Timing of manipulation under anaesthesia for stiffness after total knee arthroplasty

No clinical advantage with customized individually made implants over conventional off-the-shelf implants in total knee arthroplasty: a systematic review and meta-analysis

INTRODUCTION

Total knee arthroplasty (TKA) can be performed with either conventional off-the-shelf (OTS) or customized individually-made (CIM) implants. The evidence for CIM implants is limited and variable, and the aim of this review was to compare clinical and radiological outcomes between CIM and OTS implants.

METHODS

A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Studies reporting on clinical, radiological, or alignment outcomes for CIM and OTS implants were selected. The studies were appraised using the Methodical index for non-randomized studies tool.

RESULTS

Twenty-three studies fulfilled the inclusion criteria. The studies comprised 2856 CIM and 1877 OTS TKAs. Revision rate was higher with CIM (5.9%) compared to OTS (3.7%) implants [OR 1.23(95% CI 0.69-2.18)]. Manipulation under anesthesia (MUA) was higher in CIM (2.2%) compared to OTS (1.1%) group [OR 2.95(95% CI 0.95-9.13)] and complications rate was higher in CIM (5%) vs. OTS (4.5%) [OR 1.45(95% CI 0.53-3.96)] but neither reached statistical significance. Length of stay was significantly shorter in CIM group 2.9 days vs. 3.5 days [MD - 0.51(95% CI - 0.82 to - 0.20)]. Knee Society Score showed no difference between CIM and OTS groups for Knee 90.5 vs. 90.6 [MD - 0.27(95% CI - 4.27 to 3.73)] and Function 86.1 vs. 83.1 [MD 1.51(95% CI - 3.69 to 6.70)].

CONCLUSION

CIM implants in TKA have theoretical benefits over OTS prostheses. However, in this present review, CIM implants were associated with higher revisions, MUA, and overall complication rates. There was no difference in outcome score and CIM implants did not improve overall target alignment; however, more CIM TKAs were found to be in the HKA target zone compared to OTS TKAs. The findings of this review do not support the general utilization of CIM over OTS implants in TKA.

Use of Botulinum Toxin A to Manage Hamstring-Induced Flexion Contracture Following Total Knee Arthroplasty: A Case Series

Introduction Flexion contractures following total knee arthroplasty (TKA) greatly affect patient function and satisfaction. Botulinum toxin A (BTX) has been described in the literature as a means of addressing post-operative flexion contractures due to hamstring muscle rigidity. Methods We retrospectively report a case series of eight patients with range of motion (ROM) who developed a flexion contracture status post-TKA and were managed with the use of physical therapy, diagnostic hamstring lidocaine injections, and therapeutic hamstring BTX injections. Results All patients had an improvement in extension ROM following diagnostic lidocaine hamstring injections and were therefore considered candidates for therapeutic hamstring BTX injections. Prior to therapeutic hamstring BTX injections, patients had an average flexion contracture of 19° (range: 15°-22°). All patients had an improvement in extension ROM two to four weeks following the therapeutic hamstring BTX injection, with an average improvement in ROM of 7° (range: 2°-19°). At the final follow-up, all patients continued to sustain an improvement in extension ROM with an average deficit of 9° (range: 0°-17°). Conclusion Our case series highlights the use of diagnostic hamstring lidocaine injections to confirm hamstring rigidity as an etiology for flexion contracture following TKA. In addition, we showed a persistent improvement in flexion contracture for all patients after hamstring BTX injections. Therefore, when the appropriate patient is selected, BTX may provide an additional treatment option for a flexion contracture following TKA.

Cementless Compared to Cemented Total Knee Arthroplasty is Associated With More Revisions Within 1 Year of Index Surgery

Background

Cementless total knee arthroplasties (TKAs) have gained renewed interest due to improved implant designs and lower rates of revision than its cemented counterparts. The purpose of this study was to compare revision rates between cemented vs cementless TKAs within 1 year of primary arthroplasty.

Methods

This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone cemented and cementless TKAs and subsequent surgical revisions. An unadjusted univariate analysis of patient demographics, Charlson Comorbidity Index score, and surgical revisions at 90 days and 1 year after TKA was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for 1-year surgical complications requiring revision.

