An exploratory study of the long-term impact of difficulty kneeling after total knee replacement

The efficacy of patellar denervation on prognosis and kneeling capacity after unicompartmental knee arthroplasty: a randomized clinical trial

OBJECTIVE

The aim of this study was to investigate the effect of patellar denervation (PD) on pain, function and ability to kneel after unicompartmental knee arthroplasty (UKA).

METHODS

Patients with medial knee osteoarthritis who underwent UKA were prospectively selected. Patients were randomly divided into PD and non-PD groups based on whether patellar denervation was performed. Clinical assessment was performed using the Hospital for Special Surgery (HSS) knee score, Kujiala score, visual analogue scale (VAS) and forgotten joint score (FJS-12), as well as postoperative complications were recorded. The patients' postoperative self-perception and actual ability to perform different kneeling positions were assessed in the two groups.

RESULTS

UKA patients treated with PD achieved better Kujiala scores and FJS-12 scores, reduced anterior knee pain and improved kneeling ability postoperatively, validating the effectiveness of PD in UKA. Perception and actual performance of kneeling remained mismatched in PD patients, but performance during different kneeling activities was generally better than in non-PD patients.

TRIAL REGISTRATION

Clinical Trial Registration: ChiCTR1900025669.

CONCLUSION

Patellar denervation can safely and effectively improve patellofemoral joint function, pain and kneeling ability in the early postoperative period after UKA.

Skin sensory alteration and kneeling ability following cruciate retaining total knee arthroplasty are not affected by the incision position: A randomised controlled trial of simultaneous bilateral surgery

PURPOSE

The purpose of this randomised controlled trial was to assess the impact of skin incision location on the patients' ability to kneel.

METHODS

A total of 29 patients undergoing bilateral total knee arthroplasty (58 knees) were randomised to receive a lateral or midline incision, with the contralateral limb receiving the alternative option. Cruciate retaining implants were used in all cases by three experienced arthroplasty surgeons. The primary outcome measures assessed functional ability to kneel using an innovative five-point kneeling scale, preferred knee to kneel on and the area of cutaneous sensory loss around the incision at 6 weeks, 6 months and 12 months. Secondary outcome measures were the OKS, KOOS JR, FJS and EQ5D patient reported outcome measures (PROMS), length of surgical scar, overall knee preference and range of motion (ROM).

RESULTS

There were no significant differences between the two groups for any primary or secondary outcome measures. Flexion range however, had a significant positive correlation with kneeling score (r = 0.335, p = 0.010). The kneeling score increased at each time point after surgery and was significantly greater at 12 months than preoperatively (2.7 v 3.5, p = 0.015). The area of sensory loss lateral to the incision was significantly less at 6 and 12 months than at 6 weeks (43.6cm2 and 40.1cm2 v 84.1cm2, p < 0.0001).

CONCLUSION

The ability to kneel following cruciate retaining total knee arthroplasty is not affected by the incision position but by time and flexion range. TKA improves the ability to kneel by 12 months post-surgery. Sensory loss lateral to the incision reduces with time.

LEVEL OF EVIDENCE

Therapeutic Level 2.

Patellar resurfacing and kneeling ability after total knee arthroplasty: a systematic review

BACKGROUND

Difficulty kneeling following total knee arthroplasty (TKA) remains highly prevalent, and has cultural, social, and occupational implications. With no clear evidence of superiority, whether or not to resurface the patella remains debatable. This systematic review examined whether resurfacing the patella (PR) or not (NPR) influences kneeling ability following TKA.

METHODS

This systematic review was conducted by following PRISMA guidelines. Three electronic databases were searched utilizing a search strategy developed with the aid of a department librarian. Study quality was assessed using MINROS criteria. Article screening, methodological quality assessment and data extraction were performed by two independent authors, and a third senior author was consulted if consensus was not reached.

RESULTS

A total of 459 records were identified, with eight studies included in the final analysis, and all deemed to be level III evidence. The average MINORS score was 16.5 for comparative studies and 10.5 for non-comparative studies. The total number of patients was 24,342, with a mean age of 67.6 years. Kneeling ability was predominantly measured as a patient-reported outcome measure (PROM), with two studies also including an objective assessment. Two studies demonstrated a statistically significant link between PR and kneeling, with one demonstrating improved kneeling ability with PR and the other reporting the opposite. Other potential factors associated with kneeling included gender, postoperative flexion, and body mass index (BMI). Re-operation rates were significantly higher in the NPR cohort whereas PR cohorts had higher Feller scores, patient-reported limp and patellar apprehension.

