Patient-reported outcome measures (PROMs) in patients undergoing patellofemoral arthroplasty and total knee replacement: A comparative study

Should we recommend patellofemoral arthroplasties to patients?

Aims

With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting.

Methods

MEDLINE, EMBASE via OVID, CINAHL, and EBSCO were searched from inception to January 2022. Any study addressing surgical treatment of primary patellofemoral joint OA using second generation PFA and TKA in patients aged above 18 years with follow-up data of 30 days were included. Studies relating to OA secondary to trauma were excluded. ROB-2 and ROBINS-I bias tools were used.

Results

A total of nine studies were included, made up of four randomized controlled trials (domain 1) and five cohort studies (domain 2). PROMs and knee function specific scores developed for reporting TKA were unable to detect any difference between PFA and TKA. There was no significant difference in complications between PFA and TKA. PFAs were found to have a better postoperative range of motion.

Conclusion

TKA and PFA are both viable options for patients with primary PFJ OA. Over time, we have seen an emphasis on patient satisfaction and better quality of life. Recommending sacrificing healthy medial and lateral compartments to treat patellofemoral joint arthritis should be given further thought.

A decreased tibial tuberosity-trochlear groove distance is associated with lateral patellofemoral joint degeneration after implantation of medial fixed-bearing unicompartmental knee arthroplasty - a minimum five year follow-up

PURPOSE

The influence of lateral patellofemoral osteoarthritis (PFOA) in medial unicompartmental knee arthroplasty (UKA) is controversial. Our aim was to identify radiographic factors that may lead to progressive PFOA after implantation of a fixed-bearing medial UKA and their impact on patient-reported outcomes (PROMs).

METHODS

A retrospective consecutive cohort of patients undergoing medial UKA with a minimum follow-up of 60 months between September 2011 and January 2017 was identified. All UKAs had a fixed-bearing design with cemented femoral and tibial components. PROMs included documentation of the Oxford Knee Score (OKS). The following radiographic parameters were evaluated on conventional radiographs and computer tomography (CT) scans: patella tilt angle, patella congruence angle, Caton-Deschamps index, medial and lateral patellofemoral degeneration (Kellgren-Lawrence Classification (KL)), mechanical anteroposterior axis, femoral torsion, tibial tuberosity to trochlear groove distance (TTTG), anteroposterior translation of the femoral component. A hierarchical multiple regression analysis and partial Pearson correlation analysis (SPSS) were used to evaluate for predictors of progression of lateral PFOA.

RESULTS

Forty-nine knees allowed PFOA assessment and had an average follow-up of 62 months (range 60-108). Twenty-three patients did not exhibit any progression of lateral PFOA. Twenty-two progressed with 1 stage, whereas four had progressed 2 stages according to the KL classification. TTTG negatively correlated with progressive lateral PFOA (r =  - 0.436, p = 0.01). Progression of lateral PFOA did not correlate with OKS at last follow-up (p = 0.613).

CONCLUSION

A decreased TTGT correlated with radiographic progression of lateral PFOA after medial fixed-bearing cemented UKA. PFOA however did not influence PROMs at a minimum of five years postoperatively.

Outcomes are Compromised When Revising Patellofemoral Arthroplasties for Patellar Component Failures

BACKGROUND

Outcomes of patellofemoral arthroplasty (PFA) to total knee arthroplasty (TKA) conversion are reported to be similar to primary cases. The purpose of this study was to determine whether the cause for conversion from PFA to TKA correlated to outcomes when compared to a matched cohort.

METHODS

A retrospective chart review was performed to identify aseptic PFA to TKA conversions between 2000 and 2021. A cohort of primary TKAs was matched by patient sex, body mass index, and American Society of Anesthesiology score. Clinical outcomes, including range of motion, complication rates, and patient reported outcomes measurement information systems scores, were compared. Chi-squared, Fisher's Exact, and t-tests were performed. There were 20 PFA to TKA conversions that met inclusion criteria and were matched to 60 primary cases.

RESULTS

There were 7 cases revised for arthritis progression, 5 for femoral component failure, 5 for patellar component failure, and 3 for patellar maltracking. PFA to TKA conversions for patellar failure (fracture, component loosening) had worse postoperative flexion (115 versus 127°, P = .023) and more complications of stiffness (40 versus 0%, P = .046) than primary TKAs. Conversions for failed patellar components had worse patient reported outcomes measurement information systems physical function (32 versus 45, P = .0046), physical health (42 versus 49, P = .0258), and pain scores (45 versus 24, P = .0465). No differences were found in rates of infection, manipulations under anesthesia, or reoperations.

