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Ramos MS, Pasqualini I, Surace PA, Molloy RM, Deren ME, Piuzzi NS. Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202312000-00001. [PMID: 38079496 DOI: 10.2106/jbjs.rvw.23.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.
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Affiliation(s)
- Michael S Ramos
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Zhang H, Cao C, Zhang H, Han S. Determining the rotational alignment of the tibial component referring to the tibial tubercle during total knee arthroplasty: the tibial tubercle-trochlear groove can be an aid. J Orthop Surg Res 2022; 17:253. [PMID: 35509006 PMCID: PMC9069815 DOI: 10.1186/s13018-022-03139-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Background There is no consensus on anatomic landmarks or reference axes with which to accurately align rotational position of tibial component. Using the tibial tubercle, commonly referring to the Akagi line and the Insall line, for anatomic reference was widely accepted. However, it is unknown about the predictors that may affect the reliability of using the tibial tubercle for aligning tibial component rotation. The aims of our study were (1) to investigate the reproducibility and accuracy of using the tibial tubercle for aligning tibial component rotation and (2) to determine predictors resulting in discrepancies of the tibial component rotation when referring to the tibial tubercle. Method A total of 160 patients with osteoarthritis were recruited before total knee arthroplasty. The angle α formed by the tibial anteroposterior (AP) axis and the Akagi line and the angle β formed by the tibial AP axis and the Insall line were measured to quantify the discrepancies of the Akagi line and the Insall line. Independent variables, including the tibial tubercle-to-trochlear groove distance (TT-TG), tibial tubercle to posterior cruciate ligament (TT-PCL), and knee rotation angle (KRA), hip–knee–ankle angle (HKA), medial proximal tibial angle (MPTA), and tibial bowing (TB), were measured. Pearson’s product moment correlation coefficients and multivariable linear regression analysis were calculated to assess relationships between independent variables and the two defined angles. Results All defined measurement were available for 140 patients. The Akagi line rotated internally with 1.03° ± 4.25° in regard to the tibial AP axis. The Insall line rotated externally in regard to the tibial AP axis with 7.93° ± 5.36°. Three variables, including TT-TG, TT-PCL, and KRA, tended to be positively correlated with the angle α and the angle β. In terms of a cutoff of TT-TG = 9 mm, 100% cases and 97% cases for using the Akagi line and Insall line, respectively, were located in the defined safe zone (− 5° to 10°). Conclusion The tibial tubercle (the Akagi line and Insall line) is found to be a useful and promising anatomic landmark for aligning the tibial component rotation. The TT-TG, with a cutoff value of 9 mm, is helpful to choose the Akagi line or Insall line, alternatively.
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Affiliation(s)
- He Zhang
- Handan Branch, Huabeiyiliao Jiankangjituan Fengfeng Zongyiyuan, Handan, 056000, Hebei, China
| | - Chengming Cao
- Handan Branch, Huabeiyiliao Jiankangjituan Fengfeng Zongyiyuan, Handan, 056000, Hebei, China
| | - Han Zhang
- Handan Branch, Huabeiyiliao Jiankangjituan Fengfeng Zongyiyuan, Handan, 056000, Hebei, China
| | - Shoujiang Han
- Department of Orthopaedic Surgery, Huabeiyiliao Jiankangjituan Fengfeng Zongyiyuan, Handan, 056000, Hebei, China.
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András G, Németh G, Oláh CZ, Lénárt G, Drén Z, Papp M. The personalized Berger method is usable to solve the problem of tibial rotation. J Exp Orthop 2021; 8:116. [PMID: 34897564 PMCID: PMC8665959 DOI: 10.1186/s40634-021-00432-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/16/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose The revision of any total knee replacement is carried out in a significant number of cases, due to the excessive internal rotation of the tibial component. The goal was to develop a personalized method, using only the geometric parameters of the tibia, without the femoral guidelines, to calculate the postoperative rotational position of tibial component malrotation within a tolerable error threshold in every case. Methods Preoperative CT scans of eighty-five osteoarthritic knees were examined by three independent medical doctors twice over 7 weeks. The geometric centre of the tibia was produced by the ellipse annotation drawn 8 mm below the tibial plateau, the sagittal and frontal axes of the ellipse were transposed to the slice of the tibial tuberosity. With the usage of several guide lines, a right triangle was drawn within which the personalized Berger angle was calculated. Results A very good intra-observer (0.89-0.925) and inter-observer (0.874) intra-class correlation coefficient (ICC) was achieved. Even if the average of the personalized Berger values were similar to the original 18° (18.32° in our case), only 70.6% of the patients are between the clinically tolerable thresholds (12.2° and 23.8°). Conclusion The method, measured on the preoperative CT scans, is capable of calculating the required correction during the planning of revision arthroplasties which are necessary due to the tibial component malrotation. The personalized Berger angle isn’t altered during arthroplasty, this way it determines which one of the anterior reference points of the tibia (medial 1/3 or the tip of the tibial tuberosity, medial border or 1/6 or 1/3 or the centre of the patellar tendon) can be used during the positioning of the tibial component. Level of evidence Level II, Diagnostic Study (Methodological Study).
