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

Incidence and risk of remnant gastric cancer after gastrectomy for gastric cancer: a population-based study from the SEER database

BACKGROUND

Gastric cancer (GC) constitutes a major global health problem, of which remnant gastric cancer (RGC) occurs less frequently. The rate of RGCs after gastrectomy for GC is increasing recently due to improved survival and screening, however, their incidence and risk have not been reported in the U.S.

POPULATION

The objective of this study was to evaluate the incidence and elevated risk of RGC after GC gastrectomy in this population, and to identify the risk factors.

METHODS

Patients underwent gastrectomy for first primary GC in 2000-2015 and those who developed RGC were identified from Surveillance, Epidemiology and End Results (SEER) database. Fine-Gray regression was used to estimate the cumulative incidence and to identify risk factors. Standardized incidence ratios (SIRs) were calculated by Poisson regression to compare the risk with the general population.

RESULTS

Among 21,566 patients included in the cohort, 227 developed RGC. The 20-year cumulative incidence of RGC was 1.88%. Multivariate analysis revealed that older age, invasion depth, male sex, marital status, and lower income are independent risk factors for RGC development. SIR was 7.70 overall and > 4.5 in each stratum.

CONCLUSIONS

Cumulative incidence and risk for RGCs increased continuously in patients underwent GC gastrectomy. Close and lifelong endoscopy surveillance should be recommended for patients who received GC gastrectomy, especially those with high-risk factors.

Successful Total Knee Arthroplasty for Hoffa and Proximal Tibial Fractures: Report of Three Complex Cases After Failed Osteosynthesis Procedures

BACKGROUND Distal femoral and proximal tibial fractures often lead to nonunion and post-traumatic osteoarthritis, and total knee arthroplasty (TKA) has emerged as an effective alternative for older patients. This report includes 3 cases of successful TKA treatment. The cases involve a 42-year-old man and a 62-year-old man with Hoffa coronal fractures of the distal femur, and a 50-year-old man with a proximal tibial fracture. These patients underwent multiple osteosynthesis procedures before receiving TKA. CASE REPORT Case 1: A 42-year-old man with a displaced Hoffa's fracture had persistent knee pain. Nonunion post-initial fixation led to reoperation with iliac bone grafting and plate fixation. TKA using a Posterior Stabilized (PS)-type implant resulted in improved motion and function after 3 years. Case 2: A 62-year-old man suffered lateral condyle and ligament injuries from a displaced Hoffa's fracture. Despite plate fixation, dislocation occurred, requiring conversion. TKA with long-stem hinge-type implant, using augmentation block, led to enhanced stability and outcomes at 2 years. Case 3: A 50-year-old man's tibial nonunion, treated with plate fixation, resulted in infection and bone fusion. TKA using a constrained PS-type implant insert addressed the lateral tibial adhesions via iliotibial band (ITB) release and treated severe tibial plateau damage. Positive results were seen at 1 year. CONCLUSIONS The challenges of pseudarthrosis, like bone defects and compromised tissue, highlight the need for precise implant selection based on evaluations of bone quality, defects, knee stability, and hyperextension, rather than resorting to overly-constrained implants.

Increased complications rates and inferior patient reported outcomes following total knee arthroplasty due to post-traumatic osteoarthritis with previous fracture treatment: a systematic review

PURPOSE

This study aims to present the existing literature relating to patient-reported outcome measures (PROMs) and complications in patients undergoing total knee arthroplasty (TKA) due to posttraumatic osteoarthritis (PTOA) with prior fracture treatment around the knee compared with patients who underwent TKA because of primary osteoarthritis (OA).

METHODS

A systematic review was undertaken and synthesised in accordance with the PRISMA guidelines by searching existing literature in the following databases: PubMed, Scopus, Cochrane Library and EMBASE. A search string according to the PECO was used. After analysing 2781 studies, 18 studies (5729 PTOA patients/149,843 OA patients) were included for a final review. An analysis revealed that 12 (67%) were retrospective cohort studies, four (22%) were register studies and the remaining two (11%) were prospective cohort studies. The mean Critical Appraisal Skills Programme (CASP) score was 23.6 out of 28, signifying studies of moderate quality.

