ratios (ORs), confidence intervals, and p-values (p) were calculated.

RESULTS

For PTA, 3509 patients had TKA. For OA, 257,611 patients with TKA served as controls. The average Charlson Comorbidity Index for both groups was five. PTA patients were younger; only eight out of 29 Elixhauser comorbidities were higher. PTA patients had higher incidence of periprosthetic infection (OR 1.72, p<0.001), cellulitis or seroma (OR 1.19, p<0.001), knee wound complications (OR 1.80, p<0.001), TKA revision (OR 1.23, p=0.01), and arthrotomy/incision and drainage (OR 1.55, p<0.001). Blood transfusion rate was lower in PTA patients. There were no significant differences in bleeding complications, prosthetic dislocation, broken prostheses, periprosthetic fracture, osteolysis and polywear, neurovascular injury, and extensor mechanism rupture.

DISCUSSION AND CONCLUSION

This study represents, to our knowledge, TKA outcomes in the largest cohort of PTA patients to date. Our findings indicate that these patients are at higher risk for many, but not all, postoperative surgical complications despite being as healthy as patients receiving TKA for primary OA.

Total Knee Arthroplasty in Patients With a Prior Tibial Plateau Fracture: A Long-Term Report at 15 Years

The goal of the current study was to determine the 15-year outcomes of 62 patients who underwent a total knee arthroplasty (TKA) after a prior tibial plateau fracture. Mean age at the index surgical intervention was 63 years. At most recent followup, there were 11 revisions. The 15-year survivorship free from revision for aseptic loosening was 96%. In unrevised cases, the components were radiographically well-fixed. There were a total of 21 complications, 90% of which occurred at <2 years. While patients undergoing TKA after a tibial plateau fracture have an increased rate of complications, the 15-year results indicate that subsequent survivorship is similar to that of patients undergoing TKA for degenerative arthritis if early complications can be avoided.

Patella Fractures Prior to Total Knee Arthroplasty: Worse Outcomes but Equivalent Survivorship

Distal femur and/or tibial plateau fractures adversely affect outcomes of TKA; however it is unknown if a previous patella fracture affects outcome. We reviewed 113 patients undergoing TKA with a previous patella fracture from 1990 to 2012. Component survival was compared to 19,641 patients undergoing TKA for osteoarthritis during the same period. The 15-year implant survivals following a previous patella fracture was 86%. There was no difference in implant survival compared to patients undergoing TKA for OA (P=0.31). Knee society scores significantly improved following TKA; however patients with a fracture had complications related to knee flexion. Patients undergoing primary TKA following a patella fracture have similar overall revision free survival compared to those undergoing TKA for OA at 15-years.

Total Knee Arthroplasty for Osteoarthritis Secondary to Fracture of the Tibial Plateau. A Prospective Matched Cohort Study

A prospective matched cohort study was performed to compare outcomes of total knee arthroplasties (TKA) between 29 patients with posttraumatic osteoarthritis (POA) after a fracture of tibial plateau and 58 patients underwent routine TKA. Mean follow-up was 6.7 years. There were no significant differences in KSS, WOMAC, SF12 scores or range of motion. In the control group there were no complications. In the posttraumatic group, complications occurred in 4 patients (13.7%) (P=0.010) including partial patellar tendon detachment, superficial infection, skin necrosis, and knee stiffness. Only this last patient required revision for manipulation under anesthesia. Also, there was a revision for tibial aseptic loosening in each group. TKA is an effective treatment for POA after tibial plateau fracture. We recommend the prior removal of hardware, as well as tibial tubercle osteotomy when necessary.

Knee megaprosthesis: a salvage solution for severe open and complex distal femoral fracture associated with an ipsilateral brachial plexus injury (a case report with literature review)

Complex distal femoral fractures in the young patient often occur as a result of high velocity trauma. Timely recognition and treatment is everything in such a situation, and it needs a robust staged management pathway to optimize the chance of limb preservation. We report a case of a motorcyclist admitted to the department of orthopedics at Chambery hospital, France, with a complex comminuted and open distal femoral fracture of the left leg, associated with a brachial plexus injury to the ipsilateral upper limb. On arrival to the emergency department, damage control stabilization and surgery was commenced, debridement of contaminated non-viable tissue, abundant antiseptic lavage and application of external fixation coupled with the use of antibiotic spacer. Following normalization of inflammatory markers and ensuring no clinical signs of infection, subsequent management consisted of joint reconstruction to achieve a functional knee. The external fixator and femoral spacer was removed and a modular megaprosthesis was implanted with a lateral gastrocnemius flap to cover the exposed knee joint and reinforce the extensor apparatus. Nerve graft to the left brachial plexus injury was performed at University Hospital of Grenoble. Our patient entered an intensive rehabilitation program and at 1 year follow-up achieved good knee function and sensation to the left upper limb.

Total knee arthroplasty following tibial plateau fracture: a matched cohort study

Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer. The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis. Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score. Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437). Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable. Cite this article: Bone Joint J 2015;97-B:532-8.