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Affiliation(s)
- Gömöri András
- Department of Traumatology, Semmelweis University - Medicine and Health Sciences, Borsod-Abaúj-Zemplén County Hospital, Üllői út 26., Budapest, 1085, Hungary.
| | - Gábor Németh
- Department of Ophthalmology, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Csaba Zsolt Oláh
- Department of Neurosurgery, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Gábor Lénárt
- Department of Radiology, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Zsanett Drén
- Department of Radiology, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Miklós Papp
- TritonLife Róbert Magánkórház, Department of Orthopaedics, Miskolci Egyetem, Egészségtudományi kar, Egyetemváros, Miskolc, 3515, Hungary
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Barker KL, Room J, Knight R, Dutton SJ, Toye F, Leal J, Kent S, Kenealy N, Schussel MM, Collins G, Beard DJ, Price A, Underwood M, Drummond A, Cook E, Lamb SE. Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT. Health Technol Assess 2020; 24:1-116. [PMID: 33250068 DOI: 10.3310/hta24650] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes. OBJECTIVES To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty. DESIGN An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study. SETTING The trial took place in 14 NHS physiotherapy departments. PARTICIPANTS People identified as being at high risk of a poor outcome after knee arthroplasty. INTERVENTIONS A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy. MAIN OUTCOME MEASURES The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries. RESULTS In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold. LIMITATIONS The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded. CONCLUSIONS This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it. TRIAL REGISTRATION Current Controlled Trials ISRCTN13517704. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jon Room
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ruth Knight
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Fran Toye
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Seamus Kent
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicola Kenealy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael M Schussel
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Gary Collins
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,School of Medicine and Health, University of Exeter, Exeter, UK
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Postoperative Serum Cytokine Levels Are Associated With Early Stiffness After Total Knee Arthroplasty: A Prospective Cohort Study. J Arthroplasty 2020; 35:S336-S347. [PMID: 32269006 PMCID: PMC8279012 DOI: 10.1016/j.arth.2020.02.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/03/2020] [Accepted: 02/21/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Inflammatory cytokines have been implicated in organ fibrosis; however, their role in the development of arthrofibrosis after total knee arthroplasty (TKA) has not been well explored. The purpose of this study is to assess whether perioperative synovial fluid or blood plasma cytokine levels are associated with reduced early post-TKA range of motion. METHODS A total of 179 patients with end-stage idiopathic osteoarthritis undergoing TKA were enrolled in this prospective cohort study. Synovial fluid and blood plasma were collected prearthrotomy and plasma was collected longitudinally in the postacute care unit and on postoperative days (PODs) 1 and 2. Stiffness was defined as ≤95° range of motion measured with a goniometer at 6 weeks (±2 weeks). RESULTS Thirty-two of 162 (19.8%) patients analyzed were stiff at 6 weeks postoperatively. Postoperative plasma levels of 9 cytokines (Eotaxin3, IL-5, IL12_23p40, IP10, VEGF, IL-7, IL-12p70, IL-16, IL-17a) were significantly different between stiff and nonstiff patients on POD1 and/or POD2. An association between preoperative plasma and synovial fluid cytokine levels and the development of postoperative stiffness was not detected. CONCLUSION The results of this study suggest that there is a distinct acute postoperative cytokine response profile in patients who develop stiffness 6 weeks after TKA. This profile was characterized by significant differences in levels of 9 cytokines over the first 2 postoperative days. These results identify cytokines that are potential biomarkers for risk of early stiffness after TKA and may play a role in the pathophysiology of this outcome.
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Thompson R, Novikov D, Cizmic Z, Feng JE, Fideler K, Sayeed Z, Meftah M, Anoushiravani AA, Schwarzkopf R. Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management. Orthop Clin North Am 2019; 50:269-279. [PMID: 31084828 DOI: 10.1016/j.ocl.2019.02.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.
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Affiliation(s)
- Ryan Thompson
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - David Novikov
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Zlatan Cizmic
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - James E Feng
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Kathryn Fideler
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Zain Sayeed
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - Morteza Meftah
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Afshin A Anoushiravani
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstructive Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA.
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Room J, Batting M, Barker KL. Development of a functional rehabilitation intervention for post knee arthroplasty patients: COmmunity based Rehabilitation post Knee Arthroplasty (CORKA) trial. Physiotherapy 2019; 106:52-64. [PMID: 32026846 DOI: 10.1016/j.physio.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 06/17/2019] [Indexed: 11/27/2022]
Abstract
Knee osteoarthritis is a common cause of disability in older people and knee arthroplasty surgery in the UK is increasing. The CORKA trial is a randomised controlled trial of rehabilitation targeted at patients identified as being at risk of a poor outcome after knee arthroplasty. This paper describes the development and delivery of the CORKA intervention. It was informed by current evidence, relevant guidelines, expert and patient opinion, practical considerations and a pilot study. The intervention is a multicomponent rehabilitation programme with the main component being an exercise programme delivered to participants in their own home. It includes functional task practice, strategies to improve adherence and where appropriate the provision of appropriate aids and equipment.