RESULTS

The most frequently reported outcome measure were postoperative complications, reported in all eighteen studies. Intraoperative complications were reported in ten (4165 PTOA/124.511 OA) and patient-reported outcome measures (PROMs) in six studies (210 PTOA/2768 OA). A total of nine different PROMs were evaluated. As far as PROMs were concerned, the scores were inferior for PTOA but did not differ statistically from OA, except for one study, which favoured the OA group. Across all studies, postoperative complications were higher in the PTOA group, reporting infections as the most common complication. Furthermore, a higher revision rate was reported in the PTOA group.

CONCLUSION

PROM analysis suggests that both patient groups benefit from a TKA in terms of functional outcome and pain relief, however, patient-reported outcomes could be inferior for PTOA patients. There is consistent evidence for increased complication rates following PTOA TKA. Patients undergoing TKA due to PTOA after fracture treatment should be informed about the risk for inferior results and refrain from comparing their knee function to patients with TKA after OA. Surgeons should be aware of the challenges that PTOA TKA poses.

LEVEL OF EVIDENCE

Level III.

Treatment of periprosthetic knee infection and coexistent periprosthetic fracture: A case report and literature review

BACKGROUND

Periprosthetic joint infection (PJI) and periprosthetic fracture (PPF) are among the most serious complications following total knee arthroplasty. Herein, we present one patient with these two complications with details on the characteristics, treatment strategy, and outcome.

CASE SUMMARY

A 69-year-old female patient who suffered from PJI and PPF following total knee arthroplasty was treated by a two-stage revision surgery. After thorough foreign material removal and debridement, we used a plate that was covered with antibiotic-loaded bone cement to link with a hand-made cement spacer to occupy the joint space and fix the fracture. Although the infection was cured, the fracture did not heal and caused bone defect due to the long interval between debridement and revision. In the revision surgery, a cemented stem and cortical allogenic splints were used to reconstruct the fracture and bone defect. At the final follow-up 27 mo after revision, the patient was satisfied with postoperative knee functions with satisfactory range of motion (104º) and Hospital for Special Surgery knee score (82 points). The radiographs showed no loosening of the prosthesis and that the bone grafts healed well with the femur.

CONCLUSION

Our two-stage revision surgery has proved to be successful and may be considered in other patients with PJI and PPF.

Conversion Total Knee Arthroplasty after Failed Osteochondral Allograft Reconstruction: Similar Functional Performance with Lower Patient Satisfaction

BACKGROUND

This study presents surgical techniques used in conversion total knee arthroplasty (cTKA) following early failure of large osteochondral allograft joint replacement and compares postoperative patient reported outcomes measures (PROMs) and satisfaction scores with a contemporary primary total knee arthroplasty (pTKA) cohort.

METHODS

We retrospectively evaluated 25 consecutive cTKA patients (26 procedures) to define utilized surgical techniques, radiographic disease severity, preoperative and postoperative PROMs (visual analog scale (VAS) pain, knee injury and osteoarthritis outcome score for joint replacement (KOOS-JR), University of California Los Angeles (UCLA) Activity), expected improvement and postoperative satisfaction (5-point Likert), and reoperations in comparison with an age and body mass index (BMI) propensity matched cohort of 50 pTKA performed for osteoarthritis (52 procedures).

RESULTS

Revision components were used in 12 cTKA cases (46.1%), with 4 cases requiring augmentation (15.4%), and 3 cases utilizing varus-valgus constraint (11.5%). While no significant differences were noted in expectation level or in other PROMs, mean patient reported satisfaction was lower in the conversion group (4.4 +/- 1.1 vs 4.8 +/- 0.5 points, P=0.02). High cTKA satisfaction was associated with higher postoperative KOOS-JR (84.4 vs 64.2 points, P=0.01) and trend towards higher UCLA activity (6.9 vs 5.7 points, P=0.08). Four patients in each group underwent manipulation (15.3 vs 7.6%, P=0.42), and one primary TKA patient was treated for early postoperative infection (0 vs 1.9%, P=1.0).