CONCLUSION

PFA to TKA conversion outcomes were similar to primary TKA, except in patients who had failed patellar components and demonstrated worse postoperative range of motion and patient-reported outcomes. Surgeons should avoid thin patellar resections and extensive lateral releases to minimize patellar failures.

Patient-Reported Outcomes and Risk Factors for Decreased Improvement after Patellofemoral Arthroplasty

Patellofemoral arthroplasty (PFA) is acknowledged as the method for the treatment of isolated patellofemoral osteoarthritis (PFOA). Few previous studies have assessed the patient-reported outcomes (PROs) and risk factors of less improvement of PROs in patients undergoing PFA. A retrospective analysis was performed, including all patients who had undergone PFA. Pre- and postoperative PROs included the Oxford Knee Score (OKS) and Kujala score. Univariate and multivariate statistical analyses were performed to assess influencing factors of less improvement of PROs including the demographic factors (gender, age, body mass index, smoking, opioid usage, and duration of symptoms [DOSs]), surgical factors (concomitant surgery), and imaging factors (trochlear dysplasia [TD], patellar height, the degree of PFOA). A total of 46 PFAs were analyzed with a mean follow-up of 37 ± 7 months. The mean age at surgery was 61.1 ± 7.7 years. Patients showed significant improvement in all PROs (p < 0.001). Patients with TD preoperatively have greater improvement in OKS and Kujala score postoperatively (19.2 ± 5.0 vs. 23.1 ± 3.6, p = 0.038). Longer DOSs (≥1 year) had a greater mean improvement in OKS and Kujala score (p = 0.011 and p = 0.000). According to the measurement of patella height, patients with patella alta (Caton-Deschamps index [CDI] ≥1.3) showed less improvement in both OKS and Kujala score (p = 0.000 and p = 0.002). PFA is a safe and efficient surgery with good PROs. Patella alta with a CDI ≥1.3 and duration of preoperative symptoms ≤ 1 year were risk factors for decreased OKS and Kujala score improvement, while the preoperative presence of TD was significantly predictive factors for increased OKS improvement.

Higher Dissatisfaction Rate Following Revision Compared With Primary Total Knee Arthroplasty: 1-Year Follow-up of 2151 Primary and 235 Aseptic Revision Surgeries

Postoperative patient satisfaction is related to preoperative expectations. Information regarding expected results following surgery is therefore important. This study evaluated patient-reported outcome measures (PROMs) and patient satisfaction up to 1 year after primary and aseptic revision total knee arthroplasty (TKA). The study included 2151 primary and 235 aseptic revision TKA surgeries conducted between 2010 and 2018. Pain, Knee Injury and Osteoarthritis Outcome Score-Physical Function-Short Form and European Quality of Life-5 Dimension surveys were recorded preoperatively and at 8 weeks and 1 year. To determine satisfaction, patients were asked to rate their knee function compared with that before surgery and to answer whether they would undergo the surgery again given their current knowledge. Patients who had primary TKA improved in all PROMs in each follow-up up to 1 year, whereas patients who had revision TKA showed improvement at 8 weeks with no further improvement at 1 year. In terms of patient satisfaction, 88% of patients in the primary TKA group reported better knee function, and 87% were willing to have the surgery again at 1 year; the proportions were lower for patients who underwent revision TKA (66% and 68%, respectively). Aseptic revision TKA demonstrates inferior PROMs compared with those of primary TKA 1 year after surgery, and more than 30% of the patients who underwent revision TKA stated that they would not have their TKA revised or were uncertain, given the outcome of the procedure. Thus, patients who are candidates for revision TKA should be informed to expect less of an improvement following revision surgery than with the primary TKA. Our findings can facilitate the shared decision-making process by surgeons and patients based on realistic expectations of surgical outcomes. [Orthopedics. 2023;46(1):e52-e57.].

Are modern knee outcomes scores appropriate for evaluating anterior knee pain and symptoms after total knee arthroplasty?

BACKGROUND

Up to 45% of patients who undergo primary total knee arthroplasty (TKA) with contemporary implants have residual anterior knee pain. While a specific evaluation of anterior knee symptoms is mandatory, little is known about the capability of patellofemoral scores to be used individually. This study aimed to assess the distribution of patellofemoral scores after TKA from a uniform cohort and to investigate their external validity and ability to detect anterior knee symptoms using floor and ceiling effects.