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Affiliation(s)
- J Room
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS FT, Oxford, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
| | - M Batting
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS FT, Oxford, United Kingdom
| | - K L Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS FT, Oxford, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Is knee biomechanics different in uphill walking on different slopes for older adults with total knee replacement? J Biomech 2019; 89:40-47. [DOI: 10.1016/j.jbiomech.2019.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 11/30/2022]
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Zhou M, An S, Feng M, Li Z, Shen H, Zhang K, Sun J, Cao G. Gait analysis of patients with continuous proximal sciatic nerve blockade in flexion contractures after primary total knee arthroplasty. Gait Posture 2018; 66:166-171. [PMID: 30195220 DOI: 10.1016/j.gaitpost.2018.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 06/30/2018] [Accepted: 08/20/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The main objective of total knee arthroplasty is to relieve pain, restore normal knee function, and improve gait stability. Significant flexion contractures can severely impair function after surgery. The purpose of this study is to evaluate the efficacy of implementing a continuous proximal sciatic nerve block in conjunction with aggressive physical therapy to treat patients with persistent flexion contractures that were recalcitrant to rehabilitation efforts following primary total knee arthroplasty (TKA). METHODS From December 2012 to January 2016, the following subjects were enrolled in this study: 20 patients (15 females and 5 males aged between 62 and 78 years old; median age = 65.7 y) with flexion contractures ranging from 15° to 25° (19.2°±5.6°) that persisted for at least 1.5 months following total knee arthroplasty and showed no significant improvement in response to conventional therapeutic methods. Demographic data, the passive range of motion, flexion contracture, pain score during stretching, and the Hospital for Special Surgery knee score were recorded. A portable motion analyzer was used to obtain the corresponding gait parameters from the flexion contractures group and control group. Repeated measurement ANOVA was used to compare the clinical results. RESULTS In combination with 2 to 4 (2.5 ± 1.3) months of aggressive knee stretching exercises, 16 out of 18 knees achieved full extension, and 2 out of 18 improved to within 5° of the full extension. An average of the 12 to 48 (26.6 ± 10.7) month follow-up showed that this improved range of motion was maintained for all the corresponding patients, and that there were no reoccurrences of deformity. The mean Hospital for Special Surgery knee scores improved from 61.2 to 93.2 points (p < 0.001). After six months of continuous proximal sciatic nerve blockage, all gait parameters for the flexion contractures group exhibited significant improvement. CONCLUSION A continuous proximal sciatic nerve block could be a useful adjunct to a physical therapy regimen for patients with knee flexion contractures, especially for patients with difficult-to-treat cases of knee flexion contracture that are recalcitrant to conservative therapy.
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Affiliation(s)
- Meng Zhou
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China; Department of Orthopedics, Beijing Jishuitan Hospital, No.31 East Street, Beijing, China.
| | - Shuai An
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China.
| | - Mingli Feng
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China.
| | - Zheng Li
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China.
| | - Huiliang Shen
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China.
| | - Kuan Zhang
- School of Biomedical Engineering, Capital Medical University, No.10 Xi Tou Tiao, Youanmen wai, Fengtai District, Beijing, China.
| | - Jun Sun
- Department of Radiology, Beijing Youan Hospital, Capital Medical University, No.8 Xi Tou Tiao, Youanmen wai, Fengtai District, Beijing, China.
| | - Guanglei Cao
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China.
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Hug KT, Amanatullah DF, Huddleston JI, Maloney WJ, Goodman SB. Protocol-Driven Revision for Stiffness After Total Knee Arthroplasty Improves Motion and Clinical Outcomes. J Arthroplasty 2018; 33:2952-2955. [PMID: 29859726 DOI: 10.1016/j.arth.2018.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/14/2018] [Accepted: 05/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Stiffness after revision total knee arthroplasty (TKA) is a difficult problem without a well-defined treatment algorithm. The purpose of this study was to evaluate the results of revision TKA for stiffness within the context of differential component replacement. METHODS Consecutive patients who underwent revision TKA were retrospectively identified and included those who received debridement and polyethylene liner exchange alone, revision of only one of the femoral or tibial fixed components, or revision of all components. Preoperative and postoperative range of motion and Knee Society score (KSS) were collected. RESULTS Sixty-nine knees were included in the study group with a mean follow-up of 43 months (range, 12-205 months). The mean prerevision flexion contracture of 17° improved to 5° after surgical intervention (P < .001). Similarly, mean flexion and motion arc improved from 70° to 92° and from 53° to 87°, respectively (P < .001). Mean KSS knee scores improved from 42 to 70 and KSS function scores improved from 41 to 68 (P < .001). Mean arc of motion improved by 45° in patients who underwent complete component revision, 32° with component retention, and 29° with single component revision (P = .046). KSS knee scores improved by 34, 25, and 28 points in these respective groups (P = .049). KSS function scores improved by 33, 27, and 25 points (P = .077). CONCLUSION Revision surgery with or without component revision can improve motion and function in patients with stiffness after TKA. Complete component revision may offer the largest improvements in these outcome measures in properly selected patients.
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Affiliation(s)
- Kevin T Hug
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
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Schiapparelli FF, Amsler F, Hirschmann MT. Medial parapatellar approach leads to internal rotation of tibial component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2018; 26:1564-1570. [PMID: 28560546 DOI: 10.1007/s00167-017-4586-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to investigate if the type of approach [medial parapatellar approach (MPA) versus lateral parapatellar approach with tibial tubercle osteotomy (LPA)] influences rotation of femoral and/or tibial component and leg axis in total knee arthroplasty (TKA). It was the hypothesis that MPA leads to an internally rotated tibial TKA component. METHODS This study included 200 consecutive patients in whom TKA was performed using either a parapatellar medial (n = 162, MPA) or parapatellar lateral approach with tibial tubercle osteotomy (n = 38, LPA). All patients underwent clinical follow-up, standardized radiographs and computed radiography (CT). TKA components' position and the whole leg axis were assessed on 3D reconstructed CT scans (sagittal, coronal and rotational). Mean values of TKA component position and the whole leg alignment of both groups were compared using a t test. The tibial component was graded as internally rotated (<3° of external rotation (ER)), neutral rotation (equal or between 3° and 6° of ER) and externally rotated (>6° ER). The femoral component was graded as internally rotated [>3° of internal rotation (IR)], neutral rotation (equal or between -3° IR and 3° of ER) and externally rotated (>3° ER). RESULTS There was no significant difference in terms of whole leg axis after TKA between both groups (MPA: 0.2° valgus ± 3.4; LPA: 0.0° valgus ± 3.5). Means of tibial component rotation were 2.7° ER ± 6.1 (MPA) and 7.6° ER ± 5.4 (LPA). Patients of group LPA presented a significantly less internally rotated (LPA: 18.4%; MPA: 48.8%) and more externally rotated (LPA: 52.6%; MPA: 22.8%) tibial component (p < 0.001). No significant differences were seen for the femoral component position, tibial valgus/varus and tibial slope. CONCLUSION The type of approach (medial versus lateral) significantly influenced tibial TKA component rotation. It appears that a MPA tends to internally rotate the tibial TKA component and a LPA tends to externally rotate the tibial TKA. The anterior cortex should not be used as landmark for tibial TKA component placement when using the lateral approach with tibial tubercle osteotomy. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Filippo-Franco Schiapparelli
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland. .,University of Basel, Basel, Switzerland.