CONCLUSION

Despite its importance to patients, kneeling remains not only under-reported but also ill-defined in the literature, with no clear consensus regarding the optimum outcome assessment tool. Conflicting evidence remains as to whether PR influences kneeling ability, and to clarify the situation, large prospective randomized studies are required.

The Effect of a Multidimensional Home Rehabilitation Program for Post-Total Knee Arthroplasty Elderly Patients

Patients with total knee arthroplasty (TKA) experience pain, decreased muscle strength, and decreased knee function, resulting in increases in depression and decreased subjective well-being. A multidimensional home program may prevent these adverse events. The aim of this study was to test the effect of a home rehabilitation program that included education, exercise, aroma massage, and phone counseling for post-TKA patients. We used a randomized control group pretest/posttest design. Fifty-nine patients participated, with 29 in the experimental group and 30 in the control group. Pain, knee joint range of motion (ROM), quadriceps strength, depression, and subjective well-being were measured as outcome variables. Data were analyzed using repeated-measures analysis of variance and generalized estimating equations. The experimental group showed significant improvement in knee pain, active ROM, muscle strength, depression, and subjective well-being with no significant between-groups difference in passive ROM. The multidimensional home rehabilitation program can be an effective nursing intervention for physical and emotional recovery of patients with TKA.

Patient perspectives of pain and function after knee replacement: a systematic review and meta-synthesis of qualitative studies

Introduction

Joint replacement surgery typically results in good clinical outcome, although some people experience suboptimal pain relief and functional improvement. Predicting surgical outcome is difficult.

Objectives

There is merit in better understanding patients' perspectives of pain and function to identify avoidable problems perceived to contribute to their outcome, to inform prognostic expectations, and to identify potential cointerventions to sit alongside surgery that might mitigate pain/functional problems. Here, we aimed to synthesise the available literature exploring perspectives of people with knee osteoarthritis about their pain and function following joint replacement.

Methods

Six electronic databases and 2 websites were searched. Two independent reviewers completed study inclusion, quality assessment, and data extraction. Data were iteratively synthesised using first-, second-, and third-order analyses.

Results

Twenty-eight studies were included. Four themes were identified; perceptions of pain and function were inseparable. Theme 1 addressed experiences of recovery after surgery, which often differed from expectations. Theme 2 described the challenges of the pain experience and its functional impact, including the difficulty navigating medication use in context of personal beliefs and perceived stigma. Theme 3 articulated the toll of ongoing problems spanning pain-function-mood, necessitating the need to "endure." Theme 4 encompassed the importance of clinical/social interactions on mood and pain, with reports of concerns dismissed and practical support missing.

Conclusions

Together, these findings show that numerous individual considerations beyond the technical aspects of surgery influence experiences of pain and function. A tailored approach addressing these considerations from the patient perspective could provide a basis for improved success of knee replacement surgery.

Surgery-related predictors of kneeling ability following total knee arthroplasty: a systematic review and meta-analysis

Purpose

Kneeling ability is among the poorest outcomes following total knee arthroplasty (TKA). The purpose of this meta-analysis was to: (1) quantify kneeling ability after TKA; (2) identify surgical approaches and prosthesis designs that improve kneeling ability following TKA; and (3) quantify the effectiveness of these approaches.

Methods

We performed a systematic review in accordance with the PRISMA guidelines of multiple medical databases. Data relating to demographics, TKA technique, prosthesis design, and kneeling-specific outcomes were extracted. Comparative outcomes data were pooled using a random effects model.

Results

Thirty-six studies met the eligibility criteria. The proportion of patients able to kneel increased with longer follow-up (36.8% at a minimum of 1 year follow-up versus 47.6% after a minimum of 3 years follow-up, p < 0.001). The odds of kneeling were greater for patients undergoing an anterolateral incision compared with an anteromedial incision (OR 3.0, 95% CI 1.3–6.9, p = 0.02); a transverse incision compared with a longitudinal incision (OR 3.5, 95% CI 1.4–8.7, p = 0.008); and a shorter incision compared with a longer incision (OR 8.5, 95% CI 2.3–30.9, p = 0.001). The odds of kneeling were worse for a mobile prosthesis compared with a fixed platform design (OR 0.3, 95% CI 0.1–0.7, p = 0.005).