Results

Of 324,508 patients, 312,988 (96.45%) underwent cemented TKAs, and 11,520 (3.55%) underwent cementless TKAs. Patients undergoing cementless TKA tended to be younger than patients undergoing cemented TKA (63.67 ± 9.15 cementless vs 66.22 ± 8.85 cemented, P < .001). Univariate chi-squared testing showed that cementless patients were more likely to require 1-component femoral or tibial revision at 90 days and 1 year, irrigation and debridement at 90 days and 1 year, and arthroscopy with lysis of adhesions at 1 year only. Similar findings were observed for these 3 revision procedures at 1 year after correcting for age, gender, and Charlson Comorbidity Index score using multivariate logistic regression analysis as cementless TKA patients had higher odds ratios for each of the revisions.

Conclusions

Small but significant differences were found in surgical revisions among cementless TKAs when compared to cemented TKAs within 1 year of the index procedure.

Intra-articular celecoxib improves knee extension regardless of surgical release in a rabbit model of arthrofibrosis

Aims

Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release.

Methods

A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) – one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks.

Results

IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)).

Conclusion

IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value.

Cite this article: Bone Joint Res 2022;11(1):32–39.

Efficacy of Knee Arthroplasty on the Outcomes of Knee Osteoarthritis in Iranian Elderly Individuals

BACKGROUND

Knee osteoarthritis is a common musculoskeletal condition in elderly individuals. This survey was conducted with the aim to identify the problems of this group of patients for compilation of healthcare programs targeted at determining the outcome of osteoarthritis before and 3 months after knee arthroplasty.

MATERIALS AND METHODS

In the present cross-sectional study, 150 elderly individuals who had volunteered for knee arthroplasty were selected through nonrandomized sampling and were evaluated using the Knee Osteoarthritis Outcome Score (KOOS) questionnaire and a demographic characteristics form before and 3 months after the surgery via nonparametric statistical tests (Wilcoxon, Mann-Whitney U, and Kruskal-Wallis tests).

RESULTS

The mean (SD) age of the study subjects was 64.40 (7.20) years. A significant difference was observed between the mean scores of all subscales (pain with Z=10.62, knee pain/knee stiffness with Z=10.54, daily activity with Z=10.62, sport with Z=2.95, and quality of life with Z=10.48) before and after knee arthroplasty based on Wilcoxon test (˂0.05). The results of the Mann-Whitney U test showed a significant statistical relationship between the difference in the mean score of daily activities and history of opium consumption (Z=1.90, p ˂ 0.05) as well as that between knee pain/knee stiffness and gender (Z=2.57, p ˂ 0.05) and educational level (Z=2.11, p ˂ 0.05).

CONCLUSIONS

Knee arthroplasty and history of opium consumption were correlated with improvement of patients' performance in their daily activities, and gender (women) and educational level (unread) were correlated with improvement of the score of the knee pain/knee stiffness subscale.

Management of Stiffness following Total Knee Arthroplasty: International Survey on Surgeon Preferences

Introduction: Stiffness following total knee arthroplasty (TKA) is a challenging complication and can result in a poor functional outcome. There is considerable debate concerning the definition, work-up, and optimal management of this complication. The aim of this study was to record the definition of stiffness, management practices, and expectations of outcome among surgeons from an international community using a peer-reviewed questionnaire. Methods: A 23-item peer-reviewed online questionnaire was sent to all members of SICOT to gauge and record the management practices and expectations of outcome in the management of patients with stiffness following TKA. Results: A total of 315 surgeons completed this peer-reviewed questionnaire. Manipulation under anaesthesia (MUA) was the preferred treatment option for stiffness post-TKA, with a majority of the surgeons opting to carry out this procedure between 6 and 12 weeks following the index TKA. Physiotherapy and a continuous passive motion device were also used by the majority of surgeons following MUA, as additional treatment measures. Discussion: MUA is perceived to be a safe and effective primary treatment option for stiffness following TKA. It is best performed between weeks 6 and 12 with expected gains in range of motion from 10 to 20 degrees in 75% of patients.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic

Purpose

Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients.

Methods

A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria.