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Kahlenberg CA, Trivellas M, Lee YY, Padgett DE. Preoperative Valgus Alignment Does Not Predict Inferior Outcome of Total Knee Arthroplasty. HSS J 2018; 14:50-54. [PMID: 29398995 PMCID: PMC5786588 DOI: 10.1007/s11420-017-9576-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 08/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preoperative valgus deformity is present in an estimated 10-20% of patients undergoing total knee replacement (TKR). QUESTIONS/PURPOSES The objective of this study was to compare the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after TKR in a matched cohort of patients with preoperative valgus and varus deformities. METHODS This is a matched cohort study of 162 patients with varus native knees and 162 patients with valgus native knees who underwent TKR and were prospectively followed in our institutional registry. Patients matched were based on age, BMI, sex, and severity of preoperative knee deformity, which was classified as mild, moderate, severe varus or valgus, or no deformity. Outcomes were evaluated using the WOMAC preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. RESULTS No significant difference was found between the matched varus and valgus cohorts in all WOMAC subdomain scores except for a marginally worse stiffness at 1 year in patients with valgus deformity (WOMAC stiffness, 75.1 varus vs. 70.1 valgus; P = 0.049). This is below the minimal clinically important difference for WOMAC scores. There was no significant difference in postoperative varus/valgus alignment between the two groups (P = 0.092). CONCLUSION We found no clinically significant difference in any of the WOMAC domains in patients with preoperative varus deformity versus valgus deformity within the first year after TKR. These findings may allow surgeons to more appropriately counsel patients with osteoarthritis with valgus deformity that they can expect similar outcomes compared to patients with varus deformity.
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Affiliation(s)
- Cynthia A. Kahlenberg
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Myra Trivellas
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Yuo-yu Lee
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Douglas E. Padgett
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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13
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McGinnis RS, Patel S, Silva I, Mahadevan N, DiCristofaro S, Jortberg E, Ceruolo M, Aranyosi AJ. Skin mounted accelerometer system for measuring knee range of motion. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:5298-5302. [PMID: 28269456 DOI: 10.1109/embc.2016.7591923] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Sufficient range of motion of the knee joint is necessary for performing many activities of daily living. Ambulatory monitoring of knee function can provide valuable information about progression of diseases like knee osteoarthritis and recovery after surgical interventions like total knee arthroplasty. In this paper, we describe a skin-mounted, conformal, accelerometer-based system for measuring knee angle and range of motion that does not require a skilled operator to apply devices. We establish the accuracy of this technique with respect to clinical gold standard goniometric measurements on a dataset collected from normative subjects during the performance of repeated bouts of knee flexion and extension tests. Results show that knee angle and range of motion estimates are highly correlated with goniometer measurements, and track differences in knee angle and range of motion to within 1%. These results demonstrate the ability of this system to characterize knee angle and range of motion, enabling future longitudinal monitoring of knee motion in naturalistic environments.
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Kim JI, Jang J, Lee KW, Han HS, Lee S, Lee MC. Anterior tibial curved cortex is a reliable landmark for tibial rotational alignment in total knee arthroplasty. BMC Musculoskelet Disord 2017; 18:252. [PMID: 28606122 PMCID: PMC5469063 DOI: 10.1186/s12891-017-1609-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/30/2017] [Indexed: 11/10/2022] Open
Abstract
Background Rotational alignment of the tibial component is important for long-term success of total knee arthroplasty (TKA). This study aimed to compare five axes in normal and osteoarthritic (OA) knees to determine a reliable landmark for tibial rotational alignment in TKA. Methods One hundred twenty patients with OA knees and 40 with normal knees were included. The angle between a line perpendicular to the surgical transepicondylar axis and each of five axes were measured on preoperative computed tomography. The five axes were as follows: a line from the center of the posterior cruciate ligament (PCL) to the medial border of the patellar tendon (PCL-PT), medial border of the tibial tuberosity (PCL-TT1), medial one-third of the tibial tuberosity (PCL-TT2), and apex of the tibial tuberosity (PCL-TT3), as well as the anteroposterior axis of the tibial prosthesis along the anterior tibial curved cortex (ATCC). Results For all five axes tested, the mean angles were smaller in OA knees than in normal knees. In normal knees, the angle of the ATCC axis had the smallest mean value and narrowest range (1.6° ± 2.8°; range, −1.7°–7.7°). In OA knees, the mean angle of the ATCC axis (0.8° ± 2.7°; range, −7.9°–9.2°) was larger than that of the PCL-TT1 axis (0.3° ± 5.5°; range, −19.7°–10.6°) (P = 0.461), while the angle of the ATCC axis had the smallest SD and narrowest range. Conclusion The ATCC was found to be the most reliable and useful anatomical landmark for tibial rotational alignment in TKA.
