Effect of the knee position during wound closure after total knee arthroplasty on early knee function recovery

Wound closure position in total knee arthroplasty: flexion versus extension-a meta-analysis of randomized controlled trials

BACKGROUND

Total knee arthroplasty (TKA) is one of the most commonly used procedures in orthopedics. However, whether different would closure positions affect the clinical outcomes after TKA remains controversial. We conducted a meta-analysis of randomized controlled trials (RCT) to assess the effect of wound closure position on clinical TKA outcomes.

METHODS

Embase, PubMed, and the Cochrane Library databases were systematically searched. A systematic review and meta-analysis of all RCTs were performed to prove the role of different wound closure positions on TKA.

RESULTS

Five RCTs containing 389 patients were included. Surgical closure of 90° flexion in TKA was associated with higher post-operative range-of-motion (ROM) at post-operative 4 weeks, lower VAS post-operative pain scores 4 weeks and 3 months, better peak torque difference of flexor muscle strength at 60 and 180°/s angular velocities between the flexion and the extension groups, and better total work difference of flexor muscle strength at 180°/s angular velocity. The American Knee Society Score did not show any significant difference between two closure techniques. No complications were described in the literature review.

CONCLUSIONS

Wound closure in 90° flexion during TKA may provide better postoperative ROM, higher pain relief, preferable muscle strength improvement in short-term follow-up, and no increase in the risks of wound complications.

LEVEL OF EVIDENCE

Level II.

Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review

OBJECTIVES

For many people with advanced osteoarthritis, total knee replacement (TKR) is an effective treatment for relieving pain and improving function. Features of perioperative care may be associated with the adverse event of chronic pain 6 months or longer after surgery; effects may be direct, for example, through nerve damage or surgical complications, or indirect through adverse events. This systematic review aims to evaluate whether non-surgical perioperative interventions prevent long-term pain after TKR.

METHODS

We conducted a systematic review of perioperative interventions for adults with osteoarthritis receiving primary TKR evaluated in a randomised controlled trial (RCT). We searched The Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL until February 2018. After screening, two reviewers evaluated articles. Studies at low risk of bias according to the Cochrane tool were included.

INTERVENTIONS

Perioperative non-surgical interventions; control receiving no intervention or alternative treatment.

PRIMARY AND SECONDARY OUTCOME MEASURES

Pain or score with pain component assessed at 6 months or longer postoperative.

RESULTS

44 RCTs at low risk of bias assessed long-term pain. Intervention heterogeneity precluded meta-analysis and definitive statements on effectiveness. Good-quality research provided generally weak evidence for small reductions in long-term pain with local infiltration analgesia (three studies), ketamine infusion (one study), pregabalin (one study) and supported early discharge (one study) compared with no intervention. For electric muscle stimulation (two studies), anabolic steroids (one study) and walking training (one study) there was a suggestion of more clinically important benefit. No concerns relating to long-term adverse events were reported. For a range of treatments there was no evidence linking them with unfavourable pain outcomes.

CONCLUSIONS

To prevent chronic pain after TKR, several perioperative interventions show benefits and merit further research. Good-quality studies assessing long-term pain after perioperative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR.

Does knee position during wound closure alter patella height following total knee arthroplasty?

BACKGROUND

Patella infera is a known complication of total knee arthroplasty, and the method of soft tissue closure is a possible contributing factor. The aim of our study was to evaluate the effect of knee position during surgical closure of capsule, subcutaneous tissue and skin on patella tendon length after total knee arthroplasty.

METHODS

A three arm retrospective cohort study was conducted in a single institution over a 3-year period; 75 patients were divided, by surgeon preference, into three groups (Flexed, Extended and Hybrid) of 25 patients. All groups had standardized prosthesis, intraoperative and postoperative protocols, and differed in knee position at closure. Patellar tendon length was assessed radiologically using Insall Salvati ratio (ISR) and modified Insall Salvati ratio, with a 12-month follow-up. Intraclass correlation coefficients were used to assess intraobserver variability.

RESULTS

There was a small but significant difference in preoperative to initial postoperative ISR change between Flexed and Extended groups (Extended group mean ISR change = -0.05; t = -2.31, P = 0.025, independent samples t-test), which was not sustained at 12 months. The incidence of patella infera was similar in Flexed and Extended groups at 12 months with only one case seen in the Hybrid group.

CONCLUSION

Our study suggests that knee position during soft tissue closure does not have a sustained impact on patella tendon length after knee replacement. A small but statistically significant reduction in patella height was found in the Extended group initially after surgery but this effect was not sustained at 12 months.