HYPOTHESIS

Patellofemoral scores have high construct validity and fewer floor/ceiling effects than general knee scores.

METHODS

We prospectively included 113 consecutive patients who underwent primary TKA for primary osteoarthritis at a single University Hospital. Clinical outcomes included patellofemoral scores (HSS Patella, Kujala and Lille scores) and general knee scores (KOOS and new KSS) at 1-year follow-up. The floor and ceiling effects were considered as significant when greater than 15%. These were determined for each score individually and for composite scores (combination of patellofemoral scores and new KSS). The construct validity of each score and their ability to detect anterior knee pain was evaluated.

RESULTS

Patellofemoral scores showed no floor effect but a significant ceiling effect (from 25% to 65%). This ceiling effect decreased when composite scores were used. The convergent validity test showed strong correlation between patellofemoral scores (from 0.741 to 0.819, p<0.00001) and a better ability to discriminate anterior knee pain than the general knee scores.

CONCLUSIONS

Patellofemoral scores showed no floor effect and a very good construct validity for anterior knee pain after TKA. However, studies aiming to monitor anterior knee symptoms after TKA should combine scoring systems to included patellofemoral-related items rather than use patellofemoral scores alone due their ceiling effects.

LEVEL OF EVIDENCE

III; prospective study.

The Mediating Effect of Perceived Injustice and Pain Catastrophizing in the Relationship of Pain on Fatigue and Sleep in Breast Cancer Survivors: A Cross-Sectional Study

OBJECTIVE

Multidimensional aspects of pain have raised awareness about cognitive appraisals, such as perceived injustice (PI) and pain catastrophizing (PC). It has been demonstrated that they play an important role in patients' pain experience. However, the mediating effect of these appraisals has not been investigated in breast cancer survivors (BCS), nor have they been related to fatigue and sleep.

METHODS

Cross-sectional data from 128 BCS were analysed by structural path analysis with the aim to examine the mediating effect of PI and PC in the relationship of pain on fatigue and sleep.

RESULTS

The indirect mediating effects of PI on fatigue (CSI*PI = 0.21; P < 0.01 and VAS*PI = 1.19; P < 0.01) and sleep (CSI*PI = 0.31; P < 0.01 and VAS*PI = 1.74; P < 0.01) were found significant for both pain measures (Central Sensitization Inventory (CSI) and Visual Analogue Scale (VAS)). PC, on the other hand, only mediated the relationship between pain measured by VAS and fatigue (VAS*PC = 0.80; P = 0.03). Positive associations were found, indicating that higher pain levels are positively correlated with PI and PC, which go hand in hand with higher levels of fatigue and sleep problems.

CONCLUSION

PI is an important mediator in the relationship of pain on fatigue and sleep, while PC is a mediator on fatigue after cancer treatment. These findings highlight that both appraisals are understudied and open new perspectives regarding treatment strategies in BCS.

Onlay Patellofemoral Arthroplasty in Patients With Isolated Patellofemoral Arthritis: A Systematic Review

BACKGROUND

Patellofemoral arthroplasty (PFA) for isolated patellofemoral osteoarthritis (OA) remains controversial due to variable postoperative outcomes and high failure rates. Second-generation (2G) onlay prostheses have been associated with improved postoperative outcomes. This systematic review was performed to assess the current overall survivorship and functional outcomes of 2G PFA.

METHODS

A search was performed using PubMed, Cochrane Library, EMBASE, and Google Scholar. Thirty-three studies published in the last 15 years (2005-2020) were included; of these 22 studies reported patient-reported outcome measures. Operative and nonoperative complications were analyzed. Pooled statistical analysis was performed for survivorship and functional scores using Excel 2016 and Stata 13.

RESULTS

The mean age of the patients was 59.7. When analyzing all studies, weighted survival at mean follow-up of 5.52 was 87.72%. Subanalysis of studies with minimum 5 years of follow up showed a survival of 94.24%. Fifteen studies reported Oxford Knee Score with a weighted mean postoperative Oxford Knee Score of 33.59. Mean American Knee Society Score pain was 79.7 while mean American Knee Society Score function was 79.3. The most common operative complication was OA progression for all implants. The percentage of revisions and conversions reported after analyzing all studies was 1.37% and 7.82% respectively.

CONCLUSION

Safe and acceptable results of functional outcomes and PFA survivorship can result from 2G PFAs at both short and mid-term follow-up for patients with isolated patellofemoral OA. However, long-term follow-up outcomes are still pending for the newer implants. More extensive studies using standardized functional outcomes and long-term cost benefits should be evaluated.