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Affiliation(s)
- Joong Il Kim
- Department of Orthopaedic Surgery, Hallym University Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 150-950, Korea
| | - Jak Jang
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea
| | - Ki Woong Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea
| | - Hyuk Soo Han
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea
| | - Sahnghoon Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea
| | - Myung Chul Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.
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15
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Liu HC, Wu WT, Yang KC, Yeh KT, Sumi S, Wang CC. An assessment of femoral rotational alignment of mini-incision total knee arthroplasty: A comparison based on the transepicondylar line from the kneeling view and the intraoperative posterior condylar line. J Orthop Sci 2017; 22:506-511. [PMID: 28126291 DOI: 10.1016/j.jos.2016.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/27/2016] [Accepted: 12/21/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Rotational alignment of the distal femur is important in total knee arthroplasty. The purpose of this study is to use a roentgenographic technique to evaluate the accuracy of mini-incision total knee arthroplasty (MIS TKA) performed based on the transepicondylar line from the kneeling view. METHODS Totally 32 patients (aged from 64 to 80 years with an average of 70.9 years) with 46 cases of knee osteoarthritis received MIS TKA were registered. Before surgery, the condylar twist angle was measured from the kneeling view. The bone cut for the external rotation was completed, with regard to the condylar twist angle. The control group including 26 patients (aged from 50 to 89 years with an average of 69.7 years) with 42 cases of knee osteoarthritis underwent TKA with built-in cutting jig design 3 degrees of femoral external rotation. This study is a prospective continuous-time duration analysis study. The level of evidence is IIc. RESULTS The mean condylar twist angle was 5.1° in the experimental group and 5.4° in the control group. The mean postoperative angle between the clinical epicondylar axis and the posterior condylar line of the femoral component was 0.46°. The same postoperative angle of the built-in external rotation in the control group was 2.7°. The condylar twist angle was significantly more accurate than the built-in design. CONCLUSION Our result substantiates that the kneeling view is practicable and reproducible as the cutting reference for femoral external rotation. The accuracy of the kneeling view shows that the epicondylar axis can be used in smaller wound surgery, such as MIS TKA. LEVEL OF EVIDENCE Level IIc.
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Affiliation(s)
- Hwa-Chang Liu
- Department of Orthopaedic Surgery, Taiwan Adventist Hospital, Taipei 10556, Taiwan
| | - Wen-Tien Wu
- Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan; Department of Orthopedic Surgery, Hualien Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Kai-Chiang Yang
- School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; Laboratory of Organ and Tissue Reconstruction, Institute for Frontier Life and Medical Sciences, Kyoto University, Kyoto 606-8507, Japan; Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan
| | - Kuang-Ting Yeh
- Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan; Department of Orthopedic Surgery, Hualien Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Shoichiro Sumi
- Laboratory of Organ and Tissue Reconstruction, Institute for Frontier Life and Medical Sciences, Kyoto University, Kyoto 606-8507, Japan
| | - Chen-Chie Wang
- Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan; Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan.
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Smith EB, Shafi KA, Greis AC, Maltenfort MG, Chen AF. Decreased flexion contracture after total knee arthroplasty using Botulinum toxin A: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2016; 24:3229-3234. [PMID: 27515301 DOI: 10.1007/s00167-016-4277-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Flexion contracture after total knee arthroplasty (TKA) can cause significant dissatisfaction. Botulinum toxin A has shown improved extension in patients with spastic flexion contractures after TKA. The purpose of this study was to evaluate whether Botulinum toxin A improves knee extension for any patient with flexion contractures following TKA. METHODS A prospective, double-blinded, randomized controlled trial was conducted. Fourteen patients (15 knees), with a flexion contracture (≥10°) one month postoperatively, were randomized to receive either Botulinum toxin A or saline placebo to the affected hamstrings. The subject, surgeon, and administering physiatrist were blinded to the treatment group throughout the study. Subject range of motion (ROM) was evaluated at 1, 6, and 12 months following injection. Differences were tested using mixed-effects regression to control for multiple measurements. RESULTS The initial post-operative flexion contracture averaged 19° ± 6° in the Botulinum toxin A group and 13° ± 3° in the saline group. Injections were performed 53 and 57 days after TKA in the Botulinum toxin A and saline groups, respectively. Post-injection extension improved to an average of 8, 5, and 1 degrees for BTX and 4, 2, and 1 degrees for SAL, at 1, 6, and 12 months, respectively, compared to pre-injection extension (p < 0.0001). Improvement in knee extension at 1 year improved 18° ± 7.5° for Botulinum toxin A and 12° ± 2° for saline (p = 0.04). No complications resulted from either injection. CONCLUSION Patients who received Botulinum toxin A or placebo were able to achieve near full extension one year after surgery. There was a statistically significant improvement in the amount of extension achieved at 1 year with Botulinum toxin A, but this may be of little clinical significance. Since achieving full extension is important for patient function and satisfaction, novel techniques to address this issue deserve special attention. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Eric B Smith
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA.