The effect of tourniquet and knee position during wound closure after total knee arthroplasty on early recovery of range of motion: a prospective, randomized study

INTRODUCTION

There is no consensus on the position of the knee joint while performing wound closure after total knee arthroplasty (TKA). Further, there are no studies focusing on the association between early functional outcomes and different wound closure strategies. Therefore, we investigated the effects of tourniquet and knee position during wound closure on early recovery of range of motion (ROM) after primary TKA. To our knowledge, this is the first study to evaluate the influence of both tourniquet and knee position during wound closure in primary TKA.

METHODS

One hundred-twenty eligible patients were consecutively enrolled in this study and randomly divided into four groups according to wound closure strategy. Wound closure was either performed with the knee in flexion at 90° or in full extension, with the combination of an inflated or deflated tourniquet. Visual analogue score (VAS), knee ROM, ROM recovery, knee society score (KSS), and wound complications were evaluated in the early postoperative period.

RESULTS

After the first postoperative week, ROM recovery in the group with knee in extension and inflated tourniquet was significantly lesser than the two groups with deflated tourniquets. Between the first and fourth postoperative weeks, ROM recovery in the group with knee inflection and deflated tourniquet was significantly higher than the two groups with knee in extension. After the first postoperative week, the visual analog score (VAS) for pain in the group with knee inflection and deflated tourniquet was significantly lesser than the two groups with inflated tourniquets. The differences in the outcomes between the four groups were not significant after the fourth postoperative week. The incidence of wound complications and KSS were not significantly different between the four groups.

CONCLUSION

Following TKA, wound closure with the knee in flexion and after deflating the tourniquet significantly decreased postoperative pain and promoted the recovery of ROM in the early postoperative period.

The role of wound closure in total knee arthroplasty: a systematic review on knee position

PURPOSE

Post-operative range of motion (ROM) is one of the most important parameters to assess, following total knee arthroplasty (TKA). The aims of the present systematic review were to analyse the available literature and determine if closing the knee in flexion or extension influences post-operative ROM, clinical outcomes, and complications following TKA.

METHODS

A systematic review was performed using the keywords "total knee arthroplasty", "total knee replacement", and "wound closure" or "joint closure" or "extension" or "flexion" with no limit regarding the year of publication. The review was limited to the English-language articles, and each article was evaluated with a modified Coleman Methodology Score (mCMS).

RESULTS

Six articles met inclusion criteria. The initial cohort included 202 TKAs in the flexion group and 201 in the extension group. Three hundred and ninety-seven TKAs were evaluated with an average follow-up of 8 months. There was no statistical difference (n.s.) between the two groups in terms of the average post-operative flexion. There were no statistical differences between the two groups regarding post-operative functional scores and VAS scores (n.s.). The average mCMS was 70.9, indicating good methodological quality in the included studies.

CONCLUSIONS

The findings of the present review did not show any statistically significant differences in terms of post-operative flexion ROM, functional scores, or complications related to the position of the knee at the time of joint and wound closure during TKA. There is no clear advantage to either closure method based on the currently available evidence, and therefore, this choice should be based on surgeon preference.

Cross-linked versus conventional polyethylene for total knee arthroplasty: a meta-analysis

BACKGROUND

Highly cross-linked polyethylene (HXLPE) has been reported as an effective material for decreasing polyethylene wear and osteolysis in total knee arthroplasty (TKA). Because no single study to date has been large enough to definitively determine the benefit of HXLPE in TKA, we conducted a meta-analysis to pool the results from randomized controlled trials (RCTs) and non-RCTs to make such a determination.

METHODS

Potential candidate articles were identified by searching the Cochrane Library, Medline (1966-2015.10), PubMed (1966-2015.10), Embase (1980-2015.10), ScienceDirect (1985-2015.10), and other databases. "Gray studies" were identified from the included articles' reference lists. Pooled data were analyzed using RevMan 5.1.

RESULTS

Three RCTs and three non-RCTs were included in the meta-analysis. There were no significant differences between the groups in the total number of reoperations (P = 0.11), reoperations for prosthesis loosening (P = 0.08), radiolucent line (P = 0.20), osteolysis (P = 0.38), prosthesis loosening (P = 0.10), and mechanical failures related to the tibial polyethylene (P = 1.00). Similarly, no significant differences between the two groups were found in postoperative total knee score (P = 0.18) or functional score (P = 0.23).

CONCLUSIONS

The meta-analysis showed that compared with conventional polyethylene, HXLPE did not improve the clinical and radiographic outcomes in mid-term follow-up after TKA. Additional high-quality multicenter prospective RCTs with good design, large study populations and long-term follow-up will be necessary to further clarify the effect of HXLPE in TKA.