Lower function, quality of life, and survival rate after total knee arthroplasty for posttraumatic arthritis than for primary arthritis

BACKGROUND AND PURPOSE

Total knee arthroplasty (TKA) for treatment of end-stage posttraumatic arthritis (PTA) has specific technical difficulties and complications. We compared clinical outcome, postoperative quality of life (QOL), and survivorship after TKA done for PTA with those after TKA performed for primary arthritis (PA).

PATIENTS AND METHODS

We retrospectively reviewed patients who were operated on at our institution for PTA between 1998 and 2005 (33 knees), and compared them to a matched group of patients who were operated on for PA during the same period (407 knees). Clinical outcomes and postoperative QOL were compared in the 2 groups using Knee Society score (KSS), range of motion (ROM) of the knee, and the knee osteoarthritis outcomes score (KOOS). Implant survival rate was calculated using Kaplan-Meier analysis.

RESULTS

At a mean follow-up of 11 (5-15) years, KSS knee increased from mean 39 (SD 18) to 87 (SD 16) in the PA group (p = 0.003), and from 31 (SD 11) to 77 (SD 15) in the PTA group (p = 0.003). KSS function increased from 55 (12) to 89 (25) in the PA group (p = 0.008) and from 44 (SD 14) to 81 (SD 10) in the PTA group (p = 0.008). Postoperative ROM also improved in both groups, from 83° to 108° in the PTA group (p < 0.001) as opposed to 116° to 127° in the PA group (p = 0.001), with lower results in the PTA group (p < 0.001). KOOS was lower in the PTA group (p < 0.001). The survival rate of TKA at 10 years with an endpoint defined as "any surgery on the operated knee" showed better results in the PA group (99%, CI: 98-100 vs. 79%, CI: 69-89; p < 0.001).

INTERPRETATION

Patients and surgeons should be aware that clinical outcome and implant survival after TKA for PTA are lower than after TKA done for PA.

Impaction bone grafting has potential as an adjunct to the surgical stabilisation of osteoporotic tibial plateau fractures: Early results of a case series

INTRODUCTION

Osteoporotic tibial plateau fractures (TPFs) are difficult to treat with either open reduction internal fixation (ORIF) or acute total knee arthroplasty (TKA). They have high complication rates, poor outcomes and often fail in the short- to mid-term. We investigated the use of impaction bone grafting (IBG) as an adjunct to stabilise the fracture in a cohort of osteoporotic TPFs.

METHODS

Nine consecutive osteoporotic TPFs were surgically stabilised with ORIF augmented with IBG or with IBG alone (one pure depression fracture) using on average allograft from 2 femoral heads/case (range 1-4 heads or 25-100 cm(3)). The median bone mineral density T-score of the patients was -2.9 (-2.5 to -4.5). All patients were mobilised weight-bearing as tolerated immediately after surgery and had regular follow-up to a minimum of 2 years where functional scores were taken and gait was assessed. Fracture reduction was assessed on plain radiographs and computed tomography (CT) scans; maintenance of fracture reduction was monitored using plain radiographs, CT and radiostereometric analysis (RSA). Bone graft remodelling was assessed by comparison of immediate post-operative CT scans with scans at a minimum of 1 year.

RESULTS

All surgeries were uneventful. All patients progressed to full weight bearing within 6 weeks of surgery and regained a normal gait by 3 months. Seven fractures healed with a cranio-caudal migration of less than 3mm (range 0-2.6mm using RSA and 0-2mm using CT). Two fractures had an isolated posterolateral fragment depression of 13.5mm and 9 mm, respectively, which did not affect the overall joint alignment or clinical outcomes at short-term follow-up. At latest CT follow-up, on average 51% of the graft area (range 36-70%) had remodelled into new host bone.

CONCLUSION

Impaction bone grafting shows promising results as an adjunct to the surgical stabilisation of osteoporotic TPFs. In this case series the technique provided enough fracture stability for patients to mobilise weight-bearing as tolerated immediately after surgery and achieve full weight-bearing by the sixth postoperative week. There was no failure of fixation and 7 of the 9 cases healed with minimal fracture displacement.

Joint instability and osteoarthritis

Joint instability creates a clinical and economic burden in the health care system. Injuries and disorders that directly damage the joint structure or lead to joint instability are highly associated with osteoarthritis (OA). Thus, understanding the physiology of joint stability and the mechanisms of joint instability-induced OA is of clinical significance. The first section of this review discusses the structure and function of major joint tissues, including periarticular muscles, which play a significant role in joint stability. Because the knee, ankle, and shoulder joints demonstrate a high incidence of ligament injury and joint instability, the second section summarizes the mechanisms of ligament injury-associated joint instability of these joints. The final section highlights the recent advances in the understanding of the mechanical and biological mechanisms of joint instability-induced OA. These advances may lead to new opportunities for clinical intervention in the prevention and early treatment of OA.