CONCLUSION

Conversion TKA following failed biological replacement was associated with similar postoperative improvement as in pTKA. Lower patient reported cTKA satisfaction was associated with lower postoperative KOOS-JR scores.

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.

Tibial metaphyseal sleeves in primary total knee arthroplasty following high tibial osteotomy and tibial plateau fracture; preliminary mid-term survival and outcome

BACKGROUND

Previous high tibial osteotomy (HTO), and tibial plateau fractures (TPF) may cause problems in subsequent total knee arthroplasty (TKA) due to altered metaphyseal bone structure. Higher rates of loosening of the tibial component have been described. In post-HTO and TPF cases, a more durable fixation could be achieved by tibial sleeves. This study investigates the preliminary short-to-midterm clinical and radiographic results in a cohort of these cases.

METHODS

A cohort of 28 patients was selected, 11 following HTO, and 17 following TPF. Standard clinical and radiologic follow-up was performed at 6 weeks, and one and two years. Revision with removal of primary prosthesis for any reason was the primary outcome. Patient reported pre- and postoperative pain, satisfaction and general health scores were collected at one and two years. Postoperative radiographs were analyzed for radiolucent lines.

RESULTS

There were no cases of aseptic loosening. Survival for all reasons was 96.4% (CI 77.2%-99.5%). One progressive radiolucent line was seen. Numerical rating scale (NRS) for pain with and without weightbearing at 2-year follow-up improved from 8 to 3 and from 5 to 2 points respectively. Overall general health scores improved with a median of 70 at ≥ 2 years, compared to 63 pre-operatively.

CONCLUSION

With no revision for aseptic loosening the use of tibial sleeves in primary TKA seems a safe and reliable method for fixation of the tibial component in metaphyseal bone with altered bone structure at short and mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, cohort study.

Clinical Outcomes, Health Care Costs and Prognostic Factors for Total Knee Arthroplasty: A Multilevel Analysis of a National Cohort Study Using Administrative Claims Data

Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgeries. The purpose of this study was to determine the 30-day postoperative mortality rate, total episode-of-care costs, and prognostic factors associated with these outcomes, for adult patients who underwent TKA in Colombia's contributory health care system. A retrospective cohort study of all adult patients enrolled in Colombia's contributory health system, who underwent TKA between January 1, 2012 and November 30, 2015 was performed. Thirty-day postoperative mortality rates, 30-day ICU admissions rates, 30-day hospital readmission rates, 1-year arthroplasty revision rates, and total episode-of-care costs were estimated. Multilevel, generalized linear models were generated, to determine the prognostic factors associated with outcomes presented. A total of 12,453 patients were included. The 30-day mortality rate was 0.13 per 100 surgeries and the ICU admissions rate at 30 days postoperative was 4.44 per 100 surgeries. The 30-day hospital readmission rate was 4.28 per 100 surgeries and the 1-year arthroplasty revision rate was 1.22 per 100 surgeries. The prognostic factors associated with mortality were age, Charlson Index, and type of insurer. The prognostic factors associated with hospital readmission were age category, Charlson Index, and geographic region; younger age and higher Charlson Index were found to be associated with a higher 1-year arthroplasty revision rate. The median of total episode-of-care costs was USD$ 6,190.07 (interquartile range: 2,299-7,282). The multivariate model found that age, the Charlson Index, the Atlantic region, and type of insurer were associated with the costs incurred by the health system. For patients undergoing TKA in Colombia, age, the Charlson Index, insurers, and geographic region are associated with mortality, ICU admissions, 30-day hospital readmissions, 1-year arthroplasty revisions, and total costs incurred by the health system.

Primary total knee replacement for tibial plateau fractures in older patients: a systematic review of 197 patients

INTRODUCTION

Tibial plateau fractures are typically treated with osteosynthesis. In older patients, osteosynthesis is associated with some complications, risk of post-traumatic osteoarthritis and long partial, or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option. The aim of this study was to evaluate all the relevant literature and summarize the current evidence-based knowledge on the treatment of tibial plateau fractures with primary TKR in older patients.

MATERIALS AND METHODS

A systematic literature search of studies on total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture was conducted using OVID Medline, Scopus, and Cochrane databases from 1946 to 18 November 2019. We included all studies without restrictions regarding total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture.