Results

Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes.

Conclusion

Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.

Manipulation under Anaesthesia for Patient Reported Stiffness after Total Knee Arthroplasty in an Asian Population

Introduction:

Stiffness after Total Knee Arthroplasty (TKA) is a complication that decreases patient satisfaction. Patients in an Asian population have potentially different requirements of knee range of motion. The authors have encountered patients who complain of subjective stiffness post TKA who do not have a severely restricting range of motion (ROM). Some patients have persistent subjective stiffness and undergone Manipulation Under Anaesthesia (MUA). We look at their functional outcomes post MUA.

Materials and Methods:

This is a retrospective study, including 48 patients from a single institution who underwent MUA for stiffness, separated into objective and subjective knee stiffness. Patients with subjective knee stiffness who underwent MUA had failed conservative management. ROM, Oxford Knee Scores (OKS), Knee Society Scores (KSS) and Short Form 36 (SF36) scores were compared at two years post MUA.

Results:

The demographics of the two patient groups were similar. The time interval between index TKA and MUA was higher in the subjective knee stiffness group. Pre-MUA OKS, KS Function Score, KSS and SF36 scores were similar in both patient subgroups. There was no significant difference in the OKS, KSS or SF36 at two year follow-up. The proportion of patients in each group who achieved the Minimum Clinically Important Difference (MCID) improvement in the scores was also similar.

Conclusions:

Patients with subjective knee stiffness can achieve similar functional outcome improvements in Oxford and Knee Society Scores with MUA at two years follow-up.

The stiff total knee arthroplasty: causes, treatment modalities and results

It is clear that the stiff total knee arthroplasty (TKA) is a multifactorial entity associated with preoperative, intraoperative and postoperative factors.

Management of the stiff TKA is best achieved by preventing its occurrence using strategies to control preoperative factors, avoid intraoperative technical errors and perform aggressive, painless postoperative physical medicine and rehabilitation; adequate pain control is paramount in non-invasive management.

Careful attention to surgical exposure, restoring gap balance, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, pain control and adequate physical medicine and rehabilitation (physiotherapy, Astym therapy) all serve to reduce its incidence.

For established stiff TKA, there are multiple treatment options available including mobilization under anaesthesia (MUA), arthroscopic arthrolysis, revision TKA, and combined procedures.

Cite this article: EFORT Open Rev 2019;4:602-610. DOI: 10.1302/2058-5241.4.180105

The effect of a preoperative education class on the rate of manipulation under anesthesia after total knee arthroplasty in a veterans population

Background

Arthrofibrosis after total knee arthroplasty (TKA) is a common complication, potentially occurring in up to 25% of patients, and may be treated during the early recovery period by manipulation under anesthesia (MUA). The majority of preoperative factors that predispose patients to postoperative stiffness are patient specific and not modifiable. The United States Veteran Affairs is a particularly challenging group given a higher baseline rate of medical comorbidities and opioid dependence than the general population. Patient education about postoperative expectations and complications has been shown to improve outcomes in certain orthopedic procedures. This retrospective study aims to determine if preoperative counseling for veterans undergoing primary TKA reduces the rate of postoperative stiffness, and consequently MUA, in this subset of patients.

Methods

We evaluated the medical records of 244 veterans at a single veteran affairs hospital who underwent 278 TKAs during a 6-year period under one surgeon. Patients were separated into groups based on attendance in the preoperative counseling session. Effects of various factors, including age, sex, body mass index, preoperative knee range of motion, and history of previous knee surgery, were compared between these 2 cohorts.

Results

Attendance in the preoperative course did not have a statistically significant impact on the rate of manipulation (odds ratio [OR], 1.07). Female gender and prior manipulation had an increased OR of knee manipulation, whereas age > 65 years had a decreased OR that did not reach significance.

Conclusions

Our results show that preoperative counseling did not have a benefit in terms of postoperative MUA rates in veterans. Preoperative education may be helpful for setting appropriate expectations of pain, recovery, and function after total joint arthroplasty and may be useful in an online or video format in small practices in which cost may be prohibitive. Further studies are needed to determine whether they provide any benefit in postoperative arthrofibrosis rates.