| | - Karim A Shafi
- Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, PA, USA
| | - Ari C Greis
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA
| | - Mitchell G Maltenfort
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA
| | - Antonia F Chen
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA
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Kawahara S, Mawatari T, Iwamoto Y, Banks SA. Femoral sizer design can increase anterior notching during total knee arthroplasty. Knee 2016; 23:890-4. [PMID: 27568364 DOI: 10.1016/j.knee.2015.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/16/2015] [Accepted: 11/26/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The anteroposterior (AP) portions of the distal femur are generally resected externally rotated relative to the posterior condylar line (PCL) in non-navigated/measured-resection total knee arthroplasty (TKA). Some femoral sizing devices allow rotational adjustment before sizing (rotation-modified sizing devices), while others do not (rotation-unmodified sizing devices). When rotation-unmodified sizing devices are used, the stylus attached to the sizing device identifies the proximal/anterior flange cut assuming the femoral component is aligned parallel to the PCL. However, if the AP cutting device is externally rotated then unexpected notching of the anterior cortex can occur. METHODS We simulated TKA surgery in 100 Japanese varus osteoarthritic knees using three-dimensional planning software. The femoral component was aligned parallel to the PCL and the AP component position was determined so proximal anterior flange was just touching the anterior cortex. Next, the femoral component was externally rotated parallel to the surgical epicondylar axis (SEA). If the proximal anterior flange penetrated femoral bone, the length and thickness of anterior notching were measured. RESULTS The proximal anterior flange rested on the anterior cortex or penetrated the femoral bone in all knees. There was a strong positive correlation between PCA and length of anterior notching. Anterior notching more than 10mm length or one-millimeter thickness occurred in most cases (82.4% and 70.6%, respectively) where the posterior condylar angle (PCA) was more than four degrees. CONCLUSIONS Anterior femoral notching is influenced by the design of the femoral sizing guide and subsequent rotation of cutting blocks, especially in knees with a large PCA.
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Affiliation(s)
- Shinya Kawahara
- Department of Mechanical & Aerospace Engineering, University of Florida, 318 MAE-A, 116250, Gainesville, FL 32611, USA; Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Taro Mawatari
- Department of Orthopaedic Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka 810-8539, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Scott A Banks
- Department of Mechanical & Aerospace Engineering, University of Florida, 318 MAE-A, 116250, Gainesville, FL 32611, USA
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The linea aspera as a rotational landmark: an anatomical MRI-based study. Surg Radiol Anat 2016; 38:1069-1074. [PMID: 26971095 DOI: 10.1007/s00276-016-1661-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE The linea aspera can be used as a landmark to assess the rotation of the distal femoral epiphysis when performing an endoprostheses. However, no study has assessed the reliability of this landmark. We therefore asked whether the linea aspera could be used as a rotational landmark for positioning distal femoral knee megaprostheses. MATERIALS This is an anatomic MRI-based study of 50 femurs (27 subjects). For each femur, multiple axial sections were obtained from the intercondylar line at the knee joint to the lesser trochanter; each axial section was superposed with that where the posterior condyles were seen and the R angle was measured. The R angle is the angle measured medially where the line passing through the linea aspera and the line tangent to the posterior condyles intersects. RESULTS There were considerable differences between and within subjects with a maximum R angle ranging from 100° to 120°. Regression models showed that the R angle was significantly associated with distance from knee joint and subjects. CONCLUSION Surgeons should have the R angle measured before performing a distal femoral reconstruction.
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Wied C, Thomsen MG, Kallemose T, Myhrmann L, Jensen LS, Husted H, Troelsen A. The risk of manipulation under anesthesia due to unsatisfactory knee flexion after fast-track total knee arthroplasty. Knee 2015; 22:419-23. [PMID: 25766466 DOI: 10.1016/j.knee.2015.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 01/08/2015] [Accepted: 02/16/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fast-track TKA has significantly shortened the time available for physiotherapists to optimize knee ROM before discharge. Safety aspects concerning knee stiffness and the need for manipulation in a fast-track setting need to be illuminated. The study aims were to analyze if fast-track TKA can be considered safe considering rates of knee manipulation and if there is an association between knee ROM at time of discharge and the need for later manipulation. METHODS Primary TKAs operated in 2011 at our institution were eligible for inclusion. The study group consisted of 359 TKAs. RESULTS Manipulation of the knee was performed in 21 of 359 TKAs (5.8%). Seventy-one percent were discharged with a flexion ≥70° combined with an extension deficit of ≤10°. The occurrence of MUA for these patients was 4.3%. The prevalence of knee manipulation showed a statistically significant association with the achieved knee flexion at discharge (p=0.02). Median length of stay was two days. CONCLUSION Compared with literature findings fast-track TKA surgery may be considered safe based on the acceptable rate of knee manipulations after TKA (5.8%). We suggest ROM of ≥70° flexion combined with an extension deficit of ≤10° as an "optimal-zone" for ROM at discharge. The reason for this is the low occurrence of MUA (4.3%) in relation to the large amount of TKAs it represents (71%). The indication for MUA is multifactorial and ROM at discharge serves only as an indicator of later MUA risk.
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Affiliation(s)
- Christian Wied
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
| | - Morten G Thomsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lis Myhrmann
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lotte S Jensen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Henrik Husted
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; The Lundbeck Foundation for Fast-track Hip and Knee Replacement, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Affiliation(s)
- Hermann O Mayr
- University Hospital Freiburg, Clinic of Orthopedic & Trauma Surgery, Hugstetter Straße55, 79106 Freiburg, Germany.