RESULTS

Of the 640 reviewed articles, 16 studies with a total of 197 patients met the inclusion criteria. No controlled trials were available, and the overall quality of the literature was low. The results, using different clinical scoring systems, were good or fair. Four-year follow-up complication (6.1%) and revision (3.6%) rates after primary TKR appeared to be lower than after secondary TKR (complication rate 20-48%, revision rate 8-20%) but higher than after elective primary TKR.

CONCLUSION

Based on low-quality evidence, TKR appears to be a useful treatment option for tibial plateau fractures in older patients. Controlled trials are mandatory to determine the relative superiority of these two options as primary treatment of tibial plateau fractures in older patients.

History of previous surgery is associated with higher risk of revision after primary total knee arthroplasty: a cohort study from the Geneva Arthroplasty Registry

Background and purpose - Prior to primary total knee arthroplasty (pTKA), 6-34% of patients have undergone surgical procedure(s) of their knee. We investigated whether history of previous surgeries influences the risk of revision of pTKA, the risk according to the type of previous surgery, and how previous surgery influences specific causes of revision and the time of revision.Patients and methods - This is a prospective cohort study from the Geneva Arthroplasty Registry. All pTKA between 2000 and 2016 were included and followed until December 31, 2019. Outcomes were risk of revision, evaluated using Kaplan-Meier survival and Cox and competing risks regression, the specific causes, and time of revision.Results - Of 3,945 pTKA included (mean age 71 years, 68% women), 21% had a history of previous surgery, with 8.3% revisions vs. 4.3%, at 3-20 years' follow-up (mean 8.6). 5- and 10-year cumulative failure by previous surgery (yes vs. no) were 6.6% (95% CI 5.1-8.5) vs. 3.3% (CI 2.7-4.0), and 8.4% (CI 6.6-10.6) vs. 4.5% (CI 3.8-5.4). Baseline differences explained only part of the higher risk (adjusted HR 1.5, CI 1.1-2.1). The risk of failure was higher for all causes of revision considered. Patients in the previous surgery group had a higher risk of an early revision.Interpretation - A history of previous surgery adversely affected the outcome with a 1.5 times higher cumulative risk of all-cause revision over the course of up to 20 years after index surgery. The increased risk was seen for all causes of revision and was highest in the first years.

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.

[Total knee arthroplasty in the young patient-an update]

The absolute number of total knee arthroplasties (TKA) continues to rise every year. About 10% of the patients are less than 55 years of age, although it is known that functional results and patient satisfaction are lower combined with an increased likelihood of revision compared to older patients. Higher physical activity and patient expectations are a major challenge in this age group. At the same time, the incidence of posttraumatic/postoperative alterations is high, including ligamentous or bony deficiencies, which can make the surgical procedure challenging. In view of these facts conservative treatments and joint sparing procedures should always be considered first. The potential correction of lower-limb deformities and unicompartmental knee arthroplasties need to be carefully evaluated before considering total knee arthroplasty. Only in advanced cases of osteoarthritis in more than one compartment of the knee of with combined ligamentous instability, can a TKA provide satisfactory results in the young patient. However, the strongest predictor of satisfaction is a realistic expectation.

Knee arthroplasty for acute fractures around the knee

Results of open reduction and internal fixation for complex articular fractures around the knee are poor, particularly in elderly osteoporotic patients.

Open reduction and internal fixation may lead to an extended hospital stay and non-weight-bearing period.

This may lead to occurrence of complications related to decubitus such as thrombo-embolic events, pneumonia and disorientation.

Primary arthroplasty can be a valuable option in a case-based and patient-specific approach. It may reduce the number of procedures and allow early full weight-bearing, avoiding the above-mentioned complications.

There are four main indications:

1) Elderly (osteoporotic) patients with pre-existing (symptomatic) end-stage osteoarthritis.

2) Elderly (osteoporotic) patients with severe articular and metaphyseal destruction.

3) Pathological fractures of the distal femur and/or tibia.

4) Young patients with complete destruction of the distal femur and/or tibia.