Total knee replacement in acute and chronic traumatic events

Total knee replacement (TKR) is a widely used procedure for the treatment of post-traumatic arthritis. This type of solution has also been used recently for the treatment of acute fractures around the knee, particularly in joints that were already arthritic before the trauma. The purpose of this paper is to present our experience with TKR in both acute and chronic traumatic events, highlighting the main problems associated with these conditions and focussing on the indications, principles of technique, tips, tricks and pitfalls of this procedure. The main issues related to post-traumatic arthritis and the problem of TKR in acute fractures are discussed, and our case series of both groups of patients is presented.

The role of cytokines in posttraumatic arthritis

The development of arthritis after joint injury is commonly known as posttraumatic arthritis (PTA). The inciting traumatic event may range from cartilage contusion and bone bruise combined with meniscus or ligament tear, to intra-articular fracture. End-stage PTA is often indistinguishable from primary osteoarthritis. However, knowing the time of the inciting traumatic event in a patient with PTA provides an opportunity to understand the events following joint injury that lead to the progression of arthritis. Joint injury often leads to mechanical alterations in loading of the injured joint, and restoration of joint mechanics through surgical repair remains an important aspect of treatment. However, the accuracy of joint reduction by itself does not account for the variability in outcome following joint injury, as evidenced by the fact that PTA remains a significant clinical problem. Emerging research in animal models and human subjects indicates that several inflammatory cytokines and related inflammatory mediators are elevated following joint injury. Data from animal studies and early clinical trials suggest that early inhibition of the intra-articular inflammatory response may improve clinical outcomes.

The predictors of outcome in total knee arthroplasty for post-traumatic arthritis

BACKGROUND

The outcomes of total knee arthroplasty (TKA) for post-traumatic arthritis are less reliable than for idiopathic osteoarthritis. These patients tend to be younger, present with varying degrees of deformity, and often have a history of prior surgery, resulting in a wide spectrum of pathology. We hypothesized that preoperative variables, in particular the location of deformity, would predict pain and functional outcomes.

METHODS

The outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 47 knees treated at our institution. All patients were administered the Knee Society Score (KSS) preoperatively and at follow-up (mean 52months, range 16 to 124). We classified the defects into four categories: intra-articular, metaphyseal, diaphyseal, and combined femoral and tibial deformities.

RESULTS

There was a significant improvement in KSS scores for pain (p<0.0001) and a trend toward higher function (p=0.06) comparing preoperative scores to final follow-up. The largest improvements in pain and functional scores were in patients with isolated articular deformities, while patients with combined tibial and femoral deformities did not have significant improvements in pain or function. Soft-tissue defects requiring flap coverage were associated with worsening in the pain score (p=0.027).

CONCLUSIONS

The location of post-traumatic deformity and compromise of the soft-tissue envelope influence the pain and functional outcomes of total knee arthroplasty for post-traumatic arthritis. Specifically, isolated articular deformities have the largest improvement in pain and function while patients with combined tibial and femoral deformities as well as patients with soft-tissue compromise experience poor outcomes.

LEVEL OF EVIDENCE

IV-Retrospective Case Series.

Total knee arthroplasty in patients with excessive external tibial torsion >45° and patella instability--surgical technique and follow up

Patients presenting with advanced knee osteoarthritis (OA), excessive external tibial torsion (EETT) and chronic patella subluxation pose significant surgical challenges. A combination of TKA, tibial derotation osteotomy, and tibial tuberosity transfer was performed in ten patients (twelve knees) with OA secondary to EETT and patellar instability. Six weeks of non weight-bearing and flexion limited to 45° was mandated after surgery. The mean follow-up and patient age was 81months (range, 14 to 159) and 56years (range, 49 to 62). The mean pre-operative external tibial torsion was 62°, with an average rotational correction of 30°. Significant improvement was found in the Knee Society Score, SF-12 and all WOMAC questionnaire score subscales (p<0.0001); 5 patients had complications, but no loosening or nonunion was seen.

One-stage procedure for total knee arthroplasty in post-traumatic osteoarthritis of the knee with wound defect. Usefulness of navigation and flap surgery

Total knee arthroplasty in post-traumatic arthritis of the knee joint is a challenging situation. Difficulties are linked to malalignment, joint stiffness, or wound complications. The authors report on a case of post-traumatic intra-articular knee arthritis with tibial malalignment and a skin defect. Using computer-assisted surgery for implant positioning, and simultaneous pedicled flap surgery for wound coverage, IKS score at 2 years follow-up was 85 and 75 for clinical and function respectively. The results of total knee replacement in post-traumatic knee arthritis are not as satisfactory as in degenerative situations. In severe malalignment due to bone landmark changes following malunions, computer-assisted surgery gives immediate correct references for final positioning of implants and restoration of limb alignment. Implant selection must allow use of normal and revision components to fit the local anatomy. Commonly-used pedicle flaps such as the gastrocnemius flap are valuable to cover wound defects after prosthesis implantation. All these procedures can be used successfully in a one-stage surgical procedure.

The operative management of osteoporotic fractures of the knee

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.