The short-term effectiveness and safety of second-generation patellofemoral arthroplasty and total knee arthroplasty on isolated patellofemoral osteoarthritis: a systematic review and meta-analysis

Background

We aimed to compare second-generation patellofemoral arthroplasty (2G PFA) with total knee arthroplasty (TKA) in treating isolated patellofemoral osteoarthritis (PFOA) by assessing the percentages of revisions, complications, and patient-reported outcome measures (PROMs).

Methods

Studies that compared the outcomes of 2G PFA and TKA in the treatment of isolated PFOA were searched in electronic databases, including MEDLINE, Embase, and Web of Science. Two researchers independently identified eligible studies, extracted the data, and evaluated the quality of the literature. Pooled risk ratios (RRs) or weighted mean differences with 95% confidence intervals were calculated using either fixed or random effects models. Descriptive analysis was used when data could not be pooled.

Results

A total of six studies were included in the review. For the revision percentage and complications, there were no significant differences between 2G PFA and TKA (RR = 2.29, 95% CI 0.69–7.58, P = 0.17; RR = 0.56, 95% CI 0.23–1.40, P = 0.22, respectively). Second, the results demonstrated that the differences in the Oxford Knee Score (OKS) and the University of California, Los Angeles (UCLA) activity score between 2G PFA and TKA were not significant (WMD −4.68, 95% CI −16.32 to 6.97, p = 0.43; WMD 0.16, 95% CI −1.21 to 1.53, P = 0.82). The Knee Injury and Osteoarthritis Outcome Score (KOOS), the American Knee Society Score (AKSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were presented in a narrative form due to methodological heterogeneity.

Conclusion

For isolated PFOA, 2G PFA demonstrated similar results to TKA with respect to the percentages of revisions, complications, and PROMs.

Patellofemoral arthroplasty versus total knee arthroplasty for isolated patellofemoral osteoarthritis: a systematic review and meta-analysis

BACKGROUND

Isolated patellofemoral osteoarthritis (PF-OA) is a common subtype of knee osteoarthritis, leading to a huge economic burden on health care systems. Although previous studies have shown that patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) have good clinical effects, it remains largely unclear which treatment is more effective for patients with isolated PF-OA. We aimed to compare postoperative function, complications, revision rates, level of physical activity, and satisfaction rate between the two surgical techniques.

METHODS

Our study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Search of literature was conducted in MEDLINE, EMBASE, Cochrane Library, and Web of Science until November 2020. The included studies were those that provided direct comparison of postoperative outcomes between PFA and TKA. Data were extracted from eligible studies and combined to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). Sensitivity analysis and subgroup analysis were conducted to evaluate heterogeneity between the two groups.

RESULTS

A total of 7 eligible studies (3 recent randomized controlled trials and 4 nonrandomized controlled trials) were included in this meta-analysis. The pooled results showed that both the PFA group and the TKA group had improved postoperative indicators, suggesting that the two operation modes could improve the knee function and quality of life of patients. Throughout the first 2 years postoperatively, higher activity level, and better functional recovery were observed for PFA compared with TKA in this study; moreover, the differences between the two operation modes were statistically significant (p < 0.05). We found no significant difference in complications, revision rates, and satisfaction rate between the two procedures.

CONCLUSION

Although there was no observed difference in the complications, revision rates, and satisfaction rate between PFA and TKA, PFA was superior to TKA in terms of knee function and physical activity in the first 2 years postoperatively. Therefore, PFA is a safe, effective, and less invasive treatment for patients with isolated PF-OA. Our findings are consistent with the systematic review of current evidence that PFA may be more suitable for younger patients with high activity needs. Patient selection is, therefore, thought to be of paramount importance. Individualized surgical plan should be designed according to the patient's age, BMI, KOA site, and activity level and combined with the doctor's personal experience.

Patellar resurfacing versus nonresurfacing in total knee arthroplasty: an updated meta-analysis of randomized controlled trials

BACKGROUND

Whether resurface the patella or not in total knee arthroplasty (TKA) was controversial. In 2013, we conducted a meta-analysis of randomized controlled trials (RTCs). After that, plenty of studies have been carried out, but there still existed a great deal of controversy. In order to update our previous study, we conducted this update meta-analysis to evaluate the efficacy of patellar resurfacing in TKA.