The principles of knee (revision) arthroplasty should be applied; choice of implant and level of constraint should be considered depending on the type of fracture and involvement of stabilizing ligaments. The aim of treatment is to obtain a stable and functional joint.

Long-term data remain scarce in the literature due to limited indications.

Cite this article: EFORT Open Rev 2020;5:713-723. DOI: 10.1302/2058-5241.5.190059

[Intra-articular osteotomy for malunion of the tibial plateau]

OBJECTIVE

Restoration of anatomy of the joint surface of the tibial plateau in posttraumatic deformity.

INDICATIONS

Malunions of the tibial plateau with significant intra-articular depression and/or steps.

CONTRAINDICATIONS

Local or systemic infection, critical soft tissues in the area of planned incisions; advanced osteoarthritis of the knee; loss of meniscus in the involved compartment; motoric or neurophysiological impairment hindering normal knee function.

SURGICAL TECHNIQUE

Malunion after posteromedial split fracture: posterior approach in prone position, osteotomy of the former fragment following the fracture lines, anatomical reduction of the fragment in extended position of the knee using the implant as reduction tool, fixation by posterior plate. Malunion after lateral and posterolateral split/depression fracture: Lateral approach with fibula head osteotomy in lateral decubitus position, intra-articular osteotomy of depressed fragments, autologous bone graft, lateral or posterolateral plate osteosynthesis. Osteosynthesis of fibula head with small fragment lag screw or tension-band.

POSTOPERATIVE MANAGEMENT

Walking with crutches starting from day 1 after surgery. Partial weight-bearing until radiographic healing of the osteotomies, usually 4-6 weeks. No limitation of range-of-motion.

RESULTS

A series of 23 patients had lateral corrective osteotomy after lateral tibial plateau fracture. Mean follow-up was 13 years (range 2-26 years). Two patients had early poor results. In all, 17 patients (74%) scored excellent in the Lysholm/Gillquist score, 3 patients good, 1 patient average and 2 patients poor.

The Old Supracondylar Fracture of Femur Treated by Gradual Deformity Correction Using the Ilizarov Technique Followed by the Second-Stage Internal Fixation in an Elderly Patient With Osteoporosis

Background:

The supracondylar nonunion of femur in elderly individuals is rare and challenging to manage. Nothing in English literatures or guidelines is available regarding this particular fracture characterized by osteoporosis, soft-tissue contracture, shortening, and joint stiffness. We report a case of an elderly patient with a supracondylar nonunion of the femur, which was successfully treated using staged Ilizarov techniques and dual plating.

Case Presentation:

An 84-year-old female patient was admitted to our orthopedic department for her pain and soft-tissue swelling around the right knee with claudication and shortening deformity of the affected extremity. She denied any specific history of trauma and had sought traditional Chinese medical attention for 6 months before she presented to our hospital. Diagnosis of the right femoral supracondylar nonunion was made based on the X-ray and computed tomography. Ilizarov external fixator was carried out for successive and slow distraction and gradual correction of the shortening deformity, in consideration of the nonunion was still present. Subsequently, internal fixation with dual plating of the distal femur was performed. Excellent function and patient satisfaction were observed at 6 months of follow-up.

Conclusion:

The protocol of Ilizarov technique with subsequent internal fixation of dual plating seems to be an efficient solution to the supracondylar nonunion of femur in elderly patients with osteoporosis. The advantage of the protocol is that it allows knee joint motion, avoids neurovascular complications, and gentle correction of soft-tissue contractures.

Gender Differences in Contribution of Smoking, Low Physical Activity, and High BMI to Increased Risk of Early Reoperation After TKA

BACKGROUND

The reliable preoperative identification of patients at a high risk of early reoperations (<2 years after primary surgery) after total knee arthroplasty (TKA) could lead to adjustments of the surgical procedure and counseling, thus lowering the percentage of revision surgeries.

METHODS

The unselected cohort consisted of 1885 patients (695 men and 1190 women) who underwent TKA implantation between September 2010 and April 2017 at a single tertiary orthopedic center. Multivariate patient similarity networks were applied to identify patient groups at a high risk of early reoperations based on 25 preoperative parameters.