Conclusion

A large majority of patients are unable to kneel following TKA, although the ability to kneel improves over time. This evidence may facilitate preoperative patient counseling. Variations in choice of incision location and length may affect ability to kneel; however, high-quality randomized trials are needed to corroborate our findings.

Unicompartmental knee arthroplasty combined with high tibial osteotomy in anteromedial osteoarthritis: A case report

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Anteromedial osteoarthritis is a common knee pathology.

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Spontaneous osteonecrosis of the knee causing anteromedial osteoarthritis can be treated with different surgical options.

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Although high tibial osteotomy and unicompartmental knee arthroplasty are alternative treatments for anteromedial osteoarthritis, successful results can be obtained using both in individual cases.

Introduction and importance

Anteromedial osteoarthritis (AMOA) is a common knee pathology. However, the best treatment of AMOA remains unclear. Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are surgical options for AMOA patients who do not benefit from conservative treatment. We aimed to show an unusual treatment option where UKA and HTO are performed simultaneously.

Case presentation

We present a 52-year-old man with AMOA secondary to spontaneous osteonecrosis of the knee (SONK) and metaphyseal tibial varus malalignment, who was successfully treated with a combined UKA and HTO. His functional scores were excellent at the 5-year follow-up.

Clinical discussion

Advanced SONK that causes AMOA can be treated with osteochondral autograft transplantation (OAT), HTO, UKA, or total knee arthroplasty (TKA). Although good results have been reported selecting appropriate patients for all of these methods, the best treatment method remains unclear.

Conclusion

Although HTO and UKA are alternative treatments for AMOA, successful results can be obtained using both in individual cases.

Body-Self Unity With a New Hip or Knee: Understanding Total Joint Replacement Within an Embodiment Framework

Medical research increasingly makes use of embodiment concepts to understand how illness disrupts unity of body and self. However, few have applied embodiment concepts in total joint replacement (TJR), an effective treatment for end‐stage arthritis. In considering why a troubling proportion of TJR recipients have continued pain and functional limitation, we ask: what role might be played by the embodied experience of living with an implant? Relevant theoretical models and prior research on embodiment in musculoskeletal health and transplantation are reviewed. Our findings suggest a research agenda with implications for addressing suboptimal outcomes in TJR.

Kneeling ability after total knee replacement

Kneeling ability is consistently the poorest patient-rated outcome after total knee replacement (TKR), with 60-80% of patients reporting difficulty kneeling or an inability to kneel.Difficulty kneeling impacts on many activities and areas of life, including activities of daily living, self-care, leisure and social activities, religious activities, employment and getting up after a fall. Given the wide range of activities that involve kneeling, and the expectation that this will be improved with surgery, problems kneeling after TKR are a source of dissatisfaction and disappointment for many patients.Research has found that there is no association between range of motion and self-reported kneeling ability. More research is needed to understand if and how surgical factors contribute to difficulty kneeling after TKR.Discrepancies between patients' self-reported ability to kneel and observed ability suggests that patients can kneel but elect not to. Reasons for this are multifactorial, including knee pain/discomfort, numbness, fear of harming the prosthesis, co-morbidities and recommendations from health professionals. There is currently no evidence that there is any clinical reason why patients should not kneel on their replaced knee, and reasons for not kneeling could be addressed through education and rehabilitation.There has been little research to evaluate the provision of healthcare services and interventions for patients who find kneeling problematic after TKR. Increased clinical awareness of this poor outcome and research to inform the provision of services is needed to improve patient care and allow patients to return to this important activity. Cite this article: EFORT Open Rev 2019;4:460-467. DOI: 10.1302/2058-5241.4.180085.

Delivery systems of local anesthetics in bone surgery: are they efficient and safe?

Management of postoperative pain following bone surgery includes administration of local anesthetics (LAs). Smart delivery systems, including triggered systems, have been designed to provide a continuous release of LA in situ. However, these systems can provide a high level of LA locally. This review will examine the state-of-the-art regarding the LA delivery systems optimized for management of postoperative pain in bone surgery and will discuss the potential adverse effects of LAs on the overall pathways of bone healing, including the inflammation response phase, hemostasis phase, tissue repair phase and remodeling phase. There is a clinical need to document these effects and the potential impacts on the clinical outcome of the patient.