METHODS

Databases were searched for RCTs comparing the outcomes of patellar resurfacing and nonresurfacing in TKA. Outcomes of knee relevant indicators were analysed. To see the short- and long-term effects, we calculated the data in total and divided the patients who were followed up for ≤ 3 years and ≥ 5 years into two subgroups as well.

RESULTS

Thirty-two trials assessing 6887 knees were eligible. There was a significant difference in terms of reoperation (in total and ≥ 5 years), Knee Society Score (KSS), function score (in total and ≥ 5 years) and noise. While no significant difference was found in the following items: reoperation (≤ 3 years), anterior knee pain (AKP), function score (≤ 3 years), range of motion (ROM), Oxford score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analogue score (VAS), Feller score, patellar tilt and the patients' satisfaction.

CONCLUSIONS

We found that patellar resurfacing could reduce the occurrence of reoperation and noise after surgery, as well as increase the KSS and function score, while it might not influence the outcomes such as AKP, ROM, Oxford score, KOOS, VAS, Feller score, patellar tilt and the patients' satisfaction. The results are different from our previous finding in the meta-analysis. In conclusion, we prefer patellar resurfacing in TKA.

Patient satisfaction reporting for patellofemoral arthroplasty is significantly lacking: a systematic review

Background: Patellofemoral Arthroplasty (PFA) has been shown to be successful in restoring knee function and quality of life in patients with the isolated patellofemoral disease. Patient satisfaction has been suggested as an indicator of the quality of elective orthopedic operations, although there remains no standardized method to collect and evaluate satisfaction. The present study offers a systematic review of the available literature concerning patient satisfaction following PFA to assess common methodologies for reporting patient satisfaction. Methods: A query of the Medline database produced 116 articles that were reviewed for inclusion in the review. The following inclusion criteria were used to identify suitable articles: English language, clinical outcomes study related to PFA, and patient-reported satisfaction as an outcome measure. Results: Seven studies met inclusion criteria and were eligible for review. The highest level of evidence was level-III. The study publication dates ranged from 2009 to 2016, with six published in 2015 & 2016. In total, 320 PFAs were performed on 267 patients. Four articles reported the proportion of included patients who had previous knee surgeries (range: 20-60%). Three studies used ordinal scales to rate patient satisfaction. Four studies (57.1%) reported the numeric proportion of patients satisfied following PFA, which ranged from 76% to 96.5%. Two studies used Visual Analog Scale methods. For these two studies, one of them reported the mean satisfaction score as 7.5/10, and the other reported a median of 90/100. Conclusions: The available literature on patient satisfaction after PFA was found to be limited, with low-quality evidence and variable methodology.

Early outcomes of an anatomic trochlear-cutting patellofemoral arthroplasty: patient selection is key

PURPOSE

The purpose of this study was to report outcomes of a recent anatomic trochlear-cutting patellofemoral arthroplasty (PFA) system at > 3 years. The hypothesis was that its functional scores and revision rates would be at least equivalent to those reported for other 'trochlear-cutting' implants in the literature.

METHODS

Twenty-eight consecutive patients that had received PFA using the same anatomic trochlear-cutting implant (KneeTech PFJ, Corin-Tornier, Montbonnot, France) with a dome-shaped patellar button and had systematic lateral facetectomy without lateral release were enrolled. Radiographic parameters collected pre-operatively included: trochlear dysplasia type and patellar height, TT-TG, patellar tilt and shape. Clinical scores collected pre-operatively and at > 3 years included: Oxford Knee Score (OKS) and Knee Society Score (KSS).

RESULTS

The initial cohort comprised 23 women (82%) and five men (18%), aged 63.3 ± 14.7 years, of which 23 had trochlear dysplasia (82%). One patient (4%) could not be reached, and three (11%) were revised to TKA due to arthritic progression, aged 77, 80 and 83 years at index operation, only one of which had trochlear dysplasia (type A). At final follow-up, none of the remaining 24 patients had complications; their OKS was 35.0 ± 10.3 and KSS symptoms and function were 19.8 ± 5.0 and 71.7 ± 13.6.

CONCLUSION

The anatomic trochlear-cutting PFA granted satisfactory scores and prevented mechanical complications, but the high incidence of early revisions, all due to spread of arthritis hence to improper patient selection. PFA should be restricted to patients with trochlear dysplasia, in whom arthritis was triggered by patellar instability and maltracking rather than degenerative or age-related diseases.

STUDY DESIGN

Retrospective case series, Level IV.