RESULTS

Early reoperations (109 cases, 5.8%) were less frequent in women (4.4%; median time to reoperation, 2.0 months) than in men (8.2%; 7.5 months), reaching the highest incidence in younger men (10.9%; <66 years). Of the tested preoperative parameters, the risk of reoperation in men was more likely associated with smoking or obesity (body mass index [BMI] > 30). In women, low physical activity and high BMI were the most likely risk factors for early reoperations. Other factors did not affect the risk of early reoperations, including the primary diagnosis, comorbidities, and surgeon-implanting TKA.

CONCLUSION

This study demonstrates the effect of smoking, physical activity, and BMI on the risk of early reoperation after TKA, with the different contribution in men/women. Identification of patient subgroups with a higher risk of early revision after TKA is needed for clinical implementation of precision medicine in orthopedics.

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.

Knee joint replacement as primary treatment for proximal tibial fractures: analysis of clinical results of twenty-two patients with mean follow-up of nineteen months

PURPOSE

Proximal tibial fractures are typically treated with osteosynthesis. In older patients, this method has been reported to be associated with a high complication rate, risk of post-traumatic osteoarthritis, and long partial or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option.

METHODS

Twenty-two patients (mean age 74 years, SD 12) underwent primary TKR due to tibial plateau fracture. Follow-up data were available for a mean of 19 (SD 16) months. Trauma mechanism, fracture classification, type of prosthesis used, complications, and re-operations during the follow-up were recorded. The Knee Society Score (KSS), Oxford Knee Score (OKS), range of flexion, and patient satisfaction were evaluated.

RESULTS

13/22 of the fractures were due to a low-energy trauma. At final follow-up, mean KSS was 160 (SD 39) and mean OKS 27 (SD 11) points. Mean flexion was 109° (SD 16°). 14/17 of the patients were satisfied or highly satisfied with their post-operative knee and 11/17 reported their knee to be same or better than pre-trauma. 2/22 of the patients had complications requiring revision surgery.

CONCLUSION

TKR as a primary definitive method seems to be a useful alternative to osteosynthesis, enabling immediate full weight bearing and rapid mobilization of patients. The risk of complications associated with primary TKR is higher than those reported after TKR due to primary osteoarthritis but lower than those reported after TKR due to secondary osteoarthritis.

Minimizing Posttraumatic Osteoarthritis After High-Energy Intra-Articular Fracture

This article serves to provide an overview of molecular and surgical interventions to minimize the progression of posttraumatic arthritis following high-energy intra-articular fractures. The roles of cartilage and the microcellular environment are discussed, as well as the response of the joint and cartilage to injury. Molecular therapies, such as glucocorticoids, mesenchymal stem cells, and bisphosphonates, are presented as potential treatments to prevent progression to posttraumatic arthritis. High-energy intra-articular fractures of the elbow, hip, knee, and ankle are discussed, with emphasis on restoring anatomic alignment, articular reduction, and stability of the joint.

Conversion Total Knee Arthroplasty: A Distinct Surgical Procedure With Increased Resource Utilization

BACKGROUND

Current Procedural Terminology coding currently makes no distinction between primary total knee arthroplasty (TKA) and conversion TKA, in which periarticular hardware components must be removed prior to or during TKA. We hypothesize that conversion TKA will carry increased operative time, blood loss, postoperative complications, and 90-day emergency department/readmission rate compared to primary TKA.

METHODS

Patients undergoing conversion TKA from 2005 to 2017 were identified from an institutional database and matched to primary TKA patients by age, gender, American Society of Anesthesiologists score, body mass index, and procedure date (±1 year). Intraoperative data and 90-day postoperative complications were compared between groups.

RESULTS

One hundred nine conversion TKA patients with periarticular hardware were removed prior to (n = 51) or during (n = 58) TKA and 109 primary TKA control patients were included. Conversion TKA was associated with increased tourniquet time (91 vs 71 minutes, P < .001), operative time (147 vs 113 minutes, P < .001), blood loss (225 vs 176 mL, P = .010), 90-day readmissions (14.6% vs 4.2%, P = .020), wound complication (5.6% vs 0.0%, P = .025), periprosthetic joint infection (7.9% vs 0.0%, P = .005), irrigation/debridement (9.0% vs 1.1%, P = .016), and a trend toward increased mechanical complication (6.7% vs 1.1%, P = .058). Timing of hardware removal did not affect intraoperative or postoperative outcomes.