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Bou Monsef J, Schraut N, Gonzalez M. Failed Total Knee Arthroplasty. JBJS Rev 2014; 2:01874474-201412000-00001. [PMID: 27490508 DOI: 10.2106/jbjs.rvw.n.00025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jad Bou Monsef
- Department of Orthopedic Surgery, University of Illinois at Chicago, 835 South Walcott Avenue, Room E270, Chicago, IL, 60612
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Kawahara S, Okazaki K, Matsuda S, Nakahara H, Okamoto S, Iwamoto Y. Internal rotation of femoral component affects functional activities after TKA--survey with the 2011 Knee Society Score. J Arthroplasty 2014; 29:2319-23. [PMID: 24388616 DOI: 10.1016/j.arth.2013.11.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/11/2013] [Accepted: 11/23/2013] [Indexed: 02/01/2023] Open
Abstract
The 2011 Knee Society Knee Scoring System (KSS) was developed as a new patient-derived outcome measure to better characterize satisfaction, expectations, and physical activities after total knee arthroplasty. The rotational alignment of the femoral and tibial components was assessed with computed tomography in 75 patients (92 knees), and its effect on the scores of the KSS was evaluated. Internal rotation of the femoral component relative to the surgical epicondylar axis significantly decreased the score of functional activities and slightly decreased the score of satisfaction. Femoral component malrotation did not affect the scores of symptoms and expectations. Tibial component malrotation did not affect any of the scores of the 2011 KSS. Surgeons should avoid internal rotation of the femoral component to preserve functional activities.
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Affiliation(s)
- Shinya Kawahara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Nakahara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigetoshi Okamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Sharkey PF, Lichstein PM, Shen C, Tokarski AT, Parvizi J. Why are total knee arthroplasties failing today--has anything changed after 10 years? J Arthroplasty 2014; 29:1774-8. [PMID: 25007726 DOI: 10.1016/j.arth.2013.07.024] [Citation(s) in RCA: 502] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/27/2013] [Accepted: 07/21/2013] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to determine the frequency and cause of failure after total knee arthroplasty and compare the results with those reported by our similar investigation conducted 10 years ago. A total of 781 revision TKAs performed at our institution over the past 10 years were identified. The most common failure mechanisms were: loosening (39.9%), infection (27.4%), instability (7.5%), periprosthetic fracture (4.7%), and arthrofibrosis (4.5%). Infection was the most common failure mechanism for early revision (<2 years from primary) and aseptic loosening was the most common reason for late revision. Polyethylene (PE) wear was no longer the major cause of failure. Compared to our previous report, the percentage of revisions performed for polyethylene wear, instability, arthrofibrosis, malalignment and extensor mechanism deficiency has decreased.
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Affiliation(s)
- Peter F Sharkey
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Paul M Lichstein
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chao Shen
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anthony T Tokarski
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Roßkopf J, Singh PK, Wolf P, Strauch M, Graichen H. Influence of intentional femoral component flexion in navigated TKA on gap balance and sagittal anatomy. Knee Surg Sports Traumatol Arthrosc 2014; 22:687-93. [PMID: 24158449 DOI: 10.1007/s00167-013-2731-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 10/14/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Navigation has proven its ability to accurately restore coronal leg axis; however, for a good clinical outcome, other factors such as sagittal anatomy and balanced gaps are at least as important. In a gap-balanced technique, the size of the flexion gap is equalled to that of the extension gap. Flexion of the femoral component has been described as a theoretical possibility to balance flexion and extension gap. Aim of this study was to assess whether intentional femoral component flexion is helpful in balancing TKA gaps and in restoring sagittal anatomy. METHODS One hundred and thirty-one patients with TKA were included in this study. Implantation was performed in a navigated, gap-balanced, tibia-first technique. The femoral component flexion needed to equal flexion to extension gap was calculated based upon the navigation data. The sagittal diameter, the anterior and posterior offset were measured pre- and postoperatively based on the lateral radiographs. Medial and lateral gaps in extension and flexion as well as flexion/extension gap differences pre- and postoperatively were analysed. Additionally range of motion (ROM) and patient satisfaction (SF 12) were obtained. RESULTS To achieve equal flexion and extension gap, the femoral component was flexed in 120 out of 131 patients showing mean flexion of 2.9° (SD 2.2°; navigation data) and 3.1° (SD 2.0°; radiological analysis), respectively. Based on this technique, it was possible to balance the extension gap (<2 mm difference) in 130 out of 131 patients (99%) and the flexion gap in 119 out of 131 (91%). The difference between extension and flexion gap was reduced from 39 to 24 out of 131 patients (81%) on the medial side and from 69 to 28 on the lateral side (79%). The sagittal diameter was restored in 114 out of 131 cases (87%); however, anterior offset was significantly reduced by 1.3 mm (SD 3.9°), and posterior offset was significantly increased by 1.6 mm (SD 3.3°). No correlation between any navigation and radiological parameter was found with ROM and SF 12. CONCLUSIONS The navigation-based, gap-balanced technique allows intentional flexion of the femoral component in order to balance gaps in more than 90% of primary TKA cases. Simultaneously, the sagittal diameter is restored in 87% of patients. However, to achieve equal gaps, the posterior offset is significantly increased by 1.6 mm and the femoral component is flexed by 3°. To evaluate the effect of this technique on the clinical outcome, future studies are needed. LEVEL OF EVIDENCE II.
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Affiliation(s)
- J Roßkopf
- Department of Arthroplasty, Asklepios Orthopaedic Hospital Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany
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Levinger P, Menz HB, Morrow AD, Feller JA, Bartlett JR, Bergman NR. Lower limb biomechanics in individuals with knee osteoarthritis before and after total knee arthroplasty surgery. J Arthroplasty 2013; 28:994-9. [PMID: 23523504 DOI: 10.1016/j.arth.2012.10.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 09/18/2012] [Accepted: 10/17/2012] [Indexed: 02/01/2023] Open
Abstract
We investigated the biomechanical changes that occur in the lower limb following total knee arthroplasty (TKA). Lower limb joint kinematics and kinetics were evaluated in 32 patients before and 12 months following TKA and 28 age-matched controls. Analysis of variance with Bonferroni-adjusted post-hoc tests showed no significant changes in knee joint kinematics and kinetics following TKA despite significant improvements in pain and function. Significant increases in peak ankle plantarflexion and dorsiflexion moments and ankle power generation were observed which may be a compensatory response to impaired knee function to allow sufficient power generation for propulsion. Differences in knee gait parameters may arise as a result of the presence of osteoarthritis and mechanical changes associated with TKA as well as retention of the pre-surgery gait pattern.