CONCLUSION

Conversion TKA is associated with higher operative time, blood loss, readmission rate, and postoperative complications compared to primary TKA. Without a proper billing code and appropriate reimbursement level to match the expected operative and postacute resource utilization by these cases, physicians may be disincentivized to perform these operations.

Bearing design influences short- to mid-term survivorship, but not functional outcomes following lateral unicompartmental knee arthroplasty: a systematic review

PURPOSE

To determine survivorship and functional outcomes of fixed and mobile-bearing designs in lateral unicompartmental knee arthroplasties (UKA).

METHODS

Medline, EMBASE and Cochrane databases were searched. Annual revision rate and functional outcomes were assessed for both fixed and mobile-bearing designs.

RESULTS

A total of 28 studies, of which 19 fixed-bearing and 9 mobile-bearing, representing 2265 lateral UKAs were included for survivorship and functional outcome analyses. The mean follow-up of fixed and mobile-bearing studies was 7.5 and 3.9 years, respectively. Annual revision rate of fixed-bearing designs was 0.94 (95% CI 0.66-1.33) compared to 2.16 (95% CI 1.54-3.04) for mobile-bearing. A subgroup analysis of the domed shaped mobile-bearing design noted an annual revision rate of 1.81 (95% CI 0.98-3.34). Good-to-excellent functional outcomes were observed following fixed and mobile-bearing lateral UKAs; no significant differences were found.

CONCLUSION

Mobile-bearing lateral UKAs have a higher rate of revision compared to fixed-bearing lateral UKAs with regard to short- to mid-term survivorship; however, the clinical outcomes are similar. Despite the introduction of the domed shaped mobile-bearing design, findings of this study suggest fixed-bearing implant design is preferable in the setting of isolated lateral osteoarthritis (OA). This systematic review was based on low to moderate evidence, therefore, future registry data are needed to confirm these findings. However, this study included a large number of patients, and could provide information regarding risk of revision and functional outcomes of mobile and fixed-bearing type lateral UKA.

LEVEL OF EVIDENCE

IV.

Osteoarthritis- a systematic review of long-term safety implications for osteoarthritis of the knee

BACKGROUND

There is no cure for knee osteoarthritis (KOA) and typically patients live approximately 30-years with the disease. Most common medical treatments result in short-term palliation of symptoms with little consideration of long-term risk. This systematic review aims to appraise the current evidence for the long-term (≥12 months) safety of common treatments for knee osteoarthritis (KOA).

METHODS

Cochrane Database of Systematic Reviews, Medline and PubMed were systematically searched from 1990 to July 2017, inclusive. Inclusion criteria were 1) peer-reviewed publications investigating treatments for KOA referred to in the Australian Clinical Care Standard and/or Therapeutic Guidelines: Rheumatology 2) specifically addressing safety of the treatments 3) with ≥12 months of follow-up and 4) Downs and Black quality score ≥ 13.

RESULTS

Thirty-four studies fulfilled the inclusion criteria. Lifestyle modifications (moderate exercise and weight loss), paracetamol, glucosamine, Intraarticular Hyaluronic Acid (IAHA) and platelet-rich-plasma (PRP) injections have a low risk of harm and beneficial ≥12 month outcomes. Although Nonsteroidal Anti-inflammatory Drugs (NSAIDs) provide pain relief, they are associated with increased risk of medical complications. Cortisone injections are associated with radiological cartilage degeneration at > 12 months. Arthroscopy for degenerative meniscal tears in KOA leads to a 3-fold increase in total knee arthroplasty (TKA). TKA improves primary outcomes of KOA but has a low rate of significant medical complications.