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Affiliation(s)
- Pazit Levinger
- Institute of Sport, Exercise and Active Living, Victoria University, Melbourne Vic, Australia
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Relationship between the tibial anteroposterior axis and the surgical epicondylar axis in varus and valgus knees. Knee Surg Sports Traumatol Arthrosc 2012; 20:2077-81. [PMID: 22205094 DOI: 10.1007/s00167-011-1826-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 12/05/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Proper rotational alignment in total knee arthroplasty (TKA) is essential for successful outcomes. The surgical epicondylar axis (SEA) has been frequently used to determine the femoral rotational alignment, and the anteroposterior (AP) axis of the tibia described in previous study has been introduced as a line perpendicular to the SEA in healthy knees. However, the rotational relationship between the distal femur and the proximal tibia would vary between normal and osteoarthritic knees, and a question remains whether the rotational relationship between the SEA and the AP axis of the tibia would be the same between normal and osteoarthritic knees. This study aims to determine whether the AP axis of the tibia is actually perpendicular to the SEA and useful for the tibial rotational alignment also in osteoarthritic knees. METHODS Preoperative computed tomography scans on 25 varus and 25 valgus knees undergoing TKA were studied. The SEA and the AP axis of the tibia were identified using a three-dimensional software, and the angle between the line perpendicular to the projected SEA and the AP axis was measured. RESULTS The AP axis of the tibia was 1.7° ± 4.3° and 2.0° ± 4.0° internally rotated relative to the line perpendicular to the SEA in the varus and valgus groups, respectively. CONCLUSIONS The AP axis of the tibia was, on average, perpendicular to the SEA in both varus and valgus knees. The AP axis would be useful for setting the tibial component with minimal rotational mismatch. LEVEL OF EVIDENCE IV.
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Pfitzner T, Röhner E, Krenn V, Perka C, Matziolis G. BMP-2 Dependent Increase of Soft Tissue Density in Arthrofibrotic TKA. Open Orthop J 2012; 6:199-203. [PMID: 22629292 PMCID: PMC3358793 DOI: 10.2174/1874325001206010199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 04/13/2012] [Accepted: 04/22/2012] [Indexed: 12/14/2022] Open
Abstract
Arthrofibrosis after total knee arthroplasty (TKA) is difficult to treat, as its aetiology remains unclear. In a previous study, we established a connection between the BMP-2 concentration in the synovial fluid and arthrofibrosis after TKA. The hypothesis of the present study was, therefore, that the limited range of motion in arthrofibrosis is caused by BMP-2 induced heterotopic ossifications, the quantity of which is dependent on the BMP-2 concentration in the synovial fluid. Eight patients with arthrofibrosis after TKA were included. The concentration of BMP-2 in the synovial fluid from each patient was determined by ELISA. Radiologically, digital radiographs were evaluated and the grey scale values were determined as a measure of the tissue density of defined areas. Apart from air, cutis, subcutis and muscle, the soft-tissue density in the area of the capsule of the suprapatellar pouch was determined. The connection between the BMP-2 concentration and the soft-tissue density was then investigated. The average BMP-2 concentration in the synovial fluid was 24.3 ± 6.9 pg/ml. The density of the anterior knee capsule was on average 136 ± 35 grey scale values. A linear correlation was shown between the BMP-2 concentration in the synovial fluid and the radiological density of the anterior joint capsule (R=0.84, p = 0.009). We were able to show that there is a connection between BMP-2 concentration and soft-tissue density in arthrofibrosis after TKA. This opens up the possibility of conducting a prophylaxis against arthrofibrosis in risk patients by influencing the BMP-2 pathway.
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Affiliation(s)
- Tilman Pfitzner
- Orthopaedic Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Chariteplatz 1, D-10117 Berlin, Germany
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Levinger P, Menz HB, Morrow AD, Perrott MA, Bartlett JR, Feller JA, Bergman NB. Knee biomechanics early after knee replacement surgery predict abnormal gait patterns 12 months postoperatively. J Orthop Res 2012; 30:371-6. [PMID: 21887700 DOI: 10.1002/jor.21545] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 08/11/2011] [Indexed: 02/04/2023]
Abstract
An abnormal flexor moment pattern is often evident following total knee replacement (TKR) surgery. We investigated whether such a pattern at 12 months post-surgery could be predicted using biomechanical gait measures assessed before surgery and at 4 months post-surgery. Thirty two TKR patients were evaluated and classified as normal (biphasic pattern) or abnormal (flexor moment pattern) at each time point. Biomechanical parameters collected before surgery and at 4 months post-surgery were then explored for their ability to predict gait patterns at 12 months post-surgery. The gait pattern at 4 months was significantly associated with the 12 month post-surgery gait pattern, with over half of those with a flexor moment pattern at 4 months retaining this pattern at 12 months. Discriminant function analysis indicated that peak knee flexion during early stance, peak knee extension, and peak knee extension moment at 4 months post-surgery were independent predictors of the gait pattern at 12 months. Thus, an abnormal knee flexor moment pattern at 12 months post-surgery can be predicted by biomechanical analysis 4 months after surgery. Therefore, interventions aimed at improving active extension may need to be implemented early after surgery to restore a normal gait pattern.
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Affiliation(s)
- Pazit Levinger
- Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria 3086, Australia.
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