CONCLUSIONS

Given the safety and effectiveness of lifestyle interventions such as weight loss and exercise, these should be advocated in all patients due to the low risk of harm. The use of NSAIDs should be minimized to avoid gastrointestinal complications. Treatment with opioids has a lack of evidence for use and a high risk of long-term harm. The use of IAHA and PRP may provide additional symptomatic benefit without the risk of harm. TKA is associated with significant medical complications but is justified by the efficacy of joint replacement in late-stage disease.

TRIAL REGISTRATION

PROSPERO International prospective register for systematic reviews; registration number CRD42017072809 .

Worsen depression after viscosupplementation treatment for geriatric people with knee osteoarthritis?

Background/objective: Knee osteoarthritis (OA) in older people may result in psychological impairment, including anxiety and depression. This study investigates the effect of intraarticular hyaluronic acid injection (IAHA) on geriatric patients with OA. Method: A total of 102 geriatric patients with knee OA undergoing IAHA were prospectively enrolled in this study. Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and Visual Analogue Scale (VAS) for pain were recorded. All outcomes were measured at baseline before injection and during two, four, and six month follow-ups. Results: IAHA had a significant short-term effect, relieving pain at the two month follow-up, but the effect was weaker at the four month follow-up. Both IKDC and WOMAC scores were significantly improved at the two month follow-up. Viscosupplementation did not improve STAI. GDS exhibited significant deterioration at the four month follow-up. Conclusions: Although IAHA for the treatment of OA provided short-term efficiency, it had no effects on anxiety and increased depression of geriatric people. Health education should be provided with caution before viscosupplementation treatment to manage expectations of the efficacy of treatment for geriatric OA patients.

A Patient with Osteoarthritis Knee and Prior Patella Fracture: Single Stage Fixation and Total Knee Arthroplasty: A Case Report

Introduction:

Osteoarthritis knee associated with periarticular fractures (femur, tibia, or patella) in geriatric patients is a treatment challenge for orthopedic surgeon. In geriatric patient, early mobilization is key for a better outcome and to prevent immobilization related complications. Hence, this case report is important for all orthopedic surgeons.

Case Report:

We had a 65-year-old male patient who came for the treatment ofhis patella fracture and deformity ofboth knees.

Conclusion:

Elderly patients who sustained a patella fracture can be treated with single stage primary total knee replacement and fixation of patella fracture. There is no need for two stage surgery. Rehabilitation and pain relief along with mobilization is better with single stage surgery.

Ten-year survival and complications of total knee arthroplasty for osteoarthritis secondary to trauma or surgery: A French multicentre study of 263 patients

BACKGROUND

Previous surgical procedures raise technical challenges in performing total knee arthroplasty (TKA) and may affect TKA outcomes. Survival rates of TKA done after trauma or surgery to the knee have not been accurately determined in large populations. The objectives of this retrospective study in 263 patients with TKA after knee trauma or surgery and a follow-up of 10 years were to assess survival, functional outcomes, and the nature and frequency of complications.

HYPOTHESIS

Knee trauma or surgery before TKA increases the risk of complications and decreases implant survival.

MATERIAL AND METHODS

Two hundred and sixty-three patients (122 [47%] females and 141 [53%] males) underwent TKA between 2005 and 2009 at nine centres in France. Mean age at surgery was 61 years. The patients had knee osteoarthritis secondary to a fracture (n=66), osteotomy (n=131), or ligament injury (n=66). Mean time from trauma or surgery to TKA was 145 months (range, 72-219 months).

RESULTS

Major complications were infection (n=12, 4.5%), skin problems (n=8, 3%), and stiffness (n=8, 3%). Ten-year survival to implant exchange for any reason was 89%±2.8%. Flexion range increased by 2.5°±17° (p=0.02) to a mean of 110° (range, 30° to 140°); extension range increased by 4°±7° (p<0.001) to a mean of -1.19 (range, -20° to 0°). Of the 263 patients, 157 (60%) reported little or no pain at last follow-up. Mean postoperative hip-knee-ankle angle was 179°±3.2° (range, 171°-188°).

CONCLUSION

TKA performed after knee injury or surgery carries a risk of specific complications (infection, skin problems, and stiffness) and may have a lower survival rate compared to primary TKA.

LEVEL OF EVIDENCE

IV, retrospective cohort study.